Journal of the Formosan Medical Association
Volume 108, Issue 12 , Pages 950-956, December 2009

Botulinum Toxin A Injection to the Bladder Neck and Urethra for Medically Refractory Lower Urinary Tract Symptoms in Men Without Prostatic Obstruction

Department of Urology, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan

Received 14 February 2009; received in revised form 2 April 2009; accepted 28 April 2009.

Article Outline

Background/Purpose

Lower urinary tract symptoms (LUTS) in men with small benign prostatic hyper-plasia (BPH) might not result from prostatic compression. Instead, bladder neck and urethral dysfunction could play an important role. We investigated the effect of botulinum toxin A (BoNT-A) injection to the bladder neck and urethra of men with small BPH and LUTS that were refractory to medical treatment.

Methods

We enrolled 30 men with a total prostate volume (TPV) of < 40 mL, International Prostate Symptom Score (IPSS) > 12, and maximum urinary flow rate (Qmax) < 15 mL/second, who were refractory to medical treatment. None had bladder outlet obstruction upon videourodynamic study. One hundred units of BoNT-A dissolved in 10 mL normal saline was injected at 10 sites at the trigone, bladder neck, proximal urethra, distal urethra and external sphincter. The values for IPSS, quality of life (QoL) index, Qmax, bladder capacity, post-void residual (PVR), TPV and global satisfaction at 1, 3 and 6 months after injection were compared with baseline.

Results

Significant improvements in empty and total IPSS were found at 1 and 3 months but not 6 months after treatment. Qmax significantly increased at 1 month and was still improved at 6 months. Bladder capacity increased and PVR decreased at 1 and 3 months but not at 6 months after treatment. QoL index and global satisfaction were improved significantly at all time points after treatment.

Conclusion

Bladder neck and urethral BoNT-A injections improved LUTS and increased Qmax in men with a small prostate. Our findings suggest that bladder neck and urethral dysfunction may play a role in LUTS in men without BPH.

Key Words:  botulinum toxin type A , prostate , urethra , urination disorders , urologic diseases

No full text is available. To read the body of this article, please view the PDF online.

 

Back to Article Outline

References 

  1. McConnell JD , Roehrborn CG , Bautista OM , et al.   The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia . N Engl J Med . 2003;349:2387–2398
  2. Lepor H . The pathophysiology of lower urinary tract symptoms in the ageing male population . Br J Urol . 1998;81(Suppl 1):29–33
  3. Caine M . Peripheral factors in urinary continence . J Urol (Paris) . 1986;92:521–530
  4. Boggs JW , Wenzel BJ , Gustafson KJ , et al.   Frequency-dependent selection of reflexes by pudendal afferents in the cats . J Physiol . 2006;577:115–126
  5. Chen JL , Kuo HC . Implications of prostatic volume measurements on the degree of bladder outlet obstruction in men with benign prostatic hyperplasia and lower urinary tract symptoms . J Taiwan Urol Assoc . 2006;17:41–47
  6. Kuo HC . Videourodynamic analysis of pathophysiology of men with both storage and voiding lower urinary tract symptoms . Urology . 2007;70:272–276
  7. Kuo HC . Prostate botulinum A toxin injection: an alternative treatment for benign prostatic obstruction in poor surgical candidates . Urology . 2005;65:670–674
  8. Maria G , Brisinda G , Civello IM , et al.   Relief by botulinum toxin of voiding dysfunction due to benign prostatic hyperplasia: results of a randomized, placebo-controlled study . Urology . 2003;62:259–265
  9. Chuang YC , Chiang PH , Yoshimura N , et al.   Sustained beneficial effects of intraprostatic botulinum toxin type A on lower urinary tract symptoms and quality of life in men with benign prostatic hyperplasia . BJU Int . 2006;98:1033–1037
  10. Smith CP , Franks ME , McNeil BK , et al.   Effect of botulinum toxin A on the autonomic nervous system of the rat lower urinary tract . J Urol . 2003;169:1896–1900
  11. Kuo HC . Botulinum A toxin urethral injection for the treatment of lower urinary tract dysfunction . J Urol . 2003;170:1908–1912
  12. Abrams P , Cardozo L , Fall M , Griffiths D , Rosier P , Ulmsten U , et al.   The standardisation of terminology in lower urinary function report from the standardisation sub-committee of the International Continence Society . Urology . 2003;61:37–49
  13. Lim CS , Abrams P . The Abrams–Griffiths nomogram . World J Urol . 1995;13:34–39
  14. Brading AF . The physiology of the mammalian urinary outflow tract . Ext Physiol . 1999;84:215–221
  15. Elbadawi A . Ultrastructure of vesicourethral innervation. II. Postganglionic axoaxonal synapses in intrinsic innervation of the vesicourethral lissosphincter: a new structural and functional concept in micturition . J Urol . 1984;131:781–790
  16. Strasser H , Klima G , Poisel S , et al.   Anatomy and innervation of the rhabdosphincter of the male urethra . Prostate . 1996;28:24–31
  17. Hollabaugh RS , Dmochowski RR , Steiner MS . Neuroanatomy of the male rhabdosphincter . Urology . 1997;49:426–434
  18. Yamanishi T , Yasuda K , Sakakibara R , et al.   The nature of detrusor bladder neck dyssynergia in non-neurogenic bladder dysfunction . J Auton Nerv Syst . 1997;66:163–168
  19. Awad SA , Downie JW , Kiruluta HG . Alpha-adrenergic agents in urinary disorders of the proximal urethra. Part II. Urethral obstruction due to “sympathetic dyssynergia” . Br J Urol . 1978;50:336–339
  20. Yalla SV , Galibondo FB , Blunt KF , et al.   Functional striated sphincter component at the bladder neck: clinical implications . J Urol . 1977;118:408–411
  21. Arnold EP . Tamsulosin in men with confirmed bladder outlet obstruction: a clinical and urodynamic analysis from a single centre in New Zealand . BJU Int . 2001;87:24–30
  22. Kuo HC . Effectiveness of baclofen plus terazosin treatment in patients with lower urinary tract symptoms caused by spastic urethral sphincter . Tzu Chi Med J . 2000;12:141–147
  23. Liu L , Mansfield KJ , Kristiana I , et al.   The molecular basis of urgency: regional difference of vanilloid receptor expression in the human urinary bladder . Neurourol Urodyn . 2007;26:433–438
  24. Kuo HC . Recovery of detrusor function after urethral botulinum A toxin injection in patients with idiopathic low detrusor contractility and voiding dysfunction . Urology . 2007;69:57–61
  25. Lim SK , Quek PL . Intraprostatic and bladder neck injection of botulinum A toxin in treatment of males with bladder-neck dyssynergia: a pilot study . Eur Urol . 2008;53:620–625
  26. Yalla SV , Resnick N . Initiation of voiding in humans: the nature and temporal relationship of urethral sphincter responses . J Urol . 1997;157:590–595
  27. Nitti VW , Lefkowitz G , Ficazzola M , et al.   Lower urinary tract symptoms in young men: videourodynamic findings and correlation with noninvasive measures . J Urol . 2002;168:135–138

PII: S0929-6646(10)60008-3

doi:10.1016/S0929-6646(10)60008-3

Journal of the Formosan Medical Association
Volume 108, Issue 12 , Pages 950-956, December 2009

Article Tools