Paraphimosis: When the Foreskin Gets Stuck

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Paraphimosis is one of those urological problems where the phrase “I’ll see how it goes overnight” is not a particularly good plan.

It occurs when the foreskin of an uncircumcised penis is pulled back behind the head of the penis (glans) and becomes trapped there. The tight band of foreskin can interfere with normal drainage of blood and fluid from the glans, causing increasing swelling. As the swelling worsens, the foreskin becomes progressively more difficult to return to its normal position.

Although the appearance can be alarming and the circumstances occasionally embarrassing, paraphimosis is a genuine urological emergency. Early treatment is usually relatively straightforward. Delay can make treatment considerably more difficult and, in severe cases, threaten the blood supply to the penis.

What is paraphimosis?

Normally, a mobile foreskin can be gently retracted behind the glans and then returned forward to cover it.

In paraphimosis, the foreskin has been retracted but cannot be brought forward again.

The retracted foreskin forms a tight constricting ring behind the glans. This initially obstructs lymphatic and venous drainage, causing fluid to accumulate and the glans and foreskin to become swollen.

This creates an unfortunate little feedback loop:

Tight foreskin → swelling → tighter constriction → more swelling.

In severe or prolonged cases, arterial blood flow can eventually be compromised.

That is why paraphimosis should not simply be regarded as “a tight foreskin”. It requires prompt assessment and treatment.

What does paraphimosis look and feel like?

The typical presentation is fairly characteristic.

Symptoms and signs can include:

  • A foreskin that is stuck behind the glans
  • A tight band or “collar” of foreskin behind the head of the penis
  • Increasing swelling of the glans
  • Swelling of the retracted foreskin
  • Penile pain or tenderness
  • Difficulty pulling the foreskin forward
  • Difficulty passing urine in more severe cases

The glans may initially look red or congested. With worsening obstruction to its circulation, it can become increasingly dark red, purple or dusky.

Severe pain, marked swelling, loss of sensation or a dark/blue/black appearance requires immediate emergency medical assessment.

What causes paraphimosis?

Paraphimosis usually occurs after the foreskin has deliberately or inadvertently been pulled backwards and then left behind the glans.

Medical procedures

A surprisingly common cause is retraction of the foreskin during:

  • Urinary catheter insertion
  • Examination of the penis
  • Cystoscopy or other urological procedures
  • Cleaning or nursing care

After manipulating an uncircumcised penis, the foreskin should always be returned to its normal position.

It is a small final step that can prevent a disproportionately large problem.

Phimosis or a tight foreskin

Men with a relatively tight foreskin may be able to retract it, but struggle to return it once it has passed behind the widest part of the glans.

Repeated episodes of inflammation or scarring can increase this risk.

Sexual activity

Retraction during sexual intercourse or masturbation can occasionally result in the foreskin becoming trapped.

Infection and inflammation

Balanitis and balanoposthitis can cause swelling of the glans and foreskin, making paraphimosis more likely.

Trauma

Penile swelling following trauma can occasionally trap a previously retracted foreskin.

Poor foreskin care

Paraphimosis can occur in elderly, debilitated or hospitalised men when a foreskin is retracted for cleaning or catheterisation and is inadvertently left in that position.

Why is paraphimosis an emergency?

The problem is not simply that the foreskin is in the wrong place.

The tight band acts rather like a tourniquet around the penis.

Venous and lymphatic drainage are affected first. Blood and fluid enter the glans more easily than they can leave, producing increasing oedema.

As the glans enlarges, the constricting ring becomes tighter.

If this progresses sufficiently, arterial circulation can also become compromised.

Rarely, severe untreated paraphimosis can result in:

  • Ischaemia
  • Ulceration
  • Tissue necrosis
  • Gangrene
  • Permanent penile injury

Fortunately, these complications are unusual when treatment is sought promptly.

Urgent treatment

The immediate objective is simple:

Reduce the swelling and return the foreskin over the glans.

Treatment depends on the degree of swelling, duration of the problem, pain and whether there are signs of compromised blood flow.

Pain relief and local anaesthesia

Reduction can be uncomfortable, particularly when substantial swelling has developed.

Depending on the circumstances, treatment may involve:

  • Oral or intravenous analgesia
  • Local anaesthetic gel
  • Penile nerve block
  • Occasionally sedation

Adequate pain control also allows the patient to relax, which can make reduction easier.

Reducing the swelling

Before attempting reduction, pressure may be applied to the swollen glans and foreskin for several minutes to encourage oedema to disperse.

Compression techniques or dressings may sometimes be used.

The principle is straightforward: make the glans smaller before asking the foreskin to travel back over it.

Manual reduction

Once swelling has been reduced, the clinician gently compresses the glans while simultaneously drawing the foreskin forward.

Successful reduction usually produces rapid improvement in the constriction and discomfort.

This should be performed carefully. Forceful repeated manipulation of a severely swollen penis can cause additional trauma.

What if manual reduction doesn’t work?

Occasionally the constricting ring is simply too tight.

In that situation, further attempts at heroic squeezing are unlikely to win any medals.

A dorsal slit may be required.

After appropriate local anaesthesia, a small incision is made through the constricting portion of the foreskin. This releases the tight band and allows the foreskin to be repositioned.

If the tissue appears significantly compromised, urgent surgical assessment is particularly important.

What happens after successful reduction?

Successful reduction solves the immediate emergency, but it does not necessarily solve the underlying problem.

There may still be:

  • Residual swelling
  • Inflammation
  • Small tears or abrasions
  • Infection
  • Phimosis
  • Scarring of the foreskin

Patients are generally advised not to repeatedly retract the foreskin while significant swelling and inflammation remain.

Any associated infection or inflammatory condition should also be treated.

Delayed treatment: preventing it happening again

Once the acute episode has settled, the underlying foreskin should be reassessed.

This is particularly important after recurrent paraphimosis or when there is significant phimosis.

Treatment options may include observation, topical therapy in selected cases, foreskin-preserving surgery or circumcision.

Circumcision

For men with significant scarring, persistent phimosis or recurrent paraphimosis, circumcision provides a definitive solution by removing the problematic foreskin.

Circumcision is usually performed after the acute swelling and inflammation have settled, rather than during the initial emergency, unless circumstances require otherwise.

Preputioplasty

Selected patients wishing to preserve their foreskin may be suitable for a foreskin-widening procedure such as preputioplasty.

Whether this is appropriate depends on the degree and cause of the narrowing.

Can paraphimosis be prevented?

Often, yes.

The most important rule is wonderfully uncomplicated:

If the foreskin is pulled back, put it back.

After catheterisation, examination, washing or any medical procedure, the foreskin should be returned to its normal position over the glans.

Men with a persistently tight foreskin, recurrent inflammation or previous paraphimosis should consider discussing definitive treatment with a urologist rather than waiting for another episode.

When should I seek medical attention?

If the foreskin is trapped behind the glans and cannot easily be returned to its normal position, seek urgent medical attention.

Do not wait for the swelling to settle by itself.

Increasing pain, rapidly worsening swelling, difficulty urinating or a glans that is becoming dark purple, blue or black requires immediate emergency assessment.

Embarrassment should never delay treatment. Urologists have seen essentially every variation the human anatomy can produce, and a stuck foreskin is very much part of the job description.

The take-home message

Paraphimosis occurs when a retracted foreskin becomes trapped behind the glans and forms a constricting band.

It may begin as an uncomfortable inconvenience, but progressive swelling can turn it into a genuine emergency.

Early treatment is usually simple and highly effective.

The priorities are to reduce swelling, restore the foreskin to its normal position and protect the circulation to the penis. Once the emergency has resolved, any underlying phimosis or foreskin disease should be assessed to reduce the chance of recurrence.

And perhaps the easiest piece of preventative urological advice to remember:

Foreskin back? Put it back.

This information is intended for general patient education and does not replace individual medical assessment. Suspected paraphimosis requires prompt medical attention.

If this happens, I’ll see you at the Emergency Department at either of the 2 Brisbane hospitals I work at: Wesley and St Andrews War Memorial hospitals. If this has been reduced and you are in need of a circumcision, come chat to your friendly Brisbane Urologist, Dr Jo Schoeman, Uro-Jo.

Does Size Matter?

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The long and the short of it

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

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

So, does penile size actually matter?

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

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

What Is a “Normal” Penis Size?

There is a wide range of normal penile sizes.

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

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

There is considerable natural variation around these averages.

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

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

Both are normal.

Length Versus Girth: Which Matters More?

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

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

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

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

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

Bigger is therefore not automatically better.

At some point, additional size can actually become uncomfortable.

Why Do So Many Men Think They Are Too Small?

Perception plays an enormous role.

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

Then there is pornography.

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

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

How Should Penile Length Be Measured?

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

The most useful clinical measurement is usually stretched penile length.

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

This last point matters.

The disappearing penis

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

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

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

Can a Penis Actually Become Shorter?

Yes.

Changes in apparent or actual penile length can occur with:

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

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

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

What Is a Micropenis?

A true micropenis is uncommon.

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

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

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

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

Does Size Affect Sexual Satisfaction?

Usually far less than expected.

Good sexual function depends on a complicated mixture of:

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

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

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

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

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

When Should You See a Urologist?

Consider seeking medical advice if you have:

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

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

The Cucumber, Banana and Asparagus Test 🥒🍌🌱

Vegetables make excellent salads.

They make terrible anatomical reference standards.

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

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

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

The Bottom Line

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

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

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

And perhaps the most important measuring advice of all:

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

Vasectomy: A Guide to Permanent Male Contraception

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Vasectomy is a safe, effective and permanent method of male contraception. It is a relatively minor surgical procedure that prevents sperm from entering the semen by interrupting the vas deferens, the tubes that carry sperm from the testicles.

For men and couples who are confident that their family is complete, vasectomy provides highly reliable contraception without the need for ongoing medication or contraceptive devices.

What Happens During a Vasectomy?

Sperm are produced in the testicles and mature within the epididymis. During ejaculation, sperm normally travel through a tube called the vas deferens, where they ultimately mix with fluid produced by the prostate and seminal vesicles to form semen.

During a vasectomy, each vas deferens is divided and sealed so that sperm can no longer reach the ejaculate.

Importantly, vasectomy does not stop the testicles from producing sperm. The sperm that continue to be produced are naturally broken down and absorbed by the body.

Who Should Consider a Vasectomy?

Vasectomy may be appropriate for men who:

  • Have completed their family and do not want more children.
  • Do not wish to have children in the future.
  • Want a highly effective permanent form of contraception.
  • Have a partner for whom pregnancy would represent a significant health risk.
  • Prefer male sterilisation rather than their partner undergoing a more invasive sterilisation procedure.
  • Wish to avoid the need for long-term hormonal or barrier contraception.

The most important consideration is that vasectomy should be regarded as permanent.

Although vasectomy reversal is possible, successful reversal cannot be guaranteed. Men who are uncertain about future fertility should carefully consider alternative contraception or, in selected circumstances, sperm banking before proceeding.

How Is Vasectomy Performed?

Vasectomy is usually performed as a day procedure, commonly under local anaesthetic, although sedation or general anaesthesia may occasionally be appropriate.

A conventional or no-scalpel technique may be used.

The vas deferens is identified through a small opening in the scrotal skin. A short segment of the vas may be removed, and the divided ends are then sealed using techniques such as cautery, ligation and/or fascial interposition.

The procedure generally takes approximately 15–30 minutes.

Patients are usually able to return home shortly afterwards.

What Should I Expect After the Procedure?

Mild discomfort, bruising and swelling of the scrotum are common during the first few days.

Simple measures can help recovery, including:

  • Wearing supportive underwear.
  • Using simple analgesia as recommended.
  • Avoiding strenuous physical activity and heavy lifting for several days.
  • Keeping the wound clean and dry according to your surgeon’s instructions.
  • Avoiding sexual activity until discomfort and swelling have settled.

Most men can return to sedentary work relatively quickly, while men involved in heavy physical work may require a longer recovery period.

Vasectomy Does Not Work Immediately

This is one of the most important facts to understand about vasectomy.

A man is not sterile immediately after the procedure.

Sperm that were already present beyond the site of the vasectomy may remain within the reproductive tract for a period after surgery.

For this reason, another reliable method of contraception must be used until a post-vasectomy semen analysis confirms that the procedure has been successful.

Your urologist will advise when the semen test should be performed according to the protocol being followed.

Do not stop contraception simply because a certain number of weeks or ejaculations have passed. Wait until appropriate semen testing has confirmed success.

How Effective Is Vasectomy?

Vasectomy is one of the most effective forms of contraception available.

However, no contraceptive procedure can be regarded as absolutely 100% effective. Rarely, the divided ends of the vas deferens can reconnect, a process known as recanalisation.

Recanalisation may occur early after surgery and be detected on semen testing, or very rarely occur later after an initially successful vasectomy.

This is one reason why post-vasectomy semen analysis is an essential part of the procedure rather than an optional extra.

Does Vasectomy Affect Testosterone?

No.

Vasectomy does not remove or damage the testicles, and testosterone production continues normally.

A vasectomy should therefore not cause:

  • Loss of masculinity.
  • Reduced testosterone levels.
  • Loss of facial or body hair.
  • Reduced muscle mass.
  • Premature ageing.

Does Vasectomy Affect Erections or Sexual Function?

Vasectomy does not normally affect the ability to obtain or maintain an erection.

It also does not interfere with orgasm.

The nerves and blood vessels responsible for erections are not interrupted during a routine vasectomy.

Will Ejaculation Be Different?

Most of the volume of semen comes from the prostate and seminal vesicles, rather than from sperm.

Consequently, ejaculation continues after vasectomy and the appearance and volume of the semen are generally essentially unchanged.

The difference is microscopic: once the vasectomy has been successful, sperm are no longer present in the ejaculate.

What Are the Possible Complications?

Vasectomy is generally a low-risk procedure, but complications can occur.

Bleeding and Haematoma

Bleeding into the scrotum can result in swelling, bruising or a collection of blood known as a haematoma.

Small haematomas usually settle with conservative management. Large or expanding haematomas occasionally require further treatment.

Infection

Infection of the skin or deeper scrotal tissues is uncommon but may occur. Symptoms can include increasing pain, redness, swelling, discharge or fever.

Pain and Swelling

Some degree of discomfort and swelling is expected during the initial recovery period and usually settles.

Sperm Granuloma

Sperm may occasionally leak from the divided end of the vas and produce a small inflammatory lump known as a sperm granuloma.

These are often harmless but can occasionally be tender.

Epididymal Congestion

Some men develop aching or discomfort around the epididymis following vasectomy, possibly related to pressure within the sperm-carrying system.

This is usually temporary but can occasionally persist.

Post-Vasectomy Pain Syndrome

A small proportion of men experience persistent or recurrent testicular or scrotal pain lasting for months or longer after vasectomy.

This is known as chronic post-vasectomy pain or post-vasectomy pain syndrome.

Treatment depends upon severity and may include:

  • Anti-inflammatory or pain medication.
  • Pelvic floor or other targeted therapy where appropriate.
  • Nerve-directed treatment.
  • Spermatic cord procedures.
  • Epididymectomy in selected cases.
  • Vasectomy reversal in carefully selected patients.

Further surgery is rarely required, but persistent pain is an important complication to discuss before deciding on vasectomy.

Vasectomy Failure and Recanalisation

Occasionally sperm remain present because the vas deferens has reconnected or the procedure has otherwise failed to achieve sterility.

Persistent sperm on semen analysis may require further testing and, occasionally, a repeat vasectomy.

Very rarely, late recanalisation can occur after a previously satisfactory semen analysis, meaning that pregnancy remains possible even after initial clearance.

Does Vasectomy Increase the Risk of Prostate Cancer?

Vasectomy has been extensively studied in relation to prostate cancer and other long-term health concerns.

Current evidence has not established vasectomy as a cause of prostate cancer, and vasectomy is not generally considered a reason to alter routine prostate cancer screening or assessment.

Men should continue appropriate prostate health checks based on their age, family history, symptoms and individual risk factors.

Can a Vasectomy Be Reversed?

Yes, but reversal is considerably more complex than the original vasectomy.

Vasectomy reversal involves microsurgically reconnecting the reproductive tract, usually with a vasovasostomy or, when necessary, a vasoepididymostomy.

Success depends on several factors, including:

  • The length of time since vasectomy.
  • The condition of the vas deferens and epididymis.
  • The surgical technique required.
  • The experience of the microsurgeon.
  • The fertility and age of both partners.

Successful return of sperm to the semen does not necessarily guarantee pregnancy.

For this reason, a vasectomy should never be undertaken on the assumption that it can simply be reversed later.

Alternatives to Vasectomy

Men who are uncertain about permanent contraception should consider reversible alternatives.

Depending upon individual circumstances, these may include condoms or contraceptive methods used by the female partner, including hormonal contraception, intrauterine devices and contraceptive implants.

The choice should take into account effectiveness, side effects, medical history, personal preference and future fertility plans.

When Should I Seek Medical Attention After Vasectomy?

Contact your doctor or urologist if you develop:

  • Increasing rather than improving scrotal pain.
  • Significant or rapidly increasing swelling.
  • Heavy bleeding.
  • Increasing redness or discharge from the wound.
  • Fever or feeling systemically unwell.
  • Persistent testicular pain.
  • A concerning new scrotal lump.

The Bottom Line

Vasectomy is a highly effective, relatively simple and permanent form of male contraception.

For appropriately selected men who have completed their families, it can remove the need for ongoing contraception while leaving testosterone production, erections, orgasm and ejaculation essentially unchanged.

The key points are to understand that vasectomy should be considered permanent, complications such as chronic scrotal pain and failure can occur, and the procedure does not provide immediate contraception.

Most importantly, continue contraception after vasectomy until your post-vasectomy semen analysis has confirmed that it is safe to stop.

This information is intended for general education and does not replace individual medical advice. Your urologist can discuss whether vasectomy is appropriate for you, the technique used, expected recovery and the post-vasectomy semen-testing protocol.

So, if you have made the careful and considered decision to cease your ability to father another kid and you are a sensible adult, come see your local Brisbane Urologist, Dr Jo Schoeman to discuss this option. Your partner needs to be in on this as this will also affect her!

Phimosis: When the Foreskin Refuses to Cooperate

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

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

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

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

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

What is phimosis?

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

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

There are two broad types.

Physiological phimosis

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

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

Pathological phimosis

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

This is particularly important in adult men.

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

What Causes Phimosis in Adults?

Recurrent inflammation or infection

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

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

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

Lichen sclerosus / Balanitis xerotica obliterans (BXO)

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

The foreskin may become:

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

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

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

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

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

Diabetes

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

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

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

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

Trauma and scarring

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

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

Trying harder is therefore not always the solution.

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

What Are the Symptoms?

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

Symptoms may include:

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

Severe phimosis can occasionally interfere significantly with urination.

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

Phimosis and Sex

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

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

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

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

Sex should not require protective headgear.

How Is Phimosis Diagnosed?

Fortunately, diagnosis usually doesn’t require complicated machinery.

Your urologist will examine the penis and assess:

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

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

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

Treatment Options

Treatment is tailored to the underlying cause and severity.

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

1. Observation

Mild phimosis without significant symptoms may simply be observed.

Good hygiene and avoiding forceful retraction are important.

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

2. Topical Steroid Treatment

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

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

The emphasis is on gentle.

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

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

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

3. Treat the Underlying Infection or Inflammation

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

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

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

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

4. Preputioplasty

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

Its major advantage is that the foreskin is retained.

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

There is also a possibility that narrowing may recur.

5. Circumcision

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

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

Circumcision may be recommended for:

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

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

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

What Happens After Circumcision?

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

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

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

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

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

Phimosis vs Paraphimosis: Don’t Confuse the Two

These names sound annoyingly similar, but the distinction matters.

Phimosis means the foreskin cannot be pulled back normally.

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

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

Paraphimosis requires urgent medical attention.

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

When Should You See a Urologist?

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

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

The Bottom Line

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

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

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

Guys, don’t suffer in silence.

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

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

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

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

Make an appointment to see Dr Jo.

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

Intravesical Botox for Overactive Bladder: A Patient’s Guide

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Overactive bladder can have a significant impact on everyday life. The sudden need to find a toilet, frequent trips to the bathroom, waking repeatedly at night and episodes of urinary leakage can interfere with work, travel, exercise, sleep and social activities.

When bladder training, pelvic floor therapy and medications have not provided adequate relief, Botox injections into the bladder can be an effective treatment option.

What is overactive bladder?

Overactive bladder (OAB) is a condition characterised by urinary urgency, usually accompanied by increased urinary frequency and waking at night to pass urine (nocturia), with or without urgency urinary incontinence.

Typical symptoms include:

  • A sudden, difficult-to-defer urge to urinate
  • Passing urine more frequently than expected
  • Waking several times during the night to urinate
  • Leakage of urine before reaching the toilet
  • Planning activities around access to toilets

Importantly, similar symptoms can sometimes be caused by urinary infection, bladder stones, bladder obstruction or other urinary tract conditions. Appropriate assessment is therefore important before treatment.

What is bladder Botox?

Botox® is the trade name for onabotulinumtoxinA, a purified form of botulinum toxin type A.

Although Botox is widely known for cosmetic treatments, it has several established medical applications, including treatment of bladder dysfunction.

When injected into the bladder muscle, Botox reduces excessive nerve signalling to the bladder and decreases involuntary bladder contractions. The bladder becomes less “trigger-happy”, allowing it to store urine for longer before producing an urgent need to empty.

Clinical studies demonstrate that intradetrusor onabotulinumtoxinA improves urgency urinary incontinence, urinary frequency, urgency and nocturia compared with placebo.

Who may benefit from bladder Botox?

Botox may be considered for patients with troublesome overactive bladder symptoms, particularly when conservative or medication-based treatments have been unsuccessful, poorly tolerated or are not desired.

Current guidelines recommend intradetrusor botulinum toxin as an established minimally invasive treatment for appropriately selected patients with OAB.

It may be particularly useful for patients experiencing:

  • Severe urinary urgency
  • Urgency urinary incontinence
  • Frequent urination
  • Significant nocturia
  • Persistent symptoms despite bladder training
  • Persistent symptoms despite pelvic floor rehabilitation
  • An inadequate response to medications
  • Unacceptable medication side effects

Some patients choose procedural treatment because they would prefer not to take long-term medication.

Other minimally invasive options for refractory OAB include sacral neuromodulation and tibial nerve stimulation.

Assessment before Botox treatment

Before proceeding, your urologist will usually assess the nature and severity of your bladder symptoms.

Depending upon the circumstances, this may include:

  • Medical and urinary history
  • Urinalysis and/or urine culture
  • Bladder or voiding diary
  • Measurement of urinary flow
  • Ultrasound assessment of the bladder
  • Measurement of the post-void residual (PVR) to determine how well the bladder empties
  • Urodynamic testing in selected patients

AUA/SUFU guidelines specifically recommend measuring the post-void residual before intradetrusor Botox treatment. Particular caution may be appropriate when the residual urine is already significantly elevated because Botox can temporarily reduce the strength of bladder emptying.

How is Botox injected into the bladder?

Bladder Botox is administered using a procedure called cystoscopy.

A fine telescope is passed through the urethra into the bladder. A specialised injection needle is then passed through the cystoscope.

Small quantities of Botox are injected at multiple sites across the bladder wall.

For idiopathic overactive bladder, onabotulinumtoxinA 100 units is a commonly used treatment regimen and is the dose recommended in European guidelines for refractory OAB/urgency urinary incontinence.

The procedure may be performed using:

  • Local anaesthetic placed into the bladder
  • Sedation, or
  • General anaesthesia

The most appropriate option depends on the patient, the clinical setting and individual preference.

The procedure itself is generally relatively short, and most patients can go home on the same day.

What happens after the procedure?

Some patients notice an improvement within several days, although the full effect may take a little longer to become apparent.

As Botox begins to work, patients may experience:

  • Less urgency
  • Fewer visits to the toilet
  • Fewer episodes of urgency incontinence
  • Less nocturia
  • Improved bladder capacity
  • Improved confidence when away from a toilet

Quality-of-life improvement following treatment can be substantial in appropriately selected patients.

How long does bladder Botox last?

Botox is not permanent.

The nerve endings gradually recover and bladder symptoms may eventually return. The duration of benefit varies considerably between individuals, but treatment commonly provides symptom control for a number of months.

When symptoms return, the injections can usually be repeated.

Evidence suggests that repeat treatment generally remains effective, although some patients eventually choose an alternative treatment.

What are the side effects of bladder Botox?

Most patients tolerate the procedure well, but Botox treatment is not without risk.

Urinary tract infection

Urinary tract infection (UTI) is one of the most important and common complications following bladder Botox.

Symptoms can include:

  • Burning when passing urine
  • Increased frequency
  • Cloudy or offensive-smelling urine
  • Lower abdominal discomfort
  • Fever or feeling unwell

Botox treatment is associated with an increased incidence of UTI.

Difficulty emptying the bladder

Botox deliberately reduces bladder muscle activity. Occasionally it works a little too effectively.

Some patients consequently develop an increased amount of urine remaining in the bladder after urination, known as an increased post-void residual.

This may cause:

  • Difficulty starting urination
  • A weak urinary stream
  • A feeling of incomplete emptying
  • Abdominal discomfort
  • Recurrent urinary infection

For this reason, bladder emptying may be reassessed following treatment, particularly if symptoms suggest incomplete emptying.

Temporary need for self-catheterisation

A small proportion of patients may be unable to empty their bladder adequately after Botox treatment.

If this occurs, clean intermittent self-catheterisation (CISC) may temporarily be required until the effect decreases and normal bladder emptying returns.

Patients should therefore understand this possibility and be willing and physically able to perform catheterisation if necessary before proceeding with treatment. Both EAU and AUA/SUFU guidance emphasise counselling patients about this risk.

Blood in the urine

A small amount of blood in the urine can occur following cystoscopy and the injections themselves. This is usually temporary.

Discomfort passing urine

Mild burning, urgency or bladder discomfort can occur for a short period following the procedure.

Rare systemic effects

Botulinum toxin can very rarely produce effects away from the injection site, potentially causing muscle weakness or other neurological symptoms.

Patients should seek medical attention if they develop significant weakness, difficulty swallowing or breathing difficulties following treatment.

Who should not have bladder Botox?

Intravesical Botox is not suitable for everybody.

Important contraindications include:

  • An active urinary tract infection
  • Acute urinary retention in a patient who is not routinely catheterising
  • Inability or unwillingness to perform intermittent catheterisation if it becomes necessary
  • Known hypersensitivity to Botox or its components
  • Certain neuromuscular disorders, including myasthenia gravis and Eaton-Lambert syndrome

These contraindications are reflected in Australian Botox product information.

Additional caution may be required in patients with:

  • Significant pre-existing incomplete bladder emptying
  • Recurrent urinary tract infections
  • Bladder outlet obstruction
  • Previous urinary retention
  • Certain neurological conditions
  • Frailty or significant medical comorbidity

Patients with recurrent UTIs require particularly careful consideration because Botox may further increase the risk of urinary infection.

Botox in men with overactive bladder

Men can also experience overactive bladder, but it is important to establish whether urinary symptoms are being caused or aggravated by bladder outlet obstruction from an enlarged prostate.

A man with urgency, frequency and nocturia may therefore require assessment of his prostate, urinary flow and residual urine before bladder Botox is considered.

In some men, treatment of prostate obstruction may need to be considered before or alongside treatment directed at the bladder.

Botox versus other treatments for overactive bladder

Botox forms part of a broader range of OAB treatments rather than being the right treatment for every patient.

Management may include:

Conservative treatment

Bladder training, modification of fluid intake, reducing caffeine, weight management where appropriate and pelvic floor rehabilitation.

Medication

Antimuscarinic medications and beta-3 adrenergic agonists can reduce urgency, frequency and urgency incontinence.

Intravesical Botox

An effective minimally invasive treatment that does not require a permanent implant, but needs to be repeated when its effect wears off.

Tibial nerve stimulation

Electrical stimulation of the tibial nerve can modify the nerve pathways involved in bladder control.

Sacral neuromodulation

A small implanted device stimulates the sacral nerves controlling bladder function and can provide longer-term treatment for selected patients.

Current OAB guidelines recognise Botox, tibial nerve stimulation and sacral neuromodulation as established minimally invasive treatment options when conservative or pharmacological therapy has provided inadequate results or unacceptable side effects.

When should I consider bladder Botox?

You may wish to discuss Botox with your urologist if overactive bladder is having a significant effect on your quality of life and:

  • Bladder training and conservative measures have not provided adequate control
  • Medications have not worked sufficiently
  • Medication side effects are unacceptable
  • You do not wish to continue long-term medication
  • You would like to consider a minimally invasive treatment

The decision should take into account both the potential benefits and the possibility of urinary infection, incomplete bladder emptying and temporary catheterisation.

The bottom line

Intravesical Botox is an effective and well-established treatment for overactive bladder and urgency urinary incontinence.

For appropriately selected patients, it can significantly reduce urinary urgency, frequency and leakage and improve quality of life. Its main limitations are that the effect is temporary and repeat injections are usually required.

The two most important complications to understand are urinary tract infection and incomplete bladder emptying, with a small proportion of patients requiring temporary intermittent catheterisation.

A consultation with a urologist can help determine whether Botox, medication, tibial nerve stimulation, sacral neuromodulation or another treatment is most appropriate for your individual bladder symptoms.

This information is intended for general patient education and does not replace individual medical advice. Treatment recommendations should be based on assessment by an appropriately qualified healthcare professional.

So. if this sounds like an option for your overactive bladder, come see your friendly Brisbane Urologist, Uro-Jo, in either Brisbane, Caboolture or on Bribie Island

Sacral Neuromodulation for Urinary Incontinence and Bladder Dysfunction

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

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

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

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

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

What is sacral neuromodulation?

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

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

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

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

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

What conditions can sacral neuromodulation treat?

1. Overactive bladder

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

Typical symptoms include:

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

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

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

2. Urgency urinary incontinence

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

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

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

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

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

What about an underactive bladder?

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

Underactive bladder and urinary retention

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

Symptoms can include:

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

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

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

Obstruction must first be excluded

In men, urinary retention may be caused by:

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

In women, causes can include:

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

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

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

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

Who may benefit from sacral neuromodulation?

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

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

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

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

What treatments are usually tried first?

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

For overactive bladder these may include:

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

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

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

The appropriate pathway varies considerably between patients.

Assessment before sacral neuromodulation

Successful treatment begins with establishing the correct diagnosis.

Assessment may include:

Medical history

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

Bladder diary

A bladder diary can record:

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

Urine testing

Urinary infection should be excluded where appropriate.

Post-void residual measurement

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

Uroflowmetry

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

Cystoscopy

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

Urodynamic studies

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

How is sacral neuromodulation performed?

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

The procedure therefore generally takes place in two stages.

Stage 1: The test phase

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

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

The lead is then connected to an external stimulator.

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

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

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

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

Stage 2: Permanent implantation

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

The device is connected to the previously positioned sacral lead.

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

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

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

What does the stimulation feel like?

Patients may notice a mild:

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

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

The stimulation should not normally be painful.

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

How successful is sacral neuromodulation?

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

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

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

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

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

Sacral neuromodulation versus Botox

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

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

SNM instead modifies the neural pathways controlling bladder function.

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

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

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

Advantages of sacral neuromodulation

Potential advantages include:

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

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

What are the risks and possible complications?

Sacral neuromodulation is a surgical procedure and complications can occur.

These include:

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

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

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

What happens if the treatment stops working?

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

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

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

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

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

Battery life and rechargeable devices

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

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

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

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

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

What about MRI scans?

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

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

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

Is sacral neuromodulation suitable for both men and women?

Yes.

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

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

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

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

Overactive versus underactive bladder: one treatment, two different problems

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

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

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

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

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

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

When should sacral neuromodulation be considered?

Sacral neuromodulation may be worth discussing when:

Overactive bladder symptoms remain troublesome despite conservative and medical treatment

or

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

The key is appropriate patient selection.

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

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

The bottom line

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

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

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

Important information

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

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

Medical Therapy for Benign Prostate Enlargement: What Are the Options?

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Benign prostate enlargement, also called benign prostatic hyperplasia (BPH), is extremely common as men get older. An enlarged prostate can narrow the urinary channel and affect the way the bladder empties, producing what doctors call lower urinary tract symptoms (LUTS).

Typical symptoms include:

  • A slow or weak urinary stream
  • Difficulty starting urination
  • Stopping and starting during urination
  • Straining to pass urine
  • A feeling that the bladder has not emptied completely
  • Passing urine frequently
  • Urgency to urinate
  • Getting up several times during the night to urinate
  • Occasionally, complete inability to pass urine, known as acute urinary retention

Importantly, urinary symptoms are not always proportional to prostate size. A relatively small prostate can cause significant obstruction, while some men with very large prostates have surprisingly few symptoms.

Medication is often the first active treatment when symptoms become bothersome. The best medication depends on the type and severity of symptoms, prostate size, PSA, urinary flow, residual urine volume, blood pressure, sexual function and risk of future prostate enlargement or urinary retention.

Before Starting Medication

Before assuming that urinary symptoms are simply caused by an enlarged prostate, an appropriate assessment is important.

Depending on the individual patient, this may include:

  • Medical history and examination
  • International Prostate Symptom Score (IPSS)
  • Urinalysis
  • PSA blood test
  • Kidney function testing when indicated
  • Ultrasound assessment of the prostate and bladder
  • Measurement of post-void residual urine
  • Urinary flow-rate testing (uroflowmetry)
  • Bladder diary, particularly for frequency and nocturia
  • Further investigations such as cystoscopy or urodynamic studies in selected men

The aim is not simply to prescribe a tablet, but to determine what is actually causing the urinary symptoms.

1. Alpha-Blockers: Relaxing the Prostate

For many men requiring medication, an alpha-blocker is the first treatment considered.

Common examples include:

  • Tamsulosin
  • Silodosin
  • Terazosin and other less-selective alpha-blockers in selected circumstances

These medications relax smooth muscle around the prostate and bladder neck, reducing resistance to urinary flow.

How quickly do they work?

Alpha-blockers have a relatively rapid onset of action. Improvement can sometimes be noticed within days, although several weeks may be required to judge their full effect.

They may improve:

  • Urinary flow
  • Hesitancy
  • Straining
  • The sensation of incomplete emptying
  • Some storage symptoms

What alpha-blockers do NOT do

Alpha-blockers do not significantly shrink the prostate.

They improve the dynamic component of prostate obstruction but do not substantially alter the underlying growth of the prostate. Therefore, they do not provide the same long-term protection against urinary retention and BPH-related surgery as 5-alpha-reductase inhibitors.

Side effects of alpha-blockers

Possible adverse effects include:

  • Dizziness
  • Light-headedness
  • A fall in blood pressure when standing
  • Fatigue
  • Nasal congestion
  • Ejaculatory problems
  • Reduced or absent ejaculation, particularly with some prostate-selective agents

Men taking alpha-blockers should also tell their ophthalmologist before cataract surgery, as medications such as tamsulosin are associated with intraoperative floppy iris syndrome.

Do Alpha-Blockers Increase the Risk of Dementia?

The possible relationship between alpha-blockers and dementia has attracted attention, particularly with tamsulosin, which is one of the most commonly prescribed medications for prostate symptoms.

Some large observational studies have reported an association between tamsulosin or other alpha-blockers and a subsequent diagnosis of dementia or Alzheimer’s disease. One frequently cited retrospective study reported an approximately 17% higher relative rate of dementia among men taking tamsulosin compared with men with BPH receiving no medication.

However, this does not establish that tamsulosin causes dementia.

Subsequent studies have produced conflicting results. Some have found no increased risk, and others have suggested that apparent associations may be explained by differences in age, cardiovascular disease, diabetes, stroke, other medications, healthcare utilisation and the underlying BPH population itself.

A systematic review examining alpha-1 blockers and cognition found no convincing causal association between alpha-blocker treatment, including tamsulosin, and cognitive impairment or dementia.

More recent large-scale analyses have provided further reassurance. A network meta-analysis involving more than 3.6 million patients found that alpha-blockers were not significantly associated with an increased risk of dementia compared with no BPH treatment.

Therefore, based on the available evidence:

  • Dementia is not considered an established adverse effect of alpha-blocker therapy.
  • Earlier observational studies raised a possible association, particularly with tamsulosin.
  • More recent studies and systematic reviews have not demonstrated a convincing causal relationship.
  • Further long-term research is still appropriate, particularly because these medications are frequently prescribed to older men who already have a higher background risk of cognitive decline.

For men who already have mild cognitive impairment, dementia, significant frailty or a high risk of falls, medication choice deserves particular consideration. In this group, dizziness, postural hypotension and falls may themselves have important consequences, irrespective of whether alpha-blockers have any direct effect on cognition.

The decision to continue an alpha-blocker should therefore be based on the individual’s urinary benefit, cardiovascular status, fall risk, cognitive health and alternative treatment options.

2. 5-Alpha-Reductase Inhibitors: Shrinking the Prostate

The second major group of medications works very differently.

The two principal drugs are:

  • Finasteride
  • Dutasteride

Testosterone is converted within the prostate to the more potent androgen dihydrotestosterone (DHT) by the enzyme 5-alpha-reductase.

Finasteride predominantly inhibits type 2 5-alpha-reductase, while dutasteride inhibits both type 1 and type 2 enzymes.

Reducing DHT gradually causes the prostate to shrink.

Who benefits most?

These medications are particularly useful for men with an enlarged prostate and an increased risk of BPH progression.

Current guidance recommends considering a 5-alpha-reductase inhibitor in men with moderate-to-severe LUTS who have an increased risk of progression, particularly when the prostate is significantly enlarged.

How effective are they?

Over several years, 5-alpha-reductase inhibitors can:

  • Reduce prostate volume by approximately 18–28%
  • Improve urinary symptoms
  • Improve urinary flow
  • Reduce the risk of acute urinary retention
  • Reduce the likelihood of eventually requiring BPH surgery

Unlike alpha-blockers, however, they work slowly. It may take three to six months or longer before a meaningful improvement becomes apparent.

An Important Point About PSA

Finasteride and dutasteride reduce serum PSA by approximately 50% after 6–12 months of treatment.

This does not mean that prostate cancer screening can simply be stopped.

Instead, the PSA result needs to be interpreted in the context of treatment. A PSA that subsequently rises while a man is taking a 5-alpha-reductase inhibitor warrants appropriate evaluation.

Side Effects of Finasteride and Dutasteride

Potential side effects include:

  • Reduced libido
  • Erectile dysfunction
  • Reduced semen volume
  • Ejaculatory dysfunction
  • Breast tenderness
  • Breast enlargement or gynaecomastia

Sexual adverse effects are among the most clinically relevant side effects of 5-alpha-reductase inhibitors.

Mood changes have also received increasing attention. Regulatory authorities have strengthened warnings concerning mood changes and suicidal ideation with finasteride, while the relationship between 5-alpha-reductase inhibitors and psychiatric symptoms continues to be studied.

What Is “Post-Finasteride Syndrome”?

Post-finasteride syndrome (PFS) is the term used to describe a collection of sexual, physical and psychological symptoms reported by some patients that persist after finasteride has been discontinued.

Reported symptoms have included:

  • Persistent reduction in libido
  • Erectile dysfunction
  • Altered orgasm or ejaculation
  • Reduced genital sensation
  • Fatigue
  • Problems with concentration or “brain fog”
  • Anxiety
  • Depressed mood

Persistent symptoms after finasteride treatment have been reported, and patients experiencing them should not have their symptoms dismissed. However, “post-finasteride syndrome” remains a controversial and incompletely understood clinical entity. Its incidence, biological mechanism, causality and predisposing factors have not been definitively established.

The possibility of sexual and psychological adverse effects should therefore be discussed before treatment, without presenting PFS as an inevitable or precisely quantified consequence of taking finasteride.

Any patient developing significant mood disturbance, depression or suicidal thoughts while taking a 5-alpha-reductase inhibitor should seek medical assessment promptly.

3. Stepping Up Treatment: Combination Therapy

Some men obtain good initial improvement from an alpha-blocker but have a prostate that remains significantly enlarged.

This creates two separate treatment objectives:

1. Improve symptoms now
Relax the prostate and bladder neck with an alpha-blocker.

2. Reduce future progression
Shrink the prostate and reduce the risk of retention and surgery with a 5-alpha-reductase inhibitor.

This is where combination therapy becomes particularly useful.

4. Duodart: Tamsulosin + Dutasteride in One Capsule

Duodart combines:

  • Tamsulosin 400 micrograms
  • Dutasteride 500 micrograms

in a single daily capsule.

Tamsulosin

Relaxes smooth muscle in the prostate and bladder neck and can provide relatively rapid improvement in urinary symptoms.

Dutasteride

Reduces DHT and gradually shrinks the prostate, reducing the longer-term risk of BPH progression.

Combination treatment is particularly appropriate in men with moderate-to-severe urinary symptoms plus a significantly enlarged prostate or other features suggesting an increased risk of progression.

Side Effects of Duodart

Because Duodart contains two medications, side effects from both drug classes can occur.

Potential side effects include:

Sexual side effects

  • Reduced libido
  • Erectile dysfunction
  • Reduced semen volume
  • Ejaculatory dysfunction or failure to ejaculate normally

Blood-pressure-related effects

  • Dizziness
  • Light-headedness
  • Postural hypotension
  • Occasionally fainting

Other possible effects

  • Breast enlargement or tenderness
  • Nasal congestion
  • Gastrointestinal symptoms
  • Sleep disturbance
  • Palpitations
  • Weakness
  • Allergic reactions

Because Duodart contains tamsulosin, the same uncertainty regarding the possible association between alpha-blockers and dementia is relevant. At present, however, the evidence does not establish that tamsulosin or Duodart causes dementia.

Combination therapy generally produces more adverse effects than either medication alone, so the decision to escalate treatment should balance the likely long-term benefit against side effects and the patient’s priorities.

Is “post-finasteride syndrome” a risk with Duodart?

Strictly speaking, Duodart does not contain finasteride. It contains dutasteride.

Both drugs are 5-alpha-reductase inhibitors and have overlapping sexual adverse effects. Persistent symptoms following treatment with 5-alpha-reductase inhibitors have been reported, but the term post-finasteride syndrome specifically arose in relation to finasteride.

It is therefore more accurate when discussing Duodart to counsel patients about the possibility of sexual, psychological and other adverse effects associated with 5-alpha-reductase inhibition, rather than stating that Duodart causes “post-finasteride syndrome”.

5. Tadalafil: Particularly Useful When Erectile Dysfunction Is Also Present

Tadalafil 5 mg daily is another option for men with lower urinary tract symptoms, particularly when erectile dysfunction is also present.

Tadalafil can improve:

  • Urinary symptoms
  • Quality of life
  • Erectile function

It does not significantly reduce prostate size or provide the same evidence for prevention of urinary retention and future BPH surgery as a 5-alpha-reductase inhibitor.

Tadalafil must not be combined with nitrate medication because of the potential for a dangerous fall in blood pressure.

Common side effects include:

  • Headache
  • Facial flushing
  • Indigestion
  • Nasal congestion
  • Muscle or back discomfort

6. What If Urgency and Frequency Are the Main Problem?

Some men have predominantly bladder storage symptoms, including urgency, frequency, urge urinary incontinence and nocturia.

Once significant urinary retention has been excluded, additional bladder-directed medication may be appropriate.

Anticholinergic medications

Potential side effects include:

  • Dry mouth
  • Constipation
  • Blurred vision
  • Cognitive effects, particularly in older or cognitively vulnerable patients
  • Increased residual urine or urinary retention in selected men

The potential cognitive effects of anticholinergic medications are particularly relevant when treating older men, and the patient’s overall anticholinergic medication burden should be considered.

Beta-3 agonists

These medications relax the bladder during filling and can improve urgency and frequency. They may have fewer dry-mouth, constipation and cognitive concerns than anticholinergic therapy, although they have their own contraindications and potential adverse effects.

The Bottom Line

There is no single “best prostate tablet”.

Alpha-blockers work relatively quickly and improve urinary flow but do not substantially shrink the prostate. Although some observational studies have suggested a possible association between alpha-blockers, particularly tamsulosin, and dementia, current evidence does not demonstrate that alpha-blockers cause dementia.

Finasteride and dutasteride work more slowly but shrink an enlarged prostate and can reduce the long-term risk of urinary retention and surgery.

Duodart combines dutasteride and tamsulosin, providing both relatively rapid symptom control and longer-term treatment of prostate enlargement in appropriately selected men.

Tadalafil is particularly attractive when urinary symptoms coexist with erectile dysfunction.

Bladder-directed medication may be added when urgency and frequency remain problematic, although anticholinergic medications require particular caution in older men because of their potential cognitive effects.

The goal is not simply to make the prostate smaller. It is to achieve comfortable urination, protect bladder and kidney function, minimise medication-related side effects and preserve quality of life.

This information is intended for general patient education and does not replace individual medical assessment. Medication choice, dose and combinations should be discussed with your treating doctor or urologist.

So, if you have any issues with your flow, come and chat to your friendly Brisbane Urologist, Dr Jo Schoeman to discuss options

Ureteric Stents: Why They Are Used, Side Effects, Complications and Treatment Options

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A ureteric stent is a thin, flexible tube placed inside the ureter, the channel that carries urine from the kidney to the bladder. Stents are commonly used in urology to maintain drainage of urine from the kidney when the ureter is blocked, narrowed, injured or at risk of becoming obstructed.

Most ureteric stents are intended to be temporary. However, some patients with chronic or recurrent ureteric obstruction require long-term stenting, with either regular stent changes or specialised longer-term stents.

Although ureteric stents can be extremely effective at protecting kidney function, they can also cause bothersome urinary symptoms. Understanding why a stent is required, how long it needs to remain in place and what symptoms to expect can make the experience considerably easier.

What Does a Ureteric Stent Look Like?

The most commonly used stent is called a double-J stent or JJ stent.

It has:

  • one curled end positioned within the kidney
  • a straight section passing down the ureter
  • another curled end positioned within the bladder

The curls help prevent the stent from migrating upwards or downwards.

Urine can drain through the hollow centre of the stent and around its outside, allowing urine to bypass an area of narrowing or obstruction.

Why Might I Need a Ureteric Stent?

There are several reasons for inserting a ureteric stent.

1. Kidney and Ureteric Stones

Urinary stones are among the most common reasons for ureteric stent placement.

A stone lodged within the ureter can obstruct urine drainage and cause:

  • severe renal colic
  • swelling of the kidney, known as hydronephrosis
  • deterioration in kidney function
  • infection behind the obstruction

A stent may be inserted urgently to relieve the obstruction.

Stents are also commonly placed temporarily following ureteroscopy and laser treatment of urinary stones, particularly when there has been swelling, instrumentation or trauma to the ureter.

2. Infection Associated With an Obstructed Kidney

An obstructed and infected kidney can represent a urological emergency.

Patients may develop:

  • fever
  • chills or rigors
  • flank pain
  • nausea or vomiting
  • low blood pressure
  • sepsis

Urgent drainage of the kidney may be required using either:

a ureteric stent

or

a percutaneous nephrostomy tube, which drains the kidney externally through the back.

The infection is generally treated before definitive treatment of the underlying stone or obstruction.

3. Ureteric Stricture

A ureteric stricture is an abnormal narrowing of the ureter.

It may occur following:

  • previous surgery
  • stone disease
  • ureteroscopy
  • radiotherapy
  • inflammation
  • endometriosis
  • retroperitoneal fibrosis
  • previous ureteric injury

A stent can maintain drainage while the underlying problem is investigated or treated.

4. Following Ureteric Surgery

Stents are frequently placed after surgery involving the ureter to allow healing while maintaining urinary drainage.

Examples include:

  • ureteroscopy
  • ureteric reconstruction
  • ureteric reimplantation
  • pyeloplasty
  • treatment of ureteric injuries

The stent effectively acts as an internal splint while the ureter heals.

5. Cancer-Related Ureteric Obstruction

Tumours within the pelvis or abdomen can compress or invade the ureters.

Examples include cancers involving the:

  • prostate
  • bladder
  • cervix
  • uterus
  • ovary
  • bowel
  • lymphatic system

Ureteric obstruction can also occur from metastatic disease or enlarged lymph nodes.

In these circumstances, long-term ureteric drainage may be required to preserve kidney function.

6. Retroperitoneal Fibrosis

Retroperitoneal fibrosis is an uncommon condition in which inflammatory or fibrotic tissue develops around structures behind the abdominal cavity.

This tissue can surround and compress one or both ureters.

Some patients require prolonged ureteric stenting while the underlying condition is treated.

What Does Having a Ureteric Stent Feel Like?

Experiences vary considerably.

Some patients hardly notice their stent.

Others experience significant symptoms.

Collectively, these are often referred to as ureteric stent-related symptoms.

Common symptoms include:

Urinary frequency

You may need to urinate more frequently than normal.

Urinary urgency

There may be a sudden and sometimes uncomfortable urge to urinate.

Bladder discomfort

The lower end of the stent can irritate the bladder and produce discomfort or pressure.

Blood in the urine

A small amount of blood in the urine is common, particularly following physical activity.

The urine may vary from slightly pink to more obviously blood-stained.

Kidney or flank discomfort

Some patients experience discomfort in the kidney when urinating.

This can occur because bladder pressure during urination may be transmitted back towards the kidney along the stent.

Pain during or after urination

Discomfort may occur in the bladder, groin, urethra or kidney.

Symptoms may fluctuate and are often worse following strenuous physical activity.

Managing Ureteric Stent Symptoms

Treatment depends upon the severity and type of symptoms.

Maintain Appropriate Hydration

Maintaining normal hydration is generally helpful.

Excessive fluid intake, however, can sometimes worsen urinary frequency, urgency and kidney discomfort. The aim is usually adequate rather than excessive hydration, unless your doctor has advised otherwise.

Simple Pain Relief

Paracetamol or anti-inflammatory medication may be appropriate for some patients.

Anti-inflammatory medications are not suitable for everyone, particularly patients with certain kidney, stomach, cardiovascular or bleeding problems.

Your treating doctor can advise which medications are appropriate.

Alpha-Blockers

Medications such as tamsulosin may reduce stent-related discomfort in selected patients.

These medications relax smooth muscle within the urinary tract and may improve:

  • flank discomfort
  • urinary frequency
  • urinary urgency
  • pain associated with the stent

Possible side effects include dizziness and lowering of blood pressure.

Medication for Bladder Overactivity

When urinary urgency and frequency are particularly troublesome, medications used for an overactive bladder may occasionally help.

These include selected:

  • antimuscarinic medications
  • beta-3 agonists

The appropriate medication depends upon the patient’s symptoms and other medical conditions.

Adjusting Physical Activity

Exercise is usually safe with a ureteric stent unless your surgeon advises otherwise.

However, strenuous exercise may increase:

  • blood in the urine
  • flank discomfort
  • bladder irritation

Reducing the intensity of activity temporarily can sometimes make symptoms considerably more manageable.

Possible Complications of Ureteric Stents

Most stents function without major problems, but complications can occur.

Urinary Infection

A stent is a foreign body within the urinary tract and bacteria may colonise its surface.

Seek medical attention if you develop:

  • fever
  • chills or rigors
  • worsening flank pain
  • feeling significantly unwell
  • persistent burning during urination

Urine testing and antibiotics may be required.

Stent Migration

Occasionally a stent moves from its intended position.

It can migrate towards the kidney or bladder and may no longer provide adequate drainage.

Imaging and repositioning or replacement may be required.

Stent Blockage

Stents can occasionally become blocked by:

  • blood clots
  • stone fragments
  • urinary debris
  • encrustation

If obstruction is significant, the stent may need to be replaced.

Encrustation and Stone Formation

Minerals within the urine gradually deposit onto the surface of a stent.

This process is known as encrustation.

The risk increases the longer a stent remains in place.

Severe encrustation can make stent removal considerably more complicated and may require additional endoscopic or stone procedures.

The Forgotten Stent

One of the most important complications is a stent inadvertently being left in place for much longer than intended.

A forgotten stent may become:

  • heavily encrusted
  • blocked
  • infected
  • fragmented
  • surrounded by stone formation

Removal can then require several procedures.

If you have a ureteric stent, you should know when it is expected to be removed or changed.

Many urology practices maintain a formal stent registry or reminder system for this reason.

When Should You Seek Urgent Medical Attention?

Contact your treating team or seek urgent medical assessment if you develop:

  • fever or rigors
  • severe or increasing kidney pain
  • inability to pass urine
  • persistent heavy bleeding or blood clots
  • persistent vomiting
  • significant deterioration in your general condition
  • severe pain that is not controlled with prescribed medication

Fever associated with an obstructed urinary system requires particularly prompt assessment.

How Long Can a Ureteric Stent Stay In?

There is no single answer because it depends upon:

  • why the stent was inserted
  • the type and material of the stent
  • stone-forming tendency
  • infection
  • pregnancy
  • cancer treatment
  • kidney function
  • the manufacturer’s recommended indwelling time

Some temporary stents remain in place for only a few days or weeks.

Other stents designed for longer-term drainage may remain for several months before planned replacement.

A stent should therefore never simply be assumed to be safe indefinitely. Follow the removal or replacement schedule provided by your urologist.

Temporary Ureteric Stents

The majority of ureteric stents are temporary polymer JJ stents.

They may be used:

  • after stone surgery
  • following ureteroscopy
  • after reconstructive surgery
  • while ureteric inflammation settles
  • while awaiting definitive treatment of an obstruction

Once the ureter has healed or the underlying obstruction has been treated, the stent is removed.

How Is a Ureteric Stent Removed?

Short-term stents may occasionally have a fine string attached to the end of the stent. This allows removal without another cystoscopic procedure in appropriately selected patients.

Most stents without strings are removed using flexible cystoscopy.

A small flexible telescope is passed through the urethra into the bladder. The lower end of the stent is identified, grasped and gently removed.

This is commonly performed as a short outpatient procedure using local anaesthetic gel.

What if Long-Term or Permanent Drainage Is Required?

Some causes of ureteric obstruction cannot easily be corrected.

In these circumstances, maintaining kidney drainage becomes a long-term management issue.

Options include:

Regularly Changed Polymer Stents

A conventional JJ stent can remain a long-term solution provided it is changed at appropriate intervals.

The disadvantage is the need for repeated procedures.

Long-Term or Metallic Ureteric Stents

Specialised metallic or reinforced stents may be considered in selected patients with chronic ureteric obstruction.

These are designed to resist external compression and, depending upon the particular device and clinical circumstances, may allow longer intervals between changes.

They can be particularly useful in selected cases of:

  • malignant ureteric obstruction
  • retroperitoneal fibrosis
  • recurrent benign ureteric strictures

They are not suitable for every patient and still require ongoing urological surveillance.

Percutaneous Nephrostomy

When a ureteric stent cannot be inserted, repeatedly fails or does not provide adequate drainage, a nephrostomy tube may be required.

This is inserted through the skin directly into the kidney and drains urine externally into a collection bag.

Definitive Reconstructive Surgery

For suitable patients with benign obstruction, correcting the underlying problem may be preferable to lifelong stenting.

Depending upon the location and length of the obstruction, options may include:

  • pyeloplasty
  • ureteric reimplantation
  • ureteroureterostomy
  • bladder flap reconstruction
  • bowel interposition
  • other specialised ureteric reconstruction

The aim is to restore natural urinary drainage and eliminate the need for a permanent stent.

Temporary Versus Long-Term Stenting

Temporary Stent Long-Term Stenting
Typical indication Stones, surgery, temporary obstruction Chronic benign or malignant obstruction
Common stent Polymer JJ stent Regularly changed polymer or specialised long-term stent
Duration Days to months Potentially years with planned surveillance/exchange
Replacement required? Usually removed once no longer needed Yes, according to stent type and clinical situation
Main concern Symptoms, infection, migration Encrustation, blockage, infection and repeated procedures
Alternative Removal after definitive treatment Reconstruction or nephrostomy in selected patients

Is There Really a “Permanent” Ureteric Stent?

The term permanent stent can be misleading.

A patient may require permanent ureteric drainage, but this does not necessarily mean that the same stent remains in place permanently.

Most long-term stent strategies require:

  • regular clinical review
  • monitoring of kidney function
  • periodic imaging when appropriate
  • surveillance for infection or obstruction
  • planned stent exchange according to the type of device being used

The objective is not simply to keep a stent in indefinitely, but to maintain safe and reliable drainage of the kidney.

Living With a Ureteric Stent

A ureteric stent can be an extremely useful device. It can relieve obstruction, control an emergency situation and protect kidney function while allowing definitive treatment to be planned.

Unfortunately, stents are not always comfortable.

Urinary frequency, urgency, blood in the urine and intermittent bladder or kidney discomfort are relatively common. These symptoms do not necessarily mean something is wrong with the stent, and several strategies and medications can make them easier to tolerate.

The most important questions to know after having a stent inserted are:

Why was my stent inserted?

When should it be removed or changed?

What symptoms should prompt me to seek medical attention?

If you are uncertain about any of these, contact your urologist or treating team.

This information is intended for general patient education and does not replace individual medical advice. The appropriate type and duration of ureteric stenting depends upon the cause of obstruction, kidney function, infection risk and individual patient circumstances.

Come chat to Dr Jo Schoeman your friendly Brisbane based Urologist to discuss your stent issues.

Minimally Invasive Prostate Biopsy

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A prostate biopsy is the definitive test used to determine whether abnormal prostate cells are cancerous. Modern biopsy techniques have changed significantly. Rather than routinely passing biopsy needles through the rectum, prostate tissue can now be sampled through the skin of the perineum, the small area between the scrotum and anus.

The TP Pivot Pro™ is a specialised needle-guidance system designed to facilitate a freehand transperineal prostate biopsy. It allows the biopsy needle to be accurately directed into different areas of the prostate using real-time ultrasound guidance, while requiring only a small number of skin puncture sites.

The transperineal approach has become increasingly attractive because it provides excellent access to the prostate while substantially reducing the risk of infection associated with passing biopsy needles through the rectum.

Why Might I Need a Prostate Biopsy?

A raised PSA does not automatically mean prostate cancer. PSA may also rise because of benign prostate enlargement, inflammation, infection, recent instrumentation or other factors.

A biopsy is generally recommended when the overall clinical picture suggests a meaningful risk of prostate cancer.

This may include:

  • A persistently or progressively elevated PSA
  • An abnormal prostate examination
  • A suspicious lesion identified on multiparametric MRI
  • An increased PSA density, which relates the PSA level to prostate volume
  • A strong family history or other recognised prostate cancer risk factors
  • Persistent suspicion of prostate cancer despite a previous negative biopsy
  • The need to reassess a known prostate cancer as part of an active surveillance programme

Modern guidelines recommend performing prostate MRI before biopsy in most men suspected of having localised prostate cancer. MRI findings, PSA density and other individual risk factors can then be combined to determine whether biopsy is appropriate. In selected men with a negative MRI and low clinical risk, biopsy may safely be avoided in favour of PSA surveillance.

What Is a TP Pivot Pro™ Transperineal Biopsy?

TP Pivot Pro™ is a single-use needle guidance device that attaches to the transrectal ultrasound probe used to visualise the prostate.

Importantly, although the ultrasound probe sits within the rectum to provide the image, the biopsy needle does not pass through the rectum.

Instead, the biopsy needle passes through the cleaned skin of the perineum.

The device incorporates an adjustable, pivoting needle guide. This allows the surgeon to change the angle and height of the biopsy needle and reach different parts of the prostate while maintaining ultrasound visualisation.

Why Use a Transperineal Approach?

Historically, many prostate biopsies were performed transrectally. During a transrectal biopsy, the needle passes from the rectum directly into the prostate.

The bowel naturally contains large numbers of bacteria. Passing multiple biopsy needles through the rectal wall therefore introduces a small but important risk of urinary infection, prostatitis and occasionally serious bloodstream infection or sepsis.

With a transperineal biopsy, the needle passes through disinfected skin instead.

A major randomised clinical trial comparing contemporary transperineal and transrectal biopsies reported no significant infections among 372 men undergoing transperineal biopsy, compared with an infection rate of 1.6% after transrectal biopsy. Cancer detection was similar between the two approaches.

The transperineal route also provides very good access to areas of the prostate that may sometimes be more difficult to sample transrectally, particularly the anterior and apical regions.

How Is the Biopsy Performed?

1. MRI and Biopsy Planning

Whenever appropriate, a multiparametric MRI of the prostate is performed before biopsy.

The MRI identifies areas that look suspicious for clinically significant prostate cancer. These are usually reported using the PI-RADS system, ranging from PI-RADS 1 to PI-RADS 5.

MRI information can then be used to guide targeted biopsy samples. Current European guidelines recommend combining targeted biopsy with appropriate regional or perilesional sampling when suspicious MRI abnormalities are present.

2. Anaesthesia

Transperineal biopsy can be performed using:

Local anaesthetic, sedation or general anaesthesia, depending on the clinical circumstances, patient preference and the technique used.

The TP Pivot Pro™ system is specifically designed to facilitate a minimally invasive freehand approach and can be used under local or general anaesthesia.

3. Ultrasound Examination

An ultrasound probe is gently inserted into the rectum.

The probe produces real-time images of the prostate, allowing the surgeon to see:

  • The prostate gland
  • Its boundaries
  • The urethra
  • The prostate apex and base
  • The planned path of the biopsy needle

The ultrasound probe is used for imaging only. The biopsy needle itself enters through the perineal skin.

4. The TP Pivot Pro™ Guide Is Positioned

The TP Pivot Pro™ biopsy guide is securely attached to the ultrasound probe.

Its pivoting mechanism allows the surgeon to alter the trajectory of the introducer needle while watching its position on the ultrasound image.

This makes it possible to reach different regions of the prostate through a very small number of skin access points.

5. Biopsy Samples Are Taken

A biopsy needle is passed through the introducer and into the prostate under direct ultrasound guidance.

Each activation of the biopsy device removes a very thin cylinder of prostate tissue known as a core.

Two complementary types of biopsy may be performed.

Targeted biopsies sample abnormalities seen on MRI.

Regional or systematic biopsies sample predetermined regions of the prostate to reduce the chance of missing important cancer elsewhere in the gland.

Modern 2026 European prostate cancer guidelines favour MRI-informed targeted and regional sampling rather than simply performing the same systematic biopsy pattern in every patient.

How Long Does the Procedure Take?

The exact time varies depending on prostate size, MRI findings and the number of biopsies required.

The procedure itself is generally relatively short, although additional time is required for preparation, anaesthesia and observation afterwards.

Most patients undergoing an uncomplicated biopsy can return home the same day.

What Happens to the Biopsy Samples?

Each biopsy core is sent to a specialist anatomical pathologist.

The pathologist determines:

  • Whether cancer is present
  • How much cancer is present in each core
  • The type of cancer
  • The aggressiveness or Grade Group of the cancer
  • The percentage or length of each biopsy involved
  • Whether other important microscopic features are present

Prostate cancer is commonly reported using ISUP Grade Groups 1 to 5.

Broadly speaking, Grade Group 1 represents the least aggressive pattern, while Grade Group 5 represents the most aggressive.

The biopsy result is then interpreted alongside the PSA, MRI findings, prostate examination, prostate volume and the patient’s overall health.

What Are the Advantages of TP Pivot Pro™?

Potential advantages of this minimally invasive transperineal technique include:

  • Very low risk of serious infection
  • Avoidance of passing biopsy needles through the rectum
  • Excellent access to the anterior, posterior and apical prostate
  • Accurate targeting under real-time ultrasound guidance
  • Ability to combine MRI-targeted and regional biopsies
  • A small number of perineal skin punctures
  • Ability to perform the procedure under local anaesthetic in appropriate patients
  • A freehand technique that allows the needle trajectory to be adjusted during the procedure

The Pivot Pro™ does not itself diagnose cancer. It is a guidance system that assists the surgeon in accurately performing a transperineal biopsy.

Possible Complications

Transperineal prostate biopsy is generally well tolerated, but no biopsy is completely risk-free.

Blood in the Urine

A small amount of blood in the urine is common after biopsy and usually settles without treatment.

Drinking adequate fluids can help unless you have been advised to restrict your fluid intake for another medical reason.

Blood in the Semen

Blood in the semen is also common after prostate biopsy.

The semen may appear pink, red, brown or rust-coloured. This can persist intermittently for several weeks and is usually harmless.

Bruising or Minor Bleeding

Some bruising or tenderness can occur around the perineal puncture sites.

Significant bleeding is uncommon.

Difficulty Passing Urine

Temporary swelling of the prostate after biopsy can occasionally make urination difficult.

Rarely, acute urinary retention occurs and a temporary urinary catheter is required.

The risk may be greater in men with a particularly large prostate, significant pre-existing urinary symptoms or when a large number of biopsy cores are required.

In the PREVENT randomised trial, urinary retention requiring intervention occurred in approximately 0.3% of men undergoing transperineal biopsy, although rates vary between different biopsy techniques and patient populations.

Infection

Infection remains possible, but it is one of the major areas in which transperineal biopsy offers an advantage.

Because the biopsy needle does not pass through the bacteria-rich rectum, the risk of infection and sepsis is substantially lower than with the traditional transrectal route.

In the PREVENT trial, there were zero grade 2 or greater infections in the transperineal biopsy group, compared with 1.6% following transrectal biopsy.

Your surgeon will advise whether antibiotics are required according to the procedure being performed and local protocols.

When Should I Seek Medical Attention After My Biopsy?

Contact your surgeon or seek urgent medical assessment if you develop:

  • Fever, chills or shaking
  • Increasing difficulty passing urine
  • Complete inability to urinate
  • Heavy or persistent bleeding
  • Large blood clots in the urine
  • Increasing pain or swelling
  • Feeling significantly unwell

Although serious infection is uncommon after transperineal biopsy, a fever or systemic illness following any prostate biopsy should be assessed promptly.

What Happens After the Prostate Biopsy?

The next step depends entirely on the pathology result.

No Cancer Is Found

A negative biopsy is reassuring, but it does not reduce the future risk of prostate cancer to zero.

Your urologist will consider:

PSA levels and PSA trend, MRI findings, PSA density, prostate size, family history, the adequacy of the biopsy and your overall prostate cancer risk.

Depending on these findings, management may involve routine PSA surveillance, repeat MRI or, less commonly, another biopsy if clinical suspicion remains high.

Low-Risk Prostate Cancer Is Found

Not every prostate cancer needs immediate treatment.

Men with low-risk prostate cancer, and selected men with favourable intermediate-risk disease, may be suitable for active surveillance.

Active surveillance typically involves repeated PSA testing, clinical review, MRI and repeat biopsy when appropriate.

The aim is to monitor the cancer carefully and offer treatment only if there is evidence that it is becoming more significant. Current guidelines continue to recommend active surveillance as the preferred approach for many men with low-risk prostate cancer.

Clinically Significant Prostate Cancer Is Found

If the biopsy demonstrates clinically significant cancer, the next step is to determine:

  • The Grade Group
  • The amount of cancer present
  • Whether the cancer appears confined to the prostate
  • Whether additional staging investigations are required
  • Your PSA level
  • Your age and general health
  • Your personal treatment priorities

Some men will undergo further imaging such as PSMA PET/CT before deciding on treatment, particularly when higher-risk disease is identified.

Treatment options may include:

Active surveillance, robotic-assisted radical prostatectomy, radiotherapy, sometimes combined with hormonal therapy, or other treatments depending on the individual situation.

There is rarely a single treatment that is correct for every man. Management should be tailored to the biological behaviour of the cancer and the patient’s individual priorities.

From PSA to Diagnosis: The Modern Prostate Cancer Pathway

Abnormal PSA or clinical concern
↓
Repeat PSA and individual risk assessment
↓
Multiparametric MRI
↓
MRI and PSA-density assessment
↓
Biopsy recommended if clinically appropriate
↓
TP Pivot Pro™ transperineal targeted ± regional biopsy
↓
Pathology result
↓
No cancer → surveillance / reassessment
Low-risk cancer → consider active surveillance
Clinically significant cancer → staging and treatment discussion

Frequently Asked Questions

Is a transperineal prostate biopsy painful?

Local anaesthetic significantly reduces discomfort. Patients commonly notice pressure, vibration or the clicking of the biopsy device rather than sharp pain. Sedation or general anaesthesia can be used in appropriate circumstances.

Does the needle go through the rectum?

No. The ultrasound probe sits in the rectum to create the images, but the biopsy needle enters through the skin of the perineum.

Can the biopsy find cancers at the front of the prostate?

Yes. One of the advantages of the transperineal approach is excellent access to anterior and apical regions of the prostate.

Does everyone with a high PSA need a biopsy?

No. PSA is only one part of the assessment. Repeat PSA measurement, prostate examination, MRI, PSA density, family history and other risk factors may all influence whether biopsy is necessary.

Can an MRI replace a prostate biopsy?

MRI is extremely useful but cannot currently provide the same definitive information as examination of prostate tissue under a microscope. In selected low-risk men with a reassuring MRI, biopsy can sometimes be avoided or deferred. When clinically significant prostate cancer remains suspected, tissue biopsy remains the standard method of confirming the diagnosis.

How long will it take to receive my results?

Timing varies between pathology laboratories. Your urologist will normally arrange a follow-up appointment to discuss the pathology rather than relying on the written report alone.

A More Precise Way to Investigate Prostate Cancer

The goal of modern prostate biopsy is not simply to take more samples. It is to obtain the right samples from the right areas of the prostate while minimising unnecessary risk.

Combining high-quality prostate MRI with a minimally invasive transperineal technique such as TP Pivot Pro™ allows suspicious lesions and relevant regions of the prostate to be sampled accurately without repeatedly passing biopsy needles through the bowel.

For appropriate patients, this represents an important evolution in the diagnosis of prostate cancer: MRI-informed, targeted, transperineal and focused on reducing complications while preserving diagnostic accuracy.

This information is intended for general education and does not replace individual medical advice. The need for prostate biopsy, choice of anaesthesia, biopsy technique and subsequent treatment should be discussed with your urologist.

Come review with your friendly Brisbane Based Urologist Dr Jo Schoeman (Uro-Jo) to discuss this minimal invasive option.

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

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Some degree of penile curvature can be completely normal. However, when a new or increasing curve develops — particularly when accompanied by pain, a noticeable lump or difficulty with sexual intercourse — it may be caused by a condition known as Peyronie’s disease.

Peyronie’s disease is a urological condition caused by the development of fibrous scar tissue, known as plaque, within the penis. This can affect the shape, length and function of the penis during an erection.

For some men the condition causes relatively minor symptoms. For others, the curvature can become significant enough to affect sexual function and quality of life.

What Is Peyronie’s Disease?

Peyronie’s disease occurs when an area of fibrous scar tissue develops within the tissue surrounding the erectile chambers of the penis.

Because this scar tissue does not stretch normally during an erection, one area of the penis may expand less than the surrounding tissue. This can result in the penis bending towards the affected side.

Changes may include:

  • Penile curvature during an erection
  • A hard lump or area of thickened tissue
  • Pain during erections
  • Shortening or narrowing of the penis
  • An indentation or hourglass appearance
  • Difficulty with sexual intercourse
  • Erectile dysfunction

The degree of curvature varies considerably between individuals.

What Causes Peyronie’s Disease?

The exact cause is not always clear.

In some cases, Peyronie’s disease is thought to develop following injury or repeated minor trauma to the penis. Healing following these injuries may result in abnormal scar tissue formation.

However, many men diagnosed with Peyronie’s disease do not remember experiencing a specific injury.

Certain factors may increase the likelihood of developing the condition, including age, family history and some connective tissue disorders.

Is a Curved Penis Always Peyronie’s Disease?

No.

Some men naturally have a degree of penile curvature that has been present since adolescence or early adulthood. This is known as congenital penile curvature and is different from Peyronie’s disease.

A curve is more suggestive of Peyronie’s disease when it develops later in life or changes progressively over time, particularly if there is associated pain or a palpable area of hardened tissue.

A urologist can help determine the cause.

Does Peyronie’s Disease Cause Erectile Dysfunction?

Peyronie’s disease and erectile dysfunction can occur together.

The physical changes caused by Peyronie’s disease may make maintaining an erection more difficult in some men. Significant curvature can also interfere mechanically with sexual intercourse.

There can also be a psychological component. Concern about pain, appearance or sexual performance may contribute to difficulties with erections.

For this reason, assessment often considers both the physical curvature and overall erectile function.

Does Peyronie’s Disease Get Worse?

Peyronie’s disease commonly develops in stages.

During the earlier or active phase, curvature may continue to change and pain may be present during erections.

Eventually, the condition may enter a more stable phase in which the curvature stops progressing and pain often improves.

Not every patient follows exactly the same pattern, which is why treatment recommendations depend on the individual’s symptoms and stage of disease.

How Is Peyronie’s Disease Diagnosed?

Diagnosis usually begins with a medical history and physical examination.

A urologist may assess the location and size of the plaque and the degree of penile curvature.

In some circumstances, photographs of the erect penis or specialised ultrasound imaging may be useful to assess the curvature, blood flow and erectile tissue.

How Is Peyronie’s Disease Treated?

Treatment depends on several factors, including:

  • Severity of the curvature
  • Whether the condition is stable or progressing
  • Presence of pain
  • Erectile function
  • Whether sexual intercourse is affected
  • How much the condition is affecting quality of life

Not every patient requires active treatment.

Observation

Mild Peyronie’s disease that does not cause significant pain or interfere with sexual function may sometimes be monitored.

Penile Traction Therapy

Specialised traction devices may be recommended for selected patients.

These devices apply controlled stretching over time and may help improve curvature or preserve penile length in appropriate cases.

Medications and Other Treatments

Various medical treatments have been investigated for Peyronie’s disease. Their suitability and effectiveness depend on the individual patient and stage of the condition.

A urologist can discuss which evidence-based options may be appropriate.

Surgery

Surgery may be considered when curvature is significant, the condition has stabilised and sexual intercourse is difficult or impossible.

Different surgical techniques are available depending on the degree of curvature, penile length and erectile function.

These can include procedures that straighten the penis, grafting procedures and, in selected patients who also have significant erectile dysfunction, penile prosthesis surgery.

When Should You See a Urologist?

Consider seeking a urological assessment if you notice:

  • A new curve developing during erections
  • Increasing penile curvature
  • Pain during erections
  • A hard lump or plaque within the penis
  • Penile shortening or narrowing
  • Difficulty having sexual intercourse because of curvature
  • Erectile dysfunction occurring alongside these changes

Early assessment can help establish whether the changes are caused by Peyronie’s disease or another condition and determine whether treatment or monitoring is appropriate.

Peyronie’s Disease Is a Treatable Urological Condition

Men can be reluctant to discuss changes involving the penis, even with their doctor.

However, Peyronie’s disease is a recognised medical condition and something urologists routinely assess and treat.

Treatment is not necessary for every patient, but when penile curvature causes pain, erectile difficulties or problems with sexual intercourse, several treatment approaches may be available.

If you have noticed a new or worsening penile curvature, speaking with a urologist can help determine the cause and the most appropriate next step.

This information is general in nature and does not replace individual medical advice.

Come chat with your local Brisbane based Urologist, Dr Jo, to discuss options with you.