Botulinum A toxin urethral sphincter injection in children with nonneurogenic neurogenic bladder.
OBJECTIVE
We evaluated botulinum-A toxin (Botox) injection into the urethral urinary sphincter in children with nonneurogenic neurogenic bladder to decrease urethral resistance and improve voiding. In these patients alpha-blocker medications had failed and injection was an alternative to unavailable biofeedback.


METHODS
Prospective treatment was performed in 10 children 6 to 17 years old (mean age 8) with nonneurogenic neurogenic bladder using botulinum-A toxin (Botox). Preoperatively all children were evaluated by ultrasound, voiding cystourethrography, excretory urography, magnetic resonance imaging and urodynamic studies, including pressure flow, electromyography and uroflowmetry. One patient had unilateral G3 reflux and 4 had bilateral G1 to G3 hydronephrosis. Using a rigid pediatric endoscope and a 4Fr injection needle 50 to 100 IU botulinum-A toxin were injected into the external sphincter at the 3, 6 and 9 o'clock positions. Followup was 6 to 15 months. Repeat injections every month were given according to the response with a maximum of 3 injections.


RESULTS
Immediately after botulinum-A toxin injection all except 1 patient were able to void without catheterization. No acute complications occurred. Four patients with bilateral hydronephrosis and the patient with the refluxing unit showed regression. Postoperatively post-void residual urine decreased by 89%, detrusor leak point pressure decreased significantly by a mean +/- SD of 66 +/- 18 vs 37 +/- 4 cm H(2)O and uroflowmetry showed a marked increase in maximum urine flow of 2 +/- 2 vs 17.8 +/- 8 ml per second. Three injections were needed in 1 patient to attain the desired response.


CONCLUSIONS
Urethral sphincter botulinum-A toxin injection could be considered a reliable treatment modality in children with nonneurogenic neurogenic bladder after the failure of conservative therapy.
Mokhless
I
I
Department of Urology, Section Pediatric Urology, Alexandria University, 21 Amin Fikery, Ramleh Station, Alexandria, Egypt. ibrahim_mokhless@yahoo.com
Gaafar
S
S
Fouda
K
K
Shafik
M
M
Assem
A
A
D000293:Adolescent; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage*; D002648:Child; D004576:Electromyography; D004724:Endoscopy; D005260:Female; D006801:Humans; D007267:Injections; D008297:Male; D009465:Neuromuscular Agents / Q000008:administration & dosage*; D014521:Urethra; D001743:Urinary Bladder / Q000503:physiopathology; D001750:Urinary Bladder, Neurogenic / Q000503:physiopathology / Q000628:therapy*; D014563:Urodynamics
D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A