Botox success with BPS/IC

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Editorial - Trigonal injection of botulinum toxin A in patients with refractory bladder pain syndrome/interstitial cystitis

Written by Philip M. Hanno, MD
Tuesday, 04 May 2010

BERKELEY, CA (UroToday.com) - Trigonal Injection of Botulinum Toxin May Be Preferred Method of Administration for BPS

The analgesic effect of Botulinum toxin A (BoNTA) results from decreased neuropeptide release at peripheral extremities, and glutamate, substance P, and calcitonin gene-related peptides from the central endings of bladder sensory nerves. In the first case, neurogenic inflammation is prevented, and in the second, nociceptive transmission becomes inhibited at the spinal cord. Most nociceptive bladder afferents are concentrated in the trigone. Previous studies that injected the entire bladder of BPS patients with BoNTA placed most of the neurotoxin far from the nociceptive fibers and increased the risk of decreasing detrusor contractility.

Dr. Rui Pinto and colleagues from Sao Joao, Portugal took the logical next step and studied the effectiveness, safety, and duration of treatment/retreatment of BPS patients with BoNTA applied exclusively to the trigone. They also monitored the urine concentration of two neurotrophic factors known to influence the activity of nociceptive afferent fibers – nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF). Twenty-six women with BPS were studied. BoNTA was injected under light sedation through a 23-gauge needle inserted 3mm into the trigonal wall under cystoscopic control. A total of only 100 units was distributed throughout 10 sites.

Two weeks after treatment, no patients reported any voiding difficulties, and none had a high post void residual or urinary infection. Sixteen patients were followed for 2 years and 10 patients had 6 month follow up. A marked decrease in the O’Leary Sant symptom and problem scores was observed. Pain intensity, daytime and nighttime voiding frequency, and quality of life all showed significant improvement, and bladder volume to first pain sensation and maximum cystometric bladder capacity also increased significantly.

The average duration of clinical improvement was 10.1+2.4 months after the first treatment. Of the 16 patients who were retreated, there was no tachyphylaxis and improvement was over 10 additional months on average. Dramatic decreases in NGF and BDNF were noted 1 month after treatment and persisted up to 6 months, though rising from the low levels in the first weeks after treatment. The duration of clinical improvement was comparable to that reported for the use of BoNTA for overactive bladder. The authors managed to use a low dose of medication, thus cutting the expense of this procedure, one that is not covered by many insurance companies in the United States when used for BPS. Morbidity was minimal and results were dramatic. If confirmed in a larger, placebo-controlled RCT, this therapy might become a part of the standard armamentarium for BPS.

Pinto R, Lopes T, Frias B, Silva A, Silva JA, Silva CM, Cruz C, Cruz F, Dinis P

Eur Urol. 2010 Mar 6. Epub ahead of print.
10.1016/j.eururo.2010.02.031

PubMed Abstract
PMID: 20227820

[kevin]

Encouraging. However, other clinical trials of Botox have not had as dramatic results. Maybe it was the injection methodology used in this study.

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A review of botulinum toxcin use for chronic pelvic pain syndrome

Thursday, 05 August 2010
Department of Urology, University of Washington, BB-Wing, Floor 11, 1959 NE Pacific Street, Box 356510, Seattle, WA 98195-6510, USA.

The inability of urologists to consistently and effectively treat men with chronic pelvic pain syndrome (CPPS), also known as chronic abacterial prostatitis, is a source of great frustration. Botulinum toxin (BTX), a potent neurotoxin, can act on most of the peripheral nerves of the pelvis through a variety of mechanisms. BTX injection therapy for CPPS treatment has shown modest improvements. BTX is ideal for integration into a multimodal treatment plan, which may help achieve pain relief in men with chronic pelvic pain.

Written by:
Gottsch HP, Yang CC, Berger RE.

Reference: Curr Urol Rep. 2010 Jul;11(4):265-70.
doi: 10.1007/s11934-010-0118-4

PubMed Abstract
PMID: 20446070

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Scand J Urol Nephrol. 2010 Nov 9. [Epub ahead of print]
A pilot study of botulinum toxin A for male chronic pelvic pain syndrome.

Gottsch HP, Yang CC, Berger RE.
Department of Urology, University of Washington, Seattle, Washington, USA.

Abstract Objective. Male chronic pelvic pain syndrome (CPPS) has been the subject of numerous clinical trials, but so far, no uniformly effective treatment has been identified. A commonly reported tender spot in men with CPPS is the bulbospongiosus muscle. A randomized placebo controlled pilot trial of botulinum toxin A (BTX-A) injection into the perineal skeletal musculature for the treatment CPPS was conducted. Material and methods. Twenty-nine men with CPPS were identified from a urology clinic. Symptom evaluation was performed using a Global Response Assessment (GRA) and the Chronic Prostatitis Symptom Index (CPSI). All subjects were randomized to receive either BTX-A 100 U or normal saline injected into the perineal body and bulbospongiosus muscle. Results. BTX-A injection was administered in 13 men. At the 1 month follow-up there was a 30% response rate for BTX-A treatment compared with 13% for placebo (p = 0.0002), based on GRA results. Total CPSI score did not reach significance in the BTX-A-treated group, compared with controls. The CPSI pain subdomain score reached statistical significance in the BTX-A patients compared with controls (p = 0.05). The injections were well tolerated. There were no complications from the injections and no patients reported side-effects. Conclusions. BTX-A injection into the perineal body and bulbospongiosus muscle results in a modest response rate on the GRA compared with placebo for overall symptoms associated with CPPS. The treatment is well tolerated and safe. BTX-A use may enhance polytherapeutic pain management.

PMID: 21062115 [PubMed - as supplied by publisher]

This is not a glowing report.