Management of Primary Bladder Neck Obstruction and Dysfunctional Voiding in Young Men: A Systematic Review and Meta-analysis.

BACKGROUND AND

OBJECTIVE

Management of young men with primary bladder neck obstruction (PBNO) and dysfunctional voiding (DV) is challenging. We systematically reviewed evidence on diagnostic strategies and treatment outcomes in men aged 18-50 yr with PBNO or DV.

METHODS

We conducted a comprehensive bibliographic search on the Embase, Medline, and Cochrane Library databases in July 2024.

KEY FINDINGS AND LIMITATIONS: Twenty-five publications were identified. Videourodynamics represents the standard diagnostic approach. Standard therapies for PBNO include alpha-blockers (ABs) as the first-line approach and bladder neck incision (BNI) in patients failing medical therapy. Pooled estimates of total International Prostate Symptom Score (IPSS) and maximum urinary flow rate (Qmax) improvements at 3 mo in patients receiving ABs are 7.0 points and 4.0 ml/s, respectively. The incidence of ejaculatory dysfunction (EjD) and failure rates range from 47% to 50% and from 23% to 52%, respectively. Corresponding figures in patients undergoing surgery are 11.2 points, 6.9 ml/s, 0-88.8%, and 11.1-13.3%, respectively. OnabotulinumtoxinA, as experimental second-line therapy in PBNO, provides 2-mo mean total IPSS and mean Qmax improvements of 14.1 points and 9.1 ml/s, respectively, with a 0% EjD rate. However, improvements deteriorate over time. Behavioral modifications plus biofeedback represent the only approach in patients with DV, providing symptom improvement of at least 50% in 83% of patients at 3 mo. Limits of evidence include few studies, mainly retrospective design, heterogeneous populations, small sample sizes, lack of direct comparisons, and short follow-up.

CONCLUSIONS AND CLINICAL IMPLICATIONS: Diagnosis of PBNO/DV in young men requires the integration of anatomical and functional data. ABs represent the first-line approach for PBNO followed by BNI in cases of failure. Behavioral modification plus biofeedback represents the only strategy tested for DV. Given the low quality of evidence, a shared decision-making approach for diagnosis and treatment is required.