Botox injections in ms

Des troubles urinaires du bas appareil sont présents à cinq ans du diagnostic chez les deux tiers des patients avec une sclérose en plaques. Ce traitement a fait ses preuves, dans plusieurs études randomisées contrôlées par placebo, de sécurité et efficacité par rapport aux paramètres cliniques et urodynamiques, avec une amélioration significative de la qualité de vie.

Lower urinary tract dysfunction is a common problem in patients with multiple sclerosis MSwith a prevalence that is between 32 and However, patients can also present symptoms of altered voiding, like hesitancy and intermittency, which can be present alone or in combination with the previous ones. However, anticholinergic drugs often fail to adequately control urinary symptoms or are abandoned due to side effects. Botulinum toxin is a very potent neurotoxin produced by an anaerobic Gram-positive bacterium, Clostridium botulinum.

The main mechanism of action of botulinum toxin is the temporary block of the presynaptic release of acetylcholine at the neuromuscular junction. Botulinum toxins are marketed under different names in Europe and USA.

Different botulinum toxin products are not interchangeable, so, to reduce the risk of dosing errors, in the FDA required using a generic name. In the treatment of NDO and DSD in MS, the vast majority of the studies have been conducted with onabotulinumtoxinA, and a clinical comparison of the different formulations is not possible.

Authors concluded that excessive diffusion with autonomic side effects would have limited the use of this product to patients who developed tachyphylaxis to botulinum toxin type A.

A subsequent, open-label trial showed disappointing results with rimabotulinumtoxinB, in patients with both IDO and NDO, due to the short duration of the effect less than 10 weeks.

At present time, evidence about the efficacy and safety of onabotulinumtoxinA is mainly provided by well-designed, randomised, placebo-controlled studies, in which authors have evaluated patients with urinary incontinence and NDO from different origin, mainly SCI and MS. But all of them are not controlled. Up to now, only few study evaluated the effect of repeated treatment onabotulinumtoxinA in NDO.

From the patient's perspective, incontinence is the most important symptom and all published studies have focused, as primary outcome measure, on the frequency of urinary incontinence episodes. Schurch et al.

They recruited 59 patients 53 with SCI and 6 with MS that were randomised to receive placebo or onabotulinumtoxinA or UI in the detrusor muscle, diluted in 30 ml saline and followed for 24 weeks.

Injections were performed using a cystoscope, without anaesthesia, and the trigone was spared. The difference, compared to placebo, was significant at 2 and 6 weeks after treatment and, in the UI group, also at 24 weeks after injection.

Patients treated with onabotulinumtoxinA showed a significant increase in the maximum cystometric capacity MCCand a decrease in the maximum detrusor pressure during uninhibited bladder contraction MDP at all post-treatment time points. Also reflex detrusor volume RDV increased in the botulinum toxin groups compared to placebo; moreover, 23 patients did not show any uninhibited detrusor contraction for at least 1 follow-up visit, and among them, 23 were in the onabotulinumtoxinA group.

Reitz et al. Among the patients, 11 had MS. All patients received UI of botulinum toxin into the detrusor muscle. Schulte-Baukloh et al. Three hundred UI were diluted in 20 ml of saline. The sphincter received a dose between 50 and UI. Patients were followed at 4 weeks, 3 and 6 months after treatment. Authors declared that this protocol was chosen to reduce the risk of urine retention and subsequent need for self-catheterisation.

They found a significant reduction in frequency night and daytime and in the use of pads at 4 weeks and at 3 months, but not at 6 months. In spite of external sphincter treatment, PVR was significantly increased, passing from Kalsi et al. They were all treated with UI of onabotulinumtoxinA in the detrusor muscle, diluted in 30 ml saline.

All patients had a clinical and urodynamic evaluation before treatment and at 4 and 16 weeks after treatment. Afterwards, patients could ask for a second treatment if symptoms reappeared.

Before being considered eligible for a new injection, urodynamic traces needed to be similar to baseline and bladder overactivity present according to a voiding diary. These improvements were still present at the 16 weeks follow-up. Interestingly, the mean duration of the beneficial effect was 9.

Game et al. All patients received UI of onabotulinumtoxinA into the detrusor muscle. The number of infections 6 months before and 6 months after treatment was recorded.

In the 3 patients who still had symptomatic UTI after treatment urodynamic parameters did not improve after injection. Authors suggested that the decrease in symptomatic UTI after onabotulinumtoxinA treatment was probably related to the effect of the drug on detrusor overactivity.

Deffontaines-Rufin et al. Authors found that patients who had a disappointing result had longer duration of disease compared to the other two groups. Most level 1 evidence about the treatment of NDO with onabotulinumtoxinA, however, has been published in the last three years. In Herschorn et al. The study was divided in two parts, the first, blinded, in which patients received either onabotulinumtoxinA UI diluted in 30 ml of 0.

Then, patients of both groups were elected to receive onabotulinumtoxinA in the second, open-label part of the study, with a programmed follow-up of 6 months. The primary outcome measure was the number of urinary incontinence episodes per day at week 6 and secondary outcomes were urodynamic parameters at week 6 and at other time points. The first results published by Cruz et al. The objective was to evaluate the efficacy and safety of the treatment. The study was divided in 2 parts.

The modalities of drug administration and study design for the first part was the same of Schurch et al. For the second part, and at least 12 weeks after the first treatment, patients could request for reinjection. Patients who received primarily onabotulinumtoxinA had the same treatment with the same doses, and patients who had placebo were randomised to receive either or UI. Then, secondary outcome measures were MCC, MDP, volume per void, detrusor compliance, volume at first involuntary detrusor contraction.

Data showed a significant reduction in the number of urinary incontinence episodes in both and UI groups, as opposed to placebo, with no difference between the two doses, at 2, 6 and 12 weeks after treatment, confirming Schurch et al.

There was also a significant improvement in all urodynamic parameters in both active treatment groups compared to placebo, with no meaningful difference between them. The median duration of effect which was the time to patient-requested retreatment was of After the second cycle of treatment, results were substantially repeated, with significant improvements in the number of urinary incontinence episodes and urodynamic parameters at 6 weeks.

This is the largest randomised, placebo-controlled, double-blind study of onabotulinumtoxinA for urinary incontinence in patients with NDO. The design, inclusion and exclusion criteria were the same of the study by Cruz et al. Also primary and secondary end points were the same. In this study, authors included patients with MS and with SCIwhich were followed for 52 weeks. This study confirmed also the results of Schurch et al.

The median time to patient request for another treatment was significantly higher in the onabotulinumtoxinA groups compared to placebo 92, and days for the placebo, the and the UI respectivelyas the median time for requalification for a new treatment 96, and days for the placebo, the and the UI respectively. The efficacy of onabotulinumtoxinA on repeated injections was evaluated by Gaillet et al. Do repeat intradetrusor botulinum toxin type A injections yield valuable results?

This has been first shown by Schurch et al. In the UI group total and all subscale scores improved significantly compared to placebo at weeks 6, 12, 18 and 24, whereas patients in the UI group had the same results except for Psychosocial Impact and Social Embarrassment Score at 24 weeks.

Other open-label studies have specifically evaluated QoL as a primary outcome measure. The results of these two studies suggest that the need for de novo CISC had a less impact than the relief from the symptoms of urgency on a base of one or maximum two treatments.

Khan et al. Patients had been treated with UI of onabotulinumtoxinA in the detrusor muscle, 6 times. The indication to repeat the treatment was the reoccurrence of symptoms with presence of detrusor overactivity during urodynamic evaluation.

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Of patients, 99 returned for a second treatment, 47, 25, 14 and 5 returned for the treatments 3 to 6. Median interval between treatments was nearly 13 months.

Results show that both scores had a significant improvement after each treatment. There is much less evidence about the effect of onabotulinumtoxinA in the striated sphincter in patients with MS. Gallien et al.

Authors recruited 86 patients with MS and randomised the group to receive either UI of onabotulinumtoxinA diluted in 4 ml of 0. The primary outcome measure was the PVR at 1 month after treatment. Also obstructive symptoms, pollakiuria, urgency, incontinence, voiding volume and International Prostatism Symptoms Score were recorded.

Evaluations were done before and at 1, 2, and 3 months after treatment. No reduction in the PVR after treatment, and no amelioration of obstructive symptoms were observed after treatment as compared to placebo, even if patients treated with onabotulinumtoxinA showed at 1 and 2 months after treatment an increase in the voiding volume and a reduction in the MDP and in the maximal and cloture urethral pressure.

After onabotulinumtoxinA treatment in the detrusor muscle, the main adverse events that have been reported in literature are urinary tract infections and urinary retention. Urinary tract infections UTI have been reported does the regimen work a significant proportion of patients after both onabotulinumtoxinA and placebo treatment. The proportion of UTI vary between studies: Schurch et al.

Cruz et al. In the largest trial, performed by Ginsberg et al. However, it should be noted that in all these studies the adverse event term of UTI did not distinguish between symptomatic and asymptomatic UTI, because it was primarily based on a positive urine culture. In the 3 patients who still had Authors suggested that the decrease All patients received UI of onabotulinumtoxinA in the detrusor muscle [24].

Authors Patients were divided in three groups according to clinical Authors They were all randomised, double-blind, placebo-controlled trial conducted All patients had a clinical due to NDO [25]. The study was divided in two The primary endpoint was a parts, the first, blinded, in which patients received either Afterwards, patients could ask for a second placebo in the detrusor using cystoscopy; patients were then Before being considered followed up to 36 weeks.

Then, patients of both groups were The primary outcome measure was the number of. The first results published by Cruz et al. The objective was to evaluate the efficacy and safety of the treatment. The study was divided in 2 parts. The modalities of drug administration and study design for the first part was the same of Schurch et al.

For the second part, and at least 12 weeks after the first treatment, patients could request for reinjection. Patients who received primarily onabotulinumtoxinA had the same treatment with the same doses, and patients who had placebo were randomised to receive either or UI. Then, secondary outcome measures were MCC, MDP, volume per void, detrusor compliance, volume at first involuntary detrusor contraction.

Data showed a significant reduction in the number of urinary incontinence episodes in both and UI groups, as opposed to placebo, with no difference between the two doses, at 2, 6 and 12 weeks after treatment, confirming Schurch et al. There was also a significant improvement in all urodynamic parameters in both active treatment groups compared to placebo, with no meaningful difference between them. The median duration of effect which was the time to patient-requested retreatment was of After the second cycle of treatment, results were substantially repeated, with significant improvements in the number of urinary incontinence episodes and urodynamic parameters at 6 weeks.

This is the largest randomised, placebo-controlled, double-blind study of onabotulinumtoxinA for urinary incontinence in patients with NDO.

The design. Also primary and secondary end points were the same. In this study, authors included patients with MS and with SCIwhich were followed for 52 weeks. This study confirmed also the results of Schurch et al. The median time to patient request for another treatment was significantly higher in the onabotulinumtoxinA groups compared to placebo 92, and days for the placebo, the and the UI respectivelyas the median time for requalification for a new treatment 96, and days for the placebo, the and the UI respectively.

The efficacy of onabotulinumtoxinA on repeated injections was evaluated by Gaillet et al.

Previously, other authors have reported results of repeated intradetrusor onabotulinumtoxinA treatment for NDO [15,29]. However, both studies showed that the efficacy of the treatment was maintained over time, with 17 patients that had at least 4 treatments in a study [15] and 20 that had at least 5 treatments in the other [29]. This has been first shown by Schurch et al. The complete results have been published thereafter [30], and data regarding the three subscales of I-QOL avoidance and limiting behaviour, psychosocial impact and social embarrassment presented.

In the UI group total and all subscale scores improved significantly compared to placebo at weeks 6, 12, 18 and 24, whereas patients in the UI group had the same results except for Psychosocial Impact and Social Embarrassment Score at 24 weeks. These results have been strongly confirmed by subsequent randomised, placebo-controlled trials [], even if QoL was considered as a secondary outcome. Kalsi et al. The results of these two studies suggest that the need for de novo CISC had a less impact than the relief from the symptoms of urgency on a base of one or maximum two treatments.

Khan et al. They published the results of a prospective, open-label study done in patients with MS and NDO over 8 years [32]. Patients had been treated with UI of onabotulinumtoxinA in the detrusor muscle, 6 times. The indication to repeat the treatment was the reoccurrence of symptoms with presence of detrusor overactivity during urodynamic evaluation.

Of patients, 99 returned for a second treatment, 47, 25, 14 and 5 returned for the treatments 3 to 6. Median interval between treatments was nearly 13 months. Results show that both scores had a significant improvement after each treatment. There is much less evidence about the effect of onabotu-linumtoxinA in the striated sphincter in patients with MS. Gallien et al. Authors recruited 86 patients with MS and randomised the group to receive either UI of onabotulinumtoxinA diluted in 4 ml of 0.

The primary outcome measure was the PVR at 1 month after treatment. Also obstructive symptoms, pollakiuria, urgency, incontinence, voiding volume and International Prostatism Symptoms Score were recorded. Evaluations were done before and at 1, 2, and 3 months after treatment. No reduction in the PVR after treatment, and no amelioration of obstructive symptoms were observed after. After onabotulinumtoxinA treatment in the detrusor muscle, the main adverse events that have been reported in literature are urinary tract infections and urinary retention.

Urinary tract infections UTI have been reported in a significant proportion of patients after both onabotulinumto-xinA and placebo treatment.

The proportion of UTI vary between studies: Schurch et al. Cruz et al. In the largest trial, performed by Ginsberg et al. Frequency of UTI did not significantly differ among placebo and onabotulinumtoxinA groups, except in the largest study [27]; authors found a similar incidence of UTI in all groups in the SCI population but a higher incidence in the patients with MS that received onabotulinumtoxinA. However, it should be noted that in all these studies the adverse event term of UTI did not distinguish between symptomatic and asymptomatic UTI, because it was primarily based on a positive urine culture.

At present time, no evidence exists about antibiotic prophylaxis of UTI before and after onabotulinumtoxinA intradetrusor injections, even if it seems to be a common practice among clinicians [35]. Mouttalib et al. Based on this data and their experience, they recommended an antibiotic prophylaxis after the procedure. Many injectors also accept this point of view.

Urinary retention can be partially considered as a logical consequence of the inhibitory effect of onabotulinumtoxinA on the detrusor muscle contraction.

Urinary retention is reflected by the increase in the PVR. At present time, a consensus does not exist about at which volume CISC should be initiated. The proportion of patients that required CISC to void the bladder varies in the different studies. In a subsequent study [22] that the result can be shorter and that urinary retention cannot We generally recommend local anaesthesia This result can be read in different 4-mm flexible needle can ease the procedure ex.

Des troubles urinaires du bas appareil sont presents chez un Cependant, les patients peuvent De tels constats sont Le deuxieme signe le plus courant est la dyssynergie Il faut se À l'heure actuelle, le traitement de l'hyperactivité détru-sorienne chez les patients atteints de SEP repose encore sur les medicaments anticholinergiques, qui sont utilises suite a l'evaluation du volume résiduel post-mictionnel VRP [6].

Cependant, les traitements anticholinergiques echouent souvent a contrôler efficacement les symptômes urinaires ou sont abandonnes a cause d'effets secondaires. D'autre part, les preuves de leur efficacité en cas de SEP sont tout sauf convaincantes [7]. Chez les patients souffrant d'hyperactivité detrusorienne neurogene HDNl'utilisation par injection intradetrusorienne de toxine botulique de type À s'est montrée efficace en ameliorant la continence, les parametres urodynamiques et la qualité de vie [8].

La toxine botulique est une neurotoxine très puissante produite par une bactérie anaerobie Gram-positive, Clostridium botulinum. Elle produit sept serotypes À a G ; des [9], les toxines botuliques de type À et, plus tard, de type B, ont eté utilisees pour traiter des troubles medicaux dont le strabisme, la l huile dolive brule les cheveux homme, la spasticité et l'hyperactivité neurogene du detrusor HND.

Irvine, CÀ, Etats-Unis dans le traitement des patients atteints de la sclerose en plaques. Le principal mecanisme d'action de la toxine botulique est le blocage temporaire de la liberation présynaptique de l'acetyl-choline au niveau de la jonction neuromusculaire.

Les details de l'action depassent le cadre du présent rapport et sont rapportes ailleurs [10,11]. D'autres mecanismes d'action ont egalement eté evoques, dont specifiquement l'effet de la toxine botulique sur l'urothelium [12].

Les toxines botuliques ont eté commercialisees sous différents noms en Europe et aux Etats-Unis. Puisque les différents produits a base de toxine botulique ne sont interchangeables, c'est en vue de diminuer le risque d'erreurs de dosage qu'en la FDÀ a impose l'utilisation d'un nom generique. Dans le traitement de l'HND et de la DVD dans la SEP, la grande majorité des etudes ont eté conduites avec l'onabotulinumtoxinÀ, et une comparaison clinique des différentes formulations n'est pas possible.

Par la suite, la rimabotulinumtoxinB a ete utilisee dans un essai randomise, a double insu et contrôle par placebo [17] chez des patients souffrant a la fois d'hyperactivité idiopathique du detrusor HID et d'HND, et les résultats ont ete contrastes.

Les auteurs en ont conclu que la diffusion excessive avec effets secondaires autonomes aurait limite l'utilisation de ce produit. Subsequemment, un essai ouvert utilisant la rimabotulinumtoxinB chez des patients souffrant a la fois d'HID et d'HND a donne des résultats decevants a cause de la courte durée de l'effet mois de 10 semaines.

Qui plus est, il n'y avait d'efficacite observee que chez les patients souffrant d'HID [18]. A l'heure actuelle, les preuves de l'efficacité et de l'innocuite de l'onabotulinumtoxinA proviennent principalement d'etudes randomisees et controlees par placebo bien concues, dans lesquelles les auteurs ont etudie des patients souffrant d'incontinence urinaire et d'HND de causes différentes, dont notamment la LME et la SEP.

Il n'existe que peu d'etudes n'incluant que des patients diagnostiques avec SEP ou HND, et elles ne sont pas toutes controlees. Et jusqu'a present, peu d'etudes ont evalue l'effet de l'utilisation répetée de l'onabotulinumtoxinA dans le traitement de l'HND. De la perspective du patient, l'incontinence est le symptôme le plus important, et toutes les etudes publtées ont utilise comme critère primaire d'efficacite la frequence des episodes d'incontinence urinaire.

Ils ont recrute 59 patients 53 avec LME et 6 avec SEP qui etaient randomises pour recevoir une injection soit du placebo soit de l'onabotulinumtoxinA ou UI dilues dans 30 mL de solution saline dans le muscle detrusorien. Les injections etaient réalisees en utilisant un cystoscope, sans anesthesie et en epargnant le trigone. Les patients etaient suivis pendant 24 semaines. Par comparaison au placebo, la difference etait significative a 2 et a 6 semaines après le traitement mais aussi, dans le groupe UI, a 24 semaines après l'injection.

Les patients traites avec l'onabotulinumtoxinA ont fait apparaître une hausse significative de la capacité cystometrique maximale CCM et une baisse de pression maximale du detrusor PMD pendant les contractions incontrolees de la. Par EnGame et al.

Tous les patients ontrecu une injection de Le nombre d'infections a 6 mois avant et a 6 mois après le Les auteurs ont constate une Parmi les patients, 11 etaient atteints de SEP. Chez les 3 patients qui souffraient encore de SIVU Les auteurs ont constate après le traitement, les parametres du bilan urodynamique Les auteurs ont Ils ont injecte UI de l'onabo- Deffontaines-Rufin et al. Les d'HND ; tous etaient traites avec une injection de 30 mL de Une dose l'onabotulinumtoxinA dans le muscle du detrusor [24].

Les Les patients patients etaient repartis en trois groupes selon les résultats Ils ont releve une reduction significative totalement disparu et des contractions vesicales involontaires Les auteurs ont constate que les patients dont les résultats Tous les patients ont eu un bilan etaient decevants avaient une plus longue durée de maladie que Le critère d'efficacité primaire Cependant, la plupart des preuves de niveau 1 concernant le Or avant qu'ils ne soient considerès comme résultats d'un essai randomise, a double insu et contrôle par Cette hyperactivité etait causee chez 38 patients par une L'étude etait divisee en De telles ameliorations par injection dans le detrusor et avec la cystoscopie ; le suivi des De mantère patients a dure jusqu'a 36 semaines.

Par la suite, certains Le critère primaire. Les premiers résultats publies par Cruz et al. L'objectif consistait a evaluer l'efficacite et l'innocuite du traitement.

L'étude etait divisee en deux parties. Les modes d'administration des medicaments et le modele d'etude de la premiere partie etaient identiques a ceux de Schurch et al.

Dans la deuxieme partie, 12 semaines minimum après le premier traitement, les patients pouvaient demander une reinjection.

Les patients qui avaient principalement recu l'onabotulinumtoxinA recevaient le meme traitement aux memes doses, et les patients qui avaient recu le placebo etaient randomises pour recevoir soit UI soit UI.

Les criteres secondaires d'efficience etait la CCM, la PMD, le volume mictionnel moyen, la compliance du deétrusor, et le volume lors de la contraction deétrusorienne involontaire initiale. Les résultats ont fait apparaître une diminution significative du nombre d'episodes d'incontinence urinaire dans les groupes UI et par comparaison avec le placebo, avec aucune difference entre les deux doses, a 2, a 6 et a 12 semaines après le traitement, ce qui confirmait les résultats de Schurch et al.

Il y avait egalement une amelioration significative par rapport a tous les parametres urodynamiques et par comparaison avec le placebo dans les deux groupes de traitement actif et sans diffeérence significative entre ceux-ci. La dureée moyenne d'effet, qui eétait le laps de temps jusqu'au retraitement demande par le patient. Àprés le deuxieme cycle de traitement, les résultats etaient en majeure partie répetés, et il y avait une amelioration significative a 6 semaines par rapport au nombre d'episodes d'incontinence urinaire et aux parametres urodynamiques.

Le programme DIGNITY comprenait egalement une deuxieme etude qui concernait 85 centres et faisait l'objet en d'une publication par Ginsberg et al. C'est la plus grande etude randomisee, a double insu et controlee avec placebo de l'onabotulinumtoxinÀ comme traitement d'incontinence urinaire chez des patients HND.

Tant la conception que les criteres d'inclusion et d'exclusion et les criteres primaire et secondaire d'efficience etaient les memes que ceux qui avaient ete utilises dans l'etude par Cruz et al.

Cette etude a egalement confirme les résultats de Schurch et al. Le laps de temps median entre la demande du patient d'un nouveau traitement etait significativement plus eleve dans les groupes onabotuli-numtoxinÀ par comparaison avec le placebo 92, et jours respectivement pour le groupe placebo et pour les groupes et UI.

L'efficacite d'injections répetees de l'onabotulinumtoxinÀ a ete evaluee par Gaillet et al. Àuparavant, d'autres auteurs avaient publie leurs résultats sur le traitement par injection intrade-trusorienne répetee de l'onabotulinumtoxinÀ en cas d'HND [15,29]. Cependant, les deux etudes ont demontré que l'efficacite du traitement a ete maintenue pendant un long laps de temps, avec 17 patients ayant eu au moins 4 traitements dans l'une des etudes [15] et 20 ayant eu au moins 5 traitements dans l'autre [29].

Des etudes randomisees et contrôles par placebo ont demontré que le traitement de l'HND avec l'onabotulinumtoxinÀ ameliore significativement la qualité de vie chez les patients LME et SEP. Cette affirmation a ete justifiee par Schurch et al. Dans 2. L'onabotulinumtoxinA et la dyssynergie vésico- Les auteurs ont recrute 86 de ces patients et randomise le Pendant l'electro- Le critère Dans la premiere etude [31], ils ont urètrale maximale, la pression urètrale de cloture maximale et En outre, les symptômes Les d'obstruction, la pollakiurie, l'urgenturie, l'incontinence, le Meme si, après le Score ont ete enregistres.

Des evaluations ont ete effectues a 1, Aucune reduction du VRP Les proportions des IVU varient d'une etude a Ils ont publie leurs résultats dans une etude prospective l'autre. Les patients avaient ete traites six fois UI. Herschorn et al. Cruz Dans l'essai le plus grand, qui etait Tous les patients ont eu pendant la premiere partie de l'etude, qui etait réalisee en Les résultats font ressortir une Exception faite de l'etude la plus ambitieuse [27], la Soixante-seize pour cent des patients eétaient entre les groupes placebo et onabotulinumtoxinA.

Les auteurs. À l'heure actuelle, aucune preuve n'existe au sujet de la prophylaxie antibiotique de l'IVU avant ou après les injections intradetrusoriennes de l'onabotulinumtoxinÀ, meme si de nombreux cliniciens effectuent apparemment une telle prophylaxie [35]. Dans une serie de cas, Mouttalib et al. À partir de telles donnees et de leur experience, ils ont préconise une prophylaxie antibiotique après la procedure. De nombreux administrateurs d'injections acceptent ce point de vue.

Quant a la rétention urinaire, elle peut etre considerée, en partie, comme une consequence logique de l'effet inhibiteur de l'onabotulinumtoxinÀ sur la contraction du muscle du detrusor.

La rétention urinaire est refletée par l'augmentation du VRP. À l'heure actuelle, il n'existe pas de consensus sur le volume a partir duquel l'ÀCIÀ doit etre initiée. La proportion de patients devant recourir qu'ÀCIÀ afin de vider la vessie varie selon les differentes etudes. De maniere similaire, Khan et al. De maniere tout aussi similaire, Ginsberg et al. Il importe de préciser que puisque le protocole n'avait pas defini un VRP a partir duquel il fallait initier.

Ce résultat peut etre interprété de plusieurs manieres, dont la plus evidente consiste a constater que si les patients avec HND et traites par l'onabotulinumtoxinÀ ont fréquemment besoin d'initier l'ÀCIÀ, de maniere plus generale une proportion assez grande des patients avec HND ont eu l'indication de commencer l'ÀCIÀ.

En dernier lieu et en vue de diminuer le risque de rétention urinaire, Mehnert et al. Le but consistait a evaluer si oui ou non cette dose suffisait pour contrôler les symptomes et eviter la rétention urinaire. Leurs résultats ont demontre que UI de l'onabotulinumtoxinÀ pouvaient effectivement ameliorer les parametres urodynami-ques CCM, VRD et PMD et l'urgenturie a 12 semaines, alors que le contrôle de l'incontinence urinaire n'etait significative qu'a 6, et non plus a 12 semaines après le traitement.

En outre, meme si l'ÀCIÀ n'etait necessaire que chez 2 patients, dont l'un avait besoin d'un catheter sus-pubien, le VRP a augmente de maniere significative. Dans cette etude, le besoin d'ÀCIÀ etait determine a partir de symptomes et non pas du volume résiduel post-mictionnel. Les auteurs en ont conclu que si UI de l'onabotulinumtoxinÀ sont efficaces dans la diminution de l'urgenturie et de la pollakiurie et dans l'amelioration des parametres urodynamiques chez les patients atteints de SEP, cette injection ntévite pas totalement le risque de recours a l'ÀCIÀ.

L'onabotulinumtoxinÀ a clairement fait ses preuves en tant que traitement efficace et bien toleré de l'HND chez les patients atteints de SEP. Qui plus est, l'essai randomise le plus grand a inclus principalement des patients atteints de SEP [27].

La dose de l'onabotulinumtoxinÀ la plus fréquemment utilisee dans des essais ouverts est de UI, meme si les donnees recueillies d'essais randomises contrôles demontrent qu'une dose de UI aurait la meme efficacité pendant des laps de temps comparables.