Enlarged Prostate (BPH): Understanding Prescription Combination Therapy

/0 Comments/in , /by

Benign prostatic hyperplasia (BPH), also called benign prostate enlargement, becomes more common as men get older. An enlarged prostate may narrow the urethra or affect the way the bladder works.

Possible symptoms include:

  • a slow or intermittent urinary stream
  • difficulty starting urination
  • straining to urinate
  • a feeling that the bladder has not emptied fully
  • urinary frequency or urgency
  • waking at night to urinate
  • dribbling after urination
  • urinary retention

These symptoms are not always caused by an enlarged prostate. Infection, overactive bladder, urethral narrowing, bladder stones, neurological conditions and prostate or bladder cancer can sometimes produce similar symptoms. An appropriate clinical assessment is therefore important before treatment is selected.

What treatments are available?

Management depends on symptom severity, prostate size, bladder emptying, general health and personal preferences. Options may include:

  • monitoring and lifestyle measures
  • prescription medicines
  • minimally invasive procedures
  • prostate surgery

No single option is best for every patient. A treatment that improves symptoms in one man may be unsuitable for another.

How prescription combination therapy works

For selected men, a doctor may prescribe two types of medicine together:

  1. An alpha blocker, such as tamsulosin, relaxes smooth muscle in the prostate and bladder neck. This may improve urine flow and symptoms relatively quickly, although response varies.
  2. A 5-alpha-reductase inhibitor, such as dutasteride or finasteride, alters the hormonal pathway involved in prostate growth. Over time, it may reduce prostate volume and lower the risk of urinary retention or BPH-related surgery in appropriately selected men.

These medicines are available only on prescription. They may be prescribed separately or, in some circumstances, in a fixed-dose combination. This article does not recommend a particular medicine or brand.

The prostate-reducing component acts gradually. Any benefit is generally assessed over months rather than days. Combination therapy is commonly considered as a longer-term treatment, but regular review remains important.

Who might be considered for combination therapy?

A doctor may consider combination treatment for a man who has moderate-to-severe urinary symptoms associated with a demonstrably enlarged prostate and an increased risk of BPH progression.

The decision may take account of:

  • how troublesome the symptoms are
  • prostate size and shape
  • PSA results, interpreted in clinical context
  • urinary flow rate
  • the amount of urine left in the bladder after voiding
  • previous urinary retention
  • the expected benefits, limitations and adverse effects of treatment
  • other illnesses and medicines
  • the patient’s preferences, including the importance of preserving sexual and ejaculatory function

Prostate size alone should not determine treatment. Some men with large prostates have few symptoms, while a smaller prostate can still cause obstruction because of its shape, a tight bladder neck or another condition.

Assessment before treatment

Depending on the individual, assessment may include:

  • a urinary, medical and medication history
  • a validated symptom questionnaire
  • physical examination, which may include a digital rectal examination
  • urine testing
  • PSA testing after discussion of its benefits and limitations
  • kidney-function blood tests
  • urinary flow measurement
  • ultrasound assessment of prostate size and post-void residual urine
  • a bladder diary
  • cystoscopy or urodynamic testing in selected cases

The purpose is to confirm the likely cause of the symptoms and identify complications or conditions that require a different approach.

Possible benefits and limitations

An alpha blocker may improve urine flow and some symptoms within days or weeks. It does not substantially shrink the prostate.

A 5-alpha-reductase inhibitor works more slowly. In men with prostate enlargement, it may reduce prostate volume and lower the long-term risk of acute urinary retention or BPH-related surgery. Not every patient will experience a worthwhile improvement.

Combination treatment may improve symptoms more than either medicine alone in appropriately selected patients, but it also exposes the patient to the adverse effects of both medicine classes. It controls BPH rather than permanently curing it. Symptoms may recur or progress, and a procedure may still be required.

Clinical-trial averages cannot predict an individual patient’s result. Benefits and harms should be reviewed with the prescribing doctor.

Possible adverse effects

Adverse effects differ between people. The Consumer Medicine Information supplied with the prescribed medicine should be read, and new or troublesome symptoms should be discussed with the prescriber or pharmacist.

Sexual and ejaculatory effects

Possible effects include:

  • reduced semen volume or absent ejaculation
  • semen passing backwards into the bladder
  • reduced sexual desire
  • difficulty achieving or maintaining an erection
  • changes in fertility or semen characteristics

Some sexual adverse effects have been reported to persist after a 5-alpha-reductase inhibitor is stopped, although their frequency, cause and predictors remain uncertain. Persistent symptoms deserve appropriate assessment.

Dizziness and low blood pressure

Alpha blockers may cause dizziness, light-headedness, weakness or, less commonly, fainting—particularly when standing up. The risk may be greater when treatment begins or when combined with other medicines that lower blood pressure. Patients who become dizzy should take care to avoid falls and seek medical advice.

Breast and other changes

5-alpha-reductase inhibitors may cause breast tenderness or enlargement. A breast lump, nipple discharge or persistent one-sided change requires medical assessment rather than being assumed to be a medicine effect.

Other reported adverse effects can include headache, tiredness, palpitations, nasal congestion, gastrointestinal discomfort, skin reactions, testicular symptoms and mood changes. The exact safety information depends on the medicine prescribed.

Seek urgent help

Urgent medical attention is appropriate for symptoms such as:

  • swelling of the face, tongue or throat, or difficulty breathing
  • collapse or fainting
  • a painful, prolonged erection
  • a severe blistering or peeling skin reaction
  • suicidal thoughts or severe psychological distress
  • inability to pass urine, especially with increasing lower abdominal pain

In Australia, call Triple Zero (000) in an emergency. Lifeline is available on 13 11 14 for crisis support. These services do not replace assessment by the treating clinician.

PSA monitoring

5-alpha-reductase inhibitors commonly lower PSA. This does not eliminate the possibility of prostate cancer.

A new PSA baseline may need to be established after treatment begins. Later results must be interpreted with knowledge that the patient is taking this type of medicine. A confirmed increase from the lowest PSA reached may require further assessment, even if the result falls within a laboratory’s usual reference range.

Patients should tell any clinician ordering or interpreting a PSA test about all current and recent prostate medicines.

Cataract or glaucoma surgery

Tamsulosin and some other alpha blockers are associated with intraoperative floppy iris syndrome, which may complicate cataract or glaucoma surgery.

Patients should tell their ophthalmologist about current or previous alpha-blocker use. They should not stop a prescribed medicine solely for an eye operation unless advised by the relevant treating clinicians, because stopping it may not remove the surgical risk.

Mood and persistent symptoms

Sexual, cognitive and mood symptoms have been reported during or after treatment with 5-alpha-reductase inhibitors. The evidence about persistent syndromes, their frequency and causation continues to evolve.

This uncertainty should be discussed without either assuming that persistent symptoms will occur or dismissing symptoms that a patient experiences. New depression, marked anxiety or sexual dysfunction should be reviewed. Suicidal thoughts require urgent assistance.

Monitoring treatment

Follow-up may include review of:

  • symptom response and quality of life
  • dizziness and postural blood pressure
  • sexual and ejaculatory function
  • mood changes
  • urinary flow and post-void residual urine
  • PSA results
  • kidney function when clinically indicated

Lack of early improvement does not necessarily mean the slower-acting component has failed. However, severe or worsening symptoms should not be managed by continuing medicine indefinitely without reassessment.

When might a procedure or surgery be considered?

A procedure may be discussed when there is:

  • recurrent or persistent urinary retention
  • catheter dependence
  • recurrent infection associated with poor bladder emptying
  • bladder stones
  • recurrent visible bleeding attributed to BPH
  • kidney or upper urinary tract effects from obstruction
  • a high or increasing post-void residual volume
  • persistent troublesome symptoms despite appropriate conservative treatment
  • unacceptable medicine adverse effects
  • a preference for a procedural option after informed discussion

Procedural choices include established operations and selected minimally invasive treatments. Suitability depends on prostate anatomy, bladder function, general health, bleeding risk, expected durability and the importance of preserving ejaculation. Each option has potential benefits, limitations and complications.

Questions to discuss with your doctor

  • What is the most likely cause of my urinary symptoms?
  • Is my prostate enlarged, and am I at risk of progression?
  • What are the reasonable alternatives, including observation, medicines and procedures?
  • How likely is each option to help in my circumstances?
  • What sexual, ejaculatory, blood-pressure and mood effects should I consider?
  • How will treatment affect the interpretation of my PSA?
  • When should treatment be reviewed or changed?
  • Which symptoms require urgent assessment?

The bottom line

Prescription combination therapy can be one option for selected men with bothersome urinary symptoms, prostate enlargement and a risk of BPH progression. It is not suitable for every urinary problem and does not guarantee that surgery will be avoided.

The choice should follow an individual assessment and a balanced discussion of expected benefit, possible harm, alternatives and the option of no immediate treatment. Do not start, stop or change a prescription medicine without advice from the prescribing clinician.

This article provides general educational information. It is not medical advice and does not promote or recommend a particular prescription medicine or brand. Treatment decisions should be made with an appropriately qualified health professional after individual assessment.

References and further reading

 

Superficial Bladder Cancer: Diagnosis, Treatment and the Risk of Progression

/0 Comments/in , /by

“Superficial bladder cancer” is an older term for cancer confined to the bladder lining or the tissue immediately beneath it. The preferred modern term is non–muscle-invasive bladder cancer, usually abbreviated to NMIBC.

Although these cancers have not invaded the bladder muscle, they do not all behave in the same way. Some are small, low-grade tumours with a relatively low risk of causing serious harm. Others, particularly high-grade T1 cancer and carcinoma in situ, can recur frequently and may progress into the bladder muscle.

Accurate staging and risk classification are therefore essential when deciding between surveillance, intravesical treatment and removal of the bladder.

What is non-muscle-invasive bladder cancer?

The bladder wall consists of several layers. Most bladder cancers begin in the urothelium, the specialised lining on the inside of the bladder.

NMIBC includes three main stages:

  • Ta: a papillary tumour growing from the bladder lining without invading the supporting tissue
  • T1: cancer that has invaded the connective tissue beneath the lining but has not reached the bladder muscle
  • Carcinoma in situ/CIS or Tis: a flat, usually high-grade cancer confined to the bladder lining

CIS can be difficult to see because it may look like a red or inflamed area rather than a typical bladder tumour. Despite being confined to the surface, CIS is biologically aggressive and requires active treatment.

Once cancer enters the bladder muscle, it becomes muscle-invasive bladder cancer—stage T2 or higher. This usually requires a different and more intensive treatment approach.

How common is superficial bladder cancer?

Approximately 70–75% of bladder cancers are non–muscle-invasive when first diagnosed. The remaining patients generally have muscle-invasive or metastatic disease at presentation.

Bladder cancer is considerably more common in men than women and occurs most frequently in people over 60. Women sometimes experience delays in diagnosis when blood in the urine is initially attributed to urinary infection.

Most bladder cancers are urothelial carcinomas. Less common types include squamous cell carcinoma, adenocarcinoma and small-cell or neuroendocrine carcinoma.

What symptoms can bladder cancer cause?

The most common presentation is visible blood in the urine, haematuria.

The urine may appear:

  • Pink
  • Red
  • Rust-coloured
  • Tea-coloured
  • Normal between episodes

The bleeding is often painless and may disappear for days or weeks. Its disappearance does not mean the underlying problem has resolved.

Other possible symptoms include:

  • Microscopic blood detected on a urine test
  • Urinary frequency
  • A sudden need to urinate
  • Burning or discomfort when passing urine
  • Recurrent symptoms resembling a urinary tract infection
  • Difficulty emptying the bladder
  • Pelvic discomfort

CIS may cause urinary urgency, frequency and burning without producing a large visible tumour.

Blood in the urine should always be investigated, particularly in an older adult or someone with a history of smoking. Infection, stones and benign prostate enlargement are common alternative explanations, but bladder and upper urinary tract cancers must be excluded.

What causes bladder cancer?

Bladder cancer develops when genetic damage causes cells in the bladder lining to grow abnormally. In many patients there is no single identifiable cause.

Cigarette smoking

Smoking is the most important preventable risk factor. Carcinogens from tobacco enter the bloodstream, are filtered by the kidneys and remain in contact with the bladder lining in the urine.

The risk increases with the amount and duration of smoking. Stopping smoking remains valuable even after diagnosis because continued smoking may increase the risk of recurrence and progression.

Occupational chemical exposure

Long-term exposure to certain aromatic amines and industrial chemicals can increase risk. Historically, higher-risk industries have included:

  • Dye and pigment manufacturing
  • Rubber and leather production
  • Painting
  • Printing
  • Metal processing
  • Petroleum and chemical industries

Modern workplace protections have reduced—but not eliminated—these exposures.

Other risk factors

Additional risk factors include:

  • Increasing age
  • Male sex
  • Previous pelvic radiotherapy
  • Previous cyclophosphamide chemotherapy
  • Chronic bladder irritation or inflammation
  • Long-term urinary catheterisation
  • Certain inherited cancer syndromes, particularly Lynch syndrome
  • A personal history of cancer elsewhere in the urinary tract

Bladder cancer is not generally considered hereditary, although familial and genetic risks exist in a minority of patients.

How is bladder cancer investigated?

Medical history and urine testing

Assessment begins with a history of the bleeding, urinary symptoms, smoking and occupational exposure. Urine testing may identify blood, infection or abnormal cells.

A negative urine test after an episode of visible haematuria does not remove the need for investigation.

Urine cytology

Urine cytology examines shed urinary cells under a microscope.

It is most useful for detecting:

  • High-grade urothelial cancer
  • Carcinoma in situ
  • Cancer elsewhere in the urinary tract

Cytology is less sensitive for low-grade tumours, so a negative result does not exclude bladder cancer.

Urinary molecular-marker tests may occasionally provide additional information, but they do not usually replace cystoscopy.

Imaging of the urinary tract

A CT urogram is commonly used to assess:

  • Kidneys
  • Renal pelvises
  • Ureters
  • Bladder
  • Enlarged lymph nodes or other abnormalities

An ultrasound may be appropriate for selected patients, particularly when CT contrast or radiation should be avoided. However, ultrasound cannot reliably exclude small bladder tumours or CIS.

Flexible cystoscopy

A flexible cystoscope is passed through the urethra under local anaesthetic to inspect the bladder directly.

If a suspicious lesion is found, the next step is generally a formal resection under anaesthesia.

Transurethral resection of bladder tumour: TURBT

TURBT is the central procedure for diagnosing and treating NMIBC.

A rigid telescope is passed through the urethra, and the visible tumour is removed using an electrical loop, bipolar instrument or other resection technique. Tissue is sent to a pathologist to determine:

  • Cancer type
  • Tumour grade
  • Depth of invasion
  • Whether bladder muscle is present in the specimen
  • Whether muscle invasion has occurred
  • Whether variant histology or lymphovascular invasion is present

A complete TURBT should remove all visible tumour where safely possible and include adequate sampling of the underlying bladder muscle.

Enhanced cystoscopy using blue-light fluorescence or narrow-band imaging may help identify small tumours or CIS in selected patients.

When is a second TURBT required?

A repeat resection, usually within approximately two to six weeks, may be recommended when:

  • The first resection was incomplete
  • No bladder muscle was present in the specimen, apart from selected clearly low-risk Ta tumours
  • The tumour is high-grade T1
  • There is uncertainty about staging
  • Residual tumour is suspected

Repeat TURBT may find residual cancer and occasionally identifies previously unrecognised muscle invasion. It can therefore materially change treatment.

Understanding low-, intermediate-, high- and very-high-risk disease

Treatment is based on more than the word “superficial.” Important risk factors include:

  • Ta, T1 or CIS stage
  • Low-grade or high-grade pathology
  • Number of tumours
  • Tumour size
  • First occurrence or recurrence
  • Frequency of previous recurrences
  • Presence of CIS
  • Depth and extent of T1 invasion
  • Variant histology
  • Lymphovascular invasion
  • Involvement of the prostatic urethra
  • Response to previous BCG treatment

Low-risk NMIBC

This usually involves a first, solitary, small, low-grade Ta tumour without CIS.

These cancers commonly recur but have a very low risk of progressing to muscle-invasive disease.

Intermediate-risk NMIBC

This is a broad group between low and high risk. It may include recurrent, multiple or larger low-grade tumours and selected other tumours without high-risk features.

The pattern and frequency of recurrence help determine treatment intensity.

High-risk NMIBC

High-risk disease includes most:

  • High-grade T1 tumours
  • Carcinoma in situ
  • High-grade Ta tumours with adverse features
  • Tumours with other aggressive pathological findings

These cancers have a meaningful risk of entering the bladder muscle and require more intensive treatment and surveillance.

Very-high-risk NMIBC

Very-high-risk disease may include combinations such as extensive high-grade T1 cancer with CIS, lymphovascular invasion, certain aggressive variant histologies or involvement of the prostatic urethra.

For these patients, early radical cystectomy may provide the best chance of cure.

Initial treatment after TURBT

Surveillance for selected low-risk disease

For a completely removed low-risk tumour, treatment may consist of:

  • TURBT
  • A single immediate dose of intravesical chemotherapy when safe
  • Follow-up cystoscopy

Small, recurrent low-grade tumours may sometimes be treated with office fulguration or carefully selected surveillance, depending on the patient and tumour history.

Intravesical treatment

“Intravesical” means that a medication is placed directly into the bladder through a catheter. The medicine is retained for a prescribed time and then drained or passed in the urine.

Because the treatment remains mainly inside the bladder, it generally causes fewer whole-body effects than intravenous chemotherapy.

The role of intravesical mitomycin C

Mitomycin C is a chemotherapy medicine that damages the DNA of rapidly dividing cancer cells.

A single immediate postoperative dose

A single dose may be placed into the bladder shortly after TURBT—preferably within 24 hours—when the procedure has been uncomplicated.

Its purpose is to destroy floating tumour cells and reduce the chance that they implant elsewhere in the bladder. It also treats microscopic tumour cells remaining at the resection site.

This treatment is particularly useful for low-risk tumours and selected intermediate-risk tumours.

Mitomycin should not be administered immediately when there is:

  • Suspected bladder perforation
  • A very deep or extensive resection
  • Significant ongoing bleeding
  • A need for continuous bladder irrigation
  • Concern that the drug could leak outside the bladder

A course of mitomycin

Patients with intermediate-risk disease may receive weekly mitomycin treatments followed by a variable maintenance schedule. The exact schedule depends on tumour characteristics, previous recurrence pattern and local protocol.

Side effects of mitomycin

Possible side effects include:

  • Burning when urinating
  • Urinary frequency and urgency
  • Bladder discomfort
  • Blood in the urine
  • Chemical cystitis
  • Skin irritation or a rash involving the hands or genital region
  • Reduced bladder capacity after repeated severe inflammation
  • Infection
  • Rare injury if the medication leaks outside the bladder

Patients should follow the treatment unit’s instructions regarding fluid intake, urine handling and washing after treatment.

The role of intravesical BCG

BCG, Bacillus Calmette–Guérin, is a live, weakened form of Mycobacterium bovis. It was originally developed as a tuberculosis vaccine but also stimulates a powerful immune response against bladder cancer cells.

BCG is generally the preferred bladder-preserving treatment for:

  • Carcinoma in situ
  • High-risk high-grade Ta cancer
  • High-grade T1 cancer after adequate resection
  • Selected recurrent or aggressive intermediate-risk tumours

How is BCG given?

The usual initial course consists of one bladder instillation each week for six weeks. This is called induction BCG.

Patients who respond may then receive maintenance BCG. For high-risk disease, treatment may continue intermittently for one to three years, depending on tolerance, availability and individual risk.

Maintenance therapy is important because induction BCG alone provides less durable protection against recurrence and progression.

Side effects of BCG

Common short-term effects include:

  • Burning when urinating
  • Frequency and urgency
  • Mild blood in the urine
  • Bladder discomfort
  • Fatigue
  • Low-grade fever
  • Flu-like symptoms

These effects usually settle within one or two days.

Less common but potentially serious complications include:

  • Severe bacterial urinary infection
  • Prostatitis
  • Epididymo-orchitis
  • Granulomatous inflammation
  • Joint inflammation
  • Hepatitis or pneumonitis
  • Systemic BCG infection or sepsis

A high or persistent fever, shaking chills, breathing difficulty, confusion or severe illness after BCG requires urgent medical assessment.

When should BCG be postponed or avoided?

BCG should not be given:

  • Within the early healing period after TURBT, generally the first two weeks
  • After traumatic catheterisation
  • When visible haematuria is present
  • During a symptomatic urinary tract infection
  • When bladder perforation is suspected
  • In some patients with significant immune suppression
  • When previous BCG caused a severe systemic reaction

BCG is handled differently from routine chemotherapy because it contains live bacteria. Patients must follow the treatment centre’s hygiene and urine-disposal instructions.

Mitomycin or BCG: which is better?

Neither treatment is best for every patient.

  • Low-risk disease: a single immediate chemotherapy instillation is usually sufficient after complete TURBT.
  • Intermediate-risk disease: a course of chemotherapy or one year of BCG may be considered according to recurrence and progression risk.
  • High-risk disease: induction and maintenance BCG is generally preferred when bladder preservation is appropriate.
  • Very-high-risk disease: early radical cystectomy should be discussed, although BCG may remain an option in carefully selected patients who understand the risk.

BCG is more effective than chemotherapy for preventing recurrence and progression in appropriately selected high-risk disease, particularly when maintenance BCG is completed. It also tends to cause more local and systemic side effects.

What is the chance of developing muscle-invasive cancer?

There is no single percentage that applies to every NMIBC patient.

Across all NMIBC categories, approximately 10–20% of patients may eventually develop muscle-invasive disease, but this average hides enormous differences between low- and high-risk tumours.

Using contemporary EAU risk categories, estimated five-year progression risks can range approximately from:

  • Around 1% or less for low-risk disease
  • Several per cent for intermediate-risk disease
  • Around 10% or higher for high-risk disease
  • Approximately 40% or more for very-high-risk disease

At ten years, the estimated risk in very-high-risk patients may exceed 50% without effective additional treatment. These figures are estimates from risk models and do not precisely predict an individual patient’s outcome. BCG, repeat resection, early cystectomy and other treatments can substantially change the risk.

Progression risk is particularly concerning with:

  • Persistent or recurrent high-grade T1 cancer
  • T1 cancer associated with CIS
  • Extensive or multifocal CIS
  • Deep invasion into the lamina propria
  • Lymphovascular invasion
  • Aggressive variant histology
  • Prostatic urethral involvement
  • Failure to respond to adequate BCG
  • Early high-grade recurrence following BCG

Recurrence and progression are different. A small low-grade Ta tumour may recur several times without becoming muscle invasive, while a high-grade T1 tumour may progress after relatively few visible recurrences.

What is BCG-unresponsive bladder cancer?

BCG-unresponsive disease is a specific high-risk situation in which high-grade cancer persists or returns despite an adequate course of BCG within a defined period.

Continuing the same BCG treatment in genuinely BCG-unresponsive disease is unlikely to provide meaningful benefit and could delay curative surgery.

For a patient fit enough for major surgery, radical cystectomy is generally the preferred oncological treatment for BCG-unresponsive high-risk NMIBC.

Alternative bladder-preserving treatments or clinical trials may be considered when a patient:

  • Is medically unfit for cystectomy
  • Declines cystectomy after informed discussion
  • Has a strong preference for bladder preservation and accepts the additional risk

However, the possibility of losing the optimal window for curative surgery must be discussed clearly.

When should removal of the bladder be considered?

Radical cystectomy means removing the bladder, nearby lymph nodes and certain adjacent organs, followed by creating a new way for urine to leave the body.

It may be considered for NMIBC when there is:

  • Very-high-risk NMIBC at initial diagnosis
  • Persistent high-grade T1 cancer after repeat TURBT
  • High-grade T1 cancer with CIS
  • Lymphovascular invasion
  • Aggressive variant histology, such as micropapillary, plasmacytoid or selected sarcomatoid differentiation
  • Extensive CIS that does not respond adequately to BCG
  • High-grade recurrence following adequate BCG
  • BCG-unresponsive disease
  • Tumour involvement of the prostatic urethra or ducts
  • Disease that cannot be completely controlled endoscopically
  • Frequent, extensive high-grade recurrences
  • Progression to muscle-invasive bladder cancer

Cystectomy may sound excessive for a cancer described as “superficial,” but high-grade T1 disease can already possess the biological ability to spread. Delaying surgery until muscle invasion or metastasis develops can reduce the chance of cure.

What does radical cystectomy involve?

In men, surgery commonly removes the:

  • Bladder
  • Prostate
  • Seminal vesicles
  • Pelvic lymph nodes

In women, surgery is tailored individually and may involve removal of the bladder, pelvic lymph nodes and selected reproductive organs. Organ-preserving approaches may be possible in carefully selected patients.

Urinary reconstruction options include:

  • Ileal conduit: urine drains through a short segment of bowel to a stoma and external bag
  • Orthotopic neobladder: bowel is used to create an internal reservoir connected to the urethra
  • Continent catheterisable reservoir: an internal pouch is emptied using a catheter through a small abdominal opening

The most appropriate option depends on cancer location, kidney function, bowel health, manual dexterity, general fitness and patient preference.

Radical cystectomy is major surgery. Potential effects on urinary, sexual and bowel function must be balanced against the danger of progression.

Why lifelong surveillance is important

NMIBC has a strong tendency to recur, even after apparently complete treatment. Follow-up commonly includes:

  • Regular cystoscopy
  • Urine cytology in higher-risk patients
  • Periodic upper urinary tract imaging
  • Biopsy or repeat TURBT when abnormalities are found
  • Monitoring for late treatment complications

Low-risk patients generally require less intensive surveillance. High-risk patients need frequent cystoscopy and cytology, particularly during the first two years, followed by long-term or lifelong monitoring.

The exact schedule should be tailored to the patient’s EAU risk group, pathology, treatment response and general health.

Can recurrence be prevented?

Not every recurrence can be prevented, but patients can improve their general and bladder health by:

  • Stopping smoking
  • Avoiding occupational carcinogen exposure
  • Completing recommended intravesical treatment
  • Attending every surveillance cystoscopy
  • Reporting recurrent blood in the urine promptly
  • Treating urinary infections appropriately
  • Maintaining good hydration unless medically restricted

Smoking cessation remains the most important modifiable step.

The bottom line

Most bladder cancers are diagnosed before they enter the bladder muscle, but the term “superficial” should not be mistaken for harmless.

Low-grade Ta tumours frequently recur but rarely progress. High-grade T1 cancer and CIS behave much more aggressively and require complete TURBT, appropriate intravesical therapy and close surveillance.

Mitomycin C is particularly useful for reducing recurrence after TURBT and treating selected low- or intermediate-risk disease. BCG is the main bladder-preserving treatment for high-risk NMIBC and CIS.

Radical cystectomy should be discussed early—not only after muscle invasion—in patients with very-high-risk features, persistent high-grade T1 cancer or BCG-unresponsive disease. For these patients, timely surgery may offer the best chance of cure.

This article provides general information and does not replace individual medical advice. Treatment should be based on formal pathology review, complete staging, medical fitness and multidisciplinary discussion.

References and further reading

So, if you are experiencing blood in your urine and have been identified by your GP as having a possible bladder cancer, come see your Urologist in Brisbane, Dr Jo Schoeman to discuss options with you.

 

Focal Therapy for Prostate Cancer: Targeting the Cancer While Preserving the Prostate

/0 Comments/in , /by

Established management of localised prostate cancer includes active surveillance for suitable low-risk disease and whole gland treatment with surgery or radiotherapy when treatment is indicated. ProFocal® is a newer focal approach that uses laser energy to destroy a selected cancerous area while leaving much of the surrounding prostate untreated.

This approach is known as focal laser therapy or focal laser ablation. Its intended aim is to control the treated cancer focus while reducing urinary and sexual side effects. Whether it provides cancer control equivalent to established whole-gland treatments over the long term has not been demonstrated.

Early Australian research is encouraging. However, ProFocal remains an investigational treatment, and important questions about its long-term cancer control have not yet been answered.

What is ProFocal therapy?

ProFocal is an Australian-developed focal therapy system designed to treat a carefully selected area of prostate cancer.

A fine laser applicator is inserted through the skin between the scrotum and anus, the perineum, and guided into the prostate using imaging. Laser energy heats the targeted tissue to a temperature that causes cancer-cell death.

The system incorporates cooling and real-time temperature monitoring. This is intended to make the area of ablation more predictable and to limit unintended heat damage to nearby structures such as the:

  • Urinary sphincter
  • Urethra
  • Bladder neck
  • Rectum
  • Neurovascular bundles involved in erections

Unlike radical prostatectomy, ProFocal does not remove the prostate. Unlike conventional radiotherapy, it does not expose the whole prostate to radiation.

Is ProFocal approved by the TGA?

This requires careful clarification.

As at September 2026, the manufacturer states that ProFocal is not included in the Australian Register of Therapeutic Goods, ARTG. It therefore does not have general TGA market authorisation for routine supply and use in Australia.

This is different from saying that the treatment has received unrestricted “TGA approval.”

ProFocal may be accessible in Australia through a clinical trial or a specific TGA pathway for an unapproved therapeutic good, such as the Authorised Prescriber Scheme or Special Access Scheme. These pathways permit access in defined circumstances; they are not equivalent to ARTG inclusion or routine TGA market authorisation. The applicable approval, governance and consent arrangements should be confirmed for the individual patient.

Authorised Prescriber access does not mean that the device has been entered on the ARTG or endorsed as routine standard treatment. Regulatory status, trial availability and funding arrangements should always be confirmed directly before treatment.

Medicare, private insurance and professional oversight in Australia

The Medicare Benefits Schedule (MBS) lists professional medical services subsidised by the Australian Government. As at September 2026, no specific MBS item for “ProFocal” or focal laser ablation of prostate cancer was identified in the current public MBS material reviewed for this article. This should not be interpreted as a definitive ruling on every component of an episode of care: consultations, anaesthesia, imaging, pathology or hospital services may each have different billing arrangements.

An MBS rebate for an associated service would not establish that ProFocal itself is TGA-approved, guideline-endorsed or proven effective. Conversely, lawful access through a TGA pathway does not guarantee Medicare or private-insurance funding. The Department of Health and Aged Care’s Medical Services Advisory Committee (MSAC) is the independent body that advises government on whether public funding of medical services and technologies is supported by evidence of safety, clinical effectiveness and cost-effectiveness.

The Australian Medical Association (AMA) is a professional representative body, not the regulator of therapeutic goods and not the agency that creates Medicare items. No AMA clinical guideline specifically recommending ProFocal was identified for this review. It would therefore be inappropriate to imply AMA endorsement. Relevant professional duties instead arise from the Medical Board of Australia’s code of conduct: patients should receive understandable information about the proposed treatment, reasonable alternatives, material risks, uncertainties, costs and any practitioner conflicts of interest so that consent is genuinely informed.

Who may be considered for ProFocal therapy?

ProFocal is principally being studied in men with localised, non-metastatic and MRI-visible prostate cancer.

In the first prospective phase II ProFocal study, eligible men had:

  • Prostate cancer confined to the prostate
  • An MRI-visible cancer target
  • ISUP Grade Group 2 or 3 disease
  • A PSA of 15 ng/mL or lower
  • A clinical stage of T2c or lower
  • Biopsy findings corresponding with the abnormality seen on MRI

Outside a clinical trial, suitability would need to be assessed individually by a multidisciplinary prostate cancer team.

A potential candidate generally requires a cancer that can be clearly identified, biopsied and safely surrounded by an adequate treatment margin. Detailed assessment usually includes:

  • Multiparametric prostate MRI
  • Targeted and systematic transperineal biopsies
  • PSA and PSA-density assessment
  • Clinical staging
  • Consideration of PSMA PET/CT in selected men
  • Review of the MRI and pathology at a multidisciplinary meeting

When may ProFocal be unsuitable?

ProFocal would generally not be considered appropriate when there is:

  • Metastatic prostate cancer
  • High-risk or locally advanced disease requiring comprehensive treatment
  • Cancer outside the prostate
  • Extensive cancer involving several areas of the gland
  • Cancer that cannot be reliably identified on MRI
  • A tumour position where an adequate and safe treatment margin cannot be achieved
  • Significant uncertainty about the true extent or grade of the cancer
  • An inability or unwillingness to undergo ongoing MRI scans and repeat biopsies
  • A medical condition that makes anaesthesia or the procedure unacceptably risky

Men with low-risk Grade Group 1 prostate cancer may be better managed with active surveillance, avoiding treatment and its potential complications altogether.

Focal therapy should not be regarded as an easier substitute for appropriate surgery or radiotherapy in men with aggressive, high-volume or advanced prostate cancer.

How is ProFocal treatment performed?

ProFocal is usually performed as a day procedure under general anaesthesia.

Treatment planning

The cancer identified on MRI and biopsy is mapped carefully. The treatment plan includes the visible tumour and an additional safety margin intended to treat microscopic cancer immediately around it.

Placement of the laser applicator

With the patient under anaesthesia, a transrectal ultrasound probe is used to visualise the prostate. A fine laser applicator is inserted through the perineum and positioned within the selected treatment area.

The route is similar to that used for a transperineal prostate biopsy.

Laser ablation

Controlled laser energy heats and destroys the targeted prostate tissue. Temperature monitoring helps the surgeon assess treatment delivery and protect surrounding structures. More than one applicator position may be needed to cover the planned treatment zone.

The published phase II study reported a median treatment time of approximately 60 minutes, although the complete anaesthetic and theatre procedure may take longer.

Recovery

A urinary catheter may be required temporarily because prostate swelling can make urination difficult. Many patients can return home on the day of treatment or after a short admission, depending on their recovery and ability to pass urine.

What are the potential advantages?

The proposed advantages of ProFocal include:

  • Treatment directed at the known cancer rather than the whole prostate
  • No abdominal incision
  • A transperineal, minimally invasive approach
  • Short hospital stay
  • Faster initial recovery than major surgery
  • No ionising radiation
  • Preservation of untreated prostate tissue
  • A potentially lower risk of persistent urinary incontinence
  • A potentially lower risk of erectile dysfunction than whole gland treatment
  • The possibility of further focal or whole-gland treatment if cancer remains or returns

These are potential benefits and should not be interpreted as guarantees.

How does it compare with established alternatives?

There is no mature randomised evidence showing that ProFocal gives the same long-term protection from metastasis or prostate-cancer death as radical prostatectomy or radiotherapy. A balanced consultation should therefore compare all reasonable options:

  • Active surveillance: avoids or delays treatment side effects and is preferred for many men with low-risk disease, but requires PSA testing, MRI and repeat biopsy, with treatment if the cancer progresses.
  • Radical prostatectomy: removes the prostate and provides complete surgical pathology. It has long-term cancer-control data, but carries risks including urinary incontinence, erectile dysfunction, loss of ejaculation and surgical complications.
  • Radiotherapy: has established long-term cancer-control data and avoids surgery, but may cause urinary, bowel and sexual adverse effects; androgen-deprivation therapy may be advised for some risk groups.
  • ProFocal/focal laser ablation: may offer quicker recovery and less short-term urinary or sexual morbidity for carefully selected men, but leaves untreated prostate tissue, requires MRI and repeat-biopsy surveillance, and has uncertain long-term comparative cancer-control outcomes.

The most appropriate option depends on cancer grade, volume and location; PSA and stage; age and general health; baseline urinary and sexual function; personal priorities; and willingness to accept surveillance or treatment uncertainty. A multidisciplinary opinion and, where useful, separate discussions with a urologist and radiation oncologist can reduce treatment-selection bias.

What did the early ProFocal study find?

The first published phase II trial included 100 men with localised, MRI-visible Grade Group 2 or 3 prostate cancer.

At the three-month biopsy:

  • 84% had no clinically significant Grade Group 2 or higher cancer within the treated area
  • Approximately 16% therefore had residual clinically significant cancer within the treatment zone
  • Erectile dysfunction was reported in 12%
  • The average sexual-function scores decreased by approximately 15%
  • Urinary-domain scores decreased by approximately 4.5%
  • No significant deterioration was reported in the other measured functional outcomes

These results are promising, but they represent very early follow-up. The study had no surgery, radiotherapy or active surveillance control group. It therefore cannot establish whether ProFocal provides equivalent long-term protection against recurrence, metastasis or death from prostate cancer.

Possible side effects and complications

Short-term effects may include:

  • Bruising or discomfort in the perineum
  • Blood in the urine
  • Blood in the semen
  • Burning or discomfort when urinating
  • Urinary frequency or urgency
  • Temporary difficulty passing urine
  • Temporary catheterisation
  • Urinary tract infection
  • Pelvic or rectal discomfort
  • Fatigue following anaesthesia

Potential longer-term or less common problems include:

  • New or worsening erectile dysfunction
  • Reduced ejaculatory volume
  • Retrograde ejaculation
  • Urinary incontinence
  • Urethral or bladder-neck scarring
  • Persistent urinary symptoms
  • Damage to tissue outside the intended treatment zone
  • Infection or abscess
  • A fistula involving the urinary tract and rectum, expected to be rare
  • Incomplete cancer treatment
  • Cancer developing or becoming apparent elsewhere in the untreated prostate
  • A requirement for repeat focal therapy, radiotherapy or radical prostatectomy

The risk of sexual or urinary dysfunction depends partly on the size and location of the tumour. A lesion near the neurovascular bundles, urethra, urinary sphincter or bladder neck may be more difficult to treat without affecting function.

The untreated prostate remains important

Prostate cancer is frequently multifocal, meaning that separate areas of cancer may exist within the same prostate. MRI is very useful but cannot detect every small or biologically significant tumour.

ProFocal treats the selected target, not every prostate cell.

This creates two possible patterns of treatment failure:

  1. In-field disease: cancer remains or returns inside the treated area.
  2. Out-of-field disease: cancer is subsequently found elsewhere in the untreated prostate.

A successful early scan does not prove that all clinically significant cancer has been eliminated.

Follow-up after ProFocal therapy

Follow-up is more intensive than simply checking the PSA.

Because the prostate remains in place, PSA will not normally fall to an undetectable level. There is also no universally accepted PSA threshold that defines successful focal treatment or recurrence.

Follow-up may include:

  • Regular PSA testing
  • Clinical review and symptom assessment
  • Multiparametric MRI
  • Quality-of-life and erectile function assessment
  • Repeat targeted biopsy of the treated area
  • Systematic biopsy of the untreated prostate
  • Additional imaging when recurrence is suspected

The Prostate Cancer Foundation of Australia cautions that PSA testing alone is not sufficient to exclude recurrent cancer after focal therapy. Patients must be willing to undergo long-term imaging and, when recommended, further prostate biopsies.

Can treatment be repeated?

Repeat focal treatment may be possible when residual or recurrent cancer remains localised and clearly targetable.

Depending on the findings, subsequent options may include:

  • Repeat focal ablation
  • Radical prostatectomy
  • External-beam radiotherapy
  • Another focal therapy technique
  • Active surveillance for selected low-volume disease
  • Systemic treatment if the cancer has spread

Salvage surgery or radiotherapy may still be possible after focal therapy, but treatment can sometimes be technically more complex because of scarring and tissue changes. The likely salvage options should therefore be discussed before proceeding with ProFocal.

Important limitations

Patients considering ProFocal should understand that:

  • ProFocal is not currently included on the Australian ARTG
  • It is not established as routine standard-of-care treatment
  • Published ProFocal evidence currently comes from a small number of men
  • The pivotal study was single-arm and had very short follow-up
  • Long-term rates of metastasis-free, cancer-specific and overall survival are unknown
  • There are no mature randomised comparisons with prostatectomy, radiotherapy or modern active surveillance
  • Approximately 16% of men in the initial study had clinically significant cancer remaining in the treated area at three months
  • Cancer may be missed elsewhere in the prostate
  • Repeat MRI scans and biopsies are required
  • Further cancer treatment may be needed
  • Access may be limited to trials or special regulatory pathways
  • Medicare or private health insurance may not cover treatment or follow-up costs

What do Australian and international guidance sources say?

The Prostate Cancer Foundation of Australia (PCFA) describes focal therapies as emerging and experimental. It notes that focal treatment may reduce side effects but that the prostate remains in place, PSA monitoring is less straightforward, and ongoing MRI and biopsy are required.

Australian evidence-based resources regard active surveillance, radical prostatectomy and radiotherapy as established pathways for appropriately selected localised disease. ProFocal has not yet acquired the same evidence base or standard-of-care status. The absence of a treatment-specific recommendation should not be reframed as support.

The European Association of Urology (EAU) states that focal therapy has favourable functional outcomes but that definitive evidence of long-term oncological benefit remains unavailable. Its guideline recommends focal HIFU or cryotherapy only within a prospective registry and other ablative methods—including focal laser therapy—only within a well-designed prospective clinical trial.

The American Urological Association and American Society for Radiation Oncology advise clinicians that comparative evidence for focal ablation is lacking and that patients must be informed that further treatment may be required. Focal or whole-gland ablation should not be offered for high-risk prostate cancer outside a clinical trial.

The UK National Institute for Health and Care Excellence (NICE) guidance for focal HIFU and focal cryoablation—not ProFocal specifically—also emphasises special governance, consent, audit/research arrangements and uncertainty about long-term cancer control. This is relevant context for focal therapy but must not be represented as device-specific approval of ProFocal.

The Prostate Cancer Foundation of Australia similarly describes focal therapies as experimental and emphasises the need for continuing MRI, biopsies and careful long-term monitoring.

The bottom line

ProFocal is an Australian-developed investigational technology that may eventually provide selected men with an additional option between surveillance and whole-gland treatment.

Its early results suggest that precisely delivered cooled laser therapy can destroy an MRI-visible prostate cancer target with relatively limited short-term urinary morbidity. However, early cancer clearance is not the same as proven long-term cancer control.

At present, ProFocal should be considered an investigational focal therapy. Consistent with current guidance for focal laser ablation, its most defensible use is within a well-designed prospective clinical trial with ethics and regulatory oversight, multidisciplinary assessment, explicit informed consent, independent outcome reporting and mandatory long-term follow-up.

The decision should be made only after comparing ProFocal with all appropriate alternatives, including active surveillance, radical prostatectomy and radiotherapy.

This article provides general information and does not replace individual medical advice. Regulatory status and treatment availability can change and should be confirmed at the time of consultation.

References and further reading

Hydrocoele in Younger Men: Causes, Fertility and Treatment Options

/0 Comments/in , /by

A hydrocoele is a collection of clear fluid around the testicle. It usually causes a painless swelling on one side of the scrotum, although both sides can occasionally be affected.

Hydrocoeles are common in babies and older men, but they can also develop during adolescence or young adulthood. In a younger man, the important question is not only “Is this a hydrocoele?” but also “Why has it developed?”

Most hydrocoeles are benign and do not threaten the testicle. Nevertheless, any new scrotal swelling should be examined because conditions such as an inguinal hernia, infection, testicular torsion or testicular tumour can sometimes produce a similar appearance or cause a secondary hydrocoele.

What causes a hydrocoele?

The testicle is partly surrounded by a thin membrane called the tunica vaginalis. This membrane normally produces a small amount of lubricating fluid, which is continually reabsorbed. A hydrocoele develops when fluid production exceeds absorption.

In younger men, possible causes include:

  • Idiopathic hydrocoele: No specific cause is identified. This is common.
  • Persistent communication with the abdomen: A small channel through which the testicle descended before birth may remain open. This is more typical in children but can occasionally persist into young adulthood and may be associated with an inguinal hernia.
  • Inflammation or infection: Epididymitis, orchitis and some sexually transmitted infections may cause fluid to collect around the testicle.
  • Trauma: A sporting injury, direct blow or previous scrotal injury can lead to a reactive hydrocoele.
  • Previous surgery: Hydrocoeles may occasionally follow groin, hernia, varicocele or testicular surgery.
  • Testicular torsion: Twisting of the spermatic cord can produce a reactive hydrocoele, although severe sudden pain is normally the dominant symptom.
  • Testicular tumour: A tumour may occasionally be accompanied by a hydrocoele. The hydrocoele itself is not cancer, but the fluid can make examination of the underlying testicle difficult.

What does a hydrocoele feel like?

A typical hydrocoele produces a smooth, soft or tense swelling around the testicle. It may fluctuate in size and often feels heavier as it enlarges.

Symptoms can include:

  • painless scrotal enlargement;
  • a dragging or heavy sensation;
  • discomfort when walking, running or exercising;
  • irritation from clothing;
  • difficulty examining the testicle;
  • embarrassment or concern about appearance; and
  • discomfort during sexual activity.

A very large hydrocoele can become inconvenient and may interfere with sport, work or everyday activities.

When is urgent assessment needed?

A hydrocoele usually develops gradually and is not an emergency. Seek urgent medical care, however, if there is:

  • sudden or severe testicular pain;
  • rapid swelling;
  • nausea or vomiting with scrotal pain;
  • redness, fever or increasing tenderness;
  • a hard lump within the testicle;
  • scrotal swelling following a significant injury; or
  • a swelling that cannot be pushed back and is associated with groin or abdominal pain.

Sudden testicular pain may represent torsion, in which the blood supply to the testicle becomes twisted. This requires emergency assessment and should never be attributed to “just a hydrocoele.”

How is a hydrocoele diagnosed?

Assessment usually begins with a discussion about how and when the swelling developed, followed by examination of the abdomen, groin and scrotum.

A hydrocoele may transmit light when a torch is placed behind it, a finding called transillumination. This can support the diagnosis, but it does not replace a proper examination.

A scrotal ultrasound is commonly arranged in a younger man, particularly when:

  • the hydrocoele is new;
  • the testicle cannot be examined clearly;
  • there is pain or tenderness;
  • the swelling developed after injury;
  • the diagnosis is uncertain; or
  • an underlying testicular abnormality needs to be excluded.

Ultrasound can confirm that the swelling contains fluid and assess the testicle, epididymis, blood flow and surrounding structures. The European Association of Urology recommends high-frequency ultrasound when investigating a suspected testicular mass because it can determine whether a lesion is inside or outside the testicle and assess the opposite testis. EAU Testicular Cancer Guideline

Urine tests, STI testing or blood tests may also be appropriate when infection or inflammation is suspected.

Can a hydrocoele affect fertility?

For most younger men, a small or moderate uncomplicated hydrocoele does not cause infertility. It does not normally block sperm transport and does not automatically mean that sperm production is abnormal.

There are, however, several important qualifications:

  1. The underlying cause may matter more than the fluid.
    Previous torsion, testicular trauma, severe infection, an undescended testicle, testicular cancer or another testicular disorder may affect fertility independently of the hydrocoele.
  2. A very large or tense hydrocoele may theoretically affect the testicle.
    Prolonged pressure or increased local temperature has been proposed as a possible mechanism for impaired testicular function. Evidence in adults remains limited, and clinically significant infertility from an isolated hydrocoele appears uncommon.
  3. Surgery carries a small fertility-related risk.
    Hydrocoele repair is performed close to the epididymis, vas deferens and testicular blood supply. Injury to one of these structures is uncommon but could affect fertility, particularly when operating on both sides or when the opposite testicle is abnormal. The British Association of Urological Surgeons lists inadvertent injury to these structures as an uncommon recognised complication of surgery. BAUS hydrocoele repair information

A semen analysis is not routinely required for every man with a hydrocoele. It may be appropriate when:

  • a couple has been unable to conceive;
  • the hydrocoele is very large or present on both sides;
  • the opposite testicle is small or abnormal;
  • there is a history of undescended testis, torsion, chemotherapy, testicular surgery or significant infection; or
  • fertility preservation is an important concern before surgery.

The EAU recommends that the assessment of male infertility include a reproductive and medical history, physical examination, semen analysis and, where indicated, hormonal tests and imaging. It also stresses that semen analysis must be interpreted as part of the couple’s overall reproductive assessment rather than as a simple “fertile or infertile” test. EAU Male Infertility Guideline

Does every hydrocoele need treatment?

No. Treatment depends on the cause, size, symptoms and effect on quality of life.

Observation

A small, painless hydrocoele with a normal underlying testicle can often be monitored. It does not need to be removed merely because it is present.

Observation may include:

  • self-awareness of any change in size or consistency;
  • periodic clinical review when appropriate; and
  • reassessment if pain, rapid enlargement or a new lump develops.

The British Association of Urological Surgeons supports observation when an adult hydrocoele is small or not bothersome. BAUS

Treating an underlying cause

If the fluid is secondary to infection, inflammation or another condition, treatment should address that cause. The hydrocoele may reduce once the underlying problem settles, although established hydrocoeles do not always disappear.

Aspiration

Aspiration involves inserting a needle and draining the fluid. Although this can provide temporary relief, the fluid usually returns because the lining that produces it remains in place.

Aspiration also carries risks of bleeding and infection. BAUS does not regard aspiration alone as curative or standard treatment because recurrence is common. It may occasionally be considered for someone who is unsuitable for surgery. In selected circumstances, a sclerosant may be injected after aspiration, but recurrence and inflammation remain concerns.

Hydrocoelectomy

Hydrocoelectomy is the most reliable definitive treatment for a bothersome adult hydrocoele. Surgery may be considered when the swelling:

  • is large or progressively enlarging;
  • causes discomfort, heaviness or skin irritation;
  • interferes with exercise, work or sexual activity;
  • causes significant cosmetic or psychological concern; or
  • makes examination of the testicle difficult.

The operation is generally performed through a small scrotal incision under general or spinal anaesthesia. The fluid is drained, and the fluid-producing sac is folded, turned behind the testicle or partly removed to reduce the likelihood of recurrence.

Most procedures are performed as day surgery.

What should you expect after surgery?

Bruising, swelling and discomfort are expected and may initially make the scrotum look larger rather than smaller. Supportive underwear, simple pain relief and protected ice packs can help during the early recovery period.

Strenuous exercise and heavy lifting are generally avoided for several weeks. The testicle may continue to feel somewhat bulkier after repair because of the folded or thickened tissues around it.

Possible complications include:

  • bleeding or a scrotal haematoma;
  • wound or testicular infection;
  • persistent swelling;
  • recurrence of the hydrocoele;
  • chronic scrotal discomfort;
  • anaesthetic complications; and
  • uncommon injury to the epididymis, vas deferens or testicular blood supply.

The current BAUS patient information notes that temporary bruising and swelling are very common, while infection, haematoma, recurrence and injury to adjacent reproductive structures occur much less often. Individual risks depend on the size and complexity of the hydrocoele, previous surgery, infection and general health. BAUS hydrocoele repair leaflet

The important message for younger men

A hydrocoele is usually harmless, and many do not require treatment. However, a new scrotal swelling in a younger man should not be self-diagnosed or ignored. Clinical examination and often an ultrasound can confirm the diagnosis and ensure that the testicle underneath is healthy.

Most isolated hydrocoeles do not impair fertility. When fertility is a concern, the entire reproductive history and both testicles should be assessed rather than assuming that the hydrocoele is responsible.

Management should be individualised. For one man, reassurance and observation may be entirely appropriate. For another, surgery may provide worthwhile relief from heaviness, discomfort or embarrassment.

This article provides general patient information and does not replace individual medical assessment. Seek urgent care for sudden testicular pain, rapid swelling, fever or a hard testicular lump.

So, if you have noted a scrotal swelling and this is concerning you and need to have this checked out, see your GP or obtain a referral to see you Brisbane Urologist, Uro-Jo, for peace of mind.

Father’s Day, Quirky Gifts and the Quiet Joy of Being Dad

/0 Comments/in /by

Father’s Day has just passed here in Australia. Across the country, dads have been celebrated with breakfasts, phone calls, handmade cards and an impressive assortment of slightly quirky gifts.

There were novelty socks, barbecue tools, coffee mugs with questionable slogans and gadgets whose purpose may never be fully understood. Some fathers received homemade creations constructed from cardboard, glue and enormous amounts of love. Others simply enjoyed a message, a hug or precious time with their children.

And truthfully, being remembered is what matters most.

The joy of fatherhood

Fatherhood is difficult to describe in a single word. It is joy, pride, worry, responsibility, frustration, laughter and love; often experienced simultaneously.

From the moment our children arrive, they occupy a permanent place in our hearts and minds. We celebrate their successes, worry about their struggles and continue offering advice long after they have stopped asking for it.

Our children also have a remarkable ability to keep us humble. They know our habits, our favourite stories and the jokes we have repeated far too many times. They see the sensible father we try to be, as well as the wonderfully quirky person underneath.

Perhaps that is why those unusual Father’s Day presents can feel so personal. A funny mug or pair of loud socks may say, “Dad, we know exactly who you are, and we love you anyway.”

The attached photo is of my new lanyard, exactly that quirky and thoughtful present from my 2 loving daughters. I realized how privileged I am to have such great daughters!

Every stage of fatherhood is different

For fathers of young children, Father’s Day may begin very early, with enthusiastic little people climbing onto the bed carrying toast that is slightly burnt and coffee that is slightly cold.

As children grow older, celebrations change. Teenagers may offer a brief hug before disappearing. Adult children may telephone from another city or bring their own children to visit. Grandfathers may find themselves watching the next generation of dads discovering the same joys and challenges.

The form of the celebration changes, but the meaning remains: connection, gratitude and belonging.

Fatherhood also continues through difficult seasons. Relationships may change, families may be separated by distance, and some fathers carry grief for children or fathers who are no longer present. Father’s Day can therefore bring mixed emotions. It is worth remembering that love and loss often sit quietly beside one another.

Dads can be quirky and that is part of the charm

Fathers are famous for having their own peculiarities.

We may insist on keeping mysterious screws “because they will be useful one day.” We can spend hours researching a new barbecue but postpone making a medical appointment. We may refuse to ask for directions, become overly invested in controlling the household thermostat, or believe that every family gathering needs the same collection of well-worn jokes.

These quirks become part of the family story. Children may roll their eyes at them today, but they are often the very things they remember fondly later.

The lesson is not that fathers need to become less quirky. It is that we should remain present, engaged and healthy enough to keep sharing those quirks for many years to come.

A Father’s Day reminder about men’s health

Men are often excellent at looking after their families while being less attentive to themselves. We may service the car on schedule, repair something the moment it breaks and remind everyone else to see a doctor, yet quietly ignore changes in our own health.

Father’s Day is a useful prompt to take stock.

Urinary difficulties, blood in the urine, testicular changes, erectile problems, pelvic pain or concerns about the prostate should not be dismissed simply because they are embarrassing. These symptoms are common, and asking for help is sensible rather than weak.

Looking after your health is not a selfish act. It allows you to remain involved in the lives of the people who value you most.

The greatest gift

The best Father’s Day gifts are rarely the most expensive ones. They are the phone call, the shared meal, the handwritten card, the private joke and the knowledge that our children thought of us.

The quirky gifts are simply the wrapping around a much deeper message:

“You matter to me. I remember you. I am glad you are my dad.”

So, to all the fathers, stepfathers, grandfathers, foster fathers, mentors and father figures: I hope you felt appreciated this Father’s Day.

Wear the bright socks. Use the strange gadget. Display the handmade card proudly. Continue telling the terrible jokes.

After all, our children do not love us despite our quirks. Very often, they love us because of them.

Peyronie’s Disease: When a Curved Erection Becomes a Medical Problem

/0 Comments/in , /by

Peyronie’s disease is a condition in which scar tissue develops within the penis, causing it to bend or curve during an erection.

A slight natural curve can be completely normal. Peyronie’s disease is different because the change is usually new, may worsen over time, and can sometimes cause pain or make sexual intercourse difficult.

What causes Peyronie’s disease?

The exact cause is not always clear.

In many cases, the condition may develop after repeated minor injury or trauma to the penis. This can lead to the formation of fibrous scar tissue, known as a plaque.

The plaque does not stretch normally during an erection, causing the penis to bend toward the affected area.

Some men do not remember any specific injury.

Common symptoms

Symptoms of Peyronie’s disease can include:

  • A new bend or curve in the penis
  • A hard area or plaque beneath the skin
  • Pain during erections
  • Shortening of the penis
  • Narrowing or indentation of the shaft
  • Difficulty with sexual intercourse
  • Erectile dysfunction

The severity can vary considerably between patients.

Does Peyronie’s disease get worse?

Peyronie’s disease commonly develops in phases.

During the early or active phase, the curvature may continue to change and erections may be painful.

After a period of time, the condition often becomes more stable.

In some men the pain settles, while the curvature remains.

When should you see a urologist?

A new or worsening penile curvature should be assessed, particularly when it causes pain, affects erections or interferes with sexual activity.

A urologist can assess the degree of curvature, check for plaque formation and determine whether treatment is necessary.

Not every patient requires surgery.

Treatment options

Treatment depends on the severity of the condition, how long it has been present and whether it is affecting sexual function.

Options may include:

  • Observation
  • Medication in selected cases
  • Penile traction therapy
  • Injection treatments
  • Surgical correction

Surgery is generally considered when the condition is stable and the curvature significantly affects sexual intercourse.

Peyronie’s disease and erectile dysfunction

Some men with Peyronie’s disease also develop erectile dysfunction.

This may occur because of changes in penile structure, blood flow or anxiety related to pain and curvature.

Assessment is therefore important so that both problems can be considered together.

Specialist assessment in Brisbane

Peyronie’s disease can be uncomfortable to discuss, but it is a recognised medical condition and treatment options are available.

If you have noticed a new change in penile shape, persistent pain during erections or difficulty with sexual activity, speak with your GP or arrange an assessment with a urologist.

 

Penis Problems: 7 Signs You Should See a Urologist

/0 Comments/in , /by

Problems affecting the penis can be difficult or embarrassing to talk about, but they are also surprisingly common.

Pain, swelling, changes in shape, difficulty with erections or unusual lumps can have many different causes. Some are minor and temporary, while others may need proper medical assessment.

If a problem persists, becomes painful or begins affecting sexual or urinary function, speaking with your GP or a urologist in Brisbane may be the right next step.

Here are seven signs that should not simply be ignored.

1. Persistent Pain in the Penis

Penile pain can occur for several reasons.

Minor irritation or injury may settle on its own, but persistent pain should be assessed, particularly when it occurs during erections or sexual activity.

Possible causes can include injury, inflammation, infection or conditions such as Peyronie’s disease.

Sudden severe pain following an injury to an erect penis can be particularly important.

A penile fracture involves tearing of tissue within the penis and may cause sudden pain, swelling, bruising or a noticeable popping sensation.

This requires urgent medical attention.

2. A New Bend or Curve During Erections

A small natural curve in the penis is common.

However, if the penis gradually becomes noticeably more curved, particularly if erections become painful or intercourse becomes difficult, it could be a sign of Peyronie’s disease.

Peyronie’s disease occurs when scar tissue develops inside the penis.

This can cause:

  • Curvature during an erection
  • Pain
  • A palpable hard area or lump
  • Shortening or narrowing of the penis
  • Difficulty with sexual intercourse
  • Erectile dysfunction

Some men delay seeking help because they assume the problem will disappear.

If the curvature is new or worsening, a urologist can assess the condition and discuss available treatment options.

3. Difficulty Getting or Maintaining an Erection

Occasional difficulty achieving an erection can happen to many men.

Persistent erectile dysfunction is different.

Erectile dysfunction, commonly referred to as ED, can have physical, psychological or combined causes.

Possible physical factors include problems with blood flow, diabetes, cardiovascular disease, hormonal issues, prostate conditions and certain medications.

Peyronie’s disease can also contribute to erectile problems.

Because erectile dysfunction can sometimes be associated with broader health conditions, persistent ED is worth discussing with a doctor rather than simply treating the symptom yourself.

A Brisbane urologist may also be involved when the problem relates to the urinary or male reproductive system.

4. Lumps or Hard Areas in the Penis

Finding a lump or hardened area can understandably cause concern.

Not every lump is cancerous.

Some may be related to scar tissue, blocked glands or other benign conditions.

A hard plaque beneath the skin may, for example, occur with Peyronie’s disease.

However, any new or unexplained lump that persists should be properly assessed.

Changes that should be checked include:

  • A persistent lump
  • Thickening of the skin
  • A hard area beneath the skin
  • Changes in colour or texture
  • A sore that does not heal

Early assessment can determine whether further investigation is necessary.

5. Persistent Swelling, Redness or Inflammation

Temporary swelling can occur after injury or irritation.

Persistent swelling, however, may indicate inflammation, infection or another underlying problem.

The penis may become:

  • Red
  • Tender
  • Painful
  • Itchy
  • Swollen
  • Difficult to retract if the foreskin is involved

Inflammation of the head of the penis is known as balanitis and can sometimes affect the foreskin as well.

Poor hygiene, irritation and infection can all contribute.

Persistent or recurrent inflammation should be discussed with a doctor.

6. Discharge, Sores or Unusual Lesions

Discharge from the penis or the appearance of sores, ulcers or unusual lesions can sometimes be associated with a sexually transmitted infection.

Possible STIs include gonorrhoea, chlamydia, herpes and syphilis.

Not every sore or discharge is caused by an STI, but these symptoms should be assessed rather than self-diagnosed.

If you believe you may have been exposed to an STI, your GP or a sexual health clinic is usually the appropriate first point of contact.

STI testing can identify infections even when symptoms are mild or absent.

What About HIV?

HIV is a viral infection that affects the immune system and is not primarily treated by a urologist.

Importantly, HIV cannot be diagnosed by looking at the penis or by relying on symptoms alone.

Someone who believes they may have been exposed to HIV should seek medical advice and appropriate testing through a GP or sexual health service.

Modern HIV treatment is highly effective, and people receiving effective treatment can live long and healthy lives.

7. Problems With the Foreskin

Foreskin problems are another common reason men seek medical advice.

These can include:

  • Difficulty retracting the foreskin
  • Pain when retracting it
  • Recurrent infections
  • Cracking or bleeding
  • Swelling
  • Difficulty cleaning underneath the foreskin

A tight foreskin is known as phimosis.

In some cases it can cause pain, infections or difficulty urinating.

Treatment depends on the severity of the problem and may include medication or, in some circumstances, a surgical procedure.

A foreskin that has been pulled back and becomes trapped behind the head of the penis is known as paraphimosis.

This can restrict blood flow and requires urgent medical treatment.

When Should You See a Doctor?

It is worth arranging an assessment if you notice a penile problem that:

  • Persists for more than a short period
  • Is becoming worse
  • Causes significant pain
  • Affects erections or sexual activity
  • Causes difficulty urinating
  • Involves a persistent lump or sore
  • Causes recurrent swelling or inflammation
  • Is associated with discharge
  • Follows a significant injury

Some problems can be treated relatively simply once the cause has been identified.

Waiting because the issue feels embarrassing can sometimes allow the problem to become more difficult to manage.

When Is It an Emergency?

Seek urgent medical attention if you experience:

  • A significant injury to an erect penis
  • Sudden severe pain and swelling
  • Heavy bleeding
  • An erection lasting several hours that will not go away
  • Inability to urinate
  • A foreskin trapped behind the head of the penis with increasing swelling or pain

These situations should not wait for a routine appointment.

Seeing a Urologist in Brisbane

Urologists specialise in conditions affecting the urinary system and the male reproductive system.

Depending on the problem, a urologist may investigate penile pain, erectile dysfunction, penile curvature, foreskin problems, injuries and other conditions affecting male genital health.

If you have a persistent penile problem or have been referred for specialist assessment speak with your GP about whether a urology referral is appropriate.

Ignoring a problem because it feels embarrassing rarely makes it easier.

Getting the right diagnosis is the first step toward deciding whether treatment is actually needed.

Urologist Brisbane: 7 Symptoms You Shouldn’t Ignore

/0 Comments/in /by

Many urinary symptoms are easy to dismiss.

You may notice that you are going to the toilet more often, getting up several times during the night, experiencing a weaker urine stream or feeling as though your bladder never fully empties.

Sometimes these changes develop gradually and become something you simply learn to live with.

However, persistent urinary symptoms can be a sign that it is worth speaking with your GP and, where appropriate, seeing a urologist in Brisbane for further investigation.

Below are seven symptoms that should not simply be ignored.

1. Blood in Your Urine

Seeing blood in your urine can be alarming, but even a small amount should be taken seriously.

Blood in the urine is known as haematuria.

There are many possible causes, including urinary tract infections, kidney stones, prostate conditions and other problems affecting the urinary system.

Importantly, blood in the urine may sometimes occur without any pain.

Because the cause cannot usually be determined from the symptom alone, further investigation may be recommended.

A urologist can assess the urinary tract and determine whether additional testing is required.

2. A Weak or Slow Urine Stream

A gradual reduction in urinary flow is particularly common in men as they get older.

You may notice that:

  • It takes longer to start urinating
  • The urine stream is weaker than it used to be
  • The stream stops and starts
  • You need to strain
  • Urination takes longer
  • You still feel full afterwards

One possible cause is an enlarged prostate.

The prostate surrounds part of the urethra, so when it enlarges it can restrict the normal flow of urine.

While an enlarged prostate is often benign, persistent symptoms should still be assessed.

A Brisbane urologist can investigate the cause and discuss whether monitoring, medication or another treatment may be appropriate.

3. Getting Up Several Times During the Night

Waking once occasionally to use the bathroom may not be unusual.

Regularly getting up several times every night is different.

This is known as nocturia and can significantly affect sleep quality.

Night-time urination can be associated with several conditions, including bladder problems and prostate enlargement.

If you find yourself automatically planning your evening around bathroom trips or waking repeatedly during the night, it may be worth discussing the problem with your doctor.

4. Feeling Like Your Bladder Never Completely Empties

One of the more frustrating urinary symptoms is finishing urination but still feeling as though there is urine left in the bladder.

Some people return to the toilet shortly afterwards.

Others may experience frequent urges because the bladder has not emptied effectively.

Incomplete bladder emptying can have several possible causes and may require further investigation.

A urologist may assess urinary flow, bladder function and the prostate where relevant to determine what is contributing to the problem.

5. Sudden or Frequent Urges to Urinate

Do you find yourself constantly looking for the nearest bathroom?

An increased need to urinate, or sudden powerful urges that are difficult to control, may indicate a bladder or urinary issue.

Some people begin changing their routine without even realising it.

They may:

  • Avoid long drives
  • Choose seats near toilets
  • Limit drinks before leaving home
  • Avoid certain social activities
  • Use the bathroom “just in case”

When urinary symptoms begin affecting everyday decisions, it is a good indication that they deserve proper assessment.

6. Urinary Leakage

Urinary leakage is common, but that does not mean it should automatically be accepted as part of ageing.

Incontinence can range from occasional small leaks to significant loss of bladder control.

Some people experience leakage when coughing, lifting or exercising.

Others experience a sudden urge to urinate and cannot reach the bathroom in time.

There are several different types of urinary incontinence, and treatment depends heavily on identifying the underlying cause.

Seeing a urologist can help determine which type of incontinence is occurring and what treatment options may be available.

7. An Abnormal PSA Result

A PSA blood test measures the level of prostate-specific antigen in the blood.

An elevated PSA does not automatically mean prostate cancer.

PSA levels can change for several reasons, including benign prostate enlargement and other prostate conditions.

However, an abnormal or rising PSA result may lead your GP to recommend further specialist assessment.

A urologist can review your PSA history, symptoms, examination findings and other relevant information before deciding whether additional investigation is needed.

Don’t Wait Until Symptoms Become Severe

One of the most common reasons people delay seeing a doctor is because their symptoms are manageable.

They may think:

“It’s annoying, but I can live with it.”

The problem is that urinary symptoms can develop slowly.

What begins as getting up once during the night may eventually become three or four bathroom trips.

A slightly weaker stream may gradually become difficulty emptying the bladder.

Minor leakage can eventually begin influencing work, exercise or social activities.

If a urinary problem is persistent, changing or interfering with everyday life, having it properly assessed is usually better than simply adapting around it.

What Happens When You See a Urologist?

Seeing a urologist does not necessarily mean you will need surgery.

The first step is usually determining why the symptoms are occurring.

Depending on the problem, assessment may involve discussing your symptoms and medical history, examining relevant areas and arranging appropriate investigations.

Once the cause is better understood, your urologist can discuss the available treatment options.

For some patients, treatment may involve monitoring or medication.

For others, additional procedures may be appropriate.

The important point is that treatment should be based on the cause of the problem rather than the symptom alone.

Looking for a Urologist in Brisbane?

If you are experiencing persistent urinary symptoms, prostate concerns, urinary leakage, kidney stone symptoms or have received an abnormal PSA result, your GP may recommend specialist assessment.

A urologist in Brisbane can investigate symptoms involving the urinary system and help determine the most appropriate next step.

Dr Jo Schoeman provides specialist urological assessment and treatment for patients in Brisbane and surrounding areas.

If you are concerned about changes in your urinary health, speak with your GP about whether a referral to a urologist is appropriate.

Benign Prostate Enlargement and Water-Vapour Therapy: A Patient Guide

/0 Comments/in , /by

Benign prostate enlargement, also called benign prostatic hyperplasia or BPH becomes more common as men age. Enlargement may narrow the urethra, increase resistance to urinary flow and affect the way the bladder stores or empties urine.

Not every enlarged prostate causes symptoms, and not every urinary symptom is caused by the prostate. Treatment should therefore begin with an assessment of the likely cause, the effect on quality of life and whether complications are present.

This article explains BPH and the role of transurethral water-vapour therapy as one of several possible treatments. It does not recommend a particular product, device, clinician or health service.

What symptoms can BPH cause?

Lower urinary tract symptoms may include:

  • a slow or weak urinary stream
  • difficulty starting urination
  • stop–start flow
  • straining to urinate
  • a feeling that the bladder has not emptied
  • passing urine frequently
  • urgency
  • waking at night to urinate
  • dribbling after urination
  • urinary retention

The size of the prostate does not always match symptom severity. A large prostate may cause few problems, while a smaller prostate can obstruct flow because of its shape, a tight bladder neck or a prominent median lobe.

What else can cause urinary symptoms?

Similar symptoms may arise from:

  • urinary tract infection
  • overactive bladder
  • urethral stricture
  • bladder stones
  • impaired bladder-muscle contraction
  • neurological disease
  • prostate or bladder cancer
  • medicines that affect bladder function
  • excessive fluid, caffeine or alcohol intake
  • constipation or sleep disorders

Visible blood in the urine, recurrent infection, kidney impairment, bladder stones, persistent retention or rapidly worsening symptoms require appropriate investigation.

How is BPH assessed?

Assessment may include:

  • a urinary, medical and medication history
  • a validated symptom questionnaire
  • physical examination
  • digital rectal examination
  • urine testing
  • PSA testing after discussion of its benefits and limitations
  • kidney-function testing when indicated
  • urinary flow measurement
  • ultrasound assessment of prostate size and post-void residual urine
  • a bladder diary
  • cystoscopy or urodynamic testing in selected cases

It is particularly important to distinguish bladder-outlet obstruction from weak bladder contraction. Opening the prostate outlet may not restore normal emptying if the bladder muscle is unable to contract adequately.

Does every man with BPH need treatment?

No. Men with mild, non-bothersome symptoms and no complications may choose observation with periodic review.

Conservative measures may include:

  • moderating excessive evening fluid intake
  • reducing caffeine or alcohol when these worsen symptoms
  • treating constipation
  • reviewing relevant medicines
  • avoiding habitual “just in case” voiding where appropriate
  • managing diabetes, sleep apnoea or leg swelling when they contribute to nocturia

Fluid should not be restricted excessively, particularly in hot weather or when dehydration is a risk.

What treatment options are available?

Depending on symptoms, anatomy and risk, options may include:

  • monitoring and lifestyle measures
  • prescription medicines
  • minimally invasive surgical therapies
  • transurethral resection or vaporisation
  • laser enucleation
  • other endoscopic enucleation techniques
  • simple prostatectomy for selected very large glands

Each option differs in speed of improvement, durability, anaesthetic requirements, catheter time, bleeding risk, sexual effects and likelihood of retreatment.

What is transurethral water-vapour therapy?

Water-vapour therapy is a minimally invasive treatment intended to reduce selected areas of benign prostate tissue that are contributing to obstruction.

A specialised instrument is passed through the urethra. A needle delivers controlled water vapour into planned areas of prostate tissue. As the vapour condenses, thermal energy disrupts the targeted cells. The body then gradually reabsorbs treated tissue over the following weeks and months.

Unlike resection or enucleation, obstructing tissue is not physically removed during the procedure. Improvement is therefore delayed while inflammation settles and treated tissue reduces.

The exact device, intended purpose, contraindications and instructions for use should be confirmed from the current Australian Register of Therapeutic Goods entry and manufacturer-approved documentation.

Who might be considered?

Water-vapour therapy may be discussed with selected men whose bothersome symptoms are likely to arise from benign prostate obstruction and who understand the alternatives and likelihood of retreatment.

Assessment may consider:

  • symptom severity and quality-of-life impact
  • prostate volume and shape
  • lateral-lobe or median-lobe obstruction
  • urinary flow and residual urine
  • bladder contractility
  • previous urinary retention
  • coexisting bladder or urethral disease
  • anaesthetic and bleeding risk
  • the importance of preserving ejaculation
  • the patient’s preference regarding recovery, durability and retreatment

The pivotal randomised study enrolled a defined group of men, including prostate volumes between 30 and 80 mL. Evidence outside the studied population is less mature and may rely on observational data.

Larger prostates, catheter-dependent retention or previous prostate procedures do not automatically determine suitability, but the expected results and evidence may differ. A tissue-removing operation may provide more predictable or faster relief in some patients.

When may it be unsuitable?

Reasons to avoid or reconsider water-vapour therapy may include:

  • active urinary infection
  • suspected prostate or bladder cancer requiring investigation
  • urethral stricture preventing safe access
  • poor bladder contractility
  • symptoms caused mainly by overactive bladder rather than obstruction
  • bladder stones or another condition better treated during a different operation
  • anatomy unlikely to be treated adequately
  • severe obstruction or complications requiring rapid, predictable decompression
  • a contraindication in the approved instructions for the proposed device

Suitability must be decided individually. A median lobe is not necessarily an exclusion, but its anatomy and treatment plan require careful assessment.

How is the procedure performed?

The procedure is performed through the urethra, without an external incision. The device is positioned within the prostatic urethra, and treatment is delivered to selected areas according to prostate length, volume and shape.

Anaesthesia and perioperative care vary by patient and facility. The procedure is often performed as day surgery, but same-day discharge is not guaranteed.

Patients should receive individual instructions about:

  • fasting and anaesthesia
  • urine testing
  • antibiotics where clinically indicated
  • anticoagulant and antiplatelet medicines
  • transport and activity after the procedure
  • catheter care
  • symptoms requiring urgent review

Anticoagulant or antiplatelet medicines must not be stopped without advice from the clinician who manages them.

Will a catheter be needed?

Many patients need a temporary urinary catheter because treatment initially causes swelling. Catheter duration varies with prostate anatomy, baseline bladder emptying, pre-existing retention and the clinical course.

Some patients cannot pass urine after the catheter is removed and require reinsertion or intermittent catheterisation. Urgent review is needed if a patient cannot urinate and develops increasing lower-abdominal pain.

When might symptoms improve?

Water-vapour therapy does not usually provide immediate improvement. Urgency, frequency, discomfort or flow may temporarily worsen because of inflammation and swelling.

Improvement may begin over several weeks and continue for several months. The timing and degree of benefit vary, and some patients obtain inadequate relief.

Possible short-term effects

Common or expected effects can include:

  • burning or discomfort when urinating
  • blood in the urine
  • blood or discolouration in the semen
  • urinary frequency or urgency
  • a temporarily weaker stream
  • pelvic or perineal discomfort
  • catheter-related discomfort
  • temporary urinary retention

Patients should follow the written aftercare advice from their treating team.

Other risks and complications

Possible complications include:

  • urinary tract infection
  • prostatitis or systemic infection
  • bleeding
  • persistent urinary retention
  • worsening urgency or incontinence
  • urethral stricture or bladder-neck narrowing
  • ejaculatory change
  • erectile or sexual symptoms
  • chronic pelvic or urinary discomfort
  • failure to improve symptoms
  • need for repeat treatment or another prostate operation

Serious complications are uncommon but possible. Fever, chills, inability to urinate, heavy bleeding, severe pain or feeling systemically unwell require prompt assessment.

What about ejaculation and erections?

Preserving sexual and ejaculatory function is an important goal for many patients considering minimally invasive treatment. Clinical studies have reported relatively low rates of new sexual dysfunction after water-vapour therapy in selected populations.

However:

  • preservation cannot be guaranteed
  • changes in ejaculation can occur
  • erectile function may change for reasons unrelated to the procedure
  • trial definitions and selected participants may not reflect every patient
  • comparison with other procedures depends on technique, anatomy and baseline function

Sexual priorities should be discussed before treatment, along with the more established risk of ejaculatory change after tissue-removing operations.

What did the pivotal five-year study find?

Five-year follow-up from a sham-controlled randomised study reported sustained average improvement in symptoms and urinary flow among study participants who received water-vapour therapy. Reported outcomes included an approximate 48% improvement in symptom score and a 4.4% surgical retreatment rate over five years.

These figures require context:

  • they are group averages, not a prediction for an individual
  • the trial used defined eligibility criteria
  • follow-up does not show what happens over a lifetime
  • some participants did not obtain adequate relief
  • “surgical retreatment” does not capture every medication restart, investigation or non-surgical intervention
  • results may differ with larger prostates, retention, previous surgery or different anatomy

The evidence supports water-vapour therapy as a possible option for selected men; it does not establish it as the best treatment for all men with BPH.

Can the prostate continue to grow?

Yes. The procedure treats selected obstructing tissue present at the time. It does not stop the biological process of benign prostate growth.

Symptoms may remain controlled, recur because of further growth, or persist for another reason such as bladder dysfunction. Younger patients should consider the possibility of needing additional treatment during their lifetime.

How does it compare with tissue-removing surgery?

Water-vapour therapy generally involves less immediate tissue removal and slower improvement than transurethral resection or enucleation.

Potential reasons a patient might consider it include a preference for a less invasive approach and a desire to reduce the chance of ejaculatory change. Potential disadvantages include delayed benefit, postoperative irritation, catheterisation, uncertainty in less-studied anatomies and the possibility of retreatment.

Tissue-removing surgery may be more suitable when there is:

  • severe or recurrent urinary retention
  • very large or complex obstructing anatomy
  • bladder stones
  • recurrent infection caused by poor emptying
  • kidney or upper-tract effects from obstruction
  • substantial bleeding attributable to BPH
  • a need for faster or more predictable relief

No procedure is best for every patient.

Follow-up

Review may assess:

  • urinary symptoms and quality of life
  • urinary flow
  • post-void residual urine
  • infection or retention
  • catheter-related problems
  • sexual or ejaculatory effects
  • need for continuing BPH medicine
  • whether another diagnosis or treatment should be considered

Persistent or worsening symptoms should prompt reassessment rather than repeated reassurance that improvement will eventually occur.

Questions to discuss with a urologist

  • Are my symptoms caused by prostate obstruction?
  • Is my bladder contracting adequately?
  • What is my prostate size and anatomy?
  • Do I have complications that favour a more definitive operation?
  • What are the alternatives, including observation and medicines?
  • How quickly is each option likely to help?
  • What are the risks to ejaculation, erections and continence?
  • How long might I need a catheter?
  • What is the likelihood of needing another procedure?
  • Is the exact proposed device included in the ARTG for this use?
  • What out-of-pocket costs may apply?

Australian regulatory considerations

The Australian Register of Therapeutic Goods (ARTG) records therapeutic goods that may be legally supplied in Australia, unless an exemption or authorised access pathway applies. Inclusion is specific to the sponsor, device and intended purpose; it is not a recommendation that the device is suitable or superior for an individual patient.

Device status, instructions for use, contraindications, reimbursement and availability can change. These should be checked at the time treatment is considered.

The bottom line

BPH is common, but urinary symptoms require assessment because prostate obstruction is only one possible cause.

Transurethral water-vapour therapy is one minimally invasive option for selected men. It may improve urinary symptoms while offering a different balance of recovery, sexual effects and retreatment risk from tissue-removing surgery. Improvement is gradual, catheterisation is common, benefit is not guaranteed and further treatment may be needed.

The choice should follow an informed discussion of observation, medicines, minimally invasive treatments and established surgical options, taking account of prostate anatomy, bladder function, complications and personal priorities.

This article provides general disease education and does not replace individual medical advice. It does not promote or recommend a particular therapeutic device, brand, clinician or health service.

References and further reading

 

Clips for Benign Prostatic Enlargement: A Minimally Invasive Treatment That Preserves Ejaculation

/0 Comments/in , /by

Benign prostatic hyperplasia, or BPH, is a non-cancerous enlargement of the prostate. As the prostate enlarges, its lateral lobes may compress the urethra and obstruct the flow of urine from the bladder.

Common lower urinary tract symptoms include:

  • A weak or interrupted urinary stream
  • Difficulty starting urination
  • Straining to pass urine
  • Urinary frequency and urgency
  • Getting up repeatedly at night
  • Dribbling after urination
  • A feeling that the bladder has not emptied properly

Medication is usually the first treatment offered to men with troublesome symptoms. However, tablets may provide insufficient relief or cause dizziness, tiredness, reduced libido, erectile problems or altered ejaculation.

The UroLift procedure, also called a prostatic urethral lift or PUL, is a minimally invasive surgical therapy, or MIST, that may provide an alternative to long-term medication and conventional prostate surgery.

What is a MIST procedure?

Minimally invasive surgical therapies are designed to improve urinary symptoms with less tissue damage, less bleeding and a shorter recovery than conventional procedures such as TURP or prostate laser surgery.

Different MIST procedures work in different ways. Some use steam or other forms of energy to destroy prostate tissue. Some temporarily remodel the urinary passage. UroLift mechanically moves the obstructing prostate tissue away from the urethra using small permanent implants.

Its principal attractions are:

  • No cutting or removal of prostate tissue
  • No heat, laser or steam
  • Rapid improvement in many patients
  • Usually brief catheterisation, if any
  • Short recovery
  • A low reported risk of new erectile or ejaculatory dysfunction

The trade-off is that symptom improvement is generally more modest than after a tissue-removing operation, permanent implants remain within the prostate, and some patients will eventually require further treatment.

How does Clips work?

The UroLift system uses small implants to hold the enlarged lateral lobes of the prostate away from the urethra.

Each implant consists of:

  • A small capsular tab placed on the outside of the prostate
  • A stainless-steel urethral end-piece
  • A permanent suture connecting the two components

The implant compresses and retracts the obstructing prostate tissue, widening the urinary channel without cutting, burning or removing tissue.

Most patients require several implants. The exact number depends on the length, size and shape of the prostate and the degree of obstruction. These implants remain permanently in position.

Who may benefit from Clips?

UroLift may be considered for men who:

  • Have moderate or severe urinary symptoms caused by BPH
  • Have obtained inadequate relief from medication
  • Cannot tolerate the side effects of BPH medication
  • Prefer not to take daily medication indefinitely
  • Want a less invasive alternative to TURP or laser surgery
  • Place a high priority on preserving forward ejaculation
  • Want a relatively rapid return to normal activities
  • Have prostate anatomy suitable for a prostatic urethral lift
  • Understand the possibility of future retreatment

It is particularly attractive for sexually active men who wish to improve their urinary symptoms while minimising the risk of dry or retrograde ejaculation.

What prostate size is suitable?

Clinical guidelines and manufacturer labelling are not identical.

Current European Association of Urology guidance recommends offering prostatic urethral lift to men interested in preserving ejaculation who have prostates smaller than 70 mL and no obstructing middle lobe.

American Urological Association guidance supports the procedure for selected men with prostates approximately 30–80 mL and without an obstructing middle lobe.

Manufacturer and regulatory indications may extend to prostates as large as 100 mL and may include selected median-lobe anatomy in some jurisdictions. However, treatment outside the populations best supported by clinical guidelines requires careful patient selection and counselling.

Prostate volume alone does not determine suitability. The shape of the prostate, length of the prostatic urethra, bladder-neck anatomy, degree of obstruction and strength of the bladder muscle must also be considered.

What about an obstructing median lobe?

The median lobe is prostate tissue that projects upwards towards the bladder and may act like a ball valve over the bladder outlet.

UroLift can be used to treat selected obstructing median lobes, and the MedLift study reported encouraging outcomes. Nevertheless, major guideline recommendations remain more conservative because the strongest long-term randomised evidence relates mainly to lateral-lobe obstruction.

A large, mobile or unusually shaped median lobe may be better treated with TURP, laser surgery, Rezūm, Aquablation or another procedure capable of removing or reducing the obstructing tissue.

This is an important anatomical caveat to discuss before choosing UroLift.

Assessment before treatment

Not every urinary symptom is caused by BPH. Infection, urethral stricture, bladder weakness, overactive bladder, neurological disease, medication and prostate or bladder cancer may produce similar symptoms.

Assessment may include:

  • Medical history and examination
  • International Prostate Symptom Score
  • Urine testing
  • PSA testing when appropriate
  • Urinary-flow measurement
  • Ultrasound measurement of residual urine
  • Prostate imaging or ultrasound
  • Flexible cystoscopy
  • Urodynamic testing in selected patients

Cystoscopy may be particularly useful because it allows the urologist to assess the lateral lobes, bladder neck, median lobe and length of the obstructing prostate.

Any urinary infection should be treated before the procedure.

Patients taking aspirin, warfarin, clopidogrel, apixaban, rivaroxaban or other blood-thinning medication require an individual plan. Do not stop blood-thinning medication without instructions from your prescribing doctor and urologist.

How is the UroLift procedure performed?

UroLift is usually performed as a day procedure under local anaesthetic with sedation or a short general anaesthetic.

A cystoscope and specialised delivery device are passed through the urethra. No external incision is required.

The urologist:

  1. Examines the urethra, prostate and bladder.
  2. Positions the delivery device within the prostatic urethra.
  3. Moves the obstructing prostate tissue away from the urinary channel.
  4. Deploys an implant to hold the tissue in its new position.
  5. Repeats the process at selected points until an adequate channel has been created.
  6. Inspects the bladder outlet and controls any bleeding.

The procedure commonly takes less than an hour, although this varies with prostate anatomy and the number of implants required.

Because no prostate tissue is removed, there is usually no specimen for laboratory examination.

Will I need a catheter?

Many men can pass urine after the procedure and go home without a catheter. A catheter may nevertheless be required if there is:

  • Significant prostate swelling
  • Inability to pass urine
  • Pre-existing urinary retention
  • A weak bladder muscle
  • Bleeding or clot formation
  • A high residual urine volume

When required, the catheter is usually temporary. Patients with chronic retention or poor bladder function have a greater risk of failing an early trial without a catheter.

What should I expect after UroLift?

Temporary urinary irritation is common during the first few days.

You may experience:

  • Burning or stinging when passing urine
  • Urinary urgency and frequency
  • Pelvic, perineal or penile discomfort
  • Light blood in the urine
  • Bladder spasms
  • A temporarily weaker or more irregular stream
  • Increased night-time urination
  • A feeling of incomplete emptying

These symptoms generally improve over several days, although urinary irritation may occasionally persist for a few weeks.

Some men notice an improved stream soon after treatment. For others, the benefit develops over the following two to six weeks as swelling and irritation settle.

Managing pain and urinary discomfort

Discomfort after UroLift is usually mild to moderate.

Management may include:

Paracetamol

Paracetamol is commonly sufficient for mild discomfort. Take it according to the instructions provided by your doctor or the directions on the packet.

Avoid accidentally taking additional paracetamol contained in cold, influenza or combination pain medicines.

Anti-inflammatory medication

Ibuprofen or another anti-inflammatory medicine may help when medically appropriate. These medicines may not be suitable for patients with kidney impairment, stomach ulcers, certain heart conditions, bleeding disorders, anti-inflammatory-sensitive asthma or anticoagulant medication.

Check with your doctor or pharmacist before taking an anti-inflammatory medicine.

Medication for urinary symptoms

An alpha blocker may be continued temporarily to assist urine flow while swelling settles. Medication for bladder spasm or urinary burning may occasionally be prescribed.

Practical measures

It may help to:

  • Maintain normal hydration without forcing excessive fluids
  • Limit coffee, tea, alcohol, fizzy drinks and energy drinks
  • Avoid constipation
  • Avoid heavy lifting and vigorous exercise for several days
  • Take pain relief before discomfort becomes severe

Severe or worsening pain should be reported rather than simply tolerated.

Possible complications

Most side effects are mild and temporary, but complications can occur.

Common temporary effects

These include:

  • Pain or burning during urination
  • Blood in the urine
  • Urinary urgency
  • Increased frequency
  • Pelvic discomfort
  • Temporary urinary leakage associated with urgency

Urinary retention

Some men cannot pass urine after the procedure and require temporary catheterisation. The risk may be greater in patients with high residual urine volumes, chronic retention, severe obstruction or a weak bladder muscle.

Urinary tract infection

Infection may cause worsening burning, cloudy or offensive urine, fever, chills or feeling generally unwell. Antibiotics may be required.

Bleeding

Light haematuria is common. Significant bleeding, clot retention or the need for further intervention is uncommon but possible.

Implant-related problems

Potential implant complications include:

  • Incorrect placement
  • Implant exposure within the bladder
  • Encrustation or stone formation
  • Migration or loosening
  • Persistent pelvic discomfort
  • The need to remove an implant
  • Difficulty or irritation during later prostate surgery

Implants placed too close to or within the bladder are more likely to develop encrustation and may require endoscopic removal.

Persistent symptoms

UroLift treats obstruction but does not correct every cause of lower urinary tract symptoms. Urgency, frequency and nocturia may persist when they are caused by bladder overactivity, excessive night-time urine production, sleep apnoea, fluid intake, diabetes or other medical conditions.

Need for further treatment

Some patients obtain insufficient relief or develop recurrent symptoms as the prostate continues to enlarge. Further treatment may involve medication, additional implants, removal of exposed implants or another procedure such as TURP, GreenLight laser, HoLEP, Rezūm or Aquablation.

When should I seek urgent help?

Contact your urologist or attend an emergency department if you:

  • Cannot pass urine
  • Develop fever, shaking or chills
  • Feel generally unwell or confused
  • Pass large blood clots
  • Have heavy or persistent bright-red bleeding
  • Develop severe or increasing pelvic pain
  • Cannot keep fluids down
  • Experience pain that is not controlled by the recommended treatment

Does UroLift affect erections or ejaculation?

Preserving sexual function is one of the main reasons patients choose UroLift.

The pivotal L.I.F.T. study reported no new sustained erectile or ejaculatory dysfunction during five years of follow-up. Because the bladder neck, prostate tissue and ejaculatory pathways are not routinely cut or heated, the risk of retrograde ejaculation is substantially lower than with conventional TURP and many tissue-removing procedures.

However, no treatment can guarantee unchanged erections, sensation, orgasm or ejaculation in every patient.

Men who already have erectile or ejaculatory difficulties should not assume that UroLift will correct those problems. It is primarily a treatment for urinary obstruction.

How effective are Clips?

Clinical studies show meaningful average improvement in:

  • Urinary symptom scores
  • Quality of life
  • Peak urinary-flow rate
  • The patient’s perception of urinary function

Symptoms may improve quickly because the urethra is mechanically opened during the procedure.

However, the average improvement in urinary flow and symptoms is generally less than that achieved with TURP or prostate enucleation. UroLift is therefore best understood as a compromise: less invasive treatment and better preservation of ejaculation in exchange for more modest de-obstruction and a greater chance of later retreatment.

How long do Clips last?

The implants are permanent, but the symptom relief is not necessarily lifelong.

The pivotal L.I.F.T. study demonstrated sustained average improvements for five years. The reported surgical retreatment rate was approximately 13.6% over five years, or roughly 2–3% per year.

Retreatment estimates vary among studies and real-world populations. The need for further treatment may be influenced by:

  • Prostate size and anatomy
  • Median-lobe obstruction
  • Implant position
  • Severity of the original obstruction
  • Bladder function
  • Continued prostate growth
  • The definition of retreatment used in a study

Patients should distinguish between an implant remaining in position and the treatment continuing to control symptoms. A permanent implant does not guarantee permanent symptom relief.

MRI considerations

UroLift implants are classified as MR Conditional, meaning MRI can generally be performed under specified scanner conditions. Patients should tell the radiology service that they have UroLift implants and provide the implant information card whenever possible.

The metallic components can create image artefact, particularly during prostate MRI. This may obscure portions of the prostate and reduce the diagnostic quality of an MRI used to investigate suspected prostate cancer.

This caveat is particularly relevant for:

  • Younger men with a long future need for prostate surveillance
  • Patients with an elevated or rising PSA
  • Men already undergoing prostate cancer monitoring
  • Patients likely to require prostate MRI or targeted biopsy

Appropriate prostate cancer assessment should be completed before UroLift when clinically indicated.

Can prostate surgery still be performed later?

Yes. TURP, laser surgery, HoLEP and other BPH procedures can be performed after UroLift.

However, the surgeon must account for the permanent implants. Clips may be encountered during resection or enucleation, may affect instruments or laser fibres, and may require removal. Some surgeons therefore consider later surgery technically more complex than treatment of an implant-free prostate.

UroLift does not close the door to future treatment, but it does leave permanent material that the future surgeon must manage.

Who should not undergo a Clip procedure?

Manufacturer contraindications include:

  • Active urinary tract infection
  • Current visible or gross haematuria
  • Urinary incontinence caused by an incompetent urinary sphincter
  • A urethral condition that prevents safe insertion of the delivery device
  • A prostate larger than the maximum permitted by the applicable product labelling

UroLift may also be unsuitable or less predictable in men with:

  • Severe chronic urinary retention
  • A poorly contracting bladder
  • Very high residual urine volumes
  • Urethral stricture disease
  • Bladder stones
  • Recurrent urinary infections
  • Significant ongoing bleeding
  • A very high bladder neck
  • A large or unfavourably shaped median lobe
  • A very large prostate
  • Suspected or untreated prostate cancer
  • Symptoms primarily caused by overactive bladder rather than obstruction
  • A need for maximal and durable removal of obstructing tissue

Advantages of Clips

Potential advantages include:

  • Minimally invasive day procedure
  • No prostate tissue removed
  • No laser, heat or steam
  • Rapid relief in many patients
  • Short recovery
  • Catheter often avoided
  • Low reported risk of new erectile dysfunction
  • Low reported risk of dry or retrograde ejaculation
  • Future BPH treatments remain possible

Limitations and important caveats

Patients should understand that:

  • Several permanent implants remain inside the prostate
  • Symptom and flow improvements are usually less than after TURP or enucleation
  • Retreatment is more common than after tissue-removing surgery
  • Not all median lobes are suitable
  • UroLift does not prevent continued prostate growth
  • Urgency and nocturia may persist if they have a bladder or medical cause
  • The implants may reduce the quality of future prostate MRI
  • Later prostate surgery remains possible but may be technically more complicated
  • Prostate cancer should be appropriately assessed before treatment
  • UroLift does not provide prostate tissue for laboratory examination

Are Clips the right option for me?

UroLift can be an excellent option for a carefully selected man who wants meaningful improvement in urinary symptoms, a rapid recovery and a low risk of ejaculatory dysfunction.

It may be less suitable for someone with severe obstruction, chronic retention, weak bladder function, unfavourable median-lobe anatomy or a need for the most powerful and durable improvement possible.

The decision should take account of:

  • Prostate size and shape
  • Presence of a median lobe
  • Severity of symptoms and obstruction
  • Bladder strength and residual urine
  • PSA and prostate cancer risk
  • Previous treatment
  • General health and medication
  • Importance of preserving ejaculation
  • Acceptance of permanent implants
  • Willingness to undergo future retreatment

A urological assessment allows UroLift to be compared fairly with medication, iTind, Rezūm, Aquablation, TURP, GreenLight laser, HoLEP and other appropriate options.

This information is intended for general education and does not replace individual medical advice. Treatment suitability, availability and costs vary. Always follow the instructions provided by your treating urologist.

References

  1. European Association of Urology: Management of non-neurogenic male lower urinary tract symptoms.
  2. American Urological Association: BPH clinical guideline.
  3. Roehrborn CG, et al. Five-year results of the prospective randomised controlled prostatic urethral L.I.F.T. study. Canadian Journal of Urology. 2017;24:8802–8813.
  4. Rukstalis D, et al. Prostatic urethral lift for the treatment of an obstructive median lobe: 12-month results of the MedLift study. Prostate Cancer and Prostatic Diseases. 2019;22:411–419.
  5. UroLift manufacturer safety information.
  6. Benidir T, et al. Impact of the UroLift device on prostate magnetic resonance image quality. Journal of Urology. 2023.