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BackTable / Urology / Article
Botox for Overactive Bladder
Ishaan Sangwan • Dec 15, 2021 • 175 hits
Botox for overactive bladder (OAB) is a relatively safe and effective treatment procedure. This article discusses the ideal patient for overactive bladder Botox therapy, side effects, and describes the bladder Botox procedure for administration and sedation.
This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable Urology Brief
• Botox injections are ideal for the patient with a neurogenic overactive bladder with impaired contractility. Patients should also be informed of urinary retention as a possible Botox in bladder side effect.
• For dosing, 200 units is the starting point for neurogenic patients, while detrusor overactivity patients start at 100 units.
• A bladder Botox procedure has the injections administered in a grid template, with a half cc for each section, and a final 1 cc for the trigone.
• Sedation for bladder Botox injections can be achieved with valium or Ativan.
Table of Contents
(1) Ideal Patient for Botox Treatment for Overactive Bladder
(2) Overactive Bladder Botox Procedure
(3) Sedation During Botox Injections for Overactive Bladder
Ideal Patient for Botox Treatment for Overactive Bladder
Botox is best for treating the patient with neurogenic overactivity or tissue overactivity with impaired contractility. As one of the most significant Botox in bladder side effects is potential urinary retention, it is ideal for the patient who is already in retention, as they won’t have to consider this possibility. Urinary retention is also the Botox side effect that makes many patients decline therapy, so it’s important to ensure that patients are well informed on it.
[Dr. Daniel Hoffman]
That is really the patient population that I think of when I think of Botox for overactive bladder. If, if you're neurogenic overactivity, or you have tissue overactivity with impaired contractility, that's the patient that I'm thinking bladder Botox for. So, you know, I had an overwhelming experience of, of, of Botox.
[Dr. Jose Silva]
Yeah definitely. I think that's the beauty of Botox. I mean, it's, it's about doing it in the office and that's the, the, the upside to it. very low risk procedure. Uh, what's your ideal patient for Botox?
[Dr. Daniel Hoffman]
My ideal patient for Botox is the patient that's in urinary retention because that's the patient that you don't really have to worry about side effects, right? Because, when you're selling patients on Botox, you're having that discussion on Botox. You lose most of them when you start talking about urinary retention and that, you know, it's a, it's a discussion that you have to have right, with your patients. So, I think that, uh, patients select themselves for therapy and they tend to de-select themselves for Botox. Once you start talking about retention of urine.
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Overactive Bladder Botox Procedure
In the neurogenic population, botox injections are started at 200 units, whereas 100 units is more typical for detrusor overactivity patients. Doses can be increased if the patient does not respond, with 3 months between injections. Dr. Hoffman states that he has gone as high as 300 units on off label use and seen results. The injections can be administered in a grid template, with half a cc in each section, and a full cc for the trigone. In regards to timing, it is important for the patient to understand that the first few injections are a trial run until a schedule can be established, with an injection frequency anywhere from once every 3 months to once every year.
[Dr. Daniel Hoffman]
So for the neurogenic population, I started 200 units. So if you're coming in with a massive stroke, you have Parkinson's you're, you're getting 200 units. Detrusor overactivity, I'll start at a hundred units. Um, go up to two, if a hundred fails. I'll usually wait three months between injections, have gone up to 300 units on some patients off-label use, but uh, can work.
Uh, I've done it, especially in the neurogenic patients. Patients can develop antibodies to Botox and, uh, the Botox stops becoming as effective. That's a tough patient population.
[...]
[Dr. Daniel Hoffman]
So, you know, when we trained, we did the umbrella thing, right. And, uh, I think we, we moved, we went in my fellowship, we moved towards a grid template, and that's what I was very used to doing. Um, just half CC injections, depending on how much Botox you're using. And I just go.
You know, from UO to UO, up and down the posterior bladder wall, up to the dome and back. And then I always save a CC for the trigone. And I believe in injecting the trigone, you know, if you believe that whole theory of, of the, the bladder contraction, I mean, it, it should involve the trigone as well. So we always injected the trigone. That last trigone shot can be a little challenging, but if you, you get it at the right angle, you'll get it in there.
[...]
[Dr. Daniel Hoffman]
first couple of injections are sort of a trial run until you figure out what that schedule is. And they will let you know, I have a lot of patients that are on a routine at this point, right. We know that every three to six, every four to six months, we're going to do an injection. Some patients that's once a year, you know, some patients can go nine to 12 months with, with a Botox injection.
Now that we have telehealth virtual visits, it makes it very easy. They just hop on, Hey doc, it's time for my Botox injection. I put the orders in for the procedure. They come in, they get it done.
Sedation During Botox Injections for Overactive Bladder
Bladder Botox injections can be done in the office with a flexible scope for female patients. For male patients, a rigid scope is usually used, and the procedure is done in an OR. Sedation during procedures can be achieved with valium or Ativan. Dr. Silva uses 5 mg of valium in his practice, whereas Dr. Hoffman uses 2 mg Ativan. It is important to note that a patient may still experience pain and anxiety despite these interventions, but medications can help minimize these symptoms.
[Dr. Daniel Hoffman]
So for the, for the women, it's preferable to use a rigid scope. If you have it, it makes it very easy. we're using a flexible scope and it's almost like a two person job, but when you're using a flexible scope.
[Dr. Jose Silva]
The ones that I have the flexible, we have the same stuff, which is pretty nice for diagnostic.
[Dr. Daniel Hoffman]
It's great for diagnostic. It's tough for procedures.
[Dr. Jose Silva]
And definitely it is. I mean, I, it is a two-man job and definitely the, the, the MA has to inject. Go ahead. Go ahead. So, so, so there's a learning curve in the, in that part
[Dr. Daniel Hoffman]
There is. And that's why, you know, like the guys, I take them to the operating room because it's just so much easier to rigid scope them and be able to do it yourself.
[Dr. Jose Silva]
Yeah. And I don't know about you, but doing a cystoscope is in the office. Every time, it's more challenging. I think. People. I mean, at least the guys are not as comfortable. I started doing some valium for patients that, that when you, when I say what a cystoscopy is, I see I looked at their face. Uh, so I started doing a five milligram valium to see if that helps. I haven't seen that much difference. If he was going to scream he’s going to scream.
[Dr. Daniel Hoffman]
I do ativan two milligrams for a lot of my procedures. you know, if the patient is very anxious and it, it, I, I find it helps to some degree, you know, always, you know, in the office, you're in a rush, you put that lidocaine jelly in, are you really waiting five or 10 minutes for it to take effect?
The tough patients going to be a tough patient, right? No matter what you do, but there are things that you can do to minimize the misery in the office. Right. And I think that those things are important.
Podcast Contributors
Dr. Daniel Hoffman
Dr. Daniel Hoffman is a practicing urologist with AdventHealth in Orlando, Florida.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2021, October 27). Ep. 20 – Advanced Treatments for Overactive Bladder (OAB) [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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