Recurrent Urinary Tract Infections: Causes, Investigation and Prevention

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Urinary tract infections are common, uncomfortable and sometimes disruptive to everyday life. For some people, however, they keep returning despite apparently appropriate treatment.

A recurrent urinary tract infection, or recurrent UTI, is generally defined as:

  • Two or more symptomatic infections within six months; or
  • Three or more symptomatic infections within 12 months.

Recurrent UTIs are much more common in women, but they also occur in men, particularly when there is prostate disease, incomplete bladder emptying, urinary stones, catheter use or an abnormality of the urinary tract.

The key to successful management is not simply prescribing another antibiotic. We need to confirm that the symptoms are genuinely caused by infection, identify why infections are recurring and develop an individual prevention strategy.

What symptoms suggest a UTI?

A lower urinary tract infection, or cystitis, commonly causes:

  • Burning or stinging when passing urine
  • Increased urinary frequency
  • Urgency
  • Passing small amounts of urine
  • Lower abdominal discomfort
  • Blood in the urine
  • Cloudy or strong-smelling urine

Fever, shaking, flank or kidney pain, vomiting, confusion or feeling seriously unwell may indicate infection involving the kidneys or bloodstream and requires prompt medical assessment.

Is it always an infection?

Not every episode of burning, urgency or bladder discomfort is caused by bacteria. Similar symptoms may result from:

  • Genitourinary syndrome of menopause or vaginal atrophy
  • Overactive bladder
  • Interstitial cystitis/bladder pain syndrome
  • Pelvic-floor muscle dysfunction
  • Urethral or vaginal inflammation
  • Sexually transmitted infections
  • Urinary stones
  • Bladder cancer
  • Prostatitis
  • Incomplete bladder emptying

Repeated antibiotics given without confirming infection can delay the correct diagnosis and increase antibiotic resistance.

Whenever practical, a midstream urine sample should be collected for culture before commencing antibiotics. The European Association of Urology recommends confirming recurrent cystitis with urine cultures.

Why do urinary infections keep returning?

Most UTIs are caused by bacteria, commonly Escherichia coli, travelling from the bowel or genital region into the urinary tract. Recurrence may represent reinfection with a new organism or relapse involving the same organism.

Common contributing factors in women

These include:

  • Sexual intercourse
  • Spermicide or diaphragm use
  • A new sexual partner
  • Pregnancy
  • Menopause and loss of vaginal oestrogen
  • Vaginal or pelvic-organ prolapse
  • Urinary incontinence
  • Incomplete bladder emptying
  • Diabetes
  • Previous antibiotic exposure
  • Urinary stones or obstruction
  • Catheterisation or urinary-tract procedures

Causes that are particularly important in men

Recurrent UTI in a man usually warrants further assessment. Possible contributors include:

  • Benign prostate enlargement and bladder-outlet obstruction
  • Chronic bacterial prostatitis
  • Urethral stricture
  • Urinary stones
  • High residual urine volumes
  • Catheter use
  • Previous urinary surgery or instrumentation
  • Neurological bladder dysfunction

How are recurrent UTIs investigated?

Assessment begins with a careful history and review of previous urine-culture results. The clinician may consider:

  • Urinalysis and urine culture during symptomatic episodes
  • Examination for vaginal atrophy or pelvic-organ prolapse
  • Measurement of the amount of urine remaining after voiding
  • Kidney and bladder ultrasound
  • Assessment of urinary flow
  • Blood tests, including kidney function and diabetes screening
  • Evaluation for prostatitis in men
  • Cystoscopy or CT imaging in selected patients

Routine cystoscopy or extensive imaging is not necessary for every otherwise healthy woman. Further investigation becomes more important when there is visible blood in the urine, recurrent kidney infection, persistent pain, stones, unusual organisms, poor bladder emptying, previous urinary surgery or failure of standard prevention.

Treating an acute infection

A symptomatic, culture-confirmed infection is usually treated with a short course of antibiotics selected according to:

  • The urine-culture result
  • Previous antibiotic exposure
  • Allergies
  • Kidney function
  • Pregnancy status
  • Local bacterial-resistance patterns

Suitable patients who recognise their symptoms reliably may be offered a prearranged “self-start” antibiotic course, ideally after submitting a urine sample.

A positive urine culture without urinary symptoms is called asymptomatic bacteriuria. It usually should not be treated, except in specific situations such as pregnancy or before certain urological procedures. Treating asymptomatic bacteriuria unnecessarily may increase adverse effects and antibiotic resistance without preventing future infections.

A stepwise prevention strategy

Prevention should normally begin with correction of contributing factors and non-antibiotic measures. Medication or antibiotic prophylaxis can then be introduced when the expected benefit outweighs the risks.

1. Hydration and bladder habits

For people who normally drink relatively little, increasing water intake may reduce infection frequency. One clinical trial found benefit from an additional 1.5 litres of water daily in premenopausal women whose usual fluid intake was below 1.5 litres per day.

Other practical measures include:

  • Avoiding prolonged delays in passing urine
  • Emptying the bladder after intercourse if this appears helpful
  • Treating constipation
  • Avoiding spermicides when infections are temporally associated with their use
  • Managing prolapse or incomplete bladder emptying
  • Reviewing catheter technique and necessity
  • Optimising diabetic control

Many traditional recommendations: such as a particular wiping direction, special underwear or mandatory post-coital voiding, have limited supporting evidence. They are generally harmless but should not be presented as guaranteed prevention.

2. Vaginal oestrogen

Vaginal oestrogen is one of the best-supported non-antibiotic treatments for postmenopausal women with recurrent UTIs, particularly when vaginal dryness, irritation or discomfort is present.

It may be supplied as a cream, pessary or vaginal tablet. Local treatment helps restore the vaginal tissues and protective bacterial environment. It is different from systemic menopausal hormone therapy and produces much lower systemic hormone exposure.

Temporary local irritation or spotting may occur. Women with a history of oestrogen-sensitive cancer should discuss treatment with their treating specialists. Oral oestrogen has not demonstrated the same UTI-prevention benefit.

The EAU gives vaginal oestrogen a strong recommendation for prevention in postmenopausal women.

3. Methenamine hippurate

Methenamine hippurate is a urinary antiseptic rather than a conventional antibiotic. In acidic urine, it is converted into formaldehyde, which suppresses bacterial growth.

The ALTAR randomised trial found that methenamine hippurate was not inferior to daily low-dose antibiotics for preventing recurrent UTIs in women over 12 months, although the antibiotic group experienced slightly fewer infections.

Methenamine can be a useful antibiotic-sparing option for selected patients without significant urinary-tract abnormalities. It may not be suitable in severe kidney or liver impairment and must not be combined with sulfonamide antibiotics. Alkalinising urinary products may reduce its effectiveness. Medical supervision is therefore important.

4. Cranberry products

Cranberry products may modestly reduce recurrent UTIs in some women, but products and doses vary greatly. Evidence is supportive but inconsistent, and there is no universally accepted dose.

Cranberry should be considered an optional supplement rather than a replacement for investigation or proven treatment. Patients taking warfarin should discuss cranberry products with their doctor because of a potential interaction.

5. D-mannose

D-mannose has been widely promoted as preventing E. coli from adhering to the bladder lining. Earlier small studies suggested benefit, but a larger placebo-controlled trial found that daily D-mannose did not significantly reduce medically attended recurrent UTIs.

It may still be chosen by some patients, but expectations should be realistic. Current evidence is weak and contradictory.

6. Probiotics

Some vaginal Lactobacillus preparations may help restore protective vaginal flora, but results depend on the bacterial strain and formulation. Evidence remains insufficient to recommend all commercially available oral or vaginal probiotics as equivalent treatments.

Prophylactic antibiotics

When infections remain troublesome despite correcting reversible causes and trying appropriate non-antibiotic measures, prophylactic antibiotics may be considered.

Post-coital prophylaxis

A single antibiotic dose taken after intercourse may be appropriate when infections are clearly related to sexual activity. It reduces total antibiotic exposure compared with daily treatment.

Continuous low-dose prophylaxis

A low-dose antibiotic may be prescribed nightly or at another regular interval, commonly for three to six months and sometimes longer. Options may include nitrofurantoin, trimethoprim, cefalexin or intermittent fosfomycin, depending on culture results, renal function, allergies and Australian resistance patterns.

Daily and post-coital prophylaxis appear similarly effective when correctly matched to the patient’s infection pattern.

Potential disadvantages include:

  • Thrush, nausea or diarrhoea
  • Allergic reactions
  • Selection of resistant bacteria
  • Clostridioides difficile infection
  • Drug-specific toxicity

Long-term nitrofurantoin, for example, can rarely affect the lungs, liver or peripheral nerves and requires appropriate clinical monitoring. Infections may return after prophylaxis is stopped.

For these reasons, antibiotic prophylaxis should be reviewed periodically rather than continued automatically.

Bladder instillations

The correct term is bladder or intravesical instillation. A small catheter is passed into the bladder, and a solution is introduced and retained for a prescribed period.

Hyaluronic acid, alone or combined with chondroitin sulphate, is intended to replenish the bladder’s protective glycosaminoglycan layer. Studies suggest that these treatments may:

  • Reduce the number of recurrent infections
  • Increase the time before the next infection
  • Improve associated bladder pain, urgency or frequency in some patients

However, the evidence is based on relatively small and mixed-quality studies. The EAU makes only a weak recommendation for these instillations after less-invasive prevention strategies have failed.

Treatment usually requires an initial series followed by maintenance instillations. Disadvantages include cost, inconvenience, temporary discomfort and the small infection or urethral-trauma risk associated with catheterisation.

Antibiotic bladder instillation, most often gentamicin, is used off-label in selected patients, particularly those performing intermittent catheterisation or those with neurological bladder dysfunction and resistant infections. Evidence is mainly observational, and treatment should be supervised by an experienced urologist or infectious-diseases team. It is not routine first-line therapy for otherwise healthy patients.

Are vaccines available for recurrent UTIs?

Several bacterial immunoactive products are sometimes described as UTI “vaccines,” although they are different from conventional childhood vaccines and are not routinely available or approved in every country.

Examples include:

  • OM-89 or Uro-Vaxom: an oral preparation containing bacterial lysates from selected E. coli strains
  • MV140 or Uromune: a sublingual spray containing inactivated whole-cell bacteria
  • StroVac: an injectable bacterial preparation available in limited settings
  • Other experimental products, including ExPEC vaccines

MV140 has produced encouraging results in a randomised trial and observational studies. However, the EAU notes that the certainty of the overall evidence remains low and currently recommends immunomodulatory prophylaxis mainly within a well-regulated clinical-trial setting.

These products should not be advertised as a guaranteed cure. Regulatory approval, supply and access vary, and some may be unapproved or available only through special-access pathways in Australia. Patients should discuss the evidence, cost, regulatory status and alternatives with their urologist before considering treatment.

When should you seek urgent help?

Prompt medical assessment is important if urinary symptoms are accompanied by:

  • Fever or shaking chills
  • Kidney or flank pain
  • Vomiting or inability to keep fluids down
  • Confusion, faintness or severe weakness
  • Pregnancy
  • Inability to pass urine
  • Significant visible blood or blood clots
  • Rapid deterioration or concern about sepsis

Men, children, pregnant women, immunocompromised patients and people with urinary obstruction, catheters or known kidney disease generally require earlier assessment.

The take-home message

Recurrent UTIs are real and can have a substantial effect on comfort, confidence, sexual relationships, work and quality of life. Management should go beyond repeated short courses of antibiotics.

A sensible strategy is to:

  1. Confirm symptomatic episodes with urine cultures.
  2. Exclude conditions that mimic infection.
  3. Identify stones, obstruction, residual urine, prolapse, vaginal atrophy or prostate disease.
  4. Correct reversible causes.
  5. Introduce evidence-based non-antibiotic prevention.
  6. Consider methenamine or carefully selected antibiotic prophylaxis when necessary.
  7. Reserve bladder instillations and immunoactive treatments for appropriately selected patients after an informed discussion.

Treatment should always be individualised according to the patient’s culture results, anatomy, medical history and personal preferences.

So, if you suffer with chronic or recurrent infections, ask your GP for a referral to your Brisbane, Caboolture Urologist, Dr Jo Schoeman for further advice.

References and further reading

  1. European Association of Urology. EAU Guidelines on Urological Infections. Section on recurrent cystitis.
  2. American Urological Association, Canadian Urological Association and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Recurrent Uncomplicated Urinary Tract Infections in Women Guideline.
  3. National Institute for Health and Care Excellence. Urinary tract infection—recurrent: antimicrobial prescribing, NG112.
  4. Harding C, Mossop H, Homer T, et al. Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women: the ALTAR non-inferiority trial. BMJ. 2022;376.
  5. Williams G, Hahn D, Stephens JH, et al. Cranberries for preventing urinary tract infections. Cochrane Database of Systematic Reviews. 2023.
  6. Hayward G, Mort S, Hay AD, et al. D-mannose for prevention of recurrent urinary tract infection among women. JAMA Internal Medicine. 2024.
  7. Infectious Diseases Society of America. Clinical practice guideline for the management of asymptomatic bacteriuria.
  8. Australian Commission on Safety and Quality in Health Care. Antimicrobial stewardship resources.

This information is intended for general education and does not replace individual medical assessment. Antibiotic choice and preventive treatment should be guided by urine cultures, kidney function, allergies, pregnancy status, local resistance patterns and current Australian prescribing guidance.

Interstitial cystitis/bladder pain syndrome: what treatments work and how successful are they?

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Interstitial cystitis, now more commonly called bladder pain syndrome (IC/BPS), is a chronic condition in which pain, pressure or discomfort is perceived to arise from the bladder and is usually accompanied by urinary frequency or urgency. Symptoms commonly worsen as the bladder fills and may improve temporarily after passing urine.

IC/BPS is not the same as recurrent bacterial cystitis. Urine cultures are usually negative, antibiotics generally do not help unless a genuine infection is present, and there is no single diagnostic test or universally effective medicine.

The honest message is that IC/BPS can usually be managed, but it is rarely cured by one treatment. The most successful strategy is often a tailored combination of education, trigger management, pelvic-floor care, pain treatment and bladder-directed therapy. Treatment should be reviewed regularly and stopped if it is ineffective.

Before treatment: make sure the diagnosis fits

IC/BPS is diagnosed from the symptom pattern after excluding other important causes. Assessment may include:

  • A detailed history and examination
  • Urinalysis and urine culture
  • A bladder diary
  • Assessment for pelvic-floor tenderness
  • Urine cytology, imaging or cystoscopy when clinically indicated

Blood in the urine, recurrent proven infection, urinary stones, endometriosis, pelvic-floor dysfunction, overactive bladder, urethral disease and malignancy may produce overlapping symptoms.

Cystoscopy is particularly useful when Hunner lesions are suspected. These inflamed areas of the bladder lining identify an important subgroup because lesion-directed treatment is often more effective than general medication.

Urodynamic studies are not routinely required to diagnose uncomplicated IC/BPS. They may be helpful when the diagnosis is uncertain or when voiding dysfunction, obstruction or another bladder disorder is suspected.

How successful is treatment overall?

Treatment results vary considerably. Clinical trials use different diagnostic criteria and definitions of success, while IC/BPS probably represents several related conditions rather than one disease. Placebo responses can also be substantial.

For example, in a large amitriptyline trial, 55% of patients taking amitriptyline reported moderate or marked improvement, compared with 45% receiving placebo. Among patients able to tolerate at least 50 mg per day, response was 66%, compared with 47% on placebo.

This illustrates why a treatment may appear impressive in an uncontrolled case series but demonstrate only modest additional benefit in a rigorous trial.

A network meta-analysis of 23 randomised trials involving 1,871 participants found possible symptom-score benefits from amitriptyline and cyclosporine. However, no medicine consistently improved every important outcome, and none significantly reduced 24-hour urinary frequency. A more recent systematic review reached a similar conclusion: several treatments show promise, but the evidence remains limited by small trials, mixed patient populations and variable study quality.

Success should therefore be defined individually. Less pain, fewer night-time trips, longer intervals between voids, improved sexual function, better sleep or a return to normal activities may be more realistic goals than complete disappearance of symptoms.

A practical treatment ladder

1. Education, self-management and flare planning

These measures are recommended for almost everyone:

  • Identify individual food and drink triggers.
  • Avoid excessive fluid intake without deliberately becoming dehydrated.
  • Use heat, gentle movement, relaxation and a written flare-management plan.
  • Address constipation, poor sleep, anxiety, painful intercourse and associated pain conditions.
  • Stop smoking.
  • Consider gradual bladder training if it does not provoke unacceptable pain.

Frequently reported triggers include caffeine, alcohol, carbonated drinks, citrus, tomatoes, chilli and artificial sweeteners. However, triggers are highly individual and the evidence for a universal restrictive “IC diet” is weak.

A short elimination period followed by careful reintroduction is more sensible than avoiding a long list of foods indefinitely.

2. Pelvic-floor physiotherapy

Many patients with IC/BPS have a tender, overactive or poorly coordinated pelvic floor. Specialist physiotherapy may include internal and external myofascial release, muscle relaxation, breathing exercises and coordination work.

A randomised trial in women with pelvic-floor tenderness found that approximately 59% responded to myofascial physiotherapy, compared with 26% receiving general therapeutic massage.

This treatment is not simply pelvic-floor strengthening. Repetitive Kegel exercises may aggravate symptoms when the muscles are already tight and painful. Physiotherapy should ideally be provided by a pelvic-health physiotherapist familiar with IC/BPS.

3. Oral medicines

Many oral medicines used for IC/BPS are off-label in Australia. This means the medicine is prescribed for a condition or purpose not included in its Australian approval.

Off-label prescribing is common and can be appropriate, but patients should be told about the limitations in the evidence, potential adverse effects and alternative treatments.

Amitriptyline: off-label

Amitriptyline can reduce neuropathic pain, urgency and night-time symptoms and may improve sleep. It is usually started at a low dose and increased gradually according to benefit and tolerability.

Overall trial benefit has been modest, although patients who tolerated at least 50 mg per day appeared more likely to respond.

Possible adverse effects include:

  • Dry mouth
  • Constipation
  • Drowsiness
  • Weight gain
  • Blurred vision
  • Dizziness and falls
  • Cardiac rhythm effects

These effects may limit its usefulness, particularly in older patients.

Hydroxyzine and other antihistamines: off-label

Antihistamines are sometimes considered when allergy or mast-cell-type symptoms appear prominent. Evidence is limited and inconsistent.

Sedation, dry mouth, constipation and cognitive effects can occur. Antihistamines should not be presented as proven routine treatment for all patients with IC/BPS.

Cimetidine: off-label

Small studies suggest that cimetidine may improve pain and nocturia in some patients. However, the evidence is sparse and it is difficult to predict who will respond. Interactions with other medicines should be checked.

Pentosan polysulfate sodium: Elmiron

Pentosan polysulfate sodium, or PPS, is registered in Australia for interstitial cystitis. It is intended to supplement or protect the bladder’s glycosaminoglycan lining.

However, its efficacy has been inconsistent across clinical trials, and it should not be described as a guaranteed “bladder lining repair.” When improvement occurs, it may take several months.

The major contemporary concern is pigmentary maculopathy, a potentially serious retinal disorder associated particularly with prolonged exposure and higher cumulative doses.

The Australian Therapeutic Goods Administration advises that patients be counselled about this risk and undergo regular ophthalmic examinations, particularly during long-term treatment. New difficulty reading, blurred vision, altered colour perception or slow adjustment to dim lighting requires prompt medical and ophthalmic review.

Gabapentin, pregabalin and duloxetine: off-label

Neuropathic-pain medicines may be considered when nerve-type pain or another chronic pain syndrome coexists. Direct evidence for IC/BPS is limited.

Possible adverse effects include dizziness, drowsiness, cognitive impairment, swelling and weight gain. These medicines should be continued only when there is measurable benefit.

Opioid medicines do not treat the underlying condition and are generally avoided for long-term management because sustained benefit is uncertain and harms can accumulate.

Cyclosporine A: off-label and specialist-only

Trials suggest that cyclosporine may be more effective than pentosan polysulfate in some people with severe, refractory disease, particularly patients with Hunner lesions.

However, cyclosporine can cause:

  • Kidney impairment
  • High blood pressure
  • Increased infection risk
  • Liver abnormalities
  • Significant medication interactions

It is unsuitable as routine therapy. If considered, it requires careful patient selection and close monitoring of blood pressure, kidney function and other safety parameters.

4. Medicines placed directly into the bladder

Bladder instillations may be considered when oral treatments are ineffective or poorly tolerated. Catheterisation can temporarily aggravate symptoms and carries a small risk of infection or urethral trauma.

Dimethyl sulfoxide: DMSO

DMSO is an established intravesical treatment in some jurisdictions. Older trials and clinical series report response rates commonly around 50–70% in selected patients, but the studies are generally small and the certainty of this estimate is low.

Treatment may cause temporary bladder discomfort, a symptom flare, and a garlic-like taste or body odour. Availability and regulatory status vary between countries.

Heparin, lignocaine and sodium bicarbonate “rescue” instillations:  off-label

Alkalinised lignocaine may provide relatively rapid, short-term pain relief. Heparin is intended to supplement the bladder’s protective surface layer.

Observational studies have reported improvement in approximately 56–73% of patients following courses of heparin-based instillations. However, controlled evidence is limited and the duration of benefit is uncertain.

These instillations may be useful during severe flares or as a monitored therapeutic trial, but they should not be described as a cure.

Hyaluronic acid and chondroitin sulphate

These bladder-coating treatments are widely used in some countries and are intended to replenish the glycosaminoglycan layer.

Some trials and observational studies report improvement, but results are inconsistent. Current comparative evidence does not reliably identify one preparation as superior.

The cost, repeated catheterisation, local availability and uncertain durability of benefit should be considered.

5. Procedures when medication is insufficient

Treatment of Hunner lesions

Fulguration, laser treatment or injection of triamcinolone into a Hunner lesion can produce substantial relief. Recurrence is common, however, and repeat treatment may be required.

This is one of the clearest reasons to identify the IC/BPS subtype rather than treating every patient identically.

Cystoscopy and hydrodistension

Low-pressure, short-duration bladder hydrodistension may help a subset of patients, usually for a limited period. Benefits are unpredictable, and symptoms may initially flare.

High-pressure or prolonged hydrodistension should be avoided because it carries greater risk without established additional benefit.

Botulinum toxin A: off-label for IC/BPS

Botulinum toxin injections into the bladder wall may reduce pain and urinary frequency in selected patients with refractory symptoms. It has sometimes been combined with hydrodistension in clinical studies.

Systematic reviews suggest possible benefit, but injection techniques, doses and study outcomes vary. Evidence for IC/BPS remains less certain than evidence supporting botulinum toxin for overactive bladder.

Risks include urinary infection, incomplete bladder emptying and the temporary need for intermittent self-catheterisation.

Neuromodulation

Posterior tibial nerve stimulation or sacral neuromodulation may be considered when urgency and frequency remain disabling.

Neither treatment reliably addresses bladder pain, and the supporting evidence specifically for IC/BPS is limited. Sacral neuromodulation involves a test phase followed by implantation of a permanent device only when the trial produces worthwhile improvement.

Major reconstructive surgery is reserved for a very small number of carefully selected patients with severe, refractory disease, particularly those with a small fibrotic bladder. Pain can persist after surgery if it is not truly bladder-centred.

Treatments that should generally be avoided

Long courses of antibiotics should not be prescribed when urine cultures do not demonstrate infection.

The American Urological Association also recommends against several historical treatments because benefit is absent or the risks outweigh it. These include:

  • Bacillus Calmette–Guérin treatment outside a clinical trial
  • Resiniferatoxin
  • High-pressure or prolonged hydrodistension
  • Long-term systemic glucocorticoids as routine IC/BPS treatment

Supplements such as quercetin, aloe vera and calcium glycerophosphate are promoted for IC/BPS, but high-quality evidence and reliable product standardisation are lacking. “Natural” does not mean risk-free, and supplements can interact with prescribed medicines.

Choosing treatment fairly

An unbiased treatment plan asks four questions:

  1. What is the dominant problem?
    Bladder-filling pain, pelvic-floor tenderness, Hunner lesions, urinary frequency and widespread pain may require different approaches.
  2. How strong is the evidence?
    Randomised controlled trials provide more reliable information than testimonials or uncontrolled case series.
  3. What is the treatment burden?
    Sedation, eye surveillance, repeated catheterisation, financial cost or the possibility of self-catheterisation may outweigh a modest benefit.
  4. Has the treatment worked enough to continue?
    Measurable goals should be agreed before treatment. Where possible, introduce one change at a time and discontinue ineffective therapy.

Combination treatment is common because IC/BPS may involve the bladder lining, sensory nerves, pelvic floor and the broader pain-processing system.

Psychological or pain-management support does not imply that symptoms are imaginary. Persistent pain can disrupt sleep, mood, relationships and nervous-system processing, and addressing these effects can improve function and quality of life.

When to seek prompt reassessment

Seek medical review for:

  • Visible blood in the urine
  • Fever or flank pain
  • Inability to pass urine
  • Recurrent positive urine cultures
  • Unexplained weight loss
  • New neurological symptoms
  • A significant change from the usual symptom pattern

These features should not automatically be attributed to IC/BPS.

The bottom line

There is no universally successful tablet or bladder instillation for interstitial cystitis/bladder pain syndrome.

Pelvic-floor physiotherapy has useful trial evidence in patients with pelvic-floor tenderness. Amitriptyline can help some patients who tolerate an adequate dose. Pentosan polysulfate offers uncertain average benefit and requires explicit discussion of retinal risk. Intravesical therapy, botulinum toxin and neuromodulation may help selected patients with refractory symptoms, while cyclosporine is reserved for exceptional specialist-managed cases.

Hunner lesions should be actively sought when clinically suspected because targeted treatment can be particularly valuable.

The best outcomes usually come from confirming the diagnosis, identifying the individual patient’s symptom pattern, setting realistic goals and building a treatment plan through monitored therapeutic trials, not from promising a single cure.

This article provides general information and is not a substitute for individual medical advice. Treatment availability, Australian regulatory approval and subsidy arrangements may change. Patients should discuss medications, off-label treatment, pregnancy, eye monitoring and possible drug interactions with their treating clinician.

Selected evidence and guidance

  1. Clemens JQ, Erickson DR, Varela NP, Lai HH. Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome. Journal of Urology. 2022;208:34–42. American Urological Association guideline.
  2. European Association of Urology. EAU Guidelines on Chronic Pelvic Pain—Primary Bladder Pain Syndrome. EAU guideline.
  3. Foster HE Jr, et al. Effect of amitriptyline on symptoms in treatment-naïve patients with interstitial cystitis/painful bladder syndrome. Journal of Urology. 2010;183:1853–1858. PubMed record.
  4. FitzGerald MP, et al. Randomized multicenter clinical trial of myofascial physical therapy in women with IC/PBS and pelvic-floor tenderness. Journal of Urology. 2012;187:2113–2118. PubMed record.
  5. Di X-P, et al. Efficacy and safety comparison of pharmacotherapies for IC/BPS: a systematic review and Bayesian network meta-analysis. International Urogynecology Journal. 2021;32:1129–1141. PubMed record.
  6. Park JJ, et al. Current updates relating to treatment for IC/BPS: systematic review and network meta-analysis. BMC Urology. 2024;24:95. Open-access article.
  7. Therapeutic Goods Administration. Pentosan polysulfate sodium—Elmiron: risk of pigmentary maculopathy. TGA safety advisory.

Artificial Urinary Sphincter After Prostatectomy: Restoring Control After Male Stress Incontinence

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Urinary leakage after prostate surgery can be frustrating, embarrassing and restrictive. When persistent leakage is caused by weakness of the urinary sphincter, an artificial urinary sphincter (AUS) is often the most reliable surgical treatment—particularly for moderate or severe stress urinary incontinence.

However, not every man who leaks after prostatectomy has the same problem. Before inserting an AUS, it is essential to establish why the leakage is occurring. An AUS treats sphincter weakness; it does not directly treat an overactive bladder.

Why can incontinence occur after prostatectomy?

Urinary continence normally depends on several structures working together:

  • The external urinary sphincter closing the urethra
  • Healthy supporting tissues around the urethra
  • A bladder that stores urine at a safe pressure
  • Coordinated bladder and sphincter function
  • Adequate pelvic-floor muscle control

During radical prostatectomy, the prostate and part of the internal continence mechanism are removed. Although every effort is made to preserve the external sphincter, it may be weakened by surgical dissection, altered support, scarring or nerve injury.

Radiotherapy, previous urethral surgery, bladder-neck contracture and urethral stricture may further affect continence and tissue quality.

Stress incontinence or overactive bladder?

This distinction is critical because the treatments are different.

Stress urinary incontinence

Stress incontinence typically causes leakage with:

  • Coughing or sneezing
  • Standing from a chair
  • Walking or exercising
  • Lifting
  • Bending
  • Changing position
  • A full bladder
  • Sexual activity

The leakage is usually caused by inadequate closure of the urinary sphincter. This is the type of incontinence that an AUS is designed to treat.

Overactive bladder

Overactive bladder generally causes:

  • A sudden, difficult-to-defer need to urinate
  • Frequent urination
  • Waking several times at night
  • Leakage before reaching the toilet
  • Leakage triggered by running water, arriving home or putting the key in the door

These symptoms may result from involuntary bladder contractions, reduced bladder capacity, bladder irritation, infection, obstruction or changes in bladder function that existed before the prostate operation.

Some men have mixed incontinence, with both stress leakage and urinary urgency. An AUS may improve the stress component while urgency, frequency or urge leakage persists and requires separate treatment.

Assessment before considering an AUS

A careful evaluation helps confirm that sphincter weakness is the principal cause of leakage and identifies conditions that should be treated before implantation.

Assessment may include:

  • A detailed symptom and surgical history
  • Physical examination
  • Urinalysis and urine culture
  • A bladder or voiding diary
  • Pad-use assessment or a formal pad-weight test
  • Measurement of urinary flow and residual urine
  • Cystoscopy to examine the urethra, sphincter region and bladder neck
  • Urodynamic studies in selected patients

Any urinary infection, bladder-neck contracture or urethral stricture should usually be treated and shown to be stable before an AUS is inserted.

The role of urodynamic studies

Urodynamics evaluates how the bladder stores and empties urine. It may help identify:

  • Genuine stress urinary incontinence
  • Detrusor overactivity or overactive bladder contractions
  • Poor bladder compliance or unsafe storage pressures
  • Reduced bladder capacity
  • Weak bladder contraction
  • Bladder-outlet obstruction
  • Mixed stress and urgency incontinence

Urodynamics is not necessarily required for every straightforward case. Current guidelines support its selective use when the diagnosis is uncertain or when the findings could change management.

It is particularly useful when a man has:

  • Marked urgency or urge leakage
  • Difficulty emptying his bladder
  • An elevated residual urine volume
  • Previous radiotherapy
  • Previous surgery for a urethral stricture or bladder-neck contracture
  • Neurological disease
  • Unexplained or mixed urinary symptoms
  • Leakage that does not follow a typical stress-incontinence pattern

Finding detrusor overactivity does not automatically exclude AUS surgery. It allows the patient and surgeon to set realistic expectations and determine whether bladder-directed treatment should be given before or after the procedure.

What is an artificial urinary sphincter?

An AUS is a fluid-filled hydraulic device with three main components:

  1. Urethral cuff: placed around the urethra to keep it gently closed.
  2. Control pump: positioned inside the scrotum, where it can be felt and operated through the skin.
  3. Pressure-regulating balloon: usually placed in the lower abdomen or pelvis.

The cuff remains closed during normal activities and prevents urine from leaking. To urinate, the patient squeezes the scrotal pump. This temporarily transfers fluid out of the cuff, allowing the urethra to open. The cuff then automatically refills over the following few minutes.

The device is entirely internal. Nothing normally remains outside the body.

Who may benefit from an AUS?

An AUS may be considered when:

  • Stress incontinence persists despite pelvic-floor rehabilitation
  • Leakage significantly affects work, exercise, travel, sleep, relationships or quality of life
  • Incontinence is moderate or severe
  • The patient has undergone prostatectomy or other prostate treatment
  • The urethra and bladder neck are open and stable
  • Urinary infection has been excluded
  • Bladder storage and emptying are sufficiently safe
  • The patient understands that the implant may eventually require revision
  • The patient has enough hand strength and dexterity to operate the pump

Guidelines recommend discussing AUS surgery with men experiencing persistent stress incontinence after prostate treatment, including selected men with mild leakage who prefer this option.

Surgery is usually deferred while natural recovery is still occurring. Incontinence that remains troublesome at approximately six months and is not improving may justify earlier discussion, while definitive surgery is commonly considered by 12 months after prostatectomy.

When may an AUS be unsuitable?

An AUS may not be appropriate when there is:

  • Active urinary infection
  • An untreated or unstable urethral stricture
  • Recurrent bladder-neck obstruction
  • Active urethral erosion
  • Inability to operate the scrotal pump
  • Severe cognitive impairment
  • An unsafe, poorly compliant bladder that has not been addressed
  • A continuing need for frequent urethral catheterisation or instrumentation

Previous pelvic radiotherapy does not necessarily prevent AUS implantation. However, radiated tissues may heal less reliably and have a higher risk of erosion, infection and future revision.

What happens during and after surgery?

The operation is performed under anaesthesia. The cuff is commonly placed around the bulbar urethra through an incision in the perineum, with the pump positioned in the scrotum and the balloon placed in the lower abdomen or pelvis.

The AUS is normally left deactivated while the tissues heal. It is commonly activated approximately four to six weeks later, depending on the patient’s recovery and the surgeon’s protocol.

Until activation, urinary leakage is expected to continue.

Patients are then taught how to:

  • Locate and operate the pump
  • Empty the bladder without repeatedly squeezing the pump
  • Recognise whether the device has cycled normally
  • Explain the implant to other healthcare providers
  • Seek assistance if catheterisation or urinary procedures are required

How successful is an AUS?

The AUS is regarded as the standard surgical treatment for moderate-to-severe male stress incontinence after prostatectomy. Most men experience a substantial reduction in leakage and improvement in quality of life.

“Success” does not always mean being completely pad-free. Many men achieve social continence, generally described as using no more than one small security pad per day. Results vary according to previous radiotherapy, urethral surgery, tissue quality, severity of leakage and how success is defined.

An AUS is a mechanical implant rather than a permanent cure. Device survival decreases over time, and some men will eventually require revision or replacement.

Possible complications

Potential complications include:

  • Bleeding, bruising or haematoma
  • Temporary urinary retention
  • Wound or device infection
  • Difficulty locating or operating the pump
  • Persistent stress leakage
  • Ongoing urgency or urge incontinence
  • Urethral cuff erosion
  • Urethral tissue thinning or atrophy
  • Mechanical malfunction or fluid leakage
  • Pump or component migration
  • Pain
  • Need for revision, replacement or removal

Infection and erosion generally require removal of part or all of the device. A new AUS may sometimes be inserted after the urethra has healed, but repeat surgery can be more complex.

Warning signs of cuff erosion or device infection

Urethral erosion occurs when the cuff gradually damages or enters the urethral wall. It may develop months or years after implantation.

Seek prompt urological review if you notice:

  • New pain or burning during urination
  • Blood in the urine
  • Recurrent urinary infections
  • Increasing perineal, urethral or scrotal discomfort
  • New swelling, redness, warmth or discharge around an incision
  • Fever or feeling generally unwell
  • Difficulty passing urine
  • A noticeably weaker urinary stream
  • Sudden urinary retention
  • A sudden return or marked worsening of leakage
  • The pump becoming unusually difficult to operate
  • Part of the device becoming visible through the skin or urethra

Fever, urinary retention, marked swelling, severe pain or an exposed implant requires urgent medical assessment.

Important precautions after AUS implantation

Always tell healthcare providers about the AUS

A urethral catheter must not be inserted while the cuff is activated. Forcing a catheter through a closed cuff may damage the urethra and cause erosion.

Before catheterisation, cystoscopy or any procedure through the urethra:

  • The AUS must be identified
  • The cuff must be fully deactivated
  • The smallest appropriate catheter should be used
  • Prolonged urethral catheterisation should be avoided when possible
  • The treating team should contact a urologist if they are unfamiliar with the device

Patients should consider carrying a medical alert card or wearing medical identification stating:

“Artificial urinary sphincter present, deactivate before urethral catheterisation.”

Protect the urethra and implant

Patients should also:

  • Avoid operating the pump until instructed after surgery
  • Follow restrictions on lifting, exercise, cycling and sexual activity during healing
  • Avoid unnecessary urethral instrumentation
  • Report urinary infections promptly
  • Attend follow-up if leakage increases or the device behaves differently
  • Tell their urologist about future pelvic procedures
  • Never repeatedly squeeze the pump in an attempt to overcome urinary obstruction

What if the AUS fails?

The first step is to determine the reason. Recurrent leakage may be caused by:

  • Mechanical device failure
  • Loss of fluid from the system
  • Incomplete cuff closure
  • Urethral tissue thinning beneath the cuff
  • Cuff erosion
  • Device infection
  • A urethral or bladder-neck obstruction
  • Overactive bladder rather than sphincter failure
  • Incorrect device use

Assessment may include examination of the pump, urinalysis, cystoscopy, imaging, pad testing and sometimes repeat urodynamics.

Depending on the cause, options include:

  • Teaching or correcting pump technique
  • Treating overactive bladder separately
  • Revising or replacing a malfunctioning component
  • Replacing the entire AUS
  • Changing cuff size or position
  • Moving the cuff to a healthier section of urethra
  • Tandem-cuff or transcorporal techniques in carefully selected complex cases
  • Removing the device when infection or erosion is present
  • Allowing the urethra to heal before considering reimplantation
  • Considering a male sling in selected men with mild recurrent stress leakage
  • External collecting devices, continence clamps, absorbent products or long-term catheter options when further implant surgery is unsuitable

Men with prior radiotherapy, erosion or multiple urethral operations may require individualised reconstructive planning.

A final perspective

An artificial urinary sphincter can be life-changing for men with persistent stress urinary incontinence after prostatectomy. Its success depends on more than inserting a device: the correct cause of leakage must first be established.

Stress incontinence, overactive bladder, obstruction and poor bladder emptying can coexist. A careful history, objective assessment, cystoscopy and selective urodynamic testing allow treatment to be tailored to the individual patient.

Patients should understand that an AUS requires manual operation, lifelong precautions and possible future revision. With appropriate patient selection, careful surgery and ongoing follow-up, it remains one of the most effective treatments available for male post-prostatectomy stress incontinence.

So, if you suffer with post prostatectomy urinary incontinence, come see your Brisbane based functional urologist, Jo Schoeman to discuss this option.

References

  1. American Urological Association, GURS and SUFU. Incontinence after Prostate Treatment: Clinical Guideline, amended 2024.
  2. Breyer BN, Kim SK, Kirkby E, et al. Updates to Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline Amendment 2024. Journal of Urology. 2024.
  3. European Association of Urology. EAU Guidelines on Non-neurogenic Male Lower Urinary Tract Symptoms—Disease Management.
  4. European Association of Urology. EAU guidance: What happens when the artificial urinary sphincter fails?.
  5. Johnson A, Abraham N, Chughtai B. Artificial urinary sphincters for moderate post-prostatectomy incontinence: current research and proposed approach. Journal of Clinical Medicine. 2023.
  6. Desai TJ, Rozanski AT. Artificial urinary sphincter erosion and infection: a contemporary review of perioperative considerations and management. Translational Andrology and Urology. 2024.
  7. Continence Foundation of Australia. Male urinary incontinence.

This information is intended for general education and does not replace individual medical assessment. Suitability for an AUS should be discussed with a urologist experienced in male continence and reconstructive surgery.

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

Bridge to Brisbane 2026: Running in Blue for Prostate Cancer

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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 since 2019, 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.