In a patient with refractory OAB who's failed Botox once due to inadequate response, do you increase the dose, switch to sacral neuromodulation, or retry — and what actually drives that decision?

If you are confident the patient received an adequate Botox injection (i.e., you did it yourself as opposed to someone who might not have done an optimal procedure) and had an inadequate response, I would review the urodynamics result or perform urodynamics if not done already.

If the patient has ve...

Great question. If the patient derived at least some response to the first Botox injection, I would probably inject a higher dose of Botox the next time. If the patient had no response at all, I would probably move on to another therapy. It goes without saying that the patient's wishes may drive the...

In general, I do not repeat an intervention that was inefficacious, so I would move on to pharmacotherapy with behavioral modification (reduce caffeine, alcohol) with a pelvic floor exercise program. If that is not helping, then sacral neuromodulation or tibial neuromodulation is indicated.

A higher...

Depends on post-void residual at 3 weeks after Botox. If PVR is low, I will offer a higher dose. If the patient is at increased risk of retention, I offer alternatives such as lifestyle modification (weight loss and caffeine reduction), trial of medications, PTNS, and sacral neuromodulation.

Defining "failed" matters. It could mean true non-response, partial/inadequate response, a waning effect, or discontinuation for tolerability (dysuria, UTI, CISC) despite some benefit. Trials define response loosely (≥50% improvement).

Partial response → retry at higher dose: reasonable and has some ...