A Case-Based Illustration of Urinary Symptoms Following Radiation Therapy for Prostate Cancer

  • Allison Polland
  • Michael S. Leapman
  • Nelson N. StoneEmail author


Radiation therapy for prostate cancer is a valuable treatment option for many patients. In counseling patients about radiation therapy it is important to understand the posttreatment course. There may be urinary side effects of radiation therapy, including lower urinary tract symptoms, hematuria, and incontinence. Some of these are common and some are uncommon, but it is critical to convey this information to patients who elect for radiation therapy. This chapter provides a number of clinical scenarios which demonstrate the possible urinary effects of external beam radiation as well as brachytherapy.


Lower urinary tract symptoms Radiation Brachytherapy Retention Hematuria 


  1. 1.
    Leapman M, et al. Findings at cystoscopy performed for cause after prostate brachytherapy. Urology. 2014;83(6):1350–5.PubMedCrossRefGoogle Scholar
  2. 2.
    Tanaka N, et al. Variations in International Prostate Symptom Scores, Uroflowmetric Parameters, and Prostate Volume After 125I Permanent Brachytherapy for Localized Prostate Cancer. Urology. 2009;74(2):407–11.PubMedCrossRefGoogle Scholar
  3. 3.
    Merrick G, et al. Dysuria After Permanent Prostate Brachytherapy. Int J Radiat Oncol Biol Phys. 2003;55(4):979–85.PubMedCrossRefGoogle Scholar
  4. 4.
    Stone N, et al. Factors Influencing Urinary Symptoms 10 Years After Permanent Prostate Seed Implantation. J Urol. 2012;187:117–23.PubMedCrossRefGoogle Scholar
  5. 5.
    Bittner N, et al. The impact of acute urinary morbidity on late urinary function after permanent prostate brachytherapy. Brachytherapy. 2007;6(4):258–66.PubMedCrossRefGoogle Scholar
  6. 6.
    Cesaretti J, Stone N, Stock R. Urinary Symptom Flare Following I-125 Prostate Brachytherapy. Int J Radiat Oncol Biol Phys. 2003;56(4):1085–92.PubMedCrossRefGoogle Scholar
  7. 7.
    Stone N, et al. Does neoadjuvant hormonal therapy improve urinary function when given to men with large prostates undergoing prostate brachytherapy? J Urol. 2010;183:634–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Kelly K, et al. Prediction of urinary symptoms after 125iodine prostate brachytherapy. Clin Oncol. 2006;18(4):326–32.CrossRefGoogle Scholar
  9. 9.
    Merrick G, et al. Relationship between the transition zone index of the prostate gland and urinary morbidity after brachytherapy. Urology. 2001;57:524–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Zelefsky M, et al. Comparison of the 5-year outcome and morbidity of three-dimensional conformal radiotherapy versus transperineal permanent iodine-125 implantation for early stage prostatic cancer. J Clin Oncol. 1999;17:517–22.PubMedCrossRefGoogle Scholar
  11. 11.
    White W, et al. Quality of Life in Men With Locally Advanced Adenocarcinoma of the Prostate: An Exploratory Analysis Using Data From the CaPSURE Database. J Urol. 2008;180:2409–14.PubMedCrossRefGoogle Scholar
  12. 12.
    Jacobs B, et al. Acute lower urinary tract symptoms after prostate brachytherapy with cesium-131. Urology. 2010;76(5):1143–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Matzkin H, et al. Iodine-125 brachytherapy for localized prostate cancer and urinary morbidity: a prospective comparison of two seed implant methods—preplanning and intraoperative planning. Urology. 2003;62:497–502.PubMedCrossRefGoogle Scholar
  14. 14.
    Desai J, Stock R, Stone N. Acute urinary morbidity following I-125 interstitial implantation of the prostate gland. Radiat Oncol Invest. 1998;6(3):135–41.CrossRefGoogle Scholar
  15. 15.
    Eton D, Lepore S, Helgeson V. Early Quality of Life in Patients with Localized Prostate Carcinoma: An Examination of Treatment-Related, Demographic, and Psychosocial Factors. Cancer. 2001;92(6):1451–9.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Brandeis J, et al. Quality of life outcomes after brachytherapy for early stage prostate cancer. J Urol. 2000;163:851–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Merrick G, et al. Long-term urinary quality of life after permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2003;56(2):454–61.PubMedCrossRefGoogle Scholar
  18. 18.
    Miller N, et al. Impact of a Novel Neoadjuvant and Adjuvant Hormone-Deprivation Approach on Quality of Life, Voiding Function, and Sexual Function after Prostate Brachytherapy. Cancer. 2003;97(5):1203–10.PubMedCrossRefGoogle Scholar
  19. 19.
    Elshaikh M, et al. Prophylactic tamsulosin (flomax) in patients undergoing prostate 125i brachytherapy for prostate carcinoma: final report of a double-blind placebo-controlled randomized study. Int J Radiat Oncol Biol Phys. 2005;62(1):164–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Merrick GS, et al. Prophylactic versus therapeutic alpha-blockers after permanent prostate brachytherapy. Urology. 2002;60(4):650–5.PubMedCrossRefGoogle Scholar
  21. 21.
    Albert M, et al. Late genitourinary and gastrointestinal toxicity after magnetic resonance image-guided prostate brachytherapy with or without neoadjuvant external beam radiation therapy. Cancer. 2003;98(5):949–54.PubMedCrossRefGoogle Scholar
  22. 22.
    Elliott SP, et al. Incidence of urethral stricture after primary treatment for prostate cancer: data From CaPSURE. J Urol. 2007;178(2):529–34.PubMedCrossRefGoogle Scholar
  23. 23.
    Wehle MJ, et al. Prediction of genitourinary tract morbidity after brachytherapy for prostate adenocarcinoma. Mayo Clin Proc. 2004;79(3):314–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Zelefsky MJ, et al. Five-year biochemical outcome and toxicity with transperineal CT-planned permanent I-125 prostate implantation for patients with localized prostate cancer. Int J Radiat Oncol Biol Phys. 2000;47(5):1261–6.PubMedCrossRefGoogle Scholar
  25. 25.
    Merrick GS, et al. The dosimetry of prostate brachytherapy-induced urethral strictures. Int J Radiat Oncol Biol Phys. 2002;52(2):461–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Sullivan L, et al. Urethral stricture following high dose rate brachytherapy for prostate cancer. Radiother Oncol. 2009;91(2):232–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Jarosek SL, et al. Propensity-weighted Long-term Risk of Urinary Adverse Events After Prostate Cancer Surgery, Radiation, or Both. Eur Urol. 2015;67(2):273–80.PubMedCrossRefGoogle Scholar
  28. 28.
    Peinemann F, et al. Low-dose rate brachytherapy for men with localized prostate cancer. Cochrane Database Syst Rev. 2011;7.Google Scholar
  29. 29.
    Merrick GS, et al. Risk factors for the development of prostate brachytherapy related urethral strictures. J Urol. 2006;175(4):1376–80.PubMedCrossRefGoogle Scholar
  30. 30.
    Glass AS, et al. Urethroplasty after radiation therapy for prostate cancer. Urology. 2012;79(6):1402–5.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Hofer MS, et al. Outcomes after Urethroplasty for Radiotherapy Induced Bulbomembranous Urethral Stricture Disease. J Urol. 2013;191(5):1307–12.PubMedCrossRefGoogle Scholar
  32. 32.
    Zelefsky MJ, et al. Secondary cancers after intensity-modulated radiotherapy, brachytherapy and radical prostatectomy for the treatment of prostate cancer: incidence and cause-specific survival outcomes according to the initial treatment intervention. BJU Int. 2012;110(11):1696–701.PubMedCrossRefGoogle Scholar
  33. 33.
    Davis R, et al. Diagnosis, Evaluation and Follow-Up of Asymptomatic Microhematuria (AMH) In Adults: AUA Guideline. J Urol. 2012;188(6 Suppl):2473–81.PubMedCrossRefGoogle Scholar
  34. 34.
    Cooperative Group Common Toxicity Criteria. Radiation Therapy Oncology Group.Google Scholar
  35. 35.
    Barker J, Wallner K, Merrick G. Gross hematuria after prostate brachytherapy. Urology. 2003;61(2):408–11.PubMedCrossRefGoogle Scholar
  36. 36.
    Anderson J, et al. Urinary Side Effects and Complications After Permanent Prostate Brachytherapy: The MD Anderson Cancer Center Experience. Urology. 2009;74(3):601–5.PubMedCrossRefGoogle Scholar
  37. 37.
    Keyes M, et al. Urinary symptom flare in 712 125I prostate brachytherapy patients: long-term follow-up. Int J Radiat Oncol Biol Phys. 2009;75(3):649–55.PubMedCrossRefGoogle Scholar
  38. 38.
    Keyes M, et al. Predictive factors for acute and late urinary toxicity after permanent prostate brachytherapy: long-term outcome in 712 consecutive patients. Int J Radiat Oncol Biol Phys. 2009;73(4):1023–32.PubMedCrossRefGoogle Scholar
  39. 39.
    Leapman MS, et al. Haematuria after prostate brachytherapy. BJU Int. 2013;111(8):319–24.CrossRefGoogle Scholar
  40. 40.
    Britton JP, et al. A community study of bladder cancer screening by the detection of occult urinary bleeding. J Urol. 1992;148(3):788–90.PubMedGoogle Scholar
  41. 41.
    Messing EM, et al. Home screening for hematuria: results of a multiclinic study. J Urol. 1992;148(2 Pt 1):289–92.PubMedGoogle Scholar
  42. 42.
    Messing EM, et al. Urinary tract cancers found by homescreening with hematuria dipsticks in healthy men over 50 years of age. Cancer. 1989;64(11):2361–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Grills I, et al. High dose rate brachytherapy as prostate cancer monotherapy reduces toxicity compared to low dose rate palladium seeds. J Urol. 2004;171:1098–104.PubMedCrossRefGoogle Scholar
  44. 44.
    Institute, N.C. Cancer Therapy Evaluation Program: Protocol Development. 2009; Available from:
  45. 45.
    Marks LB, et al. The response of the urinary bladder, urethra, and ureter to radiation and chemotherapy. Int J Radiat Oncol Biol Phys. 1995;31(5):1257–80.PubMedCrossRefGoogle Scholar
  46. 46.
    Smit SG, Heyns CF. Management of radiation cystitis. Nat Rev Urol. 2010;7(4):206–14.PubMedCrossRefGoogle Scholar
  47. 47.
    Seear MD, Dimmick JE, Rogers PC. Acute aluminum toxicity after continuous intravesical alum irrigation for hemorrhagic cystitis. Urology. 1990;36(4):353–4.PubMedCrossRefGoogle Scholar
  48. 48.
    Liu YK, et al. Treatment of radiation or cyclophosphamide induced hemorrhagic cystitis using conjugated estrogen. J Urol. 1990;144(1):41–3.PubMedGoogle Scholar
  49. 49.
    Sandhu SS, Goldstraw M, Woodhouse CRJ. The management of haemorrhagic cystitis with sodium pentosan polysulphate. BJU Int. 2004;94(6):845–7.PubMedCrossRefGoogle Scholar
  50. 50.
    Donahue LA, Frank IN. Intravesical formalin for hemorrhagic cystitis: analysis of therapy. J Urol. 1989;141(4):809–12.PubMedGoogle Scholar
  51. 51.
    Vicente J, Rios G, Caffaratti J. Intravesical formalin for the treatment of massive hemorrhagic cystitis: retrospective review of 25 cases. Eur Urol. 1990;18(3):204–6.PubMedGoogle Scholar
  52. 52.
    Knighton DR, et al. Oxygen tension regulates the expression of angiogenesis factor by macrophages. Science. 1983;221(4617):1283–5.PubMedCrossRefGoogle Scholar
  53. 53.
    Corman JM, et al. Treatment of radiation induced hemorrhagic cystitis with hyperbaric oxygen. J Urol. 2003;169(6):2200–2.PubMedCrossRefGoogle Scholar
  54. 54.
    Chong KT, Hampson NB, Corman JM. Early hyperbaric oxygen therapy improves outcome for radiation-induced hemorrhagic cystitis. Urology. 2005;65(4):649–53.PubMedCrossRefGoogle Scholar
  55. 55.
    Del Pizzo JJ, et al. Treatment of radiation induced hemorrhagic cystitis with hyperbaric oxygen: long-term followup. J Urol. 1998;160(3 Pt 1):731–3.PubMedGoogle Scholar
  56. 56.
    Linder BJ, Tarrell RF, Boorjian SA. Cystectomy for refractory hemorrhagic cystitis: contemporary etiology, presentation and outcomes. J Urol. 2014;192(6):1687–92.PubMedCrossRefGoogle Scholar
  57. 57.
    Zelefsky MJ, et al. Incidence of secondary cancer development after high-dose intensity-modulated radiotherapy and image-guided brachytherapy for the treatment of localized prostate cancer. Int J Radiat Oncol Biol Phys. 2012;83(3):953–9.PubMedCrossRefGoogle Scholar
  58. 58.
    Blasko JC, Ragde H, Grimm PD. Transperineal ultrasound-guided implantation of the prostate: morbidity and complications. Scand J Urol Nephrol Suppl. 1991;137:113–8.PubMedGoogle Scholar
  59. 59.
    Lee N, et al. Factors predicting for postimplantation urinary retention after permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2000;48(5):1457–60.PubMedCrossRefGoogle Scholar
  60. 60.
    Terk MD, Stock RG, Stone NN. Identification of patients at increased risk for prolonged urinary retention following radioactive seed implantation of the prostate. J Urol. 1998;160(4):1379–82.PubMedCrossRefGoogle Scholar
  61. 61.
    Locke J, et al. Risk factors for acute urinary retention requiring temporary intermittent catheterization after prostate brachytherapy: A prospective study. Int J Radiat Oncol Biol Phys. 2002;52:712–9.PubMedCrossRefGoogle Scholar
  62. 62.
    Sloboda RS, et al. Time course of prostatic edema post permanent seed implant determined by magnetic resonance imaging. Brachytherapy. 2010;9(4):354–61.PubMedCrossRefGoogle Scholar
  63. 63.
    Mabjeesh NJ, et al. Preimplant predictive factors of urinary retention after iodine 125 prostate brachytherapy. Urology. 2007;70(3):548–53.PubMedCrossRefGoogle Scholar
  64. 64.
    Keyes M, et al. Decline in urinary retention incidence in 805 patients after prostate brachytherapy: the effect of learning curve? Int J Radiat Oncol Biol Phys. 2006;64(3):825–34.PubMedCrossRefGoogle Scholar
  65. 65.
    D'Amico AV, et al. 6-month androgen suppression plus radiation therapy vs radiation therapy alone for patients with clinically localized prostate cancer: a randomized controlled trial. JAMA. 2004;292(7):821–7.PubMedCrossRefGoogle Scholar
  66. 66.
    Jones CU, et al. Radiotherapy and short-term androgen deprivation for localized prostate cancer. N Engl J Med. 2011;365(2):107–18.PubMedCrossRefGoogle Scholar
  67. 67.
    Crook J, et al. A phase III randomized trial of the timing of meloxicam with iodine-125 prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2010;77(2):496–501.PubMedCrossRefGoogle Scholar
  68. 68.
    Roeloffzen EMA, et al. The impact of acute urinary retention after iodine-125 prostate brachytherapy on health-related quality of life. Int J Radiat Oncol Biol Phys. 2010;77(5):1322–8.PubMedCrossRefGoogle Scholar
  69. 69.
    Kollmeier MA, et al. Urinary morbidity and incontinence following transurethral resection of the prostate after brachytherapy. J Urol. 2005;173(3):808–12.PubMedCrossRefGoogle Scholar
  70. 70.
    Mock S, et al. Risk of urinary incontinence following post-brachytherapy transurethral resection of the prostate and correlation with clinical and treatment parameters. J Urol. 2013;190(5):1805–10.PubMedCrossRefGoogle Scholar
  71. 71.
    Merrick G, Butler W, Wallner K. Effect of transurethral resection on urinary quality of life after permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys. 2004;58:81–8.PubMedCrossRefGoogle Scholar
  72. 72.
    Boone TB. Transurethral resection versus intermittent catheterization in patients with retention after combined brachytherapy/external beam radiotherapy for prostate cancer: intermittent catheterization. J Urol. 2013;189(3):801–2.PubMedCrossRefGoogle Scholar
  73. 73.
    Stone NN. Transurethral resection versus intermittent catheterization in patients with retention after combined brachytherapy/external beam radiotherapy for prostate cancer: transurethral resection. J Urol. 2013;189(3):800–1.PubMedCrossRefGoogle Scholar
  74. 74.
    Flam TA, et al. Post-brachytherapy transurethral resection of the prostate in patients with localized prostate cancer. J Urol. 2004;172(1):108–11.PubMedCrossRefGoogle Scholar
  75. 75.
    Hu K, Wallner K. Urinary incontinence in patients who have a TURP/TUIP following prostate brachytherapy. Int J Radiat Oncol Biol Phys. 1998;40(4):783–6.PubMedCrossRefGoogle Scholar
  76. 76.
    Koutrouvelis PG, et al. Prostate cancer with large glands treated with 3-dimensional computerized tomography guided pararectal brachytherapy: up to 8 years of followup. J Urol. 2003;169(4):1331–6.PubMedCrossRefGoogle Scholar
  77. 77.
    Moore K, Allen M, Voaklander D. Pad Tests and Self-Reports of Continence in Men Awaiting Radical Prostatectomy: Establishing Baseline Norms for Males. Neurourol Urodyn. 2004;23:623–6.PubMedCrossRefGoogle Scholar
  78. 78.
    Abrams P, et al. Fourth international consultation on incontinence recommendations of the international scientific committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn. 2010;29(1):213–40.PubMedCrossRefGoogle Scholar
  79. 79.
    Chrouser K, et al. Urinary fistulas following external radiation of permanent brachytherapy for the treatment of prostate cancer. J Urol. 2005;173:1953–7.PubMedCrossRefGoogle Scholar
  80. 80.
    Wallace S, et al. Bladder training for urinary incontinence in adults. Cochrane Database Syst Rev. 2004;1, CD001308.Google Scholar
  81. 81.
    Chapple C. Urinary Incontinence: Oxybutynin topical gel for overactive bladder. Nat Rev Urol. 2009;6:351–2.PubMedCrossRefGoogle Scholar
  82. 82.
    Mock S, Dmochowski R. Evaluation of fesoterodine fumarate for the treatment of an overactive bladder. Expert Opin Drug Metab Toxicol. 2013;9(12):1659–66.PubMedCrossRefGoogle Scholar
  83. 83.
    Callegari E, et al. A comprehensive non-clinical evaluation of the CNS penetration potential of antimuscarinic agents for the treatment of overactive bladder. Br J Clin Pharmacol. 2011;72:235–46.PubMedPubMedCentralCrossRefGoogle Scholar
  84. 84.
    Dmochowski R, Roehrborn C, Klise S. Urodynamic effects of once daily tadalafil in men with lower urinary tract symptoms secondary to clinical benign prostatic hyperplasia: a randomized, placebo controlled 12-week clinical trial. J Urol. 2013;189(1 Suppl):S135–40.PubMedCrossRefGoogle Scholar
  85. 85.
    Popat R, et al. A comparison between the response of patients with idiopathic detrusor overactivity and neurogenic detrusor overactivity to the first intradetrusor injection of botulinum-a toxin. J Urol. 2005;174(3):984–9.PubMedCrossRefGoogle Scholar
  86. 86.
    Litwin M. Health related quality of life in older men without prostate cancer. J Urol. 1999;161(4):1180–4.PubMedCrossRefGoogle Scholar
  87. 87.
    Fulmer B, et al. Prospective assessment of voiding and sexual function after treatment for localized prostate carcinoma: comparison of radical prostatectomy to hormonobrachytherapy with and without external beam radiotherapy. Cancer. 2001;91(11):2046–55.PubMedCrossRefGoogle Scholar
  88. 88.
    Stone N, Stock J. Complications Following Permanent Prostate Brachytherapy. Eur Urol. 2002;50:1–7.Google Scholar
  89. 89.
    Aboseif S, et al. Collagen Injection for Intrinsic Sphincter Deficiency in Men. J Urol. 1996;155(1):10–3.PubMedCrossRefGoogle Scholar
  90. 90.
    Vainshtein J, et al. Randomized phase II trial of urethral sparing intensity modulated radiation therapy in low-risk prostate cancer: implications for focal therapy. Radiat Oncol. 2012;7(82):1–9.Google Scholar
  91. 91.
    Castle E, et al. The male sling for post-prostatectomy incontinence: mean followup of 18 months. J Urol. 2005;173(5):1657–60.PubMedCrossRefGoogle Scholar
  92. 92.
    Sathianathen NJ, McGuigan SM, Moon DA. Outcomes of artificial urinary sphincter implantation in the irradiated patient. BJU Int. 2014;113(4):636–41.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Allison Polland
    • 1
  • Michael S. Leapman
    • 1
  • Nelson N. Stone
    • 1
    • 2
    Email author
  1. 1.Department of UrologyMount Sinai HospitalNew YorkUSA
  2. 2.Department of Urology and Radiation Oncology (RGS)Icahn School of Medicine at Mount SinaiNew YorkUSA

Personalised recommendations