Your Bladder and Your Bowels: The Connection Nobody Talks About

/0 Comments/in /by

The bowel–bladder connection: how good bowel habits can support bladder health

When urinary urgency or leakage is troubling you, bowel habits may be the last thing on your mind. Yet the bowel and bladder share the limited space of the pelvis, the pelvic floor muscles and parts of their nerve supply. Constipation can contribute to urinary symptoms in some people, so bowel health is often worth discussing during a bladder assessment.

This does not mean that constipation explains every bladder problem. Infection, prostate or pelvic floor conditions, medication effects, neurological conditions and other causes may need to be considered too.

How can constipation affect the bladder?

A full rectum can press on the bladder and change the space available for it to fill. In some people this may increase urinary urgency or frequency, contribute to urgency leakage, or make it harder to empty the bladder comfortably. Constipation and bladder symptoms may also occur together because of shared pelvic floor or neurological problems.

The relationship is not the same for everyone, and constipation is only one possible contributor. Bladder symptoms should be assessed on their own merits, especially if they are new, persistent or worsening.

Some medicines used for bladder symptoms, including anticholinergic medicines, can make constipation worse. Pain medicines, iron and some other medicines can also affect bowel habits. If you think a medicine may be contributing, discuss it with your doctor or pharmacist rather than stopping it yourself.

The pelvic floor connection

The pelvic floor is a group of muscles and connective tissues that supports the bladder, bowel and other pelvic organs. It helps maintain urinary and bowel control, and it must also relax and coordinate when you empty your bladder or bowel.

Repeated straining to pass hard stool can place ongoing pressure on the pelvic floor. A pelvic floor that is weak, painful, tense or poorly coordinated may affect both bladder and bowel emptying or control. Treatment therefore depends on what the muscles are doing: strengthening is useful for some forms of leakage, while people who cannot relax or coordinate the pelvic floor may need a different approach, sometimes with a pelvic health physiotherapist.

How are the bladder and bowel nerves connected?

The bladder and rectum have different jobs, but their nerve pathways meet and interact through the spinal cord, pelvic nerve networks and the brain. The pathways below are a simplified guide; the actual nerve networks are interconnected.

Nerve pathway Main spinal levels Role in bladder and bowel function
Pelvic splanchnic nerves (parasympathetic) S2–S4 Help the bladder contract to empty and contribute to rectal activity and bowel emptying. They also carry important sensation from the lower urinary tract and rectum.
Hypogastric nerves (sympathetic) About T11–L2 Support bladder storage by relaxing the bladder wall and helping maintain outlet closure. They also contribute to bowel storage and internal anal sphincter function.
Pudendal nerves (somatic) S2–S4 Provide voluntary control of the external urethral sphincter, external anal sphincter and parts of the pelvic floor. These muscles help maintain continence and must coordinate with relaxation during emptying.

Bladder filling and emptying, bowel filling and defecation are coordinated with pelvic floor activity and brain control. Because some of these pathways and muscles are shared, neurological conditions or injuries affecting the brain, spinal cord or sacral nerves can affect both bladder and bowel function. A full rectum can also alter the local pressure and sensory environment around the bladder.

Constipation is not only about how often you go

Bowel frequency varies. Not having a bowel motion every day does not, by itself, mean you are constipated. It is also important to mention:

  • hard or lumpy stools;
  • needing to strain or push repeatedly;
  • discomfort or pain when passing stool;
  • a feeling that the bowel has not emptied completely; or
  • needing to use your fingers or change position to help stool pass.

A short bowel diary, used alongside a bladder diary, can help identify whether urinary urgency or leakage changes when constipation is worse.

Good bowel habits to support pelvic health

A few practical habits may help maintain regular, comfortable bowel movements:

  1. Respond to the urge. Try not to repeatedly postpone a bowel motion. Many people find it helpful to allow unhurried time after a meal, when the bowel may be more active.
  2. Use a comfortable position. Sit with your feet supported on a small footstool so your knees are a little higher than your hips. Lean forward with your forearms on your thighs and keep your abdomen relaxed.
  3. Avoid prolonged straining. Breathe out gently rather than holding your breath and pushing hard. If stool will not pass, get up and try again later instead of sitting and straining for a long time.
  4. Eat a varied, fibre-containing diet. Whole grains, vegetables, fruit, legumes, nuts and seeds can help. Increase fibre gradually to reduce bloating. Adults’ fibre needs vary; one commonly used guide is around 22–34 grams a day, adjusted for age, health and tolerance.
  5. Drink an appropriate amount. Adequate fluid helps fibre work and can soften stool. Your needs vary, and people who have been advised to restrict fluids because of heart, kidney or other conditions should follow their treating clinician’s advice. Restricting fluids to manage urinary frequency may worsen constipation.
  6. Keep moving regularly. Walking and other suitable physical activity can support bowel function.
  7. Review medicines and ongoing symptoms. Ask your doctor or pharmacist whether medicines may be contributing. Persistent constipation may need tailored treatment; a clinician can advise whether dietary changes, a laxative or pelvic floor assessment is appropriate.

If you have difficulty relaxing the pelvic floor or feel that stool is blocked despite soft stools, simply adding more fibre or doing repeated pelvic floor squeezes may not solve the problem. Ask about an assessment of bowel emptying and pelvic floor coordination.

Looking beyond the bladder

Improving bowel habits may reduce one contributor to bladder symptoms, but it is not a substitute for investigating persistent urinary problems. A clinician may ask about both bladder and bowel symptoms, review medications, test the urine and check how well the bladder empties. Further assessment depends on the symptoms and medical history.

Seek medical advice for ongoing or worsening urgency, leakage, difficulty passing urine or constipation. Blood in the urine or stool, severe abdominal pain, vomiting, inability to pass urine, or a sudden major change in bowel or bladder control needs prompt medical attention.

This article provides general information and is not a substitute for individual medical advice.

References

  1. Queensland Spinal Cord Injuries Service. Bowel and bladder relationship.
  2. Continence Health Australia. Constipation.
  3. Australian Government Department of Health, Disability and Ageing. Bladder and bowel health: recognising a problem.
  4. National Institute of Diabetes and Digestive and Kidney Diseases. Eating, diet and nutrition for constipation and prevention of bladder control problems.
  5. de Groat WC, Griffiths D, Yoshimura N. Neural control of the lower urinary tract. Comprehensive Physiology. 2015;5(1):327–396. doi:10.1002/cphy.c130056.
  6. StatPearls. Anatomy, abdomen and pelvis: pelvic floor.

 

Painful Ejaculation: The Symptom Men Rarely Talk About

/0 Comments/in /by

Painful ejaculation: causes, assessment and treatment

Pain during or after ejaculation can be difficult to mention, even to a doctor. Some men hope it will disappear; others avoid sex because they worry the pain will return.

Painful ejaculation, sometimes called dysejaculation or dysorgasmia, is a symptom, not a diagnosis. It can have several causes, including infection, inflammation, pelvic floor problems, medication effects or, less commonly, a blockage in the passages that carry semen. The pattern of symptoms and the findings on assessment help guide the next steps.

What can painful ejaculation feel like?

The experience varies. Pain may be burning, sharp, cramping or a deeper ache. It can be felt in the penis, testicles, scrotum, perineum (the area between the scrotum and anus), lower abdomen or pelvis.

It may begin during orgasm or ejaculation, just afterwards, or continue for minutes or hours. It may occur every time or only occasionally. Some men also notice urinary symptoms, blood in the semen, changes in the amount of semen, erection or orgasm changes, or pain with bowel movements.

The details are useful: where the pain is, when it starts, how long it lasts, whether it is linked to urination or a particular activity, and whether it is changing over time.

What can cause painful ejaculation?

Prostate or pelvic pain conditions

Inflammation or infection of the prostate can cause painful ejaculation, sometimes with pelvic discomfort, urinary frequency, burning when passing urine or difficulty urinating. Acute bacterial prostatitis may cause fever and feeling unwell and needs prompt medical assessment.

Many men with persistent pelvic pain have chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). This is not necessarily a bacterial infection. Symptoms can involve the perineum, penis, testicles or lower abdomen and may include urinary or sexual symptoms. Pelvic floor muscle tension, nerve sensitivity and other factors can contribute. Repeated antibiotic courses are not appropriate when there is no evidence of a bacterial infection. Painful ejaculation is a recognised feature of chronic pelvic pain, but it can have other causes too. Oxford Academic

Urethral or genital infection

Urethritis, including a sexually transmitted infection (STI), can cause pain or burning during urination and ejaculation. Infection or inflammation involving the epididymis or testicle can also be painful. Discharge, a new sexual partner, testicular tenderness, fever or urinary burning may guide testing.

Pelvic floor muscle tension or poor coordination

The pelvic floor muscles contract and coordinate during ejaculation. If they are tender, overactive or unable to relax, ejaculation may trigger pelvic or perineal pain. This may occur on its own or as part of a broader chronic pelvic pain syndrome. A pelvic health physiotherapist can assess muscle coordination and tenderness when indicated.

Narrowing or obstruction in the semen pathway

A narrowing of the urethra, ejaculatory duct obstruction, or a problem involving the seminal vesicles may cause pain in selected cases. A previous vasectomy or surgery affecting the prostate, bladder, urethra or pelvis may also be relevant. These causes are less common and usually require targeted investigation rather than assuming that obstruction is present.

Medicines, procedures and radiotherapy

Some medicines have been reported to cause painful ejaculation or changes in orgasm. The timing of symptoms in relation to starting or changing a medicine can be helpful. Do not stop a prescribed medicine without discussing it with the prescriber.

Pain may also follow pelvic surgery, instrumentation or radiotherapy. The cause and appropriate assessment depend on the procedure and when the symptoms began.

Other contributors

Nerve-related pain, chronic medical conditions and psychological or relationship stress can influence the experience of pain. This does not mean the pain is “all in your head.” Pain is real, and several physical, nervous-system and emotional factors can interact.

Sometimes no single cause is identified. Even then, a structured assessment can help select reasonable symptom-management options.

How is painful ejaculation investigated?

Testing is guided by the history and examination. Not every man needs a scan, cystoscopy or extensive testing. Current sexual-medicine recommendations advise assessing painful ejaculation along established pelvic-pain pathways, with tests and imaging chosen according to symptoms. Oxford Academic

1. A detailed history

Your doctor may ask about:

  • where the pain occurs, when it starts and how long it lasts;
  • whether it happens with every ejaculation or only in certain situations;
  • urinary symptoms such as burning, urgency, weak stream or difficulty emptying;
  • blood in the urine or semen, discharge, fever or testicular swelling;
  • recent sexual partners or possible STI exposure;
  • previous infections, vasectomy, pelvic surgery, radiotherapy or urinary procedures;
  • medicines and recent dose changes; and
  • how the symptoms affect sexual activity, fertility plans and quality of life.

You do not need technical language. Describing what happens in your own words is a good starting point.

2. Examination

Depending on the symptoms, examination may include the abdomen, penis, testicles, epididymides and groin. A prostate or pelvic floor examination may be considered when it is likely to help identify the cause. The examination should be explained and performed with your consent.

3. Urine and infection testing

A urine test and culture may be used to look for a urinary infection. STI testing, often using a urine sample or swab, may be appropriate based on symptoms and sexual history. Blood tests are sometimes used if there are signs of systemic infection or another specific concern.

Antibiotics should be directed at a suspected or confirmed bacterial infection. Painful ejaculation alone does not prove that an infection is present.

4. Tests for urinary or structural problems

If there are urinary symptoms, a clinician may measure urine flow or check the amount left in the bladder after urination. Further investigations are selected according to the suspected cause:

  • Ultrasound or other imaging may be considered for testicular symptoms, suspected seminal vesicle or ejaculatory duct problems, or persistent unexplained pain.
  • Cystoscopy or urethral imaging may be appropriate if a urethral narrowing, bleeding or another urethral problem is suspected.
  • Prostate-specific antigen (PSA) testing is considered selectively based on age, examination and prostate-cancer risk. It is not a test for painful ejaculation itself and may be misleading during active infection or inflammation.
  • Semen testing is not routinely required for every man with painful ejaculation, but may be considered when fertility or a specific semen-pathway problem is part of the question.

How is painful ejaculation managed?

Treatment depends on the cause and on how much the symptom affects you. There is no single treatment that suits everyone. Guidelines recommend tailoring care to the likely cause; procedures are generally reserved for selected cases with a demonstrated structural problem because evidence for surgery for unexplained pain is limited. Uroweb

  • Confirmed or strongly suspected infection: treatment may include the appropriate antibiotic or other infection-specific care. If an STI is diagnosed, partner testing or treatment and avoiding sex until treatment is complete may be advised.
  • Medication-related symptoms: the prescriber may review the timing, dose or alternatives. Do not change medication on your own.
  • Chronic pelvic pain or pelvic floor tenderness: care may include pelvic floor physiotherapy focused on relaxation and coordination, pain-management strategies, and selected medicines. Strengthening exercises are not automatically appropriate if the muscles are already tight or painful.
  • Urinary symptoms: treatment may be directed at an identified urinary condition. For some men, a clinician may consider an alpha-blocker or other targeted treatment.
  • A defined obstruction or structural problem: a urologist may discuss a procedure if investigations confirm a cause and symptoms justify it. Procedures are not routine for unexplained pain, and potential effects on ejaculation and fertility should be discussed.
  • No clear cause found: trigger modification, review of sexual activity patterns, supportive counselling or a multidisciplinary chronic-pain approach may help. The plan can be adjusted over time.

The evidence for specific treatments of painful ejaculation is limited, so decisions are usually tailored to the likely cause and the individual’s priorities.

When should you seek urgent care?

Seek prompt medical attention if painful ejaculation occurs with fever or shaking chills, feeling very unwell, inability to pass urine, sudden severe testicular pain or swelling, or visible blood in the urine. These symptoms may need urgent assessment. Blood in the semen should also be discussed with a doctor, particularly if it recurs or occurs with other symptoms. NHS

Starting the conversation

You do not need medical terminology. You can simply say: “I have pain when I ejaculate.” If it is recurring, worsening or affecting intimacy, speak with your GP. They can begin the assessment and arrange urology referral if needed.

This article provides general information and is not a substitute for individual medical advice.

References

  1. Shindel AW, Serefoglu EC, et al. Review of recent data on disorders of ejaculation and orgasm in men: recommendations from the Fifth International Consultation on Sexual Medicine. Sexual Medicine Reviews. 2025;13(3):318–337. doi:10.1093/sxmrev/qeaf016.
  2. European Association of Urology. Guidelines on Sexual and Reproductive Health: Disorders of Ejaculation.
  3. American Urological Association. Diagnosis and Management of Male Chronic Pelvic Pain: AUA Guideline (2025).
  4. Donatucci CF, et al. Contemporary management of ejaculatory dysfunction. Translational Andrology and Urology. 2018. Full text.
  5. Acharya S, et al. Painful ejaculation—an ignored symptom. Sexual Medicine Reviews. 2020. Full text.
  6. NHS. Prostatitis and Blood in semen.

Hydronephrosis: what it means and how it is treated

/0 Comments/in , /by

Finding out that a kidney is swollen on a scan can be worrying. The word hydronephrosis sounds like a diagnosis, but it describes an appearance: urine is collecting and stretching the drainage system of one or both kidneys. It is a sign that needs to be understood in context. It does not, by itself, tell us why it has happened, whether a cancer is present, or whether an operation is needed.

Many causes are treatable, and some cases can be monitored safely. The right approach depends on the cause, the degree and duration of blockage, kidney function, symptoms, overall health and, when cancer is involved, what matters most to the person receiving care.

What are unilateral and bilateral hydronephrosis?

Each kidney drains urine through a tube called a ureter into the bladder. Unilateral hydronephrosis affects one kidney; bilateral hydronephrosis affects both. A blockage may be within the kidney or ureter, or lower down where it affects the bladder outlet. A full bladder or difficulty emptying can sometimes cause dilation on both sides.

One healthy kidney can often maintain overall kidney function when the other side is obstructed. This can mean that a person with a one-sided blockage has few symptoms and normal blood tests. With obstruction affecting both kidneys, or a person who has only one functioning kidney, kidney function can become impaired more quickly. The scan appearance alone does not show how well each kidney is working.

What can cause hydronephrosis?

Causes may be benign (non-cancerous) or malignant (related to cancer). They include:

  • Kidney or ureteric stones, which may block urine flow and cause pain, blood in the urine or infection.
  • Narrowing or scarring of the ureter (a stricture), sometimes following previous surgery, instrumentation, infection or radiation treatment.
  • Bladder outlet obstruction or poor bladder emptying, including from an enlarged prostate before prostate surgery, urethral narrowing, a tight bladder-neck/anastomotic scar after surgery, or a bladder that does not contract effectively.
  • Anatomical or functional conditions, such as a narrowing where the kidney joins the ureter (a pelvi-ureteric junction obstruction), reflux of urine towards the kidney, or in some circumstance, pregnancy.
  • Blood clots or inflammation, which can temporarily obstruct drainage.
  • Cancer, either growing in the urinary tract or pressing on a ureter from nearby tissues or lymph nodes. Possible cancers include prostate, bladder, bowel, gynaecological and other pelvic or abdominal cancers. A cancer-related cause is only one possibility; imaging and clinical assessment are needed to establish the cause.

Prostate cancer and hydronephrosis

Prostate cancer can affect urine drainage in different ways. A locally advanced tumour may involve the bladder outlet or the area where the ureters enter the bladder. Cancer in pelvic or abdominal lymph nodes can press on one or both ureters. These problems are more likely with locally advanced or recurrent disease than with an early cancer confined to the prostate, but each person’s situation is different.

Hydronephrosis in someone who has had prostate cancer does not automatically mean the cancer has returned. Stones, infection, scarring, bladder-emptying problems and unrelated conditions remain possible. The team will consider the person’s history, prostate-specific antigen (PSA) trend, symptoms, blood and urine tests, and the pattern seen on imaging. Further tests may be appropriate if the cause is not clear.

After radical prostatectomy

After prostate removal, the bladder is joined to the urethra. Scarring at this join (a vesicourethral anastomotic stenosis, sometimes called a bladder-neck contracture) can make it difficult to empty the bladder. Significant retention may raise pressure in the bladder and contribute to dilation of both upper urinary tracts. A ureteric injury or later narrowing is a less common possibility. Recurrent cancer or enlarged lymph nodes can also obstruct a ureter, but this is not the only explanation.

Assessment may include checking bladder emptying, kidney function and imaging, with a camera examination or contrast study if needed. Treatment is directed at the level and cause of the blockage: for example, bladder drainage, treatment of a narrowing, or drainage of an obstructed ureter.

After salvage radiation therapy

Radiation can cause inflammation and, less commonly, delayed scarring in urinary tissues. Narrowing of the urethra or bladder outlet can interfere with emptying. A ureteric stricture after pelvic radiation is uncommon, but may develop months or years later. Salvage radiation after prostatectomy is generally directed to the prostate bed; hydronephrosis that appears afterwards still needs a proper assessment rather than being assumed to be a radiation effect or a cancer recurrence.

If imaging shows a narrowed ureter, the team may use CT or MRI, a contrast study, or a functional kidney scan to clarify its site, length and effect on kidney drainage. Treatment can be more complex in previously irradiated tissue, so decisions are individualised and may involve a reconstructive urologist, radiation oncologist, medical oncologist or interventional radiologist.

Symptoms and when to seek urgent care

Hydronephrosis can cause no noticeable symptoms, particularly when it develops gradually or affects one kidney. When symptoms occur, they may include pain in the side, back or abdomen; nausea or vomiting; blood in the urine; difficulty passing urine; or repeated urinary infections.

Please seek urgent medical assessment for fever or shaking chills with suspected urinary blockage, severe or worsening pain, repeated vomiting, very little or no urine, confusion, or feeling suddenly very unwell. Infection behind a blockage can become serious and may need urgent antibiotics and drainage. Sudden inability to pass urine also needs prompt care.

How is it investigated?

The first aim is to understand whether there is a blockage that needs prompt relief and what is causing it. Assessment commonly includes:

  1. A conversation and examination, including previous cancer treatments, operations, stones, infections, urinary symptoms and medicines.
  2. Blood tests, especially creatinine and estimated kidney function, and urine tests for infection or blood.
  3. Ultrasound, which can show dilation of the kidneys and bladder and whether the bladder empties.
  4. CT or MRI, selected according to the suspected cause and the person’s kidney function, to look for stones, strictures, masses or enlarged lymph nodes.
  5. Additional tests where useful: a MAG3 renal scan can assess each kidney’s contribution and drainage; cystoscopy or contrast X-rays can clarify the bladder outlet or ureter.

Not everyone needs every test. The clinician will choose investigations that answer the question while taking account of kidney function, previous treatment and the person’s circumstances.

Management options

Treatment is tailored to the cause and the degree of risk. The goals may be to protect kidney function, treat infection or pain, restore urine flow, enable other cancer treatment, or support comfort and quality of life.

Observation and treatment of the cause

Mild, stable hydronephrosis may sometimes be monitored with repeat blood tests and imaging, particularly if there is no infection, troublesome pain or evidence of kidney function decline. A stone may pass or be treated with medication, ureteroscopy or another stone procedure. Infection is treated with antibiotics. Retention may be relieved with a bladder catheter while the cause is assessed. A benign narrowing may be treated by endoscopic incision or dilation, reconstruction, or another procedure depending on its location and the person’s health.

Draining the kidney

If drainage is needed, there are two common approaches:

  • Ureteric stent (often called a JJ stent): a thin internal tube placed between the kidney and bladder, usually using a camera. It can avoid an external collection bag, but may cause urinary frequency, urgency, discomfort, blood in the urine or infection, and it usually needs planned replacement or removal. A tight narrowing or external cancer pressure can make stent placement difficult or less reliable.
  • Percutaneous nephrostomy: a small tube placed through the skin of the back into the kidney, usually by an interventional radiologist, to drain urine into an external bag. It can be useful when a stent cannot be placed, has not drained adequately, or rapid reliable drainage is needed. The tube needs care and periodic changes and can affect daily activities.

The choice depends on the site and cause of obstruction, infection, anatomy, kidney function, expected duration, other treatment plans and personal preference. Sometimes a nephrostomy is used first, with an internal stent considered later. Drainage can relieve pressure and help kidney function, but it does not remove the underlying cause; further treatment or monitoring is often needed.

When might palliative care be part of the plan?

“Palliative” can sound frightening, but palliative care is focused on comfort, symptom relief, support and quality of life. It can be provided alongside active cancer treatment. It does not mean that someone is being abandoned or that all treatment has stopped.

When hydronephrosis is caused by advanced cancer, a stent or nephrostomy may help with pain, infection, kidney function, or the ability to receive cancer treatment. It can also bring burdens such as procedures, hospital visits, tube or stent symptoms, repeat exchanges and complications. In some situations, drainage may not improve symptoms or kidney function enough to outweigh those burdens. Evidence in this area is limited, and outcomes vary widely; population averages cannot predict an individual person’s future.

There is no single point at which palliation is “required.” The decision is made with the patient, their chosen supports and the treating team. It can help to discuss:

  • What problem are we hoping drainage will improve?
  • How likely is it to help, and how soon might we know?
  • What would living with a stent or nephrostomy involve?
  • Could the result allow another treatment that matters to me?
  • What might happen if we monitor or manage symptoms without drainage?
  • What matters most to me now: time at home, symptom relief, kidney function, further cancer treatment, or avoiding procedures?

Choosing not to have a procedure is also a valid choice when it best fits a person’s wishes and clinical circumstances. The team can still treat pain, nausea, infection and other symptoms, and provide practical and emotional support. These conversations are best held early and revisited as circumstances change.

In summary

Hydronephrosis means that urine is collecting in one or both kidneys, but it does not identify the cause on its own. Many causes are benign and treatable. Prostate cancer, previous prostate surgery and radiation can be relevant, but a careful assessment is needed before drawing conclusions. Some people need urgent drainage; others can be monitored or treated in a less invasive way. When cancer is advanced, decisions about drainage and palliative care should be compassionate, individualised and guided by what is most important to the person.

References and further reading

  1. National Kidney Foundation. Hydronephrosis. Updated 2023.
  2. Mayo Clinic. Hydronephrosis: Diagnosis and treatment. Updated 2024.
  3. European Association of Urology. EAU Guidelines on Urolithiasis. See section on sepsis and anuria in an obstructed kidney.
  4. National Institute for Health and Care Excellence. Prostate cancer: diagnosis and management (NG131). Includes recommendations on upper urinary tract decompression for obstructive uropathy secondary to hormone-relapsed prostate cancer.
  5. Chorbińska J, Krajewski W, Zdrojowy R. Urological complications after radiation therapy—nothing ventured, nothing gained: a narrative review. Transl Androl Urol. 2021;10(8):3553–3566. doi:10.21037/tau-20-1217.
  6. Carilli M, et al. Management of ureteral stricture disease after radiation therapy for pelvic malignancies. Cancers (Basel). 2024;16(21):3561. doi:10.3390/cancers16213561.
  7. Shah M, et al. Malignant upper urinary tract obstruction in cancer patients: a systematic review. BJUI Compass. 2024;5(11):915–925. doi:10.1002/bco2.340.
  8. Gauhar V, et al. Nephrostomy tube versus double J ureteral stent in patients with malignant ureteric obstruction: a systematic review and meta-analysis of comparative studies. Int Braz J Urol. 2022;48(6):903–914. doi:10.1590/S1677-5538.IBJU.2022.0225.

This page provides general information and is not a substitute for an individual assessment by a qualified health professional. If you have hydronephrosis, your clinician can explain what the scan means in your circumstances and whether further tests or treatment are needed.

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

/0 Comments/in , /by

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

/0 Comments/in , /by

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.

Nephroptosis: is a “floating kidney” really a thing?

/0 Comments/in , /by

Can a kidney move enough to cause pain? Yes. Nephroptosis is a recognised anatomical condition, and in selected people it can cause symptoms. However, finding a mobile kidney does not automatically explain abdominal or flank pain. Establishing that connection is the central challenge, and the reason this condition has attracted controversy for more than a century.[1,2]

What is nephroptosis?

The kidneys normally sit towards the back of the abdomen, supported by surrounding fat and connective tissues. Some movement with breathing and changes in posture is normal.

Nephroptosis, also called a floating or mobile kidney, is conventionally defined as downward movement of more than 5 cm, or approximately two vertebral body heights, when a person moves from lying down to standing. A kidney can also rotate or move towards the midline.[3,4]

This differs from a congenital pelvic kidney, which developed in a lower position and stays there.

Published reports describe it more often in slim women and more often on the right, although men and people with other body types can be affected. Reduced support from surrounding fat is a proposed contributor. The true prevalence of symptomatic nephroptosis is uncertain; historical figures from people undergoing particular imaging tests should not be treated as estimates for the general population.[4]

How does it present?

Many mobile kidneys cause no symptoms. When symptoms occur, a suggestive pattern is:

  • An ache, dragging sensation or intermittent pain in the flank, the side between the lower ribs and hip, or abdomen.
  • Pain that becomes worse with standing, prolonged activity or particular positions.
  • Improvement when lying down.
  • Occasionally, a feeling of something moving within the abdomen.

Some patients experience more severe episodes with nausea or vomiting. Positional pain is a useful clue, but it does not establish the diagnosis.[2,5]

Possible mechanisms include intermittent kinking of the ureter, which drains urine to the bladder; stretching or twisting of the kidney’s blood vessels; or traction on nerves around the kidney. These mechanisms may differ between patients. Severe episodic pain from intermittent upper urinary tract obstruction is sometimes called a Dietl’s crisis, but that term is not specific to nephroptosis.[4,5]

Blood in the urine or urinary infections require investigation in their own right and should not simply be attributed to a mobile kidney.

How is the diagnosis made?

There are two separate questions: Does the kidney move excessively? And is that movement responsible for symptoms or impaired function?

1. Establish the symptom pattern and assess other causes

A consultation should explore where the pain occurs, its relationship to posture and activity, what relieves it, and associated urinary or gastrointestinal symptoms. Examination, urine testing and blood tests for kidney function help guide the investigation.

Other explanations include kidney stones, infection, obstruction at the junction between the kidney and ureter, musculoskeletal pain, and gastrointestinal or gynaecological conditions. Depending on the presentation, these may be more likely. A mobile kidney can coexist with an unrelated cause of pain.[2,3]

2. Compare imaging in different positions

A normal scan performed lying down may not exclude a problem that occurs when upright. If the clinical pattern raises suspicion, the imaging request should make the positional question explicit.[3,5]

Investigation What it can contribute Main limitation
Ultrasound lying down and upright Demonstrates movement and checks for changes in collecting-system dilatation Operator dependent; requires a deliberate positional examination
Doppler ultrasound in different positions May identify posture-related changes in renal blood flow An adjunct rather than a definitive test of the cause of pain
Positional nuclear medicine renal scan Assesses drainage and each kidney’s contribution to function; may reveal changes when upright Needs an appropriate protocol and careful interpretation
Intravenous urography with supine and erect images Historically used to measure kidney descent Used less often today; involves radiation and contrast
Selected positional CT urography Can clarify anatomy, rotation or medial movement Routine supine CT may miss positional mobility; repeat imaging adds radiation

The choice should be agreed with radiology or nuclear medicine. Not every centre routinely performs these protocols, and not every patient needs every test.[3,5,6]

3. Link the findings to the symptoms

Diagnostic confidence is stronger when the side and timing of the pain match the demonstrated movement, particularly if there is associated impaired drainage or blood flow. Nevertheless, some symptomatic patients have no demonstrable obstruction. The absence of obstruction does not conclusively exclude symptomatic nephroptosis, but it makes careful exclusion of other causes especially important.[3,4,6]

Normal overall kidney function does not, by itself, exclude an intermittent positional problem. Equally, descent beyond a measurement threshold is not sufficient justification for surgery.[2,5]

What are the treatment options?

Observation and symptom management

An incidentally discovered mobile kidney without symptoms or functional consequences generally does not require surgery.[5]

For mild symptoms, an individual plan may include modifying provoking activities, appropriate pain relief and reviewing other possible contributors. Abdominal supports, exercises and nutritional measures have been used historically, but convincing evidence that they reliably correct symptomatic nephroptosis is limited. They should not be presented as proven cures. Weight gain is not a universal recommendation.[1,2]

Nephropexy: fixing the kidney in position

Nephropexy repositions the kidney and secures it to surrounding tissues to limit excessive movement. It aims to preserve the kidney and relieve symptoms or positional impairment.

It may be considered when symptoms substantially affect daily life, nephroptosis has been demonstrated with appropriate imaging, other explanations have been reasonably excluded, and the evidence suggests a meaningful relationship between movement and symptoms. Documented positional obstruction or impaired perfusion strengthens the rationale.[2,3,5]

Modern surgery is usually laparoscopic, through the abdomen or behind it. Robotic assistance has also been described, but there is no convincing comparative evidence that it produces better outcomes than conventional laparoscopy for this condition. Fixation techniques vary, and some published methods use mesh while others use sutures.[3]

Open surgery is less commonly used. Percutaneous techniques, intended to stabilise the kidney through a tract and subsequent scarring, have also been reported. A recent report involved only four patients: such evidence is too limited to establish equivalence with laparoscopic surgery or support routine use.[7]

How effective is surgery, and what are the risks?

Small surgical series describe substantial improvement in selected patients. For example, a long-term study reported 13 patients assessed at a median of 5.9 years: 11 were completely satisfied and two moderately satisfied.[8]

That is encouraging, but it is not a reliable prediction for every patient. Small numbers, selection of patients, loss to follow-up and the absence of a non-operative comparison group limit what can be concluded. Fixing the kidney successfully does not guarantee that pain will disappear.[2,8]

Potential risks include bleeding, infection, injury to nearby organs, vessels or the urinary tract, anaesthetic complications, persistent or new pain, and recurrent kidney movement. If mesh is proposed, its specific benefits and risks should be discussed. Individual risks and expected recovery depend on the technique and the patient’s circumstances.

Why is nephroptosis controversial?

The controversy concerns which patients have symptoms caused by kidney mobility, and which benefit from treatment.

Historically, nephroptosis was blamed for a wide range of nonspecific symptoms, and nephropexy was performed much more frequently than it is today. Recognition that many mobile kidneys were harmless, together with inconsistent surgical results, led to scepticism and a marked decline in treatment.[1]

Modern positional imaging and minimally invasive surgery have renewed interest. However, the evidence remains dominated by small observational series and case reports rather than robust randomised comparisons. There is also no universally accepted combination of symptoms and test findings that predicts success for an individual.[2,6,8]

The appropriate response is to take the symptoms seriously while investigating the cause carefully. A normal routine scan does not mean pain is imagined. A mobile kidney does not mean an operation will solve it.

When should you seek urgent care?

Severe or escalating flank pain, fever or rigors, persistent vomiting, visible blood in the urine, or a marked reduction in urine output warrant prompt medical assessment. These symptoms can signal infection, obstruction or another problem requiring urgent treatment, regardless of whether nephroptosis is present.

This article provides general education. Diagnosis and treatment require an individual clinical assessment.

Patient information by Dr Jo Schoeman | Evidence reviewed October 2026

References

  1. Moss SW. Floating kidneys: a century of nephroptosis and nephropexy. Journal of Urology. 1997;158(3 Pt 1):699–702. doi:10.1016/S0022-5347(01)64296-4.
  2. Barber NJ, Thompson PM. Nephroptosis and nephropexy—hung up on the past? European Urology. 2004;46(4):428–433. doi:10.1016/j.eururo.2004.03.023.
  3. Mogorovich A, Selli C, De Maria M, et al. Clinical reappraisal and state of the art of nephropexy. Urologia. 2018;85(4). doi:10.1177/0391560317749191.
  4. Senaratne R, Anderson S, Kelly C, et al. Rolling in the deep: an illustrative report of symptomatic nephroptosis. Radiology Case Reports. 2024;19(9):4044–4048. doi:10.1016/j.radcr.2024.06.047. Case report.
  5. Murari SB, Gadepalli T, Rao VP, Ram R. Renal scintigraphy in diagnosis and management of nephroptosis. Indian Journal of Nuclear Medicine. 2012;27(1):52–54. doi:10.4103/0972-3919.108874. Case report.
  6. Strohmeyer DM, Peschel R, Effert P, et al. Changes of renal blood flow in nephroptosis: assessment by color Doppler imaging, isotope renography and correlation with clinical outcome after laparoscopic nephropexy. European Urology. 2004;45:790–793. PubMed.
  7. Liu H, Gao W, Zhang Z, et al. Modified percutaneous nephropexy for nephroptosis: technical description and short-term results. Current Urology. 2025;19(3):168–172. doi:10.1097/CU9.0000000000000238. Small technical series; four patients.
  8. Plas E, Daha K, Riedl CR, Hübner WA, Pflüger H. Long-term followup after laparoscopic nephropexy for symptomatic nephroptosis. Journal of Urology. 2001;166(2):449–452. PubMed.

Ureteroceles: symptoms, investigations and treatment

/0 Comments/in , , /by

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

Vaginal vault prolapse: understanding the options

/0 Comments/in , , , , /by

Patient information | Reviewed 28 September 2026

Vaginal vault prolapse occurs when the top of the vagina descends after a hysterectomy. It can occur alone or alongside a bulge of the front vaginal wall (anterior prolapse, often called a cystocele). Some women feel a bulge, dragging or pressure; others have difficulty emptying their bladder, recurrent urinary infections, bowel symptoms or discomfort during sex. The size of a prolapse on examination does not always match how troublesome it feels. Treatment should be guided by symptoms and personal priorities, rather than the examination alone. [1,2]

Why the front wall matters

The vaginal apex helps support the front and back walls. An anterior bulge may partly reflect loss of support at the apex. Repairing only the front wall while leaving significant vault prolapse untreated may leave the underlying problem unresolved. Conversely, restoring apical support may improve some anterior prolapse, although a separate anterior repair is sometimes needed. The surgeon should assess each compartment before deciding which parts require treatment. [1,3]

Assessment and treatment without surgery

Assessment includes a history of bulge, urinary and bowel symptoms, sexual function, prior hysterectomy and prolapse operations; examination while straining; and discussion of what the woman wants treatment to achieve. A bladder scan for residual urine is useful when emptying is difficult. Urine tests, urodynamics or imaging are considered for specific questions rather than required for every woman. Stress leakage can be hidden by a large prolapse and may appear after it is reduced or repaired; this possibility deserves discussion before surgery. [1,2]

If symptoms are mild, observation is reasonable. Pelvic floor muscle training can improve symptoms, particularly with less advanced prolapse, but cannot reliably lift a substantial vault prolapse back into place. A vaginal pessary can relieve a bulge without surgery and can also help someone decide whether restoring support improves bladder or bowel symptoms. Pessaries require fitting and ongoing review. Vaginal oestrogen may help postmenopausal vaginal dryness or irritation when appropriate; it is not a cure for the prolapse. [1,2]

Surgical options

Approach How the apex is supported Main considerations
Vaginal sacrospinous fixation Stitches attach the vaginal top to a pelvic ligament, usually on one side. Avoids an abdominal incision and implanted mesh; possible temporary buttock pain and recurrent anterior bulge.
Vaginal uterosacral ligament suspension Stitches attach the vaginal top to the uterosacral ligaments. Uses the woman’s own tissues; attention to the ureters is essential, often with cystoscopy during surgery.
Sacrocolpopexy (laparoscopic, robotic or open) Mesh attached to the vagina is fixed to the ligament over the sacrum through the abdomen. Often durable apical support; abdominal operative risks and mesh-specific risks must be weighed.
Colpocleisis The vaginal canal is closed or substantially shortened. Effective option for selected women who do not wish to retain vaginal intercourse; the loss of vaginal intercourse is permanent.

An anterior repair may be added if the front wall remains significantly prolapsed after apical support is restored. These operations can also be combined with treatment of stress incontinence when the benefits and added risks justify it. The decision is individual. [1–3]

Where does robotic sacrocolpopexy fit?

Robotic sacrocolpopexy is one way to perform abdominal sacrocolpopexy through small incisions. The robot helps the surgeon control instruments; it does not perform the surgery independently. It may be considered for symptomatic, substantial or recurrent vault prolapse, especially when preserving vaginal length and durable apical support are priorities, or when multiple compartments need reconstruction. It is not necessary for every prolapse and is not suitable for every patient. Previous abdominal operations, anaesthetic risk, ability to tolerate the operating position, mesh preferences, surgeon experience and costs all matter. [1–4]

Compared with vaginal operations using the patient’s own tissue, sacrocolpopexy generally has lower rates of recurrent prolapse and repeat prolapse surgery in studies of post-hysterectomy vault prolapse. In the 2023 Cochrane review, illustrative estimates were 6 in 100 requiring repeat surgery after sacrocolpopexy versus 14 in 100 after vaginal procedures, and 8 in 100 noticing recurrent prolapse versus 18 in 100 after vaginal procedures. These are pooled comparisons, not predictions for an individual. The certainty and length of follow-up vary. [3]

A multicentre randomised trial reported a 36-month composite treatment-failure estimate of 28% with sacrocolpopexy and 43% with vaginal native-tissue repair. Its definition combined symptoms, examination findings and retreatment: it does not mean 28% underwent another operation. Women in all groups reported sustained improvement, with similar satisfaction and decision regret. [4]

The benefit shown for sacrocolpopexy should not be attributed specifically to the robot. Comparative studies have not established better long-term anatomical or patient-reported results for robotic versus conventional laparoscopic sacrocolpopexy. Operating time and cost can be higher with robotic surgery, depending on the centre and surgeon. The quality of the repair and the experience of the team may matter more than the instrument platform. [5,6]

Risks and complications

Every prolapse operation can involve bleeding, infection, clots, anaesthetic complications, injury to the bladder, bowel or ureters, temporary difficulty emptying the bladder, new or persistent urinary leakage or urgency, constipation, pain with intercourse, and recurrence. A bulge can return in a different compartment even when the apex remains well supported. Some women need further treatment. Individual risk varies with previous operations and health. [1–4]

Sacrocolpopexy adds risks associated with abdominal access and permanent mesh, including mesh exposure through the vagina, infection, pain, and rarely erosion into an organ or complications near the sacrum. Mesh complications can arise years later and sometimes require further surgery. The 2024 randomised trial reported mesh exposure in about 3% after sacrocolpopexy during its follow-up; this is a study figure, not a lifetime risk. Vaginal native-tissue surgery avoids implanted mesh but has its own risks, including buttock pain with sacrospinous fixation and ureteric obstruction or injury with uterosacral suspension. [1,3,4]

An Australian distinction: Mesh inserted through the vagina to repair prolapse is not available for routine supply in Australia. That is different from mesh inserted through the abdomen for sacrocolpopexy, which remains an available category of device. An operation should never be described simply as “mesh-free” or “mesh surgery” without explaining the route, material and specific risks. [7]

Making a decision

There is no single best operation for every woman. A useful consultation covers how bothersome the bulge is; whether a pessary has been tried; the degree of vault and anterior prolapse; bladder, bowel and sexual symptoms; previous repairs; the wish to avoid mesh; the wish to maintain vaginal intercourse; likely recovery; and the surgeon’s experience with each approach. It should distinguish improvement in symptoms from an examination-based definition of anatomical success. For women seeking a durable reconstruction, sacrocolpopexy is an important option; vaginal native-tissue surgery remains a valid choice, particularly when avoiding abdominal surgery or mesh matters more. [1–4]

This article provides general information and cannot replace an individual examination and discussion of personal risks and goals.

References

  1. NICE. Urinary incontinence and pelvic organ prolapse in women: management (NG123). 2019, subsequent updates.
  2. RCOG. Pelvic organ prolapse: patient information.
  3. Maher C, et al. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2023;7:CD012376. doi:10.1002/14651858.CD012376.pub2.
  4. Menefee SA, et al. Apical suspension repair for vaginal vault prolapse: a randomized clinical trial. JAMA Surg. 2024.
  5. Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol. 2014.
  6. Ferrari A, et al. Laparoscopic versus robot-assisted sacrocolpopexy: systematic review and meta-analysis. 2026.
  7. Therapeutic Goods Administration. About transvaginal surgical mesh devices.

Blood in the Semen: What Does It Mean?

/0 Comments/in /by

Seeing red, pink or brown discolouration in your semen can be alarming. The medical term is haematospermia. Although it often settles without treatment, it is sensible to tell your GP so they can consider the cause and whether you need further assessment.

Where might the blood come from?

Semen passes through several structures before ejaculation, including the prostate and urethra. Inflammation or infection along this pathway can sometimes cause bleeding. Blood in the semen may also appear after a recent prostate biopsy or other urinary procedure.

The colour can vary. Fresh blood may look red or pink, while older blood may give semen a brownish appearance. Colour alone cannot establish the cause.

What details should you tell your doctor?

It helps to note whether this happened once or has occurred repeatedly. Mention any recent procedure and whether you have other symptoms, such as:

  • Pain during ejaculation
  • Burning or pain when passing urine
  • Fever or pelvic discomfort
  • Blood in the urine
  • A change in your urinary stream

Your age, medical history and the presence of other symptoms all affect which investigations, if any, are appropriate.

Does blood in the semen mean cancer?

Usually, no. Infection, inflammation and recent procedures are among the possible explanations. However, a doctor should assess the symptom rather than assuming the cause. Rarely, it can be associated with a more serious condition.

What happens at an appointment?

Your doctor will ask about the bleeding and any related symptoms. Depending on your circumstances, assessment may include an examination, urine testing or other investigations. If the bleeding persists, recurs or raises concern, your GP may recommend a urology review.

The main message is reassuring but practical: blood in the semen is often not serious, yet it is worth discussing with a doctor—particularly if it happens again or you have other symptoms.

 

Why Is My Urine Stream Splitting or Spraying?

/0 Comments/in /by

A urine stream that suddenly sprays sideways or separates into two streams can be awkward and frustrating. If it happens once, you might dismiss it. If it keeps happening especially alongside a weaker flow or difficulty emptying your bladder, it is worth finding out why.

A split stream is a symptom, not a diagnosis. The cause may be near the opening where urine leaves the body, or farther along the urethra, the tube that carries urine out of the bladder.

What could cause it?

Sometimes a temporary change at the urethral opening affects the direction of the stream. In other cases, inflammation or narrowing may be involved.

One condition a urologist may consider is a urethral stricture, where scar tissue narrows part of the urethra. This can cause spraying or splitting, often with other symptoms such as a slow stream, straining or dribbling after urination.

Changes affecting the foreskin or the opening at the tip of the penis can also make the stream difficult to direct. The pattern of symptoms and an examination help determine what needs further investigation.

Which details should you mention?

Tell your doctor whether the change is new or longstanding, and whether it happens every time you pass urine. Also mention:

  • A stream that has become progressively weaker
  • Pain or burning when passing urine
  • Straining or taking longer to empty your bladder
  • Dribbling afterwards
  • Repeated urinary infections
  • Previous catheter use, urinary procedures or injury

These details can help distinguish a change in the stream’s direction from a broader problem with urine flow.

How is it assessed?

Assessment starts with your symptoms and medical history. Your urologist may examine the area and recommend a urine test or a test that measures the speed and pattern of your flow. If a narrowing is suspected, further investigation may be needed to establish where it is and how best to manage it.

The treatment depends on the cause. A split stream alone does not mean you need an operation.

When should you seek help?

Arrange a medical review if splitting or spraying persists, particularly if your flow is worsening or you have pain, blood in the urine or recurrent infections. If you cannot pass urine at all, seek urgent medical care.