Bladder neck elevation (BNE) is a disease that causes urination problems such as benign prostatic hyperplasia (BPH) and urethral stenosis in men. Complaints begin at a young age, and with advancing age, complaints increase due to the effect of prostate enlargement. In this article, I will give up-to-date information about bladder neck height and treatment in line with my own clinical experiences and the surgeries I have performed and their results.

What does bladder neck mean?

The bladder neck consists of a group of muscles that connect the bladder to the urethra. These muscles normally contract to keep urine in the bladder, and they relax during urination, helping the urine flow from the bladder to the urethra. When problems occur in the muscles that form the bladder neck, urinary problems of varying degrees occur. The bladder neck is a region that includes the periphery of the trigone and surrounds the beginning of the internal urethral orifice. In primary bladder neck obstruction, even though there is no anatomical obstruction in the bladder neck (such as BPH), the bladder neck cannot be opened during urination and the patient has difficulty urinating.

What is the bladder neck height?

The bladder neck elevation angle is normally 26.1 degrees in cystourethroscopy. If this angle is 35 degrees or above, patients are considered to have bladder neck elevation and symptoms similar to lower urinary tract complaints (BPH symptoms) occur in patients. Sometimes, in elderly male patients, it can be confused with enlargement of the prostate into the bladder (median lobe hyperplasia) and primary bladder neck stenosis. In primary bladder stenosis, the bladder neck is not high, but similar complaints occur because the bladder neck cannot be fully and adequately opened during urination in these patients. This may be due to neurological or a disorder in the bladder neck muscles, or due to the decrease in muscle tissue and its replacement by structures without muscle tissue (fibrosis). Diagnosis is made by cystourethroscopy and urodynamic tests.

Picture 1: Bladder neck and trigone structure

What are the symptoms of bladder neck elevation?

The complaints of patients with bladder neck elevation are similar to the complaints of patients with benign prostatic hyperplasia (BPH). Additionally, similar complaints are seen in patients with bladder neck stenosis and urethral stenosis. In patients with bladder neck elevation:

• Frequent urination
• Sudden feeling of urgency and urination
• Urinary incontinence with sudden feeling of urgency
• Frequent urination at night (nocturia)
• Slowdown in urine flow
• Delay in starting urination
• Feeling that the bladder is not fully emptied

How is BNE diagnosed?

The steps to be followed to diagnose these patients who apply to Urologists with the main complaint of difficulty urinating are:

• Detailed medical questioning of patients
• Urological examination
• Measurement of urine flow with uroflow test
• Urinary system USG
• Determination of post-micturition residual urine
• Urine microscopy
• Cystoscopy

How to differentiate between BNE and BPH?

BNE and benign prostatic hyperplasia present similar complaints in men. It is difficult to distinguish these two diseases. However, the age at which complaints begin may help in discrimination. In patients with BNE, urinary complaints occur at a young age. However, complaints in BPH patients usually occur at an older age, at the age of 50 and above. A clear distinction between the two diseases is possible with cystoscopy.

Is bladder neck stenosis associated with prostate enlargement (BPH)?

BNE begins at a young age. BPH is usually seen in older men, over the age of 50. Bladder neck elevation should be considered in those with early urinary complaints. Over time, with advancing age, the prostate also enlarges. In patients with BNE, complaints may be more frequent as prostate enlargement occurs at later ages. In cases where these two diseases coexist, the need for surgery may be greater.

In what cases/when should BNE be operated on?

Patients with MBY complaints can be followed up if the complaints are not too severe. Sometimes patients have too many complaints and surgical treatment is required. These patients must undergo surgery in the following cases:

• If urinary complaints are excessive and disrupt the patient’s quality of life

• If you have frequently recurring urinary tract infections

• If you have bladder stones

• If the bladder cannot be emptied completely and there is too much urine left in the bladder after urinating.

• If there is deterioration in kidney functions

What is the most effective treatment for MBY?

The cause of this disease is a congenital condition. Since the bladder neck is high in these people, there is a problem in emptying the urine from the bladder. Although some medications are given to these patients in the early stages, they are not very effective. The most effective treatment for MBY patients is surgery.

What happens if MBY is left untreated?

The course of this disease is similar to prostate enlargement seen in older ages. At first, the complaints may not be many, but over time, the complaints increase with age. If the disease is not treated in the late stages, the following complications may occur:

• Frequent urination and disruption in sleep patterns and quality of life

• Frequently recurring urinary tract infections

• Urinary system stones

• Bladder stones

• Bladder diverticulum

• Inability to urinate (blockage of globular urine)

What are the complications of MBY surgery?

No serious life-threatening problems are encountered in the surgical treatment of this disease. Since the patients are generally young, the most important and frequently encountered problem is related to ejaculation. In all prostate surgeries, semen generally leaks back into the bladder and is excreted with urine. If this procedure is to be performed at a young age and the patient has a child problem, it is necessary to consider this situation and inform the patients. After MBY surgery, an average of 5-10% of semen leaks back, that is, retrograde ejaculation occurs. This rate can be further reduced in carefully performed surgeries. Complications such as bleeding, infection, and recurrence are extremely rare.

Does MBY recur after surgery?

One of the questions frequently asked by patients is whether this disease will recur after surgery. Although very few patients experience recurrence and need for re-operation, recurrence is generally rare. We did not encounter any recurrence during the surgeries we performed. This situation is also related to the patient’s constitution. After all, this is a wound healing situation. In some people, wound healing results in fibrosis (scar tissue) and recurrence may occur. Keeping the catheter short after surgery and appropriate antibiotic treatment reduces the risk of recurrence.

What diseases is MBY associated with?

Patients with MBY primarily consult a doctor with lower urinary tract complaints. There are some diseases that cause similar symptoms to this disease and need to be distinguished. Diseases frequently confused with MBY include:

• Benign prostatic hyperplasia (BPH)

• Bladder neck stenosis

• Urethral stricture

Is there any drug treatment for this disease?

Medicines called alpha blockers used in the treatment of BPH (tamsulosin, doxazosin, terazosin) can be used in the drug treatment of bladder neck elevation, but they are not very effective. If you have frequent urinary tract infections, antibiotic treatment is appropriate. If the complaints in this disease are severe, surgery is definitely required.

Is Botox treatment effective in treatment?

There are studies on the use of Botox in BPH patients, but it is not a routine treatment option. There are no scientific studies or publications regarding the use of Botox in patients with a high bladder neck. It may be tried in these patients, especially those with mild complaints, but the effects of Botox treatment are temporary and it must be repeated after a certain period of time. This is a disadvantage as it does not result in permanent treatment of bladder neck elevation.

Is there any herbal treatment for the disease?

Herbal treatment or alternative treatment has no place in improving symptoms related to bladder neck height or eliminating the main pathology here. Although there is information on this subject in various sources, these are not controlled studies conducted on scientific principles. This is information published in serious medical journals and is not credible.

Does bladder neck height affect sexuality?

Erectile dysfunction, that is, erectile dysfunction, is not observed in patients who undergo bladder neck surgery. In a very small number of patients, semen leaks into the bladder after intercourse and comes out with urine. In the majority of patients, semen is excreted normally. This situation should be explained in advance, especially to patients who want to have children. Even if the semen leaks into the bladder after the surgery, these people can have children through in vitro fertilization. It is possible for these patients to have children through in vitro fertilization using sperm found in the urine after intercourse or sperm taken from the testicles or epididymis.

How is bladder neck surgery performed?

MBY surgery is performed endoscopically. It is a surgery with an extremely high success rate. The main surgical methods we use in the treatment of this disease are:

• Bladder neck incision: The procedure is performed under spinal or general anesthesia. Total time is around 30-45 minutes. The bladder neck and bladder interior are evaluated using a cystourethroscope. Starting from the bladder neck to the area called verumontanum in the prostatic urethra, a deep incision is made at the 05 and 07 o’clock level up to the prostate capsule. Following hemostasis, the procedure is terminated by inserting a catheter. The patient stays in the hospital for 1 night and is discharged the next day. After surgery, semen may not come after intercourse. It escapes into the bladder and comes out with urine (retrograde ejaculation). This situation can be seen in 10-50%. Complaints may persist in 1-2% of patients.

• Bladder neck incision with TUR: The bladder neck is freed by removing a piece with bilateral TUR (transurethral resection), which extends from the 5 and 7 o’clock positions to the verumontanum and extends down to the prostate capsule. In this way, the narrow and high bladder neck is relaxed and urine flow from the bladder becomes easier.

• Laser bladder neck incision: In the same manner as in TUR, a deep incision extending from the bladder neck to the prostate capsule at the 5 and 7 o’clock levels is made with the laser (HOLEP) method.

• TUR-P can be performed: It can be combined with a bladder neck incision. It is the process of removing the remaining tissue along with a bilateral incision made on the bladder neck. Or a TUR is performed directly on the bladder neck at the 5-7 level. This procedure can be done with TUR or HOLEP, that is, laser method.

In practice, I apply all three methods to my patients. If the patient is young and has only a high bladder neck, I only perform an incision; if there is an enlarged prostate, I also perform a resection of the middle lobe. Especially in patients who undergo incision, semen leaking into the bladder is extremely rare.

Picture 2a: Bladder neck height,

Figure 2b: A minor endoscopic surgery performed at the height of the bladder neck,

Picture 2c: Surgical opening of the bladder neck

Surgery, hospital stay and type of anesthesia

The surgery takes about 30-45 minutes. Generally, spinal anesthesia (numbing from the waist down) is applied, and sometimes there are cases where we give general anesthesia. It is better to leave the choice to the anesthesiologist. Patients stay in the hospital for 1 day and are discharged the next day. We remove the catheter for 3 days, sometimes 4-5, most of the time the next day.

In summary: High bladder neck is a disease that manifests itself with difficulty urinating as a result of the anatomical height of the bladder neck in men. These complaints occur from a young age, and as the age progresses, the complaints increase due to the enlargement of the prostate. If the complaints are many and complications develop, treatment is definitely required. Drug treatment of the disease is not very effective. The most effective treatment is treatment with endoscopic surgery. The success rate of surgical treatment is very high, and its complications and recurrence rates are low. It is necessary to be careful about retrograde ejaculation in young men who want children and to inform patients about this. Our success rates in our surgeries are high, similar to those in the literature.

References

1. Association of high bladder neck elevation with urodynamic bladder outlet obstruction in patients with lower urinary tract symptoms and benign prostatic hyperplasia.Kang M, Kim M, Choo MS, et al. SJ.Urology. 2014 Dec;84(6):1461-6.

2. Urodynamic Features and Significant Predictors of Bladder Outlet Obstruction in Patients With Lower Urinary Tract Symptoms/BPH and Small Prostate Volume. Kang M, Kim M, Choo MS, et al. SJ.Urology. 2016;89:96-102.

3. Transurethral incision of bladder neck in treatment of bladder neck obstruction in women. Peng CH, Kuo HC. Urology. 2005 Feb;65(2):275-8.

4. Transurethral incision of the bladder neck using KTP in the treatment of bladder neck obstruction in women. Fu Q, Xu YM.Urol Int. 2009;82(1):61-4

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY