The foreskin is normally a fairly cooperative piece of anatomy. It moves forward, it moves backward, and for the most part it quietly gets on with its job.

Phimosis occurs when the foreskin becomes too tight to comfortably pull back, or retract, over the head of the penis (glans).

Think of it as a turtleneck that has become a little too enthusiastic about the turtle part.

In young boys, a non-retractile foreskin is usually completely normal. In adult men, however, a foreskin that becomes progressively tighter may indicate inflammation, infection or scarring and deserves assessment.

The good news is that not every tight foreskin requires circumcision. Treatment depends on why it has become tight, how severe it is and how much trouble it is causing.

What is phimosis?

The foreskin, or prepuce, is the fold of skin covering the glans penis. Normally it is sufficiently elastic to retract comfortably.

With phimosis, the opening becomes too narrow to pass easily over the glans.

There are two broad types.

Physiological phimosis

In babies and young boys, the foreskin is naturally attached to the glans and often cannot be retracted. This is a normal part of development and usually resolves gradually as the child grows.

It should not be forcibly pulled back. The foreskin is not a stubborn jar lid. Forceful retraction can cause tearing, bleeding and eventually scarring.

Pathological phimosis

Pathological phimosis develops when the foreskin becomes narrowed because of inflammation, infection or scarring.

This is particularly important in adult men.

If your foreskin previously retracted normally but has progressively become tighter, something has changed and it is worth finding out why.

What Causes Phimosis in Adults?

Recurrent inflammation or infection

Repeated episodes of balanitis (inflammation of the glans) or balanoposthitis (inflammation of both the glans and foreskin) may eventually produce scarring.

Symptoms can include redness, swelling, itching, discomfort, discharge or an unpleasant odour.

One episode may simply be irritating. Repeated episodes are your foreskin submitting a formal complaint.

Lichen sclerosus / Balanitis xerotica obliterans (BXO)

Lichen sclerosus, sometimes called balanitis xerotica obliterans or BXO when affecting the penis, is an important cause of acquired phimosis.

The foreskin may become:

• White or unusually pale
• Thickened
• Scarred
• Less elastic
• Progressively tighter

A characteristic white fibrotic ring can develop around the foreskin opening.

Once significant fibrosis develops, the foreskin behaves less like elastic skin and more like a tiny belt that somebody has pulled one notch too far.

Lichen sclerosus may also involve the urethral opening and occasionally cause narrowing of the urinary passage.

Longstanding penile lichen sclerosus is associated with an increased risk of penile cancer, so persistent or suspicious changes should always be medically assessed.

Diabetes

Recurrent balanitis and phimosis can occasionally be the unexpected messenger announcing previously undiagnosed diabetes.

Elevated glucose levels can encourage fungal and bacterial infections, producing repeated inflammation and eventual scarring.

For this reason, men presenting with recurrent balanitis or newly acquired phimosis may be advised to have their blood glucose checked.

Your foreskin probably isn’t where you expected your diabetes screening programme to begin, but medicine has a sense of humour.

Trauma and scarring

Repeatedly forcing a tight foreskin backwards can cause small tears. These heal with further scar formation, producing the unfortunate cycle:

tightness → tearing → healing → scarring → even more tightness.

Trying harder is therefore not always the solution.

If it repeatedly cracks or tears, stop wrestling with it and have it assessed.

What Are the Symptoms?

Some men have surprisingly few symptoms. Others discover that their foreskin has developed a personality of its own.

Symptoms may include:

• Difficulty or inability to retract the foreskin
• Pain when attempting retraction
• Painful erections
• Cracking or splitting of the foreskin
• Bleeding after intercourse
• Recurrent redness or inflammation
• Recurrent balanitis
• Difficulty cleaning beneath the foreskin
• Discomfort during sexual intercourse
• Ballooning of the foreskin during urination
• Difficulty directing the urinary stream

Severe phimosis can occasionally interfere significantly with urination.

If passing urine starts resembling an unpredictable garden sprinkler, it may be time for a urological opinion.

Phimosis and Sex

A tight foreskin often makes its presence particularly well known during an erection.

Some men can retract the foreskin perfectly well when the penis is flaccid but experience tightness, pain or tearing when erect.

Repeated tearing during intercourse can create additional scar tissue and make the problem progressively worse.

Phimosis does not necessarily cause erectile dysfunction. However, if every erection comes with the anticipation of pain, splitting or bleeding, enthusiasm can understandably begin to decline.

Sex should not require protective headgear.

How Is Phimosis Diagnosed?

Fortunately, diagnosis usually doesn’t require complicated machinery.

Your urologist will examine the penis and assess:

• The degree of narrowing
• Whether the foreskin can be partially or completely retracted
• The presence of a fibrotic or scarred ring
• Evidence of balanitis
• Changes suggesting lichen sclerosus
• The appearance of the glans
• The urethral opening
• Any unusual skin lesion

Blood or urine tests may occasionally be required, particularly when recurrent infection raises the possibility of diabetes.

A biopsy may be recommended if there is an unusual lesion or concern regarding lichen sclerosus, precancerous changes or penile cancer.

Treatment Options

Treatment is tailored to the underlying cause and severity.

Not every tight foreskin needs an appointment with the operating theatre.

1. Observation

Mild phimosis without significant symptoms may simply be observed.

Good hygiene and avoiding forceful retraction are important.

Physiological phimosis in children generally does not require surgery unless specific complications develop.

2. Topical Steroid Treatment

A topical corticosteroid cream or ointment may be prescribed for selected patients.

It is applied to the tight portion of the foreskin, usually for several weeks, sometimes combined with careful and gentle stretching.

The emphasis is on gentle.

This is stretching, not a tug-of-war.

Steroid treatment can reduce inflammation and improve elasticity and tends to work best when there is relatively little established scarring.

A heavily fibrotic foreskin or advanced lichen sclerosus is less likely to respond permanently.

3. Treat the Underlying Infection or Inflammation

When balanitis is present, the underlying cause should be addressed.

Treatment may involve antifungal or antibacterial medication where appropriate, treatment of inflammatory skin disease and attention to penile hygiene.

Repeated infections should also prompt consideration of underlying conditions such as diabetes.

Simply treating each infection without asking why it keeps returning is rather like repeatedly mopping the floor without looking for the leaking pipe.

4. Preputioplasty

A preputioplasty is a foreskin-preserving surgical procedure in which the narrowed area is widened.

Its major advantage is that the foreskin is retained.

It may be an option for selected men who wish to avoid circumcision, but it is less suitable for severe scarring, extensive lichen sclerosus or recurrent inflammatory disease.

There is also a possibility that narrowing may recur.

5. Circumcision

Circumcision remains the definitive surgical treatment for significant or recurrent phimosis.

The narrowed foreskin is surgically removed, permanently exposing the glans.

Circumcision may be recommended for:

• Severe or scarred phimosis
• Recurrent balanitis
• Repeated tearing or bleeding
• Failure of topical treatment
• Painful erections or intercourse
• Significant lichen sclerosus
• Recurrent urinary problems
• Suspicious or abnormal foreskin tissue

Circumcision is usually performed as a day procedure under local or general anaesthesia.

Essentially, when the turtleneck has become irreparably tight, sometimes the most reliable solution is to remove the turtleneck.

What Happens After Circumcision?

Some swelling, bruising and increased sensitivity of the glans are normal during the early recovery period.

Dissolvable sutures are commonly used and healing progresses over several weeks.

Sexual intercourse and masturbation are generally avoided until the wound has adequately healed, often around 4–6 weeks, although recovery varies between individuals.

Possible complications include bleeding, infection, wound problems, scarring, cosmetic dissatisfaction and altered sensation.

Your surgeon will discuss these risks and the expected recovery before surgery.

Phimosis vs Paraphimosis: Don’t Confuse the Two

These names sound annoyingly similar, but the distinction matters.

Phimosis means the foreskin cannot be pulled back normally.

Paraphimosis occurs when a tight foreskin has been pulled behind the glans but then becomes trapped and cannot be brought forward again.

The trapped foreskin can form a constricting band, causing increasing swelling, pain and eventually impaired blood flow.

Paraphimosis requires urgent medical attention.

If the foreskin is trapped behind the glans and the penis is becoming increasingly swollen, painful or discoloured, don’t wait for it to reconsider its position. Seek urgent medical care.

When Should You See a Urologist?

Make an appointment if you develop persistent difficulty retracting the foreskin, recurrent infections, painful erections, repeated tearing or bleeding, progressive tightening, white or scarred areas, urinary difficulties or any persistent lump, ulcer or abnormal penile lesion.

In particular, new phimosis developing in an adult should be assessed.

The Bottom Line

Phimosis is common, treatable and certainly nothing to be embarrassed about.

Mild cases may respond to topical treatment and gentle stretching. Infection or inflammation should be appropriately treated. More significant scarring may require preputioplasty or circumcision.

Most importantly, don’t allow embarrassment to turn a relatively straightforward problem into a much bigger one.

Guys, don’t suffer in silence.

Urologists spend their working lives talking about bladders, prostates, testicles, erections and foreskins. You are extremely unlikely to surprise us.

If your foreskin has become progressively tighter, keeps tearing, becomes repeatedly infected or simply isn’t behaving the way it used to, come and have it assessed.

Drop the embarrassment and come and see your friendly urologist in Brisbane.

Consultations are available at The Wesley Hospital, Caboolture and Bribie Island.

Make an appointment to see Dr Jo.

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

Urinary incontinence and bladder control problems can have a significant effect on everyday life. Frequent trips to the toilet, sudden urgency, leakage, waking repeatedly at night or being unable to empty the bladder properly can interfere with work, exercise, travel, sleep and social activities.

For men and women whose symptoms have not responded adequately to conservative treatment or medication, sacral neuromodulation (SNM) can provide another treatment option.

Sacral neuromodulation is particularly useful because it can treat two apparently opposite bladder problems:

• an overactive bladder, where the bladder signals too frequently or contracts when it should not; and
• an underactive bladder or non-obstructive urinary retention, where the bladder does not empty effectively.

Rather than operating directly on the bladder, sacral neuromodulation works by modifying the nerve signals involved in bladder storage and emptying.

What is sacral neuromodulation?

The bladder, urethral sphincter, pelvic floor and brain communicate through a complex network of nerves. The sacral nerves, particularly those arising from the S3 region, form an important part of this communication system.

Sacral neuromodulation uses a small, implanted device to deliver mild electrical impulses to a sacral nerve. These impulses help modify abnormal signaling between the bladder, pelvic floor, spinal cord and brain.

A useful way of thinking about the treatment is that it attempts to recalibrate the communication system controlling the bladder, rather than simply forcing the bladder to contract or relax.

International Continence Society guidance recognises sacral neuromodulation as an established therapy for refractory urinary urgency and frequency, urgency urinary incontinence and non-obstructive urinary retention.

Importantly, SNM does not “cure” every patient with urinary incontinence. The aim is to achieve a meaningful and sustained reduction in symptoms and improvement in quality of life.

What conditions can sacral neuromodulation treat?

1. Overactive bladder

Overactive bladder (OAB) is characterised by urinary urgency, usually accompanied by increased frequency and nocturia, with or without urgency urinary incontinence.

Typical symptoms include:

• suddenly needing to pass urine;
• difficulty postponing urination;
• frequent urination during the day;
• waking several times at night to urinate;
• urinary leakage associated with urgency; and
• needing to know where the nearest toilet is whenever leaving home.

Some patients experience urgency and frequency without leakage, while others develop urgency urinary incontinence, where the urge is followed by involuntary loss of urine.

Sacral neuromodulation can be considered when symptoms remain troublesome despite appropriate conservative and/or medical treatment. Current AUA/SUFU guidance includes SNM among the minimally invasive treatment options that clinicians should offer to appropriately selected patients with OAB who have not achieved adequate improvement with behavioural or pharmacological therapy.

2. Urgency urinary incontinence

Urgency urinary incontinence is leakage associated with a sudden compelling desire to urinate.

This is different from stress urinary incontinence, where leakage occurs with coughing, sneezing, exercise or physical exertion.

Sacral neuromodulation is principally a treatment for urgency-related leakage. It is not a standard treatment for isolated stress urinary incontinence.

This distinction is particularly important in women who may have both stress and urgency incontinence and in men who develop stress incontinence following prostate surgery.

When both types of leakage are present, treatment needs to be tailored to determine which component is causing the greatest problem.

What about an underactive bladder?

The bladder does not always misbehave by being too active. Sometimes the problem lies at the other end of the spectrum.

Underactive bladder and urinary retention

An underactive bladder describes symptoms associated with inadequate bladder emptying, often related to reduced bladder contractility or impaired coordination between the bladder and urinary sphincter.

Symptoms can include:

• difficulty starting urination;
• a slow or interrupted urinary stream;
• prolonged urination;
• straining to urinate;
• feeling that the bladder has not emptied;
• recurrent urinary tract infections;
• a large residual volume of urine after voiding; and
• complete inability to empty the bladder without a catheter.

Some patients need to perform clean intermittent self-catheterisation several times each day.

However, poor bladder emptying does not automatically mean that sacral neuromodulation is appropriate.

Obstruction must first be excluded

In men, urinary retention may be caused by:

• benign prostate enlargement;
• urethral stricture;
• bladder neck obstruction; or
• scarring following previous prostate or urethral surgery.

In women, causes can include:

• previous continence surgery;
• urethral obstruction;
• pelvic organ prolapse; or
• functional outlet obstruction.

Sacral neuromodulation is primarily used for non-obstructive urinary retention rather than retention caused by a mechanical blockage.

The distinction may require urine flow testing, measurement of the post-void residual, cystoscopy and, in selected patients, urodynamic studies.

The AUA notes that sacral neuromodulation can be used in appropriately selected men and women with non-obstructive urinary retention, including patients with decreased bladder contractility.

Who may benefit from sacral neuromodulation?

SNM may be considered in appropriately selected men and women with:

• refractory overactive bladder;
• urinary urgency and frequency;
• urgency urinary incontinence;
• non-obstructive urinary retention;
• impaired bladder emptying in selected patients; or
• troublesome bladder dysfunction that has not responded adequately to other treatments.

In Australia, sacral neuromodulation is an established treatment option. The TGA describes implantable sacral nerve stimulation systems as devices used in conditions including overactive bladder, urinary retention and urinary incontinence.

It is generally not a first-line treatment. Australian TGA information relating to the InterStim X system specifically notes that the treatment is not first-line therapy and is intended for appropriately selected patients after conservative and medical management have been attempted.

What treatments are usually tried first?

The treatments used before considering SNM depend upon the underlying bladder problem.

For overactive bladder these may include:

• bladder retraining;
• modification of fluid and caffeine intake;
• pelvic floor physiotherapy;
• management of constipation and other contributing factors;
• antimuscarinic medication;
• beta-3 agonist medication;
• posterior tibial nerve stimulation; and
• bladder injections with botulinum toxin (Botox).

For an underactive bladder or urinary retention, treatment may include:

• treating an identifiable obstruction;
• reviewing medications that may impair bladder emptying;
• timed or double voiding in selected patients; and
• intermittent self-catheterisation.

The appropriate pathway varies considerably between patients.

Assessment before sacral neuromodulation

Successful treatment begins with establishing the correct diagnosis.

Assessment may include:

Medical history

Your urologist will establish whether the predominant problem is urgency, frequency, leakage, difficulty emptying the bladder or a combination of symptoms.

Bladder diary

A bladder diary can record:

• how frequently you urinate;
• urine volumes;
• fluid intake;
• urgency episodes;
• leakage episodes; and
• night-time urination.

Urine testing

Urinary infection should be excluded where appropriate.

Post-void residual measurement

An ultrasound can measure how much urine remains in the bladder after urination.

Uroflowmetry

Urinary flow testing can provide useful information about the strength and pattern of the urinary stream.

Cystoscopy

A cystoscopy may be required when obstruction, urethral narrowing, prostate-related obstruction or another bladder abnormality is suspected.

Urodynamic studies

Urodynamic testing is not required in every patient, but it can be particularly valuable when the diagnosis is uncertain, symptoms are complex, previous treatments have failed or poor bladder emptying needs further investigation.

How is sacral neuromodulation performed?

One of the most attractive features of sacral neuromodulation is that the treatment can usually be tested before committing to a permanent implant.

The procedure therefore generally takes place in two stages.

Stage 1: The test phase

A thin electrode or tined lead is positioned through a small opening in the sacrum adjacent to a sacral nerve, most commonly the S3 nerve root.

The position is confirmed using anatomical landmarks, imaging and appropriate physiological responses during the procedure.

The lead is then connected to an external stimulator.

The patient goes home and uses the system during a trial period while recording symptoms in a bladder diary.

Depending upon the reason for treatment, we look for improvements such as:

• fewer urgency episodes;
• fewer episodes of urinary leakage;
• reduced urinary frequency;
• fewer night-time toilet visits;
• improved bladder emptying;
• lower residual urine volumes; or
• reduced need for intermittent catheterisation.

A meaningful improvement during the test phase, commonly around 50% or greater improvement in the target symptoms, is generally used to determine whether proceeding to permanent implantation is worthwhile.

Stage 2: Permanent implantation

If the trial is successful, a small pulse generator is implanted beneath the skin, usually in the upper buttock.

The device is connected to the previously positioned sacral lead.

Once the incision has healed, the device remains beneath the skin and is generally not visible, although a small contour may sometimes be noticeable.

The stimulator is programmed to provide electrical impulses tailored to the individual patient.

Patients are provided with a programmer or controller that allows appropriate adjustments within parameters established by the treating team.

What does the stimulation feel like?

Patients may notice a mild:

• tingling;
• tapping;
• pulling; or
• vibration-like sensation

in the pelvic, perineal, vaginal, scrotal or anal region.

The stimulation should not normally be painful.

The device can be reprogrammed during follow-up if symptoms change or stimulation becomes uncomfortable.

How successful is sacral neuromodulation?

Success depends on the condition being treated, patient selection and how success is defined.

The major advantage of SNM is that each patient effectively undergoes their own therapeutic trial before receiving the permanent implant.

For refractory overactive bladder, clinical studies demonstrate substantial improvement in appropriately selected patients. The 2024 AUA/SUFU guideline cites a randomised study in which 86% of patients allocated to SNM initially responded and 61% met the study’s definition of therapeutic success at six months.

For non-obstructive urinary retention, treatment may substantially improve bladder emptying and can reduce or sometimes eliminate the need for intermittent catheterisation in responders. AUA evidence reviewing SNM for non-obstructive retention reported a significant reduction in post-void residual urine following treatment.

Individual results vary, and improvement rather than complete cure is a more realistic treatment goal.

Sacral neuromodulation versus Botox

Both sacral neuromodulation and intravesical botulinum toxin are established advanced treatments for refractory overactive bladder.

Botox is injected into the bladder wall during cystoscopy and temporarily reduces excessive bladder contractions.

SNM instead modifies the neural pathways controlling bladder function.

Both can be effective. One practical difference is that Botox usually needs to be repeated as its effect wears off, whereas SNM uses an implanted device designed to provide ongoing treatment.

Botox also carries a risk of urinary retention and urinary tract infection. In the ROSETTA trial, women treated with botulinum toxin had higher rates of urinary tract infection and temporary catheterisation than those treated with SNM, although both treatments produced substantial improvement in urgency incontinence.

The best option depends upon the individual patient’s priorities and bladder function.

Advantages of sacral neuromodulation

Potential advantages include:

• treatment can be tested before permanent implantation;
• no major bladder reconstruction is required;
• it can reduce urgency and urgency incontinence;
• it can improve frequency and nocturia in selected patients;
• it may improve bladder emptying in non-obstructive retention;
• it may reduce dependence on intermittent catheterisation;
• stimulation can be individually programmed;
• treatment is adjustable over time; and
• the system can be removed if necessary.

Perhaps most importantly, SNM offers another option when conventional treatment has failed but major reconstructive surgery is undesirable.

What are the risks and possible complications?

Sacral neuromodulation is a surgical procedure and complications can occur.

These include:

• pain or discomfort around the implant;
• wound infection;
• bleeding or bruising;
• lead movement or migration;
• loss of effective stimulation;
• uncomfortable stimulation;
• change in the location of the stimulation sensation;
• failure to achieve adequate symptom improvement;
• technical problems with the lead or pulse generator;
• need for reprogramming;
• battery depletion; and
• need for revision, replacement or removal of the device.

In studies of SNM for overactive bladder, recognised device-related adverse events have included changes in stimulation, implant-site pain and infection.

Modern systems have improved considerably, but patients should understand that implantation begins a long-term relationship with the device rather than being a one-off operation.

What happens if the treatment stops working?

A reduction in benefit does not necessarily mean that the treatment has permanently failed.

The first step is often to check the device and change its programming.

If this does not restore benefit, further investigation may determine whether there has been:

• lead migration;
• lead damage;
• battery depletion;
• a change in bladder function; or
• another underlying urinary problem.

Occasionally, surgical revision or replacement of the lead or pulse generator is required.

Battery life and rechargeable devices

Different sacral neuromodulation systems and pulse generators are available, including rechargeable and non-rechargeable technologies.

Battery longevity depends on the particular device and the stimulation settings required.

A non-rechargeable generator eventually requires surgical replacement when its battery reaches the end of its useful life.

Rechargeable systems can potentially reduce the frequency of generator replacement but require the patient to recharge the device periodically.

The most appropriate system depends on factors such as age, lifestyle, dexterity, expected stimulation requirements and patient preference.

What about MRI scans?

MRI compatibility has historically been an important issue for patients with implanted neuromodulation devices.

Many modern SNM systems now provide substantially broader MRI access than older devices. However, MRI eligibility depends on the exact pulse generator, lead and implanted system.

Patients should therefore keep their implant identification information and tell radiology staff that they have a sacral neuromodulation device before undergoing an MRI.

Is sacral neuromodulation suitable for both men and women?

Yes.

Although much of the early research into urgency urinary incontinence involved women, sacral neuromodulation can be used in appropriately selected men and women.

In men, it is particularly important to distinguish non-obstructive bladder dysfunction from obstruction caused by prostate enlargement, urethral stricture or previous prostate surgery.

In women, pelvic organ prolapse and previous continence or pelvic surgery may also need to be considered.

The treatment therefore depends much more on the type of bladder dysfunction than on the patient’s sex.

Overactive versus underactive bladder: one treatment, two different problems

It can initially seem strange that the same treatment can help a bladder that is too active and one that does not empty adequately.

This is because sacral neuromodulation is not simply an electrical switch telling the bladder to contract or relax.

Instead, it modifies the complex sensory and motor signalling involved in bladder storage, awareness, pelvic floor coordination and emptying.

For an overactive bladder, this can reduce inappropriate urgency and bladder activity.

For non-obstructive urinary retention or selected underactive bladder dysfunction, neuromodulation may improve the coordination of the bladder outlet and neural pathways involved in effective voiding.

This ability to influence both storage and emptying disorders makes sacral neuromodulation unusual among treatments for lower urinary tract dysfunction.

When should sacral neuromodulation be considered?

Sacral neuromodulation may be worth discussing when:

Overactive bladder symptoms remain troublesome despite conservative and medical treatment

or

Non-obstructive urinary retention is causing significant symptoms or dependence on intermittent catheterisation.

The key is appropriate patient selection.

Before proceeding, it is important to establish why the bladder is malfunctioning. In particular, a mechanical obstruction should not be mistaken for an underactive bladder.

Once the diagnosis is established, the test phase provides a valuable opportunity to determine whether neuromodulation is likely to provide meaningful benefit before committing to a permanent implant.

The bottom line

Sacral neuromodulation is an established, minimally invasive surgical treatment for selected men and women with refractory overactive bladder, urgency urinary incontinence and non-obstructive urinary retention.

A small electrode placed near the sacral nerves modifies the neural signals involved in bladder storage and emptying. Because treatment is usually performed as a staged procedure, patients can assess their response during a test phase before deciding whether to proceed with permanent implantation.

For patients who have spent years planning their lives around the nearest toilet, coping with unpredictable leakage or relying on catheters to empty their bladder, sacral neuromodulation can offer a very different approach: treating the communication network controlling the bladder rather than simply treating the bladder itself.

Important information

This information is intended for general patient education and does not replace individual medical advice. The suitability of sacral neuromodulation depends on the cause of the bladder dysfunction, previous treatments, medical history and individual treatment goals. Assessment by a urologist with experience in urinary incontinence and voiding dysfunction is recommended.

So, if you think is something that may work for you, come see me at my rooms in Brisbane, Caboolture or Bribie Island. Your friendly Brisbane based Urologist, Dr Jo will assist.

A ureteric stent is a thin, flexible tube placed inside the ureter, the channel that carries urine from the kidney to the bladder. Stents are commonly used in urology to maintain drainage of urine from the kidney when the ureter is blocked, narrowed, injured or at risk of becoming obstructed.

Most ureteric stents are intended to be temporary. However, some patients with chronic or recurrent ureteric obstruction require long-term stenting, with either regular stent changes or specialised longer-term stents.

Although ureteric stents can be extremely effective at protecting kidney function, they can also cause bothersome urinary symptoms. Understanding why a stent is required, how long it needs to remain in place and what symptoms to expect can make the experience considerably easier.

What Does a Ureteric Stent Look Like?

The most commonly used stent is called a double-J stent or JJ stent.

It has:

• one curled end positioned within the kidney
• a straight section passing down the ureter
• another curled end positioned within the bladder

The curls help prevent the stent from migrating upwards or downwards.

Urine can drain through the hollow centre of the stent and around its outside, allowing urine to bypass an area of narrowing or obstruction.

Why Might I Need a Ureteric Stent?

There are several reasons for inserting a ureteric stent.

1. Kidney and Ureteric Stones

Urinary stones are among the most common reasons for ureteric stent placement.

A stone lodged within the ureter can obstruct urine drainage and cause:

• severe renal colic
• swelling of the kidney, known as hydronephrosis
• deterioration in kidney function
• infection behind the obstruction

A stent may be inserted urgently to relieve the obstruction.

Stents are also commonly placed temporarily following ureteroscopy and laser treatment of urinary stones, particularly when there has been swelling, instrumentation or trauma to the ureter.

2. Infection Associated With an Obstructed Kidney

An obstructed and infected kidney can represent a urological emergency.

Patients may develop:

• fever
• chills or rigors
• flank pain
• nausea or vomiting
• low blood pressure
• sepsis

Urgent drainage of the kidney may be required using either:

a ureteric stent

or

a percutaneous nephrostomy tube, which drains the kidney externally through the back.

The infection is generally treated before definitive treatment of the underlying stone or obstruction.

3. Ureteric Stricture

A ureteric stricture is an abnormal narrowing of the ureter.

It may occur following:

• previous surgery
• stone disease
• ureteroscopy
• radiotherapy
• inflammation
• endometriosis
• retroperitoneal fibrosis
• previous ureteric injury

A stent can maintain drainage while the underlying problem is investigated or treated.

4. Following Ureteric Surgery

Stents are frequently placed after surgery involving the ureter to allow healing while maintaining urinary drainage.

Examples include:

• ureteroscopy
• ureteric reconstruction
• ureteric reimplantation
• pyeloplasty
• treatment of ureteric injuries

The stent effectively acts as an internal splint while the ureter heals.

5. Cancer-Related Ureteric Obstruction

Tumours within the pelvis or abdomen can compress or invade the ureters.

Examples include cancers involving the:

• prostate
• bladder
• cervix
• uterus
• ovary
• bowel
• lymphatic system

Ureteric obstruction can also occur from metastatic disease or enlarged lymph nodes.

In these circumstances, long-term ureteric drainage may be required to preserve kidney function.

6. Retroperitoneal Fibrosis

Retroperitoneal fibrosis is an uncommon condition in which inflammatory or fibrotic tissue develops around structures behind the abdominal cavity.

This tissue can surround and compress one or both ureters.

Some patients require prolonged ureteric stenting while the underlying condition is treated.

What Does Having a Ureteric Stent Feel Like?

Experiences vary considerably.

Some patients hardly notice their stent.

Others experience significant symptoms.

Collectively, these are often referred to as ureteric stent-related symptoms.

Common symptoms include:

Urinary frequency

You may need to urinate more frequently than normal.

Urinary urgency

There may be a sudden and sometimes uncomfortable urge to urinate.

Bladder discomfort

The lower end of the stent can irritate the bladder and produce discomfort or pressure.

Blood in the urine

A small amount of blood in the urine is common, particularly following physical activity.

The urine may vary from slightly pink to more obviously blood-stained.

Kidney or flank discomfort

Some patients experience discomfort in the kidney when urinating.

This can occur because bladder pressure during urination may be transmitted back towards the kidney along the stent.

Pain during or after urination

Discomfort may occur in the bladder, groin, urethra or kidney.

Symptoms may fluctuate and are often worse following strenuous physical activity.

Managing Ureteric Stent Symptoms

Treatment depends upon the severity and type of symptoms.

Maintain Appropriate Hydration

Maintaining normal hydration is generally helpful.

Excessive fluid intake, however, can sometimes worsen urinary frequency, urgency and kidney discomfort. The aim is usually adequate rather than excessive hydration, unless your doctor has advised otherwise.

Simple Pain Relief

Paracetamol or anti-inflammatory medication may be appropriate for some patients.

Anti-inflammatory medications are not suitable for everyone, particularly patients with certain kidney, stomach, cardiovascular or bleeding problems.

Your treating doctor can advise which medications are appropriate.

Alpha-Blockers

Medications such as tamsulosin may reduce stent-related discomfort in selected patients.

These medications relax smooth muscle within the urinary tract and may improve:

• flank discomfort
• urinary frequency
• urinary urgency
• pain associated with the stent

Possible side effects include dizziness and lowering of blood pressure.

Medication for Bladder Overactivity

When urinary urgency and frequency are particularly troublesome, medications used for an overactive bladder may occasionally help.

These include selected:

• antimuscarinic medications
• beta-3 agonists

The appropriate medication depends upon the patient’s symptoms and other medical conditions.

Adjusting Physical Activity

Exercise is usually safe with a ureteric stent unless your surgeon advises otherwise.

However, strenuous exercise may increase:

• blood in the urine
• flank discomfort
• bladder irritation

Reducing the intensity of activity temporarily can sometimes make symptoms considerably more manageable.

Possible Complications of Ureteric Stents

Most stents function without major problems, but complications can occur.

Urinary Infection

A stent is a foreign body within the urinary tract and bacteria may colonise its surface.

Seek medical attention if you develop:

• fever
• chills or rigors
• worsening flank pain
• feeling significantly unwell
• persistent burning during urination

Urine testing and antibiotics may be required.

Stent Migration

Occasionally a stent moves from its intended position.

It can migrate towards the kidney or bladder and may no longer provide adequate drainage.

Imaging and repositioning or replacement may be required.

Stent Blockage

Stents can occasionally become blocked by:

• blood clots
• stone fragments
• urinary debris
• encrustation

If obstruction is significant, the stent may need to be replaced.

Encrustation and Stone Formation

Minerals within the urine gradually deposit onto the surface of a stent.

This process is known as encrustation.

The risk increases the longer a stent remains in place.

Severe encrustation can make stent removal considerably more complicated and may require additional endoscopic or stone procedures.

The Forgotten Stent

One of the most important complications is a stent inadvertently being left in place for much longer than intended.

A forgotten stent may become:

• heavily encrusted
• blocked
• infected
• fragmented
• surrounded by stone formation

Removal can then require several procedures.

If you have a ureteric stent, you should know when it is expected to be removed or changed.

Many urology practices maintain a formal stent registry or reminder system for this reason.

When Should You Seek Urgent Medical Attention?

Contact your treating team or seek urgent medical assessment if you develop:

• fever or rigors
• severe or increasing kidney pain
• inability to pass urine
• persistent heavy bleeding or blood clots
• persistent vomiting
• significant deterioration in your general condition
• severe pain that is not controlled with prescribed medication

Fever associated with an obstructed urinary system requires particularly prompt assessment.

How Long Can a Ureteric Stent Stay In?

There is no single answer because it depends upon:

• why the stent was inserted
• the type and material of the stent
• stone-forming tendency
• infection
• pregnancy
• cancer treatment
• kidney function
• the manufacturer’s recommended indwelling time

Some temporary stents remain in place for only a few days or weeks.

Other stents designed for longer-term drainage may remain for several months before planned replacement.

A stent should therefore never simply be assumed to be safe indefinitely. Follow the removal or replacement schedule provided by your urologist.

Temporary Ureteric Stents

The majority of ureteric stents are temporary polymer JJ stents.

They may be used:

• after stone surgery
• following ureteroscopy
• after reconstructive surgery
• while ureteric inflammation settles
• while awaiting definitive treatment of an obstruction

Once the ureter has healed or the underlying obstruction has been treated, the stent is removed.

How Is a Ureteric Stent Removed?

Short-term stents may occasionally have a fine string attached to the end of the stent. This allows removal without another cystoscopic procedure in appropriately selected patients.

Most stents without strings are removed using flexible cystoscopy.

A small flexible telescope is passed through the urethra into the bladder. The lower end of the stent is identified, grasped and gently removed.

This is commonly performed as a short outpatient procedure using local anaesthetic gel.

What if Long-Term or Permanent Drainage Is Required?

Some causes of ureteric obstruction cannot easily be corrected.

In these circumstances, maintaining kidney drainage becomes a long-term management issue.

Options include:

Regularly Changed Polymer Stents

A conventional JJ stent can remain a long-term solution provided it is changed at appropriate intervals.

The disadvantage is the need for repeated procedures.

Long-Term or Metallic Ureteric Stents

Specialised metallic or reinforced stents may be considered in selected patients with chronic ureteric obstruction.

These are designed to resist external compression and, depending upon the particular device and clinical circumstances, may allow longer intervals between changes.

They can be particularly useful in selected cases of:

• malignant ureteric obstruction
• retroperitoneal fibrosis
• recurrent benign ureteric strictures

They are not suitable for every patient and still require ongoing urological surveillance.

Percutaneous Nephrostomy

When a ureteric stent cannot be inserted, repeatedly fails or does not provide adequate drainage, a nephrostomy tube may be required.

This is inserted through the skin directly into the kidney and drains urine externally into a collection bag.

Definitive Reconstructive Surgery

For suitable patients with benign obstruction, correcting the underlying problem may be preferable to lifelong stenting.

Depending upon the location and length of the obstruction, options may include:

• pyeloplasty
• ureteric reimplantation
• ureteroureterostomy
• bladder flap reconstruction
• bowel interposition
• other specialised ureteric reconstruction

The aim is to restore natural urinary drainage and eliminate the need for a permanent stent.

Temporary Versus Long-Term Stenting

	Temporary Stent	Long-Term Stenting
Typical indication	Stones, surgery, temporary obstruction	Chronic benign or malignant obstruction
Common stent	Polymer JJ stent	Regularly changed polymer or specialised long-term stent
Duration	Days to months	Potentially years with planned surveillance/exchange
Replacement required?	Usually removed once no longer needed	Yes, according to stent type and clinical situation
Main concern	Symptoms, infection, migration	Encrustation, blockage, infection and repeated procedures
Alternative	Removal after definitive treatment	Reconstruction or nephrostomy in selected patients

Is There Really a “Permanent” Ureteric Stent?

The term permanent stent can be misleading.

A patient may require permanent ureteric drainage, but this does not necessarily mean that the same stent remains in place permanently.

Most long-term stent strategies require:

• regular clinical review
• monitoring of kidney function
• periodic imaging when appropriate
• surveillance for infection or obstruction
• planned stent exchange according to the type of device being used

The objective is not simply to keep a stent in indefinitely, but to maintain safe and reliable drainage of the kidney.

Living With a Ureteric Stent

A ureteric stent can be an extremely useful device. It can relieve obstruction, control an emergency situation and protect kidney function while allowing definitive treatment to be planned.

Unfortunately, stents are not always comfortable.

Urinary frequency, urgency, blood in the urine and intermittent bladder or kidney discomfort are relatively common. These symptoms do not necessarily mean something is wrong with the stent, and several strategies and medications can make them easier to tolerate.

The most important questions to know after having a stent inserted are:

Why was my stent inserted?

When should it be removed or changed?

What symptoms should prompt me to seek medical attention?

If you are uncertain about any of these, contact your urologist or treating team.

This information is intended for general patient education and does not replace individual medical advice. The appropriate type and duration of ureteric stenting depends upon the cause of obstruction, kidney function, infection risk and individual patient circumstances.

Come chat to Jo your friendly Brisbane based Urologist to discuss your stent issues.

Some degree of penile curvature can be completely normal. However, when a new or increasing curve develops — particularly when accompanied by pain, a noticeable lump or difficulty with sexual intercourse — it may be caused by a condition known as Peyronie’s disease.

Peyronie’s disease is a urological condition caused by the development of fibrous scar tissue, known as plaque, within the penis. This can affect the shape, length and function of the penis during an erection.

For some men the condition causes relatively minor symptoms. For others, the curvature can become significant enough to affect sexual function and quality of life.

What Is Peyronie’s Disease?

Peyronie’s disease occurs when an area of fibrous scar tissue develops within the tissue surrounding the erectile chambers of the penis.

Because this scar tissue does not stretch normally during an erection, one area of the penis may expand less than the surrounding tissue. This can result in the penis bending towards the affected side.

Changes may include:

• Penile curvature during an erection
• A hard lump or area of thickened tissue
• Pain during erections
• Shortening or narrowing of the penis
• An indentation or hourglass appearance
• Difficulty with sexual intercourse
• Erectile dysfunction

The degree of curvature varies considerably between individuals.

What Causes Peyronie’s Disease?

The exact cause is not always clear.

In some cases, Peyronie’s disease is thought to develop following injury or repeated minor trauma to the penis. Healing following these injuries may result in abnormal scar tissue formation.

However, many men diagnosed with Peyronie’s disease do not remember experiencing a specific injury.

Certain factors may increase the likelihood of developing the condition, including age, family history and some connective tissue disorders.

Is a Curved Penis Always Peyronie’s Disease?

No.

Some men naturally have a degree of penile curvature that has been present since adolescence or early adulthood. This is known as congenital penile curvature and is different from Peyronie’s disease.

A curve is more suggestive of Peyronie’s disease when it develops later in life or changes progressively over time, particularly if there is associated pain or a palpable area of hardened tissue.

A urologist can help determine the cause.

Does Peyronie’s Disease Cause Erectile Dysfunction?

Peyronie’s disease and erectile dysfunction can occur together.

The physical changes caused by Peyronie’s disease may make maintaining an erection more difficult in some men. Significant curvature can also interfere mechanically with sexual intercourse.

There can also be a psychological component. Concern about pain, appearance or sexual performance may contribute to difficulties with erections.

For this reason, assessment often considers both the physical curvature and overall erectile function.

Does Peyronie’s Disease Get Worse?

Peyronie’s disease commonly develops in stages.

During the earlier or active phase, curvature may continue to change and pain may be present during erections.

Eventually, the condition may enter a more stable phase in which the curvature stops progressing and pain often improves.

Not every patient follows exactly the same pattern, which is why treatment recommendations depend on the individual’s symptoms and stage of disease.

How Is Peyronie’s Disease Diagnosed?

Diagnosis usually begins with a medical history and physical examination.

A urologist may assess the location and size of the plaque and the degree of penile curvature.

In some circumstances, photographs of the erect penis or specialised ultrasound imaging may be useful to assess the curvature, blood flow and erectile tissue.

How Is Peyronie’s Disease Treated?

Treatment depends on several factors, including:

• Severity of the curvature
• Whether the condition is stable or progressing
• Presence of pain
• Erectile function
• Whether sexual intercourse is affected
• How much the condition is affecting quality of life

Not every patient requires active treatment.

Observation

Mild Peyronie’s disease that does not cause significant pain or interfere with sexual function may sometimes be monitored.

Penile Traction Therapy

Specialised traction devices may be recommended for selected patients.

These devices apply controlled stretching over time and may help improve curvature or preserve penile length in appropriate cases.

Medications and Other Treatments

Various medical treatments have been investigated for Peyronie’s disease. Their suitability and effectiveness depend on the individual patient and stage of the condition.

A urologist can discuss which evidence-based options may be appropriate.

Surgery

Surgery may be considered when curvature is significant, the condition has stabilised and sexual intercourse is difficult or impossible.

Different surgical techniques are available depending on the degree of curvature, penile length and erectile function.

These can include procedures that straighten the penis, grafting procedures and, in selected patients who also have significant erectile dysfunction, penile prosthesis surgery.

When Should You See a Urologist?

Consider seeking a urological assessment if you notice:

• A new curve developing during erections
• Increasing penile curvature
• Pain during erections
• A hard lump or plaque within the penis
• Penile shortening or narrowing
• Difficulty having sexual intercourse because of curvature
• Erectile dysfunction occurring alongside these changes

Early assessment can help establish whether the changes are caused by Peyronie’s disease or another condition and determine whether treatment or monitoring is appropriate.

Peyronie’s Disease Is a Treatable Urological Condition

Men can be reluctant to discuss changes involving the penis, even with their doctor.

However, Peyronie’s disease is a recognised medical condition and something urologists routinely assess and treat.

Treatment is not necessary for every patient, but when penile curvature causes pain, erectile difficulties or problems with sexual intercourse, several treatment approaches may be available.

If you have noticed a new or worsening penile curvature, speaking with a urologist can help determine the cause and the most appropriate next step.

This information is general in nature and does not replace individual medical advice.

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Come chat with your local Brisbane based Urologist, Dr Jo, to discuss options with you.