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Botulinum Toxin Injections for Neurogenic Detrusor Overactivity Periprocedural Care

  • Author: Pamela I Ellsworth, MD; Chief Editor: Edward David Kim, MD, FACS  more...
Updated: Jan 13, 2016



Injection of botulinum toxin A may be performed by means of either rigid or flexible cystoscopy. Various different endoscopic needles may be used for the injection, in particular ultrafine 4-mm flexible needles that may be passed through the flexible cystoscope. Besides the 4-mm flexible needle, the needle used for collagen injection and the needle used for dextranomer or hyaluronic acid injection have also been used for this procedure.

Botulinum toxin A

OnabotulinumtoxinA (ie, BOTOX) is supplied in single-use 100-U and 200-U vials. Before injection, each vacuum-dried vial must be reconstituted (see below). After reconstitution, onabotulinumtoxinA should be administered within 24 hours. Reconstituted onabotulinumtoxinA should be stored in a refrigerator at a temperature of 2-8° C.

In treating adult patients for 1 or more indications, the maximum cumulative dose generally should not exceed 360 U in a 3-month period. The recommended treatment dose of onabotulinumtoxinA is 200 U per treatment, divided into 30 injections of 1 mL.

Options for reconstitution

Reconstitution of onabotulinumtoxinA may be accomplished in 1 of 2 ways. The first is to reconstitute a 200-U vial by adding 6 mL of 0.9% sterile nonpreserved saline solution, mixing gently, and withdrawing 2 mL from the vial into each of 3 separate 10-mL syringes. Reconstitution is completed by adding 8 mL of 0.9% nonpreserved saline solution into each of the 10-mL syringes and mixing gently. Each of the 3 syringes will then contain 10 mL (about 67 U of onabotulinumtoxinA), for a total of 200 U of reconstituted onabotulinumtoxinA.

The second option is to reconstitute a pair of 100-U vials by placing 6 mL of 0.9% nonpreserved saline solution into each one, mixing the vials gently, withdrawing 4 mL from each of the 2 vials into 2 separate 10-mL syringes, and withdrawing the remaining 2 mL from each vial into a third 10-mL syringe. Reconstitution is completed by adding 6 mL of 0.9% nonpreserved saline into each of the 10-mL syringes and mixing gently. As with the first option, each of the 3 syringes will then contain 10 mL (about 67 U of onabotulinumtoxinA), for a total dose of 200 U.


Patient Preparation

Intradetrusor injection of onabotulinumtoxinA may be performed via flexible or rigid cystoscopy and may involve either local anesthesia (with or without sedation) or general anesthesia, depending on the patient’s sensory status, anxiety level, and risk of autonomic dysreflexia. In patients who are at risk for autonomic dysreflexia or have experienced autonomic dysreflexia with previous bladder filling, consideration of monitoring or pretreatment may be indicated.

Patients undergoing injection of botulinum toxin A should not have an acute urinary tract infection. It is recommended that prophylactic antibiotics (except aminoglycosides, because of the potential for drug interactions) be administered 1-3 days before treatment, on the day of treatment, and 1-3 days after treatment.

Contributor Information and Disclosures

Pamela I Ellsworth, MD Professor of Urology, University of Massachusetts Medical School; Chief, Division of Pediatric Urology, Department of Urology, UMassMemorial Medical Center

Pamela I Ellsworth, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Urological Association, Phi Beta Kappa, Society of University Urologists, Society for Fetal Urology

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

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Injection sites using minimally invasive outpatient technique. Flexible cystoscope with superfine 27-gauge disposable needle is used to inject onabotulinumtoxinA (BOTOX; Allergan, Irvine, CA) into bladder while avoiding trigone. At equally spaced points, 30 distinct injections, each containing 1 mL, are introduced
Gross anatomy of the bladder.
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