Outcomes of Sacral Neuromodulation and Intradetrusor Onabotulinum Toxin in the Management of Stroke Associated Urinary Incontinence

Purpose: Urgency urinary incontinence (UUI) is a common finding in patients with a history of stroke or cerebrovascular accident (CVA). UUI is associated with impaired quality of life as well as increased morbidity, mortality, and need for institutionalization. Medical therapy is often limited by side effects and/or cost prohibitiveness. As a result, third-line therapy is often implemented. The objective is to determine the efficacy of sacral neuromodulation (SNM) and onabotulinum toxin (BTX) in the management of post-CVA UUI. Methods: Retrospective analysis was performed to identify patients with post-CVA UUI who underwent SNM or BTX at a large academic medical center. The primary outcome was patient symptom response to third-line therapy. Treatment response was determined using the global response assessment scale. Patients reporting >50% improvement were categorized as having significant response. Secondary endpoints were proportion of patients achieving total dry and duration of therapy for those achieving significant response. Results: One hundred seventy-seven patients were identified (95 BTX, 82 SNM). Patients in the BTX group were older (71.9 years vs. 67.4 years, P=0.02) with otherwise similar demographics. Rate of symptom improvement to >50% of baseline was similar between the groups (66% of BTX, 61% of SNM, P=0.46) as was rate of patients experiencing total dryness (24% of BTX, 16% of SNM, P=0.17). Among patients achieving significant improvement there was no difference in continuation of therapy between the BTX and SNM groups. Younger age was identified as a predictor of >50% symptom improvement (odds ratio, 0.96; P=0.04) and treatment discontinuation (hazard ratio, 0.97; P=0.04) in SNM. Most common adverse events were urinary tract infection in BTX (11%) and pain in SNM (4%). Conclusions: BTX and SNM show roughly equal efficacy in the management of post-CVA UUI with nearly two-thirds of patients achieving significant benefit.