Overactive bladder (OAB) syndrome is a common condition that significantly affects the quality of life of patients. Epidemiological studies have reported a prevalence of OAB ranging between 12% and 17%, with its incidence increasing with age (1). According to the International Continence Society, OAB syndrome is defined as ‘a symptom characterized by increased daytime frequency and/or nocturia, with or without urinary incontinence (OAB-wet vs. OAB-dry) in the absence of urinary tract infection or other detectable diseases’ (2). Typically, the treatment of OAB syndrome begins with the conservative treatments such as behavioral therapy, physiotherapy, and pharmacological therapy. Bladder wall injections of Botulinum Toxin-A (BTx-A) can be offered to patients who are refractory to conservative treatments (3).
While there are numerous studies in the literature investigating the effects of BTx-A in patients with OAB syndrome, none have explored the additional effects of "bladder training" and "pelvic floor muscle training" on urinary symptoms and quality of life immediately after BTx-A injection in these patients. Therefore, the aim of the present study was to investigate the effects of "bladder training" and "pelvic floor exercise training" on urinary symptoms and quality of life in patients with OAB syndrome following bladder wall injection of BTx-A.

A total of 25 female patients with non-neurogenic and wet OAB who underwent BTx-A injection were included in the non-randomized clinical study. The exclusion criteria were pregnancy, history of pelvic radiation therapy, and the presence of neurological diseases. Patients were non-randomly assigned to two study groups: "group 1 = BTx-A + physiotherapy (n=15) (age: 57.13±17.79 years, BMI: 28.98±4.66 kg/m2)" or "group 2 = BTx-A’’ (n=10) (age: 59.30±11.28 years, BMI: 28.71±5.07 kg/m2)". 
The overview of the study is presented on Figure 1. After the injection of BTx-A, patients in the first group received bladder training and pelvic floor muscle training from a trained physiotherapist. Bladder training and pelvic floor muscle training started 2 weeks after the injection of BTx-A and continued until 12 weeks post-injection. Bladder training involved a patient-specific and progressive program aimed at increasing the micturition intervals and reduce the frequency of micturition. Structured pelvic floor muscle training was applied based on principles of exercise physiology including maximal and submaximal contractions with 8 – 12 repetitions, 3 sessions per day. 
The severity of urinary symptoms, severity of urinary incontinence, quality of life, and subjective perception of improvement were evaluated using the International Consultation on Incontinence Questionnaire – Female Lower Urinary Tract symptoms (ICIQ-FLUTS), one-hour pad test, International Consultation on Incontinence Questionnaire – Lower Urinary Tract symptoms Quality of Life Module (ICIQ-LUTSqol), and the Global Improvement Perception Scale, respectively. All measurements except subjective perception of improvement were conducted at baseline, 2 weeks after the injection of BTx-A (i.e., before the application of bladder training and pelvic floor muscle training), and at 12 weeks post-injection.
Quantitative data were analyzed using the Mann-Whitney U and Friedman tests to determine differences between-groups at different assessment points and to reveal changes within group over time, respectively. The Chi-square test was used to analyze categorical data. A statistical significance level of p<0.05 was set.

When comparing the changes in outcome measures from baseline to the 12th week after the injection of BTx-A, there were significant improvements in the severity of urinary symptoms and quality of life at the 12th week after the injection of BTx-A in both groups (p<0.05) (Table 1). However, there were no significant differences in the severity of urinary symptoms and quality of life between the groups at different time-points (p>0.05) (Table 1). However, at 12 week after the injection of BTx-A, there was significant difference in the score of the one-hour pad test between the groups (p=0,015) (Table 1). Furthermore, 80% of patients in the “BTx-A + physiotherapy group” reported that their symptoms improved when compared to the baseline condition. In the “BTx-A group”, 50% of patients reported that their symptoms were better and/or much better in comparison with the baseline status (Table 2). In both groups, no side-effects were reported regarding the injection of BTx-A.

Based on the pilot data, it was found that bladder training and pelvic floor muscle training provided immediately after the BTx-A injection may be more effective in decreasing the severity of UI than BTx-A injection alone in patients with wet OAB syndrome. However, improvements in urinary symptoms and quality of life were similar in both groups.

Through collecting pilot data, our aim was to determine whether the reduction in detrusor hyperactivity following BTx-A injection might facilitate successful implementation of bladder training and pelvic floor muscle training. Thus, combined therapy (bladder training and pelvic floor muscle training + BTx-A) would have offered greater benefits in alleviating symptoms and improving quality of life. However, our findings indicated that bladder training and pelvic floor muscle training following intravesical injection of BTx-A showed similar effectiveness with BTx-A alone in terms of the improvements in symptoms and quality of life in the short-term.

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