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Recurrent Urinary Tract Infections: Causes, Investigation and Prevention

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Urinary tract infections are common, uncomfortable and sometimes disruptive to everyday life. For some people, however, they keep returning despite apparently appropriate treatment.

A recurrent urinary tract infection, or recurrent UTI, is generally defined as:

  • Two or more symptomatic infections within six months; or
  • Three or more symptomatic infections within 12 months.

Recurrent UTIs are much more common in women, but they also occur in men, particularly when there is prostate disease, incomplete bladder emptying, urinary stones, catheter use or an abnormality of the urinary tract.

The key to successful management is not simply prescribing another antibiotic. We need to confirm that the symptoms are genuinely caused by infection, identify why infections are recurring and develop an individual prevention strategy.

What symptoms suggest a UTI?

A lower urinary tract infection, or cystitis, commonly causes:

  • Burning or stinging when passing urine
  • Increased urinary frequency
  • Urgency
  • Passing small amounts of urine
  • Lower abdominal discomfort
  • Blood in the urine
  • Cloudy or strong-smelling urine

Fever, shaking, flank or kidney pain, vomiting, confusion or feeling seriously unwell may indicate infection involving the kidneys or bloodstream and requires prompt medical assessment.

Is it always an infection?

Not every episode of burning, urgency or bladder discomfort is caused by bacteria. Similar symptoms may result from:

  • Genitourinary syndrome of menopause or vaginal atrophy
  • Overactive bladder
  • Interstitial cystitis/bladder pain syndrome
  • Pelvic-floor muscle dysfunction
  • Urethral or vaginal inflammation
  • Sexually transmitted infections
  • Urinary stones
  • Bladder cancer
  • Prostatitis
  • Incomplete bladder emptying

Repeated antibiotics given without confirming infection can delay the correct diagnosis and increase antibiotic resistance.

Whenever practical, a midstream urine sample should be collected for culture before commencing antibiotics. The European Association of Urology recommends confirming recurrent cystitis with urine cultures.

Why do urinary infections keep returning?

Most UTIs are caused by bacteria, commonly Escherichia coli, travelling from the bowel or genital region into the urinary tract. Recurrence may represent reinfection with a new organism or relapse involving the same organism.

Common contributing factors in women

These include:

  • Sexual intercourse
  • Spermicide or diaphragm use
  • A new sexual partner
  • Pregnancy
  • Menopause and loss of vaginal oestrogen
  • Vaginal or pelvic-organ prolapse
  • Urinary incontinence
  • Incomplete bladder emptying
  • Diabetes
  • Previous antibiotic exposure
  • Urinary stones or obstruction
  • Catheterisation or urinary-tract procedures

Causes that are particularly important in men

Recurrent UTI in a man usually warrants further assessment. Possible contributors include:

  • Benign prostate enlargement and bladder-outlet obstruction
  • Chronic bacterial prostatitis
  • Urethral stricture
  • Urinary stones
  • High residual urine volumes
  • Catheter use
  • Previous urinary surgery or instrumentation
  • Neurological bladder dysfunction

How are recurrent UTIs investigated?

Assessment begins with a careful history and review of previous urine-culture results. The clinician may consider:

  • Urinalysis and urine culture during symptomatic episodes
  • Examination for vaginal atrophy or pelvic-organ prolapse
  • Measurement of the amount of urine remaining after voiding
  • Kidney and bladder ultrasound
  • Assessment of urinary flow
  • Blood tests, including kidney function and diabetes screening
  • Evaluation for prostatitis in men
  • Cystoscopy or CT imaging in selected patients

Routine cystoscopy or extensive imaging is not necessary for every otherwise healthy woman. Further investigation becomes more important when there is visible blood in the urine, recurrent kidney infection, persistent pain, stones, unusual organisms, poor bladder emptying, previous urinary surgery or failure of standard prevention.

Treating an acute infection

A symptomatic, culture-confirmed infection is usually treated with a short course of antibiotics selected according to:

  • The urine-culture result
  • Previous antibiotic exposure
  • Allergies
  • Kidney function
  • Pregnancy status
  • Local bacterial-resistance patterns

Suitable patients who recognise their symptoms reliably may be offered a prearranged “self-start” antibiotic course, ideally after submitting a urine sample.

A positive urine culture without urinary symptoms is called asymptomatic bacteriuria. It usually should not be treated, except in specific situations such as pregnancy or before certain urological procedures. Treating asymptomatic bacteriuria unnecessarily may increase adverse effects and antibiotic resistance without preventing future infections.

A stepwise prevention strategy

Prevention should normally begin with correction of contributing factors and non-antibiotic measures. Medication or antibiotic prophylaxis can then be introduced when the expected benefit outweighs the risks.

1. Hydration and bladder habits

For people who normally drink relatively little, increasing water intake may reduce infection frequency. One clinical trial found benefit from an additional 1.5 litres of water daily in premenopausal women whose usual fluid intake was below 1.5 litres per day.

Other practical measures include:

  • Avoiding prolonged delays in passing urine
  • Emptying the bladder after intercourse if this appears helpful
  • Treating constipation
  • Avoiding spermicides when infections are temporally associated with their use
  • Managing prolapse or incomplete bladder emptying
  • Reviewing catheter technique and necessity
  • Optimising diabetic control

Many traditional recommendations: such as a particular wiping direction, special underwear or mandatory post-coital voiding, have limited supporting evidence. They are generally harmless but should not be presented as guaranteed prevention.

2. Vaginal oestrogen

Vaginal oestrogen is one of the best-supported non-antibiotic treatments for postmenopausal women with recurrent UTIs, particularly when vaginal dryness, irritation or discomfort is present.

It may be supplied as a cream, pessary or vaginal tablet. Local treatment helps restore the vaginal tissues and protective bacterial environment. It is different from systemic menopausal hormone therapy and produces much lower systemic hormone exposure.

Temporary local irritation or spotting may occur. Women with a history of oestrogen-sensitive cancer should discuss treatment with their treating specialists. Oral oestrogen has not demonstrated the same UTI-prevention benefit.

The EAU gives vaginal oestrogen a strong recommendation for prevention in postmenopausal women.

3. Methenamine hippurate

Methenamine hippurate is a urinary antiseptic rather than a conventional antibiotic. In acidic urine, it is converted into formaldehyde, which suppresses bacterial growth.

The ALTAR randomised trial found that methenamine hippurate was not inferior to daily low-dose antibiotics for preventing recurrent UTIs in women over 12 months, although the antibiotic group experienced slightly fewer infections.

Methenamine can be a useful antibiotic-sparing option for selected patients without significant urinary-tract abnormalities. It may not be suitable in severe kidney or liver impairment and must not be combined with sulfonamide antibiotics. Alkalinising urinary products may reduce its effectiveness. Medical supervision is therefore important.

4. Cranberry products

Cranberry products may modestly reduce recurrent UTIs in some women, but products and doses vary greatly. Evidence is supportive but inconsistent, and there is no universally accepted dose.

Cranberry should be considered an optional supplement rather than a replacement for investigation or proven treatment. Patients taking warfarin should discuss cranberry products with their doctor because of a potential interaction.

5. D-mannose

D-mannose has been widely promoted as preventing E. coli from adhering to the bladder lining. Earlier small studies suggested benefit, but a larger placebo-controlled trial found that daily D-mannose did not significantly reduce medically attended recurrent UTIs.

It may still be chosen by some patients, but expectations should be realistic. Current evidence is weak and contradictory.

6. Probiotics

Some vaginal Lactobacillus preparations may help restore protective vaginal flora, but results depend on the bacterial strain and formulation. Evidence remains insufficient to recommend all commercially available oral or vaginal probiotics as equivalent treatments.

Prophylactic antibiotics

When infections remain troublesome despite correcting reversible causes and trying appropriate non-antibiotic measures, prophylactic antibiotics may be considered.

Post-coital prophylaxis

A single antibiotic dose taken after intercourse may be appropriate when infections are clearly related to sexual activity. It reduces total antibiotic exposure compared with daily treatment.

Continuous low-dose prophylaxis

A low-dose antibiotic may be prescribed nightly or at another regular interval, commonly for three to six months and sometimes longer. Options may include nitrofurantoin, trimethoprim, cefalexin or intermittent fosfomycin, depending on culture results, renal function, allergies and Australian resistance patterns.

Daily and post-coital prophylaxis appear similarly effective when correctly matched to the patient’s infection pattern.

Potential disadvantages include:

  • Thrush, nausea or diarrhoea
  • Allergic reactions
  • Selection of resistant bacteria
  • Clostridioides difficile infection
  • Drug-specific toxicity

Long-term nitrofurantoin, for example, can rarely affect the lungs, liver or peripheral nerves and requires appropriate clinical monitoring. Infections may return after prophylaxis is stopped.

For these reasons, antibiotic prophylaxis should be reviewed periodically rather than continued automatically.

Bladder instillations

The correct term is bladder or intravesical instillation. A small catheter is passed into the bladder, and a solution is introduced and retained for a prescribed period.

Hyaluronic acid, alone or combined with chondroitin sulphate, is intended to replenish the bladder’s protective glycosaminoglycan layer. Studies suggest that these treatments may:

  • Reduce the number of recurrent infections
  • Increase the time before the next infection
  • Improve associated bladder pain, urgency or frequency in some patients

However, the evidence is based on relatively small and mixed-quality studies. The EAU makes only a weak recommendation for these instillations after less-invasive prevention strategies have failed.

Treatment usually requires an initial series followed by maintenance instillations. Disadvantages include cost, inconvenience, temporary discomfort and the small infection or urethral-trauma risk associated with catheterisation.

Antibiotic bladder instillation, most often gentamicin, is used off-label in selected patients, particularly those performing intermittent catheterisation or those with neurological bladder dysfunction and resistant infections. Evidence is mainly observational, and treatment should be supervised by an experienced urologist or infectious-diseases team. It is not routine first-line therapy for otherwise healthy patients.

Are vaccines available for recurrent UTIs?

Several bacterial immunoactive products are sometimes described as UTI “vaccines,” although they are different from conventional childhood vaccines and are not routinely available or approved in every country.

Examples include:

  • OM-89 or Uro-Vaxom: an oral preparation containing bacterial lysates from selected E. coli strains
  • MV140 or Uromune: a sublingual spray containing inactivated whole-cell bacteria
  • StroVac: an injectable bacterial preparation available in limited settings
  • Other experimental products, including ExPEC vaccines

MV140 has produced encouraging results in a randomised trial and observational studies. However, the EAU notes that the certainty of the overall evidence remains low and currently recommends immunomodulatory prophylaxis mainly within a well-regulated clinical-trial setting.

These products should not be advertised as a guaranteed cure. Regulatory approval, supply and access vary, and some may be unapproved or available only through special-access pathways in Australia. Patients should discuss the evidence, cost, regulatory status and alternatives with their urologist before considering treatment.

When should you seek urgent help?

Prompt medical assessment is important if urinary symptoms are accompanied by:

  • Fever or shaking chills
  • Kidney or flank pain
  • Vomiting or inability to keep fluids down
  • Confusion, faintness or severe weakness
  • Pregnancy
  • Inability to pass urine
  • Significant visible blood or blood clots
  • Rapid deterioration or concern about sepsis

Men, children, pregnant women, immunocompromised patients and people with urinary obstruction, catheters or known kidney disease generally require earlier assessment.

The take-home message

Recurrent UTIs are real and can have a substantial effect on comfort, confidence, sexual relationships, work and quality of life. Management should go beyond repeated short courses of antibiotics.

A sensible strategy is to:

  1. Confirm symptomatic episodes with urine cultures.
  2. Exclude conditions that mimic infection.
  3. Identify stones, obstruction, residual urine, prolapse, vaginal atrophy or prostate disease.
  4. Correct reversible causes.
  5. Introduce evidence-based non-antibiotic prevention.
  6. Consider methenamine or carefully selected antibiotic prophylaxis when necessary.
  7. Reserve bladder instillations and immunoactive treatments for appropriately selected patients after an informed discussion.

Treatment should always be individualised according to the patient’s culture results, anatomy, medical history and personal preferences.

So, if you suffer with chronic or recurrent infections, ask your GP for a referral to your Brisbane, Caboolture Urologist, Dr Jo Schoeman for further advice.

References and further reading

  1. European Association of Urology. EAU Guidelines on Urological Infections. Section on recurrent cystitis.
  2. American Urological Association, Canadian Urological Association and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Recurrent Uncomplicated Urinary Tract Infections in Women Guideline.
  3. National Institute for Health and Care Excellence. Urinary tract infection—recurrent: antimicrobial prescribing, NG112.
  4. Harding C, Mossop H, Homer T, et al. Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women: the ALTAR non-inferiority trial. BMJ. 2022;376.
  5. Williams G, Hahn D, Stephens JH, et al. Cranberries for preventing urinary tract infections. Cochrane Database of Systematic Reviews. 2023.
  6. Hayward G, Mort S, Hay AD, et al. D-mannose for prevention of recurrent urinary tract infection among women. JAMA Internal Medicine. 2024.
  7. Infectious Diseases Society of America. Clinical practice guideline for the management of asymptomatic bacteriuria.
  8. Australian Commission on Safety and Quality in Health Care. Antimicrobial stewardship resources.

This information is intended for general education and does not replace individual medical assessment. Antibiotic choice and preventive treatment should be guided by urine cultures, kidney function, allergies, pregnancy status, local resistance patterns and current Australian prescribing guidance.

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

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

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

Why can incontinence occur after prostatectomy?

Urinary continence normally depends on several structures working together:

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

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

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

Stress incontinence or overactive bladder?

This distinction is critical because the treatments are different.

Stress urinary incontinence

Stress incontinence typically causes leakage with:

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

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

Overactive bladder

Overactive bladder generally causes:

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

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

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

Assessment before considering an AUS

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

Assessment may include:

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

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

The role of urodynamic studies

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

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

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

It is particularly useful when a man has:

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

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

What is an artificial urinary sphincter?

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

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

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

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

Who may benefit from an AUS?

An AUS may be considered when:

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

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

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

When may an AUS be unsuitable?

An AUS may not be appropriate when there is:

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

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

What happens during and after surgery?

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

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

Until activation, urinary leakage is expected to continue.

Patients are then taught how to:

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

How successful is an AUS?

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

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

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

Possible complications

Potential complications include:

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

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

Warning signs of cuff erosion or device infection

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

Seek prompt urological review if you notice:

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

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

Important precautions after AUS implantation

Always tell healthcare providers about the AUS

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

Before catheterisation, cystoscopy or any procedure through the urethra:

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

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

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

Protect the urethra and implant

Patients should also:

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

What if the AUS fails?

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

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

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

Depending on the cause, options include:

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

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

A final perspective

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

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

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

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

References

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

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

Bridge to Brisbane 2026: Running in Blue for Prostate Cancer

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

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

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

Why run in blue?

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

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

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

More than a fun run

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

Funds raised for medical research can contribute to:

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

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

The health benefits of a fun run

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

Regular walking, jogging or running may help to:

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

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

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

You may walk—it still counts

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

A simple preparation program might begin with:

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

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

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

A different kind of men’s health check

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

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

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

My Bridge to Brisbane journey

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

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

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

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

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

Crossing the bridge together

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

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

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

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

Looking forward to seeing many Blue-Skirts!

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

Prostate Abscess: A Rare but Serious Infection

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

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

What causes a prostate abscess?

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

Common bacteria include:

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

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

Who is at increased risk?

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

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

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

How does a prostate abscess present?

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

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

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

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

When should a prostate abscess be suspected?

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

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

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

How is it diagnosed?

Initial investigations may include:

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

Imaging may be performed using:

Transrectal ultrasound

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

CT scan

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

MRI

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

Is a prostate abscess an emergency?

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

Emergency management may involve:

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

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

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

Treatment with antibiotics

All prostate abscesses require antibiotic treatment.

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

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

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

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

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

Can antibiotics alone cure a prostate abscess?

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

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

Drainage should be considered when:

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

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

How is a prostate abscess drained?

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

Transrectal ultrasound-guided aspiration

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

Advantages include:

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

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

Transperineal drainage

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

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

Transurethral drainage

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

Transurethral drainage is often considered when:

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

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

Open or laparoscopic surgery

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

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

What happens after drainage?

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

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

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

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

What is the outlook?

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

Delayed treatment may result in:

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

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

When should you seek urgent medical attention?

Attend an emergency department urgently if you develop:

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

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

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

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

‘Bag-of-Worms” Varicocele: Causes, Symptoms, Fertility and Treatment Options

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A varicocele is an enlargement of the veins surrounding the testicle. It is similar to a varicose vein in the leg, although it occurs within the scrotum.

Varicoceles are common and often harmless. However, in some men they may cause discomfort, reduce the size or function of the affected testicle, or contribute to fertility problems. Most varicoceles do not require treatment, and the decision to intervene depends on symptoms, testicular development, semen quality and plans for future fertility.

What causes a varicocele?

Blood leaves each testicle through a network of small veins called the pampiniform plexus. These veins normally carry blood upwards towards larger veins in the abdomen.

A varicocele develops when blood pools within these veins. This is usually related to poorly functioning venous valves, together with the anatomy and pressure within the testicular veins.

Around 80–90% of clinically detected varicoceles occur on the left side. This is because the left testicular vein is longer and enters the left renal vein at a right angle, making venous drainage less efficient. A varicocele may occur on both sides, while an isolated right-sided varicocele is much less common.

Most varicoceles develop gradually during puberty and have no dangerous underlying cause.

A new varicocele in an older man, particularly one that is right-sided, develops suddenly or does not disappear when lying down, may require abdominal imaging to exclude obstruction of the vein by an abdominal or retroperitoneal condition. This is uncommon but important to recognise.

How common are varicoceles?

A varicocele is found in approximately 15% of adolescent and adult men. Many men never know that they have one.

Varicoceles are more frequently identified among men being investigated for infertility. They may be present in approximately:

  • 35–40% of men with primary infertility
  • Up to 70–80% of men with secondary infertility, where a previous pregnancy has occurred, but the couple is now having difficulty conceiving

Importantly, most men with a varicocele remain fertile. Finding a varicocele does not automatically mean that it is causing infertility.

What are the symptoms?

Many varicoceles cause no symptoms and are discovered during a routine examination, fertility assessment or scrotal ultrasound.

When symptoms occur, they may include:

  • A dull ache, dragging sensation or heaviness in the scrotum
  • Discomfort that becomes worse after standing, exercising or later in the day
  • Improvement in discomfort when lying down
  • Visible or enlarged veins above the testicle
  • A soft swelling sometimes described as feeling like a “bag of worms”
  • Reduced size or slower growth of the affected testicle
  • Abnormal semen-analysis results
  • Difficulty conceiving with a partner

A varicocele generally does not cause erectile dysfunction or difficulty urinating. Its relationship with testosterone production remains under investigation, although some men with a clinically significant varicocele may have impaired testicular function.

Sudden severe testicular pain is not typical of a varicocele and requires urgent medical assessment to exclude testicular torsion or another acute scrotal condition. An abdominal ultrasound is also required to exclude a possible lesion in the abdomen obstructing the veins.

How is a varicocele diagnosed?

Diagnosis usually begins with a physical examination. The scrotum is examined while the patient is standing and lying down. You may be asked to take a breath and gently bear down, the Valsalva manoeuvre, to make enlarged veins easier to feel.

Clinical varicoceles are commonly graded as:

  • Grade 1: Felt only during the Valsalva manoeuvre
  • Grade 2: Felt while standing without straining
  • Grade 3: Easily visible through the scrotal skin

A scrotal ultrasound may be recommended if the examination is uncertain, the testicles differ in size, pain is present, or another scrotal problem needs to be excluded. Ultrasound can measure the veins, assess backward blood flow and examine the testicles.

For fertility assessment, investigations may include:

  • One or more semen analyses
  • Testicular volume measurement
  • Hormone tests when indicated
  • Assessment of both partners, because fertility is a shared consideration

An ultrasound-only or “subclinical” varicocele that cannot be felt on examination is not usually treated for infertility.

How can a varicocele affect fertility?

The testicles work best at a temperature slightly below core body temperature. The pampiniform veins help cool the arterial blood entering the testicle.

Pooling of warm blood in a varicocele may interfere with this cooling system. Increased temperature, venous pressure, oxidative stress and altered blood flow may affect sperm production and testicular function.

Possible semen changes include:

  • Reduced sperm concentration
  • Reduced sperm movement or motility
  • Increased abnormal sperm forms
  • Increased sperm DNA damage

The degree of impact varies considerably. A large varicocele can be associated with normal fertility, while a smaller palpable varicocele may be significant in another man. The diagnosis must therefore be interpreted together with semen results, the couple’s fertility history, the female partner’s age and other fertility factors.

Does every varicocele require treatment?

No. Observation is appropriate when a varicocele:

  • Causes no troublesome symptoms
  • Is not affecting testicular growth
  • Is associated with normal semen parameters
  • Is found incidentally on ultrasound but cannot be felt
  • Is unlikely to be the main cause of the couple’s fertility difficulty

Simple measures such as supportive underwear, avoiding activities that consistently aggravate discomfort and occasional appropriate pain relief may help mild symptoms. Regular review may be recommended for adolescents with a difference in testicular size.

When should treatment be considered?

Treatment may be considered when there is:

Infertility with abnormal semen parameters

Repair is most likely to benefit a couple when the man has:

  • A varicocele that can be felt on examination
  • Difficulty conceiving
  • One or more abnormal semen parameters
  • No better explanation for the infertility
  • A reasonable opportunity for natural conception following treatment

Both the AUA/ASRM and European guidance support considering repair in men attempting conception who have a palpable varicocele and abnormal semen parameters. Treatment is not routinely recommended for a varicocele detected only by ultrasound. AUA/ASRM male infertility guideline and EAU male infertility guideline

Persistent scrotal pain

Repair may be reasonable when typical varicocele-related discomfort persists despite conservative measures and other causes of scrotal pain have been excluded.

Reduced testicular growth in an adolescent

Treatment may be discussed if the affected testicle is persistently smaller, growth is impaired, the varicocele is large or semen parameters are abnormal in an appropriately selected older adolescent.

Progressive testicular dysfunction

Selected men with deteriorating semen quality or evidence of impaired testicular function may benefit from repair after individual assessment.

What treatment procedures are available?

Treatment works by blocking or dividing the abnormal veins. Blood then returns through healthy alternative veins while the testicular artery and lymphatic drainage are preserved.

Management option How it is performed Advantages Disadvantages and risks
Observation Clinical review, with semen analysis or testicular measurements when appropriate No procedure or anaesthetic; suitable for most asymptomatic men; avoids unnecessary treatment Does not correct the varicocele; symptoms or testicular changes may require future review
Conservative symptom management Scrotal support, activity modification and appropriate pain relief Simple and non-invasive; may adequately control mild discomfort Does not remove the varicocele or improve abnormal semen parameters; long-term anti-inflammatory medication may not be suitable for everyone
Microsurgical subinguinal varicocelectomy A small incision is made near the groin. An operating microscope helps identify and divide abnormal veins while protecting the testicular artery and lymphatics Usually the lowest recurrence and hydrocele rates; no abdominal incision; effective for unilateral or bilateral disease; commonly preferred for fertility treatment Requires an anaesthetic and microsurgical expertise; temporary bruising, swelling or discomfort; uncommon risks include infection, recurrence, hydrocele or testicular artery injury
Microsurgical inguinal varicocelectomy Similar microsurgical repair through a slightly higher groin incision Good visualisation and low recurrence when performed microsurgically Requires opening the external oblique fascia; recovery may involve slightly more groin discomfort
Laparoscopic varicocelectomy Veins are clipped or divided through small abdominal keyhole incisions Both sides can be treated during the same procedure; useful in selected cases General anaesthetic; entry into the abdomen; generally higher hydrocele risk than lymphatic-sparing microsurgery; rare abdominal or vascular complications
Open high ligation The testicular vein is divided through an abdominal or groin incision without microsurgical magnification Established technique; may be effective where microsurgery is unavailable Higher recurrence and hydrocele rates than modern microsurgical repair; less precise preservation of small arteries and lymphatics
Radiological embolisation or sclerotherapy An interventional radiologist passes a catheter into the testicular vein and blocks it using coils, plugs or a sclerosant No surgical incision in the scrotum or groin; often performed with local anaesthesia or sedation; relatively quick recovery; useful for recurrence after surgery The vein cannot always be accessed; radiation and contrast exposure; recurrence or persistence may occur; coils can rarely migrate; availability depends on local expertise

How effective is treatment?

The results depend on why treatment is being performed, the technique used and whether other fertility or pain-related factors are present.

Improvement in semen quality

Following repair of a clinically significant varicocele, approximately 60–80% of appropriately selected men demonstrate improvement in at least one semen parameter. Improvement is not guaranteed, and some men show little or no measurable change.

Because sperm production takes approximately three months, semen analysis is usually repeated about three months after treatment and may be reassessed again at six months.

Pregnancy and fertility outcomes

Varicocele repair may increase the chance of natural pregnancy in selected infertile couples, but it does not guarantee conception. Studies commonly report spontaneous pregnancy in roughly 25–40% of couples after repair, although rates vary substantially according to female partner factors, duration of infertility, baseline semen quality and study design.

Treatment may also improve semen quality sufficiently to allow a couple to use a less invasive assisted-reproduction option. In other cases, IVF or intracytoplasmic sperm injection may still be required.

The couple’s overall fertility timeline is important. If the female partner has reduced ovarian reserve or advancing reproductive age, waiting several months for semen improvement may not be appropriate. Varicocele repair and assisted reproductive treatment should therefore be considered as part of a shared plan.

Relief of pain

When pain is typical of a varicocele, a dull ache or heaviness made worse by standing or activity, approximately 70–90% of appropriately selected men experience meaningful improvement after repair.

Surgery is less predictable when pain is sharp, constant or atypical, and pain may occasionally persist despite technically successful treatment.

Testicular growth

In adolescents with a persistently smaller affected testicle, repair may allow “catch-up” growth. Decisions should be based on repeated measurements rather than a single ultrasound result.

What are the possible complications?

Varicocele procedures are generally safe, but potential complications include:

  • Bruising, swelling or wound discomfort
  • Infection or bleeding
  • Persistence or recurrence of the varicocele
  • Hydrocele, caused by fluid collecting around the testicle
  • Ongoing or occasionally altered scrotal pain
  • Injury to the testicular artery, which is uncommon but potentially serious
  • Testicular shrinkage, which is rare
  • Anaesthetic complications
  • Technical failure, contrast reaction, radiation exposure or coil-related problems following embolisation

Using microsurgical magnification and preserving the lymphatic vessels usually reduces the risks of recurrence, hydrocele and arterial injury.

Recovery after varicocele repair

Most men return home on the day of treatment. Bruising, mild swelling and groin or scrotal discomfort are expected during the early recovery period.

Patients are commonly advised to:

  • Wear supportive underwear
  • Keep the wound clean and dry
  • Avoid heavy lifting and strenuous exercise for the period advised by the surgeon
  • Resume sexual activity when comfortable and medically cleared
  • Attend follow-up to assess healing and symptom improvement
  • Repeat semen analysis after approximately three months when fertility is the reason for treatment

Specific recovery instructions vary according to the procedure and the individual patient.

When should you seek medical advice?

Arrange a medical assessment if you notice:

  • A new lump or swelling in the scrotum
  • Persistent scrotal discomfort or heaviness
  • A difference in testicular size
  • Difficulty conceiving
  • A new right-sided varicocele
  • A swelling that remains when lying down

Seek urgent medical attention for sudden severe testicular pain, rapid swelling, nausea or a high-riding testicle. These features may indicate testicular torsion, which is an emergency.

The bottom line

A varicocele is common and, for most men, causes no significant harm. Treatment is not based on the ultrasound appearance alone. The most important considerations are symptoms, testicular development, semen quality and the couple’s overall fertility situation.

For men with persistent typical pain, impaired testicular growth or a palpable varicocele associated with infertility and abnormal semen parameters, treatment can be worthwhile. Microsurgical varicocelectomy generally offers the most favourable balance between effectiveness, recurrence and complication risk, while embolisation is an effective minimally invasive alternative in selected patients.

A consultation with a urologist allows the varicocele—and the patient rather than simply the scan—to be assessed before deciding whether observation, surgery or embolisation is the most appropriate approach.

This article provides general information and does not replace an individual medical assessment. Treatment recommendations depend on examination findings, semen results, symptoms, age and the fertility circumstances of both partners.

So, if this is something that you have found on your regular scrotal examinations, and you have concerns, come see your Brisbane urologist, Dr Jo Schoeman for advice.

Conservative Management of a Distal Ureteric Stone: When Can You Wait and When Is Surgery Needed?

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A distal ureteric calculus is a stone located in the lower part of the ureter—the tube carrying urine from the kidney to the bladder. These stones are often close to the ureterovesical junction, where the ureter enters the bladder.

As the stone moves towards the bladder, it can cause severe intermittent pain known as renal colic. Pain commonly begins in the side or back and travels into the lower abdomen, groin, testicle or labia. Blood in the urine, nausea, vomiting, urinary urgency and frequency may also occur.

Many small distal ureteric stones pass naturally. However, conservative management is only safe when pain is controlled, infection is absent, kidney function is satisfactory and appropriate follow-up is arranged.

When is a ureteric stone an emergency?

A stone obstructing an infected kidney is a urological emergency. Antibiotics alone may be insufficient because infected urine cannot drain normally.

Seek urgent medical assessment if stone symptoms are accompanied by:

  • Fever or shaking chills
  • Feeling severely unwell, weak, confused or drowsy
  • Persistent vomiting or inability to drink
  • Pain that remains severe despite medication
  • Passing very little or no urine
  • Known poor kidney function
  • A solitary functioning kidney
  • Pregnancy with significant pain or fever

The obstructed kidney may need urgent drainage with a ureteric stent or nephrostomy tube. Definitive stone treatment is usually delayed until the infection has been controlled. The European Association of Urology recommends immediate antibiotics and urgent drainage for sepsis associated with an obstructing stone. EAU Guidelines on Urolithiasis

Australian Healthdirect similarly advises patients with renal colic and fever to attend a doctor or hospital emergency department promptly. Healthdirect Australia—Kidney stones

What determines whether a stone will pass naturally?

The likelihood of spontaneous passage depends mainly on:

  • Stone size
  • Position within the ureter
  • Degree of obstruction
  • Ureteric anatomy
  • Whether the stone is impacted
  • Previous stone history
  • Associated swelling and inflammation
  • The duration for which the stone has remained in the same position

Smaller stones located close to the bladder have the greatest likelihood of passing.

The EAU reports that distal ureteric stones collectively have a spontaneous passage rate of approximately 68–83%. A distal ureteric stone smaller than 5 mm has an estimated passage rate of approximately 89%. The likelihood decreases as stone size increases.

These percentages describe groups of patients and cannot predict exactly what will happen to an individual stone. A 4 mm stone may occasionally become impacted, while a larger stone may sometimes pass without surgery.

The average reported passage time is approximately 17 days, although passage can occur sooner or take several weeks. EAU Guidelines on Urolithiasis

Who may be suitable for conservative management?

Conservative management, also called observation, expectant management or a trial of passage, may be appropriate when:

  • The stone is small enough to have a reasonable chance of passing
  • The stone is in the distal ureter
  • Pain can be controlled with oral medication
  • There is no fever or evidence of urinary infection
  • Kidney function is stable
  • The patient can drink and keep medication down
  • There is no complete obstruction threatening kidney function
  • The patient is passing urine normally
  • There is no high-risk situation involving a solitary kidney or bilateral obstruction
  • The patient understands the warning symptoms
  • Follow-up and repeat imaging can be arranged
  • The patient is comfortable waiting for the stone to pass

Stones of 5 mm or less are particularly suitable for observation when no complications are present.

Selected distal stones between 5 and 10 mm may also be managed conservatively. These stones are less likely to pass than smaller stones, but some patients may avoid surgery with careful observation and medical expulsive therapy.

Stones larger than 10 mm are substantially less likely to pass naturally and are more commonly treated with an intervention.

What assessment is required?

Before recommending conservative management, the diagnosis and severity of obstruction should be established.

Assessment may include:

  • A detailed history and physical examination
  • Urine dipstick testing
  • Urine culture when infection is suspected
  • Kidney-function blood tests
  • Full blood count and inflammatory markers
  • Non-contrast CT scan of the kidneys, ureters and bladder
  • Ultrasound in selected patients
  • A plain abdominal X-ray when the stone is visible on X-ray
  • Pregnancy testing when clinically relevant

A low-dose non-contrast CT scan is often the most accurate test for determining the stone’s size and location. It can also assess hydronephrosis, the swelling of the kidney caused by obstruction and identify alternative causes of pain.

Ultrasound is particularly useful when radiation should be avoided, including during pregnancy, although it may not show every ureteric stone.

What does conservative management involve?

Pain relief

Non-steroidal anti-inflammatory medicines, NSAIDs, are often the most effective initial treatment for renal colic when they are medically safe.

Depending on the patient, treatment may include:

  • Ibuprofen
  • Diclofenac
  • Paracetamol
  • A prescribed opioid for breakthrough pain
  • Medication for nausea or vomiting

NSAIDs may be unsuitable for people with:

  • Reduced kidney function
  • Previous stomach ulcers or gastrointestinal bleeding
  • Certain cardiovascular conditions
  • Anticoagulant treatment
  • NSAID allergy
  • Some stages of pregnancy

Pain medication should be selected according to the patient’s medical history rather than taken indiscriminately.

Hydration

Patients should generally remain normally hydrated and avoid becoming dehydrated.

Drinking excessive volumes of water during an episode of acute obstruction does not necessarily force the stone through and may increase discomfort. The aim is steady, sensible fluid intake unless a doctor has advised otherwise.

Straining the urine

Passing urine through a stone strainer can help recover the calculus. A captured stone can be sent for laboratory analysis, which may guide future prevention.

Pain disappearing does not always prove that the stone has passed. Occasionally a stone stops causing pain while obstruction remains, so follow-up imaging may still be required.

Activity

Normal gentle activity is usually reasonable if the patient feels well. Some patients find walking helpful, although exercise cannot guarantee stone passage.

Driving, remote travel and hazardous work may be unsafe while unpredictable severe pain or medication-related drowsiness remains possible.

Medical expulsive therapy

Medical expulsive therapy—usually abbreviated to MET, uses medication to help a ureteric stone pass.

The most frequently used medicines are alpha-blockers, including:

  • Tamsulosin
  • Silodosin
  • Alfuzosin

Tamsulosin is commonly selected because it is widely available and familiar to urologists.

Alpha-blockers are primarily used to improve urinary symptoms caused by prostate enlargement. Their use for ureteric stone passage is generally off-label, meaning that stone passage is not necessarily the indication listed in the medicine’s formal registration.

Off-label use does not mean that treatment is experimental or prohibited. It means that the potential benefits, limitations and side effects should be discussed before prescribing it.

How do alpha-blockers affect the distal ureter?

The ureter contains smooth muscle and alpha-adrenergic receptors. These receptors are particularly relevant in the distal ureter.

When a stone enters the ureter, the surrounding muscle can contract and spasm. Swelling may develop around the stone, increasing resistance to its movement.

Alpha-blockers may:

  • Relax distal ureteric smooth muscle
  • Reduce ureteric spasm
  • Reduce pressure below and around the stone
  • Increase the ureter’s ability to accommodate the calculus
  • Improve the likelihood of stone passage
  • Shorten passage time in some patients
  • Reduce episodes of renal colic and analgesic requirements in selected cases

An alpha-blocker does not:

  • Dissolve most stones
  • Make the stone physically smaller
  • Treat a urinary infection
  • Remove a completely impacted stone
  • Protect a kidney from prolonged significant obstruction
  • Replace drainage of an infected obstructed kidney

How effective are alpha-blockers?

Research into alpha-blockers has produced mixed results.

When all ureteric stones are grouped together, some large studies have shown little or no overall benefit. This may be because very small stones frequently pass without medication and very large or impacted stones remain unlikely to pass despite treatment.

The clearest benefit appears to be in patients with distal ureteric stones between approximately 5 and 10 mm.

The EAU recommends offering an alpha-blocker as one treatment option for conservatively managed distal ureteric stones in this size range, while explaining that treatment is off-label. EAU Guidelines on Urolithiasis

For a stone smaller than 5 mm, the natural passage rate is already high, so an alpha-blocker may add relatively little benefit. Treatment decisions should therefore be individualised.

Side effects and precautions with alpha-blockers

Possible side effects include:

  • Dizziness
  • Light-headedness on standing
  • Low blood pressure
  • Weakness or fatigue
  • Headache
  • Nasal congestion
  • Palpitations
  • Reduced semen volume
  • Failure of ejaculation or retrograde ejaculation

Extra caution is required in patients who:

  • Already have low blood pressure
  • Have a history of fainting or falls
  • Take several blood-pressure medicines
  • Use medication for erectile dysfunction
  • Have significant cardiovascular disease
  • Are planning cataract or glaucoma surgery

Tamsulosin has been associated with intraoperative floppy iris syndrome during cataract surgery. Patients should tell their ophthalmologist about current or previous use.

Alpha-blocker treatment should be stopped and medical advice obtained if infection, uncontrollable pain or deterioration in kidney function develops.

How long can conservative management continue?

There is no single safe waiting period for every patient. The decision depends on symptoms, obstruction, kidney function, stone movement and the likelihood of passage.

Many stones that pass naturally do so within two to four weeks. A monitored trial of passage may sometimes continue for up to approximately four to six weeks, provided that:

  • Pain remains manageable
  • Infection does not develop
  • Kidney function remains stable
  • Obstruction is not causing progressive harm
  • Follow-up imaging is performed
  • The patient still prefers conservative treatment

Observation should not become open-ended. A painless obstructing stone can still impair kidney function.

Follow-up may involve an X-ray, ultrasound or low-dose CT scan. The most suitable test depends on whether the stone was visible on the original X-ray and whether ongoing obstruction needs to be assessed.

When has conservative management failed?

Conservative management should be reconsidered when:

  • The stone has not passed within an appropriate observation period
  • Repeat imaging shows that the stone has not moved
  • Pain remains severe despite adequate medication
  • Repeated emergency presentations are required
  • Nausea or vomiting prevents oral fluids or medication
  • Fever or urinary infection develops
  • Kidney function deteriorates
  • Hydronephrosis persists or worsens
  • Urine output falls significantly
  • The stone has a low likelihood of spontaneous passage
  • The patient has a solitary kidney or bilateral obstruction
  • The patient cannot safely continue waiting
  • Work, caring responsibilities or travel make unpredictable colic unacceptable
  • The patient prefers definitive removal

The EAU identifies persistent pain, persistent obstruction, impaired kidney function and a low likelihood of spontaneous passage as indications for active stone removal. EAU Guidelines on Urolithiasis

Failure of conservative management is not a personal failure. It usually means that the stone is too large, impacted, anatomically trapped or producing complications that make further waiting unsafe.

Surgical and procedural treatment

The two main definitive treatments for a distal ureteric calculus are:

  • Ureteroscopy with laser lithotripsy or stone extraction
  • Shock wave lithotripsy

The most appropriate option depends on stone size, density and position, as well as the patient’s anatomy, medical health, preferences and treatment availability.

Ureteroscopy and laser lithotripsy

Ureteroscopy is commonly used for distal ureteric stones and generally provides the best chance of becoming stone-free after one procedure.

Under anaesthesia, a small telescope is passed through:

  1. The urethra
  2. The bladder
  3. The opening of the ureter
  4. The ureter to the level of the stone

The stone may be removed intact with a small basket or fragmented using a holmium or thulium laser. The pieces are then extracted or allowed to pass naturally.

No external incision is usually required.

Is a ureteric stent required?

A temporary ureteric stent may be inserted when:

  • The ureter is swollen
  • Access was difficult
  • Infection is a concern
  • Stone fragments remain
  • There was ureteric trauma
  • Reliable drainage is required
  • Kidney function is vulnerable

A stent extends from the kidney to the bladder. It can cause:

  • Urinary frequency and urgency
  • Bladder discomfort
  • Pain in the kidney during urination
  • Blood in the urine
  • Discomfort during activity
  • A sensation of incomplete emptying

Stents must be removed or exchanged at the planned time. A forgotten stent can become encrusted and cause serious complications.

Risks of ureteroscopy

Possible complications include:

  • Urinary infection or sepsis
  • Bleeding
  • Failure to reach or remove the stone
  • Residual fragments
  • Ureteric perforation
  • Ureteric narrowing or stricture
  • Need for a further procedure
  • Anaesthetic complications

Major ureteric injury is uncommon but can require additional surgery.

Compared with shock wave treatment, ureteroscopy generally offers a higher chance of clearing the stone in one procedure, although it is more invasive and has a higher complication rate. EAU Guidelines on Urolithiasis

Shock wave lithotripsy

Shock wave lithotripsy, SWL or ESWL, uses externally generated shock waves focused onto the stone. These waves fragment the calculus into smaller pieces that can pass down the ureter.

Advantages may include:

  • No telescope passing up the ureter
  • No surgical incision
  • Lower procedural morbidity
  • Day-treatment suitability in many patients

Limitations include:

  • Lower single-treatment stone-free rates than ureteroscopy
  • Possible need for repeat treatment
  • Pain while fragments pass
  • Residual fragments
  • Difficulty targeting some distal stones
  • Reduced success with dense or impacted stones
  • Reduced effectiveness with greater skin-to-stone distance
  • Possible need for subsequent ureteroscopy

SWL may not be suitable during pregnancy, with untreated infection, uncorrected bleeding disorders, an aneurysm near the treatment field or an anatomical obstruction below the stone.

The American Urological Association recognises both ureteroscopy and shock wave lithotripsy as options when active treatment is required for a distal ureteric stone. AUA Surgical Management of Kidney and Ureteral Stones Guideline

Emergency drainage with a ureteric stent

A ureteric stent may be inserted urgently to bypass an obstructing stone and allow urine to drain from the kidney.

This is particularly important when there is:

  • Infection or sepsis
  • Deteriorating kidney function
  • A solitary obstructed kidney
  • Bilateral obstruction
  • Uncontrollable pain
  • Severe obstruction where immediate stone removal is unsuitable

Emergency stenting relieves the obstruction but does not always remove the stone. Definitive ureteroscopy or SWL may be scheduled later.

Percutaneous nephrostomy

A nephrostomy tube is inserted through the skin of the back directly into the kidney under imaging guidance.

It may be used when:

  • Rapid drainage of an infected kidney is required
  • A ureteric stent cannot be inserted
  • The patient is too unwell for a longer procedure
  • Ureteric anatomy prevents retrograde access

Both ureteric stenting and nephrostomy provide effective emergency drainage. The choice depends on clinical circumstances, local expertise and the patient’s condition.

Open, laparoscopic or robotic stone removal

Open or keyhole ureterolithotomy is now rarely required for an isolated distal ureteric stone.

It may occasionally be considered for:

  • A very large impacted stone
  • Unusual urinary anatomy
  • Failure of less invasive treatments
  • A stone requiring treatment during another planned reconstruction

Most distal stones can be treated successfully with ureteroscopy or SWL.

Which treatment is best?

There is no single procedure that is best for every patient.

Ureteroscopy may be preferred when:

  • Rapid and reliable stone clearance is important
  • The stone is impacted
  • The stone is dense or unlikely to fragment with SWL
  • Previous SWL has failed
  • The patient has significant obesity
  • The stone is difficult to target externally
  • The patient wishes to minimise the likelihood of repeat treatment

SWL may be preferred when:

  • The stone can be targeted clearly
  • The stone has favourable size and density
  • The patient wishes to avoid ureteroscopy
  • Anaesthetic considerations favour a less invasive approach
  • The patient accepts the possibility of repeat treatment

The decision should include a discussion of success rates, anaesthesia, stent requirements, recovery, complications and the possible need for another procedure.

Preventing another stone

Once the acute episode has resolved, prevention becomes important.

General measures may include:

  • Drinking enough fluid to produce at least 2–2.5 litres of urine daily, unless medically restricted
  • Reducing excessive salt intake
  • Maintaining normal dietary calcium rather than eliminating calcium
  • Moderating excessive animal-protein intake
  • Maintaining a healthy body weight
  • Avoiding recurrent dehydration
  • Capturing the stone for analysis
  • Completing blood and urine testing when indicated

Patients with recurrent stones, a solitary kidney, childhood stone disease, unusual stone types or a strong family history may require a formal metabolic evaluation, including 24-hour urine testing.

Prevention should be tailored to the stone composition and the patient’s metabolic risk factors.

The bottom line

Many small distal ureteric stones can be managed safely without surgery. Stones smaller than 5 mm near the bladder have the greatest likelihood of passing naturally.

Conservative treatment usually involves appropriate pain relief, sensible hydration, urine straining, follow-up imaging and—in selected patients—an alpha-blocker such as tamsulosin.

Alpha-blockers relax the smooth muscle of the distal ureter. Their greatest likely benefit is for distal stones between approximately 5 and 10 mm. They do not dissolve the stone and should not delay treatment when infection, uncontrolled pain, persistent obstruction or declining kidney function develops.

Ureteroscopy with laser treatment provides the most reliable single-procedure clearance for many distal stones. Shock wave lithotripsy is less invasive but may require repeat treatment. An infected obstructed kidney requires urgent drainage rather than continued observation.

This article provides general information and does not replace individual medical assessment. Anyone with renal colic and fever, inability to pass urine, persistent vomiting or uncontrollable pain should seek urgent medical care.

Need help deciding whether your ureteric stone can safely pass?

If you have been diagnosed with a distal ureteric calculus, appropriate management depends on more than its size alone. Stone position, pain, infection, kidney function and the degree of obstruction must all be considered.

Your local Brisbane urologist, Dr Jo Schoeman, can assess whether observation, medical expulsive therapy, ureteroscopy or shock wave treatment is the most appropriate option for you.

References and further reading

Balanitis Xerotica Obliterans and Lichen Sclerosus of the Foreskin

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Balanitis xerotica obliterans—usually abbreviated to BXO, is the traditional urological name for male genital lichen sclerosus.

Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects the foreskin and head of the penis. It can cause whitening, inflammation, splitting and progressive scarring of the foreskin. In some men it also narrows the urinary opening or extends into the urethra.

BXO is not simply an infection or ordinary balanitis. Early recognition and treatment can relieve symptoms and reduce permanent scarring. Long-term observation is also important because genital lichen sclerosus is associated with a small but genuine risk of penile squamous cell carcinoma.

Is BXO different from lichen sclerosus?

The names are often used interchangeably:

  • Lichen sclerosus is the preferred modern medical term.
  • Balanitis xerotica obliterans describes lichen sclerosus affecting the glans penis and foreskin, particularly when scarring has developed.

The condition may involve:

  • The inner and outer foreskin
  • The glans penis
  • The frenulum
  • The urinary opening—the meatus
  • The fossa navicularis and penile urethra

The disease is usually confined to the genital region in men, although lichen sclerosus can occasionally affect skin elsewhere.

What causes lichen sclerosus?

The exact cause remains uncertain. It is probably produced by a combination of inflammation, immune-system dysfunction, genetic susceptibility, skin injury and local environmental factors.

Possible associations include:

  • Autoimmune or inflammatory activity
  • Chronic exposure of susceptible skin to trapped urine
  • Repeated friction or minor trauma
  • A tight foreskin
  • Previous inflammation beneath the foreskin
  • Obesity and a “buried” penis
  • Diabetes or metabolic disease
  • Cigarette smoking
  • Genetic susceptibility

The moist, occluded environment beneath the foreskin may contribute to continuing inflammation in susceptible men.

Lichen sclerosus is:

  • Not caused by poor personal character or behaviour
  • Not usually a sexually transmitted infection
  • Not contagious
  • Not something that can be passed to a partner through ordinary sexual contact

Yeast or bacterial infection may occur at the same time, particularly in men with diabetes, but infection is not the underlying cause of lichen sclerosus.

Who can develop it?

Male genital lichen sclerosus can occur at any age.

It is recognised in:

  • Boys with acquired or severe scarring phimosis
  • Adolescents
  • Younger and middle-aged men
  • Older men
  • Men with a previously retractable foreskin that has gradually tightened

It is much less common in men who were circumcised early in life, although circumcision does not make the risk absolutely zero.

How does lichen sclerosus present?

The appearance varies considerably. Early disease can be subtle and may initially be mistaken for thrush, dermatitis, recurrent balanitis or ordinary phimosis.

Possible signs include:

  • White, pale or porcelain-coloured foreskin
  • A white, firm ring around the foreskin opening
  • Thickened or hardened skin
  • Shiny, crinkled or “cigarette-paper” skin
  • Red or inflamed areas
  • Small cracks or splits
  • Easy bleeding or bruising
  • Painful erosions
  • Adhesions between the foreskin and glans
  • Progressive tightening of the foreskin
  • Shortening or scarring of the frenulum
  • Whitening around the urinary opening
  • Narrowing of the meatus
  • Loss of the normal shape or definition of the glans and foreskin

Some men have significant visible disease with surprisingly little discomfort.

Symptoms patients may notice

Symptoms can include:

  • Difficulty retracting the foreskin
  • Inability to replace or retract the foreskin fully
  • Pain during erections
  • Splitting or bleeding during intercourse
  • Itching, burning or soreness
  • Recurrent “balanitis”
  • Pain or reduced enjoyment during sexual activity
  • Spraying or deflection of the urinary stream
  • A weak or narrowed stream
  • Straining to urinate
  • Dribbling after urination
  • Ballooning of the foreskin
  • Recurrent urinary infections
  • Difficulty emptying the bladder

A narrow urinary opening may be the first sign that the disease has extended beyond the foreskin.

Lichen sclerosus and phimosis

Phimosis means that the foreskin cannot be retracted comfortably behind the glans.

A non-retractile foreskin is normal in young boys and does not automatically indicate disease. However, a previously retractable foreskin that becomes tight, particularly when accompanied by a white scarred ring is suspicious for lichen sclerosus.

Forceful stretching of a scarred foreskin is not recommended. Repeated tearing may cause additional inflammation and scarring.

Paraphimosis, where a retracted tight foreskin becomes trapped behind the glans, requires urgent medical attention.

How is lichen sclerosus diagnosed?

The diagnosis is often made from the history and characteristic appearance.

Assessment should include examination of:

  • The complete foreskin
  • Glans penis
  • Frenulum
  • Urinary opening
  • Palpable tissue beneath abnormal skin
  • Urinary stream and bladder emptying when relevant
  • Groin lymph nodes if cancer is suspected

Other conditions that can resemble lichen sclerosus include:

  • Fungal or bacterial balanitis
  • Irritant or allergic dermatitis
  • Psoriasis
  • Lichen planus
  • Zoon balanitis
  • Vitiligo
  • Genital warts
  • Penile intraepithelial neoplasia: PeIN
  • Squamous cell carcinoma

Diabetes testing may be appropriate in men with recurrent inflammation or other risk factors.

Is a biopsy always necessary?

Not every typical case requires a biopsy before treatment. However, biopsy is important when:

  • The diagnosis is uncertain
  • Treatment has not produced the expected response
  • An erosion or ulcer does not heal
  • There is a persistent red or thickened area
  • A lump or hardened area can be felt
  • The skin bleeds easily without an obvious cause
  • Pigmentation changes unexpectedly
  • Penile intraepithelial neoplasia or cancer is suspected

When circumcision is performed for suspected lichen sclerosus, the foreskin should usually be sent for pathological examination.

A biopsy should be taken from any suspicious persistent lesion rather than relying only on the appearance.

Medical management

The goals of medical treatment are to:

  • Suppress inflammation
  • Relieve discomfort and itching
  • Prevent further scarring
  • Preserve foreskin and urinary function where possible
  • Identify patients who require surgery or biopsy

General skin care

Helpful measures include:

  • Washing gently with water or a non-soap cleanser
  • Avoiding perfumed soaps, antiseptics and harsh products
  • Drying the glans and foreskin gently after urination
  • Applying a bland barrier ointment or emollient
  • Avoiding forceful foreskin retraction
  • Using adequate lubrication during sexual activity
  • Stopping smoking
  • Managing diabetes carefully
  • Addressing obesity or a buried penis where relevant

Good hygiene means gentle care. Repeated scrubbing or strong antiseptics can worsen inflamed genital skin.

Potent topical corticosteroids

A prescribed potent or ultrapotent topical corticosteroid is the usual first-line medical treatment.

Clobetasol propionate 0.05% ointment is commonly used in specialist practice. A typical initial course may involve a small amount applied to the affected skin once daily for one to three months, but the exact regimen should be determined by the treating doctor.

Patients should be shown:

  • Exactly where to apply the medication
  • How much to use
  • How long to continue
  • Whether treatment should be reduced gradually
  • When follow-up is required

When used correctly for a defined course, topical corticosteroids can reduce inflammation, soreness and early tightening. They cannot always reverse established dense scar tissue.

Possible steroid-related effects include irritation, secondary infection, skin thinning or visible small blood vessels, although these are uncommon with appropriate genital use and medical supervision.

Other topical treatments

Topical calcineurin inhibitors such as tacrolimus or pimecrolimus may occasionally be considered by a dermatologist or experienced specialist when corticosteroids are unsuitable.

They are not generally preferred over potent topical corticosteroids as initial treatment. They can cause burning or irritation, and persistent suspicious lesions must be biopsied rather than repeatedly treated empirically.

Antifungal or antibiotic medication is only useful when a secondary infection is actually present. It does not treat the underlying lichen sclerosus.

When should circumcision be considered?

Circumcision is an important and often definitive treatment for foreskin lichen sclerosus.

It should be considered when there is:

  • Established scarring phimosis
  • Painful or recurrent splitting
  • Difficulty with hygiene
  • Recurrent balanitis
  • Paraphimosis
  • Failure to respond adequately to a prescribed steroid course
  • Rapid recurrence after apparently successful medical treatment
  • Significant functional or sexual difficulty
  • Concern about premalignant or malignant change
  • A need to obtain tissue for diagnosis

Complete circumcision removes the diseased foreskin and eliminates the moist, urine-exposed environment beneath it. Many men experience long-term resolution when the disease is limited to the foreskin.

Partial circumcision or simply making a slit in the scarred foreskin is generally less reliable because affected skin remains and may scar again.

Will circumcision cure lichen sclerosus?

Circumcision is often highly effective when the condition is limited to the foreskin. However, it is not an absolute guarantee of cure.

Disease may persist or recur on the:

  • Glans
  • Coronal sulcus
  • Frenulum
  • Urinary opening
  • Urethra

Ongoing symptoms or abnormal skin after circumcision should therefore be reviewed rather than assumed to be normal postoperative scarring.

Circumcision appears to reduce the risk associated with chronic inflammation and phimosis, but it does not completely eliminate the future risk of penile cancer.

Surgery for meatal narrowing

Lichen sclerosus can scar the urinary opening, producing meatal stenosis.

Symptoms may include:

  • A thin urinary stream
  • Spraying or deflection
  • Prolonged urination
  • Straining
  • Discomfort
  • Incomplete emptying

Treatment may require a meatotomy or meatoplasty, in which the opening is enlarged and reconstructed.

Simple dilatation may provide temporary improvement but often does not control active scar disease. Medical treatment of the surrounding lichen sclerosus and continued surveillance may still be required.

What if the disease involves the urethra?

In some men, scarring extends from the meatus into the penile urethra and occasionally further towards the bulbar urethra.

Assessment may include:

  • Urinary flow-rate testing
  • Post-void residual ultrasound
  • Flexible cystoscopy
  • Retrograde urethrogram
  • Voiding cystourethrogram
  • Urethral ultrasound in selected cases

Short strictures may sometimes be managed endoscopically, but repeated dilatation or urethrotomy has a significant recurrence risk when active lichen sclerosus remains.

Longer or recurrent strictures may require urethroplasty. Oral lining tissue, usually buccal mucosa from the inside of the cheek, is commonly used for reconstruction.

The European Association of Urology recommends that genital skin should not be used as a graft for lichen-sclerosus-related urethral strictures, because the disease can affect the graft and recurrence rates are poor.

Complex cases are best managed by a urologist experienced in reconstructive urethral surgery.

Other surgical options

Depending on the extent of disease, specialist procedures may include:

  • Frenuloplasty in carefully selected cases without extensive LS
  • Complete circumcision
  • Meatotomy or meatoplasty
  • Excision or biopsy of suspicious lesions
  • Glans resurfacing when premalignant disease is present
  • Oral-mucosa graft urethroplasty
  • Staged urethral reconstruction
  • Perineal urethrostomy for severe or recurrent extensive stricture disease

The operation should be tailored to the location and activity of the condition. Preserving diseased genital skin simply to avoid circumcision may produce repeated scarring and further procedures.

Lichen sclerosus and penile cancer

Male genital lichen sclerosus is associated with squamous cell carcinoma of the penis and with penile intraepithelial neoplasia, which is a precancerous change.

Published studies have reported widely differing cancer rates among men with genital lichen sclerosus, from close to zero in some groups to approximately 12.5% in highly selected specialist series. Frequently quoted estimates place the risk at roughly 2–6%, but the precise lifetime risk for an individual man remains uncertain.

This does not mean that most men with lichen sclerosus will develop penile cancer. Penile cancer remains rare, and appropriate treatment of inflammation and phimosis is expected to reduce risk.

It is also reported that lichen sclerosus is found in a substantial proportion of penile cancer specimens. This association cannot be reversed to mean that the same proportion of men with lichen sclerosus will develop cancer.

Risk is likely to be greater when there is:

  • Long-standing uncontrolled inflammation
  • Severe phimosis
  • Persistent ulceration or thickening
  • Poor visibility of the glans
  • Cigarette smoking
  • Immune suppression
  • Coexisting penile intraepithelial neoplasia
  • Failure to attend follow-up

Warning signs that require prompt review

A man with current or previous lichen sclerosus should seek medical assessment for:

  • A persistent ulcer or sore
  • A new lump or firm area
  • Skin thickening
  • An irregular red or velvety patch
  • A warty or cauliflower-like growth
  • Unexplained bleeding
  • Offensive discharge
  • Increasing pain
  • A lesion that does not respond to prescribed steroid treatment
  • A new lump in the groin

These findings do not necessarily mean cancer, but they should not be treated repeatedly as thrush or simple inflammation without further investigation.

Follow-up and self-examination

Lichen sclerosus can recur, and cancer-related changes may develop many years after initial treatment.

Patients should become familiar with the normal appearance of their penis and perform regular self-examination. When possible, the entire glans, foreskin and urinary opening should be inspected.

Medical follow-up should be tailored to disease severity. More frequent review is appropriate during active treatment, after surgery or when urethral involvement is present. Once stable, periodic or annual review may be appropriate, together with lifelong self-monitoring.

Circumcised men should still report new or persistent abnormalities.

The outlook

When recognised early, male genital lichen sclerosus can often be controlled successfully with appropriate topical corticosteroid treatment, good skin care and follow-up.

Established scarring is less likely to resolve with medication alone. Circumcision is usually highly effective for disease confined to the foreskin, while meatal and urethral disease may require more specialised reconstruction.

The important message is not to ignore a foreskin that is becoming progressively white, scarred or tight. Early assessment may prevent painful erections, urinary obstruction and more complex surgery.

The bottom line

Balanitis xerotica obliterans is the older name for male genital lichen sclerosus involving the foreskin and glans.

It commonly presents with white or scarred skin, acquired phimosis, splitting, painful erections or urinary-stream changes. Potent prescribed topical corticosteroids are the first medical treatment for suitable early disease, while circumcision is often required for established phimosis, recurrent disease or failure of medical treatment.

Meatal or urethral involvement requires urological assessment and may need reconstructive surgery.

The risk of penile squamous cell carcinoma is small but real. Persistent thickening, ulceration, bleeding, a lump or a lesion that does not respond to treatment requires prompt examination and often biopsy.

This article provides general information and does not replace personalised medical assessment. Do not use potent topical corticosteroids on genital skin without appropriate medical advice.

So guys, if you cannot retract the foreskin and has the typical appearance discussed in this article, take the time to review with your GP to have this checked out. There is effective management for this which will also then reduce your risk for penile cancer. Do not vary your head in the send and ignore this, have it seen to and let your GP refer you to your local Brisbane urologist, Dr Jo Schoeman.

References and further reading

Superficial Bladder Cancer: Diagnosis, Treatment and the Risk of Progression

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“Superficial bladder cancer” is an older term for cancer confined to the bladder lining or the tissue immediately beneath it. The preferred modern term is non–muscle-invasive bladder cancer, usually abbreviated to NMIBC.

Although these cancers have not invaded the bladder muscle, they do not all behave in the same way. Some are small, low-grade tumours with a relatively low risk of causing serious harm. Others, particularly high-grade T1 cancer and carcinoma in situ, can recur frequently and may progress into the bladder muscle.

Accurate staging and risk classification are therefore essential when deciding between surveillance, intravesical treatment and removal of the bladder.

What is non-muscle-invasive bladder cancer?

The bladder wall consists of several layers. Most bladder cancers begin in the urothelium, the specialised lining on the inside of the bladder.

NMIBC includes three main stages:

  • Ta: a papillary tumour growing from the bladder lining without invading the supporting tissue
  • T1: cancer that has invaded the connective tissue beneath the lining but has not reached the bladder muscle
  • Carcinoma in situ/CIS or Tis: a flat, usually high-grade cancer confined to the bladder lining

CIS can be difficult to see because it may look like a red or inflamed area rather than a typical bladder tumour. Despite being confined to the surface, CIS is biologically aggressive and requires active treatment.

Once cancer enters the bladder muscle, it becomes muscle-invasive bladder cancer—stage T2 or higher. This usually requires a different and more intensive treatment approach.

How common is superficial bladder cancer?

Approximately 70–75% of bladder cancers are non–muscle-invasive when first diagnosed. The remaining patients generally have muscle-invasive or metastatic disease at presentation.

Bladder cancer is considerably more common in men than women and occurs most frequently in people over 60. Women sometimes experience delays in diagnosis when blood in the urine is initially attributed to urinary infection.

Most bladder cancers are urothelial carcinomas. Less common types include squamous cell carcinoma, adenocarcinoma and small-cell or neuroendocrine carcinoma.

What symptoms can bladder cancer cause?

The most common presentation is visible blood in the urine, haematuria.

The urine may appear:

  • Pink
  • Red
  • Rust-coloured
  • Tea-coloured
  • Normal between episodes

The bleeding is often painless and may disappear for days or weeks. Its disappearance does not mean the underlying problem has resolved.

Other possible symptoms include:

  • Microscopic blood detected on a urine test
  • Urinary frequency
  • A sudden need to urinate
  • Burning or discomfort when passing urine
  • Recurrent symptoms resembling a urinary tract infection
  • Difficulty emptying the bladder
  • Pelvic discomfort

CIS may cause urinary urgency, frequency and burning without producing a large visible tumour.

Blood in the urine should always be investigated, particularly in an older adult or someone with a history of smoking. Infection, stones and benign prostate enlargement are common alternative explanations, but bladder and upper urinary tract cancers must be excluded.

What causes bladder cancer?

Bladder cancer develops when genetic damage causes cells in the bladder lining to grow abnormally. In many patients there is no single identifiable cause.

Cigarette smoking

Smoking is the most important preventable risk factor. Carcinogens from tobacco enter the bloodstream, are filtered by the kidneys and remain in contact with the bladder lining in the urine.

The risk increases with the amount and duration of smoking. Stopping smoking remains valuable even after diagnosis because continued smoking may increase the risk of recurrence and progression.

Occupational chemical exposure

Long-term exposure to certain aromatic amines and industrial chemicals can increase risk. Historically, higher-risk industries have included:

  • Dye and pigment manufacturing
  • Rubber and leather production
  • Painting
  • Printing
  • Metal processing
  • Petroleum and chemical industries

Modern workplace protections have reduced—but not eliminated—these exposures.

Other risk factors

Additional risk factors include:

  • Increasing age
  • Male sex
  • Previous pelvic radiotherapy
  • Previous cyclophosphamide chemotherapy
  • Chronic bladder irritation or inflammation
  • Long-term urinary catheterisation
  • Certain inherited cancer syndromes, particularly Lynch syndrome
  • A personal history of cancer elsewhere in the urinary tract

Bladder cancer is not generally considered hereditary, although familial and genetic risks exist in a minority of patients.

How is bladder cancer investigated?

Medical history and urine testing

Assessment begins with a history of the bleeding, urinary symptoms, smoking and occupational exposure. Urine testing may identify blood, infection or abnormal cells.

A negative urine test after an episode of visible haematuria does not remove the need for investigation.

Urine cytology

Urine cytology examines shed urinary cells under a microscope.

It is most useful for detecting:

  • High-grade urothelial cancer
  • Carcinoma in situ
  • Cancer elsewhere in the urinary tract

Cytology is less sensitive for low-grade tumours, so a negative result does not exclude bladder cancer.

Urinary molecular-marker tests may occasionally provide additional information, but they do not usually replace cystoscopy.

Imaging of the urinary tract

A CT urogram is commonly used to assess:

  • Kidneys
  • Renal pelvises
  • Ureters
  • Bladder
  • Enlarged lymph nodes or other abnormalities

An ultrasound may be appropriate for selected patients, particularly when CT contrast or radiation should be avoided. However, ultrasound cannot reliably exclude small bladder tumours or CIS.

Flexible cystoscopy

A flexible cystoscope is passed through the urethra under local anaesthetic to inspect the bladder directly.

If a suspicious lesion is found, the next step is generally a formal resection under anaesthesia.

Transurethral resection of bladder tumour: TURBT

TURBT is the central procedure for diagnosing and treating NMIBC.

A rigid telescope is passed through the urethra, and the visible tumour is removed using an electrical loop, bipolar instrument or other resection technique. Tissue is sent to a pathologist to determine:

  • Cancer type
  • Tumour grade
  • Depth of invasion
  • Whether bladder muscle is present in the specimen
  • Whether muscle invasion has occurred
  • Whether variant histology or lymphovascular invasion is present

A complete TURBT should remove all visible tumour where safely possible and include adequate sampling of the underlying bladder muscle.

Enhanced cystoscopy using blue-light fluorescence or narrow-band imaging may help identify small tumours or CIS in selected patients.

When is a second TURBT required?

A repeat resection, usually within approximately two to six weeks, may be recommended when:

  • The first resection was incomplete
  • No bladder muscle was present in the specimen, apart from selected clearly low-risk Ta tumours
  • The tumour is high-grade T1
  • There is uncertainty about staging
  • Residual tumour is suspected

Repeat TURBT may find residual cancer and occasionally identifies previously unrecognised muscle invasion. It can therefore materially change treatment.

Understanding low-, intermediate-, high- and very-high-risk disease

Treatment is based on more than the word “superficial.” Important risk factors include:

  • Ta, T1 or CIS stage
  • Low-grade or high-grade pathology
  • Number of tumours
  • Tumour size
  • First occurrence or recurrence
  • Frequency of previous recurrences
  • Presence of CIS
  • Depth and extent of T1 invasion
  • Variant histology
  • Lymphovascular invasion
  • Involvement of the prostatic urethra
  • Response to previous BCG treatment

Low-risk NMIBC

This usually involves a first, solitary, small, low-grade Ta tumour without CIS.

These cancers commonly recur but have a very low risk of progressing to muscle-invasive disease.

Intermediate-risk NMIBC

This is a broad group between low and high risk. It may include recurrent, multiple or larger low-grade tumours and selected other tumours without high-risk features.

The pattern and frequency of recurrence help determine treatment intensity.

High-risk NMIBC

High-risk disease includes most:

  • High-grade T1 tumours
  • Carcinoma in situ
  • High-grade Ta tumours with adverse features
  • Tumours with other aggressive pathological findings

These cancers have a meaningful risk of entering the bladder muscle and require more intensive treatment and surveillance.

Very-high-risk NMIBC

Very-high-risk disease may include combinations such as extensive high-grade T1 cancer with CIS, lymphovascular invasion, certain aggressive variant histologies or involvement of the prostatic urethra.

For these patients, early radical cystectomy may provide the best chance of cure.

Initial treatment after TURBT

Surveillance for selected low-risk disease

For a completely removed low-risk tumour, treatment may consist of:

  • TURBT
  • A single immediate dose of intravesical chemotherapy when safe
  • Follow-up cystoscopy

Small, recurrent low-grade tumours may sometimes be treated with office fulguration or carefully selected surveillance, depending on the patient and tumour history.

Intravesical treatment

“Intravesical” means that a medication is placed directly into the bladder through a catheter. The medicine is retained for a prescribed time and then drained or passed in the urine.

Because the treatment remains mainly inside the bladder, it generally causes fewer whole-body effects than intravenous chemotherapy.

The role of intravesical mitomycin C

Mitomycin C is a chemotherapy medicine that damages the DNA of rapidly dividing cancer cells.

A single immediate postoperative dose

A single dose may be placed into the bladder shortly after TURBT—preferably within 24 hours—when the procedure has been uncomplicated.

Its purpose is to destroy floating tumour cells and reduce the chance that they implant elsewhere in the bladder. It also treats microscopic tumour cells remaining at the resection site.

This treatment is particularly useful for low-risk tumours and selected intermediate-risk tumours.

Mitomycin should not be administered immediately when there is:

  • Suspected bladder perforation
  • A very deep or extensive resection
  • Significant ongoing bleeding
  • A need for continuous bladder irrigation
  • Concern that the drug could leak outside the bladder

A course of mitomycin

Patients with intermediate-risk disease may receive weekly mitomycin treatments followed by a variable maintenance schedule. The exact schedule depends on tumour characteristics, previous recurrence pattern and local protocol.

Side effects of mitomycin

Possible side effects include:

  • Burning when urinating
  • Urinary frequency and urgency
  • Bladder discomfort
  • Blood in the urine
  • Chemical cystitis
  • Skin irritation or a rash involving the hands or genital region
  • Reduced bladder capacity after repeated severe inflammation
  • Infection
  • Rare injury if the medication leaks outside the bladder

Patients should follow the treatment unit’s instructions regarding fluid intake, urine handling and washing after treatment.

The role of intravesical BCG

BCG, Bacillus Calmette–Guérin, is a live, weakened form of Mycobacterium bovis. It was originally developed as a tuberculosis vaccine but also stimulates a powerful immune response against bladder cancer cells.

BCG is generally the preferred bladder-preserving treatment for:

  • Carcinoma in situ
  • High-risk high-grade Ta cancer
  • High-grade T1 cancer after adequate resection
  • Selected recurrent or aggressive intermediate-risk tumours

How is BCG given?

The usual initial course consists of one bladder instillation each week for six weeks. This is called induction BCG.

Patients who respond may then receive maintenance BCG. For high-risk disease, treatment may continue intermittently for one to three years, depending on tolerance, availability and individual risk.

Maintenance therapy is important because induction BCG alone provides less durable protection against recurrence and progression.

Side effects of BCG

Common short-term effects include:

  • Burning when urinating
  • Frequency and urgency
  • Mild blood in the urine
  • Bladder discomfort
  • Fatigue
  • Low-grade fever
  • Flu-like symptoms

These effects usually settle within one or two days.

Less common but potentially serious complications include:

  • Severe bacterial urinary infection
  • Prostatitis
  • Epididymo-orchitis
  • Granulomatous inflammation
  • Joint inflammation
  • Hepatitis or pneumonitis
  • Systemic BCG infection or sepsis

A high or persistent fever, shaking chills, breathing difficulty, confusion or severe illness after BCG requires urgent medical assessment.

When should BCG be postponed or avoided?

BCG should not be given:

  • Within the early healing period after TURBT, generally the first two weeks
  • After traumatic catheterisation
  • When visible haematuria is present
  • During a symptomatic urinary tract infection
  • When bladder perforation is suspected
  • In some patients with significant immune suppression
  • When previous BCG caused a severe systemic reaction

BCG is handled differently from routine chemotherapy because it contains live bacteria. Patients must follow the treatment centre’s hygiene and urine-disposal instructions.

Mitomycin or BCG: which is better?

Neither treatment is best for every patient.

  • Low-risk disease: a single immediate chemotherapy instillation is usually sufficient after complete TURBT.
  • Intermediate-risk disease: a course of chemotherapy or one year of BCG may be considered according to recurrence and progression risk.
  • High-risk disease: induction and maintenance BCG is generally preferred when bladder preservation is appropriate.
  • Very-high-risk disease: early radical cystectomy should be discussed, although BCG may remain an option in carefully selected patients who understand the risk.

BCG is more effective than chemotherapy for preventing recurrence and progression in appropriately selected high-risk disease, particularly when maintenance BCG is completed. It also tends to cause more local and systemic side effects.

What is the chance of developing muscle-invasive cancer?

There is no single percentage that applies to every NMIBC patient.

Across all NMIBC categories, approximately 10–20% of patients may eventually develop muscle-invasive disease, but this average hides enormous differences between low- and high-risk tumours.

Using contemporary EAU risk categories, estimated five-year progression risks can range approximately from:

  • Around 1% or less for low-risk disease
  • Several per cent for intermediate-risk disease
  • Around 10% or higher for high-risk disease
  • Approximately 40% or more for very-high-risk disease

At ten years, the estimated risk in very-high-risk patients may exceed 50% without effective additional treatment. These figures are estimates from risk models and do not precisely predict an individual patient’s outcome. BCG, repeat resection, early cystectomy and other treatments can substantially change the risk.

Progression risk is particularly concerning with:

  • Persistent or recurrent high-grade T1 cancer
  • T1 cancer associated with CIS
  • Extensive or multifocal CIS
  • Deep invasion into the lamina propria
  • Lymphovascular invasion
  • Aggressive variant histology
  • Prostatic urethral involvement
  • Failure to respond to adequate BCG
  • Early high-grade recurrence following BCG

Recurrence and progression are different. A small low-grade Ta tumour may recur several times without becoming muscle invasive, while a high-grade T1 tumour may progress after relatively few visible recurrences.

What is BCG-unresponsive bladder cancer?

BCG-unresponsive disease is a specific high-risk situation in which high-grade cancer persists or returns despite an adequate course of BCG within a defined period.

Continuing the same BCG treatment in genuinely BCG-unresponsive disease is unlikely to provide meaningful benefit and could delay curative surgery.

For a patient fit enough for major surgery, radical cystectomy is generally the preferred oncological treatment for BCG-unresponsive high-risk NMIBC.

Alternative bladder-preserving treatments or clinical trials may be considered when a patient:

  • Is medically unfit for cystectomy
  • Declines cystectomy after informed discussion
  • Has a strong preference for bladder preservation and accepts the additional risk

However, the possibility of losing the optimal window for curative surgery must be discussed clearly.

When should removal of the bladder be considered?

Radical cystectomy means removing the bladder, nearby lymph nodes and certain adjacent organs, followed by creating a new way for urine to leave the body.

It may be considered for NMIBC when there is:

  • Very-high-risk NMIBC at initial diagnosis
  • Persistent high-grade T1 cancer after repeat TURBT
  • High-grade T1 cancer with CIS
  • Lymphovascular invasion
  • Aggressive variant histology, such as micropapillary, plasmacytoid or selected sarcomatoid differentiation
  • Extensive CIS that does not respond adequately to BCG
  • High-grade recurrence following adequate BCG
  • BCG-unresponsive disease
  • Tumour involvement of the prostatic urethra or ducts
  • Disease that cannot be completely controlled endoscopically
  • Frequent, extensive high-grade recurrences
  • Progression to muscle-invasive bladder cancer

Cystectomy may sound excessive for a cancer described as “superficial,” but high-grade T1 disease can already possess the biological ability to spread. Delaying surgery until muscle invasion or metastasis develops can reduce the chance of cure.

What does radical cystectomy involve?

In men, surgery commonly removes the:

  • Bladder
  • Prostate
  • Seminal vesicles
  • Pelvic lymph nodes

In women, surgery is tailored individually and may involve removal of the bladder, pelvic lymph nodes and selected reproductive organs. Organ-preserving approaches may be possible in carefully selected patients.

Urinary reconstruction options include:

  • Ileal conduit: urine drains through a short segment of bowel to a stoma and external bag
  • Orthotopic neobladder: bowel is used to create an internal reservoir connected to the urethra
  • Continent catheterisable reservoir: an internal pouch is emptied using a catheter through a small abdominal opening

The most appropriate option depends on cancer location, kidney function, bowel health, manual dexterity, general fitness and patient preference.

Radical cystectomy is major surgery. Potential effects on urinary, sexual and bowel function must be balanced against the danger of progression.

Why lifelong surveillance is important

NMIBC has a strong tendency to recur, even after apparently complete treatment. Follow-up commonly includes:

  • Regular cystoscopy
  • Urine cytology in higher-risk patients
  • Periodic upper urinary tract imaging
  • Biopsy or repeat TURBT when abnormalities are found
  • Monitoring for late treatment complications

Low-risk patients generally require less intensive surveillance. High-risk patients need frequent cystoscopy and cytology, particularly during the first two years, followed by long-term or lifelong monitoring.

The exact schedule should be tailored to the patient’s EAU risk group, pathology, treatment response and general health.

Can recurrence be prevented?

Not every recurrence can be prevented, but patients can improve their general and bladder health by:

  • Stopping smoking
  • Avoiding occupational carcinogen exposure
  • Completing recommended intravesical treatment
  • Attending every surveillance cystoscopy
  • Reporting recurrent blood in the urine promptly
  • Treating urinary infections appropriately
  • Maintaining good hydration unless medically restricted

Smoking cessation remains the most important modifiable step.

The bottom line

Most bladder cancers are diagnosed before they enter the bladder muscle, but the term “superficial” should not be mistaken for harmless.

Low-grade Ta tumours frequently recur but rarely progress. High-grade T1 cancer and CIS behave much more aggressively and require complete TURBT, appropriate intravesical therapy and close surveillance.

Mitomycin C is particularly useful for reducing recurrence after TURBT and treating selected low- or intermediate-risk disease. BCG is the main bladder-preserving treatment for high-risk NMIBC and CIS.

Radical cystectomy should be discussed early—not only after muscle invasion—in patients with very-high-risk features, persistent high-grade T1 cancer or BCG-unresponsive disease. For these patients, timely surgery may offer the best chance of cure.

This article provides general information and does not replace individual medical advice. Treatment should be based on formal pathology review, complete staging, medical fitness and multidisciplinary discussion.

References and further reading

So, if you are experiencing blood in your urine and have been identified by your GP as having a possible bladder cancer, come see your Urologist in Brisbane, Dr Jo Schoeman to discuss options with you.

 

Focal Therapy for Prostate Cancer: Targeting the Cancer While Preserving the Prostate

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Established management of localised prostate cancer includes active surveillance for suitable low-risk disease and whole gland treatment with surgery or radiotherapy when treatment is indicated. ProFocal® is a newer focal approach that uses laser energy to destroy a selected cancerous area while leaving much of the surrounding prostate untreated.

This approach is known as focal laser therapy or focal laser ablation. Its intended aim is to control the treated cancer focus while reducing urinary and sexual side effects. Whether it provides cancer control equivalent to established whole-gland treatments over the long term has not been demonstrated.

Early Australian research is encouraging. However, ProFocal remains an investigational treatment, and important questions about its long-term cancer control have not yet been answered.

What is ProFocal therapy?

ProFocal is an Australian-developed focal therapy system designed to treat a carefully selected area of prostate cancer.

A fine laser applicator is inserted through the skin between the scrotum and anus, the perineum, and guided into the prostate using imaging. Laser energy heats the targeted tissue to a temperature that causes cancer-cell death.

The system incorporates cooling and real-time temperature monitoring. This is intended to make the area of ablation more predictable and to limit unintended heat damage to nearby structures such as the:

  • Urinary sphincter
  • Urethra
  • Bladder neck
  • Rectum
  • Neurovascular bundles involved in erections

Unlike radical prostatectomy, ProFocal does not remove the prostate. Unlike conventional radiotherapy, it does not expose the whole prostate to radiation.

Is ProFocal approved by the TGA?

This requires careful clarification.

As at September 2026, the manufacturer states that ProFocal is not included in the Australian Register of Therapeutic Goods, ARTG. It therefore does not have general TGA market authorisation for routine supply and use in Australia.

This is different from saying that the treatment has received unrestricted “TGA approval.”

ProFocal may be accessible in Australia through a clinical trial or a specific TGA pathway for an unapproved therapeutic good, such as the Authorised Prescriber Scheme or Special Access Scheme. These pathways permit access in defined circumstances; they are not equivalent to ARTG inclusion or routine TGA market authorisation. The applicable approval, governance and consent arrangements should be confirmed for the individual patient.

Authorised Prescriber access does not mean that the device has been entered on the ARTG or endorsed as routine standard treatment. Regulatory status, trial availability and funding arrangements should always be confirmed directly before treatment.

Medicare, private insurance and professional oversight in Australia

The Medicare Benefits Schedule (MBS) lists professional medical services subsidised by the Australian Government. As at September 2026, no specific MBS item for “ProFocal” or focal laser ablation of prostate cancer was identified in the current public MBS material reviewed for this article. This should not be interpreted as a definitive ruling on every component of an episode of care: consultations, anaesthesia, imaging, pathology or hospital services may each have different billing arrangements.

An MBS rebate for an associated service would not establish that ProFocal itself is TGA-approved, guideline-endorsed or proven effective. Conversely, lawful access through a TGA pathway does not guarantee Medicare or private-insurance funding. The Department of Health and Aged Care’s Medical Services Advisory Committee (MSAC) is the independent body that advises government on whether public funding of medical services and technologies is supported by evidence of safety, clinical effectiveness and cost-effectiveness.

The Australian Medical Association (AMA) is a professional representative body, not the regulator of therapeutic goods and not the agency that creates Medicare items. No AMA clinical guideline specifically recommending ProFocal was identified for this review. It would therefore be inappropriate to imply AMA endorsement. Relevant professional duties instead arise from the Medical Board of Australia’s code of conduct: patients should receive understandable information about the proposed treatment, reasonable alternatives, material risks, uncertainties, costs and any practitioner conflicts of interest so that consent is genuinely informed.

Who may be considered for ProFocal therapy?

ProFocal is principally being studied in men with localised, non-metastatic and MRI-visible prostate cancer.

In the first prospective phase II ProFocal study, eligible men had:

  • Prostate cancer confined to the prostate
  • An MRI-visible cancer target
  • ISUP Grade Group 2 or 3 disease
  • A PSA of 15 ng/mL or lower
  • A clinical stage of T2c or lower
  • Biopsy findings corresponding with the abnormality seen on MRI

Outside a clinical trial, suitability would need to be assessed individually by a multidisciplinary prostate cancer team.

A potential candidate generally requires a cancer that can be clearly identified, biopsied and safely surrounded by an adequate treatment margin. Detailed assessment usually includes:

  • Multiparametric prostate MRI
  • Targeted and systematic transperineal biopsies
  • PSA and PSA-density assessment
  • Clinical staging
  • Consideration of PSMA PET/CT in selected men
  • Review of the MRI and pathology at a multidisciplinary meeting

When may ProFocal be unsuitable?

ProFocal would generally not be considered appropriate when there is:

  • Metastatic prostate cancer
  • High-risk or locally advanced disease requiring comprehensive treatment
  • Cancer outside the prostate
  • Extensive cancer involving several areas of the gland
  • Cancer that cannot be reliably identified on MRI
  • A tumour position where an adequate and safe treatment margin cannot be achieved
  • Significant uncertainty about the true extent or grade of the cancer
  • An inability or unwillingness to undergo ongoing MRI scans and repeat biopsies
  • A medical condition that makes anaesthesia or the procedure unacceptably risky

Men with low-risk Grade Group 1 prostate cancer may be better managed with active surveillance, avoiding treatment and its potential complications altogether.

Focal therapy should not be regarded as an easier substitute for appropriate surgery or radiotherapy in men with aggressive, high-volume or advanced prostate cancer.

How is ProFocal treatment performed?

ProFocal is usually performed as a day procedure under general anaesthesia.

Treatment planning

The cancer identified on MRI and biopsy is mapped carefully. The treatment plan includes the visible tumour and an additional safety margin intended to treat microscopic cancer immediately around it.

Placement of the laser applicator

With the patient under anaesthesia, a transrectal ultrasound probe is used to visualise the prostate. A fine laser applicator is inserted through the perineum and positioned within the selected treatment area.

The route is similar to that used for a transperineal prostate biopsy.

Laser ablation

Controlled laser energy heats and destroys the targeted prostate tissue. Temperature monitoring helps the surgeon assess treatment delivery and protect surrounding structures. More than one applicator position may be needed to cover the planned treatment zone.

The published phase II study reported a median treatment time of approximately 60 minutes, although the complete anaesthetic and theatre procedure may take longer.

Recovery

A urinary catheter may be required temporarily because prostate swelling can make urination difficult. Many patients can return home on the day of treatment or after a short admission, depending on their recovery and ability to pass urine.

What are the potential advantages?

The proposed advantages of ProFocal include:

  • Treatment directed at the known cancer rather than the whole prostate
  • No abdominal incision
  • A transperineal, minimally invasive approach
  • Short hospital stay
  • Faster initial recovery than major surgery
  • No ionising radiation
  • Preservation of untreated prostate tissue
  • A potentially lower risk of persistent urinary incontinence
  • A potentially lower risk of erectile dysfunction than whole gland treatment
  • The possibility of further focal or whole-gland treatment if cancer remains or returns

These are potential benefits and should not be interpreted as guarantees.

How does it compare with established alternatives?

There is no mature randomised evidence showing that ProFocal gives the same long-term protection from metastasis or prostate-cancer death as radical prostatectomy or radiotherapy. A balanced consultation should therefore compare all reasonable options:

  • Active surveillance: avoids or delays treatment side effects and is preferred for many men with low-risk disease, but requires PSA testing, MRI and repeat biopsy, with treatment if the cancer progresses.
  • Radical prostatectomy: removes the prostate and provides complete surgical pathology. It has long-term cancer-control data, but carries risks including urinary incontinence, erectile dysfunction, loss of ejaculation and surgical complications.
  • Radiotherapy: has established long-term cancer-control data and avoids surgery, but may cause urinary, bowel and sexual adverse effects; androgen-deprivation therapy may be advised for some risk groups.
  • ProFocal/focal laser ablation: may offer quicker recovery and less short-term urinary or sexual morbidity for carefully selected men, but leaves untreated prostate tissue, requires MRI and repeat-biopsy surveillance, and has uncertain long-term comparative cancer-control outcomes.

The most appropriate option depends on cancer grade, volume and location; PSA and stage; age and general health; baseline urinary and sexual function; personal priorities; and willingness to accept surveillance or treatment uncertainty. A multidisciplinary opinion and, where useful, separate discussions with a urologist and radiation oncologist can reduce treatment-selection bias.

What did the early ProFocal study find?

The first published phase II trial included 100 men with localised, MRI-visible Grade Group 2 or 3 prostate cancer.

At the three-month biopsy:

  • 84% had no clinically significant Grade Group 2 or higher cancer within the treated area
  • Approximately 16% therefore had residual clinically significant cancer within the treatment zone
  • Erectile dysfunction was reported in 12%
  • The average sexual-function scores decreased by approximately 15%
  • Urinary-domain scores decreased by approximately 4.5%
  • No significant deterioration was reported in the other measured functional outcomes

These results are promising, but they represent very early follow-up. The study had no surgery, radiotherapy or active surveillance control group. It therefore cannot establish whether ProFocal provides equivalent long-term protection against recurrence, metastasis or death from prostate cancer.

Possible side effects and complications

Short-term effects may include:

  • Bruising or discomfort in the perineum
  • Blood in the urine
  • Blood in the semen
  • Burning or discomfort when urinating
  • Urinary frequency or urgency
  • Temporary difficulty passing urine
  • Temporary catheterisation
  • Urinary tract infection
  • Pelvic or rectal discomfort
  • Fatigue following anaesthesia

Potential longer-term or less common problems include:

  • New or worsening erectile dysfunction
  • Reduced ejaculatory volume
  • Retrograde ejaculation
  • Urinary incontinence
  • Urethral or bladder-neck scarring
  • Persistent urinary symptoms
  • Damage to tissue outside the intended treatment zone
  • Infection or abscess
  • A fistula involving the urinary tract and rectum, expected to be rare
  • Incomplete cancer treatment
  • Cancer developing or becoming apparent elsewhere in the untreated prostate
  • A requirement for repeat focal therapy, radiotherapy or radical prostatectomy

The risk of sexual or urinary dysfunction depends partly on the size and location of the tumour. A lesion near the neurovascular bundles, urethra, urinary sphincter or bladder neck may be more difficult to treat without affecting function.

The untreated prostate remains important

Prostate cancer is frequently multifocal, meaning that separate areas of cancer may exist within the same prostate. MRI is very useful but cannot detect every small or biologically significant tumour.

ProFocal treats the selected target, not every prostate cell.

This creates two possible patterns of treatment failure:

  1. In-field disease: cancer remains or returns inside the treated area.
  2. Out-of-field disease: cancer is subsequently found elsewhere in the untreated prostate.

A successful early scan does not prove that all clinically significant cancer has been eliminated.

Follow-up after ProFocal therapy

Follow-up is more intensive than simply checking the PSA.

Because the prostate remains in place, PSA will not normally fall to an undetectable level. There is also no universally accepted PSA threshold that defines successful focal treatment or recurrence.

Follow-up may include:

  • Regular PSA testing
  • Clinical review and symptom assessment
  • Multiparametric MRI
  • Quality-of-life and erectile function assessment
  • Repeat targeted biopsy of the treated area
  • Systematic biopsy of the untreated prostate
  • Additional imaging when recurrence is suspected

The Prostate Cancer Foundation of Australia cautions that PSA testing alone is not sufficient to exclude recurrent cancer after focal therapy. Patients must be willing to undergo long-term imaging and, when recommended, further prostate biopsies.

Can treatment be repeated?

Repeat focal treatment may be possible when residual or recurrent cancer remains localised and clearly targetable.

Depending on the findings, subsequent options may include:

  • Repeat focal ablation
  • Radical prostatectomy
  • External-beam radiotherapy
  • Another focal therapy technique
  • Active surveillance for selected low-volume disease
  • Systemic treatment if the cancer has spread

Salvage surgery or radiotherapy may still be possible after focal therapy, but treatment can sometimes be technically more complex because of scarring and tissue changes. The likely salvage options should therefore be discussed before proceeding with ProFocal.

Important limitations

Patients considering ProFocal should understand that:

  • ProFocal is not currently included on the Australian ARTG
  • It is not established as routine standard-of-care treatment
  • Published ProFocal evidence currently comes from a small number of men
  • The pivotal study was single-arm and had very short follow-up
  • Long-term rates of metastasis-free, cancer-specific and overall survival are unknown
  • There are no mature randomised comparisons with prostatectomy, radiotherapy or modern active surveillance
  • Approximately 16% of men in the initial study had clinically significant cancer remaining in the treated area at three months
  • Cancer may be missed elsewhere in the prostate
  • Repeat MRI scans and biopsies are required
  • Further cancer treatment may be needed
  • Access may be limited to trials or special regulatory pathways
  • Medicare or private health insurance may not cover treatment or follow-up costs

What do Australian and international guidance sources say?

The Prostate Cancer Foundation of Australia (PCFA) describes focal therapies as emerging and experimental. It notes that focal treatment may reduce side effects but that the prostate remains in place, PSA monitoring is less straightforward, and ongoing MRI and biopsy are required.

Australian evidence-based resources regard active surveillance, radical prostatectomy and radiotherapy as established pathways for appropriately selected localised disease. ProFocal has not yet acquired the same evidence base or standard-of-care status. The absence of a treatment-specific recommendation should not be reframed as support.

The European Association of Urology (EAU) states that focal therapy has favourable functional outcomes but that definitive evidence of long-term oncological benefit remains unavailable. Its guideline recommends focal HIFU or cryotherapy only within a prospective registry and other ablative methods—including focal laser therapy—only within a well-designed prospective clinical trial.

The American Urological Association and American Society for Radiation Oncology advise clinicians that comparative evidence for focal ablation is lacking and that patients must be informed that further treatment may be required. Focal or whole-gland ablation should not be offered for high-risk prostate cancer outside a clinical trial.

The UK National Institute for Health and Care Excellence (NICE) guidance for focal HIFU and focal cryoablation—not ProFocal specifically—also emphasises special governance, consent, audit/research arrangements and uncertainty about long-term cancer control. This is relevant context for focal therapy but must not be represented as device-specific approval of ProFocal.

The Prostate Cancer Foundation of Australia similarly describes focal therapies as experimental and emphasises the need for continuing MRI, biopsies and careful long-term monitoring.

The bottom line

ProFocal is an Australian-developed investigational technology that may eventually provide selected men with an additional option between surveillance and whole-gland treatment.

Its early results suggest that precisely delivered cooled laser therapy can destroy an MRI-visible prostate cancer target with relatively limited short-term urinary morbidity. However, early cancer clearance is not the same as proven long-term cancer control.

At present, ProFocal should be considered an investigational focal therapy. Consistent with current guidance for focal laser ablation, its most defensible use is within a well-designed prospective clinical trial with ethics and regulatory oversight, multidisciplinary assessment, explicit informed consent, independent outcome reporting and mandatory long-term follow-up.

The decision should be made only after comparing ProFocal with all appropriate alternatives, including active surveillance, radical prostatectomy and radiotherapy.

This article provides general information and does not replace individual medical advice. Regulatory status and treatment availability can change and should be confirmed at the time of consultation.

References and further reading

Hydrocoele in Younger Men: Causes, Fertility and Treatment Options

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A hydrocoele is a collection of clear fluid around the testicle. It usually causes a painless swelling on one side of the scrotum, although both sides can occasionally be affected.

Hydrocoeles are common in babies and older men, but they can also develop during adolescence or young adulthood. In a younger man, the important question is not only “Is this a hydrocoele?” but also “Why has it developed?”

Most hydrocoeles are benign and do not threaten the testicle. Nevertheless, any new scrotal swelling should be examined because conditions such as an inguinal hernia, infection, testicular torsion or testicular tumour can sometimes produce a similar appearance or cause a secondary hydrocoele.

What causes a hydrocoele?

The testicle is partly surrounded by a thin membrane called the tunica vaginalis. This membrane normally produces a small amount of lubricating fluid, which is continually reabsorbed. A hydrocoele develops when fluid production exceeds absorption.

In younger men, possible causes include:

  • Idiopathic hydrocoele: No specific cause is identified. This is common.
  • Persistent communication with the abdomen: A small channel through which the testicle descended before birth may remain open. This is more typical in children but can occasionally persist into young adulthood and may be associated with an inguinal hernia.
  • Inflammation or infection: Epididymitis, orchitis and some sexually transmitted infections may cause fluid to collect around the testicle.
  • Trauma: A sporting injury, direct blow or previous scrotal injury can lead to a reactive hydrocoele.
  • Previous surgery: Hydrocoeles may occasionally follow groin, hernia, varicocele or testicular surgery.
  • Testicular torsion: Twisting of the spermatic cord can produce a reactive hydrocoele, although severe sudden pain is normally the dominant symptom.
  • Testicular tumour: A tumour may occasionally be accompanied by a hydrocoele. The hydrocoele itself is not cancer, but the fluid can make examination of the underlying testicle difficult.

What does a hydrocoele feel like?

A typical hydrocoele produces a smooth, soft or tense swelling around the testicle. It may fluctuate in size and often feels heavier as it enlarges.

Symptoms can include:

  • painless scrotal enlargement;
  • a dragging or heavy sensation;
  • discomfort when walking, running or exercising;
  • irritation from clothing;
  • difficulty examining the testicle;
  • embarrassment or concern about appearance; and
  • discomfort during sexual activity.

A very large hydrocoele can become inconvenient and may interfere with sport, work or everyday activities.

When is urgent assessment needed?

A hydrocoele usually develops gradually and is not an emergency. Seek urgent medical care, however, if there is:

  • sudden or severe testicular pain;
  • rapid swelling;
  • nausea or vomiting with scrotal pain;
  • redness, fever or increasing tenderness;
  • a hard lump within the testicle;
  • scrotal swelling following a significant injury; or
  • a swelling that cannot be pushed back and is associated with groin or abdominal pain.

Sudden testicular pain may represent torsion, in which the blood supply to the testicle becomes twisted. This requires emergency assessment and should never be attributed to “just a hydrocoele.”

How is a hydrocoele diagnosed?

Assessment usually begins with a discussion about how and when the swelling developed, followed by examination of the abdomen, groin and scrotum.

A hydrocoele may transmit light when a torch is placed behind it, a finding called transillumination. This can support the diagnosis, but it does not replace a proper examination.

A scrotal ultrasound is commonly arranged in a younger man, particularly when:

  • the hydrocoele is new;
  • the testicle cannot be examined clearly;
  • there is pain or tenderness;
  • the swelling developed after injury;
  • the diagnosis is uncertain; or
  • an underlying testicular abnormality needs to be excluded.

Ultrasound can confirm that the swelling contains fluid and assess the testicle, epididymis, blood flow and surrounding structures. The European Association of Urology recommends high-frequency ultrasound when investigating a suspected testicular mass because it can determine whether a lesion is inside or outside the testicle and assess the opposite testis. EAU Testicular Cancer Guideline

Urine tests, STI testing or blood tests may also be appropriate when infection or inflammation is suspected.

Can a hydrocoele affect fertility?

For most younger men, a small or moderate uncomplicated hydrocoele does not cause infertility. It does not normally block sperm transport and does not automatically mean that sperm production is abnormal.

There are, however, several important qualifications:

  1. The underlying cause may matter more than the fluid.
    Previous torsion, testicular trauma, severe infection, an undescended testicle, testicular cancer or another testicular disorder may affect fertility independently of the hydrocoele.
  2. A very large or tense hydrocoele may theoretically affect the testicle.
    Prolonged pressure or increased local temperature has been proposed as a possible mechanism for impaired testicular function. Evidence in adults remains limited, and clinically significant infertility from an isolated hydrocoele appears uncommon.
  3. Surgery carries a small fertility-related risk.
    Hydrocoele repair is performed close to the epididymis, vas deferens and testicular blood supply. Injury to one of these structures is uncommon but could affect fertility, particularly when operating on both sides or when the opposite testicle is abnormal. The British Association of Urological Surgeons lists inadvertent injury to these structures as an uncommon recognised complication of surgery. BAUS hydrocoele repair information

A semen analysis is not routinely required for every man with a hydrocoele. It may be appropriate when:

  • a couple has been unable to conceive;
  • the hydrocoele is very large or present on both sides;
  • the opposite testicle is small or abnormal;
  • there is a history of undescended testis, torsion, chemotherapy, testicular surgery or significant infection; or
  • fertility preservation is an important concern before surgery.

The EAU recommends that the assessment of male infertility include a reproductive and medical history, physical examination, semen analysis and, where indicated, hormonal tests and imaging. It also stresses that semen analysis must be interpreted as part of the couple’s overall reproductive assessment rather than as a simple “fertile or infertile” test. EAU Male Infertility Guideline

Does every hydrocoele need treatment?

No. Treatment depends on the cause, size, symptoms and effect on quality of life.

Observation

A small, painless hydrocoele with a normal underlying testicle can often be monitored. It does not need to be removed merely because it is present.

Observation may include:

  • self-awareness of any change in size or consistency;
  • periodic clinical review when appropriate; and
  • reassessment if pain, rapid enlargement or a new lump develops.

The British Association of Urological Surgeons supports observation when an adult hydrocoele is small or not bothersome. BAUS

Treating an underlying cause

If the fluid is secondary to infection, inflammation or another condition, treatment should address that cause. The hydrocoele may reduce once the underlying problem settles, although established hydrocoeles do not always disappear.

Aspiration

Aspiration involves inserting a needle and draining the fluid. Although this can provide temporary relief, the fluid usually returns because the lining that produces it remains in place.

Aspiration also carries risks of bleeding and infection. BAUS does not regard aspiration alone as curative or standard treatment because recurrence is common. It may occasionally be considered for someone who is unsuitable for surgery. In selected circumstances, a sclerosant may be injected after aspiration, but recurrence and inflammation remain concerns.

Hydrocoelectomy

Hydrocoelectomy is the most reliable definitive treatment for a bothersome adult hydrocoele. Surgery may be considered when the swelling:

  • is large or progressively enlarging;
  • causes discomfort, heaviness or skin irritation;
  • interferes with exercise, work or sexual activity;
  • causes significant cosmetic or psychological concern; or
  • makes examination of the testicle difficult.

The operation is generally performed through a small scrotal incision under general or spinal anaesthesia. The fluid is drained, and the fluid-producing sac is folded, turned behind the testicle or partly removed to reduce the likelihood of recurrence.

Most procedures are performed as day surgery.

What should you expect after surgery?

Bruising, swelling and discomfort are expected and may initially make the scrotum look larger rather than smaller. Supportive underwear, simple pain relief and protected ice packs can help during the early recovery period.

Strenuous exercise and heavy lifting are generally avoided for several weeks. The testicle may continue to feel somewhat bulkier after repair because of the folded or thickened tissues around it.

Possible complications include:

  • bleeding or a scrotal haematoma;
  • wound or testicular infection;
  • persistent swelling;
  • recurrence of the hydrocoele;
  • chronic scrotal discomfort;
  • anaesthetic complications; and
  • uncommon injury to the epididymis, vas deferens or testicular blood supply.

The current BAUS patient information notes that temporary bruising and swelling are very common, while infection, haematoma, recurrence and injury to adjacent reproductive structures occur much less often. Individual risks depend on the size and complexity of the hydrocoele, previous surgery, infection and general health. BAUS hydrocoele repair leaflet

The important message for younger men

A hydrocoele is usually harmless, and many do not require treatment. However, a new scrotal swelling in a younger man should not be self-diagnosed or ignored. Clinical examination and often an ultrasound can confirm the diagnosis and ensure that the testicle underneath is healthy.

Most isolated hydrocoeles do not impair fertility. When fertility is a concern, the entire reproductive history and both testicles should be assessed rather than assuming that the hydrocoele is responsible.

Management should be individualised. For one man, reassurance and observation may be entirely appropriate. For another, surgery may provide worthwhile relief from heaviness, discomfort or embarrassment.

This article provides general patient information and does not replace individual medical assessment. Seek urgent care for sudden testicular pain, rapid swelling, fever or a hard testicular lump.

So, if you have noted a scrotal swelling and this is concerning you and need to have this checked out, see your GP or obtain a referral to see you Brisbane Urologist, Uro-Jo, for peace of mind.