Obstruction of Bladder Neck : Signs, Treatment and Outlook

1. Define Bladder Neck Obstruction 

   Bladder neck obstruction is a condition characterized by the partial or complete blockage of the bladder neck.⁽¹⁾

   The bladder neck is a muscular area where the bladder connects to the urethra. The muscles play the role of tightening and holding urine in the bladder and relaxing to release it through the urethra. Abnormalities that block the bladder neck and prevent it from opening completely lead to urinary problems.

   The condition may lead to complications such as recurrent urinary tract infections, bladder stones, and in severe cases kidney damage.

2. Importance of Bladder Neck Function

   The bladder neck has a crucial role to play in the urinary system. Its proper functioning is essential for maintaining urinary continence and effective voiding.

   There are several key aspects in which the bladder neck functions: 

   • Urinary Continence: The bladder neck acts as a sphincter, controlling the release of urine from the bladder into the urethra.
   • Voiding Control: The coordination of contraction and relaxation of the muscle at the bladder neck are important for the controlled release of urine during voiding. Dysfunction of the bladder neck leads to difficulties in initiating or completing urination.
   • Prevention of Reflux: The bladder neck plays a role in preventing the flow of urine from the bladder to the urethra and kidney.
   • Structural Support: The structural integrity of the bladder neck is essential for overall pelvic support. Weakness or dysfunction of this area may contribute to pelvic organ prolapse. 

   Understanding the importance of bladder neck function is crucial for managing and treating conditions related to urinary continence and overall urological health.

The signs of bladder neck obstruction include: 

• Difficulty in initiating urination. The blockage may impede the flow of urine from the bladder into the urethra.
• Weak or diminished urine stream that could result in incomplete emptying of the bladder.
• The flow of urine may start and stop intermittently.
• Straining during urination as the muscles need to work harder to overcome the resistance caused by the blockage.
• Persistent sensation of bladder not being empty after urination.
• Increased frequency of urination due to the compromised ability of the bladder to store urine.
• There may be a sudden and strong urge to urinate even when the bladder is not full.
• Bladder neck obstruction may also contribute to increased frequency of urination during the night, which may disrupt normal sleep patterns.
• In severe cases, there may be urinary retention where the individual is unable to empty the bladder. This may cause discomfort and may require medical intervention.
• Due to incomplete emptying of the bladder, the individuals may experience overflow incontinence, characterized by involuntary leakage of a small amount of urine.

The above signs and symptoms may be indicative of various urinary conditions and a healthcare professional needs to be consulted for proper diagnosis.

There are various causes of bladder neck obstruction and they may vary between men and women. The common factors include: 

• Benign Prostatic Hyperplasia (BPH): This is the most common cause of bladder neck obstruction in men.⁽¹⁾ BPH is a non-cancerous enlargement of the prostate gland that surrounds the urethra. As the prostate enlarges, it compresses the bladder neck, and urethra, leading to obstruction.
• Prostate Cancer: It contributes to obstruction of the bladder neck especially if the tumor grows and affects the surrounding tissues.
• Bladder Neck Contracture: Scar tissue formation or narrowing of the bladder neck can occur due to surgery, radiation therapy, or inflammation.⁽³⁾ This condition is known as bladder neck contracture.
• Urethral Stricture: Narrowing of the urethra impedes the flow of urine and contributes to bladder-neck obstruction. Strictures occur due to inflammation, trauma, or scarring.
• Pelvic Organ Prolapse: In females, prolapse of pelvic organs, including prolapse of the bladder into the vaginal canal, can put pressure on the bladder neck leading to obstruction.⁽⁴⁾
• Neurological Conditions: Certain neurological conditions such as spinal cord injury or multiple sclerosis can affect the nerves controlling the bladder function. Disruption of these nerve signals can lead to improper coordination of the muscles around the bladder neck leading to obstruction.
• Congenital Abnormalities: Some individuals have congenital abnormalities (present by birth) of the bladder neck or urethra. This predisposes them to obstruction.
• Bladder Stones: Stones in the bladder can obstruct the urethra or bladder neck, disrupting the normal flow of urine.
• Infection and Inflammation: Infection or inflammation of the bladder or urethra can lead to swelling and narrowing of the passage causing obstruction.
• Post Operative Complications: Surgical procedures of the pelvic area such as prostate or bladder surgery can sometimes lead to complications like scarring or narrowing of the bladder neck.

The cause of bladder neck obstruction may vary from person to person. A healthcare professional, typically a urologist conducts a thorough evaluation including medical history, physical examination, and diagnostic test to determine the underlying cause of the obstruction and recommend an appropriate treatment plan.

For diagnosing bladder neck obstruction video urodynamic testing may be used.⁽¹⁾ This test can help show how well the bladder can store and empty urine. It can also help assess the pressure and flow of urine, check bladder neck obstructions, and measure sphincter activity.

In video urodynamic testing there are X-rays or ultrasounds of the bladder to see how it fills and empties.

For the test, people may need to alter their fluid intake or stop taking certain medications. 

Cystoscopy may also be done to diagnose bladder neck obstruction. It involves using a cystoscope to look into the bladder. A cystoscope is a long thin tube with a camera and has a light attached at the end.

During the procedure, the doctor inserts the cystoscope through the urethra and into the bladder. A liquid can be used to fill and stretch the bladder the bladder for a better view.

Examination may be done to assess the size of the prostate. In females’ pelvic examination may be needed to check organ prolapse or any other cause of urinary problems.

Bladder neck obstruction can be treated with medication and surgery. Specific treatment plans will depend on the overall health and cause of the condition. 

• Medication: Alpha-blocker drug therapy is the first line of treatment for bladder neck obstruction. It includes tamsulosin and alfuzosin as these help in relaxing the bladder muscles. 5-alpha-reductase is a second type of medication that can be prescribed for the treatment of bladder neck obstruction. These medications include finasteride and dutasteride, which work by reducing enlarged prostate.
• Self-Catheterization: In some cases, self-catheterization may be needed along with medications. It is a safe and painless procedure that will help empty the bladder of urine. Catheterization is temporary or ongoing and depends on the severity of the condition and how well the symptoms are responding to medication. The patient is advised by the doctor on how to keep the catheter in the bladder and how to keep it clean.
• Surgery: For individuals who do not benefit from medication and self-catheterization surgery may be needed. Transurethral resection of the prostate is a standard surgical treatment for bladder neck obstruction (TURP). It is a minimally invasive procedure in which healing and recovery are easy. the portions of the prostate are resected or cut away and any blocked duct can also be removed. Laser removal is preferred over TURP. Greenlight laser and holmium laser enucleation (HoLep) use different types of lasers to remove or destroy any tissue on the prostate that might be blocking the urine flow. These procedures are preferred for some patient’s anatomy. These are preferred over standard TURP as there is lesser blood loss and a shorter recovery period. UroLift is another newer surgical option that involves inserting small clips in any blocked urinary pathway to help them be open. This procedure was approved in 2013 and is also known as prostatic urethral lift (PUL).⁽²⁾ Aquablation has also shown promising results in recent years. It is a newer therapy for bladder neck obstruction that involves using high-pressure saline instead of a knife or laser to remove tissue from the prostate.⁽⁵⁾

The outlook for bladder neck obstruction depends on the individual symptoms, treatment procedure, period of obstruction, and any changes in the upper urinary tract.

Treating with alpha-blockers for bladder neck obstruction may cause a significant decrease in symptoms and flow rates. However, some may find it difficult to continue the treatment due to the side effects of the medications.

The outcome for TURP may vary depending on the type of incision. Retrograde ejaculation is a possible risk factor for TURP but is less likely to occur due to unilateral incision. In females, TURP procedures are known to be effective with no serious complications.

The bladder neck is a critical anatomical structure responsible for maintaining urinary continence and proper bladder function. Obstruction of the bladder neck can result from various causes and this can impact both men and women. These include benign prostatic hyperplasia in men, bladder neck contracture, urethral stricture, pelvic organ prolapse in women, neurological disorders, congenital abnormalities, bladder stones, infections, inflammation, and postoperative complications.

Bladder neck obstruction may lead to issues with urine stream and related discomfort. It can be managed with medication and surgery.

Individuals with persistent symptoms should consult a healthcare professional for a thorough assessment and personalized care.