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Testicular rupture: causes, warning signs, diagnosis and treatment

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Testicular rupture is a surgical emergency. It occurs when trauma tears the tough outer covering of the testis (the tunica albuginea), allowing testicular tissue to protrude through the defect. Prompt assessment offers the best opportunity to control bleeding, relieve pain and preserve viable testicular tissue.

Seek urgent medical care: After an injury, go promptly to the nearest emergency department if there is severe or increasing scrotal pain, marked swelling or bruising, nausea or vomiting, a testis that feels abnormal or cannot be clearly felt, an open wound, or blood at the urinary opening or in the urine. Do not delay assessment while waiting to see whether the swelling settles.

What causes a testicular rupture?

Most ruptures follow a forceful, direct blow that compresses the testis against the pubic bone. Causes include:

  • contact sport, particularly without an appropriate protective cup;
  • bicycle or motorcycle accidents and straddle injuries;
  • falls, motor-vehicle trauma, workplace injuries or assault;
  • a kick, ball or other high-impact object striking the scrotum; and
  • penetrating trauma, such as a stab, gunshot, machinery injury or animal bite.

A major blunt injury can also cause a scrotal haematoma, haematocele (blood around the testis), testicular contusion, torsion, fracture without tunical rupture, or injury to the epididymis or spermatic cord. These conditions can look similar, and more than one injury may be present.

How does it present?

Typical features include immediate severe pain followed by rapidly developing swelling, tenderness and bruising. Nausea, vomiting or faintness may occur. The normal outline of the testis may be difficult to feel because of pain and swelling. An open injury, scrotal skin loss or bleeding may be present after penetrating or high-energy trauma.

Symptoms alone cannot reliably distinguish rupture from torsion or other serious injury. Testicular torsion may occur with or without trauma and is also time-critical. A seemingly modest external bruise does not exclude a significant internal injury.

Assessment and investigation

Assessment begins with the circumstances and timing of the injury, examination of both testes and the scrotum, and checking for injury to the penis, urethra, pelvis and abdomen where relevant. Blood at the urethral opening, difficulty passing urine or visible blood in the urine requires assessment for associated urinary-tract injury.

Ultrasound with Doppler

High-resolution scrotal ultrasound with colour Doppler is the preferred first-line imaging test for blunt testicular trauma. Findings that may indicate rupture include:

  • loss of the smooth testicular contour;
  • disruption of the tunica albuginea;
  • heterogeneous testicular tissue;
  • protrusion of tissue through a tunical defect;
  • reduced or absent blood flow; and
  • a surrounding haematocele.

Ultrasound is very useful but is not infallible. Pain, extensive swelling, haematoma and operator or equipment factors can make interpretation difficult. The 2026 European Association of Urology (EAU) guideline strongly recommends ultrasound for testicular trauma and surgical exploration for confirmed rupture and for inconclusive ultrasound when rupture remains a concern. Imaging should not cause an avoidable delay when the clinical findings clearly warrant surgery.

CT is useful for associated abdominal or pelvic trauma but is not the usual test for deciding whether the testis has ruptured. MRI is occasionally considered when ultrasound is equivocal and immediate exploration is not otherwise indicated, but it should not delay necessary surgery.

Treatment

Immediate care

In hospital, initial treatment may include appropriate pain relief, fasting in preparation for possible anaesthesia, scrotal support and management of other injuries. Open or contaminated wounds require wound care; tetanus status and antimicrobial treatment are considered according to the mechanism, contamination and local protocols.

Surgical exploration and repair

Confirmed or strongly suspected rupture is generally treated by urgent scrotal exploration. During surgery, the surgeon will usually:

  1. evacuate blood clot and inspect the testis and surrounding structures;
  2. control bleeding;
  3. remove only tissue that is clearly non-viable;
  4. preserve as much healthy, perfused testicular tissue as possible; and
  5. close the tunica albuginea, sometimes using local tissue coverage when primary closure would place the remaining testis under excessive tension.

Associated injuries to the epididymis or spermatic cord are addressed where possible. A drain may occasionally be used. After surgery, patients commonly require scrotal support, analgesia, wound care and temporary restriction of sport, heavy lifting and sexual activity. The exact plan depends on the injury and operation.

Older clinical series reported testicular salvage rates around 80–90% when rupture was recognised and repaired promptly. These figures describe groups of patients and cannot predict an individual result. The chance of salvage depends on the energy and type of trauma, the amount of tissue destruction, blood supply, contamination, associated injuries and time to treatment.

Is non-operative treatment ever suitable?

Minor trauma with an intact tunica, preserved blood flow and a small, stable haematoma may sometimes be managed with observation, analgesia, ice used safely, scrotal support and arranged review. This is not the usual management for a confirmed rupture. Increasing pain, swelling, fever or other deterioration requires urgent reassessment.

When is orchidectomy necessary?

Orchidectomy means removal of a testis. It is not the preferred treatment when viable tissue can be repaired. It may nevertheless be necessary when the testis is completely shattered, devascularised or infarcted; the spermatic cord is irreparably damaged or avulsed; bleeding cannot otherwise be controlled; contamination and tissue destruction are extreme; or no meaningful viable tissue remains.

The decision is usually made during exploration after blood supply and tissue viability have been assessed. Surgeons aim to conserve viable testicular tissue, but retaining a completely non-viable testis can expose the patient to infection, persistent pain and further surgery. Severe penetrating injuries and delayed treatment are more likely to require orchidectomy than a limited rupture treated early.

If removal is required, a testicular prosthesis can be discussed. It is cosmetic and does not make sperm or testosterone. Placement may be performed at the same operation or later, depending on contamination, swelling, patient preference and clinical circumstances.

Effects on fertility and testosterone

The effect on fertility varies considerably.

  • Unilateral injury: A healthy opposite testis will often produce enough testosterone and sperm for normal sexual development, erections and natural conception. However, normal fertility cannot be guaranteed. Trauma itself, loss of testicular volume, later atrophy and unilateral orchidectomy can reduce sperm reserve.
  • Testicular repair: Preserving viable tissue is generally preferred and may better preserve sperm-producing and hormonal function. Small human follow-up studies suggest that semen abnormalities can occur after trauma even when testosterone remains normal; the evidence is limited by small patient numbers.
  • Bilateral injury or a solitary testis: The risk to fertility and testosterone production is much greater. Loss of both testes causes permanent infertility and requires long-term testosterone replacement. Preservation of even a portion of viable tissue may therefore be especially important.

For severe bilateral injury, injury to a solitary testis, pre-existing subfertility, or concern about future family planning, early discussion with a urologist and fertility specialist is appropriate. Semen analysis, reproductive hormone testing and sperm cryopreservation may be considered when feasible; emergency surgery should not be dangerously delayed to obtain a sample. Follow-up may include examination, ultrasound when indicated, testosterone, LH and FSH testing, and semen analysis after recovery if fertility is a concern.

Possible complications

Even after appropriate treatment, complications can include:

  • infection, wound problems or recurrent haematoma;
  • testicular atrophy or loss of blood supply;
  • persistent scrotal discomfort or chronic pain;
  • impaired sperm production or subfertility;
  • reduced testosterone production, particularly after bilateral injury;
  • the need for later surgery or orchidectomy; and
  • psychological distress or concern about body image and fertility.

Increasing pain or swelling, fever, wound discharge, skin discolouration, difficulty passing urine or feeling generally unwell after discharge warrants urgent medical review.

The practical message

Following significant scrotal trauma, early assessment matters. Ultrasound with Doppler is the main imaging investigation, but a reassuring-looking exterior, or an uncertain scan, does not safely exclude rupture. Timely exploration and repair provide the best opportunity to save viable testicular tissue. Orchidectomy is reserved for a testis that cannot be safely or meaningfully salvaged.

Important information

This article provides general health information and does not replace an examination, diagnosis, individual medical advice or informed consent. Treatment and outcomes vary according to the mechanism, severity, timing, associated injuries, health history and operative findings. If testicular rupture or torsion is suspected, seek urgent assessment at an emergency department.

References

  1. European Association of Urology. EAU Guidelines on Urological Trauma: Urogenital Trauma Guidelines (2026). Uroweb guideline.
  2. Morey AF, Brandes S, Dugi DD III, et al. Urotrauma: AUA Guideline. Journal of Urology. 2014;192:327–335. Full text via PubMed Central. Updated guideline information: American Urological Association.
  3. Morey AF, Broghammer JA, Hollowell CMP, McKibben MJ, Souter L. Urotrauma Guideline 2020: AUA Guideline. Journal of Urology. 2021;205(1):30–35. PubMed.
  4. Buckley JC, McAninch JW. Use of ultrasonography for the diagnosis of testicular injuries in blunt scrotal trauma. Journal of Urology. 2006;175(1):175–178. PubMed.
  5. Cass AS, Luxenberg M. Testicular injuries. Urology. 1991;37(6):528–530. PubMed.
  6. Lin WW, Kim ED, Quesada ET, Lipshultz LI, Coburn M. Unilateral testicular injury from external trauma: evaluation of semen quality and endocrine parameters. Journal of Urology. 1998;159(3):841–843. PubMed.
  7. Kukadia AN, Ercole CJ, Gleich P, Hensleigh H, Pryor JL. Testicular trauma: potential impact on reproductive function. Journal of Urology. 1996;156(5):1643–1646. PubMed.
  8. Yagil Y, Naroditsky I, Milhem J, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. Journal of Ultrasound in Medicine. 2010;29(1):11–21. PubMed.
  9. Australian Health Practitioner Regulation Agency. Guidelines for advertising a regulated health service and acceptable evidence in health advertising. Ahpra Advertising Hub.
  10. Therapeutic Goods Administration. Advertising health services that involve therapeutic goods (updated 18 June 2026). TGA guidance.

 

Penile Fracture: Presentation, Investigation, Treatment and Long-Term Outlook

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Penile fracture is a urological emergency. Despite its name, no bone is broken. The injury is a tear in the tunica albuginea, the tough sleeve surrounding one or both erectile cylinders (corpora cavernosa) while the penis is erect. Bleeding then occurs within and around the erectile tissues.

If you hear or feel a crack or pop during intercourse or other bending of an erect penis, followed by pain, loss of the erection, swelling or bruising, stop sexual activity and attend the nearest emergency department immediately. Do not wait to see whether it settles, and do not eat or drink until assessed in case an anaesthetic is required.

This article provides general education. It cannot diagnose an injury, replace examination, or provide individual medical advice.

How does a penile fracture happen?

During an erection, the tunica albuginea becomes much thinner and is vulnerable to sudden buckling. The most frequent mechanism is an erect penis slipping out during intercourse and striking the partner’s pubic bone or perineum. It can also occur during masturbation, intentional forceful bending, rolling onto an erect penis, or less commonly through other trauma.

Penile fracture can happen in any sexual position. It is an accident rather than evidence of wrongdoing, and embarrassment should never delay treatment.

The urethra, the tube carrying urine through the penis, may be injured at the same time. The 2026 European Association of Urology (EAU) guideline reports associated corpus spongiosum or urethral injury in approximately 10–22% of cases; rates vary among populations and mechanisms of injury.[1]

Typical presentation

The classic sequence is:

  • a sudden crack, snap or popping sensation;
  • immediate pain;
  • rapid loss of the erection (detumescence);
  • quickly developing swelling and bruising;
  • bending or deformity of the penis, often away from the injured side; and
  • sometimes a palpable defect in the tunica.

Bruising may spread into the scrotum, perineum or lower abdominal wall. The dramatic “aubergine” appearance described in medical literature is not present in every case.

Warning signs of urethral injury

Tell the treating team immediately if there is:

  • blood at the urinary opening;
  • blood in the urine;
  • pain or difficulty passing urine;
  • inability to pass urine; or
  • a weak or interrupted urinary stream after the injury.

The absence of these findings does not completely exclude urethral injury. Clinical assessment remains important.

Conditions that can look similar

Not every swollen or bruised penis after intercourse has a tunical tear. Rupture of a superficial vein or artery, injury to the suspensory ligament, or bleeding beneath the skin can produce a “false penile fracture.” Slow rather than immediate loss of erection and absence of the characteristic crack may make a true fracture less likely, but no single feature is conclusive.

Because missing a fracture can have lasting consequences, significant swelling, pain or deformity after trauma to an erect penis requires urgent medical assessment.

How is it investigated?

History and examination

When the history and examination are classic, penile fracture is primarily a clinical diagnosis. Testing should not unnecessarily delay repair. The clinician will assess the penis, scrotum and perineum and ask specifically about the mechanism, the speed of detumescence, urination and visible blood. A urine test is generally performed.

Ultrasound

Ultrasound can help locate a tear and haematoma, particularly when the diagnosis is uncertain. It is quick and widely available, but its accuracy depends on the operator, the size and position of the tear, and the amount of swelling. A negative or inconclusive ultrasound does not necessarily exclude fracture when the clinical findings are convincing.

MRI

MRI gives excellent soft-tissue detail and is generally more accurate than ultrasound for detecting a tunical tear. It may be useful in equivocal cases, but availability, cost and delay can limit its emergency use. It is not routinely required when the diagnosis is already clear.[1]

Assessment of the urethra

If urethral injury is suspected, evaluation may include retrograde urethrography (contrast imaging of the urethra) or flexible cystoscopy. Visible haematuria, blood at the meatus, difficulty voiding and bilateral corporal injury increase concern. The EAU and American Urological Association (AUA) both recommend evaluating for associated urethral injury when indicated.[1,2]

CT is not the preferred test for an isolated penile fracture, although it may be obtained when wider pelvic or abdominal trauma is suspected.

Recommended management

Prompt surgical repair

Current EAU and AUA guidance recommends prompt surgical exploration and repair for an acute penile fracture.[1,2] The operation is usually performed under general or regional anaesthesia and involves:

  1. exposing the injured erectile tissue through a circumferential degloving incision or a targeted incision over the tear;
  2. evacuating the clot and controlling bleeding;
  3. identifying and closing the tunica albuginea tear with sutures; and
  4. inspecting and repairing the urethra if it is injured.

A urinary catheter may be used, especially when the urethra has been assessed or repaired. The exact incision, catheter duration, hospital stay and follow-up depend on the injury and the surgeon’s findings.

The EAU guideline advises repair within 24 hours of presentation when feasible, but late presentation is not a reason to withhold assessment or repair.[1] A person presenting after a delay should still seek urgent urological review.

Why is conservative treatment generally avoided?

Ice, compression, pain relief, erection-suppressing medication and observation were historically used. Conservative treatment may occasionally be appropriate when imaging and specialist assessment confirm that the tunica is intact, but it is not the standard treatment for a confirmed fracture.

A meta-analysis of 58 studies involving 3,213 patients found significantly fewer overall complications and less erectile dysfunction, curvature and painful erections with surgery than with conservative management.[3] Non-operative treatment of a true fracture carries greater risks of persistent haematoma, infection or abscess, missed urethral injury, fibrosis, penile curvature and erectile dysfunction.[1,3]

Recovery after repair

Patients should follow their treating surgeon’s instructions, which may include:

  • wound and catheter care;
  • simple analgesia and other prescribed medicines;
  • avoiding strenuous activity until reviewed;
  • avoiding intercourse and masturbation, commonly for about six weeks or until healing is confirmed; and
  • follow-up to assess erections, curvature, pain and urinary function.

Night-time or spontaneous erections during healing may be uncomfortable. Medication is sometimes used selectively, but there is no universal post-operative drug regimen. Do not start or stop prescription medicines without advice.

Seek urgent review after treatment for fever, increasing redness or swelling, wound discharge, worsening pain, inability to urinate, heavy bleeding, or a catheter that stops draining.

Possible complications

Most patients do well after prompt repair, but no treatment can guarantee a complication-free outcome. Possible early or late problems include:

  • wound infection, bleeding or haematoma;
  • altered penile sensation, palpable stitches, scar or nodules;
  • painful erections;
  • penile curvature, indentation or shortening;
  • erectile dysfunction;
  • urethral narrowing (stricture), urinary spraying or reduced flow;
  • urethrocutaneous fistula after a significant urethral injury or repair;
  • need for further investigation or surgery; and
  • anxiety, avoidance of intimacy or relationship distress.

The EAU guideline summarises reported post-surgical rates of plaques or nodules, curvature and erectile dysfunction as approximately 13.9%, 2.8% and 1.9%, respectively, while noting that complications overall have been reported in up to 20% of cases.[1] These pooled figures are not a personalised prediction: published studies differ in injury severity, definitions, follow-up and measurement. Risk is higher with extensive or bilateral tears, associated urethral injury, delayed or missed diagnosis, and in some studies age over 50.[1,4]

What is the risk of erectile dysfunction?

Erectile dysfunction after a fracture may result from corporal scarring, impaired blood trapping, arterial or nerve injury, pain, anxiety, or a combination of physical and psychological factors. Prompt repair markedly reduces the risk compared with conservative management, but does not eliminate it.[1,3]

Persistent difficulty should be assessed rather than endured in silence. Evaluation can include a sexual and medical history, validated questionnaires, examination and, when indicated, penile Doppler ultrasound. Treatment is individualised and may include counselling, oral erectile-dysfunction medication when safe, vacuum therapy, injections or, rarely, reconstructive surgery or a penile prosthesis.

Does penile fracture cause Peyronie’s disease?

Healing after a penile fracture can produce a local scar, palpable nodule or post-traumatic curvature. These findings may resemble Peyronie’s disease, which is an acquired fibrotic disorder of the tunica albuginea. However, a curve after fracture should not automatically be labelled Peyronie’s disease: it may arise directly from the repaired tear, asymmetric healing or corporal fibrosis.

The distinction is made through history, examination and, if needed, photographs of the erect penis or ultrasound. Review is advisable if there is a new or worsening bend, a hard plaque, painful erections, loss of length, narrowing, instability or difficulty with intercourse. Management depends on whether the deformity is changing or stable, its severity, erectile function and how much it affects the patient. Options may include observation, penile traction in selected cases, treatment of erectile dysfunction, or reconstructive surgery once the deformity is stable. Treatment should be discussed with a urologist experienced in penile reconstruction or andrology.

The essential message

A suspected penile fracture is time-sensitive. A crack or pop followed by immediate loss of erection, swelling and bruising warrants immediate emergency assessment. Diagnosis is often clinical; ultrasound or MRI is reserved mainly for uncertainty, and the urethra must be assessed when injury is suspected. Prompt surgical repair offers the best prospect of preserving penile shape, erections and urinary function.

References

  1. European Association of Urology. EAU Guidelines on Urological Trauma. 2026 edition, sections on genital trauma and penile fracture. https://uroweb.org/guidelines/urological-trauma/chapter/urogenital-trauma-guidelines
  2. Morey AF, Brandes S, Dugi DD III, et al. Urotrauma: AUA Guideline. J Urol. 2014;192(2):327–335; amended guideline statements available from the American Urological Association. doi:10.1016/j.juro.2014.05.004. https://www.auanet.org/guidelines-and-quality/guidelines/urotrauma-guideline
  3. Amer T, Wilson R, Chlosta P, et al. Penile fracture: a meta-analysis. Urol Int. 2016;96(3):315–329. doi:10.1159/000444884.
  4. Barros R, Schulze L, Ornellas AA, Koifman L, Favorito LA. Impact of surgical treatment of penile fracture on sexual function. Urology. 2019;126:128–133. doi:10.1016/j.urology.2018.11.027.
  5. Wong NC, Dason S, Bansal RK, Davies TO, Braga LH. Can it wait? A systematic review of immediate vs delayed surgical repair of penile fractures. Can Urol Assoc J. 2017;11(1–2):53–60. doi:10.5489/cuaj.4032.
  6. Koifman L, Barros R, Júnior RAS, Cavalcanti AG, Favorito LA. Penile fracture: diagnosis, treatment and outcomes of 150 patients. Urology. 2010;76(6):1488–1492. doi:10.1016/j.urology.2010.05.043.

Website publication note

This material is general health information and was prepared from the sources listed above. It is not a substitute for emergency assessment, diagnosis, informed consent or personalised advice from a qualified practitioner. Outcomes and risks vary between individuals.

Prostate Artery Embolisation: Who May Benefit, Important Caveats, and Can It Be Done After Radiotherapy?

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Lower urinary tract symptoms: poor flow, hesitancy, incomplete emptying, frequency, urgency and nocturia, are common as men age. When benign enlargement of the prostate (BPH) is genuinely responsible, treatment may include lifestyle measures, medication, minimally invasive procedures or surgery. Prostate artery embolisation (PAE) is one option that may be considered for appropriately assessed patients.

PAE is not simply a “smaller TURP”. It works differently, is performed by an experienced interventional radiologist, and has a different balance of benefits, limitations and risks. The most important question is not whether the prostate looks large, but whether prostatic obstruction is actually causing the patient’s symptoms.

What is prostate artery embolisation?

PAE is a minimally invasive, image-guided procedure. A small catheter is introduced through an artery, usually at the wrist or groin, and guided into the arteries supplying the prostate. Tiny permanent particles or, in selected expert practice, a liquid embolic agent are delivered to reduce blood flow to the hyperplastic prostate tissue. This causes controlled ischaemia, gradual shrinkage of the transition zone and reduced compression of the urethra.

The procedure can often be performed without a general anaesthetic and does not require instruments to pass through the urethra. Improvement, when it occurs, is usually progressive rather than immediate and may take several weeks or months. Results vary, and some men obtain little benefit or require another treatment.

Regulatory note for Australian readers: The TGA regulates therapeutic goods, including medicines and medical devices; it does not “approve” or endorse a medical procedure or an individual health service. References to PAE in this article should not be interpreted as TGA endorsement. Any embolic agent, catheter or other medical device used must be lawfully supplied in Australia and used in accordance with its applicable regulatory status, intended purpose and clinical governance requirements.

Important Wesley Hospital research

Associate Professor Nicholas Brown, an interventional radiologist affiliated with The University of Queensland and I-MED Radiology at The Wesley Hospital, led the following Australian studies of PAE.

The P-EASY ADVANCE randomised controlled trial, published in BJU International in 2024, compared PAE with combined tamsulosin and dutasteride therapy in 39 treatment-naïve men with enlarged prostates, moderate-to-severe symptoms and obstructed or equivocal urodynamic studies. At follow-up, 63% of men treated with PAE were urodynamically unobstructed, compared with 28% receiving medication. Within this study population and follow-up period, the PAE group had greater improvements in prostate volume, urinary flow, incomplete emptying, overall symptom score and quality of life. The trial was small, the estimates should not be generalised to every patient, and larger comparative trials with longer follow-up are required.

The follow-up P-EASY PLUS study, published in BJU International in 2025, assessed 105 men at a mean of 18 months. Mean prostate volume fell by 30.6%, total symptom scores improved by 55%, quality-of-life scores improved by 65.9%, and maximum urinary flow increased by 5 mL/second. Among the 57 men who completed paired urodynamic testing, the proportion classified as obstructed fell from 66.7% to 29.8%. No major procedural complication or new urinary incontinence was reported in this cohort; new retrograde ejaculation occurred in 2%. These are group-level study outcomes and do not guarantee an individual result. The authors noted that longer-term comparative research is required.

The P-EASY ADVANCE publication received the BJUI Global Prize for 2026. This statement describes the publication award only; it is not a patient-outcome claim, regulatory endorsement or guarantee of treatment effectiveness.

Author disclosure: I, Dr Joseph Schoeman, was a co-author of both Wesley Hospital studies. I performed some of the urodynamic studies for this article. Readers should take this relationship into account when considering the discussion. The results are reported with their limitations and placed alongside independent guidelines, randomised trials and systematic reviews. No patient testimonial or individual outcome has been used in this article.

Who may be a good candidate?

PAE may be considered when a man has:

  • bothersome moderate-to-severe urinary symptoms attributable to benign prostatic obstruction;
  • an enlarged prostate, particularly a moderately large or very large gland;
  • inadequate relief, unacceptable adverse effects or a preference not to take long-term medication;
  • a wish to avoid transurethral or more invasive surgery;
  • increased anaesthetic or surgical risk;
  • a preference for an option with lower reported rates of ejaculatory dysfunction or urinary incontinence in some studies, while recognising that these complications can still occur;
  • catheter-dependent urinary retention where obstruction from BPH is considered reversible and bladder contractility is adequate; or
  • recurrent or refractory bleeding shown to arise from the prostate in selected circumstances.

Current European Association of Urology guidance recommends offering PAE to men with moderate-to-severe LUTS due to benign prostatic obstruction who want a minimally invasive option and accept that outcomes may be less optimal than TURP. The American Urological Association also permits PAE as a treatment option when performed by appropriately trained clinicians, but grades the evidence as conditional.

What assessment is needed before PAE?

A large prostate does not prove obstruction, and urinary symptoms are not always caused by the prostate. Appropriate assessment may include:

  • symptom and quality-of-life scoring;
  • urinalysis and urine culture when indicated;
  • PSA assessment and prostate-cancer evaluation appropriate to age and risk;
  • digital rectal examination;
  • urinary flow rate and post-void residual measurement;
  • ultrasound or MRI assessment of prostate size and anatomy;
  • cystoscopy where haematuria, urethral stricture, bladder-neck pathology, stones or bladder disease is suspected;
  • urodynamic studies when the diagnosis is uncertain, symptoms are mixed, bladder contractility may be poor, or prior pelvic treatment has complicated the picture; and
  • CT or MR angiographic assessment of pelvic arterial anatomy, renal function and contrast risk when requested by the interventional radiologist.

The best decisions are generally made jointly by a urologist and an experienced PAE interventional radiologist.

Potential advantages of PAE

Potential advantages include:

  • no prostate tissue resection and usually no general anaesthetic;
  • day-stay or short hospital admission in many patients;
  • lower reported rates of major bleeding and transfusion than some operative procedures in comparative studies;
  • low reported, but not zero, rates of urinary incontinence;
  • a lower reported likelihood of retrograde ejaculation than with TURP or enucleation procedures in available studies;
  • usefulness in some very large prostates and medically complex patients; and
  • preservation of later surgical options if symptoms persist or recur.

Caveats: what PAE may not do as well

Compared with TURP or endoscopic enucleation, PAE generally produces a less immediate and less pronounced improvement in urinary flow and objective relief of obstruction. A Cochrane review found that short-term symptom improvement may be similar to TURP, but the certainty of evidence was low and retreatment may be more likely after PAE. Meta-analyses and longer-term randomised data generally show stronger objective improvement after TURP. Comparisons across studies must be interpreted cautiously because patient selection, technique, follow-up and outcome definitions differ.

PAE also does not provide prostate tissue for histology. Prostate cancer must therefore be considered and investigated before treatment rather than assumed to be excluded by a fall in prostate size or PSA afterward.

Technical success depends heavily on operator experience. Prostatic arteries are tiny, variable and sometimes severely atherosclerotic. Embolic material can rarely reach non-target vessels supplying the bladder, rectum or penis. Pre-procedure vascular imaging and cone-beam CT can reduce this risk but add iodinated contrast exposure and ionising radiation.

Side effects and complications

Common short-term effects form part of a post-embolisation syndrome and may include pelvic or perineal discomfort, urinary frequency and urgency, dysuria, fatigue, nausea, low-grade fever or a small amount of blood in the urine or semen. Temporary difficulty passing urine and the need for a catheter can occur.

Less common complications include urinary infection, access-site bruising or haematoma, contrast reaction, kidney injury, arterial injury, prostate infection or abscess, and passage of necrotic prostate tissue. Rare but important complications of non-target embolisation include ischaemic injury to the bladder, rectum or penis. Severe skin injury from fluoroscopic radiation is also rare but is a recognised procedural concern, particularly during prolonged or technically difficult cases.

Contraindications and reasons to pause

PAE is generally unsuitable, or requires correction and specialist review first, when there is:

  • an active urinary tract or systemic infection;
  • suspected or untreated prostate or bladder cancer requiring diagnostic clarification;
  • symptoms predominantly caused by urethral stricture, bladder-neck contracture, bladder stone, neurogenic dysfunction, overactive bladder or another non-BPH condition;
  • a poorly contractile or decompensated bladder unlikely to empty even if outlet resistance is reduced;
  • severe pelvic arterial atherosclerosis, occlusion, tortuosity or anatomy that prevents safe selective catheterisation;
  • an uncorrectable bleeding disorder;
  • a severe iodinated-contrast allergy that cannot be safely managed;
  • significant renal impairment where contrast risk is unacceptable; or
  • inability to tolerate arterial access, fluoroscopy or the required aftercare.

Small prostate size is not an absolute prohibition, but it makes careful confirmation of the cause of obstruction particularly important and may reduce the likelihood of benefit. A prominent obstructing median lobe is not automatically a contraindication in experienced hands, although prostate anatomy should be considered alongside all alternative treatments.

Can PAE be performed after prostate radiotherapy?

Potentially yes, but prior pelvic or prostate radiotherapy is not a routine indication, and the decision must be individualised. It is neither sensible to call radiotherapy an automatic absolute contraindication nor appropriate to assume that PAE will relieve every post-radiation urinary symptom.

After radiotherapy, poor flow, urgency, frequency, pain, retention or bleeding may result from:

  • persistent benign prostatic obstruction;
  • radiation cystitis and reduced bladder capacity;
  • detrusor overactivity or poor bladder contractility;
  • urethral stricture or bladder-neck stenosis;
  • prostate-cancer recurrence or progression;
  • infection, stones or clot retention; or
  • a combination of these problems.

PAE is most likely to help only when a meaningful component of the problem is supplied by vascular, enlarged prostate tissue or confirmed prostatic obstruction. It will not correct a urethral stricture, a scarred bladder neck, radiation cystitis, a small fibrotic low-capacity bladder or detrusor failure.

Evidence specifically studying PAE for BPH-type obstruction after completed radiotherapy is sparse. Most major BPH trials did not establish a dedicated post-radiotherapy evidence base. Radiotherapy can also alter pelvic tissues and small blood vessels, making angiographic anatomy and tissue response less predictable. For that reason, these patients should be assessed in a multidisciplinary setting and often benefit from cystoscopy, flow and residual testing, imaging and formal urodynamics before treatment.

PAE has been studied in men with prostate cancer and is being investigated before radiotherapy to reduce gland size and urinary symptoms. Embolisation has also been used for refractory bleeding of prostatic origin, including bleeding associated with malignancy or radiation. However, embolisation for life-threatening radiation-related haematuria may target vesical or other pelvic arteries and is a different clinical problem from PAE for benign outlet obstruction. These two indications should not be confused.

In a post-radiotherapy patient, PAE may therefore be reasonable when:

  1. recurrent cancer, infection and urethral or bladder-neck stenosis have been excluded or appropriately managed;
  2. investigations demonstrate an enlarged, vascular prostate with genuine outlet obstruction;
  3. bladder function is adequate enough to benefit from reducing resistance;
  4. pelvic arterial anatomy permits safe selective embolisation; and
  5. the patient understands that outcome data are limited and that further treatment may still be required.

How does PAE compare with surgery?

There is no universally “best” procedure. TURP, GreenLight laser, HoLEP or other enucleation procedures usually provide faster and more complete mechanical relief of obstruction. PAE is less invasive and some comparative studies report fewer ejaculatory or perioperative adverse effects; however, symptom relief can be slower, objective improvement may be smaller and retreatment may be more likely.

The right option depends on prostate size and configuration, the severity and cause of symptoms, bladder function, cancer risk, medical fitness, sexual priorities, arterial anatomy, previous pelvic treatment and the patient’s tolerance for the possibility of later retreatment.

The take-home message

PAE is an available treatment option for selected men with symptomatic benign prostatic obstruction. The Wesley Hospital P-EASY studies contribute Australian randomised and urodynamic data on symptoms, quality of life and obstruction, but their findings should be considered with the study designs, sample sizes, follow-up and declared author relationships.

It remains essential to diagnose the cause of symptoms before treating the scan. PAE is not a cure for every urinary problem and does not replace cancer assessment, cystoscopy or urodynamics when these are clinically indicated. After radiotherapy, PAE may be technically and clinically possible, but the evidence is limited and patient selection must be particularly rigorous.

References and further reading

  1. Brown N, et al. P-EASY ADVANCE: a randomised controlled trial of prostate embolisation versus medication for BPH. BJU International. 2024. doi: 10.1111/bju.16479.
  2. Brown N, et al. P-EASY PLUS: preliminary and follow-up urodynamic studies. BJU International. 2025. doi: 10.1111/bju.16808.
  3. Mark P, Brown NI, Ormiston WEL. Current considerations in prostate artery embolisation. CVIR Endovascular. 2026;9:45. doi: 10.1186/s42155-026-00689-5.
  4. European Association of Urology. Guidelines on the Management of Non-neurogenic Male LUTS: Disease Management. Current online edition accessed September 2026.
  5. Sandhu JS, et al. Management of Lower Urinary Tract Symptoms Attributed to BPH: AUA Guideline Amendment 2023. Journal of Urology. 2024;211:11–19. doi: 10.1097/JU.0000000000003698.
  6. Jung JH, et al. Prostatic arterial embolisation for the treatment of lower urinary tract symptoms in men with BPH. Cochrane Database of Systematic Reviews. 2022. Cochrane evidence summary.
  7. Müllhaupt G, et al. Prostatic artery embolisation versus TURP for benign prostatic obstruction: long-term outcomes of a randomised trial. European Urology. 2024. PubMed record.
  8. Zumstein V, et al. Prostatic artery embolization versus standard surgical treatment for LUTS secondary to BPH: systematic review and meta-analysis. European Urology Focus. 2019;5:1091–1100. doi: 10.1016/j.euf.2018.09.005.
  9. Parikh N, et al. Prostate artery embolization in the setting of prostate cancer. Seminars in Interventional Radiology. 2025. Full text.
  10. Kably I, et al. Prostatic artery embolization in refractory haematuria of prostatic origin. Techniques in Vascular and Interventional Radiology. 2020. PubMed record.
  11. Therapeutic Goods Administration. Advertising health services that involve therapeutic goods. Updated 18 June 2026.
  12. Therapeutic Goods Administration. General requirements for advertising therapeutic goods to the public. Updated 11 March 2025.
  13. Australian Health Practitioner Regulation Agency. Advertising guidelines and other guidance. Accessed 22 September 2026.

Australian publication and advertising statement

This article is intended as balanced disease and treatment education. It does not advertise a named embolic product, catheter, medicine or device; offer an inducement; use testimonials; promise a cure; or claim that PAE is safe, risk-free, superior or effective in every case. Mention of the TGA, Ahpra, professional guidelines, a hospital, a journal or an award does not imply endorsement of this article, the author or the treatment.

Clinical claims are linked to identified publications and should be reviewed when the article is updated. Any future addition of brand names, booking prompts, prices, before-and-after images, patient stories, sponsored links or manufacturer-supplied material may change the regulatory character of the page and should undergo a fresh compliance review.

This article provides general information current at the stated review date and is not personal medical advice. It does not establish a doctor–patient relationship. Benefits and risks differ between individuals. Suitability for PAE should be decided after assessment by appropriately qualified clinicians, commonly including a urologist and an interventional radiologist. Patients should seek urgent medical care for inability to pass urine, fever or sepsis symptoms, severe pain, heavy bleeding or clot retention.

PAE BJU article

Vesico-ureteric reflux: when urine travels in the wrong direction

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Vesico-ureteric reflux, also called vesicoureteral reflux or VUR, occurs when urine flows backwards from the bladder into one or both ureters and sometimes as far as the kidneys.

Normally, each ureter enters the bladder through a short tunnel in the bladder wall. As the bladder fills and contracts, this tunnel is compressed, acting like a one-way valve. In VUR, the valve does not close effectively.

VUR itself does not always cause symptoms. Its importance is that infected urine may travel towards the kidneys, increasing the risk of pyelonephritis, renal scarring and, in a small number of higher-risk patients, long-term kidney damage.

Primary and secondary reflux

Primary VUR

Primary VUR is usually a developmental condition. The ureter’s tunnel through the bladder wall is too short or positioned in a way that prevents reliable closure. It is most commonly diagnosed in infancy or childhood.

As a child grows, the bladder and ureteric junction mature. For this reason, many cases particularly lower-grade reflux, improve or resolve without surgery.

Secondary VUR

Secondary reflux develops because pressure within the bladder is abnormally high or because the bladder does not empty properly. Causes may include:

  • posterior urethral valves or another bladder-outlet obstruction
  • dysfunctional voiding
  • constipation and bladder–bowel dysfunction
  • neurogenic bladder, including spina bifida or spinal cord disease
  • urethral stricture or an enlarged prostate in adults
  • previous bladder or ureteric surgery
  • a poorly compliant, high-pressure bladder.

Treating the underlying bladder or outlet problem is essential. Correcting the reflux alone may fail if the bladder remains unsafe or under excessive pressure.

How does VUR present in children?

Most children do not feel the reflux itself. It is commonly discovered while investigating a urinary tract infection.

Possible presentations include:

  • a fever without an obvious cause, particularly in an infant
  • recurrent urinary tract infections
  • febrile UTIs or kidney infections
  • vomiting, lethargy, irritability or poor feeding in babies
  • abdominal, loin or back pain
  • painful or frequent urination
  • urinary urgency or wetting
  • poor urinary stream or straining
  • antenatal ultrasound showing hydronephrosis or an abnormal urinary tract
  • poor growth
  • high blood pressure or impaired kidney function in more advanced reflux nephropathy.

A child with fever, vomiting, flank pain or marked lethargy may have pyelonephritis and should receive prompt medical assessment.

How does VUR present in adults?

VUR is much less commonly diagnosed for the first time in adulthood. Some adults have persistent congenital reflux that was never detected in childhood, while others develop secondary reflux due to bladder dysfunction or obstruction.

Adults may present with:

  • recurrent febrile UTIs
  • repeated kidney infections
  • loin or flank pain
  • renal scarring found on imaging
  • high blood pressure
  • protein or blood detected in the urine
  • reduced kidney function
  • pregnancy-associated urinary infections
  • lower urinary tract symptoms or incomplete bladder emptying.

Adult VUR should prompt assessment for an underlying cause such as bladder-outlet obstruction, neurogenic bladder, poor bladder compliance or dysfunctional voiding. The evidence guiding adult treatment is less extensive than the paediatric literature, so management is individualised.

How is VUR investigated?

Not every child who has one uncomplicated UTI requires an invasive reflux study. Imaging is selected according to age, clinical presentation, ultrasound findings and whether the infection is atypical or recurrent.

Urine testing

Urinalysis and urine culture confirm infection and help guide antibiotic treatment. A properly collected urine specimen is particularly important in babies and young children.

Kidney and bladder ultrasound

Ultrasound is painless and does not use radiation. It can assess:

  • kidney size and development
  • hydronephrosis or ureteric dilatation
  • bladder-wall appearance
  • congenital urinary abnormalities
  • residual urine after voiding.

A normal ultrasound does not completely exclude VUR.

Micturating cystourethrogram

A micturating cystourethrogram, also called an MCUG or VCUG, is the standard test for confirming and grading reflux.

A small catheter is placed into the bladder, contrast is introduced, and X-ray images are taken while the bladder fills and during urination. The test shows whether contrast travels backwards into the ureters or kidneys and also provides information about the bladder and urethra.

Because catheterisation and a small radiation exposure are involved, MCUG is generally reserved for children in whom the result is likely to influence management.

Contrast-enhanced voiding urosonography

In centres where it is available, contrast-enhanced ultrasound can identify reflux without ionising radiation. Availability and local expertise vary, and conventional MCUG may still be required when detailed urethral anatomy needs assessment.

DMSA renal scan

A DMSA scan assesses the functioning renal cortex and can identify established renal scars. It is not required for every child but may be considered after recurrent febrile infections, in higher-grade reflux, when ultrasound is abnormal or when renal damage is suspected.

Additional assessment

Depending on the circumstances, investigation may also include:

  • blood pressure measurement
  • serum creatinine and estimated kidney function
  • urine protein assessment
  • a bladder and bowel history
  • uroflowmetry and measurement of residual urine
  • a bladder diary
  • urodynamic studies when a high-pressure, neurogenic or poorly emptying bladder is suspected
  • CT or other upper-tract imaging in selected adults.

The five grades of reflux

VUR is graded from I to V according to the international grading system.

Grade Imaging appearance General interpretation
Grade I Reflux reaches the ureter but not the kidney Mild
Grade II Reflux reaches the renal pelvis without dilatation Mild
Grade III Mild to moderate dilatation of the ureter and renal collecting system Moderate
Grade IV Moderate ureteric and collecting-system dilatation with some twisting of the ureter High-grade
Grade V Severe dilatation and tortuosity with loss of normal calyceal detail Severe

The grade is important, but it is not the only factor determining treatment. Age, recurrent infections, kidney scarring, bladder and bowel function, whether reflux affects one or both sides, and family preferences all matter.

What is the aim of treatment?

Treatment aims to:

  • prevent febrile UTIs and pyelonephritis
  • reduce the risk of further renal scarring
  • preserve kidney function
  • treat bladder, bowel or outlet dysfunction
  • avoid unnecessary medication, radiation and surgery.

It is important to understand that repairing reflux cannot reverse established renal scars. Treatment is intended to prevent further infection and injury.

Observation and conservative management

Observation is appropriate for many children, particularly those with lower-grade reflux, healthy kidneys and no recurrent febrile infections.

Conservative care may include:

  • prompt urine testing when fever or urinary symptoms occur
  • regular and complete bladder emptying
  • adequate fluid intake
  • avoiding prolonged holding of urine
  • treating constipation
  • timed voiding
  • management of daytime wetting or dysfunctional voiding
  • periodic clinical and ultrasound review.

Lower-grade reflux is more likely to resolve as the child grows. Higher grades, bilateral reflux and reflux associated with renal abnormalities are less likely to resolve spontaneously.

Continuous low-dose antibiotic prophylaxis

A low dose of antibiotic may be prescribed daily to reduce recurrent infections while waiting for reflux to improve or while deciding whether intervention is required.

Prophylaxis is more likely to be considered in:

  • infants with VUR following a febrile UTI
  • recurrent febrile UTIs
  • higher-grade reflux
  • bladder–bowel dysfunction
  • renal cortical abnormalities
  • children considered at increased risk of another kidney infection.

Antibiotics can reduce recurrent UTIs in appropriately selected children, but they do not mechanically correct the reflux. Disadvantages include medication side effects, adherence difficulties and antibiotic resistance. The need for ongoing prophylaxis should therefore be reviewed rather than continued automatically.

Treating bladder and bowel dysfunction

Constipation, urinary urgency, wetting, infrequent voiding and incomplete bladder emptying increase the risk of recurrent infection and may reduce the success of reflux treatment.

Management can include:

  • regular timed voiding
  • relaxed toilet posture
  • treatment of constipation
  • pelvic-floor or continence physiotherapy
  • medication for selected bladder conditions
  • intermittent self-catheterisation when emptying is inadequate.

In secondary reflux, treating the bladder or outlet disorder may reduce or occasionally eliminate the reflux.

When is a procedure considered?

Intervention may be discussed when there is:

  • a febrile breakthrough UTI despite appropriate prophylaxis
  • recurrent pyelonephritis
  • new or progressive renal scarring
  • persistent high-grade reflux
  • reflux unlikely to resolve spontaneously
  • difficulty tolerating or adhering to antibiotic prophylaxis
  • an anatomical abnormality requiring correction
  • significant family preference after discussion of the alternatives
  • persistent symptomatic reflux in a carefully selected adult.

The two main corrective options are endoscopic injection and ureteric reimplantation.

The STING procedure

STING stands for subureteric transurethral injection. A small telescope is passed through the urethra into the bladder under anaesthesia. A bulking material is injected beneath or within the lower end of the ureter to support and lengthen the valve mechanism.

Dextranomer/hyaluronic-acid copolymer, commonly known by the brand name Deflux, is the best-known injection material. Modified techniques such as HIT or double-HIT place the material within the intramural ureter rather than only beneath its opening.

Advantages

  • minimally invasive
  • no abdominal incision
  • usually performed as day surgery
  • relatively short anaesthetic and recovery
  • low risk of major complications
  • can be repeated if reflux persists.

Limitations and risks

  • success is lower and less predictable than formal reimplantation
  • results are generally better for lower grades of reflux
  • more than one injection may be required
  • reflux may persist or recur
  • temporary blood in the urine, discomfort or infection can occur
  • ureteric obstruction is uncommon but important
  • reflux may occasionally appear on the opposite side
  • long-term durability is not as certain as with successful reimplantation.

Published cure rates vary considerably because they depend on reflux grade, anatomy, injection technique, material used and how success is defined. A single injection commonly corrects approximately 70–80% of refluxing ureters overall, with lower success in grades IV–V. Additional injections can increase the cumulative success rate.

Ureteric reimplantation

Ureteric reimplantation is reconstructive surgery that creates a longer tunnel for the ureter through the bladder wall, restoring the one-way valve mechanism.

The operation may be performed using:

  • an open extravesical approach
  • an open intravesical approach
  • laparoscopic surgery
  • robot-assisted surgery in selected centres and patients.

Open reimplantation has a long-established success rate of approximately 95–98% for primary VUR when performed in suitable patients.

Advantages

  • highest and most durable anatomical correction rate
  • effective for high-grade reflux
  • allows correction of some associated ureteric abnormalities
  • usually requires only one definitive operation.

Limitations and risks

  • more invasive than injection
  • longer anaesthetic and recovery
  • temporary bladder spasms, pain or blood in the urine
  • urinary infection
  • transient urinary retention, particularly after some bilateral extravesical repairs
  • ureteric obstruction
  • persistent reflux or reflux on the opposite side
  • rare need for further surgery.

Robotic or laparoscopic reimplantation can reduce incision size, but it is still major reconstructive surgery and has not made open surgery obsolete. The best approach depends on the child’s anatomy, age, surgeon’s expertise and the reason for intervention.

STING versus reimplantation

Consideration Endoscopic injection Ureteric reimplantation
Invasiveness Minimally invasive Reconstructive surgery
Typical stay Usually day surgery Often one or more nights
Recovery Generally quicker Longer
Success after one procedure Lower and grade-dependent Approximately 95–98%
Repeat treatment Sometimes required Uncommon after successful repair
Best suited to Selected low- or moderate-grade reflux and families prioritising minimal invasiveness High-grade, persistent or complicated reflux; failed injection; selected anatomical abnormalities
Main trade-off Easier recovery but less predictable cure More invasive but more reliable correction

Neither operation is automatically “best.” STING may be attractive when a minimally invasive approach is preferred and its probability of success is acceptable. Reimplantation may be more appropriate when the highest likelihood of definitive correction is important.

VUR in adults

Adults with incidentally detected reflux and no infections, renal deterioration or high-pressure bladder may not require corrective surgery.

Treatment is more likely to be considered when there is:

  • recurrent febrile UTI or pyelonephritis
  • progressive kidney damage
  • troublesome reflux-associated flank pain
  • an untreated bladder-outlet or functional abnormality
  • pregnancy planning in a patient with recurrent infections or reflux nephropathy.

The underlying bladder problem must be identified before anti-reflux surgery. Endoscopic injection can be effective in selected adults, although the supporting evidence is mainly from smaller observational studies. Ureteric reimplantation remains an option when a durable anatomical repair is required.

Women with previous VUR or reflux nephropathy who are considering pregnancy may benefit from pre-pregnancy assessment of blood pressure, kidney function, urine protein and infection risk.

Follow-up

Follow-up should be tailored to reflux grade, renal findings, treatment and infection history.

During observation

Review may include:

  • interval history of UTIs or unexplained fevers
  • height, weight and growth in children
  • blood pressure
  • urine testing when symptoms occur
  • assessment of constipation and bladder symptoms
  • renal and bladder ultrasound
  • serum creatinine and urine protein testing when renal damage is present or suspected
  • selective repeat MCUG, contrast-enhanced urosonography or radionuclide cystography
  • DMSA scanning when new scarring is suspected.

Routine repeated invasive imaging is not necessary for every child. The timing and type of imaging should be chosen only when the result is likely to alter management.

After STING

Follow-up commonly includes an ultrasound to exclude obstruction and clinical monitoring for further UTIs. A repeat reflux study may be recommended after several months, particularly in high-grade reflux, recurrent febrile infection or when confirmation of cure will affect treatment.

Any fever or urinary symptoms after injection should prompt urine testing. Flank pain, vomiting, reduced urine output or significant hydronephrosis requires assessment for the uncommon complication of ureteric obstruction.

After reimplantation

Ultrasound is commonly performed after surgery to check drainage. Routine postoperative MCUG may not be necessary after an uncomplicated reimplantation with a reassuring recovery, but it may be appropriate after breakthrough infection, persistent hydronephrosis or an atypical clinical course.

Long-term surveillance

Patients with renal scarring, bilateral severe reflux, a solitary functioning kidney, proteinuria, hypertension or impaired renal function may require long-term follow-up into adulthood.

Monitoring can include:

  • blood pressure
  • kidney function
  • urine protein
  • recurrent infection
  • pregnancy counselling when relevant.

Even when reflux has resolved, established reflux nephropathy can remain clinically important.

When should urgent medical advice be sought?

Seek prompt medical assessment for:

  • fever with loin or back pain
  • vomiting or marked lethargy
  • reduced urine output
  • a very unwell infant
  • urinary symptoms during pregnancy
  • fever or flank pain after a reflux procedure.

Early diagnosis and treatment of pyelonephritis are particularly important in patients with known VUR.

The key message

Vesico-ureteric reflux ranges from a mild childhood condition that resolves with growth to high-grade reflux associated with recurrent kidney infections and renal scarring.

Treatment should not be based on grade alone. The safest plan considers infection history, kidney health, age, bladder and bowel function, likelihood of spontaneous resolution and the advantages and disadvantages of observation, antibiotic prophylaxis, endoscopic injection and ureteric reimplantation.

References and further reading

  1. European Association of Urology. EAU Guidelines on Paediatric Urology: Vesicoureteric reflux. EAU Paediatric Urology Guidelines
  2. American Urological Association. Management and Screening of Primary Vesicoureteral Reflux in Children. AUA Vesicoureteral Reflux Guideline
  3. National Institute for Health and Care Excellence. Urinary tract infection in under 16s: diagnosis and management (NG224). NICE guideline NG224
  4. RIVUR Trial Investigators. Antimicrobial prophylaxis for children with vesicoureteral reflux. New England Journal of Medicine. 2014;370:2367–2376. PubMed
  5. Mattoo TK, Chesney RW, Greenfield SP, et al. Renal scarring in the Randomized Intervention for Children with Vesicoureteral Reflux trial. Clinical Journal of the American Society of Nephrology. 2016;11:54–61. PubMed
  6. Läckgren G, Cooper CS, Neveus T, Kirsch AJ. Management of vesicoureteral reflux: what have we learned over the last 20 years? Frontiers in Pediatrics. 2021;9:650326. Full text
  7. Salib A, Pizzi M, Landman J, et al. Vesicoureteral reflux in adults with urinary tract infections: is there a role for treatment? Current Urology Reports. 2020. PubMed record

This article provides general education and does not replace individual medical advice. Decisions about imaging, antibiotic prophylaxis or surgery should be made with an appropriately experienced urologist or paediatric urologist.

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

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

Common lower urinary tract symptoms include:

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

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

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

What is a MIST procedure?

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

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

Its principal attractions are:

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

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

How does Clips work?

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

Each implant consists of:

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

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

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

Who may benefit from Clips?

UroLift may be considered for men who:

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

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

What prostate size is suitable?

Clinical guidelines and manufacturer labelling are not identical.

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

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

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

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

What about an obstructing median lobe?

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

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

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

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

Assessment before treatment

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

Assessment may include:

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

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

Any urinary infection should be treated before the procedure.

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

How is the UroLift procedure performed?

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

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

The urologist:

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

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

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

Will I need a catheter?

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

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

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

What should I expect after UroLift?

Temporary urinary irritation is common during the first few days.

You may experience:

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

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

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

Managing pain and urinary discomfort

Discomfort after UroLift is usually mild to moderate.

Management may include:

Paracetamol

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

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

Anti-inflammatory medication

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

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

Medication for urinary symptoms

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

Practical measures

It may help to:

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

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

Possible complications

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

Common temporary effects

These include:

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

Urinary retention

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

Urinary tract infection

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

Bleeding

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

Implant-related problems

Potential implant complications include:

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

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

Persistent symptoms

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

Need for further treatment

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

When should I seek urgent help?

Contact your urologist or attend an emergency department if you:

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

Does UroLift affect erections or ejaculation?

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

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

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

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

How effective are Clips?

Clinical studies show meaningful average improvement in:

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

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

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

How long do Clips last?

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

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

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

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

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

MRI considerations

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

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

This caveat is particularly relevant for:

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

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

Can prostate surgery still be performed later?

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

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

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

Who should not undergo a Clip procedure?

Manufacturer contraindications include:

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

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

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

Advantages of Clips

Potential advantages include:

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

Limitations and important caveats

Patients should understand that:

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

Are Clips the right option for me?

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

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

The decision should take account of:

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

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

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

References

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

A Temporary Stent for Benign Prostatic Enlargement: Temporary Treatment Without a Permanent Implant

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Benign prostatic hyperplasia or BPH is a non-cancerous enlargement of the prostate. As the prostate grows, it may compress the urethra and interfere with emptying the bladder.

Typical symptoms include:

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

Medication is often the first treatment. However, tablets do not help every patient and may cause dizziness, tiredness, reduced ejaculation, erectile difficulties or reduced libido. The iTind procedure offers selected men a minimally invasive alternative to long-term medication or conventional prostate surgery.

What is iTind / Temporary Stent?

The iTind is a small temporary device made from nitinol, a flexible nickel–titanium alloy with “shape memory.”

It is sometimes called a temporary prostatic stent, although it differs from a traditional stent because it is not intended to remain permanently within the prostate. The device is left in place for only five to seven days and is then removed completely.

While in position, three expanding struts apply controlled pressure to specific areas of the prostate and bladder neck. This remodels the prostatic urethra and creates channels through which urine can flow more easily.

The procedure does not:

  • Permanently implant metal within the prostate
  • Remove prostate tissue
  • Use laser, heat or steam
  • Prevent future prostate treatments if symptoms return

Who may benefit from iTind?

iTind may be considered for men who have bothersome urinary symptoms caused by BPH and who:

  • Have obtained insufficient benefit from medication
  • Have developed side effects from BPH tablets
  • Prefer not to take daily medication indefinitely
  • Want a less invasive alternative to TURP or laser surgery
  • Wish to minimise the risk of ejaculatory or erectile side effects
  • Prefer not to have a permanent prostatic implant
  • Have prostate size and anatomy suitable for the device

The procedure is generally best suited to men with moderate-to-severe symptoms and a prostate measuring approximately 25–75 mL, without a significantly obstructing median lobe.

These measurements are a guide rather than a guarantee of suitability. The shape of the prostate, severity of obstruction and function of the bladder are as important as prostate size.

Assessment before treatment

Urinary symptoms are not always caused by an enlarged prostate. Similar problems can result from infection, urethral narrowing, bladder weakness, an overactive bladder, neurological disease, medication or, less commonly, cancer.

Assessment may therefore include:

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

Any urinary infection should be treated before the procedure.

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

How is the iTind procedure performed?

Insertion

The folded iTind device is passed through the urethra using a small cystoscope. It is positioned in the prostatic urethra immediately below the bladder neck and then released.

The procedure is usually performed as day surgery. Depending on the patient and treatment setting, local anaesthetic, intravenous sedation or a short general anaesthetic may be used.

A soft retrieval string remains attached to the device and passes out through the urethra. It is usually secured to the penis until the device is removed.

Most patients can return home on the same day without a urinary catheter. Occasionally, temporary catheterisation is necessary if the patient is unable to pass urine.

The treatment period

The device remains inside the prostate for five to seven days. Its struts gradually apply pressure to the prostate and bladder neck, creating three longitudinal channels within the urinary passage.

Patients remain at home during this treatment period.

Removal

The device must be removed after five to seven days. It is collapsed into a soft catheter and withdrawn in one piece, usually during a brief outpatient visit.

Local anaesthetic gel is often sufficient, although additional pain relief or sedation may be offered when appropriate. No metal or permanent implant remains inside the prostate after removal.

What should I expect while the device is in place?

The five-to-seven-day treatment period is generally the most uncomfortable part of the process. Common temporary symptoms include:

  • Pelvic or perineal pressure
  • Burning or stinging when passing urine
  • Urinary urgency and frequency
  • Discomfort at the tip of the penis
  • Bladder spasms
  • Light bleeding in the urine
  • Interrupted sleep
  • Awareness of the retrieval string
  • A temporarily weak or irregular urinary stream

These symptoms are usually mild to moderate and commonly improve soon after the device is removed.

Patients should generally avoid heavy lifting, vigorous exercise, cycling and sexual activity while the device and retrieval string are in place. Follow the particular instructions provided by your urologist.

The retrieval string should not be pulled, cut, repositioned or removed by the patient.

How can pain and discomfort be managed?

Pain varies considerably between patients. Some men experience only mild pressure, while others find urinary urgency, bladder spasm or discomfort from the retrieval string more troublesome.

A pain-management plan may include the following measures.

Paracetamol

Paracetamol is usually the first choice for mild-to-moderate discomfort. Take it according to your doctor’s instructions or the directions on the packet.

Check cold, influenza and combination pain medicines carefully, as these may also contain paracetamol. Do not exceed the recommended daily dose.

Patients with significant liver disease or heavy alcohol consumption should discuss paracetamol use with their doctor.

Anti-inflammatory medication

An anti-inflammatory medicine such as ibuprofen may help reduce pain and inflammation when medically appropriate.

These medications may not be suitable for patients with:

  • Kidney impairment
  • Stomach ulcers or gastrointestinal bleeding
  • Heart failure or certain cardiovascular conditions
  • Asthma triggered by anti-inflammatory medication
  • Bleeding disorders
  • Anticoagulant or antiplatelet treatment

Check with your urologist, general practitioner or pharmacist before taking an anti-inflammatory medication.

Medication for bladder irritation

An alpha blocker may occasionally be continued or prescribed temporarily to help urine flow. A bladder-calming medication may be considered if urgency or bladder spasms are particularly troublesome.

These medicines are not necessary for every patient and have their own potential side effects.

Practical measures

It may also help to:

  • Maintain normal hydration without forcing excessive fluids
  • Reduce coffee, tea, cola drinks, alcohol and energy drinks
  • Avoid constipation
  • Wear loose, supportive underwear
  • Avoid heavy lifting and strenuous exercise
  • Take pain relief early rather than waiting until discomfort becomes severe

Strong opioid medication is not usually required. It may worsen constipation and, in susceptible patients, contribute to difficulty emptying the bladder.

Severe or increasing pain is not considered something that should simply be tolerated. Contact the treating practice if the discomfort is not controlled by the recommended measures.

What happens after removal?

Burning, urinary urgency and light bleeding may continue briefly after the device is removed, but these symptoms should progressively improve.

Some patients notice an improvement in their stream soon after removal. For others, improvement develops more gradually over several weeks as irritation settles and the remodelled urinary channels stabilise.

Many patients return to normal daily activities within a few days. Your urologist will advise when you may resume strenuous exercise and sexual activity.

Follow-up may include:

  • Review of urinary symptoms
  • Repeat symptom scoring
  • A urinary-flow test
  • Measurement of residual urine
  • Discussion about continuing or stopping BPH medication

Do not stop established prostate medication unless advised to do so.

Side effects and possible complications

Most side effects are temporary and occur while the device is in place. Reported problems include:

  • Burning during urination
  • Urinary frequency and urgency
  • Pelvic discomfort or pain
  • Blood in the urine
  • Temporary difficulty passing urine
  • Urinary tract infection
  • Bladder spasm
  • Movement or incorrect positioning of the device
  • Temporary catheterisation
  • Failure to obtain sufficient symptom relief

Published studies report different complication rates, but most events have been mild and self-limiting. Temporary haematuria, dysuria, urgency and pelvic discomfort are the most frequently reported problems.

Acute urinary retention, urinary infection or significant bleeding are less common but important complications.

When should I seek urgent medical attention?

Contact your urologist or attend an emergency department if you:

  • Cannot pass urine
  • Develop fever, shaking or chills
  • Feel generally unwell or confused
  • Develop severe or increasing pelvic pain
  • Pass large blood clots
  • Have heavy or persistent bright-red bleeding
  • Cannot keep fluids down
  • Notice that the retrieval string or device has moved
  • Develop pain that is not controlled by the agreed treatment plan

Does iTind affect erections or ejaculation?

One of the principal attractions of iTind is its favourable sexual side-effect profile.

Clinical studies have reported preservation of erectile and ejaculatory function in most treated patients. This contrasts with tissue-removing prostate procedures, which may carry a significant risk of retrograde or absent ejaculation.

Nevertheless, no treatment can guarantee that sexual or ejaculatory function will remain unchanged in every patient.

How effective is iTind?

Studies have demonstrated average improvements in:

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

The improvement may be less dramatic than that achieved with a tissue-removing operation such as TURP or laser enucleation. The advantage is that iTind is less invasive, usually requires little recovery time and has a low reported risk of sexual side effects.

It is therefore best viewed as a balance between symptom improvement and treatment invasiveness.

How long does the benefit last?

Although the implant remains in place for only five to seven days, the channels produced within the prostate may remain open for several years.

Prospective studies have demonstrated sustained benefit for more than four years in some appropriately selected patients. This does not mean that iTind is guaranteed to last for four years—or that it will provide lifelong relief.

BPH may continue to progress as a man ages. Some patients will eventually need to restart medication or undergo another procedure. Longer-term evidence for iTind remains more limited than that available for established procedures such as TURP or laser enucleation.

Because nothing is left permanently inside the prostate, iTind does not generally prevent later treatment. Options may include medication, another minimally invasive procedure, TURP, GreenLight laser treatment, HoLEP or another form of prostate surgery.

Who should not undergo iTind?

Contraindications described in the manufacturer’s information include:

  • Active urinary tract infection
  • Acute prostatitis
  • Known prostate cancer
  • Known bladder cancer
  • An artificial urinary sphincter or another implant within the urethra
  • Bladder atonia or a non-contractile bladder
  • Neurogenic bladder dysfunction
  • Urinary obstruction caused by a urethral stricture or something other than BPH

The procedure may also be unsuitable or less predictable in men with:

  • A significantly obstructing median prostatic lobe
  • A prostate outside the best-studied size range
  • Severe chronic urinary retention
  • Very high residual urine volumes
  • Recurrent urinary infections
  • Bladder stones
  • Significant ongoing haematuria
  • Advanced bladder weakness
  • A need for rapid and substantial removal of obstructing tissue
  • Anatomy that prevents safe cystoscopic access

Previous prostate surgery, urethral surgery, nickel sensitivity and blood-thinning medication require individual consideration.

Patients with obstruction causing kidney impairment, repeated retention, recurrent infections, bladder stones or significant bleeding may receive more reliable relief from a definitive tissue-removing procedure.

Advantages of iTind

Potential advantages include:

  • Minimally invasive day procedure
  • No cutting, laser, steam or thermal energy
  • No permanent implant
  • Usually no postoperative catheter
  • Rapid return to ordinary activities
  • Low reported risk of new erectile dysfunction
  • Low reported risk of ejaculatory dysfunction
  • Does not usually compromise future BPH treatment

Limitations of iTind

Potential limitations include:

  • Discomfort during the treatment week
  • A retrieval string for five to seven days
  • A second procedure to remove the device
  • Not suitable for every prostate shape or size
  • Less improvement than some tissue-removing procedures
  • Possibility of persistent or recurrent symptoms
  • Potential need for future medication or surgery
  • Less very-long-term evidence than TURP or laser enucleation

Is iTind the right treatment for me?

iTind is not simply a smaller version of TURP. It offers a different compromise: a less invasive procedure with no permanent implant and a favourable sexual side-effect profile, but generally more modest improvement and less long-term evidence than tissue-removing surgery.

The best treatment depends on:

  • The severity of your symptoms
  • The size and shape of your prostate
  • The amount of urinary obstruction
  • Bladder strength and residual urine
  • Previous treatment
  • General health and medication
  • The importance of preserving ejaculation
  • Your willingness to accept possible future retreatment

A urological assessment is essential to confirm that BPH is responsible for the symptoms and to compare iTind fairly with medication, Rezūm, UroLift, TURP, GreenLight laser, HoLEP and other appropriate treatments.

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. Sandhu JS, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline Amendment 2023. Journal of Urology. 2024.
  2. Chughtai B, et al. The iTind Temporarily Implanted Nitinol Device for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Multicentre, Randomised, Controlled Trial. Urology. 2021;153:270–276.
  3. Kadner G, et al. Second generation of temporary implantable nitinol device in men with lower urinary tract symptoms: two-year results of the MT-02 study. World Journal of Urology. 2020;38:3235–3244.
  4. Amparore D, et al. Three-year results following treatment with the second-generation temporary implantable nitinol device. Prostate Cancer and Prostatic Diseases. 2021;24:349–357.
  5. Amparore D, et al. Temporary implantable nitinol device for BPH-related lower urinary tract symptoms: over 48-month results. Minerva Urology and Nephrology. 2023;75:743–751.
  6. NICE: iTind for lower urinary tract symptoms caused by BPH.
  7. Olympus: iTind clinical and procedural information.

Protecting the Rectum During Prostate Radiotherapy: A Patient Guide

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

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

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

Why can prostate radiotherapy affect the bowel?

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

Possible bowel effects during or after radiotherapy include:

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

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

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

How is the rectum protected?

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

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

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

What is a rectal spacer?

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

Materials used in currently available spacer systems include:

  • polyethylene-glycol hydrogel
  • stabilised hyaluronic-acid gel

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

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

Do all men having prostate radiotherapy need a spacer?

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

Potential benefit depends on factors such as:

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

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

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

What does the evidence show?

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

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

These findings are relevant but require context:

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

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

How is a spacer inserted?

The procedure is generally performed before radiotherapy planning.

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

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

  • local anaesthesia
  • sedation
  • general anaesthesia

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

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

Why does correct placement matter?

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

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

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

Who may be unsuitable?

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

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

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

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

Possible short-term effects

Temporary effects may include:

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

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

Uncommon but important complications

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

Reported or plausible complications include:

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

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

What happens to the spacer?

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

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

Different spacer materials

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

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

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

What about previous surgery or salvage radiotherapy?

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

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

Questions to ask before deciding

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

Australian regulatory considerations

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

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

The bottom line

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

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

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

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

References and further reading

 

Advanced and Metastatic Prostate Cancer: Modern Treatment and New Hope

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

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

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

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

What does “advanced” prostate cancer mean?

Advanced prostate cancer is not one single condition.

Locally advanced prostate cancer

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

Metastatic hormone-sensitive prostate cancer

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

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

but remains sensitive to testosterone suppression.

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

Metastatic castration-resistant prostate cancer

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

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

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

1. Androgen Deprivation Therapy: The Foundation of Treatment

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

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

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

ADT remains the backbone of treatment for metastatic prostate cancer.

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

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

2. Double Therapy

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

Examples include:

Abiraterone + prednisone

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

Potential side effects include:

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

Enzalutamide

This blocks signalling through the androgen receptor.

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

Apalutamide

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

Darolutamide

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

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

3. Triple Therapy: Three Treatments From the Starting Line

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

Instead of:

ADT alone

or:

ADT + one additional treatment

selected patients may receive:

ADT + chemotherapy + an androgen-receptor pathway inhibitor

Two landmark trials helped establish this approach.

ARASENS

The phase III ARASENS trial investigated:

ADT + docetaxel + darolutamide

compared with:

ADT + docetaxel + placebo

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

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

PEACE-1

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

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

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

Who may benefit from triple therapy?

Triplet therapy is particularly considered in men who:

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

Treatment nevertheless needs to be individualised.

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

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

4. Chemotherapy

Docetaxel

Docetaxel remains an important chemotherapy for advanced prostate cancer.

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

Potential side effects include:

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

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

Cabazitaxel

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

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

5. Should ADT Ever Be Intermittent?

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

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

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

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

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

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

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

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

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

6. What Happens When the Cancer Becomes Castration Resistant?

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

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

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

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

Options can include:

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

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

7. Genetic Testing Has Become Part of Treatment

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

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

Important abnormalities include mutations involving:

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

These mutations may make the cancer susceptible to PARP inhibitors.

Examples include:

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

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

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

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

8. Immunotherapy: Exciting, But Not for Everyone

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

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

However, there is an important exception.

Pembrolizumab

A small proportion of prostate cancers have abnormalities known as:

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

These cancers may respond to the immune checkpoint inhibitor pembrolizumab.

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

This is another reason why molecular testing has become important.

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

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

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

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

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

9. PSMA Radioligand Therapy

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

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

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

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

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

Potential side effects include:

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

10. Radium-223 for Bone-Dominant Disease

Prostate cancer has a particular tendency to spread to bone.

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

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

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

11. Don’t Forget the Prostate Itself

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

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

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

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

12. Side Effects of Long-Term Hormonal Treatment

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

Long-term ADT may cause:

Sexual effects

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

Hot flushes

These can range from mildly annoying to profoundly disruptive.

Muscle loss

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

Weight gain

Fat tends to accumulate particularly around the abdomen.

Metabolic changes

ADT can increase the risk of:

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

Bone thinning

Long-term ADT accelerates osteoporosis and increases fracture risk.

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

Mood and cognition

Some men experience:

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

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

Exercise Is Part of Cancer Treatment

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

A programme incorporating:

resistance training + aerobic exercise + balance work

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

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

Bone Health Matters

Men receiving prolonged ADT should have their fracture risk assessed.

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

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

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

A New Way of Thinking About Metastatic Prostate Cancer

The old treatment pathway was fairly linear:

ADT → wait for progression → chemotherapy → another treatment.

Modern treatment looks very different.

It is increasingly:

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

For some patients this means:

ADT + ARPI

For others:

ADT + docetaxel + darolutamide

or:

ADT + docetaxel + abiraterone

And later, depending on the tumour:

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

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

The Bottom Line

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

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

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

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

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

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

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

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

Penile Cancer: Symptoms, Diagnosis and Treatment in Australia

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Penile cancer is rare, but early diagnosis matters

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

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

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

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

Treatment in Australia will depend on:

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

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

 

What causes penile cancer?

There is rarely one single identifiable cause.

Important risk factors include:

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

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

What symptoms should men look for?

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

Symptoms can include:

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

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

A persistent penile lesion deserves examination

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

The important issue is persistence.

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

Embarrassment is considerably easier to treat than advanced cancer.

How is penile cancer diagnosed?

Examination

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

The urologist will assess:

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

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

Biopsy

The diagnosis usually requires a biopsy.

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

Depending upon the lesion, this may be:

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

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

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

What is PeIN?

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

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

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

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

Treatment: from creams to major surgery

There is no single operation or treatment for penile cancer.

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

1. Circumcision

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

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

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

2. Treatment with creams

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

The two most commonly used treatments are:

5-fluorouracil (5-FU)

5-FU is a topical chemotherapy medication.

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

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

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

Imiquimod

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

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

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

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

Importantly, the area must be reassessed after treatment.

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

3. Laser and other local treatments

Very superficial lesions can sometimes be treated using laser therapy.

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

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

4. Penile-preserving surgery

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

Whenever oncologically safe, the aim is:

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

Operations may include:

Wide local excision

The cancer and a margin of surrounding tissue are removed.

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

Glans resurfacing

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

A skin graft is then placed over the glans.

This can be particularly useful for extensive superficial disease.

Glansectomy

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

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

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

5. Partial penectomy

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

This is called a partial penectomy.

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

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

6. Total penectomy

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

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

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

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

What is a perineal urethrostomy?

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

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

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

This opening is called a:

Perineal urethrostomy

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

A catheter is generally left temporarily while the area heals.

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

Potential problems include:

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

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

The lymph nodes are extremely important

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

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

Penile cancer generally spreads in a predictable sequence:

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

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

What if there are no enlarged lymph nodes?

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

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

This may involve:

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

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

What if a groin lymph node is enlarged?

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

If metastatic penile cancer is confirmed, treatment may involve:

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

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

Early treatment of lymph-node disease is extremely important.

Radiation therapy

Radiotherapy has an important but selective role in penile cancer.

Treatment of the primary cancer

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

Treatment can involve:

External beam radiotherapy

Radiation is directed at the tumour from outside the body.

Brachytherapy

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

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

Potential complications can include:

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

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

Chemotherapy

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

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

One regimen used in advanced disease is:

TIP: paclitaxel + ifosfamide + cisplatin

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

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

This is called neoadjuvant chemotherapy.

The aim is to:

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

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

Chemoradiotherapy

Radiotherapy and chemotherapy can sometimes be combined.

This may be considered for selected patients with:

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

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

What about immunotherapy?

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

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

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

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

What happens to sexual function?

This depends enormously on treatment.

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

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

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

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

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

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

What is the prognosis?

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

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

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

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

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

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

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

Follow-up after treatment

Penile cancer requires ongoing surveillance.

Follow-up may include:

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

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

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

Do not ignore a change in the penis

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

Nevertheless, a persistent:

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

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

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

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

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

The crucial message is simple:

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

Australian and international resources

Cancer Council Australia: Penile Cancer

Cancer Institute NSW: Penile Cancer

eviQ Australian Penile Cancer Chemotherapy Protocol

2026 EAU-ASCO Penile Cancer Guidelines

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

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

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

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One of the most curable cancers in men

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

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

The most important message is therefore:

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

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

The importance of checking your testicles

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

This makes testicular awareness particularly important.

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

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

Nevertheless, knowing your own anatomy makes sense.

How do I check my testicles?

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

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

Become familiar with:

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

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

Seek medical advice if you discover:

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

How often?

There is some variation between international recommendations.

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

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

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

What is testicular cancer?

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

They are divided into two broad groups:

Seminoma

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

Non-seminomatous germ-cell tumour (NSGCT)

This group includes:

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

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

An important clinical rule is:

Pure seminoma should not produce AFP.

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

Other testicular tumours

Less common tumours include:

Leydig cell tumours

Most are benign, although malignant variants occur.

Sertoli cell tumours

Again, most are benign but malignant variants are recognised.

Testicular lymphoma

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

Occasionally another cancer can metastasise to the testicle.

How does testicular cancer present?

The classic presentation is a:

Painless testicular lump

A man may notice:

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

Testicular cancer can also cause discomfort or pain.

Therefore:

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

Symptoms of more advanced disease

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

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

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

Diagnosis in Australia

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

Step 1: Examination

Both testicles should be examined.

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

Step 2: Testicular ultrasound

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

It determines whether a lesion is:

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

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

Step 3: Tumour markers

Blood should ideally be collected before orchidectomy for:

AFP, Alpha-fetoprotein

May be elevated with:

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

β-hCG, Beta human chorionic gonadotropin

Can be elevated in:

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

LDH, Lactate dehydrogenase

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

Importantly:

Normal tumour markers do not exclude testicular cancer.

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

Step 4: Staging

Staging commonly involves CT imaging of the:

  • Chest
  • Abdomen
  • Pelvis

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

MRI can be used in selected circumstances.

PET scanning is not routinely recommended for initial staging.

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

Should the testicular lump be biopsied?

Usually no.

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

The standard procedure is:

Radical inguinal orchidectomy

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

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

Fertility before treatment

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

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

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

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

Management of testicular cancer in Australia

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

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

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

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

Stage I seminoma

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

For most reliable patients:

Active surveillance is generally preferred

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

Surveillance involves scheduled:

  • Clinical review
  • Imaging
  • Tumour markers where appropriate

If recurrence occurs, treatment is usually extremely successful.

Adjuvant carboplatin

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

Radiotherapy

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

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

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

Stage I non-seminomatous germ-cell cancer

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

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

Without lymphovascular invasion

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

With lymphovascular invasion

The risk of recurrence is considerably greater.

Options include:

  • Surveillance
  • One cycle of BEP chemotherapy

BEP consists of:

Bleomycin
Etoposide
Platinum – cisplatin

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

Retroperitoneal lymph-node dissection, RPLND

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

It has an important but selective role.

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

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

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

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

Stage II seminoma

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

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

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

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

Metastatic seminoma and non-seminoma

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

Common treatment includes:

BEP

Bleomycin + etoposide + cisplatin.

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

EP

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

VIP

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

Surgery after chemotherapy

Surgery can remain crucial even after successful chemotherapy.

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

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

  • Fibrosis or necrosis
  • Mature teratoma
  • Persistent viable cancer

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

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

What about immunotherapy?

Immunotherapy has revolutionised treatment for several urological cancers.

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

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

Therefore:

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

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

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

The reassuring answer is:

The major principles are remarkably similar.

All emphasise:

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

There are, however, some interesting differences in emphasis.

European approach: EAU

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

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

Routine adjuvant radiotherapy is not recommended.

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

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

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

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

British approach

British practice is broadly similar to European practice.

The NHS pathway centres around:

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

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

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

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

British cancer services place considerable emphasis on:

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

This is very similar to contemporary Australian practice.

How does the American approach differ?

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

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

  • RPLND
  • One cycle of BEP

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

For Stage IB NSGCT, American guidance recognises:

  • Surveillance
  • RPLND
  • One or two cycles of BEP

as options following shared decision-making.

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

Another evolving difference: RPLND for Stage II seminoma

Traditionally seminoma involving retroperitoneal lymph nodes was treated with either:

Radiotherapy or chemotherapy.

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

European recommendations are also evolving in this direction.

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

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

Australia: where do we sit?

Australian practice sits comfortably between these international approaches.

For most Australian patients:

Stage I seminoma

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

Stage I NSGCT without LVI

Surveillance is generally preferred.

Stage I NSGCT with LVI

Surveillance or one cycle of BEP following individualised discussion.

Stage II seminoma

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

Marker-positive metastatic disease

Cisplatin-based chemotherapy according to IGCCCG prognostic classification.

Residual NSGCT after chemotherapy

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

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

Why avoiding unnecessary treatment matters

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

That changes the treatment equation.

The question is no longer simply:

“Which treatment will cure the cancer?”

It is also:

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

This is why surveillance has become so important.

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

Prognosis

The prognosis for testicular cancer is excellent.

Stage I disease has survival approaching 100%.

Even metastatic disease is frequently curable.

Prognosis depends upon:

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

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

After treatment: don’t forget the other testicle

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

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

Long-term survivorship care may also address:

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

The take-home message

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

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

Know your testicles.

Become familiar with what is normal for you.

Don’t ignore a change.

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

Don’t be embarrassed.

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

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

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