Neurogenic bladder represents a significant clinical challenge for patients with spinal cord injuries, multiple sclerosis, or other neuropathies. Neurogenic detrusor overactivity often fails to respond adequately to oral pharmacological therapy with antimuscarinics or beta-3 agonists, or results in intolerable side effects. Intradetrusorial botulinum toxin injection is an effective and safe second-line therapy. Literature has demonstrated its efficacy in reducing urinary leakage episodes (between 60% and 80%), with approximately 40-50% of patients achieving complete continence. Furthermore, it increases maximum cystometric capacity (often >100-150 ml from baseline), significantly reduces detrusor pressure during involuntary contractions—thereby protecting the upper urinary tract from reflux—and improves overall Quality of Life (QoL).
To analyze the feasibility of using Botulinum Toxin Type A (onabotulinumtoxinA) as a second-line treatment, administered via sedoanalgesia without anesthesiological assistance, in patients with neurogenic bladder of various etiologies.

Intradetrusorial administration of 200 IU of Botulinum Toxin Type A was performed via flexible cystoscopy, involving 30 injections across all bladder walls except the trigone and base. The procedure was conducted under sedoanalgesia (50 mcg IV fentanyl -0.7 mcg/kg), followed after approximately 20 minutes by 3 mg of midazolam—diluted to 5 ml with saline), combined with local anesthesia via intraurethral lidocaine gel (2% lidocaine and 0.05% chlorhexidine, three 12 ml pre-filled syringes).
The study analyzed 15 patients, each undergoing three injection cycles over 36 months (01/2022–01/2025) with a 9-month interval between treatments. Etiologies included: 8 cases of Multiple Sclerosis (EDSS 3–5.5; already on CIC), 3 cases of myelomeningocele (2 on CIC), 3 cases of spinal cord injury (2 post-traumatic, 1 post-infectious; 3 on CIC), and 1 case of Parkinson’s disease. All the patients had failed trial with either oral antimuscarinic drugs or beta3 agonists. The mean age was 40 years (range 32–76); 8 females and 7 males. Postoperative pain was assessed using the validated Numerical Rating Scale (NRS).

All patients benefited from the toxin's effects on OAB symptoms, with symptoms typically recurring 6–9 months after the last administration. Data show excellent tolerance of the procedure under the proposed sedoanalgesia protocol, with peri- and postoperative NRS scores consistently <4 in all cases. Patients were discharged after a few hours of observation, accompanied by a family member or caregiver. No peri- or post-procedural complications were recorded.

The adoption of the proposed sedoanalgesia protocol for intradetrusorial botulinum toxin injections represents an essential alternative to hospitalization with anesthesiological assistance. In terms of procedural feasibility, this approach has a significant positive impact on urology department organization and waiting lists, particularly given the current staffing challenges regarding anesthesiologists within the National Health Service (SSN).

Based on the results of our study, we propose the adoption of this protocol for intradetrusor botulinum toxin injection in neurogenic patients, highlighting its significant practical implications for the sustainability of the procedure.