OnabotulinumtoxinA for neurogenic detrusor overactivity not only reduces the frequency and severity of autonomic dysreflexia safely but significantly improves quality of life for individuals with spinal cord injury
1Kran S, 1Walter M, 2Nigro M, 2Stothers L, 2Rapoport D, 2Kavanagh A, 1Krassioukov A
1International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; 2Department of Urologic Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
Management of neurogenic lower urinary tract dysfunction is among the highest priorities for individuals with spinal cord injury (SCI). Neurogenic detrusor overactivity (NDO), i.e. spontaneous uninhibited contractions of the detrusor, results in urinary incontinence and is a risk factor for urinary tract infection (UTI), long-term renal failure, and a leading cause of sudden increases in systolic blood pressure (BP), i.e. autonomic dysreflexia (AD. Both urinary incontinence and AD combine to place a tremendous burden on individuals with SCI. We hypothesize that by treating NDO, thereby reducing the frequency and severity of AD, quality of life (QOL) in this population can be improved.
Thirty-two individuals with chronic, traumatic SCI at or above the spinal segment T6, underwent intradetrusor onabotulinumtoxinA (Botox) injections with 200 IU to treat NDO in a prospective, open-labelled study from 2013 to 2017.
Using two validated, standardized questionnaires, i.e. incontinence QOL (I-QOL) and AD health-related QOL (AD HR QOL), all individuals were assessed pre- and one month post-treatment to subjectively measure QOL. The I-QOL comprise 22 items over three domains, i.e. avoidance and limiting behaviour (ALB), psychosocial impacts (PSI), and social embarrassment (SE). Each item can have a value on a 5-point scale from 1 (extremely) to 5 (not at all). The AD HR QOL utilizes symptoms characteristics of AD to subjectively score frequency and severity of AD episodes on a daily basis and upon bladder filling.
Changes in BP and heart rate were recorded during urodynamic investigations pre- and one month post-treatment to capture artificially induced AD. The latter was defined according to the International Standards to document remaining Autonomic Function after Spinal Cord Injury (ISAFSCI) as an increase in systolic BP of 20mmHg or more from baseline. In addition, 24-hour ambulatory BP monitoring (ABPM) pre- and one month post-treatment was applied to detect spontaneous episodes of AD.
Complications post-treatment were monitored and documented using the Clavien-Dindo (CD) classification of surgical complications up to 30 days’ post-treatment.
Participants self-reported a significant (p<0.001) improvement in incontinence-related QOL one month post- vs. pre-treatment. This improvement was seen across all three domains, i.e. ALB (31 vs. 26), PSI (36 vs. 29), and SE (18 vs. 14), and overall score (85 vs. 69).
Symptoms of AD on a daily basis and upon bladder filling were significantly (p<0.001) decreased post-treatment and subjectively eliminated in 4 individuals. Furthermore, 19 individuals self-reported a decrease in either AD frequency, severity, or both.
This was corroborated by the objective BP measures, showing elimination of AD in 9 individuals and reduced AD severity in 15 individuals. Only minor complications (CD I) or UTI (CD II) occurred, i.e. 20 or 6 participants, respectively.
Treatment of NDO not only objectively reduces the frequency and severity of AD safely but also subjectively improves incontinence-related QOL for individuals with SCI significantly.
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