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Primary Bladder Neck Obstruction: Urodynamic Findings and Treatment Results in 36 Men
0022-5347/9s/156&1418$03.00/0
Vol. 156,1418-1420, October 1996 Printed in U.S.A.
THEJOURNAL OF U R O u x i Y Copyright 0 1996 by AMER~cANU R O ~ ~ ; I ASSOCIATION, CAL INC.
PRIMARY BLADDER NECK OBSTRUCTION: URODYNAMIC FINDINGS AND TREATMENT RESULTS IN 36 MEN BRETT A. TROCKMAN," JILL GERSPACH, ROGER DMOCHOWSKI,t FRANCOIS HAAI3, PHILLIPPE E. ZIMMERNS AND GARY E. LEACH From the Departments of Urodynamics and Urology, Kaiser Permanente Medical Center, Los Angeles, California
ABSTRACT
Purpose: We reviewed the urodynamic findings and treatment outcomes of a large series of men with primary bladder neck obstruction. Materials and Methods: A retrospective review was done of the presenting symptoms and urodynamic findings of 36 men with primary bladder neck obstruction. Outcomes after treatment with a-blockers, transurethral incision of the bladder neck and prostate, or no long-term therapy were determined by chart review and patient survey in the majority of cases. Results: Mean age of the men was 41 years. Patients had significant lower urinary tract symptoms, decreased peak urinary flow rates, elevated post-void residual, markedly elevated peak voiding pressures and poor funneling of the bladder neck during voiding. Although most patients initially chose a-blocker therapy, only 30%of those beginning a-blockers continued them long term, usually due to inadequate symptomatic improvement. A total of 18 men underwent transurethral incision, which resulted in significant improvements in symptom scores, peak urinary flow rates, post-void residual and peak voiding pressures. Patients reported a mean 87% overall improvement in symptoms after transurethral incision. Conclusions: Video urodynamics facilitate diagnosis of primary bladder neck obstruction. Transurethral incision is the most effective therapy for primary bladder neck obstruction. KEY WORDS:bladder neck obstruction, bladder diseases, urodynamics Primary bladder neck obstruction is a poorly understood cause of lower urinary tract symptoms in men. Men with primary bladder neck obstruction are often misdiagnosed with chronic nonbacterial prostatitis, neurogenic bladder dysfunction and psychogenic voiding dysfunction, and often complain of symptoms for many years before the correct diagnosis is made.1-4 These men are typically 20 to 50 years old, and have long-standing obstructive and irritative voiding symptoms. Urinary flow rates are less than normal, and cystoscopy may demonstrate nonspecific findings of a small prostate, tight bladder neck and bladder wall trabeculation. Diagnosis is most accurate with video urodynamics and pressure-flow studies, which demonstrate elevated pressure, decreased flow and the site of obstruction at the bladder neck. Transurethral incision of the bladder neck is the standard treatment for primary bladder neck obstruction, and is effective at improving urinary flow rates and lower urinary tract symptoms.*-4 Primary bladder neck obstruction has been recognized for many years, and has also been termed Marion's disease: dysfunctional bladder neck3 and bladder neck dyssynergia.6.7 The different terms used to describe this disorder reflect the evolving understanding of its pathogenesis. In 1933 Marion suggested that obstruction was due to a fibrous narrowing of the bladder outlet.5 However, subsequent investigators have found no histological evidence of increased fibrosis of the bladder neck.2 Abnormalities of bladder neck musculature and innervation have also been implicated.8.9 The recent neuropeptide mapping study of Crowe et a1 supports the
modern theory of sympathetic nervous dysfunction as a major cause of primary bladder neck o b ~ t r u c t i o nThis . ~ theory provides the rationale for use of a-blocking agents to treat this disorder. Although some have suggested the possible beneficial role of a-blocking agents,4 Kaplan et a1 reported that none of 24 patients with primary bladder neck obstruction treated with a-blocking agents experienced significant symptomatic improvement.1 We report our experience with evaluation and treatment of a large series of 36 men with primary bladder neck obstruction. The long-term outcome of pharmocological and surgical therapy for this disorder is examined. METHODS
We reviewed the charts of 36 men with primary bladder neck obstruction treated consecutively at our institution. An attempt was also made to contact all patients by telephone to complete a followup survey. All telephone interviews were conducted by a physician not involved in evaluation or care of the patient. Patients underwent an initial evaluation that included a complete history and physical examination, American Urological Association (AUA) 6 question symptom score, uroflowmetry and ultrasound post-void residual determinations, cystoscopy and medium-fill multichannel video urodynamics, including pressure-flow analysis. All definitions conform to the recommendations of the International Continence Society.lo Most patients also underwent upper tract screening with renal ultrasound or a n excretory urogram. After diagnosis of primary bladder neck obstruction, Accepted for publication April 19, 1996. * Current address: Department of Urolo Loyola University patients were offered medical therapy with a-blockers (5mg. Medical Center, 2160 S. First Ave., Maywoorhinois 60153. terazosin at bedtime or 2 mg. prazosin twice daily) or transf Current address: Department of Urology, University of Tennes- urethral incision of the bladder neck and prostate. Patients see, 956 Court Ave., Memphis, Tennessee 38163. $ Current address: Division of Urology, University of Texas South- failing a-blocker therapy were offered surgery. Subjective western Medical Center, 5323 Harry Hines Blvd., Dallas, Texas and objective followup data were determined by chart review 75235. and the telephone survey, which included AUA-6 symptom 1418
URODYNAMICS AND TREATMENT RESULTS IN MEN WITH PRIMARY BLADDER NECK OBSTRUCTION
score determination, and assessment of overall patient reported subjective improvement, sexual function and ejaculatory ability. A subset of 13 patients underwent repeat video urodynamic evaluation during followup. Transurethral incision of the bladder neck and prostate was performed through a 24F resectoscope using the Collins knife. The choice of general, spinal or local anesthesia was determined by patient preference. Transperineal periprostatic infiltration of lidocaine and bupivacaine for local anesthesia was preferred.1l.l2 Incisions were made at the 5 and 7 o’clock positions from approximately 1 cm. distal to each ureteral orifice through the bladder neck t o just proximal to the verumontanum. The incisions were deepened until no ridge was visible a t the bladder neck and fat could be visualized through the distracted capsular fibers.11 A Foley catheter was inserted and gentle traction was applied if necessary to control bleeding. In most patients the catheter was removed, and they were discharged home the morning after surgery. More recently, transurethral incision has been performed on an outpatient basis with the catheters removed the next day in the office. AUA-6 symptom scores, peak urinary flow rates, post-void residual and overall subjective improvement among the transurethral incision, a-blocker and no treatment groups were compared statistically with Student’s t test. Significance was defined as p <0.05.
Video urodynamic study from patient with primary bladder neck obstruction demonstrates increased detrusor pressure, decreased urinary flow rate and poor funneling of bladder neck during voiding. P , true detrusor pressure.
TABLE2. Treatment results in 34 men Transurethral Incision a-Blockers No Treatment
RESULTS
Mean age of the 36 men evaluated was 40.8 years (range 21 to 52). Mean duration of lower urinary tract symptoms before initial evaluation was 6.7 years (range 1 to 52). Three men (8%)had a history of urinary tract infection and 4 (11%) had a history of urinary retention. All patients were neurologically normal. Results of the initial evaluation are summarized in table 1. All 33 patients completing video fluoroscopy demonstrated poor funneling of the bladder neck during voiding (see figure). Followup data were available for 34 of the 36 men initially evaluated (26 also completed the followup telephone interview). Mean followup was 30.4 months (range 3 to 75). Of the 36 men 23 (68%) initially chose a-blockers but 16 (70%) discontinued therapy usually because of inadequate symptomatic improvement. Eight men refused further treatment after failing medical therapy. Of 36 men 18 (50%)underwent transurethral incision. Ten men initially chose surgical therapy and 8 underwent transurethral incision only after medical therapy failed. One patient refused treatment after initial evaluation, while 2 recently underwent transurethral incision and followup data are not yet available. Pretreatment and followup mean AUA-6 symptom scores, mean peak urinary flow rates, mean post-void residual and overall patient reported subjective improvement for each treatment group are summarized in table 2. The only patient with hydronephrosis underwent transurethral incision with complete resolution on renal ultrasonography. Statistical analysis of the results by treatment group revealed significant differences only between the transurethral incision and no treatment groups (AUAS symptom score, peak urinary flow rate and overall subjective improvement, p
TABLE1. Initial evaluation results in 36 men Mean 2 SD: AUA-6 score Peak flow rate (ml./sec.) Post-void residual (ml.) Bladder capacity (ml.) Peak voiding pressure (cm. water) No. nts. (%>. =.. ~.,. Detrusor instability Poor compliance (less than 12.5 ml./cm. water)
1419
Total No.pts. Mean followup ? SD (mas.) AUA-6: Preop. Postop. p Value Mean free peak flow rate 2 SD (ml./sec.): Preop. Postop. p Value Mean post-void residual ? SD (mI.1: Preop. Postop. p Value ’X Mean subjective improvement 2 SD
18 30 t 18
7 25 2 14
9 36 t- 16
17.1 i 5.2 4.3 t- 4.5 (0.01
18.6 2 4.6 10.3 t- 9.9 0.09
16.4 2 4.2 10.5 t 6.8
8.2 t 4.5 26.7 t- 11.8 <0.01
11.0 2 3.6 22.1 t- 13.9 0.12
9.9 2 2.7 14.6t- 6.9 0.05
161 t 132 23 2 33 <0.01 87 t 16
65 z 62 45 t- 30 0.26 67 t 24
103 t 109 47 2 48 0.11 38 t 30
0.06
<0.05). Followup post-void residuals were not significantly different. Mean pretreatment and posttreatment peak voiding pressures for the 13 patients who underwent repeat urodynamic evaluations are listed in table 3. Only patients who underwent transurethral incision demonstrated fluoroscopic evidence of adequate funneling of the bladder neck during voiding. Transurethral incision was not associated with any significant perioperative complications and no blood products were transfused. New erectile dysfunction was not reported by any men on long-term a-blocker therapy or after transurethral incision. Of 15 men 11 (73%)reported antegrade ejaculation after transurethral incision. One patient required transurethral resection of the prostate for recurrent symptoms 4
TABLE3. Pretreatment and posttreatment voiding Dressures
17.72 5.2 8.92 4.2 123 2 118 397 t- 149 106 t- 45
~
11 (31) 1 (3)
No. F’ts.
Mean Peak Voiding Pressure (cm. water) Preop.
9 116 Transurethral incision 1 60 a-Blocker No treatment 2 130 * Simificantlv different. D <0.01. Student’s t test. -. .......~~~~~”
..
Postop.
48* 49 93
incision is associated with minimal complications and is now routinely performed on an outpatient basis. The bilateral 5 and 7 o'clock incisions used in our study resulted in a greater incidence of retrograde ejaculation (27%)than that reported by others using unilateral incisions a t the 5 or 7 o'clock DISCUSSION position.1.2.4 Webstel" and Kaplanl et al used a unilateral Primary bladder neck obstruction can result in severe lower urinary tract symptoms in relatively young men. Un- incision technique in 16 and 31 men, respectively, with both fortunately, diagnosis often is overlooked for many years. A studies reporting preservation of antegrade ejaculation in all high index of suspicion is required for an accurate and timely patients. Preoperative and postoperative semen analyses, diagnosis. Once primary bladder neck obstruction is sus- and fertility data after transurethral incision have not been pected diagnosis should be confirmed with video urodynam- reported. It seems likely that any procedure designed to ics, including pressure-flow studies. All of our patients had disrupt bladder neck closure may result in some degree of poor peak urinary flow rates and elevated voiding pres- retrograde ejaculation. Therefore, we counsel all patients sures (some up to 200 cm. water). Our mean peak void- about the potential negative impact of transurethral incision ing pressure of 106 cm. water was considerably greater than on fertility even if a unilateral technique is used. that reported by Kaplan (76.3 cm. water)' and Webster (60 CONCLUSIONS cm. water14 et a1 but similar to that reported by Norlen and Blaivas (110 cm. water1.2 Poor funneling of the bladder neck Video urodynamics with pressure-flow studies facilitate during voiding was also noted in all patients completing diagnosis of primary bladder neck obstruction. Although video fluoroscopy. Although the diagnosis can probably be a-blocker therapy may be useful in a minority of patients, made without video fluoroscopy, we prefer to have visual transurethral incision is the most effective therapy for priconfirmation of the site of obstruction before recommending mary bladder neck obstruction. invasive therapy to these relatively young men. Cystoscopy is useful to rule out other urethral, prostatic and bladder paREFERENCES thology as the source of symptoms. However, cystoscopic 1. Kaplan, S. A., Te, A. E. and Jacobs, B. Z.: Urodynamic evidence findings of a high or tight bladder neck are nonspecific and of vesical neck obstruction in men with misdiagnosed chronic should not be considered diagnostic of primary bladder neck bacterial prostatitis and the therapeutic role of endoscopic obstruction. incision of the bladder neck. J. Urol., 152:2063, 1994. We do not routinely use electromyography for evaluation of 2. Norlen, L. J. and Blaivas, J . G.: Unsuspected proximal urethral neurologically normal men with suspected primary bladder obstruction in young and middle-aged men. J . Urol., 135 972, neck obstruction. Detrusor external sphincter dyssynergia 1986. should not occur without an identifiable neurological lesion. 3. Woodside, J . R.: Urodynamic evaluation of dysfunctional bladder neck obstruction in men. J . Urol., 124:673, 1980. Furthermore, the site of obstruction can be clearly identified 4. Webster, G. D., Lockhart, J . L. and Older, R. A,: The evaluation at the bladder neck by voiding fluoroscopy. of bladder neck dysfunction. J . Urol., 123 196, 1980. In our experience as well as that of others? relatively 5. Marion, G.: Surgery of the neck of the bladder. Brit. J . Urol., 5 young symptomatic men without video fluoroscopic evidence 351, 1933. of high pressure, low flow voiding and poor funneling of the 6. Turner-Wanvick, R.: Bladder outflow obstruction in the male. bladder neck do not benefit from invasive therapy to disrupt In: Urodynamics. Principles, Practice and Application. Edited the bladder neck. Because the etiology of the lower urinary by A. R. Mundy, T. P. Stephenson and A. J . Wein. Edinburgh: tract symptoms in these men is not clear and may have a Churchill Livingstone, pp. 183-204, 1984. psychologicalcomponent,13 we avoid empirical surgical treat7. Crowe, R., Noble, J., Robson, T., Soediono, P., Milroy, E. J. G. and Burnstock, G.: An increase of neuropeptide Y but not ment in these cases. nitric oxide synthase-immunoreactive nerves in the bladder The high density of excitatory a-adrenergic receptors a t neck from male patients with bladder neck dyssynergia. the bladder outlet reflects the important influence of the J . Urol., 154 1231, 1995. sympathetic nervous system on bladder neck function.7.14 8. Turner-Warwick, R., Whiteside, C. G., Worth, P. H. L., Milroy, Crowe et a1 suggested that increased density of neuropeptide E. J . G. and Bates, C. P.: A urodynamic view of the clinical Y-immunoreactive nerves at the bladder neck in patients problems associated with bladder neck dysfunction and its with bladder neck dyssynergia represents an imbalance of treatment by endoscopic incision and transtrigonal posterior the complex neuronal composition of the bladder neck.7 Preprostatectomy. Brit. J. Urol., 4 5 44, 1973. vious reports of a-blockers to treat primary bladder neck 9. Awad, S. A., Downie, J. W., Lywood, D. W., Young, R. A. and obstruction have been unimpressive.l Although only 30% of Jarzylo, S. V.: Sympathetic activity in the proximal urethra in patients with urinary obstruction. J . Urol., 115: 545, 1976. our patients continued long-term a-blocker therapy, the 7 who continued pharmacological therapy reported a mean 10. Abrams, P., Blaivas, J . G., Stanton, S. L. and Andersen, J . T.: The standardisation of terminology of lower urinary tract 67%overall improvement in symptoms. Furthermore, larger function. The International Continence Society Committee on doses of a-blockers may have been more effective. For these Standardisation of Terminology. Scand. J . Urol. Nephrol., reasons we continue to offer a-blockers as a first line treatsuppl., 114:5, 1988. ment option, especially for younger men with primary blad- 11. Sirls, L. T., Ganabathi, K., Zimmern, P. E., Roskamp, D. A., der neck obstruction in whom fertility considerations are Wolde-Tsadik, G. and Leach, G. E.: Transurethral incision of paramount. the prostate: a n objective and subjective evaluation of longterm efficacy. J . Urol., part 2, 150 1615, 1993. Our study confirms that transurethral incision is the most effective treatment for primary bladder neck obstruction. 12. Sinha, B., Haikel, G., Lange, P. H., Moon, P. D. and Narayan, P.: Transurethral resection of the prostate with local anesthesia After transurethral incision, AUA-6 symptom scores, urinary in 100 patients. J. Urol., 135: 719, 1986. flow rates and post-void residual were significantly improved, and men reported an average 87% overall improve- 13. George, N. J. R. and Slade, N.: Hesitancy and poor stream in younger men without outflow tract obstruction-the anxious ment in symptoms. In addition, the 9 patients undergoing bladder. Brit. J . Urol., 51: 506, 1979. repeat urodynamics after transurethral incision had a mean 14. Nergarth, A. and Boreus, L. 0.:Autonomic receptor function in decrease in peak voiding pressure of 68 cm. water, urodythe lower urinary tract of man and cat. Scand. J . Urol. Nephnamically documenting relief of obstruction. Transurethral rol., 6 32, 1972. years aRer incision. One patient had urodynamically documented recurrent obstruction 2 years &r transurethral incision but he refixed further treatment.
Vol. 156,1418-1420, October 1996 Printed in U.S.A.
THEJOURNAL OF U R O u x i Y Copyright 0 1996 by AMER~cANU R O ~ ~ ; I ASSOCIATION, CAL INC.
PRIMARY BLADDER NECK OBSTRUCTION: URODYNAMIC FINDINGS AND TREATMENT RESULTS IN 36 MEN BRETT A. TROCKMAN," JILL GERSPACH, ROGER DMOCHOWSKI,t FRANCOIS HAAI3, PHILLIPPE E. ZIMMERNS AND GARY E. LEACH From the Departments of Urodynamics and Urology, Kaiser Permanente Medical Center, Los Angeles, California
ABSTRACT
Purpose: We reviewed the urodynamic findings and treatment outcomes of a large series of men with primary bladder neck obstruction. Materials and Methods: A retrospective review was done of the presenting symptoms and urodynamic findings of 36 men with primary bladder neck obstruction. Outcomes after treatment with a-blockers, transurethral incision of the bladder neck and prostate, or no long-term therapy were determined by chart review and patient survey in the majority of cases. Results: Mean age of the men was 41 years. Patients had significant lower urinary tract symptoms, decreased peak urinary flow rates, elevated post-void residual, markedly elevated peak voiding pressures and poor funneling of the bladder neck during voiding. Although most patients initially chose a-blocker therapy, only 30%of those beginning a-blockers continued them long term, usually due to inadequate symptomatic improvement. A total of 18 men underwent transurethral incision, which resulted in significant improvements in symptom scores, peak urinary flow rates, post-void residual and peak voiding pressures. Patients reported a mean 87% overall improvement in symptoms after transurethral incision. Conclusions: Video urodynamics facilitate diagnosis of primary bladder neck obstruction. Transurethral incision is the most effective therapy for primary bladder neck obstruction. KEY WORDS:bladder neck obstruction, bladder diseases, urodynamics Primary bladder neck obstruction is a poorly understood cause of lower urinary tract symptoms in men. Men with primary bladder neck obstruction are often misdiagnosed with chronic nonbacterial prostatitis, neurogenic bladder dysfunction and psychogenic voiding dysfunction, and often complain of symptoms for many years before the correct diagnosis is made.1-4 These men are typically 20 to 50 years old, and have long-standing obstructive and irritative voiding symptoms. Urinary flow rates are less than normal, and cystoscopy may demonstrate nonspecific findings of a small prostate, tight bladder neck and bladder wall trabeculation. Diagnosis is most accurate with video urodynamics and pressure-flow studies, which demonstrate elevated pressure, decreased flow and the site of obstruction at the bladder neck. Transurethral incision of the bladder neck is the standard treatment for primary bladder neck obstruction, and is effective at improving urinary flow rates and lower urinary tract symptoms.*-4 Primary bladder neck obstruction has been recognized for many years, and has also been termed Marion's disease: dysfunctional bladder neck3 and bladder neck dyssynergia.6.7 The different terms used to describe this disorder reflect the evolving understanding of its pathogenesis. In 1933 Marion suggested that obstruction was due to a fibrous narrowing of the bladder outlet.5 However, subsequent investigators have found no histological evidence of increased fibrosis of the bladder neck.2 Abnormalities of bladder neck musculature and innervation have also been implicated.8.9 The recent neuropeptide mapping study of Crowe et a1 supports the
modern theory of sympathetic nervous dysfunction as a major cause of primary bladder neck o b ~ t r u c t i o nThis . ~ theory provides the rationale for use of a-blocking agents to treat this disorder. Although some have suggested the possible beneficial role of a-blocking agents,4 Kaplan et a1 reported that none of 24 patients with primary bladder neck obstruction treated with a-blocking agents experienced significant symptomatic improvement.1 We report our experience with evaluation and treatment of a large series of 36 men with primary bladder neck obstruction. The long-term outcome of pharmocological and surgical therapy for this disorder is examined. METHODS
We reviewed the charts of 36 men with primary bladder neck obstruction treated consecutively at our institution. An attempt was also made to contact all patients by telephone to complete a followup survey. All telephone interviews were conducted by a physician not involved in evaluation or care of the patient. Patients underwent an initial evaluation that included a complete history and physical examination, American Urological Association (AUA) 6 question symptom score, uroflowmetry and ultrasound post-void residual determinations, cystoscopy and medium-fill multichannel video urodynamics, including pressure-flow analysis. All definitions conform to the recommendations of the International Continence Society.lo Most patients also underwent upper tract screening with renal ultrasound or a n excretory urogram. After diagnosis of primary bladder neck obstruction, Accepted for publication April 19, 1996. * Current address: Department of Urolo Loyola University patients were offered medical therapy with a-blockers (5mg. Medical Center, 2160 S. First Ave., Maywoorhinois 60153. terazosin at bedtime or 2 mg. prazosin twice daily) or transf Current address: Department of Urology, University of Tennes- urethral incision of the bladder neck and prostate. Patients see, 956 Court Ave., Memphis, Tennessee 38163. $ Current address: Division of Urology, University of Texas South- failing a-blocker therapy were offered surgery. Subjective western Medical Center, 5323 Harry Hines Blvd., Dallas, Texas and objective followup data were determined by chart review 75235. and the telephone survey, which included AUA-6 symptom 1418
URODYNAMICS AND TREATMENT RESULTS IN MEN WITH PRIMARY BLADDER NECK OBSTRUCTION
score determination, and assessment of overall patient reported subjective improvement, sexual function and ejaculatory ability. A subset of 13 patients underwent repeat video urodynamic evaluation during followup. Transurethral incision of the bladder neck and prostate was performed through a 24F resectoscope using the Collins knife. The choice of general, spinal or local anesthesia was determined by patient preference. Transperineal periprostatic infiltration of lidocaine and bupivacaine for local anesthesia was preferred.1l.l2 Incisions were made at the 5 and 7 o’clock positions from approximately 1 cm. distal to each ureteral orifice through the bladder neck t o just proximal to the verumontanum. The incisions were deepened until no ridge was visible a t the bladder neck and fat could be visualized through the distracted capsular fibers.11 A Foley catheter was inserted and gentle traction was applied if necessary to control bleeding. In most patients the catheter was removed, and they were discharged home the morning after surgery. More recently, transurethral incision has been performed on an outpatient basis with the catheters removed the next day in the office. AUA-6 symptom scores, peak urinary flow rates, post-void residual and overall subjective improvement among the transurethral incision, a-blocker and no treatment groups were compared statistically with Student’s t test. Significance was defined as p <0.05.
Video urodynamic study from patient with primary bladder neck obstruction demonstrates increased detrusor pressure, decreased urinary flow rate and poor funneling of bladder neck during voiding. P , true detrusor pressure.
TABLE2. Treatment results in 34 men Transurethral Incision a-Blockers No Treatment
RESULTS
Mean age of the 36 men evaluated was 40.8 years (range 21 to 52). Mean duration of lower urinary tract symptoms before initial evaluation was 6.7 years (range 1 to 52). Three men (8%)had a history of urinary tract infection and 4 (11%) had a history of urinary retention. All patients were neurologically normal. Results of the initial evaluation are summarized in table 1. All 33 patients completing video fluoroscopy demonstrated poor funneling of the bladder neck during voiding (see figure). Followup data were available for 34 of the 36 men initially evaluated (26 also completed the followup telephone interview). Mean followup was 30.4 months (range 3 to 75). Of the 36 men 23 (68%) initially chose a-blockers but 16 (70%) discontinued therapy usually because of inadequate symptomatic improvement. Eight men refused further treatment after failing medical therapy. Of 36 men 18 (50%)underwent transurethral incision. Ten men initially chose surgical therapy and 8 underwent transurethral incision only after medical therapy failed. One patient refused treatment after initial evaluation, while 2 recently underwent transurethral incision and followup data are not yet available. Pretreatment and followup mean AUA-6 symptom scores, mean peak urinary flow rates, mean post-void residual and overall patient reported subjective improvement for each treatment group are summarized in table 2. The only patient with hydronephrosis underwent transurethral incision with complete resolution on renal ultrasonography. Statistical analysis of the results by treatment group revealed significant differences only between the transurethral incision and no treatment groups (AUAS symptom score, peak urinary flow rate and overall subjective improvement, p
TABLE1. Initial evaluation results in 36 men Mean 2 SD: AUA-6 score Peak flow rate (ml./sec.) Post-void residual (ml.) Bladder capacity (ml.) Peak voiding pressure (cm. water) No. nts. (%>. =.. ~.,. Detrusor instability Poor compliance (less than 12.5 ml./cm. water)
1419
Total No.pts. Mean followup ? SD (mas.) AUA-6: Preop. Postop. p Value Mean free peak flow rate 2 SD (ml./sec.): Preop. Postop. p Value Mean post-void residual ? SD (mI.1: Preop. Postop. p Value ’X Mean subjective improvement 2 SD
18 30 t 18
7 25 2 14
9 36 t- 16
17.1 i 5.2 4.3 t- 4.5 (0.01
18.6 2 4.6 10.3 t- 9.9 0.09
16.4 2 4.2 10.5 t 6.8
8.2 t 4.5 26.7 t- 11.8 <0.01
11.0 2 3.6 22.1 t- 13.9 0.12
9.9 2 2.7 14.6t- 6.9 0.05
161 t 132 23 2 33 <0.01 87 t 16
65 z 62 45 t- 30 0.26 67 t 24
103 t 109 47 2 48 0.11 38 t 30
0.06
<0.05). Followup post-void residuals were not significantly different. Mean pretreatment and posttreatment peak voiding pressures for the 13 patients who underwent repeat urodynamic evaluations are listed in table 3. Only patients who underwent transurethral incision demonstrated fluoroscopic evidence of adequate funneling of the bladder neck during voiding. Transurethral incision was not associated with any significant perioperative complications and no blood products were transfused. New erectile dysfunction was not reported by any men on long-term a-blocker therapy or after transurethral incision. Of 15 men 11 (73%)reported antegrade ejaculation after transurethral incision. One patient required transurethral resection of the prostate for recurrent symptoms 4
TABLE3. Pretreatment and posttreatment voiding Dressures
17.72 5.2 8.92 4.2 123 2 118 397 t- 149 106 t- 45
~
11 (31) 1 (3)
No. F’ts.
Mean Peak Voiding Pressure (cm. water) Preop.
9 116 Transurethral incision 1 60 a-Blocker No treatment 2 130 * Simificantlv different. D <0.01. Student’s t test. -. .......~~~~~”
..
Postop.
48* 49 93
incision is associated with minimal complications and is now routinely performed on an outpatient basis. The bilateral 5 and 7 o'clock incisions used in our study resulted in a greater incidence of retrograde ejaculation (27%)than that reported by others using unilateral incisions a t the 5 or 7 o'clock DISCUSSION position.1.2.4 Webstel" and Kaplanl et al used a unilateral Primary bladder neck obstruction can result in severe lower urinary tract symptoms in relatively young men. Un- incision technique in 16 and 31 men, respectively, with both fortunately, diagnosis often is overlooked for many years. A studies reporting preservation of antegrade ejaculation in all high index of suspicion is required for an accurate and timely patients. Preoperative and postoperative semen analyses, diagnosis. Once primary bladder neck obstruction is sus- and fertility data after transurethral incision have not been pected diagnosis should be confirmed with video urodynam- reported. It seems likely that any procedure designed to ics, including pressure-flow studies. All of our patients had disrupt bladder neck closure may result in some degree of poor peak urinary flow rates and elevated voiding pres- retrograde ejaculation. Therefore, we counsel all patients sures (some up to 200 cm. water). Our mean peak void- about the potential negative impact of transurethral incision ing pressure of 106 cm. water was considerably greater than on fertility even if a unilateral technique is used. that reported by Kaplan (76.3 cm. water)' and Webster (60 CONCLUSIONS cm. water14 et a1 but similar to that reported by Norlen and Blaivas (110 cm. water1.2 Poor funneling of the bladder neck Video urodynamics with pressure-flow studies facilitate during voiding was also noted in all patients completing diagnosis of primary bladder neck obstruction. Although video fluoroscopy. Although the diagnosis can probably be a-blocker therapy may be useful in a minority of patients, made without video fluoroscopy, we prefer to have visual transurethral incision is the most effective therapy for priconfirmation of the site of obstruction before recommending mary bladder neck obstruction. invasive therapy to these relatively young men. Cystoscopy is useful to rule out other urethral, prostatic and bladder paREFERENCES thology as the source of symptoms. However, cystoscopic 1. Kaplan, S. A., Te, A. E. and Jacobs, B. Z.: Urodynamic evidence findings of a high or tight bladder neck are nonspecific and of vesical neck obstruction in men with misdiagnosed chronic should not be considered diagnostic of primary bladder neck bacterial prostatitis and the therapeutic role of endoscopic obstruction. incision of the bladder neck. J. Urol., 152:2063, 1994. We do not routinely use electromyography for evaluation of 2. Norlen, L. J. and Blaivas, J . G.: Unsuspected proximal urethral neurologically normal men with suspected primary bladder obstruction in young and middle-aged men. J . Urol., 135 972, neck obstruction. Detrusor external sphincter dyssynergia 1986. should not occur without an identifiable neurological lesion. 3. Woodside, J . R.: Urodynamic evaluation of dysfunctional bladder neck obstruction in men. J . Urol., 124:673, 1980. Furthermore, the site of obstruction can be clearly identified 4. Webster, G. D., Lockhart, J . L. and Older, R. A,: The evaluation at the bladder neck by voiding fluoroscopy. of bladder neck dysfunction. J . Urol., 123 196, 1980. In our experience as well as that of others? relatively 5. Marion, G.: Surgery of the neck of the bladder. Brit. J . Urol., 5 young symptomatic men without video fluoroscopic evidence 351, 1933. of high pressure, low flow voiding and poor funneling of the 6. Turner-Wanvick, R.: Bladder outflow obstruction in the male. bladder neck do not benefit from invasive therapy to disrupt In: Urodynamics. Principles, Practice and Application. Edited the bladder neck. Because the etiology of the lower urinary by A. R. Mundy, T. P. Stephenson and A. J . Wein. Edinburgh: tract symptoms in these men is not clear and may have a Churchill Livingstone, pp. 183-204, 1984. psychologicalcomponent,13 we avoid empirical surgical treat7. Crowe, R., Noble, J., Robson, T., Soediono, P., Milroy, E. J. G. and Burnstock, G.: An increase of neuropeptide Y but not ment in these cases. nitric oxide synthase-immunoreactive nerves in the bladder The high density of excitatory a-adrenergic receptors a t neck from male patients with bladder neck dyssynergia. the bladder outlet reflects the important influence of the J . Urol., 154 1231, 1995. sympathetic nervous system on bladder neck function.7.14 8. Turner-Warwick, R., Whiteside, C. G., Worth, P. H. L., Milroy, Crowe et a1 suggested that increased density of neuropeptide E. J . G. and Bates, C. P.: A urodynamic view of the clinical Y-immunoreactive nerves at the bladder neck in patients problems associated with bladder neck dysfunction and its with bladder neck dyssynergia represents an imbalance of treatment by endoscopic incision and transtrigonal posterior the complex neuronal composition of the bladder neck.7 Preprostatectomy. Brit. J. Urol., 4 5 44, 1973. vious reports of a-blockers to treat primary bladder neck 9. Awad, S. A., Downie, J. W., Lywood, D. W., Young, R. A. and obstruction have been unimpressive.l Although only 30% of Jarzylo, S. V.: Sympathetic activity in the proximal urethra in patients with urinary obstruction. J . Urol., 115: 545, 1976. our patients continued long-term a-blocker therapy, the 7 who continued pharmacological therapy reported a mean 10. Abrams, P., Blaivas, J . G., Stanton, S. L. and Andersen, J . T.: The standardisation of terminology of lower urinary tract 67%overall improvement in symptoms. Furthermore, larger function. The International Continence Society Committee on doses of a-blockers may have been more effective. For these Standardisation of Terminology. Scand. J . Urol. Nephrol., reasons we continue to offer a-blockers as a first line treatsuppl., 114:5, 1988. ment option, especially for younger men with primary blad- 11. Sirls, L. T., Ganabathi, K., Zimmern, P. E., Roskamp, D. A., der neck obstruction in whom fertility considerations are Wolde-Tsadik, G. and Leach, G. E.: Transurethral incision of paramount. the prostate: a n objective and subjective evaluation of longterm efficacy. J . Urol., part 2, 150 1615, 1993. Our study confirms that transurethral incision is the most effective treatment for primary bladder neck obstruction. 12. Sinha, B., Haikel, G., Lange, P. H., Moon, P. D. and Narayan, P.: Transurethral resection of the prostate with local anesthesia After transurethral incision, AUA-6 symptom scores, urinary in 100 patients. J. Urol., 135: 719, 1986. flow rates and post-void residual were significantly improved, and men reported an average 87% overall improve- 13. George, N. J. R. and Slade, N.: Hesitancy and poor stream in younger men without outflow tract obstruction-the anxious ment in symptoms. In addition, the 9 patients undergoing bladder. Brit. J . Urol., 51: 506, 1979. repeat urodynamics after transurethral incision had a mean 14. Nergarth, A. and Boreus, L. 0.:Autonomic receptor function in decrease in peak voiding pressure of 68 cm. water, urodythe lower urinary tract of man and cat. Scand. J . Urol. Nephnamically documenting relief of obstruction. Transurethral rol., 6 32, 1972. years aRer incision. One patient had urodynamically documented recurrent obstruction 2 years &r transurethral incision but he refixed further treatment.