Tag Archive for: Caboolture urologist

Urethral Caruncle: A Small Lump That Can Cause Big Concern

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Finding a red or fleshy lump around the opening of the urethra can understandably be alarming. Fortunately, one of the most common causes, particularly in women after menopause, is a urethral caruncle.

A urethral caruncle is usually benign (non-cancerous) and may cause no problems at all. However, because several other conditions can look similar, a new, enlarging, bleeding or unusual urethral lesion deserves proper assessment.

What is a urethral caruncle?

A urethral caruncle is a small, fleshy growth arising from the lining of the urethral opening, or urethral meatus.

It typically appears as a soft red, pink or sometimes darker-red polypoid lesion at the edge of the urethral opening. It most commonly arises from the posterior or lower margin of the urethral meatus.

Caruncles occur predominantly in postmenopausal women, although they can occasionally occur in younger women.

Importantly, a urethral caruncle is not considered a precancerous condition. Its significance lies mainly in the symptoms it can produce and the fact that other urethral conditions can occasionally imitate its appearance.

What causes a urethral caruncle?

The exact cause is not completely understood, but several factors are thought to contribute.

Reduced oestrogen after menopause

This is probably the most important association.

After menopause, falling oestrogen levels cause thinning and reduced elasticity of the tissues surrounding the vagina and urethra. This is part of what is now commonly called genitourinary syndrome of menopause (GSM).

The urethral lining may become more fragile and susceptible to irritation, inflammation and prolapse.

Chronic inflammation and irritation

Repeated local irritation may contribute to inflammation around the urethral opening and subsequent formation of a caruncle.

Urethral mucosal prolapse

A caruncle may represent a localised form of prolapse of the urethral lining. This helps explain why the lesion usually occurs at the edge of the urethral opening.

What does a urethral caruncle look like?

A typical caruncle is:

  • Small and fleshy
  • Red or pink
  • Soft
  • Usually located along the lower edge of the urethral opening
  • Occasionally friable, meaning that it bleeds easily when touched
  • Sometimes tender or inflamed

They vary considerably in size. Some are barely noticeable, while larger lesions may protrude sufficiently to be felt or seen by the patient.

Although the appearance may be quite characteristic, appearance alone should not always be relied upon when a lesion is atypical.

What symptoms can it cause?

Many urethral caruncles are discovered incidentally during a pelvic examination and cause absolutely no symptoms.

When symptoms do occur, they may include:

Bleeding

The surface of a caruncle can be delicate and vascular. Patients may notice:

  • Spotting on underwear
  • Blood after wiping
  • Bleeding after intercourse
  • Blood noticed after passing urine

One important distinction is determining whether the blood is actually coming from the urethral lesion or whether there is true blood within the urine (haematuria).

Persistent haematuria may require additional investigation.

Pain or tenderness

An inflamed caruncle can become uncomfortable, particularly with wiping, intercourse or local pressure.

Burning when passing urine

Some patients experience dysuria or a stinging sensation as urine passes across the inflamed tissue.

A visible or palpable lump

Some women first become aware of the condition because they see or feel a small lump at the urethral opening.

Urinary symptoms

Large caruncles only rarely interfere significantly with urinary flow. If there is difficulty passing urine, a weak stream or urinary retention, other causes should also be considered.

How is a urethral caruncle diagnosed?

Diagnosis usually begins with a careful examination of the urethral opening and surrounding genital tissues.

A typical small caruncle in a postmenopausal woman often has a characteristic appearance.

Your doctor may also assess for associated vaginal and urethral atrophy and ask about urinary symptoms, recurrent urinary infections, bleeding and haematuria.

Depending on the circumstances, investigations may include:

  • Urinalysis
  • Urine culture if infection is suspected
  • Assessment for haematuria
  • Cystoscopy if there are unexplained urinary symptoms or blood in the urine
  • Biopsy or removal of the lesion when its appearance is atypical

Does a urethral caruncle need treatment?

Not necessarily.

A small, typical caruncle that causes no symptoms may simply be observed.

Treatment is generally considered when the lesion causes bleeding, pain, irritation or bothersome urinary symptoms, or when there is uncertainty about the diagnosis.

1. Observation

If the lesion is small, has a typical appearance and causes no symptoms, reassurance and observation may be all that is required.

This avoids treating something that is essentially harmless.

2. Topical vaginal oestrogen

In postmenopausal women, topical oestrogen therapy is frequently used, particularly when there are accompanying features of genitourinary syndrome of menopause.

Oestrogen can improve the quality and thickness of the tissues around the urethra and vagina and may allow a small caruncle to shrink considerably or resolve.

Treatment usually requires several weeks rather than several days.

The suitability of vaginal oestrogen should be discussed with your doctor, particularly if you have a history of an oestrogen-sensitive malignancy or another reason to avoid hormonal therapy.

3. Anti-inflammatory and supportive treatment

Where local inflammation is prominent, conservative measures may occasionally include:

  • Avoidance of irritating soaps and products
  • Treatment of associated infection if present
  • Appropriate topical therapy
  • Simple analgesia when required

These treatments may improve symptoms but do not necessarily remove the lesion itself.

When is surgery required?

Surgical removal may be recommended when the caruncle is:

  • Persistently painful
  • Repeatedly bleeding
  • Large or bothersome
  • Not responding to conservative treatment
  • Increasing in size
  • Firm, irregular, ulcerated or otherwise atypical
  • Associated with uncertainty about the diagnosis

Surgery usually involves excision of the lesion at its base, often as a relatively minor procedure.

The removed tissue can then be sent to a pathologist for examination under the microscope.

Possible complications are uncommon but can include bleeding, infection, discomfort, recurrence and, rarely, scarring or narrowing of the urethral opening.

Can a urethral caruncle be cancerous?

A true urethral caruncle is benign.

The more important question is whether a lesion that looks like a caruncle could occasionally be something else.

Several conditions may resemble a caruncle, including:

  • Urethral mucosal prolapse
  • Urethral polyps
  • Periurethral cysts
  • Urethral diverticulum
  • Genital warts
  • Inflammatory lesions
  • Melanoma
  • Urethral carcinoma
  • Other uncommon benign or malignant tumours

Cancer masquerading as an apparently innocent urethral lesion is uncommon, but this is precisely why an atypical lesion should not simply be labelled a caruncle and forgotten.

When should a biopsy be considered?

Biopsy or complete excision is particularly worth considering when a lesion is:

  • Irregular or unusually firm
  • Ulcerated
  • Pigmented
  • Rapidly enlarging
  • Persistently bleeding
  • Unusually large
  • Not responding as expected to conservative treatment
  • Associated with enlarged groin lymph nodes
  • Clinically inconsistent with a typical caruncle

In medicine, sometimes the smallest lump deserves a second look rather than a dramatic name.

Urethral caruncle versus urethral prolapse

These conditions can look similar but are not quite the same.

A urethral caruncle generally involves only a portion of the circumference of the urethral opening, most commonly its posterior margin.

A urethral prolapse usually involves the entire circumference of the urethral lining, creating a circular or doughnut-shaped ring of tissue surrounding the opening.

The distinction can influence management.

What about blood in the urine?

This is particularly important.

A caruncle may bleed externally and make it appear that blood has come from the urine. However, visible haematuria should not automatically be attributed to a urethral caruncle.

Depending on age, symptoms and individual risk factors, haematuria may require investigation of the bladder, kidneys and urinary tract.

The presence of a convenient little red lump should therefore not distract from investigating genuine haematuria appropriately.

Will a urethral caruncle come back?

Recurrence after treatment is possible, particularly if the underlying postmenopausal tissue changes persist.

Treatment of associated genitourinary syndrome of menopause may therefore remain useful even after the immediate caruncle has improved or been removed.

When should you see a urologist?

Consider seeking medical assessment if you notice:

  • A new lump around the urethral opening
  • Persistent urethral pain
  • Recurrent bleeding
  • Blood in the urine
  • A lesion that is enlarging
  • Difficulty passing urine
  • Recurrent urinary infections
  • A lesion that does not improve with treatment

Most urethral caruncles turn out to be harmless, but examination provides reassurance and ensures that less common conditions are not overlooked.

The Bottom Line

A urethral caruncle is a common benign lesion of the urethral opening, seen particularly in postmenopausal women.

Many require no treatment at all. When symptoms occur, topical vaginal oestrogen and conservative measures are often appropriate first-line options. Persistent, troublesome or atypical lesions may require surgical excision and pathological examination.

The most important message is simple: a typical urethral caruncle is usually nothing to fear, but an unusual urethral lesion deserves proper assessment rather than assumption.

Patient information disclaimer

This information is intended for general education and should not replace individual medical advice. A urethral or vulval lump, unexplained bleeding or blood in the urine should be assessed by an appropriately qualified healthcare professional.

Intravesical Drugs for Non-Muscle-Invasive Bladder Cancer

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Treating the tumour and reducing the risk of it coming back

Bladder cancer has an inconvenient habit: even after a visible tumour has been completely removed, new tumours can sometimes return elsewhere in the bladder.

For selected patients with non-muscle-invasive bladder cancer (NMIBC), previously often called superficial bladder cancer, Mitomycin C can be placed directly into the bladder to destroy residual cancer cells and reduce the chance of recurrence. It is one of the therapies available. It will be discussed on its own.

This treatment is called intravesical Mitomycin C.

The advantage of intravesical treatment is rather elegant: instead of sending chemotherapy around the entire body, the medication is delivered directly to the bladder lining where it is needed.

What is Mitomycin C?

Mitomycin C is an anti-cancer chemotherapy medication originally derived from Streptomyces bacteria.

When used for bladder cancer, the medication is usually introduced directly into the bladder through a urinary catheter rather than being given intravenously.

This allows a relatively high concentration of chemotherapy to come into direct contact with the urothelium while limiting systemic exposure.

Intravesical Mitomycin is used particularly following transurethral resection of bladder tumour (TURBT) and in selected patients requiring an induction course of intravesical chemotherapy.

Why is Mitomycin C used?

The first and most important treatment for most visible non-muscle-invasive bladder tumours is a TURBT.

During TURBT, the visible tumour is removed and tissue is sent to pathology to determine:

  • tumour type
  • tumour grade
  • depth of invasion
  • presence or absence of carcinoma in situ (CIS)
  • whether muscle is present in the specimen
  • whether cancer has invaded the bladder muscle.

The pathology results allow the tumour to be classified into a recurrence and progression risk category.

Mitomycin C may then be recommended to reduce the risk of tumour recurrence.

When is Mitomycin C used?

There are several different situations in which intravesical Mitomycin C may be considered.

1. A single dose immediately after TURBT

In appropriately selected patients, a single dose of intravesical chemotherapy can be given following TURBT.

Australian eviQ guidance describes administration within 24 hours and preferably within six hours of TURBT. AUA guidance similarly recommends considering a single postoperative instillation within 24 hours for suspected or known low- or intermediate-risk disease.

The purpose is to destroy:

  • microscopic tumour cells remaining after resection
  • free-floating tumour cells released during surgery
  • tumour cells that might otherwise implant elsewhere on the bladder lining.

Think of TURBT as removing the weeds you can see, while the immediate intravesical treatment targets some of the microscopic seeds left behind.

Importantly, a single postoperative instillation primarily reduces recurrence. It has not been shown to provide the same benefit for progression or survival.

2. Induction Mitomycin C

Some patients with intermediate-risk NMIBC may benefit from a course of intravesical chemotherapy rather than a single treatment.

A commonly used regimen is:

Mitomycin C once weekly for six weeks.

Australian eviQ protocols include a six-week induction course for appropriate patients with Ta, T1 or CIS-containing urothelial carcinoma classified as intermediate risk, as an alternative to BCG in selected circumstances.

The exact treatment schedule should be individualised according to:

  • tumour grade
  • pathological stage
  • tumour size
  • number of tumours
  • previous recurrence rate
  • previous intravesical therapy
  • presence of CIS
  • tolerance of treatment
  • overall risk of progression.

What about aggressive superficial bladder cancer?

The term “superficial bladder cancer” can be misleading.

A cancer can remain confined to the bladder lining or lamina propria and still behave aggressively.

Higher-risk features include:

  • high-grade urothelial carcinoma
  • T1 disease
  • carcinoma in situ
  • multiple tumours
  • large tumours
  • frequently recurrent disease
  • certain adverse pathological features.

For genuinely high-risk NMIBC, particularly high-grade T1 disease and CIS, intravesical BCG immunotherapy generally has a central role when bladder preservation is appropriate.

Mitomycin C should therefore not automatically be regarded as a substitute for BCG in every patient with aggressive NMIBC.

Treatment needs to be based on the patient’s pathological risk group and previous response to therapy.

In selected circumstances, Mitomycin may nevertheless be considered, including when BCG is unsuitable, poorly tolerated, unavailable or as part of specific sequential intravesical treatment protocols.

Patients with very-high-risk disease also require discussion about whether bladder-preserving intravesical treatment remains appropriate or whether radical cystectomy should be considered.

How does Mitomycin C work?

Mitomycin C is an alkylating anti-tumour agent.

After entering a cancer cell, the drug is activated and produces reactive metabolites that bind to DNA.

It causes cross-linking of DNA strands, preventing the DNA from separating normally.

As a result, the cancer cell has difficulty:

  • replicating its DNA
  • dividing
  • repairing damaged DNA
  • continuing normal cellular function.

Ultimately, susceptible tumour cells die.

Because Mitomycin is placed directly into the bladder, it can attack residual malignant cells while generally producing much less systemic exposure than intravenous chemotherapy.

What happens during treatment?

Intravesical treatment is usually performed as an outpatient procedure.

A small urinary catheter is passed through the urethra into the bladder.

The bladder is emptied completely and the Mitomycin solution is then introduced through the catheter.

The catheter may then be removed or temporarily clamped, depending upon the treatment protocol.

The medication is usually retained within the bladder for approximately one to two hours.

Patients are generally advised to restrict fluids beforehand so that the medication is not excessively diluted. Australian eviQ protocols advise restricting fluids for approximately four to six hours before and during treatment, with appropriate adjustment of diuretic medication where relevant.

After the prescribed treatment period, the medication is passed out with the urine or drained through the catheter.

Side effects of intravesical Mitomycin C

Most patients tolerate treatment reasonably well because relatively little of the medication is normally absorbed into the bloodstream.

The commonest problems involve irritation of the bladder.

Chemical cystitis

Mitomycin can irritate the bladder lining and cause:

  • burning when passing urine
  • urinary frequency
  • urgency
  • bladder discomfort
  • pelvic discomfort
  • mild haematuria.

These symptoms frequently develop within hours of treatment and usually settle over the following few days.

Urinary tract infection

A urinary infection can occasionally occur following catheterisation.

Symptoms may include:

  • increasing dysuria
  • cloudy or offensive urine
  • fever
  • chills
  • worsening urinary frequency
  • feeling generally unwell.

A urine culture may be required if infection is suspected.

Skin irritation

Mitomycin is a cytotoxic medication and contact with the skin should be avoided.

Urine containing residual medication may irritate the skin around the urethra or genital area.

Patients should therefore follow the specific hygiene and toilet precautions provided by their treating unit.

Allergic reaction

Hypersensitivity reactions are uncommon but possible.

Symptoms can include:

  • skin rash
  • itching
  • facial redness
  • wheezing
  • breathlessness
  • dizziness
  • fever or chills.

Severe allergic reactions are rare but require urgent medical attention.

Less common but important complications

Although uncommon, Mitomycin can occasionally produce significant complications.

Severe chemical cystitis

Repeated bladder irritation can occasionally become severe.

Persistent inflammation may lead to:

  • chronic bladder pain
  • reduced bladder capacity
  • bladder fibrosis
  • rarely, bladder contraction.

Patients who already have a small-capacity bladder require particular caution because of the potential risk of further bladder contraction.

Extravasation

One of the most important complications is Mitomycin extravasation.

This means that Mitomycin escapes through an injured or perforated bladder wall into the surrounding tissues.

Although rare, this can produce significant tissue injury.

Reported complications include:

  • severe pelvic inflammation
  • tissue necrosis
  • abscess formation
  • bladder injury
  • fistula formation
  • damage to surrounding genital tissues.

Symptoms can occur immediately, but importantly they may also appear weeks or even months after treatment. Persistent or unexplained pelvic or abdominal pain following intravesical Mitomycin therefore deserves investigation.

An important precaution after TURBT

Intravesical Mitomycin should not simply be administered automatically following every TURBT.

If there is any suspicion that the bladder has been perforated, the medication should not be given.

AUA guidance advises against postoperative intravesical chemotherapy following a suspected perforation or extensive resection. Australian eviQ guidance similarly excludes postoperative Mitomycin when bladder perforation has occurred.

This is important because chemotherapy escaping through a bladder perforation can cause substantial tissue injury.

When should Mitomycin treatment be postponed?

Intravesical Mitomycin is generally avoided or postponed in the presence of:

  • visible haematuria
  • confirmed urinary tract infection
  • traumatic catheterisation
  • fever or unexplained febrile illness
  • known allergy to Mitomycin
  • suspected or confirmed bladder perforation
  • significant bladder injury following surgery.

Australian protocols specifically advise against treatment following traumatic catheterisation, with visible haematuria, active UTI or recent bladder injury.

If catheterisation is traumatic or produces bleeding on the day of treatment, the treatment is usually deferred.

Does Mitomycin cause the usual chemotherapy side effects?

Usually not.

Because the medication is placed into the bladder rather than routinely given intravenously, systemic absorption is generally very low.

Therefore classic chemotherapy problems such as:

  • hair loss
  • severe nausea
  • widespread immunosuppression
  • profound fatigue
  • bone marrow suppression

are unusual with standard intravesical therapy.

Systemic absorption can occur rarely, however, particularly when the bladder lining has been significantly disrupted. Myelosuppression is considered a potential but uncommon complication, and a full blood count may be appropriate if a patient becomes unexpectedly systemically unwell.

Precautions after treatment

Mitomycin remains a cytotoxic chemotherapy drug, even when delivered directly into the bladder.

Patients should therefore follow their treating unit’s instructions carefully regarding:

  • toilet hygiene
  • handling urine
  • washing contaminated skin
  • hand washing
  • fluid intake following treatment
  • management of contaminated clothing.

Patients should also tell their treating team about all medications they are taking and whether they are receiving antibiotics, diuretics or other cancer treatments.

When should you seek urgent medical advice?

Contact your treating team promptly if you develop persistent or worsening urinary symptoms after treatment.

More urgent assessment is required for symptoms such as:

  • temperature of 38°C or higher
  • inability to pass urine
  • significant or persistent haematuria
  • severe pelvic or abdominal pain
  • chills or shaking
  • shortness of breath
  • severe rash or suspected allergic reaction
  • persistent symptoms that are worsening rather than settling.

Severe pelvic or abdominal pain following intravesical Mitomycin is particularly important because, although uncommon, it may indicate bladder injury or extravasation.

Mitomycin does not replace surveillance

One of the most important points about NMIBC is that successful treatment does not mean surveillance can stop.

Even after apparently complete removal and intravesical chemotherapy, urothelial tumours can recur.

Depending upon the original tumour’s risk category, ongoing surveillance may include:

  • flexible cystoscopy
  • urine cytology
  • repeat TURBT
  • upper urinary tract imaging
  • further intravesical treatment.

Patients with higher-risk disease require considerably closer surveillance than those with a solitary low-grade tumour.

Mitomycin C versus BCG

These treatments are sometimes discussed together, but they work differently.

Mitomycin C is chemotherapy. It directly damages the DNA of susceptible tumour cells.

BCG is immunotherapy. It stimulates a local immune response within the bladder that attacks urothelial cancer cells.

The appropriate treatment depends upon the biological behaviour and risk category of the tumour.

For some patients, Mitomycin provides an effective and relatively well-tolerated strategy for reducing recurrence. For patients with higher-risk disease, BCG or more aggressive treatment may be preferable.

The important question is therefore not simply:

“Mitomycin or BCG?”

It is:

“What is the risk of this particular bladder cancer recurring or progressing, and which treatment provides the safest and most effective way of reducing that risk?”

The Bottom Line

Intravesical Mitomycin C is an established treatment for selected patients with non-muscle-invasive urothelial carcinoma of the bladder.

It may be used as a single treatment immediately following TURBT or as a course of intravesical chemotherapy in appropriately selected patients.

By placing chemotherapy directly into the bladder, Mitomycin can destroy residual cancer cells and reduce tumour recurrence while limiting exposure of the rest of the body.

Most side effects are related to temporary bladder irritation. Serious complications such as bladder injury, extravasation, fibrosis and tissue necrosis are uncommon but important, which is why careful patient selection and attention to precautions are essential.

And perhaps the most important message: Mitomycin reduces risk. It does not make follow-up optional.

Bladder cancer has a reputation for making return appearances, so regular cystoscopic surveillance remains an essential part of treatment.

This information is intended for general education and should not replace individual medical advice. Treatment of non-muscle-invasive bladder cancer should be tailored to the tumour’s stage, grade and recurrence/progression risk, previous treatments and the individual patient’s circumstances.

Intravesical Therapy for High-Risk Bladder Cancer

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BCG treatment, what is it?

BCG, short for Bacillus Calmette–Guérin, is one of the most effective treatments available for high-risk non-muscle-invasive bladder cancer (NMIBC).

BCG is best known as a vaccine originally developed against tuberculosis. In bladder cancer, however, it is used in a very different way. Rather than being injected as a vaccination, a solution containing BCG is placed directly into the bladder through a fine urinary catheter.

BCG is not conventional chemotherapy. It is a form of local immunotherapy. Its purpose is to stimulate the body’s immune system inside the bladder so that immune cells recognise and attack remaining bladder cancer cells.

For appropriately selected patients, BCG can significantly reduce the risk of bladder cancer returning and, importantly, reduce the risk of progression to more invasive disease.

Which bladder cancers are treated with BCG?

BCG is primarily used for high-risk or locally aggressive non-muscle-invasive urothelial carcinoma following adequate transurethral resection of the bladder tumour (TURBT).

Typical indications include:

  • Carcinoma in situ (CIS or Tis)
  • High-grade Ta urothelial carcinoma, particularly when large, multifocal or recurrent
  • High-grade T1 urothelial carcinoma
  • Recurrent high-grade non-muscle-invasive bladder cancer
  • Selected patients with multiple adverse pathological features
  • Selected patients with urothelial CIS involving the prostatic urethra as part of a bladder-preserving strategy

Current international guidelines recommend a six-week induction course of BCG for high-risk NMIBC, followed by maintenance treatment in patients who respond.

BCG is generally not required for a solitary low-risk, low-grade Ta bladder tumour. These cancers have a different biological behaviour and are usually managed with TURBT, sometimes combined with immediate intravesical chemotherapy and subsequent surveillance.

Why is BCG particularly important for carcinoma in situ?

Carcinoma in situ (CIS) deserves special attention.

Unlike the familiar papillary bladder tumour that projects into the bladder cavity, CIS can appear as a relatively flat, red or velvety abnormality of the bladder lining. Despite looking less dramatic, it is biologically aggressive.

CIS has a significant risk of recurrence and progression to muscle-invasive bladder cancer if inadequately treated. It cannot simply be “scraped away” by TURBT and forgotten.

For this reason, CIS generally requires either:

BCG immunotherapy
or, in selected very-high-risk circumstances,
radical cystectomy.

BCG produces substantially better response rates for CIS than intravesical chemotherapy in appropriate patients and has been shown to reduce the risk of progression.

How does BCG actually work?

The mechanism is fascinating because BCG does not simply poison cancer cells in the way traditional chemotherapy does.

Think of it less as dropping a bomb on the tumour and more as turning on the bladder’s local security system.

After BCG is introduced into the bladder, organisms interact with the urothelial surface and tumour cells. This produces a strong local inflammatory and immune response.

The process includes:

BCG attachment and internalisation

BCG interacts with urothelial cells, tumour cells and immune cells within the bladder.

Activation of innate immunity

Neutrophils, macrophages, dendritic cells and other immune cells are recruited into the bladder.

Cytokine release

A complex inflammatory signalling response develops, involving multiple cytokines and chemokines.

Activation of adaptive immunity

T lymphocytes and other components of the immune system become involved in recognising and destroying malignant urothelial cells.

The end result is an intentionally stimulated immune environment that makes the bladder a considerably less comfortable neighbourhood for residual cancer cells.

Before starting BCG

Successful BCG treatment starts with adequate staging and tumour clearance.

Patients will usually have undergone TURBT with pathological assessment confirming the tumour grade and stage.

In high-grade T1 disease, a repeat or second-look TURBT is frequently recommended to ensure complete resection and exclude previously unrecognised muscle-invasive disease.

Depending upon the tumour characteristics, assessment may also include:

  • Urine cytology
  • CT urography or other upper urinary tract imaging
  • Repeat cystoscopy
  • Re-resection of the original tumour site
  • Assessment of the prostatic urethra in selected patients
  • Review of pathology where variant histology or unusual findings are present

Very-high-risk cases are increasingly appropriate for multidisciplinary discussion because some patients may benefit more from early radical cystectomy than prolonged attempts at bladder preservation.

How is BCG given?

BCG is administered as an outpatient procedure.

A small catheter is gently passed through the urethra into the bladder. After the bladder has been drained, the BCG solution is instilled through the catheter.

The catheter is then removed unless there is a particular reason for it to remain temporarily.

The BCG solution is generally retained within the bladder for approximately two hours, where tolerated.

Patients receive specific instructions regarding fluid intake before treatment and safe handling of urine afterwards because BCG contains live attenuated Mycobacterium bovis.

The standard induction course

The traditional induction course consists of:

BCG once weekly for six weeks

This remains the standard initial regimen for high-risk disease.

Importantly, attempts to substantially reduce the number of induction and maintenance instillations have resulted in inferior cancer control. The six-week induction course therefore remains an important part of established treatment.

What happens after the first six treatments?

Following induction BCG, the bladder is reassessed.

This will generally involve:

  • Cystoscopy
  • Urinary cytology
  • Biopsy or repeat TURBT if an abnormality is detected
  • Additional investigation when cytology remains suspicious despite a normal-looking bladder

The key question is simple:

Has the cancer responded?

If it has, the next step is usually maintenance BCG.

Maintenance BCG

BCG works better in high-risk bladder cancer when appropriate maintenance treatment is added rather than simply giving six doses and stopping.

A widely used maintenance schedule consists of:

Induction

Once weekly × 6 weeks

followed by:

Maintenance

Once weekly × 3 weeks at:

  • 3 months
  • 6 months
  • 12 months
  • 18 months
  • 24 months
  • 30 months
  • 36 months

This is often referred to as a SWOG-style maintenance schedule.

Current European guidance recommends full-dose BCG for one to three years in high-risk disease, with the benefit of years two and three balanced against toxicity, patient tolerance and BCG availability. Three years of maintenance provides additional protection against recurrence in high-risk patients compared with one year.

Not every patient will receive every planned dose. Treatment may need to be delayed, reduced or discontinued because of side effects, infection, BCG availability or changes in the cancer.

When should BCG NOT be given?

Because BCG contains live attenuated bacteria, certain precautions are essential.

BCG should not be administered:

  • Within the first two weeks after TURBT
  • When there is visible haematuria
  • Following traumatic catheterisation
  • In the presence of a symptomatic urinary tract infection

Treatment should instead be delayed until it can be administered safely.

Additional caution is required in significantly immunocompromised patients, and individual circumstances should be discussed with the treating urologist.

Common side effects of BCG

BCG deliberately produces inflammation within the bladder, so some urinary symptoms are expected.

The most common side effects include:

Urinary frequency and urgency

Patients may feel the need to urinate frequently or suddenly.

Burning during urination

Mild-to-moderate dysuria is common for a day or two following treatment.

Blood in the urine

A small amount of haematuria can occur.

Bladder discomfort

Some patients describe suprapubic discomfort, cramping or a sensation resembling cystitis.

Flu-like symptoms

Fatigue, muscle aches, chills and a low-grade temperature can occur as the immune system responds to treatment.

These symptoms usually settle within approximately 24–48 hours.

The bladder may complain rather loudly about BCG, but mild short-lived irritation is usually part of the intended inflammatory response rather than evidence that something has gone wrong.

When should you contact your urologist?

Patients should contact their treating team if symptoms are unusually severe or fail to settle.

Particular attention should be paid to:

  • Persistent fever
  • High fever or rigors
  • Severe urinary symptoms
  • Inability to pass urine
  • Persistent or heavy haematuria
  • Significant deterioration in general wellbeing
  • Symptoms continuing substantially longer than expected

Persistent fever after BCG deserves particular attention.

Serious complications of BCG

Serious complications are uncommon, but they are important because BCG contains viable attenuated bacteria.

Potential complications include:

Severe BCG cystitis

Persistent bladder inflammation may occasionally become sufficiently troublesome that treatment needs to be delayed or discontinued.

Granulomatous prostatitis

BCG can produce an inflammatory reaction within the prostate. This can occasionally produce an abnormal prostate examination or elevated PSA and may mimic prostate cancer clinically.

Epididymo-orchitis

Rarely, BCG-related inflammation or infection can involve the epididymis or testis.

Upper urinary tract involvement

Granulomatous infection of the kidney is uncommon but recognised.

BCG infection

Localised or systemic infection with Mycobacterium bovis can occur.

BCG sepsis

This is a rare but potentially life-threatening complication.

A patient who becomes systemically unwell with persistent high fever, rigors, hypotension, respiratory symptoms or other features of sepsis following BCG requires urgent medical assessment.

Treatment may require hospital admission, infectious diseases involvement, anti-mycobacterial therapy and other supportive treatment.

BCG should therefore be respected. It is an extraordinarily useful treatment, but it is not simply another bladder wash.

What if BCG is poorly tolerated?

Treatment does not always have to proceed according to the calendar regardless of symptoms.

Depending upon severity, management can include:

  • Postponing the next instillation
  • Symptomatic treatment
  • Investigation for bacterial urinary infection
  • Assessment for BCG-related infection
  • Dose modification in selected circumstances
  • Discontinuation of BCG when toxicity becomes unacceptable

Persistent significant symptoms should be assessed rather than repeatedly giving further BCG and hoping the bladder eventually stops protesting.

What if the cancer returns after BCG?

This is one of the most important aspects of BCG treatment.

Not every recurrence after BCG means the same thing. The timing, pathology and amount of previous BCG exposure all matter.

Terms such as:

  • BCG-exposed
  • BCG-relapsing
  • BCG-refractory
  • BCG-unresponsive

describe different clinical situations.

Of these, BCG-unresponsive disease is particularly important because these tumours are unlikely to benefit from simply giving more BCG.

Current guidelines recommend radical cystectomy as the oncologically preferred treatment for appropriate patients with BCG-unresponsive high-grade disease.

When should radical cystectomy be considered?

BCG is intended to preserve the bladder, but preserving the bladder should never become more important than controlling the cancer.

Early radical cystectomy should be discussed in patients with very-high-risk features such as:

  • Persistent high-grade T1 disease
  • Recurrent high-grade disease despite adequate BCG
  • BCG-unresponsive disease
  • T1 disease associated with CIS
  • Certain variant histologies
  • Lymphovascular invasion
  • Extensive or multifocal high-grade disease
  • Other features suggesting a particularly high risk of progression

For very-high-risk NMIBC, current EAU guidance recommends discussing radical cystectomy upfront. BCG for one to three years remains an option for appropriately selected patients, particularly those who decline cystectomy or are medically unsuitable for major surgery.

Delaying cystectomy in a biologically aggressive tumour that is clearly failing BCG may compromise cancer outcomes.

Are there alternatives when BCG fails?

For patients with BCG-unresponsive disease who are unable or unwilling to undergo radical cystectomy, bladder-preserving alternatives are evolving rapidly.

Depending upon availability, tumour characteristics and local regulatory approval, options may include:

  • Sequential intravesical gemcitabine/docetaxel
  • Other intravesical chemotherapy combinations
  • Novel intravesical therapies
  • Systemic immunotherapy for selected CIS
  • Gene-based intravesical therapy in jurisdictions where available
  • Device-assisted intravesical therapy
  • Clinical trials

These treatments should not automatically be considered equivalent substitutes for radical cystectomy in a surgically fit patient with genuinely BCG-unresponsive aggressive disease. The risk of progression needs to remain at the centre of the decision.

Surveillance after BCG

BCG treatment does not eliminate the need for careful surveillance.

High-risk bladder cancer requires long-term follow-up because recurrence can occur even after an excellent initial response.

Follow-up generally involves:

Cystoscopy + urine cytology

initially at approximately 3 months, with subsequent surveillance determined by tumour risk and previous findings.

High-risk patients typically undergo frequent cystoscopy during the first two years, with gradually increasing intervals thereafter if they remain disease-free.

Periodic upper urinary tract imaging is also appropriate because high-risk urothelial carcinoma can occasionally develop within the ureters or kidneys.

Surveillance is usually long term and, for high-risk disease, often lifelong.

A practical BCG pathway

A typical pathway for high-risk non-muscle-invasive urothelial carcinoma is:

TURBT

↓

Histological confirmation of high-risk NMIBC

↓

Repeat TURBT when indicated, particularly high-grade T1 disease

↓

BCG induction: weekly × 6

↓

Cystoscopy + cytology and assessment of response

↓

If responding:

Maintenance BCG

3 weekly treatments at 3, 6 and 12 months, with continued maintenance to as long as 36 months in appropriate high-risk patients.

↓

Long-term cystoscopic surveillance

If persistent or recurrent high-grade disease:

Re-stage the bladder and determine whether the tumour represents BCG-unresponsive disease.

↓

Discuss radical cystectomy versus carefully selected bladder-preserving alternatives/clinical trials where appropriate.

The bottom line

Intravesical BCG remains a cornerstone of treatment for high-risk non-muscle-invasive urothelial carcinoma of the bladder.

Its strength lies in stimulating a powerful local immune response that reduces recurrence and helps prevent progression of aggressive superficial bladder cancer.

The usual treatment begins with six weekly instillations, followed by maintenance therapy for appropriately responding high-risk patients.

But BCG is not appropriate for every bladder tumour, and it should not be continued indefinitely when aggressive cancer is clearly failing treatment.

The most important principle is therefore not simply:

“Can we preserve the bladder?”

It is:

“Can we preserve the bladder safely without compromising cancer control?”

For patients with very-high-risk or BCG-unresponsive disease, timely discussion of radical cystectomy can be every bit as important as the BCG treatment itself.

This information is intended as general patient education and does not replace individual assessment by a urologist. BCG protocols, product availability and management of BCG-resistant disease may vary between patients and treatment centres.

Superficial Urothelial Carcinoma of the Bladder

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Understanding non-muscle-invasive bladder cancer, TURBT, intravesical therapy and long-term surveillance

Being told that you have a bladder tumour is understandably alarming. The reassuring part is that many bladder cancers are discovered while they are still confined to the inner layers of the bladder and have not invaded the bladder muscle.

This is called non-muscle-invasive bladder cancer (NMIBC), historically referred to as superficial bladder cancer. NMIBC includes Ta tumours, T1 tumours and carcinoma in situ (CIS). These tumours behave very differently depending on their stage, grade and other pathological features, so treatment is tailored according to the risk of the cancer coming back (recurrence) or becoming more aggressive (progression).

The good news is that most NMIBC can initially be treated through the urethra without making an incision in the abdomen. The less convenient news is that bladder cancer has a habit of returning, which is why careful surveillance becomes an important part of treatment.

What is urothelial carcinoma?

The inside of the bladder is lined by specialised cells called urothelial cells. Cancer arising from these cells is known as urothelial carcinoma.

Urothelial carcinoma can develop anywhere along the urinary tract, including the:

  • renal collecting system
  • ureters
  • bladder
  • urethra

The bladder is by far the most common site.

When a bladder tumour has not invaded the muscular wall of the bladder, it is classified as non-muscle-invasive bladder cancer.

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What causes bladder cancer?

There is rarely one identifiable cause. Instead, bladder cancer develops following genetic changes within urothelial cells, often influenced by environmental exposures over many years.

Smoking

Cigarette smoking is the most important preventable risk factor for bladder cancer.

Chemicals absorbed through cigarette smoke enter the bloodstream, are filtered by the kidneys and eventually become concentrated in the urine. The bladder lining is therefore repeatedly exposed to these carcinogens.

Stopping smoking after a bladder cancer diagnosis is strongly encouraged.

Other risk factors

These include:

  • increasing age
  • occupational exposure to certain industrial chemicals
  • previous pelvic radiotherapy
  • previous treatment with cyclophosphamide
  • chronic urinary tract irritation in selected circumstances
  • a personal history of urothelial carcinoma

Sometimes there is no obvious risk factor at all.

How does bladder cancer present?

Blood in the urine

The classic presentation is haematuria, or blood in the urine.

This may be:

Visible haematuria

The urine may suddenly become:

  • pink
  • red
  • burgundy
  • tea-coloured
  • or contain blood clots

Importantly, bleeding from a bladder tumour is frequently painless and intermittent.

The bleeding may disappear completely for days, weeks or even months. Its disappearance does not necessarily mean that the underlying problem has resolved.

Unexplained visible haematuria should always be investigated.

Microscopic haematuria

Sometimes blood is detected only on urine testing and cannot be seen with the naked eye.

Other possible symptoms

Some patients, particularly those with carcinoma in situ (CIS), may experience bladder irritation rather than obvious bleeding.

Symptoms can include:

  • urinary frequency
  • urgency
  • burning when passing urine
  • nocturia
  • pelvic or bladder discomfort
  • recurrent symptoms resembling a urinary tract infection

Persistent urinary symptoms with repeatedly negative urine cultures may therefore warrant further investigation.

Investigating suspected bladder cancer

The investigation usually involves a combination of urine testing, imaging and direct examination of the bladder.

Urine testing

A urine sample may be checked for:

  • blood
  • infection
  • inflammatory cells
  • abnormal malignant cells

Urine cytology

Urine cytology examines cells shed from the urinary tract under a microscope.

It is particularly useful for detecting high-grade urothelial carcinoma and CIS, but is considerably less sensitive for low-grade tumours.

A negative cytology therefore does not exclude bladder cancer.

Imaging the urinary tract

Patients with haematuria may require imaging of the kidneys, ureters and bladder.

Depending on the clinical circumstances, this may include:

  • renal tract ultrasound
  • CT urinary tract imaging
  • CT urography

CT urography is particularly useful when investigating haematuria because urothelial carcinoma can occasionally arise within the renal collecting system or ureters as well as the bladder.

Cystoscopy

A cystoscopy allows the urologist to look directly inside the bladder.

A thin flexible telescope is passed through the urethra, usually under local anaesthetic.

Most bladder tumours have a characteristic appearance. They may resemble delicate fronds, seaweed or a tiny underwater cauliflower attached to the bladder wall.

Flat lesions such as CIS can be much more difficult to see.

If a suspicious lesion is identified, the next step is usually a transurethral resection of bladder tumour (TURBT).

TURBT: biopsy and removal of the bladder tumour

TURBT stands for:

Transurethral Resection of Bladder Tumour

This procedure serves two important purposes:

  1. Treatment: removing all visible tumour where possible.
  2. Diagnosis and staging: providing tissue for the pathologist to determine exactly what type of tumour is present and how deeply it has invaded.

The procedure is usually performed under general or spinal anaesthesia.

A telescope called a resectoscope is passed through the urethra into the bladder. The tumour is carefully removed, usually using an electrical or bipolar resection system.

There is therefore generally no external incision or abdominal scar.

Why obtaining bladder muscle matters

An adequate TURBT should establish how deeply the tumour extends.

For many tumours, particularly T1 and high-grade lesions, the specimen should contain muscularis propria (detrusor muscle) so that the pathologist can determine whether the cancer has reached the muscle layer. The pathological report should document the presence and involvement of muscularis propria where applicable.

This distinction dramatically changes treatment.

Understanding bladder cancer staging

A simplified view of the bladder wall is:

Urine

↓

Urothelium

↓

Lamina propria

↓

Detrusor muscle

↓

Fat surrounding the bladder

The important early stages are:

Ta

The tumour is confined to the urothelial surface and has not invaded the supporting tissue underneath.

Tis: carcinoma in situ

CIS is a flat, high-grade malignant lesion confined to the urothelium.

Unlike the typical papillary bladder tumour, CIS may be difficult to identify visually.

Despite being superficial anatomically, CIS is biologically aggressive and requires appropriate treatment.

T1

The tumour has invaded into the lamina propria, but has not invaded the muscularis propria.

T1 disease, particularly high-grade T1 disease, carries a greater risk of recurrence and progression.

T2

The cancer has invaded the bladder muscle.

Once muscle invasion is identified, the disease is no longer classified as NMIBC and requires a different treatment pathway.

Stage and grade are not the same thing

This distinction frequently causes confusion.

Stage describes how deeply the cancer has travelled into the bladder wall.

Grade describes how abnormal and biologically aggressive the cancer cells appear under the microscope.

A tumour may therefore be superficial but still be high grade.

Broadly, urothelial tumours are classified as:

Low grade

These generally grow more slowly and have a relatively low risk of progressing to muscle-invasive cancer, although they may recur.

High grade

These cells look significantly abnormal and have a greater potential for:

  • recurrence
  • invasion
  • progression
  • spread beyond the bladder

Risk stratification

Following TURBT, the tumour is classified into a risk category.

Risk assessment considers factors such as:

  • stage
  • grade
  • tumour size
  • number of tumours
  • previous recurrence rate
  • presence of CIS
  • T1 disease
  • pathological features including lymphovascular invasion
  • certain variant histological subtypes

This classification helps determine whether the patient requires:

TURBT alone → intravesical chemotherapy → BCG → or, in selected very-high-risk situations, consideration of radical cystectomy.

Modern guidelines emphasise risk-adapted rather than one-size-fits-all management.

Do I need another TURBT?

Sometimes.

A second-look or re-staging TURBT may be recommended when:

  • the initial tumour was incompletely removed
  • adequate muscle was not present in an important specimen
  • high-grade disease is present in selected circumstances
  • T1 disease is identified
  • there is concern that the original tumour may have been understaged
  • certain variant histologies are identified

The aim is to ensure that residual tumour has not been left behind and, crucially, that muscle-invasive disease has not been missed.

Intravesical treatment

Intravesical simply means that medication is placed directly into the bladder through a catheter.

This allows the treatment to come into direct contact with the bladder lining while reducing systemic exposure compared with intravenous chemotherapy.

Two important treatments are:

Mitomycin C

and

BCG

They are not interchangeable and are used for different risk groups.

Intravesical Mitomycin C

Mitomycin C is a chemotherapy drug that can be placed directly into the bladder.

Immediate Mitomycin C following TURBT

For appropriate patients with suspected low- or intermediate-risk NMIBC, a single postoperative instillation of intravesical chemotherapy may be given soon after TURBT.

Current guidelines recommend that, when used, the immediate instillation should generally occur within 24 hours of TURBT.

Its purpose is to destroy microscopic tumour cells remaining in the bladder and tumour cells released during the resection.

This reduces the risk of recurrence.

When should immediate Mitomycin C be avoided?

It should generally not be administered if there is:

  • suspected bladder perforation
  • significant bleeding requiring bladder irrigation
  • an extensive or very deep resection where perforation is a concern

This is important because chemotherapy leaking outside the bladder can cause significant local tissue injury.

Further courses of intravesical chemotherapy

Selected patients with recurrent or intermediate-risk low-grade NMIBC may receive a course of intravesical chemotherapy rather than simply a single postoperative dose.

The exact drug, schedule and duration depend upon the tumour risk profile and local treatment protocols.

Side effects of intravesical Mitomycin C

Most patients tolerate treatment reasonably well.

Possible side effects include:

  • urinary frequency
  • urgency
  • burning
  • bladder discomfort
  • haematuria
  • chemical cystitis
  • skin irritation if the medication contacts the genital skin

Rarely, severe bladder inflammation or tissue injury can occur.

Intravesical BCG

BCG stands for Bacillus Calmette-Guérin.

Yes, it originated as a tuberculosis vaccine. In the bladder it performs a completely different job.

BCG stimulates a powerful local immune response against urothelial cancer cells and remains one of the most effective bladder-preserving treatments for high-risk NMIBC.

Who should receive BCG?

BCG is principally considered for patients with:

  • high-grade Ta tumours
  • high-grade T1 tumours
  • carcinoma in situ
  • other appropriately selected high-risk or intermediate-risk NMIBC

For high-risk NMIBC, full-dose BCG with maintenance treatment for one to three years remains a guideline-supported treatment, while immediate radical cystectomy should also be discussed in appropriate high-risk and particularly very-high-risk disease.

How is BCG given?

BCG is inserted into the bladder through a small catheter.

A typical induction course consists of:

One treatment per week for six weeks.

The solution is retained within the bladder for a prescribed period and then passed out in the urine.

Patients who respond may subsequently receive maintenance BCG.

A commonly used maintenance approach involves three weekly treatments at defined intervals after induction. In high-risk disease, guideline schedules may continue maintenance for up to three years depending upon tumour risk, treatment tolerance and BCG availability.

When should BCG not be given?

BCG is a live attenuated organism and must be administered carefully.

Treatment should generally be postponed in patients with:

  • visible haematuria
  • symptomatic urinary tract infection
  • traumatic catheterisation
  • very recent TURBT

The EAU lists the first two weeks following TURBT, visible haematuria, traumatic catheterisation and symptomatic urinary infection as absolute contraindications to an intravesical BCG instillation.

Side effects of BCG

A degree of bladder irritation is common.

Patients may experience:

  • frequency
  • urgency
  • burning
  • bladder discomfort
  • mild haematuria
  • fatigue
  • low-grade fever
  • flu-like symptoms

These symptoms usually settle.

Rarely, BCG can cause a more significant systemic infection or inflammatory reaction.

Persistent high fever, chills, marked deterioration or severe illness following BCG requires urgent medical assessment.

What if BCG does not work?

Persistent or recurrent high-grade cancer despite adequate BCG treatment requires careful reassessment.

This situation should not simply be managed by repeatedly giving more BCG indefinitely.

Patients meeting criteria for BCG-unresponsive NMIBC should be counselled regarding further treatment, and radical cystectomy remains the oncological standard for suitable patients with BCG-unresponsive high-risk disease. Bladder-preserving alternatives may be considered for patients who are medically unsuitable for cystectomy or decline surgery, ideally within appropriate specialist or clinical-trial pathways.

When should radical cystectomy be considered?

Most patients with superficial bladder cancer will never require removal of their bladder.

However, early radical cystectomy may be discussed for very-high-risk disease, including selected patients with:

  • aggressive high-grade T1 disease
  • associated CIS
  • variant histology
  • lymphovascular invasion
  • persistent high-grade disease
  • BCG-unresponsive disease
  • other features associated with a high risk of progression

The decision involves balancing the risks of major surgery against the danger of allowing biologically aggressive disease to progress.

Surveillance after treatment

Removing the tumour is only the first chapter.

NMIBC has a significant tendency to recur, and some high-risk tumours can progress. Consequently, regular cystoscopic surveillance is essential.

The first surveillance cystoscopy is generally performed approximately three months after TURBT.

After this, surveillance is tailored to the patient’s risk category.

A practical risk-adapted surveillance framework

Risk group Typical cystoscopy schedule Cytology Upper tract imaging
Low risk 3 months, 12 months, then annually Usually not routinely required Not routinely required
Intermediate risk 3 months, then approximately every 6 months for 2 years, then annually Risk-dependent Selected patients
High / very high risk Approximately every 3 months initially, with intervals gradually extended Usually included Periodic upper urinary tract imaging

The 2026 EAU guidance continues to recommend that follow-up intensity and duration be determined by the patient’s risk category, with the first cystoscopy at three months.

Individual surveillance schedules may differ depending on pathology, previous recurrences, treatment response, age, comorbidities and the treating urologist’s protocol.

Why is surveillance so important?

A recurrence does not automatically mean that treatment has failed or that the cancer has become life-threatening.

Low-grade papillary tumours may recur while remaining superficial and biologically low risk.

The purpose of surveillance is to identify recurrence early, while it can still be treated appropriately.

High-grade disease requires closer attention because the consequences of missing progression are considerably greater.

Can bladder cancer come back after years?

Yes.

This is why follow-up for intermediate- and particularly high-risk NMIBC can continue for many years.

The frequency of cystoscopy usually decreases when repeated examinations remain clear, but high-risk patients generally require prolonged surveillance.

What can I do after a diagnosis?

One of the most important modifiable factors is:

Stop smoking

Smoking cessation reduces exposure to the carcinogens responsible for many urothelial cancers and provides substantial additional cardiovascular, respiratory and general health benefits.

Patients should also:

  • attend every scheduled cystoscopy
  • report recurrent visible haematuria
  • complete prescribed intravesical treatment
  • report significant side effects from BCG or chemotherapy
  • maintain appropriate hydration unless medically restricted
  • discuss occupational chemical exposure where relevant

The bottom line

Non-muscle-invasive urothelial carcinoma is bladder cancer that has not invaded the muscular wall of the bladder.

The pathway typically involves:

Haematuria or urinary symptoms
↓
Urine tests + imaging
↓
Cystoscopy
↓
TURBT and pathological examination
↓
Stage + grade + risk classification
↓
Risk-adapted treatment

For some patients, TURBT followed by surveillance may be sufficient.

Others benefit from intravesical Mitomycin C or another intravesical chemotherapy to reduce recurrence.

Patients with high-grade disease, T1 cancer or CIS frequently require intravesical BCG, usually incorporating induction and maintenance treatment.

Very-high-risk or BCG-unresponsive disease may require consideration of radical cystectomy.

Most importantly, bladder cancer treatment does not finish when the initial tumour has been removed. Long-term cystoscopic surveillance is an integral part of treatment.

A final word

Bladder cancer can be a persistent visitor, but surveillance means we do not leave the front door unattended.

Early detection, complete TURBT, accurate pathological staging, appropriate intravesical therapy and structured follow-up provide the best opportunity to keep non-muscle-invasive bladder cancer under control.

This information is intended as general patient education and does not replace individual assessment or treatment advice from your urologist. Management should be tailored to the pathology, tumour risk category, general health and individual circumstances of each patient.

Urodynamic Studies: Understanding How Your Bladder Works

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Bladder problems are not always as straightforward as they appear.

Two people may both complain of urinary urgency, leakage or difficulty emptying their bladder, yet the underlying causes can be completely different. One bladder may be contracting when it should be relaxing, another may not contract strongly enough, and sometimes the bladder is behaving perfectly well while the outlet is causing all the trouble.

This is where urodynamic studies, often simply called urodynamics, can help.

Think of urodynamics as a stress test for the bladder. Rather than simply looking at its anatomy, we observe how the bladder fills, stores urine and empties while simultaneously measuring pressures, urine flow and sometimes pelvic floor activity.

The aim is not merely to produce a collection of colourful graphs. The important question is:

What is the bladder actually doing, and will knowing this change the treatment?

What Are Urodynamic Studies?

Urodynamics refers to a group of tests that assess the function of the bladder, urethra and urinary sphincter.

Depending on the clinical situation, testing may evaluate:

  • How much urine the bladder can comfortably hold
  • Bladder sensation during filling
  • Whether the bladder remains relaxed while filling
  • Whether involuntary bladder contractions occur
  • Whether urinary leakage occurs and why
  • The pressure required to store urine
  • The strength of the bladder muscle during urination
  • Whether there is obstruction to urinary flow
  • Whether the bladder empties completely
  • How the urinary sphincter and pelvic floor behave during filling and voiding

Urodynamics therefore investigates function rather than simply structure.

An ultrasound or cystoscopy may show us what the urinary tract looks like. Urodynamics tells us what it is doing.

Who May Need Urodynamic Testing?

Not every patient with urinary symptoms requires urodynamics.

For many straightforward urinary problems, the diagnosis can be made from the history, examination, bladder diary, urine testing, flow studies and ultrasound.

Urodynamics becomes particularly useful when the diagnosis is uncertain, symptoms are complex, previous treatments have failed, neurological disease is present, or an invasive treatment is being considered where understanding bladder function may alter the choice of treatment.

Common indications include:

Urinary Incontinence

Urodynamics may be useful when assessing:

  • Stress urinary incontinence
  • Urgency urinary incontinence
  • Mixed urinary incontinence
  • Persistent leakage following previous continence surgery
  • Incontinence following prostate surgery
  • Complex or unexplained urinary leakage

In straightforward female stress urinary incontinence, urodynamics is not necessarily required before treatment. It becomes more useful when symptoms and clinical findings do not agree or when there are complicating factors.

Overactive Bladder

Patients with overactive bladder may experience:

  • Urinary urgency
  • Frequent urination
  • Nocturia
  • Urgency urinary incontinence

Urodynamics can sometimes demonstrate detrusor overactivity, where the bladder muscle contracts involuntarily during filling.

Importantly, a normal urodynamic study does not necessarily exclude overactive bladder. Symptoms and urodynamic findings do not always travel together.

Difficulty Emptying the Bladder

Patients may report:

  • Poor urinary flow
  • Hesitancy
  • Straining
  • Intermittent flow
  • Incomplete emptying
  • Urinary retention

The challenge is determining why.

Is there an obstruction?

Or is the bladder muscle simply not contracting strongly enough?

The symptoms can look remarkably similar, but the treatments can be very different.

Men With Lower Urinary Tract Symptoms

In men with prostate enlargement, urodynamics may help distinguish between:

Bladder outlet obstruction

and

Detrusor underactivity, where the bladder muscle has insufficient strength to empty effectively.

This distinction may be particularly valuable before prostate surgery when there is uncertainty about whether removing the obstruction will improve urinary flow.

Neurological Bladder Dysfunction

Urodynamics has an especially important role in patients with neurological conditions such as:

  • Spinal cord injury
  • Multiple sclerosis
  • Parkinson’s disease
  • Spina bifida
  • Stroke
  • Certain spinal disorders

In these patients, we are interested not only in urinary symptoms but also in whether bladder pressures could potentially damage the kidneys.

Before or After Certain Urinary Procedures

Urodynamics may also be considered:

  • Before complex continence surgery
  • Following unsuccessful continence surgery
  • Before some bladder outlet procedures
  • Following prostate surgery when symptoms persist
  • When considering treatments such as bladder Botox or sacral neuromodulation in selected complex patients

What Happens During a Urodynamic Study?

The test is usually performed as an outpatient procedure.

It generally takes approximately 30–60 minutes, although this varies depending on the type of study being performed.

You can usually eat, drink and take your normal medications unless specifically instructed otherwise.

Step 1: Arriving With a Comfortably Full Bladder

You may be asked to arrive with a reasonably full bladder.

You will urinate into a special toilet called a uroflowmeter.

This measures:

  • Urine volume
  • Maximum urinary flow rate
  • Average flow rate
  • The shape of the urinary flow curve
  • How long urination takes

An ultrasound may then measure how much urine remains in the bladder.

This is called the post-void residual.

Step 2: Placement of Small Catheters

A very fine catheter is gently passed through the urethra into the bladder.

A second small pressure catheter is usually placed into the rectum, or occasionally the vagina.

Why two pressure measurements?

Because pressure inside the abdomen affects pressure inside the bladder.

By measuring both, the computer can calculate the pressure generated specifically by the bladder muscle:

Detrusor pressure = bladder pressure − abdominal pressure

This simple equation sits at the heart of conventional urodynamics.

Step 3: Filling the Bladder

The bladder is slowly filled with sterile fluid.

During filling, you will be asked to describe what you feel.

We may record:

  • First sensation of bladder filling
  • First desire to urinate
  • Strong desire to urinate
  • Maximum bladder capacity

The pressure inside the bladder is continuously monitored.

Normal filling cystometrogram

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4

Normal filling cystometrogram. During filling, the bladder accommodates increasing volume while detrusor pressure (Pdet) remains relatively stable. Coughs cause corresponding rises in Pves and Pabd without a true detrusor contraction. Sensations such as first sensation, first desire and strong desire can be marked on the tracing.

 

Step 4: Provocative Testing

You may be asked to:

  • Cough
  • Strain
  • Stand
  • Change position
  • Listen to running water

These manoeuvres are not designed to make the test unnecessarily theatrical. They help reproduce the circumstances under which your symptoms normally occur.

If urinary leakage occurs during coughing without an involuntary bladder contraction, this may demonstrate urodynamic stress incontinence.

Step 5: Voiding

Once the bladder is comfortably full, you will be asked to urinate.

During urination we simultaneously measure:

  • Urinary flow
  • Bladder pressure
  • Abdominal pressure
  • Detrusor pressure

This is called a pressure-flow study.

It can be extremely useful when determining whether poor urinary flow is caused by obstruction or weak bladder contraction.

What Does Urodynamics Measure?

Bladder Sensation

We assess when you first become aware that the bladder is filling and when the desire to urinate becomes stronger.

Sensation may be:

  • Normal
  • Increased
  • Reduced
  • Absent

Abnormal bladder sensation may occur in several neurological and functional bladder disorders.

Bladder Capacity

The amount of urine the bladder can comfortably hold is measured.

A small functional capacity may occur with conditions such as severe urgency or bladder hypersensitivity, although capacity must always be interpreted in clinical context.

Bladder Compliance

A healthy bladder should behave rather like a flexible reservoir.

As it fills, its volume should increase without a major rise in pressure.

Poor bladder compliance means pressure rises excessively as the bladder fills.

This is particularly important in some neurological bladder disorders because persistently elevated storage pressures can potentially threaten the upper urinary tract.

Detrusor Overactivity

If the bladder muscle contracts involuntarily during filling, this is called:

Detrusor overactivity.

It may be associated with:

  • Urgency
  • Urgency incontinence
  • Frequency
  • Nocturia

When associated with an underlying neurological condition, it may be described as neurogenic detrusor overactivity.

Examples of terminal, phasic, wet and dry detrusor overactivity.

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Detrusor overactivity. During bladder filling there is an involuntary increase in Pdet that cannot be explained by a corresponding increase in abdominal pressure. The contraction may be associated with urgency and, when leakage occurs, urgency urinary incontinence.

View the LABORIE-based detrusor-overactivity tracings

Stress Urinary Incontinence

If urine leaks when coughing or straining without a detrusor contraction, this supports a diagnosis of:

Urodynamic stress incontinence.

Additional measurements such as leak-point pressures may occasionally contribute to assessment in selected patients.

Bladder Outlet Obstruction

During urination, a pattern of:

High bladder pressure + low urinary flow

may suggest obstruction.

In men, benign prostate enlargement is a common cause.

Other causes include:

  • Urethral stricture
  • Bladder neck obstruction
  • Previous continence surgery
  • Dysfunctional voiding

Bladder outlet obstruction: pressure-flow study

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Bladder outlet obstruction. During voiding the bladder generates a relatively high detrusor pressure, but urinary flow remains reduced. This high-pressure, low-flow relationship is characteristic of increased bladder outlet resistance.

In men, pressure-flow studies allow calculation of the Bladder Outlet Obstruction Index (BOOI):

BOOI = PdetQmax − 2(Qmax)

For men, BOOI >40 is generally classified as obstructed, 20–40 as equivocal and <20 as unobstructed.

Detrusor Underactivity

Sometimes the urinary flow is poor because the bladder muscle does not generate sufficient pressure.

This is known as:

Detrusor underactivity.

This distinction matters.

Operating on the prostate of a patient whose main problem is a very weak bladder may not produce the expected improvement in urinary flow.

Urodynamics can therefore occasionally prevent us from treating the wrong end of the plumbing.

Dysfunctional Voiding

Some patients involuntarily contract their pelvic floor or urinary sphincter while attempting to urinate.

Instead of the outlet opening smoothly, it intermittently closes.

Pelvic floor electromyography may help identify this pattern in selected patients.

Understanding the Urodynamic Tracing

A urodynamic report typically contains several pressure and flow curves.

At first glance, the tracing can resemble an enthusiastic seismograph.

The important measurements usually include:

Pves: pressure measured inside the bladder.

Pabd: pressure measured within the abdomen.

Pdet: pressure generated by the bladder muscle.

Flow: the rate at which urine leaves the bladder.

The relationship between these measurements allows us to understand what is happening during bladder filling and emptying.

Common Findings and What They May Mean for Treatment

Urodynamic Finding Possible Interpretation Potential Treatment Direction
Normal storage and emptying Normal urodynamic study Treatment guided by symptoms and other investigations
Detrusor overactivity Overactive bladder physiology Bladder training, medication, Botox, neuromodulation
Stress leakage Stress urinary incontinence Pelvic floor therapy, bulking agents, sling or other continence surgery
High pressure + low flow Bladder outlet obstruction Treatment of obstruction where appropriate
Low pressure + low flow Detrusor underactivity Emptying strategies, intermittent catheterisation or selected treatments
Poor compliance High-pressure storage Pressure-reducing treatment and upper urinary tract surveillance
Pelvic floor activation during voiding Dysfunctional voiding Pelvic floor physiotherapy/biofeedback
Significant residual urine Incomplete bladder emptying Identify obstruction versus impaired bladder contraction

The urodynamic result is not a treatment plan by itself.

It must be interpreted alongside symptoms, examination findings, bladder diaries, ultrasound, cystoscopy and other investigations where appropriate.

How Urodynamics Can Guide Treatment

If Detrusor Overactivity Is Found

Initial treatment may include:

  • Bladder training
  • Fluid modification
  • Pelvic floor physiotherapy
  • Antimuscarinic medication
  • Beta-3 agonist medication

For persistent symptoms, options may include:

  • Intravesical Botox injections
  • Sacral neuromodulation
  • Other specialist treatments in selected patients

If Stress Incontinence Is Demonstrated

Treatment depends on severity, sex, previous surgery and individual circumstances.

Options may include:

  • Pelvic floor rehabilitation
  • Continence devices
  • Peri-urethral bulking agents
  • Sling procedures
  • Colposuspension in selected women
  • Male sling following prostate surgery
  • Artificial urinary sphincter in appropriate men

If Bladder Outlet Obstruction Is Demonstrated

Treatment depends on the underlying cause.

For benign prostate enlargement, options may include:

  • Medication
  • Minimally invasive prostate treatments
  • Laser prostate surgery
  • Transurethral prostate surgery
  • Other surgical procedures appropriate to prostate size and anatomy

A urethral stricture or bladder neck obstruction requires a different treatment strategy.

If the Bladder Muscle Is Weak

Treatment may involve:

  • Double voiding
  • Timed voiding
  • Reviewing medications
  • Treating reversible causes
  • Intermittent self-catheterisation when necessary
  • Long-term catheterisation in selected circumstances
  • Sacral neuromodulation in carefully selected patients with non-obstructive urinary retention

The key issue is avoiding unnecessary outlet surgery when obstruction is not actually the problem.

If Bladder Storage Pressures Are High

This is particularly important in neurological bladder disease.

Treatment may include:

  • Medication
  • Intermittent catheterisation
  • Intravesical Botox
  • Regular renal imaging
  • Monitoring kidney function
  • Repeat urodynamic assessment
  • Reconstructive bladder surgery in uncommon severe cases

Here the objective extends beyond improving symptoms. We may also be trying to protect kidney function over the long term.

Are Urodynamic Studies Uncomfortable?

Most patients tolerate the investigation well.

Passing the small catheter can cause brief discomfort, and there may be some mild burning when urinating afterwards.

Having an audience while your bladder performs under laboratory conditions is admittedly not anyone’s preferred afternoon entertainment, but the clinical staff performing these studies do this routinely and will make the process as private and comfortable as possible.

Possible Side Effects and Complications

Urodynamic testing is generally safe.

Possible side effects include:

  • Temporary burning during urination
  • Urinary urgency
  • Minor urethral discomfort
  • A small amount of blood in the urine
  • Urinary tract infection
  • Temporary difficulty urinating

Significant complications are uncommon.

Patients should seek medical advice if they develop fever, chills, worsening urinary symptoms, significant bleeding or an inability to urinate following the test.

Does Everyone With Bladder Symptoms Need Urodynamics?

No.

This is an important point.

Urodynamics should generally be performed when the result is likely to answer a clinically relevant question or potentially alter management.

The investigation is particularly valuable when:

  • Symptoms are complex
  • The diagnosis remains uncertain
  • Symptoms and examination findings disagree
  • Previous treatment has failed
  • Neurological bladder dysfunction is suspected
  • There is significant urinary retention
  • Complex surgery is being considered
  • Understanding bladder pressure or contractility could change treatment

Testing simply because “we haven’t done one yet” is not a particularly compelling indication.

Urodynamics: Turning Symptoms Into Physiology

Patients often arrive describing urgency, leakage, poor flow or difficulty emptying their bladder.

These symptoms tell us what is happening.

Urodynamics can sometimes tell us why.

By measuring how the bladder stores and releases urine, we can distinguish between problems involving the bladder muscle, urinary sphincter, pelvic floor and bladder outlet.

Most importantly, urodynamics can help ensure that treatment is directed at the underlying problem rather than simply the symptom.

The Bottom Line

Urodynamics is not necessary for every bladder problem. But when the diagnosis is uncertain or treatment decisions depend on understanding bladder function, it can provide exceptionally useful information.

A good urodynamic study does more than generate graphs.

It helps answer the question that matters most:

What treatment is most likely to work for this particular bladder?

This information is intended for general patient education and does not replace individual medical assessment. The need for urodynamic testing and interpretation of results should be discussed with your treating urologist or continence specialist.

The Long Foreskin: When a Little Extra Skin Is Just… Extra

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Foreskins come in all shapes and sizes. Some are short, some sit neatly over the tip of the penis, and others extend well beyond the glans, occasionally giving the penis the appearance that it has ordered the extra-long sleeve option.

A long foreskin, sometimes described medically as a redundant or elongated prepuce, is usually simply a normal anatomical variation. Length alone is not a disease and does not automatically require treatment.

The important question is not “How long is it?” but rather:

Does it cause any problems?

What is a long or redundant foreskin?

The foreskin, or prepuce, is the fold of skin covering the glans (head) of the penis. Its length varies considerably between men.

In some men, the foreskin extends only slightly beyond the glans when the penis is flaccid. In others, there may be a considerable amount of skin extending beyond the tip.

The appearance can also change substantially between the flaccid and erect states. A foreskin that looks impressively generous when flaccid may retract quite normally during an erection.

There is therefore no particular measurement at which a foreskin suddenly becomes “too long.”

If it retracts comfortably, causes no symptoms and can be kept clean, there is generally no medical reason to shorten it.

Can a very long foreskin cause problems?

Most men with a long foreskin have no problems whatsoever.

Occasionally, however, additional foreskin can contribute to several issues.

Hygiene

A longer foreskin may make cleaning beneath the foreskin slightly more important.

Smegma, dead skin cells and moisture can accumulate underneath the foreskin if it is not regularly retracted and washed. This may produce irritation or an unpleasant smell.

Fortunately, the solution is usually wonderfully low-tech: water, gentle washing and regular hygiene.

Aggressive scrubbing, strong soaps, antiseptics and fragranced products can actually irritate this rather sensitive real estate.

Recurrent balanitis

Balanitis is inflammation of the glans. When both the glans and foreskin are inflamed, the condition is called balanoposthitis.

Symptoms may include:

  • Redness
  • Swelling
  • Itching or burning
  • Discomfort
  • Discharge
  • Unpleasant odour
  • Difficulty retracting the foreskin

Recurrent inflammation deserves assessment because there may be an underlying cause such as infection, dermatitis, diabetes or a chronic inflammatory skin condition.

Difficulty retracting the foreskin

A long foreskin and a tight foreskin are not the same thing.

A very long foreskin that retracts easily is generally harmless. If the opening is too narrow to retract comfortably over the glans, however, this is phimosis.

Phimosis can cause discomfort, recurrent infections, painful erections or difficulty with sexual activity.

Paraphimosis

Occasionally a tight foreskin is pulled behind the glans and becomes trapped there. The foreskin swells and cannot be returned to its normal position.

This is called paraphimosis.

Unlike having a long foreskin, paraphimosis is not merely an interesting anatomical conversation starter. It can compromise blood flow to the glans and requires urgent medical attention.

Problems during sex

Some men with considerable redundant foreskin notice excessive movement or bunching of the skin during intercourse.

Others experience:

  • Irritation
  • Small tears
  • Discomfort
  • Difficulty using condoms
  • Foreskin becoming trapped behind the glans
  • Problems associated with an accompanying short frenulum

Importantly, many men with long foreskins have completely normal and comfortable sexual function.

Urination

A long foreskin may occasionally balloon during urination or cause the urinary stream to spray.

A little post-urination dribbling from urine retained beneath a long foreskin can also occur.

If the foreskin opening is normal and there are no other symptoms, this is often more inconvenient than medically significant. Persistent ballooning associated with a very narrow opening, pain or difficulty passing urine should be assessed.

Does a long foreskin increase the risk of cancer?

Having a long foreskin by itself does not mean that a man will develop penile cancer.

Penile cancer is uncommon, particularly in Australia. Important risk factors include persistent HPV infection, smoking, chronic inflammation and certain foreskin disorders such as lichen sclerosus.

Any persistent penile ulcer, lump, thickened area, bleeding lesion, unusual discharge or change in the skin should therefore be examined rather than waiting for it to disappear.

The penis, regrettably, has never been particularly good at diagnosing itself.

Does a long foreskin need treatment?

Usually, no.

If the foreskin:

  • Retracts comfortably
  • Can be cleaned easily
  • Does not cause recurrent infections
  • Does not interfere with urination
  • Does not cause pain during erections or intercourse
  • Does not bother the patient cosmetically

then no treatment is required.

The medical principle here is refreshingly simple:

If it isn’t causing a problem, there may be nothing to fix.

Conservative management

When symptoms are minor, treatment may involve improving foreskin hygiene and treating any underlying inflammation or infection.

Where there is associated mild phimosis, a doctor may recommend a course of topical corticosteroid cream combined with gentle stretching.

Forceful stretching should be avoided. Small tears can produce scarring, and scarring can make the foreskin progressively tighter, turning a relatively minor problem into a considerably more stubborn one.

Surgical options

Surgery may be considered when there are significant or recurrent problems.

Circumcision

Circumcision removes the foreskin and permanently exposes the glans.

It is a reliable treatment for recurrent balanitis, troublesome phimosis and certain chronic foreskin diseases.

Potential complications include bleeding, infection, altered sensation, cosmetic dissatisfaction, wound problems and, rarely, more significant complications.

Foreskin-preserving surgery

Not every foreskin problem requires complete circumcision.

Depending upon the anatomy and underlying problem, procedures such as preputioplasty can widen a tight foreskin while preserving much of the foreskin.

In selected men with excessive redundant skin but an otherwise healthy foreskin, surgical shortening may also be discussed.

The appropriate operation depends upon the reason for treatment rather than simply the number of centimetres of foreskin involved.

What about appearance?

Some men simply dislike having a long foreskin.

That is a legitimate concern to discuss with a urologist, but cosmetic surgery deserves careful consideration because surgery permanently changes normal anatomy.

It is particularly important to distinguish between a genuinely troublesome anatomical issue and anxiety created by comparisons with pornography, photographs or other men.

There is an enormous range of normal penile anatomy.

Normal does not come in one factory setting.

When should you see a urologist?

Consider seeking medical advice if you have recurrent infections, difficulty retracting or replacing the foreskin, painful erections, tearing or bleeding, problems during intercourse, difficulty passing urine, persistent skin changes or simply uncertainty about whether your foreskin is normal.

A foreskin that suddenly becomes swollen and trapped behind the glans requires urgent assessment, particularly if the glans becomes increasingly swollen, painful or discoloured.

The bottom line

A very long foreskin is usually a variation of normal anatomy rather than a medical condition.

There is no prize for having the shortest foreskin, and fortunately no excess-baggage fee for having the longest.

What matters is function.

If your foreskin retracts normally, stays healthy, allows comfortable erections and intercourse, and can be kept clean, its length alone is unlikely to require treatment.

If it becomes tight, painful, repeatedly inflamed or simply troublesome, however, a urological assessment can determine whether conservative treatment or surgery is appropriate.

When it comes to foreskins, longer isn’t necessarily better or worse. Sometimes it is simply… longer.

Vasectomy: A Guide to Permanent Male Contraception

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

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

What Happens During a Vasectomy?

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

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

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

Who Should Consider a Vasectomy?

Vasectomy may be appropriate for men who:

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

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

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

How Is Vasectomy Performed?

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

A conventional or no-scalpel technique may be used.

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

The procedure generally takes approximately 15–30 minutes.

Patients are usually able to return home shortly afterwards.

What Should I Expect After the Procedure?

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

Simple measures can help recovery, including:

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

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

Vasectomy Does Not Work Immediately

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

A man is not sterile immediately after the procedure.

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

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

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

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

How Effective Is Vasectomy?

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

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

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

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

Does Vasectomy Affect Testosterone?

No.

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

A vasectomy should therefore not cause:

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

Does Vasectomy Affect Erections or Sexual Function?

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

It also does not interfere with orgasm.

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

Will Ejaculation Be Different?

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

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

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

What Are the Possible Complications?

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

Bleeding and Haematoma

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

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

Infection

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

Pain and Swelling

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

Sperm Granuloma

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

These are often harmless but can occasionally be tender.

Epididymal Congestion

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

This is usually temporary but can occasionally persist.

Post-Vasectomy Pain Syndrome

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

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

Treatment depends upon severity and may include:

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

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

Vasectomy Failure and Recanalisation

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

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

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

Does Vasectomy Increase the Risk of Prostate Cancer?

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

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

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

Can a Vasectomy Be Reversed?

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

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

Success depends on several factors, including:

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

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

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

Alternatives to Vasectomy

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

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

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

When Should I Seek Medical Attention After Vasectomy?

Contact your doctor or urologist if you develop:

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

The Bottom Line

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

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

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

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

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

Pelvic Floor Rehabilitation Before and After Prostate Surgery

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Preparing the Pelvic Floor for Recovery

Urinary leakage is one of the most common concerns men have when preparing for prostate surgery, particularly radical prostatectomy for prostate cancer. Fortunately, urinary control usually improves progressively after surgery, and pelvic floor rehabilitation can play an important role in helping men regain continence.

Pelvic floor rehabilitation is more than simply “doing Kegels”. It involves learning which muscles to use, how to contract them correctly, when to relax them, and how to incorporate them into everyday activities.

Importantly, more exercise is not necessarily better. The aim is a pelvic floor that is strong, coordinated and responsive, rather than one that is constantly clenched.

What Is the Male Pelvic Floor?

The pelvic floor is a group of muscles forming a supportive sling beneath the pelvis. These muscles contribute to:

  • urinary continence;
  • bowel control;
  • support of the pelvic organs;
  • sexual function; and
  • control of pressure generated during coughing, lifting and physical activity.

After radical prostatectomy, the anatomy of the urinary continence mechanism changes. The prostate and prostatic urethra are removed and the bladder is reconnected to the remaining urethra. Urinary control consequently becomes more dependent upon the remaining urinary sphincter and its supporting pelvic floor musculature.

This is why pelvic floor rehabilitation is particularly relevant after prostate cancer surgery.

Why Start Pelvic Floor Rehabilitation Before Surgery?

Ideally, pelvic floor rehabilitation begins before the operation.

The principal advantage of pre-operative training is not necessarily building dramatically stronger muscles. Rather, it gives the patient an opportunity to identify and correctly activate the pelvic floor before surgery, when there is no catheter, discomfort or postoperative urinary leakage.

Evidence regarding whether pre-operative pelvic floor muscle training independently improves long-term continence rates is mixed. Current European guidelines conclude that pre-operative training has not consistently demonstrated an additional long-term benefit. However, pelvic floor muscle training after radical prostatectomy may shorten the time taken to recover continence.

For many patients, a consultation with a physiotherapist experienced in men’s pelvic health before surgery is therefore useful.

Finding the Correct Pelvic Floor Muscles

A pelvic floor contraction should feel as though you are trying to:

stop yourself passing wind while simultaneously shortening or drawing the penis slightly inward and lifting the scrotum.

The movement should be subtle.

During the contraction:

  • continue breathing normally;
  • avoid holding your breath;
  • keep the abdomen relatively relaxed;
  • avoid strongly squeezing the buttocks;
  • avoid excessive tightening of the thighs; and
  • completely relax the pelvic floor between contractions.

Some men find the correct muscles immediately. Others inadvertently brace their abdominal, buttock or thigh muscles.

This is one reason why an assessment by a pelvic floor physiotherapist can be valuable.

Should I stop my urine flow to find the muscles?

Stopping the urinary stream once can sometimes help identify the muscles involved, but repeatedly practising pelvic floor exercises by interrupting urination is generally not recommended.

Regularly stopping and starting the stream can interfere with normal bladder emptying.

A Practical Pelvic Floor Exercise Programme

There is no single exercise prescription that is perfect for every man. Pelvic floor strength, endurance, coordination and postoperative continence vary considerably.

A physiotherapist may therefore modify the programme according to your examination and progress.

A typical programme contains several components.

1. Slow contractions: strength and endurance

Gently contract and lift the pelvic floor.

Hold the contraction for approximately:

5–10 seconds

Then relax completely for approximately:

5–10 seconds

Repeat approximately:

8–10 times

The quality of the contraction is more important than achieving a particular number.

If you can only maintain a good contraction for three seconds initially, three good seconds are preferable to ten seconds of straining.

2. Quick contractions

The urinary sphincter also needs to react rapidly.

Contract the pelvic floor firmly for approximately one second, then completely release it.

Repeat:

5–10 times

These faster contractions help train the pelvic floor to respond to sudden increases in abdominal pressure.

3. The “Knack”

One of the most useful techniques is learning to contract the pelvic floor immediately before an activity that normally produces leakage.

For example, gently activate the pelvic floor just before:

  • coughing;
  • sneezing;
  • standing from a chair;
  • bending;
  • lifting;
  • getting out of a car; or
  • performing physical exercise.

This anticipatory contraction is sometimes called the Knack.

It turns pelvic floor training from an isolated exercise into a functional skill.

How Often Should I Exercise?

This is where the principle of quality rather than quantity becomes important.

For many men, a structured programme performed two to three times per day is sufficient during active rehabilitation.

A session might consist of:

8–10 controlled slow contractions followed by 5–10 quick contractions.

However, this should not be regarded as a universal prescription. Your physiotherapist or surgeon may recommend a different programme according to your muscle strength, continence and ability to relax the pelvic floor.

The pelvic floor is skeletal muscle. Like other muscles, it needs work, recovery and progression.

Doing hundreds of contractions every day is rarely necessary.

Can You Do Too Many Pelvic Floor Exercises?

Yes.

One of the common misconceptions after prostate surgery is:

“If ten exercises are good, one hundred must be better.”

Unfortunately, pelvic floor muscles can become fatigued just like any other muscle.

Excessive training or constantly holding the pelvic floor contracted can potentially cause:

  • pelvic or perineal discomfort;
  • difficulty relaxing the pelvic floor;
  • urinary urgency;
  • difficulty starting urination;
  • interrupted urinary flow;
  • a sensation of incomplete bladder emptying;
  • pelvic muscle fatigue; and
  • occasionally worsening leakage later in the day as the muscles tire.

A healthy pelvic floor needs to be able to contract strongly and relax completely.

Continence does not require walking around all day with the pelvic floor permanently switched on.

How Do I Know When I Am Doing Enough?

Your programme is probably adequate when you can:

  • identify the pelvic floor reliably;
  • contract it without excessive abdominal or buttock activity;
  • maintain several controlled contractions without losing strength;
  • completely relax between contractions;
  • activate the muscles quickly before coughing or lifting; and
  • progressively incorporate pelvic floor control into normal activities.

Progress after prostatectomy is often better measured by continence rather than the number of exercises performed.

Useful measures include:

  • number of pads used each day;
  • degree of pad wetness;
  • a 24-hour pad-weight test;
  • leakage during walking or exercise;
  • ability to remain dry overnight;
  • ability to reach the toilet without leakage; and
  • changes over several weeks rather than from one day to the next.

When Should Exercises Restart After Surgery?

Follow the instructions given by your surgeon.

Pelvic floor contractions are usually stopped while the urinary catheter is in place.

Training can generally recommence after catheter removal once your surgical team considers it appropriate. European guidance notes that pelvic floor muscle training is commonly started approximately 7–10 days after catheter removal, although individual postoperative protocols vary.

Early exercises should be gentle.

This is not the time to test how hard you can squeeze.

As healing progresses, the programme can gradually move from basic contractions to functional training while standing, walking, coughing, lifting and exercising.

What Should I Expect After the Catheter Comes Out?

The first few days can be confronting.

Some men have relatively little leakage immediately. Others experience considerable leakage, particularly when:

  • standing;
  • walking;
  • coughing;
  • exercising;
  • getting out of a chair; or
  • becoming tired later in the day.

This does not necessarily predict the final outcome.

Continence often improves substantially during the first weeks and months following radical prostatectomy.

Recovery is a marathon measured in millilitres rather than kilometres.

How Successful Is Pelvic Floor Physiotherapy?

This question is more complicated than it initially appears.

Urinary continence frequently improves naturally following prostatectomy, making it difficult for studies to separate the effect of pelvic floor physiotherapy from normal postoperative recovery.

The research is consequently mixed.

The European Association of Urology notes that systematic reviews and trials suggest pelvic floor muscle training can shorten the time to continence recovery, although the evidence regarding supervised training, biofeedback and additional therapies remains inconsistent.

For example, one randomised study cited by the EAU compared supervised physiotherapist-directed pelvic floor training with verbal and written instructions. At 12 months, complete pad-free continence was reported in 65.2% of the supervised group versus 31.6% of the comparison group. This result should not be interpreted as the expected success rate for every patient, because continence definitions, surgical techniques and rehabilitation programmes differ considerably between studies.

A 2023 Cochrane review was considerably more cautious. After reviewing 25 trials, the authors concluded that uncertainty remains regarding the magnitude of benefit from conservative treatments because studies vary considerably in their techniques, combinations of treatments and methodological quality.

The practical message is therefore:

Pelvic floor rehabilitation is an important first-line treatment and may accelerate recovery, but it cannot guarantee continence.

What If Pelvic Floor Exercises Are Not Working?

Persistent leakage does not automatically mean you need to exercise harder.

If continence is failing to improve, the first question should be:

Why am I leaking?

Post-prostatectomy urinary incontinence may result from:

  • weakness of the urinary sphincter;
  • bladder overactivity;
  • urinary urgency;
  • incomplete bladder emptying;
  • bladder-neck or urethral narrowing;
  • a combination of stress and urgency incontinence; or
  • less commonly, other urinary tract problems.

The AUA guideline emphasises distinguishing stress incontinence, where leakage occurs with coughing, walking, lifting or exertion, from urgency incontinence, where leakage accompanies a sudden compelling desire to urinate.

No amount of extra squeezing will correct every one of these problems.

When Should Further Investigation Be Considered?

Further assessment may be appropriate when urinary leakage is:

  • severe;
  • worsening rather than improving;
  • associated with difficulty urinating;
  • associated with significant urgency or frequency;
  • persistent despite appropriate rehabilitation; or
  • sufficiently troublesome that surgical treatment is being considered.

Assessment may include:

Bladder diary

Records fluid intake, urinary frequency, urinary volumes and leakage episodes.

Pad-weight testing

Provides an objective measurement of the amount of urine being lost.

Urinary flow measurement and bladder ultrasound

Can identify poor urinary flow or incomplete bladder emptying.

Cystoscopy

May be recommended when urethral or bladder-neck pathology is suspected.

Urodynamic studies

Can sometimes help distinguish sphincter weakness from bladder dysfunction when the cause of persistent leakage is uncertain or before further treatment.

What Alternatives Are Available if Physiotherapy Is Not Enough?

Pelvic floor rehabilitation is only one part of managing post-prostatectomy incontinence.

Lifestyle and bladder strategies

These may include:

  • appropriate fluid intake;
  • reducing excessive caffeine;
  • avoiding constipation;
  • weight management where appropriate;
  • bladder training;
  • management of urinary urgency; and
  • modifying activities that provoke significant leakage during early recovery.

Continence pads

Modern male continence pads provide discreet protection while continence is recovering.

Using pads does not mean rehabilitation has failed. They are simply a tool for allowing normal activity during recovery.

Penile compression devices

A penile clamp can temporarily reduce leakage in selected men, although these devices must be fitted and used correctly and released regularly to avoid excessive pressure or tissue injury.

Medication

Medication does not generally correct true post-prostatectomy sphincter weakness.

However, medication may be useful when overactive bladder or urinary urgency contributes significantly to leakage.

Biofeedback

Biofeedback can help some patients understand whether they are contracting the correct muscles and how effectively they are doing so.

Electrical stimulation

Electrical stimulation has also been investigated. Some studies suggest an early benefit when combined with pelvic floor training, although evidence remains inconsistent.

When Is Surgery Considered?

A small proportion of men continue to experience significant stress urinary incontinence despite adequate healing and rehabilitation.

If the leakage remains bothersome, further treatment should be discussed rather than simply continuing increasingly intensive pelvic floor exercises indefinitely.

The two principal surgical options are:

Male Sling

A male sling supports and repositions the urethral continence mechanism.

It is generally most suitable for selected men with mild to moderate stress urinary incontinence and adequate residual sphincter function.

Results tend to be less favourable when incontinence is severe. The AUA guideline specifically notes that male sling outcomes are poorer in men with severe sphincteric incontinence.

Artificial Urinary Sphincter

The artificial urinary sphincter (AUS) remains an important treatment for moderate to severe post-prostatectomy stress urinary incontinence.

A fluid-filled cuff is placed around the urethra and controlled by a small pump positioned within the scrotum. The patient operates the pump when he wishes to urinate.

Both male sling surgery and artificial urinary sphincter implantation can significantly reduce pad use and improve quality of life in appropriately selected men.

When Should I Stop Pelvic Floor Rehabilitation?

There is rarely a precise finishing date.

Once continence has returned and pelvic floor control is good, intensive rehabilitation can usually be reduced.

Many men transition from a rehabilitation programme to a simple maintenance programme, incorporating occasional pelvic floor exercises and functional contractions during activities that generate abdominal pressure.

If you are completely dry, have good pelvic floor control and can cough, lift and exercise without leakage, performing increasingly large numbers of exercises is unlikely to provide additional benefit.

The goal is not to become a professional Kegel athlete.

The goal is normal function.

The Bottom Line

Pelvic floor rehabilitation is an important component of recovery following radical prostatectomy.

Learning the technique before surgery can make it easier to identify and activate the correct muscles after the catheter is removed. Following surgery, a structured programme focusing on strength, endurance, rapid contractions, relaxation and functional activation may help accelerate the return of urinary control. Current evidence supports pelvic floor muscle training as part of postoperative management, while acknowledging that the precise additional benefit of intensive supervised physiotherapy remains uncertain.

Just as importantly, more is not always better. Persistent leakage should not automatically be treated with ever-increasing numbers of pelvic floor contractions.

If urinary incontinence remains troublesome despite appropriate rehabilitation, further assessment can determine whether the problem is persistent sphincter weakness, bladder dysfunction or another cause. Treatments ranging from bladder therapy and medication to a male sling or artificial urinary sphincter can then be considered.

A useful rule

Train the pelvic floor, don’t exhaust it.

Correct technique, consistency and functional control matter far more than the number of contractions performed.

This information is intended for general patient education and does not replace individual medical advice. The timing and intensity of pelvic floor rehabilitation should be discussed with your surgeon and/or a physiotherapist experienced in male pelvic health.

Active Surveillance for Prostate Cancer

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Being diagnosed with prostate cancer does not always mean that treatment needs to start immediately.

Many prostate cancers grow very slowly and may never cause symptoms or threaten a man’s life. For carefully selected men, active surveillance allows the cancer to be closely monitored while avoiding, or at least delaying, treatments such as surgery or radiation therapy.

Importantly, active surveillance does not mean ignoring the cancer. It is a structured programme of PSA testing, clinical review, prostate MRI and, when appropriate, repeat prostate biopsy. If there are signs that the cancer is becoming more significant, treatment can be recommended while the disease is still potentially curable.

Current international guidelines consider active surveillance the preferred or standard management approach for most suitable men with low-risk localised prostate cancer, and it may also be considered in carefully selected men with favourable intermediate-risk disease.

What Is Active Surveillance?

Active surveillance is a management strategy for prostate cancer in which curative treatment is deliberately postponed while the cancer is carefully monitored.

The aim is simple:

Avoid unnecessary treatment and its potential side effects, without compromising the opportunity for cure if the cancer changes.

This is particularly relevant because prostate cancer behaves very differently from one man to another. Some cancers are aggressive and require treatment, while others may remain small and slow-growing for many years.

Australian patient guidance describes active surveillance as close monitoring of low-risk prostate cancer that is not causing symptoms, with treatment initiated if investigations indicate that the cancer is becoming more aggressive.

Who Qualifies for Active Surveillance?

Active surveillance is most commonly recommended for men with low-risk prostate cancer.

Typical features include:

  • Cancer confined to the prostate
  • Grade Group 1 / Gleason score 3+3=6
  • PSA generally less than 10 ng/mL
  • Clinical stage T1 to T2a
  • Relatively small volume of cancer on prostate biopsy
  • Favourable findings on multiparametric MRI
  • A PSA density that supports low-volume disease
  • No clinical or imaging evidence suggesting more aggressive cancer

The AUA/ASTRO risk classification defines low-risk disease as PSA below 10 ng/mL, Grade Group 1 and clinical stage T1–T2a. For these patients, active surveillance is recommended as the preferred management strategy.

However, no single number determines suitability. Age, general health, family history, MRI findings, PSA density, biopsy findings, life expectancy and personal preferences all contribute to the decision.

Can Men With Gleason 3+4 / Grade Group 2 Cancer Have Active Surveillance?

Sometimes.

Active surveillance is increasingly considered for carefully selected men with favourable intermediate-risk prostate cancer, particularly when there is only a small amount of Gleason pattern 4 disease.

The 2026 European Association of Urology guidelines support active surveillance for selected men with favourable Grade Group 2 cancer. Features favouring surveillance include a small amount of pattern 4 disease, PSA below 10 ng/mL, limited tumour volume on biopsy and favourable imaging.

Similarly, AUA/ASTRO guidance suggests that favourable intermediate-risk patients with low PSA density, low tumour volume and a low percentage of Gleason pattern 4 disease may be considered for active surveillance.

These men require careful counselling because their risk of progression is higher than for men with Grade Group 1 disease.

Active surveillance is generally not appropriate for Grade Group 3 or higher-risk prostate cancer in men otherwise suitable for curative treatment.

What Happens Before Starting Active Surveillance?

The first step is making sure that the cancer really is suitable for surveillance.

Assessment may include:

PSA and PSA Density

PSA is considered together with prostate volume to calculate the PSA density.

A relatively low PSA density, commonly around less than 0.15 ng/mL/cc, provides additional reassurance in men being considered for surveillance, although it should not be interpreted as an absolute cut-off in isolation.

Multiparametric MRI of the Prostate

A high-quality multiparametric MRI (mpMRI) provides important information about:

  • The location of the tumour
  • Tumour size
  • Suspicious areas within the prostate
  • Possible extension outside the prostate
  • Areas that should be targeted during biopsy

MRI has become an important part of modern active surveillance, but MRI alone does not completely replace prostate biopsy.

Review or Confirmation of the Biopsy

The initial biopsy determines the Grade Group, Gleason score and volume of cancer.

Depending on how the original diagnosis was made, a confirmatory biopsy may be recommended. MRI-targeted biopsies can specifically sample suspicious lesions, while systematic or regional biopsies assess other areas of the prostate.

How Is Active Surveillance Performed?

Active surveillance is an ongoing programme rather than a single test.

The exact protocol varies according to the patient’s age, cancer characteristics, previous investigations and the treating urologist or institution.

A typical programme may include:

PSA Testing

PSA is usually measured approximately every 3–6 months initially, although intervals may become longer in men with very stable disease.

Current EAU guidance recommends PSA testing at least every six months, while Australian Cancer Council information describes PSA testing every 3–6 months.

The trend in PSA is usually more informative than one isolated reading.

An unexpected rise does not automatically mean that the cancer has progressed. PSA can fluctuate because of benign prostate enlargement, inflammation, infection and other factors.

For this reason, an unexpected PSA rise will often be repeated before further decisions are made.

Clinical Review

Regular appointments allow your urologist to review:

  • PSA changes
  • Urinary symptoms
  • General health
  • Examination findings
  • MRI results
  • Whether further investigation is required

A digital rectal examination may form part of surveillance, although its frequency can be individualised.

Repeat Prostate MRI

Repeat mpMRI may be performed periodically or earlier if PSA or other findings become concerning.

MRI allows comparison with previous scans to determine whether a lesion is:

  • Stable
  • Increasing in size
  • Becoming more suspicious
  • Showing features suggesting progression

Importantly, a change on MRI will often lead to a repeat biopsy rather than automatically triggering treatment. The EAU recommends confirming suspected histological progression before changing treatment strategy where appropriate.

Repeat Prostate Biopsy

Repeat biopsy remains an important component of active surveillance.

The frequency varies according to individual risk, previous MRI and biopsy findings and the surveillance protocol being followed.

The biopsy may involve:

  • Targeted biopsy of an MRI abnormality
  • Systematic sampling
  • A combination of targeted and regional/systematic biopsies

Modern surveillance programmes increasingly tailor biopsy frequency according to the individual’s risk rather than applying exactly the same schedule to every patient.

What Are We Looking for During Surveillance?

The purpose of surveillance is to identify reclassification or progression before the cancer becomes difficult to cure.

Your urologist will be looking for several possible warning signs.

These include:

Increasing cancer grade

For example, a cancer initially classified as Grade Group 1 may subsequently demonstrate a significant amount of Gleason pattern 4 disease.

Increasing cancer volume

More biopsy samples may contain cancer, or individual samples may contain a greater amount of cancer.

Changes on MRI

An existing lesion may enlarge or become more suspicious, or a new lesion may appear.

Persistent PSA changes

A progressively increasing PSA, particularly when accompanied by increasing PSA density or concerning MRI findings, may trigger further investigation.

Clinical progression

Changes on examination or other investigations may suggest that the cancer is no longer behaving as expected.

When Should Active Surveillance Stop?

Active surveillance should generally continue for as long as the cancer remains suitable for surveillance and curative treatment remains relevant.

The decision to move to treatment should ideally be based on the overall picture rather than PSA alone.

Treatment may be recommended when there is:

  • Significant upgrading of the cancer on repeat biopsy
  • Increasing amounts of higher-grade cancer
  • Significant increase in tumour volume
  • Concerning progression on MRI confirmed by appropriate investigation
  • Evidence suggesting progression beyond the original low-risk category
  • A change in the patient’s preference after informed discussion

AUA/ASTRO guidance recommends that significantly higher-volume or higher-grade disease on surveillance biopsy should prompt discussion about definitive therapy.

What Happens If the Cancer Progresses?

The important concept behind active surveillance is that treatment has been postponed, not abandoned.

If investigations demonstrate clinically significant progression, curative treatment can be considered.

Depending on the man’s age, general health, cancer characteristics and preferences, options may include:

Radical Prostatectomy

Surgical removal of the prostate, increasingly performed using robotic-assisted radical prostatectomy.

Focal therapy

Nanoknife electroporation

ProFocal laser ablation

Radiation Therapy

Options may include:

  • External beam radiation therapy
  • Stereotactic radiation therapy in appropriate patients
  • Brachytherapy in selected cases
  • Radiation combined with hormonal therapy where clinically indicated

Other Selected Treatments

In carefully selected circumstances, other approaches may be discussed. The evidence for focal ablative therapies remains less mature than that for established treatments such as surgery and radiation therapy, and suitability needs individual assessment.

What Are the Benefits of Active Surveillance?

For appropriately selected men, the major advantage is avoiding treatment that may never have been necessary.

Avoiding or Delaying Treatment Side Effects

Radical treatment can potentially cause:

  • Urinary incontinence
  • Erectile dysfunction
  • Ejaculatory changes
  • Urinary symptoms
  • Bowel symptoms following some forms of radiation therapy

Active surveillance allows men to maintain their existing urinary, sexual and bowel function for longer.

Maintaining Quality of Life

Many men can continue normal work, exercise, travel and sexual activity without the recovery period or functional consequences associated with immediate treatment.

Avoiding Overtreatment

Some low-risk prostate cancers may never become clinically significant during a man’s lifetime.

Treating every prostate cancer immediately would therefore expose some men to treatment complications without providing a meaningful survival advantage.

Treatment Remains Available

Active surveillance preserves the opportunity for curative treatment if the cancer subsequently demonstrates significant progression.

Long-term outcomes from well-conducted active surveillance programmes are reassuring. The EAU reports 10-year prostate cancer-specific survival rates of approximately 98–100% in active surveillance cohorts, although outcomes depend on appropriate patient selection and follow-up.

What Are the Risks of Active Surveillance?

Active surveillance is not completely risk-free.

The Cancer May Progress

Some cancers initially thought to be low risk will subsequently demonstrate more aggressive features.

In fact, a significant proportion of men are eventually reclassified during long-term surveillance and may proceed to treatment.

The Initial Biopsy May Underestimate the Cancer

A prostate biopsy samples only part of the prostate.

Occasionally, higher-grade cancer may already be present but was not captured during the original biopsy. Modern MRI and targeted biopsy techniques help reduce this risk but cannot eliminate it completely.

Small Risk of Losing the Optimal Window for Treatment

This is one of the main reasons that regular follow-up is essential.

In appropriately selected men who comply with structured surveillance, the risk is low, but surveillance must be active rather than passive.

Repeat Investigations

Active surveillance may involve:

  • Repeated blood tests
  • MRI scans
  • Urology appointments
  • Repeat prostate biopsies

Biopsies can cause discomfort, bleeding and infection, although contemporary transperineal biopsy techniques can substantially reduce the risk of serious infection.

Psychological Impact

Some men find living with untreated cancer surprisingly easy. Others find it difficult.

Anxiety may occur around:

  • PSA tests
  • MRI scans
  • Repeat biopsies
  • Waiting for results
  • Concern that the cancer may be progressing

For some men, the psychological burden becomes an important factor when deciding whether to remain on surveillance.

Active Surveillance Is Not the Same as Watchful Waiting

These terms are sometimes confused, but they describe different approaches.

Active surveillance is generally used for men with potentially curable prostate cancer. The cancer is actively monitored, with the intention of offering curative treatment if clinically significant progression occurs.

Watchful waiting is more commonly used in older men or men with significant other medical conditions where prostate cancer is unlikely to affect life expectancy. Monitoring is less intensive, and treatment is generally introduced to control symptoms rather than with the intention of cure.

Does Active Surveillance Mean Doing Nothing?

No.

This is perhaps the most important misconception about active surveillance.

A better description might be:

“Treatment if and when it becomes necessary.”

The cancer is being monitored carefully so that unnecessary treatment can be avoided while retaining the opportunity to intervene if its behaviour changes.

For the right patient, this can provide an excellent balance between cancer control and preservation of quality of life.

The Bottom Line

Active surveillance has become an established standard of care for appropriately selected men with low-risk prostate cancer and can also be considered for some men with carefully selected favourable intermediate-risk disease.

The decision should take into account:

  • PSA and PSA density
  • Grade Group and Gleason score
  • Amount of cancer found on biopsy
  • MRI findings
  • Clinical stage
  • Age and life expectancy
  • General health
  • Family and genetic risk factors
  • Personal preferences

Most importantly, active surveillance requires a partnership between the patient and his urologist.

The goal is not simply to avoid treatment.

The goal is to avoid treatment that is unnecessary, while identifying the point at which treatment becomes worthwhile.

This information is intended for general education and does not replace individual medical advice. Recommendations for prostate cancer management should be based on a detailed assessment of the individual patient, pathology, PSA results, imaging, general health and personal preferences.

PSA Screening for Prostate Cancer in Australia: Should You Have a PSA Test?

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Prostate cancer is one of the most commonly diagnosed cancers in Australian men. One of the difficulties with prostate cancer is that early prostate cancer usually causes no symptoms. By the time symptoms develop, some cancers may already have progressed beyond the prostate.

A simple blood test called the prostate-specific antigen (PSA) test can help identify men who may be at increased risk of prostate cancer. However, PSA testing is not a perfect cancer test and deciding whether to have regular PSA testing involves balancing the potential benefits of early diagnosis against the risks of unnecessary investigation and treatment.

In Australia, there is currently no national population-based prostate cancer screening program. Instead, PSA testing is based on an informed discussion between a man and his doctor, taking into account age, family history, overall health, life expectancy and personal preferences.

What is PSA?

PSA, or prostate-specific antigen, is a protein produced by prostate cells. A small amount normally enters the bloodstream and can be measured with a simple blood test.

An elevated PSA does not automatically mean that you have prostate cancer.

PSA can rise because of:

  • prostate cancer
  • benign enlargement of the prostate (BPH)
  • inflammation or infection of the prostate
  • urinary infection
  • recent ejaculation or sexual activity
  • recent instrumentation of the urinary tract
  • manipulation of the prostate.

Conversely, some men with prostate cancer can have a PSA within the expected range. PSA is therefore best considered a marker of prostate activity and prostate cancer risk rather than a test that diagnoses cancer.

Who Should Consider PSA Testing in Australia?

Current Australian guidance supports informed, individualized PSA testing rather than universal population screening.

For men at average risk who have been informed about the potential benefits and harms and decide to undergo regular testing, current RACGP guidance recommends offering PSA testing every two years between the ages of 50 and 69 years.

Men with a significant family history may be advised to start earlier. Depending on the strength of the family history, testing may begin from approximately 40–45 years of age and continue every two years to age 69.

A stronger family history includes having a father, brother or multiple close relatives diagnosed with prostate cancer, particularly when prostate cancer occurred at a younger age.

Other factors, including ancestry, genetic predisposition and an individual’s general health and life expectancy, may also influence the decision about when to begin testing.

Importantly, these recommendations apply to men without symptoms. Men with symptoms or clinical findings that raise concern about prostate cancer require individual assessment rather than simply entering a screening program.

What Does an Elevated PSA Mean?

An elevated PSA is not a diagnosis of prostate cancer.

For men aged 50–69 undergoing early detection testing, a PSA above 3.0 ng/mL generally prompts further assessment under current Australian guidance. An abnormal result will often be repeated because PSA levels can fluctuate and temporary elevations are common.

Depending on the PSA level, age, prostate size, family history and other risk factors, further assessment may include:

Repeat PSA → assessment of PSA trend and other risk factors → specialist review → prostate MRI → possible prostate biopsy

Modern prostate cancer assessment has changed substantially. An abnormal PSA no longer necessarily means proceeding directly to a prostate biopsy. Multiparametric MRI (mpMRI) can help identify suspicious areas within the prostate and assist the urologist in deciding whether biopsy is necessary.

The Potential Benefits of PSA Screening

The principal advantage of PSA testing is straightforward:

It may detect a significant prostate cancer while it is still curable.

Aggressive prostate cancer can spread to lymph nodes, bones and other organs. Once metastatic prostate cancer develops, treatment is generally aimed at controlling rather than curing the disease.

Regular PSA testing provides an opportunity to identify some clinically important cancers years before they would otherwise become apparent.

Large screening trials have produced differing results, which is one reason PSA screening remains controversial. European screening data have demonstrated a reduction in prostate cancer mortality associated with PSA-based screening, while other trials have shown less convincing mortality benefits.

For an individual man, therefore, the potential benefit is significant: early detection may identify an aggressive cancer at a stage when curative treatment remains possible.

What Are the Downsides of PSA Screening?

The difficulty is that prostate cancer is not one disease.

Some prostate cancers are aggressive and potentially life-threatening. Others grow extremely slowly and may never cause symptoms during a man’s lifetime.

PSA testing can detect both.

False-positive PSA results

An elevated PSA may lead to anxiety, repeat blood tests, MRI scans and sometimes biopsy even when no cancer is ultimately found.

Overdiagnosis

PSA testing can identify a prostate cancer that would never have caused illness or shortened the man’s life.

This is known as overdiagnosis.

Overtreatment

If an insignificant cancer is diagnosed and subsequently treated, the man can potentially experience treatment complications without gaining a meaningful survival benefit.

Potential consequences of prostate cancer treatment include:

  • erectile dysfunction
  • urinary incontinence
  • urinary symptoms
  • ejaculatory changes
  • bowel symptoms following some forms of radiotherapy.

This is one of the major reasons Australia does not currently have a universal PSA population-screening program.

Importantly, however, diagnosing prostate cancer does not automatically mean treating it.

Many men with low-risk prostate cancer are now managed with active surveillance, involving PSA monitoring, MRI and selective repeat biopsy. Treatment is reserved for evidence that the cancer is becoming more significant.

What Are the Implications of Not Having PSA Screening?

Choosing not to undergo PSA testing is also a legitimate decision, particularly after considering the benefits and disadvantages.

The advantage is avoiding the potential cascade of:

PSA testing → abnormal result → anxiety → MRI → biopsy → diagnosis of an insignificant cancer → possible unnecessary treatment.

However, there is another side to this decision.

Because early prostate cancer frequently produces no symptoms, a man who does not undergo PSA testing may remain unaware that he has prostate cancer.

For most men who never develop clinically significant disease, this causes no harm.

For a smaller group who develop aggressive prostate cancer, however, the first indication of the disease may occur after the cancer has grown substantially or spread beyond the prostate.

At that stage, the opportunity for curative treatment may have been reduced or lost.

The decision is therefore not simply:

“Do I want to know whether I have prostate cancer?”

A more useful question is:

“Given my age, health, family history and personal priorities, do the potential benefits of finding a significant prostate cancer early outweigh the potential harms of investigating and possibly diagnosing a cancer that may never affect me?”

This is why shared decision-making with your GP or urologist is important.

What About a Digital Rectal Examination?

The digital rectal examination, or DRE, involves a doctor gently inserting a gloved, lubricated finger into the rectum to examine the back surface of the prostate.

The doctor assesses the prostate for abnormalities such as:

  • unusual hardness
  • nodules
  • asymmetry
  • irregularity
  • loss of the normal contour of the gland.

Historically, DRE was routinely combined with PSA testing for prostate cancer screening.

This has changed.

DRE is no longer recommended as a routine screening test in asymptomatic men

Current Australian guidance states that DRE should not routinely be added to PSA testing for early detection in asymptomatic men in primary care.

There are several reasons.

A finger can examine only part of the prostate. Small cancers may not be palpable, and cancers in areas of the prostate that cannot be reached during examination can be missed. A normal DRE therefore does not exclude prostate cancer.

Conversely, benign prostate enlargement and other abnormalities can sometimes produce an abnormal examination.

Does DRE Still Have a Role?

Yes.

Not recommending DRE as a routine screening test does not mean that the examination has become obsolete.

A urologist may perform a DRE when assessing a man with:

  • an elevated or rising PSA
  • urinary symptoms
  • suspected prostate disease
  • an abnormal MRI
  • concern about locally advanced prostate cancer
  • other pelvic or rectal symptoms.

Occasionally, a prostate cancer may produce a distinctly hard or irregular prostate even when the PSA is not dramatically elevated. An abnormal DRE can therefore remain clinically important and may prompt further investigation. Cancer Council Australia notes that urologists will commonly perform DRE as part of prostate assessment even though GPs no longer routinely use it for screening asymptomatic men.

The key distinction is:

DRE has a role in clinical examination and investigation, but it is not recommended as a routine population-screening test in an otherwise well man undergoing PSA testing.

PSA Screening Is About Risk, Not Just a Number

One of the most important changes in modern prostate cancer detection is moving away from treating PSA as simply “normal” or “abnormal.”

A PSA result should be interpreted in context.

Your doctor or urologist may consider:

your age + PSA level + change in PSA over time + family history + prostate size + symptoms + examination findings + MRI findings + overall health

Together, these provide a much more meaningful assessment of prostate cancer risk than a single PSA result.

Should I Have a PSA Test?

There is no single answer that is appropriate for every man.

For a healthy man in the appropriate age group, particularly someone with a family history of prostate cancer, the potential benefit of identifying an aggressive cancer while it remains curable may be important.

For an older man with substantial medical problems or limited life expectancy, the likelihood that PSA screening will provide meaningful benefit becomes considerably smaller. Current Australian guidance advises against PSA testing in men whose life expectancy is likely to be less than approximately seven years because a mortality benefit from early detection is unlikely to occur within that period.

The decision should therefore be individual rather than automatic.

The Bottom Line

PSA testing can save lives by detecting clinically significant prostate cancer at an earlier and potentially curable stage, but it can also detect cancers that would never have caused harm.

Australia therefore does not currently operate a universal PSA screening program. Instead, men are encouraged to make an informed decision about PSA testing after discussing their individual risk and the potential benefits and harms with their doctor.

For men who choose screening, current Australian guidance generally supports PSA testing every two years from age 50–69 for men at average risk, with earlier testing considered for men with a significant family history.

A digital rectal examination is no longer recommended as a routine addition to PSA screening in asymptomatic men, but it remains an important component of specialist prostate assessment in selected circumstances.

Concerned about your prostate cancer risk?

If you are considering PSA testing, have a family history of prostate cancer, have noticed a change in your PSA, or have urinary symptoms, discuss your individual risk with your GP or urologist.

Early detection should not simply be about finding more prostate cancers. The goal is to identify the cancers that matter, at a time when something useful can still be done about them.

This information is intended for general education and does not replace individual medical advice. Recommendations may differ according to your age, family history, medical conditions and previous PSA results.

Further information

Australian patient information and guidance are available from Cancer Council Australia: Prostate cancer screening and early detection and the RACGP Guidelines for preventive activities in general practice.