Bladder Neck: Contracture of the Bladder Neck

Overview

What is contracture of the bladder neck?

Contracture of the bladder neck is a rare condition that can occur in men after prostate surgery. Various telescopic procedures are commonly performed for benign enlargement of the prostate, known as benign prostate hyperplasia. This condition may be treated with medication or by telescopic surgical removal of a portion of the prostate gland. Following such surgical procedures on the prostate, a bladder neck contracture or scar tissue can form at the junction of the bladder outlet and the prostate. The prostate gland is located between the bladder and the urethra, the tube through which urine leaves the body.

For individuals who have prostate cancer, one treatment option is the removal of the prostate. If the prostate gland is removed, the bladder neck, which had been connected to the prostate, is reconnected to the urethra. This connection is called an anastomosis. In rare cases following prostate surgery, fibrous connective tissue replaces the normal muscle tissue of the bladder neck. The scar tissue at the site of the anastomosis may cause the opening between the bladder and urethra to narrow or to close completely.

In very rare situations, a bladder neck contracture may lead to more serious problems, such as bladder or kidney damage.

Symptoms and Causes

What causes contracture of the bladder neck?

No one is completely sure why bladder neck contractures develop. One possible cause is gaps in the anastomosis or surgical connection of the bladder neck to the urethra. After surgical removal of the prostate, a blood clot called a hematoma may form underneath or between the surgical sutures (stitches), causing them to stretch. The stitches may break or tear. In either case, gaps may form in the anastomosis, which tend to be filled by fibrotic or scar tissue. The scarring can cause the opening between the bladder and urethra to become narrower, resulting in the bladder neck contracture.

Poor blood supply to the anastomosis may be another possible cause. Stitches that are too tight can cut off the blood vessels near the anastomosis, reducing blood supply to the site. Some medical conditions, such as diabetes and heart disease, are associated with poor blood flow, so men with these diseases may be more likely to develop bladder neck scarring. Bladder neck contractures tend to occur more often in older men than young men for similar reasons.

What are symptoms of contracture of the bladder neck?

Men usually begin to experience symptoms of bladder neck contracture within three to six months after prostate surgery. At first, a man may notice a gradual reduction in the flow of urine. This symptom may be overlooked at first, and can progress to the point where he becomes unable to urinate. In other cases, a man might experience urine leakage when the bladder becomes too full. This condition is known as overflow incontinence.

Some of the symptoms associated with contracture of the bladder neck include:

  • Needing to push to begin urination
  • Delayed onset of urination (following the urge to urinate)
  • Slow or diminished force of urine stream
  • Urine stream that starts and stops
  • Sensation of incomplete emptying

Diagnosis and Tests

How is contracture of the bladder neck diagnosed?

Several tests may be performed to detect whether a bladder neck contracture is present in men who are experiencing symptoms such as urinary retention or incontinence. A urologist may simply look inside with a small telescope in the office called cystoscopy. The cystoscope is a long thin instrument with a small lens and light at one end and an eyepiece at the other. After a local anesthetic is administered, the doctor passes the cystoscope through the urethra into the bladder. A liquid such as sterile water or saline (salt water) may be used to fill and stretch the bladder to provide a better view. The procedure usually can be completed in two minutes.

Alternatively, an X-ray study called a cystourethrogram may be ordered to detect whether there are any structural problems in the bladder or urethra. The test requires a thin flexible tube called a urinary catheter to be inserted into the bladder through the urethra. A liquid called a contrast material is introduced into the bladder via the catheter so that X-rays may be obtained while the bladder is full. If an X-ray is taken while the patient is urinating, it is called a voiding cystourethrogram.

If a bladder neck contracture is present, there are several treatment options.

Management and Treatment

How is contracture of the bladder neck treated?

The contracture may be treated by dilation, a nonsurgical procedure that can be performed in a doctor’s office. Tubes of increasing diameter are inserted through the urethra so that the opening can be gradually widened (dilated) to allow a urinary catheter to be inserted to drain urine from the bladder.

A surgical procedure called a transurethral incision may be performed to relieve symptoms of bladder neck contracture. It is performed while the patient is under anesthesia. A resectoscope (a type of cystoscope) is inserted through the urethra to allow the surgeon to visualize the bladder neck. Using the cystoscope, tiny incisions can be made in the bladder neck to open it so that the urine can flow more easily out of the bladder.

Last reviewed by a Cleveland Clinic medical professional on 05/09/2019.

References

  • Simhan J, Ramirez D, Hudak S, Morey A. . Translational Andrology and Urology. 2014 June; 3(2): 214-220. Accessed 6/18/2019. Bladder neck contracture (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4708160/)
  • Cho HJ, Jung TY, Kim DY, et al. Prevalence and risk factors of bladder neck contracture after radical prostatectomy. Korean J Urol. 2013;54(5):297-302.
  • Nitti VW. Primary bladder neck obstruction in men and women. Rev Urol. 2005;7 Suppl 8:S12-7.
  • Ramirez D, Simhan J, Hudak SJ, Morey AF. Standardized approach for the treatment of refractory bladder neck contractures. Urol Clin North Am. 2013;40(3):371-80.

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