More Than Just A Pretty Face

More than just a pretty face: the holistic impact of muscle relaxing injections for patients with urinary urge incontinence.

Muscle relaxing injections are more than the fountain of youth for many. They have revolutionized the world of patients who suffer from medical conditions that negatively impact on their wellbeing, comfort and quality of life. This article will discuss; holistic wellbeing in relation to comfort; muscle relaxing injections; urinary incontinence; review the literature on muscle relaxing detrusor injections and evaluate their impact on quality of life and patient comfort.

1. Holistic Wellbeing

Holistic wellbeing is to have a degree of wellness in each aspect of your physical, social and emotional life. Each domain is equally valuable in contributing to the quality of life and wellness of individuals and groups (Kolcaba, 2003). However, patients dealing with chronic conditions are not always well and are often required to manage conditions rather than treat or cure them. In Kolcaba’s Comfort Care Theory, holistic wellbeing is the state of achieving comfort or transcending states of discomfort (Kolcaba, 2003). Healthcare professionals and nurses in particular, have the opportunity to assist patients to achieve comfort in each of the four domains of holistic wellbeing. Kolcaba (2003) describes each domain of comfort:

Physical: the physical body and state of comfort of the patient. Physical aspects of comfort can include homeostasis, pain, blood pressure, heart rate, positioning and physical illness.
Psychospirtual: the emotional and mental comfort. This deals with self esteem, thoughts, feelings, emotional responses and world views.
Sociocultural: encompassing the external relationships the patient has, including significant others, family, friends, community groups and religion, as well as continuity of care and activity planning.
Environmental: the surrounding environment that patient experiences, such as temperature, noise, odours, shelter, pollution, synthetic environments and access to nature.

If we consider what cultural beliefs are held about muscle relaxing injections use, it may be seen that anti wrinkle injection deals with only the physical and emotional comfort of patients. However, if we look more closely at urinary incontinence management, holistic wellbeing and comfort theory, it can be seen that the effects of botulinum are far beyond noticeable, physical changes.

2. Muscle Relaxing injections

Muscle relaxing injections work at the synaptic cleft at the neuromuscular junction. Receptors in the synaptic cleft of a muscle cell release acetylcholine. The synaptic vessel transports acetylcholine across the neuromuscular junction to the axon terminal (Crowther-Radulewicz, 2010). Muscle relaxants act directly on acetylcholine. Heavy chain and light chain neurotoxin molecules enter the synaptic cleft and synaptic vessels, replacing acetylcholine. Without acetylcholine transmission, muscles remain in a relaxed state (Habrawi, 2011). In results across several studies, a significant proportion of patients experienced results for longer than 12 months (Apostolidis, et al., 2009; Brubaker, et al., 2008; Hoebeke, et al., 2006; Mangera, et al., 2011). However, the effects on the neuromuscular junction are not permanent.

The development of the use of muscle relaxants to manage urinary incontinence was a logical progression from other uses in treating muscular conditions such as blepharospasm, upper limb spasticity and cervical dystonia. Muscle relaxant injections are an effective treatment because they target the neuromuscular aspect of incontinence (Schurch, Denys, Kozma, Reese, Slaton & Baron, 2007).

3. Urinary Incontinence

Urinary incontinence is loss of or inability to maintain control of bladder function. Men and women of all age groups are affected by urinary incontinence. The causes of urinary incontinence are varied and each cause has a specific treatment plan. Urinary incontinence is first managed with urinary incontinence pads, however; frequent incontinence despite conservative treatment may impact so severely on patients’ quality of life, that intervention is required to manage the condition successfully (Schurch, Denys, Kozma, Rees, Slaton & Barron, 2007a). Muscle relaxant injections are successfully used for urge incontinence and results indicate increased quality of life factors for these patient groups (Schurch, et al., 2007a).

The impact of urinary incontinence on the quality of life of patients can be debilitating. It can have a significant impact on the physical, psychosocial, sociocultural and environmental wellbeing of the patient. (Huether & Forshee, 2010; Schurch, et al., 2007a; Schurch, Denys, Kozma, Rees, Slaton & Barron, 2007b). Urinary incontinence is not a desirable state and has social impacts such as embarrassment due to wetness, odour and frequent need to manage the condition.

Urinary continence is controlled by the detrusor motor area, the pontine micturation centre and the urethral sphincter. Lesions at any level of the sensory or motor nervous system can cause an urge incontinence. Urge incontinence is described as an “involuntary loss of urine associated with an abrupt and strong desire to void (urgency). Often associated with involuntary contractions of the detrusor” (Huether & Forshee, 2010, p. 1369). There are many causes of urge incontinence, which cause 3 specific types of urge incontinence:

bladder-carcinoma — Bladder muscle anatomy

Detrusor hyperreflexia is caused by lesions above C2, above the pontine micturation centre. Patients experience an automatic emptying of the bladder once it is full. As the pontine micturation centre functions, the urinary sphincter muscle acts normally and relaxes, causing incontinence. Causes of detrusor hyperreflexia include stroke, traumatic brain injury, tumours, multiple sclerosis, Alzheimer’s disease and hydrocephalus (Huether & Forshee, 2010). Detrusor hyerreflexia is an upper motor neuron disorder.
Detrusor hyperreflexia with vescicosphincter dyssynergia occurs when lesions form between the pontine and sacral micturation centre. Pontine communication is lost and the bladder and urinary sphincter contract simultaneously, obstructing the bladder outlet. The bladder is unable to relax completely, resulting in an increased intravesicular pressure (bladder pressure). Patients develop overactive bladder syndrome, suffering from frequency, urgency and an increased risk of urinary tract infections. Overactive bladder syndrome (OAB) has been identified with; an increase of health costs; decreased quality of life, including physical illness, mental health problems and social isolation; urinary tract infections; and frequency related increased risk of falls (Huether & Forshee, 2010). Patients without neurogenic disorders experience OAB (MFMER, 2011), however, the main pathological causes include; spinal injuries between C2 and T12; multiple sclerosis; and Guillain-Barre syndrome (Huether & Forshee, 2010). Destrusor hyperreflexia with vesicosphincter dyssynergia is an upper motor neuron disorder.

Peripheral lesions and lesions including the sacral micturation centre result in detrusor areflexia. The detrusor does not contract, resulting in the patient feeling full, without the ability to empty the bladder. Patients will experience overflow incontinence and stress incontinence, when they sneeze or cough. This is known as an underactive bladder syndrome and occurs in patients with multiple sclerosis, peripheral polyneuropathies, spinal injuries between T12 and the sacrum, herpes zoster and cauda equina syndrome (Huether & Forshee, 2010). Detrusor areflexia is a lower motor neuron disorder.

4. Muscle Relaxing Injections & Urge Incontinence Research

Most commonly, muscle relaxants are injected into the urinary sphincter at the neck of the bladder via cystoscopy, under local anaesthesia (Brubaker, Richter, Visco, Mahajan, Nygaard, Braun, Barber, Menefee, Schaffer et al., 2008). Apostolidis, Dasgupta, Denys, Elneil, Fowler, Giannantoni, Karsenty, Schulte-Baukloh, Schurch et al. (2009), highlighted that depth and location of the injections must be injected into the detruser below the trigone. Injection dosage varies, and further research into botulinum type A dosage for urge incontinence is required across different patient groups, including children (Apostolidis, et al., 2009; Brubaker, et al., 2008).

Muscle relaxant detrusor injections have shown that a significant proportion of patients experience long-term results. In a double-blind, placebo controlled randomised control trial (Brubaker, et al., 2008) of 210 women with OAB urge incontinence, 60% saw a significant reduction of symptoms. The average response for results lasting 373 days, compared to 62 days placebo (p<0.0001). Furthermore, in a study of children with urge incontinence (Hoebeke, De Caestecker, Vande Walle, Dehoorne, Raes, Verleyen, Van Laecke, 2006), 70% of participants had results lasting greater than one year. Both studies highlighted that though results were long lasting for many and a proportion of patients experienced side effects such as urinary tract infection, post void residual urine and retention (Brubaker, et al., 2008; Hoebeke, et al., 2006). Patients must be monitored closely following detrusor injections, to observe for product efficacy and unwanted side effects.

Two preparations of muscle relaxing detrusor injections are available to patients with urinary incontinence. A systematic review found that onabotulinum and abotulinum both show high level evidence to support their use in urinary incontinence, however, onabotulinum had a broader efficacy across different types of urinary incontinence (Mangera, Andersson, Apostolidis, Chapple, Dasgupta, Giannantoni, Gravas, Madersbacher, 2011). Patient counselling and education about product efficacy and expected results is vital when more than one option is available. Reviews of the evidence suggest that dosage of either product is varied and further research is needed to determine efficacy of treatment doses (Apostolidis, et al., 2009; Brubaker, et al., 2008; Mangera, et al., 2011).

5. Holistic Comfort, Quality of Life & Muscle Relaxing Injections

Schurch, et al. (2007a), examined the quality of life effect muscle relaxing injections have on patients with urge incontinence. The authors used the Incontinence Quality of Life scale [I-QOL] to measure quality of life outcomes of 59 patients across eight centres. Measured outcomes included Intervention patients showed significant increases in I-QOL scores compared to placebo groups. Muscle relaxing injections are shown to improve the quality of life scores of patients. However; the qualitative aspects of this treatment are limited and this author believes that further mixed method studies would improve research.

Holistic wellbeing

Comfort care planning for urinary incontinence

Three domains in Comfort Theory care planning include relief, ease and transcending discomfort (Kolcaba, 2003). Muscle relaxing injections and other incontinence interventions may provide complete relief of, ease of or allow patients to transcend urge incontinence. Relief can be described as providing complete resolution to a state of discomfort. Below is an example of a comfort care plan that might be made for Penny, a 52 year old woman who suffered a traumatic brain injury 15 years ago. She now has urge incontinence, which stops her from going to the beach because feels like she cannot wear bathing suits, or go on long walks with her friends as there is no toilet. This causes her discomfort, anxiety and often she finds herself in a low mood due to her increased isolation. Detrusor botulinum injections have been considered as part of her treatment plan. The aim is to provide relief or ease in all of the domains of holistic wellbeing for Penny.

Adapted from Kolcaba (2003).

Summary

Patients who suffer from urge incontinence are likely to benefit from a management plan that includes muscle relaxing detrusor injections. If we consider the impact that urinary incontinence has on top of the burden of disease for many patients, it is essential that care plans consider intervention sooner rather than later. Patients that continue to use conservative treatment without success, are at risk of harm to physical, psychospiritual, sociocultural and environmental suffering.

Evidence to support the use of muscle relaxing injections in the treatment of incontinence is growing for patients with urge type urinary incontinence. Patients are not only benefiting from improved symptom control, but also improved holistic wellbeing. Muscle relaxing injections are enabling many patients to have an improved quality of life and better health outcomes. Further study into improved dosage requirements will increase the success of detrusor injection site interventions.

The Pharmaceutical Benefits Scheme subsidises injections for incontinence treatment for eligible patients.

For more information see the Department of Human Services website

www.humanservices.gov.au/health-professionals/enablers/botulinum-toxin-program

6. Reference List

Apostolidis, A., Dasgupta, P., Denys, P., Elneil, S., Fowler, C.J., Giannantoni, A., Karsenty, G., Schulte-Baukloh, H., Schurch, B., & Wyndaele, J.J. (2009). Recommendations on the use of botulinum toxin in the treatment of lower urinary tract disorders and pelvic floor dysfunctions: a European census report. European Urology, 55(1), 100-120. Abstract retrieved from ScienceDirect
Brubaker, L., Richter, H.E., Visco, A., Mahajan, S., Nygaard, I., Braun, T.M., Barber, M.D., Menefee, S., Schaffer, J., et al. (2008). Refractory idiopathic urge urinary incontinence and botulinum A injection. The Journal of Urology, 180(1), 217-222.
Bladder carcinoma. (2011). Bladder carcinoma. http://3.bp.blogspot.com/-f0NyiSXaNnM/TjjxXHOW9YI/AAAAAAAAAQ4/ARV0ZahESds/s1600/bladder-cancer.jpg
Crowther-Radulewicz, C.L. (2010). Structure and function of the musculoskeletal system. In McCance, Huether, Brashers & Rote, Pathophysiology: the biologic basis for disease in adults and children (6^th ed, 1365-1401). Missouri: Mosby.
Habrawi, Z. (2011). The poison that become a medicine. ePharmapedia
Hiding face. (n.d.) Rgbstock. http://l.rgbimg.com/cache1nNv5h/users/s/sc/scottmliddell/600/mjQpmss.jpg
Hoebeke, P., De Caestecker, K., Vande Walle, J., Dehoorne, J., Raes, A., Verleyen, P., & Van Laecke, E. (2006). The effect of botulinum-a toxin in incontinent children with therapy resistant overactive detrusor. The Journal of Urology, 176(1), 328-331. Abstract retrieved from ScienceDirect
Huether, S.E., & Forshee, B.A. (2010). Alterations of renal and urinary tract function. In McCance, Huether, Brashers & Rote, Pathophysiology: the biologic basis for disease in adults and children (6^th ed, 1540-1567). Missouri: Mosby.
Karsenty, G., Denys. P., Amarenco, G., De Seze, M., Game´, X., Haab, F., Kerdraon, J., Perrouihn-Verbe, B., & Ruffion, A., et al. (2007). Botulinum toxin A (Botox) intradetrusor injections in adults with neurogenic detrusor overactivity/neurogenic overactive bladder: a systematic literature review. European Urology, 53(2), 275-287.
Kolcaba, K.Y. (2003). Comfort theory and practice. New York, New York: Springer.
Mangera, A., Andersson, K.E., Apostolidis, A., Chapple, C., Dasgupta, P., Giannantoni, A., Gravas, S., & Madersbacher, S. (2011). Contemporary management of lower urinary tract disease with botulinum toxin A: a systematic review of Botox (onabotulinumtoxinA) and Dysport (abobotulinumtoxinA). European Urology, 60(4), 784-795. Abstract retrieved from ScienceDirect
MFMER. (2011). Urinary incontinence. MayoClinic.com
Patrick, D.L., Martin, M.L., Bushnell, D.M., Yalcin, I., Wagner, T.H., & Buesching, D.P. (1999). Quality of life of women with urinary incontinence: further development of the incontinence quality of life instrument (I-QOL). Urology, 53(1), 71-76. Abstract retrieved from ScienceDirect
Schurch, B., Denys, P., Kozma, C.M., Rees, P.R., Slaton, T., & Barron, R.L. (2007a). Botulinum toxin A improves the quality of life of patients with neurogenic urinary incontinence. European Urology, 52(3), 850-859.
Schurch, B., Denys, P., Kozma, C.M., Rees, P.R., Slaton, T., & Barron, R.L. (2007b). Reliability and validity of the incontinence quality of life questionary in patients with neurogenic urinary incontinence. Archives of physical medicine and rehabilitation, 88(5), 246-252. Abstract retrieved from ScienceDirect
Temml, C., Haidinger, G., Schmidbauer, J., Schatzl, G. & Madersbacher, S. (2000). Urinary incontinence in both sexes: prevalence rates and impact on quality of life and sexual life. Neurourolgy and Urodynmics, 19(3), 259–271.