OnabotulinumtoxinA injection is a safe and effective treatment for adults with refractory
overactive bladder. There is sufficient level 1 evidence to support offering
onabotulinumtoxinA injections as a second-line treatment to patients who have failed behavioral
therapy and oral medications such as
antimuscarinics and β3 agonists. An intradetrusor injection of 100 U of
onabotulinumtoxinA is likely the optimal dose to balance risks and benefits, and this is the dose approved by the US Food and Drug Administration. Improvement in urgency
urinary incontinence episodes, as well as symptom scores and quality of life, were seen in around 60%-65% of patients, and were significantly improved compared with those on placebo. Most studies have reported a duration of symptom relief ranging from 6 to 12 months, with repeat
injections being safe and efficacious. Overall, the risk of
urinary retention was around 6% across the study populations.