PBNO is a dysfunction of the bladder neck, where either the bladder neck is too narrow or fails to open properly for normal voiding. The diagnosis of PBNO also assumes a lack of an intraprostatic median lobe which may contribute to obstruction. The exact pathophysiology of PBNO is not well understood, with an estimated incidence of 28-54% of young men (18-50 years of age) with LUTS.412 PBNO is often misdiagnosed as chronic prostatitis or dysfunctional voiding which may lead to delays in treatment.413 In a single center, retrospective study of 1,229 men with LUTS compared to men diagnosed with BPH, those diagnosed with PBNO were more likely to be younger (42 years of age versus 61 years of age; p<0.001) and had a smaller prostate volume (26 cc versus 61 cc; p<0.0001), but had significantly worse IPSS (16 points versus 12 points; p=0.01).414 When PBNO was suspected, adequate diagnosis typically involved additional imaging (e.g., voiding cystourethrogram and TRUS) and diagnostic studies, including UDS and cystoscopy.413 Video UDS, in particular, can be of value in the assessment for PBNO, as it can provide visualization of the bladder neck during the voiding phase. Treatment options for men with PBNO include watchful waiting, medical management, and surgical interventions. First-line interventions for men with suspected PBNO are ABs, with the intention of relaxing the smooth muscle of the bladder neck thereby decreasing outlet resistance.413 Unfortunately, there is a lack of placebo-controlled trials in these patients with data coming from observational studies. A meta-analysis assessed the utilization of selective and non-selective ABs in men with PBNO. The meta-analysis showed pooled estimated improvement in IPSS and quality of life of 7 points (P<0.001) and 1.7 points (P<0.001) at 3 months, respectively. The same study showed pooled estimated improvements in Qmax and PVR of 4.0 mL/s (p<0.001) and 31.1 mL (p<0.001) at 3 months, respectively. Notably, in this study, the retrograde ejaculation rate was 47-50%.415 Additionally, there is a high treatment discontinuation in this population with only 24-30% of patients continuing this therapy after 1 year.416, 417 In men who desire procedural interventions, the main goal of therapy should be disrupting the bladder neck whether via incision or resection of the obstructing tissue. Multiple techniques have been described including single versus multiple incision of the prostate, TURP, and limited TURBN. Multiple technologies have also been used in these patients including athermal techniques, electrocautery, and multiple laser technologies. A meta-analysis assessed the pooled outcomes of men who underwent surgery for PBNO and included single bladder incision (n=243), bilateral bladder neck incision (n=96), TURP (n=9), and TURBN (n=1). The mean improvement in IPSS was 11.2 points (p<0.0001) at 3 months with a mean improvement in quality of life between 1.9-2.2 points. The mean improvement in Qmax was 4.2-18.5 mL/s, with a pooled estimate of 6.9 mL/s (p=0.014). EjD was 0-88%, but when the authors performed a pooled estimate with a single and bilateral bladder neck incision the rate of EjD decreased to 3%.415 There is unfortunately limited long-term data about outcomes in this population, therefore the Panel focused the recommendation on the procedural options for PBNO to procedures with the ability to disrupt the bladder neck while minimizing harm. A TURBN has the goal of opening up the bladder neck while minimizing destruction of non-obstructing portions of the prostate to minimize potential EjD and bladder neck contractures. The Panel also felt that TIPD would also be effective for these patients, as it theoretically replicates a TUIP in an athermal fashion with incisions at 5, 7, and 12 o’clock. Patients should be counseled about the limited data available in men with PBNO, therefore long-term efficacy, durability, and side effects are not well characterized.