Dysfunctional voiding and reflux – combined treatment with botulinum toxin A and dextranomer/hyaluronic acid
Background Dysfunctional voiding (DV) may exacerbate vesicoureteral reflux(VUR) or cause breakthrough UTI. DV has also been implicated as a risk factor for failure of Dextranomer/Hyaluronic acid (Deflux) injection. Endoscopic injection of botulinum toxin A (Botox) at the external sphincter has been used for DV, but simultaneous therapy for VUR with Deflux has not been reported. Methods Retrospective review of children undergoing endoscopic therapy with Botox or Deflux was performed over 2 years to identify children receiving simultaneous injections. Results Over a 2 year period, 31 children underwent subureteric injection of Deflux for VUR and 11 children underwent intrasphincteric injection of Botox for DV. Of these cases, 5 involved simultaneous therapy. These children ranging in age from 5–16 years, presented with incontinence, constipation, and/or prior pyelonephritis. In spite of biofeedback in 80%, symptoms persisted with urodynamic testing showing an interrupted uroflow pattern / increased EMG activity and postvoid residual. VUR ranged from grade 2-4, on the more severely affected side, with 50% showing reflux nephropathy. Botox injection of 100 units was transurethral in boys, and periurethral in girls with EMG guidance. All patients showed improvement in voiding parameters and symptoms. Deflux injections were successful in all cases of primary VUR. Conclusion VUR and DV often coexist. Combined therapy with Botox / Deflux allows both disorders to be treated simultaneously, with good outcomes.