Overview.
Bladder neck contracture is an important bladder neck obstruction problem. The bladder neck is a tubular structure that extends from the internal urethral opening into the urethra for a length of 1 to 2 cm. It includes the internal sphincter, but the internal sphincter is not the entirety of the bladder neck. Contracture of the bladder neck can be congenital or acquired. In congenital cases, there is often no clear cause other than localized typical pathological changes, and it is more common in males; in acquired cases, it is often due to localized chronic inflammation, such as posterior urethritis, prostatitis, and deltoiditis, and the incidence in females is not lower than that in males. The congenital ones are mostly seen in children, and often have dysuria before the age of six, but it is not uncommon to see the onset of the disease after the age of 20 or 30.
Etiology
It is thought to be related to chronic inflammation. Pathologically, the smooth muscle of the submucosal layer of the neck is replaced by fibrous connective tissue, the bladder neck becomes pale, stiff and fixed, and the neck opening becomes narrow. There is a manifestation of bladder neck obstruction, i.e. prolonged dysuria. In men, bladder neck contracture can occur in conjunction with prostatic hyperplasia. Therefore, the bladder neck should also be molded after prostate removal, otherwise the symptoms of obstruction cannot be relieved.
Symptoms
The main symptom of bladder neck contracture is difficulty in urination. Difficulty in urination, straining to urinate, segmental urination, crying in children, dribbling of urine stream, and sometimes reflexive urination. When combined with urinary tract infection, the above symptoms are more obvious. On physical examination, the bladder may be distended in the lower abdomen, but it is not always obvious. In the early stage, there is delayed micturition, slow urine flow, thinning of the urine line, and gradually developing into straining to urinate; in the late stage, there is urinary retention, and urinary loss and incontinence can also occur, often combined with urinary tract infections. In severe cases, bilateral hydronephrosis and chronic renal insufficiency may occur.
Examination
1. Cystoscopy
It is best to use cystourethroscopy or full bladder cystoscopy, which can not only check the bladder, but also understand the situation in the urethra. On examination, the posterior border of the urethral opening is slightly raised, the deltoid region is also elevated, most trabecular depressions are visible, and the ureteral orifice can often be seen. Through this examination, other lesions in the bladder and urethra can be ruled out, such as bladder diverticulum, hypertrophy of the ureteric ridge, bladder tuberculosis, urethral stenosis, posterior urethral valves, and hypertrophy of the seminal caruncle.
2.X-ray examination
Plain film can exclude positive urinary stone disease. Intravenous pyelogram is very important to understand the renal function of both sides.
3. Determination of residual urine
It is also important for this disease, but sometimes not very reliable.
Diagnosis
1. Bladder neck palpation
When the bladder neck is palpated transvaginally, it can be felt that there are different degrees of thickening of the bladder neck tissues. If a catheter is left in the urethra, the thickening of the above tissues will be more obvious.
2. Urethroscopy
Urethroscopy is the most important and reliable method to confirm the diagnosis. Obvious lesions such as trabeculae and small chambers can be seen in the bladder. In addition, rigid edema of the mucosa of the bladder neck, protrusion of the posterior lip of the neck opening to form a steep ridge of the dike can be seen, and sometimes the bladder neck can be seen to be ring-shaped stenosis, and the inner opening is collar-like protrusion.
3. Excretory cystourethrography
Stiff neck, incomplete opening and neck stenosis may be seen, and in some cases vesicoureteral reflux may be seen.
4. Cystometric and urodynamic examination
In the early stage of obstruction, compensatory hyperplasia and hypertrophy of the urethral muscle, the pressure of urinary discharge in the bladder is higher than normal; when the obstruction is aggravated, the uroflow rate can be significantly decreased, and more residual urine appears.
5. Upper urinary tract examination
Intravenous pyelography should be done for those suspected of upper urinary tract damage to observe the functional status and morphological changes of the upper urinary tract.
Differential diagnosis
1. Posterior urethral valve
Both have symptoms of lower urinary tract obstruction, dysuria, bladder enlargement and vesicoureteral reflux. Renal pelvis, ureteral effusion and renal hypoplasia, but posterior urethral valves are more common in boys under 10 years of age. The valves are formed by folds of the posterior urethral mucosa, with the concave surface upward, and have a bottom-up, unidirectional, living flap action. There is no resistance to urethral dilatation, but urination is difficult. Retrograde urethrography showed no positive findings, and urethrography during urination showed dilatation and growth of the urethra above the valves, thinning of the urethra below the valves, and striated shadowing of the valves. Urethroscopy, see the posterior urethral valve as a diaphragm, mostly located in the anterior wall, is decisive for the diagnosis.
2. Congenital hyperplasia of the seminal caruncle
The hyperplasia of caruncle is 2-3 times larger than normal, obstructing the posterior urethra and causing difficulty in urination, which often occurs at an early age. It is difficult to distinguish it from posterior urethral valve. Urography shows a filling defect in the posterior urethra. Urethroscopy shows that the seminal caruncle is significantly enlarged obstructing the posterior urethra and extending into the bladder.
3. Posterior urethral stricture
Posterior urethral stricture is mostly caused by trauma and instrumental injury. Patients have a history of trauma. Clinical manifestations include thin and weak urination, interruption of urination and divergence of urinary stream. Urethrography shows that the posterior urethra is narrow, the mucosa is not smooth or there is pseudo-tract formation, the contrast agent spills into the tissues outside the urethra, there is resistance to urethral dilatation, and in severe cases, the dilatator can not pass. Urethroscopy shows that the posterior urethra is narrowed or even completely occluded, and the surrounding tissues are hard, so the urethroscope cannot pass through.
4. Neurogenic bladder
Neurogenic bladder is divided into two categories, one is forced urethral hyperreflexia. One type is forced urethral non-reflex, the latter type needs to be identified with bladder neck contracture. Both have dysuria, urinary retention, bladder enlargement, vesicoureteral reflux, and renal hypoplasia. Both need to be differentiated. Neurogenic bladder although there is difficulty in urination, but increase the abdominal pressure can still urine flow into a line. Neurological examination, such as spinal cord injury. Often combined with double lower limb motor disorder. If there is no spinal cord injury, patients often have hypesthesia in the saddle area. Urethral dilatation without resistance. Anal palpation, anal sphincter relaxation, often with constipation. Bladder manometry, bladder urethral muscle has no reflex, manometric curve is a horizontal line.
Treatment
1. Urethral dilatation
Urethral dilatation can be used in early stage patients with little residual urine, no infection and good renal function.
2. Transurethral resection of bladder neck hypertrophic tissue
Nowadays, electrocautery is mostly used. In children, 5-8 pieces of tissue can be removed, but in adults, more tissue has to be removed, and special instruments are needed for this operation.
3. Surgical treatment
(1) Cut open the bladder, check the bladder neck, if the tissue is hypertrophied, poor elasticity, the urethral opening is tightly closed, the fingertip can be probed, but it is very tight, and sometimes the posterior lip can be seen protruding into the bladder. It is possible to incise the mucosa of the posterior lip and suture the mucosa by wedge resection of the submucosal tissue. A Ferris catheter is left in place for traction and compression to stop bleeding, which in turn keeps the bladder neck enlarged. The advantage of this procedure is that in addition to unblocking the bladder neck, the bladder can be further visualized.
(2) The bladder is exposed suprapubicly, but the bladder neck is exposed post-pubicly without incision. A Y-shaped incision is made directly in front of the bladder neck, and a V-shaped suture is placed to enlarge the bladder neck. This procedure is very effective in enlarging the bladder neck, but it has the disadvantage of not being able to explore the bladder at the same time.
Questions you may have
What if bladder neck contracture recurs?
Recurrence of bladder neck contracture can be treated with anti-inflammatory drugs such as levofloxacin, antispasmodic and analgesic drugs such as atropine, urethral dilatation, and transurethral electrolysis.
1. Anti-inflammatory drugs: bladder neck contracture is mainly caused by chronic inflammation, it is recommended to use anti-inflammatory drugs, preferred levofloxacin, levofloxacin has a strong antibacterial effect, can inhibit a variety of bacteria.
2. Antispasmodic and analgesic drugs: patients with bladder neck contracture, the most typical symptom is lower abdominal pain, can be treated with antispasmodic and analgesic drugs (atropine), which can promote local blood circulation to relieve pain.
3. Urethral dilatation: For early stage patients, who are functioning well in all aspects without any infection, urethral dilatation can be used for treatment.
4. Transurethral electrolysis: Transurethral electrolysis, which is based on electrocautery, can treat patients with different conditions and remove different tissues.
Patients must use the medication under the guidance of the doctor. During the treatment period, they should pay attention to drink more water, urinate more, and do not eat spicy and irritating food in their diet. Patients with recurrent bladder neck contracture are advised to consult a doctor in time to avoid delay in treatment.
How long does it take to recover from bladder neck contracture surgery?
The full recovery period after bladder neck contracture surgery takes 1 to 3 months, which varies from person to person.
Bladder neck contracture can be caused by congenital lesions, inflammation, surgery, bladder neck smooth muscle thickening, etc. It is mainly common in males, and manifests itself as effortful or incomplete urination. It can usually be treated by conservative and surgical methods. Bladder neck contracture surgery is mainly a bladder enlargement and molding surgery, which can effectively expand the bladder capacity and release the bladder neck obstruction.
The recovery time for bladder neck contracture surgery needs to be determined by the individual’s physical condition. If you have a strong constitution, you will be able to fully recover in about a month. If there are post-operative complications or other underlying medical conditions, the recovery time may be longer, varying from person to person, around 3 to 4 months.
After the bladder neck contracture surgery, pay attention to the dryness and hygiene of the urethra area to avoid infection. Pay more attention to your daily diet, do not eat spicy and greasy food, and focus on a light diet.
After the bladder neck contracture surgery, patients may still have contracture again. If the patient again experiences symptoms such as difficulty in urination, frequent urination, incomplete urination, etc., it is recommended to consult a doctor in time.