Sudden testicular pain is an emergency. This is not a “wait until tomorrow and see how it goes” situation.

There are few occasions in life when being twisted is definitely not a good thing. Testicular torsion is one of them.

Testicular torsion occurs when a testicle rotates around the spermatic cord, twisting the blood vessels that supply it. Think of a garden hose being twisted until the water stops flowing, except this particular hose supplies a rather important piece of anatomy.

The result can be sudden, severe pain and, if the blood supply is not restored quickly enough, permanent damage or loss of the testicle.

The good news is that prompt treatment can often save the testicle. The important word here is prompt.

Sudden severe testicular pain should be treated as testicular torsion until proven otherwise. Go directly to an Emergency Department.

What exactly is testicular torsion?

Normally, each testicle has enough mobility to accommodate everyday movement without being able to rotate freely.

Some boys and men have an anatomical arrangement commonly called a “bell-clapper” deformity, in which the testicle is more mobile within the scrotum than usual. This allows it to rotate around the spermatic cord.

When the cord twists, venous drainage is obstructed first, followed by arterial blood flow. The testicle becomes swollen, increasingly painful and eventually starved of oxygen.

This is why testicular torsion is a time-critical surgical emergency.

Although torsion is particularly common in adolescents, it can occur at almost any age, including infancy and adulthood.

What does testicular torsion feel like?

The classic presentation is difficult to ignore:

• Sudden onset of severe pain in one testicle
• Rapidly increasing scrotal pain or swelling
• A testicle sitting higher than usual or lying at an unusual angle
• Lower abdominal or groin pain
• Nausea and vomiting
• Marked tenderness of the affected testicle
• Occasionally pain that wakes someone from sleep

Some patients experience previous episodes of sudden testicular pain that disappear spontaneously. This may represent intermittent torsion, where the testicle twists and then untwists itself.

A disappearing pain does not necessarily mean that the problem has disappeared.

The clock starts ticking immediately

With torsion, time matters.

The two major factors determining whether a testicle survives are how long it has been twisted and how tightly the spermatic cord has rotated. Current European Association of Urology guidance recommends surgical exploration as soon as possible and notes that the best outcomes occur with very early intervention, ideally within approximately 4–6 hours of symptom onset.

There isn’t a magical cliff at six hours where the testicle suddenly gives up and packs its bags. Salvage may still be possible later, which is precisely why patients should seek emergency treatment regardless of how long the pain has been present.

Don’t wait to see whether it gets better.

And perhaps more importantly:

Don’t be embarrassed.

Emergency doctors and urologists have seen testicles before. Quite a few of them.

How is testicular torsion diagnosed?

The diagnosis begins with the history and examination.

A doctor will examine the abdomen, groin and scrotum and assess the position, swelling and tenderness of the affected testicle.

A Doppler ultrasound can assess blood flow to the testicle and is extremely useful when the diagnosis is uncertain.

However, there is an important catch.

An ultrasound should not delay surgery when torsion is strongly suspected.

The EAU specifically recommends that Doppler ultrasound be used as an adjunct without delaying intervention.

In other words, when the clinical picture is shouting “torsion”, we shouldn’t spend precious time politely asking the ultrasound machine for a second opinion.

Can the testicle simply be untwisted?

Sometimes a doctor can attempt manual detorsion while arrangements for surgery are being made.

This involves carefully rotating the testicle in the direction that releases the twist. Relief of pain may be dramatic when successful.

But this is important:

Successful manual detorsion does not replace surgery.

Residual twisting may remain even when the pain improves, and the testicle can twist again. EAU guidance therefore states that manual detorsion may be attempted while awaiting surgery but must not delay surgical exploration.

Emergency surgery: scrotal exploration

Definitive treatment is an operation called scrotal exploration.

Under anaesthesia, the surgeon makes an incision in the scrotum and examines the affected testicle.

The spermatic cord is untwisted and the testicle is allowed time to recover its blood supply.

Sometimes a rather alarming blue or purple testicle gradually becomes reassuringly pink again. Few colour changes make a urologist happier.

If the testicle appears viable, it is preserved.

Orchiopexy: preventing another twist

If the testicle can be saved, it is secured inside the scrotum using an operation called an orchiopexy or orchidopexy.

The testicle is fixed so that it cannot freely rotate around the spermatic cord again.

But there is another important part of the operation.

We usually fix the other testicle too.

The anatomical predisposition that allowed one testicle to twist may also be present on the opposite side. Therefore, when torsion is confirmed, the unaffected testicle is commonly fixed during the same operation.

Current guidance recommends contralateral orchiopexy at the time of surgery rather than returning later for an elective procedure.

Think of it as discovering that one wheel on the car was loose and sensibly checking the other one while you’re already holding the spanner.

What if the testicle cannot be saved?

Unfortunately, sometimes the blood supply has been absent for too long and the testicular tissue is irreversibly damaged.

If the testicle is clearly non-viable or necrotic, it may need to be removed.

This operation is called an orchidectomy or orchiectomy.

Losing a testicle can understandably be upsetting, particularly for an adolescent or young man. Concerns about appearance, masculinity, testosterone, sexual function and fertility are extremely common.

These concerns deserve a proper conversation rather than a hurried reassurance.

The encouraging news is that one healthy testicle is generally sufficient to maintain normal testosterone production, sexual function and fertility.

What about fertility after testicular torsion?

This subject is more complicated than simply asking whether the testicle survived.

Torsion can damage sperm-producing tissue through the original loss of blood supply and potentially through ischaemia-reperfusion injury when circulation returns.

Long-term studies have therefore reported abnormalities in semen parameters in some men following torsion. The EAU notes reported rates of subfertility of approximately 36–39%, although study results vary considerably and long-term paternity may remain comparable with control populations.

Importantly, having had testicular torsion does not automatically mean that a man will be infertile.

Many men subsequently have normal fertility, particularly when the other testicle is healthy. Studies have also reported normal pregnancy rates following unilateral torsion, whether the affected testicle was preserved or ultimately removed.

For patients concerned about future fertility, particularly after severe torsion, testicular atrophy or problems involving the remaining testicle, subsequent assessment may include:

• Testicular examination and ultrasound
• Measurement of testicular volume
• Semen analysis when appropriate
• Testosterone and reproductive hormone testing
• Fertility counselling where indicated

Can a rescued testicle shrink later?

Unfortunately, yes.

A testicle may look viable during surgery and still subsequently undergo testicular atrophy, becoming smaller over the following months.

Current EAU guidance notes that testicular atrophy can occur even following timely detorsion and fixation, which is why appropriate follow-up is important.

This does not mean the operation failed. The initial period without adequate blood supply may simply have caused microscopic damage that wasn’t visible during surgery.

What about testosterone and sexual function?

For most patients with a normal opposite testicle, testosterone production remains adequate.

Long-term studies suggest that hormonal measurements may differ somewhat following torsion, but overall endocrine testicular function generally remains within the normal range.

Removal of one testicle therefore does not normally cause erectile dysfunction, loss of masculinity or the need for testosterone replacement.

The remaining testicle usually quietly gets on with the job.

Testicular prosthesis: replacing what has been lost

Some patients are bothered by the cosmetic asymmetry following removal of a testicle.

A testicular prosthesis can be placed inside the scrotum to restore a more natural appearance and feel.

The prosthesis does not produce sperm or testosterone. Its purpose is cosmetic and psychological rather than functional.

Depending upon the circumstances, a prosthesis may be inserted during the original operation or at a later date. Prosthesis placement is an established option following orchidectomy, and current EAU guidance recommends that patients undergoing removal of a testicle be offered the opportunity to discuss a testicular prosthesis.

The decision is entirely personal.

Some men want one.

Some don’t.

Both decisions are perfectly reasonable.

Recovery after torsion surgery

Most patients recover relatively quickly following uncomplicated orchiopexy.

There will usually be some swelling, bruising and discomfort for several days. Supportive underwear can be surprisingly valuable during this period. The humble pair of supportive briefs finally gets its moment of glory.

Patients are generally advised to avoid strenuous activity, heavy lifting, cycling and contact sports until healing is satisfactory.

Timing for returning to work, school, sport and sexual activity should be discussed with the treating surgeon because this varies according to the operation and individual recovery.

Could torsion happen again after orchiopexy?

It is unusual, but recurrent torsion after orchiopexy is possible.

The EAU guideline describes recurrence after fixation as rare, but documented.

Therefore, even someone who has previously undergone orchiopexy should seek urgent medical attention if they develop sudden severe testicular pain.

Previous surgery doesn’t grant a testicle diplomatic immunity.

The message worth remembering

Testicular torsion is one of the true emergencies in urology.

If you or your son develops sudden severe pain in one testicle, particularly when associated with swelling, nausea, vomiting or an abnormally positioned testicle:

Don’t wait.

Don’t Google for three hours.

Don’t go to bed hoping it will disappear.

Go to an Emergency Department.

When it comes to testicular torsion, hours matter.

Early surgery may mean the difference between fixing a testicle in place and having to remove it.

And in this particular corner of medicine, keeping both passengers on board is very much the preferred destination.

Medical disclaimer

This information is intended for general patient education and does not replace individual medical assessment. Acute or sudden testicular pain requires urgent medical evaluation. If testicular torsion is suspected, attend an Emergency Department immediately. Your local Brisbane Urologist is on an on-call roster at both the Wesley Hospital and St Andrews War Memorial Hospital. Don’t delay!

The long and the short of it

Penile size is one of those subjects that generates enormous interest, considerable anxiety and, unfortunately, a remarkable amount of questionable information on the internet.

Men may quietly compare themselves with partners, friends’ exaggerated stories, pornography, locker-room mythology or, apparently, the occasional cucumber.

So, does penile size actually matter?

The short answer is: sometimes, but usually much less than men think.

From a urological perspective, most men who are concerned about penile size have a penis that falls within the normal range. Sexual satisfaction is influenced by many factors, including erection quality, communication, attraction, confidence, technique and intimacy. A measuring tape tells us surprisingly little about most of these.

What Is a “Normal” Penis Size?

There is a wide range of normal penile sizes.

Large systematic studies in which measurements were performed by healthcare professionals suggest that the average adult penis is approximately:

• Flaccid length: about 9 cm
• Erect length: about 13–14 cm
• Erect circumference: about 11–12 cm

There is considerable natural variation around these averages.

Importantly, flaccid size is a poor predictor of erect size.

This has given rise to the decidedly non-medical but useful distinction between the “grower” and the “shower.” Some penises change dramatically between the flaccid and erect states, while others start larger but change proportionately less.

Both are normal.

Length Versus Girth: Which Matters More?

This is where the cucumber, banana and asparagus comparison becomes surprisingly educational.

A cucumber may win the girth competition.
An asparagus spear may have impressive length.
The banana brings curvature and enthusiasm to the proceedings.

But none of them is an appropriate benchmark for human anatomy.

When researchers ask about sexual satisfaction, penile dimensions are generally far less important than men often assume. For many partners, girth may have somewhat more influence on sensation than additional length, but there is no universally “ideal” penis.

The vagina is also a highly adaptable organ, and sexual pleasure depends on considerably more than penetration.

Bigger is therefore not automatically better.

At some point, additional size can actually become uncomfortable.

Why Do So Many Men Think They Are Too Small?

Perception plays an enormous role.

A man looking down at his own penis views it from an angle that tends to make it appear shorter. Looking at someone else from the front produces a completely different perspective.

Then there is pornography.

Pornography is not a random anatomical survey of the male population. Performers may be selected partly because of unusual anatomy, and camera angles, grooming and perspective can further exaggerate apparent dimensions.

Using pornography to determine whether your penis is normal is rather like watching the Olympics to decide whether you’re reasonably fit.

How Should Penile Length Be Measured?

If measurement is medically relevant, it needs to be performed consistently.

The most useful clinical measurement is usually stretched penile length.

The penis is gently stretched and measured along its upper surface from the pubic bone to the tip of the glans. The ruler is pressed through the fat overlying the pubic bone.

This last point matters.

The disappearing penis

Weight gain, particularly around the lower abdomen and pubic region, can make a normal penis appear significantly shorter because part of the shaft becomes hidden within the surrounding tissue.

The penis has not necessarily become smaller. More of it has simply gone undercover.

Weight reduction can therefore increase the visible penile length without changing the anatomical length of the penis itself.

Can a Penis Actually Become Shorter?

Yes.

Changes in apparent or actual penile length can occur with:

• increasing body weight
• ageing
• erectile dysfunction
• Peyronie’s disease
• penile fibrosis or scarring
• pelvic or penile surgery
• radical prostatectomy
• hormonal abnormalities in selected circumstances
• a buried penis

Peyronie’s disease deserves particular mention. Scar tissue within the penis can produce curvature, narrowing, indentation and loss of length, sometimes accompanied by painful erections.

A noticeable change in penile shape or length should therefore be assessed rather than simply attributed to ageing.

What Is a Micropenis?

A true micropenis is uncommon.

It is a medical diagnosis based on stretched penile length being significantly below the expected range for age and population, generally more than 2.5 standard deviations below the mean.

This is very different from simply having a penis that is below average.

Remember, approximately half of all men must mathematically be below the average. Statistics can be cruel that way.

If there is genuine concern about unusually small penile size, assessment by a urologist can establish whether the anatomy is within the normal range and whether further investigation is appropriate.

Does Size Affect Sexual Satisfaction?

Usually far less than expected.

Good sexual function depends on a complicated mixture of:

Erection quality + sensation + arousal + communication + technique + confidence + relationship factors.

Penile length is only one variable in a much larger equation.

For penetrative intercourse, an erection that is sufficiently firm and sustainable is generally considerably more important than gaining another centimetre of length.

This is why a man concerned about “size” sometimes actually has an erection-quality problem. A partially rigid penis may appear shorter and narrower than during a full erection.

Treating erectile dysfunction can consequently improve both function and perceived size.

When Should You See a Urologist?

Consider seeking medical advice if you have:

• a significant or progressive reduction in penile length
• new penile curvature
• painful erections
• penile narrowing or an hourglass deformity
• difficulty obtaining or maintaining erections
• a buried or concealed penis
• concerns about a genuinely very small penis
• problems following prostate or pelvic surgery
• persistent anxiety about penile size
• an interest in penile enlargement procedures

A clinical assessment can distinguish normal anatomical variation from a condition that may benefit from treatment.

The Cucumber, Banana and Asparagus Test 🥒🍌🌱

Vegetables make excellent salads.

They make terrible anatomical reference standards.

Penises vary naturally in length, circumference, curvature, proportion and appearance. There is no single ideal shape.

The largest cucumber does not automatically make the best salad, and the largest penis does not automatically produce the best sexual experience.

Sexual satisfaction is much more complicated, and fortunately much more interesting, than a ruler measurement.

The Bottom Line

For the overwhelming majority of men, penile size matters considerably less than they fear.

A healthy penis that provides comfortable erections, sensation and satisfactory sexual function is far more important than whether it wins a theoretical locker-room measuring competition.

If you’re worried about penile size, erection quality, curvature or a change in penile appearance, a urological assessment can provide an objective measurement and determine whether there is actually a medical problem.

And perhaps the most important measuring advice of all:

Measure against medical standards, not pornography, internet advertising or the vegetable aisle.

The foreskin is normally a fairly cooperative piece of anatomy. It moves forward, it moves backward, and for the most part it quietly gets on with its job.

Phimosis occurs when the foreskin becomes too tight to comfortably pull back, or retract, over the head of the penis (glans).

Think of it as a turtleneck that has become a little too enthusiastic about the turtle part.

In young boys, a non-retractile foreskin is usually completely normal. In adult men, however, a foreskin that becomes progressively tighter may indicate inflammation, infection or scarring and deserves assessment.

The good news is that not every tight foreskin requires circumcision. Treatment depends on why it has become tight, how severe it is and how much trouble it is causing.

What is phimosis?

The foreskin, or prepuce, is the fold of skin covering the glans penis. Normally it is sufficiently elastic to retract comfortably.

With phimosis, the opening becomes too narrow to pass easily over the glans.

There are two broad types.

Physiological phimosis

In babies and young boys, the foreskin is naturally attached to the glans and often cannot be retracted. This is a normal part of development and usually resolves gradually as the child grows.

It should not be forcibly pulled back. The foreskin is not a stubborn jar lid. Forceful retraction can cause tearing, bleeding and eventually scarring.

Pathological phimosis

Pathological phimosis develops when the foreskin becomes narrowed because of inflammation, infection or scarring.

This is particularly important in adult men.

If your foreskin previously retracted normally but has progressively become tighter, something has changed and it is worth finding out why.

What Causes Phimosis in Adults?

Recurrent inflammation or infection

Repeated episodes of balanitis (inflammation of the glans) or balanoposthitis (inflammation of both the glans and foreskin) may eventually produce scarring.

Symptoms can include redness, swelling, itching, discomfort, discharge or an unpleasant odour.

One episode may simply be irritating. Repeated episodes are your foreskin submitting a formal complaint.

Lichen sclerosus / Balanitis xerotica obliterans (BXO)

Lichen sclerosus, sometimes called balanitis xerotica obliterans or BXO when affecting the penis, is an important cause of acquired phimosis.

The foreskin may become:

• White or unusually pale
• Thickened
• Scarred
• Less elastic
• Progressively tighter

A characteristic white fibrotic ring can develop around the foreskin opening.

Once significant fibrosis develops, the foreskin behaves less like elastic skin and more like a tiny belt that somebody has pulled one notch too far.

Lichen sclerosus may also involve the urethral opening and occasionally cause narrowing of the urinary passage.

Longstanding penile lichen sclerosus is associated with an increased risk of penile cancer, so persistent or suspicious changes should always be medically assessed.

Diabetes

Recurrent balanitis and phimosis can occasionally be the unexpected messenger announcing previously undiagnosed diabetes.

Elevated glucose levels can encourage fungal and bacterial infections, producing repeated inflammation and eventual scarring.

For this reason, men presenting with recurrent balanitis or newly acquired phimosis may be advised to have their blood glucose checked.

Your foreskin probably isn’t where you expected your diabetes screening programme to begin, but medicine has a sense of humour.

Trauma and scarring

Repeatedly forcing a tight foreskin backwards can cause small tears. These heal with further scar formation, producing the unfortunate cycle:

tightness → tearing → healing → scarring → even more tightness.

Trying harder is therefore not always the solution.

If it repeatedly cracks or tears, stop wrestling with it and have it assessed.

What Are the Symptoms?

Some men have surprisingly few symptoms. Others discover that their foreskin has developed a personality of its own.

Symptoms may include:

• Difficulty or inability to retract the foreskin
• Pain when attempting retraction
• Painful erections
• Cracking or splitting of the foreskin
• Bleeding after intercourse
• Recurrent redness or inflammation
• Recurrent balanitis
• Difficulty cleaning beneath the foreskin
• Discomfort during sexual intercourse
• Ballooning of the foreskin during urination
• Difficulty directing the urinary stream

Severe phimosis can occasionally interfere significantly with urination.

If passing urine starts resembling an unpredictable garden sprinkler, it may be time for a urological opinion.

Phimosis and Sex

A tight foreskin often makes its presence particularly well known during an erection.

Some men can retract the foreskin perfectly well when the penis is flaccid but experience tightness, pain or tearing when erect.

Repeated tearing during intercourse can create additional scar tissue and make the problem progressively worse.

Phimosis does not necessarily cause erectile dysfunction. However, if every erection comes with the anticipation of pain, splitting or bleeding, enthusiasm can understandably begin to decline.

Sex should not require protective headgear.

How Is Phimosis Diagnosed?

Fortunately, diagnosis usually doesn’t require complicated machinery.

Your urologist will examine the penis and assess:

• The degree of narrowing
• Whether the foreskin can be partially or completely retracted
• The presence of a fibrotic or scarred ring
• Evidence of balanitis
• Changes suggesting lichen sclerosus
• The appearance of the glans
• The urethral opening
• Any unusual skin lesion

Blood or urine tests may occasionally be required, particularly when recurrent infection raises the possibility of diabetes.

A biopsy may be recommended if there is an unusual lesion or concern regarding lichen sclerosus, precancerous changes or penile cancer.

Treatment Options

Treatment is tailored to the underlying cause and severity.

Not every tight foreskin needs an appointment with the operating theatre.

1. Observation

Mild phimosis without significant symptoms may simply be observed.

Good hygiene and avoiding forceful retraction are important.

Physiological phimosis in children generally does not require surgery unless specific complications develop.

2. Topical Steroid Treatment

A topical corticosteroid cream or ointment may be prescribed for selected patients.

It is applied to the tight portion of the foreskin, usually for several weeks, sometimes combined with careful and gentle stretching.

The emphasis is on gentle.

This is stretching, not a tug-of-war.

Steroid treatment can reduce inflammation and improve elasticity and tends to work best when there is relatively little established scarring.

A heavily fibrotic foreskin or advanced lichen sclerosus is less likely to respond permanently.

3. Treat the Underlying Infection or Inflammation

When balanitis is present, the underlying cause should be addressed.

Treatment may involve antifungal or antibacterial medication where appropriate, treatment of inflammatory skin disease and attention to penile hygiene.

Repeated infections should also prompt consideration of underlying conditions such as diabetes.

Simply treating each infection without asking why it keeps returning is rather like repeatedly mopping the floor without looking for the leaking pipe.

4. Preputioplasty

A preputioplasty is a foreskin-preserving surgical procedure in which the narrowed area is widened.

Its major advantage is that the foreskin is retained.

It may be an option for selected men who wish to avoid circumcision, but it is less suitable for severe scarring, extensive lichen sclerosus or recurrent inflammatory disease.

There is also a possibility that narrowing may recur.

5. Circumcision

Circumcision remains the definitive surgical treatment for significant or recurrent phimosis.

The narrowed foreskin is surgically removed, permanently exposing the glans.

Circumcision may be recommended for:

• Severe or scarred phimosis
• Recurrent balanitis
• Repeated tearing or bleeding
• Failure of topical treatment
• Painful erections or intercourse
• Significant lichen sclerosus
• Recurrent urinary problems
• Suspicious or abnormal foreskin tissue

Circumcision is usually performed as a day procedure under local or general anaesthesia.

Essentially, when the turtleneck has become irreparably tight, sometimes the most reliable solution is to remove the turtleneck.

What Happens After Circumcision?

Some swelling, bruising and increased sensitivity of the glans are normal during the early recovery period.

Dissolvable sutures are commonly used and healing progresses over several weeks.

Sexual intercourse and masturbation are generally avoided until the wound has adequately healed, often around 4–6 weeks, although recovery varies between individuals.

Possible complications include bleeding, infection, wound problems, scarring, cosmetic dissatisfaction and altered sensation.

Your surgeon will discuss these risks and the expected recovery before surgery.

Phimosis vs Paraphimosis: Don’t Confuse the Two

These names sound annoyingly similar, but the distinction matters.

Phimosis means the foreskin cannot be pulled back normally.

Paraphimosis occurs when a tight foreskin has been pulled behind the glans but then becomes trapped and cannot be brought forward again.

The trapped foreskin can form a constricting band, causing increasing swelling, pain and eventually impaired blood flow.

Paraphimosis requires urgent medical attention.

If the foreskin is trapped behind the glans and the penis is becoming increasingly swollen, painful or discoloured, don’t wait for it to reconsider its position. Seek urgent medical care.

When Should You See a Urologist?

Make an appointment if you develop persistent difficulty retracting the foreskin, recurrent infections, painful erections, repeated tearing or bleeding, progressive tightening, white or scarred areas, urinary difficulties or any persistent lump, ulcer or abnormal penile lesion.

In particular, new phimosis developing in an adult should be assessed.

The Bottom Line

Phimosis is common, treatable and certainly nothing to be embarrassed about.

Mild cases may respond to topical treatment and gentle stretching. Infection or inflammation should be appropriately treated. More significant scarring may require preputioplasty or circumcision.

Most importantly, don’t allow embarrassment to turn a relatively straightforward problem into a much bigger one.

Guys, don’t suffer in silence.

Urologists spend their working lives talking about bladders, prostates, testicles, erections and foreskins. You are extremely unlikely to surprise us.

If your foreskin has become progressively tighter, keeps tearing, becomes repeatedly infected or simply isn’t behaving the way it used to, come and have it assessed.

Drop the embarrassment and come and see your friendly urologist in Brisbane.

Consultations are available at The Wesley Hospital, Caboolture and Bribie Island.

Make an appointment to see Dr Jo.

This information is intended for general patient education and does not replace individual medical assessment or advice.

Urinary incontinence and bladder control problems can have a significant effect on everyday life. Frequent trips to the toilet, sudden urgency, leakage, waking repeatedly at night or being unable to empty the bladder properly can interfere with work, exercise, travel, sleep and social activities.

For men and women whose symptoms have not responded adequately to conservative treatment or medication, sacral neuromodulation (SNM) can provide another treatment option.

Sacral neuromodulation is particularly useful because it can treat two apparently opposite bladder problems:

• an overactive bladder, where the bladder signals too frequently or contracts when it should not; and
• an underactive bladder or non-obstructive urinary retention, where the bladder does not empty effectively.

Rather than operating directly on the bladder, sacral neuromodulation works by modifying the nerve signals involved in bladder storage and emptying.

What is sacral neuromodulation?

The bladder, urethral sphincter, pelvic floor and brain communicate through a complex network of nerves. The sacral nerves, particularly those arising from the S3 region, form an important part of this communication system.

Sacral neuromodulation uses a small, implanted device to deliver mild electrical impulses to a sacral nerve. These impulses help modify abnormal signaling between the bladder, pelvic floor, spinal cord and brain.

A useful way of thinking about the treatment is that it attempts to recalibrate the communication system controlling the bladder, rather than simply forcing the bladder to contract or relax.

International Continence Society guidance recognises sacral neuromodulation as an established therapy for refractory urinary urgency and frequency, urgency urinary incontinence and non-obstructive urinary retention.

Importantly, SNM does not “cure” every patient with urinary incontinence. The aim is to achieve a meaningful and sustained reduction in symptoms and improvement in quality of life.

What conditions can sacral neuromodulation treat?

1. Overactive bladder

Overactive bladder (OAB) is characterised by urinary urgency, usually accompanied by increased frequency and nocturia, with or without urgency urinary incontinence.

Typical symptoms include:

• suddenly needing to pass urine;
• difficulty postponing urination;
• frequent urination during the day;
• waking several times at night to urinate;
• urinary leakage associated with urgency; and
• needing to know where the nearest toilet is whenever leaving home.

Some patients experience urgency and frequency without leakage, while others develop urgency urinary incontinence, where the urge is followed by involuntary loss of urine.

Sacral neuromodulation can be considered when symptoms remain troublesome despite appropriate conservative and/or medical treatment. Current AUA/SUFU guidance includes SNM among the minimally invasive treatment options that clinicians should offer to appropriately selected patients with OAB who have not achieved adequate improvement with behavioural or pharmacological therapy.

2. Urgency urinary incontinence

Urgency urinary incontinence is leakage associated with a sudden compelling desire to urinate.

This is different from stress urinary incontinence, where leakage occurs with coughing, sneezing, exercise or physical exertion.

Sacral neuromodulation is principally a treatment for urgency-related leakage. It is not a standard treatment for isolated stress urinary incontinence.

This distinction is particularly important in women who may have both stress and urgency incontinence and in men who develop stress incontinence following prostate surgery.

When both types of leakage are present, treatment needs to be tailored to determine which component is causing the greatest problem.

What about an underactive bladder?

The bladder does not always misbehave by being too active. Sometimes the problem lies at the other end of the spectrum.

Underactive bladder and urinary retention

An underactive bladder describes symptoms associated with inadequate bladder emptying, often related to reduced bladder contractility or impaired coordination between the bladder and urinary sphincter.

Symptoms can include:

• difficulty starting urination;
• a slow or interrupted urinary stream;
• prolonged urination;
• straining to urinate;
• feeling that the bladder has not emptied;
• recurrent urinary tract infections;
• a large residual volume of urine after voiding; and
• complete inability to empty the bladder without a catheter.

Some patients need to perform clean intermittent self-catheterisation several times each day.

However, poor bladder emptying does not automatically mean that sacral neuromodulation is appropriate.

Obstruction must first be excluded

In men, urinary retention may be caused by:

• benign prostate enlargement;
• urethral stricture;
• bladder neck obstruction; or
• scarring following previous prostate or urethral surgery.

In women, causes can include:

• previous continence surgery;
• urethral obstruction;
• pelvic organ prolapse; or
• functional outlet obstruction.

Sacral neuromodulation is primarily used for non-obstructive urinary retention rather than retention caused by a mechanical blockage.

The distinction may require urine flow testing, measurement of the post-void residual, cystoscopy and, in selected patients, urodynamic studies.

The AUA notes that sacral neuromodulation can be used in appropriately selected men and women with non-obstructive urinary retention, including patients with decreased bladder contractility.

Who may benefit from sacral neuromodulation?

SNM may be considered in appropriately selected men and women with:

• refractory overactive bladder;
• urinary urgency and frequency;
• urgency urinary incontinence;
• non-obstructive urinary retention;
• impaired bladder emptying in selected patients; or
• troublesome bladder dysfunction that has not responded adequately to other treatments.

In Australia, sacral neuromodulation is an established treatment option. The TGA describes implantable sacral nerve stimulation systems as devices used in conditions including overactive bladder, urinary retention and urinary incontinence.

It is generally not a first-line treatment. Australian TGA information relating to the InterStim X system specifically notes that the treatment is not first-line therapy and is intended for appropriately selected patients after conservative and medical management have been attempted.

What treatments are usually tried first?

The treatments used before considering SNM depend upon the underlying bladder problem.

For overactive bladder these may include:

• bladder retraining;
• modification of fluid and caffeine intake;
• pelvic floor physiotherapy;
• management of constipation and other contributing factors;
• antimuscarinic medication;
• beta-3 agonist medication;
• posterior tibial nerve stimulation; and
• bladder injections with botulinum toxin (Botox).

For an underactive bladder or urinary retention, treatment may include:

• treating an identifiable obstruction;
• reviewing medications that may impair bladder emptying;
• timed or double voiding in selected patients; and
• intermittent self-catheterisation.

The appropriate pathway varies considerably between patients.

Assessment before sacral neuromodulation

Successful treatment begins with establishing the correct diagnosis.

Assessment may include:

Medical history

Your urologist will establish whether the predominant problem is urgency, frequency, leakage, difficulty emptying the bladder or a combination of symptoms.

Bladder diary

A bladder diary can record:

• how frequently you urinate;
• urine volumes;
• fluid intake;
• urgency episodes;
• leakage episodes; and
• night-time urination.

Urine testing

Urinary infection should be excluded where appropriate.

Post-void residual measurement

An ultrasound can measure how much urine remains in the bladder after urination.

Uroflowmetry

Urinary flow testing can provide useful information about the strength and pattern of the urinary stream.

Cystoscopy

A cystoscopy may be required when obstruction, urethral narrowing, prostate-related obstruction or another bladder abnormality is suspected.

Urodynamic studies

Urodynamic testing is not required in every patient, but it can be particularly valuable when the diagnosis is uncertain, symptoms are complex, previous treatments have failed or poor bladder emptying needs further investigation.

How is sacral neuromodulation performed?

One of the most attractive features of sacral neuromodulation is that the treatment can usually be tested before committing to a permanent implant.

The procedure therefore generally takes place in two stages.

Stage 1: The test phase

A thin electrode or tined lead is positioned through a small opening in the sacrum adjacent to a sacral nerve, most commonly the S3 nerve root.

The position is confirmed using anatomical landmarks, imaging and appropriate physiological responses during the procedure.

The lead is then connected to an external stimulator.

The patient goes home and uses the system during a trial period while recording symptoms in a bladder diary.

Depending upon the reason for treatment, we look for improvements such as:

• fewer urgency episodes;
• fewer episodes of urinary leakage;
• reduced urinary frequency;
• fewer night-time toilet visits;
• improved bladder emptying;
• lower residual urine volumes; or
• reduced need for intermittent catheterisation.

A meaningful improvement during the test phase, commonly around 50% or greater improvement in the target symptoms, is generally used to determine whether proceeding to permanent implantation is worthwhile.

Stage 2: Permanent implantation

If the trial is successful, a small pulse generator is implanted beneath the skin, usually in the upper buttock.

The device is connected to the previously positioned sacral lead.

Once the incision has healed, the device remains beneath the skin and is generally not visible, although a small contour may sometimes be noticeable.

The stimulator is programmed to provide electrical impulses tailored to the individual patient.

Patients are provided with a programmer or controller that allows appropriate adjustments within parameters established by the treating team.

What does the stimulation feel like?

Patients may notice a mild:

• tingling;
• tapping;
• pulling; or
• vibration-like sensation

in the pelvic, perineal, vaginal, scrotal or anal region.

The stimulation should not normally be painful.

The device can be reprogrammed during follow-up if symptoms change or stimulation becomes uncomfortable.

How successful is sacral neuromodulation?

Success depends on the condition being treated, patient selection and how success is defined.

The major advantage of SNM is that each patient effectively undergoes their own therapeutic trial before receiving the permanent implant.

For refractory overactive bladder, clinical studies demonstrate substantial improvement in appropriately selected patients. The 2024 AUA/SUFU guideline cites a randomised study in which 86% of patients allocated to SNM initially responded and 61% met the study’s definition of therapeutic success at six months.

For non-obstructive urinary retention, treatment may substantially improve bladder emptying and can reduce or sometimes eliminate the need for intermittent catheterisation in responders. AUA evidence reviewing SNM for non-obstructive retention reported a significant reduction in post-void residual urine following treatment.

Individual results vary, and improvement rather than complete cure is a more realistic treatment goal.

Sacral neuromodulation versus Botox

Both sacral neuromodulation and intravesical botulinum toxin are established advanced treatments for refractory overactive bladder.

Botox is injected into the bladder wall during cystoscopy and temporarily reduces excessive bladder contractions.

SNM instead modifies the neural pathways controlling bladder function.

Both can be effective. One practical difference is that Botox usually needs to be repeated as its effect wears off, whereas SNM uses an implanted device designed to provide ongoing treatment.

Botox also carries a risk of urinary retention and urinary tract infection. In the ROSETTA trial, women treated with botulinum toxin had higher rates of urinary tract infection and temporary catheterisation than those treated with SNM, although both treatments produced substantial improvement in urgency incontinence.

The best option depends upon the individual patient’s priorities and bladder function.

Advantages of sacral neuromodulation

Potential advantages include:

• treatment can be tested before permanent implantation;
• no major bladder reconstruction is required;
• it can reduce urgency and urgency incontinence;
• it can improve frequency and nocturia in selected patients;
• it may improve bladder emptying in non-obstructive retention;
• it may reduce dependence on intermittent catheterisation;
• stimulation can be individually programmed;
• treatment is adjustable over time; and
• the system can be removed if necessary.

Perhaps most importantly, SNM offers another option when conventional treatment has failed but major reconstructive surgery is undesirable.

What are the risks and possible complications?

Sacral neuromodulation is a surgical procedure and complications can occur.

These include:

• pain or discomfort around the implant;
• wound infection;
• bleeding or bruising;
• lead movement or migration;
• loss of effective stimulation;
• uncomfortable stimulation;
• change in the location of the stimulation sensation;
• failure to achieve adequate symptom improvement;
• technical problems with the lead or pulse generator;
• need for reprogramming;
• battery depletion; and
• need for revision, replacement or removal of the device.

In studies of SNM for overactive bladder, recognised device-related adverse events have included changes in stimulation, implant-site pain and infection.

Modern systems have improved considerably, but patients should understand that implantation begins a long-term relationship with the device rather than being a one-off operation.

What happens if the treatment stops working?

A reduction in benefit does not necessarily mean that the treatment has permanently failed.

The first step is often to check the device and change its programming.

If this does not restore benefit, further investigation may determine whether there has been:

• lead migration;
• lead damage;
• battery depletion;
• a change in bladder function; or
• another underlying urinary problem.

Occasionally, surgical revision or replacement of the lead or pulse generator is required.

Battery life and rechargeable devices

Different sacral neuromodulation systems and pulse generators are available, including rechargeable and non-rechargeable technologies.

Battery longevity depends on the particular device and the stimulation settings required.

A non-rechargeable generator eventually requires surgical replacement when its battery reaches the end of its useful life.

Rechargeable systems can potentially reduce the frequency of generator replacement but require the patient to recharge the device periodically.

The most appropriate system depends on factors such as age, lifestyle, dexterity, expected stimulation requirements and patient preference.

What about MRI scans?

MRI compatibility has historically been an important issue for patients with implanted neuromodulation devices.

Many modern SNM systems now provide substantially broader MRI access than older devices. However, MRI eligibility depends on the exact pulse generator, lead and implanted system.

Patients should therefore keep their implant identification information and tell radiology staff that they have a sacral neuromodulation device before undergoing an MRI.

Is sacral neuromodulation suitable for both men and women?

Yes.

Although much of the early research into urgency urinary incontinence involved women, sacral neuromodulation can be used in appropriately selected men and women.

In men, it is particularly important to distinguish non-obstructive bladder dysfunction from obstruction caused by prostate enlargement, urethral stricture or previous prostate surgery.

In women, pelvic organ prolapse and previous continence or pelvic surgery may also need to be considered.

The treatment therefore depends much more on the type of bladder dysfunction than on the patient’s sex.

Overactive versus underactive bladder: one treatment, two different problems

It can initially seem strange that the same treatment can help a bladder that is too active and one that does not empty adequately.

This is because sacral neuromodulation is not simply an electrical switch telling the bladder to contract or relax.

Instead, it modifies the complex sensory and motor signalling involved in bladder storage, awareness, pelvic floor coordination and emptying.

For an overactive bladder, this can reduce inappropriate urgency and bladder activity.

For non-obstructive urinary retention or selected underactive bladder dysfunction, neuromodulation may improve the coordination of the bladder outlet and neural pathways involved in effective voiding.

This ability to influence both storage and emptying disorders makes sacral neuromodulation unusual among treatments for lower urinary tract dysfunction.

When should sacral neuromodulation be considered?

Sacral neuromodulation may be worth discussing when:

Overactive bladder symptoms remain troublesome despite conservative and medical treatment

or

Non-obstructive urinary retention is causing significant symptoms or dependence on intermittent catheterisation.

The key is appropriate patient selection.

Before proceeding, it is important to establish why the bladder is malfunctioning. In particular, a mechanical obstruction should not be mistaken for an underactive bladder.

Once the diagnosis is established, the test phase provides a valuable opportunity to determine whether neuromodulation is likely to provide meaningful benefit before committing to a permanent implant.

The bottom line

Sacral neuromodulation is an established, minimally invasive surgical treatment for selected men and women with refractory overactive bladder, urgency urinary incontinence and non-obstructive urinary retention.

A small electrode placed near the sacral nerves modifies the neural signals involved in bladder storage and emptying. Because treatment is usually performed as a staged procedure, patients can assess their response during a test phase before deciding whether to proceed with permanent implantation.

For patients who have spent years planning their lives around the nearest toilet, coping with unpredictable leakage or relying on catheters to empty their bladder, sacral neuromodulation can offer a very different approach: treating the communication network controlling the bladder rather than simply treating the bladder itself.

Important information

This information is intended for general patient education and does not replace individual medical advice. The suitability of sacral neuromodulation depends on the cause of the bladder dysfunction, previous treatments, medical history and individual treatment goals. Assessment by a urologist with experience in urinary incontinence and voiding dysfunction is recommended.

So, if you think is something that may work for you, come see me at my rooms in Brisbane, Caboolture or Bribie Island. Your friendly Brisbane based Urologist, Dr Jo will assist.