Pharmacotherapy in Pediatric Neurogenic Bladder Intravesical Botulinum Toxin Type A

Abstract

When the neurogenic bladder is refractory to anticholinergics, botulinum toxin type A is used as an alternative. The neurotoxin type A reduces bladder pressure and increases its capacity and wall compliance. Additionally, it contributes to improving urinary continence and quality of life. This novel therapy is ambulatory with a low incidence of adverse effects. Due to its transitory effect, it is necessary to repeat the injections in order to sustain its therapeutic effect. In these review article we talk about Mechanism of Action, Indications, effects, administration and presentations of the Botulinum Neurotoxin Type A in pediatric patients. Also, we make references to controversial issues surrounding its use. A bibliographic search was done selecting articles and revisions from Pubmed. The key words used were botulinum toxin A, neurogenic bladder, and children. The search was limited to patients younger than 18 years of age and reports written in English in the past ten years.

Preclinical assessment of potential interactions between botulinum toxin and neuromodulation for bladder micturition reflex

“…Clinically BoNT-A results in an increase in cystometric capacity. In studies reported increases of 60 % ([ 23 ], spinal cord injured patients with detrusor overactivity), 35-80 % ([ 24 ], pediatric neurogenic bladder), and 100-200 % ([ 25 ], neurogenic detrusor overactivity patients) have been observed.…”

Pharmacology

“…Neurotoxin A works to reduce bladder pressure by targeting protein receptors within nerve terminals. The toxin prevents the release of acetylcholine from the terminals and into the neuromuscular junction, consequently eliminating muscular contractility and reducing pressure (Sager et al, 2012). However, studies have shown that these injections may not be clinically meaningful in patients with MMC (Hascoet et al, 2018).…”

EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part II operative management

“…In patients with a neurogenic bladder refractory to anticholinergics/antimuscarinics, botulinum toxin A injections into the detrusor muscle should be considered as the next step to restore a low pressure, high capacity reservoir. 4,5 A recent systematic review in children with a neurogenic bladder, demonstrated that continence can be achieved in 32% to 100%, the maximum detrusor pressure is decreased by 32% to 54%, maximum cystometric capacity is increased by 27% to 162% and bladder compliance was improved (28-176%). 4 Onabotulinum toxin A (maximum 300 IU injected at 20-30 different sites) seems to be more effective in bladders with detrusor muscle overactivity, whereas noncompliant bladders without detrusor overactivity are unlikely to respond.…”