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PUJ obstruction: when urine cannot drain freely from the kidney

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Understanding pelvi-ureteric junction obstruction, its symptoms, investigations and treatment, including robotic-assisted pyeloplasty.

The kidneys produce urine, which collects in a funnel-shaped area called the renal pelvis before travelling down the ureter to the bladder. The pelvi-ureteric junction (PUJ) is where this funnel joins the ureter.

PUJ obstruction means urine does not pass freely through this junction. It is also called ureteropelvic junction obstruction, or UPJ obstruction. The collecting system can enlarge, a finding called hydronephrosis, and significant obstruction may eventually damage the affected kidney. However, a dilated collecting system does not automatically mean surgery is needed. Assessment must establish whether drainage is impaired and whether kidney function is at risk. [1,2]

What causes PUJ obstruction?

Some people are born with a short segment that is narrow or does not propel urine normally. Other anatomical causes include kinking or a ureter that joins the renal pelvis unusually high up. A blood vessel supplying the lower part of the kidney may cross the junction and contribute to compression. Seeing a crossing vessel on a scan does not, by itself, prove that it is causing obstruction.

A congenital problem may first become apparent in adulthood. Acquired narrowing can follow scarring, inflammation or previous surgery. Stones and other causes of upper urinary tract blockage must also be considered during investigation. [2,12]

How does it present?

Symptoms range from none at all to episodes of significant pain. Possible presentations include:

  • Aching or intermittent pain in the flank, the side of the back below the ribs.
  • Episodes of more severe pain, sometimes with nausea or vomiting.
  • Pain after a large fluid intake, when urine production increases.
  • Recurrent urinary infections, including infection of the kidney.
  • Blood in the urine or kidney stones.
  • An incidental finding of hydronephrosis on a scan.

Intermittent painful distension is sometimes called a Dietl’s crisis. These symptoms can also have other causes, so pain or blood in the urine should not simply be attributed to a known PUJ problem. [3,12]

Children may be diagnosed following an antenatal ultrasound. Childhood assessment and treatment decisions differ from those in adults and should involve a paediatric urology team. [3]

Which investigations are useful?

The investigation plan answers three questions: What does the anatomy look like? How well does each kidney function? Is urine drainage genuinely obstructed?

Urine and blood tests

Urine testing looks for blood and evidence of infection; a urine culture is useful when infection is suspected. Blood tests include creatinine and estimated glomerular filtration rate (eGFR). These assess overall kidney function, but can remain normal when the other kidney compensates for an affected kidney. [2,10]

Ultrasound

Ultrasound shows collecting-system dilatation and assesses the thickness of the kidney tissue. It is useful for follow-up because it does not involve radiation. Ultrasound alone cannot reliably establish the functional significance of a PUJ narrowing. [2,3]

CT or MR urography

CT urography can define the junction, identify stones and assess surrounding structures, including crossing vessels. The use of intravenous contrast depends on kidney function and other clinical factors.

MR urography is an alternative in selected patients, particularly when avoiding radiation is desirable. The choice of scan is individualised. [1,2]

MAG3 diuretic renogram

This nuclear medicine scan follows a small injected tracer through the kidneys. A diuretic, usually furosemide, helps assess drainage.

It measures:

  • Differential or split renal function: the proportion contributed by each kidney.
  • Drainage: how effectively tracer leaves the collecting system.

Interpretation considers the images, drainage curves, kidney function, hydration and bladder emptying. A slow drainage number alone is insufficient to diagnose clinically significant obstruction: a large collecting system or poorly functioning kidney can make interpretation difficult. [4]

Further tests in selected cases

A retrograde pyelogram introduces contrast into the ureter during a telescopic bladder examination. It can clarify anatomy when other imaging is incomplete. It is not routinely needed in every patient. [2]

Does every PUJ obstruction need treatment?

No. Observation can be appropriate when symptoms are absent or minor, kidney function is stable, and assessment does not suggest harmful obstruction. Monitoring may include symptoms, ultrasound and repeat functional imaging when indicated. The interval depends on the findings. [5]

Intervention is more likely to be recommended for persistent or troublesome symptoms, recurrent kidney infections, associated stones, or deteriorating function. Decisions use the overall clinical picture rather than the ultrasound appearance alone. [2]

What are the treatment options?

Option When it may be considered Main limitation
Observation Stable function with few symptoms Requires planned follow-up
Ureteric stent or nephrostomy Urgent drainage or temporary management Usually does not permanently correct the narrowing
Endopyelotomy or balloon dilatation Selected narrowings or recurrent obstruction Generally less durable than reconstructive repair
Pyeloplasty A significant obstruction requiring reconstruction Requires an operation and recovery

Temporary or emergency drainage

A ureteric stent passes internally from the kidney to the bladder. A nephrostomy drains the kidney through a tube placed through the skin of the back. These can relieve obstruction while infection is treated or definitive surgery is planned. [5,9]

An infected obstructed kidney is an emergency. Antibiotics may be needed together with urgent drainage. Definitive reconstruction is usually considered after the acute problem has been controlled. [9,10]

Endoscopic treatment

Endopyelotomy opens the narrowed segment from inside the urinary tract; balloon dilatation stretches it. Suitability depends on the anatomy, kidney function and previous treatment.

A large observational study found more repeat procedures after endopyelotomy than after pyeloplasty. Because patients were not randomly assigned to treatment, these results inform discussion but cannot predict an individual outcome. [1,6]

Robotic-assisted pyeloplasty: how is the repair performed?

Pyeloplasty reconstructs the junction to improve drainage. It can be performed through an open incision, conventional laparoscopic keyhole surgery, or robotic-assisted keyhole surgery.

The commonly used Anderson–Hynes dismembered pyeloplasty removes the narrowed segment. The surgeon opens the ureter more widely and stitches it back to the renal pelvis, creating a broader connection. Where a crossing vessel contributes to obstruction, the reconstruction can be positioned in front of it while preserving the vessel. [3]

During robotic-assisted surgery, the surgeon controls the instruments from a console. Magnified three-dimensional vision and articulated instruments assist dissection and suturing. The robot does not operate independently. [7]

A temporary internal stent is commonly placed to support healing. A bladder catheter and, sometimes, a drain may also be used initially. [5,7]

How successful is pyeloplasty, and is robotic surgery better?

Published literature commonly reports success above 90% for primary pyeloplasty, including open, laparoscopic and robotic approaches. Success may mean symptom relief, improved drainage or freedom from further surgery; definitions and follow-up differ between studies. These figures are not a guarantee. [1]

Robotic surgery is an established option, but it should not be presented as necessary or universally superior. Comparative research supports good outcomes with both conventional laparoscopic and robotic repair. Much of the evidence is observational, with differences in patient selection, surgical experience and follow-up. The choice should consider anatomy, surgeon expertise, availability and cost. [8]

The goals are to improve drainage, relieve attributable symptoms and preserve function. Previously lost kidney function may not fully recover, even after a technically successful operation. [11]

What are the risks and recovery expectations?

Risks include bleeding, infection, urine leakage, injury to nearby structures, recurrent narrowing, persistent pain and the need for another procedure. Anaesthetic complications and blood clots are also possible. Occasionally, conversion to open surgery is required. [5,7]

Stents can cause urinary frequency, urgency, blood in the urine and discomfort. Their removal must be arranged. Many patients leave hospital after approximately one to three days following uncomplicated keyhole repair, but recovery varies. Stents are often removed after four to six weeks. [5,7]

Follow-up may include ultrasound and a repeat drainage scan. Residual dilatation does not automatically mean the repair has failed; symptoms, drainage and function are assessed together. [4]

What if the kidney already functions poorly?

A low split-function result does not automatically mean the kidney must be removed. Selected patients may benefit from reconstruction or temporary drainage followed by reassessment. A systematic review found that pyeloplasty may relieve symptoms and stabilise function in poorly functioning kidneys, but the evidence was limited and recovery was unpredictable. [11]

Nephrectomy may be considered if the kidney has negligible useful function and causes ongoing pain or infection. This requires an individual discussion, including the health of the other kidney.

When should I seek urgent help?

Seek urgent medical assessment for fever or shaking chills with flank pain, severe uncontrolled pain, persistent vomiting, markedly reduced urine output, or feeling seriously unwell. The threshold for urgent assessment is particularly low if you have a single functioning kidney. [9,10]

This page provides general education and does not replace an individual assessment. The most suitable investigation and treatment depend on symptoms, anatomy, kidney function and overall health.

References

  1. Khan F, Ahmed K, Lee N, et al. Management of ureteropelvic junction obstruction in adults. Nature Reviews Urology. 2014;11:629–638. doi:10.1038/nrurol.2014.240.
  2. Borin JF. Ureteropelvic Junction Obstruction in Adults. Reviews in Urology. 2017;19(4):261–264. Full text.
  3. Oxford University Hospitals NHS Foundation Trust. PUJ Obstruction and Pyeloplasty: information for parents and carers. 2025. Patient leaflet. Used for congenital presentation and reconstruction principles; adult management differs.
  4. SNMMI/EANM. Procedure Standard/Practice Guideline for Diuretic Renal Scintigraphy in Adults With Suspected Upper Urinary Tract Obstruction 1.0. 2018. Guideline.
  5. British Association of Urological Surgeons. Keyhole reconstruction of the kidney pelvis: laparoscopic pyeloplasty. 2023. Patient leaflet.
  6. Jacobs BL, Lai JC, Seelam R, et al. The comparative effectiveness of treatments for ureteropelvic junction obstruction. Urology. 2018;111:72–77. doi:10.1016/j.urology.2017.09.002.
  7. Kingston and Richmond NHS Foundation Trust. Kidney obstruction removal with robot. Patient information.
  8. Uhlig A, Uhlig J, Trojan L, et al. Surgical approaches for treatment of ureteropelvic junction obstruction—a systematic review and network meta-analysis. BMC Urology. 2019;19:112. doi:10.1186/s12894-019-0544-7.
  9. Guy’s and St Thomas’ NHS Foundation Trust. Nephrostomy catheter to drain urine from the kidney. Patient information.
  10. NHS. Hydronephrosis. Patient information.
  11. Pyeloplasty in Adults With Ureteropelvic Junction Obstruction in Poorly Functioning Kidneys: A Systematic Review. 2021. PubMed.
  12. Cleveland Clinic. Ureteropelvic Junction Obstruction. Reviewed 2024. Patient information.

Prepared October 2026.

Nephroptosis: is a “floating kidney” really a thing?

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Can a kidney move enough to cause pain? Yes. Nephroptosis is a recognised anatomical condition, and in selected people it can cause symptoms. However, finding a mobile kidney does not automatically explain abdominal or flank pain. Establishing that connection is the central challenge, and the reason this condition has attracted controversy for more than a century.[1,2]

What is nephroptosis?

The kidneys normally sit towards the back of the abdomen, supported by surrounding fat and connective tissues. Some movement with breathing and changes in posture is normal.

Nephroptosis, also called a floating or mobile kidney, is conventionally defined as downward movement of more than 5 cm, or approximately two vertebral body heights, when a person moves from lying down to standing. A kidney can also rotate or move towards the midline.[3,4]

This differs from a congenital pelvic kidney, which developed in a lower position and stays there.

Published reports describe it more often in slim women and more often on the right, although men and people with other body types can be affected. Reduced support from surrounding fat is a proposed contributor. The true prevalence of symptomatic nephroptosis is uncertain; historical figures from people undergoing particular imaging tests should not be treated as estimates for the general population.[4]

How does it present?

Many mobile kidneys cause no symptoms. When symptoms occur, a suggestive pattern is:

  • An ache, dragging sensation or intermittent pain in the flank, the side between the lower ribs and hip, or abdomen.
  • Pain that becomes worse with standing, prolonged activity or particular positions.
  • Improvement when lying down.
  • Occasionally, a feeling of something moving within the abdomen.

Some patients experience more severe episodes with nausea or vomiting. Positional pain is a useful clue, but it does not establish the diagnosis.[2,5]

Possible mechanisms include intermittent kinking of the ureter, which drains urine to the bladder; stretching or twisting of the kidney’s blood vessels; or traction on nerves around the kidney. These mechanisms may differ between patients. Severe episodic pain from intermittent upper urinary tract obstruction is sometimes called a Dietl’s crisis, but that term is not specific to nephroptosis.[4,5]

Blood in the urine or urinary infections require investigation in their own right and should not simply be attributed to a mobile kidney.

How is the diagnosis made?

There are two separate questions: Does the kidney move excessively? And is that movement responsible for symptoms or impaired function?

1. Establish the symptom pattern and assess other causes

A consultation should explore where the pain occurs, its relationship to posture and activity, what relieves it, and associated urinary or gastrointestinal symptoms. Examination, urine testing and blood tests for kidney function help guide the investigation.

Other explanations include kidney stones, infection, obstruction at the junction between the kidney and ureter, musculoskeletal pain, and gastrointestinal or gynaecological conditions. Depending on the presentation, these may be more likely. A mobile kidney can coexist with an unrelated cause of pain.[2,3]

2. Compare imaging in different positions

A normal scan performed lying down may not exclude a problem that occurs when upright. If the clinical pattern raises suspicion, the imaging request should make the positional question explicit.[3,5]

Investigation What it can contribute Main limitation
Ultrasound lying down and upright Demonstrates movement and checks for changes in collecting-system dilatation Operator dependent; requires a deliberate positional examination
Doppler ultrasound in different positions May identify posture-related changes in renal blood flow An adjunct rather than a definitive test of the cause of pain
Positional nuclear medicine renal scan Assesses drainage and each kidney’s contribution to function; may reveal changes when upright Needs an appropriate protocol and careful interpretation
Intravenous urography with supine and erect images Historically used to measure kidney descent Used less often today; involves radiation and contrast
Selected positional CT urography Can clarify anatomy, rotation or medial movement Routine supine CT may miss positional mobility; repeat imaging adds radiation

The choice should be agreed with radiology or nuclear medicine. Not every centre routinely performs these protocols, and not every patient needs every test.[3,5,6]

3. Link the findings to the symptoms

Diagnostic confidence is stronger when the side and timing of the pain match the demonstrated movement, particularly if there is associated impaired drainage or blood flow. Nevertheless, some symptomatic patients have no demonstrable obstruction. The absence of obstruction does not conclusively exclude symptomatic nephroptosis, but it makes careful exclusion of other causes especially important.[3,4,6]

Normal overall kidney function does not, by itself, exclude an intermittent positional problem. Equally, descent beyond a measurement threshold is not sufficient justification for surgery.[2,5]

What are the treatment options?

Observation and symptom management

An incidentally discovered mobile kidney without symptoms or functional consequences generally does not require surgery.[5]

For mild symptoms, an individual plan may include modifying provoking activities, appropriate pain relief and reviewing other possible contributors. Abdominal supports, exercises and nutritional measures have been used historically, but convincing evidence that they reliably correct symptomatic nephroptosis is limited. They should not be presented as proven cures. Weight gain is not a universal recommendation.[1,2]

Nephropexy: fixing the kidney in position

Nephropexy repositions the kidney and secures it to surrounding tissues to limit excessive movement. It aims to preserve the kidney and relieve symptoms or positional impairment.

It may be considered when symptoms substantially affect daily life, nephroptosis has been demonstrated with appropriate imaging, other explanations have been reasonably excluded, and the evidence suggests a meaningful relationship between movement and symptoms. Documented positional obstruction or impaired perfusion strengthens the rationale.[2,3,5]

Modern surgery is usually laparoscopic, through the abdomen or behind it. Robotic assistance has also been described, but there is no convincing comparative evidence that it produces better outcomes than conventional laparoscopy for this condition. Fixation techniques vary, and some published methods use mesh while others use sutures.[3]

Open surgery is less commonly used. Percutaneous techniques, intended to stabilise the kidney through a tract and subsequent scarring, have also been reported. A recent report involved only four patients: such evidence is too limited to establish equivalence with laparoscopic surgery or support routine use.[7]

How effective is surgery, and what are the risks?

Small surgical series describe substantial improvement in selected patients. For example, a long-term study reported 13 patients assessed at a median of 5.9 years: 11 were completely satisfied and two moderately satisfied.[8]

That is encouraging, but it is not a reliable prediction for every patient. Small numbers, selection of patients, loss to follow-up and the absence of a non-operative comparison group limit what can be concluded. Fixing the kidney successfully does not guarantee that pain will disappear.[2,8]

Potential risks include bleeding, infection, injury to nearby organs, vessels or the urinary tract, anaesthetic complications, persistent or new pain, and recurrent kidney movement. If mesh is proposed, its specific benefits and risks should be discussed. Individual risks and expected recovery depend on the technique and the patient’s circumstances.

Why is nephroptosis controversial?

The controversy concerns which patients have symptoms caused by kidney mobility, and which benefit from treatment.

Historically, nephroptosis was blamed for a wide range of nonspecific symptoms, and nephropexy was performed much more frequently than it is today. Recognition that many mobile kidneys were harmless, together with inconsistent surgical results, led to scepticism and a marked decline in treatment.[1]

Modern positional imaging and minimally invasive surgery have renewed interest. However, the evidence remains dominated by small observational series and case reports rather than robust randomised comparisons. There is also no universally accepted combination of symptoms and test findings that predicts success for an individual.[2,6,8]

The appropriate response is to take the symptoms seriously while investigating the cause carefully. A normal routine scan does not mean pain is imagined. A mobile kidney does not mean an operation will solve it.

When should you seek urgent care?

Severe or escalating flank pain, fever or rigors, persistent vomiting, visible blood in the urine, or a marked reduction in urine output warrant prompt medical assessment. These symptoms can signal infection, obstruction or another problem requiring urgent treatment, regardless of whether nephroptosis is present.

This article provides general education. Diagnosis and treatment require an individual clinical assessment.

Patient information by Dr Jo Schoeman | Evidence reviewed October 2026

References

  1. Moss SW. Floating kidneys: a century of nephroptosis and nephropexy. Journal of Urology. 1997;158(3 Pt 1):699–702. doi:10.1016/S0022-5347(01)64296-4.
  2. Barber NJ, Thompson PM. Nephroptosis and nephropexy—hung up on the past? European Urology. 2004;46(4):428–433. doi:10.1016/j.eururo.2004.03.023.
  3. Mogorovich A, Selli C, De Maria M, et al. Clinical reappraisal and state of the art of nephropexy. Urologia. 2018;85(4). doi:10.1177/0391560317749191.
  4. Senaratne R, Anderson S, Kelly C, et al. Rolling in the deep: an illustrative report of symptomatic nephroptosis. Radiology Case Reports. 2024;19(9):4044–4048. doi:10.1016/j.radcr.2024.06.047. Case report.
  5. Murari SB, Gadepalli T, Rao VP, Ram R. Renal scintigraphy in diagnosis and management of nephroptosis. Indian Journal of Nuclear Medicine. 2012;27(1):52–54. doi:10.4103/0972-3919.108874. Case report.
  6. Strohmeyer DM, Peschel R, Effert P, et al. Changes of renal blood flow in nephroptosis: assessment by color Doppler imaging, isotope renography and correlation with clinical outcome after laparoscopic nephropexy. European Urology. 2004;45:790–793. PubMed.
  7. Liu H, Gao W, Zhang Z, et al. Modified percutaneous nephropexy for nephroptosis: technical description and short-term results. Current Urology. 2025;19(3):168–172. doi:10.1097/CU9.0000000000000238. Small technical series; four patients.
  8. Plas E, Daha K, Riedl CR, Hübner WA, Pflüger H. Long-term followup after laparoscopic nephropexy for symptomatic nephroptosis. Journal of Urology. 2001;166(2):449–452. PubMed.

Ureteroceles: symptoms, investigations and treatment

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A ureterocoele (also spelt ureterocele) is a balloon-like swelling at the lower end of a ureter: the tube carrying urine from the kidney to the bladder. The swelling usually projects into the bladder. Its opening may be narrow, slowing urine drainage and sometimes causing infection, stones or pressure on the kidney.

Some ureterocoeles cause no problems and are found incidentally. Others need treatment to improve drainage and protect kidney function. [1,2]

Congenital or acquired?

Most true ureteroceles are congenital, meaning they develop before birth. They may be detected on pregnancy ultrasound, during childhood or much later in adult life. A diagnosis in adulthood does not necessarily mean the ureterocele developed recently.

A ureterocoele can occur with a single ureter or a duplex collecting system, in which a kidney has two drainage systems. In a duplex kidney, the ureterocoele commonly involves the ureter draining the upper part of the kidney.

An intravesical or orthotopic ureterocoele lies within the bladder. An ectopic ureterocoele extends into the bladder neck or urethra and may interfere with bladder emptying. Adults more often have an intravesical ureterocoele associated with a single drainage system. [1,3]

The term “acquired ureterocoele” needs care. An acquired swelling of the lower ureter that resembles a ureterocoele is often called a pseudoureterocoele. A stone or a lesion involving the bladder near the ureteric opening can cause this appearance. An irregular or unusual swelling should therefore be investigated rather than assumed to be a harmless congenital abnormality. [4]

Presentation and symptoms

A ureterocoele may be discovered during investigations for an unrelated problem. When symptoms occur, they can include:

  • Recurrent urinary tract infections.
  • Pain in the side, back or lower abdomen.
  • Burning, urgency or frequent urination, particularly with infection.
  • Blood in the urine.
  • Stones trapped within the ureterocoele.
  • Difficulty emptying the bladder or, occasionally, urinary retention.

Children may present with unexplained fever, feeding difficulties or poor growth associated with infection. Rarely, a large ureterocoele can prolapse through the urethra.

Symptoms depend on whether the swelling obstructs drainage, contains a stone or affects the bladder outlet. Prolonged obstruction and repeated kidney infections can damage kidney function. [2,5]

What investigations are needed?

Investigations establish the anatomy, assess drainage and kidney function, and look for infection or reflux. Not everyone needs every test.

Investigation What it helps assess
Urine testing and culture Infection and the appropriate antibiotic
Blood tests Kidney function; inflammatory markers when infection is suspected
Kidney and bladder ultrasound The ureterocoele, stones and swelling of the kidney or ureter
CT, sometimes CT urography Stones and detailed urinary tract anatomy, particularly in adults
MR urography Complex anatomy, including duplicated drainage systems
MAG3 or DMSA kidney scan Drainage and relative function, or functioning kidney tissue and scarring
Micturating cystourethrogram (MCUG/VCUG) Urine flowing backwards from the bladder into a ureter
Cystoscopy Direct inspection of the bladder and ureteric openings

CT involves radiation; contrast use depends on kidney function and the clinical question. Reflux testing is particularly relevant in children or when infection, complex anatomy or postoperative concerns warrant it. Cystoscopy can clarify an uncertain diagnosis and allow treatment during the same procedure. [1,3,5]

Does every ureterocoele need surgery?

No. Observation with planned follow-up may be appropriate when there are no troublesome symptoms, significant obstruction or recurrent infections, and kidney function is satisfactory.

Monitoring may include ultrasound and review of symptoms. Antibiotics treat infection but do not correct the swelling. Preventive antibiotics are considered selectively, particularly in children at increased infection risk. [6]

An infected, obstructed kidney requires urgent assessment and drainage, alongside antibiotics. Drainage may involve endoscopic opening of the ureterocoele or a nephrostomy, a tube placed through the skin into the kidney. Antibiotics alone may be insufficient when infected urine cannot drain. [1]

Endoscopic incision or deroofing

Treatment can often be performed through a telescope passed along the urethra into the bladder, usually under general anaesthesia.

Incision or puncture creates an opening in the wall of the ureterocoele. Deroofing removes part of its wall to create a broader opening. Both aim to let urine drain freely and reduce the balloon-like swelling.

The choice depends on anatomy, obstruction and associated stones. Instruments using electrical energy or a laser may be used. A stone within the sac can sometimes be fragmented and removed at the same operation.

A bladder catheter may be needed temporarily. Endoscopic treatment can be sufficient for a straightforward adult intravesical ureterocoele, while complex duplex or ectopic cases may need further surgery. [5,7,8]

Where does a ureteric stent fit in?

A double-J stent is a soft internal tube extending from the kidney to the bladder. It may be used selectively to support drainage after treatment, during associated stone surgery or while swelling settles. It is not required in every case and does not necessarily provide a permanent solution to the ureterocoele. [8]

Stents can cause frequency, urgency, bladder discomfort, blood in the urine and flank pain, sometimes after urination. Infection, displacement and mineral encrustation are other possible problems.

Every temporary stent needs a clear removal or exchange plan. The duration depends on the procedure and clinical circumstances. Contact the treating team if the removal date is unclear or overdue. [9]

Possible complications, including vesicoureteric reflux

Possible complications of endoscopic treatment include bleeding, infection, discomfort, injury to nearby urinary tract structures, persistent obstruction or narrowing as the opening heals. Repeat treatment or reconstructive surgery may be needed. [3,5,7]

Vesicoureteric reflux (VUR) means urine travels backwards from the bladder towards the kidney. It may already be present before treatment, particularly in a duplex system, or develop after opening the ureterocoele alters the natural anti-reflux mechanism.

Reflux does not automatically mean kidney damage or another operation. Its significance depends on its severity, infections, kidney function and bladder function. Monitoring may be appropriate; persistent significant reflux with recurrent infections can require further treatment, including ureteric reimplantation.

Risk varies with anatomy and technique. Ectopic ureterocoeles and duplex systems have higher rates of postoperative reflux and additional surgery than simpler intravesical cases. [1,7]

In one small adult study, reflux was detected in two of 23 patients followed after endoscopic incision, persisting in one at six months. These results illustrate the possibility of reflux; they do not predict an individual patient’s risk. Adult evidence largely comes from small studies. [7]

Further surgery and follow-up

Reconstructive options include reimplanting the ureter into the bladder or joining it to another healthy ureter in a duplex system. Occasionally, a severely damaged, poorly functioning kidney segment causing problems may require removal. Specialist assessment determines whether reconstruction, observation or removal is appropriate. [1]

Follow-up checks that drainage has improved and looks for recurrent infection, obstruction or reflux. Ultrasound is commonly used; further imaging is selected according to the findings. Symptom improvement alone does not confirm that drainage is normal. [5,7]

Seek urgent medical care for fever or shaking chills with flank pain, inability to pass urine, severe worsening pain, persistent vomiting or feeling seriously unwell. These symptoms may indicate infection or obstruction, including after treatment or with a stent in place. [1,9]

This article provides general education. Treatment should be tailored to the patient’s anatomy, symptoms and kidney function in consultation with their urologist.

References

  1. European Association of Urology. EAU Guidelines on Paediatric Urology: Ureterocele and ectopic ureter. Current online guideline, accessed 5 October 2026. https://uroweb.org/guidelines/paediatric-urology/chapter/ureterocele-and-ectopic-ureter
  2. European Association of Urology. Patient information: Ureterocele. https://patients.uroweb.org/condition/duplex-congenital-malformations-of-the-urinary-tract/ureterocele
  3. The Outcome of Transurethral Electro-Endoscopic Resection of Orthotopic Single System Ureterocoeles in Adults Nigerians. https://pmc.ncbi.nlm.nih.gov/articles/PMC11073836/
  4. Thornbury JR, Silver TM, Vinson RK. Ureteroceles vs. pseudoureteroceles in adults. Urographic diagnosis. Radiology. 1977;122(1):81–84. doi:10.1148/122.1.81. https://pubmed.ncbi.nlm.nih.gov/830358/
  5. An adult ureterocele complicated by a large stone: A case report. International Journal of Surgery Case Reports. 2018. https://pmc.ncbi.nlm.nih.gov/articles/PMC5927814/
  6. European Association of Urology. Watchful waiting for ureterocele. https://patients.uroweb.org/condition/duplex-congenital-malformations-of-the-urinary-tract/ureterocele/wait-and-see-ureterocele
  7. Vijay MK, et al. The safety and efficacy of endoscopic incision of orthotopic ureterocele in adult. Saudi Journal of Kidney Diseases and Transplantation. 2011;22(6):1169–1174. https://pubmed.ncbi.nlm.nih.gov/22089776/
  8. A Large Stone Within a Ureteroceles: A Diagnostic Pitfall and the Utility of Holmium Laser Deroofing as a Viable Surgical Option. https://pubmed.ncbi.nlm.nih.gov/29468199/
  9. British Association of Urological Surgeons. Information about your ureteric stent. https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Stent%20advice.pdf

A kidney tumour larger than 3 cm: what does it mean?

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By Dr Jo Schoeman | Patient information | September 2026

Finding a kidney mass can be frightening. The first question is whether it is cancer; the next is whether it is confined to the kidney. A mass measuring 3.1 cm is not automatically advanced cancer. If a renal cell carcinoma (RCC) is no more than 4 cm and remains within the kidney, it is classified as T1a. A tumour over 4 cm but no more than 7 cm, still confined to the kidney, is T1b. Lymph-node and distant spread are assessed separately. Some kidney masses are benign, and imaging alone cannot always tell us which. [1–3]

How might it present?

Many tumours are discovered by chance during an ultrasound or CT scan for another problem. Others cause blood in the urine, persistent pain in the side or back, or occasionally a palpable lump. Unexplained weight loss, fatigue, anaemia or fever warrant assessment, although they have many possible causes. The combination of blood in the urine, pain and a palpable mass is uncommon. Visible blood in the urine should always be investigated; a kidney mass does not rule out another source of bleeding. [2]

What investigations are needed?

  • Dedicated imaging: A multiphase contrast CT of the kidneys and abdomen shows whether the lesion enhances, its exact position, its relationship to major blood vessels and the collecting system, and whether there are enlarged nodes or signs of spread. Chest imaging completes staging; its extent is tailored to the tumour and clinical circumstances. MRI may clarify an uncertain lesion or suspected tumour extension into a vein, or be useful when CT contrast is unsuitable. A complex kidney cyst needs its own imaging assessment. [2]
  • Blood and urine tests: Kidney function (creatinine and eGFR), a full blood count and other tests guided by the clinical picture help assess fitness for treatment and preserve kidney function. Urine testing may identify infection or another cause of bleeding. [2]
  • Biopsy: A needle biopsy can be useful if its result will change management, particularly before ablation or drug treatment without prior tissue diagnosis. A typical surgically removable solid mass does not always need a biopsy beforehand. A biopsy can occasionally be inconclusive. [2]
  • Further staging: Bone or brain scans are generally reserved for relevant symptoms or suspected advanced disease. Routine PET scans and bone scans are not recommended for initial RCC staging. [2]

The team should review the images, kidney function, other medical conditions and the patient’s priorities together. An indeterminate mass should not be labelled definitively as RCC before appropriate assessment.

A note about my practice: I no longer perform nephrectomies. I can assess your kidney mass, discuss the findings and treatment options with you, and, if an operation is appropriate, refer you to a colleague who performs kidney surgery. We can also arrange input from a multidisciplinary team where needed.

Treatment when the tumour is confined to the kidney

Partial nephrectomy removes the tumour while preserving the rest of the kidney. This is generally preferred for T1 cancers when technically feasible, particularly if kidney function is reduced or there is only one functioning kidney. It can be performed by robotic, laparoscopic or open surgery according to tumour complexity and surgical expertise. Risks include bleeding, urine leak, infection, reduced kidney function and, occasionally, the need to remove the whole kidney. [1]

Radical nephrectomy removes the kidney and may be appropriate when a safe partial nephrectomy is not feasible, particularly with a larger or more complex tumour. Robotic or laparoscopic surgery offers an approach to the operation; it does not change the underlying choice between partial and radical removal. [1]

Active surveillance may suit selected people with a small, slow-growing mass, competing health risks or a strong preference to defer treatment. It involves planned scans and a clear trigger to reconsider treatment. A tumour just above 3 cm needs a particularly careful discussion because the room for further growth before 4 cm is limited. Thermal ablation, such as cryoablation or radiofrequency or microwave ablation, may suit selected small tumours, especially when surgery is unsuitable; a biopsy is recommended before ablation. Local recurrence and the possible need for repeat treatment should be discussed. [1, 2]

Stereotactic ablative radiotherapy (SABR) is also being used in specialist centres for selected patients with localised RCC who cannot undergo surgery. It is a distinct option from routine radiation after an operation, and its long-term comparative evidence continues to mature. [1]

What if lymph nodes look enlarged?

An enlarged node on a scan is suspicious, not proof of cancer; inflammation can also enlarge nodes. The team considers the appearance and site of the nodes, whether there is disease elsewhere and whether tissue confirmation will change treatment. If nephrectomy is planned, visibly enlarged regional nodes may be removed for diagnosis and staging. Removing normal-looking nodes routinely has not been shown to improve survival for organ-confined RCC. The survival benefit of removing involved nodes is uncertain. [1]

Confirmed regional node involvement is a substantial change in risk even if the kidney tumour is small. It calls for multidisciplinary discussion about whether all visible disease can be removed, whether postoperative drug treatment is appropriate, and how closely to monitor. Nodes beyond the regional area, or spread to organs such as the lung or bone, may represent metastatic disease and require a different plan. Surgery on the kidney is not automatically the best first step when cancer is widespread. [1, 3]

When does immunotherapy help?

For selected patients with clear-cell RCC at higher risk of recurrence after complete surgery, a course of pembrolizumab may lower recurrence risk and has shown an overall survival benefit in the KEYNOTE-564 study. The eligible groups include some patients with confirmed regional node involvement and no distant metastases. A 3–4 cm node-negative tumour confined to the kidney would not usually qualify based on size alone. The final pathology, stage and overall health matter. [1, 4]

If cancer has spread and cannot all be removed, initial treatment for clear-cell RCC often combines immune checkpoint drugs with each other (nivolumab plus ipilimumab) or combines immunotherapy with an oral targeted drug (for example, pembrolizumab plus axitinib, pembrolizumab plus lenvatinib, or nivolumab plus cabozantinib). The best regimen depends on risk group, other illnesses, kidney function, previous treatment and the specific cancer subtype. Papillary and other non-clear-cell cancers may need different approaches. Availability and subsidy in Australia should be checked for the individual indication. [1]

Immunotherapy can cause serious inflammation of the bowel, lungs, liver, kidneys or hormone-producing glands; targeted drugs can cause high blood pressure, diarrhoea, fatigue and other adverse effects. Some immune effects can persist after treatment ends. Benefits and risks need an individual discussion with a medical oncologist. [1, 4]

Is chemotherapy useful?

Conventional cytotoxic chemotherapy is generally ineffective for the common types of RCC and is not standard treatment for ordinary clear-cell RCC. Rare subtypes, including collecting duct and renal medullary carcinoma, are exceptions in which chemotherapy may have a role. A cancer arising from the lining of the renal pelvis (upper-tract urothelial carcinoma) is a different disease with different chemotherapy options; establishing the diagnosis matters. [1]

Does radiation offer a benefit?

Radiotherapy is not routinely given after nephrectomy to prevent recurrence of localised RCC. Its clearest established role is treating specific problems from spread, such as painful bone lesions, brain metastases or symptoms from another site. Precisely targeted radiation may also control selected limited metastases or treat a primary tumour in someone unsuitable for surgery. Whether it adds benefit to systemic therapy or surgery in an individual case depends on the site, number and behaviour of lesions and is best decided with radiation oncology input. It should not be presented as a standard substitute for an operable partial nephrectomy. [1, 5]

Questions worth asking at your consultation

  1. Is this definitely a solid enhancing kidney tumour, and what is its exact size and location?
  2. Is the disease confined to the kidney? Are any nodes merely enlarged, or proven to contain cancer?
  3. Can we safely preserve part of the kidney? What is my current kidney function?
  4. Would a biopsy change the plan?
  5. If the cancer is clear-cell and higher risk, would adjuvant pembrolizumab be suitable?
  6. Would drug treatment or targeted radiation offer a benefit in my particular situation?

Seek prompt medical attention for heavy bleeding with clots, inability to pass urine, severe persistent pain, or sudden neurological symptoms. This article is general information and cannot replace review of your scans and pathology at a multidisciplinary meeting.

References

  1. European Association of Urology. EAU Guidelines on Renal Cell Carcinoma: Disease Management. 2026.
  2. European Association of Urology. EAU Guidelines on Renal Cell Carcinoma: Diagnostic Evaluation. 2026.
  3. European Association of Urology. EAU Guidelines on Renal Cell Carcinoma: Staging and Classification Systems. 2026.
  4. National Cancer Institute. Adjuvant Keytruda improves kidney cancer survival, reporting updated KEYNOTE-564 outcomes. 2024.
  5. National Cancer Institute. Renal Cell Cancer Treatment (PDQ), Health Professional Version. Accessed September 2026.

Coffee Break

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Coffee, oat milk and the start of my day at the Wesley

By Dr Jo Schoeman

Before a busy day of consultations or operating at the Wesley, I enjoy a small ritual: stopping for a coffee with oat milk at Steamtrain Espresso Bar and Kitchen, beside Auchenflower train station and just outside the hospital. It gives me a moment to gather my thoughts before the day begins. I also simply enjoy a good coffee.

 “A quiet coffee before the working day.” 

What is good about coffee?

For many of us, caffeine helps us feel more alert and focused in the morning. Coffee also contains a range of naturally occurring plant compounds. Large reviews have found that people who drink moderate amounts of coffee tend to have lower rates of several health problems than people who do not drink it. These are mostly associations: they do not prove that coffee itself prevents disease, and they are no reason to start drinking it if you do not enjoy it.[1]

The amount that suits one person may be too much for another. Coffee can disturb sleep or cause jitters and palpitations, especially in people who are sensitive to caffeine. I prefer mine early in the day, when I can enjoy the lift without letting it interfere with the night ahead.

Why oat milk?

I like its taste and the creamy texture it brings to coffee. It is a practical dairy-free option for people who avoid cow’s milk. If oat milk is a regular replacement for dairy, however, it pays to check the carton: products vary, and oat milk usually provides less protein than cow’s milk. Choosing an unsweetened product fortified with calcium can help, while vitamin B12 and iodine are also worth considering in the context of your overall diet.[2,3] A splash in a coffee is a pleasure, rather than a nutritional strategy in itself.

A urologist’s small caveat

I cannot write about coffee without mentioning the bladder. Caffeine can make urinary urgency, frequency or night-time trips to the toilet worse for some people. If that sounds familiar, try a smaller coffee, have it earlier, or see whether decaf makes a difference. Keep drinking an appropriate amount of water; cutting fluids too far can make bladder symptoms worse. Persistent symptoms deserve an assessment rather than being blamed on your morning coffee alone.[4]

For me, that oat milk coffee at Steamtrain marks the start of the working day. It is a pleasant pause, a familiar stop by the station, and a chance to arrive at the Wesley ready to see my patients. Like most good habits, it works best with a little balance.

References and further reading

  1. Poole R, et al. Coffee consumption and health: umbrella review of meta-analyses of multiple health outcomes. BMJ. 2017;359. https://www.bmj.com/content/359/bmj.j5024
  2. Dietitians Australia. Plant-based milks. https://dietitiansaustralia.org.au/health-advice/plant-based-milks
  3. Food Standards Australia New Zealand. Plant-based milk alternatives. https://www.foodstandards.gov.au/consumer/nutrition/milkaltern
  4. Continence Health Australia. Caring for your bladder at night (nocturia). https://www.continence.org.au/about-incontinence/urinary-incontinence/nocturia/caring-for-your-bladder-at-night-nocturia/

This article offers general information and reflects my personal routine. Individual nutrition and bladder needs vary.

How a Stroke Can Affect Bladder Function

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A cerebrovascular accident (CVA), more commonly called a stroke, can affect much more than movement and speech. It can also disrupt the communication between the brain and bladder, leading to urgency, urinary leakage, difficulty emptying the bladder or a combination of these problems.

Bladder difficulties are common after stroke, particularly during the early stages of recovery. They can cause embarrassment, interfere with rehabilitation, disturb sleep and increase the risks of falls, skin problems and urinary tract infection. Fortunately, many patients improve as the brain recovers, and persistent symptoms can usually be managed with an individualised bladder rehabilitation and treatment plan.

How does the brain normally control the bladder?

The bladder stores urine at a low pressure until it is convenient to empty. This depends on coordinated communication between:

  • The frontal lobes, which help recognise bladder filling and suppress urination until an appropriate time.
  • Deeper brain centres involved in bladder sensation and behavioural control.
  • The pontine micturition centre in the brainstem, which coordinates contraction of the bladder with relaxation of the urinary sphincter.
  • The spinal cord and peripheral nerves that carry messages between the brain, bladder and sphincter.

A stroke may interrupt one or more of these pathways. The resulting bladder problem depends on the location and extent of the stroke, the patient’s previous bladder function and the presence of other conditions such as prostate enlargement, diabetes, constipation or reduced mobility.

What bladder problems can occur after a stroke?

Urgency and urge urinary incontinence

The most common problem is a sudden, compelling need to pass urine that may be difficult to postpone. Some patients leak before reaching the toilet.

This often results from detrusor overactivity, in which the bladder muscle contracts involuntarily during filling because the brain is no longer suppressing it normally.

Associated symptoms can include:

  • Passing urine frequently.
  • Waking several times at night to urinate.
  • Sudden urgency.
  • Leakage associated with urgency.
  • Bedwetting.
  • Reduced warning before urination.

Difficulty emptying the bladder

Some patients develop a weak or poorly coordinated bladder contraction and cannot empty effectively. This may cause:

  • Difficulty starting urination.
  • A slow or interrupted urinary stream.
  • Straining to pass urine.
  • A sensation of incomplete emptying.
  • Frequent passage of small amounts.
  • Overflow leakage from an overfilled bladder.
  • Recurrent urinary infections.

Urinary retention may be more likely during the acute phase of stroke because of reduced consciousness, immobility, constipation, medication effects, pain, infection or a pre-existing obstruction such as an enlarged prostate.

Functional incontinence

Not every episode of leakage is caused by abnormal bladder contractions. A patient may recognise the need to urinate but be unable to reach or use the toilet because of:

  • Weakness or paralysis.
  • Poor balance or slow mobility.
  • Visual impairment.
  • Difficulty removing clothing.
  • Communication problems.
  • Confusion, memory loss or reduced awareness.
  • An inaccessible toilet or lack of timely assistance.

This is called functional incontinence. Treating the bladder alone will not solve it; the physical and environmental barriers must also be addressed.

Loss of bladder awareness

A stroke can reduce awareness of bladder filling. The patient may not recognise the need to urinate until leakage occurs—or may remain unaware that the bladder is full.

Stress urinary incontinence

Leakage with coughing, sneezing, standing or exertion is not usually caused directly by stroke, but pre-existing pelvic-floor weakness may become more noticeable when mobility and general muscle function decline.

Nocturia and nighttime incontinence

Nighttime urination may be caused by an overactive bladder, sleep disturbance, leg swelling, obstructive sleep apnoea, medication timing or increased nighttime urine production. It is important because repeated attempts to reach the bathroom can significantly increase the risk of falls.

Does the site of the stroke predict the bladder problem?

There are broad associations between the area of brain injury and the type of bladder dysfunction, but the relationship is not exact enough to base treatment on the brain scan alone.

Frontal and subcortical strokes are frequently associated with urgency and detrusor overactivity. Brainstem strokes can interfere with coordination between the bladder and urinary sphincter, while larger strokes may impair bladder sensation, mobility and awareness.

The bladder pattern can also change during recovery. This is why treatment should be based on the patient’s current symptoms and objective bladder assessment rather than the location of the stroke alone.

How is bladder dysfunction assessed?

Assessment should consider the bladder, the patient’s neurological recovery and the practical circumstances surrounding each episode of leakage.

Medical and medication history

Important questions include:

  • Was urgency, nocturia or poor urinary flow present before the stroke?
  • When did the symptoms begin?
  • Is the patient aware of bladder filling?
  • Can the patient reach and use the toilet independently?
  • Is there constipation, pain, visible blood in the urine or fever?
  • What fluids, caffeine and alcohol are being consumed?
  • Could medication be contributing?

Diuretics, sedatives, opioids and some medications with anticholinergic effects can aggravate urinary symptoms, confusion or retention.

Bladder diary

A bladder diary records fluid intake, the time and volume of each urination, urgency and leakage episodes. It can help distinguish reduced bladder capacity from excessive urine production or predominantly functional incontinence.

Physical examination

The assessment may include examination of the abdomen, genital area, prostate where appropriate, pelvic floor, mobility, cognition, sensation and neurological function.

Urine testing

Urinalysis and urine culture when clinically indicated, can identify infection or blood in the urine. Bacteria in the urine without urinary symptoms do not automatically require antibiotics.

Bladder scan and post-void residual

A painless ultrasound bladder scan measures the urine remaining after urination. This is particularly useful when there is a weak stream, retention, recurrent infection, overflow leakage or before treatments that could make emptying more difficult.

Additional investigations

Depending on the circumstances, evaluation may include:

  • Kidney function blood tests.
  • Urinary flow testing.
  • Ultrasound of the kidneys and bladder.
  • Cystoscopy when there is haematuria, suspected obstruction or another appropriate indication.
  • Urodynamic studies.

Are urodynamic studies always necessary?

No. Many patients with straightforward urgency or functional incontinence can begin conservative treatment after clinical assessment, urine testing and measurement of the post-void residual.

Urodynamic studies may be helpful when:

  • The symptoms and clinical findings do not agree.
  • Both urgency and poor emptying are present.
  • There is persistent or unexplained urinary retention.
  • Initial treatment has failed.
  • An invasive treatment such as bladder Botox is being considered.
  • There is concern about obstruction, weak bladder contraction or poor bladder compliance.
  • Previous prostate, bladder or continence surgery complicates the diagnosis.

Urodynamics can distinguish an overactive bladder from impaired bladder contractility, obstruction or sphincter discoordination. This helps avoid giving treatment that reduces bladder contractions to someone who already empties poorly.

Treatment options

Treatment should be based on the bladder abnormality, the patient’s functional ability and their personal goals. Family members, continence nurses, physiotherapists, occupational therapists, rehabilitation physicians and urologists may all contribute.

Treat reversible factors

The first step is to identify problems that may be aggravating bladder control, including:

  • Urinary infection.
  • Constipation or faecal impaction.
  • Excessive caffeine or alcohol.
  • Excessive or poorly timed fluid intake.
  • Uncontrolled diabetes.
  • Leg swelling and nighttime fluid redistribution.
  • Medication side effects.
  • Prostate obstruction.
  • Reduced access to the toilet.

Adequate hydration remains important. Simply restricting fluid can produce concentrated urine, constipation and bladder irritation.

Prompted or timed toileting

Scheduled toileting can be very effective, particularly when memory, mobility or awareness is impaired.

Options include:

  • Timed voiding: visiting the toilet at regular planned intervals.
  • Prompted voiding: a carer reminds and assists the patient to use the toilet.
  • Habit retraining: the schedule is matched to the patient’s usual bladder pattern.
  • Bladder training: gradually increasing the interval between toilet visits when the patient can recognise and suppress urgency.

Easy-to-remove clothing, a bedside commode, urinal, improved lighting and a clear path to the toilet can make a considerable difference.

Pelvic-floor rehabilitation

Pelvic-floor muscle training may improve urinary control in appropriately selected patients who can identify and contract these muscles. A continence or pelvic-floor physiotherapist can adapt the program for weakness, impaired coordination or cognitive limitations following stroke.

Medication for urgency and overactive bladder

Medication may be considered when conservative measures are insufficient.

Antimuscarinic medication

Medicines such as solifenacin, darifenacin, oxybutynin or trospium can reduce involuntary bladder contractions. Possible adverse effects include:

  • Dry mouth.
  • Constipation.
  • Blurred vision.
  • Difficulty emptying the bladder.
  • Confusion or cognitive deterioration.

These medicines should be selected cautiously after stroke, particularly in older patients, those with cognitive impairment, constipation, glaucoma or an elevated post-void residual. The total anticholinergic burden from all medications should be reviewed.

Beta-3 agonists

Mirabegron relaxes the bladder during filling and may have fewer dry-mouth and cognitive adverse effects than antimuscarinic treatment. Blood pressure should be checked because mirabegron may worsen hypertension. Residual urine should also be monitored when there is concern about poor emptying.

Vibegron is another beta-3 agonist, although availability and funding can vary.

Management of incomplete emptying or retention

Treatment depends on the cause and severity.

Options may include:

  • Reviewing medicines that impair bladder contraction.
  • Treating constipation and infection.
  • Managing prostate or urethral obstruction when present.
  • Double voiding.
  • Intermittent catheterisation.

Clean intermittent catheterisation is generally preferred when the bladder cannot empty safely and the patient or carer can perform it. An indwelling urethral catheter may sometimes be necessary during the acute phase, but prolonged unnecessary use should be avoided because of infection, urethral trauma and bladder-stone risks.

A suprapubic catheter may be considered when long-term catheter drainage is unavoidable and urethral catheterisation is unsuitable.

Botulinum toxin injections into the bladder

Botulinum toxin A, commonly called bladder Botox, can reduce severe detrusor overactivity when medication has been ineffective or poorly tolerated.

It may significantly improve urgency and leakage, but it can also weaken bladder emptying. The patient must understand that intermittent catheterisation may be required, sometimes for several months. Careful selection, measurement of residual urine and appropriate follow-up are essential.

Neuromodulation

Posterior tibial nerve stimulation may help some patients with urgency and overactive bladder symptoms. It is minimally invasive but usually requires repeated treatment sessions.

Sacral neuromodulation can be effective in selected people with refractory urinary urgency, urge incontinence or non-obstructive retention. Evidence specifically in post-stroke patients is more limited than in the general overactive-bladder population. The patient’s neurological stability, cognition, mobility, ability to operate the device and need for future MRI examinations should be considered.

Continence products and skin care

Pads, absorbent underwear, mattress protection and external collecting devices can preserve dignity while recovery and treatment continue. They should support, not replace, proper assessment and rehabilitation.

Regular skin care is important, particularly when mobility is limited. Condom drainage systems may help selected men, but correct fitting and skin monitoring are essential.

Can bladder control improve after a stroke?

Yes. Many patients experience substantial improvement during the first weeks and months as consciousness, mobility, communication and neurological control recover.

Persistent urinary incontinence, however, can be a marker of a more severe stroke and may be associated with greater disability. It should not be dismissed as an inevitable consequence of ageing or brain injury. Early assessment and an active continence program can improve independence, participation in rehabilitation and quality of life.

When should medical help be sought urgently?

Prompt medical assessment is required for:

  • Complete inability to pass urine.
  • A painful or visibly swollen lower abdomen.
  • Fever, chills, confusion or suspected urinary infection.
  • Visible blood in the urine.
  • New flank pain.
  • Recurrent infections.
  • Increasing residual urine.
  • New leg weakness, numbness or loss of bowel control.
  • Sudden new neurological symptoms, which may represent another stroke.

In Australia, sudden facial weakness, arm weakness or speech disturbance should be treated as an emergency—call 000 immediately.

The key message

Bladder problems following a stroke are common, but they are not all the same. Leakage may result from an overactive bladder, impaired awareness, poor mobility, urinary retention, obstruction or several factors acting together.

Successful management begins by determining why the problem is occurring. A combination of bladder rehabilitation, environmental assistance, pelvic-floor therapy, carefully selected medication, catheterisation or specialist intervention can then be tailored to the individual patient.

References

  1. Agapiou E, et al. Lower urinary tract dysfunction following stroke. Bladder. 2024. PubMed Central
  2. Agapiou E, et al. Bladder dysfunction following stroke: an updated review on diagnosis and management. Bladder. 2024. PubMed Central
  3. European Association of Urology. EAU Guidelines on Neuro-Urology. 2026. EAU Neuro-Urology Guideline
  4. Stroke Foundation Australia. Incontinence after stroke. Stroke Foundation patient fact sheet
  5. Stroke Foundation Australia. Urinary continence and stroke—resources for health professionals. InformMe
  6. Canadian Stroke Best Practices. Bladder and Bowel Function Following Stroke. Heart & Stroke Foundation of Canada
  7. National Institute for Health and Care Excellence. Stroke rehabilitation in adults (NG236). Updated 2023. NICE recommendations
  8. National Institute for Health and Care Excellence. Urinary incontinence in neurological disease: assessment and management (CG148). NICE guideline
  9. American Urological Association and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Adult Neurogenic Lower Urinary Tract Dysfunction Guideline. AUA/SUFU guideline
  10. Intercollegiate Stroke Working Party. National Clinical Guideline for Stroke: Rehabilitation and recovery—activity and participation. National Clinical Guideline for Stroke

This article provides general educational information and does not replace individual medical assessment. Treatment should be tailored to the type of bladder dysfunction, other medical conditions, current medications and the patient’s rehabilitation goals.

The Story Behind The “Happy Prostate”

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More than a logo

The Happy Prostate is not simply a practice logo. It began as an original artwork that I painted myself, and it now hangs in my study at home.

Its cheerful expression reflects what I hope to achieve when caring for men with prostate and urinary problems: less worry, better understanding, improved bladder function and renewed confidence.

The prostate may be a small gland, but when it misbehaves, it can have an enormous effect on daily life. It can interrupt sleep, dictate travel plans, interfere with intimacy and leave a man constantly searching for the nearest toilet.

The Happy Prostate represents the other side of that story the moment when a man feels that he has regained control of his life. Having had prostate surgery myself, I am on the same page as my patients, I get you. And no, I did not do it myself!

When a growing prostate becomes a grumpy prostate

Benign prostatic hyperplasia, or BPH, is the non-cancerous enlargement of the prostate that commonly develops as men age.

An enlarged prostate may compress the urinary passage and cause:

  • A slow or interrupted urinary stream
  • Difficulty starting urination
  • Straining to pass urine
  • A feeling that the bladder has not emptied
  • Urgency and frequent urination
  • Getting up repeatedly during the night
  • Urinary retention or recurrent infections

Not every enlarged prostate needs surgery. Treatment begins with understanding the symptoms, examining the prostate and assessing bladder emptying, urinary flow, PSA and other relevant factors.

When a procedure is needed, there is no single operation that suits every man. Modern BPH treatment can be tailored according to prostate size and shape, symptom severity, bladder function, general health and the importance of preserving ejaculation.

Steam

Water-vapour therapy delivers small amounts of controlled steam into selected areas of enlarged prostate tissue. The treated tissue gradually shrinks, creating more room for urine to pass.

It may suit selected men looking for a minimally invasive option with a relatively low risk of sexual side effects. Improvement develops gradually rather than overnight.

Clips or a prostatic urethral lift

Tiny implants can be used to hold enlarged prostate tissue away from the urinary channel. Nothing is cut away.

This approach may offer a rapid recovery and a good chance of preserving ejaculation in appropriately selected men. Prostate anatomy is important, and some men may require further treatment later.

Temporary prostate stents or implants

A temporary implant can reshape the prostatic urethra without leaving a permanent device behind. It is usually removed after several days.

This can be useful for carefully selected prostates, although symptom improvement and long-term durability may not equal those achieved with more definitive tissue-removing procedures.

Laser treatment

Laser surgery can vaporise or enucleate obstructing prostate tissue. The technique selected depends on prostate size, anatomy, bleeding risk and the available equipment and expertise.

Laser treatment can provide powerful relief of obstruction, but temporary urgency, burning, bleeding and changes in ejaculation may occur during recovery.

Bipolar energy

Bipolar electrical energy can remove or enucleate enlarged prostate tissue while controlling bleeding. Bipolar TURP remains an established surgical option for many men with bothersome urinary obstruction.

Robotic-assisted enucleation

Very large prostates may be treated by robotic-assisted simple prostatectomy or enucleation. The obstructing inner portion of the prostate is removed while the outer capsule remains.

This is a more substantial procedure than a minimally invasive treatment, but it can provide excellent relief when a very large prostate is causing severe obstruction, retention, infections, bladder stones or kidney problems.

The right procedure is not necessarily the newest or the biggest. It is the procedure that best matches the individual man and his priorities. Current guidelines emphasise shared decision-making because treatments differ in effectiveness, recovery, durability and effects on sexual function. (EAU Male LUTS guideline)

When the diagnosis is prostate cancer

The words “prostate cancer” naturally produce fear, but prostate cancer is not one uniform disease. Some cancers grow so slowly that immediate treatment may cause more harm than benefit. Others require timely and decisive treatment.

The goal is to understand the cancer accurately and choose a strategy that balances cancer control with urinary, sexual and general health.

Active surveillance

For appropriately selected men with low-risk—and some favourable intermediate-risk—prostate cancer, active surveillance can avoid or delay unnecessary treatment.

It does not mean ignoring the cancer. It is a structured programme that may include:

  • Regular PSA testing
  • Clinical review
  • Prostate MRI
  • Repeat biopsy when indicated
  • Conversion to active treatment if there are signs of progression

The aim is to preserve quality of life while retaining the opportunity for curative treatment if the cancer changes. (EAU Prostate Cancer guideline)

Robotic-assisted radical prostatectomy

Robotic-assisted radical prostatectomy removes the prostate and seminal vesicles with the intention of curing localised prostate cancer.

Where it is oncologically safe, nerve-sparing and careful reconstruction may help preserve erectile function and accelerate recovery of urinary control. Cancer clearance remains the first priority, and continence and sexual outcomes vary between men.

Focal therapy

Focal therapy treats the cancerous area while attempting to preserve as much normal prostate tissue as possible. Techniques may include irreversible electroporation, focal laser ablation, high-intensity focused ultrasound or cryotherapy.

It may be considered for carefully selected men with localised, MRI-visible disease who understand the need for close follow-up. Focal therapy is not suitable for every prostate cancer, and long-term comparative evidence continues to develop. Some international guidelines recommend that it be performed within structured prospective studies or registries.

When continence is preserved, improved or restored

Urinary continence is one of the most important themes represented by the Happy Prostate.

Whenever possible, treatment planning aims to preserve continence. This involves careful patient selection, thoughtful surgical technique, protection of the urinary sphincter and appropriate pelvic-floor preparation and rehabilitation.

When leakage occurs, it should never be dismissed as something a man must simply tolerate. Assessment may include a bladder diary, pad testing, urine-flow measurement, ultrasound, cystoscopy or urodynamic studies. This helps distinguish weakness of the urinary sphincter from urgency, overactive bladder, obstruction or poor bladder emptying.

Depending on the cause, continence may be improved or restored through:

  • Pelvic-floor rehabilitation
  • Bladder training and lifestyle measures
  • Medication for urgency or overactive bladder
  • Treatment of residual obstruction
  • A male urethral sling
  • An artificial urinary sphincter
  • Other carefully selected continence procedures

The joyful progression shown in the Happy Prostate GIF represents this recovery: uncertainty giving way to hope, improvement and confidence. As urinary control returns, the character stands taller, moves with greater freedom and finally throws away his diaper.

The humour is intentional, but so is the dignity behind it. Incontinence can affect work, exercise, travel, intimacy and self-esteem. Restoring continence is not merely about keeping underwear dry, it is about helping a man feel comfortable in the world again.

As I like to put it:

When treatment works, the bladder stops writing the day’s itinerary and the diaper can take the day off.

A small painting with a larger purpose

The original Happy Prostate painting hanging in my home study reminds me that urology is not only about scans, PSA results, flow rates and surgical technology. It is about the man sitting on the other side of the desk.

A prostate becomes truly “happy” when its owner:

  • Understands what is happening
  • Feels comfortable discussing embarrassing symptoms
  • Has treatment suited to his individual circumstances
  • Maintains or regains urinary control
  • Can return to sleep, exercise, travel and intimacy with confidence
  • Feels that he has been heard and treated with dignity

A little humour can open the door, but dignity keeps the conversation going.

That is the story of the Happy Prostate: an original painting, a slightly cheeky character and a serious commitment to helping men regain comfort, confidence and joy.

Dr Jo Schoeman
The “Happy-Prostate” Urologist

This article provides general information and does not replace an individual medical assessment. The suitability, benefits and potential complications of each treatment should be discussed with a urologist.

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

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

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

Why can incontinence occur after prostatectomy?

Urinary continence normally depends on several structures working together:

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

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

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

Stress incontinence or overactive bladder?

This distinction is critical because the treatments are different.

Stress urinary incontinence

Stress incontinence typically causes leakage with:

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

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

Overactive bladder

Overactive bladder generally causes:

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

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

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

Assessment before considering an AUS

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

Assessment may include:

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

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

The role of urodynamic studies

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

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

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

It is particularly useful when a man has:

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

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

What is an artificial urinary sphincter?

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

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

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

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

Who may benefit from an AUS?

An AUS may be considered when:

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

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

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

When may an AUS be unsuitable?

An AUS may not be appropriate when there is:

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

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

What happens during and after surgery?

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

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

Until activation, urinary leakage is expected to continue.

Patients are then taught how to:

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

How successful is an AUS?

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

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

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

Possible complications

Potential complications include:

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

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

Warning signs of cuff erosion or device infection

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

Seek prompt urological review if you notice:

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

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

Important precautions after AUS implantation

Always tell healthcare providers about the AUS

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

Before catheterisation, cystoscopy or any procedure through the urethra:

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

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

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

Protect the urethra and implant

Patients should also:

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

What if the AUS fails?

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

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

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

Depending on the cause, options include:

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

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

A final perspective

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

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

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

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

References

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

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

Bridge to Brisbane 2026: Running in Blue for Prostate Cancer

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On Sunday, 13 September 2026, Brisbane will once again come alive with runners, walkers, families, friends and more than a few wonderfully questionable costumes for the annual Bridge to Brisbane.

This year’s event includes the RBWH Foundation Blue Run 5 km, raising awareness and support for prostate cancer research and care. Participants are encouraged to turn the course blue—whether that means blue shirts, blue socks or the increasingly popular blue skirts and tutus.

The blue skirts may attract a smile, but the message behind them is serious: men’s health deserves to be seen, discussed and supported.

Why run in blue?

Blue is widely recognised as the colour of prostate cancer awareness. Wearing blue creates a visible show of support for men diagnosed with prostate cancer, those undergoing treatment, survivors and the families who travel the journey beside them.

Prostate cancer remains the most commonly diagnosed cancer among Australian men. It can often develop without causing obvious symptoms, particularly in its early stages. Community events such as the Blue Run help bring prostate health into everyday conversation and encourage men to learn about their individual risk.

The blue skirt also carries a distinctly Australian message: we can address an important issue without losing our sense of humour. If pulling on a tutu prompts one man to discuss prostate cancer with his brother, friend or doctor, it has done something worthwhile.

More than a fun run

Bridge to Brisbane enables participants to raise funds for causes that matter to them. Through the RBWH Foundation Blue Run, the community can help support prostate cancer research, clinical care and greater awareness of early detection.

Funds raised for medical research can contribute to:

  • Better methods of identifying significant prostate cancer
  • Improvements in surgery, radiation therapy and medical treatment
  • Research into advanced and metastatic prostate cancer
  • Better management of treatment-related urinary and sexual side effects
  • Support for patients and their families

The Blue Run is therefore not simply about reaching the finish line. Every registration, donation and conversation can help improve the outlook for men affected by prostate cancer. Information about joining or supporting the event is available through the RBWH Foundation and the official Bridge to Brisbane website.

The health benefits of a fun run

You do not have to be an elite runner to benefit. Preparing for a 5 km or 10 km event can provide a realistic goal and a reason to exercise more consistently.

Regular walking, jogging or running may help to:

  • Improve cardiovascular and lung fitness
  • Assist with weight, blood pressure and blood-sugar control
  • Strengthen muscles and bones
  • Improve balance, mobility and physical confidence
  • Reduce stress and improve sleep
  • Support mood and mental wellbeing
  • Maintain independence as we grow older
  • Create valuable social connection

For men living with or recovering from prostate cancer, appropriately prescribed exercise can also help maintain strength, fitness and quality of life. It may be particularly valuable for men receiving androgen-deprivation therapy, which can contribute to fatigue, muscle loss, weight gain and reduced bone density.

Exercise is not a substitute for prostate cancer assessment or treatment, but it is an important part of looking after the whole person.

You may walk—it still counts

The word “run” should not frighten anyone away. Bridge to Brisbane can be approached as a run, jog, walk or a cheerful combination of all three.

A simple preparation program might begin with:

  1. Three comfortable walks each week.
  2. Gradually increasing the time or distance.
  3. Introducing short jogging intervals if appropriate.
  4. Including two weekly sessions of light strength training.
  5. Allowing rest days and increasing activity gradually.

Supportive footwear, hydration and sun protection are important. Anyone with chest pain, unexplained breathlessness, dizziness, significant joint problems or an unstable medical condition should speak with their GP before commencing vigorous exercise.

Men undergoing prostate cancer treatment should seek individual guidance from their treating team or an accredited exercise physiologist.

A different kind of men’s health check

A fun run is not a prostate cancer screening test—but it can start an important conversation.

Men should discuss their prostate cancer risk and the potential benefits and limitations of PSA testing with their GP, particularly if they have a father, brother or son diagnosed with the disease. Aboriginal and Torres Strait Islander men and men with a strong family history may also benefit from an earlier, individualised discussion.

A blue skirt cannot diagnose prostate cancer. It can, however, make the subject difficult to ignore.

My Bridge to Brisbane journey

For me Bridge to Brisbane is more than a single morning of exercise. I participated in the 10 km event since 2019, joining thousands of Queenslanders crossing the Gateway Bridge in support of fitness, community spirit and charitable causes.

Each run has brought its own combination of early-morning nerves, Brisbane sunshine, tired legs and the satisfaction of reaching the finish line. I aim for a sub-50 min each year…

Although achieving a personal best is rewarding, I believe the greater value of the event lies in simply taking part. And for me, having my family participate with me is GOLD. Training provides a reason to remain active, while race day brings people together around important causes—including prostate cancer awareness, research and patient care.

As a urological surgeon, I have seen how prostate cancer can affect not only a man’s physical health but also his continence, sexual function, emotional wellbeing and family life. Running the 10 km course is therefore both a personal challenge and an opportunity to encourage men to pay attention to their health.

The 2026 Blue Run adds special meaning to that involvement. Wearing blue—and perhaps even a blue skirt or tutu—helps turn a private men’s health issue into a visible community conversation. The time on the clock matters, but helping another man think about his prostate health matters even more.

Crossing the bridge together

Prostate cancer affects more than the prostate. It can influence continence, sexual function, relationships, emotional wellbeing and a man’s sense of identity. It also affects partners, children, friends and caregivers.

Bridge to Brisbane reminds us that health challenges are easier to face when we do not face them alone.

So, lace up your shoes, gather your family or mates and add something blue. Walk if you wish, run if you can—and wear the blue skirt with pride.

The finish-line photograph may not be dignified, but the reason behind it certainly is.

Looking forward to seeing many Blue-Skirts!

This article provides general health information and does not replace individual medical advice. Speak with your GP or urologist about prostate symptoms, PSA testing or your personal prostate cancer risk.

Prostate Abscess: A Rare but Serious Infection

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A prostate abscess is a collection of pus within the prostate gland. It usually develops as a complication of acute bacterial prostatitis when infection progresses despite treatment or when treatment has been delayed.

Prostate abscesses are uncommon, but they can become life-threatening if the infection spreads into the bloodstream. Early diagnosis, intravenous antibiotics and, when necessary, drainage of the abscess are essential.

What causes a prostate abscess?

Most prostate abscesses develop when bacteria enter the prostate from the urinary tract. The infection may begin in the bladder or urethra and travel backwards through the prostatic ducts.

Common bacteria include:

  • Escherichia coli
  • Klebsiella species
  • Pseudomonas species
  • Proteus species
  • Enterococcus species
  • Staphylococcus aureus, including resistant strains such as MRSA

Less commonly, bacteria reach the prostate through the bloodstream from an infection elsewhere in the body. Fungal and tuberculosis-related abscesses are rare but may occur in people with significant immune suppression.

Who is at increased risk?

A prostate abscess is more likely to develop in men with:

  • Diabetes, particularly when blood glucose is poorly controlled
  • A weakened immune system
  • Long-term corticosteroid or immunosuppressive treatment
  • HIV or another significant immune disorder
  • Difficulty emptying the bladder
  • Benign prostate enlargement
  • A urethral stricture
  • A long-term urinary catheter
  • Recent urinary tract instrumentation
  • Recent prostate biopsy or prostate surgery
  • Recurrent urinary tract infections
  • Chronic kidney disease or dialysis
  • Intravenous drug use
  • Acute bacterial prostatitis that is not improving with appropriate antibiotics

Diabetes is one of the most frequently identified risk factors. High blood glucose can impair the immune response and make infection more difficult to control.

How does a prostate abscess present?

The symptoms often resemble acute prostatitis or a severe urinary tract infection. A man may experience:

  • Fever, chills or shaking
  • Pain or burning when passing urine
  • Frequent or urgent urination
  • Difficulty starting or maintaining the urinary stream
  • Inability to pass urine
  • Pain in the pelvis, perineum, groin or lower back
  • Painful ejaculation
  • Blood in the urine
  • Cloudy or unpleasant-smelling urine
  • General weakness, nausea or confusion

On examination, the prostate may be enlarged, tender or feel unusually soft or fluctuant. However, the absence of a typical prostate examination does not exclude an abscess.

Forceful prostate massage should be avoided in someone with acute prostatitis or a suspected abscess because it may push bacteria into the bloodstream.

When should a prostate abscess be suspected?

A prostate abscess should be considered when a patient with acute prostatitis:

  • Remains febrile after approximately 48–72 hours of appropriate antibiotics
  • Becomes more unwell despite treatment
  • Develops urinary retention
  • Has persistent pelvic or perineal pain
  • Has recurrent infection with the same organism
  • Has diabetes, immune suppression or another major risk factor

Symptoms alone cannot reliably distinguish an abscess from uncomplicated prostatitis. Imaging is usually needed to confirm the diagnosis.

How is it diagnosed?

Initial investigations may include:

  • Urine microscopy and culture
  • Blood cultures, preferably before antibiotics when this does not delay treatment
  • Full blood count
  • Kidney function and electrolyte tests
  • Inflammatory markers
  • Blood glucose testing
  • Blood lactate and other sepsis investigations when the patient is seriously unwell

Imaging may be performed using:

Transrectal ultrasound

Transrectal ultrasound can demonstrate one or more fluid-filled cavities within the prostate. It can also be used to guide needle drainage.

CT scan

A CT scan of the pelvis is particularly useful when the patient is very unwell or when infection may have spread beyond the prostate. It can also identify urinary obstruction, stones or another source of infection.

MRI

MRI provides detailed images of the prostate and surrounding tissues. It may be helpful when ultrasound or CT findings are unclear, but it is not always the most practical first investigation in an emergency.

Is a prostate abscess an emergency?

A prostate abscess can lead to bloodstream infection, sepsis and septic shock. Patients with fever, shaking chills, confusion, low blood pressure, rapid breathing, severe weakness or inability to pass urine require urgent hospital assessment.

Emergency management may involve:

  • Immediate assessment for sepsis
  • Blood and urine cultures
  • Intravenous fluids
  • Prompt intravenous antibiotics
  • Pain relief
  • Monitoring of blood pressure, urine output and kidney function
  • Treatment of uncontrolled diabetes
  • Urgent urinary drainage if the bladder cannot empty
  • Early consultation with a urologist and, when appropriate, an infectious diseases physician

Antibiotics should not be delayed in a patient who is septic while waiting for scans or culture results.

If urinary retention is present, bladder drainage is required. A urethral catheter may sometimes be used carefully, but a suprapubic catheter inserted through the lower abdomen may be preferred when urethral catheterisation is difficult or likely to cause significant prostate irritation. The best approach depends on the patient’s condition and anatomy.

Treatment with antibiotics

All prostate abscesses require antibiotic treatment.

A patient who is systemically unwell will usually begin treatment with broad-spectrum intravenous antibiotics. The initial antibiotic choice depends on:

  • The likely source of infection
  • Local bacterial resistance patterns
  • Previous urine culture results
  • Recent hospital admission or antibiotic exposure
  • Recent catheterisation or urinary surgery
  • Kidney function
  • Drug allergies
  • The possibility of resistant bacteria or Staphylococcus aureus

Once culture results become available, treatment can be narrowed to an antibiotic that targets the identified organism and penetrates prostate tissue effectively.

After clear clinical improvement, intravenous treatment may be changed to an appropriate oral antibiotic. Treatment is usually longer than for a simple bladder infection and commonly continues for several weeks. The exact duration depends on the organism, abscess size, success of drainage, immune status and response to treatment.

Follow-up urine cultures and repeat imaging may be required to confirm that the infection and abscess have resolved.

Can antibiotics alone cure a prostate abscess?

Occasionally, a small abscess in a clinically stable patient can be treated with antibiotics and close observation. This is more likely to succeed when the collection is small, often less than approximately 1 cm, and drains naturally into the prostatic ducts.

There is no single size threshold that applies to every patient. Larger, multiloculated or persistent abscesses are less likely to resolve with antibiotics alone.

Drainage should be considered when:

  • The patient is septic or clinically deteriorating
  • Fever persists despite appropriate antibiotics
  • The abscess is relatively large
  • There are several abscess cavities
  • The abscess is not shrinking on repeat imaging
  • Urinary obstruction is present
  • The infecting organism is difficult to eradicate
  • The patient has diabetes or significant immune suppression
  • The infection repeatedly returns

Current European guidance recognises that both conservative treatment and drainage may be appropriate in selected patients, with abscess size and clinical response helping to guide the decision. EAU Guidelines on Urological Infections

How is a prostate abscess drained?

Several drainage techniques are available. The method chosen depends on the size and position of the abscess, whether it has multiple compartments, the patient’s condition and local expertise.

Transrectal ultrasound-guided aspiration

A needle is passed through the rectum into the abscess under ultrasound guidance, and the pus is aspirated.

Advantages include:

  • Minimally invasive treatment
  • Usually limited anaesthesia
  • Collection of pus for culture

However, the abscess may refill, particularly if it is large, thick-walled or divided into several compartments. Repeat aspiration may be needed.

Transperineal drainage

A needle or drain is inserted through the skin between the scrotum and anus under ultrasound or imaging guidance.

This approach avoids passing through the rectal wall and may allow a drainage catheter to remain temporarily. It can be useful for appropriately positioned abscesses or when repeated drainage is anticipated.

Transurethral drainage

A telescope is passed through the urethra, and the abscess cavity is opened internally so that it can drain into the urinary channel. This may be performed by incision, deroofing or limited resection of the involved prostate tissue.

Transurethral drainage is often considered when:

  • The abscess is large
  • There are multiple or deep cavities
  • Needle aspiration has failed
  • The abscess has recurred
  • Prostate enlargement is contributing to obstruction
  • Rapid and complete drainage is required

Possible complications include bleeding, urinary infection, temporary worsening of urinary symptoms, retrograde ejaculation, urethral stricture and, less commonly, urinary incontinence or injury to surrounding structures.

Open or laparoscopic surgery

Open, laparoscopic or robotic drainage is rarely required. It may be considered if the abscess extends outside the prostate, cannot be reached by less invasive methods or is associated with another condition requiring surgery.

Antibiotics plus effective drainage remain the central principles of treatment. Management of prostate abscess in the absence of guidelines and MSD Manual: Prostate Abscess

What happens after drainage?

The drained fluid is sent for microbiological testing. This is important because the organism within the abscess may differ from that found in the urine.

Following drainage, the patient usually continues antibiotics. Clinical improvement is monitored by checking:

  • Temperature and general wellbeing
  • Pain and urinary symptoms
  • White blood cell count and inflammatory markers
  • Kidney function
  • Blood glucose in patients with diabetes
  • Urine and blood culture results
  • Follow-up ultrasound, CT or MRI when indicated

Any contributing problem, such as bladder obstruction, a urethral stricture, a catheter or poorly controlled diabetes, should also be addressed to reduce the risk of recurrence.

What is the outlook?

With early recognition, appropriate antibiotics and adequate drainage, most prostate abscesses can be successfully treated.

Delayed treatment may result in:

  • Sepsis or septic shock
  • Spread of infection beyond the prostate
  • Fistula formation into nearby structures
  • Recurrent urinary infection
  • Chronic pelvic discomfort
  • Prolonged difficulty passing urine
  • Rarely, death from overwhelming infection

A prostate abscess should therefore be regarded as a potentially serious complication of prostatitis rather than an ordinary urinary infection.

When should you seek urgent medical attention?

Attend an emergency department urgently if you develop:

  • Fever or shaking chills with urinary symptoms
  • Confusion, faintness or severe weakness
  • Inability to pass urine
  • Severe pelvic or perineal pain
  • Rapid breathing or a racing heartbeat
  • Persistent fever despite antibiotics
  • Worsening symptoms after treatment for prostatitis

Early assessment is particularly important for men with diabetes, immune suppression, a urinary catheter or recent urinary tract surgery.

This information is intended for general education and does not replace individual medical assessment. A suspected prostate abscess requires urgent assessment by a medical practitioner and usually early involvement of a urologist.

So, if this is happening to you, attend your local Emergency Department ASAP, or if you are still OK, ask your GP for an urgent referral to see your local Brisbane Urologist Dr Jo Schoeman ASAP