Treatment of detrusor sphincter dyssynergia by transperineal injection of botulinum toxin

doi:10.1016/S0003-9993(98)90050-8

Archives of Physical Medicine and Rehabilitation

Volume 79, Issue 6, June 1998, Pages 715-717

https://doi.org/10.1016/S0003-9993(98)90050-8 Get rights and content

Abstract

Detrusor-sphincter dyssynergia is an involuntary contraction of the external urethral sphincter during the detrusor contraction. It causes voiding dysfunction and can lead to urologic complications such as hydroureteronephrosis and renal failure. Patients with spinal cord injuries are particularly vulnerable. Botulinum toxin has been used via cystoscopy to decrease the activity of the external urethral sphincter. This report describes the treatment of 5 tetraplegic patients by single transperineal injections of botulinum toxin for detrusor-sphincter dyssynergia, proved by a urodynamic study with electromyography. A total of 15 injections was given, resulting in improved bladder function in all patients. Urodynamic assessment after treatment showed an increase of the functional detrusor capacity and a decrease of the maximal detrusor pressure during voiding. These results confirm the consideration of botulinum toxin as a treatment for detrusor sphincter dyssynergia. A single transperineal injection is a valuable, less invasive treatment using a cystoscopic technique.

References (16)

JT Andersen et al.
The syndrome of detrusor sphincter dyssynergia
J Urol
(1976)
JG Blaivas et al.
Detrusor external sphincter dyssynergia in men with multiple sclerosis: an onimous urologic condition
J Urol
(1984)
K Yasuda et al.
The effect of urapidil on neurogenic bladder: a placebo controlled double-blind study
J Urol
(1996)
DD Dykstra et al.
Effects of botulinum A toxin on detrusor sphincter dyssynergia in spinal cord injury patients
J Urol
(1988)
B Schurch et al.
Botulinum A toxin as a treatment of detrusor-sphincter dyssynergia: a prospective study in 24 spinal cord injury patients
J Urol
(1996)
H Petit et al.
Toxin ebotulinique A et traitement de la dyssynergie vésico-sphinctérienne [abstract]
Ann Réad Med Phys
(1995)
SC Trop et al.
Autonomic dysreflexia and its urological implications: a review
J Urol
(1991)
S Yalla et al.
Spinal cord injury

There are more references available in the full text version of this article.

Cited by (67)

Treatment of detrusor external sphincter dyssynergia using ultrasound-guided trocar catheter transurethral botulinum toxin A injection in men with spinal cord injury
2015, Archives of Physical Medicine and Rehabilitation
To evaluate the effects of transrectal ultrasound-guided trocar catheter transurethral botulinum toxin A (BTX-A) injection into the external urethral sphincter (EUS) for treating detrusor external sphincter dyssynergia (DESD) in men with spinal cord injury (SCI).
Descriptive study.
Hospital rehabilitation department.
Patients (N=15; mean age, 40.5y; range, 22–64y) with suprasacral SCI with confirmed DESD determined by urodynamic study.
A single dose of 100U BTX-A was injected into the EUS via transrectal ultrasound-guided trocar catheter transurethral injection.
Maximal detrusor pressure, detrusor leak point pressure, maximal pressure on static urethral pressure profilometry, postvoid residual volume, and maximal flow rate.
After BTX-A transurethral injection, 4 (28.5%) patients showed an excellent result and 7 (46.7%) patients showed an improved result, whereas 4 (28.5%) patients experienced treatment failure. The overall success rate was 75.2%. We observed a significant decrease in static urethral pressure (P<.05) and detrusor leak point pressure after treatment (P<.05), but not in detrusor pressure. The postvoid residual volume were significantly decreased in the fourth week after treatment (P<.05).
Transrectal ultrasound-guided trocar catheter transurethral BTX-A injection into the EUS effectively suppresses or ameliorates DESD. A potential advantage of the method is that ultrasound guidance may not be necessary in the next injection.
Botulinum A toxin and detrusor sphincter dyssynergia: Retrospective study of 47 patients
2014, Progres en Urologie
Évaluer les injections de toxine botulique A (TB-A) dans le sphincter urétral pour le traitement de la dyssynergie vésico-sphinctérienne (DVS).
Étude observationnelle rétrospective rapportant l’expérience de notre centre de 2002 à 2010 portant sur des patients présentant une DVS confirmée en urodynamique (étiologies neurologiques et non neurologiques). Tous les patients avaient reçu la dose de 300 UI DYSPORT^® par voie transpérinéale et repérage électromyographique. En se basant sur une échelle visuelle analogique (EVA) pour les symptômes mictionnels et la mesure du résidu post-mictionnel (RPM), les résultats ont été jugés « non satisfaisants » (diminution EVA < 2 ou diminution RPM < 20 %), « partiels » (diminution EVA ≥ 2 ou diminution RPM ≥ 20 %) ou « satisfaisants » (diminution EVA > 3 et diminution RPM > 40 %) à j30, j60, j90 et au-delà de j120.
Les dossiers de 47 patients (7 femmes et 40 hommes) ont été étudiés. Le suivi moyen a été de 14,2 mois. En définitif, il y avait 23,4 % (11) de résultats « satisfaisants », 19,1 % (9) de résultats « partiels », 42,6 % (20) de résultats « non satisfaisants » et 14,9 % (7) de patients perdus de vue. Il y a eu une baisse de la moyenne du RPM de 60 mL (de 212 à 152 mL).
Dans cette courte série rapportant les résultats de l’injection de TB-A dans le sphincter urétral pour DVS, nous avons observé 42,5 % de résultats « satisfaisants » ou « partiels » sans effets secondaires associés.
4.
To assess the efficacy of injections of botulinum toxin type A (BT-A) in the urethral sphincter for treating detrusor sphincter dyssynergia (DSD).
Retrospective observational study of patients with confirmed urodynamic DSD (neurological and non-neurological etiologies) treated at our center from 2002 to 2010. All patients received 300 IU of DYSPORT^® injected transperineally under electromyographic control. Using a visual analog scale (VAS) for mictional disorders and the measure of the post-void residual (PVR) as criteria of efficacy, results were classified as “non-satisfactory” (decrease in the VAS < 2 or decrease in the PVR < 20%), “intermediate” (decrease in the VAS ≥ 2 or decrease in the PVR ≥ 20%) or “satisfactory” (decrease in the VAS > 3 or decrease in the PVR > 40%).
Records of 47 patients (7 women and 40 men) were studied. Mean follow-up was 14.2 months. At the end of follow-up, there were 23.4% (11) of “satisfactory” results, 19.1% (9) of “intermediate” results, 42.6% (20) of “non-satisfactory” results and 14.9% (7) of patients lost for follow-up. The mean decrease in PVR was 60 mL (from an average of 212 to an average of 152 mL). No side effect was observed.
In this small series reporting the results of the injection of BT-A in the urethral sphincter for DSD, we observed 42.5% of satisfactory or intermediate results without associated side effects.
A meta-analysis of botulinum toxin sphincteric injections in the treatment of incomplete voiding after spinal cord injury
2012, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
After BTX-A treatment, individuals previously using a urethral catheter and a suprapubic catheter all began to spontaneously void, while 11 of the individuals previously using IC reduced its use from 5 to 2 times a day, 3 began spontaneous voiding, and 1 remained unchanged. Gallien18 found that 2 of 5 individuals previously using catheters discontinued after BTX-A treatment; however, the study did not report the type of catheter used. De Sèze et al12 reported 2 individuals using voluntary voiding; 1, sacral stimulation; 1, reflex voiding; and 1, IC.
Mehta S, Hill D, Foley N, Hsieh J, Ethans K, Potter P, Baverstock R, Teasell RW, Wolfe D, the Spinal Cord Injury Rehabilitation Evidence Research Team. A meta-analysis of botulinum toxin sphincteric injections in the treatment of incomplete voiding after spinal cord injury.
To conduct a systematic review and meta-analysis to examine the effect of injecting botulinum toxin A (BTX-A) into the detrusor sphincter on improving bladder emptying in individuals with spinal cord injury (SCI).
MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for all relevant articles published from 1980 to September 2011.
All trials examining the use of BTX-A injections into the detrusor sphincter for the treatment for incomplete bladder emptying after SCI were included if at least 50% of the study sample comprised subjects with SCI, and if the SCI sample size was 3 or greater.
A standardized mean difference (SMD) ± SE and 95% confidence interval (CI) were calculated for each outcome of interest, and the results were pooled using a fixed or random effects model, as appropriate. Outcomes assessed included postvoid residual urine volume (PRV), detrusor pressure (PDet), and urethral pressure (UP). Effect sizes were interpreted as small, 0.2; moderate, 0.5; and large, 0.8.
A relatively limited number of studies (2 randomized controlled trials, 6 uncontrolled trials) were identified. The 8 studies included results from 129 subjects. There was a statistically significant decrease in PRV at 1 month (SMD=1.119±.140; 95% CI, .844–1.394; P<.001), with a pooled mean PRV decrease from 251.8 to 153.0mL. There was a moderate statistical effect on PDet (SMD=.570±.217; 95% CI, .145–.995; P=.009); pooled PDet decreased from 88.7 to 20.5cmH₂O. A large statistical effect size on UP (SMD=.896±.291; 95% CI, .327–1.466; P=.002) and an improvement from 119.7 to 102.3cmH₂O were seen. The systematic review also indicated a 50% reduction in urinary tract infections based on 3 studies. Discontinuation or reduction in catheter usage was reported in 4 studies after BTX-A.
Results of the meta-analysis indicate that BTX-A is effective in reducing PRV and demonstrating a statistically significant reduction in PDet and UP 1 month postinjection. However, the clinical utility of BTX-A is yet to be determined.
Transrectal Ultrasound-Guided Transperineal Botulinum Toxin A Injection to the External Urethral Sphincter for Treatment of Detrusor External Sphincter Dyssynergia in Patients With Spinal Cord Injury
2010, Archives of Physical Medicine and Rehabilitation
Chen S-L, Bih L-I, Chen G-D, Huang Y-H, You Y-H, Lew HL. Transrectal ultrasound–guided transperineal botulinum toxin A injection to the external urethral sphincter for treatment of detrusor external sphincter dyssynergia in patients with spinal cord injury.
To evaluate the effects of a single transrectal ultrasound (TRUS)–guided transperineal injection of botulinum toxin A (BTX-A) to the external urethral sphincter (EUS) for treating detrusor external sphincter dyssynergia (DESD).
Descriptive study.
Rehabilitation hospital affiliated with a medical university.
Patients (N=18) with suprasacral spinal cord injury who had DESD confirmed on video-urodynamic study.
A single dose of 100U BTX-A was applied into the EUS via TRUS-guided transperineal route injection.
Maximal detrusor pressure, detrusor leak-point pressure, integrated electromyography (iEMG), maximal pressure on static urethral pressure profilometry, and postvoiding residuals.
There were significant reductions in iEMG (P=.008) and static (P=.012) and dynamic urethral pressure (P=.023), but not in detrusor pressure and detrusor leak-point pressure after treatment. Postvoiding residuals also significantly decreased in the first and second month after treatment (P<.012).
TRUS-guided transperineal injection of BTX-A has beneficial effects in treating DESD.
Transperineal Injection of Botulinum Toxin A for Treatment of Detrusor Sphincter Dyssynergia: Localization With Combined Fluoroscopic and Electromyographic Guidance
2009, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
BTX-A has been reported as an alternative treatment for DSD in patients with SCI for whom other treatment options are either ineffective or undesirable. Its effect lasts from 3 to 9 months, depending on different treatment protocols.4,6,7,10 BTX-A can be injected transurethrally or transperineally; however, limitations to both approaches exist.
Tsai S-J, Ying T-H, Huang Y-H, Cheng J-W, Bih LI, Lew HL. Transperineal injection of Botulinum Toxin A for treatment of detrusor sphincter dyssynergia: localization with combined fluoroscopic and electromyographic guidance.
To determine the effectiveness of a combined method for localizing external urethral sphincter for transperineal injection of botulinum toxin A (BTX-A) in the treatment of detrusor sphincter dyssynergia (DSD) in patients with spinal cord injury (SCI).
A prospective, open-label trial.
A rehabilitation hospital affiliated with a medical university.
Eighteen SCI patients with voiding dysfunction resulting from urodynamically confirmed DSD.
100 units of BTX-A injected transperineally into the external urethral sphincter, which was localized using combined fluoroscopic and electromyographic guidance, using a Foley catheter inserted for visualization of vesicourethral anatomy.
(1) postvoid residual volume, (2) leak point pressure, (3) maximal intravesical pressure, (4) maximal urethral pressure, (5) quality of life measures for urination, quantified by the Quality of Life Index (QLI).
Positive clinical outcomes were observed in all 18 patients in this study. The mean reductions in postvoid residual volume, leak point pressure, maximal intravesical pressure, and maximal urethral pressure before and after BTX-A injection were 183ml, 37cm H₂O, 45cm H₂O, and 92cm H₂O, respectively (all P values <.05). The mean QLI significantly improved from −0.68±0.27 to 0.66±0.19 (P<.01). No significant side effects were noted after injection. The clinical therapeutic effects have shown reductions in occurrence and degree of autonomic dysreflexia, vesicoureteral reflux, hydronephrosis, and urinary tract infection. The bladder management programs also obtained improvements in our patients, either doing intermittent catheterizations less frequently, or resuming spontaneous voiding without indwelling catheters.
With this combined method for localization of the external urethral sphincter, transperineal injection of BTX-A was safe, accurate, easy to perform, and effective for treatment of DSD in patients with SCI.
Recommendations on the Use of Botulinum Toxin in the Treatment of Lower Urinary Tract Disorders and Pelvic Floor Dysfunctions: A European Consensus Report
2009, European Urology
The increasing body of evidence and number of potential indications for the use of botulinum neurotoxins (BoNTs) in the lower urinary tract (LUT) underlines the pressing need for evidence-based guidelines.
A European expert panel consensus conference was convened with the main aim of evaluating the evidence and clinical considerations for the use of BoNTs in the treatment of urologic and pelvic-floor disorders and to propose relevant recommendations.
The quality of evidence from fully published English-language literature in the PubMed and EMBASE databases was assessed using the European Association of Urology (EAU) levels of evidence (LoE). Recommendations were graded and approved by a unanimous consensus of the panel.
The use of botulinum neurotoxin type A (BoNTA) is recommended in the treatment of intractable symptoms of neurogenic detrusor overactivity (NDO) or idiopathic detrusor overactivity (IDO) in adults (grade A). Caution is recommended in IDO because the risk of voiding difficulty and duration of effect have not yet been accurately evaluated. Repeated treatment can be recommended in NDO (grade B). The depth and location for bladder injections should be within the detrusor muscle outside the trigone (grade C). Dosage in children should be determined by body weight, with caution regarding total dose if also being used for treatment of spasticity, and minimum age (grade B). Existing evidence is inconclusive for recommendations in neurogenic detrusor–sphincter dyssynergia, bladder pain syndrome, prostate diseases, and pelvic-floor disorders. The use of BoNTA in the LUT with the current dosages and techniques is considered to be safe overall (grade A).
The consensus committee recommends larger placebo-controlled and comparative trials to evaluate the efficacy of single and repeat injections, the duration of effect, the optimal dosage and injection technique, the timing for repeat injection, and the short- and long-term safety of the treatment in LUT and pelvic-floor disorders.

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Clinical noteTreatment of detrusor sphincter dyssynergia by transperineal injection of botulinum toxin☆

Abstract

J Urol

J Urol

J Urol

J Urol

J Urol

Ann Réad Med Phys

Autonomic dysreflexia and its urological implications: a review

J Urol

Spinal cord injury

Clinical note
Treatment of detrusor sphincter dyssynergia by transperineal injection of botulinum toxin☆