Treatment of neuropathic bladder using botulinum toxin A in a 1-year-old child with myelomeningocele


Sirs, Intramuscular injection of botulinum toxin A (BTX/A) is an effective and safe therapy for children and adults with dystonic and spastic movement disorders [1, 2]. Furthermore, clinical trials have been successfully carried out treating neuropathic bladder under various conditions [3, 4, 5, 6]. We report the successful treatment with BTX/A of a neuropathic bladder in a 1-year-old boy with myelomeningocele (MMC), which has not, to our knowledge, been described in the literature before. The 1-year-old male patient showed MMC extending from Th9 to L1. Consolidation of the large wound on his back was complicated by recurrent infections. The child had an Arnold-Chiari malformation with severe hydrocephalus and showed no active lower limb movements. However, there was severe muscular hypertonus of the rectus femoris muscle and the adductor muscles. Rectal palpation suggested a highly active sphincter ani externus muscle, causing severe constipation. Starting at the age of 9 months, the child suffered from recurrent urinary tract infections with multi-resistant Pseudomonas, at a frequency of up to twice a month, although he had been circumcised. Over a period of 12 weeks, repeated sonographic evaluation of the urinary tract revealed post-void residual urine volumes of 75, 100, 150, and 80 ml. Each measurement was performed three times post voiding and the lowest value was taken. Neither reflux nor hydronephrosis was observed. Intermittent catheterization was carried out, but was not accepted as a first-line treatment by the parents. Extensive urodynamic studies were not undertaken because a prolonged supine position was strictly prohibited due to the wound on his back. In order to evaluate the external urethral sphincter, we performed a needle electromyogram (EMG), which revealed an overactive muscle. Treatment with BTX/A was carried out after obtaining approval from the local ethics committee and informed consent from the parents. The external urethral sphincter was treated with 40 units BTX/A (Botox, Merz, Frankfurt, Germany, 100 units diluted in 2 ml), by transperineal injection using EMG guidance. Two injection points were used. The child was sedated with midazolam. Thereafter, we performed a sonographic evaluation of post-void residual urine volume at weekly intervals. The volume before treatment with BTX/A was about 80 ml; during the 3 weeks after treatment, it decreased to below 5 ml (Fig. 1).

DOI: 10.1007/s004670100055

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@article{Mall2001TreatmentON, title={Treatment of neuropathic bladder using botulinum toxin A in a 1-year-old child with myelomeningocele}, author={Volker Mall and Franz Xaver Glocker and Alexander Frankenschmidt and Nader Gordjani and Florian R. Heinen and Matthias Brandis and Rudolf Korinthenberg}, journal={Pediatric Nephrology}, year={2001}, volume={16}, pages={1161-1162} }