Chronic bladder pain is the hallmark of interstitial cystitis/bladder pain syndrome  (IC/BPS), which is a debilitating disease.  IC/BPS symptoms result in poor quality of life with sleep dysfunction, depression, anxiety and stress . Repeated intravasical OnabotulinumtoxinA injections was studied and found to decreases the expression of vascular endothelial growth factor which play an important role in the pathogenesis of IC/BPS. To our knowledge , there is no study that looked at the local experience in Saudi Arabia. We aim to evaluate the outcome, safety, complications and patient’s tolerability of repeated intravesical OnabotulinumtoxinA (BOTOX) injection for interstitial cystitis/bladder pain syndrome in one center in Saudi Arabia

Retrospectively we reviewed medical charts of 26 adult patients (4 males and 22 females with mean age of 40.9 years) who underwent BOTOX injections for painful bladder syndrome from March 2010 to June 2017 in a single tertiary care center. Intravesical BOTOX injections of 100, 150 or 200 units were given depending on patient’s condition and side effects risk.
Preoperative data (demographic data ,medical history , comorbidities and body mass index), Intraoperative data (Operation time , Botox dose, injection sites, ulcerations number, and intraoperative complications) and  Pre, same day post-operative and 4 months post treatment pain score via visual analogue score (VAS) were collected from the files. The procedure is performed as a day case activity under general anesthesia. The outcome was determined at 4 months post BOTOX injection treatment via clinic visit interview about improvement of pain and following changes in bladder ulceration during future cystoscopies. Patient’s satisfaction rate was assessed through a short survey: fully satisfied, partially satisfied (50% or more) or not satisfied, if patient will repeat the injections, and if patient will recommend this therapy to other patients.

26 charts were reviewed. All patients underwent total of 114 procedures. 23/26( 88.46%) patients underwent repeated procedures ( at least twice ) with a mean of 5.15 procedures /patient and mean of 10.64 months between repeated procedures . Mean operative time was 7.2 minutes. 30.77% of the patients (8) were morbid obese, 7.7 %( 2) had diabetes mellitus, 11.54 %( 3) had Hypertension.
50 %( 13) of the patients received 200 units of BOTOX, 23 %( 6) received 100 units and 27 %( 7) received 150 units. Adjustment of BOTOX dose was performed in 10 patients (3 patients had their doses increased for more control and 7 patients were reduced the dose to minimize voiding difficulties.

The pain score via visual analogue score dropped to 0.62 after the procedure from 8.7 at the time of the diagnosis of IC/PBS. 5/26 patients with classic bladder wall ulcerations. 3/5 had complete resolutions of the bladder wall ulcers after two repeated BOTOX intravesical injections. 2/5 had significant improvement (more than 50%) of the ulcers.
There was no major intraoperative or postoperative complications. Postoperative urinary retention was observed in 3 patients and they were managed by clean intermittent catheterization. Other 3 patients had urinary tract infection and treated with oral antibiotics and did not required admission.
16/23 (69.6%) were fully satisfied and 7/23 (30.4%) were partially satisfied. 88.46% of all patients would repeat the treatment and 77% would recommend the treatment to other patient.

Repeated intravesical BOTOX injection is an effective, well tolerated and safe treatment modality for patients with IC/PBS. It has a very good outcome in controlling the disease pain symptom and treating bladder wall ulcers.