Botox Injection into the Bladder
Botox injection of the bladder is useful to treat overactive bladder (both idiopathic overactive bladder and overactive bladder secondary to other neurological diseases). Botox is a highly potent toxin known to man and is produced by a bacterium called Clostridium Botulinum. This is a very potent muscle relaxant and injecting this toxin in very minute quantities in the bladder muscle helps to relax to bladder muscle and increases the capacity to hold urine. When patients are diagnosed with bladder over activity, Botox injections do help and result a substantial improvement of their symptoms. The use of Botox for other conditions in cosmetic surgery and as well as in muscle spasms in the other parts of the body is well established. Botox works by blocking the nerve fibres in the muscle thereby preventing the muscle contractions in the part where the Botox is injected. Botox injection into the bladder is a fairly recent method of treatment and it has been in practice just over ten years. However when over activity of the bladder is treated with Botox injections the results are about 70-80% improvement in incontinence and reduction in the frequency. The improvement after the Botox injection lasts for about six months. After this the Botox effects do wear off and it is necessary to repeat the injections of Botox.
How is Botox injected into the bladder?
The Botox is a powder preparation which is reconstituted with by adding in fluid which is used as an injection. It is injected through a special needle which is passed down an instrument called a cystoscope. This can be done under either local anaesthetic or general anaesthetic. The entire procedure can take from 15 to 20 minutes.
What are the long term effects of Botox?
Since the Botox treatment has been in practice for only the past ten years, it is difficult to predict the long term consequences of injecting Botox into the bladder. Therefore urologists are cautious about using this method of treatment for very young patients with a long life expectancy. Since Botox treatments need to be repeated on regular interval to achieve the ongoing control of the symptoms, it is a concern for urologists and patients alike with regard to long term effect on the bladder function.
What is Sacral Neuro-modulation?
This is a special type of treatment which is useful to re-establish the normal bladder function. This is done by applying electrical stimulation to the nerves of the sacral spinal cord level that controls the bladder.
What conditions are treatable with Sacral Neuro-modulation?
Sacral Neuro-modulation is used to treat the following:
Non-obstructive urinary retention (female urinary retention). This is a condition where women find it impossible to pass urine due to blockage at the level of the urethra without any obvious blockage.
Overactive bladder with the typical symptoms of urgency and frequency with a bit of urge incontinence.
What is involved in this treatment?
The Sacral Neuro-modulation is done by a device called Intestim which generates a pulse. This is done in two phases. In the first phase, which is called test phase, a temporary electrode is inserted into the sacral spine touching the S2/S3 nerves. Then the electrodes are connected to a temporary nerve stimulator device. Patients will be assessed for a few weeks with this device to see if this enables them to better control their bladder or improves their urinary retention. If the temporary device is effective, then they would move onto the second phase of implanting the permanent device which would be implanted in the buttocks and connected to the electrodes. Recently the electrodes which are used for the test phase are permanent electrodes though they are connected to the temporary device. This avoids the insertion of the second electrode into the spinal canal.
How effective is this treatment?
This treatment is effective in the range of 70-80% of those treated for retention. More than 70% of the patients can be rendered catheter free or they can be made free of having to use self catheterisation. With regard to overactive bladder symptoms, the success rates are about 70%. This treatment is uniquely different from Botox or other treatment because this neural modulation treatment helps to re-establish the bladder function. This is an appropriate treatment method for a group of patients who respond favourably to the test phase treatment.
Posterior Tibial Nerve Stimulation
Posterior tibial nerve stimulation is a non-invasive method of achieving better bladder control. The nerve endings in the leg are stimulated by using the nerve stimulator which is a small gadget attached to very tiny needle electrodes that are inserted in the skin of the lower leg and in the hind foot. Stimulating the sensitive nerves in this area does give better control of the bladder by its action at the spinal root level. After placing the needle electrode through two pads which are applied just above the ankle and near the hind foot which is connected to the small gadget device (called a pulse generator), the entire treatment takes about 30 minutes. This treatment is repeated on a weekly basis for twelve weeks. PTNS does not have any significant side effects. It is a fairly less risky procedure. The minor side effects are irritation from the pads or from the needles. This may include minor skin irritation. There are a few studies which effectiveness of this treatment. Overall the results are broadly similar with 70-80% of patients showing some improvement in their overactive bladder symptoms.
This is offered for patients with extreme symptoms of overactive bladder with diminished bladder capacity. This involves taking a piece of small bowel and put it as a patch to increase the capacity of the bladder. This involves a major operation and the after effects may include the need to use self catheterisation and problems with mucous secretion from the bowel segment. Over the long term there is slightly increased risk of malignancy and therefore regular surveillance cystoscopy is necessary.