Parkinson’s Disease and the Bladder: When the Brain–Bladder Signal Misbehaves

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Parkinson’s disease is best known for tremor, stiffness and slowed movement, but it can also affect many automatic body functions: including bladder control. Urinary symptoms may disturb sleep, restrict social activities and increase the risk of falls when someone rushes to the toilet.

The reassuring message is that bladder symptoms can usually be improved. The important first step is to identify what the bladder is doing, because not every urinary problem in a person with Parkinson’s is caused by Parkinson’s itself.

How does Parkinson’s affect the bladder?

The bladder normally stores urine quietly and empties only when the brain decides that the time and place are appropriate. Dopamine-dependent circuits in the brain help suppress unwanted bladder contractions during filling.

Parkinson’s can weaken this “hold on” signal. The bladder muscle may contract before it is full, a condition called detrusor overactivity. This produces the familiar overactive-bladder symptoms of urgency, frequency and urge incontinence.

This is a form of neurogenic lower urinary tract dysfunction; bladder or sphincter function altered by disease of the nervous system. However, Parkinson’s does not create one single bladder pattern. Age-related bladder changes, prostate enlargement, pelvic-floor problems, constipation, diabetes, mobility limitations and medications may all contribute.

Common urinary symptoms

People may experience:

  • a sudden, difficult-to-defer need to pass urine;
  • frequent urination during the day;
  • waking several times at night to urinate (nocturia);
  • leakage before reaching the toilet (urge incontinence);
  • bedwetting;
  • hesitancy, a slow stream or straining;
  • a feeling that the bladder has not emptied; or
  • recurrent urinary infections.

Some apparent bladder leakage is partly functional: the person recognises the urge but rigidity, slow movement, poor balance or difficulty managing clothing prevents timely access to the toilet.

Difficulty emptying can occur, but substantial urinary retention is less typical of uncomplicated Parkinson’s disease. It may indicate prostate or urethral obstruction, an underactive bladder, medication effects, severe constipation, pelvic-organ prolapse, or another neurological disorder. Prominent retention, erectile dysfunction or severe postural blood-pressure problems early in a parkinsonian illness may warrant neurological review for conditions such as multiple system atrophy.

How is the bladder evaluated?

A careful assessment is more useful than assuming that every symptom is “just the Parkinson’s”. It may include:

  1. History and medication review: urinary symptoms, fluid intake, bowel function, mobility, cognition, falls and all prescribed and non-prescribed medicines.
  2. Bladder diary: usually recording drinks, voided volumes, urgency and leakage for three days. This is particularly helpful for nocturia.
  3. Examination: abdominal, neurological and, when appropriate, prostate or pelvic assessment.
  4. Urine test: to look for infection or blood.
  5. Post-void residual measurement: a bladder ultrasound after urination shows whether emptying is adequate.
  6. Uroflowmetry: measures the strength and pattern of the urinary stream.
  7. Further tests when indicated: renal function, ultrasound, cystoscopy or prostate assessment according to the clinical findings.

Blood in the urine, pain, fever, recurrent infection or a sudden major change in bladder function needs separate investigation and should not automatically be attributed to Parkinson’s.

Are urodynamic studies always necessary?

No. A patient with straightforward urgency and urge leakage, a normal urine test and a low residual volume can often begin conservative treatment without invasive testing.

Urodynamics may be particularly useful when:

  • symptoms and initial test results do not agree;
  • there is a high or rising post-void residual;
  • weak flow, retention or obstruction is suspected;
  • symptoms persist despite appropriate treatment;
  • the diagnosis is uncertain, for example, overactivity versus poor bladder contraction;
  • previous prostate, bladder or continence surgery complicates the picture; or
  • Botox or another invasive treatment is being considered and the result would alter management.

During urodynamics, thin catheters measure bladder and abdominal pressure while the bladder fills and empties. The test may demonstrate detrusor overactivity, impaired contraction, obstruction or, less commonly, unsafe storage pressure. It should answer a specific clinical question not simply be performed because Parkinson’s is present.

First steps: practical and behavioural treatment

Management should be individualised and, where helpful, involve the urologist, neurologist, Parkinson’s nurse, continence physiotherapist, occupational therapist and carer.

Useful measures include:

  • treating urinary infection and constipation;
  • reviewing diuretics and other medicines with the prescribing doctor;
  • spreading fluid intake through the day while avoiding dehydration;
  • reducing late-evening fluids, caffeine and alcohol when nocturia is troublesome;
  • timed or prompted voiding;
  • bladder training when cognition and mobility permit;
  • pelvic-floor physiotherapy where appropriate;
  • improving toilet access, lighting, clothing and mobility aids; and
  • using a bedside urinal or commode when falls are a concern.

Nocturia is not always caused solely by an overactive bladder. Leg swelling, sleep apnoea, excessive urine production overnight and disturbed sleep may require different treatment.

Medication options

Antimuscarinic medicines

Medicines such as solifenacin, darifenacin, tolterodine, fesoterodine, oxybutynin or trospium can reduce involuntary bladder contractions. They may improve urgency, frequency and urge leakage.

The trade-off is important in Parkinson’s disease. Anticholinergic burden may worsen dry mouth, constipation, blurred vision, urinary retention, confusion or memory. Older people, those with cognitive impairment, glaucoma or poor bladder emptying need particular caution. Oxybutynin can be especially troublesome cognitively in susceptible patients. Drug choice should consider the person’s complete medication list and residual urine.

Beta-3 agonists

Mirabegron relaxes the bladder during filling without adding the same anticholinergic burden and has shown benefit in people with Parkinson’s and overactive-bladder symptoms. Blood pressure should be checked because it can rise, and interactions and cardiac history should be reviewed. Vibegron is another beta-3 agonist available for overactive bladder in Australia; Parkinson-specific evidence is more limited.

Combination treatment may be considered in selected patients when one medicine provides incomplete relief, with monitoring of blood pressure, side effects and bladder emptying.

If emptying is the main problem

Treatment depends on the cause. Prostate medication or surgery will help only if genuine bladder-outlet obstruction is present. An alpha-blocker may worsen dizziness or postural hypotension, already common in Parkinson’s. If significant residual urine persists, clean intermittent self-catheterisation, performed by the patient or a carer where feasible, is generally preferable to a long-term urethral catheter. A suprapubic catheter may be considered when intermittent catheterisation is not practical.

Botox injections into the bladder

Botulinum toxin A (Botox) can be effective for troublesome detrusor overactivity or overactive-bladder symptoms that have not responded to, or cannot tolerate, tablets. It is injected through a cystoscope into multiple areas of the bladder wall, usually as a day procedure.

Benefits may include fewer urgency episodes, fewer leaks and better sleep and quality of life. The effect is temporary, commonly lasting several months, so repeat treatment may be required.

Important risks include:

  • urinary infection;
  • blood in the urine or short-lived discomfort;
  • incomplete bladder emptying or urinary retention; and
  • the possible need for temporary or occasionally ongoing intermittent catheterisation.

Before treatment, the patient’s hand function, cognition and support network matter: could the patient or carer perform catheterisation if retention occurred? Measuring residual urine before and after treatment is essential. Urodynamics is often helpful if the underlying bladder behaviour or emptying ability is uncertain, although it is not mandatory in every otherwise clear case.

Can sacral neuromodulation be used in Parkinson’s disease?

Yes, in carefully selected patients. Sacral neuromodulation (SNM) sends mild electrical impulses to the sacral nerves involved in bladder control. It can be considered for refractory urgency, frequency, urge incontinence and, in selected circumstances, non-obstructive urinary retention.

Treatment begins with a test or staged phase. A temporary or tined lead is used to assess whether symptoms improve meaningfully, commonly by at least 50%, before a permanent battery is implanted. This trial is particularly valuable because Parkinson’s symptoms and bladder patterns differ between patients.

Small observational studies and systematic reviews suggest that some people with Parkinson’s achieve worthwhile improvement. However, the Parkinson-specific evidence is less extensive than the evidence for non-neurogenic overactive bladder, and response cannot be guaranteed.

Points to consider include:

  • confirming that infection, obstruction and severe retention have been addressed;
  • whether symptoms are likely to be modulated by SNM;
  • the person’s ability, or carer support, to operate and attend follow-up for the device;
  • falls, mobility and future disease progression;
  • possible lead movement, pain, infection, device revision or battery replacement; and
  • future MRI requirements. Modern systems may be MRI-conditional, but the exact device and scanning conditions must always be checked.

SNM is therefore not automatically excluded because a person has Parkinson’s. It is best considered through shared decision-making after appropriate evaluation and failure or intolerance of simpler measures.

Botox or sacral neuromodulation?

Feature Bladder Botox Sacral neuromodulation
How it works Temporarily reduces bladder-muscle overactivity Modulates sacral nerve signalling
Treatment pathway Cystoscopic injections, repeated when effect wears off Test phase followed by an implant if successful
Main advantage No permanent implant; established effect on detrusor overactivity Testable before permanent implantation; no routine bladder injections
Main limitation UTI and retention; intermittent catheterisation may be required Implant surgery, programming, revisions and battery management
Parkinson-specific evidence Supportive but based mainly on relatively small studies Promising but still limited; careful selection is essential
Particularly important question Could the patient or carer catheterise if necessary? Can the patient manage the device and follow-up as Parkinson’s progresses?

Neither option is universally “better”. The choice depends on bladder-emptying ability, infection history, dexterity, cognition, mobility, MRI needs, willingness to have repeat procedures or an implant, and the individual’s priorities.

When should you seek prompt medical attention?

Contact a doctor urgently for inability to pass urine, fever with urinary symptoms, flank pain, visible blood in the urine or a sudden neurological or bladder deterioration. New persistent incontinence also deserves assessment rather than simply adding pads.

The take-home message

Bladder symptoms are common and often overlooked in Parkinson’s disease. Urgency, frequency, nocturia and urge leakage are the usual pattern, but obstruction and poor emptying must not be missed. Most patients do not require urodynamics at the outset; it becomes valuable when the diagnosis is uncertain, emptying is impaired, treatment has failed or an invasive procedure is being planned.

Treatment progresses from practical measures and medication to Botox or sacral neuromodulation in suitable patients. The best plan balances symptom control with cognition, blood pressure, constipation, mobility, manual dexterity and the likely course of Parkinson’s disease.

Patient information: This article provides general education and is not a substitute for an individual medical assessment. Do not stop Parkinson’s, blood-pressure or bladder medication without discussing it with your treating doctor.

References and further reading

  1. European Association of Urology. EAU Guidelines on Neuro-Urology. 2026.
  2. Ginsberg DA, et al. AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction. J Urol. 2021; amendment 2024.
  3. Li FF, et al. Prevalence of lower urinary tract symptoms, urinary incontinence and retention in Parkinson’s disease: a systematic review and meta-analysis. Front Aging Neurosci. 2022;14:977572.
  4. Sakakibara R, et al. A guideline for the management of bladder dysfunction in Parkinson’s disease and other gait disorders. Neurourol Urodyn. 2016;35:551–563.
  5. Cho SY, et al. Mirabegron for treatment of overactive bladder symptoms in patients with Parkinson’s disease: a randomised, placebo-controlled trial. Neurourol Urodyn. 2021.
  6. Greenberg DR, et al. Sacral nerve stimulation in Parkinson’s disease patients with overactive bladder symptoms. Urology. 2020;144:99–105.
  7. Smith MD, et al. Neuromodulation for storage lower urinary tract symptoms in Parkinson disease: a systematic review. Neuromodulation. 2022.

 

Multiple Sclerosis and the Bladder: Symptoms, Tests and Treatment Options

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Multiple sclerosis (MS) affects the brain and spinal cord, the same nervous system pathways that coordinate bladder storage, bladder emptying and urinary sphincter control. As a result, bladder symptoms are common and may change as MS changes.

The important message is that “an MS bladder” is not one single condition. Some people develop an overactive bladder, some cannot empty properly, and others have a mixture of both. Treatment should therefore be based on the individual bladder pattern, not simply on the diagnosis of MS.

How does MS affect bladder control?

Normally, the bladder stores urine at low pressure while the urinary sphincter stays closed. When it is convenient to urinate, the brain allows the bladder muscle (detrusor) to contract while the sphincter relaxes.

MS plaques can interrupt these signals in different places. This may cause:

  • Neurogenic detrusor overactivity: the bladder contracts unexpectedly during filling, causing urgency, frequency, nocturia and urge incontinence.
  • Detrusor sphincter dyssynergia: the bladder contracts while the sphincter fails to relax properly, rather like pressing the accelerator and brake together. This may produce poor flow, straining, incomplete emptying, high bladder pressure and recurrent urinary infection.
  • Detrusor underactivity: the bladder contraction is too weak or does not last long enough, causing slow emptying or retention.
  • A mixed pattern: urgency and leakage can coexist with a significant residual urine volume.

The European Association of Urology (EAU) reports that approximately 75% of people develop voiding dysfunction within ten years of MS. Reported urodynamic patterns include neurogenic detrusor overactivity in 43–65%, detrusor sphincter dyssynergia in about 35%, and detrusor underactivity in about 25%. These patterns can overlap and can change over time.

Symptoms that deserve assessment

Bladder symptoms may include:

  • sudden urgency and difficulty postponing urination;
  • frequent urination by day or night;
  • leakage before reaching the toilet;
  • hesitancy, interrupted or weak urinary flow;
  • straining to urinate;
  • a feeling of incomplete emptying;
  • recurrent urinary tract infections (UTIs);
  • new bedwetting or unexpected leakage; and
  • an inability to pass urine.

Seek prompt medical review for fever, flank pain, visible blood in the urine, severe bladder pain, inability to urinate, or a sudden major change in bladder function. A UTI can temporarily worsen neurological MS symptoms (a pseudo-relapse), while a true neurological relapse can also alter bladder function.

How is the bladder assessed?

Assessment is tailored to symptoms, disability, MS course and previous treatment. It may include:

  1. A detailed urinary, neurological, bowel, medication and mobility history.
  2. A three-day bladder diary recording fluid intake, voids, urgency, leakage and catheter volumes.
  3. Urinalysis and urine culture when infection is suspected.
  4. Measurement of post-void residual urine with a bladder scan.
  5. Kidney-function blood tests where appropriate.
  6. Urinary tract ultrasound in selected patients, particularly where retention, recurrent infection, stones or upper-tract risk is suspected.
  7. Uroflowmetry, which measures the strength and pattern of the urinary stream.
  8. Urodynamic studies when the result is likely to clarify the diagnosis or change treatment.

Urodynamic studies: useful, but used selectively

Urodynamics measures bladder pressure, abdominal pressure, urine flow and sphincter activity during filling and emptying. It can distinguish urgency caused by detrusor overactivity from poor emptying caused by detrusor weakness, outlet obstruction or detrusor–sphincter dyssynergia. Video urodynamics can additionally show the bladder outlet, reflux and anatomical changes.

Urodynamics is especially useful when:

  • symptoms and residual urine measurements do not tell the same story;
  • both storage and emptying symptoms are present;
  • recurrent UTIs, retention or raised bladder pressures are suspected;
  • invasive treatment such as bladder Botox is being considered;
  • previous treatment has failed or produced unexpected problems;
  • there is concern about kidney or upper urinary tract safety; or
  • bladder function has changed significantly.

Precautions before and during urodynamics

  • Active symptomatic UTI should be treated before an elective invasive study.
  • The team should know about antibiotics, anticoagulants, allergies, pregnancy possibility and previous difficulty with catheterisation.
  • Mobility, spasms, fatigue, cognition, hand function and transfer needs should be planned for in advance.
  • Catheter placement and rapid filling can alter the result; artefacts must be recognised and the study interpreted alongside the person’s normal symptoms and bladder diary.
  • A single study is a snapshot. Results may vary, and repeat testing may be appropriate when findings are inconsistent or the clinical situation changes.
  • Autonomic dysreflexia is mainly a concern in susceptible people with high spinal cord lesions rather than typical MS, but blood pressure and heart rate must be monitored whenever an individual is considered at risk.
  • Preventive antibiotics are not automatically required for every patient; use should be individualised according to urine findings and infection risk.

Treatment: matching the solution to the bladder problem

The aims are to improve continence and quality of life, empty the bladder safely, reduce infections, protect the kidneys and preserve independence.

Everyday measures

Useful first steps may include:

  • timed voiding or bladder training;
  • adjusting excessive, poorly timed fluid intake without becoming dehydrated;
  • reducing caffeine, alcohol or other individual bladder irritants;
  • treating constipation;
  • improving toilet access, clothing and mobility support;
  • pelvic-floor physiotherapy where muscle control and the bladder pattern make this appropriate; and
  • continence pads, sheaths or other products as support, not as a substitute for investigating retention.

Medication for urgency and neurogenic overactive bladder

Antimuscarinic medicines can reduce involuntary bladder contractions and improve capacity. Possible side effects include dry mouth, constipation, blurred vision and impaired bladder emptying. Cognitive burden is relevant, particularly where fatigue, memory concerns or multiple anticholinergic medicines are already present.

Beta-3 agonists, may improve urgency and frequency with less dry mouth and constipation. Blood pressure and drug interactions require consideration. In neurogenic detrusor overactivity, symptom improvement does not necessarily mean that bladder pressures have normalised.

Before and after starting storage medication, the residual urine may need checking because suppressing bladder contractions can reveal or worsen incomplete emptying. Combination therapy is sometimes used under specialist supervision.

An alpha-blocker may occasionally be used to reduce outlet resistance in selected patients with voiding difficulty, although it will not correct every cause of neurogenic retention.

Catheterisation and intermittent self-catheterisation (ISC)

If the bladder cannot empty safely, intermittent catheterisation is often preferred to leaving a catheter in continuously. A small catheter is passed at planned intervals and removed once the bladder is empty.

ISC may:

  • reduce residual urine and overflow leakage;
  • improve bladder-pressure control;
  • make storage medicines or Botox safer; and
  • protect the upper urinary tract in selected patients.

However, it must be practical. Hand dexterity, tremor, spasticity, vision, fatigue, cognition, body position, urethral anatomy, bathroom access and carer support all matter. Training by an experienced continence nurse is valuable, and adaptive equipment or a different catheter may make a major difference.

Possible difficulties include discomfort, urethral trauma, bleeding, false passage and UTI. Bacteria in the urine without symptoms do not always require antibiotics. The EAU emphasises shared decision-making because ISC can increase treatment burden; one cited MS study found a higher UTI rate after starting intermittent catheterisation without a corresponding improvement in quality of life or symptom score.

If ISC is impossible and drainage is essential, an indwelling urethral or suprapubic catheter may be considered. Long-term catheters carry risks including infection, blockage, encrustation, leakage, bladder stones and urethral damage. When long-term drainage is necessary, a suprapubic catheter may offer practical advantages for selected patients, but it is not complication-free.

Bladder Botulinum Toxin injections

Botulinum toxin type A is injected through a cystoscope into multiple areas of the bladder wall. It reduces the nerve signals that trigger involuntary detrusor contractions and is well supported for MS-related neurogenic detrusor overactivity when tablets are ineffective or poorly tolerated.

Benefits may include fewer urgency-incontinence episodes, improved bladder capacity and lower storage pressure. The effect is temporary, commonly lasting several months, so successful treatment usually requires repeat injections.

The main precautions are:

  • UTI must be excluded or treated around the procedure according to local protocol.
  • Botox may weaken bladder emptying and cause urinary retention.
  • A patient who does not already catheterise must be willing and physically able to perform ISC, or have reliable help, if retention develops.
  • UTIs, temporary blood in the urine and discomfort can occur; generalised muscle weakness is rare.
  • Residual urine and symptoms require follow-up, and urodynamics may occasionally be repeated to confirm safe bladder pressures.

Dose and injection technique are individualised. In MS patients who still void spontaneously, a lower dose may reduce—but does not eliminate—the likelihood of needing catheterisation.

Sacral neuromodulation (SNM)

SNM delivers mild electrical stimulation to the sacral nerves, usually via a lead placed near the S3 nerve root and connected to a small implanted pulse generator. It can be considered in carefully selected patients with refractory urgency, urgency incontinence, frequency or non-obstructive urinary retention.

A major advantage is that treatment can be tested first. During a trial phase, symptom diaries help determine whether stimulation produces a meaningful improvement before the permanent battery is implanted.

Important considerations in MS include:

  • the evidence base is smaller and less disease-specific than the evidence supporting Botox for neurogenic detrusor overactivity;
  • results may be less predictable if neurological disease progresses or the bladder pattern changes;
  • implantation requires a procedure and ongoing programming;
  • pain, infection, lead movement, loss of effect, device malfunction and future revision or replacement can occur; and
  • people with MS commonly require future MRI scans. Modern systems may be MRI-conditional, but the exact lead and generator combination and the scanner conditions must be verified before implantation and before every MRI.

SNM does not remove the need to monitor residual urine, infection risk or upper-tract safety when clinically indicated.

Botox versus sacral neuromodulation in MS

Feature Bladder Botox Sacral neuromodulation
Main role Neurogenic detrusor overactivity with urgency and urge incontinence after medication is inadequate or poorly tolerated Selected refractory urgency, urge incontinence, frequency or non-obstructive retention
MS-specific evidence Stronger; supported by randomised trials in neurogenic detrusor overactivity Promising, but fewer MS-specific studies and less certainty about ideal candidates
How it works Temporarily reduces detrusor nerve activity and contractions Modulates sacral nerve signalling to the bladder and pelvic floor
Procedure Cystoscopic injections into the bladder Trial lead followed by permanent implant if successful
Reversibility Effect wears off over months Stimulation can be adjusted or switched off; device can be removed
Repeat treatment Usually repeat injections are required Programming and eventual battery/device revision or replacement may be required
Retention/ISC risk Important; new ISC may become necessary Generally less likely to cause retention; may also treat selected non-obstructive retention
Infection considerations UTI is a common adverse event; urinary infection should be addressed before treatment Surgical-site or device infection can require antibiotics or device removal
MRI considerations No implanted device restriction Confirm that the complete implanted system is MRI-conditional and follow device-specific conditions
Best fit Proven high-pressure or overactive bladder where reducing contractions is the priority and catheterisation is feasible if needed A carefully selected patient who values a test phase, has suitable symptoms and accepts an implant and follow-up
Key limitation Temporary effect and possible urinary retention Implant-related complications and less certain outcomes as MS evolves

Which is better?

Neither treatment is universally “better.” Botulinum Toxin is often favoured when urodynamics demonstrates neurogenic detrusor overactivity and the main goal is to suppress involuntary bladder contractions or unsafe storage pressure. SNM may be attractive in a carefully selected patient with refractory urgency or non-obstructive retention who wants a testable, adjustable treatment and wishes to avoid the higher catheterisation risk associated with Botox.

The decision should consider urodynamic findings, current residual urine, ability to perform ISC, recurrent UTIs, hand function, mobility, expected MRI needs, disease stability, patient preference and access to long-term follow-up.

Other interventional and surgical options

For selected patients, posterior tibial nerve stimulation may improve overactive bladder symptoms without an implant, although evidence in MS is less robust. When severe high-pressure bladder dysfunction remains unsafe despite medication, catheterisation and minimally invasive treatment, reconstructive options such as augmentation cystoplasty or urinary diversion may be considered in a specialist neuro-urology service. These are major procedures reserved for carefully selected cases and require lifelong follow-up.

Follow-up matters

MS and bladder function can both evolve. Review may include symptom assessment, bladder diary, urinalysis when symptomatic, residual urine measurement, renal function, urinary tract imaging and repeat urodynamics according to risk and clinical change.

A useful treatment plan is therefore not simply “stop the leakage.” It should answer four questions:

  1. Is the bladder storing urine at a safe pressure?
  2. Is it emptying adequately?
  3. Is the treatment practical and sustainable for this patient?
  4. Are the kidneys and quality of life being protected over time?

Take-home message

Bladder problems in MS are common, treatable and often more complex than the symptoms suggest. Urgency does not exclude retention, and leakage does not prove that the bladder empties well. A structured assessment, including a residual urine measurement and selective use of urodynamics, allows treatment to be matched to the actual dysfunction.

Medication, ISC, Botox and sacral neuromodulation all have valuable roles. The best choice is the one that safely addresses the individual bladder pattern while fitting the person’s abilities, priorities, MS course and future care needs.

This article provides general information and does not replace individual medical assessment. Treatment availability, indications and funding vary. Patients should discuss their symptoms with their GP, neurologist, continence clinician or urologist.

References and further reading

  1. European Association of Urology. EAU Guidelines on Neuro-urology. Current online guideline: https://uroweb.org/guidelines/neuro-urology/chapter/the-guideline
  2. National Institute for Health and Care Excellence. Urinary incontinence in neurological disease: assessment and management (CG148). https://www.nice.org.uk/guidance/cg148
  3. Gajewski JB, Schurch B, Hamid R, et al. An International Continence Society report on the terminology for adult neurogenic lower urinary tract dysfunction. Neurourology and Urodynamics. 2018;37(3):1152–1161.
  4. Ginsberg D, Gousse A, Keppenne V, et al. Phase 3 efficacy and tolerability study of onabotulinumtoxinA for urinary incontinence from neurogenic detrusor overactivity. Journal of Urology. 2012;187(6):2131–2139.
  5. Cruz F, Herschorn S, Aliotta P, et al. Efficacy and safety of onabotulinumtoxinA in patients with urinary incontinence due to neurogenic detrusor overactivity. European Urology. 2011;60(4):742–750.
  6. American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Adult Neurogenic Lower Urinary Tract Dysfunction Guideline. https://www.auanet.org/guidelines-and-quality/guidelines/adult-neurogenic-lower-urinary-tract-dysfunction

Hydronephrosis and Urinary Stones in Pregnancy What expectant mothers should know about flank pain, infection, premature labour and safe imaging

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Pregnancy changes the urinary tract. The kidneys filter more blood, the hormone progesterone relaxes the ureters, and the enlarging uterus can compress them. As a result, the kidney drainage system and ureters often become dilated, a finding called hydronephrosis or hydroureter.

In most women this is a normal, temporary effect of pregnancy. However, hydronephrosis can also be caused by a kidney or ureteric stone, infection or, less commonly, another obstruction. The challenge is deciding whether the dilatation is physiological or whether the kidney is genuinely blocked and needs treatment.

Seek urgent medical assessment for flank pain accompanied by fever, chills, feeling faint or very unwell, persistent vomiting, difficulty passing urine, reduced fetal movement, contractions, vaginal bleeding or fluid loss. An infected, obstructed kidney is a urological emergency.

Why does hydronephrosis occur during pregnancy?

Physiological hydronephrosis usually develops during the second trimester, becomes most marked around 24–28 weeks and is often greater on the right. It results from:

  • progesterone-related relaxation of ureteric smooth muscle;
  • compression of the ureters by the growing uterus at the pelvic brim;
  • rotation of the uterus, which tends to place more pressure on the right ureter; and
  • increased urine production during pregnancy.

This dilatation commonly settles within several weeks after delivery. Physiological hydronephrosis is not itself a stone and does not automatically require a stent or operation.

Features that make pathological obstruction more likely include severe colicky flank pain, blood in the urine, a visible stone, dilatation extending below the pelvic brim, an absent or reduced ureteric jet on the symptomatic side, impaired kidney function, infection or worsening hydronephrosis. No single ultrasound sign is perfect; the symptoms, blood and urine tests, imaging and obstetric assessment must be considered together.

Kidney and ureteric calculi in pregnancy

Urinary calculi are stones located in the kidney or ureter. They are an important cause of non-obstetric abdominal or flank pain during pregnancy and occur most often in the second or third trimester. Typical symptoms include:

  • sudden pain in the loin, flank, abdomen or groin, which may come in waves;
  • nausea and vomiting;
  • visible or microscopic blood in the urine;
  • urinary frequency, urgency or burning; and
  • fever or rigors if infection is present.

Pregnancy increases urinary calcium and urate excretion, while other natural protective factors also rise. For this reason, pregnancy does not necessarily increase the overall number of stones, although the stone pattern may differ and calcium-phosphate stones are relatively more common.

Why infection matters

Pregnancy-related ureteric dilatation and slower urinary drainage encourage urinary stasis. A stone can worsen this by partly or completely blocking the ureter. Bacteria trapped above an obstruction may cause pyelonephritis, pyonephrosis, bacteraemia or sepsis.

All women with suspected renal colic should therefore have urinalysis and a urine culture. Blood tests commonly include a full blood count, kidney function, electrolytes and inflammatory markers. Antibiotics are selected according to pregnancy safety, local resistance patterns and culture results.

Antibiotics alone are not sufficient when infection is trapped behind an obstructed kidney. Urgent decompression with a ureteric stent or percutaneous nephrostomy is required, together with intravenous antibiotics and coordinated obstetric care. Definitive stone treatment is usually delayed until sepsis has resolved.

Is there a risk of premature labour?

Observational studies associate symptomatic stones and renal obstruction in pregnancy with higher rates of urinary infection, hospital admission, preterm contractions and preterm delivery. Severe pain, dehydration, inflammation and infection may all contribute. However, the absolute risk for an individual woman varies, and an association does not mean that every renal colic episode will trigger premature labour.

The condition requiring intervention may itself be responsible for some of the reported risk. For this reason, treatment decisions should not be based on procedure statistics alone. The balance is between allowing a stable stone time to pass and promptly treating uncontrolled pain, infection or threatened kidney function. Depending on gestational age and clinical circumstances, fetal monitoring and assessment for contractions may be appropriate.

How is it investigated?

1. Ultrasound first

Renal and bladder ultrasound is the preferred first-line test because it uses sound waves rather than ionising radiation. It can show hydronephrosis, some kidney or ureteric stones, ureteric jets and alternative diagnoses. Transvaginal ultrasound may help identify a distal ureteric stone.

Ultrasound has limitations: physiological hydronephrosis can resemble obstruction, and a small ureteric stone may not be visible. A normal or inconclusive scan does not always exclude a stone.

2. MRI or MR urography when uncertainty remains

MRI without gadolinium can identify the level and pattern of obstruction without ionising radiation. Stones usually appear as signal voids rather than being seen as clearly as on CT. MRI is therefore a useful second-line test, particularly when ultrasound is inconclusive and the patient is clinically stable. Gadolinium contrast is not routinely used during pregnancy.

3. Low-dose non-contrast CT only when clinically necessary

Low-dose CT is the most accurate test for a urinary stone, but it uses ionising radiation. European Association of Urology guidance places low-dose CT as a last-line option in pregnancy, after ultrasound and usually MRI, when diagnostic uncertainty could change urgent management.

The practical radiation principles are:

  • use imaging only when it will answer an important clinical question;
  • prefer ultrasound, followed by MRI without contrast, when suitable;
  • if CT is necessary, use a pregnancy-adapted low-dose protocol and limit the scanned area;
  • avoid repeated or multiphase CT examinations unless clearly justified; and
  • involve an experienced radiologist and document the risk–benefit discussion.

Diagnostic imaging should not be withheld when delay or uncertainty poses a greater risk to the mother or baby. The EAU notes that deterministic fetal effects require substantially higher exposure than most diagnostic studies and considers doses below 50 mGy safe in this context; nevertheless, any ionising-radiation examination must be justified and kept as low as reasonably achievable. Ultrasound and MRI do not use ionising radiation.

Management options

Treatment is individualised by symptoms, infection status, stone size and location, kidney function, gestational age, obstetric factors and local expertise. Close collaboration between urology, obstetrics, radiology, anaesthesia and neonatology may be needed.

Conservative management

Most uncomplicated cases are initially managed without surgery. This may include:

  • oral or intravenous fluids sufficient to correct dehydration, forced overhydration does not “flush out” a stone;
  • anti-nausea medication;
  • analgesia suitable for the stage of pregnancy;
  • urine culture and pregnancy-compatible antibiotics when infection is confirmed; and
  • follow-up to ensure symptoms resolve and kidney drainage and function remain satisfactory.

Paracetamol is commonly used first-line. Opioids may be used for severe pain under medical supervision. Non-steroidal anti-inflammatory drugs such as ibuprofen and diclofenac should not be self-administered in pregnancy; their fetal renal, amniotic-fluid and ductus arteriosus risks depend on gestation, dose and duration. The evidence for medical expulsive therapy with alpha-blockers during pregnancy is limited, and such treatment should only be considered after specialist discussion.

Conservative treatment is unsuitable when there is sepsis, deteriorating kidney function, a solitary obstructed kidney, bilateral obstruction, persistent vomiting, uncontrolled pain, severe or progressive hydronephrosis, renal forniceal rupture, threatened premature labour or failure of the stone to pass with ongoing clinically important obstruction.

Ureteric stent

A JJ stent bypasses the obstruction and drains urine from the kidney to the bladder. It can be inserted with minimal or no fluoroscopy, using ultrasound guidance where appropriate. Stents can cause urinary frequency, urgency, discomfort, blood in the urine, infection and encrustation. Encrustation develops faster in pregnancy, so regular review and sometimes exchange every 4–6 weeks are required. A stent must not be forgotten after delivery.

Percutaneous nephrostomy

A nephrostomy tube drains the kidney through the back and can often be placed with ultrasound guidance. It is particularly useful when retrograde stenting is not possible or when urgent drainage is required in selected circumstances. Disadvantages include an external bag, discomfort, blockage, displacement, infection and rapid encrustation, with possible repeat exchanges.

Ureteroscopy and laser treatment

Ureteroscopy allows a surgeon to pass a fine telescope through the bladder into the ureter, remove the stone or fragment it with a laser, often without fluoroscopy. It provides definitive treatment and avoids prolonged drainage in selected patients. If a non-urgent procedure is required, the second trimester is generally preferred, and it should be performed by an experienced team with obstetric and neonatal support available. Ureteroscopy is not the first step in an untreated septic obstruction; drainage and infection control come first.

Treatments generally avoided

Shock-wave lithotripsy is contraindicated during pregnancy. Percutaneous stone removal is rarely required and is reserved for carefully selected cases in highly experienced centres. Routine definitive treatment can often wait until after delivery when symptoms and kidney function permit.

After delivery

Follow-up should confirm that hydronephrosis has resolved, any stent or nephrostomy has been removed, the stone has passed or been treated, and kidney function is normal. A retrieved stone should be analysed. Women with recurrent stones, a strong family history, infection stones or other risk factors may benefit from a metabolic evaluation after pregnancy, when physiology and diet have stabilised.

The important message

Most hydronephrosis in pregnancy is physiological, and many stones pass with careful conservative management. The dangerous combination is obstruction plus infection. Fever, rigors or systemic illness with flank pain requires urgent assessment because prompt antibiotics and drainage can protect the mother, kidney and pregnancy. Imaging should follow a stepwise approach, ultrasound first, MRI second and low-dose CT only when the clinical benefit justifies it.

References

  1. European Association of Urology. EAU Guidelines on Urolithiasis: Diagnostic imaging during pregnancy; management of urinary stones during pregnancy. Current online guideline. https://uroweb.org/guidelines/urolithiasis/chapter/guidelines
  2. Lee MS, Fenstermaker MA, Naoum EE, et al. Management of nephrolithiasis in pregnancy: multi-disciplinary guidelines from an academic medical center. Front Surg. 2021;8:796876. https://doi.org/10.3389/fsurg.2021.796876
  3. Chan K, Shakir T, El-Taji O, et al. Management of urolithiasis in pregnancy. Curr Urol. 2023;17(1):1–6. https://doi.org/10.1097/CU9.0000000000000181
  4. American College of Obstetricians and Gynecologists. Guidelines for diagnostic imaging during pregnancy and lactation. Committee Opinion No. 723. Obstet Gynecol. 2017;130–e216. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/10/guidelines-for-diagnostic-imaging-during-pregnancy-and-lactation
  5. Drescher M, Blackwell RH, Patel PM, et al. Antepartum nephrolithiasis and the risk of preterm delivery. Urolithiasis. 2019;47:441–448. https://doi.org/10.1007/s00240-018-1085-3

This information is general education and does not replace individual medical or obstetric advice. Medication and imaging decisions in pregnancy should be made with the treating obstetric, urology and radiology teams.

Vesico-ureteric reflux: when urine travels in the wrong direction

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Vesico-ureteric reflux, also called vesicoureteral reflux or VUR, occurs when urine flows backwards from the bladder into one or both ureters and sometimes as far as the kidneys.

Normally, each ureter enters the bladder through a short tunnel in the bladder wall. As the bladder fills and contracts, this tunnel is compressed, acting like a one-way valve. In VUR, the valve does not close effectively.

VUR itself does not always cause symptoms. Its importance is that infected urine may travel towards the kidneys, increasing the risk of pyelonephritis, renal scarring and, in a small number of higher-risk patients, long-term kidney damage.

Primary and secondary reflux

Primary VUR

Primary VUR is usually a developmental condition. The ureter’s tunnel through the bladder wall is too short or positioned in a way that prevents reliable closure. It is most commonly diagnosed in infancy or childhood.

As a child grows, the bladder and ureteric junction mature. For this reason, many cases particularly lower-grade reflux, improve or resolve without surgery.

Secondary VUR

Secondary reflux develops because pressure within the bladder is abnormally high or because the bladder does not empty properly. Causes may include:

  • posterior urethral valves or another bladder-outlet obstruction
  • dysfunctional voiding
  • constipation and bladder–bowel dysfunction
  • neurogenic bladder, including spina bifida or spinal cord disease
  • urethral stricture or an enlarged prostate in adults
  • previous bladder or ureteric surgery
  • a poorly compliant, high-pressure bladder.

Treating the underlying bladder or outlet problem is essential. Correcting the reflux alone may fail if the bladder remains unsafe or under excessive pressure.

How does VUR present in children?

Most children do not feel the reflux itself. It is commonly discovered while investigating a urinary tract infection.

Possible presentations include:

  • a fever without an obvious cause, particularly in an infant
  • recurrent urinary tract infections
  • febrile UTIs or kidney infections
  • vomiting, lethargy, irritability or poor feeding in babies
  • abdominal, loin or back pain
  • painful or frequent urination
  • urinary urgency or wetting
  • poor urinary stream or straining
  • antenatal ultrasound showing hydronephrosis or an abnormal urinary tract
  • poor growth
  • high blood pressure or impaired kidney function in more advanced reflux nephropathy.

A child with fever, vomiting, flank pain or marked lethargy may have pyelonephritis and should receive prompt medical assessment.

How does VUR present in adults?

VUR is much less commonly diagnosed for the first time in adulthood. Some adults have persistent congenital reflux that was never detected in childhood, while others develop secondary reflux due to bladder dysfunction or obstruction.

Adults may present with:

  • recurrent febrile UTIs
  • repeated kidney infections
  • loin or flank pain
  • renal scarring found on imaging
  • high blood pressure
  • protein or blood detected in the urine
  • reduced kidney function
  • pregnancy-associated urinary infections
  • lower urinary tract symptoms or incomplete bladder emptying.

Adult VUR should prompt assessment for an underlying cause such as bladder-outlet obstruction, neurogenic bladder, poor bladder compliance or dysfunctional voiding. The evidence guiding adult treatment is less extensive than the paediatric literature, so management is individualised.

How is VUR investigated?

Not every child who has one uncomplicated UTI requires an invasive reflux study. Imaging is selected according to age, clinical presentation, ultrasound findings and whether the infection is atypical or recurrent.

Urine testing

Urinalysis and urine culture confirm infection and help guide antibiotic treatment. A properly collected urine specimen is particularly important in babies and young children.

Kidney and bladder ultrasound

Ultrasound is painless and does not use radiation. It can assess:

  • kidney size and development
  • hydronephrosis or ureteric dilatation
  • bladder-wall appearance
  • congenital urinary abnormalities
  • residual urine after voiding.

A normal ultrasound does not completely exclude VUR.

Micturating cystourethrogram

A micturating cystourethrogram, also called an MCUG or VCUG, is the standard test for confirming and grading reflux.

A small catheter is placed into the bladder, contrast is introduced, and X-ray images are taken while the bladder fills and during urination. The test shows whether contrast travels backwards into the ureters or kidneys and also provides information about the bladder and urethra.

Because catheterisation and a small radiation exposure are involved, MCUG is generally reserved for children in whom the result is likely to influence management.

Contrast-enhanced voiding urosonography

In centres where it is available, contrast-enhanced ultrasound can identify reflux without ionising radiation. Availability and local expertise vary, and conventional MCUG may still be required when detailed urethral anatomy needs assessment.

DMSA renal scan

A DMSA scan assesses the functioning renal cortex and can identify established renal scars. It is not required for every child but may be considered after recurrent febrile infections, in higher-grade reflux, when ultrasound is abnormal or when renal damage is suspected.

Additional assessment

Depending on the circumstances, investigation may also include:

  • blood pressure measurement
  • serum creatinine and estimated kidney function
  • urine protein assessment
  • a bladder and bowel history
  • uroflowmetry and measurement of residual urine
  • a bladder diary
  • urodynamic studies when a high-pressure, neurogenic or poorly emptying bladder is suspected
  • CT or other upper-tract imaging in selected adults.

The five grades of reflux

VUR is graded from I to V according to the international grading system.

Grade Imaging appearance General interpretation
Grade I Reflux reaches the ureter but not the kidney Mild
Grade II Reflux reaches the renal pelvis without dilatation Mild
Grade III Mild to moderate dilatation of the ureter and renal collecting system Moderate
Grade IV Moderate ureteric and collecting-system dilatation with some twisting of the ureter High-grade
Grade V Severe dilatation and tortuosity with loss of normal calyceal detail Severe

The grade is important, but it is not the only factor determining treatment. Age, recurrent infections, kidney scarring, bladder and bowel function, whether reflux affects one or both sides, and family preferences all matter.

What is the aim of treatment?

Treatment aims to:

  • prevent febrile UTIs and pyelonephritis
  • reduce the risk of further renal scarring
  • preserve kidney function
  • treat bladder, bowel or outlet dysfunction
  • avoid unnecessary medication, radiation and surgery.

It is important to understand that repairing reflux cannot reverse established renal scars. Treatment is intended to prevent further infection and injury.

Observation and conservative management

Observation is appropriate for many children, particularly those with lower-grade reflux, healthy kidneys and no recurrent febrile infections.

Conservative care may include:

  • prompt urine testing when fever or urinary symptoms occur
  • regular and complete bladder emptying
  • adequate fluid intake
  • avoiding prolonged holding of urine
  • treating constipation
  • timed voiding
  • management of daytime wetting or dysfunctional voiding
  • periodic clinical and ultrasound review.

Lower-grade reflux is more likely to resolve as the child grows. Higher grades, bilateral reflux and reflux associated with renal abnormalities are less likely to resolve spontaneously.

Continuous low-dose antibiotic prophylaxis

A low dose of antibiotic may be prescribed daily to reduce recurrent infections while waiting for reflux to improve or while deciding whether intervention is required.

Prophylaxis is more likely to be considered in:

  • infants with VUR following a febrile UTI
  • recurrent febrile UTIs
  • higher-grade reflux
  • bladder–bowel dysfunction
  • renal cortical abnormalities
  • children considered at increased risk of another kidney infection.

Antibiotics can reduce recurrent UTIs in appropriately selected children, but they do not mechanically correct the reflux. Disadvantages include medication side effects, adherence difficulties and antibiotic resistance. The need for ongoing prophylaxis should therefore be reviewed rather than continued automatically.

Treating bladder and bowel dysfunction

Constipation, urinary urgency, wetting, infrequent voiding and incomplete bladder emptying increase the risk of recurrent infection and may reduce the success of reflux treatment.

Management can include:

  • regular timed voiding
  • relaxed toilet posture
  • treatment of constipation
  • pelvic-floor or continence physiotherapy
  • medication for selected bladder conditions
  • intermittent self-catheterisation when emptying is inadequate.

In secondary reflux, treating the bladder or outlet disorder may reduce or occasionally eliminate the reflux.

When is a procedure considered?

Intervention may be discussed when there is:

  • a febrile breakthrough UTI despite appropriate prophylaxis
  • recurrent pyelonephritis
  • new or progressive renal scarring
  • persistent high-grade reflux
  • reflux unlikely to resolve spontaneously
  • difficulty tolerating or adhering to antibiotic prophylaxis
  • an anatomical abnormality requiring correction
  • significant family preference after discussion of the alternatives
  • persistent symptomatic reflux in a carefully selected adult.

The two main corrective options are endoscopic injection and ureteric reimplantation.

The STING procedure

STING stands for subureteric transurethral injection. A small telescope is passed through the urethra into the bladder under anaesthesia. A bulking material is injected beneath or within the lower end of the ureter to support and lengthen the valve mechanism.

Dextranomer/hyaluronic-acid copolymer, commonly known by the brand name Deflux, is the best-known injection material. Modified techniques such as HIT or double-HIT place the material within the intramural ureter rather than only beneath its opening.

Advantages

  • minimally invasive
  • no abdominal incision
  • usually performed as day surgery
  • relatively short anaesthetic and recovery
  • low risk of major complications
  • can be repeated if reflux persists.

Limitations and risks

  • success is lower and less predictable than formal reimplantation
  • results are generally better for lower grades of reflux
  • more than one injection may be required
  • reflux may persist or recur
  • temporary blood in the urine, discomfort or infection can occur
  • ureteric obstruction is uncommon but important
  • reflux may occasionally appear on the opposite side
  • long-term durability is not as certain as with successful reimplantation.

Published cure rates vary considerably because they depend on reflux grade, anatomy, injection technique, material used and how success is defined. A single injection commonly corrects approximately 70–80% of refluxing ureters overall, with lower success in grades IV–V. Additional injections can increase the cumulative success rate.

Ureteric reimplantation

Ureteric reimplantation is reconstructive surgery that creates a longer tunnel for the ureter through the bladder wall, restoring the one-way valve mechanism.

The operation may be performed using:

  • an open extravesical approach
  • an open intravesical approach
  • laparoscopic surgery
  • robot-assisted surgery in selected centres and patients.

Open reimplantation has a long-established success rate of approximately 95–98% for primary VUR when performed in suitable patients.

Advantages

  • highest and most durable anatomical correction rate
  • effective for high-grade reflux
  • allows correction of some associated ureteric abnormalities
  • usually requires only one definitive operation.

Limitations and risks

  • more invasive than injection
  • longer anaesthetic and recovery
  • temporary bladder spasms, pain or blood in the urine
  • urinary infection
  • transient urinary retention, particularly after some bilateral extravesical repairs
  • ureteric obstruction
  • persistent reflux or reflux on the opposite side
  • rare need for further surgery.

Robotic or laparoscopic reimplantation can reduce incision size, but it is still major reconstructive surgery and has not made open surgery obsolete. The best approach depends on the child’s anatomy, age, surgeon’s expertise and the reason for intervention.

STING versus reimplantation

Consideration Endoscopic injection Ureteric reimplantation
Invasiveness Minimally invasive Reconstructive surgery
Typical stay Usually day surgery Often one or more nights
Recovery Generally quicker Longer
Success after one procedure Lower and grade-dependent Approximately 95–98%
Repeat treatment Sometimes required Uncommon after successful repair
Best suited to Selected low- or moderate-grade reflux and families prioritising minimal invasiveness High-grade, persistent or complicated reflux; failed injection; selected anatomical abnormalities
Main trade-off Easier recovery but less predictable cure More invasive but more reliable correction

Neither operation is automatically “best.” STING may be attractive when a minimally invasive approach is preferred and its probability of success is acceptable. Reimplantation may be more appropriate when the highest likelihood of definitive correction is important.

VUR in adults

Adults with incidentally detected reflux and no infections, renal deterioration or high-pressure bladder may not require corrective surgery.

Treatment is more likely to be considered when there is:

  • recurrent febrile UTI or pyelonephritis
  • progressive kidney damage
  • troublesome reflux-associated flank pain
  • an untreated bladder-outlet or functional abnormality
  • pregnancy planning in a patient with recurrent infections or reflux nephropathy.

The underlying bladder problem must be identified before anti-reflux surgery. Endoscopic injection can be effective in selected adults, although the supporting evidence is mainly from smaller observational studies. Ureteric reimplantation remains an option when a durable anatomical repair is required.

Women with previous VUR or reflux nephropathy who are considering pregnancy may benefit from pre-pregnancy assessment of blood pressure, kidney function, urine protein and infection risk.

Follow-up

Follow-up should be tailored to reflux grade, renal findings, treatment and infection history.

During observation

Review may include:

  • interval history of UTIs or unexplained fevers
  • height, weight and growth in children
  • blood pressure
  • urine testing when symptoms occur
  • assessment of constipation and bladder symptoms
  • renal and bladder ultrasound
  • serum creatinine and urine protein testing when renal damage is present or suspected
  • selective repeat MCUG, contrast-enhanced urosonography or radionuclide cystography
  • DMSA scanning when new scarring is suspected.

Routine repeated invasive imaging is not necessary for every child. The timing and type of imaging should be chosen only when the result is likely to alter management.

After STING

Follow-up commonly includes an ultrasound to exclude obstruction and clinical monitoring for further UTIs. A repeat reflux study may be recommended after several months, particularly in high-grade reflux, recurrent febrile infection or when confirmation of cure will affect treatment.

Any fever or urinary symptoms after injection should prompt urine testing. Flank pain, vomiting, reduced urine output or significant hydronephrosis requires assessment for the uncommon complication of ureteric obstruction.

After reimplantation

Ultrasound is commonly performed after surgery to check drainage. Routine postoperative MCUG may not be necessary after an uncomplicated reimplantation with a reassuring recovery, but it may be appropriate after breakthrough infection, persistent hydronephrosis or an atypical clinical course.

Long-term surveillance

Patients with renal scarring, bilateral severe reflux, a solitary functioning kidney, proteinuria, hypertension or impaired renal function may require long-term follow-up into adulthood.

Monitoring can include:

  • blood pressure
  • kidney function
  • urine protein
  • recurrent infection
  • pregnancy counselling when relevant.

Even when reflux has resolved, established reflux nephropathy can remain clinically important.

When should urgent medical advice be sought?

Seek prompt medical assessment for:

  • fever with loin or back pain
  • vomiting or marked lethargy
  • reduced urine output
  • a very unwell infant
  • urinary symptoms during pregnancy
  • fever or flank pain after a reflux procedure.

Early diagnosis and treatment of pyelonephritis are particularly important in patients with known VUR.

The key message

Vesico-ureteric reflux ranges from a mild childhood condition that resolves with growth to high-grade reflux associated with recurrent kidney infections and renal scarring.

Treatment should not be based on grade alone. The safest plan considers infection history, kidney health, age, bladder and bowel function, likelihood of spontaneous resolution and the advantages and disadvantages of observation, antibiotic prophylaxis, endoscopic injection and ureteric reimplantation.

References and further reading

  1. European Association of Urology. EAU Guidelines on Paediatric Urology: Vesicoureteric reflux. EAU Paediatric Urology Guidelines
  2. American Urological Association. Management and Screening of Primary Vesicoureteral Reflux in Children. AUA Vesicoureteral Reflux Guideline
  3. National Institute for Health and Care Excellence. Urinary tract infection in under 16s: diagnosis and management (NG224). NICE guideline NG224
  4. RIVUR Trial Investigators. Antimicrobial prophylaxis for children with vesicoureteral reflux. New England Journal of Medicine. 2014;370:2367–2376. PubMed
  5. Mattoo TK, Chesney RW, Greenfield SP, et al. Renal scarring in the Randomized Intervention for Children with Vesicoureteral Reflux trial. Clinical Journal of the American Society of Nephrology. 2016;11:54–61. PubMed
  6. Läckgren G, Cooper CS, Neveus T, Kirsch AJ. Management of vesicoureteral reflux: what have we learned over the last 20 years? Frontiers in Pediatrics. 2021;9:650326. Full text
  7. Salib A, Pizzi M, Landman J, et al. Vesicoureteral reflux in adults with urinary tract infections: is there a role for treatment? Current Urology Reports. 2020. PubMed record

This article provides general education and does not replace individual medical advice. Decisions about imaging, antibiotic prophylaxis or surgery should be made with an appropriately experienced urologist or paediatric urologist.

Spina Bifida and the Bladder: Protecting the Kidneys and Improving Continence

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Spina bifida is a congenital condition in which the spine and spinal cord do not develop normally. Although it is often associated with reduced leg movement or sensation, it can also affect the nerves controlling the bladder, urethral sphincter and bowel.

This is called neurogenic lower urinary tract dysfunction, or more simply a neurogenic bladder.

The bladder problem is not always obvious from the person’s mobility or the appearance of the spinal abnormality. Someone with a relatively small or “closed” spinal defect may still have significant bladder dysfunction. Conversely, urinary leakage does not necessarily mean that bladder pressures are safe.

The principal goals of urological care are to:

  • Protect the kidneys from high bladder pressures and infection.
  • Ensure that the bladder empties safely.
  • Improve urinary continence and independence.
  • Minimise infections, stones and catheter-related complications.
  • Provide a management plan that remains practical throughout childhood and adult life.

What are the different types of spina bifida?

Spina bifida occulta

This is the mildest anatomical form. One or more vertebrae have not completely closed, but there may be no visible sac or exposed spinal tissue.

Many people have no neurological symptoms. Others may have an associated tethered spinal cord, fatty lesion or other form of closed spinal dysraphism that affects bladder, bowel or leg function.

Meningocele

The coverings around the spinal cord protrude through a spinal defect and form a fluid-filled sac. The spinal cord itself may remain relatively preserved, although neurological and bladder dysfunction can still occur.

Myelomeningocele

In myelomeningocele, both the spinal cord or nerves and their coverings protrude through the spinal defect. This is the form most commonly associated with leg weakness, altered sensation, bowel dysfunction and significant neurogenic bladder problems.

Closed spinal dysraphism and tethered cord

A lipoma, abnormal attachment or other congenital spinal abnormality may tether the spinal cord. Symptoms can appear or worsen as a child grows or later in adult life.

New urinary leakage, recurrent infections, difficulty catheterising, increasing residual urine, leg weakness, back pain or changes in bowel function may indicate tethering and require further assessment.

How does spina bifida affect the bladder?

Normal bladder function requires coordination between the bladder muscle, the detrusor, and the urinary sphincter.

During filling, the bladder should remain relaxed and at low pressure while the sphincter stays closed. When it is time to urinate, the bladder should contract and the sphincter should relax.

Spina bifida can disrupt these signals in several ways.

An overactive bladder

The bladder may contract unexpectedly during filling. This can cause:

  • Urgency.
  • Frequent urination.
  • Urge incontinence.
  • Leakage between catheterisations.
  • Bedwetting.
  • A small functional bladder capacity.

A poorly compliant, high-pressure bladder

A stiff bladder does not stretch normally as it fills. Pressure rises even when the volume is relatively small.

This is sometimes called a hostile bladder. It is particularly important because high pressure may be transmitted to the ureters and kidneys, causing:

  • Vesicoureteric reflux.
  • Hydronephrosis.
  • Recurrent infections.
  • Kidney scarring.
  • Progressive loss of kidney function.

A high-pressure bladder may be dangerous even when the patient has few symptoms.

Failure of bladder emptying

The bladder muscle may be weak or unable to contract effectively. This can result in:

  • Difficulty starting urination.
  • A weak or intermittent stream.
  • Straining to pass urine.
  • A sensation of incomplete emptying.
  • A large residual volume.
  • Overflow leakage.
  • Recurrent urinary infections.

Some people have very little bladder sensation and may not recognise that the bladder is full.

Detrusor-sphincter dyssynergia

In this situation, the bladder contracts while the urinary sphincter remains closed or tight. The bladder must generate high pressure against the obstruction.

This combination can cause incomplete emptying, leakage, infections and upper urinary tract damage.

A weak bladder outlet

If the bladder neck or sphincter does not close adequately, stress-type leakage may occur with coughing, transfers, exercise or movement. Some patients have both a high-pressure bladder and a weak outlet, which makes treatment more complex.

Bladder dysfunction is reported in up to 96% of people with spina bifida, while more than half experience urinary incontinence. Importantly, open and closed spinal defects can produce equally significant bladder dysfunction. European Association of Urology Neuro-urology Guideline

How is the bladder investigated?

Investigation is tailored to the patient’s age, symptoms, previous surgery and risk to the kidneys.

Clinical assessment

The consultation should consider:

  • The person’s usual method of passing urine.
  • Daytime and night-time leakage.
  • Urinary urgency and frequency.
  • Catheterisation frequency and volumes.
  • Recurrent symptomatic urinary infections.
  • Previous kidney or bladder stones.
  • Bowel function and constipation.
  • Mobility, hand function and available carer support.
  • Previous spinal, bladder or continence surgery.
  • Changes that may suggest a tethered spinal cord.

A bladder and catheterisation diary can document fluid intake, voided volumes, catheter volumes and episodes of leakage.

Urine testing

Urinalysis and urine culture may be required when there are symptoms of infection. Bacteria are frequently found in the urine of people who catheterise, but bacteriuria without symptoms does not always require antibiotic treatment.

Symptoms may be less typical than in someone with normal bladder sensation. Warning signs can include fever, new leakage, pelvic or back discomfort, cloudy or offensive urine, malaise or an unexplained change in bladder behaviour.

Blood tests

Kidney function and electrolytes should be monitored. Serum creatinine can underestimate kidney impairment in people with low muscle mass, so an alternative measurement such as cystatin C or measured renal clearance may occasionally be helpful.

Vitamin B12, acid–base balance and other blood tests may be required following urinary reconstruction using bowel.

Ultrasound

Renal and bladder ultrasound can assess:

  • Kidney size and appearance.
  • Hydronephrosis.
  • Bladder wall thickening.
  • Stones.
  • Residual urine after voiding.

Ultrasound is important for surveillance, but a normal ultrasound does not prove that bladder pressures are safe.

Urodynamic studies

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

  • Neurogenic detrusor overactivity.
  • Reduced bladder capacity.
  • Poor compliance and unsafe filling pressures.
  • Stress incontinence.
  • Detrusor-sphincter dyssynergia.
  • A weak or non-contractile bladder.
  • Incomplete emptying.

Video urodynamics combines pressure measurements with imaging and can also demonstrate reflux, bladder shape and the level of outlet obstruction.

Urodynamic testing is particularly useful when there are changes in continence, recurrent infections, hydronephrosis, kidney deterioration or consideration of major treatment changes.

People with spina bifida require lifelong urological surveillance, because bladder behaviour can change with growth, ageing, tethering, surgery or reduced ability to catheterise. Spina Bifida Association Urology Guideline

Treatment options

There is no single treatment suitable for every neurogenic bladder. Management depends on bladder pressure, emptying, continence, kidney health, dexterity, mobility and personal goals.

Clean intermittent self-catheterisation

Clean intermittent catheterisation, often abbreviated to CIC or CISC, is a central part of treatment when the bladder does not empty safely.

A catheter is passed through the urethra at regular intervals and removed after the bladder has drained. Depending on age and physical ability, catheterisation may be performed by the patient, a parent or a carer.

Potential benefits include:

  • Reliable bladder emptying.
  • Lower residual urine volumes.
  • Reduced overflow leakage.
  • Better control of bladder pressure when combined with medication.
  • Greater independence and predictability.
  • Protection of the kidneys.

The frequency is individualised according to fluid intake, bladder capacity, pressures and catheterised volumes. Proper education, catheter selection and ongoing review are important.

If urethral catheterisation is difficult because of mobility, body shape, poor access, pain or urethral damage, a continent catheterisable channel may be considered.

Bladder medication

Antimuscarinic medicines such as oxybutynin, solifenacin or other agents may reduce involuntary bladder contractions and improve storage at lower pressures.

A beta-3 agonist such as mirabegron may be considered in selected patients. Combination treatment is sometimes used, although medication choice and licensing differ between children and adults.

Possible adverse effects include dry mouth, constipation, blurred vision and, with some medications, cognitive effects or changes in blood pressure. Constipation should be treated actively because a loaded bowel can worsen bladder pressure, leakage and infection risk.

Botulinum toxin: Botox

Botulinum toxin A can be injected through a cystoscope into the bladder muscle. It temporarily reduces involuntary bladder contractions and may improve capacity, continence and storage pressures.

Botox is generally considered when oral or intravesical medication has not provided sufficient control or has caused unacceptable side effects.

Important considerations include:

  • Its effect is temporary, so repeat treatment is usually required.
  • Intermittent catheterisation may still be necessary and may become necessary in someone who previously emptied without a catheter.
  • Urinary infection, temporary retention and blood in the urine can occur.
  • Follow-up urodynamics may be required to confirm that bladder pressure has improved, rather than relying only on reduced leakage.

The evidence supporting Botox is strongest across neurogenic detrusor overactivity populations generally. Individual assessment remains particularly important in congenital spina bifida. The EAU recommends detrusor Botox when antimuscarinic therapy has been ineffective. EAU Neuro-urology Guideline

Sacral neuromodulation

Sacral neuromodulation uses an implanted lead near a sacral nerve root, usually S3, to modify communication between the bladder, sphincter and nervous system.

It may be considered for selected patients with:

  • Urgency and urge incontinence.
  • Urinary frequency.
  • Non-obstructive urinary retention.
  • Some forms of neurogenic bladder dysfunction.

However, its role in spina bifida is more selective than in non-neurogenic overactive bladder. Abnormal sacral anatomy, previous spinal surgery, tethering and the exact neurological pattern may influence feasibility and response.

A test or staged phase is generally used before permanent implantation. Sacral neuromodulation should not be expected to correct a severely fibrotic, very small or dangerously high-pressure bladder. Evidence in neuro-urological patients is growing, but it remains uncertain which neurological conditions respond best. EAU Neuro-urology Guideline

Surgery to improve the bladder outlet

If bladder pressures and emptying have been made safe but significant stress leakage remains, surgery may be considered to increase outlet resistance.

Options may include:

  • A bladder-neck reconstruction.
  • An autologous fascial sling.
  • An artificial urinary sphincter in selected patients.
  • Bladder-neck closure in complex circumstances.

Any procedure that tightens the outlet can make catheterisation essential. The ability to catheterise reliably through the urethra or a catheterisable channel, must therefore be established before surgery.

Mitrofanoff catheterisable channel

A Mitrofanoff is a narrow channel, commonly created using the appendix, that connects the bladder to a small opening on the abdominal wall. The opening is often placed at or near the umbilicus.

A catheter is passed through this channel to empty the bladder. There is no continuously draining external bag.

A Mitrofanoff may be helpful when:

  • Urethral catheterisation is difficult or painful.
  • Wheelchair positioning makes urethral access impractical.
  • Greater independence is desired.
  • Urethral damage or reconstruction prevents reliable catheterisation.

It is often created at the same time as bladder augmentation, although it can also be performed without augmentation when bladder capacity and pressure are already satisfactory.

Possible complications include stomal narrowing, leakage, difficulty catheterising, false passages, stones and the need for revision surgery.

Clam augmentation cystoplasty

A clam cystoplasty, also called augmentation cystoplasty or ileocystoplasty, enlarges the bladder using a patch of bowel. The bladder is opened widely, rather like opening a clam, and the bowel patch is added to create a larger, lower-pressure reservoir.

It may be considered when there is:

  • Persistently poor bladder compliance.
  • A small, high-pressure bladder.
  • Refractory neurogenic detrusor overactivity.
  • Continuing risk to the kidneys despite catheterisation, medication and Botox.
  • Severe incontinence caused by inadequate bladder storage.

The operation can be highly effective in improving capacity and lowering pressure, but it is major lifelong reconstructive surgery rather than a simple continence procedure.

Most patients need lifelong intermittent catheterisation after augmentation. A Mitrofanoff may be added if catheterisation through the urethra is difficult.

Long-term considerations include:

  • Mucus production from the bowel patch.
  • The need for regular bladder irrigation in some patients.
  • Urinary infections and stones.
  • Metabolic and electrolyte abnormalities.
  • Vitamin B12 deficiency, depending on the bowel segment used.
  • Bladder perforation, which is uncommon but potentially life-threatening.
  • Possible need for further surgery.
  • A small long-term risk of malignancy.
  • Lifelong specialist follow-up.

The EAU recommends augmentation for low bladder compliance or neurogenic detrusor overactivity that remains refractory to less invasive treatment. EAU Neuro-urology Guideline

Mitrofanoff versus ileal conduit: an important distinction

These procedures are sometimes confused, but they work differently.

A Mitrofanoff is a continent catheterisable channel connected to the bladder or an augmented bladder. The person remains dry between catheterisations and empties the reservoir periodically with a catheter.

An ileal conduit is an incontinent urinary diversion. The ureters are connected to a short segment of bowel that drains continuously through a stoma into an external appliance.

An ileal conduit may be considered when:

  • Safe catheterisation is not possible.
  • Previous reconstruction has failed.
  • Severe incontinence cannot otherwise be controlled.
  • The bladder or urethra is badly damaged.
  • The upper urinary tract is threatened.
  • A simpler continuously draining diversion is more practical for the patient or carers.

Therefore, the usual surgical comparison is not “a conduit with or without a Mitrofanoff.” More commonly, the alternatives are:

  • Native bladder with urethral catheterisation.
  • Native or augmented bladder with a Mitrofanoff channel.
  • A continent urinary reservoir.
  • An incontinent diversion such as an ileal conduit.

The best reconstruction depends on kidney function, bowel health, previous surgery, hand function, mobility, cognition, family or carer support and the patient’s own priorities.

The importance of bowel management

Bladder and bowel problems frequently coexist in spina bifida. Constipation can increase bladder pressure, worsen leakage, make catheterisation more difficult and contribute to urinary infections.

A coordinated bladder and bowel programme may include dietary measures, fluids, oral medication, suppositories, enemas, transanal irrigation or in selected patients, a surgical catheterisable bowel channel.

Warning signs requiring medical review

Prompt assessment is advisable if there is:

  • Fever or suspected symptomatic urinary infection.
  • New flank, pelvic or back pain.
  • Blood in the urine.
  • New or worsening urinary leakage.
  • Increasing catheterisation volumes or difficulty passing a catheter.
  • Reduced urine output.
  • Recurrent catheter blockage.
  • New hydronephrosis or deterioration in kidney function.
  • New leg weakness, sensory changes or bowel dysfunction.
  • Sudden abdominal pain in someone with an augmented bladder.

The key message

In spina bifida, a dry bladder is not necessarily a safe bladder and a leaking bladder is not always a high-pressure bladder. The most important questions are whether the bladder stores urine at a safe pressure, empties reliably and protects the kidneys.

With regular surveillance and an individualised combination of catheterisation, medication, Botox, selected neuromodulation or reconstructive surgery, many people can achieve good kidney protection, improved continence and greater independence.

Management is best coordinated through an experienced multidisciplinary team involving urology, rehabilitation, neurosurgery, continence nursing and bowel-management services.

This information is general and does not replace individual medical assessment. Treatment decisions should be based on symptoms, kidney function, imaging, urodynamic findings, physical ability and the patient’s personal goals.

References and further reading

  1. European Association of Urology: Guidelines on Neuro-urology
  2. Spina Bifida Association: Urology Guideline
  3. Augmentation cystoplasty in neurogenic bladder—review
  4. Long-term complications and outcomes of augmentation cystoplasty
  5. Risk of malignancy after augmentation cystoplasty—systematic review

Urge Incontinence After Sling Surgery: Why Timing Matters

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A sling procedure is designed to treat stress urinary incontinence, leakage with coughing, laughing, exercising or lifting. It supports the urethra so that it remains closed when abdominal pressure rises.

A sling does not directly treat an overactive bladder. Some women notice that pre-existing urgency improves after surgery, while others continue to experience urgency or develop new symptoms. When urgency begins soon after surgery, the possible causes differ from those arising several years later.

The most important message is that urgency after a sling is a symptom, not a diagnosis. Treatment should be directed at the cause rather than automatically prescribing bladder medication.

What is urge urinary incontinence?

Urinary urgency is a sudden, compelling need to pass urine that is difficult to defer. When urine leaks before reaching the toilet, this is called urgency urinary incontinence.

Other overactive bladder symptoms may include:

  • Frequent urination during the day
  • Waking at night to urinate
  • “Key-in-the-door” urgency
  • Leakage while rushing to the toilet
  • Bladder spasms
  • Leakage without coughing or physical exertion

This differs from recurrent stress incontinence, where leakage occurs with coughing, sneezing, exercise or lifting. Some women experience both types, known as mixed urinary incontinence.

How common is urgency after a sling?

The reported frequency varies because studies use different definitions, sling types and follow-up periods.

A systematic review of 32 studies involving 3,139 women estimated that new overactive bladder symptoms occur in approximately 9% of women after a mid-urethral sling. Rates were broadly similar among retropubic, transobturator and single-incision slings.[1]

Women who had urgency or urgency incontinence before surgery have a greater chance of persistent symptoms afterwards. Published studies have reported persistent overactive bladder symptoms in approximately 30–40% of women with preoperative mixed incontinence, although estimates vary considerably.[2,3]

These figures should be interpreted carefully. Urgency occurring soon after an operation may be temporary, whereas symptoms developing years later may reflect ageing, menopause, infection or an unrelated bladder disorder rather than a direct surgical complication.

Urgency in the early postoperative period

Urgency during the first days or weeks after sling surgery is relatively common and does not necessarily mean that the sling has failed.

Possible early causes

1. Temporary irritation and inflammation

Anaesthesia, catheterisation, cystoscopy, postoperative swelling and manipulation around the urethra can temporarily irritate the bladder. Pain, constipation, reduced mobility and changes in fluid intake may contribute.

These symptoms often settle as postoperative inflammation resolves.

2. Urinary tract infection

A urinary infection can cause urgency, frequency, burning, bladder discomfort, cloudy urine and urge leakage. Infection should be considered particularly after catheterisation or difficulty emptying the bladder.

A urine culture is preferable when symptoms are significant, recurrent or atypical. Antibiotics should be selected according to the clinical circumstances and culture result rather than given indefinitely for unexplained urgency.

3. Incomplete bladder emptying

Postoperative pain, swelling, pelvic-floor guarding, medication or temporary bladder weakness can make urination difficult. Retained urine may produce frequency, urgency, overflow leakage or recurrent infection.

Symptoms can include:

  • A slow or interrupted stream
  • Hesitancy
  • Straining to urinate
  • A feeling of incomplete emptying
  • Passing small amounts frequently
  • Lower abdominal fullness
  • Inability to pass urine

A bladder scan measuring the post-void residual volume is an important early test.

4. Excessive outlet resistance from the sling

A sling should support the urethra without obstructing it. Occasionally, it produces too much resistance. Obstruction may present dramatically as retention, but it may also cause subtle symptoms such as a slow stream, urgency, recurrent infections or worsening urge incontinence.

When genuinely new urgency begins immediately after surgery particularly when accompanied by deterioration in urine flow or a raised residual volume, bladder outlet obstruction must be actively considered.[2,4]

There is no single test that perfectly proves or excludes female bladder outlet obstruction. The diagnosis depends on the timing of symptoms, examination, urine flow, residual volume and, in selected patients, pressure-flow urodynamics.

5. Bladder or urethral perforation or sling exposure

Unrecognised urinary-tract injury is uncommon but important. A sling or suture entering the bladder or urethra may cause urgency, pain, bleeding, recurrent infection or difficulty urinating.

Cystoscopy may be recommended when symptoms are severe or persistent, or when there is haematuria, recurrent infection, pelvic pain or suspicion of erosion.

6. Pre-existing overactive bladder

Some women had urgency before surgery but were understandably more concerned about stress leakage. Once the stress incontinence has improved, the remaining urgency may become more noticeable.

A sling may improve the stress component of mixed incontinence without curing the underlying overactive bladder.

How should early postoperative urgency be assessed?

Assessment may include:

  • A detailed comparison of symptoms before and after surgery
  • The precise timing of symptom onset
  • Urinalysis and urine culture
  • Examination for prolapse, vaginal healing, sling exposure and pelvic-floor tenderness
  • Measurement of urinary flow and post-void residual urine
  • A bladder diary
  • Cystoscopy when erosion, perforation, bleeding or recurrent infection is suspected
  • Urodynamic testing when the diagnosis remains uncertain or a further invasive procedure is being considered

The type of sling and its operative details should be reviewed whenever possible.

Management of early urgency

Treatment depends on the findings.

If there is infection, constipation, pain or temporary inflammation, these conditions should be treated first. Short-term catheterisation or intermittent self-catheterisation may be required when the bladder is not emptying safely.

When emptying is normal and no surgical complication is evident, a period of observation, bladder training and appropriately selected overactive bladder medication may be reasonable.

However, significant suspected obstruction should not simply be masked with bladder-relaxing medication. Antimuscarinic medication can aggravate incomplete emptying in susceptible patients.

If there is convincing evidence that the sling is too tight, early sling mobilisation, loosening, incision or division may be considered. The procedure and its timing must be individualised. Earlier mobilisation may be technically easier before dense scarring develops, but unnecessary sling division may cause recurrent stress incontinence.

Published expert reviews emphasise balancing two risks:

  1. Waiting too long when meaningful obstruction is present may lead to persistent urgency, infection and impaired bladder function.
  2. Releasing a functioning sling unnecessarily may restore stress leakage.[2,4,5]

Urgency developing months or years after sling surgery

Urgency appearing years later should not automatically be blamed on the sling. A direct sling-related problem remains possible, but other causes become increasingly important.

Possible delayed causes

Age-related overactive bladder

Overactive bladder becomes more common with age. Changes in bladder sensation, detrusor function, mobility, sleep, fluid regulation and neurological health can produce urgency independently of previous surgery.

Menopause and genitourinary syndrome of menopause

Reduced oestrogen levels may contribute to vaginal and urethral tissue changes, discomfort, recurrent infection and urinary urgency. Selected postmenopausal women may benefit from local vaginal oestrogen, provided there is no contraindication and the treatment is discussed with their doctor.

Recurrent urinary infection

Repeated urgency episodes associated with pain, dysuria or cloudy urine require appropriate cultures. Persistent symptoms with repeatedly negative cultures should prompt consideration of overactive bladder, pelvic-floor dysfunction, bladder pain syndrome, stones or sling-related complications rather than repeated empirical antibiotics.

Pelvic organ prolapse

A cystocele or other vaginal prolapse may alter bladder emptying and cause urgency, frequency or infection. Examination is important, particularly when there is a vaginal bulge, pressure or difficulty emptying.

Delayed obstruction or scarring

Progressive scarring around the urethra or sling can occasionally produce delayed voiding difficulty. Comparing the present urinary stream and residual volume with earlier results can be informative.

Vaginal, urethral or bladder erosion

Delayed sling exposure or erosion may present with vaginal discharge, bleeding, pain during intercourse, pelvic pain, recurrent infections, haematuria or urgency. Cystoscopy and vaginal examination are usually required when this is suspected.

Other bladder or neurological disease

Diabetes, neurological disorders, impaired mobility, diuretic medication, excessive fluid intake, bladder stones and, less commonly, bladder tumours can produce urgency. Visible blood in the urine should never be attributed to overactive bladder without appropriate investigation.

Investigating delayed urgency

A sensible assessment commonly includes:

  • Review of preoperative and postoperative symptoms
  • Urinalysis and urine culture
  • A three-day bladder diary
  • Examination for vaginal atrophy, prolapse, pelvic-floor dysfunction and sling exposure
  • Urinary flow rate and post-void residual measurement
  • Review of medications, fluid intake, caffeine and bowel function
  • Cystoscopy when there is haematuria, pain, recurrent infection or suspected erosion
  • Urodynamic studies when symptoms are complex, emptying is abnormal, previous treatment has failed or further surgery is contemplated

Urodynamics may demonstrate detrusor overactivity, impaired bladder contraction or a pressure-flow pattern suggesting outlet obstruction. A normal study does not invalidate genuine urgency, and urodynamics cannot always determine whether the sling is the cause.

Treatment when obstruction and sling complications have been excluded

When evaluation supports overactive bladder rather than a mechanical complication, management generally follows established overactive bladder principles.[6–8]

Lifestyle and bladder strategies

Options include:

  • Reducing excessive fluid intake
  • Moderating caffeine, alcohol and carbonated drinks
  • Treating constipation
  • Weight management where appropriate
  • Bladder training with gradually increasing voiding intervals
  • Urgency-suppression techniques
  • Pelvic-floor physiotherapy
  • Improving access to the toilet and managing mobility limitations

Pelvic-floor treatment should focus on both strength and relaxation. Continually “squeezing harder” may worsen symptoms in women with an overactive or painful pelvic floor.

Medication

Medication options include:

Antimuscarinic medicines

Examples include solifenacin, oxybutynin, tolterodine and darifenacin. Possible adverse effects include dry mouth, constipation, blurred vision and cognitive effects. Medication selection should consider age, other medicines, glaucoma, bowel function and the ability to empty the bladder.

Beta-3 adrenergic agonists

Mirabegron relaxes the bladder during storage and may cause fewer dry-mouth and constipation symptoms than antimuscarinic therapy. Blood pressure and drug interactions require consideration.

Combination treatment may help selected patients who have an inadequate response to one medication. Residual urine should be monitored when there is concern about impaired emptying.

Vaginal oestrogen

Local vaginal oestrogen may be appropriate for postmenopausal women with vaginal atrophy, recurrent infection or associated urinary symptoms. It is different from systemic hormone replacement and should be prescribed after individual assessment.

Percutaneous tibial nerve stimulation

Tibial nerve stimulation uses electrical stimulation near the ankle to influence the neural pathways controlling the bladder. It is minimally invasive but usually requires a course of repeated treatment sessions and sometimes maintenance therapy.

Intravesical botulinum toxin

Botulinum toxin can reduce involuntary bladder contractions and urgency incontinence. Potential complications include urinary infection and difficulty emptying the bladder. Patients should understand that temporary intermittent self-catheterisation may occasionally be required.

Sacral neuromodulation

Sacral neuromodulation modifies the nerve signals involved in bladder storage and emptying. It may be considered for persistent urgency and urgency incontinence that have not responded adequately to conservative or medication-based treatment.

A test phase is normally performed before permanent implantation. It can be effective after previous continence surgery, provided that infection, significant obstruction and sling erosion have first been addressed.

When is sling revision appropriate years later?

Sling incision, partial excision or more extensive removal may be appropriate when there is evidence of:

  • Clinically important bladder outlet obstruction
  • Urethral or bladder erosion
  • Symptomatic vaginal exposure
  • Persistent infection associated with the sling
  • Significant sling-related pain
  • A clear relationship between the sling and disabling urinary symptoms

Sling revision is not a reliable treatment for otherwise unexplained overactive bladder. Urgency may persist after revision, particularly when it is caused by detrusor overactivity, ageing or another bladder disorder.

Possible consequences of sling revision include:

  • Recurrent stress urinary incontinence
  • Bleeding or infection
  • Urethral or bladder injury
  • Persistent pain or urgency
  • Need for further continence treatment

Shared decision-making is therefore essential.

The role of sling release and urethrolysis

When urgency or urge incontinence follows sling surgery, an important question is whether the sling has created excessive resistance to bladder emptying. If meaningful obstruction is present, treating the bladder alone may not solve the underlying problem.

Sling release is not routinely recommended for isolated urgency when urinary flow and bladder emptying are normal. It is most useful when the history, examination and investigations suggest that the urethra is being mechanically obstructed.

When should sling-related obstruction be suspected?

Features that may indicate excessive sling tension or postoperative scarring include:

  • New difficulty passing urine after surgery
  • Complete or intermittent urinary retention
  • A urinary stream that became slower after the sling
  • Hesitancy, straining or an interrupted stream
  • A persistent feeling of incomplete emptying
  • An increased post-void residual volume
  • Recurrent urinary infections
  • New urgency or urgency incontinence associated with impaired emptying
  • Worsening bladder function that began soon after surgery
  • A pressure-flow study suggesting bladder outlet obstruction
  • Cystoscopic or examination findings suggesting sling erosion, distortion or excessive urethral elevation

Women do not need to be in complete retention to have clinically important obstruction. Some can empty the bladder by generating higher bladder pressures or straining, but may develop urgency, frequency, infections and progressive bladder dysfunction.

There is no universally accepted urodynamic definition of female bladder outlet obstruction. A normal or equivocal urodynamic study does not completely exclude it. The diagnosis therefore combines the timing of symptoms, changes in urinary flow, residual urine, examination findings and, when useful, cystoscopy and pressure-flow urodynamics.[5,10]

Sling mobilisation or loosening

When voiding difficulty is recognised soon after a mid-urethral sling procedure, the sling may sometimes be mobilised or loosened before dense scar tissue forms around it.

Through a small vaginal incision, the surgeon identifies the sling and gently pulls it away from the urethra to reduce its tension. The sling is usually preserved rather than cut.

Early mobilisation may:

  • Restore bladder emptying
  • Relieve excessive outlet resistance
  • Reduce the need for prolonged catheterisation
  • Preserve more of the original stress-incontinence benefit than complete sling division

Temporary catheterisation remains appropriate for mild early retention that is improving. However, prolonged observation may be undesirable when significant obstruction persists, particularly when repeated voiding trials fail or the patient remains dependent on catheterisation.

The IUGA committee opinion notes that early sling mobilisation often resolves postoperative voiding dysfunction with relatively low morbidity. The exact timing should be individualised rather than dictated by one fixed number of days.[5]

Sling incision or division

If mobilisation is not possible or is unsuccessful, the sling may be cut through a vaginal incision. This is known as sling incision, division or lysis.

It may be considered when there is:

  • Persistent retention
  • A consistently elevated residual volume
  • Marked deterioration in urinary flow
  • Recurrent infection associated with poor emptying
  • New urgency or urge incontinence strongly associated with obstruction
  • Persistent obstructive symptoms despite an initial period of conservative management

Dividing the sling reduces its compression on the urethra. Urinary flow and emptying often improve, but urgency does not always disappear immediately. A bladder that has worked against obstruction may take time to recover, and some women have coexisting detrusor overactivity requiring additional treatment.

The principal trade-off is recurrent stress urinary incontinence. The risk varies between studies and depends on the type of sling, the location and extent of the incision, the time since implantation and the patient’s underlying urethral function. This possibility should be discussed before surgery.

Partial sling excision

Partial excision removes the central vaginal portion of the sling beneath or adjacent to the urethra. It may be appropriate when simple division is inadequate or when there is:

  • Vaginal sling exposure
  • Localised pain or tenderness
  • Infection involving the sling
  • Urethral or bladder erosion
  • Dense scarring around the urethra
  • Persistent obstruction after a previous sling incision

Removing more sling material may provide greater decompression but can also increase the risk of recurrent stress leakage and operative injury.

What is formal urethrolysis?

Urethrolysis is a more extensive operation that frees the urethra and bladder neck from surrounding scar tissue or restrictive sling material.

It is generally reserved for established or complex obstruction, particularly when:

  • Symptoms have been present for months or years
  • Dense fibrosis has developed
  • Previous sling incision or partial excision has failed
  • The original operation involved an autologous fascial or bladder-neck sling
  • The urethra remains fixed, elevated or compressed
  • Multiple previous continence procedures have been performed

The operation may be performed through a vaginal, retropubic or combined approach, depending on the original procedure and the location of the scar tissue. The aim is to restore urethral mobility and reduce outlet resistance while avoiding injury to the urethra and bladder.[10]

Formal urethrolysis is now required less often after uncomplicated mid-urethral slings because many cases can be managed with early mobilisation, sling division or partial excision. It remains valuable in delayed, recurrent or anatomically complex obstruction.

Will sling release cure the urgency?

Not necessarily.

Urgency is most likely to improve when:

  • It began soon after sling placement
  • It was accompanied by a weaker urinary stream
  • Residual urine increased after surgery
  • There is persuasive clinical or urodynamic evidence of obstruction
  • The obstruction is relieved before permanent bladder changes develop

Urgency may persist when it was present before surgery or when it is primarily caused by:

  • Idiopathic overactive bladder
  • Age-related bladder change
  • Detrusor overactivity
  • Menopause or genitourinary syndrome of menopause
  • Recurrent infection
  • Pelvic-floor dysfunction
  • Neurological disease
  • Diabetes or another medical condition

Sling release should therefore not be presented as a guaranteed treatment for urgency. Some patients require subsequent bladder training, medication, botulinum toxin, tibial nerve stimulation or sacral neuromodulation even after obstruction has been corrected.

Risks of sling release or urethrolysis

Potential complications include:

  • Recurrent stress urinary incontinence
  • Persistent urgency or urge incontinence
  • Bleeding or infection
  • Injury to the urethra or bladder
  • Urethrovaginal fistula, although uncommon
  • Ongoing pain or scarring
  • Continued difficulty emptying
  • Need for further continence surgery

One comparative series reported new stress incontinence in approximately one-quarter of women following urethrolysis or partial sling excision without simultaneous placement of another sling. This figure should not be treated as a universal prediction because outcomes vary with the original operation, indication and surgical technique.[11]

Placing another continence procedure at the same time as urethrolysis is controversial. In many cases it is preferable to relieve the obstruction first, allow bladder function to stabilise and then reassess any recurrent stress incontinence. This avoids immediately replacing one potentially obstructive procedure with another, although management must be individualised.

Why timely recognition matters

Persistent outlet obstruction can contribute to recurrent infections, detrusor overactivity, impaired bladder contraction and potentially irreversible bladder dysfunction. Conversely, releasing a sling without convincing evidence of obstruction can unnecessarily restore stress leakage.

The decision should therefore be based on the complete clinical picture and shared decision-making—not urgency alone.

When should you seek urgent medical attention?

Contact your surgeon or seek urgent assessment if you:

  • Cannot pass urine
  • Develop fever, chills or worsening pelvic pain
  • Have heavy vaginal bleeding
  • See blood in the urine
  • Develop severe lower abdominal swelling or discomfort
  • Experience rapidly worsening leakage with difficulty emptying
  • Have recurrent infections, vaginal mesh exposure or unexplained discharge

The take-home message

Urge incontinence after sling surgery deserves a structured assessment.

In the early postoperative period, infection, swelling, incomplete emptying and excessive sling-related outlet resistance are particularly important. New urgency accompanied by a weaker stream or increased residual urine should raise concern about obstruction.

When urgency develops years later, ageing, menopause, recurrent infection, prolapse, medication effects and idiopathic overactive bladder become more likely, although delayed obstruction or sling erosion must still be considered.

Once infection, obstruction and sling complications have been excluded, treatment can include bladder training, pelvic-floor physiotherapy, medication, tibial nerve stimulation, bladder botulinum toxin or sacral neuromodulation. Sling revision should be reserved for appropriately selected patients because it may reintroduce stress incontinence and does not guarantee that urgency will resolve.

So, if new urgency symptoms have developed and this is making life miserable for you, come see your local Brisbane urologist, Dr Jo Schoeman for advice.

References

  1. Pergialiotis V, et al. De novo overactive bladder following midurethral sling procedures: a systematic review and meta-analysis. International Urogynecology Journal. 2017;28:1631–1638. PubMed
  2. Gomelsky A, et al. Urgency and urgency incontinence following stress urinary incontinence surgery: a review of evaluation and management. Indian Journal of Urology. 2022. Full text
  3. Shin JH, Choo MS. De novo or resolved urgency and urgency urinary incontinence after midurethral sling operations. Investigative and Clinical Urology. 2019;60:373–379. Full text
  4. Marcelissen T, Van Kerrebroeck P. Urgency after a sling: review of the management. Current Urology Reports. 2014;15:402. PubMed
  5. Bazi T, et al. Management of post-midurethral sling voiding dysfunction: IUGA Research and Development Committee opinion. International Urogynecology Journal. 2018;29:23–28. PubMed
  6. American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder. 2024. AUA/SUFU guideline
  7. European Association of Urology. Guidelines on Non-neurogenic Female Lower Urinary Tract Symptoms. EAU guideline
  8. International Urogynecological Association. Management of mixed urinary incontinence: IUGA Committee Opinion. International Urogynecology Journal. 2024. Full text
  9. American Urological Association. Stress Urinary Incontinence Guideline. AUA guideline
  10. Gleich LD, Goldman HB. Urethrolysis. Neurourology and Urodynamics. 2024. Full-text clinical review
  11. Drain A, et al. Current role of urethrolysis and partial excision in patients seeking revision of anti-incontinence sling. Female Pelvic Medicine & Reconstructive Surgery. 2019;25:362–366. Article
  12. Pinsard M, et al. Comparison of early loosening versus delayed section of mid-urethral slings in patients with postoperative bladder outlet obstruction. International Urogynecology Journal. 2023. Article

This information is intended for general patient education and does not replace individual medical assessment. Management should be tailored to the type of sling, timing of symptoms, examination findings, bladder emptying and the patient’s priorities.

Dysfunctional Voiding in Men: When Urgency and a Poor Stream Occur Together

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Men with urinary urgency, frequency and nocturia are often presumed to have an overactive bladder. Those with a slow stream, hesitancy or incomplete emptying may be presumed to have an enlarged prostate. However, when storage and voiding symptoms occur together, the explanation may be more complicated.

Some men have true prostate or bladder-neck obstruction. Others have an underactive bladder, an overactive bladder, a urethral narrowing, or dysfunctional voiding, in which the urinary sphincter or pelvic-floor muscles fail to relax properly while the bladder is trying to empty. Several problems may also coexist.

This distinction matters. Removing prostate tissue will not necessarily correct a pelvic floor that is closing at the wrong time and an unnecessary operation can introduce bleeding, sexual side effects, scarring or urinary leakage.

What is dysfunctional voiding?

During normal urination, the bladder muscle contracts while the bladder neck, external urinary sphincter and pelvic floor relax. It is a coordinated sequence: the bladder pushes and the outlet opens.

In dysfunctional voiding, this coordination is disturbed. The external sphincter or pelvic-floor muscles remain partly contracted or repeatedly tighten during urination. The resulting functional obstruction may produce an intermittent, fluctuating or “stop–start” stream.

The International Continence Society describes dysfunctional voiding as intermittent or fluctuating urinary flow caused by inadequate or variable relaxation of the urinary sphincter during voiding in a person without a recognised neurological disorder.

Dysfunctional voiding must be distinguished from:

  • Benign prostatic obstruction caused by an enlarged prostate.
  • Primary bladder-neck obstruction, in which the bladder neck does not open adequately.
  • Urethral stricture disease.
  • Detrusor underactivity, where the bladder contraction is too weak or too brief.
  • Neurological detrusor–sphincter dyssynergia.
  • Overactive bladder or detrusor overactivity.
  • Chronic prostatitis or chronic pelvic-pain syndrome.
  • Medication-related voiding difficulty.

The symptoms alone frequently cannot identify which of these mechanisms is responsible.

What symptoms may occur?

Men may report a mixture of storage and emptying symptoms.

Overactive-bladder-type symptoms

  • Sudden urgency to pass urine.
  • Increased daytime frequency.
  • Waking repeatedly at night to urinate.
  • Urgency urinary leakage.
  • Passing small amounts frequently.
  • Bladder discomfort when trying to delay urination.

Outflow-obstruction-type symptoms

  • Hesitancy before the stream begins.
  • A weak, intermittent or spraying stream.
  • Straining to pass urine.
  • A feeling that the pelvic floor will not “let go.”
  • Prolonged urination.
  • Post-void dribbling.
  • A sensation of incomplete emptying.
  • Recurrent urinary infections or episodes of retention.

An important principle is that overactive bladder is a symptom syndrome, not proof of the underlying cause. Urgency may arise from primary detrusor overactivity, but it can also develop when the bladder works against an obstructed or poorly relaxing outlet.

Likewise, a weak stream does not automatically mean that the prostate is obstructing the bladder.

How should these symptoms be investigated?

The assessment begins with a detailed history. The duration and pattern of symptoms, previous pelvic or prostate surgery, urinary infections, pelvic pain, constipation, medication use, neurological symptoms and sexual function are all relevant.

A practical initial assessment may include:

  • A validated symptom questionnaire, such as the IPSS or ICIQ-MLUTS.
  • A three-day bladder diary recording fluid intake, voided volumes, urgency and leakage.
  • Urinalysis and urine culture when indicated.
  • Examination of the abdomen, prostate, genitalia and neurological system.
  • Assessment of pelvic-floor tone and the ability to relax the pelvic floor.
  • Uroflowmetry, preferably with an adequately full bladder.
  • Ultrasound measurement of the post-void residual urine.
  • Assessment of prostate size.
  • PSA testing when clinically appropriate and after informed discussion.
  • Kidney-function testing when retention or upper-tract risk is suspected.
  • Cystoscopy when urethral stricture, bladder-neck disease, haematuria or another anatomical abnormality is possible.

A low maximum urinary flow or a raised residual suggests impaired emptying, but neither finding reliably distinguishes prostate obstruction from dysfunctional voiding or a weak bladder. The European Association of Urology advises that non-invasive tests should not be treated as substitutes for pressure-flow urodynamics when a definite diagnosis of bladder outlet obstruction is required.

The role of pelvic-floor physiotherapy

In true dysfunctional voiding, the first treatment should usually be directed at improving coordinationnot immediately removing prostate tissue.

Specialist pelvic-floor physiotherapy may include:

  • Learning to recognise and release pelvic-floor tension.
  • Diaphragmatic breathing.
  • Relaxed, unhurried voiding.
  • Avoidance of abdominal straining.
  • Biofeedback using surface electromyography or uroflowmetry.
  • Treatment of pelvic pain and muscle trigger points.
  • Management of constipation.
  • Timed or double voiding when appropriate.

This is generally pelvic-floor down-training rather than routine strengthening. Repeated forceful Kegel exercises may aggravate symptoms in a man whose pelvic floor is already overactive.

The 2026 EAU guideline recommends behavioural modification and biofeedback as first-line treatment for dysfunctional voiding in younger men. The evidence is limited, but one small study reported at least a 50% symptom improvement in 83% of treated men at three months.

Can medication be tried first?

Medication is often reasonable, provided it is matched to the suspected mechanism and the response is monitored objectively.

Alpha-blockers

An alpha-blocker such as tamsulosin, alfuzosin or silodosin may reduce smooth-muscle resistance at the prostate and bladder neck. It is particularly relevant when benign prostatic obstruction or primary bladder-neck obstruction is suspected.

Possible side effects include:

  • Dizziness or postural hypotension.
  • Fatigue.
  • Nasal congestion.
  • Ejaculatory disturbance.
  • Reduced or absent forward ejaculation.

Alpha-blockers do not directly retrain an external sphincter or pelvic floor that is contracting during voiding. A poor response should therefore prompt reconsideration of the diagnosis rather than automatic progression to prostate surgery.

Overactive-bladder medications

An antimuscarinic medication or a beta-3 agonist may be considered when urgency, frequency or urgency incontinence remains troublesome.

Antimuscarinic side effects may include dry mouth, constipation, blurred vision and cognitive adverse effects in susceptible patients. Beta-3 agonists may cause hypertension, headache or palpitations in some patients.

These medicines can be used cautiously in appropriately selected men with coexisting outlet symptoms, but baseline and follow-up residual urine measurements are advisable when emptying is impaired. A marked residual, weak bladder contraction or previous retention increases the importance of careful monitoring.

The EAU guideline supports adding a beta-3 agonist to an alpha-blocker when storage symptoms persist, although the average additional benefit is modest.

Other prostate medications

A 5-alpha-reductase inhibitor, such as finasteride or dutasteride, is useful only when genuine prostate enlargement and a risk of progression are present. It does not treat dysfunctional sphincter relaxation.

Daily tadalafil may improve male lower urinary tract symptoms and erectile function in selected men, although its effect on urinary flow is usually modest.

When are urodynamic studies important?

Urodynamics become particularly valuable when the symptoms and non-invasive tests tell different stories, when medication has failed, or when an irreversible operation is being considered.

A pressure-flow study assesses:

  • Bladder sensation during filling.
  • Detrusor overactivity.
  • Bladder compliance.
  • The strength of the bladder contraction.
  • Urinary flow in relation to bladder pressure.
  • Whether high-pressure, low-flow voiding confirms obstruction.
  • Whether low-pressure, low-flow voiding suggests detrusor underactivity.
  • Residual urine after voiding.

Adding pelvic-floor electromyography can demonstrate inappropriate external-sphincter activity. Videourodynamics can show where the obstruction occurs while pressure and flow are measured simultaneously.

Videourodynamics is regarded as the most informative investigation for distinguishing primary bladder-neck obstruction from dysfunctional voiding in younger men. The 2026 EAU guideline recommends videourodynamics, or standard urodynamics combined with voiding cystourethrography, with or without electromyography when either diagnosis is suspected.

Urodynamics is not required before every treatment for uncomplicated male urinary symptoms. It is particularly useful when:

  • The man is young and prostate enlargement is unlikely to explain the symptoms.
  • Symptoms are severe but the prostate is small.
  • The flow pattern is intermittent or unusual.
  • The residual urine is persistently elevated.
  • There is a history of retention.
  • Previous prostate treatment has failed.
  • Detrusor underactivity is possible.
  • Dysfunctional voiding or primary bladder-neck obstruction is suspected.
  • OAB symptoms and voiding symptoms coexist.
  • The result would determine whether surgery, neuromodulation, medication or physiotherapy is selected.

The purpose is not simply to produce a graph. It is to answer a treatment-changing question: is the outlet anatomically obstructed, functionally closed, or is the bladder failing to generate an adequate contraction?

Should bladder-neck incision or TURP be considered?

The answer depends on what has been demonstrated.

Bladder-neck incision

A bladder-neck incision may be considered when videourodynamics confirms primary bladder-neck obstruction and an adequate trial of an alpha-blocker has failed or has caused unacceptable adverse effects.

The procedure divides restricting bladder-neck fibres without removing a large amount of prostate tissue. A single, ejaculation-preserving incision may be considered in appropriately selected younger men.

Potential adverse effects include:

  • Bleeding or infection.
  • Temporary urgency, frequency and discomfort.
  • Temporary difficulty urinating or catheter dependence.
  • Retrograde or reduced-volume ejaculation.
  • Rare erectile or continence problems.
  • Bladder-neck scarring or recurrent obstruction.
  • Need for further treatment.

Across heterogeneous studies, the EAU guideline reports ejaculatory dysfunction rates ranging widely according to technique. Its pooled estimate was approximately 3% after bladder-neck incision, with lower reported rates after a single incision than after bilateral incisions. Fertility and ejaculatory priorities should always be discussed before surgery.

A bladder-neck incision is not the usual treatment for dysfunctional voiding at the external sphincter or pelvic floor.

TURP

A TURP removes obstructing prostate tissue and remains an effective operation for confirmed benign prostatic obstruction, particularly in men with a prostate in the conventional 30–80 mL range.

It may be reasonable when there is convincing evidence of prostatic obstruction, especially with:

  • Recurrent retention.
  • Recurrent infection caused by poor emptying.
  • Bladder stones.
  • Renal consequences of obstruction.
  • Persistent significant symptoms despite appropriate medication.
  • High-pressure obstruction demonstrated on urodynamics.

TURP should be approached cautiously when urodynamics shows no prostate obstruction. If the main problem is dysfunctional sphincter closure or a weak bladder, TURP may fail to improve the stream, urgency or residual urine.

What are the possible side effects of disobstruction surgery?

Short-term effects can include:

  • Burning and frequency while the prostate or bladder neck heals.
  • Visible blood in the urine.
  • Clot retention.
  • Urinary infection.
  • Temporary inability to urinate.
  • A temporary increase in urgency or urgency leakage.
  • Catheter-related discomfort.
  • Bleeding requiring readmission or, less commonly, transfusion.

Longer-term effects may include:

  • Retrograde ejaculation.
  • Persistent urgency or urgency incontinence.
  • Urethral stricture.
  • Bladder-neck contracture.
  • Recurrent obstruction or need for another procedure.
  • Persistent incomplete emptying when detrusor underactivity is present.
  • Rare persistent stress urinary incontinence.
  • Possible changes in erectile or orgasmic function.

Retrograde ejaculation is common after conventional TURP, affecting approximately 65–75% of men in contemporary patient-information estimates. It is not dangerous, but it changes the experience of ejaculation and can impair fertility.

What is the risk of urinary incontinence?

Urinary control may temporarily worsen after TURP or bladder-neck surgery because:

  • The bladder has become overactive from longstanding obstruction.
  • Postoperative inflammation produces urgency.
  • The bladder suddenly encounters much less outlet resistance.
  • The urinary sphincter needs time to adapt.
  • Pre-existing detrusor overactivity remains after the obstruction is relieved.

Early urgency and occasional leakage are therefore more common than permanent sphincter damage. Historical research suggests that some incontinence may occur initially after TURP, while persistent incontinence at approximately 12 months is around 1% in conventional series. Reported rates vary according to the definition used, the procedure, pre-existing bladder dysfunction and the characteristics of the patient.

Persistent leakage may be:

  • Urgency incontinence, caused by ongoing detrusor overactivity.
  • Stress incontinence, caused by sphincter weakness or injury.
  • Overflow leakage, caused by inadequate bladder emptying.
  • A mixture of these mechanisms.

These types require different treatment. Persistent leakage should therefore be investigated rather than simply labelled “postoperative incontinence.”

Men with preoperative urgency, demonstrable detrusor overactivity, poor bladder compliance, previous pelvic surgery, neurological disease or sphincter weakness require individualised counselling. Surgery may relieve the obstruction without curing the bladder dysfunction that developed alongside it.

Where does sacro-neuromodulation fit?

Sacro-neuromodulation uses a small implanted system to stimulate the sacral nerves involved in bladder sensation, storage, emptying and pelvic-floor coordination. Treatment starts with a temporary test phase. A permanent battery is implanted only if the test produces worthwhile improvement.

Sacral neuromodulation is an established option for appropriately selected patients with:

  • Refractory urgency-frequency syndrome.
  • Refractory urgency urinary incontinence.
  • Non-obstructive urinary retention.

It may be particularly attractive when a man has both storage and emptying dysfunction without a surgically correctable obstruction. It may also be considered in selected patients with detrusor underactivity after obstruction has been excluded.

Potential benefits include:

  • Reduced urgency and leakage.
  • Improved voiding.
  • Lower residual urine.
  • Reduced need for intermittent catheterisation.
  • A reversible test phase before permanent implantation.

Potential disadvantages include:

  • Failure of the test phase.
  • Pain at the implant or lead site.
  • Infection.
  • Lead movement or loss of benefit.
  • Unpleasant stimulation.
  • Need for reprogramming.
  • Battery replacement or revision surgery.
  • Device removal in some patients.

Published long-term studies report clinically meaningful benefit in many implanted patients with refractory OAB or non-obstructive retention. However, outcomes from predominantly female or mixed study populations should not be assumed to apply equally to every man.

Importantly, the evidence for sacral neuromodulation specifically for male dysfunctional voiding remains limited. The 2026 EAU male LUTS guideline describes it as experimental for this particular indication and recommends using the test phase to identify whether an individual is likely to benefit.

Sacral neuromodulation should not be used as a substitute for relieving proven high-pressure anatomical obstruction.

A practical treatment pathway

A sensible approach is:

  1. Confirm the symptom pattern with a history, examination, questionnaire and bladder diary.
  2. Exclude infection, haematuria, urethral stricture, neurological disease and medication-related causes.
  3. Measure urinary flow and post-void residual urine.
  4. Assess prostate size and perform cystoscopy when anatomy needs clarification.
  5. Begin conservative treatment, including fluid and bowel management and pelvic-floor relaxation.
  6. Trial an alpha-blocker when bladder-neck or prostatic resistance is possible.
  7. Add carefully selected OAB medication when storage symptoms persist, with residual monitoring where appropriate.
  8. Use pressure-flow urodynamics, ideally with video and pelvic-floor EMG, when the diagnosis remains uncertain or surgery is contemplated.
  9. Reserve bladder-neck incision for demonstrated primary bladder-neck obstruction.
  10. Reserve TURP or another prostate disobstruction procedure for demonstrated or strongly supported benign prostatic obstruction.
  11. Consider sacral neuromodulation for refractory OAB or non-obstructive retention after correctable obstruction has been excluded.
  12. Use intermittent self-catheterisation when emptying remains unsafe or inadequate despite other treatment.

The key message

In men with urgency and a poor stream, the most important question is not simply, “Is the prostate enlarged?” It is, “What are the bladder and outlet doing during urination?”

Dysfunctional voiding, primary bladder-neck obstruction, benign prostatic obstruction, detrusor overactivity and detrusor underactivity can produce remarkably similar symptoms. Treatment is most successful when it is directed at the demonstrated mechanism.

Pelvic-floor relaxation and biofeedback are appropriate first-line treatments for dysfunctional voiding. Alpha-blockers may help bladder-neck or prostatic resistance. OAB medicines can be added carefully when storage symptoms remain troublesome. Urodynamics can prevent an inappropriate disobstruction procedure in an uncertain case. Bladder-neck incision or TURP should be used for confirmed obstructionnot simply because the stream is poor. Sacral neuromodulation may be valuable for selected refractory patients, but its role specifically in male dysfunctional voiding is still evolving.

So, if you are in this unfortunate situation and you need help, come see your Brisbane functional urologist, dr Jo Schoeman for advice.

References and further reading

  1. European Association of Urology. EAU Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms, 2026. Full guideline
  2. European Association of Urology. Diagnostic evaluation of male LUTS. EAU diagnostic chapter
  3. European Association of Urology. Disease management of male LUTS, including voiding dysfunction in younger men. EAU treatment chapter
  4. International Continence Society. Dysfunctional voiding during male pressure-flow studies. ICS terminology resource
  5. Cameron AP, et al. The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder. Journal of Urology. 2024. PubMed record
  6. Creta M, et al. Management of Primary Bladder Neck Obstruction and Dysfunctional Voiding in Young Men: A Systematic Review and Meta-analysis. European Urology Focus. 2025. PubMed record
  7. Drake MJ, et al. Diagnostic Assessment of Lower Urinary Tract Symptoms in Men Considering Prostate Surgery: The UPSTREAM Randomised Controlled Trial. European Urology. 2020;78:701–710. PubMed record
  8. D’Ancona C, et al. The International Continence Society report on terminology for adult male lower urinary tract and pelvic-floor symptoms and dysfunction. Neurourology and Urodynamics. 2019;38:433–477. PubMed record
  9. British Association of Urological Surgeons. TURP for benign disease: patient information. BAUS information page
  10. Jairam R, et al. Predictive factors in sacral neuromodulation: a systematic review. Urologia Internationalis. 2022;106:323–342. Open-access review

This article provides general information and does not replace individual assessment. Medication and procedural decisions should be based on the patient’s examination, prostate and bladder anatomy, residual urine, urodynamic findings, comorbidities, fertility priorities and personal treatment goals.

The Story Behind The “Happy Prostate”

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More than a logo

The Happy Prostate is not simply a practice logo. It began as an original artwork that I painted myself, and it now hangs in my study at home.

Its cheerful expression reflects what I hope to achieve when caring for men with prostate and urinary problems: less worry, better understanding, improved bladder function and renewed confidence.

The prostate may be a small gland, but when it misbehaves, it can have an enormous effect on daily life. It can interrupt sleep, dictate travel plans, interfere with intimacy and leave a man constantly searching for the nearest toilet.

The Happy Prostate represents the other side of that story the moment when a man feels that he has regained control of his life. Having had prostate surgery myself, I am on the same page as my patients, I get you. And no, I did not do it myself!

When a growing prostate becomes a grumpy prostate

Benign prostatic hyperplasia, or BPH, is the non-cancerous enlargement of the prostate that commonly develops as men age.

An enlarged prostate may compress the urinary passage and cause:

  • A slow or interrupted urinary stream
  • Difficulty starting urination
  • Straining to pass urine
  • A feeling that the bladder has not emptied
  • Urgency and frequent urination
  • Getting up repeatedly during the night
  • Urinary retention or recurrent infections

Not every enlarged prostate needs surgery. Treatment begins with understanding the symptoms, examining the prostate and assessing bladder emptying, urinary flow, PSA and other relevant factors.

When a procedure is needed, there is no single operation that suits every man. Modern BPH treatment can be tailored according to prostate size and shape, symptom severity, bladder function, general health and the importance of preserving ejaculation.

Steam

Water-vapour therapy delivers small amounts of controlled steam into selected areas of enlarged prostate tissue. The treated tissue gradually shrinks, creating more room for urine to pass.

It may suit selected men looking for a minimally invasive option with a relatively low risk of sexual side effects. Improvement develops gradually rather than overnight.

Clips or a prostatic urethral lift

Tiny implants can be used to hold enlarged prostate tissue away from the urinary channel. Nothing is cut away.

This approach may offer a rapid recovery and a good chance of preserving ejaculation in appropriately selected men. Prostate anatomy is important, and some men may require further treatment later.

Temporary prostate stents or implants

A temporary implant can reshape the prostatic urethra without leaving a permanent device behind. It is usually removed after several days.

This can be useful for carefully selected prostates, although symptom improvement and long-term durability may not equal those achieved with more definitive tissue-removing procedures.

Laser treatment

Laser surgery can vaporise or enucleate obstructing prostate tissue. The technique selected depends on prostate size, anatomy, bleeding risk and the available equipment and expertise.

Laser treatment can provide powerful relief of obstruction, but temporary urgency, burning, bleeding and changes in ejaculation may occur during recovery.

Bipolar energy

Bipolar electrical energy can remove or enucleate enlarged prostate tissue while controlling bleeding. Bipolar TURP remains an established surgical option for many men with bothersome urinary obstruction.

Robotic-assisted enucleation

Very large prostates may be treated by robotic-assisted simple prostatectomy or enucleation. The obstructing inner portion of the prostate is removed while the outer capsule remains.

This is a more substantial procedure than a minimally invasive treatment, but it can provide excellent relief when a very large prostate is causing severe obstruction, retention, infections, bladder stones or kidney problems.

The right procedure is not necessarily the newest or the biggest. It is the procedure that best matches the individual man and his priorities. Current guidelines emphasise shared decision-making because treatments differ in effectiveness, recovery, durability and effects on sexual function. (EAU Male LUTS guideline)

When the diagnosis is prostate cancer

The words “prostate cancer” naturally produce fear, but prostate cancer is not one uniform disease. Some cancers grow so slowly that immediate treatment may cause more harm than benefit. Others require timely and decisive treatment.

The goal is to understand the cancer accurately and choose a strategy that balances cancer control with urinary, sexual and general health.

Active surveillance

For appropriately selected men with low-risk—and some favourable intermediate-risk—prostate cancer, active surveillance can avoid or delay unnecessary treatment.

It does not mean ignoring the cancer. It is a structured programme that may include:

  • Regular PSA testing
  • Clinical review
  • Prostate MRI
  • Repeat biopsy when indicated
  • Conversion to active treatment if there are signs of progression

The aim is to preserve quality of life while retaining the opportunity for curative treatment if the cancer changes. (EAU Prostate Cancer guideline)

Robotic-assisted radical prostatectomy

Robotic-assisted radical prostatectomy removes the prostate and seminal vesicles with the intention of curing localised prostate cancer.

Where it is oncologically safe, nerve-sparing and careful reconstruction may help preserve erectile function and accelerate recovery of urinary control. Cancer clearance remains the first priority, and continence and sexual outcomes vary between men.

Focal therapy

Focal therapy treats the cancerous area while attempting to preserve as much normal prostate tissue as possible. Techniques may include irreversible electroporation, focal laser ablation, high-intensity focused ultrasound or cryotherapy.

It may be considered for carefully selected men with localised, MRI-visible disease who understand the need for close follow-up. Focal therapy is not suitable for every prostate cancer, and long-term comparative evidence continues to develop. Some international guidelines recommend that it be performed within structured prospective studies or registries.

When continence is preserved, improved or restored

Urinary continence is one of the most important themes represented by the Happy Prostate.

Whenever possible, treatment planning aims to preserve continence. This involves careful patient selection, thoughtful surgical technique, protection of the urinary sphincter and appropriate pelvic-floor preparation and rehabilitation.

When leakage occurs, it should never be dismissed as something a man must simply tolerate. Assessment may include a bladder diary, pad testing, urine-flow measurement, ultrasound, cystoscopy or urodynamic studies. This helps distinguish weakness of the urinary sphincter from urgency, overactive bladder, obstruction or poor bladder emptying.

Depending on the cause, continence may be improved or restored through:

  • Pelvic-floor rehabilitation
  • Bladder training and lifestyle measures
  • Medication for urgency or overactive bladder
  • Treatment of residual obstruction
  • A male urethral sling
  • An artificial urinary sphincter
  • Other carefully selected continence procedures

The joyful progression shown in the Happy Prostate GIF represents this recovery: uncertainty giving way to hope, improvement and confidence. As urinary control returns, the character stands taller, moves with greater freedom and finally throws away his diaper.

The humour is intentional, but so is the dignity behind it. Incontinence can affect work, exercise, travel, intimacy and self-esteem. Restoring continence is not merely about keeping underwear dry, it is about helping a man feel comfortable in the world again.

As I like to put it:

When treatment works, the bladder stops writing the day’s itinerary and the diaper can take the day off.

A small painting with a larger purpose

The original Happy Prostate painting hanging in my home study reminds me that urology is not only about scans, PSA results, flow rates and surgical technology. It is about the man sitting on the other side of the desk.

A prostate becomes truly “happy” when its owner:

  • Understands what is happening
  • Feels comfortable discussing embarrassing symptoms
  • Has treatment suited to his individual circumstances
  • Maintains or regains urinary control
  • Can return to sleep, exercise, travel and intimacy with confidence
  • Feels that he has been heard and treated with dignity

A little humour can open the door, but dignity keeps the conversation going.

That is the story of the Happy Prostate: an original painting, a slightly cheeky character and a serious commitment to helping men regain comfort, confidence and joy.

Dr Jo Schoeman
The “Happy-Prostate” Urologist

This article provides general information and does not replace an individual medical assessment. The suitability, benefits and potential complications of each treatment should be discussed with a urologist.

Recurrent Urinary Tract Infections: Causes, Investigation and Prevention

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

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

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

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

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

What symptoms suggest a UTI?

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

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

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

Is it always an infection?

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

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

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

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

Why do urinary infections keep returning?

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

Common contributing factors in women

These include:

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

Causes that are particularly important in men

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

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

How are recurrent UTIs investigated?

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

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

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

Treating an acute infection

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

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

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

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

A stepwise prevention strategy

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

1. Hydration and bladder habits

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

Other practical measures include:

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

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

2. Vaginal oestrogen

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

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

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

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

3. Methenamine hippurate

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

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

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

4. Cranberry products

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

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

5. D-mannose

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

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

6. Probiotics

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

Prophylactic antibiotics

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

Post-coital prophylaxis

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

Continuous low-dose prophylaxis

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

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

Potential disadvantages include:

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

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

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

Bladder instillations

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

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

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

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

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

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

Are vaccines available for recurrent UTIs?

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

Examples include:

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

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

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

When should you seek urgent help?

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

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

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

The take-home message

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

A sensible strategy is to:

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

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

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

References and further reading

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

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

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

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

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

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

Before treatment: make sure the diagnosis fits

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

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

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

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

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

How successful is treatment overall?

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

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

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

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

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

A practical treatment ladder

1. Education, self-management and flare planning

These measures are recommended for almost everyone:

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

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

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

2. Pelvic-floor physiotherapy

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

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

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

3. Oral medicines

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

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

Amitriptyline: off-label

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

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

Possible adverse effects include:

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

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

Hydroxyzine and other antihistamines: off-label

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

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

Cimetidine: off-label

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

Pentosan polysulfate sodium: Elmiron

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

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

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

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

Gabapentin, pregabalin and duloxetine: off-label

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

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

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

Cyclosporine A: off-label and specialist-only

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

However, cyclosporine can cause:

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

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

4. Medicines placed directly into the bladder

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

Dimethyl sulfoxide: DMSO

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

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

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

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

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

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

Hyaluronic acid and chondroitin sulphate

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

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

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

5. Procedures when medication is insufficient

Treatment of Hunner lesions

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

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

Cystoscopy and hydrodistension

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

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

Botulinum toxin A: off-label for IC/BPS

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

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

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

Neuromodulation

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

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

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

Treatments that should generally be avoided

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

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

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

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

Choosing treatment fairly

An unbiased treatment plan asks four questions:

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

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

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

When to seek prompt reassessment

Seek medical review for:

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

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

The bottom line

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

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

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

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

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

Selected evidence and guidance

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