Persistent sperm after vasectomy: does this mean the procedure has failed?

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Finding sperm in a semen sample after vasectomy can be worrying. However, a positive result does not always mean that the vasectomy has failed.

Sperm may remain in the reproductive tract for several weeks or months after the procedure. The most important questions are:

  • How long has it been since the vasectomy?
  • How many sperm are present?
  • Are any of the sperm still moving?
  • Is the sperm count decreasing on repeat testing?

A vasectomy does not work immediately

During a vasectomy, the two vas deferens, the tubes carrying sperm from the testicles, are divided and sealed. Sperm already present beyond the site of the vasectomy may remain in the seminal tract and appear in subsequent ejaculations.

It can take several months and approximately 20 ejaculations to clear these remaining sperm. Australian patient guidance commonly recommends the first post-vasectomy semen analysis at approximately three months. International guidelines generally allow testing within about 8–16 weeks, depending on the surgeon’s protocol.

Another form of contraception must be used until your surgeon has reviewed the semen result and formally confirmed clearance.

What is a post-vasectomy semen analysis?

A post-vasectomy semen analysis, or PVSA, examines the semen for:

  • The presence or absence of sperm
  • The number of sperm present
  • Whether the sperm are motile or non-motile

The desired result is azoospermia, meaning that no sperm are detected. However, complete azoospermia is not always necessary for a vasectomy to be considered successful.

When should azoospermia occur?

Many men are azoospermic by approximately three months after vasectomy, particularly if they have ejaculated regularly. Others take longer to clear their residual sperm.

Delayed clearance may be associated with:

  • A relatively low number of ejaculations
  • Individual differences in reproductive-tract anatomy
  • Older age
  • A long interval between ejaculations
  • Laboratory technique and the timing of sample examination
  • Temporary early recanalisation of the vasectomy site

Persistent sperm at the first test should therefore not automatically be interpreted as surgical failure. The type of sperm and the trend on repeat testing are more informative.

What does an “immotile sperm count” mean?

Immotile or non-motile sperm are sperm that are present but show no movement when examined under the microscope.

Following vasectomy, this commonly represents old residual sperm that have not yet been completely cleared. Non-motile sperm have extremely limited capacity to cause pregnancy, particularly when present in very small numbers.

The generally accepted categories are:

Semen-analysis result Usual interpretation
No sperm detected Azoospermia, vasectomy clearance can usually be given
No motile sperm and ≤100,000 non-motile sperm/mL Rare non-motile sperm, generally regarded as successful vas occlusion
More than 100,000 non-motile sperm/mL Repeat testing and assessment of the trend are required
Any motile sperm Clearance should not be given; repeat testing is required

The report should be interpreted carefully because some laboratories report the concentration per millilitre, while others may report a total number or simply state that “occasional sperm” were seen.

A fresh sample is important when assessing motility. If examination is substantially delayed, sperm that were initially moving may have stopped, potentially producing a misleading “non-motile” result.

What are rare non-motile sperm?

Rare non-motile sperm, often abbreviated as RNMS, usually means that no moving sperm are seen and the concentration is no more than 100,000 non-motile sperm per millilitre.

Current Australian and American guidance generally regards either azoospermia or RNMS at or below this threshold as evidence of successful vas occlusion. Depending on the laboratory method and local protocol, your surgeon may provide clearance after one satisfactory sample or request another confirmatory sample.

The estimated risk of pregnancy after clearance based on azoospermia or RNMS is approximately 1 in 2,000. Vasectomy is therefore extremely reliable, but no method of contraception is completely infallible.

What happens if sperm are detected at three months?

Management depends on the result.

A small number of non-motile sperm

This is usually reassuring. If the count is no more than 100,000/mL and no motile sperm are present, clearance may be appropriate according to the treating surgeon’s protocol.

More than 100,000 non-motile sperm/mL

Continue contraception and repeat the semen analysis. A steadily decreasing count suggests delayed clearance rather than vasectomy failure.

Motile sperm

Continue contraception and arrange another semen analysis. Motile sperm early after vasectomy do not invariably mean that a repeat operation will be required, particularly if the number is low and decreasing. Persistent or increasing motile sperm are more concerning for incomplete occlusion or recanalisation.

What is recommended at six months?

Six months is an important decision point.

Motile sperm persisting at six months

If any motile sperm remain at six months, the vasectomy should generally be regarded as an occlusive failure. A repeat vasectomy should be discussed.

Possible explanations include:

  • One vas deferens was not successfully divided
  • An unusual or duplicated vas deferens was present
  • The divided ends have reconnected
  • A small channel has developed across the vasectomy site

More than 100,000 non-motile sperm/mL at six months

This result requires individual assessment rather than an automatic decision.

The surgeon will consider:

  • Whether the count is decreasing, stable or increasing
  • Whether motile sperm were present in earlier samples
  • The reliability and timing of sample collection
  • The vasectomy technique used
  • The couple’s tolerance for even a very small pregnancy risk
  • Whether further semen analyses are likely to provide clarity

Repeat vasectomy, continued contraception or further surveillance may be considered through shared decision-making.

Fewer than 100,000 non-motile sperm/mL at six months

If no motile sperm are present and the count is at or below 100,000/mL, most contemporary guidance considers this compatible with successful vasectomy. Formal clearance must nevertheless come from the treating surgeon.

When should a repeat vasectomy be considered?

A repeat procedure is usually considered when:

  • Motile sperm persist at six months
  • Motile sperm counts increase on consecutive tests
  • There is no meaningful reduction in the sperm count
  • More than 100,000 non-motile sperm/mL persist beyond six months and the results remain concerning
  • A pregnancy occurs after the vasectomy
  • Clinical or operative findings suggest that one vas deferens may not have been successfully occluded

Repeat vasectomy is required in no more than approximately 1% of procedures when an effective occlusion technique has been used.

Is repeat vasectomy the same as vasectomy reversal?

No. A repeat vasectomy aims to divide and seal the vas deferens again because the first procedure has not produced reliable contraception.

A vasectomy reversal is a different microsurgical procedure that attempts to restore fertility by reconnecting the vas deferens.

What should I do while waiting for another test?

Until formal clearance has been provided:

  • Continue using reliable contraception
  • Ejaculate regularly if comfortable
  • Follow the laboratory’s collection instructions carefully
  • Collect the entire sample
  • Record the collection time accurately
  • Deliver the sample within the laboratory’s required timeframe
  • Do not assume that “non-motile” automatically means that clearance has been granted

The important message

Persistent sperm after vasectomy does not necessarily mean that the procedure has failed.

A small number of non-motile sperm is common and may be compatible with successful vasectomy. Motile sperm, a persistently high non-motile count or a count that is increasing requires continued contraception and further assessment.

At six months, persistent motile sperm generally prompts consideration of repeat vasectomy. Persistent non-motile sperm above 100,000/mL requires review of serial results and an individual discussion with the treating urologist.

Do not stop contraception until your surgeon has confirmed in writing that your post-vasectomy semen analysis meets the required clearance criteria.

This information is intended for general education and does not replace individual medical advice or interpretation of your laboratory result.

References and further information

So, if you are having issues, come see your Brisbane Urologist to discuss management options.

Barrigel® Rectal Spacer During Prostate Cancer Radiation Therapy

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Creating a temporary safety zone between the prostate and rectum

Radiation therapy is an effective treatment for many men with prostate cancer. Modern radiation techniques are remarkably accurate, but there is one anatomical challenge: the prostate sits immediately in front of the rectum.

This means that while radiation is directed at the prostate, part of the rectum may also receive radiation.

One approach to reducing this exposure is to temporarily create a small space between the prostate and rectum before radiation treatment begins.

Barrigel® is a biodegradable hyaluronic acid rectal spacer designed specifically for this purpose.

Why does the rectum need protection?

The prostate and rectum normally sit almost against each other, separated by only a thin layer of tissue.

During prostate radiation therapy, some radiation therefore inevitably reaches the anterior wall of the rectum.

This can contribute to bowel symptoms such as:

  • increased bowel frequency
  • urgency
  • loose stools or diarrhoea
  • rectal discomfort
  • mucus discharge
  • rectal bleeding
  • radiation proctitis

Most bowel symptoms following modern radiation therapy are mild and temporary, but occasionally they can persist or become troublesome.

The basic idea behind a rectal spacer is delightfully simple:

Prostate → spacer → rectum

Instead of asking radiation technology to perform an anatomical magic trick, we physically move the rectum a little farther away.

Even approximately 1 cm of additional separation can substantially reduce the radiation dose received by the anterior rectal wall.

What is Barrigel?

Barrigel is a sterile, biodegradable gel made from stabilised, non-animal-derived hyaluronic acid.

Hyaluronic acid occurs naturally in many tissues within the human body and is widely used in medical applications.

Barrigel is injected into the tissue plane between the prostate and anterior rectal wall before prostate radiation therapy.

The gel creates a temporary cushion that pushes the rectum away from the prostate.

Importantly, Barrigel does not treat the prostate cancer itself.

Its purpose is to protect surrounding normal tissue while radiation treats the cancer.

How is Barrigel inserted?

Barrigel is usually inserted before radiation planning.

The procedure is performed using ultrasound guidance.

A needle is passed through the skin of the perineum, the area between the scrotum and anus, rather than through the rectum.

The needle is carefully positioned between the back of the prostate and the front wall of the rectum.

Barrigel is then slowly injected while the position of the gel is continuously monitored with ultrasound.

Typically several millilitres of gel are used to create the required separation.

The procedure may be performed using:

  • local anaesthetic
  • sedation
  • or another form of anaesthesia depending upon the patient and treating centre.

Fiducial markers used for radiation targeting may sometimes be inserted during the same procedure.

Antibiotic prophylaxis and strict sterile technique are important.

Who may benefit from Barrigel?

Barrigel may be considered for men undergoing radiation therapy for localised prostate cancer where reducing radiation exposure to the rectum is desirable.

This may include men undergoing:

Conventional external-beam radiation therapy

A spacer may reduce the amount of radiation reaching the rectum during a multi-week course of treatment.

Hypofractionated radiation therapy

Modern prostate radiation is increasingly delivered using larger doses over fewer treatment sessions.

A randomised clinical trial involving 201 men demonstrated that a hyaluronic-acid spacer significantly reduced rectal radiation exposure during hypofractionated prostate radiotherapy.

Acute grade 2 or greater gastrointestinal side effects occurred in approximately 2.9% of spacer-treated patients compared with 13.8% without a spacer.

Stereotactic body radiation therapy: SBRT

SBRT delivers relatively high radiation doses over only a few treatments. Precise protection of surrounding structures therefore becomes particularly important.

Selected salvage radiation situations

Spacer placement may occasionally be considered in more complex circumstances, although previous prostate or pelvic treatment can alter the normal tissue planes and make insertion more difficult.

These cases require individual assessment by the radiation oncologist and urologist.

When should Barrigel not be used?

Barrigel is contraindicated in patients with clinical T4 prostate cancer.

It should also be approached cautiously in men with conditions that may make insertion difficult or increase the risk of complications.

These include:

  • active infection or inflammation near the injection site
  • bleeding disorders
  • anticoagulant or thrombolytic therapy
  • significant antiplatelet medication
  • known allergy to hyaluronic-acid products
  • significant anorectal stenosis or anatomical abnormalities
  • previous surgery causing extensive scarring around the prostate or rectum
  • significant haemorrhoidal disease
  • immunodeficiency or significant immunosuppressive therapy.

Anticoagulant and antiplatelet medications should not simply be stopped without medical advice. Their management needs to be individualised according to the reason they are being taken.

What are the potential side effects?

Most patients tolerate spacer insertion well.

Temporary symptoms may include:

  • discomfort in the perineum
  • minor bleeding or bruising
  • a sensation of rectal fullness
  • temporary discomfort when opening the bowels
  • urinary frequency or discomfort
  • weak urinary stream
  • temporary constipation.

The feeling that there is “something there” behind the prostate can occur initially and generally settles.

What are the uncommon but important complications?

Although rectal spacer insertion is generally considered a low-risk procedure, it is still an invasive procedure.

Possible complications include:

  • infection
  • prostatitis
  • bleeding or haematoma
  • urinary retention
  • significant rectal pain
  • difficult or painful defaecation
  • incorrect positioning of the spacer
  • injection into the prostate
  • injury to the urethra or bladder
  • rectal-wall injury
  • rectal ulceration or tissue necrosis
  • vascular injection or embolisation
  • very rarely, fistula formation or severe pelvic infection.

This is why spacer insertion should be performed by clinicians experienced in transperineal ultrasound-guided procedures.

Correct placement matters just as much as the choice of spacer.

What happens to Barrigel afterwards?

Barrigel is biodegradable.

It remains between the prostate and rectum during the period when radiation treatment is being delivered and is subsequently broken down and absorbed by the body.

No second operation is normally required to remove it.

Barrigel versus SpaceOAR®

Barrigel and SpaceOAR are designed to solve the same anatomical problem, but they use different materials.

Barrigel SpaceOAR
Material Stabilised hyaluronic acid Polyethylene glycol hydrogel
Main purpose Separate prostate and rectum Separate prostate and rectum
Placement Transperineal injection Transperineal injection
Imaging guidance Ultrasound Ultrasound
Biodegradable Yes Yes
Remains permanently No No
Material characteristics Hyaluronic-acid gel that can be progressively shaped during injection PEG hydrogel formed after injection
Radiopaque version No equivalent to SpaceOAR Vue SpaceOAR Vue contains iodine for CT visibility
Evidence Randomised evidence demonstrating improved rectal dosimetry and reduced acute GI toxicity Extensive clinical experience and randomised/prospective evidence supporting rectal dose reduction

Both therefore create a temporary physical separation between the prostate and rectum.

Is Barrigel better than SpaceOAR?

At present it would be too simplistic to say that one spacer is universally “better”.

Both can substantially reduce radiation exposure to the rectum when correctly placed.

There are, however, some practical differences.

Barrigel can be shaped during insertion

Barrigel is injected as hyaluronic-acid gel. The operator can progressively deposit and shape the material while watching the developing space with ultrasound.

This can be useful when trying to achieve an appropriate distribution behind the prostate.

SpaceOAR has a long clinical track record

SpaceOAR has been extensively studied and is widely used internationally.

SpaceOAR Vue also contains iodine, making the spacer readily visible on CT. This may be helpful when MRI is unsuitable or when CT-based radiation planning is required.

Placement may matter more than the label on the syringe

An important point is that the quality, volume and position of the spacer can significantly influence the radiation dose received by the rectum.

A 2025 real-world comparative study found differences in dosimetry between Barrigel and SpaceOAR that were strongly influenced by the amount of spacer inserted. At comparable volumes, Barrigel performed favourably for some dosimetric measurements.

Interestingly, rectal-wall infiltration occurred in 7 of 287 SpaceOAR procedures (2.44%) and none of the Barrigel procedures in that particular study.

This does not prove that Barrigel is universally safer, but it highlights the importance of spacer material, injection technique and careful positioning.

What if Barrigel is not perfectly positioned?

One potentially useful characteristic of hyaluronic acid is that it can potentially be treated with hyaluronidase, an enzyme that breaks down hyaluronic acid.

This provides a theoretical and practical advantage if significant malposition is recognised.

The Queensland Clinical Excellence guidance specifically notes Barrigel’s potential to be hydrolysed in situations of spacer misplacement.

This does not make incorrect placement harmless, however. Prevention through meticulous ultrasound-guided insertion remains far preferable to correction afterwards.

Do all men having prostate radiation need a spacer?

No.

Modern radiation techniques such as IMRT, VMAT and image-guided radiotherapy already provide highly sophisticated targeting.

Whether a spacer provides meaningful additional benefit depends upon:

  • prostate anatomy and size
  • distance between prostate and rectum
  • radiation technique
  • radiation dose and fractionation
  • previous prostate or pelvic treatment
  • bowel disease
  • anticoagulation
  • individual risk of radiation toxicity
  • and the experience of the treating radiation team.

Some patients may gain considerable benefit while others may gain relatively little.

The decision should therefore be made jointly between the patient, radiation oncologist and urologist.

What does the evidence tell us?

The European Association of Urology recognises biodegradable rectal spacers as a method of increasing the distance between the prostate and rectum and reducing rectal radiation exposure.

Evidence across rectal spacer studies suggests reductions in both acute and late grade 2 or greater rectal toxicity.

For Barrigel specifically, a multicentre randomised trial demonstrated impressive dosimetric results during hypofractionated radiotherapy.

98.5% of patients receiving the hyaluronic-acid spacer achieved at least a 25% reduction in the volume of rectum receiving 54 Gy.

The average reduction was approximately 85%.

The same study demonstrated substantially fewer acute grade 2 or greater gastrointestinal side effects in patients receiving the spacer.

These findings support rectal spacing as a useful tool for appropriately selected men receiving prostate radiation therapy.

The bottom line

Barrigel is a temporary hyaluronic-acid rectal spacer used to create additional distance between the prostate and rectum before prostate cancer radiation therapy.

It does not improve the radiation by attacking the cancer. Instead, it gives the radiation oncologist a little more anatomical breathing room.

For appropriately selected patients it can:

increase prostate-to-rectum separation → reduce rectal radiation dose → reduce the risk of bowel toxicity.

Barrigel and SpaceOAR both achieve this objective using different biomaterials. Neither should automatically be regarded as the best option for every patient.

The choice should take into account the planned radiation technique, individual anatomy, previous treatment, medical history and the experience of the treating team.

Most importantly, a rectal spacer is an additional protective tool, not a guarantee against radiation-related bowel complications.

When should I discuss a rectal spacer?

If you are considering external-beam radiation therapy or SBRT for prostate cancer, it is reasonable to ask your radiation oncologist or urologist:

“Would I benefit from a rectal spacer, and would Barrigel or SpaceOAR be more appropriate for me?”

That conversation should occur before radiation planning begins.

This information is intended for patient education and does not replace individual assessment by your urologist or radiation oncologist.

So, if you have discussed this with your radiation oncologist and you would like the benefit of protecting your rectum against the effects of radiation, come see your local Brisbane urologist, Dr Jo, to discuss this option.

Advanced and Metastatic Prostate Cancer: Modern Treatment and New Hope

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A diagnosis of advanced or metastatic prostate cancer can be frightening. However, the treatment landscape has changed dramatically over the past decade.

Where doctors once relied mainly on testosterone-lowering treatment, we now have combinations of androgen deprivation therapy (ADT), modern androgen-receptor medicines, chemotherapy, targeted treatments, radioligand therapy and, for selected cancers, immunotherapy.

Importantly, these treatments are increasingly being used earlier and in combination, rather than waiting for one treatment to fail before introducing the next.

The aim is not simply to lower the PSA. It is to control the cancer for as long as possible while maintaining quality of life.

What does “advanced” prostate cancer mean?

Advanced prostate cancer is not one single condition.

Locally advanced prostate cancer

The cancer has grown beyond the prostate or into nearby structures but has not necessarily spread to distant organs.

Metastatic hormone-sensitive prostate cancer

The cancer has spread elsewhere in the body, commonly to:

  • lymph nodes
  • bones
  • lungs
  • liver or other organs

but remains sensitive to testosterone suppression.

This is often abbreviated to mHSPC or metastatic hormone-sensitive prostate cancer.

Metastatic castration-resistant prostate cancer

Over time, prostate cancer cells may learn to grow despite very low testosterone levels.

This is called metastatic castration-resistant prostate cancer (mCRPC).

“Castration resistant” does not mean that there are no further treatments available. Quite the opposite. We now have several effective treatment classes that can be used at this stage.

1. Androgen Deprivation Therapy: The Foundation of Treatment

Prostate cancer cells are usually heavily dependent on male hormones, particularly testosterone.

Androgen deprivation therapy (ADT) reduces testosterone to very low levels.

This can be achieved with regular injections or implants using GnRH/LHRH agonists or antagonists. Surgical removal of the testosterone-producing portion of the testes, called an orchidectomy, remains effective but is now used less frequently.

ADT remains the backbone of treatment for metastatic prostate cancer.

However, an important change in modern prostate cancer management is that ADT alone is usually no longer considered adequate initial treatment for a fit man presenting with metastatic hormone-sensitive disease.

Current EAU recommendations favour combining ADT with another effective systemic treatment whenever the patient is sufficiently fit.

2. Double Therapy

One approach combines ADT with a modern androgen-receptor pathway inhibitor (ARPI).

Examples include:

Abiraterone + prednisone

Abiraterone blocks androgen production not only from the testes but also from the adrenal glands and within the cancer itself.

Potential side effects include:

  • high blood pressure
  • low potassium
  • fluid retention
  • abnormal liver function
  • cardiac problems in susceptible patients
  • steroid-related effects

Enzalutamide

This blocks signalling through the androgen receptor.

Possible side effects include fatigue, hypertension, falls, cognitive effects and, rarely, seizures.

Apalutamide

Another potent androgen-receptor inhibitor. Side effects may include fatigue, rash, hypertension, falls and thyroid abnormalities.

Darolutamide

Darolutamide also inhibits androgen-receptor signalling and has relatively limited penetration into the central nervous system, which may be advantageous for some patients.

Current EAU guidance strongly supports treatment intensification rather than ADT alone in suitable patients with metastatic hormone-sensitive disease.

3. Triple Therapy: Three Treatments From the Starting Line

One of the biggest developments in metastatic prostate cancer has been triplet therapy.

Instead of:

ADT alone

or:

ADT + one additional treatment

selected patients may receive:

ADT + chemotherapy + an androgen-receptor pathway inhibitor

Two landmark trials helped establish this approach.

ARASENS

The phase III ARASENS trial investigated:

ADT + docetaxel + darolutamide

compared with:

ADT + docetaxel + placebo

The addition of darolutamide reduced the risk of death by approximately 32.5%, with a hazard ratio for death of 0.68.

Four-year overall survival was approximately 62.7% with triplet therapy compared with 50.4% in the control group.

PEACE-1

The PEACE-1 trial investigated the addition of abiraterone to standard treatment in men with newly diagnosed metastatic prostate cancer.

Among patients receiving ADT and docetaxel, adding abiraterone improved both radiographic progression-free survival and overall survival.

These studies have fundamentally changed how we approach a fit patient presenting with metastatic prostate cancer.

Who may benefit from triple therapy?

Triplet therapy is particularly considered in men who:

  • present initially with metastatic disease
  • have a significant metastatic burden
  • are medically fit enough to receive chemotherapy
  • have an expected lifespan sufficient to benefit from treatment intensification.

Treatment nevertheless needs to be individualised.

The EAU now recommends that when docetaxel is used for first-line metastatic hormone-sensitive disease, it should generally be given as part of combination treatment with ADT plus abiraterone or darolutamide in patients fit enough for chemotherapy.

One important scientific caveat remains: trials clearly demonstrated that triplet treatment is superior to ADT + docetaxel, but direct randomised evidence comparing triplet therapy against ADT + a modern ARPI without chemotherapy remains limited.

4. Chemotherapy

Docetaxel

Docetaxel remains an important chemotherapy for advanced prostate cancer.

It damages rapidly dividing cancer cells and is commonly given intravenously every three weeks for a defined number of cycles when used in hormone-sensitive metastatic disease.

Potential side effects include:

  • fatigue
  • temporary hair loss
  • lowered white blood cell count
  • infection
  • febrile neutropenia
  • anaemia
  • altered taste
  • nail changes
  • peripheral neuropathy
  • fluid retention.

Modern supportive treatment has made chemotherapy considerably more manageable than many patients expect.

Cabazitaxel

Cabazitaxel is generally used later, particularly when metastatic castration-resistant cancer has progressed following docetaxel and androgen-receptor pathway treatment.

Current ASCO recommendations include cabazitaxel as an important later-line treatment following appropriate prior ARPI and docetaxel therapy.

5. Should ADT Ever Be Intermittent?

This is an important question because ADT has significant long-term effects.

With intermittent ADT, treatment is stopped after a good PSA response and restarted when the PSA or cancer activity rises again.

The attraction is obvious: periods away from treatment may allow testosterone recovery and improvements in:

  • sexual function
  • hot flushes
  • energy
  • mood
  • muscle strength
  • metabolic health.

However, metastatic disease is different from some non-metastatic situations.

The large SWOG 9346 study could not establish that intermittent treatment was non-inferior to continuous ADT in metastatic disease. Consequently, a small survival disadvantage from intermittent therapy cannot be excluded.

The 2026 EAU guideline therefore notes that intermittent ADT has largely been superseded by continuous ADT-based combination therapy for metastatic disease.

For most men with metastatic prostate cancer, therefore, continuous hormonal suppression remains the standard.

Intermittent treatment may occasionally be considered in carefully selected circumstances after detailed discussion of the potential quality-of-life benefits and oncological uncertainty.

6. What Happens When the Cancer Becomes Castration Resistant?

A rising PSA despite very low testosterone does not automatically mean treatment has “stopped working.”

Rather, it tells us that the biology of the cancer has changed.

Importantly, ADT is usually continued even after castration resistance develops.

The next treatment depends heavily upon what the patient has already received.

Options can include:

  • docetaxel
  • cabazitaxel
  • abiraterone
  • enzalutamide
  • PARP inhibitors
  • radioligand therapy
  • radium-223
  • selected immunotherapy
  • clinical trials.

Simply moving repeatedly from one androgen-receptor drug to another is becoming less attractive because of significant cross-resistance.

7. Genetic Testing Has Become Part of Treatment

One of the most important changes in advanced prostate cancer management is the move toward precision medicine.

Men with metastatic disease should increasingly be considered for tumour genomic testing and, where appropriate, germline genetic testing.

Important abnormalities include mutations involving:

BRCA1, BRCA2 and other homologous recombination repair (HRR) genes.

These mutations may make the cancer susceptible to PARP inhibitors.

Examples include:

  • olaparib
  • niraparib
  • talazoparib
  • rucaparib in appropriate settings.

Some PARP inhibitors can now be combined with androgen-receptor treatments in appropriately selected patients.

The 2026 EAU guidelines specifically recommend testing metastatic patients for somatic or germline HRR abnormalities because the results may directly change treatment.

In other words, we increasingly need to know not only where the prostate cancer has spread, but what is driving it genetically.

8. Immunotherapy: Exciting, But Not for Everyone

Immunotherapy has transformed several cancers, but prostate cancer has proved more resistant to conventional immune checkpoint therapy.

For the average patient with metastatic prostate cancer, immunotherapy is not currently routine first-line treatment.

However, there is an important exception.

Pembrolizumab

A small proportion of prostate cancers have abnormalities known as:

  • MSI-high
  • mismatch-repair deficient (dMMR)
  • or, in relevant jurisdictions, sufficiently high tumour mutational burden.

These cancers may respond to the immune checkpoint inhibitor pembrolizumab.

ASCO’s 2026 living guideline recognises clinical activity of pembrolizumab in selected MSI-high/mismatch-repair-deficient metastatic castration-resistant prostate cancer.

This is another reason why molecular testing has become important.

For unselected prostate cancer patients, however, large trials combining pembrolizumab with treatments such as docetaxel, enzalutamide or olaparib have not demonstrated the hoped-for survival improvement.

Immunotherapy therefore currently works best as a biomarker-selected treatment rather than a universal prostate cancer therapy.

Possible immune-related side effects include inflammation of normal organs, including:

  • thyroid dysfunction
  • skin inflammation
  • colitis and diarrhoea
  • hepatitis
  • pneumonitis
  • adrenal or pituitary abnormalities.

Although uncommon, some immune complications can be serious and require corticosteroid treatment.

9. PSMA Radioligand Therapy

Another major advance is lutetium-177 PSMA radioligand therapy, often written as ¹⁷⁷Lu-PSMA-617.

The treatment uses a molecule that recognises PSMA on prostate cancer cells and carries a radioactive isotope directly to those cells.

It is therefore rather like delivering radiation with a molecular address label attached.

For appropriately selected men with PSMA-positive metastatic castration-resistant prostate cancer, it can provide another life-prolonging systemic treatment option.

The exact timing of ¹⁷⁷Lu-PSMA therapy is evolving rapidly as clinical trial evidence matures and regulatory indications change. Current EAU and ASCO recommendations include it among established systemic options for appropriately selected mCRPC patients.

Potential side effects include:

  • fatigue
  • dry mouth
  • nausea
  • reduced blood counts
  • anaemia
  • thrombocytopenia.

10. Radium-223 for Bone-Dominant Disease

Prostate cancer has a particular tendency to spread to bone.

Radium-223 is a radioactive treatment that preferentially targets areas of increased bone turnover.

It may be appropriate for selected men with symptomatic bone-predominant metastatic castration-resistant prostate cancer without visceral metastases.

Its role needs to be carefully coordinated with other treatments and bone-health management.

11. Don’t Forget the Prostate Itself

It may seem strange to treat the prostate once cancer has already spread.

However, clinical studies have demonstrated that treating the primary prostate tumour with radiotherapy can improve outcomes in selected men presenting with low-volume metastatic disease.

The EAU therefore recommends prostate radiotherapy for appropriately selected patients presenting with low-volume metastatic hormone-sensitive prostate cancer.

This does not mean every man with metastatic prostate cancer should have prostate surgery or radiation. The benefit depends on the pattern and burden of metastatic disease.

12. Side Effects of Long-Term Hormonal Treatment

Because men may now live for many years with advanced prostate cancer, treatment side effects deserve almost as much attention as the cancer itself.

Long-term ADT may cause:

Sexual effects

Reduced libido, erectile dysfunction and loss of spontaneous erections are common.

Hot flushes

These can range from mildly annoying to profoundly disruptive.

Muscle loss

Testosterone suppression causes loss of muscle mass and strength unless actively countered.

Weight gain

Fat tends to accumulate particularly around the abdomen.

Metabolic changes

ADT can increase the risk of:

  • insulin resistance
  • diabetes
  • abnormal cholesterol
  • cardiovascular disease.

Bone thinning

Long-term ADT accelerates osteoporosis and increases fracture risk.

Current EAU guidance recommends formal assessment of osteoporosis risk, including DEXA scanning when commencing long-term ADT, together with appropriate bone protection.

Mood and cognition

Some men experience:

  • fatigue
  • low mood
  • reduced motivation
  • sleep disturbance
  • difficulty concentrating.

These symptoms deserve recognition and treatment rather than being dismissed as simply part of ageing.

Exercise Is Part of Cancer Treatment

Regular exercise is one of the most useful supportive treatments for men receiving long-term ADT.

A programme incorporating:

resistance training + aerobic exercise + balance work

can help preserve muscle, bone strength, cardiovascular fitness and independence.

Nutrition, weight management, smoking cessation, alcohol moderation and optimisation of cardiovascular risk factors should form part of long-term prostate cancer care.

Bone Health Matters

Men receiving prolonged ADT should have their fracture risk assessed.

Depending on bone density and metastatic involvement, treatment may include:

  • calcium and vitamin D when appropriate
  • resistance and weight-bearing exercise
  • bisphosphonates
  • denosumab.

Men receiving denosumab or bisphosphonates require appropriate calcium monitoring and usually dental assessment because of the uncommon but important risk of osteonecrosis of the jaw.

A New Way of Thinking About Metastatic Prostate Cancer

The old treatment pathway was fairly linear:

ADT → wait for progression → chemotherapy → another treatment.

Modern treatment looks very different.

It is increasingly:

Diagnose → accurately stage → molecularly profile → intensify treatment early → continuously reassess → select the next therapy according to previous treatment and tumour biology.

For some patients this means:

ADT + ARPI

For others:

ADT + docetaxel + darolutamide

or:

ADT + docetaxel + abiraterone

And later, depending on the tumour:

chemotherapy → PARP inhibition → PSMA radioligand therapy → radium-223 → selected immunotherapy or clinical trials.

There is no longer a single treatment pathway that suits every patient.

The Bottom Line

Advanced prostate cancer remains a serious disease, but its treatment has undergone a remarkable transformation.

The strongest contemporary evidence supports early treatment intensification for suitable men with metastatic hormone-sensitive prostate cancer rather than relying on ADT alone.

The ARASENS and PEACE-1 trials established an important role for triplet therapy in appropriately selected patients, while modern guidelines increasingly emphasise genomic testing, targeted treatment, radioligand therapy and careful sequencing of chemotherapy and androgen-receptor treatments.

Intermittent ADT is attractive from a quality-of-life perspective but is not the routine standard for metastatic disease, where continuous ADT-based combination treatment remains preferred.

Perhaps most importantly, treatment should not focus exclusively on the PSA.

Bone health, cardiovascular health, muscle strength, sexual health, psychological wellbeing and maintaining independence are all part of successful prostate cancer treatment.

For many men, metastatic prostate cancer can now be controlled for years through carefully planned sequences and combinations of treatment.

This information is intended for general patient education. Treatment of advanced prostate cancer should be individualised through discussion with a urologist, medical oncologist and radiation oncologist experienced in prostate cancer management.

Sexually Transmitted Infections in Men: What You Need to Know

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More than just an uncomfortable infection

Sexually transmitted infections (STIs) are extremely common and can affect people of any age who are sexually active.

For men, an STI may present with something obvious such as penile discharge, burning when passing urine, genital ulcers or warts. However, there is an important catch:

Many sexually transmitted infections cause no symptoms at all.

Chlamydia, for example, is frequently asymptomatic. A man may therefore carry and transmit an infection without knowing it.

Most STIs can be successfully treated or controlled. The reason they should not be ignored is that untreated infection can occasionally lead to significant complications, including:

  • epididymitis or epididymo-orchitis
  • chronic testicular or pelvic discomfort
  • urethritis
  • urethral scarring and stricture disease
  • impaired fertility
  • transmission to sexual partners
  • increased susceptibility to other infections
  • and, in the case of persistent high-risk HPV infection, an increased risk of penile and other cancers.

The good news is that modern STI testing is generally straightforward, discreet and highly accurate.

What exactly is an STI?

An STI is an infection that can be transmitted during sexual contact.

Transmission does not necessarily require penetrative intercourse. Depending upon the infection, transmission can occur through:

  • vaginal intercourse
  • anal intercourse
  • oral sex
  • genital-to-genital skin contact
  • contact with infected genital lesions
  • sharing sex toys
  • exposure to infected blood.

Some infections, particularly HPV and herpes, can be transmitted by intimate skin-to-skin contact even when condoms are used correctly.

Common STIs affecting men

Chlamydia

Chlamydia trachomatis is one of the most frequently diagnosed STIs in Australia and is particularly common in younger sexually active people. Most infections produce few or no symptoms.

When symptoms occur, men may notice:

  • burning or stinging when urinating
  • clear or cloudy penile discharge
  • urethral irritation
  • testicular discomfort
  • epididymal pain or swelling.

Untreated infection can occasionally progress to epididymo-orchitis, where infection and inflammation involve structures around the testicle.

This is particularly relevant to fertility because the epididymis is part of the pathway through which sperm travel.

Gonorrhoea

Gonorrhoea is caused by Neisseria gonorrhoeae.

It classically produces:

  • significant burning during urination
  • yellow, white or green penile discharge
  • urethral discomfort
  • occasionally testicular pain.

However, gonorrhoea can also occur in the throat or rectum and may be asymptomatic.

Diagnosis is usually made with a nucleic acid amplification test (NAAT/PCR). Culture may also be obtained, particularly because monitoring antibiotic resistance is increasingly important.

Untreated gonorrhoea may lead to persistent urethritis and occasionally epididymo-orchitis.

Historically, severe gonococcal urethritis was also an important cause of urethral stricture disease.

Mycoplasma genitalium

Mycoplasma genitalium, often shortened to M. genitalium, is another cause of sexually acquired urethritis.

Men may experience:

  • burning during urination
  • penile discharge
  • urethral discomfort
  • persistent or recurrent urethritis.

It becomes particularly relevant when symptoms continue despite apparently appropriate treatment for more common infections.

Treatment needs to be carefully selected because antibiotic resistance has become an important issue.

Syphilis

Syphilis is caused by Treponema pallidum.

It has sometimes been called the “great imitator” because it can produce an extraordinary range of symptoms.

Early infection may cause a painless genital ulcer or chancre.

Later symptoms can include:

  • rash
  • swollen lymph nodes
  • fever
  • neurological symptoms
  • cardiovascular complications.

Importantly, the initial ulcer can disappear without treatment.

That does not mean the infection has gone away.

Diagnosis usually involves blood tests, although PCR/NAAT testing may sometimes be performed directly from suitable lesions.

Syphilis remains an important STI in Australia. Treatment protocols depend upon the stage of infection and individual circumstances. Australian STI guidelines should be followed because treatment recommendations and medication availability can change.

Genital herpes

Genital herpes is caused predominantly by herpes simplex virus type 1 or type 2 (HSV-1 and HSV-2).

Symptoms may include:

  • clusters of painful blisters
  • genital ulcers
  • burning
  • tingling
  • painful urination
  • swollen groin lymph nodes
  • flu-like symptoms during an initial infection.

The virus subsequently remains dormant within sensory nerves and may reactivate.

Some people experience frequent outbreaks, while others have few or no further symptoms.

Antiviral medications such as valaciclovir, aciclovir or famciclovir can reduce the duration and severity of outbreaks. Suppressive antiviral therapy can be considered for frequent or troublesome recurrences.

There is currently no treatment that completely eliminates HSV from the body.

HPV and genital warts

Human papillomavirus, or HPV, deserves particular attention in men’s urological health.

There are more than 200 recognised HPV types. Some predominantly cause benign genital warts, while persistent infection with certain high-risk HPV types can contribute to cancer.

Genital warts can appear as:

  • small raised bumps
  • flat lesions
  • clusters of lesions
  • cauliflower-like growths
  • lesions around the penile shaft, foreskin, glans, urethral opening, pubic region or anus.

Treatment options can include topical medication, cryotherapy, diathermy, laser treatment or surgical removal depending upon their location and extent.

Does HPV cause penile cancer?

This is an important question.

Certain high-risk HPV infections are associated with penile cancer.

Persistent infection with oncogenic HPV can produce precancerous cellular changes known as penile intraepithelial neoplasia (PeIN), which in some men may eventually progress to squamous cell carcinoma.

WHO recognises persistent high-risk HPV infection as being associated with cancers of the penis as well as the anus and mouth/throat.

This does not mean that having HPV means you will develop penile cancer.

HPV infection is extraordinarily common and, in most people, the immune system controls the infection without it causing cancer.

However, a penile lesion that:

  • does not heal
  • repeatedly bleeds
  • becomes ulcerated
  • changes colour
  • gradually enlarges
  • produces persistent discharge
  • or remains despite treatment

should be examined by a doctor.

Persistent penile lesions occasionally require biopsy rather than repeated creams and crossed fingers.

HPV vaccination matters for men too

HPV vaccination is not simply a cervical cancer vaccine.

Vaccination can reduce the risk of acquiring important HPV types associated with genital warts and HPV-related cancers.

Australian STI guidelines recommend considering HPV vaccination in appropriate patients who have not previously been vaccinated. Importantly, the vaccine does not treat an existing wart, but may provide protection against future acquisition of other vaccine-covered HPV types.

Your GP or sexual health clinician can advise whether vaccination is appropriate for you.

Can an STI cause infertility?

Yes, although this is not inevitable.

The male reproductive tract is rather like a carefully organised plumbing system. Sperm have to travel from the testicle through the epididymis and vas deferens before eventually joining the ejaculatory pathway.

Inflammation or infection along that pathway can occasionally interfere with sperm transport or testicular function.

Chlamydia, for example, is recognised as a potential cause of epididymo-orchitis and infertility.

Epididymo-orchitis

STIs such as chlamydia and gonorrhoea may cause inflammation of the epididymis and sometimes the testicle.

Symptoms can include:

  • unilateral testicular pain
  • scrotal swelling
  • tenderness
  • urinary symptoms
  • urethral discharge
  • occasionally fever.

Severe or recurrent inflammation can potentially damage the reproductive tract.

Bilateral disease is of greater concern for fertility.

A very important warning

Sudden severe testicular pain should never simply be assumed to be an STI.

Testicular torsion can produce similar symptoms and is a surgical emergency. A suddenly painful testicle requires urgent medical assessment.

STIs and urethral strictures

One of the less frequently discussed long-term complications of severe or recurrent urethritis is urethral stricture disease.

A urethral stricture is an area of scar tissue that narrows the urethra, the tube carrying urine from the bladder through the penis.

Repeated inflammation can injure the urethral lining. Healing may subsequently produce fibrosis and scarring.

The result can be rather like replacing a wide garden hose with a drinking straw.

Symptoms of a urethral stricture include:

  • weakening urinary stream
  • spraying or splitting of the stream
  • straining to urinate
  • prolonged urination
  • incomplete bladder emptying
  • recurrent urinary infections
  • dribbling
  • urinary retention.

In modern Australian practice, sexually transmitted infection is only one of several potential causes of urethral strictures. Previous urethral instrumentation, catheterisation, trauma, surgery and inflammatory conditions such as lichen sclerosus are also important causes.

How is a urethral stricture investigated?

Depending upon the symptoms, investigation may include:

Uroflowmetry

The patient urinates into a specialised flow meter to measure the strength and pattern of the urinary stream.

Bladder ultrasound

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

Flexible cystoscopy

A small flexible telescope is passed into the urethra to identify the location and severity of narrowing.

Retrograde urethrogram

Contrast is introduced into the urethra and X-rays are obtained to demonstrate the length and position of the stricture.

Treatment depends upon the length, location and severity of the narrowing and may include dilation, endoscopic urethrotomy or reconstructive surgery (urethroplasty).

How are STIs diagnosed?

There is no single universal “STI test.”

Testing is selected according to your symptoms, sexual history and sites of sexual exposure.

Testing may include:

Urine testing

A first-pass urine sample can be tested using NAAT/PCR for infections such as:

  • chlamydia
  • gonorrhoea.

Swabs

Depending upon sexual practices and symptoms, swabs may be taken from:

  • urethra
  • throat
  • rectum
  • genital ulcers or lesions.

Testing only the urine can therefore miss an infection elsewhere.

Australian STI guidelines recommend site-specific testing according to sexual exposure.

Blood tests

Blood testing may be recommended for:

  • HIV
  • syphilis
  • hepatitis B
  • hepatitis C in appropriate circumstances.

Examination and biopsy

Genital warts are often diagnosed clinically.

Persistent, unusual, pigmented, ulcerated or suspicious penile lesions may require biopsy to exclude PeIN, penile cancer or another dermatological condition.

What happens if an STI is diagnosed?

Management depends entirely upon the infection.

Bacterial infections such as chlamydia, gonorrhoea and syphilis can usually be treated with appropriate antibiotics.

Viral infections such as HSV and HPV behave differently. Treatment may control symptoms, outbreaks or visible lesions rather than completely eliminating the virus.

Depending upon the infection, management may also involve:

1. Treating the infection

Use the recommended antibiotic or antiviral therapy and complete treatment exactly as prescribed.

2. Partner notification

Current or recent sexual partners may require testing and treatment.

This is important because treating only one person can create an unfortunate game of microbial ping-pong, with infection repeatedly passing between partners.

3. Temporarily avoiding sexual contact

Your treating clinician will advise when sexual activity can safely resume.

4. Testing for other STIs

Finding one STI may indicate exposure to others, so broader testing may be appropriate.

5. Repeat testing

Some infections require repeat testing or retesting after an appropriate interval.

What about HIV?

Modern HIV prevention and treatment have changed dramatically.

People at increased risk of HIV may benefit from pre-exposure prophylaxis (PrEP).

After a significant recent exposure, post-exposure prophylaxis (PEP) may also be appropriate and should be sought urgently because treatment needs to begin promptly.

People living with HIV who receive effective antiretroviral treatment can achieve an undetectable viral load. HIV care should be coordinated through clinicians experienced in HIV medicine.

When should I see a doctor?

Arrange medical assessment if you develop:

  • penile discharge
  • burning when urinating
  • genital ulcers
  • genital blisters
  • genital warts
  • unexplained penile lumps
  • persistent redness of the glans or foreskin
  • testicular discomfort
  • scrotal swelling
  • persistent urethral discomfort
  • weakening urinary stream
  • or concern following unprotected sexual contact.

Seek urgent medical attention for:

Sudden severe testicular pain

This may represent testicular torsion rather than infection.

Inability to pass urine

This may indicate severe obstruction.

A persistent ulcer, lump or abnormal area on the penis

Particularly if it is enlarging, bleeding or failing to heal.

“But I feel completely normal”

This is one of the most important messages about STIs:

No symptoms does not necessarily mean no infection.

Australian STI guidelines specifically recognise that STIs can exist without producing symptoms.

Testing may therefore be sensible after:

  • a new sexual partner
  • multiple partners
  • condomless sex
  • notification from a sexual partner
  • known STI exposure
  • or when recommended as part of routine sexual health screening.

The type and frequency of testing should reflect your individual circumstances rather than embarrassment, assumptions or relationship status.

Prevention

Reducing STI risk may involve several complementary strategies:

  • using condoms appropriately
  • regular STI screening when indicated
  • HPV vaccination
  • hepatitis B vaccination where appropriate
  • HIV PrEP for people at increased risk
  • prompt testing following symptoms or partner notification
  • treating infections completely
  • ensuring relevant partners are tested or treated
  • avoiding sexual contact for the recommended period following treatment.

No strategy other than abstaining from sexual contact eliminates every possible STI risk, particularly because HPV and herpes can spread through areas of skin not covered by a condom.

A urologist’s perspective

Most STIs are diagnosed and managed very effectively by GPs and sexual health clinics.

A urologist becomes particularly useful when the infection has left something behind.

This may include:

  • persistent urethral symptoms
  • recurrent epididymitis
  • chronic testicular pain
  • suspected obstruction of the reproductive tract
  • fertility concerns
  • urethral stricture
  • recurrent urinary infections
  • genital lesions requiring biopsy
  • suspected penile intraepithelial neoplasia
  • or possible penile cancer.

In these circumstances, treating the original infection may only be part of the solution. The structural or functional consequences also need assessment.

The bottom line

Sexually transmitted infections are common, and having one should be regarded as a health issue rather than a moral judgement.

The greatest problems often arise not from the initial infection but from an infection that remains undiagnosed or untreated.

For men, potentially important consequences include urethritis, epididymo-orchitis, fertility problems and urethral stricture disease. Persistent infection with certain high-risk HPV types is also associated with penile cancer.

If something looks different, burns, discharges, ulcerates, grows, hurts or simply does not seem right, getting it checked is usually far easier than spending three weeks consulting Dr Google at midnight.

Early testing → appropriate treatment → partner management → fewer complications.

Australian resources

The Australian STI Management Guidelines provide evidence-based recommendations for STI testing, diagnosis and treatment in Australia.

Australian STI Management Guidelines

Medical disclaimer

This information is intended for general patient education and does not replace individual medical advice, examination or diagnosis. STI treatment recommendations can change, particularly because of antimicrobial resistance and medication availability. Patients with symptoms or concerns about possible exposure should discuss appropriate testing and treatment with their GP, sexual health service or urologist.

So, if you have a STD and battling to get over this with the condition, come see your Brisbane Urologist, Dr Jo to discuss this further.

Penile Cancer: Symptoms, Diagnosis and Treatment in Australia

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Penile cancer is rare, but early diagnosis matters

Penile cancer is an uncommon cancer affecting the skin and tissues of the penis. In Australia, approximately 165 men were estimated to be diagnosed with penile cancer in 2025, with the average age at diagnosis around 68 years. About 95% of penile cancers are squamous cell carcinomas (SCC).

Although the diagnosis can understandably be frightening, there is an important message:

When penile cancer is detected early, treatment is frequently curative and, in many men, much or all of the penis can be preserved.

Modern treatment has therefore moved increasingly towards penile-preserving therapy whenever this can be achieved safely.

Treatment in Australia will depend on:

  • whether the abnormality is precancerous or invasive cancer
  • the size and location of the tumour
  • how deeply it has invaded
  • the grade of the cancer
  • whether lymph nodes in the groin are involved
  • whether cancer has spread elsewhere
  • the man’s general health and personal preferences.

Because penile cancer is rare, patients with invasive or complicated disease benefit from discussion by a multidisciplinary team (MDT) involving urology, medical oncology, radiation oncology, radiology, pathology and specialist nursing.

 

What causes penile cancer?

There is rarely one single identifiable cause.

Important risk factors include:

  • infection with human papillomavirus (HPV)
  • smoking
  • phimosis, where the foreskin cannot be retracted
  • chronic inflammation of the penis
  • penile intraepithelial neoplasia (PeIN)
  • increasing age
  • some chronic penile skin disorders
  • immunosuppression.

HPV plays an important role in a proportion of penile cancers, although penile cancer can certainly occur without HPV infection.

What symptoms should men look for?

Penile cancer often begins as a visible or palpable abnormality, particularly involving the glans or foreskin.

Symptoms can include:

  • a red or discoloured area that does not disappear
  • persistent irritation or inflammation
  • thickening of the skin
  • a lump
  • a wart-like growth
  • an ulcer or sore that does not heal
  • bleeding
  • persistent discharge
  • an unpleasant smell from beneath the foreskin
  • increasing difficulty retracting the foreskin
  • pain or tenderness
  • swelling of the end of the penis
  • a lump beneath the foreskin
  • enlarged lymph nodes or lumps in the groin.

More advanced disease can occasionally cause difficulty passing urine, fatigue or unexplained weight loss.

A persistent penile lesion deserves examination

Most rashes, spots and lumps on the penis are not cancer. Infection, inflammation, dermatitis and benign skin conditions are much more common.

The important issue is persistence.

A penile ulcer, lump, bleeding area or unusual skin change that does not resolve should not be hidden away in the hope that it will disappear.

Embarrassment is considerably easier to treat than advanced cancer.

How is penile cancer diagnosed?

Examination

The first step is careful examination of the penis and foreskin.

The urologist will assess:

  • the site of the lesion
  • its size
  • whether it involves the glans, foreskin or shaft
  • whether deeper tissues appear involved
  • whether the foreskin can be retracted
  • whether there are enlarged lymph nodes in either groin.

Both groins are particularly important because penile cancer usually spreads first through the lymphatic system to the inguinal lymph nodes.

Biopsy

The diagnosis usually requires a biopsy.

A small piece of the abnormal tissue is removed and examined by a pathologist.

Depending upon the lesion, this may be:

  • a punch biopsy
  • an incisional biopsy, taking part of the lesion
  • an excisional biopsy, removing the whole small lesion.

A biopsy determines whether cancer is present and, importantly, identifies the type and grade of the tumour.

Histological confirmation is particularly important before treatments such as topical therapy, laser treatment or radiotherapy.

What is PeIN?

Penile intraepithelial neoplasia (PeIN) is a precancerous or very early cancerous change confined to the surface epithelium.

It has previously been described using terms such as carcinoma in situ.

PeIN is important because it can progress to invasive squamous cell carcinoma. Current European guidelines estimate progression to invasive disease despite treatment in approximately 2.6–13% of patients.

The good news is that PeIN can often be treated without removing part of the penis.

Treatment: from creams to major surgery

There is no single operation or treatment for penile cancer.

Modern management follows a ladder, beginning with the least invasive treatment capable of reliably controlling the cancer.

1. Circumcision

For abnormalities confined to the foreskin, circumcision may remove the lesion completely.

Circumcision is also frequently an important first step when PeIN involves the glans and foreskin because it allows the glans to be properly examined and treated.

For superficial disease, contemporary guidelines regard circumcision as an important primary surgical treatment.

2. Treatment with creams

Selected cases of biopsy-confirmed PeIN can be treated with medication applied directly to the penis.

The two most commonly used treatments are:

5-fluorouracil (5-FU)

5-FU is a topical chemotherapy medication.

It destroys abnormal rapidly dividing cells in the superficial layers of the penis.

Treatment usually produces inflammation of the treated area, which can include:

  • redness
  • burning
  • crusting
  • discomfort
  • erosion of the surface skin.

Imiquimod

Imiquimod is different. Rather than being conventional chemotherapy, it stimulates the local immune system to attack abnormal cells.

It can similarly cause substantial redness, swelling, ulceration or crusting during treatment.

These reactions can look alarming but often indicate that the medication is producing its intended biological effect.

Current EAU-ASCO guidance supports either 5-FU or imiquimod for appropriately selected biopsy-confirmed PeIN.

Importantly, the area must be reassessed after treatment.

If the abnormality persists, repeat biopsy or alternative treatment may be necessary. Repeated courses of topical treatment should not simply continue indefinitely when the lesion has failed to respond, because invasive cancer may be hiding beneath the surface.

3. Laser and other local treatments

Very superficial lesions can sometimes be treated using laser therapy.

Depending upon expertise and availability, other local treatments such as photodynamic therapy or cryotherapy have also been used.

These approaches can preserve the penis but require careful long-term surveillance because local recurrence is possible.

4. Penile-preserving surgery

One of the major changes in penile cancer surgery has been the move away from automatically removing a substantial portion of the penis.

Whenever oncologically safe, the aim is:

remove the cancer, obtain clear margins and preserve as much normal penis as possible.

Operations may include:

Wide local excision

The cancer and a margin of surrounding tissue are removed.

The defect may be closed directly or reconstructed with a skin graft.

Glans resurfacing

The abnormal surface layer of the glans is removed while preserving the deeper erectile tissue.

A skin graft is then placed over the glans.

This can be particularly useful for extensive superficial disease.

Glansectomy

If cancer is confined to the glans but is too extensive or invasive for simpler treatment, part or all of the glans may be removed.

Reconstruction can then be performed, often using a skin graft to create a new glans-like surface.

Current guidelines favour organ-preserving surgery for appropriately selected PeIN and T1–T2 tumours involving the glans or prepuce, provided the patient understands the need for careful follow-up.

5. Partial penectomy

More deeply invasive cancer may require removal of part of the penis.

This is called a partial penectomy.

The surgeon attempts to retain enough penile length to permit comfortable urination and, where possible, sexual function.

This may be necessary when cancer extends more deeply into the erectile tissues and cannot be reliably removed using penile-preserving techniques.

6. Total penectomy

Occasionally a cancer is too large, too proximal or too deeply invasive for part of the penis to be safely preserved.

A total penectomy may then provide the best opportunity for cure.

This understandably sounds confronting. It is generally reserved for circumstances in which less radical treatment would compromise cancer control.

Current EAU-ASCO recommendations support total penectomy with perineal urethrostomy for large invasive tumours that cannot safely be treated by partial penectomy.

What is a perineal urethrostomy?

This is sometimes mistakenly referred to as a “perineotomy”.

Following total removal of the penis, urine still needs a pathway from the bladder to the outside world.

The urethra is therefore brought to the skin of the perineum, the area between the scrotum and anus.

This opening is called a:

Perineal urethrostomy

The patient subsequently passes urine through this opening while sitting on the toilet.

A catheter is generally left temporarily while the area heals.

Once healed, most men can empty their bladder normally through the new opening and do not require a permanent catheter.

Potential problems include:

  • narrowing or stenosis of the opening
  • spraying
  • infection
  • wound complications
  • occasionally the need for further surgery.

A perineal urethrostomy does not mean that the bladder or kidneys have stopped functioning. It simply changes the final few centimetres of the urinary plumbing.

The lymph nodes are extremely important

Treating the penis itself is only one half of penile cancer management.

The other half is determining whether cancer has reached the inguinal lymph nodes in the groin.

Penile cancer generally spreads in a predictable sequence:

Penis → inguinal lymph nodes → pelvic lymph nodes → distant organs

Lymph-node involvement is the single most important prognostic factor in penile cancer.

What if there are no enlarged lymph nodes?

Unfortunately, normal-feeling groins do not completely exclude microscopic cancer.

Men with higher-risk primary tumours may therefore require further lymph-node assessment despite having no palpable lumps.

This may involve:

  • ultrasound of the groins
  • ultrasound-guided needle biopsy of abnormal nodes
  • dynamic sentinel lymph-node biopsy
  • inguinal lymph-node dissection in selected circumstances.

Current EAU-ASCO guidance recommends surgical lymph-node staging for patients at significant risk of microscopic metastatic disease, particularly T1b disease or higher.

What if a groin lymph node is enlarged?

An abnormal lymph node may be assessed using ultrasound and needle biopsy.

If metastatic penile cancer is confirmed, treatment may involve:

  • inguinal lymph-node dissection
  • pelvic lymph-node dissection in selected patients
  • chemotherapy
  • radiotherapy
  • combinations of these treatments.

Patients with clinically node-positive disease are generally staged with CT or FDG-PET/CT to assess pelvic and distant disease before definitive treatment.

Early treatment of lymph-node disease is extremely important.

Radiation therapy

Radiotherapy has an important but selective role in penile cancer.

Treatment of the primary cancer

Selected smaller T1 or T2 cancers can potentially be treated with radiation instead of surgery.

Treatment can involve:

External beam radiotherapy

Radiation is directed at the tumour from outside the body.

Brachytherapy

Radioactive sources are temporarily positioned within or very close to the tumour, allowing a concentrated radiation dose to be delivered while limiting exposure to surrounding tissues.

Radiotherapy may therefore provide another means of preserving the penis in appropriately selected patients.

Potential complications can include:

  • skin irritation
  • ulceration
  • fibrosis
  • narrowing of the urethra
  • changes in penile sensation
  • erectile dysfunction
  • tissue damage or necrosis in uncommon circumstances.

Radiotherapy is also used in selected patients for regional lymph-node disease, as part of chemoradiotherapy for advanced disease, or for palliation of symptoms from metastatic cancer.

Chemotherapy

Chemotherapy is generally reserved for more advanced penile cancer, particularly when significant lymph-node disease or metastatic disease is present.

In Australia, contemporary treatment may involve platinum-based combination chemotherapy.

One regimen used in advanced disease is:

TIP: paclitaxel + ifosfamide + cisplatin

Australia’s eviQ cancer treatment resource includes TIP as an option in neoadjuvant, adjuvant and metastatic penile cancer settings.

For bulky or fixed inguinal lymph-node disease or pelvic lymph-node involvement, chemotherapy may be given before surgery.

This is called neoadjuvant chemotherapy.

The aim is to:

  1. treat microscopic disease throughout the body,
  2. shrink the cancer in the lymph nodes,
  3. determine whether the cancer is responding,
  4. make subsequent surgery more effective or technically achievable.

Current international guidance recommends cisplatin- and taxane-based neoadjuvant chemotherapy for suitable patients with extensive inguinal or pelvic nodal disease, followed by surgery when appropriate.

Chemoradiotherapy

Radiotherapy and chemotherapy can sometimes be combined.

This may be considered for selected patients with:

  • locally advanced disease
  • unresectable cancer
  • extensive lymph-node disease
  • disease where major surgery is unsuitable
  • palliative treatment requirements.

The evidence is evolving, and these decisions should generally be made through a specialist penile cancer MDT.

What about immunotherapy?

Immunotherapy is an exciting area of cancer treatment, but its role in penile cancer is still developing.

Checkpoint inhibitors such as pembrolizumab and related drugs have demonstrated activity in some patients with advanced penile cancer, and newer combinations of chemotherapy and immunotherapy are being investigated.

However, response rates to checkpoint inhibitors alone are relatively modest and there is not yet sufficient evidence to use biomarkers such as HPV or PD-L1 routinely to determine which penile cancer patients should receive immunotherapy.

Clinical trials are particularly important for men whose cancer progresses despite standard platinum-based chemotherapy.

What happens to sexual function?

This depends enormously on treatment.

After topical treatment, circumcision, laser therapy, glans resurfacing or limited local excision, satisfactory sexual function may often be preserved.

After glansectomy or partial penectomy, intercourse may remain possible depending upon remaining penile length, erectile function and reconstruction.

After total penectomy, penetrative intercourse using the penis is no longer possible.

This does not mean that intimacy, sexual sensation or orgasm automatically disappears.

Sexual rehabilitation, psychological support and discussion with the patient and his partner can be an important component of recovery.

These conversations should ideally begin before treatment, not after it.

What is the prognosis?

Penile cancer is potentially highly curable when diagnosed before it has spread to lymph nodes.

The most important predictor of survival is not simply the size of the penile lesion but whether cancer has reached the lymph nodes.

Current EAU-ASCO data report approximate five-year cancer-specific survival according to nodal stage of:

Lymph-node stage Approximate 5-year cancer-specific survival
N0 – no lymph-node metastases 95%
N1 80%
N2 65%
N3 – advanced nodal disease 35%

These are population figures, not predictions for an individual patient.

Prognosis depends upon the tumour’s stage and grade, lymph-node involvement, response to treatment, general health and other pathological features.

The figures do, however, demonstrate why early diagnosis and appropriate assessment of the groin lymph nodes are so important.

Follow-up after treatment

Penile cancer requires ongoing surveillance.

Follow-up may include:

  • examination of the penis or reconstructed area
  • examination of both groins
  • assessment of the perineal urethrostomy where applicable
  • imaging in higher-risk patients
  • biopsy of suspicious recurrent lesions
  • monitoring urinary and sexual function
  • psychological and sexual-health support.

Penile-preserving treatment requires particularly careful surveillance because local recurrence can occur.

Importantly, a local recurrence identified early can often still be successfully treated.

Do not ignore a change in the penis

Penile cancer is uncommon, and most penile skin problems are benign.

Nevertheless, a persistent:

lump, ulcer, red patch, bleeding area, discharge, thickened foreskin or lesion that simply will not heal deserves examination.

There should be no embarrassment in asking your GP or urologist to have a look.

For early disease, treatment may be surprisingly conservative: sometimes circumcision, a cream, laser treatment or limited surgery is all that is required.

Even when invasive cancer is present, modern penile cancer surgery increasingly focuses on preserving penile tissue, urinary function and quality of life whenever this can be achieved without compromising cure.

For advanced disease, treatment becomes more complex and may involve partial or total penectomy, perineal urethrostomy, lymph-node surgery, radiotherapy and chemotherapy.

The crucial message is simple:

The earlier penile cancer is diagnosed, the greater the opportunity to cure it while preserving the penis.

Australian and international resources

Cancer Council Australia: Penile Cancer

Cancer Institute NSW: Penile Cancer

eviQ Australian Penile Cancer Chemotherapy Protocol

2026 EAU-ASCO Penile Cancer Guidelines

This information is intended for patient education and does not replace individual medical assessment. Treatment of penile cancer should be tailored to the tumour stage, pathology, lymph-node status, general health and preferences of the individual patient.

So, if you have noticed a lesion on your penis and it is growing, don’t ignore it and hope it will go away, go see your GP and come see your friendly Brisbane Urologist, Dr Jo, to discuss management options with you.

Testicular Cancer: Symptoms, Self-Examination, Diagnosis, Treatment and Prognosis

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One of the most curable cancers in men

A lump in the testicle can be frightening, particularly because testicular cancer often occurs in younger men. The reassuring news is that testicular cancer is one of the most successfully treated solid cancers.

When detected early, cure rates approach 100%. Even when the cancer has spread to lymph nodes, lungs or other parts of the body, modern chemotherapy and surgery can still cure many men.

The most important message is therefore:

Know what is normal for you, and if something changes, have it checked.

Most testicular lumps are not cancer, but a new lump, enlargement, hardness or persistent change in a testicle deserves medical assessment and usually an ultrasound.

The importance of checking your testicles

There is no population screening program for testicular cancer in Australia.

This makes testicular awareness particularly important.

Cancer Council Australia recommends that men become familiar with the normal shape, size and feel of their testicles and seek medical attention if they notice a lump, swelling, heaviness, aching or another change.

This is slightly different from recommending a rigid population-wide screening program. There is currently insufficient evidence that formal scheduled self-examination reduces mortality from testicular cancer.

Nevertheless, knowing your own anatomy makes sense.

How do I check my testicles?

A convenient time is during or after a warm shower or bath when the scrotal skin is relaxed.

Gently examine one testicle at a time between your fingers and thumb.

Become familiar with:

  • The usual size of each testicle
  • Its shape
  • Its firmness
  • The fact that one testicle commonly hangs slightly lower
  • The epididymis, which feels like a soft cord-like structure behind the testicle

You are not searching for microscopic abnormalities. You are simply learning what is normal for you.

Seek medical advice if you discover:

  • A new hard lump
  • Enlargement of one testicle
  • A change in shape
  • Increasing firmness
  • Persistent swelling
  • A heavy or dragging sensation
  • Persistent testicular discomfort
  • An unexplained difference from how the testicle normally feels

How often?

There is some variation between international recommendations.

The NHS in the United Kingdom advises checking the testicles regularly, approximately monthly, whereas Cancer Research UK emphasises awareness of what is normal rather than insisting upon a rigid monthly examination schedule.

In Australia, the practical message is best described as testicular awareness: become familiar with your testicles and investigate a persistent change rather than waiting to see whether it disappears.

Men at increased risk, including those with a previous undescended testicle, previous testicular cancer or significant family history, should discuss their individual surveillance with their doctor.

What is testicular cancer?

Approximately 90–95% of primary testicular cancers are germ-cell tumours.

They are divided into two broad groups:

Seminoma

Seminoma tends to behave in a relatively predictable manner and is extremely sensitive to both chemotherapy and radiotherapy.

Non-seminomatous germ-cell tumour (NSGCT)

This group includes:

  • Embryonal carcinoma
  • Yolk sac tumour
  • Choriocarcinoma
  • Teratoma
  • Mixed germ-cell tumours

A tumour containing both seminoma and non-seminomatous components is treated as a non-seminomatous germ-cell tumour.

An important clinical rule is:

Pure seminoma should not produce AFP.

If AFP is significantly elevated, the tumour is managed clinically as a non-seminomatous germ-cell cancer even if seminoma is reported in the pathological specimen.

Other testicular tumours

Less common tumours include:

Leydig cell tumours

Most are benign, although malignant variants occur.

Sertoli cell tumours

Again, most are benign but malignant variants are recognised.

Testicular lymphoma

Lymphoma becomes particularly important in older men and is managed quite differently from conventional germ-cell cancer.

Occasionally another cancer can metastasise to the testicle.

How does testicular cancer present?

The classic presentation is a:

Painless testicular lump

A man may notice:

  • Enlargement of one testicle
  • A hard area
  • A new lump
  • Alteration in shape
  • Increasing firmness
  • Scrotal heaviness

Testicular cancer can also cause discomfort or pain.

Therefore:

Pain does not rule cancer in, and absence of pain does not rule cancer out.

Symptoms of more advanced disease

When cancer has spread beyond the testicle, symptoms can include:

  • Back pain
  • Abdominal discomfort
  • Persistent cough
  • Shortness of breath
  • Chest symptoms
  • Enlarged lymph nodes
  • Weight loss
  • Fatigue
  • Breast tenderness or enlargement

Back pain can result from enlarged retroperitoneal lymph nodes behind the abdominal organs.

Diagnosis in Australia

The Australian diagnostic pathway is broadly consistent with European and British practice.

Step 1: Examination

Both testicles should be examined.

The abdomen and lymph-node regions may also be assessed.

Step 2: Testicular ultrasound

A high-resolution scrotal ultrasound with Doppler assessment is usually the first imaging investigation.

It determines whether a lesion is:

  • Within the testicle
  • Outside the testicle
  • Solid
  • Cystic
  • Vascular
  • Potentially malignant

A solid intratesticular mass should generally be considered malignant until proven otherwise.

Step 3: Tumour markers

Blood should ideally be collected before orchidectomy for:

AFP, Alpha-fetoprotein

May be elevated with:

  • Yolk sac tumour
  • Embryonal carcinoma
  • Mixed germ-cell tumours

β-hCG, Beta human chorionic gonadotropin

Can be elevated in:

  • Choriocarcinoma
  • Embryonal carcinoma
  • Mixed germ-cell tumours
  • Some seminomas

LDH, Lactate dehydrogenase

LDH is less specific but provides information regarding tumour burden and prognosis.

Importantly:

Normal tumour markers do not exclude testicular cancer.

Markers are repeated after orchidectomy because the rate at which AFP and β-hCG fall provides valuable information regarding whether active cancer remains elsewhere.

Step 4: Staging

Staging commonly involves CT imaging of the:

  • Chest
  • Abdomen
  • Pelvis

The retroperitoneal lymph nodes are particularly important because they represent the characteristic first lymphatic landing zone for many testicular cancers.

MRI can be used in selected circumstances.

PET scanning is not routinely recommended for initial staging.

FDG-PET has a specialised role after chemotherapy in selected patients with seminoma and a persistent residual mass.

Should the testicular lump be biopsied?

Usually no.

A needle biopsy through the scrotum is generally avoided when a germ-cell malignancy is suspected.

The standard procedure is:

Radical inguinal orchidectomy

The testicle and spermatic cord are removed through an incision in the groin.

This provides both treatment of the primary tumour and the tissue required for an accurate pathological diagnosis.

Fertility before treatment

This is particularly important because many patients are diagnosed while young.

The possibility of sperm banking should be discussed before chemotherapy, radiotherapy or other treatments that may impair fertility.

Ideally this conversation begins at diagnosis rather than after treatment has started.

One healthy remaining testicle will usually produce adequate testosterone and sperm, but some men with testicular cancer already have impaired sperm production before treatment.

Management of testicular cancer in Australia

Australian treatment is generally delivered through a multidisciplinary cancer team involving:

  • Urologists
  • Medical oncologists
  • Radiation oncologists
  • Radiologists
  • Pathologists
  • Fertility specialists when required

Complex metastatic, recurrent and post-chemotherapy disease is particularly suited to treatment through centres experienced in germ-cell cancer.

Australian practice broadly follows international evidence-based principles and is closely aligned with European and British practice, while incorporating Australian multidisciplinary cancer-care pathways.

Stage I seminoma

After radical inguinal orchidectomy, approximately 80% of men with unselected Stage I seminoma are cured by surgery alone.

For most reliable patients:

Active surveillance is generally preferred

This avoids exposing the majority of men who have already been cured to unnecessary chemotherapy or radiotherapy.

Surveillance involves scheduled:

  • Clinical review
  • Imaging
  • Tumour markers where appropriate

If recurrence occurs, treatment is usually extremely successful.

Adjuvant carboplatin

A single cycle of carboplatin may be considered for selected patients who prefer adjuvant treatment or for whom surveillance is unsuitable.

Radiotherapy

Radiotherapy is extremely effective against seminoma but is now used much less frequently for Stage I disease because of concern regarding long-term:

  • Secondary malignancies
  • Cardiovascular effects
  • Other radiation-related complications

Thus, in contemporary Australian practice, routine adjuvant radiotherapy for uncomplicated Stage I seminoma has largely moved into the background.

Stage I non-seminomatous germ-cell cancer

Approximately 70% of patients overall are cured by orchidectomy alone.

Management is influenced particularly by the presence or absence of lymphovascular invasion – LVI.

Without lymphovascular invasion

Surveillance is generally preferred for a reliable patient who is able to comply with follow-up.

With lymphovascular invasion

The risk of recurrence is considerably greater.

Options include:

  • Surveillance
  • One cycle of BEP chemotherapy

BEP consists of:

Bleomycin
Etoposide
Platinum – cisplatin

The advantages of avoiding unnecessary chemotherapy must be balanced against the increased likelihood of requiring several cycles of chemotherapy if metastatic recurrence subsequently occurs.

Retroperitoneal lymph-node dissection, RPLND

RPLND involves removal of lymph nodes from the retroperitoneum at the back of the abdomen.

It has an important but selective role.

In contemporary European and Australian-style practice, RPLND may be considered particularly for:

  • Selected marker-negative Stage II NSGCT
  • Residual masses after chemotherapy
  • Teratoma
  • Selected recurrent disease
  • Particular patients in whom chemotherapy is undesirable

Modern nerve-sparing RPLND attempts to preserve the sympathetic nerves responsible for normal antegrade ejaculation.

These procedures should ideally be performed in experienced high-volume centres.

Stage II seminoma

For limited Stage IIA or IIB seminoma, treatment options can include:

  • Radiotherapy
  • Cisplatin-based chemotherapy
  • In highly selected cases, specialist nerve-sparing RPLND

The precise choice depends upon lymph-node size, disease distribution, patient factors and the potential long-term consequences of each treatment.

For more extensive Stage IIB and Stage IIC disease, chemotherapy becomes increasingly favoured.

Metastatic seminoma and non-seminoma

Cisplatin-based combination chemotherapy transformed testicular cancer from a frequently fatal metastatic disease into one of the most curable metastatic solid cancers.

Common treatment includes:

BEP

Bleomycin + etoposide + cisplatin.

Depending upon the IGCCCG prognostic classification, treatment commonly consists of three or four cycles.

EP

Etoposide + cisplatin can be used in selected good-prognosis patients when bleomycin is unsuitable.

VIP

Etoposide + ifosfamide + cisplatin has a role in selected circumstances.

Surgery after chemotherapy

Surgery can remain crucial even after successful chemotherapy.

This is particularly important in non-seminomatous germ-cell cancer.

If tumour markers normalise but a residual retroperitoneal mass remains, surgery may reveal:

  • Fibrosis or necrosis
  • Mature teratoma
  • Persistent viable cancer

Teratoma is particularly important because it can be relatively resistant to chemotherapy and radiotherapy.

The EAU recommends surgical resection of visible residual NSGCT masses greater than 1 cm when serum tumour markers are normal or normalising.

What about immunotherapy?

Immunotherapy has revolutionised treatment for several urological cancers.

Unfortunately, germ-cell cancer has not followed the same script.

Checkpoint inhibitors targeting PD-1, PD-L1 and related pathways have been investigated in chemotherapy-resistant germ-cell tumours, but responses have generally been disappointing.

Therefore:

Immunotherapy is not standard first-line treatment for conventional seminoma or NSGCT in Australia, Europe, Britain or the United States.

Its role is currently largely confined to highly selected refractory disease and clinical trials.

European, British, Australian and American guidelines – are they different?

The reassuring answer is:

The major principles are remarkably similar.

All emphasise:

  1. Prompt ultrasound of a suspicious testicular mass
  2. AFP, β-hCG and LDH assessment
  3. Radical inguinal orchidectomy
  4. Appropriate CT staging
  5. Histological distinction between seminoma and non-seminoma
  6. Fertility discussion and sperm banking
  7. Surveillance for many Stage I cancers
  8. Cisplatin-based chemotherapy for metastatic germ-cell cancer
  9. Specialist surgery for appropriate residual or retroperitoneal disease

There are, however, some interesting differences in emphasis.

European approach: EAU

The European Association of Urology guidelines strongly favour avoiding unnecessary treatment.

For Stage I seminoma, surveillance is preferred when the patient can comply with follow-up.

Routine adjuvant radiotherapy is not recommended.

For Stage I NSGCT, the EAU uses lymphovascular invasion prominently for risk-adapted counselling:

  • LVI negative → surveillance generally preferred
  • LVI positive → surveillance or one cycle of BEP

Primary RPLND has a relatively limited role in Stage I NSGCT.

For marker-negative Stage IIA NSGCT, however, the 2026 EAU guideline supports nerve-sparing RPLND in an experienced specialised centre.

British approach

British practice is broadly similar to European practice.

The NHS pathway centres around:

Ultrasound → tumour markers → inguinal orchidectomy → staging → multidisciplinary oncology review.

Surveillance is commonly used following orchidectomy for appropriate Stage I disease.

Carboplatin remains an option for Stage I seminoma, while BEP chemotherapy is used for appropriate non-seminomatous and metastatic disease.

Radiotherapy retains a role predominantly in selected seminoma rather than non-seminomatous cancer.

British cancer services place considerable emphasis on:

  • Specialist germ-cell cancer multidisciplinary teams
  • Fertility preservation
  • Long-term follow-up
  • Minimising unnecessary treatment toxicity

This is very similar to contemporary Australian practice.

How does the American approach differ?

American management follows the same oncological principles, but the American Urological Association – AUA – gives RPLND somewhat greater prominence as an acceptable primary treatment option in selected early-stage disease.

For Stage IA NSGCT, the AUA recommends surveillance but recognises:

  • RPLND
  • One cycle of BEP

as alternatives for appropriate patients who decline surveillance or may not comply reliably.

For Stage IB NSGCT, American guidance recognises:

  • Surveillance
  • RPLND
  • One or two cycles of BEP

as options following shared decision-making.

This differs subtly from the EAU approach, where primary RPLND in Stage I NSGCT has a considerably narrower role.

Another evolving difference: RPLND for Stage II seminoma

Traditionally seminoma involving retroperitoneal lymph nodes was treated with either:

Radiotherapy or chemotherapy.

American guidelines have increasingly recognised primary RPLND as an option for carefully selected Stage IIA/IIB seminoma with limited retroperitoneal disease, particularly for patients wishing to avoid the potential long-term toxicity of chemotherapy or radiotherapy.

European recommendations are also evolving in this direction.

The 2026 EAU guideline now incorporates nerve-sparing RPLND and newer de-escalation strategies into the management discussion for selected Stage IIA/B seminoma.

This is an excellent example of why testicular cancer management continues to evolve.

Australia: where do we sit?

Australian practice sits comfortably between these international approaches.

For most Australian patients:

Stage I seminoma

Surveillance is generally preferred, with carboplatin available for selected patients.

Stage I NSGCT without LVI

Surveillance is generally preferred.

Stage I NSGCT with LVI

Surveillance or one cycle of BEP following individualised discussion.

Stage II seminoma

Radiotherapy or cisplatin-based chemotherapy depending upon disease volume, with increasingly selective consideration of surgical strategies in specialist centres.

Marker-positive metastatic disease

Cisplatin-based chemotherapy according to IGCCCG prognostic classification.

Residual NSGCT after chemotherapy

Surgical resection when indicated, ideally through an experienced germ-cell cancer service.

Australian cancer care increasingly emphasises multidisciplinary decision-making and treatment that achieves cure while reducing unnecessary long-term toxicity.

Why avoiding unnecessary treatment matters

A 25-year-old cured of testicular cancer may live another 60 years.

That changes the treatment equation.

The question is no longer simply:

“Which treatment will cure the cancer?”

It is also:

“Which treatment will cure this cancer while leaving the smallest possible footprint over the next several decades?”

This is why surveillance has become so important.

Chemotherapy and radiotherapy are extraordinarily effective, but they should be used when their benefit justifies their immediate and long-term risks.

Prognosis

The prognosis for testicular cancer is excellent.

Stage I disease has survival approaching 100%.

Even metastatic disease is frequently curable.

Prognosis depends upon:

  • Seminoma versus non-seminoma
  • Stage
  • Tumour-marker levels
  • Sites of metastatic disease
  • Response to chemotherapy
  • Tumour-marker decline
  • Presence of residual disease
  • Ability to completely resect appropriate residual masses

Importantly, doctors genuinely use the word cure when discussing metastatic testicular cancer.

After treatment: don’t forget the other testicle

Having had one testicular cancer increases the risk of developing cancer in the remaining testicle.

Men should therefore remain familiar with the remaining testicle and report any new abnormality promptly.

Long-term survivorship care may also address:

  • Testosterone levels
  • Fertility
  • Cardiovascular health
  • Kidney function
  • Hearing
  • Peripheral neuropathy
  • Lung health following bleomycin
  • Psychological wellbeing
  • Sexual health
  • Risk of late treatment complications

The take-home message

Testicular cancer tends to arrive at an inconvenient age, when most men are thinking about careers, relationships, families and weekend plans rather than cancer.

Fortunately, it is also one of medicine’s most impressive cancer success stories.

Know your testicles.

Become familiar with what is normal for you.

Don’t ignore a change.

A lump, enlargement, hardness, heaviness or persistent discomfort deserves examination.

Don’t be embarrassed.

Your urologist has quite literally made a career out of discussing these things.

And don’t assume a diagnosis of testicular cancer means the worst.

With modern surveillance, surgery, chemotherapy and selective radiotherapy, the overwhelming majority of men diagnosed with testicular cancer can expect to be cured.

So, if you have felt a testis lump and you are concerned, come see me your local Brisbane Urologist, Dr Jo, to chat to you about treatment. This is URGENT and I will squeeze you in!

Pornography and Men’s Health: When Sexual Entertainment Starts Taking More Than It Gives

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Pornography has never been easier to access. What once required some effort to obtain is now available privately, instantly and endlessly through a phone.

For many men, occasional pornography use does not necessarily cause a medical or psychological problem. However, frequent, escalating or compulsive use can become troublesome. It may affect sexual arousal, erections, orgasm, mood, self-esteem, relationships and the way a man experiences intimacy.

For some men, pornography gradually changes from something they choose to watch into something they feel they need to watch.

That distinction matters.

When does pornography use become a problem?

There is no medically defined number of minutes, videos or episodes per week that automatically makes pornography use unhealthy.

The more useful questions are:

  • Do you repeatedly watch pornography for longer than you intended?
  • Have you tried unsuccessfully to cut down?
  • Do you need increasingly novel, intense or specific material to maintain interest?
  • Is pornography replacing sexual intimacy with your partner?
  • Do erections seem easier with pornography than with a real partner?
  • Do you struggle to reach orgasm during partnered sex?
  • Are you hiding your pornography use?
  • Is it interfering with sleep, work, exercise or family life?
  • Do you feel anxious, irritable or preoccupied when trying not to use it?
  • Do you continue despite knowing that it is hurting your relationship?

When several of these occur together, pornography may no longer simply be entertainment.

It may have become part of a compulsive behavioural pattern.

Pornography, the brain and sexual arousal

Male sexual arousal is not simply a hydraulic event involving blood entering the penis.

It begins in the brain.

Sexual images activate attention, motivation, reward and arousal pathways. The brain then communicates through the spinal cord and autonomic nerves to produce genital arousal and erection.

Internet pornography can provide an unusually powerful combination:

sexual stimulation + novelty + instant availability + almost unlimited choice.

With repeated exposure, some men describe needing more novelty or more stimulating material to achieve the same degree of excitement.

Importantly, this does not mean that every pornography user develops an “addicted brain”, nor should every sexual difficulty automatically be blamed on pornography. Human sexual behaviour is considerably more complicated.

But in some men, repeated pornography use can become strongly linked to masturbation and arousal. The man’s sexual response may become increasingly conditioned to a particular combination of screen, imagery, novelty, masturbation technique and privacy.

A real partner cannot, and should not have to, compete with an endless stream of rapidly changing digital stimulation.

Can pornography cause erectile dysfunction?

This is one of the most common questions men ask.

The relationship is complicated.

Some observational studies have found associations between problematic pornography use and sexual dissatisfaction or erectile difficulties, but this does not prove that pornography directly causes erectile dysfunction in every man.

Erectile dysfunction can also result from:

  • ageing
  • diabetes
  • cardiovascular disease
  • high blood pressure
  • obesity
  • smoking
  • medications
  • low testosterone
  • neurological disease
  • prostate surgery
  • depression
  • anxiety
  • relationship difficulties
  • performance anxiety.

Nevertheless, some younger men report an interesting pattern:

Good erections during pornography and masturbation, but unreliable erections with a partner.

When this occurs, physical erectile function may actually be relatively intact.

The difficulty may instead involve arousal conditioning, anxiety, expectations, relationship factors or a combination of these.

A urological assessment is still worthwhile because physical causes should not simply be assumed away.

Delayed ejaculation and difficulty reaching orgasm

Problematic pornography use may also be associated with difficulty reaching orgasm during partnered sex.

Some men become accustomed to a very particular masturbation technique: specific pressure, speed, position and visual stimulation.

Partnered sexual activity is different.

The result can sometimes be:

normal erection → prolonged intercourse → increasing effort → frustration → loss of erection → disappointment for both partners.

Sex gradually stops feeling spontaneous and starts feeling like an examination nobody volunteered to sit.

Reducing pornography use, modifying masturbation habits and removing the pressure to “perform” can sometimes help restore a more natural sexual response.

Mental health

Pornography can also become a way of managing uncomfortable emotions.

A man may reach for pornography when he feels:

  • stressed
  • lonely
  • rejected
  • bored
  • anxious
  • angry
  • depressed
  • emotionally disconnected.

The behaviour temporarily provides distraction or relief.

But afterwards there may be regret, secrecy or shame.

A cycle can develop:

stress → pornography → temporary relief → guilt or isolation → more stress → pornography again.

The pornography may therefore be only part of the problem.

The more important question can become:

“What am I using pornography to escape from?”

That question often opens a much more useful conversation.

Pornography and relationships

The greatest harm may sometimes occur outside the bedroom.

Secret or compulsive pornography use can affect trust between partners.

A partner may wonder:

Am I attractive enough?
Why does he prefer pornography to me?
What has he been watching?
Why did he hide it?
Can I trust him?

For the man, the experience may be equally difficult. He may genuinely love his partner while simultaneously feeling unable to control a behaviour that is damaging the relationship.

Arguments about pornography therefore often become arguments about something much deeper:

trust, intimacy, honesty, vulnerability and connection.

Unrealistic expectations about sex

Pornography is entertainment. It is not sex education.

Bodies are selected. Scenes are edited. Performances are exaggerated. Erections appear permanently reliable. Sexual encounters often progress with very little communication, awkwardness, humour or emotional connection.

Real sexuality is considerably more human.

Bodies change.

Erections occasionally disappear.

Orgasms do not always occur.

People need reassurance.

Couples sometimes laugh.

Sometimes sex simply does not work particularly well that evening.

That is normal.

When pornography becomes a man’s principal source of sexual education, however, unrealistic expectations can develop regarding penis size, erection duration, sexual positions, frequency of intercourse and what partners supposedly enjoy.

Effects on partners and families

Problematic pornography use can extend beyond the couple’s sexual relationship.

Secrecy may produce emotional distance.

Late-night viewing may interfere with sleep.

Preoccupation can reduce attention given to children or a partner.

Arguments may become increasingly frequent.

In severe situations, substantial amounts of time or money can disappear into online sexual activity.

The man may be physically sitting in the family home while psychologically living somewhere entirely different.

That disconnection is often what families feel most strongly.

Is pornography addiction a recognised diagnosis?

The terminology requires some care.

“Porn addiction” is widely used in everyday conversation, but clinicians may instead assess whether a person has compulsive sexual behaviour.

Compulsive Sexual Behaviour Disorder is recognised in the World Health Organization’s ICD-11 classification. It involves persistent difficulty controlling intense repetitive sexual impulses or behaviours that result in significant impairment in personal, family, social, educational or occupational life.

Simply having a strong sex drive does not qualify.

Nor should distress caused purely by moral or religious disagreement with one’s own sexual behaviour automatically be labelled a disorder.

The issue is loss of control and meaningful harm.

What can a man do about it?

Recovery does not necessarily require declaring war on sexuality.

The goal is to regain choice.

A useful starting point is to honestly observe the pattern.

1. Identify your triggers

Ask when pornography use tends to occur.

Is it when you are:

  • alone?
  • stressed?
  • drinking alcohol?
  • lying awake at night?
  • arguing with your partner?
  • bored?
  • feeling rejected?

Understanding the trigger is often more useful than simply trying to suppress the behaviour.

2. Make access less automatic

Consider removing pornography from your phone, deleting saved material, unfollowing triggering accounts and using website or device restrictions.

Most importantly, change the environment associated with the behaviour.

A smartphone beside the bed at midnight can become a surprisingly persuasive little rectangle.

3. Take a break from pornography

For men experiencing sexual difficulties, a period without pornography can be useful.

This is not based on the idea that the brain requires a magical predetermined “reset period”.

Rather, it provides an opportunity to discover how much pornography has become connected to arousal, masturbation and emotional regulation.

4. Reconsider masturbation habits

If masturbation has become very frequent, rushed or dependent on intense visual stimulation, try changing the pattern.

Slower masturbation without pornography and with less intense pressure may help some men reconnect sexual arousal with bodily sensation rather than constant visual novelty.

5. Rebuild partnered intimacy

Do not make every sexual encounter a test of whether the penis works.

Spend time touching, kissing and being physically close without demanding intercourse or orgasm.

Sexual confidence often returns more readily when the scoreboard disappears.

6. Exercise, sleep and reconnect

Exercise, meaningful social contact, adequate sleep, hobbies and time outdoors sound remarkably ordinary.

That is precisely their strength.

Compulsive behaviours often flourish in isolation, boredom and emotional exhaustion.

Building a fuller life leaves less territory for pornography to occupy.

Talk to your partner

If pornography has damaged trust, simply promising:

“I’ll never do it again.”

may not repair the relationship.

Trust usually returns through consistent behaviour rather than dramatic promises.

A more constructive conversation might acknowledge:

  • what has happened
  • the effect on your partner
  • what you are changing
  • what support you are seeking
  • what boundaries you will agree upon together.

Couples counselling can be extremely valuable when pornography has become entangled with intimacy, resentment or secrecy.

Psychological treatment can help

A psychologist, counsellor or appropriately trained sex therapist can help identify why the behaviour has become difficult to control.

Treatment may include:

  • cognitive behavioural therapy
  • strategies for managing urges and triggers
  • mindfulness-based approaches
  • treatment of anxiety or depression
  • addressing loneliness or trauma
  • sexual therapy
  • couples counselling
  • rebuilding intimacy and communication.

Seeking psychological help does not mean that the problem is “all in your head”.

Sexual function lives at the intersection of the brain, body, emotions and relationship.

Treating only one part can miss the larger picture.

When should you see a urologist?

Consider discussing the problem with your GP or urologist if you are experiencing:

  • erectile dysfunction
  • reduced libido
  • delayed ejaculation
  • inability to orgasm
  • penile pain or curvature
  • concerns about testosterone
  • loss of morning erections
  • significant changes in sexual function.

It is important not to assume that pornography explains every sexual problem.

Diabetes, cardiovascular disease, hormonal abnormalities, medication effects and other medical conditions can produce very similar symptoms.

A proper assessment helps separate the physical from the psychological, and frequently discovers elements of both.

Where can men get help in Australia?

There is no need to wait until pornography has destroyed a relationship before asking for help.

Centre for Men and Families

The Centre for Men and Families provides counselling and support for men as well as men’s circles and programs designed to create genuine connection between men.

For some men, this is particularly valuable because problematic pornography use can thrive in secrecy and isolation. Being able to speak honestly with another person can be an important part of breaking that cycle.

MensLine Australia

MensLine Australia provides free professional telephone and online counselling to Australian men, 24 hours a day, seven days a week.

Phone: 1300 78 99 78

Men can seek help with relationships, mental health, loneliness, stress, addiction and other personal difficulties.

Your GP can also arrange referral to a psychologist, psychiatrist, relationship counsellor or sexual-health professional where appropriate.

If pornography use is accompanied by severe depression, hopelessness or thoughts of suicide, seek urgent professional help. In Australia, Lifeline can be contacted on 13 11 14. If there is immediate danger, call 000.

There is a way forward

Pornography does not make someone a bad man.

But when a behaviour begins stealing intimacy, sexual confidence, sleep, honesty, relationships or time with the people who matter, it deserves attention.

The objective is not shame.

It is awareness.

It is learning to recognise what drives the behaviour, restoring control over sexual choices and rediscovering something pornography can imitate visually but cannot provide:

genuine intimacy with another human being.

For many men, recovery begins with a surprisingly small act:

telling someone the truth.