Botulinum-A Toxin in the Treatment of Neurogenic Bladder in Children
H. Schulte-Baukloh, MDH. H. Knispel, MD
St Hedwig Hospital
Teaching Hospital of University Hospital Charite
Department of Urology
Berlin, Germany
T. Michael, MD
Clinic of Neuropediatrics
University of Hospital Charite
Berlin, Germany
To the Editor.—
Children who have neurogenic bladder attributable to myelomeningocele are threatened by high intravesical pressure caused by a hyperreflexic "spastic" detrusor muscle. This leads to morphologic and functional changes in the bladder, vesicoureteral reflux, and, worst of all, damage to kidney function. The established treatment consists of the use of anticholinergic drugs and clean intermittent catheterization (CIC), sometimes in combination with 
-adrenergic blocking agents to lower bladder outlet resistance. Problems arise when this therapy fails, either because the drugs are insufficiently effective or because side effects occur, as often happens. In 8% to 12% of children in whom treatment fails, surgery, such as bladder augmentation, is unavoidable. We seek alternatives to close this gap between conservative and surgical treatment. Encouraged by results of Schurch et al, 1 who successfully treated adults who had neurogenic incontinence after spinal cord injury, we investigated the action of botulinum-A toxin in children.
So far in our study, we have included 20 children whose bladder pressure was intolerably high despite the use of anticholinergic drugs and CIC. Before inclusion, all medications except antibiotics were stopped and baseline urodynamic measurements were recorded. During the filling phase, we documented the reflex volume (the volume when the first uninhibited bladder contraction occurs), the number of reflexive detrusor waves, the maximal detrusor pressure, and the maximal bladder volume. The extent of incontinence was graded on a scale of 0 (dry at all times) to 3 (always wet). A weight-adapted dose of 85–300 units of botulinum-A toxin (Botox) was injected into 40 to 50 sites of the detrusor muscle with cystoscopic guidance. All 20 children underwent follow-up cystometry within 4 weeks; 6 already had a control examination after 3 months. In the first cystometry, urodynamic measures in all patients were significantly better.2 Specifically, the maximal bladder pressure had decreased by 32.6%, the reflex volume had more than doubled, and the bladder capacity had increased by 56% in comparison with baseline values. There were no side effects. In 6 children with 3-month follow-up, incontinence improved from 2.4 to 1.4, and the effect of botulinum toxin is still detectable, although it seems to vanish gradually (Table 1).
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These results raise hopes of keeping high-risk children with neurogenic bladder under conservative control longer and avoiding surgery.
REFERENCES
- Schurch B, Stohrer M, Kramer G, et al. Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results. J Urol.2000; 164(3 pt 1) :692 –697[CrossRef][Web of Science][Medline]
- Schulte-Baukloh H, Michael T, Schobert J, Stolze T, Knispel HH. Efficacy of botulinum-A toxin in children with detrusor hyperreflexia due to myelomeningocele: preliminary results. Urology.2002; 59 :325 –327. Discussion 327–328[Medline]
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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