Refractory overactive bladder symptoms improve days after Botox injection

Refractory overactive bladder patients treated with 100 units of intradetrusor onabotulinumtoxinA (BTX-A) reported a median time to improvement at 3 days post treatment, with maximum improvement at 7 days, according to research presented at the 2021 American Urological Association Annual Meeting.1

“Prior to this study, there was really no data on exactly how long it takes until Botox begins to take effect in the bladder. Patients always ask the question, ‘How many days till I will notice an improvement?’ The original studies could really only give us an idea that it should happen by two weeks,” said study author Howard B. Goldman, MD, professor and vice chair, Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.

Cleveland Clinic investigators conducted a prospective, non-randomized study of 51 patients (including 3 males) with non-neurogenic, refractory urgency-frequency syndrome and urgency urinary incontinence undergoing first-time BTX-A injection. Patients’ median age was about 72 years with an average body mass index of 33.8. All stopped taking overactive bladder medications and completed a daily Patient Global Impression of Improvement diary for 3 weeks following BTX-A treatment.

“We chose non-neurogenic patients with refractory overactive bladder and at least one overactive bladder medication for a number of reasons. First of all, insurance will only cover Botox for the bladder if a patient has tried and failed conservative treatments and at least one…medication. So, those are the patients that get Botox, in general,” Goldman said. “We chose non-neurogenic patients because the cause of overactive bladder in neurogenic patients may be different and, thus, we wanted to use a homogeneous population.”

Forty-eight patients reported symptom improvement according to Patient Global Impression of Improvement scores.

“We can now tell patients that most of them will notice some improvement by 3 days, a lot of improvement by 5 days and that maximum improvement is generally at 7 days and then continues,” Goldman said.

There were a few adverse events. Three patients had urinary tract infections (UTIs) and 2 had symptomatic retention.

“The fact that patients noted improvement by 3 days and a lot of improvement by 5 days was earlier than we had really expected. We also had a very high rate of overall improvement, with 92% of the patients having improvement,” Goldman said. “The rate of urinary tract infections was quite low, at 6%, which is less than we had expected. And 80% of patients did not restart previous overactive bladder medications during the study time period.”

The findings change how Goldman counsels patients.

“I can reassure them of excellent success, low urinary tract infection rate and can let them know that by 5 days, they should be noting significant improvement in their symptoms. I can also tell them that the majority do not need to take the overactive bladder medication anymore after the Botox treatment,” he said. “We would not, however, utilize Botox in patients who had difficulty emptying their bladders or in patients that also have bowel problems. Those patients might be better served with sacral neuromodulation.”


1. Kocher NJ, Zillioux Z, Martin S, et al. Patient-reported onset of symptom improvement following initial intradetrusor onabotulinumtoxina injections for overactive bladder. Paper presented at: 2021 American Urological Association Annual Meeting; September 10-13; virtual. Abstract MP52-11.