Tight Bladder Neck

What is a tight bladder neck?

The bladder neck is the gatekeeper where the bladder and urethra (water pipe) meet. Its primary function is to control urine flow out of the bladder.

This region can become constricted or fail to relax appropriately, known as a tight bladder neck, which can lead to bladder neck obstruction (BNO).

In men, an enlarged prostate can also contribute to the urinary voiding issue.

How common is a tight bladder neck?

Tight bladder neck is more common in men and is often linked to changes that come with getting older, like benign prostatic hyperplasia (BPH), which can affect up to half of men by age 60.

In females, the incidence is significantly lower, and the reason is often linked to prior surgical interventions or pelvic trauma.

What causes a tight bladder neck?

The neck of the bladder can get physically smaller if the smooth muscles around it get bigger or if an enlarged prostate moves in on it.

Functionally, the bladder neck may not relax sufficiently during micturition (dysnergism).

What are the symptoms of a tight bladder neck?

Patients with a tight bladder neck may present with a variety of lower urinary tract symptoms (LUTS), which may include:

• A weakened urinary stream (poor flow)
• Difficulty initiating urination (hesitancy)
• Intermittency
• A sensation of incomplete bladder emptying
• Urgency and, in severe cases, urinary retention

How is a tight bladder neck diagnosed?

A thorough patient history and physical examination, including a digital rectal exam in men to assess the prostate gland, are typically the first steps.

Key investigations include:

• Uroflowmetry to assess the pressure of your urine stream
• Post-void residual volume measurement to assess how much urine you are retaining
• Cystoscopy, a camera test done under local anaesthetic for direct visualisation
• Urodynamic studies to assess bladder function and bladder neck competence
• Imaging studies, such as ultrasound or MRI of the prostate gland, assess the size of the prostate and exclude other abnormalities.

What are the treatment options for a tight bladder neck?

Treatments are tailored based on symptom severity and patient preference. Options include:

• Pharmacological treatment, such as alpha-blockers (Tamsulosin, Alfuzocin, etc), which are reported to be effective in up to 60% of cases
• Surgical interventions, including transurethral bladder neck incision (BNI), transurethral resection of the prostate (TURP), and Urolift, have success rates varying from 70% to 90%, depending on the surgical technique and patient selection.
• Minimally invasive procedures such as laser therapy or botulinum toxin injections into the bladder neck have been tried, but results vary, and robust data is still lacking.
• Patients with recurrent bladder neck narrowing or restriction may require intermittent catheterisation.

Conclusion

A tight bladder neck can significantly impact the quality of life.

It requires a nuanced approach to diagnosis and management, which must consider the patient's unique clinical picture.