How Can We Personalize the Delivery of Onabotulinumtoxin-A for Patients With Neurogenic Lower Urinary Tract Dysfunction?

[BACKGROUND & AIMS] Neurogenic lower urinary tract dysfunction (NLUTD) can produce bothersome urinary symptoms, impact quality of life, and in some cases, lead to deterioration of upper urinary tract function. Intradetrusor injection of onabotulinumtoxin-A (BoNT-A) is approved for NLUTD in patients who have an inadequate response to or intolerance of oral pharmacologic therapy (with beta-3 agonists and/or antimuscarinics) for urinary frequency, urgency, urgency incontinence, and/or impaired compliance. Modifications of its use, including dose, injection location, number of injections, setting of procedure, combination therapy with oral agents, and use among different patient populations have since been explored. Here, we aim to review the literature on BoNT-A in NLUTD with a focus on unique neurologic patient groups as well as patient and technical factors to inform personalized treatment strategies.

[METHODS] We performed a narrative review evaluating the existing literature on BoNT-A in NLUTD, focusing on outcomes across neurologic etiologies, and variation in patient-specific and technical factors.

[RESULTS] Across neurologic etiologies, BoNT-A improves quality of life and urodynamic parameters with low rates of adverse effects. Patient factors, including baseline voiding status, ability to self-catheterize, and age are important considerations in treatment selection and initial dosing of BoNT-A. Technical modifications such as reduced injection sites or trigone-including templates have been suggested to reduce adverse effects or improve efficacy but require further study.

[CONCLUSIONS] BoNT-A is an established therapy for NLUTD. Individualized treatment strategies that account for patients' neurologic etiology and functional status are beneficial in optimizing outcomes.