OBJECTIVE To investigate satisfaction with urination quality of life (QoL) after treatment with urethral sphincter botulinum toxin A (BoNT-A) injection for difficult urination in patients with spinal cord lesions and detrusor sphincter dyssynergia (DSD). METHODS Thirty-three patients with spinal cord lesion and DSD were treated with transurethral sphincter injection of 100 U of BoNT-A (BOTOX) for the main symptom of difficult urination. The urodynamic parameters, QoL scores obtained using UDI-6 and IIQ-7 and general satisfaction and dissatisfaction were assessed. RESULTS An overall satisfactory result was perceived by 60.6% of patients. Urodynamic parameters showed significant improvement in voiding detrusor pressure (45.7 +/- 22.7 vs. 30.7 +/- 15.5 cmH(2)O, P = 0.016), maximum flow rate (6.8 +/- 5.7 vs. 9.2 +/- 7.7 ml/sec, P = 0.047) and postvoid residual volume (PVR, 160 +/- 124 vs. 75 +/- 105 ml, P = 0.025). IIQ-7 scores showed significant improvement (19.0 +/- 2.4 vs. 17.1 +/- 2.9, P = 0.001) but not in UDI-6 scores (8.6 +/- 2.7 vs. 7.9 +/- 3.7, P = 0.252). Less difficult urination and less PVR needing clean intermittent catheterization were the major reasons for satisfaction, whereas increase in incontinence grade was the major reason for dissatisfaction in patients receiving urethral BoNT-A injection. CONCLUSIONS This study found that urethral sphincter BoNT-A injection for DSD does not prove convincing results in all patients and should be done only exceptionally in well-chosen patients with spinal cord lesions. Dissatisfaction in the patients was mainly due to an increased incontinence grade that was not anticipated before urethral BoNT-A injection.