A new method of treating urinary disorders based on the use of botulinum toxin preparations has appeared in the arsenal of urologists. Estet-portal.com offers you answers to some questions about the possibilities of botulinum therapy in urology, which were given by Victoria Valerievna Romikh, urologist, head of the laboratory of urodynamics and functional disorders of the pelvic organs of the Research Institute of Urology (Moscow)
, Urologist, Head of the Laboratory of Urodynamics and Functional Disorders of the Pelvic Organs, Research Institute of Urology (Moscow)
Which patients are eligible for this type of therapy?
- The mechanism of action of botulinum toxin is the chemical denervation of the muscle. The therapeutic effect is to interrupt the pathological stimulation of the muscle, due to which it is in a state of spasm. This property of botulinum toxin is used in urology, for example in patients with neurogenic detrusor overactivity. During urodynamic examination, these patients show detrusor contractions in the filling phase, which should not be normal. Thus, the detrusor is in a state of periodic spasm. In advanced cases, when there is denervation on the background of spinal injury and severe neuropathy, the detrusor is so spasmodic that it does not enter the relaxation phase at all. At small volumes of filling, a spasm occurs, the functional capacity of the bladder (MP) is sharply lost, this leads to imperative urinary incontinence,
Another area of application of botulinum toxin in urology is the treatment of chronic urinary retention caused by functional obstruction, such as in patients with meningomyelocele. Another area is interstitial cystitis and chronic pelvic pain syndrome. The level of pain is significantly reduced, the functional capacity of the bladder is restored.One of the main merits of botulinum therapy is the possibility of getting rid of cystostomy in wheelchair patients with severe detrusor hyperactivity, reflux, constant attacks of pyelonephritis, who were unable to urinate on their own and lived with a cystostomy. Botulinum therapy allows you to increase the capacity of the bladder, save the patient from cystostomy, prevent pyelonephritis, reflux, and sometimes even restore independent urination.
Is a drug test required before using botulinum toxin?
– Not required. If we see severe hyperactivity or severe neurogenic disorders that lead to detrusor sphincter dyssenergia (DSD), then only in rare cases do we carry out drug therapy. This applies to cases when, for some reason, botulinum therapy is delayed or contraindicated. Severe urodynamic disturbances are a direct indication for botulinum toxin therapy.
Can a urologist suspect a diagnosis of DDD based on clinical symptoms, or is it a purely urodynamic diagnosis?
– Detrusor-sphincter dyssenergia is a purely urodynamic diagnosis, it is established on the basis of the CUD, but it can still be suspected. Neuropathy as a result of injuries of the spinal cord and spine, multiple sclerosis, congenital spinal hernia, protrusion of the intervertebral discs can lead to impaired urination due to the development of DSD. The first thing that the urologist should pay attention to is the combination of neurological disorders and difficulty urinating. In favor of DSD, the young age of the patient often speaks, for example, in men who do not have BPH, urethral strictures, and the maximum urination rate is 5-6 ml / s. DSD can also be suspected with a sharply difficult start of urination or an intermittent urination curve during uroflowmetry.
When does the positive effect develop? How long will the injection last?
- The effect begins to develop after 3-7 days and reaches a maximum after a month. In some cases, we observe the effect already on the 2nd day. The duration of the effect of botulinum therapy is different. There are works by Czech urologists who talk about an 18-month effect of the botulinum toxin type A preparation. It must be borne in mind that there is a difference in the duration of the effect when the drug is injected into the detrusor or external sphincter. When the toxin is injected into the detrusor, the effect is observed for a longer time. If injections are carried out in the zone of the external sphincter, which is a striated muscle tissue with somatic innervation, then the effect is shorter. Among our patients, the maximum duration of effectiveness is 8 months, but at the moment the effect is not lost, and monitoring is ongoing.
Can the injections be repeated? How often?
- We have experience with 2 injections (after 8 months) of botulinum toxin in patients with detrusor overactivity. International experience speaks of ten injections of the drug without the development of side effects and complications.
Does botulinum toxin become addictive?
- According to foreign literature, according to foreign colleagues, as well as in our experience, addiction does not develop.
Does this procedure involve anesthesia?
– The technology allows the introduction of local anesthetic into the bladder in the form of instillations with an exposure of up to 15 minutes. Men undergo short-term intravenous anesthesia. If the toxin is injected transperineally into the external sphincter zone, anesthesia is not required for either women or men. It uses the thinnest EMG needle with injection port, which is painless to puncture.
Please tell us about the method of the procedure
– The patient is placed in the cystoscopy position, the cystoscope is inserted, and a needle is passed through a special channel. We use a metal inflexible needle with insertion depth marks. The dilution of the drug is standard, which is indicated in the technology. From 100 to 300 IU of the drug is injected into the bladder, 1 ml of the solution at each point. In the sphincter zone, 4 injections are performed at 3, 6, 9 and 12 hours of the conventional dial. Chinese colleagues have experience in injecting botulinum toxin into 8 sphincter points at various distances from the neck, which is effective in cases of pronounced spasm.
Are there any downsides to botulinum toxin therapy? What are the complications? How are they eliminated?
- There may be slight hematuria in the first 2 hours after botulinum toxin administration. We haven't seen any downsides yet. However, the patient must be hospitalized for at least one day in the hospital, we do not consider botulinum toxin therapy to be a completely outpatient procedure.
A catheter is being placed for all patients?
– No, not everyone. Patients who had virtually no spontaneous urination and who were on intermittent self-catheterization, a catheter is installed for the first 4 days, i.e. for the period of time during which the botulinum toxin will begin to act.
Is there any experience with botulinum toxin in BPH and other prostate conditions?
– In BPH, there are positive symptoms after injections of botulinum toxin – urination improves, its speed increases. But the method of treatment of urination disorders in BPH requires a deeper consideration both in terms of morphological changes and in terms of clinical significance.
What are the prospects for the use of botulinum therapy in urology?
- In addition to OAB, CMM against the background of functional obstruction, the first results of botulinum therapy are promising also in such widespread conditions as chronic pelvic pain syndrome (CPPS), interstitial cystitis.
According to id-journal.ru
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