AU2006225233C1 - Use of neurotoxin therapy for treatment of urologic and related disorders - Google Patents

Description

P/00/0 II Regulation 3.2 AUSTRALIA Patents Act 1990 COMPLETE SPECIFICATION STANDARD PATENT (ORIGINAL) Name of Applicant(s): The Regents of the University of Colorado, of 201 Regent Administration Center, 3 SYS Boulder, Colorado, 80309, United States of America Actual Inventor(s): Richard A. SCHMIDT Address for Service: DAVIES COLLISON CAVE, Patent & Trademark Attorneys, of 1 Nicholson Street, Melbourne, 3000, Victoria, Australia Ph: 03 9254 2777 Fax: 03 9254 2770 Attorney Code: DM Invention Title: "Use of neurotoxin therapy for treatment of urologic and related disorders" The following statement is a full description of this invention, including the best method of performing it known to us:- P:\OPER\TNB\SPEC1\I2839190-DV3 doc-2809/A6 -2 USE OF NEUROTOXIN THERAPY FOR TREATMENT OF UROLOGIC AND RELATED DISORDERS FIELD OF THE INVENTION The present invention relates to the treatment of neuronally-mediated urologic and 5 related disorders, for example, overactive bladder. This is accomplished by administering a composition that includes at least one neurotoxic compound or by conventional therapies. BACKGROUND OF THE INVENTION Many medical conditions in urology are rooted in a spastic dysfunction of the sacral 10 reflex arcs. Examples of such conditions include pelvic pain (e.g., interstitial cystitis, endometriosis, prostatodynia, urethral instability syndromes), pelvic myofascial elements (e.g., levator sphincter, dysmenorrhea, anal fistula, hemorrhoid), urinary incontinence (e.g., unstable bladder, unstable sphincter), prostate disorders (e.g., BPH, prostatits, prostate cancer), recurrent infection (secondary to sphincter spasticity), and urinary retention 15 (secondary to spastic sphincter, hypertrophied bladder neck) and neurogenic bladder dysfunction (e.g., Parkinson's Disease, spinal cord injury, stroke, multiple sclerosis, spasm reflex). The prostate is a partially glandular and partially firbromuscular gland of the male reproductive system. During aging, the prostate tends to enlarge (hypertrophy). This 20 prostatic enlargement can lead to urethral obstruction and voiding dysfunction. Prostatic enlargement is a common occurrence in older men. Lytton et al. (Lytton, B., Emery, J.M. and Harvard, B.M. [1973] 99: 639-645) estimated that a 45 year old male had a 10% risk of prostate surgery by age 70. The U.S. Census Report estimates that there are 30 million people today over age 65. This segment of the population is projected to 25 rise to 50 million over the next 30 years. Therefore, the number of men with prostatic enlargement also will increase. According to draft reports of the National Kidney and Urologic Disease Advisory Board, 425,000 prostatectoinies were performed in the United States in 1989. Based on population growth estimat s, the number of prostatectomies performed annually will rise to 800,000/year by the year 2020. 30 The urethra passes through the prostate (prostatic urethra) as it courses to the external urethral orifice. The prostate has five distinct lobes that are apparent at 12 -3 weeks in the human fetus (Lowsley, O.S. Am. J. Anat. [1912] 13: 299-349.). Although the lobular branching found in the fetus is not visible in the prepubescent prostate, the lateral middle anterior and posterior lobes are used to describe the enlarged prostate. A more recent viewpoint is that the prostate also is comprised of several 5 morphologically distinct zones (McNeal, J. Urol. Clin. North Am. [1990] 17(3): 477 486). The majority of the glandular volume is composed of the peripheral zone (70 75%). The remainder of glandular volume is divided into the central zone (20-25%), the transition zone (-5-10%) and the periurethral glandular zone McNeal (1990) reported that BPH develops in the transition zone and the 10 periurethral glandular zone. BPH nodules develop either within or immediately adjacent to the preprostatic sphincteric zone. The transition zone is a small region close to the urethra intimately related to the proximal urethral sphincter. The stroma of the transition zone is dense and compact, and is unusually susceptible to neurologically induced disturbances of growth control. Its glands penetrate the sphincter, while 15 sphincter muscle fibers penetrate the transition stroma. The periurethral glandular zone has a similar urogenic sinus origin as the transition zone. BPH may be associated with increased amounts of stroma relative to epithelium (Bartsch, G., Muller, H. R., Oberholzer, M., Rohr, H., P., J. Urol. [1979] 122: 487-491). A significant portionofthe stroma is smooth muscle (McNeal, 1990) which is under 20 sympathetic nervous control. The contractile properties of this smooth muscle could account for the dynamic component of obstruction in BPH (Bruschini, H. et al. [1978] Invest. Urol. 15(4): 288-90; Lepor, H. [1990] Urol. Clin. North Am. 17(3): 651-658). In addition to sympathetic control of prostatic stroma, the prostate is highly innervated. The prostate nerve fibers enter the prostate from the posterior lateral aspect, 25 with a concentration of ganglia near the junction between the prostate and the seminal vesicles (Maggi, C.A., ed. [1993] Nervous control of the Urogenital System, Harwood Academic Publishers; Higgins, J.R.A. and Gosling, J.A. [1989] Prostate Suppl. 2: 5-16). Acetylcholine (ACH), neuropeptide Y (NPY), vasoactive intestinal peptide (VIP) and noradrenaline fibers have been described in this gland A rich plexus of ACH-positive 30 nerve cell bodies is associated with secretory acini in all parts of the gland. Some of the ACH fibers also contain NPY neurons. VIP-containing neurons have been found associated with ACH-containing nerve cell bodies. Occasional neurons have been found between the ACH staining nerve fibers, suggesting that both NPY and noradrenergic H:\annam\keep\specis TNB\P58945 unitechcorp div.doc 16/11/05 -4 neurons supply smooth muscle (Higgins, J.R.A. and Gosling, J.A. [1989] Prostate Suppl. 2: 5-16). Autonomic nerves are distributed evenly between the central and peripheral zones of the prostate (Higgins, J.R.A. and Gosling, J.A. [1989] Prostate Suppl. 2: 5-16). 5 Peripheral neuronal control is similar. In addition, th re is no difference in the type of nerve fibers found associated with either epithelial or stromal elements of the gland. The anatomical studies of nerve fiber types in the prostate, coupled with other studies of innervation of prostatic stroma (Brushing H., Schmidt,R.k, Tanagho, E.A., [1978] Invest. Urol. 15(4): 288-290; Watanabe, H., Shima, M., Kojima, M., Ohe, H.L. 10 [1989] Pharmacol. Res. 21(Suppl 2): 85-94) suggest that cholinergic innervation influences epithelial behavior, while adrenergic innervation influences stromal tonus (excitability). These observations have provided a rationale for the use of, for example, alpha blockers in the treatment of BPH. The effects of alpha blockers (Downie, J.W. and Bialik, G.J. [1988] J. Pharmacol. Exp. Ther. 246(1): 352-358) can also account for 15 improvements in symptoms of BPH as a result of dam pening of dysfunctional striated sphincter behavior by the alpha blockers. Studies have also shown that there are several tachykinins (for example, substance P [SP], calcitonin gene related peptide [CGRP], neurokinin A, bradykinin, and nerve growth factor [NGF]) that can influenced the tonus of smooth muscle 20 (Hakanson, et al., [1 987] Neuroscience 21(3): 943-950). Neurotransmitter receptors have been quantified throughout the prostate (e.g., NPY, VIP, SP, leu-enkephalin (L enk), met-enkephalin, 5-HT, somatostatin, acetylcholinesterase positive fibers (ACTH), and dopamine beta-hydroxylase (DBH) (Crowe, R., ChIapple, C.R., Burnstock, G. The Human Prostate Gland: A Histochemical and Immunohistochemical Study of 25 Neuropeptides, Serotonins, Dopamine beta-Hydroxylase and Acetylcholinesterase in Autonomic Nerves and Ganglia). There is some variation in receptor density at different prostatic sites in benign prostatic hyperplasia. cha ges in electrophysiologically recorded cellular behavior and in concentration of neuropeptides within the spinal cord have been shown to be a secondary consequence of mechanical pinch to the tail muscles 30 of a rat, catheter stimulation of the posterior urethra, and electrostimulation of a peripheral nerve. Dyssynergia between the detrusor and the urethral sphincter is a significant finding in prostatodynia patients. Denervation of the prostate has been shown to produce dramatic changes within the pro static epithelium. Thus there is H.\annam\keep\apecia TNB\P58945 unitechcorp div.doc 16/11/05 -5 evidence that experimentally induced alterations in neurological influences can be produced in the sacral, spinal cord, bladder or urethra through mechano-, electro-, chemical or thermal (microwave, laser) methods. to change irritative behavior. However, there have been no known attempts to use neurotoxins for therapeutic 5 applications. There is poor correlation between the degree of prostatic enlargement and the severity of symptoms. While 80% of men age 70 show BPH on transrectal ultrasound scans, only 20% seek surgery (Coffey, D.S. and Walsh, P.C. [1990] Urol. Clin. North Am. 17(3): 461-475), the treatment of choice for BPH (Fowler, F.J. Jr., Wennberg, J.E., 10 Timothy, R.P. [1988] J. Amer. Med. Assoc., 259(20): 3022-3028). Symptoms of irritation may far exceed symptoms expected based on the size of the prostate. Symptoms may improve after surgical treatment of BPH by procedures such as transurethral resection of the prostate (TURP) (Christensen, Aagaard, M.M. J., Madsen, P.O. [1990] Urol. Clin. North Am. 17(3): 621629), alloon dilation (Dowd, J.B. and 15 Smith, J.J. III [1990] Urol. Clin. North Am. 17(3): 671-677), or prostatic hyperthermia (Baert, L., Ameye, F., Willemen, P., et al., [19901 J. Urol.144:1383-1386). However, symptoms persist in as many as 15% of all BPH patients (Baert, L., Ameye, F., Willemen, P., et al., [1990] J. Urol. 144: 1383-1386, Wennberg, J.E., Mullly, A.G., Hanley, D., Timothy, R.P., Fowler, F. J., Roos, R.P.,Barmy, M.J. et al., [1988] J. Amer. 20 Med. Assoc. 259: 3027-3030). Up to 25% of BPH patients have secondary procedures in long term follow-up studies, suggesting that surgical approaches do not address the fundamental mechanisms that produce BPH, i.e., the faulty neurological influence (control mechanism) on the integrity of the lower urinary tract. The need for repeated surgeries, the morbidity and mortality associated with 25 TURP and the cost of surgery have led to the development of some non-surgical approaches such as androgen ablation (McConnell, J.D, [1990] Urol. Clin. North Am. 17(3): 661-670) and the use of alpha blockers discussed above, but few medical or surgical treatments to date have produced a restoration of void behavior to normal state (flow rate of about 25cc/sec and void volume of about 400cc). 30 The present invention uses chemical and non-chemical methods, particularly neurotoxins, to modulate neuronally-mediated urologic and related disorders. For example, such methods can be used to treat BPH and related conditions such as prostatitis. The instant invention also may remove triggers of changes in the CNS by H:\annam\keep\specjs TNB\P58945 unitechcorp div.doc 16/11/05 P:\OPER\TNB\SPECl9I 283919thDIV3 d.-28A9/6 -6 non-chemical methods including biofeedback, or by chemical methods that treat BPH and other urological conditions by the administration of substances that block various neurological activities, such as, for example, selected neurotoxins. 5 SUMMARY OF THE INVENTION The present invention provides the use of a botulinum toxin in the preparation of a pharmaceutical composition for treating at least one symptom of overactive bladder. In one form, the symptoms of overactive bladder is selected from the group consisting of urinary incontinence and urinary retention. 10 The use of claim I or claim 2, wherein the composition is provided in a form that is suitable for administration into the urinary tract of a patient. In another form, the composition is provided in a form that is suitable for administration into the urinary tract of a patient. In another form, the composition is provided in a form that is suitable for 15 administration to the bladder of the patient. In another form, the botulinum toxin is formulated in a pharmaceutically acceptable formulation selected from the group consisting of: a liquid, a powder, a cream, an emulsion, a pill, a troche, a suppository, a suspension, and a solution. In another form, the composition is an injectable composition.

20 In another form, the botulinum toxin is a botulinnulm toxin type A. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT "Urological-neurological condition or disorder" includes many medical conditions in urology rooted in a spastic dysfunction and/or degeneration of the sacral reflex arcs. Examples of such conditions include pelvic pain (e.g.,' interstitial cystitis, endometriosis, P %OPER\TNB\SPECI%127M790 I pa doc-21AM -7 prostatodynia, urethral instability syndromes), pelvic myofascial elements (e.g., levator sphincter, dysmenorrhea, anal fistula, hemorrhoid), urinary incontinence (e.g., motor or sensory, unstable bladder, unstable sphincter), prostate disorder (e.g., BPH, prostate cancer), recurrent infection (secondary to sphincter spasticity), and urinary retention 5 (secondary to spastic sphincter, hypertrophied bladder neck), and neurogenic bladder dysfunction (e.g., Parkinson's Disease, spinal cord injury, stroke, multiple sclerosis, spasm reflex) and other such urological conditions of a nervous etiology. The prostatic enlargement that can be treated according to the methods of the instant invention can be of any etiology. The instant invention is particularly suited for the 10 treatment of pro static hyperplasia, especially benign prostatic hyperplasia. The present invention can also be used for the treatment of enlargement of the prostate with inflammation (prostatitis), particularly a bacterial prostatitis. In addition, the methods of the instant invention can be used for the treatment of prostatodynia. Without being bound by theory, the basis for the treatment of the neurological 15 urological conditions according to the instant invention is the removal or modulation of the neural basis for the dysfunctional regulation of the affected tissue. For example, the -8 modulation of the neural basis of prostate glandular dysfunction can be accomplished by any non-surgical means known in the art. Such means can include, for example, biofeedback, a-blockers, pharmacological methods, and the use of one or more neurotoxins to inhibit synaptic function in the affected gland. It is preferred that the 5 neurotoxin cause long-lasting inhibition of synaptic function, preferably greater than one week, more preferably greater than one month, most preferably six to eight months or longer. Such neurotoxins can include, for example, capsaicin, resinoferatoxin, a bungotoxin, terodotoxin and botulinum toxin. Botulinum toxin is a preferred neurotoxin according to the instant invention, particularly botulinum toxin A, more particularly 10 Botox (Allergen). The toxin can be formulated in any pharmaceutically acceptable formulation in any pharmaceutically acceptable form. Such forms and formulations include liquids, powders, creams, emulsions, pills, troches, suppositories, suspensions, solutions, and the like. The toxin can also be used in any pharmaceutically acceptable form supplied 15 by any manufacturer. In a preferred embodiment in accordance with the method of the instant invention, the neurotoxin is botulinum toxin type A. Therapeutically effective amounts of botulinum toxin can be any amounts or doses tl at are less than a toxic dose, for example, less than about 3000 IU/70 kg male, preferably between 100 IU/70 kg male to 20 1200 IU/70 kg. The dosages can be given as a single dose, or as divided doses, for example, divided over the course of four weeks. The neurotoxins of the instant invention can, be administered by any suitable means. In the preferred embodiment of the invention, botulinum toxin is administered 25 by injection. Such injection can be administered to any affected area. For example, the neurotoxin can be injected urethroscopically into the prostate with 200 IU with single or serial dosing. Preferably, the neurotoxin is injected every three days until a therapeutic effect is achieved or up to about 2500 units. 30 The following techniques are used in this invention: Tissue Preparation for Light Microscopy H:\annam\keep\specis TNB\P58945 unitechcorp div.doc 16/11/05 -9 Tissues are fixed in 6% paraformaldehyde in 0.1 M phosphate buffer, pH 7.2, for 24 hours, dehydrated in graded alcohol and xylene, and embedded in paraffin. Sections are cut and stained with appropriate stains, such as hematoxylin/eosin. Tissue Preparation for Electron Microscopy 5 Tissues are collected and fixed in 2.5% glutaraldehyde in 0.1 M phosphate buffer, pH 7.2, for 1 hour at 40C, then incubated withO. 1% osmium tetroxide for I hour and embedded in EPON. Ultrathin sections (80 nm) re prepared and stained with lead citrate/uranyl acetate and examined with an electron rhicroscope (Philips, model 201). Tunel Stain for Apoptosis 10 The tissue is fixed and embedded as described above. The tissues are deparaffinized and reacted with Proteinase K (Boehringer). They are further treated with peroxidase and TDT enzyme and placed in a humidifier set at 37'C for one hour. The sections are washed and anti-digoxigenin-peroxidase is added for 30 minutes, followed by staining with nickel DAB (diaminobenzene). 15 Immunohistochemistry Studles The presence of the neuropeptides VIP, SP, NPY, L-Enk and calcitonin gene related peptide (CGRP) as well as the expression of transforming growth factor beta (TGF-beta), transforming growth factor alpha (TGF-alpha), epidermal growth factor (EGF) and basic fibroblast growth factor (bFGF) are determined in prostatic tissues 20 using appropriate monoclonal antibodies. Use of neurotoxins results in prostatic atrophy, which should be renecrea Dy lower levels of'growth factors in treated prostatic tissue. Sections are incubated overnight at room temperature with primary antibodies followed by immunostaining with avidin-biotin-peroxidase (Vectastain Elite ABC, 25 Vector Labs, USA). Rabbit polyclonal antiserum against the neurotransmitters VIP, CGRP, SP,NPY and L-Enk (Peninsula Labs, USA) is used in these preparations, at dilutions of 1:8000 tol:12,000. Immunocytochemical controls consistof preabsorbing the primary antiserum with appropriate antigen, or their substitution with normal serum (Blasi, J., Chapman, E.R., Yamaskai, S., Binz, T., Niemann, H andJahn, R. [1993] The 30 EMBO Journal 12: 4821-4828; Black, J.D. and Dolly, J.O. [1986] J. Cell Biol. 103; 535-544; Linial, M. [1995] Is. J. Med. Sci. 31: 5911595). After mounting on slides, sections are counterstained with eosin, dehydrated and: coverslipped. H:\annam\keep\apecio TNB\P58945 unitechcorp div.doc 16/11/05 - 10 Western Blot Analysis of Growth Factor Expression Treated and untreated prostate cell homogenates are examined for expression of growth factors by Western blot analysis. Cell homogenate protein is separated by electrophoresis on SDS-PAGE (7%), then transferred electrophoretically overnight to 5 nitrocellulose paper (Towbin, H., et al., [1979] Proc. Nat. Acad. Sci. 76(9): 4350 4379).The nitrocellulose paper is soaked for one hour at room temperature in 0.5% non fat dry milk dissolved in phosphate buffered saline, ar d further soaked overnight at 4*C in blocking solution (2% bovine serum albumin in 10 mM Tris/ 0.15 M NaCl/ 0.1% sodium azide, pH 7.4). The nitrocellulose membranes are incubated with antibodies 10 (IgG fractions of anti TGF-beta, anti-TGF-alpha, anti-EGF and anti-bFGF) purified by protein A (1 x 106 cpm/ml) in blocking buffer for I hour. The membrane is washed with PBS containing Nonidet P-40 between incubations. X-O-mat AR2 film (Kodak) is exposed to the membrane at -70*C and films are developed to examine the expression of growth factors. 15 Determination of c-fos and c-myc Expression Expression of c-fos and c-myc in treated and untreated prostatic tissue is determined by Northern blot analysis as follows. Tissue is homogenized in lysis buffer for 15 seconds or until the tissue homogenizes. Sodium acetate is added and the solution is mixed by swirling. An equal volume of water-saturated phenol is added and 20 mixed by inversion, followed by addition of chloroform/isoamyl alcohol. The solution is vortexed vigorously for 30 seconds, -and allowed to settle on ice for 15 minutes. The solution is centrifuged for 10-20 minutes at 4*C. After centrifugation, the aqueous phase is carefully aspirated and placed in a new polypropylene tube. One volume of isopropanol is added and the solution is mixed by swirling. The solution is placed in a 25 20*C freezer for at least 60 minutes to precipitate RNA. After precipitation, the tube is centrifuged for 10 minutes, and the supernatant is decanted, leaving the RNA pellet. One mi of ethanol is added, and the tube is centrifuged for an additional 10 minutes. The aqueous phase is discarded, and the pellet is washed with 100% ethanol by vortexing. The RNA pellet is redissolved in 0.4 ml of lysis buffer. The RNA is 30 reprecipitated by the addition of 100% ethanol and incubation at -20*C freezer for at least 60 minutes. The solution is centrifuged and the supernatant discarded. RNA concentration is determined by diluting 5 p.L of sample into 995, ptL of DEPC water and measuring the ratio of absorbance at 260/280 nm. H:\annam\keep\specie TNB\P58945 unitechcorp div.doc 16/11/05 - 11 The following examples are provided by way of describing specific embodiments without intending to limit the scope of the invention in any way. Example 1 Denervation of the Prostate 5 Unilateral denervation of the prostate is carri ed out by removal of the pelvic ganglia, which overlie the prostate of the rat. This approach preserves the functional integrity of the bladder and posterior urethra and removes the possibility for artifact arising from major disturbances in blood flow or mict ration. Control animals undergo sham operations without concurrent denervation of the prostate. After denervation, the 10 animals are allowed to recover and maintained prior to collection of the prostate. The prostate is preserved, prepared for light microscopy and examined histologically. The major findings are (1) reduced epithelial cell height primarily due to a decrease in the clear supranuclear zone (due to a reduction in the amount and size of the apical cisternae and the endoplasmic reticulum); (2) major changes in protein expression on 15 SDS gel electrophoresis (the endoplasmic reticulum is important in protein synthesis) (3) modest reduction in the number of secretory granules; (4) an increase in intracellular vacuoles, intercellular empty spaces and reduction in niicrovilli on the cell surface; and (5) a significant increase in nerve growth factor (NIGF) content ipsilateral to the denervation relative to the control group (188 ± 10 vs.. 46 ± 20 vs. 29 ± 16 pg/g wet 20 tissue (± SD) NGF is known to influence only sympathetic and sensory neurons. N = 15 in both the control and experimental groups. Example 2 Effect of Neurotoxin Injection on Normal Prostate: Rat Prostate Rats were randomly assigned into three groups. The first group received a single 25 acute dose of Botulinum toxin type A (Botox, Allergen) of 5, 10 or 15 IU. These animals were sacrificed one week after injection. The second group received a series of 4 weekly injections of 5 IU of Botulinum toxin and were sacrificed at 5 weeks. Control rats received saline injections. Injections were performed as single or serial injections into the left and/or right ventral lobe of the prostate. Note that an injection of methylene 30 blue into one lobe of the rat prostate showed immediate diffusion into the opposite lobe. Thus, there was communication between the prostate lobes and therefore the contralateral lobe could not be used as a true comparative control. H:\annam\keep\9pecis TNB\P58945 unitechcorp div.doc 16/11/05 - 12 The weight of each prostate ventral lobe collected from healthy animals was approximately 0.50 gram. All toxin-treated animals showed shrinkage of prostate volume, first in the injected lobe, and with subsequent injections, reduction in the overall volume. After four serial injections, the left prostate lobe weighed 0.12-0.17 5 gram, while the right lobe weighed 0.10-0.14 grams. This represented a reduction of over two-thirds of the original size. Example 3 Effect of Neurotoxin Injection on Urological Dysfunctions: Human Data Three patients with recalcitrant voiding dysfunction were treated with injections 10 of botulinum toxin (Botox) as follows. Patient I was a 47-year-old male who was incontinent secondary to an injury sustained at the cervical vertebrae (level C6-C7) sustained 14 months previously. Urodynamics on presentation revealed a bladder capacity of 30 cc and a weak sphincter (peak urethral pressure of 40 cm water). He had failed multiple pharmacological regimes and was intolerant to penile clamp/condom 15 devices. He received four weekly 200 IU botulinum toxin injections into the bladder neck for total dose of 800 IU. Post-injection, his bladder capacities ranged from 300 400 cc with oxybutinin and 150-200 cc without oxybutinin. Peak bladder pressures pre injection had been 200-cm water, compared to post injection bladder pressures of 40 cm 20 of water. The patient was continent with a penile clarip after treatment with botulinum toxin. In addition, walking and erections improved due' to reduced bladder spasticity. Patient 2 was a 55 year old T12 paraparetic female secondary to traumatic injury 14 years previous. The patient presented with urge incIontinence, and had been on self catheterization every 2 hours during the day and two times at night. The patient 25 received injections into the lateral bladder wall in two weekly injections of 200 IU each for a total of 4001 U of botulinum toxin. The patient's voiding diary data revealed pre injection capacities of between 150-200 cc. Post injection, diary data indicated bladder capacity increased to 300-400 cc. In addition, the patient no longer had annoying constant urge type dysfunction, slept through the night and was continent on self 30 catheterization every 4 hours. Patient 3 was a 65 year old male with disabling perineal pain following radiation treatment for prostatic cancer. The patient had failed medical therapy. He was treated H:\annam\keep\specis TNB\P58945 unitechcorp div.doc 16/11/05 - 13 with one 200 IU injection of botulinum toxin into the external urethral sphincter. The patient experienced a dramatic relief of testicle pain and had far less severe pain in the shaft of the penis. Erections were not affected. Example 4 5 Determination of Smallest Effective Dose Rats are injected in the prostate ventral lob s with single and serial doses of botulinum toxin (Botox). The prostates are harvested at different time intervals to determine the smallest effective dose, as well as the morphological and physiological changes taking place with time. The smallest effective dose is defined as that dose that 10 would demonstrate a decrease in prostate volume. To assess the response to electrical field stimulation, preparations are mounted between two platinum electrodes placed in the 6rgan bath. The tension of the preparations is adjusted. Transmural stimulation of nerves is performed using a Danted Neuromatic 2000 Stimulator delivering single square-wave pulses at supramaximal 15 voltage with a duration of 0.8 milliseconds at a frequency of 0.5 to 80 hertz. The polarity of the electrodes is changed after each pulse by means of a polarity-changing unit. The train duration is five seconds and the train interval 120 seconds. Isometric tension is recorded by using a Gould thermo-array 8-channel recorder. Separate experiments are performed to determine the preload tension producing optimal 20 responses. In addition, the effect of the electric field stimulation in the presence of different concentrations of individual neuropeptides is determined. These neuropeptides are 10-20 pM adrenaline, 10 pM clonidine, 5-50 mM regitine, 10 nM - 0.l,pM acetylcholine, 1 - 3 pM atropine, 1 pM - 10 pM nifedipine, I - 10 nM VIP and 1 - 250 nM NPY. The effect of nitroprusside (a nitric oxide releasing substance) and methylene 25 blue (a guanylate cyclase inhibitor) on prostate tone and contraction resulting from field stimulation also is examined in these tissues. Example 5 Effect of Botulinum Toxin on Rat Prostatic Tissue: Comparison of Hormonally Intact Rats to Hormonally Deprived Rats 30 To determine if there is any interaction between the neurotoxin and testicularly derived hormones, studies are performed which will examine the interaction of the neurotoxin with hormonal components. These studies will compare prostatic tissue H:\annam\keep\specie TB\P58945 unitechcorp div.doc 16/11/05

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- 14 treated with botulinum toxin harvested from rats that have undergone orchiectomy (hormonally depleted rats) and prostatic tissue from rats treated with botulinum toxin that did not undergo orchiectomy. Fifty-two age-ma ched rats are treated as described below. Four healthy rats will undergo a sham operation consisting of anesthesia 5 induction, exposure of the prostate and injection of 0.2 cc saline into the left ventral lobe of the prostate. Three rats are given bilateral orchiectomy with no injection to the prostate (hormonally depleted controls), five rats will have orchiectomy and injection of 0.2 ml saline in the left ventral lobe (hormonal depletion + surgical stress control). Four groups of rats receive botulinum injections of 0.5 IU, 1.0 IU, 1.5 IU and 2.5 IU only 10 (hormonally intact experimental rats). Sixteen rats undergo bilateral orchiectomy. Eight of these rats are treated with a single injection of 2.5 IU botulinum toxin into the left ventral lobe S weeks after surgery. All rats are sacrificed after six weeks, and the harvested prostate is prepared for examination as described above. A similar atrophic effect on glandular epithelium is expected. 15 Example 6 Effects of Botulinum Toxin on Patients Patients affected by benign prostatic hyperplasia, abacterial prostatis, or prostatodynia are studied both before and after treatment with botulinum toxin. Patients are eligible for inclusion in this study if they are affected by BPH between the ages of 20 40 and 80, or if they are between 25 and 60 and have been diagnosed with abacterial prostatitis or prostatodynia. Preferred patients are those who are not good surgical candidates. Patients are evaluated prior to treatment by determination of prostate specific antigen levels (PSA), evaluation of urodynamic parameters (cystometrogram, urethral pressure profile and flowmetry), determination of American Urological 25 Association (AUA) symptom score (Barry, M.J., et al., [1992] J. Urol., 148: 1549 1557), maintenance of a voiding diary, and examination of the prostate by transrectal ultrasound with biopsy (for BPH patients only). One week after initial evaluation is completed, the patient is injected urethroscopically with 200 IU of botulinum toxin as either single unilateral injections, serial unilateral injections or bilateral injections. BPH 30 patients are treated by TURP or undergo control TURP-biopsy 7 days after single injection or 5 weeks after serial injections. The harvested prostatic tissues are prepared for examination as described in Examples 1,2,3, and 7-10. The patients are re-evaluated after injection using the same parameters examined during the initial evaluation. H:\annam\keep\specis TNB\P58945 unitechcorp div.doc 16/11/05 P %OPER\TNBSPECi1"2700790 I spa doc-23A86 - 15 The foregoing description of the invention is exemplary for purposes of illustration and explanation. It will be apparent to those skilled in the art that changes and modifications are possible without departing from the spirit and scope of the invention. All documents cited herein are hereby incorporated by reference. It is intended that the 5 following claims be interpreted to embrace all such changes and modifications. The reference in this specification to any prior publication (or information derived from it), or to any matter which is known, is not, and should not be taken as an acknowledgment or admission or any form of suggestion that that prior publication (or information derived from it) or known matter forms part of the common general 10 knowledge in the field of endeavour to which this specification relates.

Claims (7)

1. The use of a botulinum toxin in the preparation of a pharmaceutical composition for treating at least one symptom of overactive bladder. 5

2. The use of claim 1, wherein the symptom of overactive bladder is urinary incontinence.

3. The use of claim 1 or claim 2, wherein the composition is provided in a 10 form that is suitable for administration into the urinary tract of a patient.

4. The use of claim I or claim 2, wherein the composition is provided in a form that is suitable for administration to the bladder of the patient. 15

5. The use of claim 1 or claim 2, wherein the botulinum toxin is formulated in a pharmaceutically acceptable formulation selected from the group consisting of: a liquid, a powder, a cream, an emulsion, a pill, a troche, a suppository, a suspension, and a solution. 20

6. The use of claim 1 or claim 2, wherein the composition is an injectable composition.

7. The use of claim I or claim 2, wherein the botulinum toxin is a botulinum toxin type A.