The Evolution of Botulinum Toxin

Background: Botulinum neurotoxin has evolved from a feared cause of food-borne paralysis into a versatile therapeutic agent. In paediatric urology, onabotulinumtoxinA has become an important minimally invasive option for neurogenic detrusor overactivity and selected refractory lower urinary tract dysfunctions. Objective: This narrative review aims to trace the major historical and scientific milestones in the development of botulinum toxin, describe its mechanism of action and evolution as a urological therapy, and critically summarise current paediatric urological applications, injection techniques, limitations, adverse events, and emerging technologies. Methods: A narrative literature search was performed using PubMed/MEDLINE and reference lists of relevant reviews and landmark articles, with emphasis on the history of botulinum toxin, mechanism of action, detrusor-sphincter dyssynergia, neurogenic detrusor overactivity, paediatric neurogenic bladder, injection techniques, safety, treatment failure, neutralising antibodies, and novel delivery systems. Historical primary reports, pivotal clinical studies, paediatric trials, systematic reviews, and recent relevant publications available through August 2026 were prioritised. Results: The historical progression from Kerner's early clinical observations and van Ermengem's microbiological isolation to Scott's therapeutic use and subsequent urological applications is closely linked to advances in neurophysiology and drug delivery. Paediatric evidence supports meaningful improvements in continence and urodynamic parameters in appropriately selected patients; however, repeated procedures, urinary tract infection, transient retention, incomplete response in poorly compliant or fibrotic bladders, possible immunogenic failure, cost, and anaesthesia burden remain clinically relevant limitations. Conclusion: Emerging longer-acting formulations and non-invasive delivery systems are promising but remain investigational for paediatric urology. Keywords: Botulinum neurotoxin; History of medicine; Neurogenic bladder; Overactive bladder; Paediatric urology