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Excerpt
The authors report their preliminary experience with botulinum toxin type A (BTX; Botox, Allergan Inc., Irvine, CA, USA) in the treatment of chronic pelvic pain. Medical record forms of 11 men 32-66 years of age (mean 47.4) suffering from chronic pelvic pain were reviewed. Patients were investigated by history, physical and neuro-urological examination. Pelvic floor function was evaluated by digital rectal examination. Pain was scored on a visual analogue scale. Pressure-flow study and urethral profilometry were carried out. Discomfort associated with urethral catheter movements was quantified on a three-point scale. Cystoscopy was carried out to investigate possible morphological changes of bladder and urethra; the sensory nociceptive level of urethral sphincter, bladder neck and bladder wall was evaluated. Patients with hypersensitivity/hyperalgesia of the urethra, sphincter or bladder neck, spastic pelvic floor dysfunction, rest urethral maximum pressure greater than 80 cm H2O or Qmax less than 15 ml/s were scheduled for BTX treatment. Two hundred units of BTX were injected transurethrally in the external sphincter under direct vision using a 21-Ch cystoscope and a 22 gauge needle. All patients had chronic prostatic pain for over 12 months and had already been treated with antibiotics or analgesics with no success. Seven patients complained of irritative lower urinary tract symptoms. All patients had muscle tenderness or myofascial trigger points elicitable on digital rectal examination. The motion of pelvic floor muscles appeared to be restricted in all cases. Nine out of 11 patients had marked levels of discomfort associated with urethral catheter movements. The average value of maximum bladder capacity and volume at first sensation were 386.7 and 167 ml, respectively. Ten out of 11 patients had normal bladder compliance. The average functional urethral length at rest and urethral closure pressure were 3.9 and 97.4 cm H2O, respectively. The average value of maximum and mean urine flow was 17.5 and 8.5 ml/s, respectively. Cystoscopy was always negative; the severity of sensory disturbance proved to be maximal at the level of the urethral sphincter. BTX injection was well tolerated, and no immediate or delayed complications occurred. Subjective pain relief (visual analogue scale 1.6) was reported in nine out of 11 cases. Two patients who were in retention before BTX injection could void afterwards. One patient suffered transient (2 weeks) mild stress incontinence after treatment. Pelvic floor tenderness, sphincter tension and pain elicited on digital rectal examination decreased in all patients. A comparison of pre- and post-treatment urodynamic parameters suggested a decrease of urethral functional length and closure pressure, a decrease of post-void residual urine, and an increase of maximum and average urine flow. In conclusion, the results of this study encourage further investigation into the use of BTX in the treatment of chronic prostatic and pelvic pain.
