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98 CUAJ %u2022 APRIL 2025 %u2022 VOLUME 19, ISSUE 4 Doiron et al SummaryA variety of agents, at variable dosages and combinations, have been studied for the treatment of IC/BPS. Based on small, heterogeneous studies, it appears that intravesical therapy provides a marginal benefit in some patients with IC/BPS. Patients with a bladdercentric phenotype or whose bladder pain is particularly bothersome may benefit the most from this treatment approach. Intravesical therapy appears safe with minimal risk. Access to intravesical therapy may be limited in some centers due to hospital pharmacy restrictions and nursing resources.Is intradetrusor onabotulinumtoxin-A (BTX-A) indicated for the treatment of IC/BPS?%u2588 RECOMMENDATION 3Intradetrusor BTX-A, with or without hydrodistension, is conditionally recommended as an option for the treatment of IC/BPS patients refractory to other treatments (very low certainty in evidence of effects). Note: The panel judged BTX-A to have a small magnitude of benefit and a small magnitude of harm, the balance of which probably favors the intervention in the context of important uncertainty in patient values and preferences. This underscores that the decision to proceed with BTX-A should be sensitive to patient values and preferences. The panel%u2019s opinion is that this approach may be more effective in a patient population that has more bothersome urgency and frequency, but the ideal population remains suboptimally defined. BTX-A is a bacterial neurotoxin acting as a neuromuscular blocking agent and inhibiting the release of acetylcholine from presynaptic nerve fiber endings. It is currently indicated for the treatment of various disorders, including OAB, but remains off-label for the IC/BPS indication.The panel reviewed seven small RCTs providing a total of 291 participants from which to draw evidence.84-89Observational studies were not included. Most studies were limited due to short duration of followup, with a mean of 4.7 months. It is difficult to comment on the effect of BTX-A alone, as all studies, except one, combined BTX-A with hydrodistension (HD). All treatment regimens were with 100 units except a subgroup from Kuo et al (15 patients treated with 200 units)84 and Manning et al, who used 500 units of abobotulinumtoxinA.85 Additionally, there was variation in the technique of BTX-A injection across studies. Small improvements in pain (assessed via visual analogue scale, [VAS]) (MD 0.6, 95% CI 1.3 lower to 0.2 higher), ICSI (MD 1.6, 95% CI 3.0 lower to 0.3 lower), and ICPI (MD 1.7, 95% CI 3.0 lower to 0.4 lower) symptom scores were observed for patients treated with BTX-A compared to control (HD or placebo) based on the panel%u2019s pooled analysis; however, uncertainty remains whether BTX-A results in little vs. no difference in pain in this patient population. It is worth mentioning that a potential increase in bladder capacity with BTX-A was not well-captured across studies and could potentially contribute to the overall clinical improvement IC/BPS patients may experience. Therefore, no absolute indication in favor of its efficacy can be assumed considering the paucity of data, risk of bias, and heterogeneity of study designs. In terms of adverse events (AEs), the pooled results of three RCTs found that 39 more patients receiving BTX-A, compared to control, would experience acute urinary retention out of every 1000 IC/BPS patients (relative risk [RR] 1.56, 95% CI 0.44%u20135.53). Based on four RCTs, UTI would occur in 42 more patients receiving BTX-A, compared to control, out of every 1000 IC/BPS patients (RR 1.34, 95% CI 0.60, 3.02). Other known potential AEs include transient, mild gross hematuria, injection site pain, and flulike symptoms (Supplementary Table 3; available at cuaj.ca). It should be highlighted that acute urinary retention requiring clean intermittent catheterization (CIC), although rare, may be quite troublesome in patients with IC/BPS due to their underlying pain. A thorough conversation about the possibility of needing to CIC should be undertaken. In some situations, it may be appropriate to teach patients how to do CIC in case it is needed post-injection of BTX-A. Despite moderate resource requirements, shortterm durability, and the need to appropriately counsel patients with regard to the possibility of self-catheterization, the panel deemed that it is acceptable and feasible to offer this as a treatment option, while emphasizing the need for further multicentric RCTs with prospective comparison and longer followup. In addition, studies should focus on eliciting the most effective technique for the administration of BTX-A injections. A multicenter, placebo-controlled RCT had completed accrual, with data collection ongoing at the time of publication (NCT05141006) and should provide important insight into this question.