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AUA2023: REFLECTIONS Second Opinion Cases: Challenging Scenarios: Irritative Urinary Symptoms in Men

By: O. Lenaine Westney, MD, MD Anderson Cancer Center, Houston, Texas; Joshua Cohn, MD, Fox Chase Cancer Center, Philadelphia, Pennsylvania; Brian Flynn, MD, University of Colorado, Denver; Melissa Kaufman, MD, Vanderbilt University, Nashville, Tennessee; Jaspreet Sandhu, MD, Memorial Sloane Kettering Cancer Center, New York, New York | Posted on: 20 Jul 2023


Dr Westney framed the difficulties of treating the male patient with irritative symptoms due to the diversity of clinical scenarios which may be present and the lack of guiding evidence. Compared to an index overactive bladder patient, the male patient presenting with symptoms may be complicated by the presence of the prostate and/or multimodality treatment for pelvic cancer. Males treated for prostate and colorectal cancer constitute the bulk of male cancer survivors.1 A high percentage of these patients have undergone radiation due to the pivotal role of radiation in the treatment algorithms for these malignancies.

As described by Kan et al, the prostate cancer patient treated with radical retropubic prostatectomy reports a de novo storage dysfunction of over 25% (Figure 1).2 The addition of radiation has been demonstrated to intensify overactive bladder and lower urinary tract symptoms.3 Posttreatment bladder dysfunction may be further complicated by bladder neck contracture (Figure 2). The panel was charged with utilizing the best available evidence and expert opinion to manage 4 clinically challenging scenarios.

Figure 1. Proportion of patients with de novo storage dysfunction (and 95% confidence interval) based on months after radical prostatectomy (RP).
Figure 2. Lower urinary tract symptoms after radiation therapy (prostate in situ).

Lower Urinary Tract Symptoms After Radiation Therapy (Prostate in Situ)

Dr Sandhu presented 2 cases focused on symptomatology in the radiated patient with a prostate in situ. The first highlighted the indications and complications for an outlet-reducing procedure in the setting of radiation. In addition to anatomical evaluation with cystoscopy, Dr Kaufman emphasized the utility of multichannel urodynamics in the high-risk population to yield the information required to counsel and generate a treatment plan. In the management of outlet reduction in this patient, Dr Flynn stated his preference for utilization of a laser procedure, either GreenLight or thulium, rather than loop resection. Dr Cohn mentioned the selective use of prostate enucleation after careful patient evaluation. In counseling this patient population, incontinence, residual symptoms, and future development of fistula must be discussed. Dr Sandhu presented data revealing that age and the presence of preoperative urinary urgency are associated with an elevated risk of posttransurethral prostatectomy incontinence.4

The second case focused on the treatment options in the radiated patient with the nonobstructive prostate gland. This underscored the paucity of publications discussing the efficacy of second- and third-line overactive bladder therapies in the male and/or radiated patients.5 In selecting a pharmacological agent for these patients who are often elderly, Dr Kaufman stated her preference for a hydrophilic agent, such as trospium chloride, or a β-3adrenergic agent (mirabegron or vibegron). In the application of third-line therapies, both Drs Flynn and Cohn had experienced a high success rate with botulinum toxin over neuromodulation in this population.6 Drs Kaufman and Westney supported the use of urodynamics in guiding selection between therapies with botulinum toxin as the first choice in those with high amplitude detrusor contractions.

Urinary Incontinence and Incomplete Emptying

Dr Flynn presented 2 cases illustrating the management of vesicourethral anastomotic stricture. During the first, Dr Cohn discussed the caliber of stricture requiring intervention with emphasis on the ability to navigate the outlet with a flexible cystoscope and ability to place a catheter in the event of surgical procedures. Subsequently, Dr Sandhu reviewed a graded approach to addressing bladder neck contractures. In general, patients are likely to have undergone prior dilation, thus, he proceeds with 2-4 incisions with or without fibrinostatic agents. The need for avoiding the anterior and posterior midline was reiterated. The utilization of injectable agents was then discussed by the panel. Drs Kaufman and Westney advised judicious and limited use of steroids and mitomycin in the radiated patient. Dr Cohn advocated for the recently introduced mucosal advancement technique. Dr Westney summarized the standard practice of waiting at least 3 months after treatment of a bladder neck contracture prior to proceeding with an anti-incontinence procedure.

Dr Flynn’s second case featured a patient with a bladder neck contracture after salvage prostatectomy. Endoscopic methods for reestablishing lumen failed, thus, the patient progressed to robotic bladder neck reconstruction (Figure 3, A and B). Artificial urinary sphincter (AUS) was discussed as a common treatment modality under these conditions. The patient was, however, successfully treated with adjustable continence balloons (Figure 4).

Figure 3. A, Dissection of bladder neck and scar excision. B, Preparation for bladder outlet reconfiguration.
Figure 4. Postprostatectomy and radiated patient with pad weight reduction of 653 to 157 g with adjustable continence balloons.
Figure 5. Vascular change typical of radiation cystitis in the trigone and posterior bladder wall.
Figure 6. Necrotic bladder neck lined with dystrophic calcification.

Radiation Cystitis/Refractory Gross Hematuria

Dr Cohn presented the case of a patient who suffered from severe radiation cystitis with debilitating irritative symptoms complicated by multiple operative interventions for clot irrigation (Figure 5). Dr Sandhu discussed his practice of introducing hyperbaric oxygen as early as possible. In the setting of a patient with irritative symptoms without hematuria, Dr Flynn supported the utilization of hyperbaric oxygen with successful resolution of symptoms.7 Dr Kaufman discussed the high likelihood that patients with history will progress to the need for cystectomy and urinary diversion. Dr Westney supplemented the importance of counseling patients regarding the transient stabilization of the urethra and the possibility of major surgery in the future.

As an adjunct to the above scenario, the panel discussed their endoscopic approach to clot evacuation in the patient with a functional AUS in place. The practice of performing a perineal incision and uncoupling the cuff was standard strategy to safely pass a resectoscope for adequate irrigation and fulguration. Alternatively, Dr Cohn suggested an antegrade approach via suprapubic access to bypass the need for device manipulation.8

Persistent Dystrophic Calcification

Time did not permit full elaboration on this topic (Figure 6). However, in prior discussions with the panelists, there was agreement on the challenges of managing patients with bladder neck calcifications. There was division regarding whether to monitor these patients serially or wait for development of obstructive symptoms. However, in the patient with an AUS in situ, the panel agreed more aggressive monitoring is indicated. Endoscopic clearance of obstructive calculi may be accomplished with small-caliber scopes with laser, with more severe cases necessitating techniques similar to those for clot evacuation in the AUS patient, as discussed above. Dr Flynn weighed in on the poor suitability of these patients for bladder neck reconstruction in favor of urinary diversion.


Management of the male patient with irritative symptoms requires careful evaluation coupled with a wide range of endoscopic and reconstructive techniques outside the standard management of overactive bladder.

  1. Miller KD, Siegel RL, Lin CC, et al. Cancer treatment and survivorship statistics, 2016. CA Cancer J Clin. 2016;66(4):271-289.
  2. Kan KM, Tin AL, Stearns GL, Eastham JA, Sjoberg DD, Sandhu JS. De novo urinary storage symptoms are common after radical prostatectomy: incidence, natural history and predictors. J Urol. 2022;207(3):601-608.
  3. Hosier GW, Tennankore KK, Himmelman JG, Gajewski J, Cox AR. Overactive bladder and storage lower urinary tract symptoms following radical prostatectomy. Urology. 2016;94:193-197.
  4. Polland A, Vertosick EA, Sjoberg DD, et al. Preoperative symptoms predict continence after post-radiation transurethral resection of the prostate. Can J Urol. 2017;24(4):8903-8909.
  5. Patrick Selph J, Saidian A. The pharmacologic management of voiding dysfunction, stress incontinence and the overactive bladder in men and women who have had prior treatment for pelvic malignancies with surgery or radiation therapy. Curr Bladder Dysfunct Rep. 2017; 12(2):143-152.
  6. Zillioux J, Welk B, Suskind AM, Gormley EA, Goldman HB. SUFU white paper on overactive bladder anticholinergic medications and dementia risk. Neurourol Urodyn. 2022;41(8):1928-1933.
  7. Oscarsson N, Müller B, Rosén A, et al. Radiation-induced cystitis treated with hyperbaric oxygen therapy (RICH-ART): a randomised, controlled, phase 2-3 trial. Lancet Oncol. 2019;20(11):1602-1614.
  8. Abramowitz DJ, Balzano FL, Ruel NH, Chan KG, Warner JN. Transurethral incision with transverse mucosal realignment for the management of bladder neck contracture and vesicourethral anastomotic stenosis. Urology. 2021;152:102-108.