Transperineal injection of botulinum toxin A for treatment of detrusor sphincter dyssynergia: localization with combined fluoroscopic and electromyographic guidance

Abstract

Objective: To determine the effectiveness of a combined method for localizing external urethral sphincter for transperineal injection of botulinum toxin A (BTX-A) in the treatment of detrusor sphincter dyssynergia (DSD) in patients with spinal cord injury (SCI).

Design: A prospective, open-label trial.

Setting: A rehabilitation hospital affiliated with a medical university.

Participants: Eighteen SCI patients with voiding dysfunction resulting from urodynamically confirmed DSD.

Interventions: 100 units of BTX-A injected transperineally into the external urethral sphincter, which was localized using combined fluoroscopic and electromyographic guidance, using a Foley catheter inserted for visualization of vesicourethral anatomy.

Main outcome measures: (1) postvoid residual volume, (2) leak point pressure, (3) maximal intravesical pressure, (4) maximal urethral pressure, (5) quality of life measures for urination, quantified by the Quality of Life Index (QLI).

Results: Positive clinical outcomes were observed in all 18 patients in this study. The mean reductions in postvoid residual volume, leak point pressure, maximal intravesical pressure, and maximal urethral pressure before and after BTX-A injection were 183ml, 37cm H2O, 45cm H2O, and 92cm H2O, respectively (all P values <.05). The mean QLI significantly improved from -0.68+/-0.27 to 0.66+/-0.19 (P<.01). No significant side effects were noted after injection. The clinical therapeutic effects have shown reductions in occurrence and degree of autonomic dysreflexia, vesicoureteral reflux, hydronephrosis, and urinary tract infection. The bladder management programs also obtained improvements in our patients, either doing intermittent catheterizations less frequently, or resuming spontaneous voiding without indwelling catheters.

Conclusion: With this combined method for localization of the external urethral sphincter, transperineal injection of BTX-A was safe, accurate, easy to perform, and effective for treatment of DSD in patients with SCI.