Bladder neck angle as an anatomical predictor of conservative treatment failure and the need for surgery in benign prostatic hyperplasia

Purpose To determine the predictive value of bladder neck angle (BNA) for trial without catheter (TWOC) following acute urinary retention (AUR) due to benign prostatic hyperplasia (BPH), and to evaluate its role in predicting response to combination therapy in patients with lower urinary tract symptoms (LUTS). Methods Outpatients presenting with bothersome LUTS or acute urinary retention (AUR) due to benign prostatic hyperplasia were included in the cohort. The prostate volume, intravesical prostatic protrusion, BNA, and postvoid residual volume were recorded. In patients with AUR, TWOC was performed after 2 weeks of alpha-blocker therapy; those with LUTS received alpha-blockers and 5-alpha reductase inhibitors for 12 months. Surgery was recommended for patients who experienced failure of conservative treatment. The uroflowmetry and International Prostate Symptom Score (IPSS) changes were assessed from baseline to 12 months after treatment. Results In the efficacy analysis, 66 patients with AUR were recruited, and 32 patients (48.5%) experienced unsuccessful TWOC. The AUC for BNA to predict unsuccessful TWOC was 0.855 (95% CI 0.76–0.94), and for intravesical prostatic protrusion, the AUC was 0.794 (95% CI 0.68–0.91). In 335 patients with LUTS, from baseline to month 3, the change in IPSS after combination therapy was − 2.17 and − 4.89 in patients with large and small BNAs, respectively. Conclusions BNA is a promising anatomical predictor of TWOC outcome in AUR and may help identify LUTS patients who are likely to experience greater benefit from combination therapy. Incorporating BNA into clinical assessment may improve risk stratification and treatment planning in BPH management.