The internalized neurotoxin is cleaved into two protein chains which deactivate the soluble N-ethylmaleimide-sensitive factor attachment receptor SNARE family proteins required for exocytosis of synaptic vesicles at the nerve ending. A number of authors have demonstrated that botulinum toxin also inhibits the urothelial and suburothelial release of various mediators acetylcholine, ATP, substance P, glutamate, etc. This suggests an effect on both the efferent part of the voiding reflex and regulation of the afferent message.
Modified expression of certain receptors has also been reported by Apostolidis et al. Intradetrusor injections of botulinum toxin are performed on an outpatient basis or during day hospitalization. The urine must be germ-free. Prophylaxis with antibiotics is not always justified. Injections comment faire pour maigrir le visage homme made at between 20 and 30 detrusor sites depending on the research protocol in question and outside the trigonal region, in most cases ; this corresponds to four to six sites in the posterior, upper and left and right faces, respectively.
The injections are performed in the upper part of the detrusor muscle. It is not medically justified to leave an indwelling catheter in the bladder. The procedure usually takes around 20 minutes.
By analogy with other indications in striated muscle, intramuscular injections were performed initially. Will suburothelial injection of small dose of botulinum toxin have similar therapeutic effects and less adverse events on refractory detrusor overactivity? Its effect persists for between six and nine months, depending on the study in question.
In the absence of specific studies, the reinjection criteria and frequency remain to be established. On the whole, two strategies can be used: reinjection before the recurrence of symptoms or following the reappearance of urine leakage or urgency. Table 1 summarizes the various studies on the efficacy of botulinum toxin in the symptomatic treatment of NNDO. In all, 19 studies have been performed. Only three of these were randomized; the remainder were open-label studies.
The primary inclusion criterion in these studies generally corresponded to second-line treatment for refractory or intolerably troublesome bladder overactivity or contraindication of anticholinergic drugs.
The criteria used to evaluate the efficacy of botulinum toxin in this situation vary considerably from one group to another. This latter method of leakage quantification must, however, be used with caution, since it has not been validated for urge incontinence.
Urodynamic parameters are also used to evaluate the effect of the toxin on bladder function, both in terms of efficacy and safety of use risk of retention. Other urodynamic parameters such as the maximum urinary flow rate and bladder contractility are monitored to detect possible complications of treatment with botulinum toxin.
InSchmid et al. The dose injected avoiding the trigone was U. The absence of clinical and urodynamic improvement was noted in eight patients who initially had compliance disorders. This study had the advantage of being prospective and investigated a large number of patients. Sahai is one of the few authors to have performed a randomized, placebo-controlled study. Botulinum toxin injection into the detrusor: an effective treatment in idiopathic and neurogenic detrusor overactivity?
The results were judged to be excellent i. Five patients felt better after treatment. However, the improvement in urodynamic parameters seen three and six months after treatment was not always statistically significant. In this study, the use of a rigid fibre-optic endoscope prevented injection into the anterior bladder wall leading to heterogeneous distribution of the toxin within the detrusor and may thus have biased the study results.
Efficacy of botulinum toxin A in the treatment of detrusor overactivity incontinence. The urodynamic data reported by Schmid et al.
The treatment remained effective for five to nine months Table 2. Is the bladder a reliable witness for predicting detrusor overactivity?
However, the performance of a urodynamic status check before and after treatment can be justified when seeking to identify patients who are not likely to respond to botulinum toxin treatment or those likely to present side effects and thus require close monitoring. Large-scale, long-term clinical and urodynamic follow-up could help better identify factors that are predictive of the success or failure of botulinum toxin treatment.
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In fact, in the absence of a comparative study of patients with or without detrusor overactivity, it is not possible to tell whether this latter factor is predictive of success or failure.
Overactivity syndrome can lead to depression, sexual disorders, sleep disorders and absenteeism from work.
Hence, it can have a clearly negative impact on quality of life.
Kalsi et al. The results were compared with cystometric and voiding diary data. This effect lasted for nine months and then declined. Après que votre enfant se réveille et se sent capable de consommer des liquides, il peut rentrer chez lui.
Cela est normal. Il peut continuer à manger normalement; cependant, encouragez-le à consommer plus de liquides. De plus, ceci aide à prévenir toute infection dans cet endroit infection urinaire.
Votre enfant aura des examens de suivi avec le médecin. Votre médecin fera du suivi régulier auprès de votre enfant au moyen de différentes méthodes.
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Les résultats durent pendant à peu près 6 mois. These guidelines have been validated by a group of 13 experts quoting proposals, subsequently reviewed by an independent group of experts. Before proposing an injection, it is recommended to ensure the feasibility and acceptability of self-catheterisation by patient.
The injection can be performed after local anesthesia of the bladder and urethra lidocainesupplemented where necessary by nitrous oxide inhalation and sometimes under general anesthesia. Injection is performed in the operating room or endoscopy suite.