Vaginal vault prolapse: understanding the options

September 28, 2026/0 Comments/in Bladder Surgery, Blog Post, Incontinence Surgery, Vaginal Mesh, Vaginal Surgery/by drjo

Patient information | Reviewed 28 September 2026

Vaginal vault prolapse occurs when the top of the vagina descends after a hysterectomy. It can occur alone or alongside a bulge of the front vaginal wall (anterior prolapse, often called a cystocele). Some women feel a bulge, dragging or pressure; others have difficulty emptying their bladder, recurrent urinary infections, bowel symptoms or discomfort during sex. The size of a prolapse on examination does not always match how troublesome it feels. Treatment should be guided by symptoms and personal priorities, rather than the examination alone. [1,2]

Why the front wall matters

The vaginal apex helps support the front and back walls. An anterior bulge may partly reflect loss of support at the apex. Repairing only the front wall while leaving significant vault prolapse untreated may leave the underlying problem unresolved. Conversely, restoring apical support may improve some anterior prolapse, although a separate anterior repair is sometimes needed. The surgeon should assess each compartment before deciding which parts require treatment. [1,3]

Assessment and treatment without surgery

Assessment includes a history of bulge, urinary and bowel symptoms, sexual function, prior hysterectomy and prolapse operations; examination while straining; and discussion of what the woman wants treatment to achieve. A bladder scan for residual urine is useful when emptying is difficult. Urine tests, urodynamics or imaging are considered for specific questions rather than required for every woman. Stress leakage can be hidden by a large prolapse and may appear after it is reduced or repaired; this possibility deserves discussion before surgery. [1,2]

If symptoms are mild, observation is reasonable. Pelvic floor muscle training can improve symptoms, particularly with less advanced prolapse, but cannot reliably lift a substantial vault prolapse back into place. A vaginal pessary can relieve a bulge without surgery and can also help someone decide whether restoring support improves bladder or bowel symptoms. Pessaries require fitting and ongoing review. Vaginal oestrogen may help postmenopausal vaginal dryness or irritation when appropriate; it is not a cure for the prolapse. [1,2]

Surgical options

Approach	How the apex is supported	Main considerations
Vaginal sacrospinous fixation	Stitches attach the vaginal top to a pelvic ligament, usually on one side.	Avoids an abdominal incision and implanted mesh; possible temporary buttock pain and recurrent anterior bulge.
Vaginal uterosacral ligament suspension	Stitches attach the vaginal top to the uterosacral ligaments.	Uses the woman’s own tissues; attention to the ureters is essential, often with cystoscopy during surgery.
Sacrocolpopexy (laparoscopic, robotic or open)	Mesh attached to the vagina is fixed to the ligament over the sacrum through the abdomen.	Often durable apical support; abdominal operative risks and mesh-specific risks must be weighed.
Colpocleisis	The vaginal canal is closed or substantially shortened.	Effective option for selected women who do not wish to retain vaginal intercourse; the loss of vaginal intercourse is permanent.

An anterior repair may be added if the front wall remains significantly prolapsed after apical support is restored. These operations can also be combined with treatment of stress incontinence when the benefits and added risks justify it. The decision is individual. [1–3]

Where does robotic sacrocolpopexy fit?

Robotic sacrocolpopexy is one way to perform abdominal sacrocolpopexy through small incisions. The robot helps the surgeon control instruments; it does not perform the surgery independently. It may be considered for symptomatic, substantial or recurrent vault prolapse, especially when preserving vaginal length and durable apical support are priorities, or when multiple compartments need reconstruction. It is not necessary for every prolapse and is not suitable for every patient. Previous abdominal operations, anaesthetic risk, ability to tolerate the operating position, mesh preferences, surgeon experience and costs all matter. [1–4]

Compared with vaginal operations using the patient’s own tissue, sacrocolpopexy generally has lower rates of recurrent prolapse and repeat prolapse surgery in studies of post-hysterectomy vault prolapse. In the 2023 Cochrane review, illustrative estimates were 6 in 100 requiring repeat surgery after sacrocolpopexy versus 14 in 100 after vaginal procedures, and 8 in 100 noticing recurrent prolapse versus 18 in 100 after vaginal procedures. These are pooled comparisons, not predictions for an individual. The certainty and length of follow-up vary. [3]

A multicentre randomised trial reported a 36-month composite treatment-failure estimate of 28% with sacrocolpopexy and 43% with vaginal native-tissue repair. Its definition combined symptoms, examination findings and retreatment: it does not mean 28% underwent another operation. Women in all groups reported sustained improvement, with similar satisfaction and decision regret. [4]

The benefit shown for sacrocolpopexy should not be attributed specifically to the robot. Comparative studies have not established better long-term anatomical or patient-reported results for robotic versus conventional laparoscopic sacrocolpopexy. Operating time and cost can be higher with robotic surgery, depending on the centre and surgeon. The quality of the repair and the experience of the team may matter more than the instrument platform. [5,6]

Risks and complications

Every prolapse operation can involve bleeding, infection, clots, anaesthetic complications, injury to the bladder, bowel or ureters, temporary difficulty emptying the bladder, new or persistent urinary leakage or urgency, constipation, pain with intercourse, and recurrence. A bulge can return in a different compartment even when the apex remains well supported. Some women need further treatment. Individual risk varies with previous operations and health. [1–4]

Sacrocolpopexy adds risks associated with abdominal access and permanent mesh, including mesh exposure through the vagina, infection, pain, and rarely erosion into an organ or complications near the sacrum. Mesh complications can arise years later and sometimes require further surgery. The 2024 randomised trial reported mesh exposure in about 3% after sacrocolpopexy during its follow-up; this is a study figure, not a lifetime risk. Vaginal native-tissue surgery avoids implanted mesh but has its own risks, including buttock pain with sacrospinous fixation and ureteric obstruction or injury with uterosacral suspension. [1,3,4]

An Australian distinction: Mesh inserted through the vagina to repair prolapse is not available for routine supply in Australia. That is different from mesh inserted through the abdomen for sacrocolpopexy, which remains an available category of device. An operation should never be described simply as “mesh-free” or “mesh surgery” without explaining the route, material and specific risks. [7]

Making a decision

There is no single best operation for every woman. A useful consultation covers how bothersome the bulge is; whether a pessary has been tried; the degree of vault and anterior prolapse; bladder, bowel and sexual symptoms; previous repairs; the wish to avoid mesh; the wish to maintain vaginal intercourse; likely recovery; and the surgeon’s experience with each approach. It should distinguish improvement in symptoms from an examination-based definition of anatomical success. For women seeking a durable reconstruction, sacrocolpopexy is an important option; vaginal native-tissue surgery remains a valid choice, particularly when avoiding abdominal surgery or mesh matters more. [1–4]

This article provides general information and cannot replace an individual examination and discussion of personal risks and goals.

References

NICE. Urinary incontinence and pelvic organ prolapse in women: management (NG123). 2019, subsequent updates.
RCOG. Pelvic organ prolapse: patient information.
Maher C, et al. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2023;7:CD012376. doi:10.1002/14651858.CD012376.pub2.
Menefee SA, et al. Apical suspension repair for vaginal vault prolapse: a randomized clinical trial. JAMA Surg. 2024.
Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol. 2014.
Ferrari A, et al. Laparoscopic versus robot-assisted sacrocolpopexy: systematic review and meta-analysis. 2026.
Therapeutic Goods Administration. About transvaginal surgical mesh devices.

Urethral bulking for stress urinary incontinence: a first procedure or an option after a sling?

September 23, 2026/0 Comments/in Blog Post, Incontinence Surgery, Urethral Surgery/by agileadmin

Leaking urine when you cough, laugh, exercise or lift something is called stress urinary incontinence (SUI). It differs from urgency incontinence, when a sudden need to pass urine leads to leakage. Some women have both. Identifying which symptom is most troublesome matters because an injection aimed at SUI will not reliably treat urgency.

Urethral bulking involves placing small deposits of material into the wall of the urethra, usually through a fine instrument passed into the urethra. The deposits help the urethra close when pressure rises. You may hear this described as periurethral bulking, although many contemporary injections are delivered through the urethra into its surrounding wall. This is generally a day procedure under local anaesthesia or sedation/general anaesthesia, depending on the circumstances. It does not place a sling or mesh tape.

Could bulking be my first procedure?

Yes. After a trial of pelvic floor muscle training and discussion of other conservative measures, bulking can be chosen as a first procedure for appropriately assessed SUI. It may appeal to someone seeking a shorter procedure and recovery, or wishing to avoid a sling. It is also an option when a larger operation or anaesthetic carries additional risk. It is not usually the first treatment before conservative care. USANZ’s 2026 position statement lists bulking alongside autologous fascial slings, colposuspension and synthetic midurethral slings among the standard options that should be discussed. UGSA’s patient information stresses its lower success and frequent need for repeat treatment. [1–3]

Bulking, synthetic midurethral sling surgery, a sling made from the patient’s own fascia, and colposuspension have different benefits and risks. A donated-tissue (allograft) sling is distinct from a sling made from your own tissue (autograft) and from a synthetic mesh sling; the strength and duration of evidence for each are different. No single procedure is best for every woman. [1,4]

How effective and durable is it?

The realistic aim is often less leakage, rather than guaranteed dryness. Success figures change substantially depending on whether researchers count complete dryness, improvement, satisfaction, or avoidance of further treatment. UGSA’s patient leaflet quotes about 40–50% cure or improvement and reports that approximately 30% need a further injection within two years. These are broad counselling figures, not a prediction for an individual. [2]

Some women remain improved for years, but repeat injections or another operation may be needed. In a randomised comparison of polyacrylamide hydrogel injection and synthetic tension-free vaginal tape for primary SUI, the tape achieved better objective continence at one year (negative cough test 95.0% versus 66.4%). The five-year follow-up did not establish that injection was non-inferior to tape. The EAU similarly advises that bulking is generally less effective than slings or colposuspension for cure, and that repeat injection is likely. These findings do not mean everyone should have a tape: the value of a less invasive procedure and the acceptability of a possible repeat treatment are personal considerations. [4–6]

What if I still leak after a sling?

Bulking can be considered for persistent leakage soon after a sling or recurrent leakage after an initial period of improvement. It can sometimes reduce leakage without placing another sling. A 2022 systematic review of 11 studies after synthetic midurethral sling failure reported a pooled 75% cure-or-improvement rate, but also pooled failure and further-operation rates of 32% and 25%. The studies differed considerably in their patients, products, follow-up and definitions of success; the 75% figure should not be presented as a personal chance of cure. An American Urogynecologic Society clinical practice statement also recognises bulking as an option after a sling. [7,8]

After an allograft sling, the same clinical possibility exists, but the published post-sling bulking evidence is mainly about synthetic midurethral slings. We should not simply transfer those success figures to donated-tissue slings. The precise graft, previous surgery and examination findings should guide an individual discussion.

An injection should not be used to mask a sling complication. Before offering more treatment, I would review the original operation, check urine and bladder emptying, examine for prolapse, scarring and vaginal exposure, and assess whether leakage occurs with coughing or with urgency. Cystoscopy, a bladder diary, pad testing or urodynamics may be appropriate, especially after previous surgery, mixed symptoms, pain, blood in the urine or difficulty emptying. A tape or graft causing obstruction, exposure, erosion, infection or pain may require its own assessment and treatment. [1,3,7]

Is it safe? What are the side effects?

Most reported problems are short lived, but no injection is risk free. Possible effects include:

burning when passing urine and a little blood in the urine;
urinary tract infection;
temporary difficulty emptying the bladder, occasionally requiring short-term catheterisation;
new or persisting urgency symptoms; and
incomplete benefit, recurrence or the need for another injection or operation.

Less commonly, there may be persistent pain, a collection or infection at the injection site, or a reaction or complication related to the particular material. Risks also depend on anaesthesia, previous surgery and the chosen product. Emptying should be checked before discharge. Seek prompt assessment if you cannot pass urine, develop fever, worsening pain or heavy bleeding. [2,4,8]

Choosing a treatment

The first step is to confirm the type and severity of leakage and clarify your goals: complete dryness, meaningful improvement, shorter recovery, avoiding mesh, or avoiding the likelihood of repeat treatment. Pelvic floor therapy remains an initial option. When a procedure is appropriate, we can compare bulking with sling and colposuspension procedures using your examination findings, health history and preferences. If you have already had a sling, the reason for the continuing leakage deserves a fresh assessment before choosing another procedure.

This page is general education, not a recommendation for a particular product or a promise of a result. Treatment, including its material, risks, costs and alternatives, should be discussed during an individual consultation.

References

Urological Society of Australia and New Zealand (USANZ). Surgical Treatment of Stress Urinary Incontinence: Position Statement Pol 054, version 2.0. Approved 9 May 2026.
Urogynaecological Society of Australasia (UGSA). Urethral Bulking: Patient Information.
UGSA. Stress Urinary Incontinence: Patient Resources.
European Association of Urology. Guidelines on Non-neurogenic Female Lower Urinary Tract Symptoms: Disease Management, section 4.2.4.c.2.c.
Itkonen Freitas A-M, et al. Tension-free vaginal tape surgery versus polyacrylamide hydrogel injection for primary stress urinary incontinence: a randomised clinical trial. Journal of Urology. 2020.
Itkonen Freitas A-M, et al. Tension-free vaginal tape versus polyacrylamide hydrogel injection for stress urinary incontinence: five-year follow-up. NEJM Evidence. 2025.
Braga A, et al. Urethral bulking agents for the treatment of recurrent stress urinary incontinence: a systematic review and meta-analysis. Maturitas. 2022. doi:10.1016/j.maturitas.2022.05.007.
American Urogynecologic Society. Urethral Bulking: Clinical Practice Statement. Urogynecology. 2024. doi:10.1097/SPV.0000000000001548.

Urinary Incontinence After Prostatectomy and Salvage Radiotherapy

September 19, 2026/0 Comments/in Blog Post, Incontinence Surgery, Prostate Surgery/by drjo

Why leakage may become more complex after both treatments

Urinary leakage after radical prostatectomy is common in the early recovery period and usually improves with healing and pelvic floor rehabilitation. Some men, however, require salvage radiotherapy because their PSA remains detectable or rises after surgery.

Radiotherapy can help control recurrent prostate cancer, but it may also affect tissues that have already been altered by surgery. Radiation can cause progressive scarring, reduced blood supply and loss of elasticity in the urethra, bladder neck and bladder. These effects may develop months or even years later.

As a result, leakage after prostatectomy and salvage radiotherapy is not always caused by a weak urinary sphincter alone. A man may have:

Stress urinary incontinence: leakage with coughing, standing, lifting, walking or exercise because the sphincter does not close effectively.
Urgency urinary incontinence: leakage accompanied by a sudden, difficult-to-defer urge, often caused by an overactive or irritated bladder.
Overflow leakage: leakage associated with poor bladder emptying, a weak bladder muscle or obstruction.
Mixed incontinence: a combination of stress and urgency leakage.
Radiation-related complications: bladder-neck contracture, urethral stricture, radiation cystitis, poor bladder compliance, fistula, tissue necrosis or, in severe cases, a severely damaged bladder outlet.

Correctly identifying the cause is essential. Tightening the outlet when the bladder cannot store or empty safely may replace one problem with another.

When should the problem be assessed?

Continence can continue to improve during the first year after prostatectomy. Pelvic floor muscle training should begin early, and surgical treatment may be considered as early as six months when severe leakage is clearly not improving. Persistent, bothersome stress incontinence at approximately 12 months deserves formal assessment.

Following salvage radiotherapy, earlier review is appropriate if there is:

worsening leakage;
blood in the urine;
recurrent urinary infection;
pain, burning or severe urgency;
a weak stream or difficulty emptying;
urinary retention;
pelvic or perineal pain; or
urine leaking through an abnormal opening.

Visible haematuria, fever, inability to pass urine or severe pain requires prompt medical attention.

Investigating incontinence after salvage radiotherapy

1. A careful history

The first step is to establish what type of leakage is occurring, when it began and whether it changed after radiotherapy. Important questions include:

Is leakage triggered by activity, or by urgency?
How many pads are used, and how wet are they?
Is the patient dry at night or when lying down?
Is there a weak stream, straining or incomplete emptying?
Are there recurrent infections, haematuria or pelvic pain?
Were there previous bladder-neck or urethral procedures?
How much does leakage affect work, exercise, sleep, intimacy and quality of life?

Manual dexterity and cognition are also important if an artificial urinary sphincter is being considered, because the patient must be able to locate and operate a small scrotal pump.

2. Bladder diary and pad assessment

A three-day bladder diary records fluid intake, voided volumes, urgency and leakage. Pad number gives a useful impression, but pads differ greatly. A 24-hour pad-weight test can quantify the actual volume lost and help grade severity and monitor progress.

3. Examination and basic tests

Assessment commonly includes:

abdominal, genital, perineal and neurological examination;
observation for leakage while coughing or standing with a comfortably full bladder;
urinalysis and urine culture when infection is suspected;
uroflowmetry;
ultrasound measurement of the post-void residual; and
renal function testing or upper-tract imaging when clinically indicated.

4. Cystoscopy

Cystoscopy is particularly important before continence surgery in a previously irradiated urinary tract. It allows the urologist to inspect the urethra, bladder neck and bladder for:

urethral stricture or bladder-neck contracture;
radiation damage, stones or tumour;
erosion from a previous implant;
tissue quality and sphincter appearance; and
fistula or necrosis in complex cases.

Any clinically important obstruction or unstable urethral disease usually needs to be treated and shown to be stable before an anti-incontinence device is implanted.

What is the role of urodynamic studies?

Urodynamics is not mandatory for every man with straightforward stress leakage. It becomes more useful when symptoms are mixed, the diagnosis is uncertain, previous radiation has made the situation more complex, or the result may change treatment.

The study can assess:

stress leakage and sphincter weakness;
involuntary bladder contractions;
bladder capacity and sensation;
reduced bladder compliance or unsafe storage pressures;
obstruction;
weak bladder contraction; and
the ability of the bladder to empty against a future sling or sphincter cuff.

Urodynamics is especially worth considering when there is marked urgency, nocturnal leakage, retention, a raised residual, poor flow, recurrent infection, prior outlet reconstruction or concern about a small, painful or poorly compliant radiation-damaged bladder.

The test does not simply decide whether a man “qualifies” for an operation. Its value is in identifying bladder dysfunction that should be treated first or a bladder that may not tolerate additional outlet resistance.

Initial and non-surgical management

Pelvic floor rehabilitation

Supervised pelvic floor muscle training can improve control and teach correct muscle activation. It is most useful early after prostatectomy but may still improve coping and control later. Repeated forceful exercises are not always better; poor technique can worsen pelvic tension or urgency.

Bladder and lifestyle measures

Management may include weight reduction where relevant, treating constipation, moderating caffeine and alcohol, adjusting the timing of fluids and diuretics, bladder training and treating urinary infection. Antimuscarinic medication or a beta-3 agonist may help an overactive-bladder component, but medication does not restore a damaged sphincter.

Pads, sheaths and clamps

Absorbent pads remain a practical option for mild leakage or while awaiting treatment. A condom drainage sheath can direct urine into a leg bag when penile skin and anatomy permit.

A penile clamp may provide short-term control for selected men with good sensation, intact skin and adequate bladder emptying. It must be released regularly and should not be used overnight. Extra caution is required after radiation because pressure injury may heal poorly.

Catheter options

Catheters manage drainage; they do not repair stress incontinence. They may nevertheless be appropriate when there is retention, very poor emptying, severe frailty, failed reconstruction or a need for temporary urinary control.

Intermittent self-catheterisation

Intermittent self-catheterisation is generally preferred when the bladder fails to empty but the patient has sufficient dexterity and urethral access. It avoids a continuously indwelling tube, although irradiated strictures or a false passage may make catheterisation difficult.

Long-term urethral catheter

An indwelling urethral catheter may be necessary in selected patients, but long-term use can cause infection, discomfort, blockage, bladder stones, urethral erosion and further outlet damage. A catheter passing through an activated AUS cuff can also cause serious urethral erosion; healthcare providers must be told that an AUS is present and the device should be deactivated before urethral instrumentation.

Suprapubic catheter

A suprapubic catheter enters the bladder through the lower abdomen. For long-term drainage it often avoids continuing urethral pressure and may be easier to manage than a urethral catheter. It still requires regular changes and carries risks including infection, blockage, bladder stones, leakage and skin problems.

Male sling versus artificial urinary sphincter

Male sling

A male sling supports and repositions or compresses the urethra. Its advantages include no scrotal pump and no need to operate the device each time the patient urinates. In carefully selected, non-irradiated men with mild-to-moderate stress incontinence, a sling can be effective.

However, previous pelvic radiotherapy is a recognised predictor of poorer sling outcomes. Fibrosis limits urethral mobility and tissue recovery, and moderate-to-severe leakage further reduces success. A sling may still be discussed in a highly selected patient with very mild leakage, good residual sphincter function and a stable, healthy-looking urethra, but expectations must be conservative.

Artificial urinary sphincter (AUS)

The AUS consists of a fluid-filled cuff around the urethra, a pressure-regulating balloon and a pump in the scrotum. The cuff stays closed to control leakage. The patient squeezes the pump to open it temporarily when passing urine.

For men with moderate-to-severe stress incontinence, the AUS remains the most established surgical treatment. Importantly, the AUA/GURS/SUFU guideline recommends offering an AUS rather than a male sling or adjustable balloons to men seeking surgery after primary, adjuvant or salvage radiotherapy.

Radiation does not make AUS implantation impossible, but outcomes are less predictable than in non-irradiated men. Radiation increases the risks of urethral erosion, infection, tissue atrophy, revision and device removal. Mechanical parts also have a limited lifespan, so further surgery may eventually be required.

Practical comparison

Consideration	Male sling	Artificial urinary sphincter
Best-established role	Mild-to-moderate stress leakage in selected men	Moderate-to-severe stress leakage
Previous salvage radiotherapy	Lower success; generally not preferred	Guideline-preferred surgical option, with higher complication risk than in non-irradiated men
Patient operation	No pump	Scrotal pump must be squeezed for each void
Manual dexterity required	Minimal	Yes
Retention risk	Possible	Possible if device is not cycled correctly or obstruction develops
Long-term considerations	Persistent leakage or failure may require AUS	Mechanical failure, erosion, infection or atrophy may require revision or removal

Neither operation guarantees complete dryness. The choice should consider pad weight, bladder function, urethral health, prior strictures or surgery, dexterity, patient priorities and the reconstructive surgeon’s assessment.

When an AUS or sling is not enough

A small group of men develop a severely scarred, painful or repeatedly obstructed outlet, sometimes called a devastated bladder outlet. This may include recurrent bladder-neck contracture or urethral stricture, fistula, radionecrosis, repeated AUS erosion, severe radiation cystitis or an unsafe low-capacity bladder.

Further implant surgery may then be unlikely to succeed. The priority changes from preserving normal voiding to obtaining dependable drainage, protecting the kidneys and improving quality of life.

Options at a specialist reconstructive centre may include:

long-term suprapubic drainage;
closure of the bladder neck with a suprapubic catheter in selected cases;
a catheterisable abdominal channel in carefully selected patients;
an ileal conduit, in which urine drains through a short segment of bowel to a urostomy bag on the abdomen;
another form of continent urinary diversion in selected fit patients; or
cystectomy with urinary diversion when the bladder is severely painful, contracted, bleeding, fistulating or otherwise unsalvageable.

These are major, irreversible procedures with substantial risks. They should be considered only after detailed imaging and functional assessment, review of cancer status, discussion with an experienced reconstructive team and consultation with a stomal therapy nurse.

A sensible treatment pathway

Define the leakage: stress, urgency, overflow or mixed.
Measure its severity: diary, pads and preferably pad weight.
Check storage and emptying: urine testing, flow and residual; use urodynamics when the findings may alter treatment.
Inspect the outlet: cystoscopy before implant surgery, particularly after radiation.
Treat infection, obstruction and bladder dysfunction first.
Use conservative or catheter strategies when appropriate.
For persistent radiated stress incontinence, discuss AUS as the usual preferred operation.
Reserve sling surgery for exceptional, carefully selected radiated patients after frank counselling.
Refer severe outlet or bladder destruction to a high-volume reconstructive centre to discuss reconstruction versus diversion.

The take-home message

Urinary incontinence after prostatectomy and salvage radiotherapy is treatable, but it needs more than a pad count and a one-size-fits-all operation. The bladder, sphincter and urethra must each be assessed.

For straightforward sphincter weakness after radiation, the artificial urinary sphincter usually offers the most reliable surgical option, although radiation increases the likelihood of erosion and future revision. A male sling is less invasive but is less dependable in irradiated tissue. When the outlet or bladder is severely damaged, catheter drainage, bladder-neck closure or urinary diversion may provide a safer and more durable solution than repeated continence procedures.

This article provides general information and does not replace an individual assessment. Treatment should be tailored to the patient’s symptoms, examination, bladder function, urethral condition, cancer status and personal priorities.

References

Breyer BN, Kim SK, Kirkby E, et al. Updates to Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline (2024). Journal of Urology. 2024. AUA guideline | Journal update
European Association of Urology. EAU Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms: urinary incontinence assessment and treatment. Current online edition. EAU guideline
American Urological Association, ASTRO and SUO. Salvage Therapy for Prostate Cancer Guideline. AUA/ASTRO/SUO salvage therapy guideline
National Institute of Diabetes and Digestive and Kidney Diseases. Urodynamic testing. NIDDK patient information
British Association of Urological Surgeons. Urinary diversion into an ileal conduit. BAUS patient information

Evidence note: Most data specific to men who have undergone both prostatectomy and salvage radiotherapy come from observational series rather than large randomised trials. Recommendations therefore combine guideline evidence, reconstructive-urology experience and individualised shared decision-making.

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

September 17, 2026/0 Comments/in Blog Post, Incontinence Surgery, Urinary Incontinence/by drjo

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

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

How does Parkinson’s affect the bladder?

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

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

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

Common urinary symptoms

People may experience:

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

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

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

How is the bladder evaluated?

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

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

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

Are urodynamic studies always necessary?

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

Urodynamics may be particularly useful when:

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

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

First steps: practical and behavioural treatment

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

Useful measures include:

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

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

Medication options

Antimuscarinic medicines

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

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

Beta-3 agonists

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

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

If emptying is the main problem

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

Botox injections into the bladder

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

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

Important risks include:

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

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

Can sacral neuromodulation be used in Parkinson’s disease?

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

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

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

Points to consider include:

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

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

Botox or sacral neuromodulation?

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

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

When should you seek prompt medical attention?

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

The take-home message

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

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

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

References and further reading

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

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

September 17, 2026/0 Comments/in Blog Post, Incontinence Surgery, Urinary Incontinence/by drjo

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

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

How does MS affect bladder control?

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

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

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

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

Symptoms that deserve assessment

Bladder symptoms may include:

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

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

How is the bladder assessed?

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

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

Urodynamic studies: useful, but used selectively

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

Urodynamics is especially useful when:

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

Precautions before and during urodynamics

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

Treatment: matching the solution to the bladder problem

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

Everyday measures

Useful first steps may include:

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

Medication for urgency and neurogenic overactive bladder

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

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

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

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

Catheterisation and intermittent self-catheterisation (ISC)

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

ISC may:

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

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

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

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

Bladder Botulinum Toxin injections

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

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

The main precautions are:

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

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

Sacral neuromodulation (SNM)

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

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

Important considerations in MS include:

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

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

Botox versus sacral neuromodulation in MS

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

Which is better?

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

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

Other interventional and surgical options

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

Follow-up matters

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

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

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

Take-home message

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

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

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

References and further reading

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

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

September 16, 2026/0 Comments/in Blog Post, Incontinence Surgery/by drjo

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

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

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

The principal goals of urological care are to:

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

What are the different types of spina bifida?

Spina bifida occulta

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

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

Meningocele

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

Myelomeningocele

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

Closed spinal dysraphism and tethered cord

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

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

How does spina bifida affect the bladder?

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

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

Spina bifida can disrupt these signals in several ways.

An overactive bladder

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

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

A poorly compliant, high-pressure bladder

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

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

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

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

Failure of bladder emptying

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

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

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

Detrusor-sphincter dyssynergia

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

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

A weak bladder outlet

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

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

How is the bladder investigated?

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

Clinical assessment

The consultation should consider:

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

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

Urine testing

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

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

Blood tests

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

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

Ultrasound

Renal and bladder ultrasound can assess:

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

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

Urodynamic studies

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

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

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

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

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

Treatment options

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

Clean intermittent self-catheterisation

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

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

Potential benefits include:

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

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

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

Bladder medication

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

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

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

Botulinum toxin: Botox

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

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

Important considerations include:

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

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

Sacral neuromodulation

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

It may be considered for selected patients with:

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

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

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

Surgery to improve the bladder outlet

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

Options may include:

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

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

Mitrofanoff catheterisable channel

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

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

A Mitrofanoff may be helpful when:

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

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

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

Clam augmentation cystoplasty

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

It may be considered when there is:

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

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

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

Long-term considerations include:

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

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

Mitrofanoff versus ileal conduit: an important distinction

These procedures are sometimes confused, but they work differently.

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

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

An ileal conduit may be considered when:

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

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

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

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

The importance of bowel management

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

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

Warning signs requiring medical review

Prompt assessment is advisable if there is:

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

The key message

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

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

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

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

References and further reading

Urge Incontinence After Sling Surgery: Why Timing Matters

September 16, 2026/0 Comments/in Blog Post, Incontinence Surgery/by drjo

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

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

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

What is urge urinary incontinence?

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

Other overactive bladder symptoms may include:

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

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

How common is urgency after a sling?

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

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

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

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

Urgency in the early postoperative period

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

Possible early causes

1. Temporary irritation and inflammation

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

These symptoms often settle as postoperative inflammation resolves.

2. Urinary tract infection

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

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

3. Incomplete bladder emptying

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

Symptoms can include:

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

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

4. Excessive outlet resistance from the sling

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

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

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

5. Bladder or urethral perforation or sling exposure

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

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

6. Pre-existing overactive bladder

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

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

How should early postoperative urgency be assessed?

Assessment may include:

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

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

Management of early urgency

Treatment depends on the findings.

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

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

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

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

Published expert reviews emphasise balancing two risks:

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

Urgency developing months or years after sling surgery

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

Possible delayed causes

Age-related overactive bladder

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

Menopause and genitourinary syndrome of menopause

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

Recurrent urinary infection

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

Pelvic organ prolapse

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

Delayed obstruction or scarring

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

Vaginal, urethral or bladder erosion

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

Other bladder or neurological disease

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

Investigating delayed urgency

A sensible assessment commonly includes:

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

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

Treatment when obstruction and sling complications have been excluded

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

Lifestyle and bladder strategies

Options include:

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

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

Medication

Medication options include:

Antimuscarinic medicines

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

Beta-3 adrenergic agonists

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

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

Vaginal oestrogen

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

Percutaneous tibial nerve stimulation

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

Intravesical botulinum toxin

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

Sacral neuromodulation

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

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

When is sling revision appropriate years later?

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

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

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

Possible consequences of sling revision include:

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

Shared decision-making is therefore essential.

The role of sling release and urethrolysis

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

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

When should sling-related obstruction be suspected?

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

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

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

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

Sling mobilisation or loosening

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

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

Early mobilisation may:

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

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

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

Sling incision or division

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

It may be considered when there is:

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

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

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

Partial sling excision

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

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

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

What is formal urethrolysis?

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

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

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

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

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

Will sling release cure the urgency?

Not necessarily.

Urgency is most likely to improve when:

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

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

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

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

Risks of sling release or urethrolysis

Potential complications include:

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

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

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

Why timely recognition matters

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

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

When should you seek urgent medical attention?

Contact your surgeon or seek urgent assessment if you:

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

The take-home message

Urge incontinence after sling surgery deserves a structured assessment.

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

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

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

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

References

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

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

Artificial Urinary Sphincter After Prostatectomy: Restoring Control After Male Stress Incontinence

September 14, 2026/0 Comments/in Blog Post, Incontinence Surgery, Urinary Incontinence/by drjo

Urinary leakage after prostate surgery can be frustrating, embarrassing and restrictive. When persistent leakage is caused by weakness of the urinary sphincter, an artificial urinary sphincter (AUS) is often the most reliable surgical treatment—particularly for moderate or severe stress urinary incontinence.

However, not every man who leaks after prostatectomy has the same problem. Before inserting an AUS, it is essential to establish why the leakage is occurring. An AUS treats sphincter weakness; it does not directly treat an overactive bladder.

Why can incontinence occur after prostatectomy?

Urinary continence normally depends on several structures working together:

The external urinary sphincter closing the urethra
Healthy supporting tissues around the urethra
A bladder that stores urine at a safe pressure
Coordinated bladder and sphincter function
Adequate pelvic-floor muscle control

During radical prostatectomy, the prostate and part of the internal continence mechanism are removed. Although every effort is made to preserve the external sphincter, it may be weakened by surgical dissection, altered support, scarring or nerve injury.

Radiotherapy, previous urethral surgery, bladder-neck contracture and urethral stricture may further affect continence and tissue quality.

Stress incontinence or overactive bladder?

This distinction is critical because the treatments are different.

Stress urinary incontinence

Stress incontinence typically causes leakage with:

Coughing or sneezing
Standing from a chair
Walking or exercising
Lifting
Bending
Changing position
A full bladder
Sexual activity

The leakage is usually caused by inadequate closure of the urinary sphincter. This is the type of incontinence that an AUS is designed to treat.

Overactive bladder

Overactive bladder generally causes:

A sudden, difficult-to-defer need to urinate
Frequent urination
Waking several times at night
Leakage before reaching the toilet
Leakage triggered by running water, arriving home or putting the key in the door

These symptoms may result from involuntary bladder contractions, reduced bladder capacity, bladder irritation, infection, obstruction or changes in bladder function that existed before the prostate operation.

Some men have mixed incontinence, with both stress leakage and urinary urgency. An AUS may improve the stress component while urgency, frequency or urge leakage persists and requires separate treatment.

Assessment before considering an AUS

A careful evaluation helps confirm that sphincter weakness is the principal cause of leakage and identifies conditions that should be treated before implantation.

Assessment may include:

A detailed symptom and surgical history
Physical examination
Urinalysis and urine culture
A bladder or voiding diary
Pad-use assessment or a formal pad-weight test
Measurement of urinary flow and residual urine
Cystoscopy to examine the urethra, sphincter region and bladder neck
Urodynamic studies in selected patients

Any urinary infection, bladder-neck contracture or urethral stricture should usually be treated and shown to be stable before an AUS is inserted.

The role of urodynamic studies

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

Genuine stress urinary incontinence
Detrusor overactivity or overactive bladder contractions
Poor bladder compliance or unsafe storage pressures
Reduced bladder capacity
Weak bladder contraction
Bladder-outlet obstruction
Mixed stress and urgency incontinence

Urodynamics is not necessarily required for every straightforward case. Current guidelines support its selective use when the diagnosis is uncertain or when the findings could change management.

It is particularly useful when a man has:

Marked urgency or urge leakage
Difficulty emptying his bladder
An elevated residual urine volume
Previous radiotherapy
Previous surgery for a urethral stricture or bladder-neck contracture
Neurological disease
Unexplained or mixed urinary symptoms
Leakage that does not follow a typical stress-incontinence pattern

Finding detrusor overactivity does not automatically exclude AUS surgery. It allows the patient and surgeon to set realistic expectations and determine whether bladder-directed treatment should be given before or after the procedure.

What is an artificial urinary sphincter?

An AUS is a fluid-filled hydraulic device with three main components:

Urethral cuff: placed around the urethra to keep it gently closed.
Control pump: positioned inside the scrotum, where it can be felt and operated through the skin.
Pressure-regulating balloon: usually placed in the lower abdomen or pelvis.

The cuff remains closed during normal activities and prevents urine from leaking. To urinate, the patient squeezes the scrotal pump. This temporarily transfers fluid out of the cuff, allowing the urethra to open. The cuff then automatically refills over the following few minutes.

The device is entirely internal. Nothing normally remains outside the body.

Who may benefit from an AUS?

An AUS may be considered when:

Stress incontinence persists despite pelvic-floor rehabilitation
Leakage significantly affects work, exercise, travel, sleep, relationships or quality of life
Incontinence is moderate or severe
The patient has undergone prostatectomy or other prostate treatment
The urethra and bladder neck are open and stable
Urinary infection has been excluded
Bladder storage and emptying are sufficiently safe
The patient understands that the implant may eventually require revision
The patient has enough hand strength and dexterity to operate the pump

Guidelines recommend discussing AUS surgery with men experiencing persistent stress incontinence after prostate treatment, including selected men with mild leakage who prefer this option.

Surgery is usually deferred while natural recovery is still occurring. Incontinence that remains troublesome at approximately six months and is not improving may justify earlier discussion, while definitive surgery is commonly considered by 12 months after prostatectomy.

When may an AUS be unsuitable?

An AUS may not be appropriate when there is:

Active urinary infection
An untreated or unstable urethral stricture
Recurrent bladder-neck obstruction
Active urethral erosion
Inability to operate the scrotal pump
Severe cognitive impairment
An unsafe, poorly compliant bladder that has not been addressed
A continuing need for frequent urethral catheterisation or instrumentation

Previous pelvic radiotherapy does not necessarily prevent AUS implantation. However, radiated tissues may heal less reliably and have a higher risk of erosion, infection and future revision.

What happens during and after surgery?

The operation is performed under anaesthesia. The cuff is commonly placed around the bulbar urethra through an incision in the perineum, with the pump positioned in the scrotum and the balloon placed in the lower abdomen or pelvis.

The AUS is normally left deactivated while the tissues heal. It is commonly activated approximately four to six weeks later, depending on the patient’s recovery and the surgeon’s protocol.

Until activation, urinary leakage is expected to continue.

Patients are then taught how to:

Locate and operate the pump
Empty the bladder without repeatedly squeezing the pump
Recognise whether the device has cycled normally
Explain the implant to other healthcare providers
Seek assistance if catheterisation or urinary procedures are required

How successful is an AUS?

The AUS is regarded as the standard surgical treatment for moderate-to-severe male stress incontinence after prostatectomy. Most men experience a substantial reduction in leakage and improvement in quality of life.

“Success” does not always mean being completely pad-free. Many men achieve social continence, generally described as using no more than one small security pad per day. Results vary according to previous radiotherapy, urethral surgery, tissue quality, severity of leakage and how success is defined.

An AUS is a mechanical implant rather than a permanent cure. Device survival decreases over time, and some men will eventually require revision or replacement.

Possible complications

Potential complications include:

Bleeding, bruising or haematoma
Temporary urinary retention
Wound or device infection
Difficulty locating or operating the pump
Persistent stress leakage
Ongoing urgency or urge incontinence
Urethral cuff erosion
Urethral tissue thinning or atrophy
Mechanical malfunction or fluid leakage
Pump or component migration
Pain
Need for revision, replacement or removal

Infection and erosion generally require removal of part or all of the device. A new AUS may sometimes be inserted after the urethra has healed, but repeat surgery can be more complex.

Warning signs of cuff erosion or device infection

Urethral erosion occurs when the cuff gradually damages or enters the urethral wall. It may develop months or years after implantation.

Seek prompt urological review if you notice:

New pain or burning during urination
Blood in the urine
Recurrent urinary infections
Increasing perineal, urethral or scrotal discomfort
New swelling, redness, warmth or discharge around an incision
Fever or feeling generally unwell
Difficulty passing urine
A noticeably weaker urinary stream
Sudden urinary retention
A sudden return or marked worsening of leakage
The pump becoming unusually difficult to operate
Part of the device becoming visible through the skin or urethra

Fever, urinary retention, marked swelling, severe pain or an exposed implant requires urgent medical assessment.

Important precautions after AUS implantation

Always tell healthcare providers about the AUS

A urethral catheter must not be inserted while the cuff is activated. Forcing a catheter through a closed cuff may damage the urethra and cause erosion.

Before catheterisation, cystoscopy or any procedure through the urethra:

The AUS must be identified
The cuff must be fully deactivated
The smallest appropriate catheter should be used
Prolonged urethral catheterisation should be avoided when possible
The treating team should contact a urologist if they are unfamiliar with the device

Patients should consider carrying a medical alert card or wearing medical identification stating:

“Artificial urinary sphincter present, deactivate before urethral catheterisation.”

Protect the urethra and implant

Patients should also:

Avoid operating the pump until instructed after surgery
Follow restrictions on lifting, exercise, cycling and sexual activity during healing
Avoid unnecessary urethral instrumentation
Report urinary infections promptly
Attend follow-up if leakage increases or the device behaves differently
Tell their urologist about future pelvic procedures
Never repeatedly squeeze the pump in an attempt to overcome urinary obstruction

What if the AUS fails?

The first step is to determine the reason. Recurrent leakage may be caused by:

Mechanical device failure
Loss of fluid from the system
Incomplete cuff closure
Urethral tissue thinning beneath the cuff
Cuff erosion
Device infection
A urethral or bladder-neck obstruction
Overactive bladder rather than sphincter failure
Incorrect device use

Assessment may include examination of the pump, urinalysis, cystoscopy, imaging, pad testing and sometimes repeat urodynamics.

Depending on the cause, options include:

Teaching or correcting pump technique
Treating overactive bladder separately
Revising or replacing a malfunctioning component
Replacing the entire AUS
Changing cuff size or position
Moving the cuff to a healthier section of urethra
Tandem-cuff or transcorporal techniques in carefully selected complex cases
Removing the device when infection or erosion is present
Allowing the urethra to heal before considering reimplantation
Considering a male sling in selected men with mild recurrent stress leakage
External collecting devices, continence clamps, absorbent products or long-term catheter options when further implant surgery is unsuitable

Men with prior radiotherapy, erosion or multiple urethral operations may require individualised reconstructive planning.

A final perspective

An artificial urinary sphincter can be life-changing for men with persistent stress urinary incontinence after prostatectomy. Its success depends on more than inserting a device: the correct cause of leakage must first be established.

Stress incontinence, overactive bladder, obstruction and poor bladder emptying can coexist. A careful history, objective assessment, cystoscopy and selective urodynamic testing allow treatment to be tailored to the individual patient.

Patients should understand that an AUS requires manual operation, lifelong precautions and possible future revision. With appropriate patient selection, careful surgery and ongoing follow-up, it remains one of the most effective treatments available for male post-prostatectomy stress incontinence.

So, if you suffer with post prostatectomy urinary incontinence, come see your Brisbane based functional urologist, Jo Schoeman to discuss this option.

References

American Urological Association, GURS and SUFU. Incontinence after Prostate Treatment: Clinical Guideline, amended 2024.
Breyer BN, Kim SK, Kirkby E, et al. Updates to Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline Amendment 2024. Journal of Urology. 2024.
European Association of Urology. EAU Guidelines on Non-neurogenic Male Lower Urinary Tract Symptoms—Disease Management.
European Association of Urology. EAU guidance: What happens when the artificial urinary sphincter fails?.
Johnson A, Abraham N, Chughtai B. Artificial urinary sphincters for moderate post-prostatectomy incontinence: current research and proposed approach. Journal of Clinical Medicine. 2023.
Desai TJ, Rozanski AT. Artificial urinary sphincter erosion and infection: a contemporary review of perioperative considerations and management. Translational Andrology and Urology. 2024.
Continence Foundation of Australia. Male urinary incontinence.

This information is intended for general education and does not replace individual medical assessment. Suitability for an AUS should be discussed with a urologist experienced in male continence and reconstructive surgery.