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.