Cases Report: Promising Treatment Result of Alpha Blocker for Female Primary Bladder Neck Dysfunction Presented as Refractory Frequency
Wei-Quen Tee, Yuan-Chi Shen
Department of Urology, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
Primary bladder neck obstruction (PBNO) is a relative rare condition of the lower urinary tract functional obstruction in young and middle-aged patients. The videourodynamic study is the gold standard for confirming diagnosis. We present 2 cases of initially presented with refractory frequency and repeat urinary tract infection. LUTS women, with history of frequent urinary tract infection, diagnosed of functional bladder outlet obstruction by videourodynamic study with subsequent improving storage and voiding symptoms after alpha-blocker therapy.
[Presentation of case 1]
This 47 years old woman with history of ovarian cyst status post bilateral salphingectomy and right oophorectomy on 4 years ago, caesarean section history. This time she transfered to our out-patient-department due to frequent urinary tract infection with aggravated urinary frequency (every 15mins for 1.5 month) and nocturia even after treatment of antibiotic and antimuscarinics. Besides, she also suffered from bladder distension sensation and suprapubic discomfort. There was no remarkable finding on urine analysis and fibercystoscope. Uroflowmetry showed compressive plateau flow pattern. Video urodynamic study showed BOO with delayed bladder neck opening by fluoroscopy (lag time 10s). Pressure of detrusor Qmax showed 52cm. Thus, she was treated with alpha blocker with tamsulosin 0.2mg per day. Her voiding symptoms and urinary frequency were improving gradually. We followed up her uroflowmetry 3 months later showed increasing voiding volume with bell shape flow pattern.
[Presentation of case 2]
This 43 years old woman with history of caesarean section history suffered from frequent urinary tract infection for long time. Associated symptoms included lower abdominal soreness, frequency, and occasionally voiding difficulty. There was no response to antibiotic treatment or muscle relaxant. Uroflowmetry showed compressive plateau flow pattern. Video urodynamic study showed poor bladder neck relaxation and dysfunctional voiding. Pressure of detrusor Qmax showed 36cm. There was smoothly voiding noted after alpha blocker with Silodosin 8mg per day administrated. Uroflowmetry followed up 2 months later showed good flow rate with bell shaped flow pattern.
These two cases presented with repeat UTI and refractory frequency initially but then diagnosed of functional BOO (PBNO) by video-urodynamic study. They both had classical urodynamic pattern which are high voiding pressure, low flow rate with delayed bladder neck opening and a non-tunneling appearance of bladder neck on fluoroscope. The treatment included clean intermittent catheterization, alpha blocker, transurethral incision of bladder neck and neuromodulation. Alpha blocker should be tried before invasive therapy although there are few of side effect.
For female patient with repeat UTI or refractory storage symptom and uroflowmetry showed compressive or flat obstructive pattern, we should consider the possibility of functional bladder outlet obstruction such as PBNO. Patients will get benefit from video-urodynamic study to confirm the PBNO diagnosis and the subsequent alpha blocker therapy.