What is the initial treatment for a patient with bladder neck contracture?

Initial Treatment for Bladder Neck Contracture

For patients with bladder neck contracture, the initial treatment should be dilation, bladder neck incision, or transurethral resection, with comparable outcomes expected regardless of which approach is chosen. 1

Diagnostic Approach

• Confirm diagnosis with retrograde urethrography (RUG) with voiding cystourethrogram (VCUG) and/or retrograde cystoscopy
• Assess the extent and severity of the contracture
• Determine if the contracture is post-endoscopic prostate procedure, post-prostatectomy, or due to other causes

Treatment Algorithm

First-Line Treatment Options

1. Endoscopic Management:

   • Dilation: Simple urethral dilation using sequential dilators
   • Direct Vision Internal Urethrotomy (DVIU): Cold knife incisions of the bladder neck
   • Transurethral Resection: Resection of the contracture tissue

2. Urinary Drainage:

   • Urinary drainage should be obtained as soon as possible 1, 2
   • In adults, urethral catheter drainage is recommended 1
   • In pediatric patients, suprapubic cystostomy is recommended 1

Efficacy of First-Line Treatment

• Direct vision internal urethrotomy has shown success rates approaching 90% with 6 months of follow-up 3
• However, many patients experience recurrence, particularly those with:
  • Smoking history >10 pack/years 4
  • ≥2 previous endoscopic procedures 4

For Recurrent Bladder Neck Contractures

If initial endoscopic management fails, consider:

1. Repeat Endoscopic Procedure with Adjunctive Therapy:

   • Deep lateral transurethral incisions have shown 86% success rate after two procedures 4
   • Internal urethrotomy with intralesional mitomycin C injection:
     • 75% success rate after one procedure
     • 87.5% success rate after two procedures 5
     • Lower success rates in patients with history of radiation (76% vs 94% in non-radiated patients) 6

2. Delayed Urethroplasty:

   • Consider for cases where endoscopic management has repeatedly failed 1
   • Should be delayed until other injuries have stabilized if associated with pelvic trauma 1

Special Considerations

Post-Prostatectomy Vesicourethral Anastomotic Stenosis

• Similar approach to bladder neck contracture with endoscopic management as first-line
• Higher risk of urinary incontinence after treatment
• May require artificial urinary sphincter placement after resolution of contracture 4

Complex Cases

• Complex bladder neck contractures (associated with pelvic fracture, vaginal or rectal injuries) should be explored and surgically repaired 1
• For patients with complete urethral obliteration or stenosis of the entire posterior urethra, more complex reconstruction may be necessary

Follow-up

• Cystoscopic evaluation after treatment to assess patency
• Typically performed at 2-3 months post-procedure 4
• Patients with recurrence may require additional procedures

By following this algorithmic approach, most patients with bladder neck contracture can achieve successful outcomes with endoscopic management, reserving more invasive surgical approaches for refractory cases.