Benign prostatic hyperplasia—usually called BPH or benign prostate enlargement—is a common cause of urinary symptoms as men get older.

An enlarged prostate can compress the urethra and interfere with bladder emptying, causing symptoms such as:

• A slow or intermittent urinary stream
• Difficulty starting urination
• Straining to urinate
• A feeling that the bladder has not emptied
• Urinary frequency or urgency
• Waking repeatedly at night to urinate
• Dribbling after urination
• Episodes of urinary retention

Duodart® combines two established BPH medicines in a single daily capsule. One component relaxes the prostate relatively quickly, while the other gradually reduces its size and lowers the long-term risk of urinary retention and prostate surgery.

Duodart can be very effective in appropriately selected men, but it is not the right treatment for every urinary symptom or every prostate.

What does Dutasteride contain?

Each Duodart capsule contains:

• Dutasteride 0.5 mg
• Tamsulosin hydrochloride 0.4 mg

These medicines work in different but complementary ways.

Tamsulosin: relaxing the prostate

Tamsulosin is an alpha-1 adrenergic receptor blocker. It relaxes smooth muscle within the prostate and bladder neck, reducing resistance to urinary flow.

It may improve:

• Urinary stream
• Hesitancy
• Straining
• Bladder emptying
• Some frequency and urgency symptoms

Improvement may begin within days, although the full response can take several weeks.

Tamsulosin improves urinary symptoms but does not substantially reduce prostate size or prevent long-term prostate growth.

Dutasteride: gradually shrinking the prostate

Dutasteride is a 5-alpha-reductase inhibitor—5-ARI. It blocks both type 1 and type 2 forms of the enzyme that converts testosterone into dihydrotestosterone—DHT.

DHT is an important driver of prostate growth. Reducing DHT gradually causes susceptible prostate tissue to shrink.

According to the European Association of Urology, 5-ARIs can:

• Reduce prostate volume by approximately 18–28%
• Improve urinary symptom scores by approximately 15–30%
• Reduce PSA by approximately 50% after six to twelve months
• Reduce the long-term risk of acute urinary retention
• Reduce the likelihood of requiring BPH surgery

The dutasteride component works slowly. A meaningful benefit may take three to six months, with further improvement occurring over several years.

Who may benefit from Duodart?

Duodart is most appropriate for men with moderate-to-severe urinary symptoms caused by an enlarged prostate who also have an increased risk of BPH progression.

It may be considered when there is:

• A prostate volume of approximately 40 mL or greater
• A clearly enlarged prostate on examination or ultrasound
• An elevated PSA consistent with benign prostate enlargement
• A reduced urinary flow rate
• An increased post-void residual urine volume
• Increasing symptoms despite alpha-blocker treatment
• A risk of future urinary retention
• A desire to reduce the likelihood of BPH-related surgery
• A need for both relatively rapid symptom relief and long-term reduction in prostate size

Some men with prostates between 30 and 40 mL may also benefit, depending on their PSA, symptoms, urinary flow and other risk factors.

Combination treatment is generally intended for long-term use rather than a short trial lasting only a few weeks.

Who may not benefit?

Duodart is less likely to help when:

• The prostate is small
• Symptoms are primarily caused by an overactive bladder
• There is poor bladder-muscle contraction
• A urethral stricture is present
• Prostate or bladder cancer is causing the obstruction
• A bladder stone is responsible for the symptoms
• Neurological bladder dysfunction is present
• Symptoms are mild and not troublesome

A large prostate and severe symptoms do not always occur together. Some men with a very large prostate urinate reasonably well, while others with a small prostate have significant obstruction from a tight bladder neck, urethral narrowing or abnormal prostate shape.

This is why treatment should be based on an assessment rather than prostate size alone.

What assessment is recommended before starting Duodart?

Depending on the patient, assessment may include:

• A detailed urinary and medication history
• International Prostate Symptom Score—IPSS
• Physical examination
• Digital rectal examination
• Urine testing
• PSA testing
• Kidney-function blood tests
• Urinary flow-rate measurement
• Ultrasound measurement of prostate size
• Post-void residual urine measurement
• A bladder diary when frequency or nocturia is prominent
• Cystoscopy or urodynamic testing in selected patients

Prostate cancer and other important causes of urinary obstruction should be considered before symptoms are attributed to BPH.

How is Duodart taken?

The usual dose is one capsule once daily, taken approximately 30 minutes after the same meal each day.

The capsule should be swallowed whole. It should not be opened, crushed or chewed because its contents may irritate the mouth and throat.

Taking the capsule consistently after the same meal helps maintain predictable absorption of tamsulosin.

If treatment is stopped, urinary symptoms and prostate growth may gradually return. Duodart should not be stopped or restarted without discussing this with the prescribing doctor.

What benefits can be expected?

Tamsulosin provides the earlier benefit by relaxing the prostate and bladder neck. Dutasteride provides the slower, longer-term benefit by reducing prostate volume and the risk of progression.

In long-term clinical studies, dutasteride plus tamsulosin produced greater improvement in urinary symptoms and urinary flow than either medicine alone in appropriately selected men.

The EAU reports that, compared with tamsulosin alone at four years, combination treatment reduced the relative risk of:

• Acute urinary retention by approximately 68%
• BPH-related surgery by approximately 71%
• Symptom deterioration by approximately 41%

These are relative reductions from clinical-trial populations. The individual absolute benefit depends on the patient’s original risk, prostate size, PSA and degree of obstruction.

Duodart controls BPH; it does not permanently cure it.

Common side effects

Because Duodart contains two medicines, it can cause side effects associated with either component.

Ejaculatory changes

Tamsulosin can interfere with ejaculation. Patients may notice:

• Reduced semen volume
• Dry ejaculation
• Failure to ejaculate
• Semen passing backwards into the bladder—retrograde ejaculation

This is usually harmless but can affect sexual satisfaction and fertility.

Combination treatment has a higher risk of ejaculatory dysfunction than either an alpha blocker or 5-ARI used alone.

Reduced sexual desire

Dutasteride reduces DHT and may cause a decrease in libido. The effect may be mild for some men but troubling for others.

Erectile dysfunction

Difficulty achieving or maintaining an erection can occur. BPH itself, increasing age, vascular disease, diabetes and other medications can also contribute, so the cause is not always straightforward.

Breast changes

Dutasteride can occasionally cause:

• Breast tenderness
• Nipple sensitivity
• Breast enlargement—gynaecomastia

A breast lump, nipple discharge or persistent one-sided change should be assessed promptly rather than assumed to be a medication effect.

Dizziness and low blood pressure

Tamsulosin may lower blood pressure, particularly when standing. This can cause:

• Dizziness
• Light-headedness
• Weakness
• Fainting
• An increased risk of falling

Extra care is needed when treatment begins, after a dose change or when Duodart is combined with other blood-pressure-lowering medicines.

Other possible side effects

Other reported effects include:

• Headache
• Tiredness
• Palpitations
• Nasal congestion
• Gastrointestinal discomfort
• Skin rash or itching
• Testicular discomfort or swelling
• Mood changes or depression
• Reduced fertility or changes in semen quality

Semen-volume and sperm changes do not necessarily cause infertility, but men planning a pregnancy should discuss this before treatment.

Rare but important reactions

Urgent medical assistance is required for:

• Swelling of the face, tongue or throat
• Difficulty breathing
• A severe allergic reaction
• Fainting
• A painful erection lasting several hours—priapism
• Severe blistering or peeling skin
• Marked depression or suicidal thoughts

These reactions are uncommon but require prompt assessment.

Duodart and cataract surgery

Tamsulosin is associated with intraoperative floppy iris syndrome, which can make cataract or glaucoma surgery more difficult.

Patients should tell their ophthalmologist if they:

• Currently take Duodart
• Previously took Duodart
• Previously used another medicine containing tamsulosin

Stopping tamsulosin shortly before surgery may not completely remove this risk. The decision should be made between the ophthalmologist and prescribing doctor rather than by the patient alone.

Contraindications and important precautions

Duodart should not be used in:

• Women
• Children or adolescents
• Anyone allergic to dutasteride, tamsulosin, another 5-ARI or a capsule ingredient
• Patients with a history of significant postural or orthostatic hypotension
• Patients with severe liver impairment

Additional caution is required in men with:

• Recurrent dizziness or falls
• Significant cardiovascular disease
• Liver disease
• Severe kidney impairment
• Planned cataract or glaucoma surgery
• A history of depression or major mood disturbance
• Suspected prostate cancer
• Severe urinary retention
• A very high post-void residual urine volume
• Other medicines that substantially lower blood pressure

Duodart changes the interpretation of PSA

Dutasteride generally lowers PSA by approximately 50% after six to twelve months.

This does not mean that prostate cancer risk has disappeared. A new PSA baseline should be established after treatment begins, and subsequent results must be interpreted in the context of dutasteride use.

A confirmed rise from the lowest PSA reached while taking Duodart may require investigation—even when the result remains within the laboratory’s usual “normal” range.

Patients should tell any doctor ordering or interpreting a PSA test that they are taking dutasteride.

PSA monitoring and appropriate prostate cancer assessment should continue while using Duodart.

What is “post-finasteride syndrome”?

“Post-finasteride syndrome” is a term used to describe persistent symptoms reported by some patients during or after stopping finasteride.

Reported symptoms have included:

• Reduced libido
• Erectile dysfunction
• Altered genital sensation
• Ejaculatory or orgasmic changes
• Fatigue
• Poor concentration or “brain fog”
• Anxiety
• Depressed mood
• Sleep disturbance

The existence, frequency, biological mechanism and diagnostic criteria of post-finasteride syndrome remain debated. Some patients report very real and persistent symptoms, but current research has not established a reliable way to predict who may be affected or to prove that every reported symptom is directly caused by the medicine.

It should therefore neither be presented as a guaranteed consequence nor dismissed when a patient reports persistent symptoms.

Is post-finasteride syndrome relevant to Duodart?

Duodart does not contain finasteride. It contains dutasteride.

However, finasteride and dutasteride belong to the same 5-ARI medicine class and both reduce DHT. Sexual side effects such as reduced libido, erectile dysfunction and ejaculatory changes are recognised with both medicines.

Dutasteride inhibits both type 1 and type 2 5-alpha-reductase and remains in the body much longer than finasteride. Its terminal half-life is approximately five weeks, so adverse effects may not disappear immediately after stopping treatment.

Persistent sexual symptoms have been reported after treatment with 5-ARIs, although the frequency and causal relationship remain uncertain.

A 2025 European Medicines Agency safety review found insufficient evidence to establish a causal association between dutasteride and suicidal thoughts. Nevertheless, because of a possible class effect, the EMA recommended precautionary information about mood changes for dutasteride products.

Patients taking Duodart should contact their doctor if they develop:

• New or worsening sexual dysfunction
• Persistent loss of libido
• Depressed mood
• Significant anxiety
• Suicidal thoughts
• Symptoms that continue after stopping treatment

Stopping Duodart suddenly may allow urinary obstruction to worsen, so medication changes should usually be supervised. Suicidal thoughts or severe psychological distress require urgent assistance.

Monitoring treatment

Patients should usually be reviewed after starting Duodart to assess:

• Improvement in urinary symptoms
• Dizziness or postural blood-pressure changes
• Sexual and ejaculatory function
• Mood changes
• Urinary flow rate
• Post-void residual urine
• PSA response
• Kidney function when clinically indicated

The tamsulosin component should produce an earlier response, while the dutasteride benefit is judged over several months.

A lack of rapid improvement does not necessarily mean dutasteride has failed. Conversely, ongoing severe symptoms should not automatically be managed by continuing the medication indefinitely without reassessment.

When should surgery be considered?

Medication is often the first treatment for uncomplicated BPH, but surgery should not be regarded merely as a last resort. For some patients it offers more reliable relief and prevents further bladder or kidney damage.

Surgery should be considered when there is:

• Recurrent or persistent urinary retention
• Dependence on a urinary catheter
• Recurrent urinary tract infections caused by poor emptying
• Bladder stones
• Recurrent visible bleeding attributable to BPH
• Overflow urinary incontinence
• Progressive bladder diverticula associated with obstruction
• Dilatation of the kidneys or ureters
• Kidney impairment caused by bladder outlet obstruction
• A very high or increasing residual urine volume
• Persistent bothersome symptoms despite adequate medication
• Intolerable medication side effects
• A preference for a procedural solution rather than lifelong tablets
• Poor urinary flow with objective evidence of significant obstruction

Earlier surgery may also be appropriate when obstruction is beginning to damage bladder function. Waiting until the bladder has become severely stretched or weak can reduce the improvement achievable after surgery.

When is Duodart unlikely to prevent surgery?

Surgery may still be needed when:

• The prostate obstruction is mechanically severe
• A large middle lobe acts like a ball valve at the bladder outlet
• Urinary retention has already occurred repeatedly
• Bladder stones or recurrent infections are present
• Residual urine continues to increase
• Kidney function or upper urinary tract drainage is affected
• Symptoms remain troublesome after an adequate trial
• The bladder has become poorly contractile
• Side effects make long-term treatment unacceptable

Duodart can reduce future risk; it cannot reliably reverse every established complication of obstruction.

What surgical options are available?

The appropriate procedure depends on prostate size, prostate shape, bleeding risk, bladder function, general health and the importance of preserving ejaculation.

Options may include:

• Transurethral resection of the prostate—TURP
• GreenLight laser prostate vaporisation
• Holmium laser enucleation—HoLEP
• Rezūm water-vapour therapy
• UroLift
• Temporary implantable nitinol device—iTind
• Robotic or open simple prostatectomy for very large glands
• Other enucleation or minimally invasive techniques

Some minimally invasive treatments are best suited to selected prostate sizes and shapes. Not every option provides the same durability, improvement in urinary flow or preservation of ejaculation.

The bottom line

Duodart combines the relatively quick muscle-relaxing effect of tamsulosin with the slower prostate-shrinking and progression-reducing effect of dutasteride.

It is most useful for men with moderate-to-severe urinary symptoms, a genuinely enlarged prostate and a meaningful risk of future urinary retention or surgery.

Sexual and ejaculatory side effects, dizziness, breast changes and possible mood effects should be discussed before treatment. Duodart also lowers PSA, so ongoing prostate cancer surveillance must be interpreted differently.

The term “post-finasteride syndrome” remains scientifically debated. Duodart does not contain finasteride, but dutasteride acts on the same hormonal pathway, and persistent symptoms reported by a patient deserve careful assessment.

Medication should not be continued indefinitely when symptoms remain severe, complications develop or bladder and kidney function are threatened. In those circumstances, timely prostate surgery may be safer and more effective than simply adding another tablet.

This article provides general information and does not replace personalised medical advice. Patients should not start, stop or alter Duodart without consulting their treating doctor.

So, if you are having difficulty with your lower urinary tract symptoms and you wish to remain conservative in your management and not to fussed about your erectile function and libido, come see your local Brisbane urologist, dr Jo Schoeman, to discuss further options

References and further reading

• Therapeutic Goods Administration—Duodart ARTG and Australian Product Information
• European Association of Urology—Management of Non-neurogenic Male Lower Urinary Tract Symptoms
• European Medicines Agency—Finasteride and dutasteride safety review
• Healthdirect Australia—Benign prostate enlargement

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

Common lower urinary tract symptoms include:

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

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

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

What is a MIST procedure?

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

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

Its principal attractions are:

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

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

How does UroLift work?

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

Each implant consists of:

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

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

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

Who may benefit from UroLift?

UroLift may be considered for men who:

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

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

What prostate size is suitable?

Clinical guidelines and manufacturer labelling are not identical.

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

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

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

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

What about an obstructing median lobe?

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

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

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

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

Assessment before treatment

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

Assessment may include:

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

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

Any urinary infection should be treated before the procedure.

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

How is the UroLift procedure performed?

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

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

The urologist:

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

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

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

Will I need a catheter?

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

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

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

What should I expect after UroLift?

Temporary urinary irritation is common during the first few days.

You may experience:

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

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

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

Managing pain and urinary discomfort

Discomfort after UroLift is usually mild to moderate.

Management may include:

Paracetamol

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

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

Anti-inflammatory medication

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

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

Medication for urinary symptoms

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

Practical measures

It may help to:

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

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

Possible complications

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

Common temporary effects

These include:

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

Urinary retention

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

Urinary tract infection

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

Bleeding

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

Implant-related problems

Potential implant complications include:

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

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

Persistent symptoms

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

Need for further treatment

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

When should I seek urgent help?

Contact your urologist or attend an emergency department if you:

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

Does UroLift affect erections or ejaculation?

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

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

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

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

How effective is UroLift?

Clinical studies show meaningful average improvement in:

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

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

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

How long does UroLift last?

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

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

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

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

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

MRI considerations

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

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

This caveat is particularly relevant for:

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

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

Can prostate surgery still be performed later?

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

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

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

Who should not undergo UroLift?

Manufacturer contraindications include:

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

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

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

Advantages of UroLift

Potential advantages include:

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

Limitations and important caveats

Patients should understand that:

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

Is UroLift the right option for me?

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

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

The decision should take account of:

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

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

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

References

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

If you are troubled by lower urinary tract symptoms but are not yet ready to farewell your forward ejaculation, come and see your Brisbane urologist, Dr Jo, Uro-Jo, to discuss whether UroLift may be an appropriate option for your BPH.

Creating a temporary safety zone between the prostate and rectum

Radiation therapy is an effective treatment for many men with prostate cancer. Modern radiation techniques are remarkably accurate, but there is one anatomical challenge: the prostate sits immediately in front of the rectum.

This means that while radiation is directed at the prostate, part of the rectum may also receive radiation.

One approach to reducing this exposure is to temporarily create a small space between the prostate and rectum before radiation treatment begins.

Barrigel® is a biodegradable hyaluronic acid rectal spacer designed specifically for this purpose.

Why does the rectum need protection?

The prostate and rectum normally sit almost against each other, separated by only a thin layer of tissue.

During prostate radiation therapy, some radiation therefore inevitably reaches the anterior wall of the rectum.

This can contribute to bowel symptoms such as:

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

Most bowel symptoms following modern radiation therapy are mild and temporary, but occasionally they can persist or become troublesome.

The basic idea behind a rectal spacer is delightfully simple:

Prostate → spacer → rectum

Instead of asking radiation technology to perform an anatomical magic trick, we physically move the rectum a little farther away.

Even approximately 1 cm of additional separation can substantially reduce the radiation dose received by the anterior rectal wall.

What is Barrigel?

Barrigel is a sterile, biodegradable gel made from stabilised, non-animal-derived hyaluronic acid.

Hyaluronic acid occurs naturally in many tissues within the human body and is widely used in medical applications.

Barrigel is injected into the tissue plane between the prostate and anterior rectal wall before prostate radiation therapy.

The gel creates a temporary cushion that pushes the rectum away from the prostate.

Importantly, Barrigel does not treat the prostate cancer itself.

Its purpose is to protect surrounding normal tissue while radiation treats the cancer.

How is Barrigel inserted?

Barrigel is usually inserted before radiation planning.

The procedure is performed using ultrasound guidance.

A needle is passed through the skin of the perineum, the area between the scrotum and anus, rather than through the rectum.

The needle is carefully positioned between the back of the prostate and the front wall of the rectum.

Barrigel is then slowly injected while the position of the gel is continuously monitored with ultrasound.

Typically several millilitres of gel are used to create the required separation.

The procedure may be performed using:

• local anaesthetic
• sedation
• or another form of anaesthesia depending upon the patient and treating centre.

Fiducial markers used for radiation targeting may sometimes be inserted during the same procedure.

Antibiotic prophylaxis and strict sterile technique are important.

Who may benefit from Barrigel?

Barrigel may be considered for men undergoing radiation therapy for localised prostate cancer where reducing radiation exposure to the rectum is desirable.

This may include men undergoing:

Conventional external-beam radiation therapy

A spacer may reduce the amount of radiation reaching the rectum during a multi-week course of treatment.

Hypofractionated radiation therapy

Modern prostate radiation is increasingly delivered using larger doses over fewer treatment sessions.

A randomised clinical trial involving 201 men demonstrated that a hyaluronic-acid spacer significantly reduced rectal radiation exposure during hypofractionated prostate radiotherapy.

Acute grade 2 or greater gastrointestinal side effects occurred in approximately 2.9% of spacer-treated patients compared with 13.8% without a spacer.

Stereotactic body radiation therapy – SBRT

SBRT delivers relatively high radiation doses over only a few treatments. Precise protection of surrounding structures therefore becomes particularly important.

Selected salvage radiation situations

Spacer placement may occasionally be considered in more complex circumstances, although previous prostate or pelvic treatment can alter the normal tissue planes and make insertion more difficult.

These cases require individual assessment by the radiation oncologist and urologist.

When should Barrigel not be used?

Barrigel is contraindicated in patients with clinical T4 prostate cancer.

It should also be approached cautiously in men with conditions that may make insertion difficult or increase the risk of complications.

These include:

• active infection or inflammation near the injection site
• bleeding disorders
• anticoagulant or thrombolytic therapy
• significant antiplatelet medication
• known allergy to hyaluronic-acid products
• significant anorectal stenosis or anatomical abnormalities
• previous surgery causing extensive scarring around the prostate or rectum
• significant haemorrhoidal disease
• immunodeficiency or significant immunosuppressive therapy.

Anticoagulant and antiplatelet medications should not simply be stopped without medical advice. Their management needs to be individualised according to the reason they are being taken.

What are the potential side effects?

Most patients tolerate spacer insertion well.

Temporary symptoms may include:

• discomfort in the perineum
• minor bleeding or bruising
• a sensation of rectal fullness
• temporary discomfort when opening the bowels
• urinary frequency or discomfort
• weak urinary stream
• temporary constipation.

The feeling that there is “something there” behind the prostate can occur initially and generally settles.

What are the uncommon but important complications?

Although rectal spacer insertion is generally considered a low-risk procedure, it is still an invasive procedure.

Possible complications include:

• infection
• prostatitis
• bleeding or haematoma
• urinary retention
• significant rectal pain
• difficult or painful defaecation
• incorrect positioning of the spacer
• injection into the prostate
• injury to the urethra or bladder
• rectal-wall injury
• rectal ulceration or tissue necrosis
• vascular injection or embolisation
• very rarely, fistula formation or severe pelvic infection.

This is why spacer insertion should be performed by clinicians experienced in transperineal ultrasound-guided procedures.

Correct placement matters just as much as the choice of spacer.

What happens to Barrigel afterwards?

Barrigel is biodegradable.

It remains between the prostate and rectum during the period when radiation treatment is being delivered and is subsequently broken down and absorbed by the body.

No second operation is normally required to remove it.

Barrigel versus SpaceOAR®

Barrigel and SpaceOAR are designed to solve the same anatomical problem, but they use different materials.

	Barrigel	SpaceOAR
Material	Stabilised hyaluronic acid	Polyethylene glycol hydrogel
Main purpose	Separate prostate and rectum	Separate prostate and rectum
Placement	Transperineal injection	Transperineal injection
Imaging guidance	Ultrasound	Ultrasound
Biodegradable	Yes	Yes
Remains permanently	No	No
Material characteristics	Hyaluronic-acid gel that can be progressively shaped during injection	PEG hydrogel formed after injection
Radiopaque version	No equivalent to SpaceOAR Vue	SpaceOAR Vue contains iodine for CT visibility
Evidence	Randomised evidence demonstrating improved rectal dosimetry and reduced acute GI toxicity	Extensive clinical experience and randomised/prospective evidence supporting rectal dose reduction

Both therefore create a temporary physical separation between the prostate and rectum.

Is Barrigel better than SpaceOAR?

At present it would be too simplistic to say that one spacer is universally “better”.

Both can substantially reduce radiation exposure to the rectum when correctly placed.

There are, however, some practical differences.

Barrigel can be shaped during insertion

Barrigel is injected as hyaluronic-acid gel. The operator can progressively deposit and shape the material while watching the developing space with ultrasound.

This can be useful when trying to achieve an appropriate distribution behind the prostate.

SpaceOAR has a long clinical track record

SpaceOAR has been extensively studied and is widely used internationally.

SpaceOAR Vue also contains iodine, making the spacer readily visible on CT. This may be helpful when MRI is unsuitable or when CT-based radiation planning is required.

Placement may matter more than the label on the syringe

An important point is that the quality, volume and position of the spacer can significantly influence the radiation dose received by the rectum.

A 2025 real-world comparative study found differences in dosimetry between Barrigel and SpaceOAR that were strongly influenced by the amount of spacer inserted. At comparable volumes, Barrigel performed favourably for some dosimetric measurements.

Interestingly, rectal-wall infiltration occurred in 7 of 287 SpaceOAR procedures (2.44%) and none of the Barrigel procedures in that particular study.

This does not prove that Barrigel is universally safer, but it highlights the importance of spacer material, injection technique and careful positioning.

What if Barrigel is not perfectly positioned?

One potentially useful characteristic of hyaluronic acid is that it can potentially be treated with hyaluronidase, an enzyme that breaks down hyaluronic acid.

This provides a theoretical and practical advantage if significant malposition is recognised.

The Queensland Clinical Excellence guidance specifically notes Barrigel’s potential to be hydrolysed in situations of spacer misplacement.

This does not make incorrect placement harmless, however. Prevention through meticulous ultrasound-guided insertion remains far preferable to correction afterwards.

Do all men having prostate radiation need a spacer?

No.

Modern radiation techniques such as IMRT, VMAT and image-guided radiotherapy already provide highly sophisticated targeting.

Whether a spacer provides meaningful additional benefit depends upon:

• prostate anatomy and size
• distance between prostate and rectum
• radiation technique
• radiation dose and fractionation
• previous prostate or pelvic treatment
• bowel disease
• anticoagulation
• individual risk of radiation toxicity
• and the experience of the treating radiation team.

Some patients may gain considerable benefit while others may gain relatively little.

The decision should therefore be made jointly between the patient, radiation oncologist and urologist.

What does the evidence tell us?

The European Association of Urology recognises biodegradable rectal spacers as a method of increasing the distance between the prostate and rectum and reducing rectal radiation exposure.

Evidence across rectal spacer studies suggests reductions in both acute and late grade 2 or greater rectal toxicity.

For Barrigel specifically, a multicentre randomised trial demonstrated impressive dosimetric results during hypofractionated radiotherapy.

98.5% of patients receiving the hyaluronic-acid spacer achieved at least a 25% reduction in the volume of rectum receiving 54 Gy.

The average reduction was approximately 85%.

The same study demonstrated substantially fewer acute grade 2 or greater gastrointestinal side effects in patients receiving the spacer.

These findings support rectal spacing as a useful tool for appropriately selected men receiving prostate radiation therapy.

The bottom line

Barrigel is a temporary hyaluronic-acid rectal spacer used to create additional distance between the prostate and rectum before prostate cancer radiation therapy.

It does not improve the radiation by attacking the cancer. Instead, it gives the radiation oncologist a little more anatomical breathing room.

For appropriately selected patients it can:

increase prostate-to-rectum separation → reduce rectal radiation dose → reduce the risk of bowel toxicity.

Barrigel and SpaceOAR both achieve this objective using different biomaterials. Neither should automatically be regarded as the best option for every patient.

The choice should take into account the planned radiation technique, individual anatomy, previous treatment, medical history and the experience of the treating team.

Most importantly, a rectal spacer is an additional protective tool, not a guarantee against radiation-related bowel complications.

When should I discuss a rectal spacer?

If you are considering external-beam radiation therapy or SBRT for prostate cancer, it is reasonable to ask your radiation oncologist or urologist:

“Would I benefit from a rectal spacer, and would Barrigel or SpaceOAR be more appropriate for me?”

That conversation should occur before radiation planning begins.

This information is intended for patient education and does not replace individual assessment by your urologist or radiation oncologist.

So, if you have discussed this with your radiation oncologist and you would like the benefit of protecting your rectum against the effects of radiation, come see your local Brisbane urologist, Dr Jo, to discuss this option.