Skip to main content

Advertisement

SpringerLink
Log in

Clinical Factors to Decide Between Sacral Neuromodulation and Onabotulinum Toxin—When Is One Clearly Better?

  • Neurogenic Bladder (C Powell, Section Editor)
  • Published:
Current Bladder Dysfunction Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This article provides a review of the current literature on the applicability of each treatment for OAB, as well as unique clinical scenarios. In addition, the authors provide their own practical insight on how to approach third-line therapies for OAB.

Recent Findings

The treatment of overactive bladder (OAB) is increasingly common amongst specialists. OnabotulinumtoxinA and sacral neuromodulation are both highly effective third-line therapies for OAB, but work via very different mechanisms. The differences between the two are associated with potential benefits and complications unique for each.

Summary

The OAB clinician must account for several clinical and personal factors in counseling patients on options.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010;21(1):5–26.

    Article  PubMed  Google Scholar 

  2. Coyne KS, Sexton CC, Vats V, et al. National community prevalence of overactive bladder in the United States stratified by sex and age. Urology. 2011;77(5):1081–7.

    Article  PubMed  Google Scholar 

  3. Gormley EA, Lightner DJ, Faraday M, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline amendment. J Urol. 2015;193(5):1572–80.

    Article  PubMed  Google Scholar 

  4. Veenboer PW, Bosch JL. Long-term adherence to antimuscarinic therapy in everyday practice: a systematic review. J Urol. 2014;191(4):1003–8.

    Article  CAS  PubMed  Google Scholar 

  5. Smith A, Bevan D, Douglas HR, et al. Management of urinary incontinence in women: summary of updated NICE guidance. BMJ. 2013;f5170:347.

    Google Scholar 

  6. Rachaneni S, Latthe P. Effectiveness of BTX-A and neuromodulation in treating OAB with or without detrusor overactivity: a systematic review. Int Urogynecol J. 2017;28(6):805–16.

    Article  PubMed  Google Scholar 

  7. South MM, Romero AA, Jamison MG, et al. Detrusor overactivity does not predict outcome of sacral neuromodulation test stimulation. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(12):1395–8.

    Article  PubMed  Google Scholar 

  8. Chancellor MB. OnabotulinumtoxinA for overactive bladder and urinary incontinence. J Urol. 2017;197(2S):S224–S5.

    Article  PubMed  Google Scholar 

  9. Dolly O. Synaptic transmission: inhibition of neurotransmitter release by botulinum toxins. Headache. 2003;43(Suppl 1):S16–24.

    Article  PubMed  Google Scholar 

  10. Söllner T, Whiteheart SW, Brunner M, et al. SNAP receptors implicated in vesicle targeting and fusion. Nature. 1993;362(6418):318–24.

    Article  PubMed  Google Scholar 

  11. Dmochowski R, Chapple C, Nitti VW, et al. Efficacy and safety of onabotulinumtoxinA for idiopathic overactive bladder: a double-blind, placebo controlled, randomized, dose ranging trial. J Urol. 2010;184(6):2416–22.

    Article  CAS  PubMed  Google Scholar 

  12. Smith CP, Boone TB, de Groat WC, et al. Effect of stimulation intensity and botulinum toxin isoform on rat bladder strip contractions. Brain Res Bull. 2003;61(2):165–71.

    Article  CAS  PubMed  Google Scholar 

  13. Yoshida M, Miyamae K, Iwashita H, et al. Management of detrusor dysfunction in the elderly: changes in acetylcholine and adenosine triphosphate release during aging. Urology. 2004;63(3 Suppl 1):17–23.

    Article  PubMed  Google Scholar 

  14. Khera M, Somogyi GT, Kiss S, et al. Botulinum toxin A inhibits ATP release from bladder urothelium after chronic spinal cord injury. Neurochem Int. 2004;45(7):987–93.

    Article  CAS  PubMed  Google Scholar 

  15. Apostolidis A, Dasgupta P, Fowler CJ. Proposed mechanism for the efficacy of injected botulinum toxin in the treatment of human detrusor overactivity. Eur Urol. 2006;49(4):644–50.

    Article  CAS  PubMed  Google Scholar 

  16. Anger JT, Weinberg A, Suttorp MJ, et al. Outcomes of intravesical botulinum toxin for idiopathic overactive bladder symptoms: a systematic review of the literature. J Urol. 2010;183(6):2258–64.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Chapple C, Sievert KD, MacDiarmid S, et al. OnabotulinumtoxinA 100 U significantly improves all idiopathic overactive bladder symptoms and quality of life in patients with overactive bladder and urinary incontinence: a randomised, double-blind, placebo-controlled trial. Eur Urol. 2013;64(2):249–56.

    Article  CAS  PubMed  Google Scholar 

  18. • Nitti VW, Dmochowski R, Herschorn S, et al. OnabotulinumtoxinA for the treatment of patients with overactive bladder and urinary incontinence: results of a phase 3, randomized, placebo controlled trial. J Urol. 2017;197(2S):S216–S23. The EMBARK trial was a prospective randomized trial that compared urge incontinence episodes in patients receiving onabotulinumtoxinA injections to placebo. 23% of patients were continent following treatment with onabotulinumtoxinA, compared to 7% in the placebo group.

    Article  CAS  PubMed  Google Scholar 

  19. Drake MJ, Nitti VW, Ginsberg DA, et al. Comparative assessment of the efficacy of onabotulinumtoxinA and oral therapies (anticholinergics and mirabegron) for overactive bladder: a systematic review and network meta-analysis. BJU Int. 2017. https://doi.org/10.1111/bju.13945.

  20. Nitti VW, Ginsberg D, Sievert KD, et al. Durable efficacy and safety of long-term onabotulinumtoxinA treatment in patients with overactive bladder syndrome: final results of a 3.5-year study. J Urol. 2016;196(3):791–800.

    Article  CAS  PubMed  Google Scholar 

  21. Ginsberg DA, Drake MJ, Kaufmann A, et al. Long-term treatment with onabotulinumtoxinA results in consistent, durable improvements in health related quality of life in patients with overactive bladder. J Urol. 2017. https://doi.org/10.1016/j.juro.2017.05.068.

  22. Sahai A, Khan MS, Dasgupta P. Efficacy of botulinum toxin-A for treating idiopathic detrusor overactivity: results from a single center, randomized, double-blind, placebo controlled trial. J Urol. 2007;177(6):2231–6.

    Article  CAS  PubMed  Google Scholar 

  23. Brubaker L, Richter HE, Visco A, et al. Refractory idiopathic urge urinary incontinence and botulinum A injection. J Urol. 2008;180(1):217–22.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Peters KM, Kandagatla P, Killinger KA, et al. Clinical outcomes of sacral neuromodulation in patients with neurologic conditions. Urology. 2013;81(4):738–43.

    Article  PubMed  Google Scholar 

  25. Engeler DS, Meyer D, Abt D, et al. Sacral neuromodulation for the treatment of neurogenic lower urinary tract dysfunction caused by multiple sclerosis: a single-centre prospective series. BMC Urol. 2015;15:105.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Puccini F, Bhide A, Elneil S, et al. Sacral neuromodulation: an effective treatment for lower urinary tract symptoms in multiple sclerosis. Int Urogynecol J. 2016;27(3):347–54.

    Article  PubMed  Google Scholar 

  27. Schober MS, Ching CB, Peters KM, et al. Novel use of pudendal neuromodulation in a pediatric patient with caudal regression and partial sacral agenesis for refractory bowel bladder dysfunction. Urology. 2016;94:224–6.

    Article  PubMed  Google Scholar 

  28. Mahran A, Soriano A, Safwat AS, et al. The effect of sacral neuromodulation on pregnancy: a systematic review. Int Urogynecol J. 2017. https://doi.org/10.1007/s00192-017-3272-0.

  29. Amend B, Khalil M, Kessler TM, et al. How does sacral modulation work best? Placement and programming techniques to maximize efficacy. Curr Urol Rep. 2011;12(5):327–35.

    Article  PubMed  Google Scholar 

  30. Le NB, Kim JH. Expanding the role of neuromodulation for overactive bladder: new indications and alternatives to delivery. Curr Bladder Dysfunct Rep. 2011;6(1):25–30.

    Article  PubMed  Google Scholar 

  31. Siegel S, Noblett K, Mangel J, et al. Results of a prospective, randomized, multicenter study evaluating sacral neuromodulation with InterStim therapy compared to standard medical therapy at 6-months in subjects with mild symptoms of overactive bladder. Neurourol Urodyn. 2015;34(3):224–30.

    Article  PubMed  Google Scholar 

  32. Noblett K, Siegel S, Mangel J, et al. Results of a prospective, multicenter study evaluating quality of life, safety, and efficacy of sacral neuromodulation at twelve months in subjects with symptoms of overactive bladder. Neurourol Urodyn. 2016;35(2):246–51.

    Article  CAS  PubMed  Google Scholar 

  33. • Siegel S, Noblett K, Mangel J, et al. Five-year follow-up results of a prospective, multicenter study in overactive bladder subjects treated with sacral neuromodulation. J Urol. 2017. https://doi.org/10.1016/j.juro.2017.07.010. The InSite trial followed patients with overactive bladder after initiation of sacral neuromodulation. Overall therapeutic success rate was 82% at five years, and 45% of patients were completely dry.

  34. Spinelli M, Giardiello G, Gerber M, et al. New sacral neuromodulation lead for percutaneous implantation using local anesthesia: description and first experience. J Urol. 2003;170(5):1905–7.

    Article  PubMed  Google Scholar 

  35. Siddiqui NY, Amundsen CL, Corey EG, et al. Lead migration after sacral neuromodulation: surgical revision in fascial versus tined anchoring systems. Int Urogynecol J. 2011;22(4):419–23.

    Article  PubMed  Google Scholar 

  36. Hoag N, Plagakis S, Pillay S, et al. Sacral neuromodulation for refractory overactive bladder after prior intravesical onabotulinumtoxinA treatment. Neurourol Urodyn. 2017;36(5):1377–81.

    Article  CAS  PubMed  Google Scholar 

  37. Bartley JM, Killinger KA, Boura JA, et al. The impact of prior back surgery on neuromodulation outcomes: a review of over 500 patients. Neurourol Urodyn. 2017;36(6):1535–42.

    Article  PubMed  Google Scholar 

  38. White WM, Mobley JD 3rd, Doggweiler R, et al. Incidence and predictors of complications with sacral neuromodulation. Urology. 2009;73(4):731–5.

    Article  PubMed  Google Scholar 

  39. Latini JM, Alipour M, Kreder KJ Jr. Efficacy of sacral neuromodulation for symptomatic treatment of refractory urinary urge incontinence. Urology. 2006;67(3):550–3. discussion 3–4

    Article  PubMed  Google Scholar 

  40. van Kerrebroeck PE, van Voskuilen AC, Heesakkers JP, et al. Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. J Urol. 2007;178(5):2029–34.

    Article  PubMed  Google Scholar 

  41. Brazzelli M, Murray A, Fraser C. Efficacy and safety of sacral nerve stimulation for urinary urge incontinence: a systematic review. J Urol. 2006;175(3):835–41.

    Article  PubMed  Google Scholar 

  42. Riemsma R, Hagen S, Kirschner-Hermanns R, et al. Can incontinence be cured? A systematic review of cure rates. BMC Med. 2017;15(1):63.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Siegel S, Noblett K, Mangel J, et al. Three-year follow-up results of a prospective, multicenter study in overactive bladder subjects treated with sacral neuromodulation. Urology. 2016;94:57–63.

    Article  PubMed  Google Scholar 

  44. Cohn JA, Kowalik CG, Kaufman MR, et al. Evaluation of the axonics modulation technologies sacral neuromodulation system for the treatment of urinary and fecal dysfunction. Expert Rev Med Devices. 2017;14(1):3–14.

    Article  CAS  PubMed  Google Scholar 

  45. Siegel SW, Catanzaro F, Dijkema HE, et al. Long-term results of a multicenter study on sacral nerve stimulation for treatment of urinary urge incontinence, urgency-frequency, and retention. Urology. 2000;56(6):87–91.

    Article  CAS  PubMed  Google Scholar 

  46. Hijaz A, Vasavada SP, Daneshgari F, et al. Complications and troubleshooting of two-stage sacral neuromodulation therapy: a single-institution experience. Urology. 2006;68(3):533–7.

    Article  PubMed  Google Scholar 

  47. Blandon RE, Gebhart JB, Lightner DJ, et al. Re-operation rates after permanent sacral nerve stimulation for refractory voiding dysfunction in women. BJU Int. 2008;101(9):1119–23.

    Article  PubMed  Google Scholar 

  48. Peters KM, Killinger KA, Gilleran JP, et al. Predictors of reoperation after sacral neuromodulation: a single institution evaluation of over 400 patients. Neurourol Urodyn. 2017;36(2):354–9.

    Article  PubMed  Google Scholar 

  49. Kalsi V, Popat RB, Apostolidis A, et al. Cost-consequence analysis evaluating the use of botulinum neurotoxin-A in patients with detrusor overactivity based on clinical outcomes observed at a single UK centre. Eur Urol. 2006;49(3):519–27.

    Article  CAS  PubMed  Google Scholar 

  50. Siddiqui NY, Amundsen CL, Visco AG, et al. Cost-effectiveness of sacral neuromodulation versus intravesical botulinum a toxin for treatment of refractory urge incontinence. J Urol. 2009;182(6):2799–804.

    Article  PubMed  Google Scholar 

  51. Bertapelle MP, Vottero M, Popolo GD, et al. Sacral neuromodulation and Botulinum toxin A for refractory idiopathic overactive bladder: a cost-utility analysis in the perspective of Italian Healthcare System. World J Urol. 2015;33(8):1109–17.

    Article  CAS  PubMed  Google Scholar 

  52. Leong RK, de Wachter SG, Joore MA, et al. Cost-effectiveness analysis of sacral neuromodulation and botulinum toxin A treatment for patients with idiopathic overactive bladder. BJU Int. 2011;108(4):558–64.

    Article  CAS  PubMed  Google Scholar 

  53. Whitehead WE, Borrud L, Goode PS, et al. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology. 2009;137(2):512–7. 7 e1-2.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Meyer I, Richter HE. Impact of fecal incontinence and its treatment on quality of life in women. Womens Health (Lond). 2015;11(2):225–38.

    Article  CAS  Google Scholar 

  55. Malouf AJ, Vaizey CJ, Nicholls RJ, et al. Permanent sacral nerve stimulation for fecal incontinence. Ann Surg. 2000;232(1):143–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  56. Devroede G, Giese C, Wexner SD, et al. Quality of life is markedly improved in patients with fecal incontinence after sacral nerve stimulation. Female Pelvic Med Reconstr Surg. 2012;18(2):103–12.

    Article  PubMed  Google Scholar 

  57. McNevin MS, Moore M, Bax T. Outcomes associated with Interstim therapy for medically refractory fecal incontinence. Am J Surg. 2014;207(5):735–7. discussion 7–88.

    Article  PubMed  Google Scholar 

  58. Janssen PT, Kuiper SZ, Stassen LP, et al. Fecal incontinence treated by sacral neuromodulation: long-term follow-up of 325 patients. Surgery. 2017;161(4):1040–8.

    Article  PubMed  Google Scholar 

  59. Coyne KS, Cash B, Kopp Z, et al. The prevalence of chronic constipation and faecal incontinence among men and women with symptoms of overactive bladder. BJU Int. 2011;107(2):254–61.

    Article  PubMed  Google Scholar 

  60. Ghazwani YQ, Elkelini MS, Hassouna MM. Efficacy of sacral neuromodulation in treatment of bladder pain syndrome: long-term follow-up. Neurourol Urodyn. 2011;30(7):1271–5.

    PubMed  Google Scholar 

  61. Marcelissen T, Jacobs R, van Kerrebroeck P, et al. Sacral neuromodulation as a treatment for chronic pelvic pain. J Urol. 2011;186(2):387–93.

    Article  CAS  PubMed  Google Scholar 

  62. Kuo HC, Jiang YH, Tsai YC, et al. Intravesical botulinum toxin-a injections reduce bladder pain of interstitial cystitis/bladder pain syndrome refractory to conventional treatment—a prospective, multicenter, randomized, double-blind, placebo-controlled clinical trial. Neurourol Urodyn. 2016;35(5):609–14.

    Article  CAS  PubMed  Google Scholar 

  63. Morrissey D, El-Khawand D, Ginzburg N, et al. Botulinum toxin a injections into pelvic floor muscles under electromyographic guidance for women with refractory high-tone pelvic floor dysfunction: a 6-month prospective pilot study. Female Pelvic Med Reconstr Surg. 2015;21(5):277–82.

    Article  PubMed  Google Scholar 

  64. Abrams P, Andersson KE, Birder L, et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn. 2010;29(1):213–40.

    Article  CAS  PubMed  Google Scholar 

  65. Kurpad R, Kennelly MJ. The evaluation and management of refractory neurogenic overactive bladder. Curr Urol Rep. 2014;15(10):444.

    Article  PubMed  Google Scholar 

  66. Schurch B, Stohrer M, Kramer G, et al. Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results. J Urol. 2000;164(3 Pt 1):692–7.

    Article  CAS  PubMed  Google Scholar 

  67. Schurch B, de Seze M, Denys P, et al. Botulinum toxin type a is a safe and effective treatment for neurogenic urinary incontinence: results of a single treatment, randomized, placebo controlled 6-month study. J Urol. 2005;174(1):196–200.

    Article  CAS  PubMed  Google Scholar 

  68. Cheng T, Shuang WB, Jia DD, et al. Efficacy and safety of OnabotulinumtoxinA in patients with neurogenic detrusor Overactivity: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2016;11(7):e0159307.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Hohenfellner M, Schultz-Lampel D, Dahms S, et al. Bilateral chronic sacral neuromodulation for treatment of lower urinary tract dysfunction. J Urol. 1998;160(3 Pt 1):821–4.

    Article  CAS  PubMed  Google Scholar 

  70. Ishigooka M, Suzuki Y, Hashimoto T, et al. A new technique for sacral nerve stimulation: a percutaneous method for urinary incontinence caused by spinal cord injury. Br J Urol. 1998;81(2):315–8.

    Article  CAS  PubMed  Google Scholar 

  71. Chartier-Kastler EJ, Ruud Bosch JL, Perrigot M, et al. Long-term results of sacral nerve stimulation (S3) for the treatment of neurogenic refractory urge incontinence related to detrusor hyperreflexia. J Urol. 2000;164(5):1476–80.

    Article  CAS  PubMed  Google Scholar 

  72. Hohenfellner M, Humke J, Hampel C, et al. Chronic sacral neuromodulation for treatment of neurogenic bladder dysfunction: long-term results with unilateral implants. Urology. 2001;58(6):887–92.

    Article  CAS  PubMed  Google Scholar 

  73. Kessler TM, La Framboise D, Trelle S, et al. Sacral neuromodulation for neurogenic lower urinary tract dysfunction: systematic review and meta-analysis. Eur Urol. 2010;58(6):865–74.

    Article  PubMed  Google Scholar 

  74. Knupfer SC, Liechti MD, Mordasini L, et al. Protocol for a randomized, placebo-controlled, double-blind clinical trial investigating sacral neuromodulation for neurogenic lower urinary tract dysfunction. BMC Urol. 2014;14:65.

    Article  PubMed  PubMed Central  Google Scholar 

  75. •• Amundsen CL, Richter HE, Menefee SA, et al. OnabotulinumtoxinA vs sacral neuromodulation on refractory urgency urinary incontinence in women: a randomized clinical trial. JAMA. 2016;316(13):1366–74. This is the only randomized trial comparing onabotulinumtoxinA to sacral neuromodulation in patients with refractory urge incontinence. A total of 364 women were included, and the primary outcome was mean reduction in number of urge incontinence episodes, which was greater in patients undergoing onabotulinumtoxinA injection.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  76. Anger JT, Cameron AP, Madison R, et al. Predictors of implantable pulse generator placement after sacral neuromodulation: who does better? Neuromodulation. 2014;17(4):381–4. discussion 4

    Article  PubMed  Google Scholar 

  77. Blok BF. OnabotulinumtoxinA vs sacral neuromodulation for urgency incontinence. JAMA. 2017;317(5):534–5.

    Article  PubMed  Google Scholar 

  78. Malmsten UG, Molander U, Peeker R, et al. Urinary incontinence, overactive bladder, and other lower urinary tract symptoms: a longitudinal population-based survey in men aged 45-103 years. Eur Urol. 2010;58(1):149–56.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Urology, Beaumont Health Systems, 31157 Woodward Avenue, Royal Oak, MI, 48073, USA

    Laura N. Nguyen, Esther Han, Alec Wilson & Jason P. Gilleran

  2. William Beaumont School of Medicine, Oakland University, 586 Pioneer Dr., Rochester, MI, 48309, USA

    Jason P. Gilleran

Authors
  1. Laura N. Nguyen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Esther Han
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alec Wilson
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jason P. Gilleran
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jason P. Gilleran.

Ethics declarations

Conflict of Interest

Drs. Nguyen, Wilson, Han, and Gilleran do not have any conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the authors.

Additional information

This article is part of the Topical Collection on Neurogenic Bladder

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Nguyen, L.N., Han, E., Wilson, A. et al. Clinical Factors to Decide Between Sacral Neuromodulation and Onabotulinum Toxin—When Is One Clearly Better?. Curr Bladder Dysfunct Rep 12, 328–336 (2017). https://doi.org/10.1007/s11884-017-0454-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11884-017-0454-z

Keywords

Search

Navigation