Primary bladder neck obstruction is one of the rare causes for renal failure in young adult males

Background Primary bladder neck obstruction (PBNO) is one of the causes of bladder outlet obstruction (BOO) and rarely results in renal failure. We are presenting the clinical characteristics of young male patients with PBNO and renal failure. Methods Medical records of patients between 18 and 40 years old with PBNO and renal failure were retrospectively reviewed (2014–2020). Patients with anatomical cause of BOO, and any urological or systemic disease or previous history of any surgical procedure associated with renal failure and/or lower urinary tract dysfunction were excluded. Serum creatinine measurement, ultrasonography, uroflowmetry, cystoscopy, and videourodynamics were performed. Results Seven male patients were identified, and the mean age of the patients was 28.8 years. Symptom duration was > 5 years in all patients. Two patients presented with difficult voiding, and five patients presented with both storage and voiding lower urinary tract symptoms (LUTS). Three patients were previously misdiagnosed as overactive bladder. At presentation, serum creatinine levels were between 1.7 and 2.4 mg/dl. One patient was under hemodialysis treatment and waiting for renal transplantation. Mean detrusor pressure at maximum measured flow rate, mean maximum flow rate (Qmax), and mean average flow rate (Qave) was 67.6 cm H2O, 9.5 ml/s, and 5.5 ml/s, respectively. With α-blocker treatment, serum creatinine levels were stable or decreased after 12 months follow-up and mean Qmax and Qave were increased to 14.8 ml/s and 10.1 ml/s, respectively. Conclusions PBNO is a common disease in young men presenting with a long history of LUTS. Videourodynamics is mandatory for accurate diagnosis, but having a high clinical suspicion for PBNO is key to ensure the diagnosis. Clinicians should pay more attention to PBNO in young male patients with a long history of LUTS to prevent misdiagnosis, incorrect treatment, and possible decrease in renal function by years.

A Preliminary Validation of a New Surgical Procedure for the Treatment of Primary Bladder Neck Obstruction Using a Computational Modeling Approach

A new surgical procedure for the treatment of primary bladder neck obstruction with maintenance of anterograde ejaculation is proposed. In place of monolateral or bilateral bladder neck incision, associated with a loss of ejaculation rate of up to 30%, the new surgical procedure consists of laser drilling the bladder neck with a number of holes and without muscle fiber disruption. The effect of this novel procedure has been studied numerically, with a simplified two-dimensional numerical model of the internal urethral sphincter, varying the position and the number of holes in the fibrotic region of the urethral tissue. Results show an improvement of the urethral sphincter opening by increasing the number of holes, ranging from about 6% to 16% of recovery. Moreover, a non-aligned position of holes positively influences the opening recovery. The concentrations of maximum principal strain and stress have been registered in the proximity of the interface between the physiologic and diseased sphincter, and in those regions where the radial thickness is significantly thinner. The effects on the first five patients have been included in the study, showing improvement in micturition, lower urinary tract symptoms, sustained ejaculatory function, and quality of life.

Severe urinary tract damage secondary to primary bladder neck obstruction in women

Objective To present the clinical and radiological characteristics of women with severe structural deterioration of the bladder and upper urinary tract secondary to Primary Bladder Neck Obstruction (PBNO), and their outcomes after bladder neck incision (BNI). Methods Retrospective evaluation of adult women who underwent BNI for PBNO at one institution. Patients were assessed for symptoms, renal function, structural abnormalities of the urinary tract and video-urodynamics. PBNO diagnosis was confirmed with video-urodynamics in all patients. BNI was performed at the 4–5 and/or 7–8 o’clock positions. Postoperative symptoms, PVR, uroflowmetry and renal function were evaluated and compared to baseline. Results Median patient age was 56.5 years (range 40–80). All presented with urinary retention–four were on clean intermittent Catheterization (CIC) and two with a Foley catheter. All patients had bladder wall thickening and diverticula. Four women had elevated creatinine levels, bilateral hydronephrosis was present in five (83.3%). After BNI, all patients resumed spontaneous voiding without the need for CIC. Median Qmax significantly improved from 2.0 [1.0–4.0] mL/s to 15 [10–22.7] mL/s (p = 0.031). Median PVR decreased from 150 to 46 [22–76] mL (p = 0.031). There were no postoperative complications. Creatinine levels returned to normal in 3/4 (75%) patients. Conclusion PBNO in women may result in severe damage to the bladder and upper urinary tract. Despite severe structural abnormalities of the bladder, BNI was effective in reducing symptoms and improving structural and functional abnormalities of the lower and upper urinary tract.

Patients presenting with lower urinary tract symptoms who most deserve to be investigated for primary bladder neck obstruction

We aimed to investigate clinical features potentially useful in primary bladder neck obstruction (PBNO) diagnosis in men presenting with lower urinary tract symptoms (LUTS). Data from 1229 men presenting for LUTS as their primary complaint at a single centre were retrospectively analysed. All patients underwent a comprehensive medical and physical assessment, and completed the International Prostate Symptoms Score. All patients were investigated with uroflowmetry, and trans-rectal ultrasound imaging to define prostate volume. Urodynamic evaluation was performed when the diagnosis of benign prostatic enlargement was not confirmed and the patient presented a significant chance of detrusor overactivity or underactivity. As per our internal protocol, patients < 60 years old with bothersome LUTS and > 60 years with a prostate volume (PV) < 40 mL were also investigated with urethrocystoscopy to rule out urethral stricture. Logistic regression analysis tested clinical predictors of possible PBNO. Of 1229 patients, 136 (11%) featured a clinical profile which was consistent with PBNO. Overall, these patients were younger (p < 0.0001), had lower BMI (p < 0.0001), less comorbidities (p = 0.004) and lower PSA values (p < 0.0001), but worse IPSS scores (p = 0.01) and lower PV values (p < 0.0001) compared to patients with other-aetiology LUTS. At multivariable analysis, younger age (OR 0.90; p = 0.003) and higher IPSS scores (OR 1.12; p = 0.01) were more likely to be associated with this subset of patients, after accounting for other clinical variables. One out of ten young/middle-aged men presenting for LUTS may be affected from PBNO. Younger patients with more severe LUTS systematically deserve an extensive assessment to rule out PBNO, thus including urethrocystoscopy and urodynamics with voiding-cysto-urethrogram.

Primary Bladder Neck Obstruction (Pbno): A Cause of Luts in Young Men

Not Available Bangladesh Journal of Urology, Vol. 19, No. 2, July 2016 p.57

Transurethral Resection of Bladder Neck in the Management of Primary Bladder Neck Obstruction in Female: Our Preliminary Experience in Bangladesh

Objectives: To determine the effectiveness of transurethral resection of bladder neck in the management of primary bladder neck obstruction (PBNO) in female Patients and Methods: This prospective study has been done with thirty female patients aged from 27 to 48 years who were presented with difficult micturition or urinary retention. These patients had unremarkable physical findings with normal perianal sensation, anal sphincter tone and lower extremity reflexes. Patients associated with cystocele, meatal stenosis, stricture urethra, urethral caruncle and urethral diverticula that may lead to mechanical bladder outflow obstruction were excluded from the study. Preoperative investigations include uroflowmetry, ultrasonography, serum creatinine, urethrocystoscopy with simultaneous “water flow test” was done. Seven patients presented with obstructed voiding symptom without renal impairment (serum creatinine, mean±SEM 1.24±0.04) and were initially treated with á-blocker (category A). Among the other 23 patients those had renal impairment 18 presented with near retention and these patients were on indwelling catheterization before operation (category B, serum creatinine, mean±SEM 2.72±0.13).Rest of the 5 patients presented with nausea, vomiting, and disorientation in addition to near retention and were put on haemodialysis along with indwelling catheterization to reach near normal creatinine level before operation(category C, serum creatinine, mean±SEM,9.34±0.96 ). PBNO causing voiding difficulty were diagnosed in all the cases and were undergone transurethral bladder neck resection (BNR). Three months after operations, their pre- and post-operative symptoms were analyzed, and serum creatinine levels, ultrasonographic findings (MCC, PVR), uroflowmetric study were compared. Results: Twenty-nine (96.33%) Patients become symptom free. Their average pre- and post-operative values of MCC (Maximum Cystometric Capacity), PVR (Post Voidal Residual urine), Qmax (Peak urinary flow during uroflowmetric study, Serum creatinine level were changed from 679.50 to 482.17ml, from 574.50 to 29.37ml, from 8.43 to 29.37ml/sec, from 3.48 to 1.13 mg/dl respectively. One patient (3.33%) did not continent ever postoperatively. One patient had become dry after using pad for stress incontinent for one month only. Serum creatinine level of category C patient did not reach to the normal level (post operative creatinine level Mean±SEM,2.8±0.15)within this three moths follow up period. Conclusions: Our short term follow-up suggests that judicious Transurethral BNR is effective in relieving voiding difficulty due to primary bladder neck obstruction in female. A thorough gynaecological, neurological and urological examination is essential along with uroflowmetric, ultrasonographic and cystoscopic study to reach a correct diagnosis and making a treatment plan. Bangladesh Journal of Urology, Vol. 16, No. 1, Jan 2014 p.23-28