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Urinary Incontinence After Prostatectomy and Salvage Radiotherapy

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Why leakage may become more complex after both treatments

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

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

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

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

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

When should the problem be assessed?

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

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

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

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

Investigating incontinence after salvage radiotherapy

1. A careful history

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

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

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

2. Bladder diary and pad assessment

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

3. Examination and basic tests

Assessment commonly includes:

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

4. Cystoscopy

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

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

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

What is the role of urodynamic studies?

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

The study can assess:

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

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

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

Initial and non-surgical management

Pelvic floor rehabilitation

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

Bladder and lifestyle measures

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

Pads, sheaths and clamps

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

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

Catheter options

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

Intermittent self-catheterisation

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

Long-term urethral catheter

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

Suprapubic catheter

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

Male sling versus artificial urinary sphincter

Male sling

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

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

Artificial urinary sphincter (AUS)

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

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

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

Practical comparison

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

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

When an AUS or sling is not enough

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

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

Options at a specialist reconstructive centre may include:

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

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

A sensible treatment pathway

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

The take-home message

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

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

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

So, if this is happening to you after your salvage radiation for your prostate cancer and you want to investigate options in regaining continence, come chat to your local Brisbane urologist, Uro-Jo.

References

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

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

Hydronephrosis and Urinary Stones in Pregnancy What expectant mothers should know about flank pain, infection, premature labour and safe imaging

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Pregnancy changes the urinary tract. The kidneys filter more blood, the hormone progesterone relaxes the ureters, and the enlarging uterus can compress them. As a result, the kidney drainage system and ureters often become dilated, a finding called hydronephrosis or hydroureter.

In most women this is a normal, temporary effect of pregnancy. However, hydronephrosis can also be caused by a kidney or ureteric stone, infection or, less commonly, another obstruction. The challenge is deciding whether the dilatation is physiological or whether the kidney is genuinely blocked and needs treatment.

Seek urgent medical assessment for flank pain accompanied by fever, chills, feeling faint or very unwell, persistent vomiting, difficulty passing urine, reduced fetal movement, contractions, vaginal bleeding or fluid loss. An infected, obstructed kidney is a urological emergency.

Why does hydronephrosis occur during pregnancy?

Physiological hydronephrosis usually develops during the second trimester, becomes most marked around 24–28 weeks and is often greater on the right. It results from:

  • progesterone-related relaxation of ureteric smooth muscle;
  • compression of the ureters by the growing uterus at the pelvic brim;
  • rotation of the uterus, which tends to place more pressure on the right ureter; and
  • increased urine production during pregnancy.

This dilatation commonly settles within several weeks after delivery. Physiological hydronephrosis is not itself a stone and does not automatically require a stent or operation.

Features that make pathological obstruction more likely include severe colicky flank pain, blood in the urine, a visible stone, dilatation extending below the pelvic brim, an absent or reduced ureteric jet on the symptomatic side, impaired kidney function, infection or worsening hydronephrosis. No single ultrasound sign is perfect; the symptoms, blood and urine tests, imaging and obstetric assessment must be considered together.

Kidney and ureteric calculi in pregnancy

Urinary calculi are stones located in the kidney or ureter. They are an important cause of non-obstetric abdominal or flank pain during pregnancy and occur most often in the second or third trimester. Typical symptoms include:

  • sudden pain in the loin, flank, abdomen or groin, which may come in waves;
  • nausea and vomiting;
  • visible or microscopic blood in the urine;
  • urinary frequency, urgency or burning; and
  • fever or rigors if infection is present.

Pregnancy increases urinary calcium and urate excretion, while other natural protective factors also rise. For this reason, pregnancy does not necessarily increase the overall number of stones, although the stone pattern may differ and calcium-phosphate stones are relatively more common.

Why infection matters

Pregnancy-related ureteric dilatation and slower urinary drainage encourage urinary stasis. A stone can worsen this by partly or completely blocking the ureter. Bacteria trapped above an obstruction may cause pyelonephritis, pyonephrosis, bacteraemia or sepsis.

All women with suspected renal colic should therefore have urinalysis and a urine culture. Blood tests commonly include a full blood count, kidney function, electrolytes and inflammatory markers. Antibiotics are selected according to pregnancy safety, local resistance patterns and culture results.

Antibiotics alone are not sufficient when infection is trapped behind an obstructed kidney. Urgent decompression with a ureteric stent or percutaneous nephrostomy is required, together with intravenous antibiotics and coordinated obstetric care. Definitive stone treatment is usually delayed until sepsis has resolved.

Is there a risk of premature labour?

Observational studies associate symptomatic stones and renal obstruction in pregnancy with higher rates of urinary infection, hospital admission, preterm contractions and preterm delivery. Severe pain, dehydration, inflammation and infection may all contribute. However, the absolute risk for an individual woman varies, and an association does not mean that every renal colic episode will trigger premature labour.

The condition requiring intervention may itself be responsible for some of the reported risk. For this reason, treatment decisions should not be based on procedure statistics alone. The balance is between allowing a stable stone time to pass and promptly treating uncontrolled pain, infection or threatened kidney function. Depending on gestational age and clinical circumstances, fetal monitoring and assessment for contractions may be appropriate.

How is it investigated?

1. Ultrasound first

Renal and bladder ultrasound is the preferred first-line test because it uses sound waves rather than ionising radiation. It can show hydronephrosis, some kidney or ureteric stones, ureteric jets and alternative diagnoses. Transvaginal ultrasound may help identify a distal ureteric stone.

Ultrasound has limitations: physiological hydronephrosis can resemble obstruction, and a small ureteric stone may not be visible. A normal or inconclusive scan does not always exclude a stone.

2. MRI or MR urography when uncertainty remains

MRI without gadolinium can identify the level and pattern of obstruction without ionising radiation. Stones usually appear as signal voids rather than being seen as clearly as on CT. MRI is therefore a useful second-line test, particularly when ultrasound is inconclusive and the patient is clinically stable. Gadolinium contrast is not routinely used during pregnancy.

3. Low-dose non-contrast CT only when clinically necessary

Low-dose CT is the most accurate test for a urinary stone, but it uses ionising radiation. European Association of Urology guidance places low-dose CT as a last-line option in pregnancy, after ultrasound and usually MRI, when diagnostic uncertainty could change urgent management.

The practical radiation principles are:

  • use imaging only when it will answer an important clinical question;
  • prefer ultrasound, followed by MRI without contrast, when suitable;
  • if CT is necessary, use a pregnancy-adapted low-dose protocol and limit the scanned area;
  • avoid repeated or multiphase CT examinations unless clearly justified; and
  • involve an experienced radiologist and document the risk–benefit discussion.

Diagnostic imaging should not be withheld when delay or uncertainty poses a greater risk to the mother or baby. The EAU notes that deterministic fetal effects require substantially higher exposure than most diagnostic studies and considers doses below 50 mGy safe in this context; nevertheless, any ionising-radiation examination must be justified and kept as low as reasonably achievable. Ultrasound and MRI do not use ionising radiation.

Management options

Treatment is individualised by symptoms, infection status, stone size and location, kidney function, gestational age, obstetric factors and local expertise. Close collaboration between urology, obstetrics, radiology, anaesthesia and neonatology may be needed.

Conservative management

Most uncomplicated cases are initially managed without surgery. This may include:

  • oral or intravenous fluids sufficient to correct dehydration, forced overhydration does not “flush out” a stone;
  • anti-nausea medication;
  • analgesia suitable for the stage of pregnancy;
  • urine culture and pregnancy-compatible antibiotics when infection is confirmed; and
  • follow-up to ensure symptoms resolve and kidney drainage and function remain satisfactory.

Paracetamol is commonly used first-line. Opioids may be used for severe pain under medical supervision. Non-steroidal anti-inflammatory drugs such as ibuprofen and diclofenac should not be self-administered in pregnancy; their fetal renal, amniotic-fluid and ductus arteriosus risks depend on gestation, dose and duration. The evidence for medical expulsive therapy with alpha-blockers during pregnancy is limited, and such treatment should only be considered after specialist discussion.

Conservative treatment is unsuitable when there is sepsis, deteriorating kidney function, a solitary obstructed kidney, bilateral obstruction, persistent vomiting, uncontrolled pain, severe or progressive hydronephrosis, renal forniceal rupture, threatened premature labour or failure of the stone to pass with ongoing clinically important obstruction.

Ureteric stent

A JJ stent bypasses the obstruction and drains urine from the kidney to the bladder. It can be inserted with minimal or no fluoroscopy, using ultrasound guidance where appropriate. Stents can cause urinary frequency, urgency, discomfort, blood in the urine, infection and encrustation. Encrustation develops faster in pregnancy, so regular review and sometimes exchange every 4–6 weeks are required. A stent must not be forgotten after delivery.

Percutaneous nephrostomy

A nephrostomy tube drains the kidney through the back and can often be placed with ultrasound guidance. It is particularly useful when retrograde stenting is not possible or when urgent drainage is required in selected circumstances. Disadvantages include an external bag, discomfort, blockage, displacement, infection and rapid encrustation, with possible repeat exchanges.

Ureteroscopy and laser treatment

Ureteroscopy allows a surgeon to pass a fine telescope through the bladder into the ureter, remove the stone or fragment it with a laser, often without fluoroscopy. It provides definitive treatment and avoids prolonged drainage in selected patients. If a non-urgent procedure is required, the second trimester is generally preferred, and it should be performed by an experienced team with obstetric and neonatal support available. Ureteroscopy is not the first step in an untreated septic obstruction; drainage and infection control come first.

Treatments generally avoided

Shock-wave lithotripsy is contraindicated during pregnancy. Percutaneous stone removal is rarely required and is reserved for carefully selected cases in highly experienced centres. Routine definitive treatment can often wait until after delivery when symptoms and kidney function permit.

After delivery

Follow-up should confirm that hydronephrosis has resolved, any stent or nephrostomy has been removed, the stone has passed or been treated, and kidney function is normal. A retrieved stone should be analysed. Women with recurrent stones, a strong family history, infection stones or other risk factors may benefit from a metabolic evaluation after pregnancy, when physiology and diet have stabilised.

The important message

Most hydronephrosis in pregnancy is physiological, and many stones pass with careful conservative management. The dangerous combination is obstruction plus infection. Fever, rigors or systemic illness with flank pain requires urgent assessment because prompt antibiotics and drainage can protect the mother, kidney and pregnancy. Imaging should follow a stepwise approach, ultrasound first, MRI second and low-dose CT only when the clinical benefit justifies it.

References

  1. European Association of Urology. EAU Guidelines on Urolithiasis: Diagnostic imaging during pregnancy; management of urinary stones during pregnancy. Current online guideline. https://uroweb.org/guidelines/urolithiasis/chapter/guidelines
  2. Lee MS, Fenstermaker MA, Naoum EE, et al. Management of nephrolithiasis in pregnancy: multi-disciplinary guidelines from an academic medical center. Front Surg. 2021;8:796876. https://doi.org/10.3389/fsurg.2021.796876
  3. Chan K, Shakir T, El-Taji O, et al. Management of urolithiasis in pregnancy. Curr Urol. 2023;17(1):1–6. https://doi.org/10.1097/CU9.0000000000000181
  4. American College of Obstetricians and Gynecologists. Guidelines for diagnostic imaging during pregnancy and lactation. Committee Opinion No. 723. Obstet Gynecol. 2017;130–e216. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/10/guidelines-for-diagnostic-imaging-during-pregnancy-and-lactation
  5. Drescher M, Blackwell RH, Patel PM, et al. Antepartum nephrolithiasis and the risk of preterm delivery. Urolithiasis. 2019;47:441–448. https://doi.org/10.1007/s00240-018-1085-3

This information is general education and does not replace individual medical or obstetric advice. Medication and imaging decisions in pregnancy should be made with the treating obstetric, urology and radiology teams.

Urge Incontinence After Sling Surgery: Why Timing Matters

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

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

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

What is urge urinary incontinence?

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

Other overactive bladder symptoms may include:

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

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

How common is urgency after a sling?

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

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

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

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

Urgency in the early postoperative period

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

Possible early causes

1. Temporary irritation and inflammation

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

These symptoms often settle as postoperative inflammation resolves.

2. Urinary tract infection

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

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

3. Incomplete bladder emptying

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

Symptoms can include:

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

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

4. Excessive outlet resistance from the sling

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

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

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

5. Bladder or urethral perforation or sling exposure

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

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

6. Pre-existing overactive bladder

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

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

How should early postoperative urgency be assessed?

Assessment may include:

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

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

Management of early urgency

Treatment depends on the findings.

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

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

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

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

Published expert reviews emphasise balancing two risks:

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

Urgency developing months or years after sling surgery

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

Possible delayed causes

Age-related overactive bladder

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

Menopause and genitourinary syndrome of menopause

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

Recurrent urinary infection

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

Pelvic organ prolapse

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

Delayed obstruction or scarring

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

Vaginal, urethral or bladder erosion

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

Other bladder or neurological disease

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

Investigating delayed urgency

A sensible assessment commonly includes:

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

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

Treatment when obstruction and sling complications have been excluded

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

Lifestyle and bladder strategies

Options include:

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

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

Medication

Medication options include:

Antimuscarinic medicines

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

Beta-3 adrenergic agonists

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

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

Vaginal oestrogen

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

Percutaneous tibial nerve stimulation

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

Intravesical botulinum toxin

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

Sacral neuromodulation

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

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

When is sling revision appropriate years later?

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

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

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

Possible consequences of sling revision include:

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

Shared decision-making is therefore essential.

The role of sling release and urethrolysis

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

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

When should sling-related obstruction be suspected?

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

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

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

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

Sling mobilisation or loosening

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

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

Early mobilisation may:

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

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

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

Sling incision or division

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

It may be considered when there is:

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

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

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

Partial sling excision

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

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

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

What is formal urethrolysis?

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

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

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

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

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

Will sling release cure the urgency?

Not necessarily.

Urgency is most likely to improve when:

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

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

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

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

Risks of sling release or urethrolysis

Potential complications include:

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

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

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

Why timely recognition matters

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

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

When should you seek urgent medical attention?

Contact your surgeon or seek urgent assessment if you:

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

The take-home message

Urge incontinence after sling surgery deserves a structured assessment.

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

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

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

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

References

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

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

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

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

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

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

What is dysfunctional voiding?

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

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

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

Dysfunctional voiding must be distinguished from:

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

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

What symptoms may occur?

Men may report a mixture of storage and emptying symptoms.

Overactive-bladder-type symptoms

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

Outflow-obstruction-type symptoms

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

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

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

How should these symptoms be investigated?

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

A practical initial assessment may include:

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

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

The role of pelvic-floor physiotherapy

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

Specialist pelvic-floor physiotherapy may include:

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

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

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

Can medication be tried first?

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

Alpha-blockers

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

Possible side effects include:

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

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

Overactive-bladder medications

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

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

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

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

Other prostate medications

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

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

When are urodynamic studies important?

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

A pressure-flow study assesses:

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

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

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

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

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

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

Should bladder-neck incision or TURP be considered?

The answer depends on what has been demonstrated.

Bladder-neck incision

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

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

Potential adverse effects include:

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

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

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

TURP

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

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

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

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

What are the possible side effects of disobstruction surgery?

Short-term effects can include:

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

Longer-term effects may include:

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

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

What is the risk of urinary incontinence?

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

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

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

Persistent leakage may be:

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

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

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

Where does sacro-neuromodulation fit?

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

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

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

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

Potential benefits include:

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

Potential disadvantages include:

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

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

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

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

A practical treatment pathway

A sensible approach is:

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

The key message

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

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

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

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

References and further reading

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

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

The Story Behind The “Happy Prostate”

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More than a logo

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

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

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

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

When a growing prostate becomes a grumpy prostate

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

An enlarged prostate may compress the urinary passage and cause:

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

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

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

Steam

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

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

Clips or a prostatic urethral lift

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

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

Temporary prostate stents or implants

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

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

Laser treatment

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

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

Bipolar energy

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

Robotic-assisted enucleation

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

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

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

When the diagnosis is prostate cancer

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

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

Active surveillance

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

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

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

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

Robotic-assisted radical prostatectomy

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

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

Focal therapy

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

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

When continence is preserved, improved or restored

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

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

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

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

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

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

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

As I like to put it:

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

A small painting with a larger purpose

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

A prostate becomes truly “happy” when its owner:

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

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

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

Dr Jo Schoeman
The “Happy-Prostate” Urologist

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

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

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

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

Why can incontinence occur after prostatectomy?

Urinary continence normally depends on several structures working together:

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

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

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

Stress incontinence or overactive bladder?

This distinction is critical because the treatments are different.

Stress urinary incontinence

Stress incontinence typically causes leakage with:

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

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

Overactive bladder

Overactive bladder generally causes:

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

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

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

Assessment before considering an AUS

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

Assessment may include:

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

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

The role of urodynamic studies

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

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

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

It is particularly useful when a man has:

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

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

What is an artificial urinary sphincter?

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

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

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

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

Who may benefit from an AUS?

An AUS may be considered when:

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

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

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

When may an AUS be unsuitable?

An AUS may not be appropriate when there is:

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

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

What happens during and after surgery?

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

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

Until activation, urinary leakage is expected to continue.

Patients are then taught how to:

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

How successful is an AUS?

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

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

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

Possible complications

Potential complications include:

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

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

Warning signs of cuff erosion or device infection

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

Seek prompt urological review if you notice:

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

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

Important precautions after AUS implantation

Always tell healthcare providers about the AUS

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

Before catheterisation, cystoscopy or any procedure through the urethra:

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

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

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

Protect the urethra and implant

Patients should also:

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

What if the AUS fails?

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

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

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

Depending on the cause, options include:

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

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

A final perspective

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

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

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

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

References

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

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

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

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.

 

iTind for Benign Prostatic Enlargement: Temporary Treatment Without a Permanent Implant

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Benign prostatic hyperplasia—or BPH—is a non-cancerous enlargement of the prostate. As the prostate grows, it may compress the urethra and interfere with emptying the bladder.

Typical symptoms include:

  • A weak or interrupted urinary stream
  • Difficulty starting urination
  • Straining to pass urine
  • Urinary frequency or urgency
  • Getting up repeatedly at night
  • Dribbling after urination
  • A feeling that the bladder has not emptied completely

Medication is often the first treatment. However, tablets do not help every patient and may cause dizziness, tiredness, reduced ejaculation, erectile difficulties or reduced libido. The iTind procedure offers selected men a minimally invasive alternative to long-term medication or conventional prostate surgery.

What is iTind?

The iTind is a small temporary device made from nitinol, a flexible nickel–titanium alloy with “shape memory.”

It is sometimes called a temporary prostatic stent, although it differs from a traditional stent because it is not intended to remain permanently within the prostate. The device is left in place for only five to seven days and is then removed completely.

While in position, three expanding struts apply controlled pressure to specific areas of the prostate and bladder neck. This remodels the prostatic urethra and creates channels through which urine can flow more easily.

The procedure does not:

  • Permanently implant metal within the prostate
  • Remove prostate tissue
  • Use laser, heat or steam
  • Prevent future prostate treatments if symptoms return

Who may benefit from iTind?

iTind may be considered for men who have bothersome urinary symptoms caused by BPH and who:

  • Have obtained insufficient benefit from medication
  • Have developed side effects from BPH tablets
  • Prefer not to take daily medication indefinitely
  • Want a less invasive alternative to TURP or laser surgery
  • Wish to minimise the risk of ejaculatory or erectile side effects
  • Prefer not to have a permanent prostatic implant
  • Have prostate size and anatomy suitable for the device

The procedure is generally best suited to men with moderate-to-severe symptoms and a prostate measuring approximately 25–75 mL, without a significantly obstructing median lobe.

These measurements are a guide rather than a guarantee of suitability. The shape of the prostate, severity of obstruction and function of the bladder are as important as prostate size.

Assessment before treatment

Urinary symptoms are not always caused by an enlarged prostate. Similar problems can result from infection, urethral narrowing, bladder weakness, an overactive bladder, neurological disease, medication or, less commonly, cancer.

Assessment may therefore include:

  • Medical history and examination
  • International Prostate Symptom Score
  • Urine testing
  • PSA testing when appropriate
  • Urinary-flow measurement
  • Ultrasound measurement of residual urine
  • Prostate ultrasound or other imaging
  • Flexible cystoscopy
  • Urodynamic testing in selected patients

Any urinary infection should be treated before the procedure.

Patients taking aspirin, warfarin, clopidogrel, apixaban, rivaroxaban or other blood-thinning medication require an individual management plan. Do not stop blood thinners without instructions from your prescribing doctor and urologist.

How is the iTind procedure performed?

Insertion

The folded iTind device is passed through the urethra using a small cystoscope. It is positioned in the prostatic urethra immediately below the bladder neck and then released.

The procedure is usually performed as day surgery. Depending on the patient and treatment setting, local anaesthetic, intravenous sedation or a short general anaesthetic may be used.

A soft retrieval string remains attached to the device and passes out through the urethra. It is usually secured to the penis until the device is removed.

Most patients can return home on the same day without a urinary catheter. Occasionally, temporary catheterisation is necessary if the patient is unable to pass urine.

The treatment period

The device remains inside the prostate for five to seven days. Its struts gradually apply pressure to the prostate and bladder neck, creating three longitudinal channels within the urinary passage.

Patients remain at home during this treatment period.

Removal

The device must be removed after five to seven days. It is collapsed into a soft catheter and withdrawn in one piece, usually during a brief outpatient visit.

Local anaesthetic gel is often sufficient, although additional pain relief or sedation may be offered when appropriate. No metal or permanent implant remains inside the prostate after removal.

What should I expect while the device is in place?

The five-to-seven-day treatment period is generally the most uncomfortable part of the process. Common temporary symptoms include:

  • Pelvic or perineal pressure
  • Burning or stinging when passing urine
  • Urinary urgency and frequency
  • Discomfort at the tip of the penis
  • Bladder spasms
  • Light bleeding in the urine
  • Interrupted sleep
  • Awareness of the retrieval string
  • A temporarily weak or irregular urinary stream

These symptoms are usually mild to moderate and commonly improve soon after the device is removed.

Patients should generally avoid heavy lifting, vigorous exercise, cycling and sexual activity while the device and retrieval string are in place. Follow the particular instructions provided by your urologist.

The retrieval string should not be pulled, cut, repositioned or removed by the patient.

How can pain and discomfort be managed?

Pain varies considerably between patients. Some men experience only mild pressure, while others find urinary urgency, bladder spasm or discomfort from the retrieval string more troublesome.

A pain-management plan may include the following measures.

Paracetamol

Paracetamol is usually the first choice for mild-to-moderate discomfort. Take it according to your doctor’s instructions or the directions on the packet.

Check cold, influenza and combination pain medicines carefully, as these may also contain paracetamol. Do not exceed the recommended daily dose.

Patients with significant liver disease or heavy alcohol consumption should discuss paracetamol use with their doctor.

Anti-inflammatory medication

An anti-inflammatory medicine such as ibuprofen may help reduce pain and inflammation when medically appropriate.

These medications may not be suitable for patients with:

  • Kidney impairment
  • Stomach ulcers or gastrointestinal bleeding
  • Heart failure or certain cardiovascular conditions
  • Asthma triggered by anti-inflammatory medication
  • Bleeding disorders
  • Anticoagulant or antiplatelet treatment

Check with your urologist, general practitioner or pharmacist before taking an anti-inflammatory medication.

Medication for bladder irritation

An alpha blocker may occasionally be continued or prescribed temporarily to help urine flow. A bladder-calming medication may be considered if urgency or bladder spasms are particularly troublesome.

These medicines are not necessary for every patient and have their own potential side effects.

Practical measures

It may also help to:

  • Maintain normal hydration without forcing excessive fluids
  • Reduce coffee, tea, cola drinks, alcohol and energy drinks
  • Avoid constipation
  • Wear loose, supportive underwear
  • Avoid heavy lifting and strenuous exercise
  • Take pain relief early rather than waiting until discomfort becomes severe

Strong opioid medication is not usually required. It may worsen constipation and, in susceptible patients, contribute to difficulty emptying the bladder.

Severe or increasing pain is not considered something that should simply be tolerated. Contact the treating practice if the discomfort is not controlled by the recommended measures.

What happens after removal?

Burning, urinary urgency and light bleeding may continue briefly after the device is removed, but these symptoms should progressively improve.

Some patients notice an improvement in their stream soon after removal. For others, improvement develops more gradually over several weeks as irritation settles and the remodelled urinary channels stabilise.

Many patients return to normal daily activities within a few days. Your urologist will advise when you may resume strenuous exercise and sexual activity.

Follow-up may include:

  • Review of urinary symptoms
  • Repeat symptom scoring
  • A urinary-flow test
  • Measurement of residual urine
  • Discussion about continuing or stopping BPH medication

Do not stop established prostate medication unless advised to do so.

Side effects and possible complications

Most side effects are temporary and occur while the device is in place. Reported problems include:

  • Burning during urination
  • Urinary frequency and urgency
  • Pelvic discomfort or pain
  • Blood in the urine
  • Temporary difficulty passing urine
  • Urinary tract infection
  • Bladder spasm
  • Movement or incorrect positioning of the device
  • Temporary catheterisation
  • Failure to obtain sufficient symptom relief

Published studies report different complication rates, but most events have been mild and self-limiting. Temporary haematuria, dysuria, urgency and pelvic discomfort are the most frequently reported problems.

Acute urinary retention, urinary infection or significant bleeding are less common but important complications.

When should I seek urgent medical attention?

Contact your urologist or attend an emergency department if you:

  • Cannot pass urine
  • Develop fever, shaking or chills
  • Feel generally unwell or confused
  • Develop severe or increasing pelvic pain
  • Pass large blood clots
  • Have heavy or persistent bright-red bleeding
  • Cannot keep fluids down
  • Notice that the retrieval string or device has moved
  • Develop pain that is not controlled by the agreed treatment plan

Does iTind affect erections or ejaculation?

One of the principal attractions of iTind is its favourable sexual side-effect profile.

Clinical studies have reported preservation of erectile and ejaculatory function in most treated patients. This contrasts with tissue-removing prostate procedures, which may carry a significant risk of retrograde or absent ejaculation.

Nevertheless, no treatment can guarantee that sexual or ejaculatory function will remain unchanged in every patient.

How effective is iTind?

Studies have demonstrated average improvements in:

  • Urinary symptom scores
  • Quality of life
  • Peak urinary-flow rate
  • The patient’s perception of urinary function

The improvement may be less dramatic than that achieved with a tissue-removing operation such as TURP or laser enucleation. The advantage is that iTind is less invasive, usually requires little recovery time and has a low reported risk of sexual side effects.

It is therefore best viewed as a balance between symptom improvement and treatment invasiveness.

How long does the benefit last?

Although the implant remains in place for only five to seven days, the channels produced within the prostate may remain open for several years.

Prospective studies have demonstrated sustained benefit for more than four years in some appropriately selected patients. This does not mean that iTind is guaranteed to last for four years—or that it will provide lifelong relief.

BPH may continue to progress as a man ages. Some patients will eventually need to restart medication or undergo another procedure. Longer-term evidence for iTind remains more limited than that available for established procedures such as TURP or laser enucleation.

Because nothing is left permanently inside the prostate, iTind does not generally prevent later treatment. Options may include medication, another minimally invasive procedure, TURP, GreenLight laser treatment, HoLEP or another form of prostate surgery.

Who should not undergo iTind?

Contraindications described in the manufacturer’s information include:

  • Active urinary tract infection
  • Acute prostatitis
  • Known prostate cancer
  • Known bladder cancer
  • An artificial urinary sphincter or another implant within the urethra
  • Bladder atonia or a non-contractile bladder
  • Neurogenic bladder dysfunction
  • Urinary obstruction caused by a urethral stricture or something other than BPH

The procedure may also be unsuitable or less predictable in men with:

  • A significantly obstructing median prostatic lobe
  • A prostate outside the best-studied size range
  • Severe chronic urinary retention
  • Very high residual urine volumes
  • Recurrent urinary infections
  • Bladder stones
  • Significant ongoing haematuria
  • Advanced bladder weakness
  • A need for rapid and substantial removal of obstructing tissue
  • Anatomy that prevents safe cystoscopic access

Previous prostate surgery, urethral surgery, nickel sensitivity and blood-thinning medication require individual consideration.

Patients with obstruction causing kidney impairment, repeated retention, recurrent infections, bladder stones or significant bleeding may receive more reliable relief from a definitive tissue-removing procedure.

Advantages of iTind

Potential advantages include:

  • Minimally invasive day procedure
  • No cutting, laser, steam or thermal energy
  • No permanent implant
  • Usually no postoperative catheter
  • Rapid return to ordinary activities
  • Low reported risk of new erectile dysfunction
  • Low reported risk of ejaculatory dysfunction
  • Does not usually compromise future BPH treatment

Limitations of iTind

Potential limitations include:

  • Discomfort during the treatment week
  • A retrieval string for five to seven days
  • A second procedure to remove the device
  • Not suitable for every prostate shape or size
  • Less improvement than some tissue-removing procedures
  • Possibility of persistent or recurrent symptoms
  • Potential need for future medication or surgery
  • Less very-long-term evidence than TURP or laser enucleation

Is iTind the right treatment for me?

iTind is not simply a smaller version of TURP. It offers a different compromise: a less invasive procedure with no permanent implant and a favourable sexual side-effect profile, but generally more modest improvement and less long-term evidence than tissue-removing surgery.

The best treatment depends on:

  • The severity of your symptoms
  • The size and shape of your prostate
  • The amount of urinary obstruction
  • Bladder strength and residual urine
  • Previous treatment
  • General health and medication
  • The importance of preserving ejaculation
  • Your willingness to accept possible future retreatment

A urological assessment is essential to confirm that BPH is responsible for the symptoms and to compare iTind fairly with medication, Rezūm, UroLift, TURP, GreenLight laser, HoLEP and other appropriate treatments.

This information is intended for general education and does not replace individual medical advice. Treatment suitability, availability and costs vary. Always follow the instructions provided by your treating urologist.

References

  1. Sandhu JS, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline Amendment 2023. Journal of Urology. 2024.
  2. Chughtai B, et al. The iTind Temporarily Implanted Nitinol Device for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Multicentre, Randomised, Controlled Trial. Urology. 2021;153:270–276.
  3. Kadner G, et al. Second generation of temporary implantable nitinol device in men with lower urinary tract symptoms: two-year results of the MT-02 study. World Journal of Urology. 2020;38:3235–3244.
  4. Amparore D, et al. Three-year results following treatment with the second-generation temporary implantable nitinol device. Prostate Cancer and Prostatic Diseases. 2021;24:349–357.
  5. Amparore D, et al. Temporary implantable nitinol device for BPH-related lower urinary tract symptoms: over 48-month results. Minerva Urology and Nephrology. 2023;75:743–751.
  6. NICE: iTind for lower urinary tract symptoms caused by BPH.
  7. Olympus: iTind clinical and procedural information.

So, if you are experiencing LUTS, lower urinary tract symptoms, and you are not yet ready to farewell your prograde ejaculation function, come see your Brisbane urologist, Dr Jo, Uro-Jo and discuss this option for your BPH.

Prostate Health

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Understanding Prostate Health: Insights from Dr. Jo Schoeman, Your Trusted Urologist in Brisbane

When it comes to men’s health, the prostate gland plays a crucial role. As a leading urologist in Brisbane, Dr. Jo Schoeman is dedicated to providing comprehensive care and expert advice on prostate health. Understanding the importance of the prostate, common issues, and available treatments can significantly impact your overall well-being.

 

What is the Prostate?

The prostate is a small gland located below the bladder and in front of the rectum. It surrounds the urethra, the tube responsible for carrying urine out of the body. Despite its small size, the prostate has a significant function in male reproductive health, primarily contributing to the production of seminal fluid, which nourishes and transports sperm.

 

Common Prostate Issues

1. Benign Prostatic Hyperplasia (BPH) :
BPH is a non-cancerous enlargement of the prostate gland, commonly occurring as men age. Symptoms include difficulty urinating, a frequent need to urinate, and a weak urine stream. While BPH is not life-threatening, it can significantly impact the quality of life.

2. Prostatitis :
Prostatitis is an inflammation of the prostate gland, which can be either acute or chronic. Symptoms include pelvic pain, painful urination, and flu-like symptoms in acute cases. Chronic prostatitis can be more challenging to treat and may require a comprehensive approach.

3.  Prostate Cancer :
Prostate cancer is one of the most common cancers among men. Early detection is crucial for successful treatment. Symptoms can be similar to BPH but may also include blood in the urine or semen and erectile dysfunction. Regular screenings and consultations with a urologist in Brisbane, such as Dr. Jo Schoeman, are essential for early detection and effective management.

 

Importance of Regular Screenings

Regular prostate screenings are vital, especially for men over the age of 50 or those with a family history of prostate issues. Screenings typically involve a Prostate-Specific Antigen (PSA) blood test and a Digital Rectal Exam (DRE). These tests help detect any abnormalities early, allowing for prompt treatment.

 

Treatment Options

Dr. Jo Schoeman offers a range of treatment options tailored to each patient’s needs. These may include:

– Medication:  For conditions like BPH and prostatitis, medications can help manage symptoms and reduce prostate size.
– Minimally Invasive Procedures: Techniques such as Transurethral Resection of the Prostate (TURP) or laser therapy can effectively treat BPH.
– Surgery: In cases of prostate cancer, surgical options like prostatectomy may be necessary.
– Radiation Therapy : For prostate cancer, radiation therapy can target and destroy cancer cells.

Lifestyle and Prostate Health

Maintaining a healthy lifestyle can positively impact prostate health. Dr. Jo Schoeman recommends a balanced diet rich in fruits, vegetables, and healthy fats, regular exercise, and staying hydrated. Avoiding excessive alcohol and quitting smoking are also beneficial.

 

Why Choose Dr. Jo Schoeman as Your Urologist in Brisbane?

Dr. Jo Schoeman is a highly experienced urologist in Brisbane, committed to providing personalised and compassionate care. With a deep understanding of prostate health and a patient-centered approach, Dr. Schoeman ensures that each patient receives the best possible treatment tailored to their specific needs.

If you have concerns about your prostate health or are due for a screening, don’t hesitate to schedule an appointment with Dr. Jo Schoeman, your trusted urologist in Brisbane. Early detection and proactive management are key to maintaining a healthy prostate and overall well-being.

 

For appointments and more information, contact Dr. Jo Schoeman’s clinic today and take the first step towards optimal prostate health.

dr jo schoeman logo,

Dr. Jo Schoeman 

Phone : (07) 3371 7288

Location :

WESLEY HOSPITAL

Suite 10, Level 9
Evan Thomson Building
24 Chasely Street
Auchenflower, 4066