Using Botox to Treat Overactive Bladder in Multiple Sclerosis

An option for those who cannot take or do not get relief from medications

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Bladder problems in multiple sclerosis are common, affecting approximately 80 percent of people. They have medical and psychological consequences too, as they may cause urinary tract infections, kidney problems, social isolation, and a decrease in self-esteem and/or quality of life.

The good news is that there are effective ways to manage this distressing and uncomfortable MS symptom. These therapies include traditional ones like lifestyle interventions and medications, as well as not so traditional ones like Botox injections.

Before considering Botox as a therapy for your MS-related bladder problems, it is sensible to first grasp the basics of how the bladder works and how it is affected by MS.

Healthy Bladder Function

In a healthy person, urine travels from the kidneys to the bladders through two tubes called ureters. Once the bladder is carrying about four to eight ounces of urine, it expands, triggering nerves to send signals to the spinal cord (which then signals the brain) that the bladder needs emptying. This process is what gives you the feeling that you need to urinate.

Then, after you find a bathroom, the nerves in the brain transmit signals to the spinal cord to initiate the voiding reflex. During this reflex, your detrusor (bladder) muscle contracts or squeezes to release urine from the bladder. At the same time, your external sphincter muscle relaxes to allow urine to flow out of the bladder, through the urethra, and out of the body.

Bladder Dysfunction in Multiple Sclerosis

In multiple sclerosis, lesions block nerve signaling in the brain and spinal cord that normally control the detrusor muscle and the external sphincter muscle. This can lead to three different bladder problems:

  • Bladder storing problems
  • Bladder emptying problems
  • Combined bladder storing and emptying problems

    Bladder Storing Problems (Overactive Bladder)

    In some people with MS, the detrusor muscle can contract (or squeeze) when it is not supposed too (when your bladder is carrying little urine) making you feel like you need to urinate all the time. These symptoms are referred to as urinary urgency and frequency. You may also notice that you are getting up at night to use the bathroom, or you may experience a loss of urine—called urge incontinence.

    Bladder Emptying Problems (Overfilled Bladder)

    In others, the voiding reflex is impaired so the bladder over-expands without signaling to the brain and spinal cord that a person needs to urinate. This can lead to urine dribbling, hesitancy in initiating urination, or an uncontrolled loss of urine called overflow incontinence.

    Combined Bladder Storage and Emptying Problems

    Still other people experience a combination of the two types of bladder problems. In this instance, MS lesions in the brain and spinal cord cause impaired coordination between the detrusor muscle and the external sphincter muscles, causing them to both contract at the same time.

    This traps urine in the bladder causing urinary urgency (like you need to urinate suddenly), hesitancy in starting to urinate, urine dribbling (many people wear an absorbent pad), or a loss of urine.

    Traditional Treatments for Overactive or Spastic Bladder in MS

    If you have MS and are experiencing symptoms of an overactive bladder (like experiencing a sudden urge to urinate and urinating frequently) your neurologist will likely first recommend lifestyle interventions and an anticholinergic medication.

    Common lifestyle interventions include limiting caffeine and alcohol use and avoiding fluids after dinner and before bedtime. Your neurologist may also recommend that women wear an absorbent pad or men wear a condom catheter to ease worries of any loss of urine during the day out in public.

    Anticholinergic medications like Detrol (tolterodine) or Vesicare (solifenacin succinate) can be helpful in reducing symptoms of urinary frequency, urgency, and incontinence—although they may cause unpleasant side effects like constipation, sleepiness, and dry mouth. Do not be surprised though if you have to try a couple before finding the medication that works for you.

    A newer medication called Myrbetriq (mirabegron) works by relaxing the muscle that surround the bladder, allowing it to hold more urine. Research shows that it is as effective as the anicholinergics in reducing urinary incontinence (except not as effective as Vesicare).

    Research suggests it may be better tolerated, as it does not cause dry mouth, a significant limiting side effect of many anticholinergics. That being said, common side effects of Myrbetriq include headache, cold symptoms, increased blood pressure, and urinary tract infection.

    Botox May Be the Next Step if Medications Do Not Work

    If you continue to experience bladder emptying problems related to your MS despite anticholinergic medications, your neurologist may recommend onabotulinumtoxin A (BOTOX)—a therapy that is approved by the United States Food and Drug Administration (FDA) for treating incontinence from an overactive bladder.

    Does Botox Work in Treating Overactive Bladder in MS?

    A large study in European Urology examined the effects of Botox on reducing incontinence in people with overactive bladder from either MS or a spinal cord injury. Results of the study found that after 12 weeks, participants with MS who were treated with Botox experienced urinary incontinence about 1.5 times less per day than participants with MS who were treated with a placebo injection.

    In addition, the study also found that the participants with MS treated with BOTOX voided approximately 86 milliliters more urine each void than the participants who underwent placebo.

    What to Expect During Your Botox Injection

    Your doctor will first examine the inside of your bladder using a cystoscope—a thin tube with a camera on the end.

    The doctor will then inject the detrusor muscle at multiple sites (around 30) with Botox, causing it to relax. This allows the bladder to hold more urine so that the muscle is not contracting or squeezing all the time, thereby reducing symptoms of urinary urgency, frequency, and incontinence.

     The two most common side effects of BOTOX are:

    • urinary tract infection
    • retaining urine in the bladder

    In order to prevent a bladder infection from occurring as a result of the procedure, your doctor will most likely prescribe an antibiotic to take before, during, and for a few days after the BOTOX treatment.

    Also, due to the risk of urinary retention after Botox treatment, your doctor will want to ensure that you are comfortable performing clean intermittent self-catheterization before you undergo the treatment, as this is a fairly common effect.

    In fact, in the clinical study mentioned above in European Urology, approximately 30 percent of participants who had not previously had to undergo self-catheterization prior to Botox (and most were participants with MS), needed self-catheterization for urinary retention after Botox treatment.

    Botox also carries a boxed warning for its potential to cause serious, even life-threatening side effects like problems swallowing, speaking, or breathing due to weakening of muscles. The botulinum toxin may also spread to other areas of the body and cause a number of serious symptoms like generalized muscle weakness or vision problems. While rare, these warnings emphasize the important of having a careful and thoughtful discussion with your doctor before undergoing Botox.

    A Word From Verywell

    Urinary problems in MS are common, so do not feel worried or embarrassed to discuss them with your doctor. The good news is that there are a number of lifestyle and medical therapies that can help you manage the symptoms and the potential complications—and Botox is also a reasonable option if other therapies don't work.

    Sources:

    Allergan. (January 2016). Approved by the U.S. Food and Drug Administration. Medication Guide: Botox.

    Cruz F et al. Efficacy and safety of onabotulinumtoxinA in patients with urinary incontinence due to neurogenic detrusor overactivity: a randomised, double-blind, placebo-controlled trial. Eur Urol. 2011 Oct;60(4):742-50.

    Maman K et al. Comparative efficacy and safety of medical treatments for the management of overactive bladder: a systematic literature review and mixed treatment comparison. Eur Urol. 2014 Apr;65(4):755-65.

    National MS Society. (2016). Urinary Dysfunction and MS.

    Weckx F, Tutolo M, De Ridder D, Van der Aa F. The role of botulinum toxin A in treating neurogenic bladder. Transl Androl Urol. 2016 Feb;5(1):63-71.

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