Spinal cord injuries above T10 generally result in a spastic bladder rather than a flaccid bladder. Unmanaged, a spastic bladder causes problems — some embarrassing and some life-threatening. The danger is that when the urethral sphincter clamps down, urine has nowhere to go and the high pressure can cause dysreflexia, damage to the bladder, and reflux — urine backing up into kidneys and causing further damage.
Although a spastic bladder can often be managed with anticholergenics such as Ditropan or Detrol, there are other options, including treatment with Botox. Interestingly, the stuff the rich and famous get injected into their facial muscles to temporarily smooth wrinkles can also be used “off-label” to quiet the bladder.
The treatment consists injecting 300-500 units of Botulinum toxin type A into the bladder wall. This is done by passing a cystoscope (a catheter with a tiny camera on the end) that has a tiny syringe on it, through the urethra into the bladder. There, a pattern of 30 injections of Botox is made on the bladder wall. The injections temporarily block the nerve impulses to the bladder wall and stop the muscles from contracting.
Botox has been used to treat bladder spasticity for more than five years but has become more popular in the past year or so, as more and more Botox studies have shown significant improvement for people with MS and SCI. Benefits include reduced incontinence, lower bladder pressure and reduced incidence of urinary tract infections.
If you are interested in the procedure, your urologist will first administer a urodynamics test — fluid is injected into the bladder via a catheter to measure how much volume you can hold before your bladder spasms — to make sure you are a good candidate for the treatment.
Although the procedure is fairly straightforward, it may require anesthesia, depending the level of sensation and susceptibility to dysreflexia. To be safe, it should be scheduled with standby anesthesia in case of dysreflexia. Results are usually noticed within the first day or so.
Darol Kubacz from Phoenix, Ariz., had the Botox procedure and is pleased with the results. Kubacz, 33, an avid outdoor adventurer, became a T4 paraplegic while in the Army 13 years ago. “I had an extremely spastic bladder from day one,” he says. “My doctors said my bladder pressures were so high that, without constant management, I was a prime candidate for kidney failure within eight to 10 years.”
Kubacz takes his health seriously and went back to the VA for a urodynamics test every 6 months. “I tried Ditropan, both the pill and the patch, but they really messed with my brain and my body, so I quit taking them. Instead I managed my bladder the best I could, which meant really watching my fluid intake and cathing all the time.” He had to stop and cath any time his bladder volume got up to 150 ccs (a little over half a cup). But this wasn’t enough, and his urologist said he was going to have to do something to quiet his bladder.
“I didn’t like the options they gave me,” Kubacz recalls. “They said I could go back on Ditropan and have my brain fogged up, have a sphincterotomy that would leave me permanently incontinent, or have bladder augmentation, which was major surgery.”
Kubacz started doing research and kept asking about other options. The urologist at the San Diego VA came up with a unique solution. He suggested crushing Ditropan tablets, mixing them in sterile water and injecting 30 ccs of the solution through a catheter into his bladder three times a day. The solution worked, his bladder spasms stopped, and he didn’t have any adverse side effects.
After three years the Ditropan solution was still working. However, mixing up batches of the solution, carrying it with him and injecting it three times a day didn’t fit well with an active adventure schedule. Kubacz kept researching and calling the San Diego VA, asking for more options. Early in 2007 Kubacz’s urologist told him about the Botox procedure, and it sounded like a perfect fit.
In February 2007 Kubacz went to the San Diego VA for a urodnyamics test and the next day went in for the Botox procedure. “I’m a prime candidate for dysreflexia, so the anesthesiologist did an epidural on me just to be safe. I got to watch the entire procedure on a monitor, which was pretty cool,” he says. “I didn’t have any side effects — it really didn’t seem any more invasive than standard cathing.”
Kubacz saw results right away. After the procedure, he drank lots of fluids to wash his bladder out. Before the procedure his bladder would spasm at about 200 ccs, and he would get dysreflexic and incontinent. The morning after the procedure, he voided 900 ccs, yet his bladder was totally relaxed.
Botox wears off over time. When Kubacz had the procedure done, he was told he would probably have to get it redone in about six months. Thirteen months have passed, and he is just now starting to notice some bladder spasticity and has an appointment to get the procedure redone. “I’ve been able to let go of this pressure to constantly cath. My lifestyle has been greatly improved by it,” he says. “Next to having LASIK surgery for my eyes, this is the best thing I have done to improve my quality of life.”
Steve Ackerman, 52, from Fort Collins, Colo., heard about the procedure from Kubacz and called Craig Hospital to find out more about it. A T9 para for 18 years, Ackerman thought the benefits Kubacz described seemed like a good fit for his busy life. “I had to use a legbag and internally cath, which is a tough combination,” he explains. “My bladder would kick off, it would leak into the bag, and I would know it’s time to cath.” He went in to Craig for a urodynamics check and was a good candidate. In September 2007, Ackerman had Botox injections done at the Urology Center of Colorado in Denver.
He says he didn’t require any anesthesia and was in and out in about an hour. He did have some blood in his urine for about a day after the procedure, and it took about a week for it to really take effect. “Once it took effect, it’s been great,” he says. “I don’t have a problem with incontinence anymore, and I was able to get rid of the legbag. I also notice my bladder is flaccid — there isn’t much pressure when I cath.”
Ackerman’s bladder started spasming again in January, and he went back for a Botox tune-up. The staff at the Urology Center of Colorado says the procedure lasts somewhere between three months and a year, and then needs to be repeated. Physiatrists and urologists elsewhere have reported that the procedures have lasted an average of 12 to 13 months for the first set of injections; subsequent procedures can last even longer.
But even if it lasts more than a year, it does wear off — and therein lies the biggest drawback of Botox. The VA, Medicare, and private insurance companies have covered the procedure, but will they do so again and again? At up to $3,000 a pop, repeated coverage is no sure thing. So, as always, document all your bladder-related expenses to show potential insurance savings. If this procedure is a good fit for your health and lifestyle, you may still have to prove its financial value to payers. Let us know how it goes.