title: Is it reasonable to treat refractory voiding dysfunction in children with botulinum-A toxin?
abstract: OBJECTIVE
  We present our results with botulinum-A toxin transperineal pelvic floor/external sphincter injection combined with behavioral and biofeedback reeducation in children with voiding dysfunction who had been resistant to previously applied therapies.
  
  
  METHODS
  Eight boys and 12 girls between 7 and 12 years old (mean age 9) with recurrent urinary tract infection, an interrupted or fractional voiding pattern and high post-void residual urine in whom behavioral, short biofeedback and alpha-blocker therapies had failed were included in the study. They were treated with botulinum-A toxin at a dose of 50 to 100 U. Botulinum-A toxin was injected transperineally into the pelvic floor and/or external sphincter in all patients. In boys the sphincter was localized endoscopically before injection (endoscopically assisted transperineal approach). Behavioral and biofeedback reeducation started 15 days after injection.
  
  
  RESULTS
  Followup was between 9 and 14 months. All patients were without urinary tract infection and fever, while 5 were still on chemoprophylaxis. Six months after treatment residual urine decreased in 17 of 20 patients by 0 to 130 ml (mean +/- SD 45.75 +/- 32.17 ml, t = 6.360, p <0.001). Nine patients reestablished a normal voiding curve and 8 showed improvement. Three did not manifest any significant improvement. In 1 girl transitory incontinence resolved spontaneously within 48 hours. There were no other complications.
  
  
  CONCLUSIONS
  The effect of botulinum is transitory. However, it can break the circle of detrusor-sphincter dyssynergia and the period when it is sustained can be used for retraining the patient in normal voiding. At this moment botulinum-A toxin is one of last options in refractory cases of voiding dysfunction.
authors.affiliation: Department of Urology, University Children's Hospital, Tirsova 10, 11000 Belgrade, Yugoslavia-Serbia. zotiogiv@Eunet.yu
authors.forename: Zoran I
authors.initials: ZI
authors.lastname: Radojicic
authors.forename: Sava V
authors.initials: SV
authors.lastname: Perovic
authors.forename: Natasa M
authors.initials: NM
authors.lastname: Milic
mesh_terms: D019274:Botulinum Toxins, Type A / Q000008:administration & dosage*; D002648:Child; D004576:Electromyography; D005260:Female; D006801:Humans; D007273:Injections, Intramuscular; D008297:Male; D009465:Neuromuscular Agents / Q000008:administration & dosage*; D017773:Pelvic Floor; D011859:Radiography; D014521:Urethra / Q000000981:diagnostic imaging; D001743:Urinary Bladder / Q000000981:diagnostic imaging; D014549:Urinary Incontinence / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000503:physiopathology; D014554:Urination; D014563:Urodynamics
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A