Tag Archive for: Urinary Incontinence

Urethral bulking for stress urinary incontinence: a first procedure or an option after a sling?

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Leaking urine when you cough, laugh, exercise or lift something is called stress urinary incontinence (SUI). It differs from urgency incontinence, when a sudden need to pass urine leads to leakage. Some women have both. Identifying which symptom is most troublesome matters because an injection aimed at SUI will not reliably treat urgency.

Urethral bulking involves placing small deposits of material into the wall of the urethra, usually through a fine instrument passed into the urethra. The deposits help the urethra close when pressure rises. You may hear this described as periurethral bulking, although many contemporary injections are delivered through the urethra into its surrounding wall. This is generally a day procedure under local anaesthesia or sedation/general anaesthesia, depending on the circumstances. It does not place a sling or mesh tape.

Could bulking be my first procedure?

Yes. After a trial of pelvic floor muscle training and discussion of other conservative measures, bulking can be chosen as a first procedure for appropriately assessed SUI. It may appeal to someone seeking a shorter procedure and recovery, or wishing to avoid a sling. It is also an option when a larger operation or anaesthetic carries additional risk. It is not usually the first treatment before conservative care. USANZ’s 2026 position statement lists bulking alongside autologous fascial slings, colposuspension and synthetic midurethral slings among the standard options that should be discussed. UGSA’s patient information stresses its lower success and frequent need for repeat treatment. [1–3]

Bulking, synthetic midurethral sling surgery, a sling made from the patient’s own fascia, and colposuspension have different benefits and risks. A donated-tissue (allograft) sling is distinct from a sling made from your own tissue (autograft) and from a synthetic mesh sling; the strength and duration of evidence for each are different. No single procedure is best for every woman. [1,4]

How effective and durable is it?

The realistic aim is often less leakage, rather than guaranteed dryness. Success figures change substantially depending on whether researchers count complete dryness, improvement, satisfaction, or avoidance of further treatment. UGSA’s patient leaflet quotes about 40–50% cure or improvement and reports that approximately 30% need a further injection within two years. These are broad counselling figures, not a prediction for an individual. [2]

Some women remain improved for years, but repeat injections or another operation may be needed. In a randomised comparison of polyacrylamide hydrogel injection and synthetic tension-free vaginal tape for primary SUI, the tape achieved better objective continence at one year (negative cough test 95.0% versus 66.4%). The five-year follow-up did not establish that injection was non-inferior to tape. The EAU similarly advises that bulking is generally less effective than slings or colposuspension for cure, and that repeat injection is likely. These findings do not mean everyone should have a tape: the value of a less invasive procedure and the acceptability of a possible repeat treatment are personal considerations. [4–6]

What if I still leak after a sling?

Bulking can be considered for persistent leakage soon after a sling or recurrent leakage after an initial period of improvement. It can sometimes reduce leakage without placing another sling. A 2022 systematic review of 11 studies after synthetic midurethral sling failure reported a pooled 75% cure-or-improvement rate, but also pooled failure and further-operation rates of 32% and 25%. The studies differed considerably in their patients, products, follow-up and definitions of success; the 75% figure should not be presented as a personal chance of cure. An American Urogynecologic Society clinical practice statement also recognises bulking as an option after a sling. [7,8]

After an allograft sling, the same clinical possibility exists, but the published post-sling bulking evidence is mainly about synthetic midurethral slings. We should not simply transfer those success figures to donated-tissue slings. The precise graft, previous surgery and examination findings should guide an individual discussion.

An injection should not be used to mask a sling complication. Before offering more treatment, I would review the original operation, check urine and bladder emptying, examine for prolapse, scarring and vaginal exposure, and assess whether leakage occurs with coughing or with urgency. Cystoscopy, a bladder diary, pad testing or urodynamics may be appropriate, especially after previous surgery, mixed symptoms, pain, blood in the urine or difficulty emptying. A tape or graft causing obstruction, exposure, erosion, infection or pain may require its own assessment and treatment. [1,3,7]

Is it safe? What are the side effects?

Most reported problems are short lived, but no injection is risk free. Possible effects include:

  • burning when passing urine and a little blood in the urine;
  • urinary tract infection;
  • temporary difficulty emptying the bladder, occasionally requiring short-term catheterisation;
  • new or persisting urgency symptoms; and
  • incomplete benefit, recurrence or the need for another injection or operation.

Less commonly, there may be persistent pain, a collection or infection at the injection site, or a reaction or complication related to the particular material. Risks also depend on anaesthesia, previous surgery and the chosen product. Emptying should be checked before discharge. Seek prompt assessment if you cannot pass urine, develop fever, worsening pain or heavy bleeding. [2,4,8]

Choosing a treatment

The first step is to confirm the type and severity of leakage and clarify your goals: complete dryness, meaningful improvement, shorter recovery, avoiding mesh, or avoiding the likelihood of repeat treatment. Pelvic floor therapy remains an initial option. When a procedure is appropriate, we can compare bulking with sling and colposuspension procedures using your examination findings, health history and preferences. If you have already had a sling, the reason for the continuing leakage deserves a fresh assessment before choosing another procedure.

This page is general education, not a recommendation for a particular product or a promise of a result. Treatment, including its material, risks, costs and alternatives, should be discussed during an individual consultation.

References

  1. Urological Society of Australia and New Zealand (USANZ). Surgical Treatment of Stress Urinary Incontinence: Position Statement Pol 054, version 2.0. Approved 9 May 2026.
  2. Urogynaecological Society of Australasia (UGSA). Urethral Bulking: Patient Information.
  3. UGSA. Stress Urinary Incontinence: Patient Resources.
  4. European Association of Urology. Guidelines on Non-neurogenic Female Lower Urinary Tract Symptoms: Disease Management, section 4.2.4.c.2.c.
  5. Itkonen Freitas A-M, et al. Tension-free vaginal tape surgery versus polyacrylamide hydrogel injection for primary stress urinary incontinence: a randomised clinical trial. Journal of Urology. 2020.
  6. Itkonen Freitas A-M, et al. Tension-free vaginal tape versus polyacrylamide hydrogel injection for stress urinary incontinence: five-year follow-up. NEJM Evidence. 2025.
  7. Braga A, et al. Urethral bulking agents for the treatment of recurrent stress urinary incontinence: a systematic review and meta-analysis. Maturitas. 2022. doi:10.1016/j.maturitas.2022.05.007.
  8. American Urogynecologic Society. Urethral Bulking: Clinical Practice Statement. Urogynecology. 2024. doi:10.1097/SPV.0000000000001548.

Urinary Incontinence After Prostatectomy and Salvage Radiotherapy

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Why leakage may become more complex after both treatments

Urinary leakage after radical prostatectomy is common in the early recovery period and usually improves with healing and pelvic floor rehabilitation. Some men, however, require salvage radiotherapy because their PSA remains detectable or rises after surgery.

Radiotherapy can help control recurrent prostate cancer, but it may also affect tissues that have already been altered by surgery. Radiation can cause progressive scarring, reduced blood supply and loss of elasticity in the urethra, bladder neck and bladder. These effects may develop months or even years later.

As a result, leakage after prostatectomy and salvage radiotherapy is not always caused by a weak urinary sphincter alone. A man may have:

  • Stress urinary incontinence: leakage with coughing, standing, lifting, walking or exercise because the sphincter does not close effectively.
  • Urgency urinary incontinence: leakage accompanied by a sudden, difficult-to-defer urge, often caused by an overactive or irritated bladder.
  • Overflow leakage: leakage associated with poor bladder emptying, a weak bladder muscle or obstruction.
  • Mixed incontinence: a combination of stress and urgency leakage.
  • Radiation-related complications: bladder-neck contracture, urethral stricture, radiation cystitis, poor bladder compliance, fistula, tissue necrosis or, in severe cases, a severely damaged bladder outlet.

Correctly identifying the cause is essential. Tightening the outlet when the bladder cannot store or empty safely may replace one problem with another.

When should the problem be assessed?

Continence can continue to improve during the first year after prostatectomy. Pelvic floor muscle training should begin early, and surgical treatment may be considered as early as six months when severe leakage is clearly not improving. Persistent, bothersome stress incontinence at approximately 12 months deserves formal assessment.

Following salvage radiotherapy, earlier review is appropriate if there is:

  • worsening leakage;
  • blood in the urine;
  • recurrent urinary infection;
  • pain, burning or severe urgency;
  • a weak stream or difficulty emptying;
  • urinary retention;
  • pelvic or perineal pain; or
  • urine leaking through an abnormal opening.

Visible haematuria, fever, inability to pass urine or severe pain requires prompt medical attention.

Investigating incontinence after salvage radiotherapy

1. A careful history

The first step is to establish what type of leakage is occurring, when it began and whether it changed after radiotherapy. Important questions include:

  • Is leakage triggered by activity, or by urgency?
  • How many pads are used, and how wet are they?
  • Is the patient dry at night or when lying down?
  • Is there a weak stream, straining or incomplete emptying?
  • Are there recurrent infections, haematuria or pelvic pain?
  • Were there previous bladder-neck or urethral procedures?
  • How much does leakage affect work, exercise, sleep, intimacy and quality of life?

Manual dexterity and cognition are also important if an artificial urinary sphincter is being considered, because the patient must be able to locate and operate a small scrotal pump.

2. Bladder diary and pad assessment

A three-day bladder diary records fluid intake, voided volumes, urgency and leakage. Pad number gives a useful impression, but pads differ greatly. A 24-hour pad-weight test can quantify the actual volume lost and help grade severity and monitor progress.

3. Examination and basic tests

Assessment commonly includes:

  • abdominal, genital, perineal and neurological examination;
  • observation for leakage while coughing or standing with a comfortably full bladder;
  • urinalysis and urine culture when infection is suspected;
  • uroflowmetry;
  • ultrasound measurement of the post-void residual; and
  • renal function testing or upper-tract imaging when clinically indicated.

4. Cystoscopy

Cystoscopy is particularly important before continence surgery in a previously irradiated urinary tract. It allows the urologist to inspect the urethra, bladder neck and bladder for:

  • urethral stricture or bladder-neck contracture;
  • radiation damage, stones or tumour;
  • erosion from a previous implant;
  • tissue quality and sphincter appearance; and
  • fistula or necrosis in complex cases.

Any clinically important obstruction or unstable urethral disease usually needs to be treated and shown to be stable before an anti-incontinence device is implanted.

What is the role of urodynamic studies?

Urodynamics is not mandatory for every man with straightforward stress leakage. It becomes more useful when symptoms are mixed, the diagnosis is uncertain, previous radiation has made the situation more complex, or the result may change treatment.

The study can assess:

  • stress leakage and sphincter weakness;
  • involuntary bladder contractions;
  • bladder capacity and sensation;
  • reduced bladder compliance or unsafe storage pressures;
  • obstruction;
  • weak bladder contraction; and
  • the ability of the bladder to empty against a future sling or sphincter cuff.

Urodynamics is especially worth considering when there is marked urgency, nocturnal leakage, retention, a raised residual, poor flow, recurrent infection, prior outlet reconstruction or concern about a small, painful or poorly compliant radiation-damaged bladder.

The test does not simply decide whether a man “qualifies” for an operation. Its value is in identifying bladder dysfunction that should be treated first or a bladder that may not tolerate additional outlet resistance.

Initial and non-surgical management

Pelvic floor rehabilitation

Supervised pelvic floor muscle training can improve control and teach correct muscle activation. It is most useful early after prostatectomy but may still improve coping and control later. Repeated forceful exercises are not always better; poor technique can worsen pelvic tension or urgency.

Bladder and lifestyle measures

Management may include weight reduction where relevant, treating constipation, moderating caffeine and alcohol, adjusting the timing of fluids and diuretics, bladder training and treating urinary infection. Antimuscarinic medication or a beta-3 agonist may help an overactive-bladder component, but medication does not restore a damaged sphincter.

Pads, sheaths and clamps

Absorbent pads remain a practical option for mild leakage or while awaiting treatment. A condom drainage sheath can direct urine into a leg bag when penile skin and anatomy permit.

A penile clamp may provide short-term control for selected men with good sensation, intact skin and adequate bladder emptying. It must be released regularly and should not be used overnight. Extra caution is required after radiation because pressure injury may heal poorly.

Catheter options

Catheters manage drainage; they do not repair stress incontinence. They may nevertheless be appropriate when there is retention, very poor emptying, severe frailty, failed reconstruction or a need for temporary urinary control.

Intermittent self-catheterisation

Intermittent self-catheterisation is generally preferred when the bladder fails to empty but the patient has sufficient dexterity and urethral access. It avoids a continuously indwelling tube, although irradiated strictures or a false passage may make catheterisation difficult.

Long-term urethral catheter

An indwelling urethral catheter may be necessary in selected patients, but long-term use can cause infection, discomfort, blockage, bladder stones, urethral erosion and further outlet damage. A catheter passing through an activated AUS cuff can also cause serious urethral erosion; healthcare providers must be told that an AUS is present and the device should be deactivated before urethral instrumentation.

Suprapubic catheter

A suprapubic catheter enters the bladder through the lower abdomen. For long-term drainage it often avoids continuing urethral pressure and may be easier to manage than a urethral catheter. It still requires regular changes and carries risks including infection, blockage, bladder stones, leakage and skin problems.

Male sling versus artificial urinary sphincter

Male sling

A male sling supports and repositions or compresses the urethra. Its advantages include no scrotal pump and no need to operate the device each time the patient urinates. In carefully selected, non-irradiated men with mild-to-moderate stress incontinence, a sling can be effective.

However, previous pelvic radiotherapy is a recognised predictor of poorer sling outcomes. Fibrosis limits urethral mobility and tissue recovery, and moderate-to-severe leakage further reduces success. A sling may still be discussed in a highly selected patient with very mild leakage, good residual sphincter function and a stable, healthy-looking urethra, but expectations must be conservative.

Artificial urinary sphincter (AUS)

The AUS consists of a fluid-filled cuff around the urethra, a pressure-regulating balloon and a pump in the scrotum. The cuff stays closed to control leakage. The patient squeezes the pump to open it temporarily when passing urine.

For men with moderate-to-severe stress incontinence, the AUS remains the most established surgical treatment. Importantly, the AUA/GURS/SUFU guideline recommends offering an AUS rather than a male sling or adjustable balloons to men seeking surgery after primary, adjuvant or salvage radiotherapy.

Radiation does not make AUS implantation impossible, but outcomes are less predictable than in non-irradiated men. Radiation increases the risks of urethral erosion, infection, tissue atrophy, revision and device removal. Mechanical parts also have a limited lifespan, so further surgery may eventually be required.

Practical comparison

Consideration Male sling Artificial urinary sphincter
Best-established role Mild-to-moderate stress leakage in selected men Moderate-to-severe stress leakage
Previous salvage radiotherapy Lower success; generally not preferred Guideline-preferred surgical option, with higher complication risk than in non-irradiated men
Patient operation No pump Scrotal pump must be squeezed for each void
Manual dexterity required Minimal Yes
Retention risk Possible Possible if device is not cycled correctly or obstruction develops
Long-term considerations Persistent leakage or failure may require AUS Mechanical failure, erosion, infection or atrophy may require revision or removal

Neither operation guarantees complete dryness. The choice should consider pad weight, bladder function, urethral health, prior strictures or surgery, dexterity, patient priorities and the reconstructive surgeon’s assessment.

When an AUS or sling is not enough

A small group of men develop a severely scarred, painful or repeatedly obstructed outlet, sometimes called a devastated bladder outlet. This may include recurrent bladder-neck contracture or urethral stricture, fistula, radionecrosis, repeated AUS erosion, severe radiation cystitis or an unsafe low-capacity bladder.

Further implant surgery may then be unlikely to succeed. The priority changes from preserving normal voiding to obtaining dependable drainage, protecting the kidneys and improving quality of life.

Options at a specialist reconstructive centre may include:

  • long-term suprapubic drainage;
  • closure of the bladder neck with a suprapubic catheter in selected cases;
  • a catheterisable abdominal channel in carefully selected patients;
  • an ileal conduit, in which urine drains through a short segment of bowel to a urostomy bag on the abdomen;
  • another form of continent urinary diversion in selected fit patients; or
  • cystectomy with urinary diversion when the bladder is severely painful, contracted, bleeding, fistulating or otherwise unsalvageable.

These are major, irreversible procedures with substantial risks. They should be considered only after detailed imaging and functional assessment, review of cancer status, discussion with an experienced reconstructive team and consultation with a stomal therapy nurse.

A sensible treatment pathway

  1. Define the leakage: stress, urgency, overflow or mixed.
  2. Measure its severity: diary, pads and preferably pad weight.
  3. Check storage and emptying: urine testing, flow and residual; use urodynamics when the findings may alter treatment.
  4. Inspect the outlet: cystoscopy before implant surgery, particularly after radiation.
  5. Treat infection, obstruction and bladder dysfunction first.
  6. Use conservative or catheter strategies when appropriate.
  7. For persistent radiated stress incontinence, discuss AUS as the usual preferred operation.
  8. Reserve sling surgery for exceptional, carefully selected radiated patients after frank counselling.
  9. Refer severe outlet or bladder destruction to a high-volume reconstructive centre to discuss reconstruction versus diversion.

The take-home message

Urinary incontinence after prostatectomy and salvage radiotherapy is treatable, but it needs more than a pad count and a one-size-fits-all operation. The bladder, sphincter and urethra must each be assessed.

For straightforward sphincter weakness after radiation, the artificial urinary sphincter usually offers the most reliable surgical option, although radiation increases the likelihood of erosion and future revision. A male sling is less invasive but is less dependable in irradiated tissue. When the outlet or bladder is severely damaged, catheter drainage, bladder-neck closure or urinary diversion may provide a safer and more durable solution than repeated continence procedures.

This article provides general information and does not replace an individual assessment. Treatment should be tailored to the patient’s symptoms, examination, bladder function, urethral condition, cancer status and personal priorities.

References

  1. Breyer BN, Kim SK, Kirkby E, et al. Updates to Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline (2024). Journal of Urology. 2024. AUA guideline | Journal update
  2. European Association of Urology. EAU Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms: urinary incontinence assessment and treatment. Current online edition. EAU guideline
  3. American Urological Association, ASTRO and SUO. Salvage Therapy for Prostate Cancer Guideline. AUA/ASTRO/SUO salvage therapy guideline
  4. National Institute of Diabetes and Digestive and Kidney Diseases. Urodynamic testing. NIDDK patient information
  5. British Association of Urological Surgeons. Urinary diversion into an ileal conduit. BAUS patient information

Evidence note: Most data specific to men who have undergone both prostatectomy and salvage radiotherapy come from observational series rather than large randomised trials. Recommendations therefore combine guideline evidence, reconstructive-urology experience and individualised shared decision-making.

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.

Parkinson’s Disease and the Bladder: When the Brain–Bladder Signal Misbehaves

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Parkinson’s disease is best known for tremor, stiffness and slowed movement, but it can also affect many automatic body functions: including bladder control. Urinary symptoms may disturb sleep, restrict social activities and increase the risk of falls when someone rushes to the toilet.

The reassuring message is that bladder symptoms can usually be improved. The important first step is to identify what the bladder is doing, because not every urinary problem in a person with Parkinson’s is caused by Parkinson’s itself.

How does Parkinson’s affect the bladder?

The bladder normally stores urine quietly and empties only when the brain decides that the time and place are appropriate. Dopamine-dependent circuits in the brain help suppress unwanted bladder contractions during filling.

Parkinson’s can weaken this “hold on” signal. The bladder muscle may contract before it is full, a condition called detrusor overactivity. This produces the familiar overactive-bladder symptoms of urgency, frequency and urge incontinence.

This is a form of neurogenic lower urinary tract dysfunction; bladder or sphincter function altered by disease of the nervous system. However, Parkinson’s does not create one single bladder pattern. Age-related bladder changes, prostate enlargement, pelvic-floor problems, constipation, diabetes, mobility limitations and medications may all contribute.

Common urinary symptoms

People may experience:

  • a sudden, difficult-to-defer need to pass urine;
  • frequent urination during the day;
  • waking several times at night to urinate (nocturia);
  • leakage before reaching the toilet (urge incontinence);
  • bedwetting;
  • hesitancy, a slow stream or straining;
  • a feeling that the bladder has not emptied; or
  • recurrent urinary infections.

Some apparent bladder leakage is partly functional: the person recognises the urge but rigidity, slow movement, poor balance or difficulty managing clothing prevents timely access to the toilet.

Difficulty emptying can occur, but substantial urinary retention is less typical of uncomplicated Parkinson’s disease. It may indicate prostate or urethral obstruction, an underactive bladder, medication effects, severe constipation, pelvic-organ prolapse, or another neurological disorder. Prominent retention, erectile dysfunction or severe postural blood-pressure problems early in a parkinsonian illness may warrant neurological review for conditions such as multiple system atrophy.

How is the bladder evaluated?

A careful assessment is more useful than assuming that every symptom is “just the Parkinson’s”. It may include:

  1. History and medication review: urinary symptoms, fluid intake, bowel function, mobility, cognition, falls and all prescribed and non-prescribed medicines.
  2. Bladder diary: usually recording drinks, voided volumes, urgency and leakage for three days. This is particularly helpful for nocturia.
  3. Examination: abdominal, neurological and, when appropriate, prostate or pelvic assessment.
  4. Urine test: to look for infection or blood.
  5. Post-void residual measurement: a bladder ultrasound after urination shows whether emptying is adequate.
  6. Uroflowmetry: measures the strength and pattern of the urinary stream.
  7. Further tests when indicated: renal function, ultrasound, cystoscopy or prostate assessment according to the clinical findings.

Blood in the urine, pain, fever, recurrent infection or a sudden major change in bladder function needs separate investigation and should not automatically be attributed to Parkinson’s.

Are urodynamic studies always necessary?

No. A patient with straightforward urgency and urge leakage, a normal urine test and a low residual volume can often begin conservative treatment without invasive testing.

Urodynamics may be particularly useful when:

  • symptoms and initial test results do not agree;
  • there is a high or rising post-void residual;
  • weak flow, retention or obstruction is suspected;
  • symptoms persist despite appropriate treatment;
  • the diagnosis is uncertain, for example, overactivity versus poor bladder contraction;
  • previous prostate, bladder or continence surgery complicates the picture; or
  • Botox or another invasive treatment is being considered and the result would alter management.

During urodynamics, thin catheters measure bladder and abdominal pressure while the bladder fills and empties. The test may demonstrate detrusor overactivity, impaired contraction, obstruction or, less commonly, unsafe storage pressure. It should answer a specific clinical question not simply be performed because Parkinson’s is present.

First steps: practical and behavioural treatment

Management should be individualised and, where helpful, involve the urologist, neurologist, Parkinson’s nurse, continence physiotherapist, occupational therapist and carer.

Useful measures include:

  • treating urinary infection and constipation;
  • reviewing diuretics and other medicines with the prescribing doctor;
  • spreading fluid intake through the day while avoiding dehydration;
  • reducing late-evening fluids, caffeine and alcohol when nocturia is troublesome;
  • timed or prompted voiding;
  • bladder training when cognition and mobility permit;
  • pelvic-floor physiotherapy where appropriate;
  • improving toilet access, lighting, clothing and mobility aids; and
  • using a bedside urinal or commode when falls are a concern.

Nocturia is not always caused solely by an overactive bladder. Leg swelling, sleep apnoea, excessive urine production overnight and disturbed sleep may require different treatment.

Medication options

Antimuscarinic medicines

Medicines such as solifenacin, darifenacin, tolterodine, fesoterodine, oxybutynin or trospium can reduce involuntary bladder contractions. They may improve urgency, frequency and urge leakage.

The trade-off is important in Parkinson’s disease. Anticholinergic burden may worsen dry mouth, constipation, blurred vision, urinary retention, confusion or memory. Older people, those with cognitive impairment, glaucoma or poor bladder emptying need particular caution. Oxybutynin can be especially troublesome cognitively in susceptible patients. Drug choice should consider the person’s complete medication list and residual urine.

Beta-3 agonists

Mirabegron relaxes the bladder during filling without adding the same anticholinergic burden and has shown benefit in people with Parkinson’s and overactive-bladder symptoms. Blood pressure should be checked because it can rise, and interactions and cardiac history should be reviewed. Vibegron is another beta-3 agonist available for overactive bladder in Australia; Parkinson-specific evidence is more limited.

Combination treatment may be considered in selected patients when one medicine provides incomplete relief, with monitoring of blood pressure, side effects and bladder emptying.

If emptying is the main problem

Treatment depends on the cause. Prostate medication or surgery will help only if genuine bladder-outlet obstruction is present. An alpha-blocker may worsen dizziness or postural hypotension, already common in Parkinson’s. If significant residual urine persists, clean intermittent self-catheterisation, performed by the patient or a carer where feasible, is generally preferable to a long-term urethral catheter. A suprapubic catheter may be considered when intermittent catheterisation is not practical.

Botox injections into the bladder

Botulinum toxin A (Botox) can be effective for troublesome detrusor overactivity or overactive-bladder symptoms that have not responded to, or cannot tolerate, tablets. It is injected through a cystoscope into multiple areas of the bladder wall, usually as a day procedure.

Benefits may include fewer urgency episodes, fewer leaks and better sleep and quality of life. The effect is temporary, commonly lasting several months, so repeat treatment may be required.

Important risks include:

  • urinary infection;
  • blood in the urine or short-lived discomfort;
  • incomplete bladder emptying or urinary retention; and
  • the possible need for temporary or occasionally ongoing intermittent catheterisation.

Before treatment, the patient’s hand function, cognition and support network matter: could the patient or carer perform catheterisation if retention occurred? Measuring residual urine before and after treatment is essential. Urodynamics is often helpful if the underlying bladder behaviour or emptying ability is uncertain, although it is not mandatory in every otherwise clear case.

Can sacral neuromodulation be used in Parkinson’s disease?

Yes, in carefully selected patients. Sacral neuromodulation (SNM) sends mild electrical impulses to the sacral nerves involved in bladder control. It can be considered for refractory urgency, frequency, urge incontinence and, in selected circumstances, non-obstructive urinary retention.

Treatment begins with a test or staged phase. A temporary or tined lead is used to assess whether symptoms improve meaningfully, commonly by at least 50%, before a permanent battery is implanted. This trial is particularly valuable because Parkinson’s symptoms and bladder patterns differ between patients.

Small observational studies and systematic reviews suggest that some people with Parkinson’s achieve worthwhile improvement. However, the Parkinson-specific evidence is less extensive than the evidence for non-neurogenic overactive bladder, and response cannot be guaranteed.

Points to consider include:

  • confirming that infection, obstruction and severe retention have been addressed;
  • whether symptoms are likely to be modulated by SNM;
  • the person’s ability, or carer support, to operate and attend follow-up for the device;
  • falls, mobility and future disease progression;
  • possible lead movement, pain, infection, device revision or battery replacement; and
  • future MRI requirements. Modern systems may be MRI-conditional, but the exact device and scanning conditions must always be checked.

SNM is therefore not automatically excluded because a person has Parkinson’s. It is best considered through shared decision-making after appropriate evaluation and failure or intolerance of simpler measures.

Botox or sacral neuromodulation?

Feature Bladder Botox Sacral neuromodulation
How it works Temporarily reduces bladder-muscle overactivity Modulates sacral nerve signalling
Treatment pathway Cystoscopic injections, repeated when effect wears off Test phase followed by an implant if successful
Main advantage No permanent implant; established effect on detrusor overactivity Testable before permanent implantation; no routine bladder injections
Main limitation UTI and retention; intermittent catheterisation may be required Implant surgery, programming, revisions and battery management
Parkinson-specific evidence Supportive but based mainly on relatively small studies Promising but still limited; careful selection is essential
Particularly important question Could the patient or carer catheterise if necessary? Can the patient manage the device and follow-up as Parkinson’s progresses?

Neither option is universally “better”. The choice depends on bladder-emptying ability, infection history, dexterity, cognition, mobility, MRI needs, willingness to have repeat procedures or an implant, and the individual’s priorities.

When should you seek prompt medical attention?

Contact a doctor urgently for inability to pass urine, fever with urinary symptoms, flank pain, visible blood in the urine or a sudden neurological or bladder deterioration. New persistent incontinence also deserves assessment rather than simply adding pads.

The take-home message

Bladder symptoms are common and often overlooked in Parkinson’s disease. Urgency, frequency, nocturia and urge leakage are the usual pattern, but obstruction and poor emptying must not be missed. Most patients do not require urodynamics at the outset; it becomes valuable when the diagnosis is uncertain, emptying is impaired, treatment has failed or an invasive procedure is being planned.

Treatment progresses from practical measures and medication to Botox or sacral neuromodulation in suitable patients. The best plan balances symptom control with cognition, blood pressure, constipation, mobility, manual dexterity and the likely course of Parkinson’s disease.

Patient information: This article provides general education and is not a substitute for an individual medical assessment. Do not stop Parkinson’s, blood-pressure or bladder medication without discussing it with your treating doctor.

References and further reading

  1. European Association of Urology. EAU Guidelines on Neuro-Urology. 2026.
  2. Ginsberg DA, et al. AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction. J Urol. 2021; amendment 2024.
  3. Li FF, et al. Prevalence of lower urinary tract symptoms, urinary incontinence and retention in Parkinson’s disease: a systematic review and meta-analysis. Front Aging Neurosci. 2022;14:977572.
  4. Sakakibara R, et al. A guideline for the management of bladder dysfunction in Parkinson’s disease and other gait disorders. Neurourol Urodyn. 2016;35:551–563.
  5. Cho SY, et al. Mirabegron for treatment of overactive bladder symptoms in patients with Parkinson’s disease: a randomised, placebo-controlled trial. Neurourol Urodyn. 2021.
  6. Greenberg DR, et al. Sacral nerve stimulation in Parkinson’s disease patients with overactive bladder symptoms. Urology. 2020;144:99–105.
  7. Smith MD, et al. Neuromodulation for storage lower urinary tract symptoms in Parkinson disease: a systematic review. Neuromodulation. 2022.

 

Multiple Sclerosis and the Bladder: Symptoms, Tests and Treatment Options

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Multiple sclerosis (MS) affects the brain and spinal cord, the same nervous system pathways that coordinate bladder storage, bladder emptying and urinary sphincter control. As a result, bladder symptoms are common and may change as MS changes.

The important message is that “an MS bladder” is not one single condition. Some people develop an overactive bladder, some cannot empty properly, and others have a mixture of both. Treatment should therefore be based on the individual bladder pattern, not simply on the diagnosis of MS.

How does MS affect bladder control?

Normally, the bladder stores urine at low pressure while the urinary sphincter stays closed. When it is convenient to urinate, the brain allows the bladder muscle (detrusor) to contract while the sphincter relaxes.

MS plaques can interrupt these signals in different places. This may cause:

  • Neurogenic detrusor overactivity: the bladder contracts unexpectedly during filling, causing urgency, frequency, nocturia and urge incontinence.
  • Detrusor sphincter dyssynergia: the bladder contracts while the sphincter fails to relax properly, rather like pressing the accelerator and brake together. This may produce poor flow, straining, incomplete emptying, high bladder pressure and recurrent urinary infection.
  • Detrusor underactivity: the bladder contraction is too weak or does not last long enough, causing slow emptying or retention.
  • A mixed pattern: urgency and leakage can coexist with a significant residual urine volume.

The European Association of Urology (EAU) reports that approximately 75% of people develop voiding dysfunction within ten years of MS. Reported urodynamic patterns include neurogenic detrusor overactivity in 43–65%, detrusor sphincter dyssynergia in about 35%, and detrusor underactivity in about 25%. These patterns can overlap and can change over time.

Symptoms that deserve assessment

Bladder symptoms may include:

  • sudden urgency and difficulty postponing urination;
  • frequent urination by day or night;
  • leakage before reaching the toilet;
  • hesitancy, interrupted or weak urinary flow;
  • straining to urinate;
  • a feeling of incomplete emptying;
  • recurrent urinary tract infections (UTIs);
  • new bedwetting or unexpected leakage; and
  • an inability to pass urine.

Seek prompt medical review for fever, flank pain, visible blood in the urine, severe bladder pain, inability to urinate, or a sudden major change in bladder function. A UTI can temporarily worsen neurological MS symptoms (a pseudo-relapse), while a true neurological relapse can also alter bladder function.

How is the bladder assessed?

Assessment is tailored to symptoms, disability, MS course and previous treatment. It may include:

  1. A detailed urinary, neurological, bowel, medication and mobility history.
  2. A three-day bladder diary recording fluid intake, voids, urgency, leakage and catheter volumes.
  3. Urinalysis and urine culture when infection is suspected.
  4. Measurement of post-void residual urine with a bladder scan.
  5. Kidney-function blood tests where appropriate.
  6. Urinary tract ultrasound in selected patients, particularly where retention, recurrent infection, stones or upper-tract risk is suspected.
  7. Uroflowmetry, which measures the strength and pattern of the urinary stream.
  8. Urodynamic studies when the result is likely to clarify the diagnosis or change treatment.

Urodynamic studies: useful, but used selectively

Urodynamics measures bladder pressure, abdominal pressure, urine flow and sphincter activity during filling and emptying. It can distinguish urgency caused by detrusor overactivity from poor emptying caused by detrusor weakness, outlet obstruction or detrusor–sphincter dyssynergia. Video urodynamics can additionally show the bladder outlet, reflux and anatomical changes.

Urodynamics is especially useful when:

  • symptoms and residual urine measurements do not tell the same story;
  • both storage and emptying symptoms are present;
  • recurrent UTIs, retention or raised bladder pressures are suspected;
  • invasive treatment such as bladder Botox is being considered;
  • previous treatment has failed or produced unexpected problems;
  • there is concern about kidney or upper urinary tract safety; or
  • bladder function has changed significantly.

Precautions before and during urodynamics

  • Active symptomatic UTI should be treated before an elective invasive study.
  • The team should know about antibiotics, anticoagulants, allergies, pregnancy possibility and previous difficulty with catheterisation.
  • Mobility, spasms, fatigue, cognition, hand function and transfer needs should be planned for in advance.
  • Catheter placement and rapid filling can alter the result; artefacts must be recognised and the study interpreted alongside the person’s normal symptoms and bladder diary.
  • A single study is a snapshot. Results may vary, and repeat testing may be appropriate when findings are inconsistent or the clinical situation changes.
  • Autonomic dysreflexia is mainly a concern in susceptible people with high spinal cord lesions rather than typical MS, but blood pressure and heart rate must be monitored whenever an individual is considered at risk.
  • Preventive antibiotics are not automatically required for every patient; use should be individualised according to urine findings and infection risk.

Treatment: matching the solution to the bladder problem

The aims are to improve continence and quality of life, empty the bladder safely, reduce infections, protect the kidneys and preserve independence.

Everyday measures

Useful first steps may include:

  • timed voiding or bladder training;
  • adjusting excessive, poorly timed fluid intake without becoming dehydrated;
  • reducing caffeine, alcohol or other individual bladder irritants;
  • treating constipation;
  • improving toilet access, clothing and mobility support;
  • pelvic-floor physiotherapy where muscle control and the bladder pattern make this appropriate; and
  • continence pads, sheaths or other products as support, not as a substitute for investigating retention.

Medication for urgency and neurogenic overactive bladder

Antimuscarinic medicines can reduce involuntary bladder contractions and improve capacity. Possible side effects include dry mouth, constipation, blurred vision and impaired bladder emptying. Cognitive burden is relevant, particularly where fatigue, memory concerns or multiple anticholinergic medicines are already present.

Beta-3 agonists, may improve urgency and frequency with less dry mouth and constipation. Blood pressure and drug interactions require consideration. In neurogenic detrusor overactivity, symptom improvement does not necessarily mean that bladder pressures have normalised.

Before and after starting storage medication, the residual urine may need checking because suppressing bladder contractions can reveal or worsen incomplete emptying. Combination therapy is sometimes used under specialist supervision.

An alpha-blocker may occasionally be used to reduce outlet resistance in selected patients with voiding difficulty, although it will not correct every cause of neurogenic retention.

Catheterisation and intermittent self-catheterisation (ISC)

If the bladder cannot empty safely, intermittent catheterisation is often preferred to leaving a catheter in continuously. A small catheter is passed at planned intervals and removed once the bladder is empty.

ISC may:

  • reduce residual urine and overflow leakage;
  • improve bladder-pressure control;
  • make storage medicines or Botox safer; and
  • protect the upper urinary tract in selected patients.

However, it must be practical. Hand dexterity, tremor, spasticity, vision, fatigue, cognition, body position, urethral anatomy, bathroom access and carer support all matter. Training by an experienced continence nurse is valuable, and adaptive equipment or a different catheter may make a major difference.

Possible difficulties include discomfort, urethral trauma, bleeding, false passage and UTI. Bacteria in the urine without symptoms do not always require antibiotics. The EAU emphasises shared decision-making because ISC can increase treatment burden; one cited MS study found a higher UTI rate after starting intermittent catheterisation without a corresponding improvement in quality of life or symptom score.

If ISC is impossible and drainage is essential, an indwelling urethral or suprapubic catheter may be considered. Long-term catheters carry risks including infection, blockage, encrustation, leakage, bladder stones and urethral damage. When long-term drainage is necessary, a suprapubic catheter may offer practical advantages for selected patients, but it is not complication-free.

Bladder Botulinum Toxin injections

Botulinum toxin type A is injected through a cystoscope into multiple areas of the bladder wall. It reduces the nerve signals that trigger involuntary detrusor contractions and is well supported for MS-related neurogenic detrusor overactivity when tablets are ineffective or poorly tolerated.

Benefits may include fewer urgency-incontinence episodes, improved bladder capacity and lower storage pressure. The effect is temporary, commonly lasting several months, so successful treatment usually requires repeat injections.

The main precautions are:

  • UTI must be excluded or treated around the procedure according to local protocol.
  • Botox may weaken bladder emptying and cause urinary retention.
  • A patient who does not already catheterise must be willing and physically able to perform ISC, or have reliable help, if retention develops.
  • UTIs, temporary blood in the urine and discomfort can occur; generalised muscle weakness is rare.
  • Residual urine and symptoms require follow-up, and urodynamics may occasionally be repeated to confirm safe bladder pressures.

Dose and injection technique are individualised. In MS patients who still void spontaneously, a lower dose may reduce—but does not eliminate—the likelihood of needing catheterisation.

Sacral neuromodulation (SNM)

SNM delivers mild electrical stimulation to the sacral nerves, usually via a lead placed near the S3 nerve root and connected to a small implanted pulse generator. It can be considered in carefully selected patients with refractory urgency, urgency incontinence, frequency or non-obstructive urinary retention.

A major advantage is that treatment can be tested first. During a trial phase, symptom diaries help determine whether stimulation produces a meaningful improvement before the permanent battery is implanted.

Important considerations in MS include:

  • the evidence base is smaller and less disease-specific than the evidence supporting Botox for neurogenic detrusor overactivity;
  • results may be less predictable if neurological disease progresses or the bladder pattern changes;
  • implantation requires a procedure and ongoing programming;
  • pain, infection, lead movement, loss of effect, device malfunction and future revision or replacement can occur; and
  • people with MS commonly require future MRI scans. Modern systems may be MRI-conditional, but the exact lead and generator combination and the scanner conditions must be verified before implantation and before every MRI.

SNM does not remove the need to monitor residual urine, infection risk or upper-tract safety when clinically indicated.

Botox versus sacral neuromodulation in MS

Feature Bladder Botox Sacral neuromodulation
Main role Neurogenic detrusor overactivity with urgency and urge incontinence after medication is inadequate or poorly tolerated Selected refractory urgency, urge incontinence, frequency or non-obstructive retention
MS-specific evidence Stronger; supported by randomised trials in neurogenic detrusor overactivity Promising, but fewer MS-specific studies and less certainty about ideal candidates
How it works Temporarily reduces detrusor nerve activity and contractions Modulates sacral nerve signalling to the bladder and pelvic floor
Procedure Cystoscopic injections into the bladder Trial lead followed by permanent implant if successful
Reversibility Effect wears off over months Stimulation can be adjusted or switched off; device can be removed
Repeat treatment Usually repeat injections are required Programming and eventual battery/device revision or replacement may be required
Retention/ISC risk Important; new ISC may become necessary Generally less likely to cause retention; may also treat selected non-obstructive retention
Infection considerations UTI is a common adverse event; urinary infection should be addressed before treatment Surgical-site or device infection can require antibiotics or device removal
MRI considerations No implanted device restriction Confirm that the complete implanted system is MRI-conditional and follow device-specific conditions
Best fit Proven high-pressure or overactive bladder where reducing contractions is the priority and catheterisation is feasible if needed A carefully selected patient who values a test phase, has suitable symptoms and accepts an implant and follow-up
Key limitation Temporary effect and possible urinary retention Implant-related complications and less certain outcomes as MS evolves

Which is better?

Neither treatment is universally “better.” Botulinum Toxin is often favoured when urodynamics demonstrates neurogenic detrusor overactivity and the main goal is to suppress involuntary bladder contractions or unsafe storage pressure. SNM may be attractive in a carefully selected patient with refractory urgency or non-obstructive retention who wants a testable, adjustable treatment and wishes to avoid the higher catheterisation risk associated with Botox.

The decision should consider urodynamic findings, current residual urine, ability to perform ISC, recurrent UTIs, hand function, mobility, expected MRI needs, disease stability, patient preference and access to long-term follow-up.

Other interventional and surgical options

For selected patients, posterior tibial nerve stimulation may improve overactive bladder symptoms without an implant, although evidence in MS is less robust. When severe high-pressure bladder dysfunction remains unsafe despite medication, catheterisation and minimally invasive treatment, reconstructive options such as augmentation cystoplasty or urinary diversion may be considered in a specialist neuro-urology service. These are major procedures reserved for carefully selected cases and require lifelong follow-up.

Follow-up matters

MS and bladder function can both evolve. Review may include symptom assessment, bladder diary, urinalysis when symptomatic, residual urine measurement, renal function, urinary tract imaging and repeat urodynamics according to risk and clinical change.

A useful treatment plan is therefore not simply “stop the leakage.” It should answer four questions:

  1. Is the bladder storing urine at a safe pressure?
  2. Is it emptying adequately?
  3. Is the treatment practical and sustainable for this patient?
  4. Are the kidneys and quality of life being protected over time?

Take-home message

Bladder problems in MS are common, treatable and often more complex than the symptoms suggest. Urgency does not exclude retention, and leakage does not prove that the bladder empties well. A structured assessment, including a residual urine measurement and selective use of urodynamics, allows treatment to be matched to the actual dysfunction.

Medication, ISC, Botox and sacral neuromodulation all have valuable roles. The best choice is the one that safely addresses the individual bladder pattern while fitting the person’s abilities, priorities, MS course and future care needs.

This article provides general information and does not replace individual medical assessment. Treatment availability, indications and funding vary. Patients should discuss their symptoms with their GP, neurologist, continence clinician or urologist.

References and further reading

  1. European Association of Urology. EAU Guidelines on Neuro-urology. Current online guideline: https://uroweb.org/guidelines/neuro-urology/chapter/the-guideline
  2. National Institute for Health and Care Excellence. Urinary incontinence in neurological disease: assessment and management (CG148). https://www.nice.org.uk/guidance/cg148
  3. Gajewski JB, Schurch B, Hamid R, et al. An International Continence Society report on the terminology for adult neurogenic lower urinary tract dysfunction. Neurourology and Urodynamics. 2018;37(3):1152–1161.
  4. Ginsberg D, Gousse A, Keppenne V, et al. Phase 3 efficacy and tolerability study of onabotulinumtoxinA for urinary incontinence from neurogenic detrusor overactivity. Journal of Urology. 2012;187(6):2131–2139.
  5. Cruz F, Herschorn S, Aliotta P, et al. Efficacy and safety of onabotulinumtoxinA in patients with urinary incontinence due to neurogenic detrusor overactivity. European Urology. 2011;60(4):742–750.
  6. American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Adult Neurogenic Lower Urinary Tract Dysfunction Guideline. https://www.auanet.org/guidelines-and-quality/guidelines/adult-neurogenic-lower-urinary-tract-dysfunction

Urge Incontinence After Sling Surgery: Why Timing Matters

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A sling procedure is designed to treat stress urinary incontinence, leakage with coughing, laughing, exercising or lifting. It supports the urethra so that it remains closed when abdominal pressure rises.

A sling does not directly treat an overactive bladder. Some women notice that pre-existing urgency improves after surgery, while others continue to experience urgency or develop new symptoms. When urgency begins soon after surgery, the possible causes differ from those arising several years later.

The most important message is that urgency after a sling is a symptom, not a diagnosis. Treatment should be directed at the cause rather than automatically prescribing bladder medication.

What is urge urinary incontinence?

Urinary urgency is a sudden, compelling need to pass urine that is difficult to defer. When urine leaks before reaching the toilet, this is called urgency urinary incontinence.

Other overactive bladder symptoms may include:

  • Frequent urination during the day
  • Waking at night to urinate
  • “Key-in-the-door” urgency
  • Leakage while rushing to the toilet
  • Bladder spasms
  • Leakage without coughing or physical exertion

This differs from recurrent stress incontinence, where leakage occurs with coughing, sneezing, exercise or lifting. Some women experience both types, known as mixed urinary incontinence.

How common is urgency after a sling?

The reported frequency varies because studies use different definitions, sling types and follow-up periods.

A systematic review of 32 studies involving 3,139 women estimated that new overactive bladder symptoms occur in approximately 9% of women after a mid-urethral sling. Rates were broadly similar among retropubic, transobturator and single-incision slings.[1]

Women who had urgency or urgency incontinence before surgery have a greater chance of persistent symptoms afterwards. Published studies have reported persistent overactive bladder symptoms in approximately 30–40% of women with preoperative mixed incontinence, although estimates vary considerably.[2,3]

These figures should be interpreted carefully. Urgency occurring soon after an operation may be temporary, whereas symptoms developing years later may reflect ageing, menopause, infection or an unrelated bladder disorder rather than a direct surgical complication.

Urgency in the early postoperative period

Urgency during the first days or weeks after sling surgery is relatively common and does not necessarily mean that the sling has failed.

Possible early causes

1. Temporary irritation and inflammation

Anaesthesia, catheterisation, cystoscopy, postoperative swelling and manipulation around the urethra can temporarily irritate the bladder. Pain, constipation, reduced mobility and changes in fluid intake may contribute.

These symptoms often settle as postoperative inflammation resolves.

2. Urinary tract infection

A urinary infection can cause urgency, frequency, burning, bladder discomfort, cloudy urine and urge leakage. Infection should be considered particularly after catheterisation or difficulty emptying the bladder.

A urine culture is preferable when symptoms are significant, recurrent or atypical. Antibiotics should be selected according to the clinical circumstances and culture result rather than given indefinitely for unexplained urgency.

3. Incomplete bladder emptying

Postoperative pain, swelling, pelvic-floor guarding, medication or temporary bladder weakness can make urination difficult. Retained urine may produce frequency, urgency, overflow leakage or recurrent infection.

Symptoms can include:

  • A slow or interrupted stream
  • Hesitancy
  • Straining to urinate
  • A feeling of incomplete emptying
  • Passing small amounts frequently
  • Lower abdominal fullness
  • Inability to pass urine

A bladder scan measuring the post-void residual volume is an important early test.

4. Excessive outlet resistance from the sling

A sling should support the urethra without obstructing it. Occasionally, it produces too much resistance. Obstruction may present dramatically as retention, but it may also cause subtle symptoms such as a slow stream, urgency, recurrent infections or worsening urge incontinence.

When genuinely new urgency begins immediately after surgery particularly when accompanied by deterioration in urine flow or a raised residual volume, bladder outlet obstruction must be actively considered.[2,4]

There is no single test that perfectly proves or excludes female bladder outlet obstruction. The diagnosis depends on the timing of symptoms, examination, urine flow, residual volume and, in selected patients, pressure-flow urodynamics.

5. Bladder or urethral perforation or sling exposure

Unrecognised urinary-tract injury is uncommon but important. A sling or suture entering the bladder or urethra may cause urgency, pain, bleeding, recurrent infection or difficulty urinating.

Cystoscopy may be recommended when symptoms are severe or persistent, or when there is haematuria, recurrent infection, pelvic pain or suspicion of erosion.

6. Pre-existing overactive bladder

Some women had urgency before surgery but were understandably more concerned about stress leakage. Once the stress incontinence has improved, the remaining urgency may become more noticeable.

A sling may improve the stress component of mixed incontinence without curing the underlying overactive bladder.

How should early postoperative urgency be assessed?

Assessment may include:

  • A detailed comparison of symptoms before and after surgery
  • The precise timing of symptom onset
  • Urinalysis and urine culture
  • Examination for prolapse, vaginal healing, sling exposure and pelvic-floor tenderness
  • Measurement of urinary flow and post-void residual urine
  • A bladder diary
  • Cystoscopy when erosion, perforation, bleeding or recurrent infection is suspected
  • Urodynamic testing when the diagnosis remains uncertain or a further invasive procedure is being considered

The type of sling and its operative details should be reviewed whenever possible.

Management of early urgency

Treatment depends on the findings.

If there is infection, constipation, pain or temporary inflammation, these conditions should be treated first. Short-term catheterisation or intermittent self-catheterisation may be required when the bladder is not emptying safely.

When emptying is normal and no surgical complication is evident, a period of observation, bladder training and appropriately selected overactive bladder medication may be reasonable.

However, significant suspected obstruction should not simply be masked with bladder-relaxing medication. Antimuscarinic medication can aggravate incomplete emptying in susceptible patients.

If there is convincing evidence that the sling is too tight, early sling mobilisation, loosening, incision or division may be considered. The procedure and its timing must be individualised. Earlier mobilisation may be technically easier before dense scarring develops, but unnecessary sling division may cause recurrent stress incontinence.

Published expert reviews emphasise balancing two risks:

  1. Waiting too long when meaningful obstruction is present may lead to persistent urgency, infection and impaired bladder function.
  2. Releasing a functioning sling unnecessarily may restore stress leakage.[2,4,5]

Urgency developing months or years after sling surgery

Urgency appearing years later should not automatically be blamed on the sling. A direct sling-related problem remains possible, but other causes become increasingly important.

Possible delayed causes

Age-related overactive bladder

Overactive bladder becomes more common with age. Changes in bladder sensation, detrusor function, mobility, sleep, fluid regulation and neurological health can produce urgency independently of previous surgery.

Menopause and genitourinary syndrome of menopause

Reduced oestrogen levels may contribute to vaginal and urethral tissue changes, discomfort, recurrent infection and urinary urgency. Selected postmenopausal women may benefit from local vaginal oestrogen, provided there is no contraindication and the treatment is discussed with their doctor.

Recurrent urinary infection

Repeated urgency episodes associated with pain, dysuria or cloudy urine require appropriate cultures. Persistent symptoms with repeatedly negative cultures should prompt consideration of overactive bladder, pelvic-floor dysfunction, bladder pain syndrome, stones or sling-related complications rather than repeated empirical antibiotics.

Pelvic organ prolapse

A cystocele or other vaginal prolapse may alter bladder emptying and cause urgency, frequency or infection. Examination is important, particularly when there is a vaginal bulge, pressure or difficulty emptying.

Delayed obstruction or scarring

Progressive scarring around the urethra or sling can occasionally produce delayed voiding difficulty. Comparing the present urinary stream and residual volume with earlier results can be informative.

Vaginal, urethral or bladder erosion

Delayed sling exposure or erosion may present with vaginal discharge, bleeding, pain during intercourse, pelvic pain, recurrent infections, haematuria or urgency. Cystoscopy and vaginal examination are usually required when this is suspected.

Other bladder or neurological disease

Diabetes, neurological disorders, impaired mobility, diuretic medication, excessive fluid intake, bladder stones and, less commonly, bladder tumours can produce urgency. Visible blood in the urine should never be attributed to overactive bladder without appropriate investigation.

Investigating delayed urgency

A sensible assessment commonly includes:

  • Review of preoperative and postoperative symptoms
  • Urinalysis and urine culture
  • A three-day bladder diary
  • Examination for vaginal atrophy, prolapse, pelvic-floor dysfunction and sling exposure
  • Urinary flow rate and post-void residual measurement
  • Review of medications, fluid intake, caffeine and bowel function
  • Cystoscopy when there is haematuria, pain, recurrent infection or suspected erosion
  • Urodynamic studies when symptoms are complex, emptying is abnormal, previous treatment has failed or further surgery is contemplated

Urodynamics may demonstrate detrusor overactivity, impaired bladder contraction or a pressure-flow pattern suggesting outlet obstruction. A normal study does not invalidate genuine urgency, and urodynamics cannot always determine whether the sling is the cause.

Treatment when obstruction and sling complications have been excluded

When evaluation supports overactive bladder rather than a mechanical complication, management generally follows established overactive bladder principles.[6–8]

Lifestyle and bladder strategies

Options include:

  • Reducing excessive fluid intake
  • Moderating caffeine, alcohol and carbonated drinks
  • Treating constipation
  • Weight management where appropriate
  • Bladder training with gradually increasing voiding intervals
  • Urgency-suppression techniques
  • Pelvic-floor physiotherapy
  • Improving access to the toilet and managing mobility limitations

Pelvic-floor treatment should focus on both strength and relaxation. Continually “squeezing harder” may worsen symptoms in women with an overactive or painful pelvic floor.

Medication

Medication options include:

Antimuscarinic medicines

Examples include solifenacin, oxybutynin, tolterodine and darifenacin. Possible adverse effects include dry mouth, constipation, blurred vision and cognitive effects. Medication selection should consider age, other medicines, glaucoma, bowel function and the ability to empty the bladder.

Beta-3 adrenergic agonists

Mirabegron relaxes the bladder during storage and may cause fewer dry-mouth and constipation symptoms than antimuscarinic therapy. Blood pressure and drug interactions require consideration.

Combination treatment may help selected patients who have an inadequate response to one medication. Residual urine should be monitored when there is concern about impaired emptying.

Vaginal oestrogen

Local vaginal oestrogen may be appropriate for postmenopausal women with vaginal atrophy, recurrent infection or associated urinary symptoms. It is different from systemic hormone replacement and should be prescribed after individual assessment.

Percutaneous tibial nerve stimulation

Tibial nerve stimulation uses electrical stimulation near the ankle to influence the neural pathways controlling the bladder. It is minimally invasive but usually requires a course of repeated treatment sessions and sometimes maintenance therapy.

Intravesical botulinum toxin

Botulinum toxin can reduce involuntary bladder contractions and urgency incontinence. Potential complications include urinary infection and difficulty emptying the bladder. Patients should understand that temporary intermittent self-catheterisation may occasionally be required.

Sacral neuromodulation

Sacral neuromodulation modifies the nerve signals involved in bladder storage and emptying. It may be considered for persistent urgency and urgency incontinence that have not responded adequately to conservative or medication-based treatment.

A test phase is normally performed before permanent implantation. It can be effective after previous continence surgery, provided that infection, significant obstruction and sling erosion have first been addressed.

When is sling revision appropriate years later?

Sling incision, partial excision or more extensive removal may be appropriate when there is evidence of:

  • Clinically important bladder outlet obstruction
  • Urethral or bladder erosion
  • Symptomatic vaginal exposure
  • Persistent infection associated with the sling
  • Significant sling-related pain
  • A clear relationship between the sling and disabling urinary symptoms

Sling revision is not a reliable treatment for otherwise unexplained overactive bladder. Urgency may persist after revision, particularly when it is caused by detrusor overactivity, ageing or another bladder disorder.

Possible consequences of sling revision include:

  • Recurrent stress urinary incontinence
  • Bleeding or infection
  • Urethral or bladder injury
  • Persistent pain or urgency
  • Need for further continence treatment

Shared decision-making is therefore essential.

The role of sling release and urethrolysis

When urgency or urge incontinence follows sling surgery, an important question is whether the sling has created excessive resistance to bladder emptying. If meaningful obstruction is present, treating the bladder alone may not solve the underlying problem.

Sling release is not routinely recommended for isolated urgency when urinary flow and bladder emptying are normal. It is most useful when the history, examination and investigations suggest that the urethra is being mechanically obstructed.

When should sling-related obstruction be suspected?

Features that may indicate excessive sling tension or postoperative scarring include:

  • New difficulty passing urine after surgery
  • Complete or intermittent urinary retention
  • A urinary stream that became slower after the sling
  • Hesitancy, straining or an interrupted stream
  • A persistent feeling of incomplete emptying
  • An increased post-void residual volume
  • Recurrent urinary infections
  • New urgency or urgency incontinence associated with impaired emptying
  • Worsening bladder function that began soon after surgery
  • A pressure-flow study suggesting bladder outlet obstruction
  • Cystoscopic or examination findings suggesting sling erosion, distortion or excessive urethral elevation

Women do not need to be in complete retention to have clinically important obstruction. Some can empty the bladder by generating higher bladder pressures or straining, but may develop urgency, frequency, infections and progressive bladder dysfunction.

There is no universally accepted urodynamic definition of female bladder outlet obstruction. A normal or equivocal urodynamic study does not completely exclude it. The diagnosis therefore combines the timing of symptoms, changes in urinary flow, residual urine, examination findings and, when useful, cystoscopy and pressure-flow urodynamics.[5,10]

Sling mobilisation or loosening

When voiding difficulty is recognised soon after a mid-urethral sling procedure, the sling may sometimes be mobilised or loosened before dense scar tissue forms around it.

Through a small vaginal incision, the surgeon identifies the sling and gently pulls it away from the urethra to reduce its tension. The sling is usually preserved rather than cut.

Early mobilisation may:

  • Restore bladder emptying
  • Relieve excessive outlet resistance
  • Reduce the need for prolonged catheterisation
  • Preserve more of the original stress-incontinence benefit than complete sling division

Temporary catheterisation remains appropriate for mild early retention that is improving. However, prolonged observation may be undesirable when significant obstruction persists, particularly when repeated voiding trials fail or the patient remains dependent on catheterisation.

The IUGA committee opinion notes that early sling mobilisation often resolves postoperative voiding dysfunction with relatively low morbidity. The exact timing should be individualised rather than dictated by one fixed number of days.[5]

Sling incision or division

If mobilisation is not possible or is unsuccessful, the sling may be cut through a vaginal incision. This is known as sling incision, division or lysis.

It may be considered when there is:

  • Persistent retention
  • A consistently elevated residual volume
  • Marked deterioration in urinary flow
  • Recurrent infection associated with poor emptying
  • New urgency or urge incontinence strongly associated with obstruction
  • Persistent obstructive symptoms despite an initial period of conservative management

Dividing the sling reduces its compression on the urethra. Urinary flow and emptying often improve, but urgency does not always disappear immediately. A bladder that has worked against obstruction may take time to recover, and some women have coexisting detrusor overactivity requiring additional treatment.

The principal trade-off is recurrent stress urinary incontinence. The risk varies between studies and depends on the type of sling, the location and extent of the incision, the time since implantation and the patient’s underlying urethral function. This possibility should be discussed before surgery.

Partial sling excision

Partial excision removes the central vaginal portion of the sling beneath or adjacent to the urethra. It may be appropriate when simple division is inadequate or when there is:

  • Vaginal sling exposure
  • Localised pain or tenderness
  • Infection involving the sling
  • Urethral or bladder erosion
  • Dense scarring around the urethra
  • Persistent obstruction after a previous sling incision

Removing more sling material may provide greater decompression but can also increase the risk of recurrent stress leakage and operative injury.

What is formal urethrolysis?

Urethrolysis is a more extensive operation that frees the urethra and bladder neck from surrounding scar tissue or restrictive sling material.

It is generally reserved for established or complex obstruction, particularly when:

  • Symptoms have been present for months or years
  • Dense fibrosis has developed
  • Previous sling incision or partial excision has failed
  • The original operation involved an autologous fascial or bladder-neck sling
  • The urethra remains fixed, elevated or compressed
  • Multiple previous continence procedures have been performed

The operation may be performed through a vaginal, retropubic or combined approach, depending on the original procedure and the location of the scar tissue. The aim is to restore urethral mobility and reduce outlet resistance while avoiding injury to the urethra and bladder.[10]

Formal urethrolysis is now required less often after uncomplicated mid-urethral slings because many cases can be managed with early mobilisation, sling division or partial excision. It remains valuable in delayed, recurrent or anatomically complex obstruction.

Will sling release cure the urgency?

Not necessarily.

Urgency is most likely to improve when:

  • It began soon after sling placement
  • It was accompanied by a weaker urinary stream
  • Residual urine increased after surgery
  • There is persuasive clinical or urodynamic evidence of obstruction
  • The obstruction is relieved before permanent bladder changes develop

Urgency may persist when it was present before surgery or when it is primarily caused by:

  • Idiopathic overactive bladder
  • Age-related bladder change
  • Detrusor overactivity
  • Menopause or genitourinary syndrome of menopause
  • Recurrent infection
  • Pelvic-floor dysfunction
  • Neurological disease
  • Diabetes or another medical condition

Sling release should therefore not be presented as a guaranteed treatment for urgency. Some patients require subsequent bladder training, medication, botulinum toxin, tibial nerve stimulation or sacral neuromodulation even after obstruction has been corrected.

Risks of sling release or urethrolysis

Potential complications include:

  • Recurrent stress urinary incontinence
  • Persistent urgency or urge incontinence
  • Bleeding or infection
  • Injury to the urethra or bladder
  • Urethrovaginal fistula, although uncommon
  • Ongoing pain or scarring
  • Continued difficulty emptying
  • Need for further continence surgery

One comparative series reported new stress incontinence in approximately one-quarter of women following urethrolysis or partial sling excision without simultaneous placement of another sling. This figure should not be treated as a universal prediction because outcomes vary with the original operation, indication and surgical technique.[11]

Placing another continence procedure at the same time as urethrolysis is controversial. In many cases it is preferable to relieve the obstruction first, allow bladder function to stabilise and then reassess any recurrent stress incontinence. This avoids immediately replacing one potentially obstructive procedure with another, although management must be individualised.

Why timely recognition matters

Persistent outlet obstruction can contribute to recurrent infections, detrusor overactivity, impaired bladder contraction and potentially irreversible bladder dysfunction. Conversely, releasing a sling without convincing evidence of obstruction can unnecessarily restore stress leakage.

The decision should therefore be based on the complete clinical picture and shared decision-making—not urgency alone.

When should you seek urgent medical attention?

Contact your surgeon or seek urgent assessment if you:

  • Cannot pass urine
  • Develop fever, chills or worsening pelvic pain
  • Have heavy vaginal bleeding
  • See blood in the urine
  • Develop severe lower abdominal swelling or discomfort
  • Experience rapidly worsening leakage with difficulty emptying
  • Have recurrent infections, vaginal mesh exposure or unexplained discharge

The take-home message

Urge incontinence after sling surgery deserves a structured assessment.

In the early postoperative period, infection, swelling, incomplete emptying and excessive sling-related outlet resistance are particularly important. New urgency accompanied by a weaker stream or increased residual urine should raise concern about obstruction.

When urgency develops years later, ageing, menopause, recurrent infection, prolapse, medication effects and idiopathic overactive bladder become more likely, although delayed obstruction or sling erosion must still be considered.

Once infection, obstruction and sling complications have been excluded, treatment can include bladder training, pelvic-floor physiotherapy, medication, tibial nerve stimulation, bladder botulinum toxin or sacral neuromodulation. Sling revision should be reserved for appropriately selected patients because it may reintroduce stress incontinence and does not guarantee that urgency will resolve.

So, if new urgency symptoms have developed and this is making life miserable for you, come see your local Brisbane urologist, Dr Jo Schoeman for advice.

References

  1. Pergialiotis V, et al. De novo overactive bladder following midurethral sling procedures: a systematic review and meta-analysis. International Urogynecology Journal. 2017;28:1631–1638. PubMed
  2. Gomelsky A, et al. Urgency and urgency incontinence following stress urinary incontinence surgery: a review of evaluation and management. Indian Journal of Urology. 2022. Full text
  3. Shin JH, Choo MS. De novo or resolved urgency and urgency urinary incontinence after midurethral sling operations. Investigative and Clinical Urology. 2019;60:373–379. Full text
  4. Marcelissen T, Van Kerrebroeck P. Urgency after a sling: review of the management. Current Urology Reports. 2014;15:402. PubMed
  5. Bazi T, et al. Management of post-midurethral sling voiding dysfunction: IUGA Research and Development Committee opinion. International Urogynecology Journal. 2018;29:23–28. PubMed
  6. American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder. 2024. AUA/SUFU guideline
  7. European Association of Urology. Guidelines on Non-neurogenic Female Lower Urinary Tract Symptoms. EAU guideline
  8. International Urogynecological Association. Management of mixed urinary incontinence: IUGA Committee Opinion. International Urogynecology Journal. 2024. Full text
  9. American Urological Association. Stress Urinary Incontinence Guideline. AUA guideline
  10. Gleich LD, Goldman HB. Urethrolysis. Neurourology and Urodynamics. 2024. Full-text clinical review
  11. Drain A, et al. Current role of urethrolysis and partial excision in patients seeking revision of anti-incontinence sling. Female Pelvic Medicine & Reconstructive Surgery. 2019;25:362–366. Article
  12. Pinsard M, et al. Comparison of early loosening versus delayed section of mid-urethral slings in patients with postoperative bladder outlet obstruction. International Urogynecology Journal. 2023. Article

This information is intended for general patient education and does not replace individual medical assessment. Management should be tailored to the type of sling, timing of symptoms, examination findings, bladder emptying and the patient’s priorities.

Dysfunctional Voiding in Men: When Urgency and a Poor Stream Occur Together

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Men with urinary urgency, frequency and nocturia are often presumed to have an overactive bladder. Those with a slow stream, hesitancy or incomplete emptying may be presumed to have an enlarged prostate. However, when storage and voiding symptoms occur together, the explanation may be more complicated.

Some men have true prostate or bladder-neck obstruction. Others have an underactive bladder, an overactive bladder, a urethral narrowing, or dysfunctional voiding, in which the urinary sphincter or pelvic-floor muscles fail to relax properly while the bladder is trying to empty. Several problems may also coexist.

This distinction matters. Removing prostate tissue will not necessarily correct a pelvic floor that is closing at the wrong time and an unnecessary operation can introduce bleeding, sexual side effects, scarring or urinary leakage.

What is dysfunctional voiding?

During normal urination, the bladder muscle contracts while the bladder neck, external urinary sphincter and pelvic floor relax. It is a coordinated sequence: the bladder pushes and the outlet opens.

In dysfunctional voiding, this coordination is disturbed. The external sphincter or pelvic-floor muscles remain partly contracted or repeatedly tighten during urination. The resulting functional obstruction may produce an intermittent, fluctuating or “stop–start” stream.

The International Continence Society describes dysfunctional voiding as intermittent or fluctuating urinary flow caused by inadequate or variable relaxation of the urinary sphincter during voiding in a person without a recognised neurological disorder.

Dysfunctional voiding must be distinguished from:

  • Benign prostatic obstruction caused by an enlarged prostate.
  • Primary bladder-neck obstruction, in which the bladder neck does not open adequately.
  • Urethral stricture disease.
  • Detrusor underactivity, where the bladder contraction is too weak or too brief.
  • Neurological detrusor–sphincter dyssynergia.
  • Overactive bladder or detrusor overactivity.
  • Chronic prostatitis or chronic pelvic-pain syndrome.
  • Medication-related voiding difficulty.

The symptoms alone frequently cannot identify which of these mechanisms is responsible.

What symptoms may occur?

Men may report a mixture of storage and emptying symptoms.

Overactive-bladder-type symptoms

  • Sudden urgency to pass urine.
  • Increased daytime frequency.
  • Waking repeatedly at night to urinate.
  • Urgency urinary leakage.
  • Passing small amounts frequently.
  • Bladder discomfort when trying to delay urination.

Outflow-obstruction-type symptoms

  • Hesitancy before the stream begins.
  • A weak, intermittent or spraying stream.
  • Straining to pass urine.
  • A feeling that the pelvic floor will not “let go.”
  • Prolonged urination.
  • Post-void dribbling.
  • A sensation of incomplete emptying.
  • Recurrent urinary infections or episodes of retention.

An important principle is that overactive bladder is a symptom syndrome, not proof of the underlying cause. Urgency may arise from primary detrusor overactivity, but it can also develop when the bladder works against an obstructed or poorly relaxing outlet.

Likewise, a weak stream does not automatically mean that the prostate is obstructing the bladder.

How should these symptoms be investigated?

The assessment begins with a detailed history. The duration and pattern of symptoms, previous pelvic or prostate surgery, urinary infections, pelvic pain, constipation, medication use, neurological symptoms and sexual function are all relevant.

A practical initial assessment may include:

  • A validated symptom questionnaire, such as the IPSS or ICIQ-MLUTS.
  • A three-day bladder diary recording fluid intake, voided volumes, urgency and leakage.
  • Urinalysis and urine culture when indicated.
  • Examination of the abdomen, prostate, genitalia and neurological system.
  • Assessment of pelvic-floor tone and the ability to relax the pelvic floor.
  • Uroflowmetry, preferably with an adequately full bladder.
  • Ultrasound measurement of the post-void residual urine.
  • Assessment of prostate size.
  • PSA testing when clinically appropriate and after informed discussion.
  • Kidney-function testing when retention or upper-tract risk is suspected.
  • Cystoscopy when urethral stricture, bladder-neck disease, haematuria or another anatomical abnormality is possible.

A low maximum urinary flow or a raised residual suggests impaired emptying, but neither finding reliably distinguishes prostate obstruction from dysfunctional voiding or a weak bladder. The European Association of Urology advises that non-invasive tests should not be treated as substitutes for pressure-flow urodynamics when a definite diagnosis of bladder outlet obstruction is required.

The role of pelvic-floor physiotherapy

In true dysfunctional voiding, the first treatment should usually be directed at improving coordinationnot immediately removing prostate tissue.

Specialist pelvic-floor physiotherapy may include:

  • Learning to recognise and release pelvic-floor tension.
  • Diaphragmatic breathing.
  • Relaxed, unhurried voiding.
  • Avoidance of abdominal straining.
  • Biofeedback using surface electromyography or uroflowmetry.
  • Treatment of pelvic pain and muscle trigger points.
  • Management of constipation.
  • Timed or double voiding when appropriate.

This is generally pelvic-floor down-training rather than routine strengthening. Repeated forceful Kegel exercises may aggravate symptoms in a man whose pelvic floor is already overactive.

The 2026 EAU guideline recommends behavioural modification and biofeedback as first-line treatment for dysfunctional voiding in younger men. The evidence is limited, but one small study reported at least a 50% symptom improvement in 83% of treated men at three months.

Can medication be tried first?

Medication is often reasonable, provided it is matched to the suspected mechanism and the response is monitored objectively.

Alpha-blockers

An alpha-blocker such as tamsulosin, alfuzosin or silodosin may reduce smooth-muscle resistance at the prostate and bladder neck. It is particularly relevant when benign prostatic obstruction or primary bladder-neck obstruction is suspected.

Possible side effects include:

  • Dizziness or postural hypotension.
  • Fatigue.
  • Nasal congestion.
  • Ejaculatory disturbance.
  • Reduced or absent forward ejaculation.

Alpha-blockers do not directly retrain an external sphincter or pelvic floor that is contracting during voiding. A poor response should therefore prompt reconsideration of the diagnosis rather than automatic progression to prostate surgery.

Overactive-bladder medications

An antimuscarinic medication or a beta-3 agonist may be considered when urgency, frequency or urgency incontinence remains troublesome.

Antimuscarinic side effects may include dry mouth, constipation, blurred vision and cognitive adverse effects in susceptible patients. Beta-3 agonists may cause hypertension, headache or palpitations in some patients.

These medicines can be used cautiously in appropriately selected men with coexisting outlet symptoms, but baseline and follow-up residual urine measurements are advisable when emptying is impaired. A marked residual, weak bladder contraction or previous retention increases the importance of careful monitoring.

The EAU guideline supports adding a beta-3 agonist to an alpha-blocker when storage symptoms persist, although the average additional benefit is modest.

Other prostate medications

A 5-alpha-reductase inhibitor, such as finasteride or dutasteride, is useful only when genuine prostate enlargement and a risk of progression are present. It does not treat dysfunctional sphincter relaxation.

Daily tadalafil may improve male lower urinary tract symptoms and erectile function in selected men, although its effect on urinary flow is usually modest.

When are urodynamic studies important?

Urodynamics become particularly valuable when the symptoms and non-invasive tests tell different stories, when medication has failed, or when an irreversible operation is being considered.

A pressure-flow study assesses:

  • Bladder sensation during filling.
  • Detrusor overactivity.
  • Bladder compliance.
  • The strength of the bladder contraction.
  • Urinary flow in relation to bladder pressure.
  • Whether high-pressure, low-flow voiding confirms obstruction.
  • Whether low-pressure, low-flow voiding suggests detrusor underactivity.
  • Residual urine after voiding.

Adding pelvic-floor electromyography can demonstrate inappropriate external-sphincter activity. Videourodynamics can show where the obstruction occurs while pressure and flow are measured simultaneously.

Videourodynamics is regarded as the most informative investigation for distinguishing primary bladder-neck obstruction from dysfunctional voiding in younger men. The 2026 EAU guideline recommends videourodynamics, or standard urodynamics combined with voiding cystourethrography, with or without electromyography when either diagnosis is suspected.

Urodynamics is not required before every treatment for uncomplicated male urinary symptoms. It is particularly useful when:

  • The man is young and prostate enlargement is unlikely to explain the symptoms.
  • Symptoms are severe but the prostate is small.
  • The flow pattern is intermittent or unusual.
  • The residual urine is persistently elevated.
  • There is a history of retention.
  • Previous prostate treatment has failed.
  • Detrusor underactivity is possible.
  • Dysfunctional voiding or primary bladder-neck obstruction is suspected.
  • OAB symptoms and voiding symptoms coexist.
  • The result would determine whether surgery, neuromodulation, medication or physiotherapy is selected.

The purpose is not simply to produce a graph. It is to answer a treatment-changing question: is the outlet anatomically obstructed, functionally closed, or is the bladder failing to generate an adequate contraction?

Should bladder-neck incision or TURP be considered?

The answer depends on what has been demonstrated.

Bladder-neck incision

A bladder-neck incision may be considered when videourodynamics confirms primary bladder-neck obstruction and an adequate trial of an alpha-blocker has failed or has caused unacceptable adverse effects.

The procedure divides restricting bladder-neck fibres without removing a large amount of prostate tissue. A single, ejaculation-preserving incision may be considered in appropriately selected younger men.

Potential adverse effects include:

  • Bleeding or infection.
  • Temporary urgency, frequency and discomfort.
  • Temporary difficulty urinating or catheter dependence.
  • Retrograde or reduced-volume ejaculation.
  • Rare erectile or continence problems.
  • Bladder-neck scarring or recurrent obstruction.
  • Need for further treatment.

Across heterogeneous studies, the EAU guideline reports ejaculatory dysfunction rates ranging widely according to technique. Its pooled estimate was approximately 3% after bladder-neck incision, with lower reported rates after a single incision than after bilateral incisions. Fertility and ejaculatory priorities should always be discussed before surgery.

A bladder-neck incision is not the usual treatment for dysfunctional voiding at the external sphincter or pelvic floor.

TURP

A TURP removes obstructing prostate tissue and remains an effective operation for confirmed benign prostatic obstruction, particularly in men with a prostate in the conventional 30–80 mL range.

It may be reasonable when there is convincing evidence of prostatic obstruction, especially with:

  • Recurrent retention.
  • Recurrent infection caused by poor emptying.
  • Bladder stones.
  • Renal consequences of obstruction.
  • Persistent significant symptoms despite appropriate medication.
  • High-pressure obstruction demonstrated on urodynamics.

TURP should be approached cautiously when urodynamics shows no prostate obstruction. If the main problem is dysfunctional sphincter closure or a weak bladder, TURP may fail to improve the stream, urgency or residual urine.

What are the possible side effects of disobstruction surgery?

Short-term effects can include:

  • Burning and frequency while the prostate or bladder neck heals.
  • Visible blood in the urine.
  • Clot retention.
  • Urinary infection.
  • Temporary inability to urinate.
  • A temporary increase in urgency or urgency leakage.
  • Catheter-related discomfort.
  • Bleeding requiring readmission or, less commonly, transfusion.

Longer-term effects may include:

  • Retrograde ejaculation.
  • Persistent urgency or urgency incontinence.
  • Urethral stricture.
  • Bladder-neck contracture.
  • Recurrent obstruction or need for another procedure.
  • Persistent incomplete emptying when detrusor underactivity is present.
  • Rare persistent stress urinary incontinence.
  • Possible changes in erectile or orgasmic function.

Retrograde ejaculation is common after conventional TURP, affecting approximately 65–75% of men in contemporary patient-information estimates. It is not dangerous, but it changes the experience of ejaculation and can impair fertility.

What is the risk of urinary incontinence?

Urinary control may temporarily worsen after TURP or bladder-neck surgery because:

  • The bladder has become overactive from longstanding obstruction.
  • Postoperative inflammation produces urgency.
  • The bladder suddenly encounters much less outlet resistance.
  • The urinary sphincter needs time to adapt.
  • Pre-existing detrusor overactivity remains after the obstruction is relieved.

Early urgency and occasional leakage are therefore more common than permanent sphincter damage. Historical research suggests that some incontinence may occur initially after TURP, while persistent incontinence at approximately 12 months is around 1% in conventional series. Reported rates vary according to the definition used, the procedure, pre-existing bladder dysfunction and the characteristics of the patient.

Persistent leakage may be:

  • Urgency incontinence, caused by ongoing detrusor overactivity.
  • Stress incontinence, caused by sphincter weakness or injury.
  • Overflow leakage, caused by inadequate bladder emptying.
  • A mixture of these mechanisms.

These types require different treatment. Persistent leakage should therefore be investigated rather than simply labelled “postoperative incontinence.”

Men with preoperative urgency, demonstrable detrusor overactivity, poor bladder compliance, previous pelvic surgery, neurological disease or sphincter weakness require individualised counselling. Surgery may relieve the obstruction without curing the bladder dysfunction that developed alongside it.

Where does sacro-neuromodulation fit?

Sacro-neuromodulation uses a small implanted system to stimulate the sacral nerves involved in bladder sensation, storage, emptying and pelvic-floor coordination. Treatment starts with a temporary test phase. A permanent battery is implanted only if the test produces worthwhile improvement.

Sacral neuromodulation is an established option for appropriately selected patients with:

  • Refractory urgency-frequency syndrome.
  • Refractory urgency urinary incontinence.
  • Non-obstructive urinary retention.

It may be particularly attractive when a man has both storage and emptying dysfunction without a surgically correctable obstruction. It may also be considered in selected patients with detrusor underactivity after obstruction has been excluded.

Potential benefits include:

  • Reduced urgency and leakage.
  • Improved voiding.
  • Lower residual urine.
  • Reduced need for intermittent catheterisation.
  • A reversible test phase before permanent implantation.

Potential disadvantages include:

  • Failure of the test phase.
  • Pain at the implant or lead site.
  • Infection.
  • Lead movement or loss of benefit.
  • Unpleasant stimulation.
  • Need for reprogramming.
  • Battery replacement or revision surgery.
  • Device removal in some patients.

Published long-term studies report clinically meaningful benefit in many implanted patients with refractory OAB or non-obstructive retention. However, outcomes from predominantly female or mixed study populations should not be assumed to apply equally to every man.

Importantly, the evidence for sacral neuromodulation specifically for male dysfunctional voiding remains limited. The 2026 EAU male LUTS guideline describes it as experimental for this particular indication and recommends using the test phase to identify whether an individual is likely to benefit.

Sacral neuromodulation should not be used as a substitute for relieving proven high-pressure anatomical obstruction.

A practical treatment pathway

A sensible approach is:

  1. Confirm the symptom pattern with a history, examination, questionnaire and bladder diary.
  2. Exclude infection, haematuria, urethral stricture, neurological disease and medication-related causes.
  3. Measure urinary flow and post-void residual urine.
  4. Assess prostate size and perform cystoscopy when anatomy needs clarification.
  5. Begin conservative treatment, including fluid and bowel management and pelvic-floor relaxation.
  6. Trial an alpha-blocker when bladder-neck or prostatic resistance is possible.
  7. Add carefully selected OAB medication when storage symptoms persist, with residual monitoring where appropriate.
  8. Use pressure-flow urodynamics, ideally with video and pelvic-floor EMG, when the diagnosis remains uncertain or surgery is contemplated.
  9. Reserve bladder-neck incision for demonstrated primary bladder-neck obstruction.
  10. Reserve TURP or another prostate disobstruction procedure for demonstrated or strongly supported benign prostatic obstruction.
  11. Consider sacral neuromodulation for refractory OAB or non-obstructive retention after correctable obstruction has been excluded.
  12. Use intermittent self-catheterisation when emptying remains unsafe or inadequate despite other treatment.

The key message

In men with urgency and a poor stream, the most important question is not simply, “Is the prostate enlarged?” It is, “What are the bladder and outlet doing during urination?”

Dysfunctional voiding, primary bladder-neck obstruction, benign prostatic obstruction, detrusor overactivity and detrusor underactivity can produce remarkably similar symptoms. Treatment is most successful when it is directed at the demonstrated mechanism.

Pelvic-floor relaxation and biofeedback are appropriate first-line treatments for dysfunctional voiding. Alpha-blockers may help bladder-neck or prostatic resistance. OAB medicines can be added carefully when storage symptoms remain troublesome. Urodynamics can prevent an inappropriate disobstruction procedure in an uncertain case. Bladder-neck incision or TURP should be used for confirmed obstructionnot simply because the stream is poor. Sacral neuromodulation may be valuable for selected refractory patients, but its role specifically in male dysfunctional voiding is still evolving.

So, if you are in this unfortunate situation and you need help, come see your Brisbane functional urologist, dr Jo Schoeman for advice.

References and further reading

  1. European Association of Urology. EAU Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms, 2026. Full guideline
  2. European Association of Urology. Diagnostic evaluation of male LUTS. EAU diagnostic chapter
  3. European Association of Urology. Disease management of male LUTS, including voiding dysfunction in younger men. EAU treatment chapter
  4. International Continence Society. Dysfunctional voiding during male pressure-flow studies. ICS terminology resource
  5. Cameron AP, et al. The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder. Journal of Urology. 2024. PubMed record
  6. Creta M, et al. Management of Primary Bladder Neck Obstruction and Dysfunctional Voiding in Young Men: A Systematic Review and Meta-analysis. European Urology Focus. 2025. PubMed record
  7. Drake MJ, et al. Diagnostic Assessment of Lower Urinary Tract Symptoms in Men Considering Prostate Surgery: The UPSTREAM Randomised Controlled Trial. European Urology. 2020;78:701–710. PubMed record
  8. D’Ancona C, et al. The International Continence Society report on terminology for adult male lower urinary tract and pelvic-floor symptoms and dysfunction. Neurourology and Urodynamics. 2019;38:433–477. PubMed record
  9. British Association of Urological Surgeons. TURP for benign disease: patient information. BAUS information page
  10. Jairam R, et al. Predictive factors in sacral neuromodulation: a systematic review. Urologia Internationalis. 2022;106:323–342. Open-access review

This article provides general information and does not replace individual assessment. Medication and procedural decisions should be based on the patient’s examination, prostate and bladder anatomy, residual urine, urodynamic findings, comorbidities, fertility priorities and personal treatment goals.

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.

Understanding Overactive Bladder: Symptoms, Assessment and Treatment Options

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Overactive bladder can make everyday life feel organised around the nearest toilet. Shopping, travelling, exercise, sleep and social activities may all be affected by sudden urgency, frequent urination or leakage.

It is common, but it is not simply an inevitable part of ageing. Symptoms deserve assessment because several bladder, urinary and medical conditions can produce a similar pattern.

This article explains overactive bladder as a condition and outlines the broad approaches used to investigate and manage it. It does not recommend a particular medicine, device or brand.

What is overactive bladder?

Overactive bladder (OAB) is a symptom syndrome characterised by urinary urgency, a sudden, compelling need to pass urine that is difficult to defer. It is usually accompanied by increased frequency during the day and waking at night to urinate, with or without urgency urinary incontinence.

Possible symptoms include:

  • a sudden need to urinate that is difficult to postpone
  • passing urine more frequently than expected
  • waking repeatedly at night to urinate
  • leaking urine before reaching the toilet
  • restricting travel or activities because of toilet access
  • using pads because of unpredictable urgency

OAB is a clinical diagnosis. Some people demonstrate involuntary bladder contractions, known as detrusor overactivity, during urodynamic testing; others with typical symptoms do not.

What causes the symptoms?

The bladder normally stores urine at low pressure and empties when it is convenient. OAB symptoms arise when the sensation or control of bladder filling becomes abnormal. The cause is not always identifiable.

Factors that can cause or aggravate similar symptoms include:

  • urinary tract infection
  • excessive caffeine, alcohol or fluid intake
  • medicines such as diuretics
  • constipation
  • poorly controlled diabetes
  • bladder stones
  • incomplete bladder emptying
  • bladder outlet obstruction
  • pelvic floor dysfunction
  • genitourinary syndrome of menopause
  • neurological conditions
  • reduced mobility or difficulty reaching a toilet
  • sleep disorders or fluid redistribution causing nocturia

Visible blood in the urine, recurrent infection, pelvic pain, difficulty passing urine or rapidly changing symptoms require further assessment rather than an assumption that OAB is the cause.

Overactive bladder in men

Urgency and frequency in men may occur alone or together with bladder outlet obstruction from prostate enlargement, urethral narrowing or impaired bladder contraction.

An assessment may therefore include the urinary stream, prostate, urinary flow and the amount of urine remaining after voiding. Treating urgency without recognising significant obstruction or incomplete emptying may worsen retention in some patients.

Overactive bladder after menopause

After menopause, reduced oestrogen can contribute to vaginal dryness, irritation, recurrent urinary infection, urgency and discomfort. These changes are often grouped under the term genitourinary syndrome of menopause.

Identifying vaginal or urinary tract changes is important because management may differ from treatment for isolated OAB. Any hormonal treatment requires an individual discussion of suitability, expected benefit, uncertainty and risk.

How is OAB assessed?

Assessment begins with listening to the pattern and impact of the symptoms. Depending on the individual, it may include:

  • a medical, urinary and medication history
  • examination
  • urinalysis or urine culture
  • a bladder diary
  • review of fluid, caffeine and alcohol intake
  • assessment of bowel function
  • measurement of urinary flow
  • ultrasound measurement of post-void residual urine
  • kidney-function or glucose testing when clinically indicated
  • assessment for pelvic organ prolapse or prostate enlargement

A bladder diary records the timing and volume of drinks, urination, urgency and leakage. It can help distinguish OAB from excessive urine production, nocturnal polyuria or habitual frequent voiding.

Are urodynamic studies always required?

No. Many patients with uncomplicated symptoms can begin conservative treatment without urodynamics.

Urodynamic testing may be helpful when the diagnosis is uncertain, bladder emptying is poor, previous treatment has failed, neurological dysfunction is suspected, or an invasive treatment is being considered. The test should answer a specific clinical question rather than be performed routinely.

When might cystoscopy or imaging be needed?

Cystoscopy or urinary tract imaging is not automatically required for uncomplicated OAB. It may be considered when there is blood in the urine, recurrent infection, pain, suspected stones, previous pelvic surgery, obstruction or another concerning feature.

First steps in management

Conservative treatment is often the starting point and may be used alone or with other therapies.

Bladder training

Bladder training aims to increase the interval between toilet visits and reduce the habit of urinating “just in case.” A planned program may involve:

  • recording voiding patterns
  • gradually extending the interval between voids
  • using distraction, breathing or pelvic floor contractions when urgency occurs
  • avoiding rushing to the toilet where it is safe to pause

Progress is usually gradual. An unrealistic schedule can lead to frustration or increased leakage.

Pelvic floor rehabilitation

Pelvic floor exercises may help suppress urgency and improve continence. Correct technique matters; repeatedly contracting the wrong muscles or performing excessive exercises may be unhelpful. Assessment by a pelvic floor physiotherapist can be useful.

Fluids and bladder irritants

Reducing excessive caffeine or alcohol may improve symptoms. Large volumes of fluid over a short period can also provoke urgency.

Fluid should not be restricted excessively. Concentrated urine may irritate the bladder and inadequate intake can contribute to constipation, infection or dehydration. Advice should reflect medical conditions, climate and activity.

Constipation, weight and mobility

Treating constipation may reduce pressure on the bladder. Weight reduction can improve urinary symptoms for some people. Mobility aids, clear access to the toilet and suitable clothing can reduce functional leakage even when bladder symptoms persist.

Managing nocturia

Waking at night to urinate is not always caused by OAB. Other contributors include sleep apnoea, leg swelling, heart or kidney disease, evening fluid intake and medicines.

Management should be directed at the cause. Moving a diuretic to a different time, for example, should occur only on advice from the prescribing clinician.

Where do prescription medicines fit?

Prescription medicines may be discussed when conservative measures have not provided sufficient relief, when symptoms are particularly troublesome, or when a combined approach is appropriate.

Two broad medicine classes are commonly used:

  1. Antimuscarinic medicines, which reduce muscarinic stimulation of the bladder.
  2. Beta-3 adrenergic agonists, which promote bladder relaxation during filling.

These medicines are not suitable for everyone. The choice should follow an individual assessment of symptoms, bladder emptying, other medical conditions, current medicines and personal priorities.

Antimuscarinic medicines

This class may reduce urgency, frequency and urgency incontinence in some patients. Possible adverse effects include:

  • dry mouth
  • constipation
  • blurred vision or dry eyes
  • dizziness or drowsiness
  • difficulty emptying the bladder
  • urinary retention
  • confusion or cognitive effects, particularly in susceptible older people

Caution may be required in people with impaired bladder emptying, certain forms of glaucoma, severe constipation or gastrointestinal motility disorders, cognitive impairment, or a high total anticholinergic burden.

Anticholinergic burden and cognition

Many medicines used for conditions other than OAB also have anticholinergic effects. The combined burden may contribute to dry mouth, constipation, sedation, falls, confusion and loss of function.

Observational research has found associations between prolonged exposure to medicines with strong anticholinergic effects and cognitive decline or dementia. An association does not prove that a particular medicine caused dementia in an individual patient, but the overall medication burden deserves review—especially in older people or those with cognitive concerns.

Beta-3 adrenergic agonists

This class acts differently and generally produces fewer classic anticholinergic effects. Possible adverse effects can include:

  • increased blood pressure
  • headache
  • palpitations or faster heart rate
  • urinary tract infection
  • difficulty emptying the bladder
  • medicine interactions

Blood pressure, cardiovascular history, kidney or liver function, bladder emptying and interacting medicines may influence suitability. Current Australian Product Information should guide prescribing and monitoring.

Can medicine classes be combined?

Combination therapy may be considered after a partial response to a single medicine, but additional benefit must be weighed against increased adverse effects, interactions and cost.

In men with both storage symptoms and possible bladder outlet obstruction, treatment may also need to address the obstructive component. A urinary flow test and post-void residual measurement may help guide the decision.

How is a medicine trial reviewed?

A medicine trial should have a clear purpose and review point. Reassessment may consider:

  • urgency episodes
  • daytime and night-time frequency
  • leakage and pad use
  • bladder diary findings
  • quality of life
  • blood pressure where relevant
  • constipation, dry mouth, cognition or other adverse effects
  • urinary flow and residual urine in patients at risk of retention

If there is little benefit or unacceptable harm, the diagnosis and management plan should be reconsidered. Increasing or continuing treatment indefinitely is not automatically appropriate.

Patients should not start, stop or change a prescription medicine without advice from their prescriber.

What if conservative care and medicines are insufficient?

Persistent symptoms do not mean that no further options exist. Reassessment is important before an invasive treatment to confirm the likely cause and identify incomplete emptying, obstruction or another condition.

Depending on the patient, options may include:

Intravesical botulinum toxin treatment

A prescription medicine can be injected into the bladder wall through a cystoscope to reduce involuntary bladder contractions. Some patients experience reduced urgency and leakage, but benefit varies and is temporary.

Important risks include urinary tract infection, increased residual urine and inability to empty the bladder adequately. Some patients require temporary intermittent self-catheterisation. Treatment must be selected and administered by an appropriately qualified clinician.

Tibial nerve stimulation

Electrical stimulation near the ankle can influence the nerve pathways involved in bladder control. Treatment protocols vary, and repeated sessions may be required. Response is variable.

Sacral neuromodulation

Sacral neuromodulation uses an implanted system to stimulate nerves involved in bladder and pelvic-floor control. It may be considered for selected patients after assessment and usually involves a test phase. Potential disadvantages include an operation, device-related complications, later revision and ongoing follow-up.

These treatments differ in invasiveness, risks, durability, repeat-treatment requirements, availability and cost. None is the best choice for every patient.

When should medical advice be sought promptly?

Prompt assessment is appropriate for:

  • inability to pass urine
  • visible blood in the urine
  • fever, flank pain or systemic illness with urinary symptoms
  • recurrent urinary infections
  • new leg weakness, numbness or loss of bowel control
  • significant pelvic or bladder pain
  • rapidly worsening symptoms
  • new incontinence accompanied by neurological symptoms

Urgent or emergency care may be required when symptoms are severe.

Questions to discuss with a clinician

  • Are my symptoms most consistent with OAB, or could there be another cause?
  • Am I emptying my bladder adequately?
  • Which conservative measures are most relevant to me?
  • What are the reasonable treatment options, including no immediate treatment?
  • What benefit might I realistically expect?
  • Which adverse effects or interactions matter with my other conditions and medicines?
  • How and when will treatment be reviewed?
  • Would further testing change management?
  • What symptoms should prompt urgent assessment?

The bottom line

Overactive bladder is a symptom syndrome, not a single test result. Assessment should look for infection, excessive urine production, incomplete emptying, obstruction, menopause-related changes, neurological disease and other contributors.

Management usually begins with education, bladder training, pelvic floor rehabilitation and attention to fluids, caffeine, constipation and related medical problems. Prescription medicine may be one part of treatment after an individual assessment, but benefits vary and adverse effects matter.

When symptoms remain troublesome, further evaluation and carefully selected minimally invasive treatments may be considered. The aim is not simply to prescribe another tablet; it is to understand the cause, reduce symptoms safely and improve daily life.

This article provides general disease education and does not replace individual medical advice. It does not promote or recommend a particular prescription medicine, therapeutic product, device or brand. Treatment decisions should be made with an appropriately qualified health professional after assessment of the individual patient.

References and further reading

Publication note

This draft is structured as general disease education for an Australian public-facing website. It should not be accompanied by branded medicine or device imagery, product pricing, supply information, testimonials, inducements, superiority claims, or wording that encourages a reader to request a named therapeutic good. Review the page title, search metadata, images, links, social-media caption and nearby booking prompts together, because the overall context determines whether material may be regarded as advertising.

Urodynamic Studies: Understanding How Your Bladder Works

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Bladder problems are not always as straightforward as they appear.

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

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

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

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

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

What Are Urodynamic Studies?

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

Depending on the clinical situation, testing may evaluate:

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

Urodynamics therefore investigates function rather than simply structure.

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

Who May Need Urodynamic Testing?

Not every patient with urinary symptoms requires urodynamics.

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

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

Common indications include:

Urinary Incontinence

Urodynamics may be useful when assessing:

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

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

Overactive Bladder

Patients with overactive bladder may experience:

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

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

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

Difficulty Emptying the Bladder

Patients may report:

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

The challenge is determining why.

Is there an obstruction?

Or is the bladder muscle simply not contracting strongly enough?

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

Men With Lower Urinary Tract Symptoms

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

Bladder outlet obstruction

and

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

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

Neurological Bladder Dysfunction

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

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

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

Before or After Certain Urinary Procedures

Urodynamics may also be considered:

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

What Happens During a Urodynamic Study?

The test is usually performed as an outpatient procedure.

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

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

Step 1: Arriving With a Comfortably Full Bladder

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

You will urinate into a special toilet called a uroflowmeter.

This measures:

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

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

This is called the post-void residual.

Step 2: Placement of Small Catheters

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

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

Why two pressure measurements?

Because pressure inside the abdomen affects pressure inside the bladder.

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

Detrusor pressure = bladder pressure − abdominal pressure

This simple equation sits at the heart of conventional urodynamics.

Step 3: Filling the Bladder

The bladder is slowly filled with sterile fluid.

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

We may record:

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

The pressure inside the bladder is continuously monitored.

Normal filling cystometrogram

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

 

Step 4: Provocative Testing

You may be asked to:

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

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

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

Step 5: Voiding

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

During urination we simultaneously measure:

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

This is called a pressure-flow study.

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

What Does Urodynamics Measure?

Bladder Sensation

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

Sensation may be:

  • Normal
  • Increased
  • Reduced
  • Absent

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

Bladder Capacity

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

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

Bladder Compliance

A healthy bladder should behave rather like a flexible reservoir.

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

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

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

Detrusor Overactivity

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

Detrusor overactivity.

It may be associated with:

  • Urgency
  • Urgency incontinence
  • Frequency
  • Nocturia

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

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

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

View the LABORIE-based detrusor-overactivity tracings

Stress Urinary Incontinence

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

Urodynamic stress incontinence.

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

Bladder Outlet Obstruction

During urination, a pattern of:

High bladder pressure + low urinary flow

may suggest obstruction.

In men, benign prostate enlargement is a common cause.

Other causes include:

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

Bladder outlet obstruction: pressure-flow study

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

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

BOOI = PdetQmax − 2(Qmax)

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

Detrusor Underactivity

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

This is known as:

Detrusor underactivity.

This distinction matters.

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

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

Dysfunctional Voiding

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

Instead of the outlet opening smoothly, it intermittently closes.

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

Understanding the Urodynamic Tracing

A urodynamic report typically contains several pressure and flow curves.

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

The important measurements usually include:

Pves: pressure measured inside the bladder.

Pabd: pressure measured within the abdomen.

Pdet: pressure generated by the bladder muscle.

Flow: the rate at which urine leaves the bladder.

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

Common Findings and What They May Mean for Treatment

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

The urodynamic result is not a treatment plan by itself.

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

How Urodynamics Can Guide Treatment

If Detrusor Overactivity Is Found

Initial treatment may include:

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

For persistent symptoms, options may include:

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

If Stress Incontinence Is Demonstrated

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

Options may include:

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

If Bladder Outlet Obstruction Is Demonstrated

Treatment depends on the underlying cause.

For benign prostate enlargement, options may include:

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

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

If the Bladder Muscle Is Weak

Treatment may involve:

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

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

If Bladder Storage Pressures Are High

This is particularly important in neurological bladder disease.

Treatment may include:

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

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

Are Urodynamic Studies Uncomfortable?

Most patients tolerate the investigation well.

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

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

Possible Side Effects and Complications

Urodynamic testing is generally safe.

Possible side effects include:

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

Significant complications are uncommon.

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

Does Everyone With Bladder Symptoms Need Urodynamics?

No.

This is an important point.

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

The investigation is particularly valuable when:

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

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

Urodynamics: Turning Symptoms Into Physiology

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

These symptoms tell us what is happening.

Urodynamics can sometimes tell us why.

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

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

The Bottom Line

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

A good urodynamic study does more than generate graphs.

It helps answer the question that matters most:

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

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