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Botulinum Toxin Injections for Neurogenic Detrusor Overactivity Technique

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

Approach Consideration

Intradetrusor injection of botulinum toxin A may be performed via rigid or flexible cystoscopy, depending on the urologist’s preference and the patient’s sensory level. Before injections are initiated, the injection needle should be filled (primed) with approximately 1 mL of reconstituted onabotulinumtoxinA to remove any air (the exact volume will depend on the needle used). Sufficient saline should be instilled into the bladder to achieve adequate visualization for the injections, but overdistention should be avoided.

The needle is inserted into the detrusor muscle to a depth of approximately 2 mm. A total of 30 injections (each containing 1 mL, or approximately 67 U of botulinum toxin A), equally spaced about 1 cm apart, are made into the dome, posterior, and right and left lateral walls of the bladder; the trigone is spared (see the image below). The bladder is then emptied, and the patient is observed for at least 30 minutes after injection.

Injection sites using minimally invasive outpatien 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

Kuo described a suburothelial technique that uses a rigid cystoscope and a 23-gauge injection needle.[2] In this approach, the needle is inserted into the submucosal space, and the botulinum toxin A solution is injected to form a ballooning of the bladder mucosa.

Reinjection may be performed when the clinical effect of the previous injection decreases, but no sooner than 12 weeks after the preceding bladder injection.



In 3 randomized, controlled trials, the most common adverse event (AE) of intradetrusor injection of botulinum toxin A was increased postvoid residual, which may necessitate clean intermittent catheterization. Thus, patients should be counseled about the potential need for clean intermittent self-catheterization (CIC).

A placebo-controlled study reported that the overall incidence of least 1 AE in treated patients was not significantly different from that in the placebo group.[3] The more frequently reported AEs across the studies were urinary tract infection and mild hematuria.

A dose-ranging study including both neurogenic detrusor overactivity (NDO) and idiopathic detrusor overactivity (IDO) patients reported that patients who received 100 U of botulinum toxin A had a significantly smaller postvoid residual urine volume than patients who received 150 U or 100 U at 1 month.[2] One study reported a mild case of asthenia after injection of botulinum toxin A 300 U, which persisted for 10 days.[4]

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.

  1. Apostolidis A, Popat R, Yiangou Y, Cockayne D, Ford AP, Davis JB. Decreased sensory receptors P2X3 and TRPV1 in suburothelial nerve fibers following intradetrusor injections of botulinum toxin for human detrusor overactivity. J Urol. 2005 Sep. 174(3):977-82; discussion 982-3. [Medline].

  2. Kuo HC. Clinical effects of suburothelial injection of botulinum A toxin on patients with nonneurogenic detrusor overactivity refractory to anticholinergics. Urology. 2005 Jul. 66(1):94-8. [Medline].

  3. Schurch B, de Seze M, Denys P, Chartier-Kastler E, Haab F, Everaert K. Botulinum toxin type a is a safe and effective treatment for neurogenic urinary incontinence: results of a single treatment, randomized, placebo controlled 6-month study. J Urol. 2005 Jul. 174(1):196-200. [Medline].

  4. Giannantoni A, Di Stasi SM, Stephen RL, Bini V, Costantini E, Porena M. Intravesical resiniferatoxin versus botulinum-A toxin injections for neurogenic detrusor overactivity: a prospective randomized study. J Urol. 2004 Jul. 172(1):240-3. [Medline].

  5. Kim SW, Choi JH, Lee YS, Han SW, Im YJ. Preoperative urodynamic factors predicting outcome of botulinum toxin-A intradetrusor injection in children with neurogenic detrusor overactivity. Urology. 2014 Dec. 84 (6):1480-4. [Medline].

  6. Peyronnet B, Castel-Lacanal E, Manunta A, Roumiguié M, Marque P, Rischmann P, et al. Failure of botulinum toxin injection for neurogenic detrusor overactivity: Switch of toxin versus second injection of the same toxin. Int J Urol. 2015 Sep 22. [Medline].

  7. Khan S, Game X, Kalsi V, Gonzales G, Panicker J, Elneil S. Long-term effect on quality of life of repeat detrusor injections of botulinum neurotoxin-A for detrusor overactivity in patients with multiple sclerosis. J Urol. 2011 Apr. 185(4):1344-9. [Medline].

  8. Kalsi V, Apostolidis A, Popat R, Gonzales G, Fowler CJ, Dasgupta P. Quality of life changes in patients with neurogenic versus idiopathic detrusor overactivity after intradetrusor injections of botulinum neurotoxin type A and correlations with lower urinary tract symptoms and urodynamic changes. Eur Urol. 2006 Mar. 49(3):528-35. [Medline].

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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