Bladder outlet obstruction in neurogenic patients. When is surgery mandatory?

In patients with neurogenic vesico-sphincteric disease, bladder outlet obstruction (BOO) may further increase the risk of complications to the lower and upper urinary tract, such as high post-voiding residual urine, urinary infections, bladder stones formation, vesicoureteral reflux, and ureterohydronephrosis. These complications, if not treated, can inexorably lead to a severe damage of renal function, thus forcing patients to dialysis. The main cause of BOO in patients with neurogenic bladder (NB) has a functional origin represented by detrusor sphincter dyssynergia (DSD); however, it has to be considered that also an organic obstruction can develop in these subjects, especially in men. Furthermore, in some patients, both conditions may coexist. Therefore, only a correct diagnostic approach, based on a thorough knowledge and understanding of the pathophysiologic mechanisms involved in these conditions, may contribute to establish the adequate treatment and prevent potential iatrogenic complications. According to the International Consultation on Incontinence [1] and the European Association of Urology Guidelines [2], first-line therapeutic options of BOO in NB are represented by conservative approaches. Lifestyle interventions, alpha-1-adrenergic blockers, intermittent catheterization, and external specific devices (i.e., pessary in case of pelvic organ prolapse) have to be preferred until patient’s QoL and therapeutic goals are maintained. When these treatments fail and cannot avoid the risk of the abovementioned severe complications to the urinary tract or when they do not achieve patient’s satisfaction, surgery may become necessary.