Protecting the Rectum During Prostate Radiotherapy: A Patient Guide

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Radiotherapy is an established treatment for many men with prostate cancer. Modern planning and image-guidance techniques can direct radiation accurately, but the prostate lies immediately in front of the rectum. Because the two organs are so close, part of the rectal wall may receive radiation during treatment.

Radiation teams use several methods to limit exposure to surrounding healthy tissue. For selected patients, one option is to place a temporary biodegradable material between the prostate and rectum before radiotherapy planning.

This article explains why bowel effects occur, how rectal spacing works, its possible benefits and limitations, and the questions patients should discuss with their treating team. It does not recommend a particular product, device or brand.

Why can prostate radiotherapy affect the bowel?

The front wall of the rectum normally sits very close to the back of the prostate. Radiation directed at the prostate may therefore also reach a small amount of nearby rectal tissue.

Possible bowel effects during or after radiotherapy include:

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

Many bowel symptoms are mild and settle after treatment, but some develop later or persist. Risk varies with the radiation technique, dose, fractionation schedule, individual anatomy, bowel health, medicines and previous pelvic treatment.

Rectal bleeding after radiotherapy should not automatically be attributed to radiation. Other causes, including haemorrhoids, polyps, inflammatory bowel disease and bowel cancer, may require investigation.

How is the rectum protected?

Protection begins with careful radiotherapy planning rather than with a spacer alone. Strategies may include:

  • intensity-modulated or volumetric-modulated radiotherapy
  • image guidance before and during treatment
  • accurate bladder and bowel preparation
  • management of rectal gas or stool
  • individualised dose constraints
  • limiting movement of the prostate
  • selecting an appropriate radiation schedule
  • a temporary rectal spacer in selected patients

A spacer is therefore an additional planning tool, not a substitute for high-quality radiation oncology.

What is a rectal spacer?

A rectal spacer is a temporary biodegradable material placed into the tissue plane between the prostate and the anterior rectal wall. Increasing this distance may reduce the radiation dose received by the rectum.

Materials used in currently available spacer systems include:

  • polyethylene-glycol hydrogel
  • stabilised hyaluronic-acid gel

These materials have different handling and imaging characteristics. They should not be assumed to have identical evidence, contraindications or safety profiles.

A spacer does not treat prostate cancer. Its role is to alter the anatomy temporarily while radiation treats the cancer.

Do all men having prostate radiotherapy need a spacer?

No. Many patients can receive carefully planned radiotherapy without one.

Potential benefit depends on factors such as:

  • the natural distance between the prostate and rectum
  • prostate size and shape
  • tumour position and extent
  • radiation dose and treatment schedule
  • the ability to meet rectal dose constraints without a spacer
  • previous prostate or pelvic procedures
  • bowel disease
  • bleeding risk and relevant medicines
  • whether pelvic lymph nodes are also being treated
  • local expertise and access

For some patients, the predicted reduction in rectal dose may be clinically meaningful. For others, the benefit may be small, uncertain or outweighed by the insertion risk.

The decision is usually made with the radiation oncologist. A urologist or another trained proceduralist may also be involved.

What does the evidence show?

Clinical studies of biodegradable rectal spacers generally show that increasing the distance between the prostate and rectum can reduce the radiation dose delivered to parts of the rectal wall.

A multicentre randomised trial involving 201 men receiving hypofractionated prostate radiotherapy evaluated a hyaluronic-acid spacer. The study reported improved rectal dosimetry and fewer acute grade 2 or worse gastrointestinal adverse events in the spacer group than in the control group.

These findings are relevant but require context:

  • dosimetric improvement does not guarantee that an individual patient will avoid bowel symptoms
  • trial participants and treatment protocols may differ from patients treated in routine practice
  • evidence for short-term bowel outcomes is stronger than evidence for some long-term outcomes
  • results for one spacer material or insertion technique should not automatically be applied to another
  • operator experience and correct placement affect both benefit and risk

Patients should ask how the published evidence applies to their planned radiotherapy technique and personal anatomy.

How is a spacer inserted?

The procedure is generally performed before radiotherapy planning.

Under ultrasound guidance, a needle is passed through the perineum—the skin between the scrotum and anus—into the potential space between the prostate and rectum. The tissue plane is checked carefully, and the spacer material is then introduced while its position is monitored.

Depending on the patient and treating centre, the procedure may use:

  • local anaesthesia
  • sedation
  • general anaesthesia

Fiducial markers used to help target radiotherapy may sometimes be inserted during the same procedure.

The exact preparation, antibiotic policy, management of anticoagulants and post-procedure care vary. Patients should follow the instructions given by their treating team.

Why does correct placement matter?

The spacer needs to create suitable separation along the part of the rectum closest to the planned radiation target. Too little separation, marked asymmetry or injection into the wrong tissue plane may reduce the expected dosimetric benefit.

Incorrect placement may also injure the rectal wall, prostate, urethra, bladder or nearby blood vessels. Training, real-time imaging, careful patient selection and recognition of abnormal anatomy are therefore important.

Some hyaluronic-acid materials can be broken down with an enzyme if significant malposition is recognised. This does not make incorrect placement harmless or remove the need for prevention, prompt assessment and appropriate management.

Who may be unsuitable?

Suitability depends on the particular device instructions, the patient’s anatomy and the clinical situation. Reasons to avoid or reconsider insertion may include:

  • infection or inflammation near the proposed injection site
  • inability to identify a safe tissue plane
  • tumour extending into the space behind the prostate
  • extensive scarring from previous surgery or treatment
  • significant rectal or anorectal disease
  • uncorrected bleeding disorder
  • anticoagulant or antiplatelet therapy that cannot be managed safely
  • allergy or hypersensitivity relevant to the proposed material
  • significant immunosuppression
  • a situation in which the expected dosimetric benefit is minimal

The approved Australian instructions for use for the exact device should be checked by the treating clinician.

Anticoagulant and antiplatelet medicines must not be stopped without advice from the clinician who manages them. Interrupting these medicines can cause stroke, heart attack, thrombosis or other serious harm.

Possible short-term effects

Temporary effects may include:

  • perineal discomfort or bruising
  • minor bleeding
  • a sensation of rectal fullness
  • discomfort when opening the bowels
  • urinary frequency or burning
  • a weaker urinary stream
  • constipation

The pattern and duration vary. New, severe or worsening symptoms require clinical review.

Uncommon but important complications

Spacer insertion is invasive and can cause serious complications, even when performed carefully.

Reported or plausible complications include:

  • infection, prostatitis or pelvic abscess
  • bleeding or haematoma
  • urinary retention
  • significant rectal or pelvic pain
  • spacer malposition or migration
  • injection into the rectal wall, prostate or another unintended site
  • injury to the urethra, bladder, rectum or blood vessel
  • rectal ulceration or tissue necrosis
  • embolic or vascular complications
  • fistula formation
  • need for further treatment, hospital admission or surgery

Severe pain, fever, difficulty passing urine, heavy bleeding, worsening bowel symptoms or feeling systemically unwell after the procedure should be assessed promptly.

What happens to the spacer?

Biodegradable spacers are intended to remain during the radiotherapy period and then gradually break down and be absorbed.

The expected duration and degradation process depend on the material. A second operation is not normally required solely to remove an appropriately placed biodegradable spacer.

Different spacer materials

The choice should not be reduced to a promotional comparison between brand names. Relevant clinical differences may include:

Consideration Hyaluronic-acid gel Polyethylene-glycol hydrogel
Primary purpose Temporary prostate–rectum separation Temporary prostate–rectum separation
Typical placement Transperineal, image-guided Transperineal, image-guided
Biodegradable Yes Yes
Handling Deposited and shaped during injection Forms a hydrogel after delivery
Imaging Visibility depends on material and imaging method Some formulations are designed for greater CT visibility
Evidence Randomised and observational studies are available Randomised, prospective and observational studies are available
Key limitation Insertion-related risk and dependence on correct placement Insertion-related risk and dependence on correct placement

This table is descriptive, not a claim that one material is safer or more effective. Head-to-head observational comparisons may be affected by patient selection, injected volume, operator technique, learning curve and treatment planning. They cannot by themselves establish universal superiority.

What about previous surgery or salvage radiotherapy?

Previous prostate procedures, pelvic surgery, focal therapy, radiotherapy or inflammation may alter the tissue plane behind the prostate. This can make placement more difficult or unsuitable.

The evidence for spacers in salvage or re-irradiation settings is less established than for primary prostate radiotherapy. These cases require individual assessment in an experienced multidisciplinary setting.

Questions to ask before deciding

  • What bowel risks are associated with my proposed radiotherapy plan?
  • Can the required rectal dose limits be met without a spacer?
  • What additional benefit is expected in my anatomy?
  • What spacer material is proposed, and is the exact device included in the ARTG for this intended use?
  • What evidence supports it for my radiation schedule?
  • Who will perform the procedure, and what is their experience?
  • What are the recognised contraindications and complications?
  • How will my anticoagulant or antiplatelet medicines be managed?
  • What symptoms after insertion require urgent review?
  • What are the alternatives if I choose not to have a spacer?
  • Are there additional costs or gaps?

Australian regulatory considerations

The Australian Register of Therapeutic Goods (ARTG) is the public database of therapeutic goods that may be legally supplied in Australia, unless an exemption or another authorised access pathway applies. An ARTG entry records the particular sponsor and intended purpose; it is not a general recommendation that the product is best for an individual patient.

Device inclusion, instructions for use, contraindications, availability and reimbursement can change. The treating team should confirm the current ARTG entry and approved instructions for the exact device proposed.

The bottom line

The rectum lies close to the prostate and may receive some radiation during prostate-cancer treatment. Modern planning and image guidance are the foundation of rectal protection.

A biodegradable rectal spacer can create temporary separation and may reduce rectal radiation exposure in selected patients. It does not treat the cancer, cannot guarantee freedom from bowel effects and introduces procedural risks of its own.

The decision should be individualised according to anatomy, the proposed radiation plan, expected dosimetric benefit, medical history, bleeding risk and local expertise. It should be made before radiotherapy planning through an informed discussion with the treating radiation oncology team.

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

References and further reading

 

Advanced and Metastatic Prostate Cancer: Modern Treatment and New Hope

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

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

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

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

What does “advanced” prostate cancer mean?

Advanced prostate cancer is not one single condition.

Locally advanced prostate cancer

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

Metastatic hormone-sensitive prostate cancer

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

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

but remains sensitive to testosterone suppression.

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

Metastatic castration-resistant prostate cancer

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

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

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

1. Androgen Deprivation Therapy: The Foundation of Treatment

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

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

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

ADT remains the backbone of treatment for metastatic prostate cancer.

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

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

2. Double Therapy

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

Examples include:

Abiraterone + prednisone

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

Potential side effects include:

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

Enzalutamide

This blocks signalling through the androgen receptor.

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

Apalutamide

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

Darolutamide

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

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

3. Triple Therapy: Three Treatments From the Starting Line

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

Instead of:

ADT alone

or:

ADT + one additional treatment

selected patients may receive:

ADT + chemotherapy + an androgen-receptor pathway inhibitor

Two landmark trials helped establish this approach.

ARASENS

The phase III ARASENS trial investigated:

ADT + docetaxel + darolutamide

compared with:

ADT + docetaxel + placebo

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

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

PEACE-1

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

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

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

Who may benefit from triple therapy?

Triplet therapy is particularly considered in men who:

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

Treatment nevertheless needs to be individualised.

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

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

4. Chemotherapy

Docetaxel

Docetaxel remains an important chemotherapy for advanced prostate cancer.

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

Potential side effects include:

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

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

Cabazitaxel

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

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

5. Should ADT Ever Be Intermittent?

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

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

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

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

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

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

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

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

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

6. What Happens When the Cancer Becomes Castration Resistant?

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

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

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

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

Options can include:

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

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

7. Genetic Testing Has Become Part of Treatment

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

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

Important abnormalities include mutations involving:

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

These mutations may make the cancer susceptible to PARP inhibitors.

Examples include:

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

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

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

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

8. Immunotherapy: Exciting, But Not for Everyone

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

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

However, there is an important exception.

Pembrolizumab

A small proportion of prostate cancers have abnormalities known as:

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

These cancers may respond to the immune checkpoint inhibitor pembrolizumab.

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

This is another reason why molecular testing has become important.

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

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

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

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

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

9. PSMA Radioligand Therapy

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

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

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

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

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

Potential side effects include:

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

10. Radium-223 for Bone-Dominant Disease

Prostate cancer has a particular tendency to spread to bone.

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

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

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

11. Don’t Forget the Prostate Itself

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

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

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

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

12. Side Effects of Long-Term Hormonal Treatment

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

Long-term ADT may cause:

Sexual effects

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

Hot flushes

These can range from mildly annoying to profoundly disruptive.

Muscle loss

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

Weight gain

Fat tends to accumulate particularly around the abdomen.

Metabolic changes

ADT can increase the risk of:

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

Bone thinning

Long-term ADT accelerates osteoporosis and increases fracture risk.

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

Mood and cognition

Some men experience:

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

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

Exercise Is Part of Cancer Treatment

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

A programme incorporating:

resistance training + aerobic exercise + balance work

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

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

Bone Health Matters

Men receiving prolonged ADT should have their fracture risk assessed.

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

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

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

A New Way of Thinking About Metastatic Prostate Cancer

The old treatment pathway was fairly linear:

ADT → wait for progression → chemotherapy → another treatment.

Modern treatment looks very different.

It is increasingly:

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

For some patients this means:

ADT + ARPI

For others:

ADT + docetaxel + darolutamide

or:

ADT + docetaxel + abiraterone

And later, depending on the tumour:

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

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

The Bottom Line

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

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

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

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

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

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

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

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

Sexually Transmitted Infections in Men: What You Need to Know

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More than just an uncomfortable infection

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

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

Many sexually transmitted infections cause no symptoms at all.

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

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

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

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

What exactly is an STI?

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

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

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

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

Common STIs affecting men

Chlamydia

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

When symptoms occur, men may notice:

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

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

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

Gonorrhoea

Gonorrhoea is caused by Neisseria gonorrhoeae.

It classically produces:

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

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

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

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

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

Mycoplasma genitalium

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

Men may experience:

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

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

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

Syphilis

Syphilis is caused by Treponema pallidum.

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

Early infection may cause a painless genital ulcer or chancre.

Later symptoms can include:

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

Importantly, the initial ulcer can disappear without treatment.

That does not mean the infection has gone away.

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

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

Genital herpes

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

Symptoms may include:

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

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

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

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

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

HPV and genital warts

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

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

Genital warts can appear as:

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

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

Does HPV cause penile cancer?

This is an important question.

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

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

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

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

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

However, a penile lesion that:

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

should be examined by a doctor.

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

HPV vaccination matters for men too

HPV vaccination is not simply a cervical cancer vaccine.

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

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

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

Can an STI cause infertility?

Yes, although this is not inevitable.

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

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

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

Epididymo-orchitis

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

Symptoms can include:

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

Severe or recurrent inflammation can potentially damage the reproductive tract.

Bilateral disease is of greater concern for fertility.

A very important warning

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

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

STIs and urethral strictures

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

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

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

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

Symptoms of a urethral stricture include:

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

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

How is a urethral stricture investigated?

Depending upon the symptoms, investigation may include:

Uroflowmetry

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

Bladder ultrasound

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

Flexible cystoscopy

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

Retrograde urethrogram

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

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

How are STIs diagnosed?

There is no single universal “STI test.”

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

Testing may include:

Urine testing

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

  • chlamydia
  • gonorrhoea.

Swabs

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

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

Testing only the urine can therefore miss an infection elsewhere.

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

Blood tests

Blood testing may be recommended for:

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

Examination and biopsy

Genital warts are often diagnosed clinically.

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

What happens if an STI is diagnosed?

Management depends entirely upon the infection.

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

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

Depending upon the infection, management may also involve:

1. Treating the infection

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

2. Partner notification

Current or recent sexual partners may require testing and treatment.

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

3. Temporarily avoiding sexual contact

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

4. Testing for other STIs

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

5. Repeat testing

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

What about HIV?

Modern HIV prevention and treatment have changed dramatically.

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

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

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

When should I see a doctor?

Arrange medical assessment if you develop:

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

Seek urgent medical attention for:

Sudden severe testicular pain

This may represent testicular torsion rather than infection.

Inability to pass urine

This may indicate severe obstruction.

A persistent ulcer, lump or abnormal area on the penis

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

“But I feel completely normal”

This is one of the most important messages about STIs:

No symptoms does not necessarily mean no infection.

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

Testing may therefore be sensible after:

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

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

Prevention

Reducing STI risk may involve several complementary strategies:

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

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

A urologist’s perspective

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

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

This may include:

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

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

The bottom line

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

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

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

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

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

Australian resources

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

Australian STI Management Guidelines

Medical disclaimer

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

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

Penile Cancer: Symptoms, Diagnosis and Treatment in Australia

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Penile cancer is rare, but early diagnosis matters

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

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

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

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

Treatment in Australia will depend on:

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

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

 

What causes penile cancer?

There is rarely one single identifiable cause.

Important risk factors include:

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

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

What symptoms should men look for?

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

Symptoms can include:

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

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

A persistent penile lesion deserves examination

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

The important issue is persistence.

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

Embarrassment is considerably easier to treat than advanced cancer.

How is penile cancer diagnosed?

Examination

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

The urologist will assess:

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

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

Biopsy

The diagnosis usually requires a biopsy.

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

Depending upon the lesion, this may be:

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

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

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

What is PeIN?

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

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

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

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

Treatment: from creams to major surgery

There is no single operation or treatment for penile cancer.

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

1. Circumcision

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

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

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

2. Treatment with creams

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

The two most commonly used treatments are:

5-fluorouracil (5-FU)

5-FU is a topical chemotherapy medication.

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

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

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

Imiquimod

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

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

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

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

Importantly, the area must be reassessed after treatment.

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

3. Laser and other local treatments

Very superficial lesions can sometimes be treated using laser therapy.

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

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

4. Penile-preserving surgery

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

Whenever oncologically safe, the aim is:

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

Operations may include:

Wide local excision

The cancer and a margin of surrounding tissue are removed.

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

Glans resurfacing

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

A skin graft is then placed over the glans.

This can be particularly useful for extensive superficial disease.

Glansectomy

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

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

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

5. Partial penectomy

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

This is called a partial penectomy.

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

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

6. Total penectomy

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

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

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

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

What is a perineal urethrostomy?

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

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

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

This opening is called a:

Perineal urethrostomy

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

A catheter is generally left temporarily while the area heals.

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

Potential problems include:

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

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

The lymph nodes are extremely important

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

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

Penile cancer generally spreads in a predictable sequence:

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

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

What if there are no enlarged lymph nodes?

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

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

This may involve:

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

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

What if a groin lymph node is enlarged?

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

If metastatic penile cancer is confirmed, treatment may involve:

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

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

Early treatment of lymph-node disease is extremely important.

Radiation therapy

Radiotherapy has an important but selective role in penile cancer.

Treatment of the primary cancer

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

Treatment can involve:

External beam radiotherapy

Radiation is directed at the tumour from outside the body.

Brachytherapy

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

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

Potential complications can include:

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

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

Chemotherapy

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

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

One regimen used in advanced disease is:

TIP: paclitaxel + ifosfamide + cisplatin

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

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

This is called neoadjuvant chemotherapy.

The aim is to:

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

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

Chemoradiotherapy

Radiotherapy and chemotherapy can sometimes be combined.

This may be considered for selected patients with:

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

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

What about immunotherapy?

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

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

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

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

What happens to sexual function?

This depends enormously on treatment.

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

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

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

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

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

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

What is the prognosis?

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

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

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

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

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

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

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

Follow-up after treatment

Penile cancer requires ongoing surveillance.

Follow-up may include:

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

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

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

Do not ignore a change in the penis

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

Nevertheless, a persistent:

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

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

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

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

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

The crucial message is simple:

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

Australian and international resources

Cancer Council Australia: Penile Cancer

Cancer Institute NSW: Penile Cancer

eviQ Australian Penile Cancer Chemotherapy Protocol

2026 EAU-ASCO Penile Cancer Guidelines

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

So, if you have noticed a lesion on your penis and it is growing, don’t ignore it and hope it will go away, go see your GP.

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

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One of the most curable cancers in men

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

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

The most important message is therefore:

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

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

The importance of checking your testicles

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

This makes testicular awareness particularly important.

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

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

Nevertheless, knowing your own anatomy makes sense.

How do I check my testicles?

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

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

Become familiar with:

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

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

Seek medical advice if you discover:

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

How often?

There is some variation between international recommendations.

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

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

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

What is testicular cancer?

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

They are divided into two broad groups:

Seminoma

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

Non-seminomatous germ-cell tumour (NSGCT)

This group includes:

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

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

An important clinical rule is:

Pure seminoma should not produce AFP.

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

Other testicular tumours

Less common tumours include:

Leydig cell tumours

Most are benign, although malignant variants occur.

Sertoli cell tumours

Again, most are benign but malignant variants are recognised.

Testicular lymphoma

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

Occasionally another cancer can metastasise to the testicle.

How does testicular cancer present?

The classic presentation is a:

Painless testicular lump

A man may notice:

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

Testicular cancer can also cause discomfort or pain.

Therefore:

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

Symptoms of more advanced disease

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

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

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

Diagnosis in Australia

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

Step 1: Examination

Both testicles should be examined.

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

Step 2: Testicular ultrasound

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

It determines whether a lesion is:

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

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

Step 3: Tumour markers

Blood should ideally be collected before orchidectomy for:

AFP, Alpha-fetoprotein

May be elevated with:

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

β-hCG, Beta human chorionic gonadotropin

Can be elevated in:

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

LDH, Lactate dehydrogenase

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

Importantly:

Normal tumour markers do not exclude testicular cancer.

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

Step 4: Staging

Staging commonly involves CT imaging of the:

  • Chest
  • Abdomen
  • Pelvis

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

MRI can be used in selected circumstances.

PET scanning is not routinely recommended for initial staging.

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

Should the testicular lump be biopsied?

Usually no.

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

The standard procedure is:

Radical inguinal orchidectomy

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

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

Fertility before treatment

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

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

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

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

Management of testicular cancer in Australia

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

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

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

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

Stage I seminoma

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

For most reliable patients:

Active surveillance is generally preferred

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

Surveillance involves scheduled:

  • Clinical review
  • Imaging
  • Tumour markers where appropriate

If recurrence occurs, treatment is usually extremely successful.

Adjuvant carboplatin

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

Radiotherapy

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

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

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

Stage I non-seminomatous germ-cell cancer

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

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

Without lymphovascular invasion

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

With lymphovascular invasion

The risk of recurrence is considerably greater.

Options include:

  • Surveillance
  • One cycle of BEP chemotherapy

BEP consists of:

Bleomycin
Etoposide
Platinum – cisplatin

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

Retroperitoneal lymph-node dissection, RPLND

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

It has an important but selective role.

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

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

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

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

Stage II seminoma

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

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

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

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

Metastatic seminoma and non-seminoma

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

Common treatment includes:

BEP

Bleomycin + etoposide + cisplatin.

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

EP

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

VIP

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

Surgery after chemotherapy

Surgery can remain crucial even after successful chemotherapy.

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

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

  • Fibrosis or necrosis
  • Mature teratoma
  • Persistent viable cancer

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

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

What about immunotherapy?

Immunotherapy has revolutionised treatment for several urological cancers.

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

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

Therefore:

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

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

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

The reassuring answer is:

The major principles are remarkably similar.

All emphasise:

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

There are, however, some interesting differences in emphasis.

European approach: EAU

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

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

Routine adjuvant radiotherapy is not recommended.

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

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

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

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

British approach

British practice is broadly similar to European practice.

The NHS pathway centres around:

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

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

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

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

British cancer services place considerable emphasis on:

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

This is very similar to contemporary Australian practice.

How does the American approach differ?

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

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

  • RPLND
  • One cycle of BEP

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

For Stage IB NSGCT, American guidance recognises:

  • Surveillance
  • RPLND
  • One or two cycles of BEP

as options following shared decision-making.

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

Another evolving difference: RPLND for Stage II seminoma

Traditionally seminoma involving retroperitoneal lymph nodes was treated with either:

Radiotherapy or chemotherapy.

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

European recommendations are also evolving in this direction.

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

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

Australia: where do we sit?

Australian practice sits comfortably between these international approaches.

For most Australian patients:

Stage I seminoma

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

Stage I NSGCT without LVI

Surveillance is generally preferred.

Stage I NSGCT with LVI

Surveillance or one cycle of BEP following individualised discussion.

Stage II seminoma

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

Marker-positive metastatic disease

Cisplatin-based chemotherapy according to IGCCCG prognostic classification.

Residual NSGCT after chemotherapy

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

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

Why avoiding unnecessary treatment matters

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

That changes the treatment equation.

The question is no longer simply:

“Which treatment will cure the cancer?”

It is also:

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

This is why surveillance has become so important.

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

Prognosis

The prognosis for testicular cancer is excellent.

Stage I disease has survival approaching 100%.

Even metastatic disease is frequently curable.

Prognosis depends upon:

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

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

After treatment: don’t forget the other testicle

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

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

Long-term survivorship care may also address:

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

The take-home message

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

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

Know your testicles.

Become familiar with what is normal for you.

Don’t ignore a change.

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

Don’t be embarrassed.

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

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

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

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

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

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

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

That distinction matters.

When does pornography use become a problem?

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

The more useful questions are:

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

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

It may have become part of a compulsive behavioural pattern.

Pornography, the brain and sexual arousal

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

It begins in the brain.

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

Internet pornography can provide an unusually powerful combination:

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

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

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

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

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

Can pornography cause erectile dysfunction?

This is one of the most common questions men ask.

The relationship is complicated.

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

Erectile dysfunction can also result from:

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

Nevertheless, some younger men report an interesting pattern:

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

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

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

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

Delayed ejaculation and difficulty reaching orgasm

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

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

Partnered sexual activity is different.

The result can sometimes be:

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

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

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

Mental health

Pornography can also become a way of managing uncomfortable emotions.

A man may reach for pornography when he feels:

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

The behaviour temporarily provides distraction or relief.

But afterwards there may be regret, secrecy or shame.

A cycle can develop:

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

The pornography may therefore be only part of the problem.

The more important question can become:

“What am I using pornography to escape from?”

That question often opens a much more useful conversation.

Pornography and relationships

The greatest harm may sometimes occur outside the bedroom.

Secret or compulsive pornography use can affect trust between partners.

A partner may wonder:

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

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

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

trust, intimacy, honesty, vulnerability and connection.

Unrealistic expectations about sex

Pornography is entertainment. It is not sex education.

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

Real sexuality is considerably more human.

Bodies change.

Erections occasionally disappear.

Orgasms do not always occur.

People need reassurance.

Couples sometimes laugh.

Sometimes sex simply does not work particularly well that evening.

That is normal.

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

Effects on partners and families

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

Secrecy may produce emotional distance.

Late-night viewing may interfere with sleep.

Preoccupation can reduce attention given to children or a partner.

Arguments may become increasingly frequent.

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

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

That disconnection is often what families feel most strongly.

Is pornography addiction a recognised diagnosis?

The terminology requires some care.

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

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

Simply having a strong sex drive does not qualify.

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

The issue is loss of control and meaningful harm.

What can a man do about it?

Recovery does not necessarily require declaring war on sexuality.

The goal is to regain choice.

A useful starting point is to honestly observe the pattern.

1. Identify your triggers

Ask when pornography use tends to occur.

Is it when you are:

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

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

2. Make access less automatic

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

Most importantly, change the environment associated with the behaviour.

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

3. Take a break from pornography

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

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

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

4. Reconsider masturbation habits

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

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

5. Rebuild partnered intimacy

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

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

Sexual confidence often returns more readily when the scoreboard disappears.

6. Exercise, sleep and reconnect

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

That is precisely their strength.

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

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

Talk to your partner

If pornography has damaged trust, simply promising:

“I’ll never do it again.”

may not repair the relationship.

Trust usually returns through consistent behaviour rather than dramatic promises.

A more constructive conversation might acknowledge:

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

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

Psychological treatment can help

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

Treatment may include:

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

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

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

Treating only one part can miss the larger picture.

When should you see a urologist?

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

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

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

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

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

Where can men get help in Australia?

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

Centre for Men and Families

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

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

MensLine Australia

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

Phone: 1300 78 99 78

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

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

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

There is a way forward

Pornography does not make someone a bad man.

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

The objective is not shame.

It is awareness.

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

genuine intimacy with another human being.

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

telling someone the truth.

The Centre for Men and Families Australia: Helping Men Through Crisis, Change and Transformation

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When a man says “I’m fine”, sometimes he isn’t

Men are often remarkably good at carrying things.

We carry responsibility. We carry families. We carry financial pressures, expectations, disappointments, grief and fear. And occasionally, we carry all of them at once while still answering the question “How are you going?” with the traditional Australian male response:

“Yeah, good mate.”

Sometimes we are good.

Sometimes we are anything but.

For more than 25 years, the Centre for Men and Families Australia (CFMF) has been creating places where men can put down some of what they carry, speak honestly about their lives, listen to other men and discover that they do not have to negotiate life’s difficult passages alone.

The Centre describes itself as a national harm-prevention charity supporting men’s emotional, mental, relational and spiritual wellbeing. Its work includes men’s circles, counselling, retreats, Men’s Rites of Passage, programs for younger men and community events.

Its central idea is remarkably simple:

Men need other men. Not to fix them, but to walk alongside them.

Why is this on a urologist’s website?

Because urology is about considerably more than kidneys, bladders and prostates.

Over many years of looking after men, one becomes very aware that a diagnosis rarely remains confined to an organ.

Prostate cancer can become a confrontation with mortality.

Erectile dysfunction can challenge a man’s confidence, sexuality and intimate relationship.

Urinary incontinence can affect dignity and willingness to socialise.

Infertility can challenge deeply held ideas about fatherhood.

Testicular cancer may confront a young man with questions about masculinity before he has even had much opportunity to define what masculinity means to him.

A catheter, a cancer diagnosis, sexual dysfunction or major surgery can unexpectedly open a door into much bigger questions:

Who am I now?

What if my body no longer works as it once did?

Am I still desirable?

What am I frightened of?

Who can I talk to about this?

And perhaps the most difficult question:

Do I have to carry this alone?

The answer should be no.

The origins of the Centre

The work that eventually became the Centre for Men and Families began in 1998, when Rob Jones established Men Transforming Men in Kenmore, Queensland.

Rob Jones is the founder of the Centre and a qualified counsellor and spiritual director. The early work grew from a recognition that men needed to be equipped to support other men.

What began with mentoring, community camps, breakfasts, counselling and gatherings gradually developed into a much broader men’s movement.

In 2004, Rob and his wife Sharon Jones committed themselves more fully to the work. The organisation subsequently developed relationships with other men’s organisations and with the work of Franciscan teacher Richard Rohr and the Centre for Action and Contemplation in the United States.

That relationship helped establish the Men’s Rites of Passage tradition in Australia and introduced generations of Australian men to a different understanding of masculinity: one based not simply upon achievement, independence and strength, but also upon vulnerability, contemplation, responsibility, service and emotional maturity.

The Centre continues this work today.

Rob Jones and a different vision of men’s work

Rob Jones’ contribution deserves particular recognition.

The important insight behind this work was not that men were somehow defective and needed repairing.

It was that many men had never been given a safe environment in which to explore their inner lives.

Many of us were taught how to do.

Far fewer were taught how to be.

We learned how to work, compete, provide, solve problems and endure adversity.

But what do we do with grief?

What do we do with failure?

What happens when a marriage ends?

When a child is struggling?

When someone we love dies?

When our career disappears?

When cancer arrives?

When our body begins to age?

When sexuality changes?

When the identity we constructed over decades suddenly stops making sense?

These questions cannot always be solved with a bigger toolbox.

Sometimes a man needs a circle rather than a solution.

From crisis to connection

Men can arrive at a crisis through many different doors.

It may be:

  • relationship breakdown
  • divorce or separation
  • bereavement
  • loneliness
  • unemployment or retirement
  • financial pressure
  • fatherhood
  • ageing
  • loss of purpose
  • sexual difficulties
  • chronic illness
  • cancer
  • anxiety or emotional distress
  • or simply the uncomfortable feeling that life is no longer working in the way it once did.

The Centre provides several pathways through which men can connect with others, including professional counselling, regular men’s Circle Groups, retreats, online programs and Rites of Passage experiences.

The emphasis is not simply upon talking.

It is upon being heard without judgement.

That distinction matters.

Men are often surrounded by people and yet profoundly lonely.

You can work in an office of 100 people, play golf with the same mates for 20 years and attend every family barbecue while never telling another human being what is actually happening inside you.

Connection is not the number of people around us.

It is the number of people with whom we can safely be real.

Men’s circles: putting down the armour

One of the simplest expressions of the Centre’s work is the men’s circle.

There is no requirement to arrive with a dramatic story.

A man does not need to be in crisis.

Men sit together, listen and speak honestly.

For some, this initially feels extremely unfamiliar.

We are generally comfortable discussing football, politics, work, interest rates and whether the barbecue is hot enough.

Talking about fear, loneliness, shame, ageing, sexuality or grief can require considerably more courage.

But something interesting happens when one man speaks honestly.

Another man recognises himself in the story.

Then another speaks.

The room changes.

The problem that seemed uniquely shameful becomes recognisably human.

“I thought I was the only one.”

Those can be extraordinarily liberating words.

Watching men change

One of the most powerful aspects of organisations such as the Centre is not necessarily what happens during a single weekend, retreat or meeting.

It is what happens over years.

Men return.

They continue meeting.

They become mentors.

Some eventually become elders for younger men.

A man who once arrived carrying anger may gradually discover the hurt beneath it.

A man obsessed with achievement may discover that his value is not determined by his job title.

A father may begin listening differently to his children.

A husband may become more emotionally available to his partner.

A man who spent decades avoiding grief may finally allow himself to grieve.

And the man who once needed the circle may eventually become the man holding the circle for somebody else.

That is transformation.

Not becoming a completely different person.

Perhaps becoming more fully the person who was underneath the armour all along.

The Centre’s philosophy extends this transformation beyond the individual man. When a man becomes healthier emotionally and relationally, the effects can flow outward into his marriage, children, friendships, workplace and community.

Transformation becomes generational.

Men’s Rites of Passage

The Centre’s Men’s Rites of Passage work has been strongly influenced by the tradition associated with Richard Rohr.

Rather than regarding adulthood as something that automatically arrives with a driver’s licence, mortgage or first grey hair, rites-of-passage traditions ask deeper questions about maturity.

What must a man relinquish?

What pain must he acknowledge?

What can he no longer control?

What does he have to offer others?

What kind of man does he wish to become?

CFMF currently offers a five-day Men’s Rites of Passage experience for men over 30 and Forged, a wilderness-based rites-of-passage experience for younger men aged 18–30.

These experiences use community, nature, reflection, ritual and the wisdom of older men to explore identity and mature masculinity.

From silence to poetry: when men find words

Perhaps one of the most interesting recent expressions of the Centre’s philosophy has been through poetry.

At first glance, poetry and Australian masculinity may appear slightly uneasy companions.

Give a group of Australian men a chainsaw, a fishing rod or a football and everybody knows roughly what to do.

Give them a blank sheet of paper and ask them to describe their inner life…

Things become interesting.

Yet poetry can reach places ordinary conversation sometimes cannot.

The Centre recently invited men to contribute to its “Men Like Me” Poetry Competition, encouraging original poetry exploring the experience of being a man, including vulnerability, emotional truth, spiritual growth and the complexity and struggles of modern masculinity.

This represents something important.

For generations, many men expressed emotion principally through silence.

Today’s men are gradually discovering a larger vocabulary.

Poetry provides permission to speak indirectly about things that may be difficult to say directly:

A father.

A son.

A body growing older.

Love.

Sex.

Regret.

Cancer.

Failure.

Anger.

Forgiveness.

Death.

Hope.

Sometimes a man cannot begin with:

“I am frightened.”

But perhaps he can write a poem about standing alone beside the ocean at night.

And perhaps that is where the conversation begins.

Masculinity does not require emotional silence

Supporting men’s emotional lives is sometimes mistakenly interpreted as asking men to become less masculine.

The opposite may be true.

Healthy masculinity can include strength and tenderness.

Courage and vulnerability.

Independence and belonging.

Leadership and humility.

Sexual confidence and the ability to acknowledge sexual difficulty.

Providing for others and knowing when to ask others for help.

The mature man does not necessarily carry less.

He learns what is his to carry, what he must put down and when he needs another man’s shoulder beside his own.

When illness becomes a doorway

Nobody would choose prostate cancer, incontinence, erectile dysfunction or another serious health problem as a route toward personal growth.

Illness is illness.

It deserves appropriate investigation and good medical treatment.

But illness can also interrupt the story we have been telling ourselves.

Suddenly the body demands attention.

Priorities shift.

Relationships matter differently.

Questions that were conveniently postponed become difficult to ignore.

This can be frightening.

It can also become an invitation.

An invitation to speak.

To reconnect.

To repair relationships.

To reconsider priorities.

To ask for help.

And perhaps to discover that strength does not always mean standing alone.

Supporting the whole man

Good men’s healthcare should recognise that a prostate is attached to a person.

Treating prostate cancer successfully while ignoring the man’s fear, sexual identity, relationship or emotional wellbeing is incomplete care.

Likewise, restoring continence after prostate surgery is important, but so is helping the man regain confidence in returning to work, intimacy, exercise and ordinary social life.

Sometimes that requires a urologist.

Sometimes a physiotherapist.

Sometimes a psychologist or counsellor.

Sometimes a partner.

And sometimes what a man needs most is simply another man who can sit beside him and say:

“I’ve walked some of this road too.”

That is where communities such as the Centre for Men and Families can become enormously valuable.

Where can men find support?

The Centre for Men and Families Australia welcomes men from different backgrounds and beliefs. You do not need to be experiencing a major crisis to become involved.

Men can explore:

Men’s Circle Groups
Regular gatherings where men can speak honestly, listen and develop meaningful connections with other men.

Counselling and Support
Professional counselling, including online support, for men experiencing emotional, relational or life difficulties.

Men’s Rites of Passage
A five-day experience for men aged 30 and over exploring identity, transition and mature masculinity.

Forged
A rites-of-passage experience designed for younger men aged 18–30.

Retreats, Gatherings and Workshops
Opportunities for men to reconnect, reflect and continue their personal development.

Visit the Centre for Men and Families Australia to learn more about its programs, counselling services and men’s groups.

If you or someone you know is experiencing an immediate mental health crisis or is at risk of self-harm, seek urgent professional assistance. The Centre itself directs men needing urgent support to MensLine Australia on 1300 78 99 78.

A final thought

Medicine is very good at measuring things.

We can measure PSA.

Urine flow.

Bladder pressure.

Testosterone.

Kidney function.

Tumour size.

Even erections can, rather unromantically, be measured.

But some of the things that determine whether a man is truly well are considerably harder to put on a graph.

Does he have purpose?

Can he love?

Can he receive love?

Can he admit when he is frightened?

Can he forgive?

Can he grieve?

Does he have men around him who know his real story?

And when life eventually knocks him off the path, as life has a habit of doing, does he know where to turn?

For more than two decades, Rob Jones and the men and women associated with the Centre for Men and Families Australia have been creating places where Australian men can explore precisely these questions.

The result is not simply men who talk more.

At its best, it is men becoming more emotionally present partners, fathers, friends, mentors and elders.

Men finding language for what hurts.

Men learning that vulnerability and strength are not enemies.

Men discovering that crisis does not necessarily have to be the end of a story.

Sometimes it is the place where a different story begins.

About | Centre for Men and Families