Posts Tagged ‘Botox’


May 6, 2017

Andrew Siegel MD  5/6/17 (my daughter’s 18th birthday!)

For most people, the urinary bladder is a cooperative and obedient organ, behaving and adhering to its master’s will, squeezing only when appropriate. However, some people have bladders that are unruly and disobedient, acting rashly and irrationally, squeezing at inappropriate times without their master’s permission. This condition is referred to as “overactive bladder” or OAB for short. This problem can occur in both women and men, although it is more common in females.


“Gotta go,” the urinary urgency that is the hallmark of OAB

8. UUI

Image above (artist Ashley Halsey from “The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health”) illustrates a bladder contracting involuntarily, leading to urinary leakage

OAB ( is a common condition often due to one’s bladder contracting (squeezing) at any time without warning.  This involuntary bladder contraction can give rise to the symptoms of urgency, frequency (daytime and nighttime) and urgency incontinence. The key symptom of OAB is urinary urgency (a.k.a. “gotta go”), the sudden and compelling desire to urinate that is difficult to postpone.

Although OAB symptoms can occur without specific provocation, they may be triggered by exposure to running water, cold or rainy weather, hand-washing, entering the shower, positional changes such as arising from sitting, and getting nearer and nearer to a bathroom, particularly at the time of placing the key in the door to one’s home.

An evaluation includes a urinalysis (dipstick exam of the urine), a urine culture (test for urinary infection) if indicated, and determination of the post-void residual volume (amount of urine left in bladder immediately after emptying). A 24-hour voiding diary (record of urination documenting time and volume) is an extremely helpful tool.  Urodynamics (test of storage and emptying bladder functions), cystoscopy (visual inspection of inside of bladder), and renal and bladder ultrasound (imaging tests using sound waves) may also prove helpful.

The management of OAB is challenging, yet rewarding, and necessitates a partnership between patient and physician. Successful treatment requires a willing, informed and engaged patient with a positive attitude. Management options for OAB range from non-invasive strategies to pills to surgery. It is sensible to start with the simplest and least invasive means of treatment and progress accordingly to more aggressive and invasive treatments if there is not a satisfactory response to conservative measures.  Behavioral treatments are first-line: fluid management, bladder training, bladder control strategies, pelvic floor muscle training and lifestyle measures.  Behavioral therapies may be combined with medication(s), which are considered second-line treatment. Third-line treatments include neuromodulation (stimulating specific nerves to improve OAB symptoms) and Botox injections into the urinary bladder.

References that will help the process include the following:

Book: THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health

Book: MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

DVD: Easy-to-use, follow-along, FDA-registered pelvic training program that includes a detailed instruction guide, an interactive DVD and digital access to the guided training routines:

12 Steps To Overcoming OAB

The goal of the 12 steps that follow is to re-establish control of the urinary bladder.  Providing that the recommendations are diligently adhered to, there can be significant improvement, if not resolution, of OAB symptoms.

  1. FLUID AND CAFFEINE MODERATION/MEDICATION ASSESSMENT  Symptoms of OAB will often not occur until a “critical” urinary volume is reached, and by limiting fluid intake, it will take a longer time to achieve this volume. Try to sensibly restrict your fluid intake in order to decrease the volume of urinary output. Caffeine (present in tea, coffee, colas, some energy drinks and chocolate) and alcohol increase urinary output and are urinary irritants, so it is best to limit intake of these beverages/foods.  Additionally, many foods—particularly fruits and vegetables—have hidden water content, so moderation applies here as well.  It is important to try to consume most of your fluid intake before 7:00 PM to improve nocturnal frequency. Diuretic medications (water pills) can contribute to OAB symptoms. It is worthwhile to check with your medical doctor to see if it is possible to change to an alternative, non-diuretic medication. This will not always be feasible, but if so, may substantially improve your symptoms.
  2. URGENCY INHIBITION Reacting to the first sense of urgency by running to the bathroom needs to be substituted with urgency inhibition techniques. Stop in your tracks, sit, relax and breathe deeply. Pulse your pelvic floor muscles rhythmically (see below) to deploy your own natural reflex to resist and suppress urgency.
  3. TIMED VOIDING (for incontinence) Urinating by the “clock” and not by your own sense of urgency will keep your bladder as empty as possible. By emptying the bladder before the critical volume is reached (at which urgency incontinence occurs), the incontinence can be controlled.  Voiding on a two-hour basis is usually effective, although the specific timetable has to be tailored to the individual in accordance with the voiding diary.  Such “preemptive” or “defensive” voiding is a very useful technique since purposeful urinary frequency is more desirable than incontinence.
  4. BLADDER RETRAINING (for urgency/frequency) This is imposing a gradually increasing interval between voids to establish a more normal pattern of urination. Relying on your own sense of urgency often does not give you accurate information about the status of your bladder fullness.  Urinating by the “clock” and not by your own sense of urgency will keep your voided volumes more appropriate. Voiding on a two-hour basis is usually effective as a starting point, although the specific timetable has to be tailored to the individual, based upon the voiding diary.  A gradual and progressive increase in the interval between voiding can be achieved by consciously delaying urinating.  A goal of an increase in the voiding interval by 15-30 minutes per week is desirable.  Eventually, a return to more acceptable voiding intervals is possible.  The urgency inhibiting techniques mentioned above are helpful with this process.
  5. BOWEL REGULARITY Avoidance of constipation is an important means of helping control OAB symptoms. Because of the proximity of the rectum and bladder, a full rectum can put pressure on the bladder, resulting in worsening of urgency, frequency and incontinence.
  6. PELVIC FLOOR MUSCLE TRAINING (PFMT)  *All patients need to understand the vital role of the pelvic floor muscles (PFM) in inhibiting urgency and frequency and preventing urge leakage.  PFMT voluntarily employs the PFM to help stimulate inhibitory reflexes between the pelvic floor muscles and the bladder.  Rhythmic pulsing of the PFM can inhibit an involuntary contraction once it starts and prevent an involuntary contraction before it even begins. Initially, one must develop an awareness of the presence, location, and nature of the PFM and then train these muscles to increase their strength and tone.  These are not the muscles of the abdominal wall, thighs or buttocks.  A simple means of recognizing the PFM for a female is to insert a finger inside her vagina and squeeze the PFM until the vagina tightens around her finger.  A simple means of identifying the PFM for either gender is to start urinating and when about half completed, to abruptly stop the stream. It is the PFM that allows one to do so. It is important to recognize the specific triggers that induce urgency, frequency or incontinence and prior to exposure to a trigger or at the time of the perceived urgency, rhythmic pulsing of the PFM–“snapping” the PFM several times–can either preempt the abnormal bladder contraction before it occurs or diminish or abort the bladder contraction after it begins.  Thus, by actively squeezing the PFM just before and during these trigger activities, the urgency can be diminished and the urgency incontinence can often be avoided.


Schematic diagram above illustrates the relationship of the contractile state of the bladder muscle to the contractile state of the PFM. Note that a voluntary PFM contraction can turn off an involuntary bladder contraction (+ symbol denotes contraction; – symbol denotes relaxation)

7. LIFESTYLE MEASURES: HEALTHY WEIGHT, EXERCISE, TOBACCO CESSATION   The burden of excess pounds can worsen OAB issues by putting pressure on the urinary bladder. Even a modest weight loss may improve OAB symptoms.  Pursuing physical activities can help maintain general fitness and improve urinary control. Lower impact exercises–yoga, Pilates, cycling, swimming, etc.–can best help alleviate pressure on the urinary bladder by boosting core muscle strength and tone and improving posture and alignment. The chemical constituents of tobacco constrict blood vessels, impair blood flow, decrease tissue oxygenation and promote inflammation, compromising the bladder, urethra and PFM.  By eliminating tobacco, symptoms of OAB can be improved. 

8.  BLADDER RELAXANT MEDICATIONS A variety of medications are useful to suppress OAB symptoms. It may take several trials of different medications or combinations of medications to achieve optimal results. The medications include the following: Tolterodine (Detrol LA), Oxybutynin (Ditropan XL), Transdermal Oxybutynin (Oxytrol patch), Oxybutynin gel (Gelnique), Trospium (Sanctura), Solifenacin (Vesicare), Darifenacin (Enablex) and Fesoterodine (Toviaz).  The most common side effects are dry mouth and constipation.  These medications cannot be used in the presence of urinary or gastric retention or uncontrolled narrow-angle glaucoma.  The newest medication, Mirabegron (Myrbetriq), has a different mechanism of action and fewer side effects.

9.  BIOFEEDBACK This is an adjunct to PFMT in which electronic instrumentation is used to relay feedback information about your PFM contractions.  This can enhance awareness and strength of the PFM.

10.  BOTOX TREATMENT This is a simple office procedure in which Botox is injected directly into the bladder muscle, helping reduce OAB symptoms by relaxing those areas of the bladder into which it is injected. Botox injections generally will last for six to nine months and are covered by Medicare and most insurance companies.

11.  PERCUTANEOUS TIBIAL NERVE STIMULATION (PTNS) This is a minimally invasive form of neuromodulation in which a tiny acupuncture-style needle is inserted near the tibial nerve in the ankle and a hand-held stimulator generates electrical stimulation with the intent of improving OAB symptoms. This is done once weekly for 12 weeks.

12.  INTERSTIM This is a more invasive form of neuromodulation in which electrical impulses are used to stimulate and modulate sacral nerves in an effort to relieve the OAB symptoms. A battery-powered neuro-stimulator (bladder “pacemaker”) provides the mild electrical impulses that are carried by a small lead wire to stimulate the selected sacral nerves that affect bladder function.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.


Botox: For A “Gladder” Bladder

December 19, 2015

Andrew Siegel MD   12/19/15


You are probably aware of Botox used for improving the cosmetic appearance of facial wrinkles. When injected into frown lines Botox paralyzes facial muscles resulting in creases, furrows and grooves disappearing and presto, you look a decade younger! Botox has numerous medical uses that go beyond improving one’s appearance. It is commonly used to improve internal body functions, e.g., injecting it into the bladder muscle to improve symptoms of overactive bladder (OAB).

Making Lemonade From Lemons

Botox is derived from the most poisonous substance known to man—botulinum toxin. This neurotoxin is produced by the Clostridium bacterium, responsible for botulism. Botulism is a rare but serious illness that can result in paralysis. Botulinum toxin, when used in minute quantities in a derivative known as Botox, is a magically effective and powerful potion.

How It Works

Botox is a neuromuscular blocking agent that weakens or paralyzes muscles. Beyond cosmetics, it can be beneficial for a variety of medical conditions that have in common some form of localized muscle over-activity. Its uses generally involve conditions with muscle spasticity, involuntary muscle contractions, excessive sweating and eyelid or eye muscle spasm.

Botox For The Bladder

Overactive bladder (OAB) syndrome consists of the symptoms of urinary urgency (the sudden desire to urinate), with or without urgency incontinence (urinary leakage associated with urgency), usually accompanied by frequent urination during both awake and sleep hours. OAB has been described as the “bladder squeezing without your permission to do so.”

When injected into the muscle of the bladder,  Botox treats the “wrinkles,” the thick muscle bands known in medical jargon as trabeculation, which are typically present in conditions that cause obstruction to the outflow of urine or bladder overactivity.  By temporarily paralyzing a portion of the bladder muscle, OAB symptoms can improve dramatically. 

Botox can be used in both genders.  It is usually a second line treatment for those who have not responded well or have been intolerant to oral bladder relaxant medications.  The goal of Botox is to  effectively treat persistent and disabling urinary urgency, frequency and urgency incontinence.  Botox is FDA approved in the USA in a 100 unit dose for overactive bladder and  200 unit dose for overactive bladder associated with neurological conditions.

Bladder Botox injection is a brief office procedure usually done under light sedation. It involves placing a cystoscope into the bladder and injecting  Botox into numerous sites in the bladder via a needle that fits through the cystoscope. The entire procedure takes 10 minutes or so.

Preparing for Bladder Botox/ Expectations 

  1. Stop blood thinner medications one week before Botox.
  2. Antibiotics are started 2 days before and continued for 2 days after.
  3. You may experience blood-tinged urine, burning with urination and pelvic pain for a day or so after the procedure.
  4. You may experience difficulty urinating and feel that you are not emptying completely; if so, this may require a catheter or temporarily learning how to do self-catheterization.
  5. It may take a week or two to notice improvement. Although Botox is highly effective, it is not so in everyone.
  6. Follow up urinalysis and check of the post-void residual volume (how much urine is left in the bladder after voiding) in two weeks.
  7. Botox should last 6-9 months or so. After the improvement wears off, the injection can be repeated. If ineffective or only partially effective, the Botox dosage can be increased.

Bottom line: Botox, a  neurotoxin produced by Clostridium that causes paralysis, can be beneficial when injected into virtually any muscle in the body that is in a state of hyper-contraction and spasticity.  It has found utility for a variety of medical conditions, particularly for the treatment of overactive bladder symptoms.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.

Vaginismus: Too Tight Not Right

December 12, 2015

Andrew Siegel MD   12/12/15


Vaginismus is a medical condition in which a woman’s vagina is unable to be penetrated despite her desire to be receptive to vaginal intercourse. There are often both physical and emotional factors that underlie this disorder. Spasticity of the vaginal and pelvic floor muscles as well as fear and anxiety issues are typically present. Vaginismus has significant psychological ramifications, negatively influencing self-image and potentially undermining and destroying relationships.

Even though vaginismus was initially described in the medical literature over 150 years ago, it remains a misunderstood, under-diagnosed and under-treated disorder. It renders the sufferer either unable to be vaginally penetrated or able to be penetrated, but at the cost of experiencing severe pain. This can occur whether the vaginal penetration is via a finger, tampon, at the time of a gynecological exam or with sexual intercourse. This condition causes embarrassment and frustration and is not a topic that most women are readily willing to discuss with their physician, friends or family members.

The precise underlying causes of vaginismus remain unknown, although possible contributing elements may be a history of sexual molestation,  a traumatic pelvic examination or gynecological procedure at a young age, strict sexual constraints, religious factors and excessive fear of sexual intercourse, sexually transmitted infections and pregnancy.

Men who attempt to have sexual intercourse with women suffering with vaginismus often describe “hitting a wall” or “absence of a hole down there,” reflecting the excessive tone and spasticity of the vagina and pelvic musculature.  Pelvic examination of a woman suffering with vaginismus usually demonstrates that the muscles surrounding the entry to the vagina are in spasm, akin to a tightly clenched fist.

Understandably, after attempts at unsuccessful sexual intercourse, women with vaginismus often develop an aversion to sex because of actual pain as well as anticipated pain. This sets up a vicious cycle in which emotional fear fuels more physical spasticity, further exacerbating the problem.

Fortunately, vaginismus is a manageable condition.  Treatments address both the physical and emotional aspects of the problem and include the following: vaginal dilators; pelvic floor physical therapy; sexual counseling; psychotherapy; hypnotherapy; cognitive behavioral therapy; and Botox. Combination treatment that is tailored to the specifics and nuances of the situation and individual are the most effective means of fostering vaginal and pelvic relaxation and improving this condition.

The idea behind vaginal dilation is to gradually and incrementally stretch the vagina and allow the patient to become comfortable with penetration. There are many dilation regimens varying with respect to the size of the dilators used and the length of time the dilators are retained, with some programs having the patient sleep with the dilators in place. If successful, transition to sexual intercourse can proceed.

Pelvic floor physical therapy via physical therapists who specialize in pelvic floor issues can be extremely helpful and effective, particularly trigger point release combined with pelvic floor muscle stretching and lengthening techniques to increase the flexibility of the pelvic muscles.

Psychological approaches include psychotherapy and cognitive behavioral therapy. Psychotherapy attempts to uncover deep and often unconscious motivations for feelings and behavior. Cognitive behavioral therapy aims to train the mind to replace dysfunctional thoughts, perceptions and behavior with more realistic or helpful ones in order to modify fear of vaginal penetration and avoidance behavior. 

Botox is broadly used in many medical disciplines to temporarily paralyze spastic musculature. For vaginismus, Botox is injected into the spastic vaginal muscle and adjacent pelvic floor muscles and seems to be a promising treatment.

As opposed to the chronicity of vaginismus, penis captivus is a rare acute condition in which a male’s erect penis becomes acutely stuck within a female’s vagina. It is theorized to be on the basis of intense contractions of the pelvic floor muscles, causing the vaginal walls to clamp down and entrap the penis. It usually is a limited event and after female orgasm and male ejaculation, withdrawal becomes possible. However, at times it requires emergency medical attention with a couple showing up in the emergency room tightly connected like Siamese twins.

Bottom Line:  A well-toned vagina is highly desirable from the standpoint of sexual health as well as pelvic health.  Having a fit vagina and pelvic floor muscles will often prevent pelvic organ prolapse and urinary incontinence and contribute to a healthy and enjoyable sex life. Vaginismus is an unusual–but treatable– medical problem in which the vagina and pelvic muscles are so tight that the vagina  cannot be penetrated.  The mind-body connection plays a key role in the development of this condition, which is so much more than simply a physical issue.  Vaginismus can have devastating psychological and emotional consequences, creating a vicious cycle that perpetuates the problem. 

Reference: PT Pacik: Understanding and Treating Vaginismus: a multimodal approach, International Urogynecology Journal (2014) 25:1613-1620

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: In the works and coming along nicely is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.

Botox: Not Just for a Pretty Face

January 11, 2014

Blog #136


Botox is derived from a poison produced by the Clostridium bacterium, the microorganism responsible for botulism in humans and animals.  Botulism—caused by eating foods contaminated with the Clostridium bacterium—is a rare but serious illness that can result in paralysis and is considered a potentially fatal medical emergency. The highly toxic and lethal botulinum toxin was initially identified by Kerner in rancid sausages and was refined and purified by van Ermengen in the Netherlands.

It is shocking that the most poisonous substance known to humanity—Botulinum toxinwhen used in minute quantities in a derivative known as Botox, becomes a magically effective and powerful potion to treat a variety of conditions. Talk about making lemonade from lemons!

Most people are aware of the use of Botox to prevent or improve the cosmetic appearance of facial wrinkles. When injected into the frown lines it paralyzes the facial muscles involved and makes creases, furrows and grooves disappear. Facial Botox injections are among the most common cosmetic procedures performed in the United State and have fostered a billion dollar industry. It is important to know that getting beyond cosmetics, Botox can be beneficial for a variety of medical conditions that have in common some form of localized muscle over-activity.

Technically speaking, Botox is a neuromuscular blocking agent that weakens, if not paralyzes muscles. It has numerous potential uses involving the following: overactive bladder (condition causing urinary urgency, frequency and incontinence); urinary incontinence due to neurological conditions including spinal cord injury and multiple sclerosis; chronic migraine headache; upper limb spasticity; cervical dystonia (involuntary contraction of the neck muscles causing abnormal movements and an awkward posture of the head and neck); axillary hyperhidrosis (excessive underarm sweating); blepharospasm (eyelid spasm with uncontrollable blinking); strabismus (cross-eye or wall-eye); and of course, the cosmetic usage to improve the look of frown lines and wrinkles. For all of the aforementioned conditions, the effect of Botox is temporary and needs to be repeated on an indefinite basis in order to maintain the therapeutic effect.

Overactive bladder and incontinence due to neurological conditions: Botox can be useful in those who have not responded to conservative methods including behavioral methods, pelvic floor exercises and medications. Such persistent and disabling urgency, frequency and urgency incontinence can be effectively managed by injecting Botox into the urinary bladder. It works by paralyzing or weakening the bladder muscle. It is done via cystoscopy (a visual inspection of the bladder with a lighted narrow telescope) and requires injecting the Botox into about 20 sites within the bladder muscle.

Chronic migraine headache: Botox is useful for preventing migraines in adults affected more than 15 days per month with headaches lasting for more than 4 hours daily. It is accomplished by injecting the Botox into different areas of the head and neck including muscles of the following areas: forehead; temples; back of head; and the neck and upper back.

Upper limb spasticity: Botox is helpful to decrease the severity of the excessive muscle tone in the elbow, wrist and finger flexors and works by paralyzing these spastic muscles. It is injected directly into the flexor muscles as well as the biceps.

Cervical dystonia: Botox can be effective to reduce the severity of the abnormal head position and neck pain. It works by paralyzing the dystonic muscles and is injected into the sternocleidomastoid muscle.

Axillary hyperhidrosis: Botox is useful in those with severe underarm sweating that has not been managed successfully with topical agents. The Botox functions to paralyze the sweat glands and is injected in numerous sites to cover the area of hyperhidrosis.

Blepharospasm and strabismus: Botox is indicated when these conditions are associated with dystonia as well as benign essential blepharospasm and facial nerve disorders. It works by paralyzing the eyelid and eye muscles and is injected into the eyelid muscles and extraocular muscles, respectively.

Bottom line: Botox, a toxin produced by Clostridium that causes paralysis, can be beneficial when injected into virtually any muscle in the body that is in a state of hyper-contraction and spasticity and has found utility for a variety of medical conditions.

Andrew Siegel, M.D.

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