Vaginal vault prolapse: understanding the options

September 28, 2026/0 Comments/in Bladder Surgery, Blog Post, Incontinence Surgery, Vaginal Mesh, Vaginal Surgery/by drjo

Patient information | Reviewed 28 September 2026

Vaginal vault prolapse occurs when the top of the vagina descends after a hysterectomy. It can occur alone or alongside a bulge of the front vaginal wall (anterior prolapse, often called a cystocele). Some women feel a bulge, dragging or pressure; others have difficulty emptying their bladder, recurrent urinary infections, bowel symptoms or discomfort during sex. The size of a prolapse on examination does not always match how troublesome it feels. Treatment should be guided by symptoms and personal priorities, rather than the examination alone. [1,2]

Why the front wall matters

The vaginal apex helps support the front and back walls. An anterior bulge may partly reflect loss of support at the apex. Repairing only the front wall while leaving significant vault prolapse untreated may leave the underlying problem unresolved. Conversely, restoring apical support may improve some anterior prolapse, although a separate anterior repair is sometimes needed. The surgeon should assess each compartment before deciding which parts require treatment. [1,3]

Assessment and treatment without surgery

Assessment includes a history of bulge, urinary and bowel symptoms, sexual function, prior hysterectomy and prolapse operations; examination while straining; and discussion of what the woman wants treatment to achieve. A bladder scan for residual urine is useful when emptying is difficult. Urine tests, urodynamics or imaging are considered for specific questions rather than required for every woman. Stress leakage can be hidden by a large prolapse and may appear after it is reduced or repaired; this possibility deserves discussion before surgery. [1,2]

If symptoms are mild, observation is reasonable. Pelvic floor muscle training can improve symptoms, particularly with less advanced prolapse, but cannot reliably lift a substantial vault prolapse back into place. A vaginal pessary can relieve a bulge without surgery and can also help someone decide whether restoring support improves bladder or bowel symptoms. Pessaries require fitting and ongoing review. Vaginal oestrogen may help postmenopausal vaginal dryness or irritation when appropriate; it is not a cure for the prolapse. [1,2]

Surgical options

Approach	How the apex is supported	Main considerations
Vaginal sacrospinous fixation	Stitches attach the vaginal top to a pelvic ligament, usually on one side.	Avoids an abdominal incision and implanted mesh; possible temporary buttock pain and recurrent anterior bulge.
Vaginal uterosacral ligament suspension	Stitches attach the vaginal top to the uterosacral ligaments.	Uses the woman’s own tissues; attention to the ureters is essential, often with cystoscopy during surgery.
Sacrocolpopexy (laparoscopic, robotic or open)	Mesh attached to the vagina is fixed to the ligament over the sacrum through the abdomen.	Often durable apical support; abdominal operative risks and mesh-specific risks must be weighed.
Colpocleisis	The vaginal canal is closed or substantially shortened.	Effective option for selected women who do not wish to retain vaginal intercourse; the loss of vaginal intercourse is permanent.

An anterior repair may be added if the front wall remains significantly prolapsed after apical support is restored. These operations can also be combined with treatment of stress incontinence when the benefits and added risks justify it. The decision is individual. [1–3]

Where does robotic sacrocolpopexy fit?

Robotic sacrocolpopexy is one way to perform abdominal sacrocolpopexy through small incisions. The robot helps the surgeon control instruments; it does not perform the surgery independently. It may be considered for symptomatic, substantial or recurrent vault prolapse, especially when preserving vaginal length and durable apical support are priorities, or when multiple compartments need reconstruction. It is not necessary for every prolapse and is not suitable for every patient. Previous abdominal operations, anaesthetic risk, ability to tolerate the operating position, mesh preferences, surgeon experience and costs all matter. [1–4]

Compared with vaginal operations using the patient’s own tissue, sacrocolpopexy generally has lower rates of recurrent prolapse and repeat prolapse surgery in studies of post-hysterectomy vault prolapse. In the 2023 Cochrane review, illustrative estimates were 6 in 100 requiring repeat surgery after sacrocolpopexy versus 14 in 100 after vaginal procedures, and 8 in 100 noticing recurrent prolapse versus 18 in 100 after vaginal procedures. These are pooled comparisons, not predictions for an individual. The certainty and length of follow-up vary. [3]

A multicentre randomised trial reported a 36-month composite treatment-failure estimate of 28% with sacrocolpopexy and 43% with vaginal native-tissue repair. Its definition combined symptoms, examination findings and retreatment: it does not mean 28% underwent another operation. Women in all groups reported sustained improvement, with similar satisfaction and decision regret. [4]

The benefit shown for sacrocolpopexy should not be attributed specifically to the robot. Comparative studies have not established better long-term anatomical or patient-reported results for robotic versus conventional laparoscopic sacrocolpopexy. Operating time and cost can be higher with robotic surgery, depending on the centre and surgeon. The quality of the repair and the experience of the team may matter more than the instrument platform. [5,6]

Risks and complications

Every prolapse operation can involve bleeding, infection, clots, anaesthetic complications, injury to the bladder, bowel or ureters, temporary difficulty emptying the bladder, new or persistent urinary leakage or urgency, constipation, pain with intercourse, and recurrence. A bulge can return in a different compartment even when the apex remains well supported. Some women need further treatment. Individual risk varies with previous operations and health. [1–4]

Sacrocolpopexy adds risks associated with abdominal access and permanent mesh, including mesh exposure through the vagina, infection, pain, and rarely erosion into an organ or complications near the sacrum. Mesh complications can arise years later and sometimes require further surgery. The 2024 randomised trial reported mesh exposure in about 3% after sacrocolpopexy during its follow-up; this is a study figure, not a lifetime risk. Vaginal native-tissue surgery avoids implanted mesh but has its own risks, including buttock pain with sacrospinous fixation and ureteric obstruction or injury with uterosacral suspension. [1,3,4]

An Australian distinction: Mesh inserted through the vagina to repair prolapse is not available for routine supply in Australia. That is different from mesh inserted through the abdomen for sacrocolpopexy, which remains an available category of device. An operation should never be described simply as “mesh-free” or “mesh surgery” without explaining the route, material and specific risks. [7]

Making a decision

There is no single best operation for every woman. A useful consultation covers how bothersome the bulge is; whether a pessary has been tried; the degree of vault and anterior prolapse; bladder, bowel and sexual symptoms; previous repairs; the wish to avoid mesh; the wish to maintain vaginal intercourse; likely recovery; and the surgeon’s experience with each approach. It should distinguish improvement in symptoms from an examination-based definition of anatomical success. For women seeking a durable reconstruction, sacrocolpopexy is an important option; vaginal native-tissue surgery remains a valid choice, particularly when avoiding abdominal surgery or mesh matters more. [1–4]

This article provides general information and cannot replace an individual examination and discussion of personal risks and goals.

References

NICE. Urinary incontinence and pelvic organ prolapse in women: management (NG123). 2019, subsequent updates.
RCOG. Pelvic organ prolapse: patient information.
Maher C, et al. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2023;7:CD012376. doi:10.1002/14651858.CD012376.pub2.
Menefee SA, et al. Apical suspension repair for vaginal vault prolapse: a randomized clinical trial. JAMA Surg. 2024.
Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol. 2014.
Ferrari A, et al. Laparoscopic versus robot-assisted sacrocolpopexy: systematic review and meta-analysis. 2026.
Therapeutic Goods Administration. About transvaginal surgical mesh devices.

Blood in the Semen: What Does It Mean?

September 24, 2026/0 Comments/in Blog Post/by rose

Seeing red, pink or brown discolouration in your semen can be alarming. The medical term is haematospermia. Although it often settles without treatment, it is sensible to tell your GP so they can consider the cause and whether you need further assessment.

Where might the blood come from?

Semen passes through several structures before ejaculation, including the prostate and urethra. Inflammation or infection along this pathway can sometimes cause bleeding. Blood in the semen may also appear after a recent prostate biopsy or other urinary procedure.

The colour can vary. Fresh blood may look red or pink, while older blood may give semen a brownish appearance. Colour alone cannot establish the cause.

What details should you tell your doctor?

It helps to note whether this happened once or has occurred repeatedly. Mention any recent procedure and whether you have other symptoms, such as:

Pain during ejaculation
Burning or pain when passing urine
Fever or pelvic discomfort
Blood in the urine
A change in your urinary stream

Your age, medical history and the presence of other symptoms all affect which investigations, if any, are appropriate.

Does blood in the semen mean cancer?

Usually, no. Infection, inflammation and recent procedures are among the possible explanations. However, a doctor should assess the symptom rather than assuming the cause. Rarely, it can be associated with a more serious condition.

What happens at an appointment?

Your doctor will ask about the bleeding and any related symptoms. Depending on your circumstances, assessment may include an examination, urine testing or other investigations. If the bleeding persists, recurs or raises concern, your GP may recommend a urology review.

The main message is reassuring but practical: blood in the semen is often not serious, yet it is worth discussing with a doctor—particularly if it happens again or you have other symptoms.

Why Is My Urine Stream Splitting or Spraying?

September 24, 2026/0 Comments/in Blog Post/by rose

A urine stream that suddenly sprays sideways or separates into two streams can be awkward and frustrating. If it happens once, you might dismiss it. If it keeps happening especially alongside a weaker flow or difficulty emptying your bladder, it is worth finding out why.

A split stream is a symptom, not a diagnosis. The cause may be near the opening where urine leaves the body, or farther along the urethra, the tube that carries urine out of the bladder.

What could cause it?

Sometimes a temporary change at the urethral opening affects the direction of the stream. In other cases, inflammation or narrowing may be involved.

One condition a urologist may consider is a urethral stricture, where scar tissue narrows part of the urethra. This can cause spraying or splitting, often with other symptoms such as a slow stream, straining or dribbling after urination.

Changes affecting the foreskin or the opening at the tip of the penis can also make the stream difficult to direct. The pattern of symptoms and an examination help determine what needs further investigation.

Which details should you mention?

Tell your doctor whether the change is new or longstanding, and whether it happens every time you pass urine. Also mention:

A stream that has become progressively weaker
Pain or burning when passing urine
Straining or taking longer to empty your bladder
Dribbling afterwards
Repeated urinary infections
Previous catheter use, urinary procedures or injury

These details can help distinguish a change in the stream’s direction from a broader problem with urine flow.

How is it assessed?

Assessment starts with your symptoms and medical history. Your urologist may examine the area and recommend a urine test or a test that measures the speed and pattern of your flow. If a narrowing is suspected, further investigation may be needed to establish where it is and how best to manage it.

The treatment depends on the cause. A split stream alone does not mean you need an operation.

When should you seek help?

Arrange a medical review if splitting or spraying persists, particularly if your flow is worsening or you have pain, blood in the urine or recurrent infections. If you cannot pass urine at all, seek urgent medical care.

Small renal masses: observation, surgery and image-guided ablation

September 24, 2026/0 Comments/in Blog Post, Renal Surgery/by drjo

An unexpected spot on a kidney scan can be alarming. A small renal mass usually means a solid, enhancing growth measuring 4 cm or less and confined to the kidney. It is not automatically cancer: some are benign, and many small kidney cancers grow slowly. The right approach depends on the scan, any biopsy result, kidney function, other health conditions and what matters to you. [1,2]

How do we investigate it?

I review the original imaging and usually arrange a dedicated, multiphase contrast CT or MRI to establish whether the lesion enhances, its size and position, and whether it looks like a simple cyst or another benign condition. Blood tests assess kidney function. The need for chest imaging depends on the findings and clinical circumstances. If contrast is unsuitable because of impaired kidney function, we plan an alternative with the radiologist. [1,2]

A needle biopsy can help when knowing whether a mass is benign or what type of cancer it contains would change the decision. A biopsy can occasionally be inconclusive. If ablation is planned, the European Association of Urology (EAU) recommends biopsy before a separate ablation session to avoid treating benign lesions unnecessarily. [1]

What are the choices?

Approach	When it may suit	Main consideration
Active surveillance	A very small mass, particularly under 2 cm; slow growth; or a patient who prefers to defer treatment	Planned scans and a clear trigger to reconsider treatment
Partial nephrectomy	A mass requiring treatment when kidney-sparing surgery is technically suitable	Removes the tumour and supplies a complete specimen, but requires an operation
Percutaneous ablation	A selected small mass when treatment is indicated, especially if surgery carries greater risk or preserving kidney tissue is important	Less invasive, but imaging follow-up is essential and repeat treatment may be needed
Radical nephrectomy	A tumour that cannot reasonably be treated with a kidney-sparing approach	Removes the whole kidney and may have a greater effect on kidney function

For masses under 2 cm, surveillance is often a sensible first option. For masses 2–4 cm, surveillance, partial nephrectomy and ablation may all deserve discussion. If surgery is appropriate, guidelines generally favour partial nephrectomy for a treatable small cancer. Frailty or limited life expectancy may make symptom-focused observation preferable. [1,2]

Surveillance is an active plan, not neglect. Scans are often repeated every 3–6 months initially and then every 6–12 months if stable, with timing adapted to the individual. Growth beyond 4 cm, repeated growth above approximately 5 mm a year, new concerning features or patient preference can prompt reconsideration; growth rate alone does not prove that a mass is dangerous. [2]

What is radiofrequency ablation (RFA)?

RFA destroys tissue by passing an electrical current through a thin probe, generating heat inside the mass. An interventional radiologist usually places the probe through the skin using CT or ultrasound guidance. Anaesthesia or sedation, patient positioning and sometimes fluid injected to protect nearby bowel are planned around the tumour’s location. The radiologist treats the mass and a small surrounding margin, then checks for immediate complications. Many patients have a short hospital stay, but arrangements vary. [1–3]

RFA is most established for small, accessible masses, particularly those up to 3 cm. A mass deep in the kidney, next to the urine-drainage system or bowel, or near major vessels can be harder to treat safely or completely. EAU guidance advises against routinely offering RFA for masses over 3 cm, because control becomes less reliable. A mass between 3 and 4 cm needs an individual discussion rather than an automatic exclusion. [1]

What other ablation methods are available?

Cryoablation uses probes to freeze the tumour. The visible ice ball can help the operator plan the treatment margin. It is an established alternative to RFA; the EAU advises against its routine use for tumours over 4 cm. [1,2]
Microwave ablation uses microwave energy to heat tissue. Experience is growing and the EAU describes encouraging results, though long-term comparative evidence remains less certain than for surgery. Availability and expertise vary. [1]
Irreversible electroporation delivers electrical pulses to disrupt cell membranes. Evidence for routine treatment of small renal cancers remains limited. [2]
Stereotactic ablative radiotherapy (SABR/SBRT) directs highly focused radiation without inserting a probe. It can be discussed for selected patients who need treatment but are unsuitable for surgery; long-term comparisons remain limited. [1]

The choice depends on tumour size and position, prior treatment, kidney function, local expertise and the patient’s preferences. No technique is right for every lesion.

Benefits, limitations and risks

Percutaneous ablation can avoid a surgical incision, usually involves less immediate recovery than surgery and can preserve functioning kidney tissue. Risks include bleeding, infection, pain, injury to the urine-collecting system or nearby organs, and incomplete treatment or local recurrence. Risks depend strongly on where the tumour sits. A second ablation or surgery may be possible if follow-up imaging shows persistent disease. [1,2]

Evidence comparing ablation with partial nephrectomy largely comes from observational studies involving patients with different health risks. Ablation offers good local control for carefully selected small tumours, but its long-term cancer control relative to surgery is less certain; it should not be described as a guaranteed equivalent. [1,2]

What happens after ablation?

Treatment destroys the lesion in place, so there is no whole-tumour surgical specimen. Contrast-enhanced CT or MRI checks for remaining enhancing tissue and later recurrence. One published guideline suggests imaging at 3, 6 and 12 months, then annually after ablation, adjusted to biopsy findings, renal function and the treating team’s protocol. We also monitor kidney function. A new enhancing focus requires specialist review and may lead to repeat biopsy or treatment. [1,2]

My role in your care

I can review the findings and discuss surveillance, biopsy and the treatment choices with you. I no longer perform nephrectomies. If an operation is the best option, I will refer you to a colleague who performs kidney surgery. If ablation appears suitable, I will arrange assessment by an experienced interventional radiology team; the final decision follows review of the images and your overall health.

Seek urgent medical attention for heavy visible bleeding, inability to pass urine, fever with flank pain, or severe worsening pain after a procedure.

This article provides general information. Individual advice requires assessment of your imaging, biopsy findings where relevant, kidney function and medical history.

Dr Jo Schoeman | Patient information | September 2026

References

European Association of Urology. EAU Guidelines on Renal Cell Carcinoma: Disease Management, current online edition, accessed September 2026.
Richard PO, et al. Canadian Urological Association guideline: Management of small renal masses. Canadian Urological Association Journal. 2022;16(2)–E75.
Park BK, et al. Asian Conference on Tumor Ablation guidelines for renal cell carcinoma. Investigative and Clinical Urology. 2021.
European Association of Urology. EAU Guidelines on Renal Cell Carcinoma: Follow-up, current online edition, accessed September 2026.

A kidney tumour larger than 3 cm: what does it mean?

September 24, 2026/0 Comments/in Blog Post, Renal Surgery/by drjo

By Dr Jo Schoeman | Patient information | September 2026

Finding a kidney mass can be frightening. The first question is whether it is cancer; the next is whether it is confined to the kidney. A mass measuring 3.1 cm is not automatically advanced cancer. If a renal cell carcinoma (RCC) is no more than 4 cm and remains within the kidney, it is classified as T1a. A tumour over 4 cm but no more than 7 cm, still confined to the kidney, is T1b. Lymph-node and distant spread are assessed separately. Some kidney masses are benign, and imaging alone cannot always tell us which. [1–3]

How might it present?

Many tumours are discovered by chance during an ultrasound or CT scan for another problem. Others cause blood in the urine, persistent pain in the side or back, or occasionally a palpable lump. Unexplained weight loss, fatigue, anaemia or fever warrant assessment, although they have many possible causes. The combination of blood in the urine, pain and a palpable mass is uncommon. Visible blood in the urine should always be investigated; a kidney mass does not rule out another source of bleeding. [2]

What investigations are needed?

Dedicated imaging: A multiphase contrast CT of the kidneys and abdomen shows whether the lesion enhances, its exact position, its relationship to major blood vessels and the collecting system, and whether there are enlarged nodes or signs of spread. Chest imaging completes staging; its extent is tailored to the tumour and clinical circumstances. MRI may clarify an uncertain lesion or suspected tumour extension into a vein, or be useful when CT contrast is unsuitable. A complex kidney cyst needs its own imaging assessment. [2]
Blood and urine tests: Kidney function (creatinine and eGFR), a full blood count and other tests guided by the clinical picture help assess fitness for treatment and preserve kidney function. Urine testing may identify infection or another cause of bleeding. [2]
Biopsy: A needle biopsy can be useful if its result will change management, particularly before ablation or drug treatment without prior tissue diagnosis. A typical surgically removable solid mass does not always need a biopsy beforehand. A biopsy can occasionally be inconclusive. [2]
Further staging: Bone or brain scans are generally reserved for relevant symptoms or suspected advanced disease. Routine PET scans and bone scans are not recommended for initial RCC staging. [2]

The team should review the images, kidney function, other medical conditions and the patient’s priorities together. An indeterminate mass should not be labelled definitively as RCC before appropriate assessment.

A note about my practice: I no longer perform nephrectomies. I can assess your kidney mass, discuss the findings and treatment options with you, and, if an operation is appropriate, refer you to a colleague who performs kidney surgery. We can also arrange input from a multidisciplinary team where needed.

Treatment when the tumour is confined to the kidney

Partial nephrectomy removes the tumour while preserving the rest of the kidney. This is generally preferred for T1 cancers when technically feasible, particularly if kidney function is reduced or there is only one functioning kidney. It can be performed by robotic, laparoscopic or open surgery according to tumour complexity and surgical expertise. Risks include bleeding, urine leak, infection, reduced kidney function and, occasionally, the need to remove the whole kidney. [1]

Radical nephrectomy removes the kidney and may be appropriate when a safe partial nephrectomy is not feasible, particularly with a larger or more complex tumour. Robotic or laparoscopic surgery offers an approach to the operation; it does not change the underlying choice between partial and radical removal. [1]

Active surveillance may suit selected people with a small, slow-growing mass, competing health risks or a strong preference to defer treatment. It involves planned scans and a clear trigger to reconsider treatment. A tumour just above 3 cm needs a particularly careful discussion because the room for further growth before 4 cm is limited. Thermal ablation, such as cryoablation or radiofrequency or microwave ablation, may suit selected small tumours, especially when surgery is unsuitable; a biopsy is recommended before ablation. Local recurrence and the possible need for repeat treatment should be discussed. [1, 2]

Stereotactic ablative radiotherapy (SABR) is also being used in specialist centres for selected patients with localised RCC who cannot undergo surgery. It is a distinct option from routine radiation after an operation, and its long-term comparative evidence continues to mature. [1]

What if lymph nodes look enlarged?

An enlarged node on a scan is suspicious, not proof of cancer; inflammation can also enlarge nodes. The team considers the appearance and site of the nodes, whether there is disease elsewhere and whether tissue confirmation will change treatment. If nephrectomy is planned, visibly enlarged regional nodes may be removed for diagnosis and staging. Removing normal-looking nodes routinely has not been shown to improve survival for organ-confined RCC. The survival benefit of removing involved nodes is uncertain. [1]

Confirmed regional node involvement is a substantial change in risk even if the kidney tumour is small. It calls for multidisciplinary discussion about whether all visible disease can be removed, whether postoperative drug treatment is appropriate, and how closely to monitor. Nodes beyond the regional area, or spread to organs such as the lung or bone, may represent metastatic disease and require a different plan. Surgery on the kidney is not automatically the best first step when cancer is widespread. [1, 3]

When does immunotherapy help?

For selected patients with clear-cell RCC at higher risk of recurrence after complete surgery, a course of pembrolizumab may lower recurrence risk and has shown an overall survival benefit in the KEYNOTE-564 study. The eligible groups include some patients with confirmed regional node involvement and no distant metastases. A 3–4 cm node-negative tumour confined to the kidney would not usually qualify based on size alone. The final pathology, stage and overall health matter. [1, 4]

If cancer has spread and cannot all be removed, initial treatment for clear-cell RCC often combines immune checkpoint drugs with each other (nivolumab plus ipilimumab) or combines immunotherapy with an oral targeted drug (for example, pembrolizumab plus axitinib, pembrolizumab plus lenvatinib, or nivolumab plus cabozantinib). The best regimen depends on risk group, other illnesses, kidney function, previous treatment and the specific cancer subtype. Papillary and other non-clear-cell cancers may need different approaches. Availability and subsidy in Australia should be checked for the individual indication. [1]

Immunotherapy can cause serious inflammation of the bowel, lungs, liver, kidneys or hormone-producing glands; targeted drugs can cause high blood pressure, diarrhoea, fatigue and other adverse effects. Some immune effects can persist after treatment ends. Benefits and risks need an individual discussion with a medical oncologist. [1, 4]

Is chemotherapy useful?

Conventional cytotoxic chemotherapy is generally ineffective for the common types of RCC and is not standard treatment for ordinary clear-cell RCC. Rare subtypes, including collecting duct and renal medullary carcinoma, are exceptions in which chemotherapy may have a role. A cancer arising from the lining of the renal pelvis (upper-tract urothelial carcinoma) is a different disease with different chemotherapy options; establishing the diagnosis matters. [1]

Does radiation offer a benefit?

Radiotherapy is not routinely given after nephrectomy to prevent recurrence of localised RCC. Its clearest established role is treating specific problems from spread, such as painful bone lesions, brain metastases or symptoms from another site. Precisely targeted radiation may also control selected limited metastases or treat a primary tumour in someone unsuitable for surgery. Whether it adds benefit to systemic therapy or surgery in an individual case depends on the site, number and behaviour of lesions and is best decided with radiation oncology input. It should not be presented as a standard substitute for an operable partial nephrectomy. [1, 5]

Questions worth asking at your consultation

Is this definitely a solid enhancing kidney tumour, and what is its exact size and location?
Is the disease confined to the kidney? Are any nodes merely enlarged, or proven to contain cancer?
Can we safely preserve part of the kidney? What is my current kidney function?
Would a biopsy change the plan?
If the cancer is clear-cell and higher risk, would adjuvant pembrolizumab be suitable?
Would drug treatment or targeted radiation offer a benefit in my particular situation?

Seek prompt medical attention for heavy bleeding with clots, inability to pass urine, severe persistent pain, or sudden neurological symptoms. This article is general information and cannot replace review of your scans and pathology at a multidisciplinary meeting.

References

European Association of Urology. EAU Guidelines on Renal Cell Carcinoma: Disease Management. 2026.
European Association of Urology. EAU Guidelines on Renal Cell Carcinoma: Diagnostic Evaluation. 2026.
European Association of Urology. EAU Guidelines on Renal Cell Carcinoma: Staging and Classification Systems. 2026.
National Cancer Institute. Adjuvant Keytruda improves kidney cancer survival, reporting updated KEYNOTE-564 outcomes. 2024.
National Cancer Institute. Renal Cell Cancer Treatment (PDQ), Health Professional Version. Accessed September 2026.

Coffee Break

September 24, 2026/0 Comments/in Blog Post/by drjo

Coffee, oat milk and the start of my day at the Wesley

By Dr Jo Schoeman

Before a busy day of consultations or operating at the Wesley, I enjoy a small ritual: stopping for a coffee with oat milk at Steamtrain Espresso Bar and Kitchen, beside Auchenflower train station and just outside the hospital. It gives me a moment to gather my thoughts before the day begins. I also simply enjoy a good coffee.

“A quiet coffee before the working day.”

What is good about coffee?

For many of us, caffeine helps us feel more alert and focused in the morning. Coffee also contains a range of naturally occurring plant compounds. Large reviews have found that people who drink moderate amounts of coffee tend to have lower rates of several health problems than people who do not drink it. These are mostly associations: they do not prove that coffee itself prevents disease, and they are no reason to start drinking it if you do not enjoy it.[1]

The amount that suits one person may be too much for another. Coffee can disturb sleep or cause jitters and palpitations, especially in people who are sensitive to caffeine. I prefer mine early in the day, when I can enjoy the lift without letting it interfere with the night ahead.

Why oat milk?

I like its taste and the creamy texture it brings to coffee. It is a practical dairy-free option for people who avoid cow’s milk. If oat milk is a regular replacement for dairy, however, it pays to check the carton: products vary, and oat milk usually provides less protein than cow’s milk. Choosing an unsweetened product fortified with calcium can help, while vitamin B12 and iodine are also worth considering in the context of your overall diet.[2,3] A splash in a coffee is a pleasure, rather than a nutritional strategy in itself.

A urologist’s small caveat

I cannot write about coffee without mentioning the bladder. Caffeine can make urinary urgency, frequency or night-time trips to the toilet worse for some people. If that sounds familiar, try a smaller coffee, have it earlier, or see whether decaf makes a difference. Keep drinking an appropriate amount of water; cutting fluids too far can make bladder symptoms worse. Persistent symptoms deserve an assessment rather than being blamed on your morning coffee alone.[4]

For me, that oat milk coffee at Steamtrain marks the start of the working day. It is a pleasant pause, a familiar stop by the station, and a chance to arrive at the Wesley ready to see my patients. Like most good habits, it works best with a little balance.

References and further reading

Poole R, et al. Coffee consumption and health: umbrella review of meta-analyses of multiple health outcomes. BMJ. 2017;359. https://www.bmj.com/content/359/bmj.j5024
Dietitians Australia. Plant-based milks. https://dietitiansaustralia.org.au/health-advice/plant-based-milks
Food Standards Australia New Zealand. Plant-based milk alternatives. https://www.foodstandards.gov.au/consumer/nutrition/milkaltern
Continence Health Australia. Caring for your bladder at night (nocturia). https://www.continence.org.au/about-incontinence/urinary-incontinence/nocturia/caring-for-your-bladder-at-night-nocturia/

This article offers general information and reflects my personal routine. Individual nutrition and bladder needs vary.

Prostate cancer with kidney failure: is surgery, focal therapy or radiation the right choice?

September 23, 2026/0 Comments/in Blog Post, Prostate Surgery/by drjo

A patient guide by Dr Jo Schoeman

A diagnosis of prostate cancer is unsettling. Having chronic kidney disease or needing dialysis can make treatment decisions feel even harder. The reassuring point is that kidney failure does not automatically rule out treatment. The best choice depends on the cancer, the degree of kidney impairment, other medical conditions and, crucially, whether a kidney transplant is planned.

What does Gleason 3+4 mean?

Gleason 3+4=7 is Grade Group 2 prostate cancer. Most of the sampled tumour has pattern 3, with a smaller component of pattern 4. It is generally less concerning than Gleason 4+3=7, but “3+4” alone cannot tell us whether immediate treatment is needed.

I would review the PSA and PSA density, examination, MRI findings, number and length of positive biopsy cores, percentage of pattern 4, any cribriform or intraductal cancer, and whether disease is confined to the prostate. Kidney function, dialysis schedule, life expectancy and transplant eligibility are considered alongside these findings. Some men have favourable intermediate-risk cancer; others have features that make definitive treatment more appropriate. Staging scans are selected according to overall risk rather than biopsy grade alone. [1,2]

Could active surveillance be reasonable?

Yes, for selected men with small-volume, favourable Grade Group 2 cancer. Surveillance means scheduled PSA tests, clinical review, MRI where useful and repeat biopsy when indicated. It keeps treatment available if the cancer changes. It is a particularly meaningful option when another serious illness makes the harms of immediate treatment more likely to outweigh its benefit. It does, however, require a patient who can attend follow-up and accepts a small increased risk of progression compared with immediate treatment. [1,2]

If kidney disease or other illnesses substantially limit life expectancy, watchful waiting may be more appropriate: care focuses on symptoms rather than routine testing intended to trigger curative treatment. This is a separate decision from active surveillance. [1]

Can radical prostatectomy or robotic surgery be performed?

Often, yes. Chronic kidney disease and dialysis are not automatic contraindications to radical prostatectomy. Robotic assisted surgery may offer less blood loss and a shorter hospital stay than open surgery in selected patients, but it still involves general anaesthesia, abdominal insufflation and a head-down operating position. Advanced kidney disease increases the importance of planning for bleeding, infection, fluid and electrolyte balance, medication dosing and postoperative kidney injury. Population studies find higher complication rates in patients with chronic kidney disease, particularly advanced disease; individual risk varies considerably. [3,4]

Before an operation I would coordinate with the nephrologist, anaesthetist and, where relevant, dialysis team. We would assess cardiovascular health, haemoglobin, potassium, anticoagulants, residual kidney function and the timing of dialysis. Surgery also carries the usual risks of urinary leakage or incontinence, erectile dysfunction, infertility, blood clots and possible need for further cancer treatment. Whether a robotic approach is feasible depends on the patient and the surgical team; it is not automatically a safer choice for every person with kidney failure. [1,3,4]

Is focal therapy a better option?

Not simply because the kidneys are failing. Focal therapy treats the visible cancer-bearing portion of the prostate, using a technique such as focused ultrasound, cryotherapy or another ablative method. It may appeal to men hoping to reduce urinary or sexual side effects, but the cancer can be present elsewhere in the gland, and longer-term cancer control is less certain than for established whole-gland treatments. Further MRI, biopsies and sometimes repeat treatment are necessary.

The AUA/ASTRO guideline notes a lack of high-quality comparisons with surgery, radiation and surveillance. European guidance restricts focal treatment to settings with careful prospective follow-up, such as a trial or registry. Kidney disease alone does not establish that focal treatment is preferable. In a suitable patient it can be discussed with a specialist who explains uncertainty, access, costs and a clear follow-up plan. [1,2]

Is radiotherapy an option?

Yes. External beam radiotherapy avoids major surgery and usually does not expose the kidneys directly when treating a prostate confined to the pelvis. Options include moderately shortened courses and, for selected men, more condensed schedules or brachytherapy. The radiation oncologist will tailor treatment to the cancer and urinary function. Depending on whether the disease is favourable or unfavourable intermediate risk, a course of androgen deprivation therapy (ADT) may also be advised; ADT has its own effects on energy, muscle, bone and metabolic health. [1,2]

Radiotherapy may cause temporary urinary frequency, burning or bowel upset; longer-term urinary, bowel or erectile effects are also possible. Existing urinary obstruction and kidney transplant anatomy can change planning. In a transplant recipient, the graft and ureter may sit in the pelvis, so radiation dose constraints require particular attention. Dialysis, by itself, does not make prostate radiation impossible. [1,2]

What if a kidney transplant is planned?

This is a central part of the discussion. A transplant team may need to know whether the cancer is under surveillance or has been treated, its estimated risk of progression and the proposed follow-up. The presence of prostate cancer does not automatically mean that transplantation must wait for a fixed number of years; transplant eligibility is individual and should be discussed directly with the transplant team. A transplanted kidney in the pelvis also affects the planning of later pelvic surgery or radiotherapy. [5]

How do we decide?

Option	When it may fit	Main trade-off
Active surveillance	Low-volume, favourable Grade Group 2 disease	Regular testing and a possibility of later treatment
Robotic radical prostatectomy	Fit patient seeking definitive local treatment	Anaesthetic and surgical risks, with continence and erectile side effects
Radiotherapy	Patient seeking definitive treatment without prostate removal	Urinary, bowel and sexual effects; ADT may be needed
Focal therapy	Carefully selected patient after discussion of uncertainty	Less established long-term cancer control and ongoing biopsies
Watchful waiting	Limited life expectancy or major competing health risks	Treats symptoms if they arise rather than aiming for cure

There is no universal winner between robotic surgery and radiation for Gleason 3+4 cancer with kidney failure. A multidisciplinary discussion involving urology, radiation oncology, nephrology and the transplant team, if applicable, helps align cancer control with kidney health and the patient’s priorities.

This article offers general information and cannot determine treatment for an individual patient. Decisions require review of the pathology, imaging, kidney function and overall health.

References

European Association of Urology. EAU Guidelines on Prostate Cancer: Treatment. Accessed September 2026.
American Urological Association and American Society for Radiation Oncology. Clinically Localized Prostate Cancer Guideline. 2022.
Post-surgical outcomes of patients with chronic kidney disease and end stage renal disease undergoing radical prostatectomy: 10-year results from the US National Inpatient Sample. 2019.
The Effect of Chronic Kidney Disease on Adverse In-Hospital Outcomes at Radical Prostatectomy. 2025.
Kidney Disease: Improving Global Outcomes. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. 2020.

Urethral bulking for stress urinary incontinence: a first procedure or an option after a sling?

September 23, 2026/0 Comments/in Blog Post, Incontinence Surgery, Urethral Surgery/by agileadmin

Leaking urine when you cough, laugh, exercise or lift something is called stress urinary incontinence (SUI). It differs from urgency incontinence, when a sudden need to pass urine leads to leakage. Some women have both. Identifying which symptom is most troublesome matters because an injection aimed at SUI will not reliably treat urgency.

Urethral bulking involves placing small deposits of material into the wall of the urethra, usually through a fine instrument passed into the urethra. The deposits help the urethra close when pressure rises. You may hear this described as periurethral bulking, although many contemporary injections are delivered through the urethra into its surrounding wall. This is generally a day procedure under local anaesthesia or sedation/general anaesthesia, depending on the circumstances. It does not place a sling or mesh tape.

Could bulking be my first procedure?

Yes. After a trial of pelvic floor muscle training and discussion of other conservative measures, bulking can be chosen as a first procedure for appropriately assessed SUI. It may appeal to someone seeking a shorter procedure and recovery, or wishing to avoid a sling. It is also an option when a larger operation or anaesthetic carries additional risk. It is not usually the first treatment before conservative care. USANZ’s 2026 position statement lists bulking alongside autologous fascial slings, colposuspension and synthetic midurethral slings among the standard options that should be discussed. UGSA’s patient information stresses its lower success and frequent need for repeat treatment. [1–3]

Bulking, synthetic midurethral sling surgery, a sling made from the patient’s own fascia, and colposuspension have different benefits and risks. A donated-tissue (allograft) sling is distinct from a sling made from your own tissue (autograft) and from a synthetic mesh sling; the strength and duration of evidence for each are different. No single procedure is best for every woman. [1,4]

How effective and durable is it?

The realistic aim is often less leakage, rather than guaranteed dryness. Success figures change substantially depending on whether researchers count complete dryness, improvement, satisfaction, or avoidance of further treatment. UGSA’s patient leaflet quotes about 40–50% cure or improvement and reports that approximately 30% need a further injection within two years. These are broad counselling figures, not a prediction for an individual. [2]

Some women remain improved for years, but repeat injections or another operation may be needed. In a randomised comparison of polyacrylamide hydrogel injection and synthetic tension-free vaginal tape for primary SUI, the tape achieved better objective continence at one year (negative cough test 95.0% versus 66.4%). The five-year follow-up did not establish that injection was non-inferior to tape. The EAU similarly advises that bulking is generally less effective than slings or colposuspension for cure, and that repeat injection is likely. These findings do not mean everyone should have a tape: the value of a less invasive procedure and the acceptability of a possible repeat treatment are personal considerations. [4–6]

What if I still leak after a sling?

Bulking can be considered for persistent leakage soon after a sling or recurrent leakage after an initial period of improvement. It can sometimes reduce leakage without placing another sling. A 2022 systematic review of 11 studies after synthetic midurethral sling failure reported a pooled 75% cure-or-improvement rate, but also pooled failure and further-operation rates of 32% and 25%. The studies differed considerably in their patients, products, follow-up and definitions of success; the 75% figure should not be presented as a personal chance of cure. An American Urogynecologic Society clinical practice statement also recognises bulking as an option after a sling. [7,8]

After an allograft sling, the same clinical possibility exists, but the published post-sling bulking evidence is mainly about synthetic midurethral slings. We should not simply transfer those success figures to donated-tissue slings. The precise graft, previous surgery and examination findings should guide an individual discussion.

An injection should not be used to mask a sling complication. Before offering more treatment, I would review the original operation, check urine and bladder emptying, examine for prolapse, scarring and vaginal exposure, and assess whether leakage occurs with coughing or with urgency. Cystoscopy, a bladder diary, pad testing or urodynamics may be appropriate, especially after previous surgery, mixed symptoms, pain, blood in the urine or difficulty emptying. A tape or graft causing obstruction, exposure, erosion, infection or pain may require its own assessment and treatment. [1,3,7]

Is it safe? What are the side effects?

Most reported problems are short lived, but no injection is risk free. Possible effects include:

burning when passing urine and a little blood in the urine;
urinary tract infection;
temporary difficulty emptying the bladder, occasionally requiring short-term catheterisation;
new or persisting urgency symptoms; and
incomplete benefit, recurrence or the need for another injection or operation.

Less commonly, there may be persistent pain, a collection or infection at the injection site, or a reaction or complication related to the particular material. Risks also depend on anaesthesia, previous surgery and the chosen product. Emptying should be checked before discharge. Seek prompt assessment if you cannot pass urine, develop fever, worsening pain or heavy bleeding. [2,4,8]

Choosing a treatment

The first step is to confirm the type and severity of leakage and clarify your goals: complete dryness, meaningful improvement, shorter recovery, avoiding mesh, or avoiding the likelihood of repeat treatment. Pelvic floor therapy remains an initial option. When a procedure is appropriate, we can compare bulking with sling and colposuspension procedures using your examination findings, health history and preferences. If you have already had a sling, the reason for the continuing leakage deserves a fresh assessment before choosing another procedure.

This page is general education, not a recommendation for a particular product or a promise of a result. Treatment, including its material, risks, costs and alternatives, should be discussed during an individual consultation.

References

Urological Society of Australia and New Zealand (USANZ). Surgical Treatment of Stress Urinary Incontinence: Position Statement Pol 054, version 2.0. Approved 9 May 2026.
Urogynaecological Society of Australasia (UGSA). Urethral Bulking: Patient Information.
UGSA. Stress Urinary Incontinence: Patient Resources.
European Association of Urology. Guidelines on Non-neurogenic Female Lower Urinary Tract Symptoms: Disease Management, section 4.2.4.c.2.c.
Itkonen Freitas A-M, et al. Tension-free vaginal tape surgery versus polyacrylamide hydrogel injection for primary stress urinary incontinence: a randomised clinical trial. Journal of Urology. 2020.
Itkonen Freitas A-M, et al. Tension-free vaginal tape versus polyacrylamide hydrogel injection for stress urinary incontinence: five-year follow-up. NEJM Evidence. 2025.
Braga A, et al. Urethral bulking agents for the treatment of recurrent stress urinary incontinence: a systematic review and meta-analysis. Maturitas. 2022. doi:10.1016/j.maturitas.2022.05.007.
American Urogynecologic Society. Urethral Bulking: Clinical Practice Statement. Urogynecology. 2024. doi:10.1097/SPV.0000000000001548.

Testicular rupture: causes, warning signs, diagnosis and treatment

September 22, 2026/0 Comments/in Blog Post, Scrotal Surgery/by drjo

Testicular rupture is a surgical emergency. It occurs when trauma tears the tough outer covering of the testis (the tunica albuginea), allowing testicular tissue to protrude through the defect. Prompt assessment offers the best opportunity to control bleeding, relieve pain and preserve viable testicular tissue.

Seek urgent medical care: After an injury, go promptly to the nearest emergency department if there is severe or increasing scrotal pain, marked swelling or bruising, nausea or vomiting, a testis that feels abnormal or cannot be clearly felt, an open wound, or blood at the urinary opening or in the urine. Do not delay assessment while waiting to see whether the swelling settles.

What causes a testicular rupture?

Most ruptures follow a forceful, direct blow that compresses the testis against the pubic bone. Causes include:

contact sport, particularly without an appropriate protective cup;
bicycle or motorcycle accidents and straddle injuries;
falls, motor-vehicle trauma, workplace injuries or assault;
a kick, ball or other high-impact object striking the scrotum; and
penetrating trauma, such as a stab, gunshot, machinery injury or animal bite.

A major blunt injury can also cause a scrotal haematoma, haematocele (blood around the testis), testicular contusion, torsion, fracture without tunical rupture, or injury to the epididymis or spermatic cord. These conditions can look similar, and more than one injury may be present.

How does it present?

Typical features include immediate severe pain followed by rapidly developing swelling, tenderness and bruising. Nausea, vomiting or faintness may occur. The normal outline of the testis may be difficult to feel because of pain and swelling. An open injury, scrotal skin loss or bleeding may be present after penetrating or high-energy trauma.

Symptoms alone cannot reliably distinguish rupture from torsion or other serious injury. Testicular torsion may occur with or without trauma and is also time-critical. A seemingly modest external bruise does not exclude a significant internal injury.

Assessment and investigation

Assessment begins with the circumstances and timing of the injury, examination of both testes and the scrotum, and checking for injury to the penis, urethra, pelvis and abdomen where relevant. Blood at the urethral opening, difficulty passing urine or visible blood in the urine requires assessment for associated urinary-tract injury.

Ultrasound with Doppler

High-resolution scrotal ultrasound with colour Doppler is the preferred first-line imaging test for blunt testicular trauma. Findings that may indicate rupture include:

loss of the smooth testicular contour;
disruption of the tunica albuginea;
heterogeneous testicular tissue;
protrusion of tissue through a tunical defect;
reduced or absent blood flow; and
a surrounding haematocele.

Ultrasound is very useful but is not infallible. Pain, extensive swelling, haematoma and operator or equipment factors can make interpretation difficult. The 2026 European Association of Urology (EAU) guideline strongly recommends ultrasound for testicular trauma and surgical exploration for confirmed rupture and for inconclusive ultrasound when rupture remains a concern. Imaging should not cause an avoidable delay when the clinical findings clearly warrant surgery.

CT is useful for associated abdominal or pelvic trauma but is not the usual test for deciding whether the testis has ruptured. MRI is occasionally considered when ultrasound is equivocal and immediate exploration is not otherwise indicated, but it should not delay necessary surgery.

Treatment

Immediate care

In hospital, initial treatment may include appropriate pain relief, fasting in preparation for possible anaesthesia, scrotal support and management of other injuries. Open or contaminated wounds require wound care; tetanus status and antimicrobial treatment are considered according to the mechanism, contamination and local protocols.

Surgical exploration and repair

Confirmed or strongly suspected rupture is generally treated by urgent scrotal exploration. During surgery, the surgeon will usually:

evacuate blood clot and inspect the testis and surrounding structures;
control bleeding;
remove only tissue that is clearly non-viable;
preserve as much healthy, perfused testicular tissue as possible; and
close the tunica albuginea, sometimes using local tissue coverage when primary closure would place the remaining testis under excessive tension.

Associated injuries to the epididymis or spermatic cord are addressed where possible. A drain may occasionally be used. After surgery, patients commonly require scrotal support, analgesia, wound care and temporary restriction of sport, heavy lifting and sexual activity. The exact plan depends on the injury and operation.

Older clinical series reported testicular salvage rates around 80–90% when rupture was recognised and repaired promptly. These figures describe groups of patients and cannot predict an individual result. The chance of salvage depends on the energy and type of trauma, the amount of tissue destruction, blood supply, contamination, associated injuries and time to treatment.

Is non-operative treatment ever suitable?

Minor trauma with an intact tunica, preserved blood flow and a small, stable haematoma may sometimes be managed with observation, analgesia, ice used safely, scrotal support and arranged review. This is not the usual management for a confirmed rupture. Increasing pain, swelling, fever or other deterioration requires urgent reassessment.

When is orchidectomy necessary?

Orchidectomy means removal of a testis. It is not the preferred treatment when viable tissue can be repaired. It may nevertheless be necessary when the testis is completely shattered, devascularised or infarcted; the spermatic cord is irreparably damaged or avulsed; bleeding cannot otherwise be controlled; contamination and tissue destruction are extreme; or no meaningful viable tissue remains.

The decision is usually made during exploration after blood supply and tissue viability have been assessed. Surgeons aim to conserve viable testicular tissue, but retaining a completely non-viable testis can expose the patient to infection, persistent pain and further surgery. Severe penetrating injuries and delayed treatment are more likely to require orchidectomy than a limited rupture treated early.

If removal is required, a testicular prosthesis can be discussed. It is cosmetic and does not make sperm or testosterone. Placement may be performed at the same operation or later, depending on contamination, swelling, patient preference and clinical circumstances.

Effects on fertility and testosterone

The effect on fertility varies considerably.

Unilateral injury: A healthy opposite testis will often produce enough testosterone and sperm for normal sexual development, erections and natural conception. However, normal fertility cannot be guaranteed. Trauma itself, loss of testicular volume, later atrophy and unilateral orchidectomy can reduce sperm reserve.
Testicular repair: Preserving viable tissue is generally preferred and may better preserve sperm-producing and hormonal function. Small human follow-up studies suggest that semen abnormalities can occur after trauma even when testosterone remains normal; the evidence is limited by small patient numbers.
Bilateral injury or a solitary testis: The risk to fertility and testosterone production is much greater. Loss of both testes causes permanent infertility and requires long-term testosterone replacement. Preservation of even a portion of viable tissue may therefore be especially important.

For severe bilateral injury, injury to a solitary testis, pre-existing subfertility, or concern about future family planning, early discussion with a urologist and fertility specialist is appropriate. Semen analysis, reproductive hormone testing and sperm cryopreservation may be considered when feasible; emergency surgery should not be dangerously delayed to obtain a sample. Follow-up may include examination, ultrasound when indicated, testosterone, LH and FSH testing, and semen analysis after recovery if fertility is a concern.

Possible complications

Even after appropriate treatment, complications can include:

infection, wound problems or recurrent haematoma;
testicular atrophy or loss of blood supply;
persistent scrotal discomfort or chronic pain;
impaired sperm production or subfertility;
reduced testosterone production, particularly after bilateral injury;
the need for later surgery or orchidectomy; and
psychological distress or concern about body image and fertility.

Increasing pain or swelling, fever, wound discharge, skin discolouration, difficulty passing urine or feeling generally unwell after discharge warrants urgent medical review.

The practical message

Following significant scrotal trauma, early assessment matters. Ultrasound with Doppler is the main imaging investigation, but a reassuring-looking exterior, or an uncertain scan, does not safely exclude rupture. Timely exploration and repair provide the best opportunity to save viable testicular tissue. Orchidectomy is reserved for a testis that cannot be safely or meaningfully salvaged.

Important information

This article provides general health information and does not replace an examination, diagnosis, individual medical advice or informed consent. Treatment and outcomes vary according to the mechanism, severity, timing, associated injuries, health history and operative findings. If testicular rupture or torsion is suspected, seek urgent assessment at an emergency department.

References

European Association of Urology. EAU Guidelines on Urological Trauma: Urogenital Trauma Guidelines (2026). Uroweb guideline.
Morey AF, Brandes S, Dugi DD III, et al. Urotrauma: AUA Guideline. Journal of Urology. 2014;192:327–335. Full text via PubMed Central. Updated guideline information: American Urological Association.
Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. Urotrauma Guideline 2020: AUA Guideline. Journal of Urology. 2021;205(1):30–35. PubMed.
Buckley JC, McAninch JW. Use of ultrasonography for the diagnosis of testicular injuries in blunt scrotal trauma. Journal of Urology. 2006;175(1):175–178. PubMed.
Cass AS, Luxenberg M. Testicular injuries. Urology. 1991;37(6):528–530. PubMed.
Lin WW, Kim ED, Quesada ET, Lipshultz LI, Coburn M. Unilateral testicular injury from external trauma: evaluation of semen quality and endocrine parameters. Journal of Urology. 1998;159(3):841–843. PubMed.
Kukadia AN, Ercole CJ, Gleich P, Hensleigh H, Pryor JL. Testicular trauma: potential impact on reproductive function. Journal of Urology. 1996;156(5):1643–1646. PubMed.
Yagil Y, Naroditsky I, Milhem J, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. Journal of Ultrasound in Medicine. 2010;29(1):11–21. PubMed.
Australian Health Practitioner Regulation Agency. Guidelines for advertising a regulated health service and acceptable evidence in health advertising. Ahpra Advertising Hub.
Therapeutic Goods Administration. Advertising health services that involve therapeutic goods (updated 18 June 2026). TGA guidance.

Penile Fracture: Presentation, Investigation, Treatment and Long-Term Outlook

September 22, 2026/0 Comments/in Blog Post, Penile Surgery/by drjo

Penile fracture is a urological emergency. Despite its name, no bone is broken. The injury is a tear in the tunica albuginea, the tough sleeve surrounding one or both erectile cylinders (corpora cavernosa) while the penis is erect. Bleeding then occurs within and around the erectile tissues.

If you hear or feel a crack or pop during intercourse or other bending of an erect penis, followed by pain, loss of the erection, swelling or bruising, stop sexual activity and attend the nearest emergency department immediately. Do not wait to see whether it settles, and do not eat or drink until assessed in case an anaesthetic is required.

This article provides general education. It cannot diagnose an injury, replace examination, or provide individual medical advice.

How does a penile fracture happen?

During an erection, the tunica albuginea becomes much thinner and is vulnerable to sudden buckling. The most frequent mechanism is an erect penis slipping out during intercourse and striking the partner’s pubic bone or perineum. It can also occur during masturbation, intentional forceful bending, rolling onto an erect penis, or less commonly through other trauma.

Penile fracture can happen in any sexual position. It is an accident rather than evidence of wrongdoing, and embarrassment should never delay treatment.

The urethra, the tube carrying urine through the penis, may be injured at the same time. The 2026 European Association of Urology (EAU) guideline reports associated corpus spongiosum or urethral injury in approximately 10–22% of cases; rates vary among populations and mechanisms of injury.[1]

Typical presentation

The classic sequence is:

a sudden crack, snap or popping sensation;
immediate pain;
rapid loss of the erection (detumescence);
quickly developing swelling and bruising;
bending or deformity of the penis, often away from the injured side; and
sometimes a palpable defect in the tunica.

Bruising may spread into the scrotum, perineum or lower abdominal wall. The dramatic “aubergine” appearance described in medical literature is not present in every case.

Warning signs of urethral injury

Tell the treating team immediately if there is:

blood at the urinary opening;
blood in the urine;
pain or difficulty passing urine;
inability to pass urine; or
a weak or interrupted urinary stream after the injury.

The absence of these findings does not completely exclude urethral injury. Clinical assessment remains important.

Conditions that can look similar

Not every swollen or bruised penis after intercourse has a tunical tear. Rupture of a superficial vein or artery, injury to the suspensory ligament, or bleeding beneath the skin can produce a “false penile fracture.” Slow rather than immediate loss of erection and absence of the characteristic crack may make a true fracture less likely, but no single feature is conclusive.

Because missing a fracture can have lasting consequences, significant swelling, pain or deformity after trauma to an erect penis requires urgent medical assessment.

How is it investigated?

History and examination

When the history and examination are classic, penile fracture is primarily a clinical diagnosis. Testing should not unnecessarily delay repair. The clinician will assess the penis, scrotum and perineum and ask specifically about the mechanism, the speed of detumescence, urination and visible blood. A urine test is generally performed.

Ultrasound

Ultrasound can help locate a tear and haematoma, particularly when the diagnosis is uncertain. It is quick and widely available, but its accuracy depends on the operator, the size and position of the tear, and the amount of swelling. A negative or inconclusive ultrasound does not necessarily exclude fracture when the clinical findings are convincing.

MRI

MRI gives excellent soft-tissue detail and is generally more accurate than ultrasound for detecting a tunical tear. It may be useful in equivocal cases, but availability, cost and delay can limit its emergency use. It is not routinely required when the diagnosis is already clear.[1]

Assessment of the urethra

If urethral injury is suspected, evaluation may include retrograde urethrography (contrast imaging of the urethra) or flexible cystoscopy. Visible haematuria, blood at the meatus, difficulty voiding and bilateral corporal injury increase concern. The EAU and American Urological Association (AUA) both recommend evaluating for associated urethral injury when indicated.[1,2]

CT is not the preferred test for an isolated penile fracture, although it may be obtained when wider pelvic or abdominal trauma is suspected.

Recommended management

Prompt surgical repair

Current EAU and AUA guidance recommends prompt surgical exploration and repair for an acute penile fracture.[1,2] The operation is usually performed under general or regional anaesthesia and involves:

exposing the injured erectile tissue through a circumferential degloving incision or a targeted incision over the tear;
evacuating the clot and controlling bleeding;
identifying and closing the tunica albuginea tear with sutures; and
inspecting and repairing the urethra if it is injured.

A urinary catheter may be used, especially when the urethra has been assessed or repaired. The exact incision, catheter duration, hospital stay and follow-up depend on the injury and the surgeon’s findings.

The EAU guideline advises repair within 24 hours of presentation when feasible, but late presentation is not a reason to withhold assessment or repair.[1] A person presenting after a delay should still seek urgent urological review.

Why is conservative treatment generally avoided?

Ice, compression, pain relief, erection-suppressing medication and observation were historically used. Conservative treatment may occasionally be appropriate when imaging and specialist assessment confirm that the tunica is intact, but it is not the standard treatment for a confirmed fracture.

A meta-analysis of 58 studies involving 3,213 patients found significantly fewer overall complications and less erectile dysfunction, curvature and painful erections with surgery than with conservative management.[3] Non-operative treatment of a true fracture carries greater risks of persistent haematoma, infection or abscess, missed urethral injury, fibrosis, penile curvature and erectile dysfunction.[1,3]

Recovery after repair

Patients should follow their treating surgeon’s instructions, which may include:

wound and catheter care;
simple analgesia and other prescribed medicines;
avoiding strenuous activity until reviewed;
avoiding intercourse and masturbation, commonly for about six weeks or until healing is confirmed; and
follow-up to assess erections, curvature, pain and urinary function.

Night-time or spontaneous erections during healing may be uncomfortable. Medication is sometimes used selectively, but there is no universal post-operative drug regimen. Do not start or stop prescription medicines without advice.

Seek urgent review after treatment for fever, increasing redness or swelling, wound discharge, worsening pain, inability to urinate, heavy bleeding, or a catheter that stops draining.

Possible complications

Most patients do well after prompt repair, but no treatment can guarantee a complication-free outcome. Possible early or late problems include:

wound infection, bleeding or haematoma;
altered penile sensation, palpable stitches, scar or nodules;
painful erections;
penile curvature, indentation or shortening;
erectile dysfunction;
urethral narrowing (stricture), urinary spraying or reduced flow;
urethrocutaneous fistula after a significant urethral injury or repair;
need for further investigation or surgery; and
anxiety, avoidance of intimacy or relationship distress.

The EAU guideline summarises reported post-surgical rates of plaques or nodules, curvature and erectile dysfunction as approximately 13.9%, 2.8% and 1.9%, respectively, while noting that complications overall have been reported in up to 20% of cases.[1] These pooled figures are not a personalised prediction: published studies differ in injury severity, definitions, follow-up and measurement. Risk is higher with extensive or bilateral tears, associated urethral injury, delayed or missed diagnosis, and in some studies age over 50.[1,4]

What is the risk of erectile dysfunction?

Erectile dysfunction after a fracture may result from corporal scarring, impaired blood trapping, arterial or nerve injury, pain, anxiety, or a combination of physical and psychological factors. Prompt repair markedly reduces the risk compared with conservative management, but does not eliminate it.[1,3]

Persistent difficulty should be assessed rather than endured in silence. Evaluation can include a sexual and medical history, validated questionnaires, examination and, when indicated, penile Doppler ultrasound. Treatment is individualised and may include counselling, oral erectile-dysfunction medication when safe, vacuum therapy, injections or, rarely, reconstructive surgery or a penile prosthesis.

Does penile fracture cause Peyronie’s disease?

Healing after a penile fracture can produce a local scar, palpable nodule or post-traumatic curvature. These findings may resemble Peyronie’s disease, which is an acquired fibrotic disorder of the tunica albuginea. However, a curve after fracture should not automatically be labelled Peyronie’s disease: it may arise directly from the repaired tear, asymmetric healing or corporal fibrosis.

The distinction is made through history, examination and, if needed, photographs of the erect penis or ultrasound. Review is advisable if there is a new or worsening bend, a hard plaque, painful erections, loss of length, narrowing, instability or difficulty with intercourse. Management depends on whether the deformity is changing or stable, its severity, erectile function and how much it affects the patient. Options may include observation, penile traction in selected cases, treatment of erectile dysfunction, or reconstructive surgery once the deformity is stable. Treatment should be discussed with a urologist experienced in penile reconstruction or andrology.

The essential message

A suspected penile fracture is time-sensitive. A crack or pop followed by immediate loss of erection, swelling and bruising warrants immediate emergency assessment. Diagnosis is often clinical; ultrasound or MRI is reserved mainly for uncertainty, and the urethra must be assessed when injury is suspected. Prompt surgical repair offers the best prospect of preserving penile shape, erections and urinary function.

References

European Association of Urology. EAU Guidelines on Urological Trauma. 2026 edition, sections on genital trauma and penile fracture. https://uroweb.org/guidelines/urological-trauma/chapter/urogenital-trauma-guidelines
Morey AF, Brandes S, Dugi DD III, et al. Urotrauma: AUA Guideline. J Urol. 2014;192(2):327–335; amended guideline statements available from the American Urological Association. doi:10.1016/j.juro.2014.05.004. https://www.auanet.org/guidelines-and-quality/guidelines/urotrauma-guideline
Amer T, Wilson R, Chlosta P, et al. Penile fracture: a meta-analysis. Urol Int. 2016;96(3):315–329. doi:10.1159/000444884.
Barros R, Schulze L, Ornellas AA, Koifman L, Favorito LA. Impact of surgical treatment of penile fracture on sexual function. Urology. 2019;126:128–133. doi:10.1016/j.urology.2018.11.027.
Wong NC, Dason S, Bansal RK, Davies TO, Braga LH. Can it wait? A systematic review of immediate vs delayed surgical repair of penile fractures. Can Urol Assoc J. 2017;11(1–2):53–60. doi:10.5489/cuaj.4032.
Koifman L, Barros R, Júnior RAS, Cavalcanti AG, Favorito LA. Penile fracture: diagnosis, treatment and outcomes of 150 patients. Urology. 2010;76(6):1488–1492. doi:10.1016/j.urology.2010.05.043.

Website publication note

This material is general health information and was prepared from the sources listed above. It is not a substitute for emergency assessment, diagnosis, informed consent or personalised advice from a qualified practitioner. Outcomes and risks vary between individuals.