Tag Archive for: urology brisbane

Renal cysts: when to reassure, when to investigate and when to treat

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Renal cysts are fluid-filled sacs within or on the kidney. Finding a “cyst” on a scan can be worrying, but many are harmless. The important questions are whether the cyst has a simple or complex appearance, whether it is causing symptoms, and whether it affects urine drainage or kidney function.

A large simple cyst is not automatically cancerous, and a small complex cyst is not automatically harmless. Imaging features and the clinical situation guide management.

What types of renal cysts are there?

Simple cysts have a thin, smooth wall and contain fluid. They become more common with age and usually cause no symptoms or loss of kidney function. Most need no treatment.[1]

Complex cystic masses have additional features, such as internal partitions called septa, thickened walls or tissue nodules. “Complex” describes their appearance; it does not establish a cancer diagnosis.[2]

Parapelvic cysts lie beside the renal pelvis, the funnel that collects urine before it enters the ureter. Their location can make diagnosis and treatment more difficult.[6]

Polycystic kidney disease is a separate condition, often inherited, in which multiple cysts may enlarge the kidneys and affect kidney function. Numerous cysts in both kidneys, especially with a family history, merit assessment for cystic kidney disease rather than being assumed to be ordinary simple cysts.[9]

How do renal cysts present?

Most simple cysts are discovered incidentally during an ultrasound, CT or MRI performed for another reason.

Occasionally, a cyst causes a dull ache in the flank or back, pressure or discomfort, or obstruction to urine drainage. Bleeding, infection or rupture can cause more acute symptoms. Fever with flank pain may indicate infection.[1]

Pain and blood in the urine have many possible causes, including stones and other urinary tract conditions. Finding a cyst does not prove that it caused the symptoms. Visible blood in the urine should be assessed rather than attributed to a known cyst.

What investigations are needed?

Ultrasound often identifies an uncomplicated simple cyst. If the lesion is uncertain or complex, a dedicated contrast-enhanced CT or MRI can assess its wall, septa and any solid tissue. Contrast-enhanced ultrasound is another option in centres with appropriate expertise.[3]

An important finding is enhancement: tissue becomes brighter after contrast, indicating a blood supply. Enhancement in thickened or irregular tissue or a nodule raises concern.

Urine testing and blood tests for kidney function may be appropriate. Infection symptoms may require a urine culture. Contrast choices are individualised according to kidney function, allergies and other circumstances.

Ordinary ultrasound alone may not adequately classify a complex cyst. A radiology report should ideally state which version of the Bosniak classification has been used.[2,3]

Bosniak classification: understanding the scan report

The Bosniak system groups cystic renal masses by imaging appearance. The 2019 version incorporates CT and MRI criteria. It estimates concern for malignancy; it is not a cancer stage or a substitute for specialist assessment.[2]

Category Simplified meaning Usual approach
I Simple fluid-filled cyst with a thin, smooth wall Benign; no routine follow-up if confidently classified
II Benign features, such as a few thin septa or certain non-enhancing blood/protein-containing cysts Usually no routine follow-up
IIF More septa or mild smooth thickening; “F” means follow-up Scheduled imaging to check for change
III Enhancing thick or irregular walls or septa Indeterminate; specialist discussion of surveillance or treatment
IV An enhancing tissue nodule Strong concern for cancer; specialist assessment and treatment planning

This table is deliberately simplified. Calcification or blood within a cyst does not by itself establish cancer. The pattern of enhancement and tissue architecture matters.[2,3]

When should cancer be a concern?

Concern increases with enhancing nodules, irregular or thick enhancing walls/septa, or progression to a more suspicious category on follow-up.

Bosniak III masses include both benign and malignant lesions. Bosniak IV masses have a high likelihood of malignancy. Published percentages vary with the classification version and which patients undergo surgery, so a single percentage should not be treated as an individual prediction.[3,4]

Absence of symptoms does not exclude cancer. Conversely, enlargement of an otherwise simple cyst does not alone prove malignant change.

Follow-up and active surveillance

For Bosniak IIF lesions, the Canadian Urological Association suggests imaging at 6–12 months during the first year, then annually if stable, for a total of five years without progression.

Its 2023 guideline also supports active surveillance as a preferred option for selected Bosniak III/IV masses measuring 2 cm or less; surveillance or surgery for those measuring 2–4 cm; and surgery generally for those larger than 4 cm. These recommendations have limited-certainty evidence and require shared decision-making.[4]

Other guidelines differ in emphasis. The EAU allows surveillance for selected Bosniak III lesions and generally manages Bosniak IV lesions as localised kidney cancer.[8] Age, overall health, kidney function, imaging features and patient preferences all matter.

Surveillance means planned scans and reassessment, with treatment considered if concern increases. Biopsy may help when there is a targetable solid component and the result would change management; sampling a mainly fluid-filled lesion often has a low diagnostic yield.[4]

When should a benign cyst be treated?

Treatment may be considered for persistent symptoms convincingly attributable to the cyst, obstruction, or complications such as infection. There is no universal size threshold requiring treatment for a confidently benign simple cyst.[1]

Before intervention, the team should establish that the lesion is benign and discuss whether treatment is likely to relieve the symptoms.

Treatment options

Interventional radiology: aspiration and sclerotherapy

An interventional radiologist can use ultrasound or CT to guide a needle or catheter into a suitable simple cyst. The fluid is drained, usually under local anaesthetic, sometimes with sedation.

Aspiration alone can provide temporary relief, but the cyst may refill. Sclerotherapy adds an agent to damage the fluid-producing lining and reduce recurrence. The team must exclude communication with the urine collecting system before using a sclerosant.

A systematic review of 57 studies reported treatment success in approximately 88% of patients receiving aspiration with sclerotherapy, defined as symptom resolution together with more than 50% cyst-size reduction. Techniques and study quality varied; this is not a guarantee for an individual patient.[5]

Risks include pain, bleeding, infection, leakage of the agent, injury to nearby structures and recurrence. Repeat treatment may be needed.

Laparoscopic cyst deroofing

Deroofing, also called decortication, removes part of the cyst wall so it cannot readily reform as a closed sac. The removed tissue is usually sent for pathology.

Performed through small incisions under general anaesthesia, it may suit large, accessible symptomatic cysts or cysts that recur after percutaneous treatment.

A comparative meta-analysis found lower treatment-failure rates with laparoscopic deroofing than aspiration with sclerotherapy, while percutaneous treatment generally involved shorter procedures, shorter hospital stays and fewer complications.[7]

Surgical risks include bleeding, infection, injury to nearby organs or the collecting system, urine leakage, persistent pain and recurrence. Recovery depends on the procedure and the patient’s health.

Robotic-assisted deroofing

Robotic assistance is another way to perform minimally invasive cyst surgery. It may help with dissection in selected cases, but the robot is operated by the surgeon. Its availability does not mean it is necessary or offers a better result for every cyst. Location, complexity, expertise and cost should guide the choice.[7]

If the cyst is suspicious for cancer

Simple drainage or deroofing is not an appropriate cancer operation. Management may involve surveillance, partial nephrectomy to remove the lesion while preserving kidney tissue, or occasionally removal of the whole kidney. Ablation may be considered in selected patients, although evidence for complex cystic lesions is limited.[4,8]

I no longer perform nephrectomies. If partial or radical nephrectomy is indicated, I will refer you to a colleague who performs this surgery.

Parapelvic cysts: a special situation

Parapelvic cysts are beside the kidney’s central urine collecting system and usually do not communicate with it. They can mimic hydronephrosis, a dilated collecting system, on ultrasound. Contrast imaging, sometimes including delayed images, can distinguish the two and show whether a cyst is compressing urine drainage.[6]

Many asymptomatic benign parapelvic cysts can be observed. Treatment may be considered when a cyst causes pain or demonstrable obstruction.

Options include carefully planned laparoscopic or robotic deroofing, or ureteroscopic internal drainage in selected cases. With ureteroscopy, a telescope passes through the urethra, bladder and ureter into the kidney; a laser opens the cyst into the collecting system. A temporary ureteric stent may be required. Published studies support feasibility, but long-term comparative evidence remains limited.[6,10]

Sclerotherapy is generally avoided for parapelvic cysts because leakage or inflammation near the collecting system can cause scarring and obstruction. Any proposed percutaneous approach requires specialist assessment; routine simple-cyst treatment should not be applied automatically.[6]

Their proximity to blood vessels and the collecting system also increases the technical difficulty of surgery. Risks include bleeding, urine leakage, infection, narrowing and recurrence.

When to seek prompt medical attention

Seek urgent assessment for severe flank pain with fever or rigors, significant bleeding or clots in the urine, difficulty passing urine, or pain accompanied by faintness or marked illness. Persistent visible blood in the urine also requires medical review.

References

  1. National Institute of Diabetes and Digestive and Kidney Diseases. Simple kidney cysts.
  2. Silverman SG, et al. Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment. Radiology. 2019;292:475–488. Article.
  3. European Association of Urology. Renal Cell Carcinoma Guidelines: Diagnostic evaluation.
  4. Canadian Urological Association. 2023 update: Management of cystic renal lesions. Canadian Urological Association Journal. Guideline.
  5. Brown D, et al. Radiologically guided percutaneous aspiration and sclerotherapy of symptomatic simple renal cysts: a systematic review of outcomes. Abdominal Radiology. 2021. PubMed.
  6. Ureteroscopic management of asymptomatic and symptomatic simple parapelvic renal cysts. BMC Urology. 2015. Article.
  7. Comparison of aspiration with sclerotherapy and laparoscopic deroofing for the treatment of symptomatic simple renal cysts: a systematic review and meta-analysis. Updates in Surgery. 2021. PubMed.
  8. European Association of Urology. Renal Cell Carcinoma Guidelines: Epidemiology, aetiology and pathology and Disease management.
  9. NIDDK. What is polycystic kidney disease?.
  10. Transurethral flexible ureteroscopic incision and drainage with holmium laser in the treatment of parapelvic renal cysts. International Brazilian Journal of Urology. 2022. Article.

General patient education. Individual management depends on imaging findings, symptoms, kidney function and discussion with the treating team. Reviewed October 2026.

PUJ obstruction: when urine cannot drain freely from the kidney

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

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

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

What causes PUJ obstruction?

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

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

How does it present?

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

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

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

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

Which investigations are useful?

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

Urine and blood tests

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

Ultrasound

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

CT or MR urography

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

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

MAG3 diuretic renogram

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

It measures:

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

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

Further tests in selected cases

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

Does every PUJ obstruction need treatment?

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

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

What are the treatment options?

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

Temporary or emergency drainage

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

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

Endoscopic treatment

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

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

Robotic-assisted pyeloplasty: how is the repair performed?

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

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

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

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

How successful is pyeloplasty, and is robotic surgery better?

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

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

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

What are the risks and recovery expectations?

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

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

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

What if the kidney already functions poorly?

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

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

When should I seek urgent help?

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

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

References

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

Prepared October 2026.

Ureteroceles: symptoms, investigations and treatment

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

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

Congenital or acquired?

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

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

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

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

Presentation and symptoms

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

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

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

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

What investigations are needed?

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

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

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

Does every ureterocoele need surgery?

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

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

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

Endoscopic incision or deroofing

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

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

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

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

Where does a ureteric stent fit in?

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

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

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

Possible complications, including vesicoureteric reflux

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

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

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

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

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

Further surgery and follow-up

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

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

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

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

References

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

Coffee Break

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

By Dr Jo Schoeman

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

 “A quiet coffee before the working day.” 

What is good about coffee?

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

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

Why oat milk?

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

A urologist’s small caveat

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

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

References and further reading

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

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

Penile Fracture: Presentation, Investigation, Treatment and Long-Term Outlook

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Penile fracture is a urological emergency. Despite its name, no bone is broken. The injury is a tear in the tunica albuginea, the tough sleeve surrounding one or both erectile cylinders (corpora cavernosa) while the penis is erect. Bleeding then occurs within and around the erectile tissues.

If you hear or feel a crack or pop during intercourse or other bending of an erect penis, followed by pain, loss of the erection, swelling or bruising, stop sexual activity and attend the nearest emergency department immediately. Do not wait to see whether it settles, and do not eat or drink until assessed in case an anaesthetic is required.

This article provides general education. It cannot diagnose an injury, replace examination, or provide individual medical advice.

How does a penile fracture happen?

During an erection, the tunica albuginea becomes much thinner and is vulnerable to sudden buckling. The most frequent mechanism is an erect penis slipping out during intercourse and striking the partner’s pubic bone or perineum. It can also occur during masturbation, intentional forceful bending, rolling onto an erect penis, or less commonly through other trauma.

Penile fracture can happen in any sexual position. It is an accident rather than evidence of wrongdoing, and embarrassment should never delay treatment.

The urethra, the tube carrying urine through the penis, may be injured at the same time. The 2026 European Association of Urology (EAU) guideline reports associated corpus spongiosum or urethral injury in approximately 10–22% of cases; rates vary among populations and mechanisms of injury.[1]

Typical presentation

The classic sequence is:

  • a sudden crack, snap or popping sensation;
  • immediate pain;
  • rapid loss of the erection (detumescence);
  • quickly developing swelling and bruising;
  • bending or deformity of the penis, often away from the injured side; and
  • sometimes a palpable defect in the tunica.

Bruising may spread into the scrotum, perineum or lower abdominal wall. The dramatic “aubergine” appearance described in medical literature is not present in every case.

Warning signs of urethral injury

Tell the treating team immediately if there is:

  • blood at the urinary opening;
  • blood in the urine;
  • pain or difficulty passing urine;
  • inability to pass urine; or
  • a weak or interrupted urinary stream after the injury.

The absence of these findings does not completely exclude urethral injury. Clinical assessment remains important.

Conditions that can look similar

Not every swollen or bruised penis after intercourse has a tunical tear. Rupture of a superficial vein or artery, injury to the suspensory ligament, or bleeding beneath the skin can produce a “false penile fracture.” Slow rather than immediate loss of erection and absence of the characteristic crack may make a true fracture less likely, but no single feature is conclusive.

Because missing a fracture can have lasting consequences, significant swelling, pain or deformity after trauma to an erect penis requires urgent medical assessment.

How is it investigated?

History and examination

When the history and examination are classic, penile fracture is primarily a clinical diagnosis. Testing should not unnecessarily delay repair. The clinician will assess the penis, scrotum and perineum and ask specifically about the mechanism, the speed of detumescence, urination and visible blood. A urine test is generally performed.

Ultrasound

Ultrasound can help locate a tear and haematoma, particularly when the diagnosis is uncertain. It is quick and widely available, but its accuracy depends on the operator, the size and position of the tear, and the amount of swelling. A negative or inconclusive ultrasound does not necessarily exclude fracture when the clinical findings are convincing.

MRI

MRI gives excellent soft-tissue detail and is generally more accurate than ultrasound for detecting a tunical tear. It may be useful in equivocal cases, but availability, cost and delay can limit its emergency use. It is not routinely required when the diagnosis is already clear.[1]

Assessment of the urethra

If urethral injury is suspected, evaluation may include retrograde urethrography (contrast imaging of the urethra) or flexible cystoscopy. Visible haematuria, blood at the meatus, difficulty voiding and bilateral corporal injury increase concern. The EAU and American Urological Association (AUA) both recommend evaluating for associated urethral injury when indicated.[1,2]

CT is not the preferred test for an isolated penile fracture, although it may be obtained when wider pelvic or abdominal trauma is suspected.

Recommended management

Prompt surgical repair

Current EAU and AUA guidance recommends prompt surgical exploration and repair for an acute penile fracture.[1,2] The operation is usually performed under general or regional anaesthesia and involves:

  1. exposing the injured erectile tissue through a circumferential degloving incision or a targeted incision over the tear;
  2. evacuating the clot and controlling bleeding;
  3. identifying and closing the tunica albuginea tear with sutures; and
  4. inspecting and repairing the urethra if it is injured.

A urinary catheter may be used, especially when the urethra has been assessed or repaired. The exact incision, catheter duration, hospital stay and follow-up depend on the injury and the surgeon’s findings.

The EAU guideline advises repair within 24 hours of presentation when feasible, but late presentation is not a reason to withhold assessment or repair.[1] A person presenting after a delay should still seek urgent urological review.

Why is conservative treatment generally avoided?

Ice, compression, pain relief, erection-suppressing medication and observation were historically used. Conservative treatment may occasionally be appropriate when imaging and specialist assessment confirm that the tunica is intact, but it is not the standard treatment for a confirmed fracture.

A meta-analysis of 58 studies involving 3,213 patients found significantly fewer overall complications and less erectile dysfunction, curvature and painful erections with surgery than with conservative management.[3] Non-operative treatment of a true fracture carries greater risks of persistent haematoma, infection or abscess, missed urethral injury, fibrosis, penile curvature and erectile dysfunction.[1,3]

Recovery after repair

Patients should follow their treating surgeon’s instructions, which may include:

  • wound and catheter care;
  • simple analgesia and other prescribed medicines;
  • avoiding strenuous activity until reviewed;
  • avoiding intercourse and masturbation, commonly for about six weeks or until healing is confirmed; and
  • follow-up to assess erections, curvature, pain and urinary function.

Night-time or spontaneous erections during healing may be uncomfortable. Medication is sometimes used selectively, but there is no universal post-operative drug regimen. Do not start or stop prescription medicines without advice.

Seek urgent review after treatment for fever, increasing redness or swelling, wound discharge, worsening pain, inability to urinate, heavy bleeding, or a catheter that stops draining.

Possible complications

Most patients do well after prompt repair, but no treatment can guarantee a complication-free outcome. Possible early or late problems include:

  • wound infection, bleeding or haematoma;
  • altered penile sensation, palpable stitches, scar or nodules;
  • painful erections;
  • penile curvature, indentation or shortening;
  • erectile dysfunction;
  • urethral narrowing (stricture), urinary spraying or reduced flow;
  • urethrocutaneous fistula after a significant urethral injury or repair;
  • need for further investigation or surgery; and
  • anxiety, avoidance of intimacy or relationship distress.

The EAU guideline summarises reported post-surgical rates of plaques or nodules, curvature and erectile dysfunction as approximately 13.9%, 2.8% and 1.9%, respectively, while noting that complications overall have been reported in up to 20% of cases.[1] These pooled figures are not a personalised prediction: published studies differ in injury severity, definitions, follow-up and measurement. Risk is higher with extensive or bilateral tears, associated urethral injury, delayed or missed diagnosis, and in some studies age over 50.[1,4]

What is the risk of erectile dysfunction?

Erectile dysfunction after a fracture may result from corporal scarring, impaired blood trapping, arterial or nerve injury, pain, anxiety, or a combination of physical and psychological factors. Prompt repair markedly reduces the risk compared with conservative management, but does not eliminate it.[1,3]

Persistent difficulty should be assessed rather than endured in silence. Evaluation can include a sexual and medical history, validated questionnaires, examination and, when indicated, penile Doppler ultrasound. Treatment is individualised and may include counselling, oral erectile-dysfunction medication when safe, vacuum therapy, injections or, rarely, reconstructive surgery or a penile prosthesis.

Does penile fracture cause Peyronie’s disease?

Healing after a penile fracture can produce a local scar, palpable nodule or post-traumatic curvature. These findings may resemble Peyronie’s disease, which is an acquired fibrotic disorder of the tunica albuginea. However, a curve after fracture should not automatically be labelled Peyronie’s disease: it may arise directly from the repaired tear, asymmetric healing or corporal fibrosis.

The distinction is made through history, examination and, if needed, photographs of the erect penis or ultrasound. Review is advisable if there is a new or worsening bend, a hard plaque, painful erections, loss of length, narrowing, instability or difficulty with intercourse. Management depends on whether the deformity is changing or stable, its severity, erectile function and how much it affects the patient. Options may include observation, penile traction in selected cases, treatment of erectile dysfunction, or reconstructive surgery once the deformity is stable. Treatment should be discussed with a urologist experienced in penile reconstruction or andrology.

The essential message

A suspected penile fracture is time-sensitive. A crack or pop followed by immediate loss of erection, swelling and bruising warrants immediate emergency assessment. Diagnosis is often clinical; ultrasound or MRI is reserved mainly for uncertainty, and the urethra must be assessed when injury is suspected. Prompt surgical repair offers the best prospect of preserving penile shape, erections and urinary function.

References

  1. European Association of Urology. EAU Guidelines on Urological Trauma. 2026 edition, sections on genital trauma and penile fracture. https://uroweb.org/guidelines/urological-trauma/chapter/urogenital-trauma-guidelines
  2. Morey AF, Brandes S, Dugi DD III, et al. Urotrauma: AUA Guideline. J Urol. 2014;192(2):327–335; amended guideline statements available from the American Urological Association. doi:10.1016/j.juro.2014.05.004. https://www.auanet.org/guidelines-and-quality/guidelines/urotrauma-guideline
  3. Amer T, Wilson R, Chlosta P, et al. Penile fracture: a meta-analysis. Urol Int. 2016;96(3):315–329. doi:10.1159/000444884.
  4. Barros R, Schulze L, Ornellas AA, Koifman L, Favorito LA. Impact of surgical treatment of penile fracture on sexual function. Urology. 2019;126:128–133. doi:10.1016/j.urology.2018.11.027.
  5. Wong NC, Dason S, Bansal RK, Davies TO, Braga LH. Can it wait? A systematic review of immediate vs delayed surgical repair of penile fractures. Can Urol Assoc J. 2017;11(1–2):53–60. doi:10.5489/cuaj.4032.
  6. Koifman L, Barros R, Júnior RAS, Cavalcanti AG, Favorito LA. Penile fracture: diagnosis, treatment and outcomes of 150 patients. Urology. 2010;76(6):1488–1492. doi:10.1016/j.urology.2010.05.043.

Website publication note

This material is general health information and was prepared from the sources listed above. It is not a substitute for emergency assessment, diagnosis, informed consent or personalised advice from a qualified practitioner. Outcomes and risks vary between individuals.

Tranexamic Acid for Radiation Cystitis: Benefits, Duration and Important Risks

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Blood in the urine after pelvic radiotherapy can be frightening. It may appear months or even many years after treatment for prostate, bladder, rectal or gynaecological cancer. One possible cause is radiation cystitis: delayed injury to the bladder lining and its small blood vessels.

Tranexamic acid is sometimes considered when bleeding is troublesome. It can help stabilise blood clots, but it does not repair the radiation injury itself and it is not suitable for every patient. In urinary tract bleeding, preventing a clot from dissolving may reduce bleeding but may also allow a larger clot to obstruct the bladder or ureter. Careful patient selection and medical supervision are therefore essential.

Seek urgent medical attention if you cannot pass urine, are passing large clots, feel faint or breathless, develop fever or flank pain, or the bleeding is heavy or worsening.

What is radiation cystitis?

Radiotherapy can cause progressive damage to the bladder’s small blood vessels. These vessels may become fragile and bleed easily. Patients may experience visible haematuria, urinary frequency, urgency, pain or recurrent clot retention.

Radiation cystitis should not be assumed simply because a patient has previously received radiotherapy. Infection, urinary stones, recurrent or new cancer, kidney disease and medication-related bleeding must also be considered. Assessment may include urine testing and culture, a full blood count, renal function, imaging of the upper urinary tract and cystoscopy. Biopsy is used selectively because irradiated tissue heals poorly.

How does tranexamic acid work?

The body normally breaks down blood clots through a process called fibrinolysis. Tranexamic acid blocks the binding of plasminogen and plasmin to fibrin, slowing this breakdown. It is therefore an antifibrinolytic medicine: it helps a clot remain in place rather than acting as a blood-clotting factor itself.

For radiation cystitis, tranexamic acid is intended to control active bleeding. It does not remove abnormal radiation-induced blood vessels, reverse fibrosis or prevent future bleeding once the medicine is stopped.

How effective is it for radiation cystitis?

The evidence is limited. Tranexamic acid has been used for haematuria from several causes, and a small randomised emergency-department study found that intravenous treatment reduced the amount of bladder irrigation required to clear the urine. However, it did not significantly reduce haemoglobin loss or transfusion requirements. Importantly, this study included mixed causes of haematuria and was not designed specifically for radiation cystitis.

The Canadian Urological Association best-practice report concluded that evidence was insufficient to make a formal recommendation for tranexamic acid in radiation-induced haemorrhagic cystitis. Later narrative reviews have reached a similar conclusion. Intravesical tranexamic acid, placed directly into the bladder, has shown encouraging results in small emergency-department studies of gross haematuria, but evidence specific to radiation cystitis is still inadequate and this remains a specialist, non-standard use.

In practice, tranexamic acid may be considered as a temporary adjunct in selected patients while the cause and severity of bleeding are assessed, or while more definitive treatment is arranged. It should not delay bladder washout, clot evacuation, cystoscopic treatment, hyperbaric oxygen therapy, embolisation or other appropriate care when these are required.

How long can tranexamic acid be used?

There is no well-supported universal duration for radiation cystitis. The Australian product information for oral tranexamic acid describes treatment of haematuria while blood remains macroscopically visible, but radiation cystitis is a recurrent condition and that instruction should not be interpreted as approval for indefinite therapy.

For this indication, treatment is generally best regarded as a short, medically supervised course for an active bleeding episode. The exact dose and duration depend on:

  • whether bleeding is mild, ongoing or causing clot retention;
  • whether the source is the bladder or upper urinary tract;
  • kidney function, because tranexamic acid is largely eliminated in the urine;
  • previous blood clots, cardiovascular risk and pro-thrombotic medicines;
  • anticoagulant or antiplatelet therapy; and
  • the response to treatment and need for definitive therapy.

There is no good evidence supporting continuous long-term tranexamic acid as prophylaxis for recurrent radiation cystitis. If bleeding has not clearly improved within a short course, recurs promptly after treatment, or requires repeated courses, the diagnosis and management plan should be reassessed. Longer or repeated use should occur only under specialist supervision, with renal function and thrombotic risk reviewed.

Patients should not start, extend, repeat or stop prescribed tranexamic acid without discussing it with their treating clinician.

Important side effects

Common or less serious adverse effects may include:

  • nausea, vomiting, diarrhoea or abdominal discomfort;
  • headache, dizziness or fatigue; and
  • muscle or joint discomfort.

Potentially serious adverse effects include:

Blood clots

Deep-vein thrombosis, pulmonary embolism, stroke, heart attack and other arterial or venous thromboses are uncommon but potentially serious. Risk assessment is particularly important in patients with an active or previous clot, known thrombophilia, active malignancy, prolonged immobility or concurrent pro-thrombotic medication.

Urgent assessment is required for new unilateral leg pain or swelling, sudden chest pain, shortness of breath, coughing blood, weakness on one side, difficulty speaking or sudden severe headache.

Clot retention and urinary obstruction

Tranexamic acid may stabilise clots within the urinary tract. This can contribute to painful bladder clot retention. It is particularly concerning when bleeding arises from a kidney or ureter, because a clot may obstruct the ureter and cause flank pain, hydronephrosis or loss of kidney function. Upper-tract haematuria therefore warrants particular caution and specialist assessment.

Kidney impairment

Most tranexamic acid is excreted unchanged through the kidneys. The dose must be reduced when renal function is impaired; accumulation increases the risk of toxicity, including neurological adverse effects. Significant renal impairment may make treatment inappropriate or require a substantially altered regimen.

Seizures

Seizures are a recognised, dose-related risk, reported particularly with high intravenous doses and when the medicine accumulates in renal impairment. A history of seizures requires careful consideration.

Visual disturbance

Rare visual effects, including altered colour vision, have been reported. New visual symptoms require prompt review and usually discontinuation pending medical advice. Ophthalmic monitoring may be considered when prolonged treatment is unavoidable.

Severe allergy

Facial or throat swelling, wheeze, breathing difficulty or a widespread blistering rash requires emergency care.

Who may not be suitable for treatment?

Tranexamic acid may be contraindicated or require particular caution in people with:

  • active thromboembolic disease or a substantial history or risk of thrombosis;
  • significant kidney impairment;
  • upper urinary tract bleeding or suspected ureteric obstruction;
  • a history of seizures;
  • acquired disturbances of colour vision;
  • disseminated intravascular coagulation unless managed by an experienced clinician; or
  • hypersensitivity to tranexamic acid.

Medication review is essential. Anticoagulants and antiplatelet agents can worsen bleeding, but stopping them may cause stroke, pulmonary embolism, heart attack or coronary-stent thrombosis. They should not be stopped merely because haematuria develops without an individual risk assessment involving the prescribing clinician. Likewise, combining tranexamic acid with pro-thrombotic medicines requires caution.

Where does it fit in the management pathway?

Management is guided by severity. Initial care may include resuscitation, correction of significant anaemia or coagulopathy, a large-bore catheter, manual washout and continuous bladder irrigation. Cystoscopy permits clot evacuation, exclusion of tumour and cautery or laser treatment of bleeding areas.

For persistent or recurrent radiation cystitis, options may include intravesical agents, hyperbaric oxygen therapy, selective arterial embolisation and, rarely, urinary diversion or cystectomy. Hyperbaric oxygen is one of the better-studied treatments because it aims to improve tissue oxygenation and new blood-vessel formation rather than merely suppressing an episode of bleeding.

Tranexamic acid may have a role as a bridge or adjunct in a carefully selected patient. Its value must always be balanced against the danger of thrombosis and urinary tract obstruction.

The take-home message

Tranexamic acid can reduce haematuria in some patients, but evidence specifically for radiation cystitis is weak. It is not a cure and should usually be used only for a short, active bleeding episode under medical supervision. There is no established safe or effective duration for continuous long-term use in radiation cystitis. Kidney function, clotting history, the anatomical source of bleeding and concurrent medication must be reviewed before treatment.

Visible haematuria after radiotherapy always deserves proper investigation, particularly if it is recurrent, contains clots or is accompanied by difficulty passing urine.

This article provides general information and does not replace individual medical advice. Tranexamic acid is a prescription medicine in Australia; its use for radiation cystitis must be individualised by the treating clinician.

References

  1. Goucher G, Saad F, Lukka H, Kapoor A. Canadian Urological Association Best Practice Report: Diagnosis and management of radiation-induced hemorrhagic cystitis. Can Urol Assoc J. 2019;13(2):15–23. doi:10.5489/cuaj.5788
  2. Moharamzadeh P, Ojaghihaghighi S, Amjadi M, Rahmani F, Farjamnia A. Effect of tranexamic acid on gross hematuria: a pilot randomized clinical trial study. Am J Emerg Med. 2017;35(12):1922–1925. doi:10.1016/j.ajem.2017.09.012
  3. Abramowitz D, et al. Clinical management of radiation cystitis: a narrative review. AME Med J. 2021;6:30. Clinical management of radiation cystitis
  4. Choi H, et al. Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: a before-and-after study. Am J Emerg Med. 2023;68:118–122. doi:10.1016/j.ajem.2023.03.010
  5. Pfizer Australia. Cyklokapron (tranexamic acid) Australian Product Information. Current product information should be checked through the Therapeutic Goods Administration or the sponsor before prescribing. Australian product information
  6. DailyMed. Tranexamic acid injection—prescribing information. US National Library of Medicine. DailyMed drug labelling
  7. Chauncey JM, Wieters JS. Tranexamic Acid. In: StatPearls. Updated 2025. NCBI Bookshelf

 

Radical Prostatectomy After Radiation Therapy for Prostate Cancer

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When prostate cancer returns after radiotherapy

Radiotherapy, whether external-beam radiation or brachytherapy can provide excellent long-term control of localised prostate cancer. However, a rising prostate-specific antigen (PSA) after treatment may indicate that the cancer has returned.

This does not automatically mean that the cancer is still in the prostate, nor does every PSA rise require immediate treatment. Recurrence may be confined to the prostate, present in lymph nodes or bones, or involve more than one site. Some recurrences also progress slowly enough that surveillance may be appropriate.

When clinically significant cancer is proven to have returned within the irradiated prostate, with no evidence of spread elsewhere, removal of the prostate may still offer a chance of cure. This operation is called a salvage radical prostatectomy.

What is a salvage radical prostatectomy?

A salvage radical prostatectomy removes the entire prostate and seminal vesicles after previous prostate radiotherapy. Depending on the cancer and imaging findings, pelvic lymph nodes may also be removed.

The operation may be performed using robotic-assisted or open surgery. A robotic approach can improve magnification and access, but it does not remove the biological effects of previous radiation. Surgeon and centre experience are therefore more important than the label attached to the surgical technique.

Salvage surgery is technically more difficult than a prostatectomy performed before radiotherapy. Radiation can cause:

  • scarring and fibrosis around the prostate;
  • loss of the normal tissue planes between the prostate, bladder and rectum;
  • reduced tissue blood supply;
  • poorer tissue healing; and
  • pre-existing damage to urinary, erectile or bowel function.

For these reasons, salvage prostatectomy should generally be undertaken in a centre with specific experience in complex prostate cancer surgery and access to multidisciplinary care.

When might salvage surgery be considered?

The aim is to identify a man who has a meaningful risk from his recurrent cancer, but whose disease still appears curable with local treatment. Possible indications include:

  • a rising PSA after radiotherapy, commonly assessed using the Phoenix definition: a PSA rise of at least 2 ng/mL above the lowest PSA reached after treatment;
  • prostate cancer confirmed on biopsy after radiotherapy;
  • imaging suggesting that the recurrence is confined to the prostate or immediate surrounding tissues;
  • no evidence of distant metastatic disease;
  • a life expectancy long enough to benefit from curative treatment, often more than 10 years;
  • good general health and fitness for major surgery;
  • acceptable baseline bladder function; and
  • willingness to accept a higher risk of urinary and sexual side effects than with a primary prostatectomy.

Factors such as the PSA level, PSA doubling time, interval since radiotherapy, biopsy Grade Group, clinical stage and the original cancer characteristics help estimate whether salvage treatment is likely to be worthwhile.

Assessment before considering surgery

A rising PSA is the beginning of the assessment—not the final diagnosis. Investigations commonly include:

Review of the original treatment

The radiation dose and field, use of brachytherapy, previous androgen-deprivation therapy, original biopsy grade and pre-treatment imaging should all be reviewed.

Multiparametric MRI

MRI can help identify the site and extent of a local recurrence, assess the seminal vesicles, bladder neck and rectal interface, and guide biopsy. Interpretation after radiation can be challenging and benefits from specialist radiological expertise.

PSMA PET/CT

PSMA PET/CT is used to look for disease in lymph nodes, bones or other organs. Finding metastatic disease usually changes the treatment plan and may mean that removing the prostate would not provide the expected benefit. Very small-volume disease can still be below the resolution of any scan.

Prostate biopsy

Major guidelines recommend pathological confirmation before potentially morbid local salvage therapy. Biopsy can confirm viable cancer, determine its grade and help distinguish clinically important recurrence from post-radiation change. Both targeted and systematic sampling may be considered.

Urinary-function assessment

Assessment may include symptom scores, urine testing, urinary-flow measurement, residual urine ultrasound and cystoscopy. Urodynamic testing may be helpful when there is significant urgency, leakage, poor flow, retention or uncertainty about bladder function.

Who may not be a good candidate?

Salvage prostatectomy is less likely to be appropriate when:

  • metastatic or extensive nodal disease is present;
  • the cancer is unlikely to be completely removable;
  • life expectancy is limited by age, frailty or other illness;
  • the recurrence is low risk and unlikely to threaten health;
  • severe urinary or bowel damage already exists after radiation; or
  • the anticipated harms of surgery outweigh the probability of cancer control.

These are not absolute rules. Individual circumstances should be reviewed by a multidisciplinary team involving urology, radiation oncology, medical oncology, radiology and pathology.

What are the potential benefits?

For carefully selected men, salvage prostatectomy can:

  • remove the recurrent cancer and provide complete pathological staging;
  • provide durable PSA control without immediately committing the patient to lifelong hormonal therapy; and
  • offer a possibility of cure when disease is truly confined to the prostate.

Published results vary considerably because most evidence comes from retrospective series involving highly selected patients. The European Association of Urology reports five-year biochemical recurrence-free estimates broadly around 41–52% in a large contemporary systematic review, while older selected series have reported ranges of approximately 47–82%. A broader meta-analysis of all local salvage approaches found roughly 50–60% five-year recurrence-free survival, without clear evidence that one approach was oncologically superior. These figures should not be interpreted as a personal prediction.

Cancer control is generally more favourable when the PSA is lower, the recurrent tumour is organ-confined, the cancer grade is lower, the PSA doubling time is longer and there is no nodal or distant disease.

Side effects and complications

Complication rates vary with baseline function, radiation type and dose, disease extent, surgical technique, definitions used in studies and surgeon experience. Results from specialist centres may not apply everywhere.

Urinary incontinence

Loss of urinary control is one of the most important risks. Radiation may already have affected the sphincter, bladder and urethral tissues, and surgery removes the prostate through which the urethra passes.

Leakage may range from mild stress incontinence to severe continuous leakage. Pelvic-floor rehabilitation can help, but some men may later require a male sling or artificial urinary sphincter. Continence outcomes reported in the literature vary widely because studies use different definitions; the risk of significant or persistent leakage is clearly higher than after primary prostatectomy.

Erectile dysfunction

Erectile function is often already impaired by radiotherapy, age, vascular disease or hormonal treatment. Preservation of the erectile nerves may be unsafe or technically impossible because of tumour location and radiation fibrosis. Consequently, erectile dysfunction after salvage prostatectomy is very common and recovery of unassisted erections is uncommon.

Rehabilitation and treatment options include tablets, vacuum devices, penile injections and penile prosthesis surgery. As with any radical prostatectomy, ejaculation and natural fertility are lost because the prostate and seminal vesicles are removed.

Bladder-neck contracture or urethral narrowing

Scar tissue may develop where the bladder is reconnected to the urethra. This can cause a weak stream, straining, incomplete emptying, retention or recurrent infection. Treatment may require endoscopic incision or dilatation, sometimes more than once. Repeated procedures can worsen incontinence.

Urine leak and delayed healing

The new bladder-to-urethra join may heal slowly because irradiated tissues have reduced blood supply. A urinary catheter may need to remain in place longer, and imaging may be required before its removal. Persistent leakage can require drainage or further intervention.

Rectal injury and urinary fistula

The rectum can be densely adherent to the prostate after radiotherapy. Rectal injury is uncommon in expert contemporary practice but occurs more often than during primary prostatectomy and can be serious. It may require repair, temporary bowel diversion or, rarely, more extensive surgery. An abnormal connection between the urinary tract and rectum—a rectourinary fistula—is rare but particularly difficult to treat.

Other surgical risks

Other possible complications include bleeding or transfusion, infection, blood clots, lymphocele after lymph-node dissection, injury to nearby structures, anaesthetic complications, chronic pelvic pain and the need for further procedures.

Cancer may still recur

Even when preoperative imaging suggests local disease, microscopic cancer may already exist outside the prostate. PSA may therefore remain detectable or rise again after surgery. Further treatment—such as hormonal therapy, systemic therapy or selected metastasis-directed treatment—may still be required.

Are there alternatives?

Depending on the cancer, previous treatment, anatomy, urinary function and patient priorities, alternatives may include:

  • active monitoring for a slow or low-risk recurrence;
  • androgen-deprivation therapy, sometimes with additional systemic treatment;
  • salvage brachytherapy or stereotactic re-irradiation;
  • cryotherapy;
  • high-intensity focused ultrasound (HIFU); or
  • focal salvage treatment in carefully selected cases.

No single salvage treatment is best for every patient. Available studies are mostly non-randomised and use differing definitions. A large meta-analysis found broadly similar five-year cancer control among local salvage methods, but severe urinary toxicity was higher after salvage prostatectomy than after modern re-irradiation approaches. Treatment should therefore be selected through shared decision-making rather than on cancer-control figures alone.

The bottom line

Radical prostatectomy after prostate radiotherapy is possible and can be curative, but it is not a routine operation. The best candidate is generally a fit man with biopsy-proven, clinically significant recurrence confined to the prostate, no metastatic disease on appropriate staging, a meaningful life expectancy and a clear understanding of the potential functional consequences.

Accurate staging, confirmation by biopsy, assessment of baseline urinary function and review by an experienced multidisciplinary team are essential. The decision must balance the chance of durable cancer control against the higher risks of urinary incontinence, erectile dysfunction, urinary narrowing, poor healing and rectal complications.

This article provides general information and does not replace individual medical advice. Recommendations should be tailored to the pathology, imaging, previous radiation treatment, general health and preferences of each patient.

References

  1. European Association of Urology. EAU Guidelines on Prostate Cancer: Treatment—management of PSA failure after radiation therapy and salvage radical prostatectomy. Current online edition. https://uroweb.org/guidelines/prostate-cancer/chapter/treatment
  2. Morgan TM, et al. Salvage Therapy for Prostate Cancer: AUA/ASTRO/SUO Guideline. Journal of Urology. 2024. https://www.auanet.org/guidelines-and-quality/guidelines/salvage-therapy-for-prostate-cancer
  3. Valle LF, et al. A systematic review and meta-analysis of local salvage therapies after radiotherapy for prostate cancer (MASTER). European Urology. 2021;80(3):280–292. doi:10.1016/j.eururo.2020.11.010.
  4. Grubmüller B, et al. Salvage radical prostatectomy for radio-recurrent prostate cancer: an updated systematic review of oncological, histopathological and functional outcomes and predictors. European Urology Focus. 2021;7(5):967–978.
  5. Perera M, et al. Morbidity of salvage radical prostatectomy: limited impact of the minimally invasive approach. European Urology Open Science. 2022;39:64–72.
  6. Zumsteg ZS, et al. The natural history and predictors of outcome following biochemical relapse in the dose-escalation era for prostate cancer patients undergoing definitive external beam radiotherapy. European Urology. 2015;67(6):1009–1016.

 

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

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

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

How does Parkinson’s affect the bladder?

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

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

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

Common urinary symptoms

People may experience:

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

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

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

How is the bladder evaluated?

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

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

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

Are urodynamic studies always necessary?

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

Urodynamics may be particularly useful when:

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

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

First steps: practical and behavioural treatment

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

Useful measures include:

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

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

Medication options

Antimuscarinic medicines

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

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

Beta-3 agonists

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

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

If emptying is the main problem

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

Botox injections into the bladder

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

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

Important risks include:

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

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

Can sacral neuromodulation be used in Parkinson’s disease?

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

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

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

Points to consider include:

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

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

Botox or sacral neuromodulation?

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

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

When should you seek prompt medical attention?

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

The take-home message

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

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

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

References and further reading

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

 

Vesico-ureteric reflux: when urine travels in the wrong direction

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Vesico-ureteric reflux, also called vesicoureteral reflux or VUR, occurs when urine flows backwards from the bladder into one or both ureters and sometimes as far as the kidneys.

Normally, each ureter enters the bladder through a short tunnel in the bladder wall. As the bladder fills and contracts, this tunnel is compressed, acting like a one-way valve. In VUR, the valve does not close effectively.

VUR itself does not always cause symptoms. Its importance is that infected urine may travel towards the kidneys, increasing the risk of pyelonephritis, renal scarring and, in a small number of higher-risk patients, long-term kidney damage.

Primary and secondary reflux

Primary VUR

Primary VUR is usually a developmental condition. The ureter’s tunnel through the bladder wall is too short or positioned in a way that prevents reliable closure. It is most commonly diagnosed in infancy or childhood.

As a child grows, the bladder and ureteric junction mature. For this reason, many cases particularly lower-grade reflux, improve or resolve without surgery.

Secondary VUR

Secondary reflux develops because pressure within the bladder is abnormally high or because the bladder does not empty properly. Causes may include:

  • posterior urethral valves or another bladder-outlet obstruction
  • dysfunctional voiding
  • constipation and bladder–bowel dysfunction
  • neurogenic bladder, including spina bifida or spinal cord disease
  • urethral stricture or an enlarged prostate in adults
  • previous bladder or ureteric surgery
  • a poorly compliant, high-pressure bladder.

Treating the underlying bladder or outlet problem is essential. Correcting the reflux alone may fail if the bladder remains unsafe or under excessive pressure.

How does VUR present in children?

Most children do not feel the reflux itself. It is commonly discovered while investigating a urinary tract infection.

Possible presentations include:

  • a fever without an obvious cause, particularly in an infant
  • recurrent urinary tract infections
  • febrile UTIs or kidney infections
  • vomiting, lethargy, irritability or poor feeding in babies
  • abdominal, loin or back pain
  • painful or frequent urination
  • urinary urgency or wetting
  • poor urinary stream or straining
  • antenatal ultrasound showing hydronephrosis or an abnormal urinary tract
  • poor growth
  • high blood pressure or impaired kidney function in more advanced reflux nephropathy.

A child with fever, vomiting, flank pain or marked lethargy may have pyelonephritis and should receive prompt medical assessment.

How does VUR present in adults?

VUR is much less commonly diagnosed for the first time in adulthood. Some adults have persistent congenital reflux that was never detected in childhood, while others develop secondary reflux due to bladder dysfunction or obstruction.

Adults may present with:

  • recurrent febrile UTIs
  • repeated kidney infections
  • loin or flank pain
  • renal scarring found on imaging
  • high blood pressure
  • protein or blood detected in the urine
  • reduced kidney function
  • pregnancy-associated urinary infections
  • lower urinary tract symptoms or incomplete bladder emptying.

Adult VUR should prompt assessment for an underlying cause such as bladder-outlet obstruction, neurogenic bladder, poor bladder compliance or dysfunctional voiding. The evidence guiding adult treatment is less extensive than the paediatric literature, so management is individualised.

How is VUR investigated?

Not every child who has one uncomplicated UTI requires an invasive reflux study. Imaging is selected according to age, clinical presentation, ultrasound findings and whether the infection is atypical or recurrent.

Urine testing

Urinalysis and urine culture confirm infection and help guide antibiotic treatment. A properly collected urine specimen is particularly important in babies and young children.

Kidney and bladder ultrasound

Ultrasound is painless and does not use radiation. It can assess:

  • kidney size and development
  • hydronephrosis or ureteric dilatation
  • bladder-wall appearance
  • congenital urinary abnormalities
  • residual urine after voiding.

A normal ultrasound does not completely exclude VUR.

Micturating cystourethrogram

A micturating cystourethrogram, also called an MCUG or VCUG, is the standard test for confirming and grading reflux.

A small catheter is placed into the bladder, contrast is introduced, and X-ray images are taken while the bladder fills and during urination. The test shows whether contrast travels backwards into the ureters or kidneys and also provides information about the bladder and urethra.

Because catheterisation and a small radiation exposure are involved, MCUG is generally reserved for children in whom the result is likely to influence management.

Contrast-enhanced voiding urosonography

In centres where it is available, contrast-enhanced ultrasound can identify reflux without ionising radiation. Availability and local expertise vary, and conventional MCUG may still be required when detailed urethral anatomy needs assessment.

DMSA renal scan

A DMSA scan assesses the functioning renal cortex and can identify established renal scars. It is not required for every child but may be considered after recurrent febrile infections, in higher-grade reflux, when ultrasound is abnormal or when renal damage is suspected.

Additional assessment

Depending on the circumstances, investigation may also include:

  • blood pressure measurement
  • serum creatinine and estimated kidney function
  • urine protein assessment
  • a bladder and bowel history
  • uroflowmetry and measurement of residual urine
  • a bladder diary
  • urodynamic studies when a high-pressure, neurogenic or poorly emptying bladder is suspected
  • CT or other upper-tract imaging in selected adults.

The five grades of reflux

VUR is graded from I to V according to the international grading system.

Grade Imaging appearance General interpretation
Grade I Reflux reaches the ureter but not the kidney Mild
Grade II Reflux reaches the renal pelvis without dilatation Mild
Grade III Mild to moderate dilatation of the ureter and renal collecting system Moderate
Grade IV Moderate ureteric and collecting-system dilatation with some twisting of the ureter High-grade
Grade V Severe dilatation and tortuosity with loss of normal calyceal detail Severe

The grade is important, but it is not the only factor determining treatment. Age, recurrent infections, kidney scarring, bladder and bowel function, whether reflux affects one or both sides, and family preferences all matter.

What is the aim of treatment?

Treatment aims to:

  • prevent febrile UTIs and pyelonephritis
  • reduce the risk of further renal scarring
  • preserve kidney function
  • treat bladder, bowel or outlet dysfunction
  • avoid unnecessary medication, radiation and surgery.

It is important to understand that repairing reflux cannot reverse established renal scars. Treatment is intended to prevent further infection and injury.

Observation and conservative management

Observation is appropriate for many children, particularly those with lower-grade reflux, healthy kidneys and no recurrent febrile infections.

Conservative care may include:

  • prompt urine testing when fever or urinary symptoms occur
  • regular and complete bladder emptying
  • adequate fluid intake
  • avoiding prolonged holding of urine
  • treating constipation
  • timed voiding
  • management of daytime wetting or dysfunctional voiding
  • periodic clinical and ultrasound review.

Lower-grade reflux is more likely to resolve as the child grows. Higher grades, bilateral reflux and reflux associated with renal abnormalities are less likely to resolve spontaneously.

Continuous low-dose antibiotic prophylaxis

A low dose of antibiotic may be prescribed daily to reduce recurrent infections while waiting for reflux to improve or while deciding whether intervention is required.

Prophylaxis is more likely to be considered in:

  • infants with VUR following a febrile UTI
  • recurrent febrile UTIs
  • higher-grade reflux
  • bladder–bowel dysfunction
  • renal cortical abnormalities
  • children considered at increased risk of another kidney infection.

Antibiotics can reduce recurrent UTIs in appropriately selected children, but they do not mechanically correct the reflux. Disadvantages include medication side effects, adherence difficulties and antibiotic resistance. The need for ongoing prophylaxis should therefore be reviewed rather than continued automatically.

Treating bladder and bowel dysfunction

Constipation, urinary urgency, wetting, infrequent voiding and incomplete bladder emptying increase the risk of recurrent infection and may reduce the success of reflux treatment.

Management can include:

  • regular timed voiding
  • relaxed toilet posture
  • treatment of constipation
  • pelvic-floor or continence physiotherapy
  • medication for selected bladder conditions
  • intermittent self-catheterisation when emptying is inadequate.

In secondary reflux, treating the bladder or outlet disorder may reduce or occasionally eliminate the reflux.

When is a procedure considered?

Intervention may be discussed when there is:

  • a febrile breakthrough UTI despite appropriate prophylaxis
  • recurrent pyelonephritis
  • new or progressive renal scarring
  • persistent high-grade reflux
  • reflux unlikely to resolve spontaneously
  • difficulty tolerating or adhering to antibiotic prophylaxis
  • an anatomical abnormality requiring correction
  • significant family preference after discussion of the alternatives
  • persistent symptomatic reflux in a carefully selected adult.

The two main corrective options are endoscopic injection and ureteric reimplantation.

The STING procedure

STING stands for subureteric transurethral injection. A small telescope is passed through the urethra into the bladder under anaesthesia. A bulking material is injected beneath or within the lower end of the ureter to support and lengthen the valve mechanism.

Dextranomer/hyaluronic-acid copolymer, commonly known by the brand name Deflux, is the best-known injection material. Modified techniques such as HIT or double-HIT place the material within the intramural ureter rather than only beneath its opening.

Advantages

  • minimally invasive
  • no abdominal incision
  • usually performed as day surgery
  • relatively short anaesthetic and recovery
  • low risk of major complications
  • can be repeated if reflux persists.

Limitations and risks

  • success is lower and less predictable than formal reimplantation
  • results are generally better for lower grades of reflux
  • more than one injection may be required
  • reflux may persist or recur
  • temporary blood in the urine, discomfort or infection can occur
  • ureteric obstruction is uncommon but important
  • reflux may occasionally appear on the opposite side
  • long-term durability is not as certain as with successful reimplantation.

Published cure rates vary considerably because they depend on reflux grade, anatomy, injection technique, material used and how success is defined. A single injection commonly corrects approximately 70–80% of refluxing ureters overall, with lower success in grades IV–V. Additional injections can increase the cumulative success rate.

Ureteric reimplantation

Ureteric reimplantation is reconstructive surgery that creates a longer tunnel for the ureter through the bladder wall, restoring the one-way valve mechanism.

The operation may be performed using:

  • an open extravesical approach
  • an open intravesical approach
  • laparoscopic surgery
  • robot-assisted surgery in selected centres and patients.

Open reimplantation has a long-established success rate of approximately 95–98% for primary VUR when performed in suitable patients.

Advantages

  • highest and most durable anatomical correction rate
  • effective for high-grade reflux
  • allows correction of some associated ureteric abnormalities
  • usually requires only one definitive operation.

Limitations and risks

  • more invasive than injection
  • longer anaesthetic and recovery
  • temporary bladder spasms, pain or blood in the urine
  • urinary infection
  • transient urinary retention, particularly after some bilateral extravesical repairs
  • ureteric obstruction
  • persistent reflux or reflux on the opposite side
  • rare need for further surgery.

Robotic or laparoscopic reimplantation can reduce incision size, but it is still major reconstructive surgery and has not made open surgery obsolete. The best approach depends on the child’s anatomy, age, surgeon’s expertise and the reason for intervention.

STING versus reimplantation

Consideration Endoscopic injection Ureteric reimplantation
Invasiveness Minimally invasive Reconstructive surgery
Typical stay Usually day surgery Often one or more nights
Recovery Generally quicker Longer
Success after one procedure Lower and grade-dependent Approximately 95–98%
Repeat treatment Sometimes required Uncommon after successful repair
Best suited to Selected low- or moderate-grade reflux and families prioritising minimal invasiveness High-grade, persistent or complicated reflux; failed injection; selected anatomical abnormalities
Main trade-off Easier recovery but less predictable cure More invasive but more reliable correction

Neither operation is automatically “best.” STING may be attractive when a minimally invasive approach is preferred and its probability of success is acceptable. Reimplantation may be more appropriate when the highest likelihood of definitive correction is important.

VUR in adults

Adults with incidentally detected reflux and no infections, renal deterioration or high-pressure bladder may not require corrective surgery.

Treatment is more likely to be considered when there is:

  • recurrent febrile UTI or pyelonephritis
  • progressive kidney damage
  • troublesome reflux-associated flank pain
  • an untreated bladder-outlet or functional abnormality
  • pregnancy planning in a patient with recurrent infections or reflux nephropathy.

The underlying bladder problem must be identified before anti-reflux surgery. Endoscopic injection can be effective in selected adults, although the supporting evidence is mainly from smaller observational studies. Ureteric reimplantation remains an option when a durable anatomical repair is required.

Women with previous VUR or reflux nephropathy who are considering pregnancy may benefit from pre-pregnancy assessment of blood pressure, kidney function, urine protein and infection risk.

Follow-up

Follow-up should be tailored to reflux grade, renal findings, treatment and infection history.

During observation

Review may include:

  • interval history of UTIs or unexplained fevers
  • height, weight and growth in children
  • blood pressure
  • urine testing when symptoms occur
  • assessment of constipation and bladder symptoms
  • renal and bladder ultrasound
  • serum creatinine and urine protein testing when renal damage is present or suspected
  • selective repeat MCUG, contrast-enhanced urosonography or radionuclide cystography
  • DMSA scanning when new scarring is suspected.

Routine repeated invasive imaging is not necessary for every child. The timing and type of imaging should be chosen only when the result is likely to alter management.

After STING

Follow-up commonly includes an ultrasound to exclude obstruction and clinical monitoring for further UTIs. A repeat reflux study may be recommended after several months, particularly in high-grade reflux, recurrent febrile infection or when confirmation of cure will affect treatment.

Any fever or urinary symptoms after injection should prompt urine testing. Flank pain, vomiting, reduced urine output or significant hydronephrosis requires assessment for the uncommon complication of ureteric obstruction.

After reimplantation

Ultrasound is commonly performed after surgery to check drainage. Routine postoperative MCUG may not be necessary after an uncomplicated reimplantation with a reassuring recovery, but it may be appropriate after breakthrough infection, persistent hydronephrosis or an atypical clinical course.

Long-term surveillance

Patients with renal scarring, bilateral severe reflux, a solitary functioning kidney, proteinuria, hypertension or impaired renal function may require long-term follow-up into adulthood.

Monitoring can include:

  • blood pressure
  • kidney function
  • urine protein
  • recurrent infection
  • pregnancy counselling when relevant.

Even when reflux has resolved, established reflux nephropathy can remain clinically important.

When should urgent medical advice be sought?

Seek prompt medical assessment for:

  • fever with loin or back pain
  • vomiting or marked lethargy
  • reduced urine output
  • a very unwell infant
  • urinary symptoms during pregnancy
  • fever or flank pain after a reflux procedure.

Early diagnosis and treatment of pyelonephritis are particularly important in patients with known VUR.

The key message

Vesico-ureteric reflux ranges from a mild childhood condition that resolves with growth to high-grade reflux associated with recurrent kidney infections and renal scarring.

Treatment should not be based on grade alone. The safest plan considers infection history, kidney health, age, bladder and bowel function, likelihood of spontaneous resolution and the advantages and disadvantages of observation, antibiotic prophylaxis, endoscopic injection and ureteric reimplantation.

References and further reading

  1. European Association of Urology. EAU Guidelines on Paediatric Urology: Vesicoureteric reflux. EAU Paediatric Urology Guidelines
  2. American Urological Association. Management and Screening of Primary Vesicoureteral Reflux in Children. AUA Vesicoureteral Reflux Guideline
  3. National Institute for Health and Care Excellence. Urinary tract infection in under 16s: diagnosis and management (NG224). NICE guideline NG224
  4. RIVUR Trial Investigators. Antimicrobial prophylaxis for children with vesicoureteral reflux. New England Journal of Medicine. 2014;370:2367–2376. PubMed
  5. Mattoo TK, Chesney RW, Greenfield SP, et al. Renal scarring in the Randomized Intervention for Children with Vesicoureteral Reflux trial. Clinical Journal of the American Society of Nephrology. 2016;11:54–61. PubMed
  6. Läckgren G, Cooper CS, Neveus T, Kirsch AJ. Management of vesicoureteral reflux: what have we learned over the last 20 years? Frontiers in Pediatrics. 2021;9:650326. Full text
  7. Salib A, Pizzi M, Landman J, et al. Vesicoureteral reflux in adults with urinary tract infections: is there a role for treatment? Current Urology Reports. 2020. PubMed record

This article provides general education and does not replace individual medical advice. Decisions about imaging, antibiotic prophylaxis or surgery should be made with an appropriately experienced urologist or paediatric urologist.

Recurrent Urinary Tract Infections: Causes, Investigation and Prevention

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

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

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

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

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

What symptoms suggest a UTI?

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

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

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

Is it always an infection?

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

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

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

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

Why do urinary infections keep returning?

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

Common contributing factors in women

These include:

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

Causes that are particularly important in men

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

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

How are recurrent UTIs investigated?

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

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

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

Treating an acute infection

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

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

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

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

A stepwise prevention strategy

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

1. Hydration and bladder habits

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

Other practical measures include:

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

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

2. Vaginal oestrogen

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

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

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

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

3. Methenamine hippurate

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

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

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

4. Cranberry products

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

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

5. D-mannose

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

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

6. Probiotics

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

Prophylactic antibiotics

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

Post-coital prophylaxis

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

Continuous low-dose prophylaxis

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

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

Potential disadvantages include:

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

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

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

Bladder instillations

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

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

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

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

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

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

Are vaccines available for recurrent UTIs?

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

Examples include:

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

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

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

When should you seek urgent help?

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

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

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

The take-home message

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

A sensible strategy is to:

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

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

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

References and further reading

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

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