Tag Archive for: Caboolture urologist

Pelvic Floor Rehabilitation Before and After Prostate Surgery

August 21, 2026/0 Comments/in Blog Post, Urinary Incontinence/by drjo

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

August 21, 2026/0 Comments/in Blog Post, Prostate Surgery/by drjo

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?

August 21, 2026/0 Comments/in Blog Post/by drjo

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.

Fascia Lata Allograft as a Mid-Urethral Sling for Female Stress Urinary Incontinence

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

A “new/revamped” kid on the block – Fascia Lata Allograft: A biological alternative to synthetic mesh

Stress urinary incontinence (SUI) is one of the most common forms of urinary incontinence in women. It occurs when urine leaks with activities that increase abdominal pressure, such as coughing, sneezing, laughing, exercising, lifting or running.

For women whose symptoms remain troublesome despite pelvic floor muscle training and appropriate conservative treatment, surgical treatment can provide substantial and durable improvement.

For many years, the mid-urethral sling has been one of the most effective minimally invasive surgical treatments for SUI. Synthetic mesh mid-urethral slings remain available in Australia and have extensive evidence supporting their effectiveness. However, concerns surrounding synthetic mesh have led many women to ask whether there is a biological alternative.

One such option is a fascia lata allograft, including the fascia lata allograft supplied by Samson Medical Technologies in Australia.

The important distinction is that the Samson product is not a synthetic mesh. It is human donor fascia lata, processed for use as a biological graft. Samson describes its current fascia lata allograft as 100% human-derived, without storage media, non-irradiated and processed using Super Critical CO₂ technology.

However, there is an important caveat: the published clinical evidence for fascia lata allografts in SUI largely relates to earlier cadaveric fascia products and pubovaginal sling techniques, rather than Samson’s current specific product. Therefore, the historical allograft results should not be presented as if they were Samson-specific clinical trial results.

What is an allograft sling?

An allograft is tissue obtained from a human donor rather than from the patient herself.

Traditional biological pubovaginal slings have commonly used the patient’s own rectus fascia or fascia lata. This provides a strong, durable biological support but requires an additional incision to harvest the patient’s tissue.

An allograft avoids this donor-site surgery.

The fascia lata is positioned beneath the urethra and secured to provide a supportive platform. During coughing, sneezing or physical exertion, the urethra is compressed against this support, helping prevent urine leakage.

The concept is therefore quite different from a synthetic polypropylene mid-urethral sling. Instead of leaving a permanent synthetic mesh implant, the surgeon is using processed human connective tissue.

Samson currently supplies fascia lata allografts in several dimensions, including 20 × 100 mm and 20 × 120–140 mm configurations.

How effective are fascia lata allografts?

This is where the evidence requires some careful interpretation.

There is a substantial historical literature examining cadaveric fascia lata as a sling material, but the results have been inconsistent.

Early studies

Some early studies reported excellent short-term results.

One study of 26 women treated with solvent-dehydrated cadaveric fascia lata reported that 77% were completely dry and 92% used one pad or fewer per day at a mean follow-up of 15 months.

Another series of 31 women reported complete resolution of SUI in 93% at approximately one year.

A larger series of 104 women using freeze-dried, non-irradiated cadaveric fascia lata demonstrated substantial reductions in pad use, although the study’s follow-up was relatively short.

These studies created considerable enthusiasm for allograft tissue because it offered the advantages of a biological sling without the morbidity of harvesting the patient’s own fascia.

But there was also a warning signal

Other studies produced considerably less encouraging results.

A study of 18 women using solvent-dehydrated, gamma-irradiated fascia lata found that 27.8% experienced significant failure, with recurrent incontinence occurring within 3–6 months. The authors concluded that this particular allograft material was unreliable.

A subsequent comparative study of 71 women found a concerning difference in objective urodynamic recurrence: urodynamic stress incontinence was present in 41.7% of women who received Tutoplast allograft compared with none of those receiving autologous fascia lata at follow-up. Patient-reported outcomes, however, were more favourable.

Other series have reported much better results. In a 134-patient comparison, 63 women received allograft fascia and 71 received autologous fascia. There was no statistically significant difference in overall cure of stress and urge incontinence at approximately two years, while the allograft group experienced less postoperative pain and disability.

What does this mean?

The historical evidence suggests that allograft fascia can work well, but the durability and consistency of older allograft products were variable.

This variability is important when discussing the Samson allograft. There is currently insufficient published comparative evidence to state that the Samson product has a specific cure rate such as 80%, 90% or 95%.

The more scientifically defensible statement is:

Samson fascia lata provides a contemporary biological allograft option for sling surgery, but Samson-specific long-term comparative clinical outcome data are still developing.

That distinction is important when counselling patients.

How does Samson allograft differ from older allografts?

The earlier allograft literature predominantly involved freeze-dried, solvent-dehydrated and/or gamma-irradiated cadaveric fascia lata.

The Samson product currently described by the manufacturer is different in its processing. Samson reports that its fascia lata is:

100% human-derived
non-irradiated
supplied without storage media
processed using Super Critical CO₂ technology
available in several sizes.

The rationale behind modern tissue processing is to preserve the structural characteristics of the collagenous tissue while making the graft suitable for implantation.

Nevertheless, a different processing technology does not automatically establish superior clinical continence outcomes. Laboratory characteristics, tensile strength and histological appearance are not substitutes for long-term clinical trials.

This is one of the areas where future Australian outcome data will be particularly valuable.

How does an allograft compare with synthetic mid-urethral mesh?

Synthetic mid-urethral slings have the largest evidence base of any minimally invasive SUI operation.

A Cochrane review including 81 trials and more than 12,000 women found that more than 80% of women were cured or significantly improved following mid-urethral sling surgery, with good results maintained for up to five years.

Retropubic and transobturator approaches have broadly comparable effectiveness, although their complication profiles differ.

For example, retropubic slings have a higher risk of bladder perforation, whereas transobturator procedures have more groin pain. Vaginal mesh exposure is uncommon but recognised with both approaches.

The Australian situation

It is important to distinguish mid-urethral slings from transvaginal mesh used for pelvic organ prolapse.

The Australian TGA has removed certain transvaginal mesh products from the market, particularly mesh used for prolapse and single-incision mini-slings. However, mid-urethral sling devices for SUI remain approved in Australia.

Indeed, a 2026 Australian Government review concluded that mid-urethral sling devices should remain on the Prescribed List, with their existing listing unchanged.

Therefore, synthetic MUS should not simply be described as “banned mesh” in Australia. It remains an accepted treatment for appropriately selected women.

Potential advantages of an allograft

A biological fascia lata sling potentially offers:

Advantages

No synthetic polypropylene mesh
No fascial harvest from the patient’s abdomen or thigh
Avoidance of donor-site pain
Biological rather than permanent synthetic material
Potentially useful where avoidance of synthetic mesh is an important patient preference

Potential disadvantages

Less robust long-term evidence than synthetic MUS
Historical allograft studies have shown variable durability
It is still a surgical sling and can cause obstruction, urinary retention, infection, bleeding or pain
It requires more extensive dissection than a conventional MUS
It should not currently be marketed as proven superior to synthetic MUS

What about the Burch colposuspension?

The Burch colposuspension is the classic non-mesh surgical treatment for SUI.

Rather than placing a sling beneath the urethra, sutures are placed beside the bladder neck and proximal urethra and attached to supporting pelvic tissues.

It can be performed by open or laparoscopic surgery.

Long-term studies demonstrate that Burch colposuspension can be highly effective. One classic study found an 81.6% cure rate at 5–10 years.

More contemporary comparative data are reassuring. In a large study with more than 1,300 women and long-term follow-up, the proportion reporting no ongoing SUI was 83.0% after Burch colposuspension compared with 85.0% following retropubic MUS, with no significant difference.

However, Burch surgery is more invasive than a mid-urethral sling and is generally no longer the first surgical option for uncomplicated primary SUI.

It can nevertheless be an attractive option in selected women, particularly when avoiding synthetic mesh is important.

What about peri-urethral bulking agents?

Urethral bulking agents occupy a completely different part of the treatment spectrum.

A material is injected into the urethral wall around the bladder neck or proximal urethra to increase coaptation and improve continence.

In Australia, polyacrylamide hydrogel such as Bulkamid is an established example.

The major attraction is that it is substantially less invasive than sling surgery.

It can often be performed under local anaesthesia or sedation and has a relatively favourable safety profile.

The trade-off is effectiveness and durability.

A 2024 study of Bulkamid reported that at 12 months 69% of women described themselves as cured or improved, with 40% reporting cure, while 23% underwent subsequent treatment, including repeat Bulkamid injection or MUS.

Longer-term data are more modest. In a cohort of 357 women followed for a median of approximately 2.5 years, subjective cure was 30.9%, while 52.1% reported improvement. Minor adverse events occurred in 21%, with no serious adverse events attributed to the procedure.

Current guideline evidence therefore generally considers bulking agents less effective than MUS, Burch colposuspension or autologous fascial sling surgery, and repeat injections may be necessary.

Putting the options together

Treatment	Approximate effectiveness	Main advantages	Main disadvantages
Samson fascia lata allograft sling	Samson-specific long-term cure rate not yet established; historical allograft studies range widely	Biological tissue; no synthetic mesh; no tissue harvest	Limited contemporary comparative evidence; historical allograft durability concerns; surgical sling risks
Synthetic mid-urethral sling	Generally >80% cure/improvement in medium-term evidence	Minimally invasive, rapid recovery, extensive evidence	Mesh-specific complications including exposure, pain and voiding dysfunction
Burch colposuspension	Approximately 70–85% long-term continence in many series	No vaginal mesh; durable native-tissue operation	More invasive; longer recovery; risk of prolapse and voiding problems
Autologous fascial sling	Generally high effectiveness, comparable with other established sling procedures	No synthetic mesh; patient’s own tissue	Requires tissue harvest; more postoperative morbidity
Bulking agent	Lower cure rate, but meaningful improvement for many women	Minimally invasive; useful for frail/high-risk patients or those avoiding sling surgery	Less durable; repeat injections commonly required

The Australian Government’s own review of MUS specifically considered colposuspension, native-tissue pubovaginal slings and urethral bulking agents as important comparators.

Who might consider an allograft sling?

A fascia lata allograft may be particularly attractive for a woman who:

has objectively demonstrated SUI;
has failed appropriate conservative treatment;
wishes to avoid a permanent synthetic mesh implant;
does not want an abdominal or thigh incision to harvest her own fascia;
understands that the long-term evidence base for contemporary allograft products is smaller than that for synthetic MUS;
accepts that biological tissue does not eliminate the risks associated with sling surgery.

It may also have a role in selected women with recurrent SUI, particularly where previous synthetic mesh surgery makes another synthetic procedure unattractive. However, recurrent SUI is a more complex clinical situation and requires individual assessment.

The important question: is Samson allograft better than synthetic mesh?

At present, there is not enough evidence to say that it is.

The strongest evidence remains with synthetic mid-urethral slings. Their effectiveness has been demonstrated in thousands of women and across multiple randomised trials and systematic reviews.

The potential attraction of Samson fascia lata is different.

It offers a biological alternative for women who would prefer to avoid synthetic mesh while also avoiding the morbidity of harvesting their own fascia.

That makes it an interesting addition to the surgeon’s toolbox rather than a replacement for the established mid-urethral sling.

The key unanswered question is long-term durability.

Historical cadaveric allograft studies demonstrate that some allografts performed extremely well, while others experienced substantial early failure.

Consequently, contemporary prospective data specifically evaluating Samson’s processing technology, clinical continence outcomes, complications and durability would be valuable.

What should a woman expect from the procedure?

As with any continence operation, the goal is not simply to make a stress test negative. The aim is to improve the woman’s quality of life while preserving normal bladder emptying and sexual function.

Potential complications of sling surgery include:

temporary or persistent difficulty emptying the bladder;
urinary retention requiring catheterisation;
urinary tract infection;
bleeding or haematoma;
pain;
de novo urgency or worsening overactive bladder;
recurrent or persistent SUI;
vaginal wound problems;
infection;
rarely, injury to the bladder, urethra or surrounding structures.

Synthetic mesh has additional mesh-specific risks, including vaginal exposure/erosion and chronic pain. The TGA specifically requires information regarding complications such as severe chronic pain, groin pain and bladder perforation in the instructions for use of Australian MUS devices.

An allograft avoids synthetic mesh exposure, but it does not make the operation risk-free.

The bottom line

For a woman with bothersome stress urinary incontinence, there is no single operation that is right for everyone.

Synthetic mid-urethral slings remain the most extensively studied minimally invasive surgical treatment and have excellent success rates.

Burch colposuspension remains a durable non-mesh alternative, although it is more invasive.

Bulking agents offer the least invasive surgical option but generally have lower and less durable success rates.

Fascia lata allograft represents an intriguing middle ground: a biological sling that avoids both synthetic mesh and the need to harvest the patient’s own fascia.

The Samson allograft is particularly interesting because its contemporary processing differs from several of the older cadaveric fascia products that generated the historical literature. Samson describes its current graft as non-irradiated human fascia lata processed using Super Critical CO₂ technology.

However, the enthusiasm should be matched by scientific caution. The historical literature demonstrates that allografts can achieve good continence outcomes, but it also demonstrates that not all allograft materials have behaved identically over time.

For patients considering this option, the most accurate discussion is therefore not “this is a better sling than mesh.” It is:

“This is a biological alternative to synthetic mesh, with encouraging historical experience but less mature long-term clinical evidence for the contemporary product.”

As further Australian experience and prospective follow-up accumulate, Samson fascia lata allograft may become an increasingly useful option in the treatment of female stress urinary incontinence.

Important note

This article is intended for general information and does not replace an individual assessment by a urologist or uro-gynaecologist. The choice between conservative management, bulking agent, synthetic MUS, biological or autologous sling and Burch colposuspension depends on the type and severity of incontinence, previous surgery, urethral function, pelvic anatomy, patient preference and overall health.

Post-Prostatectomy Urinary Incontinence

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

When urine leakage persists after prostate surgery

Urinary leakage after prostatectomy is common, particularly in the first few weeks and months following surgery. For most men, bladder control progressively improves as the urinary sphincter and pelvic floor recover.

For some men, however, leakage persists and can become a significant physical, social and emotional burden.

The good news is that persistent post-prostatectomy urinary incontinence is treatable, and there are several options ranging from pelvic floor rehabilitation through to highly effective surgical treatments.

What is post-prostatectomy incontinence?

Post-prostatectomy urinary incontinence (PPI) refers to involuntary leakage of urine following surgery to remove the prostate, most commonly radical prostatectomy for prostate cancer.

The most common form is stress urinary incontinence (SUI).

You may notice leakage when:

Coughing or sneezing
Standing up
Walking or exercising
Lifting something heavy
Getting out of a chair or car
Bending over
Playing sport
During sexual activity or orgasm

Some men also experience urgency urinary incontinence, where a sudden compelling desire to urinate is followed by leakage.

Others have a combination of stress and urgency incontinence.

Why does this happen?

The prostate sits immediately below the bladder and surrounds the urethra. The urinary sphincter mechanism is therefore intimately involved with prostate surgery.

After prostatectomy, continence depends on the remaining external sphincter, pelvic floor muscles and the way the bladder stores and releases urine.

Recovery is a process rather than an on/off switch.

Most men experience substantial improvement during the first year, although the rate and extent of recovery varies between individuals. A small proportion of men continue to have bothersome leakage that requires active treatment.

How severe is the leakage?

The first step is to understand exactly what type of leakage you have and how much urine you are losing.

A consultation should look at:

1. Your symptoms

We want to know:

When did the leakage begin?
Is it improving, stable or getting worse?
Does it occur with coughing, movement or exercise?
Do you experience urgency?
How frequently do you urinate?
Do you get up at night?
Do you have difficulty emptying your bladder?
Do you leak during sexual activity or orgasm?
How much does the problem interfere with your lifestyle?

A validated questionnaire such as the ICIQ-UI Short Form can provide a standardised measure of symptoms and their impact.

Objective assessment

It is useful to measure your incontinence rather than relying solely on how many pads you use.

Different men use different numbers of pads, and a pad that is changed for comfort may contain very little urine.

Pad weight testing

A pad weight test provides a more objective measurement of urine loss.

The principle is simple:

1 gram increase in pad weight ≈ 1 mL of urine.

Depending on the clinical question, testing can be performed over a defined period or as a 24-hour pad weight assessment during normal daily activities.

For example:

Dry pads: 250 g
Used pads: 650 g

Urine loss = 400 g ≈ 400 mL

Pad testing can help:

Quantify the severity of leakage
Establish a baseline
Monitor improvement
Compare the result before and after treatment

Pad weight testing is recommended as one of the objective tools for assessing male urinary incontinence.

Why pad weight can be more useful than “number of pads”

One man’s “three pads a day” may represent a few drops on each pad.

Another man’s three pads may be completely saturated.

The number of pads therefore tells only part of the story.

The weight tells us how much urine is actually being lost.

Bladder diary

A 3-day bladder diary can be remarkably informative.

You record:

What and how much you drink
Time of each drink
Time of each urination
Volume passed
Urgency
Episodes of leakage
Activity associated with leakage
Pad changes
Night-time urination

The diary helps identify patterns that may not be obvious during a consultation.

It can distinguish, for example, between:

“I am leaking because my sphincter is weak”

and

“I am leaking because my bladder is filling rapidly and becoming overactive.”

Bladder diaries are an established method for objectively assessing frequency, voided volumes, urine production and urinary leakage.

Ultrasound assessment

An ultrasound examination can provide important additional information.

A particularly useful measurement is the post-void residual (PVR).

This tells us how much urine remains in the bladder after you have urinated.

Why does this matter?

Persistent urine in the bladder may indicate:

Poor bladder emptying
Bladder outlet obstruction
Reduced bladder contractility
Dysfunctional voiding

Ultrasound may also be used to assess the urinary tract and, where clinically appropriate, investigate other anatomical abnormalities.

Measurement of PVR is recommended in the assessment of male urinary incontinence.

Urodynamic testing

Sometimes the bladder and sphincter need to be examined in considerably more detail.

This is where urodynamics can be extremely useful.

Urodynamic testing measures how the bladder and urethra behave during filling and emptying.

It can assess:

Bladder capacity
Bladder sensation
Bladder compliance
Detrusor overactivity
Bladder pressure
Urinary flow
Bladder emptying
Sphincter function
Stress leakage
Bladder outlet obstruction

Why is this important?

Not all post-prostatectomy leakage is caused by the same problem.

A man may have:

Sphincter weakness

Overactive bladder

Poor bladder compliance

Impaired bladder contractility

or a combination of these.

Urodynamics can help distinguish bladder dysfunction from sphincteric insufficiency and can be particularly useful when the diagnosis is uncertain, bladder emptying is abnormal, or invasive treatment is being considered.

Urodynamics is not necessarily required for every man with straightforward stress incontinence.

It should be used selectively when the results are likely to influence diagnosis, counselling or treatment.

Pelvic floor muscle training

The pelvic floor is part of your continence mechanism

Pelvic floor muscle training (PFMT) is an important component of recovery after prostatectomy.

The pelvic floor muscles help support the urethra and contribute to urinary control.

The aim is not simply to perform hundreds of random “Kegels”.

Effective rehabilitation involves learning to:

Identify the correct muscles
Contract them correctly
Hold the contraction
Relax completely
Coordinate the contraction with movement and changes in abdominal pressure
Use the muscles appropriately during activities that trigger leakage

A specialised pelvic floor physiotherapist can be extremely helpful.

Timing matters

Pelvic floor exercises can be started before prostatectomy and should be continued after surgery.

Following catheter removal, pelvic floor muscle exercises or formal pelvic floor muscle training should be offered to men recovering from radical prostatectomy. Evidence suggests that they can accelerate the return of continence, particularly during the earlier stages of recovery.

However, pelvic floor exercises are not a magic switch.

If significant stress incontinence persists despite appropriate rehabilitation, it is important to reassess the situation rather than simply continuing exercises indefinitely.

When should surgery be considered?

Continence often continues to improve during the first year after prostatectomy.

For men with bothersome stress urinary incontinence who are not improving despite conservative treatment, surgical treatment can be considered from around six months, particularly when the incontinence is severe.

For persistent bothersome incontinence, surgical treatment should generally be offered by approximately 12 months rather than waiting indefinitely for further spontaneous improvement.

The exact timing should be individualised.

Surgical treatment

There is no single operation that is right for every man.

The choice depends on:

Severity of leakage
Pad weight
Time since prostatectomy
Previous radiation therapy
Urethral anatomy
Bladder function
Previous continence surgery
Manual dexterity
Patient expectations and preferences

The major surgical options include:

1. Male sling

A male sling supports and/or repositions the urethra to improve urinary control.

It is generally most suitable for mild to moderate stress urinary incontinence.

A sling may be particularly attractive to men who:

Have relatively low-volume leakage
Have not received pelvic radiation
Have good bladder function
Prefer a treatment without a mechanical pump

However, male slings are not routinely recommended for severe stress incontinence, where outcomes are generally less reliable than with an artificial urinary sphincter.

2. Artificial urinary sphincter

For significant or severe post-prostatectomy stress incontinence, the artificial urinary sphincter (AUS) remains the benchmark surgical treatment.

The device consists of:

A cuff around the urethra
A small control pump in the scrotum
A pressure-regulating balloon

When the cuff is inflated, the urethra is closed.

When you want to urinate, you squeeze the pump.

The cuff temporarily opens, allowing urine to pass.

It then automatically closes again.

Who is an AUS suitable for?

An AUS can be considered for men with mild through severe stress urinary incontinence, particularly when conservative treatment has failed.

Before implantation, the patient needs sufficient manual dexterity and cognitive ability to operate the device.

What are the disadvantages?

An AUS is a mechanical implant.

Potential complications include:

Infection
Urethral erosion
Mechanical failure
Persistent or recurrent leakage
Urethral atrophy
Need for revision or replacement

The device can provide excellent long-term continence, but patients should understand that it is not necessarily a “fit it and forget it” solution. Reoperations become more common as the device ages.

3. Adjustable continence devices

Adjustable balloon systems are another option in selected men.

These devices provide external compression around the urethra and can be adjusted following implantation.

They may be considered in selected patients, particularly those with mild incontinence and appropriate anatomy.

The evidence base is less extensive than that for the AUS, and device complications and explantation need to be discussed carefully.

4. Urethral bulking injections

Injectable bulking agents have historically been used to try to improve urethral closure.

They are minimally invasive, but their effectiveness in men following prostatectomy is limited.

Patients should understand that cure is uncommon and durability is poor compared with established surgical treatments.

They are therefore not generally considered the preferred treatment for significant post-prostatectomy stress incontinence.

What if you have urgency as well?

Not every leak after prostatectomy is caused by the sphincter.

Some men develop overactive bladder symptoms, including:

Urgency
Frequency
Nocturia
Urgency-associated leakage

This may require treatment directed at the bladder rather than the sphincter.

Treatment may include:

Bladder training
Fluid modification
Pelvic floor rehabilitation
Medication
Selected minimally invasive treatments for overactive bladder

If urgency is the dominant problem, it should be treated as an overactive bladder rather than assuming that an operation on the sphincter will solve everything.

What about men who have had radiotherapy?

Previous pelvic radiotherapy is particularly important when choosing surgery.

Radiation can affect the tissues and urethral blood supply and may increase the risk of complications and treatment failure.

For men with stress incontinence following radiotherapy, an artificial urinary sphincter is generally preferred over a male sling or adjustable balloon device.

This is one reason why your previous prostate cancer treatment is an important part of the surgical decision.

The decision is about more than pads

The goal of treatment is not simply:

“How many pads can we get you down to?”

It is about getting you back to the life you want to live.

That might mean being able to:

Exercise without worrying about leakage
Play golf or tennis
Go out without carrying spare pads
Travel confidently
Sleep without constantly worrying about leakage
Wear the clothes you want
Be intimate with your partner without anxiety

The appropriate treatment depends on both the objective severity of the incontinence and how much it affects your quality of life.

A practical assessment pathway

Step 1

Understand the symptoms

Stress leakage? Urgency? Mixed symptoms? Night-time leakage?

Step 2

Measure the problem

Validated questionnaire + bladder diary + pad weight.

Step 3

Check bladder emptying

Ultrasound and post-void residual.

Step 4

Assess pelvic floor function

Pelvic floor assessment and physiotherapy where appropriate.

Step 5

Look deeper when necessary

Urodynamics, and additional investigations such as cystoscopy when clinically indicated.

Step 6

Treat the cause

Bladder-directed treatment for urgency/detrusor dysfunction.

Sphincter-directed treatment for genuine stress incontinence.

Step 7

Consider surgery when appropriate

Mild–moderate SUI: male sling may be appropriate in selected men
Moderate–severe SUI: artificial urinary sphincter is often the preferred option
Severe SUI: AUS generally favoured over sling
Previous radiotherapy: AUS generally preferred
Failed sling: AUS is usually the most effective subsequent option

Don’t just put up with it

Urinary leakage after prostatectomy is common, but persistent incontinence should not simply be accepted as the price of prostate cancer treatment.

If leakage is interfering with your life, there is a structured pathway to determine exactly what is happening and what can be done about it.

A combination of symptom assessment, bladder diary, pad weight measurement, ultrasound, pelvic floor assessment and, where appropriate, urodynamics can provide a much clearer picture.

From there, treatment can be tailored to the individual, ranging from rehabilitation through to reconstructive continence surgery.

The aim is simple: better bladder control, greater confidence and getting you back to doing the things that matter to you.

When should you seek specialist assessment?

Consider seeing a urologist specialising in male continence if:

Significant leakage persists beyond the early recovery period
You are still using multiple pads several months after surgery
Leakage is affecting exercise, work, travel or intimacy
You have both urgency and stress leakage
You have difficulty emptying your bladder
You have previously had pelvic radiation
Your incontinence is getting worse rather than better
You are considering surgical treatment

Medical disclaimer

This information is intended for general educational purposes and does not replace an individual medical assessment. The appropriate investigation and treatment of urinary incontinence depends on your medical history, previous prostate treatment, bladder function, urethral anatomy and individual circumstances.

Men’s Guide to Lower Urinary Tract Symptoms: What’s Causing Them and What Can Be Done?

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

Men’s Guide to Lower Urinary Tract Symptoms: What’s Causing Them and What Can Be Done?

Getting up at night to pee? A weaker stream? Feeling like your bladder never quite empties?

If you are a man over 40, there is a reasonable chance you have experienced one or more of these symptoms:

Getting up several times during the night to urinate
A weak or slowing urinary stream
Difficulty getting started
Having to strain or wait for the urine to start
Urgency or rushing to the toilet
Going to the toilet frequently
Dribbling after urination
Feeling that your bladder has not emptied
Stopping and starting during urination
Occasionally leaking urine

Collectively, these are called lower urinary tract symptoms, or LUTS.

The important thing to understand is that LUTS are symptoms, not a diagnosis.

And while an enlarged prostate is a common culprit, it isn’t the only one.

Your bladder, prostate, urethra, medications, fluid intake, sleep, diabetes, neurological conditions and even certain lifestyle factors can all contribute.

The good news? There is a surprisingly large toolbox available to treat bothersome urinary symptoms.

First things first: it isn’t always “just the prostate”

The prostate sits underneath the bladder and surrounds the urethra, the tube through which urine leaves the body.

As men get older, the prostate commonly enlarges. This is known as benign prostatic enlargement (BPE) and is part of the condition commonly referred to as benign prostatic hyperplasia (BPH).

An enlarged prostate can narrow the urinary channel and create bladder outlet obstruction (BOO).

But there is a twist.

A man can have a large prostate and relatively few symptoms. Another man can have a modestly enlarged prostate and significant symptoms.

And sometimes the prostate isn’t the main problem at all.

The bladder may become overactive, underactive or less compliant. A urethral stricture may narrow the urinary passage. Infection, stones, neurological disease, diabetes, excessive evening fluid intake and sleep disorders can also contribute.

This is why simply saying, “Your prostate is enlarged, let’s treat the prostate,” isn’t always the right answer.

So how do you investigate LUTS?

The aim of the assessment is not simply to measure the size of your prostate.

The real question is:

Why are you having these symptoms, and which treatment is most likely to help you?

Current European guidelines recommend a structured assessment that includes symptoms, examination and appropriate testing.

1. Your story matters

Your doctor will ask about:

What symptoms you have
How long you’ve had them
How much they bother you
How often you urinate
How many times you get up at night
Your urinary stream
Urgency and leakage
Previous urinary problems or operations
Medications
Fluid, caffeine and alcohol intake
Medical conditions such as diabetes or neurological disease
Sexual and ejaculatory function

You may be asked to complete a questionnaire such as the International Prostate Symptom Score (IPSS).

This is useful because your perception of the problem matters. A slightly abnormal test with minimal bother doesn’t necessarily require treatment, whereas quite modest objective abnormalities can be very troublesome for another man.

2. Examination

This generally includes an abdominal and genital examination and, where appropriate, a digital rectal examination (DRE) to assess the prostate.

Yes, it is brief.

No, it isn’t anyone’s favourite part of the consultation.

But it can provide useful information.

3. Urine testing

A urine dipstick or microscopy can look for:

Infection
Blood
Glucose
Protein
Other abnormalities

Blood in the urine should not simply be blamed on an enlarged prostate. It may require further investigation.

4. PSA

A prostate-specific antigen (PSA) blood test may be appropriate.

PSA is not simply a “prostate enlargement test.” It can contribute to assessment of prostate cancer risk and can also provide information relevant to prostate enlargement and the risk of future progression.

Whether you should have a PSA depends on your age, risk factors, symptoms and whether the result would change management.

5. Bladder scan

An ultrasound scan can measure the amount of urine left in the bladder after you have urinated.

This is called the post-void residual (PVR).

A large residual may indicate significant obstruction, poor bladder contraction or a combination of the two.

6. Uroflowmetry

This is one of my favourite simple urological tests because it is essentially a sophisticated way of answering:

“How fast does this man actually pee?”

You urinate into a special machine that measures the flow rate.

It provides information about the strength and pattern of the urinary stream and is particularly useful when interpreted alongside the PVR and symptoms.

Guidelines recommend performing uroflowmetry before treatment when possible.

7. Ultrasound

Ultrasound can assess:

Prostate size
Prostate shape
Median lobe enlargement
Bladder abnormalities
Residual urine
Kidneys and upper urinary tract where indicated

Knowing the size and shape of the prostate becomes particularly important if surgery or a minimally invasive procedure is being considered.

8. Bladder diary

If your main complaint is frequency or getting up repeatedly at night, a three-day bladder diary can be extremely useful.

You record:

When you drink
How much you drink
When you urinate
How much you pass
How many times you get up at night

This can reveal whether the problem is actually prostate obstruction, an overactive bladder, excessive nighttime urine production or something else.

9. Cystoscopy

A small camera can be passed through the urethra to look directly at the urethra, prostate and bladder.

It isn’t necessary for every man with LUTS.

It becomes particularly useful when there is concern about a urethral stricture, bladder pathology, haematuria, previous surgery, or before certain procedures where the findings could influence treatment selection.

10. Urodynamics

Sometimes the most important question is:

Is the prostate obstructing the bladder, or is the bladder itself struggling to push urine out?

Urodynamic testing can distinguish conditions such as bladder outlet obstruction, detrusor overactivity and impaired bladder contractility.

It isn’t necessary for everyone. It is generally reserved for selected men when the diagnosis is uncertain or when the result could change the treatment decision, particularly before invasive treatment in certain circumstances.

Treatment: there is no single “best” treatment

Treatment should be tailored to the man, not simply to his prostate.

The options range from doing nothing for now, through lifestyle measures and medication, all the way to minimally invasive procedures and major surgery.

The right treatment depends on:

Your symptoms
How much they bother you
Prostate size and anatomy
Flow rate
Residual urine
Bladder function
Your general health
Your priorities
Your attitude toward medication and procedures
Whether preservation of ejaculation is important to you

1. Watchful waiting and lifestyle changes

Not every man needs a procedure.

If symptoms are mild and aren’t significantly affecting your quality of life, monitoring may be entirely appropriate. Many men remain stable for years.

Simple measures can help:

Things worth trying

Reduce large amounts of fluid before bed
Moderate caffeine intake
Reduce evening alcohol
Avoid deliberately “holding on” for excessive periods
Treat constipation
Review medications that may worsen urinary symptoms
Manage diabetes and other medical conditions
Maintain a healthy weight
Stay physically active

For some men, these seemingly boring interventions make a surprisingly large difference.

2. Medication

If symptoms are bothersome, medication is often the first active treatment.

Alpha-blockers

Examples include:

Tamsulosin
Silodosin
Alfuzosin
Doxazosin
Terazosin

These medications relax smooth muscle around the prostate and bladder outlet, making it easier for urine to pass.

They often work relatively quickly.

Potential side effects include:

Dizziness
Low blood pressure
Nasal congestion
Ejaculatory changes

The different drugs have different side-effect profiles, so the choice can be individualised.

One important point: if you are taking an alpha-blocker and are planning cataract surgery, tell your ophthalmologist because of the association with intraoperative floppy iris syndrome.

5-alpha-reductase inhibitors

These include:

Finasteride
Dutasteride

They work differently from alpha-blockers.

Rather than simply relaxing the prostate, they reduce the hormonal stimulation responsible for prostate growth and can gradually shrink the prostate.

They are particularly useful in men with larger prostates and a higher risk of progression.

The downside?

They take considerably longer to work.

They can also reduce libido and ejaculatory volume and may affect erectile function in some men.

They also lower PSA, which needs to be taken into account when interpreting PSA results.

Combination therapy

For some men with significant symptoms and an enlarged prostate, an alpha-blocker can be combined with a 5-alpha-reductase inhibitor.

This gives relatively rapid symptom relief from the alpha-blocker while the 5-alpha-reductase inhibitor works more slowly on the underlying prostate enlargement.

Medication for an overactive bladder

Not every man with urinary urgency and frequency needs his prostate treated.

If the bladder is overactive, medications such as:

Antimuscarinic drugs
Beta-3 agonists such as mirabegron

may be appropriate.

These treatments target the bladder rather than the prostate.

Tadalafil

Interestingly, a medication better known for treating erectile dysfunction can also improve LUTS.

Tadalafil, a PDE5 inhibitor, can be useful in men who have both urinary symptoms and erectile dysfunction.

This is one of those pleasing examples where treating two problems with one tablet is possible.

3. Minimally invasive treatments

If medication isn’t working, causes side effects, or simply isn’t something you want to take indefinitely, there is now a growing middle ground between tablets and conventional surgery.

These treatments aim to relieve obstruction while generally reducing the surgical burden and, in some cases, preserving sexual or ejaculatory function.

UroLift / Prostatic Urethral Lift

Small implants are placed to pull prostate tissue away from the urethra and open the urinary channel.

The attraction is that there is no tissue removal and sexual and ejaculatory function are generally well preserved.

It is particularly suited to selected men with relatively small prostates and appropriate anatomy.

The trade-off is that symptom improvement may be less than with TURP, and retreatment rates are higher. Current EAU guidance recommends it for selected men with prostate volumes under about 70 mL and without a middle lobe.

Rezūm / water-vapour therapy

Steam is delivered into the prostate.

The heat destroys targeted prostate tissue, which subsequently shrinks, opening the urinary channel.

The procedure can be performed without conventional tissue resection and has the advantage of generally preserving sexual function.

The downside is that improvement is not immediate. There can be a period of urinary irritation, frequency and discomfort while the prostate settles.

Aquablation

Aquablation is a fascinating newer technology.

Instead of cutting the prostate with a conventional electrosurgical instrument or laser, a computer-guided high-pressure water jet removes precisely targeted prostate tissue.

Real-time imaging helps guide the treatment.

It can be particularly attractive to men who want effective tissue removal while placing a high priority on preservation of ejaculation.

Current EAU guidance supports Aquablation as an alternative to TURP in appropriately selected men with prostate volumes around 30–80 mL, particularly where preservation of ejaculatory function is important. Long-term data also support its use in selected larger prostates.

Aquablation is available in Australia, although access varies between centres.

Prostatic artery embolisation

This is performed by an interventional radiologist.

The blood supply to the prostate is selectively reduced, causing the prostate to shrink over time.

It avoids transurethral surgery and can be attractive to selected men who strongly prefer a minimally invasive approach.

However, outcomes are generally less predictable than established surgical procedures, and patient selection is important. Current EAU guidance emphasises collaboration between urologists and appropriately trained interventional radiologists.

4. Traditional surgery: still very much alive and kicking

Sometimes the best solution is simply to remove the obstruction.

And despite the arrival of a parade of newer technologies, conventional surgery remains extremely effective.

TURP

Transurethral resection of the prostate, or TURP, has been the benchmark against which many newer procedures are compared.

A telescope is passed through the penis into the prostate and obstructing tissue is removed from inside the prostate.

There is no abdominal incision.

TURP provides excellent, durable improvement in urinary flow and symptoms.

Potential complications include bleeding, infection, urethral stricture, bladder neck contracture, temporary or persistent urinary leakage and sexual side effects.

One of the most common long-term effects is retrograde ejaculation, where semen travels into the bladder rather than out through the penis during orgasm.

The orgasm can still occur, but fertility and the visible ejaculation of semen may be affected.

5. Laser prostate surgery

Laser technology has transformed prostate surgery.

Rather than using a conventional electrical cutting loop, lasers can vaporise, resect or enucleate prostate tissue.

HoLEP

Holmium Laser Enucleation of the Prostate, or HoLEP, is one of the most important modern surgical options.

The surgeon uses a laser to separate the obstructing prostate adenoma from the surrounding prostate capsule. The tissue is then removed from the bladder and sent for pathological examination.

Think of it as shelling the obstructing prostate out from inside its capsule.

HoLEP has several advantages:

Excellent symptom improvement
Excellent improvement in urinary flow
Suitable for small and very large prostates
Durable results
Excellent haemostasis
Less bleeding than some traditional approaches
Can be performed in men taking certain blood-thinning medications in appropriately selected circumstances

Current EAU guidelines strongly recommend HoLEP as an alternative to TURP or open prostatectomy for appropriate men with moderate-to-severe LUTS due to benign prostatic obstruction.

HoLEP does, however, have a learning curve. The experience of the surgeon matters.

Thulium laser enucleation

Another laser-based option is ThuLEP, or thulium laser enucleation of the prostate.

It follows similar principles to HoLEP and can provide comparable symptom and flow improvements.

The precise technology available varies between hospitals and surgeons.

GreenLight laser / laser vaporisation

Laser vaporisation uses laser energy to vaporise obstructing prostate tissue.

It can be particularly useful in selected men with smaller or medium-sized prostates and has favourable bleeding characteristics.

Laser vaporisation has also been used extensively in men taking antiplatelet or anticoagulant medications, although individual assessment is essential.

6. Very large prostates

When the prostate becomes very large, treatment choices change.

Historically, the answer was an open simple prostatectomy, where the obstructing inner portion of the prostate is surgically removed through an abdominal approach.

It remains effective, but it is considerably more invasive.

Today, endoscopic enucleation procedures such as HoLEP can often achieve similar long-term results without an open operation.

For very large glands, the choice may therefore come down to:

HoLEP or another enucleation procedure versus robotic/open simple prostatectomy, depending on anatomy, surgeon expertise and available technology.

The EAU currently recommends open prostatectomy primarily when endoscopic enucleation is unavailable for men with very large prostates.

So which treatment is best?

There isn’t one answer.

A useful way of thinking about it is:

Situation	Possible approach
Mild symptoms, little bother	Lifestyle + observation
Moderate symptoms	Medication
Enlarged prostate with progression risk	Alpha-blocker ± 5-alpha-reductase inhibitor
Urgency/frequency from overactive bladder	Bladder-directed medication
LUTS + erectile dysfunction	Consider tadalafil
Small/medium prostate, want minimally invasive treatment	UroLift, water-vapour therapy or other selected MIST
Want tissue removal with potential preservation of ejaculation	Aquablation in suitable patients
Standard durable surgical treatment	TURP
Medium/large prostate	TURP, laser or enucleation depending on anatomy
Large prostate	HoLEP/ThuLEP or simple prostatectomy
Very large prostate	Enucleation or robotic/open simple prostatectomy

The important point is that prostate size alone should not dictate the treatment.

Anatomy, bladder function, symptoms, medical history and your personal priorities all matter.

When should you stop taking tablets and consider surgery?

There is no prize for remaining on medication forever.

If medication works well and you are happy with it, excellent.

But surgery or an intervention becomes increasingly reasonable when:

Symptoms remain troublesome despite medication
Medication causes unacceptable side effects
You develop recurrent urinary retention
You have recurrent urinary tract infections
You develop bladder stones
There is significant bleeding attributed to prostate enlargement
There is significant residual urine or deterioration of bladder function
The upper urinary tract becomes affected
Your quality of life is being significantly affected

These are recognised indications for surgical intervention in appropriate patients.

And what about sex?

This deserves a proper conversation.

Urinary symptoms and sexual function frequently coexist, but treating the prostate can sometimes affect sexual function.

Depending on the treatment, there may be effects on:

Ejaculation
Erectile function
Libido
Orgasm
Fertility

For some men, preservation of ejaculation is a major priority.

For others, the priority is simply being able to empty their bladder properly and sleep through the night.

Neither priority is wrong.

The important thing is to tell your urologist what matters to you before choosing a procedure.

Different procedures have different sexual side-effect profiles, and this should form part of the decision rather than being discovered afterwards.

Don’t automatically blame everything on your prostate

One of the biggest mistakes men make is assuming:

“I’m getting older, my stream is weaker, therefore my prostate is enlarged.”

Perhaps.

But perhaps not.

LUTS can arise from several different mechanisms, and the treatment that works beautifully for one man may do very little for another.

A good assessment should answer three questions:

1. What symptoms am I actually experiencing?

2. What is causing them?

3. What treatment gives me the best balance between improvement, side effects, durability and quality of life?

Once those questions are answered, the treatment options become much clearer.

When should you see a doctor urgently?

Seek prompt medical assessment if you develop:

An inability to pass urine
Significant blood in the urine
Fever or chills with urinary symptoms
Severe pain
Recurrent urinary infections
New kidney problems
Significant deterioration in your urinary function

Acute urinary retention, in particular, is not something to simply wait out at home.

The bottom line

Lower urinary tract symptoms are common in men, but putting up with them is not an inevitable part of ageing.

There is an increasingly sophisticated range of treatments available, from lifestyle changes and medication through to minimally invasive therapies, TURP, laser procedures, Aquablation and advanced enucleation techniques such as HoLEP.

The trick is not finding the best treatment.

It is finding the best treatment for you.

And that starts with a proper assessment rather than simply assuming that every urinary problem is caused by “the prostate.”

If your bladder is running the night shift, your stream has become a garden hose on low pressure, or you are planning your day around finding toilets, it may be time to have it properly assessed.

Medical note: This is patient education rather than individual medical advice. The investigation and treatment approach should be tailored to the individual, particularly where there is haematuria, urinary retention, recurrent infection, neurological disease or concern about prostate cancer. The treatment information above reflects contemporary EAU guidance, including the 2026 guideline update.

Blood in the Urine (Haematuria): When Should You See a Urologist Brisbane?

June 22, 2026/0 Comments/in Blog Post/by rose

Discovering blood in your urine can be alarming. While there are many possible causes, blood in the urine should never be ignored. Known medically as haematuria, this symptom can sometimes indicate an underlying condition requiring specialist assessment. Consulting an experienced Urologist Brisbane patients rely on can help identify the cause and provide appropriate treatment.

What Is Haematuria?

Haematuria refers to the presence of blood in the urine. It can occur in two forms:

Visible Haematuria

The urine appears pink, red or brown due to the presence of blood.

Microscopic Haematuria

Blood cells are detected only during laboratory testing and may not be visible to the naked eye.

Both forms should be assessed by a healthcare professional.

Common Causes of Blood in the Urine

There are numerous possible causes of haematuria, including:

Urinary Tract Infections

Infections affecting the bladder, kidneys or urinary tract can cause irritation and bleeding.

Kidney Stones

Kidney stones can damage the lining of the urinary tract, resulting in blood appearing in the urine.

Enlarged Prostate

An enlarged prostate can place pressure on the urinary system and may contribute to urinary symptoms and bleeding.

Vigorous Exercise

In some cases, intense physical activity can lead to temporary blood in the urine.

Kidney Disease

Various kidney conditions may result in haematuria and require specialist management.

Urinary Tract Cancers

Although less common, blood in the urine can sometimes be associated with cancers affecting the bladder, kidney or urinary tract. This is one reason why prompt evaluation by a Urologist Brisbane specialist is important.

Symptoms That May Accompany Haematuria

Depending on the underlying cause, patients may also experience:

Pain during urination
Frequent urination
Lower abdominal discomfort
Back or flank pain
Difficulty passing urine
Fever or chills

These symptoms can provide valuable clues during diagnosis.

How Does a Urologist Brisbane Diagnose Haematuria?

A comprehensive evaluation may include:

Medical History and Physical Examination

Your specialist will discuss symptoms, medical history and risk factors.

Urine Testing

Urinalysis helps identify infection, blood cells and other abnormalities.

Blood Tests

Blood tests may assess kidney function and identify underlying conditions.

Imaging Studies

Ultrasound or CT imaging can help detect stones, tumours or structural abnormalities.

Cystoscopy

A cystoscopy allows a Urologist Brisbane specialist to examine the inside of the bladder using a small camera.

Why Early Investigation Matters

While haematuria can sometimes result from minor conditions, it may also be an early warning sign of a more serious problem. Early diagnosis often leads to more effective treatment and improved outcomes.

Delaying assessment can allow certain conditions to progress and become more difficult to treat.

When Should You Seek Medical Advice?

You should arrange an appointment if:

You notice visible blood in your urine
Blood is detected during routine testing
Haematuria occurs repeatedly
You experience pain or urinary symptoms
You have a history of smoking or urinary tract conditions

Speak with a Urologist Brisbane Today

If you have noticed blood in your urine or have concerns about your urinary health, our experienced team is here to help. We provide thorough assessments, advanced diagnostic services and personalised treatment plans to identify the cause and protect your long-term health. Contact our clinic today to book a consultation with a trusted Urologist Brisbane specialist.

Kidney Stones: Symptoms, Causes and Treatment Options Explained

June 22, 2026/0 Comments/in Blog Post/by rose

Kidney stones: symptoms, treatment and prevention

Kidney stones can cause sudden, intense pain, but some are discovered by chance and cause no symptoms. The right treatment depends on where a stone sits, its size, whether urine can drain, whether infection is present and how well the kidneys are working. If you have suspected stone pain, an assessment can establish which approach is safest for you.

What is a kidney stone?

A kidney stone forms when substances in urine crystallise and grow. Calcium-based stones are common; other types include uric acid, infection-related (struvite) and cystine stones. A stone may remain in the kidney or move into the ureter, the tube carrying urine to the bladder. A ureteric stone can obstruct urine flow and cause renal colic.

Symptoms to recognise

Severe pain in the side or back that may travel towards the lower abdomen or groin, often in waves
Blood in the urine, which may be visible or detected on a test
Nausea or vomiting
Urgency, frequent urination or discomfort passing urine, particularly when a stone is near the bladder

Cloudy urine, fever or chills may indicate infection. These symptoms also have other possible causes, so imaging and tests are important.

Seek urgent care at an emergency department if you have fever or chills with suspected stone pain, cannot pass urine, cannot keep fluids down, have pain that cannot be controlled, or have a single functioning kidney or known kidney disease with possible obstruction. An infected, obstructed kidney is a urological emergency: antibiotics and urgent drainage with a ureteric stent or nephrostomy may be needed before definitive stone treatment.

Why do stones form?

Low fluid intake, heavy sweating, a high-salt diet, previous stones and family history can increase risk. Other contributors include certain medicines and conditions such as gout, bowel disease or recurrent infection. The causes differ by stone type. Finding the type matters when planning prevention.

How are kidney stones diagnosed?

Assessment usually includes your symptoms and medical history, urine testing for blood and infection, and blood tests to check kidney function when appropriate. A low-dose CT scan without contrast is often used for adults with suspected renal colic because it shows the size and position of a stone and signs of obstruction. Ultrasound may be preferred first in pregnancy and some other circumstances. If you pass or have a stone removed, laboratory analysis can guide future prevention.

What are the treatment options?

Observation and pain relief. Many small ureteric stones pass without a procedure. This is reasonable when pain is controlled, there is no infection or concerning obstruction, and kidney function is safe. Your clinician will arrange follow-up to confirm that the stone has passed or the obstruction has resolved. Pain relief is tailored to your health; anti-inflammatory medicines may be useful but are unsuitable for some people, including those with impaired kidney function. Drink normally and avoid dehydration; forcing large amounts of water during acute colic does not push a blocked stone through.

Medication to help passage. An alpha blocker may improve passage for selected stones in the lower ureter, especially those around 5–10 mm. This use is off-label and should be discussed alongside possible adverse effects, such as dizziness. It is not suitable as a substitute for urgent treatment if infection, uncontrolled pain or worsening kidney function develops.

Shock wave lithotripsy (SWL or ESWL). Shock waves delivered from outside the body break a suitable stone into fragments. Its success depends on factors including stone size, position and density; further treatment can sometimes be needed.

Ureteroscopy and laser treatment. A fine telescope passes through the urethra and bladder into the ureter or kidney. The stone can be removed or fragmented with a laser. A temporary ureteric stent is sometimes placed and can cause urinary discomfort until removal.

Percutaneous nephrolithotomy (PCNL). For some large or complex kidney stones, instruments are passed through a small opening in the back to remove the stone. This is more invasive than ureteroscopy or shock wave treatment and has its own bleeding and infection risks.

Your urologist will discuss the expected chance of clearing the stone, anaesthetic needs, recovery, possible stenting and risks of each appropriate option.

Reducing the chance of another stone

For most people, drinking enough fluid to keep urine dilute is a useful starting point, particularly in Queensland heat. If you have heart failure or kidney disease, follow your treating team’s fluid advice instead of increasing intake on your own. Reduce excess salt, maintain a balanced diet and avoid unnecessarily restricting normal dietary calcium. Further dietary advice or preventive medication should be based on the stone’s composition and, for recurrent or higher-risk stones, blood and 24-hour urine testing. Follow-up imaging may be recommended to check for residual or new stones.

When should you see a urologist in Brisbane?

Arrange an assessment if you have a diagnosed stone that has not passed, recurrent stones, persistent pain, blood in the urine, or concerns about kidney function. If you are acutely unwell or have fever with stone symptoms, go to an emergency department rather than waiting for a routine appointment.

This article is general information and does not replace individual medical advice.

References

European Association of Urology. EAU Guidelines on Urolithiasis (2026).
National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management (NG118).
Healthdirect Australia. Kidney stones: symptoms, diagnosis and treatment.
Kidney Health Australia. Kidney stones.

Management Options for Benign Prostate Hyperplasia

June 3, 2026/0 Comments/in Blog Post, Prostate Surgery/by drjo

What is BPH?

Benign Prostate Hyperplasia

(BPH) is a non-cancerous enlargement of the prostate gland that commonly affects men as they age.

As the prostate grows, it can press on the urethra and cause urinary symptoms such as:

Frequent or urgent need to urinate
Difficulty starting urination
Weak urine stream or dribbling
Getting up multiple times at night
Feeling the bladder hasn’t fully emptied

Watchful Waiting & Lifestyle Changes

Active Monitoring

Annual check-ups with your doctor
Symptom tracking using validated scores
Prostate size monitoring
~79% of patients remain stable over 5 years

Lifestyle Adjustments

Reduce fluids before bedtime
Limit caffeine and alcohol
Avoid decongestants & antihistamines
Practice timed voiding
Stay active and maintain healthy weight

Medications

Alpha-Blockers

Fast-acting relief

Relax prostate & bladder neck muscles
Improve urine flow within days
Examples: tamsulosin, alfuzosin
May cause dizziness or low blood pressure

5-Alpha Reductase Inhibitors

Long-term shrinkage

Shrink prostate over 6-12 months
Best for larger prostates (>40 cc)
Examples: finasteride, dutasteride
Can be combined with alpha-blockers

PDE5 Inhibitors (Tadalafil)

Dual benefit

Daily low-dose relaxes smooth muscle
Also treats erectile dysfunction
Newer AUA guidelines support combos
Preserves ejaculatory function

Minimally Invasive Procedures

Rezum – Steam Therapy
UroLift – Prostatic Lift
iTIND – Temporary Implant

Surgical Options

TURP
HoLep
Greenlight Vaporization (PVP)
Robotic Simple Prostatectomy

TURP remains the traditional gold standard. HoLEP and RSP offers the best long-term durability, especially for larger prostates.

HoLEP: Lowest retreatment rate (2% at 10 years), works for all prostate sizes. GreenLight: Same-day discharge, safe on blood thinners.

Choosing the Right Treatment

Treatment depends on several individual factors. Discuss these with your doctor:

Symptom severity and how much they bother you
Prostate size (small, medium, or large)
Whether medications have been tried already
Recovery time and return-to-activity goals
Sexual function priorities (ejaculation, erections)

Key Takeaways

BPH is very common and not cancerous — effective treatments are available at every stage
Mild symptoms often improve with simple lifestyle changes and regular monitoring
Medications can significantly reduce symptoms; newer combinations offer added benefits.
Minimally invasive procedures preserve sexual function with quick recovery times.
Surgery provides the most durable results for larger prostates or severe symptoms.

Talk to your urologist about which option is right for you

How Diet & Lifestyle Can Support Prostate Health

March 28, 2026/0 Comments/in Blog Post/by agileadmin

Prostate health: food, movement and informed testing

The prostate is a small gland below the bladder that contributes fluid to semen. It surrounds the first part of the urethra, so changes in the prostate can affect urination. Prostate enlargement, inflammation and cancer are different conditions; urinary symptoms alone cannot tell us which, if any, is present.[1, 2]

A healthy diet and regular activity support overall wellbeing. They may help some people manage weight and cope with treatment, but no food or exercise programme has been shown to guarantee prevention of prostate enlargement or prostate cancer. Similarly, a “check-up” is not the same thing as screening everyone for cancer: the decision to have a PSA blood test should take account of age, individual risk, preferences and the possible harms of testing.[3, 4]

What can affect the prostate?

Benign prostate enlargement (BPH) becomes more common with age. It may cause a weak stream, hesitancy, more frequent urination or waking at night. Similar symptoms can come from bladder conditions, medicines or other causes. Treatment depends on the degree of bother and any complications, and can range from monitoring and practical changes to medicines or a procedure.[1]

Prostatitis describes inflammation of the prostate and has several forms. Pain, urinary symptoms or fever require assessment; diet alone will not diagnose or treat the cause.[1]

Prostate cancer often causes no symptoms in its early stages. Some cancers grow slowly and may never need treatment; others are more aggressive. An abnormal PSA result does not by itself establish a cancer diagnosis.[2, 4]

Is there a “prostate-friendly” diet?

It is reasonable to use this phrase for a varied, balanced eating pattern, but it should not imply that a particular menu protects the prostate. The Australian Dietary Guidelines recommend vegetables, fruit, mostly wholegrain cereals, appropriate protein foods and water as a usual drink, while limiting foods high in added salt and saturated fat.[5] Food choices should also fit a person’s other conditions and cultural preferences.

The foods often promoted for prostate health can fit into that pattern, with important limits to the evidence:

Food	What it offers	What remains unproven
Tomatoes	A vegetable source of lycopene and other nutrients	Eating tomatoes or taking lycopene supplements has not been established as a way to prevent or treat prostate cancer.[3, 6]
Broccoli and cauliflower	Vegetables that add variety and fibre	Laboratory theories about their compounds do not prove that they prevent prostate disease in people.[3]
Salmon and sardines	Protein and, in oily fish, omega-3 fats	Fish is not a proven prostate cancer treatment or prevention strategy.[3, 5]
Green tea	A beverage some people enjoy	Antioxidant content does not establish a clinical benefit for prostate cancer; caffeine may aggravate urinary urgency in some people.[3, 7]
Chia and flaxseeds	Fibre and unsaturated fats	Eating these seeds is not proven to prevent BPH or prostate cancer.[3, 5]

No supplement should be assumed to be beneficial because it is sold as “natural” or “prostate supporting.” The SELECT trial, for example, found increased prostate cancer risk among men assigned vitamin E alone. Discuss supplements with your clinician, particularly if you are receiving treatment or taking medicines.[6]

A practical meal might include vegetables, a wholegrain food and fish, beans, eggs, tofu or another suitable protein. Add fruit or unsalted nuts and seeds according to preference. The value is in the overall pattern, not a particular “superfood.” If cancer treatment is affecting appetite or weight, an accredited practising dietitian can tailor the plan.[5, 8]

Movement, weight and everyday habits

Physical activity helps cardiovascular health, strength, mood and weight management. Australia’s current adult movement recommendations encourage activity on most days, including moderate to vigorous movement for at least 30 minutes on most days, strength activities twice a week, and mobility or balance activities on several days.[9] A walk, cycling, swimming or a manageable strength routine can be a starting point; build gradually if you have been inactive.

Excess body weight is associated with some adverse health outcomes, and Cancer Council Australia reports evidence linking overweight and obesity with prostate cancer risk. That association does not mean that weight loss prevents every prostate cancer, or that a person’s weight explains an individual diagnosis.[3]

For urinary symptoms, it can help to note when and how much you drink, whether caffeine or alcohol worsens urgency, and whether constipation is present. Drinking enough is important, but forcing large volumes can make frequency worse. These measures may ease symptoms for some people; they should not delay assessment of persistent or concerning changes.[1, 7]

If you are undergoing prostate cancer treatment, exercise may support fitness and help with treatment-related effects. The safest type and intensity depend on treatment, fatigue, bone health and other conditions. Ask your treating team or an accredited exercise physiologist for an individual plan when needed.[8]

What about PSA testing and “regular check-ups”?

A PSA test measures a protein made by the prostate. PSA may rise for reasons other than cancer, and testing can find slow-growing cancers that would never have caused harm. Further investigation and treatment can carry physical and emotional burdens. Testing may also identify a cancer at a stage when treatment can help. These benefits and harms should be discussed before testing.[2, 4]

The 2026 Australian guidelines for early detection recommend, after an informed discussion, PSA testing every two years for people aged 50–69 who choose testing. Routine testing at 45–49 is generally not recommended for average-risk people, although an interested person may be offered an initial test. People at higher risk, including those with certain family histories, Black sub-Saharan ancestry or a BRCA2 mutation, may be advised to start two-yearly testing at 45. For people aged 70 or older, the decision is individualised according to health, life expectancy and preferences.[4]

These are recommendations for people without symptoms. New difficulty passing urine, blood in the urine, persistent pain or other concerning symptoms call for assessment regardless of age or a planned PSA testing schedule. A GP is a sensible first contact and can arrange testing or referral when indicated.[2, 4]

A sustainable approach

Eat a varied diet, move regularly in ways you can sustain, and talk with your GP about symptoms and whether PSA testing makes sense for your age and risk. Healthy living is valuable in its own right, while medical decisions remain individual. There is no guarantee that these steps will prevent prostate disease, and a diagnosis does not mean someone has failed to look after their health.

General information only. This article does not replace personal medical advice or a discussion of the benefits and harms of PSA testing.