1. Onabotulinum toxin for Pelvic pain Philip Toozs-Hobson Consultant Urogynaecologist Birmingham UK

2. Declaration I was sponsored by Allergan to travel to and attend this meeting I work as a consultant for Allergan and Astellas I was an author on the RELAX study I have been involved in Allergan and Astellas sponsored trials I undertake private practice

3. Onabotulinum Toxin Growing body of evidence Mainly case reports – Relatively rare Difficult to classify for research

4. What can you use Botox for… Ophthalmic – Strabismus – Blepherospasm MSK – Corticollis – Cervical dystonia Cosmetic Neurological – Migraines – severe primary axillary hyperhidrosis Urological – NDO/UDO

5. Botox and pain Torticollis Vulvodynia Back pain Fibromyalgia Tennis elbow Post mastectomy pain TMJ pain Chronic prostatic pain Whiplash Tendonitis Premature ejaculation Anal fissures

6. Mechanism of action

8. Facts Botox takes min 48 hours to get flaccid paralysis Pain relief almost instantaneous Botox migrates up nerves

9. Muscle contraction Peripheral sensitisation Central sensitisation BOTOX ® : An innovative treatment for OAB with a dual mechanism of action 1–3 Blocks peripheral release of neurotransmitter at presynaptic cholinergic nerve terminals Blocks release of neurotransmitters and down regulates expression of receptors associated with sensory afferent pathway BOTOX ® Targets both the efferent and afferent pathway Treatment benefit: Detrusor muscle relaxation Treatment benefit: Reduced urgency BOTOX ® targets both the afferent and efferent pathways Acetylcholine Sensory neuropeptides and receptors Sympathetic nervous system activity maintained as bladder fills Reduced parasympathetic nervous system activity in response to bladder distension Efferent pathway Afferent pathway OAB, overactive bladder. 1. BOTOX ® Summary of Product Characteristics, Allergan 2. Purves D, et al. Autonomic Regulation of the Bladder. Neuroscience. 2nd edition. 2001. 3. Apostolidis A, et al. Eur Urol 2006;49:644–50.

11. Site of action NMJ Autonomic ganglion Postganglionic parasympathetic nerve ending Postganglionic sympathetic nerve endings which use Ach

12. Nerve interactions

15. Differential diagnosis Vulvadynia Atrophic vaginitis PNE – After vaginal surgery Interstitial cystitis Visceral hypersensitivity Chronic Pelvic pain Fibromyalgia MS Vaginismus Myofascial trigger points Sacro-iliac joint pain Psoas problems Faccet joint problems Referred hip pain

16. Assessment History – Onset – Try to differentiate cause in history Examination – Pain mapping Treatment – Relaxation/PFE’s

17. Technique Pain map with patient awake GA 100U split doses into trigger points – Using pudendal needle Can do in outpatients in the brave – Using blue or green needles

18. A prospective cohort study 12 women dyspareunia (80 vs 28; P = 0.01) non-significant reductions in non-menstrual pelvic pain (64 vs 37) Pelvic floor muscles manometry showed a 37% reduction in resting pressure Jarvis et al ANZJOG 2004

19. Largest review >400 patients four subgroups: BPS/IC (n = 157) CPP (n = 98), vulvodynia dyspareunia (n = 40) “other” (n = 113). complaints of voiding dysfunction (70%), dyspareunia (54%) mean PUF score of 15.9 ± 6.4 positive potassium sensitivity test in 83%. Urodynamics revealed a maximal urethral pressure of 131 cm of water and an abnormal uroflow in 80%. benefit in all groups (50%, 67%, 73%, and 77% for vulvodynia, CPP, BPS/IC, “other”). International Urogynecology Journal Volume 20, Number 9 (2009), 1047-1053, Volume 20, Number 9

20. Our results Have treated around 30 patients About a 70% response rate Lasts at least 6 months – Side effects: urinary incontinence, retention, faecal incontinence

21. Refractoy Myofascial trigger points Methods 31 patients (2005-10) mainly 300 U Mean age 55 Median pain 9.5/10 – 15 repeat injections (at median of 4 months) 17 OPD treatment Results 52% pain free Median score 3/10 Side effects – Urinary retention (3) – faecal incont (2) – Constipation/pain (3) But improved in 15! Adelowo et al Female Pelvic Med Reconstructr surg 2013

22. Conclusions Increasing understanding of Mechanisms of action of Botox Increasing data on safety Can be very useful with careful patient selection