Neurogenic Bladder in Hereditary Spastic Paraplegia: Treatment, Botox and Sacral Neuromodulation

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Hereditary Spastic Paraplegia (HSP) is best known for causing progressive stiffness, weakness and spasticity of the legs. However, the neurological pathways controlling the bladder travel through the same spinal cord neighbourhood, and bladder dysfunction can therefore become an important and sometimes underestimated part of HSP.

Studies of patients with HSP have reported lower urinary tract symptoms in a substantial proportion of patients, particularly urgency, urinary frequency, nocturia and urgency urinary incontinence. Difficulty emptying the bladder can also occur. Urodynamic studies frequently demonstrate neurogenic detrusor overactivity, sometimes accompanied by detrusor-sphincter dyssynergia.

The modern term for this problem is neurogenic lower urinary tract dysfunction (NLUTD) rather than simply “neurogenic bladder”, because the neurological condition may affect the bladder, bladder outlet and urinary sphincter in different ways.

For patients with HSP, treatment therefore needs to be individualised. The aim is not merely to reduce trips to the toilet. We want to achieve a bladder that stores urine safely, empties adequately, protects the kidneys and interferes as little as possible with everyday life.

How does HSP affect the bladder?

Normal bladder control requires remarkably complicated communication between the brain, spinal cord, bladder and urinary sphincter.

During filling, the bladder should remain relaxed while the urinary sphincter remains closed. When it is appropriate to urinate, the brain permits the bladder to contract while the sphincter relaxes.

HSP can disrupt these pathways.

The commonest urodynamic abnormality reported in HSP is detrusor overactivity, where involuntary bladder contractions occur during filling.

Patients may consequently experience:

  • urinary urgency and frequency;
  • waking repeatedly at night to urinate;
  • urgency urinary incontinence;
  • difficulty postponing urination;
  • hesitancy or a poor urinary stream;
  • incomplete bladder emptying;
  • recurrent urinary tract infections; and
  • occasionally significant urinary retention.

Importantly, symptoms do not always tell us exactly what the bladder is doing. Two patients saying, “I can’t hold on,” may have quite different underlying bladder physiology.

That is where urodynamic assessment can become particularly useful.

Investigating bladder dysfunction in HSP

Assessment should be tailored to the severity of symptoms and the patient’s neurological and urological risk.

It may include a detailed history, bladder diary, urinalysis, measurement of post-void residual urine, renal function assessment and ultrasound of the kidneys and bladder.

Urodynamic studies are particularly valuable when symptoms are significant, treatment has failed, bladder emptying is abnormal or invasive treatment such as Botox is being considered.

Urodynamics can identify:

Neurogenic detrusor overactivity (NDO)
The bladder contracts involuntarily while filling.

Poor bladder compliance
Bladder pressure increases excessively as the bladder fills. This is particularly important because sustained high storage pressures can potentially threaten the upper urinary tract.

Detrusor-sphincter dyssynergia (DSD)
Instead of relaxing during urination, the urinary sphincter contracts against the bladder.

Detrusor underactivity
The bladder contracts inadequately and therefore does not empty properly.

The EAU and AUA/SUFU guidelines emphasise risk-based evaluation and ongoing surveillance of patients with neurogenic lower urinary tract dysfunction rather than treating symptoms in isolation.

First-line treatment

Treatment depends upon whether the main problem is storage, emptying or a combination of both.

Lifestyle and bladder strategies

Some patients benefit from relatively simple measures such as:

  • adjusting fluid intake;
  • reducing excessive caffeine;
  • timed voiding;
  • managing constipation;
  • bladder retraining where appropriate;
  • pelvic-floor physiotherapy in selected patients; and
  • reviewing medications that may worsen bladder function.

Mobility is an important consideration in HSP. A bladder that gives somebody 20 seconds’ warning may be considerably more disabling when that person also has difficulty walking quickly to a toilet.

Treatment goals therefore need to reflect the patient’s mobility, hand function, independence and quality of life, something specifically emphasised by neuro-urology guidelines.

Medication

For predominantly overactive bladder symptoms, treatment commonly begins with an antimuscarinic medication and/or a beta-3 adrenergic agonist.

Antimuscarinic drugs can reduce involuntary bladder contractions but may cause dry mouth, constipation, blurred vision and cognitive adverse effects in susceptible patients.

Beta-3 agonists may provide an alternative or can sometimes be combined with an antimuscarinic.

Post-void residual urine should be considered, particularly when there is already evidence of impaired bladder emptying.

Intermittent catheterisation

When significant urinary retention or incomplete bladder emptying occurs, clean intermittent catheterisation (CIC) may be required.

This can sound intimidating when first discussed, but many patients become remarkably comfortable with the technique.

HSP creates an additional consideration: progressive lower-limb disability, hand function and mobility need to be considered when deciding whether intermittent catheterisation will remain practical.

Where possible, intermittent catheterisation is generally preferable to long-term indwelling catheterisation for bladder emptying in neuro-urological patients.

Botox injections into the bladder

For patients with persistent neurogenic detrusor overactivity despite medication, Botulinum toxin A (Botox) injected into the detrusor muscle can be extremely useful.

Botox temporarily reduces excessive acetylcholine-mediated contraction of the bladder muscle.

The result is essentially a bladder that becomes a little less excitable.

How is bladder Botox performed?

Using a cystoscope, multiple small injections of Botulinum toxin A are placed into the bladder wall.

It is usually performed as a short day procedure under local anaesthetic, sedation or general anaesthesia depending upon the patient and clinical circumstances.

The treatment is temporary and therefore generally needs to be repeated when its effect wears off.

How effective is Botox?

There is strong evidence for intradetrusor onabotulinumtoxinA in neurogenic detrusor overactivity associated with spinal cord injury and multiple sclerosis.

Randomised studies in these populations show:

  • fewer episodes of urinary incontinence;
  • increased bladder capacity;
  • reduced detrusor pressures;
  • improved urodynamic storage parameters; and
  • improved quality of life.

The AUA/SUFU guideline gives this treatment a Grade A evidence recommendation in MS and spinal cord injury when oral treatment has failed.

The EAU likewise recommends detrusor Botulinum toxin A injections for neurogenic detrusor overactivity when antimuscarinic therapy is ineffective.

But what about HSP specifically?

This distinction is important.

HSP-specific clinical trials of intradetrusor Botox are very limited.

HSP therefore cannot simply inherit the strength of evidence available for MS and spinal cord injury. The AUA/SUFU guideline places Botox treatment for neurogenic disorders other than MS or spinal cord injury in a lower evidence category, although it states that treatment may be offered to appropriately selected patients whose symptoms have not responded adequately to oral medication.

In clinical practice, this makes the urodynamic diagnosis particularly important.

If an HSP patient has convincing neurogenic detrusor overactivity producing significant urgency, incontinence or unsafe bladder storage pressures despite conservative and medical treatment, intradetrusor Botox is a logical treatment option.

The evidence is therefore strongest for treating the urodynamic abnormality, rather than Botox having been proven specifically for the genetic diagnosis of HSP.

What are the disadvantages of Botox?

The most important adverse effect is incomplete bladder emptying or urinary retention.

A patient who previously urinated normally may need intermittent catheterisation after treatment.

The AUA/SUFU guideline therefore specifically recommends discussing the possibility of urinary retention and intermittent catheterisation before Botox is administered to a spontaneously voiding patient.

Other possible complications include urinary tract infection, haematuria, discomfort during urination and the need for repeated treatment.

This discussion is particularly important in HSP patients whose mobility or hand function might make self-catheterisation difficult.

Sacral neuromodulation

Another intriguing option is sacral neuromodulation (SNM).

Rather than temporarily weakening the bladder muscle, SNM attempts to modulate the neurological circuitry controlling bladder storage and emptying.

A small electrode is positioned close to a sacral nerve, usually the S3 nerve root, and connected to an electrical stimulator.

Think of it less as “shocking the bladder” and more as adjusting the electrical conversation between the bladder, spinal cord and brain.

A major advantage: it can be tested first

SNM generally begins with a trial or test phase.

A temporary or tined lead is placed near the sacral nerve and connected to an external stimulator.

Symptoms are then assessed.

A clinically meaningful improvement, commonly around 50% or greater, is generally required before proceeding to implantation of the permanent pulse generator.

That provides an important advantage: the patient effectively auditions the treatment before committing to the permanent implant.

Does sacral neuromodulation work in neurogenic bladder?

The evidence is promising but considerably less robust than the Botox evidence for MS and spinal cord injury.

The AUA/SUFU guideline states that SNM may be offered to selected patients with neurogenic lower urinary tract dysfunction who have urinary urgency, frequency and/or urgency incontinence, but rates the evidence as Grade C.

Studies involving mixed neurological populations have demonstrated improvements in:

  • urgency;
  • urinary frequency;
  • urgency incontinence;
  • voided volume;
  • bladder capacity; and
  • quality of life.

However, these studies include heterogeneous neurological diseases, making it difficult to predict outcomes for one particular condition.

The AUA/SUFU guideline specifically advises against SNM in neurogenic bladder caused by spinal cord injury or spina bifida, but HSP is not listed as an absolute contraindication.

What about sacral neuromodulation specifically for HSP?

Here we need to be particularly careful about claims of efficacy.

There is currently very limited direct evidence specifically studying SNM in patients with Hereditary Spastic Paraplegia.

Most of the evidence supporting SNM in neurological disease comes from mixed cohorts containing conditions such as multiple sclerosis, Parkinson’s disease, stroke, incomplete spinal cord disorders and other neurological conditions.

Consequently, it would be inappropriate to tell an HSP patient that sacral neuromodulation has a proven success rate specifically for HSP.

Instead, I would regard SNM as a potential treatment for carefully selected HSP patients, particularly those who:

  • continue to void spontaneously;
  • have troublesome urgency, frequency or urgency incontinence;
  • have failed conservative and pharmacological treatment;
  • do not have dangerous high-pressure bladder physiology requiring a different strategy; and
  • demonstrate a convincing response during the SNM test phase.

The test phase becomes particularly valuable when the evidence base for the underlying neurological disorder is limited.

Botox or sacral neuromodulation: which is better in HSP?

There is currently no good HSP-specific head-to-head trial demonstrating that one is superior to the other.

The choice should therefore be driven by the patient’s bladder physiology.

Botox may be particularly attractive when:

there is proven neurogenic detrusor overactivity, bladder pressures need to be reduced, medication has failed and the patient accepts the possibility of intermittent catheterisation and repeated injections.

Sacral neuromodulation may be attractive when:

urgency, frequency and urgency incontinence predominate, the patient continues to empty reasonably well, conservative and pharmacological therapy have failed, and there is no contraindication to implantation.

SNM also offers the considerable advantage of a test phase before permanent implantation.

The two therapies should therefore not necessarily be regarded as competitors. They act differently and may suit different neuro-urological phenotypes.

Why urodynamics matter before choosing treatment

For HSP, I believe one of the most useful questions is not simply:

“Does the patient have a neurogenic bladder?”

It is:

“What type of neurogenic bladder dysfunction does this particular patient have?”

An HSP patient with severe detrusor overactivity and high storage pressures is fundamentally different from an HSP patient with urgency but satisfactory storage pressures, and different again from somebody with detrusor underactivity and a large residual urine volume.

The treatment should follow the physiology.

This is particularly relevant because HSP studies confirm that detrusor overactivity is common, but voiding dysfunction and other urodynamic abnormalities also occur.

What happens when less-invasive treatments fail?

A small proportion of patients develop severe neurogenic lower urinary tract dysfunction that cannot be adequately controlled with medication, catheterisation, Botox or neuromodulation.

More invasive options can include bladder augmentation or urinary diversion, depending upon bladder pressures, continence, renal risk, mobility and the patient’s ability to catheterise.

Fortunately, these procedures are required far less commonly than the conservative, pharmacological and minimally invasive treatments discussed above.

Follow-up is important

HSP is a neurological condition that can evolve over time. Bladder function can evolve with it.

A treatment that worked well several years ago may therefore need reassessment if symptoms change.

Patients should seek review if they develop:

  • worsening urinary incontinence;
  • increasing difficulty emptying;
  • recurrent urinary infections;
  • new urinary retention;
  • haematuria;
  • flank pain; or
  • a significant change in their usual bladder pattern.

Depending upon risk, follow-up may include post-void residual measurement, renal function, renal tract imaging and repeat urodynamics.

Current EAU guidance emphasises ongoing surveillance and reassessment in neuro-urological patients, with the intensity of follow-up determined by individual risk. The 2026 EAU Neuro-Urology Guidelines have also updated recommendations regarding diagnosis, treatment, Botulinum toxin A and follow-up.

The bottom line

Bladder dysfunction is a genuine and sometimes overlooked component of Hereditary Spastic Paraplegia.

The commonest problem is neurogenic detrusor overactivity, producing urgency, frequency, nocturia and urgency incontinence, although impaired emptying and detrusor-sphincter dysfunction can also occur.

Treatment usually progresses from conservative measures and medication to intermittent catheterisation where necessary, followed by more advanced therapies in appropriately selected patients.

Intradetrusor Botox is an effective established treatment for neurogenic detrusor overactivity, although the highest-quality evidence comes from MS and spinal cord injury rather than HSP itself. Its principal trade-off is the possibility of urinary retention and the need for intermittent catheterisation.

Sacral neuromodulation is another potential option for selected HSP patients, especially those with refractory urgency, frequency and urgency incontinence who continue to void spontaneously. However, the evidence specifically for HSP remains limited, so the temporary test phase is particularly useful in determining whether an individual patient is likely to benefit.

Most importantly, treatment should be based on the patient’s symptoms, urodynamic findings, bladder-emptying ability, mobility and individual goals rather than the diagnosis of HSP alone.

So, If this is you, come have a chat to your local Brisbane functional urologist, Dr Jo Schoeman to discuss this further

References and further reading

  1. Fourtassi M, Jacquin-Courtois S, Scheiber-Nogueira MC, et al. Bladder dysfunction in hereditary spastic paraplegia: a clinical and urodynamic evaluation. Spinal Cord. 2012;50:558–562.
  2. Braschinsky M, Zopp I, Kals M, Haldre S, Gross-Paju K. Bladder dysfunction in hereditary spastic paraplegia: what to expect? J Neurol Neurosurg Psychiatry. 2010;81:263–266.
  3. Ginsberg DA, Boone TB, Cameron AP, et al. The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-up. J Urol. 2021;206:1106–1113.
  4. Ginsberg DA, Boone TB, Cameron AP, et al. The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Diagnosis and Evaluation. J Urol. 2021.
  5. European Association of Urology. EAU Guidelines on Neuro-Urology, 2026.
  6. European Association of Urology. Neuro-Urology: Botulinum toxin A injections. The guideline recommends detrusor Botulinum toxin A for neurogenic detrusor overactivity when antimuscarinic therapy is ineffective.

Important note

This information is intended for general patient education and does not replace individual medical assessment. Hereditary Spastic Paraplegia encompasses multiple genetic and clinical phenotypes, and bladder treatment should be individualised following appropriate neurological and urological assessment.

Anterior Vaginal Prolapse (Cystocele): When the Bladder Bulges into the Vagina

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An anterior vaginal prolapse, often called a cystocele, develops when the tissues supporting the bladder and the front wall of the vagina weaken. The bladder then descends and pushes into the vaginal wall, sometimes producing a noticeable vaginal bulge.

A cystocele is not cancerous and is not usually dangerous. However, it can cause pressure, discomfort, difficulty emptying the bladder, urinary leakage and recurrent urinary tract infections. Treatment depends on the severity of the prolapse and, more importantly, how much it affects daily life.

What normally supports the bladder?

The bladder rests above the front wall of the vagina. It is supported by:

  • Pelvic-floor muscles
  • Connective tissue and fascia between the bladder and vagina
  • Ligaments supporting the uterus and top of the vagina
  • The normal attachments of the vagina to the pelvic sidewalls

These structures work together rather like the ropes, fabric and anchor points of a hammock. When the supporting tissue stretches, tears or detaches, the front vaginal wall can descend and the bladder follows it.

Although commonly called a “fallen bladder,” the bladder has not become detached. It has lost some of its normal support.

How does a cystocele develop?

Usually, several factors contribute over time.

Pregnancy and vaginal childbirth

Pregnancy stretches the pelvic floor, while vaginal delivery can injure muscles, nerves and connective tissue. The risk may be higher after:

  • Multiple vaginal births
  • Forceps-assisted delivery
  • A prolonged second stage of labour
  • Delivery of a larger baby
  • Significant perineal injury

A prolapse may become apparent soon after childbirth or many years later.

Menopause and ageing

After menopause, falling oestrogen levels can make vaginal and supporting tissues thinner and less elastic. Ageing also changes collagen strength and muscle function.

Chronic pressure on the pelvic floor

Repeated increases in abdominal pressure may contribute, including:

  • Chronic constipation and straining
  • Persistent coughing
  • Heavy lifting
  • Obesity
  • High-impact activity in susceptible women

Previous pelvic surgery

A cystocele can occur after hysterectomy or previous prolapse surgery, particularly if the upper vaginal or apical support is weakened.

Inherited tissue characteristics

Some women naturally have more flexible connective tissue. Family history, joint hypermobility and certain connective-tissue disorders may increase susceptibility.

What does an anterior prolapse feel like?

A mild cystocele may cause no symptoms and may only be detected during an examination. More advanced prolapse can cause:

  • A vaginal bulge or lump
  • A sensation that “something is coming down”
  • Pelvic heaviness, dragging or pressure
  • Symptoms that worsen later in the day
  • Discomfort after prolonged standing or activity
  • Difficulty inserting a tampon
  • Discomfort or altered sensation during intercourse
  • Vaginal irritation, discharge or spotting when exposed tissue rubs on clothing

Some women describe the bulge as feeling like a small egg, golf ball or soft balloon at the vaginal opening.

The size seen during an examination does not always match symptom severity. A modest prolapse can be very troublesome, while a larger prolapse may cause surprisingly few symptoms.

How can a cystocele affect the bladder?

Because the bladder and urethra depend on coordinated pelvic support, a cystocele can produce several different and sometimes apparently contradictory urinary symptoms.

These may include:

  • A slow or intermittent urinary stream
  • Hesitancy before urine starts
  • The need to strain to urinate
  • A feeling that the bladder has not emptied
  • Needing to change position to finish urinating
  • Urinary urgency and frequency
  • Waking at night to urinate
  • Stress incontinence with coughing, laughing or exercise
  • Urge incontinence
  • Leakage after standing up from the toilet

Some women need to press the vaginal bulge backwards with a finger to empty the bladder. This is known as splinting or manual reduction.

Interestingly, a larger prolapse can sometimes kink or compress the urethra and temporarily hide stress incontinence. Once the prolapse is reduced with a pessary or repaired surgically, previously hidden leakage may become apparent. This is called occult stress urinary incontinence.

Can a cystocele cause urinary retention?

Yes. A significant prolapse may alter the angle between the bladder and urethra, obstruct urine flow or prevent the bladder muscle from emptying efficiently.

Possible consequences include:

  • Persistent residual urine after voiding
  • Recurrent urinary infections
  • Overflow leakage
  • Increasing difficulty passing urine
  • Bladder stones in uncommon cases
  • Upper urinary-tract obstruction or kidney problems in severe, longstanding prolapse

Complete acute retention is uncommon but requires urgent medical attention.

The amount remaining in the bladder can be assessed with a bladder ultrasound or catheter measurement. The prolapse may be reduced during testing to determine whether bladder emptying improves.

Why may urinary infections become more frequent?

A prolapse does not automatically cause infection. However, urine left in the bladder after voiding may provide an environment in which bacteria can multiply.

Menopause-related vaginal atrophy can add to this risk by changing the protective vaginal bacterial population and weakening the tissues around the urethra.

Not every episode of urgency, frequency or burning is an infection. Whenever practical, suspected recurrent UTIs should be confirmed with a midstream urine culture before antibiotics are prescribed.

Management may include:

  • Improving bladder emptying
  • Treating constipation
  • Using a pessary to reduce the prolapse
  • Low-dose topical vaginal oestrogen when appropriate
  • Culture-directed antibiotics for proven infection
  • Additional UTI-prevention measures in selected women

How is a cystocele assessed?

Assessment usually includes:

  • A detailed history of the bulge and urinary symptoms
  • Pelvic examination while lying down and sometimes standing
  • Asking the patient to cough or strain
  • Assessment of the front, back and top of the vagina
  • Evaluation of uterine or vaginal-vault support
  • Urine testing
  • Measurement of residual urine after voiding
  • Assessment for vaginal atrophy
  • Pelvic-floor muscle assessment

Clinicians commonly describe prolapse using the Pelvic Organ Prolapse Quantification system, known as POP-Q.

A bladder diary, kidney ultrasound, cystoscopy or urodynamic study may be appropriate when there is significant retention, recurrent infection, complex incontinence, previous pelvic surgery or uncertainty about bladder function.

Does every cystocele need treatment?

No. Treatment is generally based on symptoms, not examination findings alone.

A mild or moderate prolapse that is not bothersome can often be observed. Prolapse is not inevitably progressive, and delaying treatment does not usually make later surgery impossible.

Treatment becomes more appropriate when the prolapse causes:

  • A troublesome bulge
  • Difficulty emptying the bladder
  • Recurrent infections associated with residual urine
  • Vaginal ulceration or bleeding
  • Limitations on exercise, work or sexual activity
  • A significant effect on quality of life

Can the prolapse be reduced?

A prolapse may be gently pushed back into the vagina. This does not permanently repair the weakened support, but it can temporarily restore the anatomy and improve comfort or bladder emptying.

Some women manually reduce the prolapse before passing urine. If this is frequently necessary, medical assessment is advisable.

A clinician may also reduce the prolapse during an examination, bladder-emptying test or urodynamic study. A vaginal pessary provides more sustained non-surgical reduction.

If a prolapse suddenly becomes very painful, cannot be reduced, causes heavy bleeding or is associated with an inability to urinate, urgent assessment is required.

Conservative management

Observation

When symptoms are mild, reassurance and periodic review may be all that is required.

Pelvic-floor physiotherapy

A pelvic-floor physiotherapist can assess muscle strength, coordination and relaxation. An individualised program may:

  • Improve mild prolapse symptoms
  • Reduce the sensation of heaviness
  • Improve stress or urge incontinence
  • Teach safer lifting and pressure-management techniques
  • Assist bowel emptying without excessive straining

Exercises cannot reliably “pull back” a large prolapse permanently, but they can improve symptoms and support bladder control.

Addressing contributing factors

Helpful measures may include:

  • Treating constipation
  • Avoiding repeated straining
  • Managing chronic cough
  • Gradual weight reduction where appropriate
  • Modifying heavy lifting
  • Using good lifting and breathing techniques
  • Maintaining regular, low-impact physical activity

Women should not be frightened away from exercise. The aim is sensible modification rather than unnecessary restriction.

Vaginal pessary

A pessary is a removable silicone device placed inside the vagina to support the prolapse. Common designs include ring pessaries and space-filling pessaries.

Advantages include:

  • Avoiding or postponing surgery
  • Rapid improvement in bulge symptoms
  • Possible improvement in bladder emptying
  • Suitability for women planning future pregnancy
  • Use in women who are not medically fit for surgery
  • The ability to assess whether prolapse reduction reveals stress incontinence

Finding the correct size sometimes requires more than one fitting. Follow-up is important to check comfort, bladder emptying and vaginal health.

Possible problems include discharge, spotting, odour, difficulty removing the device and vaginal ulceration. These risks are reduced by appropriate fitting, regular review and, in suitable postmenopausal women, topical vaginal oestrogen.

When is surgery considered?

Surgery may be considered when:

  • Conservative treatment has not provided adequate relief
  • The prolapse extends to or beyond the vaginal opening
  • Bladder emptying is significantly impaired
  • The patient does not want or cannot manage a pessary
  • Symptoms substantially affect quality of life

The goal is to improve symptoms and function, not simply to make the examination look anatomically perfect.

Before surgery, the surgeon should discuss:

  • The patient’s most troublesome symptoms
  • Sexual activity and future preferences
  • Whether the uterus is present
  • Previous pelvic surgery
  • The strength of apical or upper-vaginal support
  • Existing or occult urinary incontinence
  • The possibility of recurrence
  • The benefits and complications of each surgical route

Native-tissue anterior vaginal repair

The most established vaginal operation for a cystocele is an anterior colporrhaphy, also called an anterior vaginal repair.

Through an incision in the front vaginal wall, the bladder is carefully separated from the vagina. The patient’s own supporting tissue is then folded, tightened or reattached, and the vaginal incision is closed with dissolving sutures.

This is a native-tissue repair, meaning no permanent synthetic mesh is placed through the vagina.

Possible complications include:

  • Bleeding or infection
  • Temporary difficulty emptying the bladder
  • Urinary tract infection
  • Injury to the bladder or ureters
  • New or persistent urinary urgency
  • New or unmasked stress incontinence
  • Pain during intercourse
  • Vaginal narrowing
  • Recurrence of the prolapse
  • Need for further prolapse or continence surgery

A catheter may be required temporarily until bladder emptying is satisfactory.

Why apical support matters

A cystocele is not always an isolated defect. Weakness at the top of the vagina or uterus can pull the front wall down.

Repairing only the visible cystocele without addressing significant upper-vaginal weakness may increase the likelihood of recurrence. Surgery may therefore include an apical suspension procedure, with or without hysterectomy, depending on the anatomy and the patient’s preferences.

Options may include:

  • Uterosacral ligament suspension
  • Sacrospinous fixation
  • Uterine-preserving hysteropexy
  • Abdominal or laparoscopic sacrocolpopexy

Sacrocolpopexy and abdominal mesh

Sacrocolpopexy is usually performed laparoscopically or robotically. Surgical mesh is attached to the vagina and then secured to the sacrum to restore upper-vaginal support.

This is different from placing a mesh sheet through a vaginal incision to repair a cystocele. Abdominally placed mesh remains available in Australia for selected prolapse operations.

It has its own risks, including mesh exposure or erosion, infection, pain, bowel or urinary injury and the possibility of further surgery. The benefits and risks should be discussed carefully.

Transvaginal synthetic mesh in Australia

Permanent synthetic mesh kits previously used through a vaginal incision for pelvic organ prolapse caused significant concern because of complications such as:

  • Mesh exposure through the vaginal wall
  • Chronic pelvic or vaginal pain
  • Painful intercourse
  • Infection
  • Bladder or urethral erosion
  • Urinary problems
  • Difficult or incomplete mesh removal

Following a review of safety and effectiveness, the Australian Therapeutic Goods Administration removed transvaginal mesh products intended solely for treating pelvic organ prolapse from the Australian Register of Therapeutic Goods. TGA information about urogynaecological mesh

This restriction does not mean that all uses of surgical mesh are identical. It is important to distinguish:

  • Transvaginal mesh sheets used to treat prolapse
  • Small mid-urethral slings used for stress urinary incontinence
  • Mesh placed abdominally during sacrocolpopexy
  • Biological grafts or allografts

Each involves different materials, surgical approaches, benefits and risks.

What is the role of an allograft?

An allograft is processed human donor tissue. Examples include donor fascia lata obtained from the strong tissue of the thigh.

A biological graft may be placed to reinforce weakened vaginal support. It is not the same as permanent polypropylene mesh. The material acts as a scaffold and is gradually remodelled or absorbed to varying degrees.

The proposed advantages include:

  • Avoiding permanent synthetic mesh
  • Providing reinforcement where native tissue is weak
  • Potentially reducing permanent foreign-body complications
  • Offering an option in selected reconstructive or repeat operations

However, these theoretical advantages do not mean that an allograft is routinely better than native-tissue repair.

Limitations of allograft repair

Available evidence has not established that biological graft reinforcement consistently provides better long-term outcomes than a well-performed native-tissue anterior repair. Some grafts may stretch or lose strength as they remodel, and prolapse can recur.

Potential limitations and complications include:

  • Graft failure or absorption
  • Recurrent prolapse
  • Infection
  • Inflammatory or wound-healing problems
  • Vaginal exposure, although generally less characteristic than with permanent synthetic mesh
  • Additional cost
  • Limited long-term product-specific evidence
  • An extremely low theoretical risk of disease transmission despite donor screening and processing

A major Cochrane review concluded that evidence does not support routine use of biological grafts over native-tissue repair for vaginal prolapse. Cochrane review of transvaginal mesh, grafts and native-tissue repair

For most women undergoing a first anterior repair, native tissue remains the usual vaginal surgical approach. An allograft may be considered selectively, for example, in complex reconstruction, poor-quality tissue or recurrent prolapse, but this should involve careful informed consent and discussion of the uncertainty in long-term benefit.

Women should ask:

  • What exact graft product is proposed?
  • Is it included on the Australian Register of Therapeutic Goods?
  • Why is it preferable in my particular case?
  • What evidence supports its use for anterior prolapse?
  • What are the surgeon’s results and complication rates?
  • What alternatives are available without graft material?

UGSA and USANZ guidance

The Urogynaecological Society of Australasia (UGSA) supports specialist training, credentialing and appropriate governance for clinicians implanting or removing transvaginal mesh. Its published position material emphasises that mesh procedures and mesh-complication surgery require suitable training, experience, consent and clinical oversight. UGSA position statements

The Urological Society of Australia and New Zealand (USANZ) represents urologists involved in treating urinary dysfunction, retention, recurrent infection and pelvic-floor disorders.

There is no joint UGSA–USANZ statement recommending allograft reinforcement for routine anterior prolapse repair. It would therefore be inaccurate to suggest that either organisation endorses routine allograft use.

The practical Australian approach is individualised and evidence-based:

  • Treat symptoms rather than the examination alone
  • Offer observation, pelvic-floor physiotherapy and pessary management where appropriate
  • Assess bladder emptying and culture suspected recurrent infections
  • Use native-tissue repair as the usual vaginal surgical option
  • Evaluate and restore apical support where necessary
  • Avoid routine transvaginal permanent synthetic mesh for prolapse
  • Reserve biological grafts or other specialised reconstruction for carefully selected patients
  • Provide clear consent regarding alternatives, uncertainty, recurrence and complications

Recovery after anterior prolapse surgery

Recovery varies according to the procedure. Patients can generally expect:

  • A temporary urinary catheter
  • A bladder-emptying assessment before discharge
  • Light vaginal bleeding or discharge
  • Pelvic discomfort for several days
  • Avoidance of constipation and straining
  • Gradual return to walking and daily activities
  • Temporary restrictions on heavy lifting and vaginal intercourse

Urgent advice should be sought for fever, heavy bleeding, worsening pain, inability to urinate, offensive discharge, calf swelling, chest pain or shortness of breath.

Can a cystocele return?

Yes. Surgery repairs the current weakness but cannot permanently reverse ageing, tissue quality or every future pressure placed on the pelvic floor.

Recurrence does not always require another operation. A recurrent prolapse may be mild and successfully managed with observation, physiotherapy or a pessary.

Reducing constipation, treating chronic cough, maintaining a healthy weight and using sensible lifting techniques may help protect the repair.

The take-home message

An anterior vaginal prolapse occurs when weakened support allows the bladder to bulge into the front wall of the vagina. It can cause pressure, urinary leakage, incomplete emptying, retention and recurrent infections, but treatment is only necessary when symptoms are troublesome or bladder function is affected.

Conservative measures, particularly pelvic-floor physiotherapy and a vaginal pessary, are effective options for many women. When surgery is needed, native-tissue anterior repair remains the usual vaginal procedure in Australia, often combined with restoration of upper-vaginal support.

Processed human-tissue allografts are different from permanent synthetic mesh, but current evidence does not support their routine use for every cystocele. Their role is selective and should be discussed with a surgeon experienced in female pelvic-floor reconstruction.

So, if you can feel a bulge and it is affecting your waterworks, come see your local urogynaecologist or local Brisbane urologist specialising in this field.

This article provides general information and does not replace individual medical advice. Treatment should be selected after assessment by an appropriately trained urologist, urogynaecologist or gynaecologist.

Vaginal Atrophy: How Menopause Can Affect the Bladder, Infections and Incontinence

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Vaginal dryness after menopause is common, but it is not “just part of getting older” and does not need to be silently tolerated.

The modern medical term is genitourinary syndrome of menopause (GSM). This recognises that falling oestrogen levels affect not only the vagina and vulva, but also the urethra, bladder and pelvic floor. Symptoms may therefore include dryness or painful intercourse as well as urinary urgency, recurrent urinary tract infections and leakage.

GSM is usually a chronic condition. Unlike hot flushes, it often persists or gradually worsens without treatment. Fortunately, several effective management options are available.

What causes vaginal atrophy?

Before menopause, oestrogen helps keep the vaginal and lower urinary-tract tissues:

  • Thick, elastic and well lubricated
  • Well supplied with blood
  • Naturally acidic
  • Populated by protective Lactobacillus bacteria
  • More resistant to irritation and infection

When oestrogen levels fall, most commonly during perimenopause and after menopause, the vaginal lining becomes thinner, drier and less elastic. The vaginal pH rises and the protective bacterial balance changes.

Similar changes can occur after removal of the ovaries, during breastfeeding, or following some treatments for breast or gynaecological cancer.

What symptoms can vaginal atrophy cause?

Symptoms vary considerably and may include:

Vaginal and vulval symptoms

  • Dryness, burning or irritation
  • Itching or tenderness
  • Discomfort when sitting, walking or exercising
  • Pain during or after intercourse
  • Light bleeding following intercourse
  • Reduced lubrication or altered sexual sensation

Bladder and urinary symptoms

  • Urinary urgency
  • Passing urine more frequently
  • Waking at night to urinate
  • Burning or stinging when passing urine
  • Recurrent urinary tract infections
  • Urge incontinence
  • Worsening stress urinary incontinence in some women

These symptoms can overlap with infection, overactive bladder, pelvic-floor dysfunction, skin disorders and, occasionally, more serious conditions. Persistent or recurrent symptoms should therefore be properly assessed rather than repeatedly treated with antibiotics without confirmation.

Why can vaginal atrophy increase urinary infections?

The vagina, urethra and bladder are closely connected anatomically and hormonally.

After menopause, loss of protective vaginal bacteria and an increase in vaginal pH may make it easier for bowel bacteria, particularly E. coli, to colonise the vaginal opening and enter the urinary tract. Thinning around the urethra may further reduce its natural defence against infection.

Low-dose vaginal oestrogen can help restore healthier tissue and a more protective vaginal environment. For appropriately selected peri- and postmenopausal women with recurrent urinary tract infections, it can reduce the likelihood of further infections.

However, not every episode of burning or urgency is a UTI. Whenever practical, recurrent episodes should be confirmed with a midstream urine culture before antibiotics are prescribed.

How does vaginal atrophy affect continence?

Oestrogen-sensitive tissue is present around the urethra, bladder neck, vagina and pelvic floor. Oestrogen deficiency may contribute to:

  • Increased bladder sensitivity
  • Sudden urgency
  • Increased urinary frequency
  • Urge-related leakage
  • Urethral irritation
  • Reduced tissue support around the urethra

Treating GSM may improve urgency, frequency, discomfort and recurrent infection. Some women also report improved continence.

Vaginal oestrogen is not, however, a complete treatment for all urinary leakage. Stress incontinence: leakage with coughing, laughing, exercise or lifting, often requires pelvic-floor physiotherapy and sometimes additional medical or surgical management.

How is GSM assessed?

Assessment may include:

  • A careful symptom and medical history
  • Medication review
  • Pelvic examination
  • Urine testing and culture
  • Bladder diary
  • Assessment of pelvic-floor function
  • Measurement of residual urine after voiding
  • Evaluation for prolapse, skin conditions or urethral abnormalities

Further tests such as ultrasound, cystoscopy or urodynamic studies are not required for every woman. They may be recommended when symptoms are complicated, recurrent, associated with blood in the urine, or not responding as expected.

Any postmenopausal bleeding, unexplained blood-stained discharge, visible blood in the urine, pelvic mass, ulcer or persistent vulval lesion requires prompt assessment.

Management options

Treatment should be individualised according to the symptoms, examination findings, medical history and personal preferences.

Vaginal moisturisers

A vaginal moisturiser is used regularly, often several times per week, to improve ongoing hydration. It is different from a lubricant and may be sufficient for mild symptoms.

Avoid perfumed products, douches and harsh soaps, which can worsen irritation.

Lubricants

Water- or silicone-based lubricants can reduce friction during sexual activity. These provide short-term relief but do not reverse the underlying tissue changes.

Pelvic-floor physiotherapy

Pelvic-floor physiotherapy may assist women with:

  • Stress or urge incontinence
  • Pelvic-floor weakness
  • Pelvic-floor overactivity or pain
  • Painful intercourse
  • Difficulty coordinating bladder control

Importantly, more squeezing is not always better. Some women have an overactive or painful pelvic floor and need relaxation and coordination work rather than simply stronger contractions.

Bladder-directed treatment

Persistent overactive-bladder symptoms may require bladder training, fluid and caffeine modification, medication, intravesical Botox or sacral neuromodulation. Stress incontinence may require additional treatments ranging from supervised physiotherapy to bulking injections or surgery.

Topical vaginal oestrogen: what role does it play?

Low-dose vaginal oestrogen is one of the most effective treatments for moderate or persistent GSM. It is available in different preparations, including vaginal cream, tablets or pessaries.

It acts mainly within the vagina and surrounding urinary tissues. Treatment may:

  • Improve dryness, burning and irritation
  • Restore tissue thickness and elasticity
  • Reduce pain during intercourse
  • Improve urethral discomfort
  • Reduce urinary urgency and frequency in some women
  • Lower the risk of recurrent UTIs
  • Complement other treatments for bladder symptoms

Treatment commonly begins with a short loading phase followed by a lower-frequency maintenance schedule. The exact regimen depends on the product prescribed. Improvement may begin within several weeks, but the full benefit can take several months.

Because GSM is usually ongoing, symptoms commonly return when treatment is stopped.

Is topical vaginal oestrogen safe?

For most women, low-dose vaginal oestrogen has minimal absorption into the bloodstream and has a substantially different risk profile from systemic menopausal hormone therapy.

At standard low doses:

  • A progestogen is generally not required solely to protect the uterus.
  • It has not been shown to carry the same blood-clot risk as oral systemic oestrogen.
  • Long-term treatment can be considered when symptoms persist, with periodic clinical review.

Possible adverse effects include local irritation, discharge, breast tenderness or spotting, although these are uncommon.

Unexpected postmenopausal bleeding should never simply be attributed to the oestrogen. It requires investigation.

What if I have had breast cancer?

This requires an individual discussion.

Non-hormonal treatments are usually considered first. If symptoms remain troublesome, low-dose vaginal oestrogen may sometimes be considered after shared decision-making with the patient’s treating team. Particular caution is required for women taking an aromatase inhibitor, because even small changes in circulating oestrogen may be clinically important.

Women should not stop cancer medication or commence vaginal hormones without discussing this with their oncologist, breast surgeon, GP or menopause specialist. Current specialist guidance recognises that low-dose vaginal oestrogen may be reasonable for selected women when non-hormonal measures have failed, but the decision must be personalised.

MonaLisa Touch laser therapy—and why it remains controversial

MonaLisa Touch is a branded fractional carbon-dioxide laser treatment applied inside the vagina. The laser delivers controlled thermal energy to the vaginal lining with the aim of stimulating healing, collagen formation and tissue remodelling.

It is commonly promoted as a “non-hormonal” treatment for vaginal dryness, burning, painful intercourse and some urinary symptoms. A course generally involves several treatments followed by possible maintenance sessions.

Although some women report improvement, vaginal laser therapy remains controversial.

Why has it become popular?

Vaginal laser treatment may appeal to women who:

  • Prefer not to use vaginal oestrogen
  • Have not improved with moisturisers or lubricants
  • Have concerns about hormone treatment
  • Have experienced symptoms following breast-cancer treatment
  • Prefer a procedure rather than ongoing medication

Early uncontrolled studies reported encouraging improvements. However, uncontrolled studies cannot reliably separate the true treatment effect from placebo response, increased clinical attention, lubricants used during treatment or natural variation in symptoms.

The gap between marketing and evidence

The greatest controversy is the difference between strong commercial claims and the quality of the supporting clinical evidence.

Some clinics advertise vaginal laser therapy as “rejuvenation” or suggest it can restore vaginal tissue, improve sexual function, prevent infections and treat urinary incontinence. These claims are broader than the available evidence supports.

More rigorous randomised studies, particularly those comparing laser treatment with a sham procedure, have not consistently shown a clinically meaningful benefit. The 2025 joint AUA/SUFU/AUGS guideline concluded that fractional CO₂ laser may produce little or no difference in several GSM symptoms compared with sham treatment or vaginal oestrogen. AUA/SUFU/AUGS guideline

The RACGP also notes that the long-term effectiveness and safety of vaginal laser therapy have not been established.

Regulatory concerns

Regulators have raised concerns about energy-based vaginal treatments being promoted for indications that have not been adequately supported by clinical evidence.

A device being legally supplied or registered for a particular use does not necessarily mean that every advertised claim, such as treating incontinence, preventing UTIs or providing “vaginal rejuvenation”, has been independently proven.

Regulatory reviews in Australia and warnings internationally have focused on:

  • Insufficient high-quality evidence of effectiveness
  • Lack of reliable long-term safety information
  • Promotion extending beyond authorised indications
  • The possibility of women being exposed to an expensive procedure before established treatments have been tried

Patients should be cautious about phrases such as “TGA approved.” Inclusion of a device on the Australian Register of Therapeutic Goods does not amount to endorsement of every clinical or advertising claim.

Possible complications

Vaginal laser is often described as painless or risk-free, but possible adverse effects include:

  • Burning or prolonged irritation
  • Vaginal pain
  • Bleeding or discharge
  • Infection
  • Pain during intercourse
  • Urinary discomfort
  • Tissue burns
  • Scarring or narrowing of the vagina
  • Persistence or worsening of the original symptoms

The true frequency of uncommon or delayed complications is uncertain because long-term data remain limited.

Does it treat urinary incontinence or prevent UTIs?

Evidence that vaginal laser reliably treats urinary incontinence is insufficient. Small studies have reported improvements, but many lacked sham controls, had short follow-up or used subjective outcomes.

It should not be presented as an established treatment for stress urinary incontinence, overactive bladder or recurrent UTIs. These conditions require an accurate diagnosis and may respond to better-supported treatments such as:

  • Pelvic-floor physiotherapy
  • Bladder training
  • Low-dose vaginal oestrogen
  • Overactive-bladder medication
  • Continence procedures or surgery
  • UTI-prevention strategies based on urine-culture results

What about women who cannot use oestrogen?

Vaginal laser is sometimes marketed directly to breast-cancer survivors. This is particularly controversial because these women may be vulnerable to claims that a costly procedure is their only non-hormonal option.

Non-hormonal moisturisers, lubricants, pelvic-floor therapy and multidisciplinary care should be considered first. Selected women with a history of breast cancer may also be able to use low-dose vaginal oestrogen after shared decision-making with their oncologist and treating specialists.

Laser should not automatically be assumed to be safer simply because it is “non-hormonal.” Hormonal exposure is avoided, but procedural risks and uncertainty about long-term effects remain.

Cost and conflicts of interest

Vaginal laser therapy is generally privately funded and may require an initial treatment course followed by maintenance sessions. Patients should be told the total likely cost and the possibility that any improvement may be temporary.

Some published studies have had small sample sizes, limited follow-up or connections with device manufacturers. This does not automatically invalidate the findings, but it reinforces the need for independent, sham-controlled and long-term research.

The UGSA and USANZ perspective

The Urogynaecological Society of Australasia (UGSA) and the Urological Society of Australia and New Zealand (USANZ) support evidence-based assessment and management of pelvic-floor and urinary disorders.

At the time of writing, publicly accessible UGSA or USANZ guideline specifically endorsing MonaLisa Touch for GSM, recurrent UTIs or urinary incontinence could not be found. The treatment should therefore not be described as endorsed by either organisation.

A balanced conclusion

Some women report meaningful improvement after MonaLisa Touch treatment, and research into vaginal energy-based therapy is continuing. These experiences should not be dismissed. However, individual improvement does not establish that the treatment is consistently effective, superior to placebo or safe over many years.

At present, MonaLisa Touch should not be considered first-line treatment for GSM, urinary incontinence or recurrent UTIs. If it is being considered, patients should receive balanced counselling that includes:

  • The limited and conflicting evidence
  • The absence of reliable long-term safety data
  • Possible adverse effects
  • Treatment costs and likely maintenance requirements
  • Established alternatives, particularly low-dose vaginal oestrogen
  • The clinician’s experience and any financial relationship with the device provider

Ideally, treatment should be provided by an appropriately trained medical practitioner following a proper pelvic and urinary assessment, with clear consent and structured follow-up. Participation in a well-designed clinical trial is preferable where available.

When should you seek medical advice?

Please arrange an assessment if you have:

  • Recurrent or persistent UTI symptoms
  • Blood in the urine
  • Postmenopausal vaginal bleeding
  • New or worsening urinary leakage
  • Difficulty emptying the bladder
  • Persistent vaginal, vulval or pelvic pain
  • Pain during intercourse
  • A lump, ulcer or skin change
  • Symptoms that have not improved with simple measures

The take-home message

Vaginal atrophy is better understood as genitourinary syndrome of menopause because it can affect the vagina, urethra, bladder, continence and susceptibility to infection.

Low-dose vaginal oestrogen is an effective and generally safe treatment for most women and can be particularly valuable for recurrent UTIs and urinary symptoms associated with menopause. Women with previous hormone-sensitive cancer require individualised advice.

MonaLisa Touch and similar vaginal laser therapies remain less well supported. Their long-term benefits and safety are uncertain, and they should not replace proper assessment or established treatments.

This information is general and does not replace individual medical advice. Treatment should be selected after discussion with your GP, urologist, urogynaecologist, gynaecologist or menopause specialist.

So, if your menopause is driving your bladder symptoms, ask for a review with your local urogynaecologist or come chat to your functional urologist in Brisbane, Dr Jo Schoeman

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Bridge to Brisbane 2026: Running in Blue for Prostate Cancer

On Sunday, 13 September 2026, Brisbane will once again come alive with runners, walkers, families, friends and more than a few wonderfully questionable costumes for the annual Bridge to Brisbane.

This year’s event includes the RBWH Foundation Blue Run 5 km, raising awareness and support for prostate cancer research and care. Participants are encouraged to turn the course blue—whether that means blue shirts, blue socks or the increasingly popular blue skirts and tutus.

The blue skirts may attract a smile, but the message behind them is serious: men’s health deserves to be seen, discussed and supported.

Why run in blue?

Blue is widely recognised as the colour of prostate cancer awareness. Wearing blue creates a visible show of support for men diagnosed with prostate cancer, those undergoing treatment, survivors and the families who travel the journey beside them.

Prostate cancer remains the most commonly diagnosed cancer among Australian men. It can often develop without causing obvious symptoms, particularly in its early stages. Community events such as the Blue Run help bring prostate health into everyday conversation and encourage men to learn about their individual risk.

The blue skirt also carries a distinctly Australian message: we can address an important issue without losing our sense of humour. If pulling on a tutu prompts one man to discuss prostate cancer with his brother, friend or doctor, it has done something worthwhile.

More than a fun run

Bridge to Brisbane enables participants to raise funds for causes that matter to them. Through the RBWH Foundation Blue Run, the community can help support prostate cancer research, clinical care and greater awareness of early detection.

Funds raised for medical research can contribute to:

  • Better methods of identifying significant prostate cancer
  • Improvements in surgery, radiation therapy and medical treatment
  • Research into advanced and metastatic prostate cancer
  • Better management of treatment-related urinary and sexual side effects
  • Support for patients and their families

The Blue Run is therefore not simply about reaching the finish line. Every registration, donation and conversation can help improve the outlook for men affected by prostate cancer. Information about joining or supporting the event is available through the RBWH Foundation and the official Bridge to Brisbane website.

The health benefits of a fun run

You do not have to be an elite runner to benefit. Preparing for a 5 km or 10 km event can provide a realistic goal and a reason to exercise more consistently.

Regular walking, jogging or running may help to:

  • Improve cardiovascular and lung fitness
  • Assist with weight, blood pressure and blood-sugar control
  • Strengthen muscles and bones
  • Improve balance, mobility and physical confidence
  • Reduce stress and improve sleep
  • Support mood and mental wellbeing
  • Maintain independence as we grow older
  • Create valuable social connection

For men living with or recovering from prostate cancer, appropriately prescribed exercise can also help maintain strength, fitness and quality of life. It may be particularly valuable for men receiving androgen-deprivation therapy, which can contribute to fatigue, muscle loss, weight gain and reduced bone density.

Exercise is not a substitute for prostate cancer assessment or treatment, but it is an important part of looking after the whole person.

You may walk—it still counts

The word “run” should not frighten anyone away. Bridge to Brisbane can be approached as a run, jog, walk or a cheerful combination of all three.

A simple preparation program might begin with:

  1. Three comfortable walks each week.
  2. Gradually increasing the time or distance.
  3. Introducing short jogging intervals if appropriate.
  4. Including two weekly sessions of light strength training.
  5. Allowing rest days and increasing activity gradually.

Supportive footwear, hydration and sun protection are important. Anyone with chest pain, unexplained breathlessness, dizziness, significant joint problems or an unstable medical condition should speak with their GP before commencing vigorous exercise.

Men undergoing prostate cancer treatment should seek individual guidance from their treating team or an accredited exercise physiologist.

A different kind of men’s health check

A fun run is not a prostate cancer screening test—but it can start an important conversation.

Men should discuss their prostate cancer risk and the potential benefits and limitations of PSA testing with their GP, particularly if they have a father, brother or son diagnosed with the disease. Aboriginal and Torres Strait Islander men and men with a strong family history may also benefit from an earlier, individualised discussion.

A blue skirt cannot diagnose prostate cancer. It can, however, make the subject difficult to ignore.

My Bridge to Brisbane journey

For me Bridge to Brisbane is more than a single morning of exercise. I participated in the 10 km event in previous 5 years, joining thousands of Queenslanders crossing the Gateway Bridge in support of fitness, community spirit and charitable causes.

Each run has brought its own combination of early-morning nerves, Brisbane sunshine, tired legs and the satisfaction of reaching the finish line. I aim for a sub-50 min each year.

Although achieving a personal best is rewarding, I believe the greater value of the event lies in simply taking part. And for me, having my family participate with me is GOLD. Training provides a reason to remain active, while race day brings people together around important causes—including prostate cancer awareness, research and patient care.

As a urological surgeon, I have seen how prostate cancer can affect not only a man’s physical health but also his continence, sexual function, emotional wellbeing and family life. Running the 10 km course is therefore both a personal challenge and an opportunity to encourage men to pay attention to their health.

The 2026 Blue Run adds special meaning to that involvement. Wearing blue—and perhaps even a blue skirt or tutu—helps turn a private men’s health issue into a visible community conversation. The time on the clock matters, but helping another man think about his prostate health matters even more.

Crossing the bridge together

Prostate cancer affects more than the prostate. It can influence continence, sexual function, relationships, emotional wellbeing and a man’s sense of identity. It also affects partners, children, friends and caregivers.

Bridge to Brisbane reminds us that health challenges are easier to face when we do not face them alone.

So, lace up your shoes, gather your family or mates and add something blue. Walk if you wish, run if you can—and wear the blue skirt with pride.

The finish-line photograph may not be dignified, but the reason behind it certainly is.

Looking forward to seeing many Blue-Skirts!

This article provides general health information and does not replace individual medical advice. Speak with your GP or urologist about prostate symptoms, PSA testing or your personal prostate cancer risk.

Prostate Abscess: A Rare but Serious Infection

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A prostate abscess is a collection of pus within the prostate gland. It usually develops as a complication of acute bacterial prostatitis when infection progresses despite treatment or when treatment has been delayed.

Prostate abscesses are uncommon, but they can become life-threatening if the infection spreads into the bloodstream. Early diagnosis, intravenous antibiotics and, when necessary, drainage of the abscess are essential.

What causes a prostate abscess?

Most prostate abscesses develop when bacteria enter the prostate from the urinary tract. The infection may begin in the bladder or urethra and travel backwards through the prostatic ducts.

Common bacteria include:

  • Escherichia coli
  • Klebsiella species
  • Pseudomonas species
  • Proteus species
  • Enterococcus species
  • Staphylococcus aureus, including resistant strains such as MRSA

Less commonly, bacteria reach the prostate through the bloodstream from an infection elsewhere in the body. Fungal and tuberculosis-related abscesses are rare but may occur in people with significant immune suppression.

Who is at increased risk?

A prostate abscess is more likely to develop in men with:

  • Diabetes, particularly when blood glucose is poorly controlled
  • A weakened immune system
  • Long-term corticosteroid or immunosuppressive treatment
  • HIV or another significant immune disorder
  • Difficulty emptying the bladder
  • Benign prostate enlargement
  • A urethral stricture
  • A long-term urinary catheter
  • Recent urinary tract instrumentation
  • Recent prostate biopsy or prostate surgery
  • Recurrent urinary tract infections
  • Chronic kidney disease or dialysis
  • Intravenous drug use
  • Acute bacterial prostatitis that is not improving with appropriate antibiotics

Diabetes is one of the most frequently identified risk factors. High blood glucose can impair the immune response and make infection more difficult to control.

How does a prostate abscess present?

The symptoms often resemble acute prostatitis or a severe urinary tract infection. A man may experience:

  • Fever, chills or shaking
  • Pain or burning when passing urine
  • Frequent or urgent urination
  • Difficulty starting or maintaining the urinary stream
  • Inability to pass urine
  • Pain in the pelvis, perineum, groin or lower back
  • Painful ejaculation
  • Blood in the urine
  • Cloudy or unpleasant-smelling urine
  • General weakness, nausea or confusion

On examination, the prostate may be enlarged, tender or feel unusually soft or fluctuant. However, the absence of a typical prostate examination does not exclude an abscess.

Forceful prostate massage should be avoided in someone with acute prostatitis or a suspected abscess because it may push bacteria into the bloodstream.

When should a prostate abscess be suspected?

A prostate abscess should be considered when a patient with acute prostatitis:

  • Remains febrile after approximately 48–72 hours of appropriate antibiotics
  • Becomes more unwell despite treatment
  • Develops urinary retention
  • Has persistent pelvic or perineal pain
  • Has recurrent infection with the same organism
  • Has diabetes, immune suppression or another major risk factor

Symptoms alone cannot reliably distinguish an abscess from uncomplicated prostatitis. Imaging is usually needed to confirm the diagnosis.

How is it diagnosed?

Initial investigations may include:

  • Urine microscopy and culture
  • Blood cultures, preferably before antibiotics when this does not delay treatment
  • Full blood count
  • Kidney function and electrolyte tests
  • Inflammatory markers
  • Blood glucose testing
  • Blood lactate and other sepsis investigations when the patient is seriously unwell

Imaging may be performed using:

Transrectal ultrasound

Transrectal ultrasound can demonstrate one or more fluid-filled cavities within the prostate. It can also be used to guide needle drainage.

CT scan

A CT scan of the pelvis is particularly useful when the patient is very unwell or when infection may have spread beyond the prostate. It can also identify urinary obstruction, stones or another source of infection.

MRI

MRI provides detailed images of the prostate and surrounding tissues. It may be helpful when ultrasound or CT findings are unclear, but it is not always the most practical first investigation in an emergency.

Is a prostate abscess an emergency?

A prostate abscess can lead to bloodstream infection, sepsis and septic shock. Patients with fever, shaking chills, confusion, low blood pressure, rapid breathing, severe weakness or inability to pass urine require urgent hospital assessment.

Emergency management may involve:

  • Immediate assessment for sepsis
  • Blood and urine cultures
  • Intravenous fluids
  • Prompt intravenous antibiotics
  • Pain relief
  • Monitoring of blood pressure, urine output and kidney function
  • Treatment of uncontrolled diabetes
  • Urgent urinary drainage if the bladder cannot empty
  • Early consultation with a urologist and, when appropriate, an infectious diseases physician

Antibiotics should not be delayed in a patient who is septic while waiting for scans or culture results.

If urinary retention is present, bladder drainage is required. A urethral catheter may sometimes be used carefully, but a suprapubic catheter inserted through the lower abdomen may be preferred when urethral catheterisation is difficult or likely to cause significant prostate irritation. The best approach depends on the patient’s condition and anatomy.

Treatment with antibiotics

All prostate abscesses require antibiotic treatment.

A patient who is systemically unwell will usually begin treatment with broad-spectrum intravenous antibiotics. The initial antibiotic choice depends on:

  • The likely source of infection
  • Local bacterial resistance patterns
  • Previous urine culture results
  • Recent hospital admission or antibiotic exposure
  • Recent catheterisation or urinary surgery
  • Kidney function
  • Drug allergies
  • The possibility of resistant bacteria or Staphylococcus aureus

Once culture results become available, treatment can be narrowed to an antibiotic that targets the identified organism and penetrates prostate tissue effectively.

After clear clinical improvement, intravenous treatment may be changed to an appropriate oral antibiotic. Treatment is usually longer than for a simple bladder infection and commonly continues for several weeks. The exact duration depends on the organism, abscess size, success of drainage, immune status and response to treatment.

Follow-up urine cultures and repeat imaging may be required to confirm that the infection and abscess have resolved.

Can antibiotics alone cure a prostate abscess?

Occasionally, a small abscess in a clinically stable patient can be treated with antibiotics and close observation. This is more likely to succeed when the collection is small, often less than approximately 1 cm, and drains naturally into the prostatic ducts.

There is no single size threshold that applies to every patient. Larger, multiloculated or persistent abscesses are less likely to resolve with antibiotics alone.

Drainage should be considered when:

  • The patient is septic or clinically deteriorating
  • Fever persists despite appropriate antibiotics
  • The abscess is relatively large
  • There are several abscess cavities
  • The abscess is not shrinking on repeat imaging
  • Urinary obstruction is present
  • The infecting organism is difficult to eradicate
  • The patient has diabetes or significant immune suppression
  • The infection repeatedly returns

Current European guidance recognises that both conservative treatment and drainage may be appropriate in selected patients, with abscess size and clinical response helping to guide the decision. EAU Guidelines on Urological Infections

How is a prostate abscess drained?

Several drainage techniques are available. The method chosen depends on the size and position of the abscess, whether it has multiple compartments, the patient’s condition and local expertise.

Transrectal ultrasound-guided aspiration

A needle is passed through the rectum into the abscess under ultrasound guidance, and the pus is aspirated.

Advantages include:

  • Minimally invasive treatment
  • Usually limited anaesthesia
  • Collection of pus for culture

However, the abscess may refill, particularly if it is large, thick-walled or divided into several compartments. Repeat aspiration may be needed.

Transperineal drainage

A needle or drain is inserted through the skin between the scrotum and anus under ultrasound or imaging guidance.

This approach avoids passing through the rectal wall and may allow a drainage catheter to remain temporarily. It can be useful for appropriately positioned abscesses or when repeated drainage is anticipated.

Transurethral drainage

A telescope is passed through the urethra, and the abscess cavity is opened internally so that it can drain into the urinary channel. This may be performed by incision, deroofing or limited resection of the involved prostate tissue.

Transurethral drainage is often considered when:

  • The abscess is large
  • There are multiple or deep cavities
  • Needle aspiration has failed
  • The abscess has recurred
  • Prostate enlargement is contributing to obstruction
  • Rapid and complete drainage is required

Possible complications include bleeding, urinary infection, temporary worsening of urinary symptoms, retrograde ejaculation, urethral stricture and, less commonly, urinary incontinence or injury to surrounding structures.

Open or laparoscopic surgery

Open, laparoscopic or robotic drainage is rarely required. It may be considered if the abscess extends outside the prostate, cannot be reached by less invasive methods or is associated with another condition requiring surgery.

Antibiotics plus effective drainage remain the central principles of treatment. Management of prostate abscess in the absence of guidelines and MSD Manual: Prostate Abscess

What happens after drainage?

The drained fluid is sent for microbiological testing. This is important because the organism within the abscess may differ from that found in the urine.

Following drainage, the patient usually continues antibiotics. Clinical improvement is monitored by checking:

  • Temperature and general wellbeing
  • Pain and urinary symptoms
  • White blood cell count and inflammatory markers
  • Kidney function
  • Blood glucose in patients with diabetes
  • Urine and blood culture results
  • Follow-up ultrasound, CT or MRI when indicated

Any contributing problem, such as bladder obstruction, a urethral stricture, a catheter or poorly controlled diabetes, should also be addressed to reduce the risk of recurrence.

What is the outlook?

With early recognition, appropriate antibiotics and adequate drainage, most prostate abscesses can be successfully treated.

Delayed treatment may result in:

  • Sepsis or septic shock
  • Spread of infection beyond the prostate
  • Fistula formation into nearby structures
  • Recurrent urinary infection
  • Chronic pelvic discomfort
  • Prolonged difficulty passing urine
  • Rarely, death from overwhelming infection

A prostate abscess should therefore be regarded as a potentially serious complication of prostatitis rather than an ordinary urinary infection.

When should you seek urgent medical attention?

Attend an emergency department urgently if you develop:

  • Fever or shaking chills with urinary symptoms
  • Confusion, faintness or severe weakness
  • Inability to pass urine
  • Severe pelvic or perineal pain
  • Rapid breathing or a racing heartbeat
  • Persistent fever despite antibiotics
  • Worsening symptoms after treatment for prostatitis

Early assessment is particularly important for men with diabetes, immune suppression, a urinary catheter or recent urinary tract surgery.

This information is intended for general education and does not replace individual medical assessment. A suspected prostate abscess requires urgent assessment by a medical practitioner and usually early involvement of a urologist.

So, if this is happening to you, attend your local Emergency Department ASAP, or if you are still OK, ask your GP for an urgent referral to see your local Brisbane Urologist Dr Jo Schoeman ASAP

‘Bag-of-Worms” Varicocele: Causes, Symptoms, Fertility and Treatment Options

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A varicocele is an enlargement of the veins surrounding the testicle. It is similar to a varicose vein in the leg, although it occurs within the scrotum.

Varicoceles are common and often harmless. However, in some men they may cause discomfort, reduce the size or function of the affected testicle, or contribute to fertility problems. Most varicoceles do not require treatment, and the decision to intervene depends on symptoms, testicular development, semen quality and plans for future fertility.

What causes a varicocele?

Blood leaves each testicle through a network of small veins called the pampiniform plexus. These veins normally carry blood upwards towards larger veins in the abdomen.

A varicocele develops when blood pools within these veins. This is usually related to poorly functioning venous valves, together with the anatomy and pressure within the testicular veins.

Around 80–90% of clinically detected varicoceles occur on the left side. This is because the left testicular vein is longer and enters the left renal vein at a right angle, making venous drainage less efficient. A varicocele may occur on both sides, while an isolated right-sided varicocele is much less common.

Most varicoceles develop gradually during puberty and have no dangerous underlying cause.

A new varicocele in an older man, particularly one that is right-sided, develops suddenly or does not disappear when lying down, may require abdominal imaging to exclude obstruction of the vein by an abdominal or retroperitoneal condition. This is uncommon but important to recognise.

How common are varicoceles?

A varicocele is found in approximately 15% of adolescent and adult men. Many men never know that they have one.

Varicoceles are more frequently identified among men being investigated for infertility. They may be present in approximately:

  • 35–40% of men with primary infertility
  • Up to 70–80% of men with secondary infertility, where a previous pregnancy has occurred, but the couple is now having difficulty conceiving

Importantly, most men with a varicocele remain fertile. Finding a varicocele does not automatically mean that it is causing infertility.

What are the symptoms?

Many varicoceles cause no symptoms and are discovered during a routine examination, fertility assessment or scrotal ultrasound.

When symptoms occur, they may include:

  • A dull ache, dragging sensation or heaviness in the scrotum
  • Discomfort that becomes worse after standing, exercising or later in the day
  • Improvement in discomfort when lying down
  • Visible or enlarged veins above the testicle
  • A soft swelling sometimes described as feeling like a “bag of worms”
  • Reduced size or slower growth of the affected testicle
  • Abnormal semen-analysis results
  • Difficulty conceiving with a partner

A varicocele generally does not cause erectile dysfunction or difficulty urinating. Its relationship with testosterone production remains under investigation, although some men with a clinically significant varicocele may have impaired testicular function.

Sudden severe testicular pain is not typical of a varicocele and requires urgent medical assessment to exclude testicular torsion or another acute scrotal condition. An abdominal ultrasound is also required to exclude a possible lesion in the abdomen obstructing the veins.

How is a varicocele diagnosed?

Diagnosis usually begins with a physical examination. The scrotum is examined while the patient is standing and lying down. You may be asked to take a breath and gently bear down, the Valsalva manoeuvre, to make enlarged veins easier to feel.

Clinical varicoceles are commonly graded as:

  • Grade 1: Felt only during the Valsalva manoeuvre
  • Grade 2: Felt while standing without straining
  • Grade 3: Easily visible through the scrotal skin

A scrotal ultrasound may be recommended if the examination is uncertain, the testicles differ in size, pain is present, or another scrotal problem needs to be excluded. Ultrasound can measure the veins, assess backward blood flow and examine the testicles.

For fertility assessment, investigations may include:

  • One or more semen analyses
  • Testicular volume measurement
  • Hormone tests when indicated
  • Assessment of both partners, because fertility is a shared consideration

An ultrasound-only or “subclinical” varicocele that cannot be felt on examination is not usually treated for infertility.

How can a varicocele affect fertility?

The testicles work best at a temperature slightly below core body temperature. The pampiniform veins help cool the arterial blood entering the testicle.

Pooling of warm blood in a varicocele may interfere with this cooling system. Increased temperature, venous pressure, oxidative stress and altered blood flow may affect sperm production and testicular function.

Possible semen changes include:

  • Reduced sperm concentration
  • Reduced sperm movement or motility
  • Increased abnormal sperm forms
  • Increased sperm DNA damage

The degree of impact varies considerably. A large varicocele can be associated with normal fertility, while a smaller palpable varicocele may be significant in another man. The diagnosis must therefore be interpreted together with semen results, the couple’s fertility history, the female partner’s age and other fertility factors.

Does every varicocele require treatment?

No. Observation is appropriate when a varicocele:

  • Causes no troublesome symptoms
  • Is not affecting testicular growth
  • Is associated with normal semen parameters
  • Is found incidentally on ultrasound but cannot be felt
  • Is unlikely to be the main cause of the couple’s fertility difficulty

Simple measures such as supportive underwear, avoiding activities that consistently aggravate discomfort and occasional appropriate pain relief may help mild symptoms. Regular review may be recommended for adolescents with a difference in testicular size.

When should treatment be considered?

Treatment may be considered when there is:

Infertility with abnormal semen parameters

Repair is most likely to benefit a couple when the man has:

  • A varicocele that can be felt on examination
  • Difficulty conceiving
  • One or more abnormal semen parameters
  • No better explanation for the infertility
  • A reasonable opportunity for natural conception following treatment

Both the AUA/ASRM and European guidance support considering repair in men attempting conception who have a palpable varicocele and abnormal semen parameters. Treatment is not routinely recommended for a varicocele detected only by ultrasound. AUA/ASRM male infertility guideline and EAU male infertility guideline

Persistent scrotal pain

Repair may be reasonable when typical varicocele-related discomfort persists despite conservative measures and other causes of scrotal pain have been excluded.

Reduced testicular growth in an adolescent

Treatment may be discussed if the affected testicle is persistently smaller, growth is impaired, the varicocele is large or semen parameters are abnormal in an appropriately selected older adolescent.

Progressive testicular dysfunction

Selected men with deteriorating semen quality or evidence of impaired testicular function may benefit from repair after individual assessment.

What treatment procedures are available?

Treatment works by blocking or dividing the abnormal veins. Blood then returns through healthy alternative veins while the testicular artery and lymphatic drainage are preserved.

Management option How it is performed Advantages Disadvantages and risks
Observation Clinical review, with semen analysis or testicular measurements when appropriate No procedure or anaesthetic; suitable for most asymptomatic men; avoids unnecessary treatment Does not correct the varicocele; symptoms or testicular changes may require future review
Conservative symptom management Scrotal support, activity modification and appropriate pain relief Simple and non-invasive; may adequately control mild discomfort Does not remove the varicocele or improve abnormal semen parameters; long-term anti-inflammatory medication may not be suitable for everyone
Microsurgical subinguinal varicocelectomy A small incision is made near the groin. An operating microscope helps identify and divide abnormal veins while protecting the testicular artery and lymphatics Usually the lowest recurrence and hydrocele rates; no abdominal incision; effective for unilateral or bilateral disease; commonly preferred for fertility treatment Requires an anaesthetic and microsurgical expertise; temporary bruising, swelling or discomfort; uncommon risks include infection, recurrence, hydrocele or testicular artery injury
Microsurgical inguinal varicocelectomy Similar microsurgical repair through a slightly higher groin incision Good visualisation and low recurrence when performed microsurgically Requires opening the external oblique fascia; recovery may involve slightly more groin discomfort
Laparoscopic varicocelectomy Veins are clipped or divided through small abdominal keyhole incisions Both sides can be treated during the same procedure; useful in selected cases General anaesthetic; entry into the abdomen; generally higher hydrocele risk than lymphatic-sparing microsurgery; rare abdominal or vascular complications
Open high ligation The testicular vein is divided through an abdominal or groin incision without microsurgical magnification Established technique; may be effective where microsurgery is unavailable Higher recurrence and hydrocele rates than modern microsurgical repair; less precise preservation of small arteries and lymphatics
Radiological embolisation or sclerotherapy An interventional radiologist passes a catheter into the testicular vein and blocks it using coils, plugs or a sclerosant No surgical incision in the scrotum or groin; often performed with local anaesthesia or sedation; relatively quick recovery; useful for recurrence after surgery The vein cannot always be accessed; radiation and contrast exposure; recurrence or persistence may occur; coils can rarely migrate; availability depends on local expertise

How effective is treatment?

The results depend on why treatment is being performed, the technique used and whether other fertility or pain-related factors are present.

Improvement in semen quality

Following repair of a clinically significant varicocele, approximately 60–80% of appropriately selected men demonstrate improvement in at least one semen parameter. Improvement is not guaranteed, and some men show little or no measurable change.

Because sperm production takes approximately three months, semen analysis is usually repeated about three months after treatment and may be reassessed again at six months.

Pregnancy and fertility outcomes

Varicocele repair may increase the chance of natural pregnancy in selected infertile couples, but it does not guarantee conception. Studies commonly report spontaneous pregnancy in roughly 25–40% of couples after repair, although rates vary substantially according to female partner factors, duration of infertility, baseline semen quality and study design.

Treatment may also improve semen quality sufficiently to allow a couple to use a less invasive assisted-reproduction option. In other cases, IVF or intracytoplasmic sperm injection may still be required.

The couple’s overall fertility timeline is important. If the female partner has reduced ovarian reserve or advancing reproductive age, waiting several months for semen improvement may not be appropriate. Varicocele repair and assisted reproductive treatment should therefore be considered as part of a shared plan.

Relief of pain

When pain is typical of a varicocele, a dull ache or heaviness made worse by standing or activity, approximately 70–90% of appropriately selected men experience meaningful improvement after repair.

Surgery is less predictable when pain is sharp, constant or atypical, and pain may occasionally persist despite technically successful treatment.

Testicular growth

In adolescents with a persistently smaller affected testicle, repair may allow “catch-up” growth. Decisions should be based on repeated measurements rather than a single ultrasound result.

What are the possible complications?

Varicocele procedures are generally safe, but potential complications include:

  • Bruising, swelling or wound discomfort
  • Infection or bleeding
  • Persistence or recurrence of the varicocele
  • Hydrocele, caused by fluid collecting around the testicle
  • Ongoing or occasionally altered scrotal pain
  • Injury to the testicular artery, which is uncommon but potentially serious
  • Testicular shrinkage, which is rare
  • Anaesthetic complications
  • Technical failure, contrast reaction, radiation exposure or coil-related problems following embolisation

Using microsurgical magnification and preserving the lymphatic vessels usually reduces the risks of recurrence, hydrocele and arterial injury.

Recovery after varicocele repair

Most men return home on the day of treatment. Bruising, mild swelling and groin or scrotal discomfort are expected during the early recovery period.

Patients are commonly advised to:

  • Wear supportive underwear
  • Keep the wound clean and dry
  • Avoid heavy lifting and strenuous exercise for the period advised by the surgeon
  • Resume sexual activity when comfortable and medically cleared
  • Attend follow-up to assess healing and symptom improvement
  • Repeat semen analysis after approximately three months when fertility is the reason for treatment

Specific recovery instructions vary according to the procedure and the individual patient.

When should you seek medical advice?

Arrange a medical assessment if you notice:

  • A new lump or swelling in the scrotum
  • Persistent scrotal discomfort or heaviness
  • A difference in testicular size
  • Difficulty conceiving
  • A new right-sided varicocele
  • A swelling that remains when lying down

Seek urgent medical attention for sudden severe testicular pain, rapid swelling, nausea or a high-riding testicle. These features may indicate testicular torsion, which is an emergency.

The bottom line

A varicocele is common and, for most men, causes no significant harm. Treatment is not based on the ultrasound appearance alone. The most important considerations are symptoms, testicular development, semen quality and the couple’s overall fertility situation.

For men with persistent typical pain, impaired testicular growth or a palpable varicocele associated with infertility and abnormal semen parameters, treatment can be worthwhile. Microsurgical varicocelectomy generally offers the most favourable balance between effectiveness, recurrence and complication risk, while embolisation is an effective minimally invasive alternative in selected patients.

A consultation with a urologist allows the varicocele—and the patient rather than simply the scan—to be assessed before deciding whether observation, surgery or embolisation is the most appropriate approach.

This article provides general information and does not replace an individual medical assessment. Treatment recommendations depend on examination findings, semen results, symptoms, age and the fertility circumstances of both partners.

So, if this is something that you have found on your regular scrotal examinations, and you have concerns, come see your Brisbane urologist, Dr Jo Schoeman for advice.

Erectile Dysfunction: Causes, Assessment and Treatment Options

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Erectile dysfunction, often shortened to ED, is the persistent difficulty achieving or maintaining an erection firm enough for satisfactory sexual activity.

An occasional unreliable erection is common and may simply reflect tiredness, stress, excessive alcohol or relationship pressures. When the problem becomes persistent, however, it deserves proper assessment. ED can affect confidence, intimacy and relationships, but it is important to remember that it is a medical condition, not a personal failure, and effective treatment is available.

How does an erection normally occur?

An erection depends on several systems working together:

  • Sexual interest and stimulation in the brain
  • Healthy nerves carrying signals to the penis
  • Adequate blood flow into the erectile tissue
  • Relaxation of smooth muscle within the penis
  • Healthy hormone levels
  • Sufficient trapping of blood to maintain firmness

A problem at any point in this pathway can contribute to erectile dysfunction. Many men have more than one contributing factor.

How does erectile dysfunction present?

Men may notice:

  • Difficulty achieving an erection
  • An erection that is not sufficiently firm for penetration
  • Loss of firmness during sexual activity
  • Erections that are inconsistent or unpredictable
  • Reduced spontaneous or morning erections
  • A longer time or greater stimulation needed to become erect
  • Anxiety about sexual performance
  • Reduced sexual desire
  • Avoidance of intimacy because of embarrassment or fear of failure

ED does not necessarily mean that a man has lost his libido, ability to orgasm or ability to ejaculate. These are separate aspects of sexual function, although they may sometimes be affected by the same underlying condition.

What causes erectile dysfunction?

Blood-vessel and cardiovascular conditions

Because the penile arteries are relatively small, erectile difficulties can occasionally appear before more obvious symptoms of cardiovascular disease.

Associated conditions include:

  • High blood pressure
  • High cholesterol
  • Diabetes
  • Obesity
  • Smoking
  • Physical inactivity
  • Coronary artery disease
  • Peripheral vascular disease

For this reason, a new and persistent change in erections should not simply be dismissed as ageing. It can be an opportunity to identify and treat previously unrecognised cardiovascular risk factors.

Neurological causes

Normal erections require intact nerve pathways. ED may occur with:

  • Diabetic nerve damage
  • Multiple sclerosis
  • Parkinson’s disease
  • Spinal cord injury
  • Pelvic nerve injury
  • Previous stroke
  • Surgery involving the prostate, bladder or rectum

Hormonal and medical conditions

Low testosterone can contribute to reduced sexual desire and may sometimes worsen erections, although testosterone deficiency is not the cause of every case of ED.

Other relevant conditions include:

  • Pituitary or testicular disorders
  • Thyroid disease
  • Chronic kidney or liver disease
  • Obstructive sleep apnoea
  • Peyronie’s disease
  • Chronic pelvic pain

Medication-related erectile dysfunction

Medicines that can sometimes contribute include:

  • Some antidepressants
  • Certain blood-pressure medicines
  • Anti-androgen treatments
  • Some prostate medications
  • Opioid pain medicines
  • Certain antipsychotic medicines

Do not stop a prescribed medicine without first discussing it with your doctor. In many cases, an alternative medication or dose adjustment may be possible.

Psychological and relationship factors

The mind is an important part of the erection pathway. Stress, depression, anxiety, relationship tension and fear of sexual failure can all interfere with erections.

A common cycle can develop:

  1. An erection is lost on one occasion.
  2. The man worries that it will happen again.
  3. Attention shifts from pleasure to monitoring the erection.
  4. Anxiety increases and the erection becomes less reliable.

Psychological and physical causes frequently coexist. Describing ED as “psychological” does not mean that the symptoms are imaginary.

Lifestyle and situational factors

Other contributors include:

  • Excessive alcohol
  • Recreational drug use
  • Smoking or vaping nicotine
  • Poor sleep
  • Fatigue
  • Sedentary lifestyle
  • Weight gain
  • Relationship stress
  • Pornography-related arousal patterns in selected men

How is erectile dysfunction assessed?

Assessment begins with a private and respectful discussion about:

  • When the problem began
  • Whether it developed suddenly or gradually
  • The quality of morning and spontaneous erections
  • Sexual desire, ejaculation and orgasm
  • Current relationships and psychological wellbeing
  • Medical conditions and previous operations
  • Prescription medicines and supplements
  • Smoking, alcohol and recreational drugs
  • Previous treatments and their results

Examination may include blood pressure, weight, cardiovascular assessment, genital examination and evaluation of the prostate when appropriate.

Blood tests may include:

  • Fasting glucose or HbA1c
  • Cholesterol and triglycerides
  • An early-morning testosterone level
  • Additional hormone tests if testosterone is low
  • Kidney, liver or thyroid testing when clinically indicated

Specialised testing—such as penile Doppler ultrasound—is not required for every man but may be useful when the diagnosis is unclear, following pelvic trauma, before reconstructive treatment or when initial therapies have failed.

Lifestyle changes: treatment for the whole man

Lifestyle measures can improve erections while also reducing cardiovascular risk. Useful changes include:

  • Stopping smoking
  • Limiting excessive alcohol
  • Exercising regularly
  • Reducing abdominal weight
  • Improving sleep
  • Treating sleep apnoea
  • Optimising diabetes, cholesterol and blood pressure
  • Reviewing potentially contributing medications
  • Addressing stress, depression and relationship difficulties
  • Cutting out pornography

Pelvic-floor muscle training may help selected men, particularly after prostate surgery, provided the exercises are taught and performed correctly.

Lifestyle improvements may not completely reverse established nerve or vascular damage, but they make other treatments more effective and improve general health.

Oral medications available in Australia

Prescription phosphodiesterase type 5 inhibitors—usually called PDE5 inhibitors—are generally the first medication considered. They improve the natural erectile response by increasing blood flow to the penis.

Medicines available in Australia include:

  • Sildenafil: usually taken when required and has a relatively short duration of action.
  • Tadalafil: may be taken when required or as a lower daily dose. Its longer duration can provide greater spontaneity.
  • Vardenafil: another shorter-acting option taken before anticipated sexual activity.
  • Avanafil: a more rapid-onset PDE5 inhibitor that may be suitable for selected patients, subject to availability.

These medicines require sexual stimulation; they do not automatically cause an erection and are not treatments for low sexual desire.

Possible adverse effects include:

  • Headache
  • Facial flushing
  • Nasal congestion
  • Indigestion
  • Dizziness
  • Temporary visual disturbance, particularly with sildenafil
  • Muscle or back discomfort, particularly with tadalafil

PDE5 inhibitors must not be taken with nitrate medication used for angina. Combining them can cause a dangerous fall in blood pressure. Extra caution is necessary in men using certain alpha-blockers, those with unstable cardiovascular disease and those advised that sexual activity is medically unsafe.

A tablet should not be declared ineffective after one poorly timed attempt. The correct dose, timing, food intake, sexual stimulation and several properly conducted trials should be reviewed with the prescribing doctor.

Testosterone treatment

Testosterone replacement should only be considered when symptoms are accompanied by repeatedly confirmed low morning testosterone levels and an appropriate clinical assessment.

Giving testosterone to a man with normal levels is unlikely to correct ED and may cause harm. Treatment also requires consideration of fertility, prostate health, blood count, sleep apnoea and cardiovascular factors.

Vacuum erection devices

A vacuum erection device consists of a cylinder placed over the penis and a pump that creates negative pressure, drawing blood into the erectile tissue. A constriction ring is then placed around the base of the penis to maintain the erection.

Advantages include:

  • No systemic medication
  • Usefulness after prostate surgery
  • Suitability for some men who cannot take tablets
  • A non-surgical, reusable treatment

Possible disadvantages include bruising, numbness, discomfort, a cooler-feeling penis and an erection that may feel less natural. The constriction ring should generally not remain in place for longer than 30 minutes.

Penile injection therapy

When tablets are unsuitable or ineffective, medication can be injected directly into the side of the penis using a very fine needle. Alprostadil is a commonly used agent. Specialist-supervised compounded preparations may contain combinations of vasoactive medicines.

The injection relaxes penile smooth muscle and can produce a reliable erection independently of sexual stimulation. The dose must be carefully determined, and patients should receive hands-on instruction before using injections at home.

Potential complications include:

  • Penile discomfort
  • Bruising or bleeding
  • Scar tissue or curvature
  • An erection that is excessively prolonged
  • Priapism—an erection lasting four hours or more

An erection persisting for four hours is a medical emergency because delayed treatment can permanently damage the erectile tissue. Injection medication should never be sourced or used without appropriate medical supervision.

Intraurethral medication

Alprostadil can also be delivered into the urethra in certain formulations. It avoids a needle but may be less reliable than injection therapy and can cause urethral discomfort. Availability in Australia may vary.

Psychological and sex therapy

Counselling or psychosexual therapy can be very helpful when anxiety, depression, relationship difficulties or previous negative sexual experiences are contributing.

Therapy may be combined with medical treatment. Improving erectile reliability with medication can reduce anxiety, while therapy helps break the cycle of monitoring, fear and avoidance.

Low-intensity shockwave therapy

Low-intensity shockwave therapy has been promoted as a restorative treatment for men with blood-vessel-related ED. Some studies suggest benefit in carefully selected men with mild vasculogenic dysfunction, but protocols vary and long-term evidence remains less certain than for established treatments.

It should not be presented as a guaranteed cure. Patients considering it should discuss the evidence, cost and realistic likelihood of benefit with an appropriately qualified clinician.

Treatments marketed as “regenerative”—including platelet-rich plasma or stem-cell injections—remain inadequately established for routine treatment of ED and should be approached cautiously.

Penile implants

A penile prosthesis may be considered when other treatments have failed, are unsuitable or are unacceptable to the patient.

The two principal types are:

Inflatable penile prosthesis

Inflatable cylinders are placed inside the penis and connected to a pump positioned within the scrotum. Activating the pump transfers fluid into the cylinders to create a controlled erection.

Malleable penile prosthesis

Bendable rods are inserted into the penis. The penis is manually positioned for sexual activity and returned to a concealed position afterwards.

Penile implants provide a dependable erection and have high satisfaction rates among appropriately selected patients and partners. However, implantation is irreversible and carries surgical risks, including:

  • Infection
  • Bleeding
  • Pain
  • Mechanical failure
  • Device erosion
  • Injury to surrounding structures
  • The need for revision or replacement surgery

An implant creates rigidity but does not directly increase libido, restore penile sensation or guarantee orgasm. These functions depend on the man’s underlying health and nerve function.

The role of a men’s health physician

ED often benefits from a multidisciplinary approach involving the general practitioner, urologist, men’s health physician, endocrinologist, pelvic-floor physiotherapist or psychosexual therapist.

Dr Michael Gillman is a men’s health physician with a particular clinical interest in male sexual and reproductive health. His input may be valuable when ED occurs alongside hormonal concerns, reduced libido, ejaculation difficulties, fertility issues, complex medication factors or broader men’s health concerns. Collaboration between a men’s health physician and urologist allows medical, hormonal, psychological and surgical treatment options to be considered together.

When should you seek help?

Arrange a medical assessment if ED:

  • Persists or repeatedly interferes with sexual activity
  • Develops suddenly without an obvious explanation
  • Occurs with reduced libido, fatigue or other hormonal symptoms
  • Follows prostate or pelvic surgery
  • Is associated with penile pain or curvature
  • Is accompanied by cardiovascular risk factors
  • Causes anxiety, avoidance or relationship difficulties

Seek urgent medical care for an erection lasting four hours or longer. Chest pain or significant breathlessness during sexual activity also requires prompt medical assessment.

There is usually a way forward

Erectile dysfunction is common, but it should not automatically be accepted as an unavoidable part of ageing. It may provide an early warning of a broader health problem, and it can have a significant effect on both the patient and his partner.

Treatment is individualised. For some men, improving fitness, weight, sleep and cardiovascular health makes a substantial difference. Others benefit from tablets, a vacuum device, injection therapy, psychological support or a penile implant.

The most important first step is an honest conversation. If the first treatment does not work, that does not mean treatment has failed—there are several effective options to explore.

This information is general in nature and does not replace an individual medical consultation. Prescription medicines and injection therapies should only be used following assessment by an appropriately qualified healthcare professional.

Further information

So, if this is what you are suffering with, come see Dr Michael Gillman, consulting out of your local urologist’s rooms, Dr Jo Schoeman.

Conservative Management of a Distal Ureteric Stone: When Can You Wait and When Is Surgery Needed?

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A distal ureteric calculus is a stone located in the lower part of the ureter—the tube carrying urine from the kidney to the bladder. These stones are often close to the ureterovesical junction, where the ureter enters the bladder.

As the stone moves towards the bladder, it can cause severe intermittent pain known as renal colic. Pain commonly begins in the side or back and travels into the lower abdomen, groin, testicle or labia. Blood in the urine, nausea, vomiting, urinary urgency and frequency may also occur.

Many small distal ureteric stones pass naturally. However, conservative management is only safe when pain is controlled, infection is absent, kidney function is satisfactory and appropriate follow-up is arranged.

When is a ureteric stone an emergency?

A stone obstructing an infected kidney is a urological emergency. Antibiotics alone may be insufficient because infected urine cannot drain normally.

Seek urgent medical assessment if stone symptoms are accompanied by:

  • Fever or shaking chills
  • Feeling severely unwell, weak, confused or drowsy
  • Persistent vomiting or inability to drink
  • Pain that remains severe despite medication
  • Passing very little or no urine
  • Known poor kidney function
  • A solitary functioning kidney
  • Pregnancy with significant pain or fever

The obstructed kidney may need urgent drainage with a ureteric stent or nephrostomy tube. Definitive stone treatment is usually delayed until the infection has been controlled. The European Association of Urology recommends immediate antibiotics and urgent drainage for sepsis associated with an obstructing stone. EAU Guidelines on Urolithiasis

Australian Healthdirect similarly advises patients with renal colic and fever to attend a doctor or hospital emergency department promptly. Healthdirect Australia—Kidney stones

What determines whether a stone will pass naturally?

The likelihood of spontaneous passage depends mainly on:

  • Stone size
  • Position within the ureter
  • Degree of obstruction
  • Ureteric anatomy
  • Whether the stone is impacted
  • Previous stone history
  • Associated swelling and inflammation
  • The duration for which the stone has remained in the same position

Smaller stones located close to the bladder have the greatest likelihood of passing.

The EAU reports that distal ureteric stones collectively have a spontaneous passage rate of approximately 68–83%. A distal ureteric stone smaller than 5 mm has an estimated passage rate of approximately 89%. The likelihood decreases as stone size increases.

These percentages describe groups of patients and cannot predict exactly what will happen to an individual stone. A 4 mm stone may occasionally become impacted, while a larger stone may sometimes pass without surgery.

The average reported passage time is approximately 17 days, although passage can occur sooner or take several weeks. EAU Guidelines on Urolithiasis

Who may be suitable for conservative management?

Conservative management, also called observation, expectant management or a trial of passage, may be appropriate when:

  • The stone is small enough to have a reasonable chance of passing
  • The stone is in the distal ureter
  • Pain can be controlled with oral medication
  • There is no fever or evidence of urinary infection
  • Kidney function is stable
  • The patient can drink and keep medication down
  • There is no complete obstruction threatening kidney function
  • The patient is passing urine normally
  • There is no high-risk situation involving a solitary kidney or bilateral obstruction
  • The patient understands the warning symptoms
  • Follow-up and repeat imaging can be arranged
  • The patient is comfortable waiting for the stone to pass

Stones of 5 mm or less are particularly suitable for observation when no complications are present.

Selected distal stones between 5 and 10 mm may also be managed conservatively. These stones are less likely to pass than smaller stones, but some patients may avoid surgery with careful observation and medical expulsive therapy.

Stones larger than 10 mm are substantially less likely to pass naturally and are more commonly treated with an intervention.

What assessment is required?

Before recommending conservative management, the diagnosis and severity of obstruction should be established.

Assessment may include:

  • A detailed history and physical examination
  • Urine dipstick testing
  • Urine culture when infection is suspected
  • Kidney-function blood tests
  • Full blood count and inflammatory markers
  • Non-contrast CT scan of the kidneys, ureters and bladder
  • Ultrasound in selected patients
  • A plain abdominal X-ray when the stone is visible on X-ray
  • Pregnancy testing when clinically relevant

A low-dose non-contrast CT scan is often the most accurate test for determining the stone’s size and location. It can also assess hydronephrosis, the swelling of the kidney caused by obstruction and identify alternative causes of pain.

Ultrasound is particularly useful when radiation should be avoided, including during pregnancy, although it may not show every ureteric stone.

What does conservative management involve?

Pain relief

Non-steroidal anti-inflammatory medicines, NSAIDs, are often the most effective initial treatment for renal colic when they are medically safe.

Depending on the patient, treatment may include:

  • Ibuprofen
  • Diclofenac
  • Paracetamol
  • A prescribed opioid for breakthrough pain
  • Medication for nausea or vomiting

NSAIDs may be unsuitable for people with:

  • Reduced kidney function
  • Previous stomach ulcers or gastrointestinal bleeding
  • Certain cardiovascular conditions
  • Anticoagulant treatment
  • NSAID allergy
  • Some stages of pregnancy

Pain medication should be selected according to the patient’s medical history rather than taken indiscriminately.

Hydration

Patients should generally remain normally hydrated and avoid becoming dehydrated.

Drinking excessive volumes of water during an episode of acute obstruction does not necessarily force the stone through and may increase discomfort. The aim is steady, sensible fluid intake unless a doctor has advised otherwise.

Straining the urine

Passing urine through a stone strainer can help recover the calculus. A captured stone can be sent for laboratory analysis, which may guide future prevention.

Pain disappearing does not always prove that the stone has passed. Occasionally a stone stops causing pain while obstruction remains, so follow-up imaging may still be required.

Activity

Normal gentle activity is usually reasonable if the patient feels well. Some patients find walking helpful, although exercise cannot guarantee stone passage.

Driving, remote travel and hazardous work may be unsafe while unpredictable severe pain or medication-related drowsiness remains possible.

Medical expulsive therapy

Medical expulsive therapy—usually abbreviated to MET, uses medication to help a ureteric stone pass.

The most frequently used medicines are alpha-blockers, including:

  • Tamsulosin
  • Silodosin
  • Alfuzosin

Tamsulosin is commonly selected because it is widely available and familiar to urologists.

Alpha-blockers are primarily used to improve urinary symptoms caused by prostate enlargement. Their use for ureteric stone passage is generally off-label, meaning that stone passage is not necessarily the indication listed in the medicine’s formal registration.

Off-label use does not mean that treatment is experimental or prohibited. It means that the potential benefits, limitations and side effects should be discussed before prescribing it.

How do alpha-blockers affect the distal ureter?

The ureter contains smooth muscle and alpha-adrenergic receptors. These receptors are particularly relevant in the distal ureter.

When a stone enters the ureter, the surrounding muscle can contract and spasm. Swelling may develop around the stone, increasing resistance to its movement.

Alpha-blockers may:

  • Relax distal ureteric smooth muscle
  • Reduce ureteric spasm
  • Reduce pressure below and around the stone
  • Increase the ureter’s ability to accommodate the calculus
  • Improve the likelihood of stone passage
  • Shorten passage time in some patients
  • Reduce episodes of renal colic and analgesic requirements in selected cases

An alpha-blocker does not:

  • Dissolve most stones
  • Make the stone physically smaller
  • Treat a urinary infection
  • Remove a completely impacted stone
  • Protect a kidney from prolonged significant obstruction
  • Replace drainage of an infected obstructed kidney

How effective are alpha-blockers?

Research into alpha-blockers has produced mixed results.

When all ureteric stones are grouped together, some large studies have shown little or no overall benefit. This may be because very small stones frequently pass without medication and very large or impacted stones remain unlikely to pass despite treatment.

The clearest benefit appears to be in patients with distal ureteric stones between approximately 5 and 10 mm.

The EAU recommends offering an alpha-blocker as one treatment option for conservatively managed distal ureteric stones in this size range, while explaining that treatment is off-label. EAU Guidelines on Urolithiasis

For a stone smaller than 5 mm, the natural passage rate is already high, so an alpha-blocker may add relatively little benefit. Treatment decisions should therefore be individualised.

Side effects and precautions with alpha-blockers

Possible side effects include:

  • Dizziness
  • Light-headedness on standing
  • Low blood pressure
  • Weakness or fatigue
  • Headache
  • Nasal congestion
  • Palpitations
  • Reduced semen volume
  • Failure of ejaculation or retrograde ejaculation

Extra caution is required in patients who:

  • Already have low blood pressure
  • Have a history of fainting or falls
  • Take several blood-pressure medicines
  • Use medication for erectile dysfunction
  • Have significant cardiovascular disease
  • Are planning cataract or glaucoma surgery

Tamsulosin has been associated with intraoperative floppy iris syndrome during cataract surgery. Patients should tell their ophthalmologist about current or previous use.

Alpha-blocker treatment should be stopped and medical advice obtained if infection, uncontrollable pain or deterioration in kidney function develops.

How long can conservative management continue?

There is no single safe waiting period for every patient. The decision depends on symptoms, obstruction, kidney function, stone movement and the likelihood of passage.

Many stones that pass naturally do so within two to four weeks. A monitored trial of passage may sometimes continue for up to approximately four to six weeks, provided that:

  • Pain remains manageable
  • Infection does not develop
  • Kidney function remains stable
  • Obstruction is not causing progressive harm
  • Follow-up imaging is performed
  • The patient still prefers conservative treatment

Observation should not become open-ended. A painless obstructing stone can still impair kidney function.

Follow-up may involve an X-ray, ultrasound or low-dose CT scan. The most suitable test depends on whether the stone was visible on the original X-ray and whether ongoing obstruction needs to be assessed.

When has conservative management failed?

Conservative management should be reconsidered when:

  • The stone has not passed within an appropriate observation period
  • Repeat imaging shows that the stone has not moved
  • Pain remains severe despite adequate medication
  • Repeated emergency presentations are required
  • Nausea or vomiting prevents oral fluids or medication
  • Fever or urinary infection develops
  • Kidney function deteriorates
  • Hydronephrosis persists or worsens
  • Urine output falls significantly
  • The stone has a low likelihood of spontaneous passage
  • The patient has a solitary kidney or bilateral obstruction
  • The patient cannot safely continue waiting
  • Work, caring responsibilities or travel make unpredictable colic unacceptable
  • The patient prefers definitive removal

The EAU identifies persistent pain, persistent obstruction, impaired kidney function and a low likelihood of spontaneous passage as indications for active stone removal. EAU Guidelines on Urolithiasis

Failure of conservative management is not a personal failure. It usually means that the stone is too large, impacted, anatomically trapped or producing complications that make further waiting unsafe.

Surgical and procedural treatment

The two main definitive treatments for a distal ureteric calculus are:

  • Ureteroscopy with laser lithotripsy or stone extraction
  • Shock wave lithotripsy

The most appropriate option depends on stone size, density and position, as well as the patient’s anatomy, medical health, preferences and treatment availability.

Ureteroscopy and laser lithotripsy

Ureteroscopy is commonly used for distal ureteric stones and generally provides the best chance of becoming stone-free after one procedure.

Under anaesthesia, a small telescope is passed through:

  1. The urethra
  2. The bladder
  3. The opening of the ureter
  4. The ureter to the level of the stone

The stone may be removed intact with a small basket or fragmented using a holmium or thulium laser. The pieces are then extracted or allowed to pass naturally.

No external incision is usually required.

Is a ureteric stent required?

A temporary ureteric stent may be inserted when:

  • The ureter is swollen
  • Access was difficult
  • Infection is a concern
  • Stone fragments remain
  • There was ureteric trauma
  • Reliable drainage is required
  • Kidney function is vulnerable

A stent extends from the kidney to the bladder. It can cause:

  • Urinary frequency and urgency
  • Bladder discomfort
  • Pain in the kidney during urination
  • Blood in the urine
  • Discomfort during activity
  • A sensation of incomplete emptying

Stents must be removed or exchanged at the planned time. A forgotten stent can become encrusted and cause serious complications.

Risks of ureteroscopy

Possible complications include:

  • Urinary infection or sepsis
  • Bleeding
  • Failure to reach or remove the stone
  • Residual fragments
  • Ureteric perforation
  • Ureteric narrowing or stricture
  • Need for a further procedure
  • Anaesthetic complications

Major ureteric injury is uncommon but can require additional surgery.

Compared with shock wave treatment, ureteroscopy generally offers a higher chance of clearing the stone in one procedure, although it is more invasive and has a higher complication rate. EAU Guidelines on Urolithiasis

Shock wave lithotripsy

Shock wave lithotripsy, SWL or ESWL, uses externally generated shock waves focused onto the stone. These waves fragment the calculus into smaller pieces that can pass down the ureter.

Advantages may include:

  • No telescope passing up the ureter
  • No surgical incision
  • Lower procedural morbidity
  • Day-treatment suitability in many patients

Limitations include:

  • Lower single-treatment stone-free rates than ureteroscopy
  • Possible need for repeat treatment
  • Pain while fragments pass
  • Residual fragments
  • Difficulty targeting some distal stones
  • Reduced success with dense or impacted stones
  • Reduced effectiveness with greater skin-to-stone distance
  • Possible need for subsequent ureteroscopy

SWL may not be suitable during pregnancy, with untreated infection, uncorrected bleeding disorders, an aneurysm near the treatment field or an anatomical obstruction below the stone.

The American Urological Association recognises both ureteroscopy and shock wave lithotripsy as options when active treatment is required for a distal ureteric stone. AUA Surgical Management of Kidney and Ureteral Stones Guideline

Emergency drainage with a ureteric stent

A ureteric stent may be inserted urgently to bypass an obstructing stone and allow urine to drain from the kidney.

This is particularly important when there is:

  • Infection or sepsis
  • Deteriorating kidney function
  • A solitary obstructed kidney
  • Bilateral obstruction
  • Uncontrollable pain
  • Severe obstruction where immediate stone removal is unsuitable

Emergency stenting relieves the obstruction but does not always remove the stone. Definitive ureteroscopy or SWL may be scheduled later.

Percutaneous nephrostomy

A nephrostomy tube is inserted through the skin of the back directly into the kidney under imaging guidance.

It may be used when:

  • Rapid drainage of an infected kidney is required
  • A ureteric stent cannot be inserted
  • The patient is too unwell for a longer procedure
  • Ureteric anatomy prevents retrograde access

Both ureteric stenting and nephrostomy provide effective emergency drainage. The choice depends on clinical circumstances, local expertise and the patient’s condition.

Open, laparoscopic or robotic stone removal

Open or keyhole ureterolithotomy is now rarely required for an isolated distal ureteric stone.

It may occasionally be considered for:

  • A very large impacted stone
  • Unusual urinary anatomy
  • Failure of less invasive treatments
  • A stone requiring treatment during another planned reconstruction

Most distal stones can be treated successfully with ureteroscopy or SWL.

Which treatment is best?

There is no single procedure that is best for every patient.

Ureteroscopy may be preferred when:

  • Rapid and reliable stone clearance is important
  • The stone is impacted
  • The stone is dense or unlikely to fragment with SWL
  • Previous SWL has failed
  • The patient has significant obesity
  • The stone is difficult to target externally
  • The patient wishes to minimise the likelihood of repeat treatment

SWL may be preferred when:

  • The stone can be targeted clearly
  • The stone has favourable size and density
  • The patient wishes to avoid ureteroscopy
  • Anaesthetic considerations favour a less invasive approach
  • The patient accepts the possibility of repeat treatment

The decision should include a discussion of success rates, anaesthesia, stent requirements, recovery, complications and the possible need for another procedure.

Preventing another stone

Once the acute episode has resolved, prevention becomes important.

General measures may include:

  • Drinking enough fluid to produce at least 2–2.5 litres of urine daily, unless medically restricted
  • Reducing excessive salt intake
  • Maintaining normal dietary calcium rather than eliminating calcium
  • Moderating excessive animal-protein intake
  • Maintaining a healthy body weight
  • Avoiding recurrent dehydration
  • Capturing the stone for analysis
  • Completing blood and urine testing when indicated

Patients with recurrent stones, a solitary kidney, childhood stone disease, unusual stone types or a strong family history may require a formal metabolic evaluation, including 24-hour urine testing.

Prevention should be tailored to the stone composition and the patient’s metabolic risk factors.

The bottom line

Many small distal ureteric stones can be managed safely without surgery. Stones smaller than 5 mm near the bladder have the greatest likelihood of passing naturally.

Conservative treatment usually involves appropriate pain relief, sensible hydration, urine straining, follow-up imaging and—in selected patients—an alpha-blocker such as tamsulosin.

Alpha-blockers relax the smooth muscle of the distal ureter. Their greatest likely benefit is for distal stones between approximately 5 and 10 mm. They do not dissolve the stone and should not delay treatment when infection, uncontrolled pain, persistent obstruction or declining kidney function develops.

Ureteroscopy with laser treatment provides the most reliable single-procedure clearance for many distal stones. Shock wave lithotripsy is less invasive but may require repeat treatment. An infected obstructed kidney requires urgent drainage rather than continued observation.

This article provides general information and does not replace individual medical assessment. Anyone with renal colic and fever, inability to pass urine, persistent vomiting or uncontrollable pain should seek urgent medical care.

Need help deciding whether your ureteric stone can safely pass?

If you have been diagnosed with a distal ureteric calculus, appropriate management depends on more than its size alone. Stone position, pain, infection, kidney function and the degree of obstruction must all be considered.

Your local Brisbane urologist, Dr Jo Schoeman, can assess whether observation, medical expulsive therapy, ureteroscopy or shock wave treatment is the most appropriate option for you.

References and further reading

Balanitis Xerotica Obliterans and Lichen Sclerosus of the Foreskin

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Balanitis xerotica obliterans—usually abbreviated to BXO, is the traditional urological name for male genital lichen sclerosus.

Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects the foreskin and head of the penis. It can cause whitening, inflammation, splitting and progressive scarring of the foreskin. In some men it also narrows the urinary opening or extends into the urethra.

BXO is not simply an infection or ordinary balanitis. Early recognition and treatment can relieve symptoms and reduce permanent scarring. Long-term observation is also important because genital lichen sclerosus is associated with a small but genuine risk of penile squamous cell carcinoma.

Is BXO different from lichen sclerosus?

The names are often used interchangeably:

  • Lichen sclerosus is the preferred modern medical term.
  • Balanitis xerotica obliterans describes lichen sclerosus affecting the glans penis and foreskin, particularly when scarring has developed.

The condition may involve:

  • The inner and outer foreskin
  • The glans penis
  • The frenulum
  • The urinary opening—the meatus
  • The fossa navicularis and penile urethra

The disease is usually confined to the genital region in men, although lichen sclerosus can occasionally affect skin elsewhere.

What causes lichen sclerosus?

The exact cause remains uncertain. It is probably produced by a combination of inflammation, immune-system dysfunction, genetic susceptibility, skin injury and local environmental factors.

Possible associations include:

  • Autoimmune or inflammatory activity
  • Chronic exposure of susceptible skin to trapped urine
  • Repeated friction or minor trauma
  • A tight foreskin
  • Previous inflammation beneath the foreskin
  • Obesity and a “buried” penis
  • Diabetes or metabolic disease
  • Cigarette smoking
  • Genetic susceptibility

The moist, occluded environment beneath the foreskin may contribute to continuing inflammation in susceptible men.

Lichen sclerosus is:

  • Not caused by poor personal character or behaviour
  • Not usually a sexually transmitted infection
  • Not contagious
  • Not something that can be passed to a partner through ordinary sexual contact

Yeast or bacterial infection may occur at the same time, particularly in men with diabetes, but infection is not the underlying cause of lichen sclerosus.

Who can develop it?

Male genital lichen sclerosus can occur at any age.

It is recognised in:

  • Boys with acquired or severe scarring phimosis
  • Adolescents
  • Younger and middle-aged men
  • Older men
  • Men with a previously retractable foreskin that has gradually tightened

It is much less common in men who were circumcised early in life, although circumcision does not make the risk absolutely zero.

How does lichen sclerosus present?

The appearance varies considerably. Early disease can be subtle and may initially be mistaken for thrush, dermatitis, recurrent balanitis or ordinary phimosis.

Possible signs include:

  • White, pale or porcelain-coloured foreskin
  • A white, firm ring around the foreskin opening
  • Thickened or hardened skin
  • Shiny, crinkled or “cigarette-paper” skin
  • Red or inflamed areas
  • Small cracks or splits
  • Easy bleeding or bruising
  • Painful erosions
  • Adhesions between the foreskin and glans
  • Progressive tightening of the foreskin
  • Shortening or scarring of the frenulum
  • Whitening around the urinary opening
  • Narrowing of the meatus
  • Loss of the normal shape or definition of the glans and foreskin

Some men have significant visible disease with surprisingly little discomfort.

Symptoms patients may notice

Symptoms can include:

  • Difficulty retracting the foreskin
  • Inability to replace or retract the foreskin fully
  • Pain during erections
  • Splitting or bleeding during intercourse
  • Itching, burning or soreness
  • Recurrent “balanitis”
  • Pain or reduced enjoyment during sexual activity
  • Spraying or deflection of the urinary stream
  • A weak or narrowed stream
  • Straining to urinate
  • Dribbling after urination
  • Ballooning of the foreskin
  • Recurrent urinary infections
  • Difficulty emptying the bladder

A narrow urinary opening may be the first sign that the disease has extended beyond the foreskin.

Lichen sclerosus and phimosis

Phimosis means that the foreskin cannot be retracted comfortably behind the glans.

A non-retractile foreskin is normal in young boys and does not automatically indicate disease. However, a previously retractable foreskin that becomes tight, particularly when accompanied by a white scarred ring is suspicious for lichen sclerosus.

Forceful stretching of a scarred foreskin is not recommended. Repeated tearing may cause additional inflammation and scarring.

Paraphimosis, where a retracted tight foreskin becomes trapped behind the glans, requires urgent medical attention.

How is lichen sclerosus diagnosed?

The diagnosis is often made from the history and characteristic appearance.

Assessment should include examination of:

  • The complete foreskin
  • Glans penis
  • Frenulum
  • Urinary opening
  • Palpable tissue beneath abnormal skin
  • Urinary stream and bladder emptying when relevant
  • Groin lymph nodes if cancer is suspected

Other conditions that can resemble lichen sclerosus include:

  • Fungal or bacterial balanitis
  • Irritant or allergic dermatitis
  • Psoriasis
  • Lichen planus
  • Zoon balanitis
  • Vitiligo
  • Genital warts
  • Penile intraepithelial neoplasia: PeIN
  • Squamous cell carcinoma

Diabetes testing may be appropriate in men with recurrent inflammation or other risk factors.

Is a biopsy always necessary?

Not every typical case requires a biopsy before treatment. However, biopsy is important when:

  • The diagnosis is uncertain
  • Treatment has not produced the expected response
  • An erosion or ulcer does not heal
  • There is a persistent red or thickened area
  • A lump or hardened area can be felt
  • The skin bleeds easily without an obvious cause
  • Pigmentation changes unexpectedly
  • Penile intraepithelial neoplasia or cancer is suspected

When circumcision is performed for suspected lichen sclerosus, the foreskin should usually be sent for pathological examination.

A biopsy should be taken from any suspicious persistent lesion rather than relying only on the appearance.

Medical management

The goals of medical treatment are to:

  • Suppress inflammation
  • Relieve discomfort and itching
  • Prevent further scarring
  • Preserve foreskin and urinary function where possible
  • Identify patients who require surgery or biopsy

General skin care

Helpful measures include:

  • Washing gently with water or a non-soap cleanser
  • Avoiding perfumed soaps, antiseptics and harsh products
  • Drying the glans and foreskin gently after urination
  • Applying a bland barrier ointment or emollient
  • Avoiding forceful foreskin retraction
  • Using adequate lubrication during sexual activity
  • Stopping smoking
  • Managing diabetes carefully
  • Addressing obesity or a buried penis where relevant

Good hygiene means gentle care. Repeated scrubbing or strong antiseptics can worsen inflamed genital skin.

Potent topical corticosteroids

A prescribed potent or ultrapotent topical corticosteroid is the usual first-line medical treatment.

Clobetasol propionate 0.05% ointment is commonly used in specialist practice. A typical initial course may involve a small amount applied to the affected skin once daily for one to three months, but the exact regimen should be determined by the treating doctor.

Patients should be shown:

  • Exactly where to apply the medication
  • How much to use
  • How long to continue
  • Whether treatment should be reduced gradually
  • When follow-up is required

When used correctly for a defined course, topical corticosteroids can reduce inflammation, soreness and early tightening. They cannot always reverse established dense scar tissue.

Possible steroid-related effects include irritation, secondary infection, skin thinning or visible small blood vessels, although these are uncommon with appropriate genital use and medical supervision.

Other topical treatments

Topical calcineurin inhibitors such as tacrolimus or pimecrolimus may occasionally be considered by a dermatologist or experienced specialist when corticosteroids are unsuitable.

They are not generally preferred over potent topical corticosteroids as initial treatment. They can cause burning or irritation, and persistent suspicious lesions must be biopsied rather than repeatedly treated empirically.

Antifungal or antibiotic medication is only useful when a secondary infection is actually present. It does not treat the underlying lichen sclerosus.

When should circumcision be considered?

Circumcision is an important and often definitive treatment for foreskin lichen sclerosus.

It should be considered when there is:

  • Established scarring phimosis
  • Painful or recurrent splitting
  • Difficulty with hygiene
  • Recurrent balanitis
  • Paraphimosis
  • Failure to respond adequately to a prescribed steroid course
  • Rapid recurrence after apparently successful medical treatment
  • Significant functional or sexual difficulty
  • Concern about premalignant or malignant change
  • A need to obtain tissue for diagnosis

Complete circumcision removes the diseased foreskin and eliminates the moist, urine-exposed environment beneath it. Many men experience long-term resolution when the disease is limited to the foreskin.

Partial circumcision or simply making a slit in the scarred foreskin is generally less reliable because affected skin remains and may scar again.

Will circumcision cure lichen sclerosus?

Circumcision is often highly effective when the condition is limited to the foreskin. However, it is not an absolute guarantee of cure.

Disease may persist or recur on the:

  • Glans
  • Coronal sulcus
  • Frenulum
  • Urinary opening
  • Urethra

Ongoing symptoms or abnormal skin after circumcision should therefore be reviewed rather than assumed to be normal postoperative scarring.

Circumcision appears to reduce the risk associated with chronic inflammation and phimosis, but it does not completely eliminate the future risk of penile cancer.

Surgery for meatal narrowing

Lichen sclerosus can scar the urinary opening, producing meatal stenosis.

Symptoms may include:

  • A thin urinary stream
  • Spraying or deflection
  • Prolonged urination
  • Straining
  • Discomfort
  • Incomplete emptying

Treatment may require a meatotomy or meatoplasty, in which the opening is enlarged and reconstructed.

Simple dilatation may provide temporary improvement but often does not control active scar disease. Medical treatment of the surrounding lichen sclerosus and continued surveillance may still be required.

What if the disease involves the urethra?

In some men, scarring extends from the meatus into the penile urethra and occasionally further towards the bulbar urethra.

Assessment may include:

  • Urinary flow-rate testing
  • Post-void residual ultrasound
  • Flexible cystoscopy
  • Retrograde urethrogram
  • Voiding cystourethrogram
  • Urethral ultrasound in selected cases

Short strictures may sometimes be managed endoscopically, but repeated dilatation or urethrotomy has a significant recurrence risk when active lichen sclerosus remains.

Longer or recurrent strictures may require urethroplasty. Oral lining tissue, usually buccal mucosa from the inside of the cheek, is commonly used for reconstruction.

The European Association of Urology recommends that genital skin should not be used as a graft for lichen-sclerosus-related urethral strictures, because the disease can affect the graft and recurrence rates are poor.

Complex cases are best managed by a urologist experienced in reconstructive urethral surgery.

Other surgical options

Depending on the extent of disease, specialist procedures may include:

  • Frenuloplasty in carefully selected cases without extensive LS
  • Complete circumcision
  • Meatotomy or meatoplasty
  • Excision or biopsy of suspicious lesions
  • Glans resurfacing when premalignant disease is present
  • Oral-mucosa graft urethroplasty
  • Staged urethral reconstruction
  • Perineal urethrostomy for severe or recurrent extensive stricture disease

The operation should be tailored to the location and activity of the condition. Preserving diseased genital skin simply to avoid circumcision may produce repeated scarring and further procedures.

Lichen sclerosus and penile cancer

Male genital lichen sclerosus is associated with squamous cell carcinoma of the penis and with penile intraepithelial neoplasia, which is a precancerous change.

Published studies have reported widely differing cancer rates among men with genital lichen sclerosus, from close to zero in some groups to approximately 12.5% in highly selected specialist series. Frequently quoted estimates place the risk at roughly 2–6%, but the precise lifetime risk for an individual man remains uncertain.

This does not mean that most men with lichen sclerosus will develop penile cancer. Penile cancer remains rare, and appropriate treatment of inflammation and phimosis is expected to reduce risk.

It is also reported that lichen sclerosus is found in a substantial proportion of penile cancer specimens. This association cannot be reversed to mean that the same proportion of men with lichen sclerosus will develop cancer.

Risk is likely to be greater when there is:

  • Long-standing uncontrolled inflammation
  • Severe phimosis
  • Persistent ulceration or thickening
  • Poor visibility of the glans
  • Cigarette smoking
  • Immune suppression
  • Coexisting penile intraepithelial neoplasia
  • Failure to attend follow-up

Warning signs that require prompt review

A man with current or previous lichen sclerosus should seek medical assessment for:

  • A persistent ulcer or sore
  • A new lump or firm area
  • Skin thickening
  • An irregular red or velvety patch
  • A warty or cauliflower-like growth
  • Unexplained bleeding
  • Offensive discharge
  • Increasing pain
  • A lesion that does not respond to prescribed steroid treatment
  • A new lump in the groin

These findings do not necessarily mean cancer, but they should not be treated repeatedly as thrush or simple inflammation without further investigation.

Follow-up and self-examination

Lichen sclerosus can recur, and cancer-related changes may develop many years after initial treatment.

Patients should become familiar with the normal appearance of their penis and perform regular self-examination. When possible, the entire glans, foreskin and urinary opening should be inspected.

Medical follow-up should be tailored to disease severity. More frequent review is appropriate during active treatment, after surgery or when urethral involvement is present. Once stable, periodic or annual review may be appropriate, together with lifelong self-monitoring.

Circumcised men should still report new or persistent abnormalities.

The outlook

When recognised early, male genital lichen sclerosus can often be controlled successfully with appropriate topical corticosteroid treatment, good skin care and follow-up.

Established scarring is less likely to resolve with medication alone. Circumcision is usually highly effective for disease confined to the foreskin, while meatal and urethral disease may require more specialised reconstruction.

The important message is not to ignore a foreskin that is becoming progressively white, scarred or tight. Early assessment may prevent painful erections, urinary obstruction and more complex surgery.

The bottom line

Balanitis xerotica obliterans is the older name for male genital lichen sclerosus involving the foreskin and glans.

It commonly presents with white or scarred skin, acquired phimosis, splitting, painful erections or urinary-stream changes. Potent prescribed topical corticosteroids are the first medical treatment for suitable early disease, while circumcision is often required for established phimosis, recurrent disease or failure of medical treatment.

Meatal or urethral involvement requires urological assessment and may need reconstructive surgery.

The risk of penile squamous cell carcinoma is small but real. Persistent thickening, ulceration, bleeding, a lump or a lesion that does not respond to treatment requires prompt examination and often biopsy.

This article provides general information and does not replace personalised medical assessment. Do not use potent topical corticosteroids on genital skin without appropriate medical advice.

So guys, if you cannot retract the foreskin and has the typical appearance discussed in this article, take the time to review with your GP to have this checked out. There is effective management for this which will also then reduce your risk for penile cancer. Do not vary your head in the send and ignore this, have it seen to and let your GP refer you to your local Brisbane urologist, Dr Jo Schoeman.

References and further reading

Duodart® for an Enlarged Prostate: Benefits, Side Effects and When Surgery May Be Better

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Benign prostatic hyperplasia, usually called BPH or benign prostate enlargement, is a common cause of urinary symptoms as men get older.

An enlarged prostate can compress the urethra and interfere with bladder emptying, causing symptoms such as:

  • A slow or intermittent urinary stream
  • Difficulty starting urination
  • Straining to urinate
  • A feeling that the bladder has not emptied
  • Urinary frequency or urgency
  • Waking repeatedly at night to urinate
  • Dribbling after urination
  • Episodes of urinary retention

Duodart® combines two established BPH medicines in a single daily capsule. One component relaxes the prostate relatively quickly, while the other gradually reduces its size and lowers the long-term risk of urinary retention and prostate surgery.

Duodart can be very effective in appropriately selected men, but it is not the right treatment for every urinary symptom or every prostate.

What does Dutasteride contain?

Each Duodart capsule contains:

  • Dutasteride 0.5 mg
  • Tamsulosin hydrochloride 0.4 mg

These medicines work in different but complementary ways.

Tamsulosin: relaxing the prostate

Tamsulosin is an alpha-1 adrenergic receptor blocker. It relaxes smooth muscle within the prostate and bladder neck, reducing resistance to urinary flow.

It may improve:

  • Urinary stream
  • Hesitancy
  • Straining
  • Bladder emptying
  • Some frequency and urgency symptoms

Improvement may begin within days, although the full response can take several weeks.

Tamsulosin improves urinary symptoms but does not substantially reduce prostate size or prevent long-term prostate growth.

Dutasteride: gradually shrinking the prostate

Dutasteride is a 5-alpha-reductase inhibitor, 5-ARI. It blocks both type 1 and type 2 forms of the enzyme that converts testosterone into dihydrotestosterone (DHT).

DHT is an important driver of prostate growth. Reducing DHT gradually causes susceptible prostate tissue to shrink.

According to the European Association of Urology, 5-ARIs can:

  • Reduce prostate volume by approximately 18–28%
  • Improve urinary symptom scores by approximately 15–30%
  • Reduce PSA by approximately 50% after six to twelve months
  • Reduce the long-term risk of acute urinary retention
  • Reduce the likelihood of requiring BPH surgery

The dutasteride component works slowly. A meaningful benefit may take three to six months, with further improvement occurring over several years.

Who may benefit from Duodart?

Duodart is most appropriate for men with moderate-to-severe urinary symptoms caused by an enlarged prostate who also have an increased risk of BPH progression.

It may be considered when there is:

  • A prostate volume of approximately 40 mL or greater
  • A clearly enlarged prostate on examination or ultrasound
  • An elevated PSA consistent with benign prostate enlargement
  • A reduced urinary flow rate
  • An increased post-void residual urine volume
  • Increasing symptoms despite alpha-blocker treatment
  • A risk of future urinary retention
  • A desire to reduce the likelihood of BPH-related surgery
  • A need for both relatively rapid symptom relief and long-term reduction in prostate size

Some men with prostates between 30 and 40 mL may also benefit, depending on their PSA, symptoms, urinary flow and other risk factors.

Combination treatment is generally intended for long-term use rather than a short trial lasting only a few weeks.

Who may not benefit?

Duodart is less likely to help when:

  • The prostate is small
  • Symptoms are primarily caused by an overactive bladder
  • There is poor bladder-muscle contraction
  • A urethral stricture is present
  • Prostate or bladder cancer is causing the obstruction
  • A bladder stone is responsible for the symptoms
  • Neurological bladder dysfunction is present
  • Symptoms are mild and not troublesome

A large prostate and severe symptoms do not always occur together. Some men with a very large prostate urinate reasonably well, while others with a small prostate have significant obstruction from a tight bladder neck, urethral narrowing or abnormal prostate shape.

This is why treatment should be based on an assessment rather than prostate size alone.

What assessment is recommended before starting Duodart?

Depending on the patient, assessment may include:

  • A detailed urinary and medication history
  • International Prostate Symptom Score (IPSS)
  • Physical examination
  • Digital rectal examination
  • Urine testing
  • PSA testing
  • Kidney-function blood tests
  • Urinary flow-rate measurement
  • Ultrasound measurement of prostate size
  • Post-void residual urine measurement
  • A bladder diary when frequency or nocturia is prominent
  • Cystoscopy or urodynamic testing in selected patients

Prostate cancer and other important causes of urinary obstruction should be considered before symptoms are attributed to BPH.

How is Duodart taken?

The usual dose is one capsule once daily, taken approximately 30 minutes after the same meal each day.

The capsule should be swallowed whole. It should not be opened, crushed or chewed because its contents may irritate the mouth and throat.

Taking the capsule consistently after the same meal helps maintain predictable absorption of tamsulosin.

If treatment is stopped, urinary symptoms and prostate growth may gradually return. Duodart should not be stopped or restarted without discussing this with the prescribing doctor.

What benefits can be expected?

Tamsulosin provides the earlier benefit by relaxing the prostate and bladder neck. Dutasteride provides the slower, longer-term benefit by reducing prostate volume and the risk of progression.

In long-term clinical studies, dutasteride plus tamsulosin produced greater improvement in urinary symptoms and urinary flow than either medicine alone in appropriately selected men.

The EAU reports that, compared with tamsulosin alone at four years, combination treatment reduced the relative risk of:

  • Acute urinary retention by approximately 68%
  • BPH-related surgery by approximately 71%
  • Symptom deterioration by approximately 41%

These are relative reductions from clinical-trial populations. The individual absolute benefit depends on the patient’s original risk, prostate size, PSA and degree of obstruction.

Duodart controls BPH; it does not permanently cure it.

Common side effects

Because Duodart contains two medicines, it can cause side effects associated with either component.

Ejaculatory changes

Tamsulosin can interfere with ejaculation. Patients may notice:

  • Reduced semen volume
  • Dry ejaculation
  • Failure to ejaculate
  • Semen passing backwards into the bladder: retrograde ejaculation

This is usually harmless but can affect sexual satisfaction and fertility.

Combination treatment has a higher risk of ejaculatory dysfunction than either an alpha blocker or 5-ARI used alone.

Reduced sexual desire

Dutasteride reduces DHT and may cause a decrease in libido. The effect may be mild for some men but troubling for others.

Erectile dysfunction

Difficulty achieving or maintaining an erection can occur. BPH itself, increasing age, vascular disease, diabetes and other medications can also contribute, so the cause is not always straightforward.

Breast changes

Dutasteride can occasionally cause:

  • Breast tenderness
  • Nipple sensitivity
  • Breast enlargement: gynaecomastia

A breast lump, nipple discharge or persistent one-sided change should be assessed promptly rather than assumed to be a medication effect.

Dizziness and low blood pressure

Tamsulosin may lower blood pressure, particularly when standing. This can cause:

  • Dizziness
  • Light-headedness
  • Weakness
  • Fainting
  • An increased risk of falling

Extra care is needed when treatment begins, after a dose change or when Duodart is combined with other blood-pressure-lowering medicines.

Other possible side effects

Other reported effects include:

  • Headache
  • Tiredness
  • Palpitations
  • Nasal congestion
  • Gastrointestinal discomfort
  • Skin rash or itching
  • Testicular discomfort or swelling
  • Mood changes or depression
  • Reduced fertility or changes in semen quality

Semen-volume and sperm changes do not necessarily cause infertility, but men planning a pregnancy should discuss this before treatment.

Rare but important reactions

Urgent medical assistance is required for:

  • Swelling of the face, tongue or throat
  • Difficulty breathing
  • A severe allergic reaction
  • Fainting
  • A painful erection lasting several hours: priapism
  • Severe blistering or peeling skin
  • Marked depression or suicidal thoughts

These reactions are uncommon but require prompt assessment.

Duodart and cataract surgery

Tamsulosin is associated with intraoperative floppy iris syndrome, which can make cataract or glaucoma surgery more difficult.

Patients should tell their ophthalmologist if they:

  • Currently take Duodart
  • Previously took Duodart
  • Previously used another medicine containing tamsulosin

Stopping tamsulosin shortly before surgery may not completely remove this risk. The decision should be made between the ophthalmologist and prescribing doctor rather than by the patient alone.

Contraindications and important precautions

Duodart should not be used in:

  • Women
  • Children or adolescents
  • Anyone allergic to dutasteride, tamsulosin, another 5-ARI or a capsule ingredient
  • Patients with a history of significant postural or orthostatic hypotension
  • Patients with severe liver impairment

Additional caution is required in men with:

  • Recurrent dizziness or falls
  • Significant cardiovascular disease
  • Liver disease
  • Severe kidney impairment
  • Planned cataract or glaucoma surgery
  • A history of depression or major mood disturbance
  • Suspected prostate cancer
  • Severe urinary retention
  • A very high post-void residual urine volume
  • Other medicines that substantially lower blood pressure

Duodart changes the interpretation of PSA

Dutasteride generally lowers PSA by approximately 50% after six to twelve months.

This does not mean that prostate cancer risk has disappeared. A new PSA baseline should be established after treatment begins, and subsequent results must be interpreted in the context of dutasteride use.

A confirmed rise from the lowest PSA reached while taking Duodart may require investigation, even when the result remains within the laboratory’s usual “normal” range.

Patients should tell any doctor ordering or interpreting a PSA test that they are taking dutasteride.

PSA monitoring and appropriate prostate cancer assessment should continue while using Duodart.

What is “post-finasteride syndrome”?

“Post-finasteride syndrome” is a term used to describe persistent symptoms reported by some patients during or after stopping finasteride.

Reported symptoms have included:

  • Reduced libido
  • Erectile dysfunction
  • Altered genital sensation
  • Ejaculatory or orgasmic changes
  • Fatigue
  • Poor concentration or “brain fog”
  • Anxiety
  • Depressed mood
  • Sleep disturbance

The existence, frequency, biological mechanism and diagnostic criteria of post-finasteride syndrome remain debated. Some patients report very real and persistent symptoms, but current research has not established a reliable way to predict who may be affected or to prove that every reported symptom is directly caused by the medicine.

It should therefore neither be presented as a guaranteed consequence nor dismissed when a patient reports persistent symptoms.

Is post-finasteride syndrome relevant to Duodart?

Duodart does not contain finasteride. It contains dutasteride.

However, finasteride and dutasteride belong to the same 5-ARI medicine class and both reduce DHT. Sexual side effects such as reduced libido, erectile dysfunction and ejaculatory changes are recognised with both medicines.

Dutasteride inhibits both type 1 and type 2 5-alpha-reductase and remains in the body much longer than finasteride. Its terminal half-life is approximately five weeks, so adverse effects may not disappear immediately after stopping treatment.

Persistent sexual symptoms have been reported after treatment with 5-ARIs, although the frequency and causal relationship remain uncertain.

A 2025 European Medicines Agency safety review found insufficient evidence to establish a causal association between dutasteride and suicidal thoughts. Nevertheless, because of a possible class effect, the EMA recommended precautionary information about mood changes for dutasteride products.

Patients taking Duodart should contact their doctor if they develop:

  • New or worsening sexual dysfunction
  • Persistent loss of libido
  • Depressed mood
  • Significant anxiety
  • Suicidal thoughts
  • Symptoms that continue after stopping treatment

Stopping Duodart suddenly may allow urinary obstruction to worsen, so medication changes should usually be supervised. Suicidal thoughts or severe psychological distress require urgent assistance.

Monitoring treatment

Patients should usually be reviewed after starting Duodart to assess:

  • Improvement in urinary symptoms
  • Dizziness or postural blood-pressure changes
  • Sexual and ejaculatory function
  • Mood changes
  • Urinary flow rate
  • Post-void residual urine
  • PSA response
  • Kidney function when clinically indicated

The tamsulosin component should produce an earlier response, while the dutasteride benefit is judged over several months.

A lack of rapid improvement does not necessarily mean dutasteride has failed. Conversely, ongoing severe symptoms should not automatically be managed by continuing the medication indefinitely without reassessment.

When should surgery be considered?

Medication is often the first treatment for uncomplicated BPH, but surgery should not be regarded merely as a last resort. For some patients it offers more reliable relief and prevents further bladder or kidney damage.

Surgery should be considered when there is:

  • Recurrent or persistent urinary retention
  • Dependence on a urinary catheter
  • Recurrent urinary tract infections caused by poor emptying
  • Bladder stones
  • Recurrent visible bleeding attributable to BPH
  • Overflow urinary incontinence
  • Progressive bladder diverticula associated with obstruction
  • Dilatation of the kidneys or ureters
  • Kidney impairment caused by bladder outlet obstruction
  • A very high or increasing residual urine volume
  • Persistent bothersome symptoms despite adequate medication
  • Intolerable medication side effects
  • A preference for a procedural solution rather than lifelong tablets
  • Poor urinary flow with objective evidence of significant obstruction

Earlier surgery may also be appropriate when obstruction is beginning to damage bladder function. Waiting until the bladder has become severely stretched or weak can reduce the improvement achievable after surgery.

When is Duodart unlikely to prevent surgery?

Surgery may still be needed when:

  • The prostate obstruction is mechanically severe
  • A large middle lobe acts like a ball valve at the bladder outlet
  • Urinary retention has already occurred repeatedly
  • Bladder stones or recurrent infections are present
  • Residual urine continues to increase
  • Kidney function or upper urinary tract drainage is affected
  • Symptoms remain troublesome after an adequate trial
  • The bladder has become poorly contractile
  • Side effects make long-term treatment unacceptable

Duodart can reduce future risk; it cannot reliably reverse every established complication of obstruction.

What surgical options are available?

The appropriate procedure depends on prostate size, prostate shape, bleeding risk, bladder function, general health and the importance of preserving ejaculation.

Options may include:

  • Transurethral resection of the prostate: TURP
  • GreenLight laser prostate vaporisation: TUVP
  • Holmium laser enucleation: HoLEP
  • Rezūm water-vapour therapy
  • UroLift
  • Temporary implantable nitinol device: iTind
  • Robotic or open simple prostatectomy for very large glands
  • Other enucleation or minimally invasive techniques

Some minimally invasive treatments are best suited to selected prostate sizes and shapes. Not every option provides the same durability, improvement in urinary flow or preservation of ejaculation.

The bottom line

Duodart combines the relatively quick muscle-relaxing effect of tamsulosin with the slower prostate-shrinking and progression-reducing effect of dutasteride.

It is most useful for men with moderate-to-severe urinary symptoms, a genuinely enlarged prostate and a meaningful risk of future urinary retention or surgery.

Sexual and ejaculatory side effects, dizziness, breast changes and possible mood effects should be discussed before treatment. Duodart also lowers PSA, so ongoing prostate cancer surveillance must be interpreted differently.

The term “post-finasteride syndrome” remains scientifically debated. Duodart does not contain finasteride, but dutasteride acts on the same hormonal pathway, and persistent symptoms reported by a patient deserve careful assessment.

Medication should not be continued indefinitely when symptoms remain severe, complications develop or bladder and kidney function are threatened. In those circumstances, timely prostate surgery may be safer and more effective than simply adding another tablet.

This article provides general information and does not replace personalised medical advice. Patients should not start, stop or alter Duodart without consulting their treating doctor.

So, if you are having difficulty with your lower urinary tract symptoms and you wish to remain conservative in your management and not to fussed about your erectile function and libido, come see your local Brisbane urologist, dr Jo Schoeman, to discuss further options

References and further reading