Has botulinum toxin therapy come of age: what do we know, what do we need to know, and should we use it?

To review the most recent data concerning the clinical use of botulinum toxin type A (BoNT/A) in different human lower urinary tract dysfunctions, with particular emphasis on neurogenic detrusor overactivity.

The most recent findings indicate that the repeated application of BoNT/A is effective in patients with neurogenic detrusor overactivity, maintaining sustained control of incontinence, protection of upper urinary tract and reduction of urinary infectious complications. In addition, BoNT/A injections have proved to be well tolerated and the risk of bladder fibrosis nonexistent. Other BoNT/A indications under investigation are idiopathic detrusor overactivity, benign prostatic enlargement and bladder pain syndrome/interstitial cystitis.

Although still waiting for approval, BoNT/A detrusor injections can be safely offered to well informed patients with refractory neurogenic detrusor overactivity, as an alternative to more invasive therapies, such as bladder augmentation. Ongoing studies are expected to come up with the necessary information for definitive approval of BoNT/A in neurogenic detrusor overactivity patients. Regarding other possible applications such as idiopathic detrusor overactivity, benign prostatic enlargement and bladder pain syndrome/interstitial cystitis, its use should still be restricted to research centres in well designed clinical trials.