Stesura Seveso 391Archivio Italiano di Urologia e Andrologia 2014; 86, 4 CASE REPORT Bladder neck disease and kidney damage Anna Mudoni 1, Francesco Caccetta 1, Maurizio Caroppo 1, Fernando Musio 1, Antonella Accogli 1, Maria Dolores Zacheo 1, Domenica Maria Lucia Burzo 1, Giancamillo Carluccio 2, Vitale Nuzzo 1 1 Department of Nephrology and Dialysis, “Cardinale G. Panico” Hospital, Tricase (Lecce), Italy; 2 Department of Urology “Cardinale G. Panico” Hospital, Tricase (Lecce), Italy. Primary bladder neck obstruction (PBNO) was first described in men by Marion in 1933. The precise cause of PBNO has not been clearly elucidated. This paper review the theories on etiology, clinical presentation, diagnostic evaluation and treatments for PBNO. Also this paper focuses on management of patients with complications like acute urine retention, hydroureteronephrosis and severe renal failure. The treatment options for men and women with PBNO include careful clinical evaluation, pharmacother- apy with alpha-blockers and surgical intervention. KEY WORDS: Primary bladder neck obstruction; Acute urine retention; Renal failure; Ultrasound; Videourodynamics; Alpha-blockers. Submitted 3 October 2014; Accepted 31 October 2014 Summary No conflict of interest declared. pended, for his own initiative, any type of medical treat- ment. The physical examination revealed: blood pressure 130/80 mmHg, rhythmic heart rate 105 bpm, breaks free, no lung stasis nor peripheral edema. The skin was pale and there was no signs of fluid overload. In the suprapubic area there was a hard mass, tense, sore from probable globe bladder. The diuresis was present. The laboratory tests showed a mild anemia (hematocrit 31.9 vol.%, hemoglobin 11.4 g/dl) and a severe renal impairment (blood urea 174 mg/dl, s-creatinine 7.4 mg/dl). Blood gas analysis revealed metabolic acidosis (pH 7.3, bicarbonate 18 mmol/L, BE ecf-5.6 mmol/L). Serum electrolytes were normal. Erythrocyte sedimenta- tion rate was 24 mm, and urine analysis showed a den- sity of 1010, pH 5.0, hemoglobin 0.10 mg/dl, absence of protein and some erythrocytes in the sediment. Urineculture was negative. There were not bleeding dis- orders, and liver and thyroid function were normal. The electrocardiogram highlighted sinus rhythm, tachycar- dia. The chest X-ray was negative. Abdominal ultra- sound, performed at the admission to our Department of Nephrology, showed an increase in right kidney size (Figure 1), with a 138 mm longitudinal diameter (LD), and a normal size left kidney (LD 103 mm). The parenchymal thickness was bilaterally slightly reduced with bilateral severe hydroureteronephrosis. The bladder appeared very relaxed, with thickened walls, jagged mucous design and there were presence of large particulate matter in suspension (estimated volume of 4500 ml) (Figure 2). The urologist consulted, after an unsuccessful attempt to bladder catheterization, placed suprapubic transcuta- neous Foley catheter, resulting an abundant outflow of urine hyperpigmentated. The patient underwent a hydration therapy with sodium bicarbonate and polysaline solution, and antibiotic ther- apy with levofloxacin 500 mg/day was started. During hospitalization, indices of renal function gradual- ly improved, as shown in Figure 3, with a correction of acid-base balance. In the following days, the patient was submitted to ret- rograde and voiding cystourethrography that showed the bladder retrogradely filled with finely serrated walls. In the voiding phase only a thread-like opacification of the DOI: 10.4081/aiua.2014.4.391 Presented at 19th National Congress SIEUN, Fermo 2014 INTRODUCTION The bladder neck disease is a cervico-urethral obstruc- tion that results in an obstructed flow of urine due to the incomplete opening of the bladder neck during urina- tion. To date, the etiopathogenesis is still unclear and may be given to an abnormality in the development of the blad- der neck and the detrusor musculature, whereby the blad- der neck, during urination, remains contracted (1-4). The present paper focuses on PBNO complicated by acute urine retention and severe renal failure, treated with surgery and shows clinical, laboratory and instru- mental long-term follow-up. CASE REPORT We describe the clinical history of a 48 years old male, sent to our attention from emergency room where he presented for marked asthenia, general malaise, and oliguria. His history was positive for nocturnal occasion- al urinary incontinence from childhood. For this reason he had been treated with alpha blockers for an unspeci- fied time. Since 38 years he had not carried out clinical, chemistry, and instrumental inspection and he had sus- Mudoni_Stesura Seveso 16/01/15 11:51 Pagina 391 Archivio Italiano di Urologia e Andrologia 2014; 86, 4 A. Mudoni, F. Caccetta, M. Caroppo, F. Musio, A. Accogli, M.D. Zacheo1, D.M.L.Burzo, G. Carluccio, V. Nuzzo 392 The sequential renal scintigraphy showed the ability of glomerular filtration rate less than the norm, with functional prevalence of the right kidney and absence of signs of obstructive disease. Uroflowmetry revealed flow values and flow control in the standard curve. Introduction, Discussion, Conclusions and other Figures are posted in Supplementary Materials in www.aiua.it REFERENCES 1. Marion G. Surgery of the neck of the bladder. Br J Urol. 1933; 5:351-357. 2. Leadbetter GW, Leadbetter WF. Diagnosis and treat- ment of congenital bladder neck obstruction in children N Engl. J Med.1959; 260:633. 3. Nitti VW. Primary bladder neck obstruction in men and women. Rev Urol. 2005; 7 Suppl 8:S12-7. 4. Padmanabhan P, Nitti VW. Primary bladder neck obstruction in men,women, and children. Curr Urol Rep. 2007; 8:379-84. Figure 1. Bilateral severe hydroureteronephrosis, right kidney increased size (LD 138 mm), left kidney normal size (LD 103 mm). The parenchymal thickness bilaterally slightly reduced. Figure 2. Bladder over dilated at diagnosis with thickened walls (left); post-voiding residual volume after treatment (about 100 ml) (right). urethra was appreciated, whereas, in the retrograde opa - ci fication, signals stricture of the membranous urethra was detected. Subsequently, in general anesthesia, he was submitted to urethrocystoscopy with evidence of obstructive bladder neck. Endoscopic incision of the bladder neck by laser fiber was performed with urinary catheter placement and subsequent removal of the suprapubic Foley catheter. The postoperative course was uneventful, so the urinary catheter was removed and a valid resumption of sponta- neous voiding occurred. At discharge the patient was in good general condition, with valid urination of normochromic urine and improvement in renal function (s-creatinine 2.5 mg/dl, cGFR 27 ml/min/m2MDRD formula). The patient underwent a regular clinical, laboratory and instrumental follow-up (renal and bladder ultrasonogra- phy, uroflowmetry, renal scintigraphy) and, after more than a year, resolution of symptoms, absence of urinary tract infections and improvement in renal function (s-cre- atinine 1.64 mg/dl, cGFR 88 ml/min/m2) were observed. Sonographically, the right kidney presented a normal size (LD 108 mm), regular shape, normal cortico-medullary thickness, resistive intrarenal index (RI) equal to 0.6 and pyelo-caliceal cavity not dilated without stone. Left kidney presented a small size (LD 81 mm), regular shape, thick- ness cortico-medullary reduced, (RI 0.9), with a II-III degree hydro nephrosis, without stones (Figure 4). Bladder showed thickened walls and a post-voiding residue was present (about 100 ml) (Figure 2). Correspondence Anna Mudoni, MD (Corresponding Author) mudonia@libero.it Francesco Caccetta, MD Maurizio Caroppo, MD Fernando Musio, MD Antonella Accogli, MD Maria Dolores Zacheo, MD Domenica Maria Lucia Burzo, MD Vitale Nuzzo, MD Department of Nephrology and Dialysis, “Cardinale G. Panico” Hospital Via S. Pio X 4, 73039 Tricase (Lecce), Italy Giancamillo Carluccio, MD Department of Urology, “Cardinale G. Panico” Hospital Via S. Pio X 4 - 73039 Tricase (Lecce), Italy Mudoni_Stesura Seveso 16/01/15 11:51 Pagina 392