We all know that Botox is helpful in minimizing wrinkles and making us feel young again, but its original use was for the management of muscle spasticity. Here at The Urogynecology Center we have been using Botox for the management of pelvic pain as well as bladder dysfunction. As a pioneer in its use-long before it was FDA approved for bladder spasticity-I thought a review of the history and multiple uses would be beneficial.

Botulinum toxin is an extremely potent neuro-toxin that was originally discovered in 1820 as the cause of poisoning from spoiled sausage-it was actually called “sausage fever”. Since then it has been purified and much research has been done to verify its safety and efficacy. It works by turning off the nerve’s ability to release the neurotransmitters responsible for triggering a muscle contraction and for sending pain signals to the spinal cord and on up to the brain. Its effect on muscle contractility generally lasts between 4-6 months and when blocking pain transmission along the sensory nerves the duration of effectiveness is sometimes not quite as long.

As a subspecialist in chronic pelvic pain who has seen patients from around the world it is obvious that many have at least a component of pain arising from their pelvic floor muscles. Muscle relaxers and physical therapy represent the Foundation of management for chronic pelvic pain of myofascial origin. I started using Botox injected directly into the pelvic floor muscles in approximately 2005. Many reports have followed indicating that approximately 80% of patients will have marked improvement in their pain that is typically maintained for at least 4-6 months. Most patients need follow-up injections on a regular basis just like when Botox® is used to help people with frown lines on the face. Just like cosmetic Botox®, insurance companies often do not pay for injection of Botox into pelvic floor muscles for chronic pain. There are many types of chronic pelvic pain associated with a significant myofascial pain component. A few examples include interstitial cystitis, vaginismus, vestibulodynia, peri-rectal pain and coccydynia. The good news is that over time insurance companies have realized the benefit of supporting the management of chronic pelvic floor pain
While Botox is beneficial for myofascial pain it is also being used for problems of nonrelaxing pelvic floor muscles. Here the muscles do not relax while attempting to pass stool or urine. Using Botox® injections around the anal or urethral sphincters often relaxes the sphincters and allows for elimination to occur but not so much that stool or urine control becomes a problem-most of the time. While certainly InterStim (neuromodulation of the sacral nerves by placing a small wire that is stimulated by a battery near the nerves) is ideally suited for the treatment of these kinds of problems, it is not always possible or appropriate for every patient. For these patients Botox® can markedly improve the quality of life.

One of the most exciting areas for the use of Botox® involves improvement in bladder control and pain. It was originally used in patients that had lost bladder control as a result of various neurologic injuries such as spinal cord injury or multiple sclerosis. Knowing how well it worked in some of our most difficult bladder control problems it was a natural extension to start using it for some of the more common problems that we see on a regular basis such as overactive bladder or chronic urinary frequency and urgency syndromes. Long before it was FDA approved for overactive bladder we had been using a small scope designed specifically for female bladders to inject Botox® into multiple sites along the wall of the bladder. In my practice, this is a simple office-based procedure done with local anesthesia. Unfortunately, most urologists in the Kansas City area place patients under a general anesthetic to perform this procedure every 6 months-there are certainly better ways and safer ways to use this wonderful approach to the management of urge incontinence and overactive bladder. I have been doing Botox® injections in my office longer than any other practicing physician in Kansas City. I would encourage patients not to allow a doctor to perform general anesthesia on them every 6 months-the duration of the Botox® affect.

Throughout the country I am known best for my management of patients with interstitial cystitis / painful bladder syndrome. This was once thought to be a rare bladder problem. Now we realize that between 5-7% of all women have this problem. While most patients respond well to simple therapies and if any surgical procedure is required InterStim® is almost certainly the best surgery to be done. Yet sometimes even InterStim does not work. For those patients the use of Botox® injected both into the bladder wall and into the pelvic floor muscles provides a very good response in approximately 70%. While retention (the inability to completely empty her bladder-even to the point that a catheter might be required) is a complication that might occur any time we inject Botox® into the bladder wall it is slightly more common in our patients with IC/PBS. A careful evaluation of voiding function prior to the use of Botox® plus over 10 years of experience helps guide the dosage and the technique necessary to provide symptom relief.

Botox is certainly a very potent neurotoxin, but let us show you how safe and potentially life changing this simple office approach could be for your pelvic floor problems. Call 913-307-0044

Our mission at the Urogynecology Center is to provide the highest level of care possible for women with incontinence, pelvic pain and/or pelvic organ prolapse. We provide this care in an individualized and highly compassionate manner, always keeping the needs of the patient in the forefront.

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Dr. Butrick attended a meeting to provide input on a new device for sacral nerve stimulation from Axionics. This new device greatly reduces the size of a neuromodulation device battery to the approximate size of a quarter.

AUGS – 2019

As a course faculty member, Dr. Butrick gave a presentation and updates in the field of urodynamics in Cancun, Mexico.