Stesura Seveso Archivio Italiano di Urologia e Andrologia 2015; 87, 2158 SHORT COMMUNICATION Use of transvaginal ultrasound in females with primary bladder neck obstruction. A preliminary study Vikiela Galica, Elona Toska, Pietro Saldutto, Giuseppe Paradiso Galatioto, Carlo Vicentini University of L'Aquila, Urology Department of “G. Mazzini” Hospital, Teramo, Italy. Introduction and aim: The video-urodynam- ics study is the principal exam to establish a possible primary bladder neck obstruction (PBNO) condition. While trans-rectal ultrasonography plays an important role in the evaluation of the low urinary tract symptoms (LUTS) and the severity of bladder outlet obstruction (BOO) in men, the use of the transvaginal ultrasound (TVUS) in women with symptoms suggesting BOO remains unclear. We tried to check the utility of the TVUS in women with PBNO condition. Material and methods: We selected female patients which pre- sented BOO without pelvic organ prolapse (POP). According to the data of the video-urodynamic exam we selected the patients with the suspicion of PBNO. A TVUS in basal and during micturition was performed before and after surgery. Results: TVUS showed a closed bladder neck bladder in basal condition and during micturition similarly to the fluoroscopic image during video-urodynamics. The mean distance from bladder neck to the vaginal mucosa resulted 1.3 cm in this patients. Conclusions: TVUS results worthy in the evaluation of patients with PBNO before and after surgery. KEY WORDS: Primary bladder neck obstruction; Transvaginal ultrasound; Video-urodynamics; Bladder outlet obstruction. Submitted 22 December 2014; Accepted 31 December 2014 Summary No conflict of interest declared. damental in establishing a possible PBNO condition. Ultrasonography (US) plays an important role in evalua- tion of LUTS in men and women. While the role of trans- rectal US in the evaluation of the prostate central zone in men has been used to correlate LUTS and severity of BOO (7), the use of transvaginal ultrasound (TVUS) in women with BOO remains unclear. So in this paper we tried to check the role of TVUS in women complaining LUTS from PBNO. MATERIAL AND METHODS We evaluate all female patients presented with BOO symptoms in the last three years in our ambulatory divi- sion. A detailed comprehensive history, a clinical exam and urinalysis were performed. All patients with pelvic organ prolapse were excluded previously from the study. Urinary infection was excluded by a sterile culture obtained before video-urodynamics. Fifteen patients pre- sented symptoms of BOO without POP. Uroflowmetry, video-urodynamics and electromyography (EMG) were performed and the data were analyzed by an experienced urologist. We found three patients with suspicion of PBNO according to criteria described by most authors in literature (8, 9). So patients with Maximal Flow (Qmax) < 12 ml/sec; Detrusorial Pressure at Maximal Flow (Pdet Qmax) > 20 cm H2O, silent EMG and no images for ure- thral stricture at fluoroscopy were selected (Figure 1). Subsequently the selected patients underwent a TVUS with a particular attention of urethra, periurethral tissues and bladder neck in basal condition with a comfortably full bladder and during micturition. We used a Logic 5 GE Medical Systems console with a 6.5 MHz transducer. The exam was conducted with patients lying in a lithotomic position with the probe adhering to the posterior vaginal wall. The urethra and the bladder neck was studied in both sagittal and transversal planes with particular atten- tion to the bladder neck in the sagittal plane. A possible mass compressing urethra and bladder neck was exclud- ed. The thickness from the bladder neck to the vaginal mucosa was measured. In order to exclude definitively an urethral stricture an urethrocystoscopy was performed. Patients with PBNO were treated with alpha-blockers for 3 months. Uroflowmetry and a post-voiding residual urine were performed monthly. Collected data showed a therapy failure in all patients and a transurethral bladder neck incision was programmed. TVUS during micturi- tion was repeated at 3 months after surgery. DOI: 10.4081/aiua.2015.2.158 INTRODUCTION Bladder outlet obstruction (BOO) in women without pelvic organ prolapse (POP) remains still a controversial condition. Compared with the BOO in men, represent an uncommon condition which can be found in 2.7-8% in women complaining low urinary tract symptoms (LUTS) (1, 2). The cause of BOO in women may be anatomical and/or functional (3). Whereas the anatomical causes of BOO are more common, the functional ones can only be verified during micturition. Once excluded neurological disease, diabetes mellitus and other peripheral neu- ropathies the main non neurogenic functional causes described in literature are voiding dysfunction (VD) and PBNO (4, 5). International Continence Society describes the VD such as an intermittent and/or fluctuating flow rate due to involuntary intermittent contraction of the periurethral striated or levator muscles during voiding in neurologically normal woman (6). PBNO is described as the failure of the bladder neck to open during voiding. The diagnosis of PBNO is difficult due to non-specific criteria. A video-urodynamics study is considered fun - Galica2_Stesura Seveso 02/07/15 11:28 Pagina 158 159Archivio Italiano di Urologia e Andrologia 2015; 87, 2 Use of transvaginal ultrasound in females with primary bladder neck obstruction. A preliminary study RESULTS All patients well accepted TVUS. The ure- thra and the periurethral tissue in healthy females and in the patients with PBNO appears as a hypo echoic cylindrical struc- ture (Figure 2). During micturition in the patients with PBNO the images of the bladder neck remained almost the same with little urine flow (Figu re 3). The images were evaluated separately from the urologists, gynecologists and a radiolo- gists which excluded a possible mass com- pressing the urethra. Furthermore TVUS permitted us to measure the distance from the bladder neck to the vagina which is an important information prior to the surgery Figure 5. There was a mean distance of about 1.3 cm from the blad- der neck to the vaginal wall. A trans-urethral incision of the bladder neck was performed in all patients. As it shown in Figure 5 the surgeon must be careful not to penetrate in the bladder neck to avoid perforation into the vagina. TVUS during micturition performed 3 months after surgery showed the opening of the bladder neck. TVUS after surgery in the sagittal plane showed the structure of the bladder neck, urethral and periurethral tissues as it is shown in Figure 4a and 4b. An hypoechoic image extends around the bladder neck after surgery and it seems like a stem of flower rather than cylindrical (Figure 4b). DISCUSSION For many years, physicians specialized in Urogynecology and Female Urology have utilized urodynamics and then video-urodynamics to characterize disorders of female pelvic floor. In the last years increasing availability of US and Magnetic Resonance Imaging (MRI) has triggered a Figure 1. Video-urodynamics evaluation of a forty-nine years old woman with primary bladder neck obstruction (PBNO). Figure 2. Normal urethra and periurethral tissue in a sagittal plane. Figure 3. Bladder neck during micturition in patient with primary bladder neck obstruction (PBNO). Figure 4a-b. Bladder neck and urethra in a patient with primary bladder neck obstructuion (PBNO) after surgery. Note the stem of flower-like appearance designed in white (fig. 4b). a. b. Galica2_Stesura Seveso 02/07/15 11:28 Pagina 159 Correspondence Vikiela Galica, MD Elona Toska, MD - elonatoska@yahoo.it Pietro Saldutto, MD Giuseppe Paradiso Galatioto, MD Carlo Vicentini, MD University of L'Aquila, Urology Department of “G. Mazzini” Hospital, Teramo, Italy Archivio Italiano di Urologia e Andrologia 2015; 87, 2 V. Galica, E. Toska, P. Saldutto, G. Paradiso Galatioto, C. Vicentini 160 numerous series of studies in diagnostic imaging in Urogynecology, although MRI utilize remains limited due to costs and access problems. So US are currently used to better characterize different disorders of lower urinary tract. PBNO may be difficult to distinguish and symptoms may be confused with VD. Video-urodynamics plays an important role on assessing a PBNO suspicion represent- ing the first examination to be performed in these women. Video-urodynamics with EMG evaluation show a closed bladder neck during detrusor contraction with normal sphincter activity. It’s important to distinguish between VD and PBNO because of different therapeutic strategies. US have been used widely in the assessment of organic and functional diseases of female urethra and bladder neck (10, 11). In particular authors have described the use of TVUS to check urethral disease (10). Perineal ultrasound has been largely used to evaluate urethral angle and blad- der neck mobility in women with urinary incontinence (11). It is widely accepted that the suprapubic US evalua- tion of post-void residual urine is the principal non-inva- sive method in the follow-up of patients complaining LUTS before and after any treatment. In our experience we performed TVUS to provide a further evaluation element in the study of women with PBNO. Furthermore TVUS showed an adequate evaluation of bladder neck distance to vaginal mucosa and urethra position which are worthy of consideration before a sur- gical approach. In our study there is a limited number of patients in order to depict a model image of bladder neck in PBNO, but as we mention above the use of TVUS results worthy in the pre and post-surgery evaluation. In the pre-surgery the use of TVUS may be helpful to exclude other pathologies. If the conservative treatment fails, transurethral bladder neck incision is the surgical treatment of choice (12-14). TVUS permits to know pre- ventively the distance between the bladder neck and the vaginal mucosa (15, 16), in order to prevent injuries. CONCLUSIONS Diagnosis and management of PBNO remains still con- troversial. Of course nowadays video- urodynamics with EMG remains the principal diagnostic imaging method. US plays an important role during the evaluation of the patients. 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