Introduction
55.5% of patients with cerebral palsy (CP) experience urinary incontinence. Effective management includes medications, initiation of intermittent catheterization, indwelling catheters, or urinary diversion. Onabotulinumtoxin A (Botox) has been effective in management of neurogenic detrusor overactivity causing incontinence, but it’s efficacy has not been studied in CP patients. We evaluated the efficacy and safety of bladder Botox injections in adults with CP.
Methods
We performed a retrospective review of CP patients who received Botox injections from 2015-2023 at a single institution. Patient demographics, severity of CP as defined on the Gross Motor Function Classification System (GMFCS), and adverse events, such as urinary retention and urinary tract infections (UTIs), were evaluated. Patient questionnaires (Neurogenic Bladder Symptom Score, AUA Symptom Index) supplemented the objective data.
Results
Twenty-four CP patients (median age of 45) were included for a median follow up of 3.99 years. The CP patients were predominantly female (62.5%) with spastic CP (95.8%) and significant disability (50% class 4 or 5 on GMFCS). The most common indication for botox was detrusor overactivity (79.2%) followed by poor bladder compliance. Patient reported outcome measures (PROM) indicated improvement in incontinence and storage/voiding symptoms, with average AUASI score decreasing from 13.45 to 10.04 following Botox. Adverse events included urinary retention in 3 of 79 injections and UTIs in 7 of 79 injections. While some discontinued injections due to ineffectiveness (20.8%) or adverse events (16.7%) and 8% were lost to follow up, many improved with treatment. 29.2% of patients are still receiving injections (median follow up of 4.24 years) and 20.8% discontinued due to symptom satisfaction.
Conclusion
Bladder Botox injections appear to be an effective treatment for detrusor overactivity in adults with CP with 29.2% of patients choosing to continue injections. Adverse events such as UTI and urinary retention occur at similar rates as in the general population.
References
-
Cotter, K. J., Levy, M. E., Goldfarb, R. A., Liberman, D., Katorski, J., Myers, J. B., & Elliott, S. P. (2016). Urodynamic Findings in Adults With Moderate to Severe Cerebral Palsy. Urology, 95, 216–221. https://doi.org/10.1016/j.urology.2016.05.024
-
DeWitt-Foy, M. E., Gotlieb, R., & Elliott, S. P. (2022). Long-term Follow-up of Patients With Cerebral Palsy Undergoing Catheterizable Channel Creation Without Concurrent Bladder Augmentation. Urology, 170, 234–239. https://doi.org/10.1016/j.urology.2022.09.008
-
Goldfarb, R. A., Pisansky, A., Fleck, J., Hoversten, P., Cotter, K. J., Katorski, J., Liberman, D., & Elliott, S. P. (2016). Neurogenic Lower Urinary Tract Dysfunction in Adults with Cerebral Palsy: Outcomes following a Conservative Management Approach. Journal of Urology, 195(4), 1009–1013. https://doi.org/10.1016/j.juro.2015.10.085
-
Narayan, V. M., Pariser, J. J., Gor, R. A., Katorski, J., & Elliott, S. P. (2019). Bladder changes after catheterizable channel creation in adults with cerebral palsy who are in chronic urinary retention. Neurourology and Urodynamics, 38(1), 165–170. https://doi.org/10.1002/nau.23818
-
Samijn, B., Van Laecke, E., Renson, C., Hoebeke, P., Plasschaert, F., Vande Walle, J., & Van den Broeck, C. (2017). Lower urinary tract symptoms and urodynamic findings in children and adults with cerebral palsy: A systematic review. In Neurourology and Urodynamics (Vol. 36, Issue 3, pp. 541–549). John Wiley and Sons Inc. https://doi.org/10.1002/nau.22982