Sunday, May 23, 2010

BOTOX: UTILITY IN UROLOGY

Botox, which has been smoothing wrinkles for years, now it will also help in relief of the bothersome urinary symptoms associated with an enlarged prostate or bladder conditions.



Botulinum toxin (BTX), a neurotoxin produced by the gram-positive, rod-shaped anaerobic bacterium Clostridium botulinum, was isolated in 1897 by Belgian scientist Professor Pierre Emile van Ermengem. BTX acts by blocking the release of acetylcholine at the neuromuscular junction. As a result of this chemodenervation, a temporary flaccid paralysis ensues. Different medical disciplines have taken advantage of this temporary paralysis to treat muscular hypercontraction. BTX was first approved by the US Food and Drug Administration in 1989 for use in patients with strabismus and blepharospasm. Since then, BTX has been used to treat a number of different neuromuscular disorders. BTX has been used successfully in urology to treat neurogenic and non-neurogenic detrusor overactivity, detrusor-sphincter dyssynergia, motor and sensory urge, and chronic pain syndromes.
The BOTOX toxin is of various types:A to F.The BOTOX A is the more potent with greater duration of action.It has wide urological applications.The BOTOX will bind irreversibly to presynaptic membrane and cause skeletal muscle atrophy but the axons will regenerate after 3-6 months.
BOTOX has been used in many urological consitions such as intractable overactive bladder,neurogenic bladder causing upper tract damage(kidney damage),Detrusor-External Sphicter Dyssenrgia( causing intermittent flow,obstructed stream in Neurological illnesses),chronic prostatic pain,non fibrotic bladder outflow obstruction(prostatic enlargement).
But the most common usage of BOTOX is in irritative bladder symptoms (frequency,nocturia,urgency,urge incontinence not yielding to medicines).The overactive bladder symptoms if doesnot abate with usual anti-cholinergic medications makes the life of the patient miserable. It will have physical problems-leakage causing personal inhygiene, psychological problems-embarrassment and loss of dignity, social problems-social isolation, sexual problems- because of genital skin rashes and foul smell( partner will have repulsion) etc.
The overactive bladder is widely prevalent affecting 50-100 millions of people all around the globe and some of them don’t respond to conventional treatments.These are the people who suffer silently and eventually end up in depression and self esteem.The BOTOX provides a ray of hope in such patients.
Typically 100-300 Units of BOTOX –A toxin is used. Briefly, the BoNT/A dose (200 or 300 units) is reconstituted with saline 0.9% at a total volume of 30 mL. The actual procedure of giving bladder Botox injections is fairly simple. It will take less than 20 minutes, and is minimally invasive. The procedure can be performed under local or general anaesthetic, and will not require an overnight stay in hospital.
A cystoscope – a small tube containing a camera – is passed into the bladder through the urethra so that the surgeon can inspect the inside of the bladder before performing the operation. A very thin needle is then passed through the cystoscope, and Botox is injected into between 20 and 30 different areas of the bladder muscle walls




BOTOX BEING INJECTED IN BLADDER FOR NEUROGENIC BLADDER
The BOTOX helps in alleviation of urological symptoms in 80% of the cases and the effect of BOTOX instillation lasts for 6-14 months.The injection can be repeated at those intervals.The BOTOX injection rarely causes systemic toxicity and rarely causes bladder paralysis needing long term catheterization.
One other area where BOTOX helps is neurogenic voiding dysfunction-either Detrusor Hyperreflexia or Detrusor External Sphincteric Dyssenergia in children with spina bifida/meningocele/myelomeningocele. These voiding dysfunction can gradually destroy the kidneys because of high bladder pressures.This can be brought down with BOTOX and kidney function thus preserved.
Certain novel areas like intractable chronic prostatitis and benign prostatic enlargement especially with detrusor overactivity ; many urologists have started using it with promising results.
The main implication of the BOTOX is that many patients having lower urinary tract symptoms with incontinence,urgency are elderly population with lot of other associated comorbidities like heart ailments.This makes them unsuitable for the conventional surgery if the medical line of treatment fails.In these group of patients BOTOX comes as a boon relieving them of the incontinence as it can be performed under local anaesthesia.
BOTOX although many people have reservations about its usage in urology is here to stay and its acceptance is going to increase because of its simplicity of performance and promising results.

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