From the Research
For a patient with severe urgency due to lower urinary tract symptoms (LUTS) who has failed treatment with Alfuzosin, Solifenacin, and Mirabegron, the next best step would be to consider botulinum toxin A (Botox) injections into the detrusor muscle. The standard dose is 100 units injected cystoscopically at multiple sites in the bladder wall, as supported by the most recent and highest quality study 1. This treatment typically provides relief for 6-9 months and can be repeated when symptoms return. Botox works by inhibiting acetylcholine release at neuromuscular junctions, reducing involuntary bladder contractions that cause urgency. Before proceeding with Botox, patients should be counseled about potential side effects including urinary retention (which may require temporary self-catheterization), urinary tract infection, and the need for repeat treatments. A urodynamic study should be performed before Botox therapy to confirm detrusor overactivity and rule out other causes of LUTS such as bladder outlet obstruction, as indicated by the patient's urodynamic study results showing minimal residual capacity, normal sensation, normal compliance, stable bladder, and no leak, with a voided pressure of 45cmH2O and Q max <10cc/sec 1.
Some key points to consider:
- The patient has already failed treatment with Vesicare (Solifenacin) and Betmiga (Mirabegron), and is still experiencing severe urgency, making Botox a viable next step.
- The urodynamic study results support the use of Botox, as they indicate detrusor overactivity and rule out other causes of LUTS.
- The patient should be counseled about the potential side effects of Botox and the need for repeat treatments.
- The use of Botox is supported by the most recent and highest quality study 1, which found it to be an effective treatment for overactive bladder symptoms in men.
Overall, the use of Botox is a reasonable next step for this patient, given the failure of previous treatments and the supportive urodynamic study results.