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Neuromodulation Adjuncts

Injectable biologic agents used as neuromodulatory therapy. The category is currently dominated by botulinum toxin, a chemodenervating agent. FDA-labeled intradetrusor onabotulinumtoxinA treats adults with OAB and urge urinary incontinence, adults with urinary incontinence due to neurologic detrusor overactivity, and children aged 5 years or older with NDO after inadequate response to or intolerance of anticholinergic medication.[2] Use in the external sphincter (detrusor-sphincter dyssynergia), bladder neck (primary bladder-neck obstruction), pelvic floor (hypertonicity, CP/CPPS), and bladder wall for IC/BPS (including intratrigonal injection) is off-label and rests on smaller studies. For refractory IC/BPS, the 2025 Canadian Urological Association guideline conditionally recommends intradetrusor onabotulinumtoxinA with or without hydrodistension (very low certainty).[3] This subsection covers the pharmacologic agents themselves; for the device-based neuromodulation procedures, see sacral neuromodulation, percutaneous tibial nerve stimulation and implantable tibial nerve stimulation in the Treatment Atlas, and the intradetrusor injection procedure for the technique.

For CP/CPPS, AUA 2025 found the evidence too weak to recommend botulinum toxin treatment, in an ungraded Future Directions discussion.[1]

  • Botulinum ToxinOnabotulinumtoxinA for overactive bladder and neurogenic detrusor overactivity, and its off-label pelvic uses.

References​

1. American Urological Association. Diagnosis and Management of Male Chronic Pelvic Pain (Chronic Prostatitis/Chronic Pelvic Pain Syndrome and Chronic Scrotal Content Pain): AUA Guideline (2025). Approved March 2025. Full 2025 guideline Future Directions, p43.

2. Allergan, Inc. BOTOX (onabotulinumtoxinA): US prescribing information. Revised November 2023. DailyMed

3. Doiron RC, Tadayon B, Violette PD, et al. "2025 Canadian Urological Association Guideline: Selected treatment recommendations for interstitial cystitis/bladder pain syndrome." Can Urol Assoc J. 2025;19(4):90–103. doi:10.5489/cuaj.9182