Patients presenting with lower urinary tract symptoms who most deserve to be investigated for primary bladder neck obstruction

Nicolò Schifano,Rayan Matloob,Luigi Candela,Giuseppe Fallara,Andrea Salonia,Paolo Capogrosso,Antonio Costa,Federico Belladelli,Costantino Abbate,Francesco Montorsi,Walter Cazzaniga,Edoardo Pozzi,Luca Boeri

doi:10.1038/s41598-021-83672-5

Abstract

We aimed to investigate clinical features potentially useful in primary bladder neck obstruction (PBNO) diagnosis in men presenting with lower urinary tract symptoms (LUTS). Data from 1229 men presenting for LUTS as their primary complaint at a single centre were retrospectively analysed. All patients underwent a comprehensive medical and physical assessment, and completed the International Prostate Symptoms Score. All patients were investigated with uroflowmetry, and trans-rectal ultrasound imaging to define prostate volume. Urodynamic evaluation was performed when the diagnosis of benign prostatic enlargement was not confirmed and the patient presented a significant chance of detrusor overactivity or underactivity. As per our internal protocol, patients < 60 years old with bothersome LUTS and > 60 years with a prostate volume (PV) < 40 mL were also investigated with urethrocystoscopy to rule out urethral stricture. Logistic regression analysis tested clinical predictors of possible PBNO. Of 1229 patients, 136 (11%) featured a clinical profile which was consistent with PBNO. Overall, these patients were younger (p < 0.0001), had lower BMI (p < 0.0001), less comorbidities (p = 0.004) and lower PSA values (p < 0.0001), but worse IPSS scores (p = 0.01) and lower PV values (p < 0.0001) compared to patients with other-aetiology LUTS. At multivariable analysis, younger age (OR 0.90; p = 0.003) and higher IPSS scores (OR 1.12; p = 0.01) were more likely to be associated with this subset of patients, after accounting for other clinical variables. One out of ten young/middle-aged men presenting for LUTS may be affected from PBNO. Younger patients with more severe LUTS systematically deserve an extensive assessment to rule out PBNO, thus including urethrocystoscopy and urodynamics with voiding-cysto-urethrogram.

Highlights

We aimed to investigate clinical features potentially useful in primary bladder neck obstruction (PBNO) diagnosis in men presenting with lower urinary tract symptoms (LUTS)
Male lower urinary tract symptoms (LUTS) have traditionally been related to bladder outlet obstruction (BOO), which is often associated with a benign prostate enlargement (BPE), resulting from the histologic condition of benign prostatic hyperplasia (BPH)[1]
PBNO surgical treatment is mainly based on bladder neck incision, whilst the surgical management of the other BOO-patients should be addressed according to the site of anatomical obstruction

Summary

Introduction

We aimed to investigate clinical features potentially useful in primary bladder neck obstruction (PBNO) diagnosis in men presenting with lower urinary tract symptoms (LUTS). LUTS could be the results of conditions unrelated to the prostate itself[2] In this context, primary bladder neck obstruction (PBNO), dysfunctional voiding-pseudodyssynergia, detrusor under-activity or over-activity, neurogenic bladder dysfunction, urethral strictures and urinary infections have all been described as causes of LUTS, especially in young men[1]. PBNO may present with voiding or storage symptoms, or a combination of both[9] Another feature that can be associated with PBNO is pain, which was reported to be more prevalent for male vs female patients[9]. We aimed at identifying a range of clinical predictors suggesting a PBNO condition in men seeking medical help for LUTS at a single academic outpatient centre

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Conclusion