• Botox injections are effective in about 7 in 10 patients (70%), meaning that the urgency and/or urgency incontinence are either significantly better or improved.
• The effects of the injections can last for around 6 to 9 months.
• When your symptoms start to return, you can have further injections.
• There is no limit to how many times you can have your Botox repeated, but you cannot have a repeat within 4 months of each injection.
• Most people find that having repeat injections works well over many years.
• There are no obvious long-term negative effects of having repeated Botox injections into the bladder.

The procedure involves passing a small telescope (cystoscope) into your bladder, through your urethra (water pipe), and giving several injections of Botox into your bladder wall with a needle passed through the cystoscope. Botox paralyses the muscle of the bladder wall and prevents your bladder muscle from contracting and giving you the urgency symptoms.

The aim of the injections is to reduce urinary symptoms such as frequency (passing urine often), urgency and urgency incontinence. It is unlikely that you will see immediate improvement in symptoms and it may take between 2 to 6 weeks to gain maximum benefit. 

The effects of the injections usually last between 6 and 9 months, although this can be variable. Repeat injections will be required each time the effects wear off. This can be offered no more than every 4 months due to the risk of build-up of the toxin in your body.

You are being offered invasive treatment on the basis that you have not had a good response to conservative and medical therapy for your symptoms. 

Overactive bladder may be a lifelong condition and we currently have no cure. All treatments are aimed at helping you cope with the symptoms (see ‘overactive bladder syndrome’ leaflet NBT002734). We recommend that all patients try conservative and medical treatments initially before having invasive procedures. Alternative, conservative measures include:

• Incontinence pads – you may choose not to have any invasive procedures and use incontinence pads to contain your urinary leakage.
• Conservative measures – including weight loss, improving fluid intake and reducing caffeine.
• Bladder training – learning techniques to hold on and override your urgency to pass urine.
• Medicines – these may help if conservative treatment does not work.

Botox injections are usually only tried if the above treatments are not effective. Other treatments that can be used instead of Botox injections include:

• Posterior tibial nerve stimulation (PTNS) – electrical stimulation of the tibial nerve via your ankle can be used, but is not available here in Bristol and not widely available on the NHS as it is not highly recommended by NICE (National Institute for Health and Clinical Excellence).
• Sacral neuromodulation – a device (battery and wire) is implanted in your lower back that sends electrical signals that modulates/stimulates the bladder nerves – a ‘pacemaker’ to the bladder. This is offered here in Bristol and we could make an appointment for you to discuss this in more detail (see NBT003133 leaflet).
• Enterocystoplasty – a major operation that enlarges your bladder using a piece of bowel.
• Urinary diversion (ursotomy) – creating a stoma using a piece of bowel to divert the urine into a bag.

• Botox is not given to patients who have signs or symptoms of urinary tract infection, in individuals with known hypersensitivity to any botulinum toxin preparation or to any of the components in the formulation.
• It is also contraindicated in patients who cannot perform clean and intermittent self-catheterisation or accept a long-term indwelling catheter if they go into urinary retention.
• Botox must be used with caution in patients with neuromuscular disorders, such as myasthenia gravis, as it may affect the muscles involved in breathing.

This treatment improves the bladder symptoms by essentially paralysing the bladder. This can also mean that the bladder does not empty properly and you may need to self-catheterise. Therefore, prior to your appointment for Botox treatment, if you don’t already know how to self-catheterise, you will be seen by one of the specialist nurses and taught how to perform clean intermittent self-catheterisation (CISC). 

This involves you learning how to pass a small plastic tube into your bladder in order to drain urine. This tube is thrown away once the bladder is drained and the procedure may be repeated several (usually 1-4) times a day. If you are unable to perform self-catheterisation, the alternative would be using a long term urethral or suprapubic catheter, and this can be discussed further with the specialist nurses. CISC may be required until the effect of the Botox wears off.

You will be invited to an appointment either in theatres or the outpatient’s clinic where the procedure can be performed under general, or local, anaesthetic. You will be telephoned by one of the admin team and they will ask you some very important questions and it is important to be honest in your answers or you may be cancelled on the day of the procedure.

On the phone, you will be asked questions such as:

• Do you have a catheter or can you perform CISC?
• Do you have recurrent urinary tract infections? If you suffer with recurrent urinary infections, or in the days prior to the procedure you have symptoms of a urinary tract infection, then you should attend your GP surgery to have your urine checked for an infection and a sample of urine sent to the lab to be analysed by Microscopy, Culture and Sensitivity (MC&S). If you do have an infection, please complete your treatment before coming in for the Botox injections. If your urine test taken in the hospital prior to the procedure is negative for infection and you feel well, we will go ahead with the procedure. If you have an untreated urinary infection on the day of the procedure, it will be cancelled.
• Have you had any other Botox injections anywhere else in the body in the last 3 months? If you had botulinum toxin of any formulation anywhere else in the body within the last 3 months, you will not be able to have it in your bladder unless they are 3 months apart.
• Do you have any mobility issues? We can prepare the appropriate equipment to help you.
• Are you on any medications that thin the blood? These medications may include Anticoagulants such as Clopidogrel, Warfarin, Rivaroxaban, Apixaban, Dabigatran, Edoxaban and a dose of Asprin higher than 75mg. If you are on such medications, then a preoperative assessment will need to be arranged to stop the medication safely prior to the procedure.

• If your procedure is being completed in outpatients under local anaesthesia then you may eat and drink as normal and take your usual medications.
• You will be invited to attend Gate 36 in the urology department.
• On arrival to the department, the nursing team will ask you for a urine specimen. It is important that you do this in the department so it is fresh. The procedure will not be able to go ahead if you are not able to produce a urine sample to rule out infection. If you do have an infection, the procedure will be abandoned and you will be rebooked with appropriate antibiotics beforehand.

If your procedure is being completed in theatres under local or general anaesthesia

• You will be invited to attend the theatres department.
• You may be asked not to eat and drink and not to take your medication. If you have any questions regarding this, please contact the department beforehand.
• On arrival to the department, the nursing team will ask you for a urine specimen. It is important that you do this in the department so it is fresh. The procedure will not be able to go ahead if we don’t have a sample to rule out a urine infection. If you do have an infection, the procedure will be abandoned and you will be rebooked with appropriate antibiotics beforehand.
• Wherever you have the procedure, you will be seen by the specialist nurse or doctor who will go through the plans of your procedure and ask you questions regarding your medications, allergies, previous Botox injection, and how you empty your bladder.
• Once you have answered the questions and had the opportunity to ask your own questions, you will be asked to sign a consent form which clearly states the potential risks and side effects of the procedure you are having.

What are the potential risks and side effects?

• Urinary tract infection (15%-20%) - see your GP if you have symptoms of burning/stinging when passing urine as you may require a course of antibiotics. We will give you oral antibiotics to go home with for 5 days.
• Blood in the urine (8%-20%) - this is usually minor and settles down without any treatment. If you however continue to bleed then you would need to seek medical advice and you may need a surgical procedure under general anaesthetic to stop the bleeding.
• Urinary retention (7-10%) – some patients will have difficulty emptying their bladder fully after Botox. This is helped by beginning intermittent self-catheterisation which is taught prior to the procedure, for as long as is needed. If you are unable to do self-catheterisation then you would be offered a suprapubic catheter (small permanent indwelling tube through the lower part of the ‘tummy’) to help drain the urine until the Botox wears off. We would not recommend having a permanent indwelling catheter going through the urethra for a long time due to the damage it causes to the soft tissues in the genitals.
• Bladder Pain (5%) – very occasionally, some patients develop a pain in the bladder following injections. This pain is usually controlled with simple painkillers such as paracetamol and typically resolves quickly following the injections. If this continues please attend your GP surgery.
• Generalised muscle weakness (less than 3%) – this is very rare. Some patients have reported weakness in muscles of the arms and the legs at other hospitals across the world. They have been reported to be mild and usually do not require a stay in hospital. The condition resolves with time although it can take several months. There is no specific treatment for this if it occurs.
• Allergic reaction – this is rare, however, get emergency medical help if you have any of these signs of an allergic reaction: hives, difficulty breathing, feeling like you might pass out, or swelling of your face, lips, tongue, or throat.
• Temporary ‘flu-like’ symptoms are experienced rarely – some patients who have had Botox have reported these symptoms for a week or two after the injections.

If you are happy to go ahead you will be asked to undress in privacy. You will be provided with a hospital gown to wear to cover yourself; this will avoid any water from the cystoscopy coming in contact with your clothes. If you wish to stay in your own clothing on the upper half of your body then please let the doctor or nurse know. If you wish to keep your socks on then please bring a spare pair with you in case they get wet. If you feel cold in the hospital gown, then please let one of the staff members know and they will help cover you with blankets.

In the urology department there is usually a specialist nurse or doctor and at least one other staff member in the room available to help you. There may also be visitors to the unit as we are a national and international training centre. Please let your doctor know if you do not wish to have any visitors in the room during your procedure. This is your right.

If the procedure is completed in theatres there will be a specialist nurse or doctor and a number of theatre staff to look after you and assist with the procedure. An anaesthetist will also be there if you have a general anaesthesia.

You will be asked to lie down on a couch. The specialist will then clean your genitalia with warm cleaning fluid and cover you with sterile drapes. This is important to protect you from infection after the procedure. A small amount of lubricating jelly is injected into the urethra, lubricating the area so you feel less discomfort. This may sting a little. A small telescope is then passed into your bladder. Your bladder is filled with salt-water (normal saline) through the telescope which may make you feel like you need to go to the toilet to pass urine. Sometimes there is leakage of water around the telescope but this is normal and the doctors and nurses expect it to happen. The nurse or doctor then passes a small needle down the telescope and injects between 10 and 20 injections of Botox into your bladder. The telescope and needle are then removed. You can then go and empty your bladder as normal.

The procedure may be uncomfortable but should not be painful. As the Botox is being injected, it can sting for a few seconds. If the procedure becomes uncomfortable you can ask the doctor or nurse to stop. The actual injection process may take about 10 to 15 minutes but expect to be in the department between one and two hours. In theatres however, you may expect to be there for some hours.

If this is your first time, you will receive a telephone follow up from one of our specialist nurses at around 6 weeks to check up on your progress. 

You may also be seen in the outpatient department 6-9 months after you have received your Botox if you request this. 

Following this, you will simply need to contact us once the Botox wears off to book your next session. 

You may also be approached regarding involvement in research and taking part in trials. If you are involved in a trial, your follow up plan may vary according to the trial protocol.

Your risk of getting an infection in hospital is approximately 8 in 100 (8%): this includes getting MRSA and Clostridium Difficile bowel infection. This figure is higher if you are in a ‘high-risk’ group of patients.

It is your responsibility to make sure that you are fit to drive after any surgical procedure. You only need to contact the DVLA if your ability to drive is likely to be affected for more than 3 months. If it is, you should check with your insurance company before driving again.

Thank you for taking the time to read this information sheet. 

Please make note of the link for your own records. You may be asked to sign a form saying you understand the information. 

If you do decide to proceed with the scheduled procedure, you will be asked to sign a separate consent form which will be filed in your hospital notes and you will, in addition, be provided with a copy of the form if you wish.

BAUS Botox leaflet 

Kuo HC, Liao CH, Chung SD. Adverse events of intravesical botulinum toxin a injections for idiopathic detrusor overactivity: Risk factors and influence on treatment outcome. Eur Urol. 2010;58:919–26 

Orasanu B, Mahajan ST. The use of botulinum toxin for the treatment of overactive bladder syndrome. Indian Journal of Urology : IJU : Journal of the Urological Society of India. 2013;29(1):2-11. doi:10.4103/0970- 1591.109975. 

Idiopathic overactive bladder syndrome: botulinum toxin A | Advice | NICE

Opioids provide pain relief by mimicking the body’s natural pain relief (endorphins). They are used when the pain is moderate to severe after an operation or accident. They are also used at different stages of illness.

Opioid medicines can help manage some, but not all types of pain, and they will be prescribed by your medical team in hospital or your GP if it is felt they are the best treatment for your pain.

Opioid medicines can help manage pain when other medicines are not suitable, or do not provide enough pain relief. They may help reduce your suffering or distress, and may improve your ability to function physically and socially. They may also allow you to sleep and eat better. 

The correct dose of any medicine is the lowest dose that produces a noticeable benefit. It is unusual to get complete relief of pain from opioids.

However, it is important to find the most effective dose for you to reduce your pain. The amount needed to control pain varies between people. There is no standard dose of opioid.

It is important to understand that the medication/opioids prescribed for your pain may not completely stop your pain – this is normal. The aim of these opioids is to make pain manageable, so you are able to carry out normal daily activities.

You will usually start with a low dose and gradually build up until you find the dose that helps with your pain. The doses can be changed, and other pain medicines can be trialed so your pain is kept under control. Your doctor may try more than one kind of opioid if one type is not right for you.

It is important to control background pain, which is constant and continuous, so you will take a dose at a regular time each day to prevent the pain building up again.

You may have additional medicine for breakthrough pain, which is a sudden, intense pain in addition to the background pain. This will be a short acting preparation (“immediate release”). This acts quickly but usually wears off within a few hours.

It is important to take your pain medicines as they are prescribed.

If it is almost time for your next dose, skip the missed dose and take your medication as normal (you must leave the prescribed number of hours between doses).

Never take two doses together.

If you are using opioids but are still in pain, the opioids are not effective for your pain control and should be stopped by your doctor. Please seek medical advice on weaning opioids if they are not helping to manage your pain- they should not just be stopped.

• Morphine/morphine equivalent medication doses that are 120mg or above per day (24 hour period) greatly increase the risk of harm caused to your body. Research shows there is no increased benefit to pain control above this 120mg total dose.

If you have significant pain after surgery and are sent home with an opioid prescription, it should be limited to a small amount. If you do take opioids, take them only for a day or two, three days at most. Your pain will improve significantly within a few days whether you take opioids or not.

While opioids can have a positive effect for some people living with long-term pain, research shows that opioids have little to no benefit for nerve pain.

Taking opioids long term can have serious consequences when they are not providing enough benefit or are being taken not as prescribed. It is important to consider the risks and benefits of continued opioid therapy with your prescriber on a regular basis.

Recent medical research suggests that the risks to your health increase significantly when taking prescribed opioids at high doses for a long period of time. Health risks include accidental overdose or even death.

When you first start taking opioids you can experience some side effects, which usually stop after a few days. These include:

• Feeling dizzy.
• Feeling sick (nausea).
• Being sick (vomiting).
• Feeling sleepy.
• Feeling confused.
• Feeling constipated.

Please let your doctors know if you experience any of the above. Some side effects can be helped with other medication or alternative pain medication may need to be changed.

It is important to take pain medicine for the shortest possible time. If you want to try reducing your dose, you should discuss this with your doctor and bring the dose down slowly.

Many people find they can reduce their opioid dose without the pain increasing. As fewer side effects are experienced, quality and enjoyment of life can improve. All of this contributes to greater physical fitness.

Following surgery, many patients go home with an opioid pain medicine prescription, this can sometimes trigger addiction.

It is strongly recommended to only take opioids for the shortest possible length of time. Everyone prescribed any pain medication should have them reviewed by their prescriber at regular intervals.

Remember:

• Opioid medicines should be used as little as possible, if at all, after surgery.
• Nobody should need to take them for more than a week after an operation.
• Addiction can develop after taking just a few of them.

People who are addicted to pain medicine can:

• Feel out of control about how much medicine they take or how often they take it.
• Crave the drug.
• Continue to take the drug even when it has a negative effect on their day-to-day life, physical and/or mental health.

If you have been taking opioid pain medicine for more than a week, your body may have become used to the opioid medicine and you may experience symptoms of withdrawal (sweating, stomach cramps, diarrhoea, aching muscles) and the return of your pain if you:

• Stop taking it too suddenly.
• Lower the dose too quickly.
• Run out of medicine.

You should not suddenly stop taking your opioid medicine but get advice from your doctor who will help you reduce the dose gradually and safely.

• If you are allergic to any medications.
• If you are taking any other medication, including over the counter or herbal medication (sometimes different medications can interact with each other).
• If you are pregnant or breastfeeding, or if you are planning to become pregnant in the near future.
• If you have kidney and/or liver problems.
• If you have or have previously had a history of excessive alcohol use, recreational drug use, or addiction to prescribed or over-the-counter medication.
• If you have a condition called obstructive sleep apnoea - it may not be safe to take opioids with this condition.

It is important that you read the drug information leaflet provided with your medication on discharge. This includes more advice on driving and alcohol use along with your medicines.

Taking alcohol and opioids together will cause sleepiness and reduce your ability to concentrate. When you first start taking opioids or when your dose is increased you should be more careful. When you are on a steady dose of opioid, you should be able to drink safe and modest amounts of alcohol without getting any extra unusual effects.

When you are taking opioids, you should not drink alcohol if you are going to drive or operate machinery.

UK law allows you to drive if you are taking opioid medicines. However, you are responsible for making sure you are safe to drive.

Because opioid medicines can make you feel sleepy, you should not drive or operate machinery until you see how it affects you. Your reactions and alertness will be affected. You should only consider driving regularly if you are confident that your concentration is not impaired. You should not drive if your dose has changed or if you feel unsafe. You do not have to inform the DVLA that you are starting an opioid. However, there may be other information about your illness that the DVLA needs to know.

If you have a history of chronic/long term pain and you are taking pain medicines for this at home before coming into hospital, your analgesia/pain relief will be discussed with your doctors/anaesthetist, and/or (if required) the acute pain team. 

It is important that only you take the opioids prescribed for your pain.

Opioid medicines should be kept in their original containers and clearly labelled. They should be stored as the information leaflet given with the medication suggests, usually at room temperature in a dry place.

As with all medicines they should be stored safely out of the reach and sight of children.

• Return them to the pharmacist/pharmacy for safe disposal.
• Do not share these medications with anyone, they are prescribed for you only.
• Do not flush them down the toilet or throw them away.

Resus is for the most critically unwell patients with life or limb-threatening conditions.
 

Majors is for acutely unwell patients who require regular monitoring.

See and Treat is our Minor Injuries Unit (MIU), and where most injuries get seen. 

The minor injury unit can see both children and adults. 

It can treat patients with minor injuries such as cuts, sprains, minor burns and suspected broken bones. 

We do not have a dedicated Minor Injuries team overnight, and all patients will be seen in the ED, along with the Majors and Resus patients. 

This means that after 1 am, patients with minor injuries may wait considerably longer than they would normally.

If you have a minor injury or illness overnight, you will be seen in order of clinical need alongside ambulance arrivals and emergency patients. 

At present, waiting times are much longer overnight, and you may be asked to come back the following morning, or to attend another suitable service instead. 

Other Minor Injuries units are at Yate MIU, Clevedon MIU and South Bristol Community Hospital.

The ED Observation Unit is a seated assessment area for ambulatory patients who are well, but may need further observation and treatment.

If you are unlikely to require admission to hospital, and are waiting for results, need further treatment and/or observation, you will be transferred to our seated monitored waiting area (EDOU).

Occasionally, depending on the results of certain investigations, patients may need admission to a specialised ward from the EDOU.  

The EDOU also has capacity for two surgically expected patients, this means you may be referred directly by your GP to the EDOU, depending on your GP assessment.

In the current climate, waiting times in the Emergency Department can be very long, and for many people, an emergency department is not the best place to be seen. 

The Senior Streaming Nurse may decide your condition does not need to be seen in the Emergency Department and may direct you elsewhere. 

This may happen if our team thinks your condition is not an emergency, or you have certain symptoms which mean you need to be seen by another healthcare provider.

You may be redirected to 111 (link to phoning 111 in the Emergency Department), local Minor Injuries Units (Yate and Clevedon), your GP, local pharmacies, Same Day Emergency Clinic (SDEC) (based at Gate 36, Level 1 of the hospital) or Bristol Children’s Hospital Emergency Department.

Around 10,000 people are diagnosed with bladder cancer each year. It often happens because harmful things like cigarette smoke can damage the bladder lining.   

The most common symptom is blood in the urine. If you have this see your GP immediately.  

The first step to treatment is finding out what stage your cancer is at. This is usually done with an operation called TURBT to remove the growth from the bladder to see how deep in the bladder wall it is (Day case TURBT (Transurethral Resection of the Bladder Tumour).  You may also have a scan of the rest of the body. 

Treatment for bladder cancer depends on how deep it is in the bladder wall. If it is just inside the bladder it is called intravesical.  

If it involves the lining and muscles of the bladder this is called invasive. This is a serious diagnosis and often you will need both chemotherapy and surgery to treat it. 

Find out more about treatments for bladder cancer: 

• Treatment for bladder cancer | Macmillan Cancer Support
• Action Bladder Cancer UK
• Fight Bladder Cancer 

Treatment for bladder can include surgery. Bristol Urological Institute has the most experienced surgeons in the country who provide robotic surgery for bladder cancer. Robotic assisted surgery allows smaller incisions (cuts), less blood loss, and less anaesthesia needed. This means patients recover far more quickly.

Our consultants Mr Koupparis and Mr Rowe were the first in the country to remove a patient’s bladder due to cancer and reconstruct a new bladder out of bowel using the Da Vinci robotic surgical platform. 

Kidney cancer is also known as renal cancer and is most common in people over 60.  

Find out more about kidney cancer, symptoms, treatment, and recovery:

• Home - Kidney Cancer UK
• Kidney cancer | Macmillan Cancer Support 

Cancer of the penis is quite rare. If you have any symptoms you will need further tests like a biopsy, lymph node aspiration, and scans like a CT scan.  

Once we have the results of your tests, we will work out the right treatment with you. This may be a combination of treatments that could include: 

• Surgery to remove the cancer, and possibly to reconstruct the penis.
• Radiotherapy.
• Chemotherapy.  

Find out more about penile cancer, symptoms, treatment, and recovery: 

• Penile cancer | Macmillan Cancer Support.
• Orchid Fighting Male Cancer 

Prostate cancer is the most common cancer in men in the UK. Slow-growing prostate cancer is more common and does not always cause symptoms or shorten life. It is often found on a routine blood screening. More aggressive prostate cancer can cause problems urinating (peeing) and can spread to other parts of the body like bones. 

At Bristol Urological Institute we have some of the most experienced prostate cancer specialists in the country. We work with our oncology colleagues and a team of specialist nurses. 

Find out more about treatments you may have for prostate cancer:

• Brachytherapy
• External radiotherapy
• Active surveillance
• High intensity focused ultrasound (HIFU)
• Robotic Assisted Laparoscopic Prostatectomy   

Find out more about prostate cancer, treatments, and support on the websites below:

• Prostate Cancer UK | Prostate Cancer UK
• Prostate cancer | Macmillan Cancer Support
• Prostate cancer - NHS

Testicular cancer is most common in males aged 15-40. The risk of testicular cancer over your lifetime is roughly 1 in 250 (0.4%).

It has one of the highest cure rates of all cancers. More than 90% will be cured.  

Testicular cancer is often suspected if you find a lump. Not all lumps on the testicles are tumours, and not all tumours are malignant (cancerous).  If you find a lump, get it checked by your GP. Find out more about testicle swellings and lumps: Testicle lumps and swellings - NHS.

If your GP suspects your lump is a cancer, they will refer you for scans and blood tests. You may then meet a surgeon at Bristol Urological Institute to discuss removal of the testicle – this is called an orchidectomy.

Some important things to discuss with your surgeon

• Your blood test results (tumour markers) before your operation
• Prosthesis insertion.
• Pre-operative sperm banking.

Most people will have surgery within the next 2 weeks, and you will usually go home on the same day (day case). You will be given all the information you need including when and where to go, and when to stop eating and drinking.

It is usually done under general anaesthetic (you will be asleep). When you wake up you will have a dressing on the wound on your groin. The stitches in the incision (cut) are usually dissolvable so don’t need to be removed.

Find out more about testicular cancer, symptoms, treatment, and recovery:

• Testicular cancer | Macmillan Cancer Support
• Testicular Cancer Charity | It's in the Bag