What are the possible procedures to fix urinary retention caused by bladder neck obstruction?

Procedures for Urinary Retention Caused by Bladder Neck Obstruction

Transurethral bladder neck incision/resection is the most effective surgical treatment for urinary retention caused by bladder neck obstruction, with high success rates and minimal complications. 1, 2

Initial Management Options

Medical Management

• Alpha-adrenergic blockers (first-line medical therapy)
  • May provide symptom relief in some patients with bladder neck obstruction
  • However, studies show limited effectiveness with only 4 out of 32 patients achieving significant improvement 2
  • Examples: tamsulosin, alfuzosin (non-titratable options preferred)

Catheterization

• Intermittent self-catheterization for temporary management
• Indwelling catheter for patients unable to perform self-catheterization
• Note: These are temporary measures while planning definitive treatment

Surgical Management Options

1. Transurethral Bladder Neck Procedures

• Transurethral bladder neck incision (TUNI)

  • First-line surgical approach for primary bladder neck obstruction
  • Unilateral incision typically sufficient
  • High success rate (objective and subjective improvement in all 21 patients in one study) 2
  • Shorter operating time than formal TURP
  • Important caveat: Risk of retrograde ejaculation (critical consideration in younger males) 2

• Transurethral bladder neck resection (TUBNR)

  • Effective for both male and female patients
  • Study in women showed significant improvement in flow rates (6 to 30 ml/sec) and reduction in post-void residual (680 to 173 ml) 1
  • Long-term success with follow-up of 1-10 years (median 3 years) 1

2. Sphincterotomy

• External urethral sphincterotomy
  • Option for patients with neurogenic bladder and detrusor sphincter dyssynergia
  • Irreversible procedure
  • Appropriate for patients unwilling/unable to perform clean intermittent catheterization
  • Can increase bladder emptying effectiveness and decrease UTIs 3
  • Caution: Patients will need condom catheter for urinary containment

3. Stent Placement

• Prostatic stents
  • Reserved for high-risk patients, especially those with urinary retention
  • Associated with significant complications (encrustation, infection, chronic pain)
  • Should not be first-line treatment 3
  • May be considered when other surgical options are contraindicated

4. Bladder Neck Closure (for specific cases)

• Reserved for refractory cases with specific indications:
  • Patients with neurogenic bladder and refractory stress urinary incontinence
  • Requires concomitant bladder drainage method (typically catheterizable channel)
  • High continence rates (75-100%) but risk of fistulization (up to 25%)
  • Irreversible procedure requiring thorough risk-benefit discussion 3

Special Considerations

For Neurogenic Bladder Patients

• Urodynamic studies essential before and after treatment to assess storage parameters 3
• Follow-up urodynamics recommended at appropriate intervals (≤2 years) to monitor effectiveness 3
• Consider creating catheterizable channel if bladder neck procedures might compromise ability to catheterize 3

For Female Patients

• Transurethral bladder neck resection has shown excellent outcomes
• In one study, 6 of 7 women considered themselves cured after TUBNR 1
• Minimal risk of stress incontinence (rare and mild when it occurs)

Post-Procedure Follow-up

• Urodynamic studies to assess improvement in flow rates and bladder emptying
• Monitoring for complications
• Repeat intervention if initial treatment fails to adequately relieve obstruction

Procedures to Avoid

• Balloon dilation is not recommended as a treatment option for bladder neck obstruction 3

The choice of procedure should be based on patient characteristics, urodynamic findings, and the surgeon's expertise. For most patients with primary bladder neck obstruction, transurethral bladder neck incision/resection offers the best balance of effectiveness and safety.