Botulinum Toxin Type A for the Treatment of Urinary Tract Dysfunction in Neurological Disorders

Margie O'Leary, MSN, RN, MSCN; Mary Dierich, PhD(c), RN, GNP

Disclosures

Urol Nurs. 2010;30(4):228-234. 

In This Article

Abstract and Introduction

Abstract

Botulinum toxin type A injections represent an important therapeutic option for patients with neurogenic urinary dysfunction in whom conservative treatment has not been effective. The nurse's role in ensuring that these patients receive appropriate assessment and treatment is discussed.

Introduction

Neurogenic detrusor over-activity (NDO), also called neurogenic bladder, and concurrent detrusor-sphincter dyssynergia impair the storage and emptying functions of the urinary bladder. They are consequences of neurological disorders or injuries that cause damage or dysfunction of the spinal cord above the sacral level, including cerebrovascular accident, brain tumor, cerebral palsy, Parkinson's disease, multiple system atrophy, multiple sclerosis, spinal cord injury, and autonomic hyperreflexia. NDO can also be a complication of diabetes mellitus or of major surgery in the pelvis (Wein, 2007). The symptoms of NDO are consistent with those of overactive bladder (OAB) and include urinary frequency, urgency, and nocturia, as well as urge incontinence.

Detrusor-sphincter dyssynergia refers to the impaired coordination between detrusor muscle contraction and relaxation of the sphincter muscle during voiding, which can result in difficulty emptying the bladder. These disorders are very common in patients with underlying neurologic conditions, such as stroke, multiple sclerosis, or spinal cord injury (Kalsi & Fowler, 2005; Schulte-Baukloh et al., 2006; Schurch, Stöhrer, Kramer et al., 2000).

Incontinence may be the most troublesome symptom of detrusor overactivity from both a physical and emotional perspective (Smith, 2006). Patients with neurogenic urinary dysfunction commonly experience embarrassment, social constraints, and depression (Oh, Shin, Paik, Yoo, & Ku, 2006; Stewart et al., 2003). Physically, they may develop skin breakdown, decubiti, urethral and perineal erosions, and upper urinary tract dysfunction, and ultimately, renal failure can result (Kuo, 2004, Schulte-Baukloh et al., 2006; Schulte-Baukloh, Michael, Schobert, Stolze, & Knispel, 2002).

Most patients with OAB can benefit from multimodality therapy, including bladder training, pelvic floor muscle training, and medical therapy. However, some patients with OAB are refractory to these treatments and require a more aggressive approach to achieve treatment goals.

For patients with NDO, firstline treatment usually consists of bladder emptying by intermittent self-catheterization (ISC) and the use of oral anticholinergic medication to reduce the bladder pressure and increase bladder capacity (Verpoorten & Buyse, 2008). When these options fail due to lack of efficacy or when medication side effects are not tolerable to the patient, surgical bladder augmentation may be considered. However, surgery may not be feasible for many patients due to their medical condition or the invasiveness of the procedure (Giannantoni, Mearini, Del Zingaro, & Porena, 2009). Botulinum toxin type A (BoNT-A) injections represent an option for patients in whom conservative treatment has not been effective.

Nurses play an important role in ensuring patients with neurogenic urinary dysfunction receive appropriate assessment and treatment. In addition, nurses are ideally placed to provide ongoing education regarding specific treatments in terms of the procedures, expected outcomes, and potential side effects, and to perform initial and follow-up assessments. Urologic nurses have an important role in managing patients with neurological disorders who are being treated with BoNT-A for the management of urologic symptoms.

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