When the body interrupts the life we thought we were living

Men spend a remarkable amount of their lives trying to move upward.

We grow up. We become stronger. We learn. We compete. We establish careers, relationships and families. We accumulate skills, responsibilities, possessions and, hopefully, a little wisdom along the way.

We build an identity.

Then, sometimes quite unexpectedly, life introduces the downward staircase.

A prostate cancer diagnosis. Erectile dysfunction. Urinary leakage after prostate surgery. An enlarged prostate. Infertility. Testicular cancer. Chronic pelvic pain. A catheter. The discovery that our bladder has apparently developed its own personality.

Suddenly the body that we hardly thought about has become impossible to ignore.

For many men, a health problem is therefore more than a medical diagnosis. It can challenge masculinity, independence, sexuality, confidence, relationships and our assumptions about ageing.

The writings of Franciscan priest and spiritual teacher Richard Rohr offer an interesting way of understanding this experience.

Rohr suggests that human development is not simply a continuous climb towards greater success, control and independence. Paradoxically, some of our deepest development may begin when that climb is interrupted.

Sometimes we grow by descending.

And sometimes what initially feels like falling down becomes a way of falling upward.

Who is Richard Rohr?

Richard Rohr is an American Franciscan friar, Catholic priest, author and ecumenical spiritual teacher. He founded the Center for Action and Contemplation (CAC) in Albuquerque, New Mexico, in 1987 and has spent decades teaching about Christian spirituality, contemplation, human development and transformation.

His books include Everything Belongs, Breathing Under Water, The Universal Christ, Immortal Diamond and perhaps most relevant to this discussion, Falling Upward: A Spirituality for the Two Halves of Life.

Rohr has also devoted considerable attention to male spirituality and the formation of men. His work has resonated with men trying to understand identity, fatherhood, vulnerability, ageing, suffering and what it means to mature beyond achievement and status.

His significance does not lie in providing medical or psychological theories. He is a spiritual teacher.

Rather, Rohr gives us a language for something medicine sees every day:

A man can be physically diminished by an experience while simultaneously becoming deeper because of it.

The Two Halves of Life

One of Rohr’s best-known ideas is that life contains what he calls the two halves of life.

These are not simply determined by age.

You do not automatically enter the second half of life on your 50th birthday, preferably after receiving a letter from your superannuation fund and discovering your prostate has doubled in size.

They describe different ways of understanding ourselves.

In the first half of life, our task is largely to construct an identity.

We establish:

• Who am I?
• What do I believe?
• Where do I belong?
• What am I good at?
• What can I achieve?
• How do other people see me?
• Can I provide for myself and my family?

Rohr describes this as constructing the container of our lives.

And it is necessary.

Young men need ambition, boundaries, confidence, competence and identity.

The problem arises when we mistake the container for its contents.

At some point the deeper question becomes:

What was I building all of this for?

Rohr describes the movement from the outer task towards this deeper inner task as characteristic of the second half of life. Importantly, this transition is not necessarily connected with chronological ageing.

The Ascent

The first part of life is often an ascent.

A boy becomes a man.

He develops strength and independence.

He studies.

He works.

He competes.

He finds a partner.

Perhaps he becomes a father.

He builds a career.

He becomes responsible for others.

There is nothing inherently wrong with this ascent.

Quite the opposite.

We need it.

The difficulty comes when our entire identity becomes attached to the things we have accumulated during the climb:

strength, sexual performance, status, productivity, physical appearance, money, professional success and control.

Then something happens.

Life refuses to follow the script.

The Descent

The descent may come through failure, divorce, bereavement, redundancy, ageing, disappointment or illness.

For many men, it comes through the body.

And this is where urology becomes surprisingly relevant.

Consider the man diagnosed with prostate cancer.

Yesterday he was working, exercising, travelling and planning his future.

Today he is discussing cancer staging, continence, erections and survival.

Or the man who develops erectile dysfunction.

Something that previously happened almost without thought suddenly requires tablets, injections, devices or surgery.

Or the man who leaks urine following prostate surgery.

A highly competent adult who has spent decades being independent may suddenly find himself discussing pads and pelvic-floor exercises.

These experiences can feel humiliating.

They can also expose something deeper.

“I Thought I Was in Control”

One of the hardest lessons illness teaches is remarkably simple:

We are not completely in control.

We can exercise.

We can eat well.

We can attend medical check-ups.

We can stop smoking.

We can monitor our PSA.

All of these things matter.

But none of them gives us a contract guaranteeing perfect health.

Rohr’s spirituality repeatedly returns to the idea that transformation often begins when our usual systems of control stop working. His image of “falling upward” describes the possibility that failure, suffering or loss can open a person to a broader and deeper understanding of life.

That does not mean illness is good.

Cancer is not a gift that someone ought to be grateful for.

Incontinence is not spiritually necessary.

Erectile dysfunction does not automatically make anyone wiser.

Suffering can simply hurt.

The important distinction is this:

We do not always choose what happens to us, but over time we may have some choice about what we allow the experience to teach us.

Urological Illness Strikes at Some Particularly Male Vulnerabilities

Urology deals with parts of the body closely connected with masculine identity.

The penis.

The testes.

The prostate.

Sexual function.

Fertility.

Urinary control.

Because of this, relatively small physical changes can have enormous psychological consequences.

A man may quietly interpret erectile dysfunction as:

“I am no longer a real man.”

He may interpret urinary leakage as:

“I have lost control.”

Infertility may become:

“I have failed.”

Prostate cancer may become:

“My body has betrayed me.”

After surgery he may think:

“My partner won’t see me in the same way.”

These conclusions can be far more damaging than the physical problem itself.

Part of good urological care is therefore separating the condition a man has from the man he believes he has become because of it.

Your Penis Is Important. It Is Not Your Entire Biography.

Men can attach an extraordinary amount of identity to sexual performance.

This is understandable.

Sexuality matters.

Intimacy matters.

Erections matter.

But erectile function is not a reliable measurement of masculinity.

An erection is a complicated neurovascular event involving the brain, nerves, blood vessels, hormones and psychological state.

It is physiology.

It is not a character reference.

A man can have erectile dysfunction and remain masculine, attractive, intimate, loving and sexually connected.

Likewise, losing a testicle does not make someone half a man.

Needing continence pads does not make someone childish.

Having prostate surgery does not remove masculinity.

And asking for help certainly does not diminish it.

These distinctions can be surprisingly difficult when we have spent decades unconsciously linking masculinity with strength, independence and sexual capability.

The Body Eventually Invites Every Man Down the Mountain

At 20, the body can feel indestructible.

At 40, it begins occasionally submitting complaints.

At 60, it starts sending formal correspondence.

And eventually most of us discover that ageing is not a design flaw.

Testosterone changes.

Prostates enlarge.

Erections may become less reliable.

Muscle mass decreases.

Bladders become more temperamental.

Recovery takes longer.

The male body gradually teaches a lesson the young man rarely wants to hear:

Strength is temporary.

Rohr’s challenge is not that we should despair about this.

It is that the second journey can lead somewhere the first cannot.

The goal changes from proving ourselves to knowing ourselves.

From achievement towards meaning.

From independence towards interdependence.

From certainty towards curiosity.

From controlling life towards participating in it.

The Descent Can Happen at Any Age

It would be a mistake to think Rohr’s “second half of life” begins only in old age.

A 28-year-old diagnosed with testicular cancer may confront mortality earlier than a healthy 75-year-old.

A young man experiencing infertility may suddenly question assumptions he has held since childhood.

A 40-year-old with erectile dysfunction may confront vulnerability for the first time.

A 55-year-old diagnosed with aggressive prostate cancer may completely reconsider his priorities.

A 70-year-old recovering from surgery may discover a depth of intimacy with his partner that he had never previously allowed.

Chronological age and emotional maturity are not the same thing.

The descent arrives according to its own timetable.

From Independence to Interdependence

Many men are taught:

Deal with it yourself.

This can be useful when a tyre needs changing.

It is considerably less useful when dealing with cancer.

Urological illness often forces men to accept help.

From a partner.

A doctor.

A nurse.

A physiotherapist.

A psychologist.

A friend.

Sometimes even from their children.

This can initially feel like weakness.

But perhaps mature masculinity is not independence.

Perhaps it is knowing when independence has reached its limits.

There is strength in competence.

There is another kind of strength in saying:

“I need some help with this.”

Intimacy After Urological Illness

Urological disease can also change relationships.

After prostate cancer treatment, for example, sexual intimacy may require patience, rehabilitation and experimentation.

Erections may be different.

Orgasm may feel different.

Ejaculation may disappear following prostate removal.

Urinary leakage may temporarily interfere with confidence.

Some couples withdraw from intimacy because neither partner knows how to begin the conversation.

Yet intimacy is much larger than erectile performance.

Touch.

Affection.

Humour.

Conversation.

Vulnerability.

Sexual experimentation.

Companionship.

Trust.

These can become increasingly important when the body no longer behaves exactly as it did at 25.

Paradoxically, some couples discover greater intimacy precisely because they can no longer rely on automatic sexual function.

They have to communicate.

The descent becomes an invitation to a different kind of closeness.

The Man Who Emerges

Rohr’s “falling upward” does not mean returning to exactly the person we were before the fall.

Sometimes we cannot.

The prostate is not coming back after radical prostatectomy.

A removed testicle cannot be restored.

Ageing cannot be reversed.

The challenge becomes something different:

Can I incorporate what has happened into a larger understanding of who I am?

The man who emerges may be less certain but more compassionate.

Less physically powerful but more emotionally available.

Less interested in impressing others.

More comfortable asking difficult questions.

More appreciative of his partner.

More aware of mortality.

More grateful for ordinary days.

Less frightened of appearing vulnerable.

That is not necessarily decline.

It may be maturation.

The Urologist’s Job Is Still to Treat the Problem

There is an important caution here.

Philosophy should never replace medicine.

If you have difficulty urinating, see your doctor.

If you have blood in the urine, have it investigated.

If you discover a testicular lump, seek medical attention promptly.

If erectile dysfunction develops, investigate the possible physical and psychological causes.

If your PSA is abnormal, discuss appropriate assessment.

If you are struggling psychologically following cancer or changes in sexual or urinary function, psychological support can be extremely valuable.

We should never romanticise illness when effective treatment is available.

Treat what can be treated. Rehabilitate what can be rehabilitated. Prevent what can be prevented.

And then recognise that sometimes medicine can repair the body without answering every question the experience has raised.

Perhaps There Is Another Kind of Men’s Health

We usually define men’s health through measurable things:

PSA.

Blood pressure.

Cholesterol.

Testosterone.

Weight.

Urinary flow.

Erectile function.

Cancer survival.

All are important.

But perhaps there is another dimension.

Can a man tolerate vulnerability?

Can he talk to his partner?

Can he ask for help?

Can he adapt when his body changes?

Can he distinguish sexual function from personal worth?

Can he remain connected when embarrassed?

Can he face ageing without believing that ageing makes him irrelevant?

Can he accept mortality without abandoning life?

These questions will never appear on a pathology request form.

But they matter.

From Ascent to Descent and Back Again

Richard Rohr’s Falling Upward proposes that the second half of the human journey can contain profound spiritual richness rather than simply representing decline. His central paradox is that what appears to be a fall may become movement into a larger and deeper life.

Urological illness gives this idea an unexpectedly practical setting.

A prostate cancer diagnosis.

Loss of erections.

Incontinence.

Infertility.

Testicular disease.

Ageing.

These experiences may temporarily take something away.

But they do not take away the person.

For the younger man, the lesson may be that masculinity is broader than performance.

For the middle-aged man, it may be that identity is larger than career, strength and sexuality.

For the older man, it may be discovering that physical decline does not necessarily mean personal decline.

And for every man, perhaps the invitation is similar.

Build.

Climb.

Achieve.

Love your strength while you have it.

But when life eventually asks you to descend, do not automatically assume you are travelling in the wrong direction.

Sometimes the road downward leads somewhere that the road upward could never reach.

Sometimes losing a little control allows us to discover what actually matters.

And sometimes, in Richard Rohr’s memorable language, we discover that we have been falling upward all along.

Richard Rohr’s Work in Australia: Centre for Men and Families

For Australian men interested in exploring these ideas beyond reading, the Centre for Men and Families (CFMF), formerly known as Centre for Men Australia, provides an important local connection to Richard Rohr’s work.

The organisation has supported men and families in Australia for more than 25 years, providing men’s groups, counselling, retreats, community programs and Men’s Rites of Passage (MROP).

Its Men’s Rites of Passage tradition has a direct connection with Richard Rohr and the Center for Action and Contemplation in the United States. The Australian program uses initiation, time in nature, reflection, ritual and the company of other men to explore masculinity, vulnerability, relationships, grief, purpose and the transition towards a more mature understanding of what it means to be a man.

This has particular relevance to the themes discussed in this article. A significant health event, including prostate cancer, loss of erectile function, infertility, incontinence or major surgery, can become an unexpected rite of passage of its own. Medicine treats the disease, but men may also need somewhere to explore what the experience has done to their sense of identity, masculinity, relationships and purpose.

The Centre welcomes men from a wide range of backgrounds and beliefs. Its programs are not limited to men who identify with a particular religious tradition.

Learn more:
Centre for Men and Families Australia

Men’s Rites of Passage:
Explore the Australian Men’s Rites of Passage program

Where Can Men Find Support?

Urological illness can affect much more than the urinary or reproductive system. It can touch confidence, masculinity, sexuality, relationships, identity and our sense of purpose.

Medical care remains essential, but sometimes men also benefit from having a place to talk, reflect and connect with other men.

Centre for Men and Families Australia

The Centre for Men and Families (CFMF), formerly Centre for Men Australia, provides programs designed to support men through different stages and transitions in life.

Through men’s circles, counselling, retreats and Men’s Rites of Passage, men can explore relationships, fatherhood, vulnerability, ageing, loss, purpose and what mature masculinity might look like when life does not follow the expected script.

Explore the Centre for Men and Families:
https://cfmf.org.au/

Men’s Rites of Passage:
https://cfmf.org.au/events/rites-of-passage/

For a man facing prostate cancer, erectile dysfunction, infertility, incontinence, major surgery or another significant health challenge, asking for support is not an admission of failure.

Sometimes the most important part of the journey is discovering that you do not have to make the descent alone.

Further reading

Richard Rohr, Falling Upward: A Spirituality for the Two Halves of Life.

Richard Rohr, Adam’s Return: The Five Promises of Male Initiation.

Richard Rohr, Immortal Diamond: The Search for Our True Self.

Richard Rohr, The Universal Christ.

The Center for Action and Contemplation provides further material on Rohr’s teachings concerning contemplation, male spirituality, transformation and the two halves of life.

Medical disclaimer

This article discusses the emotional, philosophical and spiritual dimensions that may accompany men’s health problems. It is not intended to suggest that illness is desirable or that spiritual reflection is a substitute for medical or psychological treatment. New or concerning urinary, genital or sexual symptoms should be assessed by an appropriately qualified healthcare professional.

Delayed ejaculation is a male sexual difficulty in which it takes an unusually long time to reach orgasm and ejaculate, or ejaculation does not occur at all, despite adequate sexual stimulation and the desire to climax.

There is no stopwatch that defines what is “normal”. Some men naturally take longer than others. Delayed ejaculation becomes a problem when the delay is persistent, causes frustration or distress, interferes with sexual enjoyment, or affects a relationship.

At the extreme end of the spectrum, a man may be unable to ejaculate at all. This is known as anejaculation.

The important message is that delayed ejaculation is a genuine sexual health problem. It is often caused by several factors acting together, and in many men it can be improved.

How Long Is Too Long?

There is no universally accepted time limit.

Some clinical definitions have suggested ejaculation taking approximately 25–30 minutes or longer, but time alone does not make the diagnosis.

A man who takes 30 minutes and is perfectly happy may not have a problem. Another man who previously ejaculated within 5–10 minutes and now cannot reach orgasm despite prolonged stimulation may be considerably distressed.

The more useful question is:

“Is ejaculation taking substantially longer than you would like, or have you become unable to ejaculate when you want to?”

Delayed ejaculation may be:

Lifelong – the difficulty has been present since the beginning of a man’s sexual life.

Acquired – ejaculation was previously normal but has become progressively or suddenly more difficult.

It may also be:

Generalised – occurring during masturbation as well as partnered sexual activity.

Situational – occurring only in particular circumstances. For example, a man may be able to orgasm during masturbation but struggle during intercourse.

That distinction can provide an important clue to the underlying cause.

Ejaculation Is More Complicated Than It Looks

Ejaculation is not simply a penile reflex.

Successful orgasm and ejaculation require cooperation between the:

• brain
• spinal cord
• autonomic nervous system
• sensory nerves from the penis
• pelvic floor muscles
• prostate and seminal tract
• hormones
• erectile response
• psychological state
• sexual stimulation and arousal

Think of it as a rather complicated neurological relay race. If one runner slows down, the finish line may suddenly become surprisingly difficult to reach.

What Causes Delayed Ejaculation?

Frequently there is more than one contributing factor.

Medications

Medication is one of the most important reversible causes.

Particular attention should be given to antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) and related medications. These drugs can be extremely effective treatments for depression and anxiety but may significantly delay orgasm and ejaculation.

Other medications that may contribute include certain:

• antidepressants
• antipsychotics
• anti-anxiety medications
• opioid pain medications
• blood pressure medications
• alpha-blockers
• medications acting on the central nervous system

If the problem started after beginning a new medication or increasing its dose, this is worth discussing with your doctor.

Do not stop antidepressants or other prescribed medications suddenly. Medication changes should be discussed with the prescribing doctor.

Ageing and Reduced Penile Sensation

Ejaculation often takes longer with increasing age.

Changes can include reduced penile sensitivity, slower nerve transmission, altered erectile quality and a greater amount of stimulation being required to achieve orgasm.

This does not mean that satisfactory sexual function has an expiry date. It may simply mean that the stimulation that worked at 30 may need some renovation at 60 or 70.

Diabetes and Nerve Problems

Ejaculation depends heavily on normal nerve function.

Conditions that can interfere with these pathways include:

• diabetes
• diabetic neuropathy
• multiple sclerosis
• spinal cord disease or injury
• pelvic nerve injury
• previous major pelvic surgery
• neurological disorders

Diabetes is particularly important because long-standing elevated blood glucose can damage the small autonomic and sensory nerves involved in erection, orgasm and ejaculation.

Hormonal Causes

Hormonal abnormalities occasionally contribute to delayed ejaculation or reduced orgasmic intensity.

These may include:

• testosterone deficiency
• thyroid abnormalities
• prolactin disorders

Low testosterone is more commonly associated with reduced sexual desire and arousal than isolated delayed ejaculation, but hormone testing may be appropriate when other symptoms are present.

Erectile Dysfunction

Erectile dysfunction and delayed ejaculation frequently overlap.

A man may be able to obtain an erection but gradually lose rigidity during prolonged intercourse. Attention then shifts from sexual pleasure to maintaining the erection:

“Am I losing it?”

That thought alone can interrupt arousal.

Treatment of associated erectile dysfunction can therefore sometimes make ejaculation easier.

Psychological and Relationship Factors

The brain is one of the most important sexual organs involved in ejaculation.

Stress, anxiety, depression and relationship difficulties can all interfere with the normal progression from sexual stimulation to arousal, orgasm and ejaculation.

Common contributors include:

• performance anxiety
• relationship conflict
• fear of disappointing a partner
• previous negative sexual experiences
• depression
• general anxiety
• excessive concentration on “trying to finish”
• reduced attraction or sexual excitement
• difficulty communicating sexual preferences
• cultural or religious inhibition surrounding sexuality

A particularly frustrating cycle can develop:

Difficulty ejaculating → trying harder → increased pressure → reduced arousal → even greater difficulty ejaculating.

Sex begins to feel like an examination rather than an experience.

Breaking that cycle can be an important part of treatment.

Masturbation Style and Sexual Conditioning

This is worth discussing openly because it is surprisingly common.

Some men develop a very specific masturbation technique involving a particular:

• pressure
• speed
• grip
• position
• fantasy
• visual stimulus

The nervous system becomes accustomed to that very specific form of stimulation.

Partnered sexual activity may then provide a different type or intensity of stimulation, making orgasm considerably more difficult.

This does not mean masturbation is harmful.

Rather, the issue may be a mismatch between the stimulation the brain has learned to associate with orgasm and the stimulation occurring during partnered sex.

Changing masturbation technique, reducing excessive pressure and introducing greater variation may help.

Alcohol and Recreational Drugs

Small amounts of alcohol may reduce inhibition, but larger quantities can impair:

• erection
• penile sensation
• arousal
• orgasm
• ejaculation

Reducing excessive alcohol intake may therefore improve sexual function.

Previous Pelvic or Prostate Surgery

Operations involving the prostate, bladder neck, pelvis or retroperitoneal nerves can alter ejaculation.

It is important, however, to distinguish delayed ejaculation from retrograde ejaculation or dry orgasm.

Following some prostate procedures, semen may travel backwards into the bladder rather than forwards through the penis.

Following radical prostatectomy, the prostate and seminal vesicles have been removed, so semen is no longer produced and ejaculation cannot occur, although orgasm may still be possible.

These are different conditions and require different counselling.

How Does Delayed Ejaculation Affect a Man?

The physical problem is only part of the story.

Men may experience:

• frustration
• reduced sexual confidence
• performance anxiety
• avoidance of sexual activity
• reduced enjoyment of sex
• difficulty achieving orgasm
• exhaustion during prolonged intercourse
• erection loss before ejaculation
• concerns about masculinity
• fertility difficulties

Some men eventually avoid intimacy because they anticipate another unsuccessful attempt.

That can allow a sexual problem to become a relationship problem.

How Does It Affect a Partner?

Delayed ejaculation can also be difficult for partners.

A partner may incorrectly wonder:

“Does he still find me attractive?”

or:

“Am I doing something wrong?”

Prolonged intercourse can also become physically uncomfortable or exhausting.

Partners may experience:

• frustration
• reduced sexual confidence
• feelings of rejection
• concern about attractiveness
• anxiety about sexual performance
• vaginal discomfort from prolonged intercourse
• reduced intimacy
• relationship tension

This is why communication is so important.

Delayed ejaculation usually should not be interpreted as a measure of attraction, love or the quality of a relationship.

Fertility

Delayed ejaculation can create difficulty when attempting to conceive, particularly when ejaculation cannot occur during vaginal intercourse.

Depending on the cause, options may include collecting semen through masturbation, penile vibratory stimulation or, in selected cases, assisted reproductive techniques.

Men experiencing fertility problems should discuss this specifically with their urologist or fertility specialist.

How Is Delayed Ejaculation Investigated?

The most important investigation is often a good conversation.

Your urologist may ask about:

• when the problem began
• whether it occurs every time
• ejaculation during masturbation
• ejaculation during intercourse
• orgasmic sensation
• penile sensation
• erectile function
• libido
• medications
• alcohol and recreational drugs
• diabetes and neurological conditions
• previous pelvic or prostate surgery
• psychological wellbeing
• relationship factors
• masturbation habits and sexual stimulation

A focused physical examination may also be appropriate.

Blood tests may include, where clinically indicated:

• testosterone
• blood glucose or HbA1c
• thyroid function
• prolactin
• other metabolic investigations

Not every man requires every test. Investigation should be directed by the history.

Can Delayed Ejaculation Be Treated?

Yes, but treatment needs to target the cause.

There is no single tablet that reliably “switches ejaculation back on”.

Management is therefore usually individualised.

1. Review Medications

This is one of the first steps.

If symptoms began after starting an antidepressant or another medication, the prescribing doctor may consider:

• reducing the dose
• changing medication
• altering the treatment regimen
• substituting an alternative drug

This should always be done under medical supervision.

2. Improve Sexual Stimulation

Sometimes the simplest changes are surprisingly useful.

Experimenting with different:

• sexual positions
• stimulation techniques
• pace
• pressure
• manual stimulation
• oral stimulation
• vibratory stimulation
• sexual settings

may increase arousal sufficiently to trigger orgasm.

The goal is not necessarily more stimulation. It is finding the right stimulation.

3. Modify Masturbation Technique

If orgasm is easy during masturbation but difficult with a partner, consider whether masturbation provides a type of stimulation that partnered sex cannot reproduce.

Reducing grip pressure, changing technique and introducing greater variety can sometimes help retrain the sexual response.

4. Penile Vibratory Stimulation

A penile vibrator can provide strong, consistent sensory stimulation and may be useful for selected men, particularly those with reduced penile sensation or neurological impairment.

This can sometimes be incorporated into partnered sexual activity rather than being viewed purely as a medical device.

5. Treat Erectile Dysfunction

If maintaining an erection is part of the problem, treating erectile dysfunction may improve the overall sexual response.

Depending on the individual, this may include lifestyle modification, oral erectile medications or other erectile dysfunction treatments.

6. Address Hormonal Problems

Testosterone replacement may be appropriate when genuine testosterone deficiency has been demonstrated and the patient has compatible symptoms.

Testosterone should not simply be prescribed as a general treatment for delayed ejaculation when testosterone levels are normal.

The Role of Psychology and Sex Therapy

Psychological input can be extremely valuable.

This does not mean the problem is imaginary.

Sexual function sits at the intersection of neurology, hormones, physical sensation, emotion, attention and relationships. Treating only one component can sometimes miss half the picture.

A psychologist or sex therapist experienced in sexual medicine can help address:

• performance anxiety
• excessive focus on ejaculation
• relationship difficulties
• communication
• sexual expectations
• anxiety or depression
• sexual inhibition
• mismatched sexual stimulation
• problematic sexual conditioning

Couples-based therapy can be particularly useful because delayed ejaculation frequently affects both partners.

One important therapeutic goal is to shift the focus away from:

“I have to ejaculate.”

and back towards:

“We are here to enjoy sexual intimacy.”

Paradoxically, removing the pressure to orgasm can sometimes make orgasm considerably easier.

Are There Medications Specifically for Delayed Ejaculation?

At present, there is no medication with strong evidence as a universally effective treatment for delayed ejaculation.

A number of medications have been investigated or used off-label, including drugs that influence dopamine, serotonin and other neurotransmitter systems.

However, evidence for these treatments remains limited and inconsistent.

For this reason, medication should generally be considered only after identifying and addressing reversible causes, and patients should understand the limitations and potential side effects.

Be cautious of internet advertisements promising a guaranteed pharmaceutical cure. Ejaculation has unfortunately not yet been reduced to an on/off button.

What Can I Do to Improve It?

A practical starting plan is:

1. Review your medications with your doctor.
2. Check for erectile dysfunction, diabetes, neurological or hormonal problems.
3. Reduce excessive alcohol consumption.
4. Stop timing yourself. Sexual performance is not an Olympic event.
5. Discuss the problem openly with your partner.
6. Experiment with different stimulation and sexual positions.
7. Consider modifying a very intense or repetitive masturbation technique.
8. Consider vibratory stimulation if additional penile stimulation is helpful.
9. Address anxiety, stress and relationship issues.
10. Consider psychosexual or couples therapy when psychological or relationship factors are contributing.

When Should I See a Urologist?

Consider seeking assessment if:

• ejaculation has become substantially slower than previously
• you frequently cannot ejaculate
• you can ejaculate during masturbation but not with a partner
• orgasm has become weaker or absent
• penile sensation has changed
• you have associated erectile dysfunction
• symptoms began after medication changes
• you have diabetes or neurological disease
• the problem is affecting your relationship
• you are trying to conceive

A sudden unexplained change in sexual function deserves medical assessment rather than simply being attributed to ageing.

Is There Hope?

Absolutely.

Delayed ejaculation can be frustrating precisely because the solution is not always a single medication or procedure. But that also means there are often several areas in which improvement can be made.

For some men, changing a medication makes a dramatic difference. For others, treating erectile dysfunction, improving penile stimulation, changing masturbation habits or addressing testosterone deficiency helps.

For many men, the greatest improvement comes from combining physical treatment with psychosexual strategies and better communication between partners.

The aim is not necessarily to achieve ejaculation within a particular number of minutes.

The aim is to restore pleasure, confidence, intimacy and control.

If ejaculation has become difficult, excessively delayed or impossible, speak with your GP, urologist or sexual medicine specialist. A careful assessment can often identify contributing factors and provide a pathway towards improvement.

This information is intended for general patient education and does not replace individual medical advice.

 

Premature ejaculation (PE) is one of the most common sexual concerns affecting men. Yet it is also one of the least discussed.

Many men worry that they are the only person experiencing it, or that it means there is something fundamentally wrong with their sexual function or relationship. Neither is necessarily true.

Premature ejaculation is common, often treatable, and usually manageable. Treatment may involve behavioural techniques, psychological or sex therapy, medication, treatment of an underlying medical problem, or a combination of these approaches.

What Is Premature Ejaculation?

There is no stopwatch that defines a satisfying sex life.

Premature ejaculation is better understood as ejaculation that repeatedly occurs sooner than a man or couple would like, with difficulty delaying ejaculation and resulting frustration, distress, avoidance of sexual activity or relationship difficulties.

In lifelong PE, ejaculation often occurs within approximately one minute of vaginal penetration, although the definition is not simply about time. In acquired PE, there is usually a noticeable and troublesome reduction in the time to ejaculation compared with the man’s previous experience.

Importantly, occasional rapid ejaculation is normal and does not necessarily mean that you have PE.

The key questions are:

• Does it happen repeatedly?
• Do you feel unable to control or delay ejaculation?
• Is it causing distress for you or your partner?
• Has something changed from how things used to be?

If the answer to several of these questions is yes, it may be worth discussing with your GP or urologist.

The Two Main Types of Premature Ejaculation

Lifelong Premature Ejaculation

Lifelong, or primary, PE usually begins with a man’s earliest sexual experiences and continues throughout adult life.

Ejaculation typically occurs very quickly during most sexual encounters and there may be very little sense of control over when ejaculation occurs.

There appears to be an important biological component to lifelong PE. Differences in serotonin signalling and individual sensitivity of the ejaculatory reflex have been proposed.

In other words, lifelong PE is not simply a matter of poor self-control.

Acquired Premature Ejaculation

Acquired, or secondary, PE develops in a man who previously had satisfactory control over ejaculation.

This distinction is important because acquired PE may have an identifiable contributing factor.

Possible associations include:

• erectile dysfunction
• performance anxiety
• relationship difficulties
• stress or depression
• prostatitis or pelvic discomfort in some men
• thyroid disorders, particularly hyperthyroidism
• changes in medications or recreational drug use
• changes in sexual circumstances
• prolonged periods without sexual activity

When PE develops relatively suddenly, identifying and treating the underlying problem may substantially improve ejaculation.

What Causes Premature Ejaculation?

There is rarely one simple explanation.

Ejaculation is controlled through a complex interaction between the brain, spinal cord, peripheral nerves, hormones, neurotransmitters, sexual stimulation and psychological factors.

Biological Factors

Serotonin is particularly important in controlling ejaculation. Certain serotonin pathways appear to delay ejaculation, which helps explain why medications that increase serotonin activity can be effective treatments for PE.

Genetic and neurobiological differences may therefore explain why some men naturally have a much shorter ejaculatory latency than others.

Erectile Dysfunction

This is an important and sometimes overlooked relationship.

A man who is worried about losing his erection may unconsciously hurry sexual activity and ejaculation. This can gradually create a pattern of rapid ejaculation.

Treating the erectile dysfunction can sometimes significantly improve the PE as well.

Is Premature Ejaculation “All in the Mind”?

No.

But psychology can certainly play a role.

This distinction is important.

Premature ejaculation can have genuine biological components, particularly in lifelong PE. Telling a man simply to “relax” is therefore unlikely to solve the problem.

At the same time, anxiety can amplify the problem.

A common cycle develops:

Rapid ejaculation → worry about the next sexual encounter → increased monitoring and performance anxiety → increased arousal → even faster ejaculation.

Sex can gradually begin to feel more like an examination than something enjoyable.

Breaking this cycle can be an important part of treatment.

The Role of Psychology and Sex Therapy

Psychological therapy can be particularly helpful when PE is associated with:

• performance anxiety
• relationship tension
• fear of sexual failure
• depression or general anxiety
• unrealistic expectations about sexual performance
• avoidance of intimacy
• reduced sexual confidence

Psychosexual counselling can also help couples communicate more openly about sexual expectations.

For some men, combining psychological or behavioural therapy with medication is more effective than relying on either approach alone.

The aim is not to suggest that PE is imaginary. Rather, treatment addresses both the physical ejaculatory reflex and the psychological environment surrounding it.

Behavioural Techniques

Several techniques can help some men develop greater awareness and control of their level of sexual arousal.

Stop-Start Technique

Sexual stimulation is stopped when ejaculation feels close. Once the sensation subsides, stimulation begins again.

With practice, this may help a man recognise the point at which ejaculation becomes difficult to stop.

Squeeze Technique

A variation involves briefly stopping stimulation and applying gentle pressure to the penis when ejaculation feels imminent.

This technique is used less commonly today but can still be useful for some couples.

Pelvic Floor Training

The pelvic floor muscles are involved in ejaculation as well as urinary control.

Some men may benefit from learning better awareness and control of these muscles, particularly under the guidance of a pelvic floor physiotherapist with experience in male sexual dysfunction.

More exercise is not necessarily better. Excessive pelvic floor tension may actually be counterproductive in some men.

Condoms and Reduced Sensitivity

Condoms reduce penile sensation and may delay ejaculation in some men.

Thicker condoms or condoms specifically designed to reduce sensitivity may provide additional benefit.

This is a simple and low-risk option worth trying before progressing to medication.

Local Anaesthetic Creams and Sprays

Topical anaesthetic preparations containing agents such as lidocaine and/or prilocaine can reduce penile sensitivity and delay ejaculation.

They are generally applied before sexual activity.

Potential problems include:

• excessive penile numbness
• reduced sexual pleasure
• irritation
• transfer of the anaesthetic to a partner, causing genital numbness

Using the correct amount and following product instructions is important. A condom may sometimes help prevent transfer to a partner.

Medication for Premature Ejaculation

Several medications can delay ejaculation.

SSRIs

Selective serotonin reuptake inhibitors, or SSRIs, were originally developed as antidepressants. One of their recognised effects is delayed ejaculation.

Medications such as paroxetine, sertraline, fluoxetine and escitalopram may therefore sometimes be prescribed for PE.

Depending on the medication and clinical circumstances, treatment may be taken daily rather than immediately before sexual activity.

Possible side effects include:

• nausea
• tiredness
• sweating
• reduced libido
• erectile difficulties
• changes in mood
• difficulty reaching orgasm

These medications should be prescribed and monitored by an appropriate medical practitioner and should not be started, stopped or altered without medical advice.

Dapoxetine

Dapoxetine is a short-acting SSRI specifically developed for premature ejaculation and is taken before anticipated sexual activity rather than continuously.

Its availability and regulatory status vary between countries, including Australia, so treatment needs to be discussed with your doctor rather than purchased from unregulated online sources.

PDE5 Inhibitors

Medications such as sildenafil or tadalafil primarily treat erectile dysfunction rather than PE.

They may nevertheless be helpful when premature ejaculation occurs together with erectile dysfunction.

For some men, improving confidence in the reliability of their erection also reduces the urge to rush sexual activity.

What About Tramadol?

Tramadol can delay ejaculation, but it is an opioid medication and carries risks including sedation, dependence, interactions with other medications and other potentially serious adverse effects.

For these reasons, it is not usually considered a preferred first-line treatment for PE.

Is Testosterone Treatment Helpful?

Usually not.

Testosterone replacement is not a routine treatment for premature ejaculation.

If symptoms or examination suggest testosterone deficiency or another hormonal problem, appropriate blood tests may be performed. Hormone treatment should only be considered when a genuine hormonal abnormality has been demonstrated.

Is Surgery the Answer?

Generally, no.

Premature ejaculation is not normally treated surgically.

Procedures designed to permanently reduce penile sensation or alter penile nerves are controversial and can potentially cause permanent numbness, altered sensation, pain or sexual dysfunction.

Treatment should usually begin with reversible, evidence-based approaches.

When Should You See a Urologist?

Consider seeking medical advice when PE:

• occurs during most sexual encounters
• is causing significant distress
• is affecting your relationship
• has developed suddenly
• occurs together with erectile dysfunction
• is associated with urinary symptoms, pelvic pain or penile discomfort
• has not responded to simple measures

A consultation does not necessarily mean extensive testing.

For many men, the most useful part of the assessment is simply a careful conversation about when the problem began, erectile function, sexual circumstances, medications, general health and any associated urinary or hormonal symptoms.

Blood tests or other investigations may occasionally be appropriate depending on the circumstances.

Is There Hope?

Absolutely.

Premature ejaculation is not a measure of masculinity, fertility or the quality of a relationship.

It is a common sexual dysfunction with several potential treatment strategies. Some men respond well to relatively simple measures. Others benefit from medication, treatment of associated erectile dysfunction, psychosexual therapy, or a combination of approaches.

Perhaps most importantly, treatment should not focus exclusively on adding minutes to a stopwatch.

The real goals are better control, less anxiety, greater sexual confidence and a more satisfying sexual experience for both partners.

There is no universally “correct” duration for sex.

If ejaculation is consistently occurring earlier than you would like and it is bothering you, that is reason enough to discuss it.

A Final Word

Premature ejaculation can be difficult to bring up in conversation, but for a urologist it is an everyday medical issue.

You will almost certainly not be the first person to mention it that day.

And occasionally, the most effective first treatment is simply getting the subject out of the bedroom shadows and into a conversation where something can actually be done about it.

This information is intended for general patient education and does not replace individual medical assessment. Treatment should be tailored to your medical history, medications, symptoms and circumstances.

OAB – Flyer – Joseph Schoeman

For patients living with interstitial cystitis/bladder pain syndrome (IC/BPS) or a persistently small functional bladder capacity, the bladder can become an unforgiving little alarm clock: filling produces pain or pressure, urinary frequency increases, and sleep may be repeatedly interrupted by trips to the bathroom.

One procedure sometimes considered in carefully selected patients is regulated bladder distension, more commonly called cystoscopic hydrodistension.

Hydrodistension has been used for decades, both to assess the bladder and as a therapeutic procedure. It can improve symptoms in some patients, but it is important to understand that it is not a cure for interstitial cystitis, and the scientific evidence for lasting benefit remains mixed. Current guidelines therefore regard it as a selective treatment rather than something that should routinely be performed in every patient with bladder pain.

What is regulated bladder distension?

Regulated bladder distension involves gradually filling the bladder with sterile irrigation fluid during cystoscopy, usually while the patient is under anaesthesia.

The important word is regulated.

Modern hydrodistension should not simply involve filling the bladder as much as possible. Pressure, volume and duration need to be carefully controlled to minimise injury to the bladder.

A commonly described technique is low-pressure, short-duration hydrodistension, traditionally using an irrigation pressure of approximately 60–80 cm H₂O for less than 10 minutes.

The procedure allows the urologist to:

• examine the bladder carefully;
• exclude other abnormalities such as bladder stones or tumours;
• identify Hunner lesions associated with a particular phenotype of IC/BPS;
• assess the bladder mucosa following distension;
• determine the bladder’s anatomical capacity under anaesthesia;
• identify a severely reduced or fibrotic bladder capacity; and
• potentially provide temporary improvement in pain, urgency and urinary frequency.

Importantly, the bladder capacity measured under anaesthesia can be very different from the volume a patient can comfortably hold while awake.

Why might bladder distension improve symptoms?

The exact mechanism remains uncertain.

Several explanations have been proposed.

Temporary increase in functional bladder capacity

Some patients with bladder pain develop progressively smaller functional voided volumes because bladder filling produces discomfort or urgency.

Hydrodistension may temporarily allow the bladder to accommodate a larger volume and may interrupt the cycle of:

bladder filling → pain → early voiding → progressively smaller functional capacity.

However, this does not necessarily mean that hydrodistension permanently enlarges a genuinely scarred or fibrotic bladder.

Alteration of bladder sensory signalling

Stretching of the bladder wall may temporarily alter afferent sensory signalling between the bladder and nervous system.

This may reduce the sensation of:

• urgency;
• bladder pressure;
• suprapubic discomfort; and
• pain associated with bladder filling.

This proposed neuromodulatory effect may explain why some patients experience considerable symptomatic improvement despite relatively little change in anatomical bladder capacity.

Diagnostic and therapeutic treatment of Hunner lesions

Cystoscopy performed during hydrodistension can make Hunner lesions more apparent. Once identified, these lesions can be treated separately with fulguration, laser treatment or steroid injection where appropriate.

It is important to distinguish improvement from treating a Hunner lesion from improvement attributable to the hydrodistension itself.

Hydrodistension for interstitial cystitis/bladder pain syndrome

This is the condition in which hydrodistension has been studied most extensively.

IC/BPS is characterised by bladder-related pain, pressure or discomfort accompanied by urinary symptoms such as frequency and urgency, after other identifiable causes have been excluded.

Hydrodistension is not required to diagnose every patient with IC/BPS, but cystoscopy and distension can be particularly useful when the diagnosis is uncertain, Hunner lesions are suspected, or invasive treatment is being considered.

The European Association of Urology notes that hydrodistension is commonly performed but that the scientific justification remains limited, describing its therapeutic role in primary bladder pain syndrome as limited.

This does not mean that it never works. Rather, we cannot reliably predict who will respond or how long the response will last.

How effective is bladder hydrodistension?

This is where expectations need to be realistic.

Older observational studies of low-pressure, short-duration hydrodistension reported clinically significant improvement in approximately:

Time after treatment	Reported symptomatic response
1 month	approximately 30–54%
2–3 months	approximately 18–56%
5–6 months	approximately 0–37%

These studies were generally small and heterogeneous, and many lacked placebo or sham controls.

AUA educational material similarly notes that observational studies have demonstrated meaningful improvement in approximately half of selected patients, sometimes lasting as long as 12 months. The absence of good sham-controlled trials, however, makes the treatment effect difficult to quantify precisely.

The EAU guidelines highlight how quickly benefit can disappear in some patients. In one comparison involving hydrodistension, approximately 70% of patients treated with hydrodistension alone had returned to their previous symptoms after one month.

What does the newer research show?

A recent systematic review provides an important update.

Lim and colleagues reviewed 14 studies involving 1,404 patients undergoing hydrodistension for interstitial cystitis. Nine studies evaluated distension lasting 15 minutes or less, while five older studies investigated considerably longer distension periods.

Some studies demonstrated significant improvements in pain and symptom scores, while others showed no statistically significant improvement.

The authors concluded that hydrodistension can provide symptomatic relief in some patients but that the available evidence remains limited by:

• heterogeneous techniques;
• small patient populations;
• observational study designs;
• differences in duration and pressure;
• inconsistent outcome measures; and
• substantial risk of bias.

Interestingly, prolonged distension appeared in some studies to produce longer-lasting responses, but this potentially comes at the cost of greater risk of serious complications, particularly bladder perforation.

This creates something of a therapeutic tightrope: more aggressive distension might theoretically produce a greater effect, but pushing harder is not necessarily safer or better.

What about a genuinely small bladder?

A distinction needs to be made between a functionally small bladder and an anatomically contracted bladder.

Functional small bladder

A patient with bladder pain may void frequently at volumes of only 100–200 mL because further filling becomes uncomfortable.

Under anaesthesia, however, the bladder may accommodate a considerably larger volume.

In this situation, hydrodistension may have both diagnostic and therapeutic value.

Anatomically small or fibrotic bladder

Some patients have genuine fibrosis and loss of bladder compliance.

Causes can include:

• severe longstanding IC/BPS;
• previous pelvic radiotherapy;
• chronic inflammatory bladder disease;
• tuberculosis or other uncommon chronic infections;
• previous bladder surgery;
• chemical cystitis; and
• other causes of bladder fibrosis.

Hydrodistension is much less likely to produce durable enlargement of a severely fibrotic, non-compliant bladder.

Indeed, determining anatomical bladder capacity during hydrodistension can help identify the subgroup of patients whose reduced capacity results from fibrosis rather than simply pain-related early voiding.

Patients with severely contracted bladders therefore require individual assessment rather than repeated attempts to mechanically stretch the bladder.

What are the potential benefits?

For appropriately selected patients, benefits may include:

• reduced bladder pain;
• reduced urgency;
• reduced urinary frequency;
• improved bladder filling tolerance;
• increased functional voided volumes;
• reduced nocturia;
• improved quality of life;
• identification of Hunner lesions;
• determination of true anatomical bladder capacity; and
• exclusion of other bladder pathology.

Some patients experience substantial improvement and occasionally request repeat hydrodistension when symptoms eventually return.

Others experience little or no improvement.

Unfortunately, there is currently no perfect test that tells us beforehand which patient will fall into which group.

What happens immediately after the procedure?

Temporary worsening of symptoms is relatively common.

For several days patients may experience:

• burning when passing urine;
• increased urinary frequency;
• urgency;
• bladder discomfort or spasms;
• pelvic pain; and
• blood in the urine.

A short-term flare of IC/BPS symptoms can also occur after hydrodistension. This is generally managed with analgesia and supportive treatment.

The bladder has, after all, just undergone considerably more filling than it normally tolerates, so it may complain rather loudly for a short period afterwards.

What are the potential complications?

Most complications are minor and temporary, but patients should understand that more significant complications are possible.

These include:

Haematuria

Blood in the urine is relatively common immediately following the procedure and generally settles spontaneously.

Bladder pain and symptom flare

Paradoxically, the procedure intended to improve bladder pain may initially make it worse.

Symptoms usually settle, but occasionally the flare can be prolonged.

Urinary tract infection

Instrumentation of the urinary tract carries a risk of infection.

Patients developing fever, chills, worsening pain or difficulty passing urine following the procedure should seek medical attention.

Urinary retention

Temporary difficulty emptying the bladder can occasionally occur, particularly following anaesthesia or when additional bladder treatments have been performed.

Temporary catheterisation may be required.

Bladder perforation or rupture

This is uncommon with carefully controlled modern techniques but represents the most important procedural complication.

The risk becomes more concerning when high pressures or prolonged distension are employed.

Anaesthetic complications

Because hydrodistension is generally performed under anaesthesia or sedation, the usual anaesthetic risks also apply.

Why pressure and duration matter

Historical hydrodistension techniques could be considerably more aggressive than contemporary practice.

The American Urological Association has specifically advised against high-pressure, long-duration hydrodistension because it has been associated with serious complications including:

• bladder rupture;
• significant bleeding; and
• sepsis.

High-pressure techniques above approximately 80–100 cm H₂O, particularly when combined with prolonged distension, have not demonstrated sufficiently consistent additional benefit to justify these increased risks.

This is why contemporary treatment should be controlled rather than heroic. The objective is therapeutic distension, not a competition to discover the maximum volume a bladder can tolerate.

Can bladder distension be repeated?

Yes, in selected patients.

If a patient obtains substantial improvement lasting several months, repeat hydrodistension may be considered when symptoms recur.

However, repeated procedures should not simply become an automatic treatment cycle.

The potential benefit needs to be balanced against:

• repeated anaesthesia;
• postoperative symptom flares;
• infection;
• bleeding;
• bladder injury;
• cost and inconvenience; and
• availability of alternative therapies.

A patient who experienced no meaningful improvement after a properly performed initial hydrodistension is unlikely to benefit from endlessly repeating the same procedure without reconsidering the diagnosis and treatment strategy.

How does hydrodistension fit into modern IC/BPS treatment?

IC/BPS is increasingly regarded as a heterogeneous condition rather than a single disease.

Treatment may therefore include combinations of:

• dietary and behavioural modification;
• bladder retraining;
• pelvic floor physiotherapy;
• pain management;
• oral medication;
• intravesical bladder instillations;
• treatment of Hunner lesions;
• hydrodistension;
• intradetrusor botulinum toxin;
• neuromodulation; and
• rarely, major reconstructive surgery for severe refractory disease.

The 2025 Canadian Urological Association guideline, for example, conditionally recommends intradetrusor botulinum toxin, with or without hydrodistension, for selected patients with IC/BPS refractory to other treatments, although the certainty of evidence remains very low.

Hydrodistension combined with Botox

There is increasing interest in combining hydrodistension with intradetrusor botulinum toxin A.

Botulinum toxin may reduce sensory signalling from the bladder as well as detrusor activity.

The EAU guideline cites studies in which patients receiving hydrodistension plus botulinum toxin had more sustained improvement in pain and bladder capacity than patients undergoing hydrodistension alone.

This does not mean Botox is appropriate for every patient. Potential complications include increased residual urine and urinary retention, occasionally requiring intermittent self-catheterisation.

So, does regulated bladder distension actually work?

Yes, for some patients, but not reliably and usually not permanently.

That is probably the fairest interpretation of the current evidence.

Hydrodistension can produce worthwhile improvement in pain, frequency and functional bladder capacity in a subset of patients with IC/BPS. Some patients experience surprisingly prolonged relief.

However:

the response is unpredictable, symptoms commonly recur, and high-quality evidence demonstrating durable long-term benefit remains limited.

The most recent systematic review reached essentially the same conclusion: hydrodistension remains a viable but controversial treatment because studies suggest benefit while the overall quality and consistency of evidence remain insufficient.

The European Association of Urology consequently considers hydrodistension to have a limited therapeutic role, despite its continued use in clinical practice.

The bottom line

Regulated bladder hydrodistension is best viewed as a selective diagnostic and therapeutic procedure rather than a cure for a small or painful bladder.

It may be particularly useful when:

• IC/BPS symptoms remain troublesome despite conservative treatment;
• bladder capacity appears markedly reduced;
• Hunner lesions are suspected;
• anatomical bladder capacity needs to be established; or
• cystoscopy is required to exclude another cause for the symptoms.

When performed, a carefully controlled, low-pressure and relatively short-duration technique has traditionally been favoured because aggressive high-pressure distension increases the risk of bladder injury without convincing evidence of superior benefit.

For patients with a genuinely scarred, contracted and poorly compliant bladder, however, hydrodistension should not be expected to magically restore normal bladder capacity. These patients may require a different and more individualised management strategy.

Ultimately, the question is not simply:

“Can the bladder be stretched?”

It is:

“Why is this bladder small or painful, and is controlled distension likely to change the underlying problem?”

That distinction is central to selecting the patients most likely to benefit.

Research and guideline references

1. Lim S, Alhamdani Z, Qin KR, et al. Optimal Duration of Hydrodistension for Symptomatic Treatment of Interstitial Cystitis: A Systematic Review. Neurourology and Urodynamics. First published 2025. The review included 14 studies and 1,404 patients and highlighted both potential symptomatic benefit and substantial heterogeneity in the evidence.
2. European Association of Urology. EAU Guidelines on Chronic Pelvic Pain: Primary Bladder Pain Syndrome. Current guidance describes the scientific basis for hydrodistension as limited and its therapeutic role as relatively limited.
3. American Urological Association. Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome. Low-pressure, short-duration hydrodistension is described as an option, while high-pressure, prolonged hydrodistension is discouraged because of the increased risk of serious adverse events.
4. Canadian Urological Association. CUA guideline: Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Observational studies reported variable and generally declining response rates following hydrodistension.
5. Canadian Urological Association. 2025 CUA Guideline: Selected treatment recommendations for interstitial cystitis/bladder pain syndrome. Discusses contemporary treatment options including intradetrusor botulinum toxin with or without hydrodistension in refractory IC/BPS.
6. Malde S, Palmisani S, Al-Kaisy A, Sahai A. Guideline of guidelines: bladder pain syndrome. BJU International. 2018. The review highlights substantial variation between international recommendations and the limited evidence supporting hydrodistension as a long-term therapeutic strategy.

This information is intended for general patient education and does not replace individual assessment by a urologist. The appropriateness and technique of bladder hydrodistension should be determined according to the underlying diagnosis, bladder characteristics, previous treatments and individual patient circumstances.

So, come see your local Brisbane Urologist, Uro-Jo to discuss this option.