Bladder Neck Incision (B.N.I.) and Urethrotomy

This information is designed to help you, your family and friends prepare for your surgery. It will also help you plan how to take care of yourself in the weeks following your discharge from hospital.

8844_B.N.I.andUrethrotomy.pdf

WHAT IS A B.N.I. AND A URETHROTOMY?

A bladder neck incision (B.N.I.) and a urethrotomy, are operations for men who have a decreased urinary stream and problems passing urine because of a bladder neck stenosis or a urethral stricture.

Scarring can occur within the urethra (the canal from which you pass your urine) for various reasons including previous surgery, catheterisation or trauma. Scarring that occurs at the neck of the bladder where it joins the prostate is known as a ‘bladder neck stenosis’ and scarring within the urethra itself is called a ‘urethral stricture’. Both of these forms of scarring cause a narrowing of the urethra, much in the same way a rubber band would if it were placed around the urethra. This narrowing may cause some or all of the following symptoms…
- weak stream
- frequency, (the need to void often)
- urgency, (the need to void in a hurry)
- nocturia (the need to get up at night to void)
- incomplete emptying of the bladder.

The aim of both a B.N.I. and the urethrotomy are to cut through these bands of tissue to resolve the narrowing and allow for an improved urinary stream and relief of your symptoms.

WHY IS A B.N.I. OR A URETHROTOMY NEEDED?

The narrowing caused by a bladder neck stenosis or a urethral stricture can cause bladder obstruction that leads to incomplete bladder emptying. Over a prolonged period, the urine build-up within the bladder can over-stretch the bladder and the urine can back log up to the kidneys causing kidney damage which can have an impact on your general health. Usually however, the operation is needed because of the unpleasant symptoms mentioned earlier.

WHAT HAPPENS DURING A B.N.I AND A URETHROTOMY?

Using anaesthetic gel for lubrication, a telescopic instrument called a resectoscope is passed up the urethra. The resectoscope has irrigation fluid flowing through it that keeps the view clear and flushes away any blood. A thin laser fiber or a cutting instrument is then passed up through the resectoscope to incise the bladder neck stenosis (B.N.I.) or the urethral stricture (urethrotomy). With a B.N.I. two cuts are usually made in the bladder neck, through the prostatic tissue, at about the 5 o’clock and 7 o’clock positions.

With a urethrotomy, usually only one incision is needed through the band or bands of scar tissue causing the stricture. These incisions remove the narrowing and obstruction of your urine flow.

Once the appropriate incisions have been completed a catheter (drainage tube that passes through the urethra into the bladder) may be placed to drain your urine.

WHAT IS THE EFFECT OF A B.N.I. AND A URETHROTOMY?

Since the obstructing scarring has been incised there will be an immediate improvement in your urine flow. As the tissues heal, urinary symptoms improve. In some men the symptoms improve rapidly, but in others the improvement in urgency, frequency and nocturia may take several weeks.

In a number of patients scarring can reoccur after surgery at the operation site as the tissues heal themselves. Despite adequate incision of scar tissue during surgery, a ring of scar tissue can redevelop during healing and may cause some renewed obstruction. In this event, further day stay surgery may be required to repeat the process.

ARE THERE ANY UNTOWARD EFFECTS AFTER SURGERY, ESPECIALLY ON MY SEX LIFE?

This is the main fear that most men have with this operation. The ability to have an erection and reach climax should not be effected. One effect which must be accepted with bladder neck surgery and at times urethrotomy, depending on where the scarring is, is that you may have dry ejaculations. This is because one of the jobs of the bladder neck and the prostatic urethra is to prevent the seminal fluid entering the bladder during ejaculation. After surgery the semen can pass freely into the bladder, called retrograde ejaculation. This is completely harmless and does not effect your health in any way, it would only be a concern to men wanting to father children in the future. Up to 90% of patients having a B.N.I. may experience retrograde ejaculations, however the operation should never be regarded as a sterilisation procedure. If you are aware of these possibilities your enjoyment of sex should not diminish and may well improve after surgery due to your other bothersome symptoms being resolved.

IS THERE A RISK THAT I MIGHT END UP INCONTINENT?

Incontinence, or leakage of urine without control, occasionally occurs but is usually temporary and only lasts a few days to weeks. Only very few patients have incontinence which lasts beyond this time. If you were to have any incontinence after your operation you would be given information and instructions about exercises that you can do to strengthen the pelvic floor muscles. These muscles help with control of your urine flow and toning these muscles helps to maintain your continence.

YOUR CONSENT

We need your permission for your operation to go ahead. Before you sign the consent form it is important that you understand the risks and effects of the operation and anaesthetic. These will be discussed with you by your doctor and the nurse, should you have any questions, your nurse or doctor would be happy to answer these.

It would be a very rare occurrence to require a blood transfusion with this surgery. However, in the unusual event that you did need a blood transfusion and you want to refuse one, it is vital that you tell your surgeon and nurse prior to your operation.

ABOUT YOUR ANAESTHETIC

You will NOT be allowed to eat or drink anything for at least six hours before your surgery. This includes chewing gum and sweets.

There are two main types of anaesthetic used for this surgery:
• General Anaesthetic: You will be asleep throughout the operation and remember nothing of it.
• Regional Anaesthetic e.g. Spinal, Epidural or Caudal:

A needle is placed into your back and a solution is injected that will numb your body from the waist down. You will be awake but may be sleepy and you will not feel the operation.

Feel free to discuss these options, and your questions with the anaesthetist.

You must not drive any vehicle or operate any machinery for 24 hours after having an anaesthetic. You will have to arrange for someone to drive you home if you go home within 24 hours of your surgery.

YOUR OPERATION

On admission you will be informed of your approximate time of surgery and prepared for theatre by your nurse.
You may be given some tablets before theatre. These are charted by your anaesthetist and may include tablets for tension, nausea and pain prevention.

You will be to theatre where you will be transferred to the theatre table. Anaesthetic staff will then insert a drip in your arm and will attach various monitoring devices.

Once you have been completely prepared and given your anaesthetic, surgery will begin. The operation usually takes about 15- 30 minutes to perform.

When the operation is completed you will go to the recovery room for a short while where you will be cared for until you are ready to be transferred to the ward.

AFTER SURGERY

Your nurse will check your blood pressure and pulse routinely.

You may still have the drip in your arm so you get enough fluid until you are drinking normally. You can usually eat and drink when you return to the ward.

You may have a catheter (a flexible drainage tube) that will drain urine from your bladder into a bag. The urine is likely to be blood stained. This usually clears within the first 24 to 48 hours. The catheter is held in place inside the bladder by a small balloon so that it can’t slip out. Your nurse will monitor your catheter and the drainage from it.

If you have had a spinal anaesthetic, you may be asked to lie flat for several hours after returning to the ward to allow for the anaesthetic to wear off.

After surgery you may or may not experience some of the following symptoms:
• A burning sensation and the desire to go to the toilet. These symptoms are not usually caused by a full bladder but by the burning irritation caused by the incision of the scar tissue. These symptoms are easily treated with mild pain relievers and medications which change the acidity of the urine.
• A stinging or burning sensation at the tip of the penis where the catheter enters- this can be due to the instruments used during the operation and is easily relieved by applying an anaesthetic gel.
• A feeling of having a full bladder- can be caused by blockage of the catheter tube either by a blood clot or by accidental kinking of the tube. The nurse can easily clear these blockages.
• Bladder spasms (short, sharp, grabbing pains)- due to the bladder trying to expel the catheter because of irritation. These are once again easily treated with medication.

Our aim is to keep you as comfortable as possible. It is important that the nurse know when the pain or discomfort starts so your symptoms can be treated and relieved as quickly and easily as possible. At all times, your nurse is there to help you, please ring your bell if you need assistance and your nurse is not nearby.

You will be asked to drink extra fluids after your surgery and for the next few days after your discharge. This helps flush the bladder, which clears up bleeding, washes away debris and helps prevent infection. You should drink approximately 1500mls, which is about eight glasses of fluid per day. Water is best, but any fluid is O.K. There is no need to drink excessive amounts of fluid, once the urine is free of blood you should drink just enough to keep your urine a pale yellow to clear colour.

If your surgery is done in the morning you may well be able to go home on the same day. Arrangements would be made for your catheter, should you have one, to be taken out at home by the district nurse the following morning. You would be shown how to empty the catheter bag and care for it before going home. If you don’t go home the day of your operation your catheter would be removed on the ward the morning after surgery. The catheter is removed by deflating the balloon using a special device located at the end of the catheter where it connects to the drainage bag. The catheter slides out easily once the balloon is deflated, causing little discomfort.

Once the catheter comes out or if you do not have a catheter in after surgery, you may at first have a burning sensation when passing urine. This is because urine is naturally acidic. Your nurse will instruct you about taking ural or citravescent to neutralise the urine to relieve these symptoms. If these symptoms continue for longer than a few days and are associated with frequency going to the toilet and cloudy, offensive smelling urine you should contact your own doctor as soon as possible as these are signs of a urine infection.

GOING HOME

Before leaving the ward, you will be given a discharge information letter that contains helpful information for when you get home. You will be given or sent an outpatient appointment usually for 4-6 weeks after your operation.

You may be given a prescription for medication to take only if specifically requested by the doctor. If you are prescribed antibiotics to take it is very important that you complete the whole course of tablets, even if you feel better and don’t think they need to be finished.

We will send a letter to your own doctor about your operation and the details of your treatment while you were in hospital.

ONCE HOME

Patients that have had a urethrotomy may need their catheter in for up to 7 days after you go home. This is to allow the area of scar tissue to heal around the width of the catheter and prevent a reoccurrence. You may also be taught how to stop the scarring from reoccurring by passing a catheter up the urethra. This is called Intermittent Self Catheterisation (I.S.C.). If you needed to do this, you would receive instructions and supplies from the district nurses.

It takes time for the raw incision surface to heal. Until it does you may have some discomfort passing urine, and experience some urgency, frequency, and nocturia. These symptoms subside as healing progresses and can be relieved with the help of mild pain relievers and other medications that you will be informed about.

You may notice that you pass a little blood when going to the toilet, this is usually at the beginning of the urine stream. The urine may clear between times but for up to 4 weeks after your surgery you may get slight bleeding. This is the normal process of healing and you need only be concerned if you have fresh, heavy bleeding that does not stop or if your are unable to pass your urine at all which may be due to a blood clot blocking the urethra. If either of these unlikely events should occur you should contact your own doctor immediately or go to your nearest emergency department.

Continue to drink plenty of fluid if bleeding persists, otherwise drink enough to keep your urine a pale yellow to clear colour.
You would be encouraged to do pelvic floor exercises if you have any problems with incontinence once your catheter is removed. Your nurse will provide further instructions about these exercises.

You can do most things after your operation except for any heavy lifting, straining or strenuous activity, which should be avoided for 2 weeks after surgery. Apart from avoiding strenuous activities you will be able to continue with your normal daily routines as you feel able.

This is routinely a straight forward operation, after which most patients have a speedy recovery and experience little pain.

While you are in hospital we will do everything we can to make your stay as comfortable as possible. The nursing and medical staff are always available to help with whatever needs you have. If you are worried about anything before or after your surgery, or if you have any further questions or would like more information, please do not hesitate to ask your nurse who will be more than happy to help.

8844_B.N.I.andUrethrotomy.pdf