A Surprising Treatment for Urinary Incontinence: Botox Shots

The diagnosis of multiple sclerosis (MS) changed Susan Brown's life. For years, she'd worked as banquet manager at the Hilton in downtown San Francisco, putting in long hours and racing miles through the hotel's dining rooms to manage the team that fed thousands of patrons a day. But MS kept making it harder and harder to walk, compelling her to retire in 2015.

Still, Brown found ways to work around her illness. She adjusted her expectations about her activities and learned to use a walker and a scooter. But one problem seemed unsolvable: her worsening urinary incontinence.

"The bladder issues started more or less right away and got progressively worse," Brown, now 56, recalls. She got up three or four times a night to urinate and visited the bathroom countless times during the day. The sensation of needing to urinate became increasingly pressing and uncontrollable, a condition known as urgency urinary incontinence or urge incontinence. Unlike stress incontinence, where pressure on the bladder (such as from laughing, sneezing or physical activity) causes leakages, urge incontinence occurs because the bladder muscle spasms or contracts. The result: a sudden, uncontrollable need to urinate, followed by the undesired release of urine.

Unfortunately, Brown's struggle with incontinence is common among MS patients, since the condition's characteristic spinal cord damage can interfere with signals between the brain and the nerves controlling the bladder. More than 80 percent of MS patients develop some type of bladder dysfunction.

It got to the point where, says Brown, "I didn't even have five seconds to get to the restroom. It was instant." She began relying on pads and disposable absorbent underwear as well as packing a change of clothes any time she left the house. The anxiety about having an accident made her feel housebound.

Brown despaired that as much as MS had shrunk her life, the worsening incontinence would make it even smaller. But then her neurologist referred her to urologist Dr. Anne Suskind at the UCSF Women's Center for Bladder and Pelvic Health. An expert in the type of incontinence Brown was suffering, Suskind understood what she was going through.

"Incontinence is such a bothersome condition," says Suskind. "It's not life-threatening, but it can certainly alter your life. A lot of people self-isolate; they don't go out or socialize. It affects their activities, their relationships, so it can be a big deal."

It's also a condition that can be hard to talk about. Part of the mission of the Center is to create a safe and welcoming environment where patients will feel comfortable seeking out the care they need.

The Center provides the full spectrum of treatments for urgency incontinence, from behavioral strategies and exercises to strengthen the pelvic floor to medications that can calm an overactive bladder to more invasive interventions such as botulinum toxin (Botox) and sacral neuromodulation, in which a device is implanted through the sacrum (just above the tailbone) to stimulate the nerve that goes to the bladder.

The doctors at the Center are committed to working collaboratively with patients to determine the right treatment. After discussing the various options, Suskind and Brown decided to start with medication and an acupuncture-based therapy that has been approved by the FDA for treating urge incontinence. But after six months of treatment, Brown's condition hadn't improved.

Suskind next suggested injections of botulinum toxin, more commonly known as Botox. Surprisingly, the same drug known for smoothing wrinkles can also relieve urge incontinence – and by the same mechanism: It relaxes muscles. Just as Botox shots in the forehead relax facial muscles and soften worry lines, Botox shots in the bladder quell the muscle spasms of urge incontinence, giving the patient time to reach the bathroom. The treatment works for about 70% of patients, according to Suskind.

Brown came to Suskind's clinic for the procedure. The nurses began by inserting a thin, flexible tube called a catheter through Brown's urethra and into her bladder to apply a topical lidocaine instillation as a numbing medicine. The lidocaine was then drained and Suskind inserted a cystoscope (a thin device with a tiny camera) to see where to inject the Botox. She delivered multiple shots through the cystoscope throughout the bladder. For Brown, each felt like a mild poke or pinch. She appreciated how Suskind and the nurses helped her relax and feel comfortable throughout the procedure, which lasted only a few minutes. "It's truly one of the most uncomfortable things you have to deal with. But everyone there was wonderful," Brown says. The whole visit took less than an hour.

The treatment can cause mild cramping, bleeding or difficulty urinating, but Brown experienced no side effects. And while it usually takes a week or two for the shots to start working, Brown began feeling the effect that very day. She was thrilled: "I was like, 'Oh my God, this is great!'"

Suskind is used to that reaction. "My Botox patients are some of my happiest patients," she says. "It really can be a game changer."

It is, however, temporary. The effects of Botox wear off in three to 12 months, so the treatment has to be repeated regularly. Since her first round of shots, Brown has had three more, scheduling a treatment whenever she feels that urinary urgency starting to return.

Botox, says Brown, "just changed my life." Now she accompanies friends on outings to the beach, museums and Golden Gate Park without worrying about accidents. With MS, she says, "I lost control over so many things. This gave me back a sense of control in my life."