New England Section of the American Urological Association

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Intravesical Botulinum Toxin Injections for Detrusor Overactivity in Patients Suffering from Multiple Sclerosis; Appropriate Clinical Practice for Retaining this Population
Michael E. Goltzman, MD1, Brendan Gontarz, MD2, Gerard Pregenzer, MD2
1UConn Health, Farmington, CT, 2Saint Francis Hospital and Medical Center, Hartford, CT

BACKGROUND
Multiple sclerosis (MS) is a progressive demyelinating disease affecting the central nervous system which is frequently related to voiding dysfunction and a wide range of urinary complications. Detrusor overactivity (DO) is the most frequently reported urodynamic abnormality. DO is often associated with an overactive bladder, defined by urgency, possibly associated with urge incontinence, daytime frequency, and nocturia. When DO is refractory to antimuscarinic medication, botulinum toxin-A (BTX-A) injections may be a reasonable alternative to improving bladder function. Muscle fiber paralysis occurs within the first few days of injection, and toxin effects in the detrusor muscle generally last 6 to 12 months. Clinically, intradetrusor injection of BTX-A has been found to decrease urinary incontinence and improve quality of life. BTX-A is an ideal therapy due to its effectiveness and long duration of action, relative ease of administration, easy learning curve, reproducibility of results on repeated administration, and low incidence of complications. There is a reported prevalence of 72% of MS patients requesting re-treatment with BTX-A.1 This study was conducted to assess adherence among MS patients who initiated BTX-A injection therapy with intent to identify the patient characteristics, comorbidities, or complications related to treatment cessation.
METHODS
After IRB approval, a retrospective chart review of patients who had been identified through a multidisciplinary MS care center were analyzed. Patients received at least 1 BTX-A detrusor injection treatment between August 2016 and October 2018. BTX-A treatment consisted of multiple trigone-sparing detrusor muscle injections consisting of 200 to 300 units of BTX-A under cystoscopic guidance.
RESULTSA total of 276 BTX-A treatments were performed on 76 patients. There was a preponderance of females (69% vs 31%) and mean patient age was 53.1 years (range 28 to 86). Of those patients, 13 received 1 injection (17%), 12 received 2 treatments (16%), and 51 received 3 or more treatments (67%). The median time between successive treatments was 7.6 months (SD 2.4). Of the patients who failed to return for subsequent treatment, the primary reasons reported for nonadherence were urinary retention requiring CIC, progression to alternative treatment (i.e. sacral nerve stimulation), or infectious complications. The majority of patients who received multiple injections reduced or even stopped taking anticholinergic drugs.
CONCLUSIONPoor patient adherence is an important area to consider in outcomes research and healthcare cost. Despite substantial sequelae, there is limited research substantiating best practices for engaging and retaining the MS population. Appreciating the high adherence rate to treatment with BTX-A will hopefully underscore the importance of thorough education efforts, exploring questions and patient misperceptions, and providing for treatment adherence. We may conclude that patients prematurely discontinue therapy for a number of possible reasons that include the treatment failure or complication, the cost (financial or personal), dosing frequency and expectations of treatment. The route of administration of medication is also a factor which influences adherence.
1. Khan S, Game X, Kalsi V, et al. Long-term effect on quality of life of repeat detrusor injections of botulinum neurotoxin-A detrusor overactivity in patients with multiples sclerosis. J Urol. 2011;185:1344-49.


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