Botulinum injection is useless on fibrotic neuropathic bladders

Area of Science:

• Pediatric Urology
• Neurology
• Pharmacology

Background:

• Neuropathic bladder in children, often due to myelomeningocele, presents challenges in management, particularly when resistant to standard anticholinergic therapy.
• Intradetrusor botulinum toxin A injections are increasingly used, but their efficacy and patient selection criteria remain subjects of study and debate.

Purpose of the Study:

• To evaluate the effectiveness of intradetrusor botulinum toxin A (BoNTA) injections in children with neuropathic bladders resistant to anticholinergic treatment.
• To identify urodynamic criteria that predict successful outcomes following BoNTA therapy.

Main Methods:

• A retrospective review of 16 children with myelomeningocele-related neuropathic bladders who received endoscopic intradetrusor BoNTA injections (10 units/kg).
• Patients were classified into 'fibrotic bladder' (noncompliant, acontractile) or 'overactive bladder' groups based on pre-treatment urodynamic findings.
• Success was defined as achieving complete dryness between clean intermittent catheterizations; urodynamic parameters (capacity, compliance) were analyzed pre- and post-injection.

Main Results:

• Of 16 initial injections, 56% (5/9) in the overactive bladder group achieved complete dryness, with significant improvements in bladder capacity and compliance.
• In contrast, patients with fibrotic bladders (n=7) showed no significant clinical improvement, with unchanged compliance and capacity post-injection.
• Urodynamic findings indicated that patients with low compliance, high pressures, and absent detrusor contractions were unlikely to benefit from BoNTA.

Conclusions:

• Intradetrusor BoNTA is effective for neuropathic detrusor overactivity and incontinence in children, particularly those with overactive bladders.
• BoNTA injections are ineffective in patients with fibrotic, noncompliant, and acontractile neuropathic bladders.
• Pre-treatment urodynamic evaluation is essential for identifying patients likely to benefit from BoNTA, distinguishing overactive from decompensated fibrotic bladders.