Autonomic nerous system response at botulinum neurotoxin treatment for idiopathic overactive bladder syndrome in women

Abstract

Background. Symptoms of idiopathic overactive bladder (iOAB) affect ∼17 % worldwide of women, and its prevalence increases with patient age. Autonomic dysfunction in the genital area can be assessed using sympathetic skin response (SSR). SSR tests can be used for the detection of early iOAB and assessing those likely to be refractory to anticholinergic drugs. Treatments options for iOAB include lifestyle modifications, behavioural therapy, pharmacotherapy, neuromodulation, Botulinum toxin therapy and surgical interventions. The American Urological Association and the European Association of Urology recommend bladder wall injection with Botulinum neurotoxin A (BoNT-A) in women with idiopathic detrusor overactivity who have not responded to conservative treatment. Case report. Pacient I., female, age 31 years, diagnosed clinical with iOAB, confirmed on urodynamics, underwent the SSR investigation for assessment of autonomic nervous system. The patient had been refractory to different anticholinergic drugs and there was no response to conservative therapy for over 10 years. Before injection, patient was asked to complete a 4-day voiding diary, to record the quantification, the frequency of voids, the number of incontinence episodes and the number of episodes of nocturia. The treatment started with antibiotic prophylaxis (ciprofloxacin 1g i/v twice daily) for 1 day before the injection procedure and continued for 3 days after treatment. Saline cystoscopy was performed using a 19-F rigid cystoscope, under i/v anaesthesia. BoNT-A (100 UI) was mixed with 10 ml 0.9 % sodium chloride and administered 1 ml over 20 different sites, each 1 cm apart, supratrigonally, using 18-gauge needle for rigid cystoscopies, inserted 3 mm into the bladder wall. After 2-3h of procedure was a successful demonstration of voiding. The woman didn’t develop any adverse effects like urinary tract infection, gross haematuria, injection site pain or urinary retention. Follow-up at 1, 3, 6, 9 and 12 months, with 4-day voiding diaries, clinical and SSR was carried out. Injections increased voided volume >90 ml, decreased urinary frequency, absence of nocturia and improved QoL. Clinical effects of BoNT-A were evident in 1 week and last up to 12 months. The results of SSR before and after a week of injection estableshed the significantly pronounced changes in time taken for the ascending wave A1 (parasympathetic component) compering with time taken for the ascending wave A2 (sympathetic component). Before injection of BoNT-A mean score was S1A1=0,5sec., S2aA2=0,94 sec., after injection respectively was 0,34 sec. and 1,1 sec. Conclusions. Botulinum toxin type A might be an alternative to invasive surgery for patients in whom conservative measures for treatment of iOAB have failed. The SSR can serve as a complex diagnostic of iOAB and assessment the efficiency of treatment with BoNT-A.