Having investigated your bladder problem and discussed the findings with you, your doctor has recommended an injection of Botox into your bladder muscle which will be done during a cystoscopy. As with most procedures, your main anxieties before Botox injections will be due to fear of the unknown. We hope the following information will be helpful to you.
The bladder is a storage organ for urine. As urine is produced it fills the bladder up. The bladder walls stretch like a balloon to accommodate the fluid. A valve like mechanism (Urethral sphincter) contains urine. This mechanism is helped by pelvic floor muscles which tense up when you cough or sneeze and hold the urine in. Once the bladder fills up, you start to be aware of the feeling that you need to pass urine but are able to hold. Once you have decided to pass urine at the convenient time (i.e. in a toilet) your brain signals the bladder muscles to squeeze. The sphincter and pelvic floor muscles relax at the same time. This allows urine to flow out. The bladder usually needs to be emptied 4-5 times per day and once at night.
OAB symptoms occur due to inappropriate squeeze of bladder muscles even when the bladder is not very full. This happens without any warning and when you do not want it to. This causes need to empty bladder frequently and may lead to the leakage of urine especially on the way to the toilet.
Botox is a trade name for Botulinum Toxin Type A (BOTA). It is extracted from bacteria under controlled laboratory conditions, in much the same way as penicillin is produced from mould. BOTA works by blocking nerve impulses to any muscles that have been injected. In this case BOTA into the bladder muscle causes the muscle to stop contracting. This in turn stops or reduces the involuntary leakage of urine, which occurs with urgency. BOTA is not effective for another common type of incontinence called stress incontinence (leakage with cough, sneeze and exercise).
A cystoscopy is an examination of the inside of the bladder and the urethra (water pipe) using a fine telescope with a light and a tiny camera at the end. Botox is administered during the cystoscopy by the doctor or specialist nurse. Most cystoscopies are carried out in the gynaecology day care unit or the Urogynaecology clinic in area S at Northampton General Hospital. It is usually carried out using General or local anaesthetic, in some cases we may suggest a spinal anaesthetic.
Before your surgery you may be asked to come to the pre-admission clinic to check that you are fit and well for the operation. We will ask you about your general health, past medical history and any medicines you are taking. If you need any investigations like blood tests, ECG or a chest x-ray we will organise these. We will tell you about your admission and your care before and after the operation. You will be able to ask any questions or raise any concerns you have. If you are having a procedure under local anaesthetic, there is no need to attend the preadmission clinic.
Let your preoperative assessment nurse and your surgeon know if you are on any blood thinning medication such as Warfarin or Clopidogrel. You will have to stop those medications for few days prior to the procedure. You may need heparin injections during this period. You will be given specific instruction about stopping this medications during your preoperative assessment appointment.
Please tell your surgeon or the nurse in the pre-admission clinic (before your surgery) if you have any of the following:
There is no special preparation for a flexible cystoscopy under local anaesthetic (LA). You should eat and drink as normal and take all your normal medication. You will be asked to empty your bladder immediately before the cystoscopy.
You will need to fast for 6 hours if the procedure is carried out under General Anaesthetic (GA). You will be advised about this in clinic or when your name is added to the waiting list.
Follow the advice about stopping medication before the operation. You should continue to take your normal medications unless you are told otherwise.
On the day of the operation
You will usually be admitted on the day of your surgery. Once you have been admitted, you will be seen by a member of the medical team which may include the consultant, specialist registrar, house officer or specialist nurse.
You will be seen by the anaesthetist and the surgeon or specialist nurse who will tell you what to expect about the anaesthetic and during the operation. They will also discuss the risks and benefits associated with the procedure. You will be asked to sign a consent form, unless you have already done so, and will have an opportunity to ask questions about anything you are still unsure about.
The treatment is very simple and is usually performed as a day stay procedure.
The procedure can be performed under local, general or spinal injections. Your doctor would have discussed the most suitable option for you.
The doctor or nurse specialist carrying out the procedure will clean your genital area with a mild antiseptic solution and then surround the area with a sterile paper sheet. If you are under anaesthetic you will not be aware of anything happening around you. If you are awake, try not to touch the sterile area with your hands. Some local anaesthetic, lubricating gel will be inserted into the urethra. This gel also has a mild local anaesthetic effect and helps reduce the risk of urinary tract irritation and infection.
The tip of the cystoscope is then inserted into the urethra. As the cystoscope passes through the urethral sphincter there may be a brief stinging sensation if you are awake. When the bladder is empty, there are folds in the lining, sterile water is run into the bladder through the cystoscope to stretch out these folds and give a clearer picture.
The needle used to inject the Botox is very small and is threaded along the cystoscope until it can be seen at the end of the scope on the screen (which relays the images sent from the camera). The doctor or nurse specialist will then administer up to 20 injections of Botox, at 1ml per injection, evenly into the bladder muscle. If the procedure is performed under local anaesthetic, there may be a pricking sensation or a minor discomfort during the procedure. It should not be painful.
The procedure should take no more than 20 minutes. The doctor or nurse specialist carrying out the procedure will explain everything to you as it happens if you are awake during the procedure. If you are anaesthetised, your doctor or nurse specialist will explain the procedure once you are awake again.
You will probably feel that you need to pass urine immediately after the procedure, because your bladder has been filled with water, you will be able to do this straight away.
You should be told how the procedure went and you should:
You may experience some discomfort for a few days after the procedure. You are usually given painkillers to take home.
You may experience some stinging or burning while passing urine for first few times following the treatment. Your urine may also be a little blood stained. This is normal and will clear over 24-48 hours.
You may not be able to empty your bladder completely or partially after the procedure. This is because BOTA works by relaxing the bladder muscle, which can reduce its capacity to contract and empty the bladder. You will have regular scans to identify if there is a problem with emptying. Do not worry if you cannot pass urine effectively. Your doctor or nurse will teach you clean intermittent self-catheterisation (CISC). This involves passing a tiny tube into the bladder up to 3 to 4 times a day. This is a simple and safe procedure. Once the effect of BOTA wears off your bladder function will return.
BOTA does not work immediately. Over about two weeks, you should begin to experience relief of sudden urges to urinate, reduction in the number of times you urinate and reduction in leakage or stop leaking all together. If you are taking tablets to relax the bladder prior to the treatment, you should be able to wean yourself off these tablets once BOTA becomes effective.
The procedure is done on a day-case basis with a length of stay less than one day.
Most procedures have possible side-effects. Although the complications listed below are well-recognised, most patients do not suffer any problems.
Common (greater than 1 in 10)
Occasional (between 1 in 10 and 1 in 50)
Rare (less than 1 in 50)
Hospital-acquired infection
Recovery after this procedure usually takes 1 to 4 days. Most patients take couple of days off work depending on their type of work. You may require pain killers such as Paracetamol or Ibuprofen (if you are able to take them) during this time. You should be able to drive and be fit enough for your usual activities within few days of the procedure. We usually advise you to wait for 2 weeks after the operation before having sexual intercourse. If you had symptoms of urinary leakage during intercourse, this procedure might make it better, but unfortunately this is not always the case.
There are some alternatives to Botox which, ideally, you should have tried before moving on to Botox, and include;
This medication is usually given in tablet form. It should reduce bladder contractions, the number of times you pass urine, urgency and leakage. They can cause unpleasant or bothersome side effects or have a limited effect on the symptoms.
If you have been doing these on your own you may like to see a physiotherapist or a specialist nurse to check that you have been doing them correctly. If this has not been suggested you should ask your doctor to refer you to a physiotherapist or nurse specialist. They may suggest the use of specialist equipment like an electrical stimulator or weighted vaginal cones to strengthen your muscles if they are very weak.
These are placed in your vagina to stop urine leaking out. They need to be replaced regularly.
Try to avoid things that may put too much stress on the bladder. For example;
These measures may improve your symptoms, help stop them getting worse or even stop them altogether
Other more invasive procedures such as sacral nerve stimulation, bladder enlargement using a segment of bowel and urinary diversion into a stoma are available.
Your doctor can discuss these options with you if necessary.
Book an Appointment if you need further help
This information booklet has been given to you to help answer some of the questions you may have about having an urodynamic test. The booklet explains what the test is, how to prepare for it and what to expect afterwards.
We would be happy to answer any of you questions or concerns.
It is a study of how the bladder works. The intention is to differentiate different bladder condition to allow us to plan appropriate treatment for you. It look at what happens when your bladder fills or empties. The test is done in three parts and can take up to 45 minutes to an hour.
There could be one of the following reasons:
The test gives a clear picture and helps to make plans regarding best possible intervention for you symptoms, warns regarding potential problems and allows us to avoid unnecessary treatment. Symptoms for different urinary conditions can be quite similar, so we need to do the test to make sure that we diagnose and treat your bladder problem correctly.
Unfortunately no other tests provide the same level of information.
Special precautions:
If you have had a heart valve replacement or any other heart conditions where you do require antibiotic cover for dental treatment etc, please let us know as we will have to give you same cover.
If you have urinary infection, the test needs to be postponed till you are treated.
You can eat and drink normally on the day.
You will need to come with a full bladder at the start of the study, so try not to pass urine for about 2-3 hours before your appointment 9or as long as you can comfortably hold on). If it is a problem and you cannot hold on that is ok.
We will discuss your current urinary symptoms, the treatment given so far and other tests or conditions. You can ask questions any time. You will then be asked to change into a hospital gown as this will make it easier and more comfortable for you.
What does the Urodynamic test involve?
You will be asked to empty your bladder into a commode (flowmeter). This measures how much urine you pass and the flow of urine. You will be left alone in the room whilst you are doing this. This is why you need to come with a full bladder.
Your urine will then be tested to make sure there is no infection. If there is we are unable to perform the test today and the doctor will advise you on what to do.
The next part of the test measures the way your bladder works as it fills up. You will be asked to lie down on the couch. One catheter (a fine tube) is passed into the bladder via the urethra (water-pipe). So the doctor can compare the pressure in your bladder with the pressure outside the bladder, a small pressure catheter is also inserted into your back passage. You may feel a stinging sensation as the catheters are inserted, but this only takes a few seconds. Once they are in place, you should not feel any discomfort, if you do please let the staff know.
Once the catheters are in the correct position you will return to the commode and you will be attached to a bag of fluid, of which runs into your bladder at a controlled rate. This slowly fills the bladder whilst recordings are printed onto the computer print-out. During the test we would like to know what you feel about your bladder. We want to reproduce the symptoms that you experience in your day to day life.
During the test, you will be asked to cough at regular intervals. Do not worry about leakage as we need to see it if it happens during the test. We may ask you to stand, squat or run on the spot if needed. Once your bladder is full, you will be asked to stand up and cough to test the bladder further. It is important to remember that we need to see how your bladder behaves on a day-to-day basis to make sure that we are providing you with the correct treatment.
You will then be asked to empty your bladder into the commode again at the end of the test with the catheters still in place.
During the test every effort will made to ensure a minimum of discomfort and a maximum of privacy.
The catheters are removed and you will be asked to change back into your clothes. You will be able to continue with your normal activities of daily life straight away.
After having an urodynamic test there is the small possibility that you may develop a urinary tract infection. You will be given antibiotics to prevent an infection. This is caused by the insertion of the catheters into your bladder during the test. To help prevent an infection after the test, you should drink extra fluids for the next 48 hours. This will help to ‘flush’ the system through.
If you are developing a urine infection, contact your G.P. He/she will test you urine and send a sample to the laboratory for testing. If you have an infection you will be given antibiotics to treat it. Take the whole course of antibiotics prescribed to make sure that the infection has totally cleared up. Please contact us if you any issues on 07714466878.
Book an Appointment if you need further help
A pessary is a device placed into the vagina, to support the uterus and vaginal walls. It is a firm ring that stretches the wall of the vagina and supports pelvic organs, (the bladder, lower bowel, womb and top of the vagina). A properly fitted pessary is not noticeable when it is in place.
Different types of pessaries are used, depending on the type and degree of prolapse, i.e. bladder, rectum, womb or vault (top of vagina).
In the Urogynaecology department we use a range of different pessaries depending on the individual needs of each patient, the different types are;
There are some other types of the pessaries that we may suggest if necessary.
The doctor or a specialist nurse will examine you to see what size/type of pessary you need. This is done by internal examination of the vagina.
The pessary is then inserted and positioned.
You may be asked to walk around to check that you are comfortable. You may also be asked to go to the toilet and pass urine to check that the pessary is secure and does not affect voiding.
This is usually every 4- 6 months either in the gynaecology clinic or with your GP surgery depending on the type of pessary inserted.
Insertion of a vaginal ring pessary may be a suggested treatment for you due to number of reasons:
Once it is in place, you should not feel it. If there is any discomfort you may need a different size or type of pessary.
Some patients may experience the following: -
If you have any of these side effects, please contact Urogynaecology department
Occasionally the ring may rub the vaginal walls causing erosion or a breakdown of the skin. The ring will need to be removed for a period to allow healing to take place.
We usually advise either a hormone based cream or pessaries to be used regularly to prevent this from happening. If you are unable to use the hormone cream, we will suggest a non-hormonal vaginal moisturiser instead.
After insertion of the ring pessary, we will ask you to cough, bear down, sit up, stand up and walk around, to test that the pessary has been fitted securely.
If, when you go home, the pessary falls out, do not panic. Please contact Urogynaecology department to arrange another appointment. Sometimes we may have to try more than one size, or type, of pessary to find the one which suits you best.
The pessary should make it easier for you to pass urine and empty your bladder more effectively, if you have any difficulties passing urine please contact the Urogynaecology Department.
You may experience more leakage soon after the insertion of pessary. This symptom usually settles in a week or two. You should contact Urogynaecology department if you continue to experience leakage.
Generally, it does not affect your bowel movement. Initially you may experience pressure which settles in few days. It is better to ensure that you are not constipated by drinking plenty of fluids and taking a high fibre diet.
It is possible to have sexual intercourse with the ring pessary in place, although your partner may feel the pessary. You may find a different position more comfortable.
If you have a shelf/or Gelhorn pessary it is not possible to have sexual intercourse, this is because of the shape of the pessary.
Some pessaries can be removed to have sexual intercourse. You can be taught how to do this. Talk to your doctor or nurse if you wish to learn this.
Normally your pessary will be changed every 4 - 6 months. Your GP or consultant will advise you regarding this.
You will have a regular appointment in the pessary clinic at Northampton General Hospital. You can have pessaries changed at the surgery if your doctor or practice nurse is happy to change it.
You should carry on as normal. We advise, however, that you refresh yourself with warm water or a wet wipe after a bowel movement, (wiping from front to back) to reduce the risk of infection.
Please contact us on 07714466878.
Your doctor has recommended medication to treat your Overactive Bladder symptoms. This leaflet explains about the medication, the most common side effects and how to cope with any you may develop whilst you are taking the medication.
Please note: This information does not replace talking to your doctor or healthcare professional about your medical condition or treatment. This leaflet does not replace the specific product information provided with the prescribed medicine.
Normally your bladder muscle contracts to empty your bladder. Sometimes these contractions happen inappropriately, often without any warning and when you do not want them to. OAB symptoms are very common, and affect women (and men) of all ages. It is an umbrella term that covers many symptoms, including;
There are a number of medications available that can reduce OAB symptoms. They work by relaxing the muscle within the bladder wall. Your doctor may prescribe one of the following;
Oxybutynin, Tolterodine, Propiverine, Trospium Chloride, Solifenacin, Darifenacin, Fesoteradine, Mirabegron.
These medications are prescribed according to the National Institute for Health and Care Excellence guidelines. The medication prescribed to you depends on local policy and efficacy/side effects of your previous treatments.
There are some common but not serious side effects with these medicines. Some simple measures can be undertaken to enable you to manage any side effects.
The commonest side effects are:
These problems can be kept to a minimum if you are prescribed the lowest dose that controls your symptoms.
Please inform your doctor if you suffer from any of the following conditions:
You should not stop taking your medication if you do not notice an improvement in your symptoms straightaway (unless you experience an allergic reaction).
You may not notice any improvement for the first few weeks; it may take some time for your bladder to adapt and your symptoms to improve so it is important to continue taking the medication for at least 2 – 3 months.
You will need to stop going to the toilet on a “just in case” basis. This will allow the bladder muscle to relax and stretch as the medication takes effect, as a result you will be able to hold on for longer and pass urine less often.
You should continue with the medication and only stop taking them if you have discussed it with your doctor, if you stop treatment too soon your overactive bladder symptoms may come back.
Once your bladder symptoms have improved, and remained stable for some time, we can discuss gradually weaning off the medication. If the OAB symptoms have completely settled we may be able to stop the medication. If they return, you will need to continue the medication for longer, but perhaps at a lower dose.
We will try to stop the medication every few months depending on your symptoms.
We may need to try several alternatives before we find the medication that doesn’t cause you any bothersome side effects and is the most effective.
We may recommend the following measures, in addition to the medication, to increase the benefits. They may also reduce your OAB symptoms if you do not wish to take medication or if it is contraindicated.
If you cannot take medications for any reasons or if you are unwilling to take medication, you may wish to discuss Botox injections in to the bladder or another treatment option called Posterior Tibial Nerve Stimulation (PTNS). We will be happy to discuss these options in detail and will provide you with written information about it.
The sacral plexus of nerves is responsible for regulating both bladder and bowel function; stimulation of these nerves can help to improve bladder and bowel problems. Nerve stimulation can be achieved by using an implantable stimulator or by PTNS. PTNS is a form of treatment which is called neuromodulation. It is a minimally invasive procedure carried out in an outpatient setting.
It is carried out to improve overactive bladder symptoms. Overactive Bladder (OAB) is a condition comprising of a set of urinary symptoms like needing to visit the toilet more frequently both during the day and at night, (nocturia) accompanied by urgency (a sudden desperate need to pass urine), with or without urgency incontinence (leaking before you can get to the toilet). OAB is common, affecting at least 10% of the adult population, men as well as women. It is more common in older people, in those who have had pelvic surgery (gynaecological or urological) and in the presence of neurological disease. However, many people have no obvious cause for their overactive bladder symptoms.
You will be asked to sit in a chair or a couch with your treatment leg elevated. Your clinician will:
To determine the optimal treatment settings your clinician will turn on the stimulator and adjust the setting. You will feel a sensation in the ankle or foot and your toes may also spread out and curl. Let your clinician know if the sensation is too strong or if you are sitting in an uncomfortable position.
The stimulator will deliver 30 minutes of therapy. You can read, listen to music or do crossword puzzles or other similar activity during your treatment.
It is difficult to say as people respond in different ways, but most patients feel a buzzing, tingling or throbbing sensation while the stimulation is occurring. Once the correct feeling is located the current can be turned down so that it is comfortable. It is not necessary to feel this throbbing sensation the whole 30 minutes. After treatment the stimulator will beep upon the completion of the treatment session. Your clinician will turn off the stimulator and remove the needle electrode. You should be able to resume normal activities immediately following treatment.
You will have an initial series of 12 weekly sessions lasting for approximately 30 minutes each. As this is a relatively new treatment it is important to collect as much information about your problem both before and after the treatment. You may be asked to fill in assessments about your symptoms and the effect they have on your quality of life. You should report any side-effects you experience.
You may need to return periodically for further treatments to maintain the improvement in your symptoms. It is very important to the success of the treatment that there are no long breaks during the initial 12 weeks of the treatment. If you have a holiday planned it is best to delay the start of the treatment until after the holiday. It is also possible to have the treatment twice a week, so only having to attend for 6 weeks. Please discuss any issues with appointments with your clinician.
Studies looking at the effect of PTNS show that up to 55% of patients find that their symptoms are cured and up to 90% are improved after a full course of treatment. However it may take up to 6 weeks before seeing any change. The effects wear off with time, but in patients who have top-up treatments beneficial effects are usually maintained.
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