Botox for Overactive Bladder

I don’t really mind getting older, but I don’t really want to look my age, either.  When I was younger, I never thought I would consider facial fillers or Botox.  But as I age, I know I would consider pretty much anything.  Botox is a common way to smooth out facial wrinkles.  I think most of us have heard of Botox.  It’s talked about in the media, and lots of celebrities use it.  It is offered by lots of different providers.  I’ve seen it advertised by plastic surgeons, dermatologists, gynecologists, primary care, naturopaths, and even nursing clinics.

Botox is the world’s most common cosmetic procedure, with nearly 3 million procedures performed annually.  But Botox is also used therapeutically and not just cosmetically.  There are eleven different therapeutic indications.  It can be used to treat eye spasms, muscle rigidity, migraines, excessive sweating, and overactive bladder.  Did you know Botox can be used to treat bladder frequency, urgency, and the associated leaking?

What is Botox?

OnabotulinumtoxinA, commonly known as Botox, is a neurotoxin that is produced by bacteria.  Using a toxin sounds a little terrifying, but we’ve figured out how to use it safely.  Botox interferes with cell signaling and temporarily paralyzes muscle fibers (specifically, it blocks the presynaptic release of acetylcholine which decreases the muscarinic receptor activation involved in muscle contraction).  This is how it prevents dynamic facial wrinkles- you can’t move the muscles to furrow your brow.  When you can’t move the muscle, the wrinkles are minimized.  When we use
Botox, for any reason, we inject into the muscle.  All of the reasons that we use Botox involve tight muscles or overactive muscles.  Botox temporarily paralyzes the muscle.  Botox works well but wears off over time, so it needs to be repeated to maintain the effect.

What is the Botox procedure for an overactive bladder like?

The idea of injecting anything into your bladder doesn’t thrill most women.  But this is something that I do every day in the office.  And many women have it done multiple times and don’t find it to be painful.  I usually ask you to avoid bladder irritants for a few days before the procedure.  And I think this makes the procedure less uncomfortable.  So here are the steps to getting Botox done:

• We make sure you don’t have a bladder infection. I won’t inject Botox if you have an infection.
• We clean the urethra.
• We number your bladder. This is done by putting a liquid numbing medication in the bladder and a gel numbing medication in the urethra.  There are no needles in this step.
• We clean the urethra again.
• I look in your bladder and injection the medication in 10 different spots in the bladder.
• I empty your bladder.

There are a few things that I would tell you about this procedure.  The first is that the needle is tiny.  It is about 1/20^th of an inch.  The size of the needle, even though it is being placed in a delicate spot, makes it less uncomfortable.  Secondly, it’s important for you to trust your team.  In-office procedures work best if you feel safe and feel like the team will listen to you if you ask them to stop.  I always tell my patients that I will stop or take a break if they need me to.  And the last point I would make is you need to understand the steps of the procedure.  I always talk the whole time.  This way, you know what I am doing and how many injections you have left.  I think this makes the process a lot easier.

How well does Botox work?

Botox is usually effective in 65% of women.  A third of women will have complete resolution of their leaking.  The remainder is much better and has a decrease in urgency, frequency, and leaking.  However, it wears off over time but can be repeated.  It will last about six months for most women, although I have seen the effects last for over a year.  Most women are very satisfied with this treatment, and it has been shown to increase the quality of life across all health scales in studies.  This means that it allows most women to ignore their bladder and do the things they enjoy.  Many of my patients feel like Botox is a miracle treatment for them.  I have lots of women who come in for their bladder Botox every six months, like clockwork.

What can go wrong?

The most common complication is a urinary tract infection.  This happens about 35% of the time.  While I treat my patients with three days of antibiotics to minimize the chance of infection, it can still happen, and some women will get several infections after Botox injections.

Bladder Botox can also work too well and cause trouble emptying.  This happens about 5-10% of the time.  Many women who have trouble emptying don’t realize it, and we keep an eye on it.  We can measure this amount with an ultrasound, but no bothersome symptoms exist.

Others really can’t empty and have to catheterize themselves until the Botox wears off.  This is uncommon and happens 1-2% of the time.  It is a nasty surprise, so it is something we discuss a lot before the first Botox treatment.  In my experience, it is very rare for poor emptying to happen for the first time after your first injection.  So, if it didn’t happen on the first injection, it is unlikely to happen on the second unless you change the dose.

All of the side effects from Botox are bladder related.  This is very different from medications which often cause symptoms throughout your whole body.  There is no associated dry mouth, dry eyes, memory issues, or constipation.  And you don’t have to remember to take it every day.

Can I start with Botox?

When treating an overactive bladder, we talk about different lines of treatment.  First-line treatment is always education, bladder retraining, and pelvic floor strengthening.  The goal of this line of therapy is to:

• Identify what habits you have that are making your bladder worse
• Retrain your bladder to function better
• Teach you strategies to decrease the urge and leakage

This line of treatment is all many women need.  Second-line therapy includes trying medications and supplements.  Some women do well with this line of treatment.  Others don’t have enough improvement.  A third group has intolerable side effects.

Third-line treatment includes Botox and the different nerve stimulations like sacral nerve stimulations and posterior tibial nerve stimulation.  We don’t start with Botox treatment.

Botox for overactive bladder symptoms works well.  And it is a common procedure that many women choose to have routinely.  It isn’t for everyone, though.  If you get Botox for other reasons, it may not be a good choice for you.  It is important to be aware of the total amount of Botox that you get and the timing of the injections.  If you get lots of bladder infections, it is a poor choice.  And if you empty poorly, it is a poor choice.  You also may not like the idea of injecting a medical-grade toxin into your body.  But it is one more therapeutic option.  And the more treatment options we have, the better.

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