Optimization of OnabotulinumtoxinA (BTX-A) Injection for the Treatment of Neurogenic Lower Urinary Tract Dysfunction

Study Overview
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Brief Summary
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The purpose of this study is to evaluate and standardize the way providers perform OnabotulinumtoxinA (BTX-A) injections into the bladder for the diagnosis of neurogenic lower urinary tract dysfunction (NLUTD)/overactive bladder (OAB). NLUTD/OAB is a syndrome that affects many people, and includes urinary frequency, urinary urgency, urgency incontinence, and nocturia. This syndrome can be challenging to treat and often requires procedural management - including BTX-A injections into the bladder.

Detailed Description
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Neurological disorders such as Multiple Sclerosis (MS), Spinal Cord Injury (SCI), Parkinson's Disease (PD), Spina Bifida (SB), and stroke disrupt neural control of voiding and lead to the development of neurogenic lower urinary tract dysfunction (NLUTD), which develops when either the detrusor muscle fails to maintain effective contractions (voiding phase) or fails to relax appropriately with low pressures (storage phase), if the urethral sphincter (internal or external) fails to lower its tonicity and resistance, or if there is an asynchrony in events eventually leading to detrusor sphincter dyssynergia (DSD). Different patterns of NLUTD (including both storage and voiding) can arise depending on the level of injury or type of neurological disease. It can be characterized by urinary urgency, frequency and incontinence or urinary hesitancy and retention that leads to urinary tract infections (UTIs). Some patients develop neurogenic overactive bladder (NOAB). Management of NOAB symptoms is complex. Treatment with BTX-A has been shown to decrease episodes of urinary incontinence and improve quality of life in this population. It has also been shown to ameliorate a multitude of devastating complications, such as upper tract deterioration, recurrent urinary tract infections, sepsis, and death. According to the current manufacturer's recommendation, a standard 200-unit vial of Botox® should be diluted in 30cc of 0.9% saline and injected across 30 different sites in the detrusor muscle (Figure 2). Despite these guidelines, there are wide variations in administration techniques, raising the question what is the best depth and location for injection, and optimal concentration and volume of toxin per injection site. The objective of this study is to determine the optimal injection schema for 200 units or more of intradetrusor BTX-A in patients with NOAB in the office setting. The investigators hypothesize that patients with NOAB symptoms undergoing intradetrusor injection of 200 units (or more) of BTX-A will be more willing to pursue additional sessions of BTX-A injections with a protocol utilizing less injection sites, while still maintaining effectiveness of the procedure.

Official Title
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Optimization of OnabotulinumtoxinA (BTX-A) Injection for the Treatment of Neurogenic Lower Urinary Tract Dysfunction

Conditions
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Neurogenic Bladder, Lower Urinary Tract Symptoms, Overactive Bladder, Neuro: Neurogenic Bladder, Neurogenic Detrusor Overactivity

Intervention / Treatment
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* Procedure: Standard number of injection sites
* Procedure: Reduced number of injection sites


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adult men and women (>18 years of age) with a diagnosis of neurological conditions such as MS, PD, CVA, myelomeningocele, SCI, or traumatic brain injury longer than 6 months prior to treatment. Diagnosis of neurogenic bladder indicated for treatment with BTX-A for OAB symptoms. Participants must be able to provide informed consent, as well as understand and be willing to undergo. follow-up procedures and completion of all questionnaires provided during the study. Exclusion Criteria: Symptomatic UTI at the time of procedure, defined as positive nitrites or high-volume leukocyte esterase on urine dip in addition to at least one of the following symptoms: dysuria, gross hematuria, suprapubic pain, frequency/urgency above baseline. Diagnosis of bladder pain syndrome or other chronic pain syndrome including fibromyalgia, chronic pelvic pain, pelvic floor dysfunction, levator myalgia. Untreated bladder malignancy. Women who are currently pregnant or breast feeding. Contraindications to intradetrusor BTX-A injections.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Standard Injection Sites<br>Standard number of injections | Procedure: Standard number of injection sites<br>* 200 units or 300 units BTX-A reconstituted in 20 mL normal saline, injected into the bladder detrusor in 20 separate injections of 1 mL including the trigone.<br>|
| Experimental: Reduced Injection Sites<br>Reduced number of injections | Procedure: Reduced number of injection sites<br>* 200 units or 300 units BTX-A reconstituted in 5 mL normal saline, injected into the bladder detrusor in 5 separate injections of 1 mL including the trigone.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Willingness to repeat procedure visual analog scale | A likert scale to measure the patient's willingness to repeat procedure. 0=Never (worst outcome), 7=Definitely (best outcome) | Immediately after injection, 6 week follow-up after BTX-A injection | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| ICIQ-UI SF Questionnaire | International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form standardized survey to measure change in neurogenic bladder symptoms before and after BTX-A. 12=Worst, 0=Best. | Immediately prior to injection, 6 week follow-up after BTX-A injection | 
| NBSS-SF | Neurogenic bladder symptom score-short form standardized survey to measure change in neurogenic bladder symptoms before and after BTX-A. 21=worst score possible, 0=best score possible | Immediately prior to injection, 6 week follow-up after BTX-A injection | 
| PGI score | Patient global impression of improvement after adminstration of BTX-A. 1=Very much worse, 7=Very much better | Immediately after injection, 6 week follow-up after BTX-A injection | 
| Numeric Pain Rating Scale | Patient's rating of pain before and after BTX-A treatment. 0=no pain (best), 10=worst pain of my life (worst outcome) | Immediately prior to injection, immediately after BTX-A injection | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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neurogenic bladder, Lower urinary tract symptoms, Neurogenic detrusor overactivity, Onabotulinum toxinA