Bladder neck sclerosis is a scar deformity of the urethro-vesical junction caused by traumatic effects, inflammatory processes. It is manifested by difficulty urinating, sluggishness of the urine stream, dysuric phenomena. It is diagnosed using uroflowmetry, retrograde and mictional urethrography, ultrasound of the urinary organs, MSCT cystourethrography, posterior urethroscopy, cystoscopy. It is treated promptly by transurethral resection of the sclerosed area. Surgical intervention is supplemented with antibacterial and anti-inflammatory therapy, with severe obstruction or obturation, epicystostomy is preceded.
ICD 10
Q64.3 N32.0
Meaning
According to the results of research in the field of clinical urology, sclerotic deformity with narrowing of the lumen of the urinary-urethral segment is detected in 0.4-1.5% of patients who underwent surgery for benign prostatic hyperplasia. Cases bladder neck sclerosis caused by other causes are less common. The probability of developing sclerosis depends on the method of performing an adenomectomy. Scarring occurs less often after a transurethral resection (TUR) with a holmium laser and bipolar plasma-kinetic resection, most often after a trans–bubble adenomectomy. Usually, bladder neck sclerosis is diagnosed in men after the age of 45, an idiopathic congenital form of the disease can manifest itself even in infants.
Causes
Bladder neck sclerosis has a polyethological basis, can be both acquired and congenital. Sclerotic processes in the neck of the bladder are usually secondary, develop against the background of other urological pathology or under the influence of various damaging factors. The immediate causes of sclerosis in the area of the urinary triangle are:
- Surgical treatment of urological diseases. Usually, sclerotic changes are detected in patients who have undergone open and endoscopic surgery for prostate adenoma. Less often, intensive sclerosis begins after radiation therapy for bladder or prostate cancer.
- Inflammation of the urinary system. The probability of sclerosis in the area of the urinary-urethral junction increases with chronic prostatitis and cystitis. In such cases, the regenerative phase of inflammation takes on a pathological character, dense connective tissue is formed in the affected areas.
- Dysembriogenesis. The idiopathic form of sclerosis of the urogenital neck is called Marion’s disease. Pathology is rare, characterized by annular fibrosis of the submucosal and muscular layers at the exit of the bladder. The factors contributing to the occurrence of congenital sclerosis have not yet been established.
The anatomical prerequisite for the development of the disease is the structural features of the bladder wall in the area of the urogenital triangle. The connective tissue of its own plate under the urothelium of this zone is less friable, which is why the mucous membrane is less stretchable and practically has no folds. As a result, sclerotic changes are poorly compensated and quickly manifest clinically.
Pathogenesis
The mechanism of sclerosis of the bladder neck is based on excessive proliferation of connective tissue elements during pathological regeneration of damaged tissues. As a rule, predisposing factors to the appearance of sclerotic changes are a violation of energy metabolism in the organ wall, a local inflammatory reaction, cellular dystrophy, microcirculatory disorders characteristic of benign prostatic hyperplasia. Sometimes the process is provoked by the action of direct damaging factors (surgical trauma, radiation radiation).
Sclerosis of the urogenital wall is formed in stages. First, after phagocytosis of destroyed cells and collagen fibers by macrophages, fibroblasts actively proliferate in the damaged area, collagen synthesis increases. In conditions of ischemia, post-traumatic inflammation, dyscirculatory phenomena, the balance between collagenogenesis and collagenolysis is disturbed with an increase in excess connective tissue, the predominance of fiber mass over cellular elements, and a decrease in the number of specialized cells. As a result, the neck of the bladder undergoes fibrosis, sclerosis or scarring with partial narrowing (stricture) or complete overlap (obliteration) of the lumen, which is manifested by the corresponding clinical picture.
Symptoms
The main clinical sign of the disease is an increasing deterioration of the outflow of urine up to its complete acute delay. At the initial stages of the pathological process, patients complain of difficulties with urination, note the sluggishness of the urinary stream. As sclerosis progresses and the amount of residual urine in the organ cavity increases, patients experience a feeling of incomplete emptying of the bladder. The addition of inflammation is indicated by frequent urge to urinate, painful urine discharge, an increase in body temperature to subfebrile figures.
Complications
Violation of the outflow of urine gradually leads to an increase in its residual volume and stagnation in the upstream organs of the urinary system. In extreme cases, the expansion of the ureters and the cup-pelvic system ends with the development of bilateral ureterohydronephrosis and chronic renal failure. The presence of vesicoureteral reflux contributes to the upward spread of uroinfections with the appearance of ureteritis, pyelonephritis.
Against the background of urinary stagnation of urine, chronic cystitis is more often observed, microdiverticules may form. In some patients, the bladder shrinks. Prolonged violation of urination contributes to the appearance of neurotic disorders, depression, social maladaptation of patients.
Diagnostics
Examination of men with suspected bladder neck sclerosis includes instrumental methods to identify signs of narrowing of the vesicourethral junction, excluding other causes of obstruction. An important role in the diagnostic search is played by the connection of the pathological process with prostate surgery, radiation therapy of pelvic organs, urological infections. The most informative have:
- Urodynamic studies. With preserved urination, patients are usually prescribed uroflowmetry. A prolonged increase and decrease in the volumetric flow rate of urine confirms the obstruction of the lower urinary system, but does not allow to identify the exact location of stenosis. Therefore, the methodology usually precedes other instrumental studies.
- Urethrography. The X-ray method makes it possible to detect an obstacle to the flow of urine in the area of the transition of the bladder to the urethra, while the urethral canal remains completely passable. Retrograde urethrography is more often used, visualizing the filling of the urethra with an X-ray contrast solution, less often — a microvision study of the urinary process.
- Echography. With the help of ultrasound of the bladder, the anatomical features of the structure of the organ, including the vesicourethral segment, are evaluated, its capacity and the volume of residual urine, which usually exceeds 20 ml in cervical sclerosis, are determined. Additional ultrasound examination of the kidneys, ureters, prostate (if any), urethra allows you to establish other causes of urination disorders.
- Multispiral computed tomography. MSCT cystourethrography, which provides the creation of a three—dimensional model of the affected area, is one of the most accurate non-invasive methods for diagnosing sclerosis. Using MSCT, it is possible to accurately determine the place of stricture of the lower urinary tract, the severity of sclerotic changes, the wall thickness of the vesical-urethral junction.
- Endoscopy. Visualization of the affected area during urethrocystoscopy makes it possible not only to identify the stricture site, but also to assess the condition of the mucous membrane, the degree of scarring. If the neck lumen is sufficient for the passage of the endoscope, the bladder cavity is examined. The examination can be supplemented with a biopsy for histological examination of tissues.
The general analysis of urine in sclerosis of the urogenital neck plays an auxiliary role, aimed at identifying possible concomitant inflammatory processes. The disease is differentiated with prostate adenoma, false passage from the urethra to the bladder, bladder pre-bubble, prostate sclerosis, malignant and benign tumors of the bladder. According to the indications, a urologist can prescribe a consultation with an oncologist, an andrologist.
Treatment
Effective conservative therapy of bladder neck sclerosis has not been proposed. The only method of restoring the patency of the urethro-vesical segment is surgical excision of scar tissue. The effect of the elimination of stricture with the help of bougie is temporary, carrying out this intervention often leads to various complications.
At the stage of preoperative preparation and in the postoperative period, the patient is given antibacterial therapy to prevent infectious complications. In the presence of signs of inflammation and pain syndrome, additional administration of nonsteroidal anti-inflammatory drugs is possible. For rapid discharge of the urinary system with significant obstruction of the neck, an open or trocar epicystostomy can be performed beforehand.
The most effective and least traumatic intervention to restore normal passage of urine is a TUR of the neck of the bladder. During transurethral resection, the sclerosed tissues are completely removed with laser or electrocoagulation knives, which eliminates the obstruction. Open invasive operations on the urogenital neck due to traumatism and high risk of complications are currently practically not used.
Prognosis and prevention
The effectiveness of surgical treatment of sclerotic deformity of the urogenital neck reaches 91%, however, with a significant narrowing of its lumen, the risk of postoperative relapses increases. Prevention of sclerosis is aimed at adequate timely therapy of urological diseases, sparing the performance of adenomectomy, other interventions on the prostate and bladder. To prevent the recurrence of obstruction after TUR, it is recommended to use modern high-energy generators operating in the mode of less traumatic bipolar cutting and coagulation.