Awake Intravesical Botulinum Toxin Injection in the Outpatient Clinic Setting Is Feasible and Well Tolerated by Pediatric Patients With Neurogenic Bladders

PURPOSE: Minimal data exist regarding awake cystoscopic injection of botulinum neurotoxin in pediatric patients with neurogenic bladders. We assess the feasibility and tolerability of awake bladder botulinum toxin injections in children with neurogenic bladders in a pediatric clinic. MATERIALS AND METHODS: Retrospective chart review was conducted from January 01, 2018, to September 30, 2025, for all pediatric patients with neurogenic bladders who received awake bladder botulinum injections. Baseline characteristics, procedural details, patients' tolerability, and subsequent awake injections were collected. RESULTS: We identified 48 patients (25 male, 23 female) and a total of 174 awake bladder botulinum injection encounters. The median age at first awake injection was 10.5 years (interquartile range 7.4, range 2-21). Thirteen patients had cognitive delay and 6 had behavioral or mental health conditions. Forty-seven patients (98%) tolerated their first awake injection well and proceeded with subsequent injections. The median time between injections was 5 months (range: 3.1-17), with a median of 3 awake injections per patient (range 1-15). Seventeen patients eventually discontinued awake injections because of anxiety or pain (n = 5; median 3 injections, range: 2-6), lack of therapeutic response (n = 4), having undergone urinary diversion (n = 5), lost to followup (n = 2), or unrelated death (n = 1). One patient (2%) poorly tolerated the initial injection due to anxiety or pain and did not receive subsequent awake injections. CONCLUSIONS: Children with neurogenic bladder can successfully undergo awake bladder botulinum toxin injections. The procedure is well tolerated and can be efficiently integrated into the workflow of the outpatient clinic setting.