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Radiation & Tissue Effects in the Genitourinary Tract

Pelvic radiotherapy can produce acute mucosal symptoms and delayed urinary, bowel and sexual dysfunction. Severity depends on the treated volume, dose distribution, fractionation, baseline function and other treatments. Some effects resolve; others persist or appear years later. A radiation history increases reconstructive risk, with variable tissue viability and graft or anastomotic outcomes.[1][2]

For occupational fluoroscopy protection, see Radiation Safety.

What Radiation Changes​

Acute effects usually develop during or soon after treatment and often improve over the following weeks. Late injury can emerge months to years later, including after a relatively mild acute course. Studies use different cutoffs for “late” toxicity; retain each study's definition when comparing outcomes.[1]

Tissue processReconstructive implication
Mucosal injury and altered barrier functionDysuria, urgency, pain and bleeding require evaluation for other causes as well as treatment effects
Microvascular injury, telangiectasia and impaired perfusionFragile bleeding surfaces and less reliable healing in affected areas
Fibrosis, extracellular matrix remodeling and cellular senescenceReduced compliance, narrowed lumens and difficult dissection planes
Neuromuscular and endocrine effects, alongside vascular injuryUrinary, bowel and sexual symptoms may have several contributors

These processes vary within the treatment field. Preserve useful vascular supply and judge the actual defect and recipient bed.[1][2]

Interpreting the Major Evidence​

EBRT is a delivery category; IMRT/VMAT describe dose delivery techniques, and SBRT describes a highly hypofractionated approach. These terms overlap. Brachytherapy, postoperative radiation and combined treatments have different populations and dose distributions.[1][3]

StudyFinding relevant to functional counselingEssential limitation
ASCENDE-RT morbidity analysis, 2017Five-year cumulative grade 3 GU events were 18.4% after LDR brachytherapy boost versus 5.2% after dose-escalated EBRT boostBoth groups received pelvic RT and androgen deprivation. Morbidity was analyzed in 383 patients according to treatment received after exclusions and crossover adjustment.[4]
PACE-B, 2024In 874 randomized men, five-fraction SBRT was noninferior for biochemical/clinical control, but cumulative late RTOG grade ≥2 GU toxicity through five years was 26.9% versus 18.3% with conventional/moderate hypofractionationTrial-specific low/intermediate-risk eligibility; no androgen deprivation. Cumulative events differ from symptoms present at the five-year visit: RTOG grade ≥2 GU toxicity at that visit was 26/355 versus 16/355.[5]
PACE-B patient-reported outcomes, 2026At five years, pad-free rates were 233/257 (91%) after SBRT and 225/250 (90%) after control RTThese are respondents to that item, not all 874 randomized men.[6]
ProtecT, 12-year patient-reported follow-up, 2023During years 7–12, pad use was 18–24% after allocation to prostatectomy, 3–8% after RT with neoadjuvant androgen deprivation, and 9–11% with active monitoringAnalysis retained randomized groups, including later treatment changes. RT used the trial's earlier treatment protocol. Urinary leakage, voiding symptoms, sexual function and bowel effects follow different trajectories.[7]

RTOG/EORTC and CTCAE grades are not interchangeable, and CTCAE definitions depend on the adverse-event term and version.[5][8]

The 2023 IMRT meta-analysis illustrates why denominators matter: its pooled RTOG and CTCAE estimates came from different subsets, and its urinary-retention estimate rested on only ten participants.[9]

Assessment Before Attributing Symptoms to Radiation​

Record the radiation target, modality, timing, fractionation and available dose plan; prior pelvic operations, instrumentation and systemic therapy; baseline and current urinary, bowel and sexual function; and the patient's priorities. New symptoms can reflect infection, recurrent cancer, a second malignancy, obstruction, stones or other disease.[2][8]

AUA/ASTRO/SUO 2024 calls for counseling about risks to urinary control, erectile function and bowel function before salvage RT after radical prostatectomy, weighed against risk from recurrent cancer, life expectancy, comorbidities and patient preferences . The discussion advises standardized assessment of baseline urinary, bowel and sexual function, using instruments such as EPIC-26 or SHIM, and identifies late hemorrhagic cystitis and secondary malignancies as potential harms.[28]

  • Hematuria: assess severity, clots, retention and hemodynamic status. Investigate the urinary tract with laboratory testing, appropriate upper-tract imaging and cystoscopy; biopsy lesions concerning for malignancy.[8]
  • Weak stream or retention: define the level and extent of obstruction, bladder function and upper-tract consequences before further instrumentation. Bulbomembranous stricture is a characteristic post-prostate-RT problem; necrosis, calcification and fistula change the management pathway.[2] After prostate radiotherapy and endoscopic outlet surgery, new suprapubic pain or difficulty walking should prompt evaluation for a urosymphyseal fistula; pelvic MRI can help confirm the diagnosis.[34] See Urethropubic Fistula.
  • Storage symptoms or incontinence: separate impaired storage, poor emptying and sphincter dysfunction. Symptom-directed medication and pelvic-floor care must follow that assessment; they do not treat a fixed stricture or restore a severely fibrotic reservoir.[2][3]

Radiation is associated with later second cancers, but absolute risks depend on population, treatment and follow-up. A Medicare-linked observational study's hazard ratio of 2.76 concerned a combined urinary and sexual complication endpoint, not urinary incontinence alone. In the same cohort, radiotherapy was associated with bladder cancer (HR 2.78, 95% CI 1.92–4.02) and radiation cystitis (HR 131.47, 95% CI 52.48–329.35) compared with untreated participants. New hematuria prompts diagnostic evaluation.[8][10]

Hemorrhagic Radiation Cystitis​

Treatment depends on bleeding severity, renal function, bladder condition and access to expertise.[8] The CUA framework separates initial care, persistent or recurrent bleeding and refractory life-threatening bleeding.[8]

Clinical situationApproach
Clots, retention or significant ongoing bleedingStabilization, drainage/irrigation, clot evacuation and cystoscopic assessment with treatment of bleeding sites as appropriate
Persistent or recurrent clinically significant bleedingConsider alum, HBOT or selected other bladder-directed treatments according to urgency and suitability. Alum requires particular caution with impaired renal function; hyaluronic acid has slower onset and limited evidence in severe acute bleeding.
Refractory or life-threatening bleedingConsider selective/superselective embolization and specialist salvage options. Formalin is reserved for failure of less invasive treatment because of substantial morbidity; exclude perforation and prevent upper-tract exposure.
Devastated bladder or unsuccessful salvageDiscuss diversion with or without cystectomy, including the substantial operative risk and possible complications of a retained bladder.

The above is a decision framework; intravesical concentrations and administration belong in the relevant drug or procedure protocol.[8]

Older retained-bladder series after supravesical diversion included a mixed benign/malignant cohort and a benign-only cohort. Neither was restricted to radiation injury, but both are informative for counseling and reported substantial morbidity when the bladder was left in situ: 80% of 30 patients had at least one complication (67% pyocystis), 43% required rehospitalization, and 30% needed reoperation, including cystectomy in 4; a second series of 24 patients reported complications in 54% (33% pyocystis) and subsequent cystectomy in 25%. Both groups argued for considering primary cystectomy at the time of diversion when undiversion is not anticipated. Weigh this retained-bladder morbidity against the added operative risk of concurrent cystectomy, particularly in the elderly, medically frail or deconditioned patients who often present for hemorrhagic-cystitis salvage.[26][27]

Hyperbaric Oxygen: What the Trials Establish​

RICH-ART's original open-label randomized comparison, published in 2019, found greater improvement in urinary symptom scores with HBOT than standard care.[11][12] The 2025 report follows treated patients after the control group was offered HBOT.[11][12]

Among 70 patients entering long-term follow-up, the mixed-model estimated improvement in EPIC urinary total score at five years was 19.1 points (95% CI 13.3–24.9). Only 39 had actual five-year observations, with 31/70 missing at that visit; 9/70 received additional HBOT for recurrence. The study excluded patients with bleeding requiring transfusion exceeding 500 mL within the preceding four weeks, a permanent catheter for incontinence, bladder capacity below 100 mL, or bladder fistula. RICH-ART did not assess HBOT for emergency hemostasis or for a devastated outlet or fistula.[12]

The 2023 Cochrane review supports possible benefit for selected late radiation injuries, with uncertainty about patient selection, timing and dose. See Hyperbaric Oxygen Therapy for treatment selection and safety.[13]

Reconstructive Planning​

The goals are durable drainage, a usable reservoir, acceptable continence and relief of pain or infection. Evaluate these together before committing to outlet reconstruction.[2]

Urethra and Outlet​

For radiation-induced bulbomembranous strictures refractory to endoscopic treatment, EAU 2026 recommends either EPA or augmentation urethroplasty for short strictures (below 2.5 cm), depending on surgeon experience, and augmentation for longer strictures (above 2.5 cm); both are weak recommendations.[2] It gives a strong recommendation to warn patients about de novo incontinence and new erectile dysfunction (reported in 19–26% and 0–35%).[2] The guideline's pooled patency estimate of approximately 80% is level 3 evidence from a systematic review of observational series.[2] In a separate two-center retrospective cohort (163 anastomotic repairs, 49 buccal-graft onlays), estimated 10-year cystoscopic recurrence was 6.8% versus 20%, respectively, and graft repair was associated with recurrence after adjustment (HR 3.43, 95% CI 1.03–11.47). Median follow-up among men without recurrence was 97 months.[29]

In Rourke's 35-patient cohort, 85.7% patency applied to the whole group, comprising 23 EPA, seven buccal-graft and five flap repairs. Adverse changes in continence and erectile function were reported, reinforcing the need to distinguish anatomical patency from functional success.[14]

In a 30-man tertiary-referral series of urinary diversion after prostate radiotherapy, patients underwent a mean of 4.4 procedures attempting to salvage native voiding before diversion.[20] A 2023 review reports 70–100% success across selected buccal-graft series with differing definitions and follow-up, and discusses robotic reconstruction.[22] In a separate ventral-onlay cohort, 15/45 men with recurrence follow-up (33%; two of 47 treated men were lost) had recurrence, defined as symptomatic need for further urethral instrumentation, during a median 44 months of follow-up.[32] In women, a series of three patients with dorsal onlay buccal graft urethroplasty for post-radiation urethral stricture reported no bothersome LUTS or stricture recurrence at 12 months and one transient case of stress incontinence; mean IPSS improved from 27.33 ± 1.15 to 3.33 ± 1.5, mean Qmax from 6.46 ± 0.6 to 23.33 ± 6.1 mL/s, and mean PVR from 56.67 ± 16.07 to 15.67 ± 8.14 mL.[23]

A vascularized flap can provide coverage or interposition when indicated by the defect, tissue quality or fistula. A free mucosal graft remains dependent on an adequate recipient bed. Extensive necrosis, intolerable bladder dysfunction or repeated unsuccessful reconstruction may favor supravesical diversion.[2] For radiation-induced bulbomembranous stricture when reconstruction is declined or performance status is poor, EAU 2026 gives a weak recommendation to consider long-term suprapubic drainage. Its cited cohort reported catheter-related complications in 27% of patients who retained a suprapubic catheter.[2]

See Radiation-Induced Stenosis for evaluation, endoscopic limits, EPA versus buccal graft selection and AUS sequencing, plus Urethral Stricture and Urethral Reconstruction Principles.

Ureter and Bladder​

Define stricture location and length, renal function and available healthy tissue. A bladder-based repair requires a bladder that can be mobilized and used safely; prior RT may limit its capacity or reach. Reimplantation, graft-based repair and bowel substitution are selected according to those findings. Vascularized coverage may be helpful, but neither an omental wrap nor a robotic approach guarantees success.[15]

In the collaborative robotic series, 35 ureteral units in 32 patients (median stricture length 2.5 cm) were repaired mainly by end-to-end (60.0%) or side-to-side (22.9%) reimplantation and an appendiceal procedure (11.4%); one repair used buccal graft ureteroplasty and one an ileal ureter. The authors advise being prepared for adjunctive procedures to gain mobility and vascularity, and note that repeat procedures raise the risk of necrosis and failure.[15]

The reported 88.2% clinical and radiologic effectiveness at median 13 months was 30/34 ureteral units with follow-up, after one early death was excluded from 35 treated units in 32 patients. The selected robotic series had short follow-up, no open-repair comparator and varied reconstruction choices.[15]

In a 73-man series of RTOG grade 4 urinary adverse events after prostate radiotherapy (71% outlet, 21% bladder and outlet, 8% bladder), final management by most invasive treatment was conservative in 21 men (29%), indwelling catheter in 11 (15%), reconstruction in 18 (25%) and urinary diversion in 23 (32%); 14/16 reconstructive surgeries with at least three months of follow-up were successful.[21] In a 30-man series of diversions after prostate radiotherapy, the indications were fistula (37%), devastated outlet (27%), end-stage bladder (20%) and combined end-stage bladder and devastated outlet (17%).[20] All patients with rectourethral fistula had prior brachytherapy seeds, and the options used were cystectomy with conduit, conduit alone or a chronic suprapubic catheter.[20] Operative planning for a conduit in an irradiated pelvis considers the treatment field, viable and mobile bowel, ureteral tissue, and the planned abdominal-wall stoma site. A retrospective series of 30 patients who received very high-dose pelvic irradiation describes transverse-colon conduits using nonirradiated bowel and ureters.[33]

Diversion decisions should account for the outlet, bladder, fistula or necrosis, pain, renal function, prior bowel exposure and surgical fitness.[2][8]

See Ureteral Stricture and Urinary Diversion Principles.

Pelvic Floor and Sexual Function​

Women​

Ask about urgency, leakage, bowel symptoms, vaginal dryness, pain, bleeding and sexual goals. Examination and multidisciplinary care can identify mucosal, muscular, endocrine and structural contributors.

A 2026 systematic review included 15 observational studies and 1,667 women treated with pelvic RT, with prior pelvic surgery or rehabilitation excluded by its eligibility criteria. Pooled prevalence was 37% for urinary incontinence (stress 34%, urgency 47%), 42% for overactive bladder, 30% for pelvic pain, 24% for anal incontinence, 20% for defecatory urgency and 19% for sexual dysfunction. Certainty was moderate for urgency incontinence and overactive bladder and low for the other outcomes. Urinary incontinence was pooled from nine studies (805 women): 37% (95% CI 27–47%), with substantial heterogeneity. The separate 47% urgency-incontinence estimate came from five studies (305 women); it is not a subgroup percentage within the 37%. Differences in populations, assessments and treatment eras limit use for individual prediction.[16]

Vaginal mucosal injury, stenosis and ovarian dysfunction may contribute to dyspareunia and dryness. Lubricants or moisturizers, individualized pelvic-floor therapy and discussion of vaginal dilation after acute injury has settled can support recovery and examination access. Dilation should be comfortable and individualized; the Cochrane review did not establish a preventive benefit from reliable comparative trials. Hormonal treatment requires assessment of the cancer type, treatment and individual suitability rather than a blanket post-RT prescription.[17][18]

Men​

Sexual recovery reflects baseline function, age, vascular or neural injury, androgen deprivation and subsequent treatment. In ProtecT, erections adequate for intercourse at seven years were reported by 27% of the RT group, 18% of the prostatectomy group and 30% of the active-monitoring group; function declined in all groups and converged to low levels by twelve years.[7]

Radiation-related ED is thought to be largely vasculogenic. A review describes vessel-sparing radiotherapy that reduces dose to the internal pudendal arteries and penile bulb.[25] In a single-arm vessel-sparing series of 135 men, 88% were sexually active with or without aids at five years.[30] A separate randomized trial of penile-bulb and corporal-body dose sparing did not detect a potency difference at 24 months (37.1% versus 31.5%; P = .53); the techniques and endpoints differ.[31] Treat established ED according to function, contraindications and patient preference.[19][35] The placebo-controlled RTOG 0831 trial did not show that daily tadalafil during and after RT preserved spontaneous erectile function.[19]

Long-term care should revisit urinary, bowel and sexual symptoms and their impact on daily life. Major trials show changing trajectories across domains; neither inevitable progression nor spontaneous resolution is a reliable universal prognosis.[5][7]

Long-Term Symptom Burden​

In a UK survey of pelvic radiotherapy survivors (418 completed questionnaires, 57.1% response), moderate or severe bowel urgency was reported by 59% of women and 45% of men, urinary urgency by 49% and 46%, and an affected ability to have a sexual relationship by 24% and 53%. Symptoms were as frequent 6–11 years after treatment as 1–5 years after it, and greater severity was associated with poorer quality of life and more depression.[24]

See Also​

References​

1. Citrin DE, Timmerman RD. Effects of radiotherapy in normal tissue. N Engl J Med. 2026;394:996–1009. DOI

2. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males, §6.3.5.a.3.c (radiation/high-energy induced posterior strictures) and §6.3.5.a.4 (urinary diversion). Guideline

3. Martin JM, Richardson M, Siva S, et al. Mechanisms, mitigation, and management of urinary toxicity from prostate radiotherapy. Lancet Oncol. 2022;23:e534–e543. doi:10.1016/s1470-2045(22)00544-7. PMID 36455582

4. Rodda S, Tyldesley S, Morris WJ, et al. ASCENDE-RT: an analysis of treatment-related morbidity for a randomized trial comparing a low-dose-rate brachytherapy boost with a dose-escalated external beam boost for high- and intermediate-risk prostate cancer. Int J Radiat Oncol Biol Phys. 2017;98:286–295. DOI

5. van As N, Griffin C, Tree A, et al. Phase 3 trial of stereotactic body radiotherapy in localized prostate cancer. N Engl J Med. 2024;391:1413–1425. DOI

6. Cooper S, Patel J, Moore C, et al. Patient-reported outcomes after prostate stereotactic body radiotherapy at 5 yr: results from the PACE-B trial. Eur Urol. 2026. DOI

7. Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported outcomes 12 years after localized prostate cancer treatment. NEJM Evid. 2023;2. DOI

8. Goucher G, Saad F, Lukka H, Kapoor A. Canadian Urological Association Best Practice Report: diagnosis and management of radiation-induced hemorrhagic cystitis. Can Urol Assoc J. 2019;13:15–23. DOI

9. David R, Buckby A, Kahokehr AA, et al. Long-term genitourinary toxicity following curative intent intensity-modulated radiotherapy for prostate cancer: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis. 2023;26:8–15. doi:10.1038/s41391-022-00520-x. PMID 35260794

10. Unger JM, Till C, Tangen CM, et al. Long-term adverse effects and complications after prostate cancer treatment. JAMA Oncol. 2024. DOI

11. 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;20:1602–1614. DOI

12. Oscarsson N, Rosén A, Müller B, et al. Radiation-induced cystitis treated with hyperbaric oxygen therapy (RICH-ART): long-term follow-up of a randomised controlled, phase 2–3 trial. EClinicalMedicine. 2025;83:103214. DOI

13. Lin ZC, Bennett MH, Hawkins GC, et al. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev. 2023;8:CD005005. DOI

14. Rourke K, Kinnaird A, Zorn J. Observations and outcomes of urethroplasty for bulbomembranous stenosis after radiation therapy for prostate cancer. World J Urol. 2016;34:377–382. doi:10.1007/s00345-015-1608-2. PMID 26047655

15. Asghar AM, Lee Z, Lee RA, et al. Robotic ureteral reconstruction in patients with radiation-induced ureteral strictures: experience from the Collaborative of Reconstructive Robotic Ureteral Surgery. J Endourol. 2021;35:144–150. doi:10.1089/end.2020.0643. PMID 32814443

16. Pérez CDA, Rocha AKL, Volpato MP, et al. Prevalence of pelvic floor dysfunction in women after pelvic radiotherapy: systematic review and meta-analysis. Int Urogynecol J. 2026. DOI

17. Miles T, Johnson N. Vaginal dilator therapy for women receiving pelvic radiotherapy. Cochrane Database Syst Rev. 2014;9:CD007291. doi:10.1002/14651858.cd007291.pub3. PMID 25198150

18. Hickey M, Basu P, Sassarini J, et al. Managing menopause after cancer. Lancet. 2024;403:984–996. doi:10.1016/s0140-6736(23)02802-7. PMID 38458217

19. Pisansky TM, Pugh SL, Greenberg RE, et al. Tadalafil for prevention of erectile dysfunction after radiotherapy for prostate cancer: the Radiation Therapy Oncology Group [0831] randomized clinical trial. JAMA. 2014;311:1300–1307. DOI

20. Faris SF, Milam DF, Dmochowski RR, et al. Urinary diversions after radiation for prostate cancer: indications and treatment. Urology. 2014;84(3):702–706. doi:10.1016/j.urology.2014.04.023. PMID 25168555

21. Mayer EN, Tward JD, Bassett M, et al. Management of Radiation Therapy Oncology Group grade 4 urinary adverse events after radiotherapy for prostate cancer. BJU Int. 2017;119(5):700–708. doi:10.1111/bju.13607. PMID 27469289

22. Sterling J, Rahman SN, Varghese A, Angulo JC, Nikolavsky D. Complications after prostate cancer treatment: pathophysiology and repair of post-radiation urethral stricture disease. J Clin Med. 2023;12(12):3950. doi:10.3390/jcm12123950. PMID 37373644

23. Gupta P, Kalra S, Dorairajan LN, et al. Dorsal onlay buccal mucosal graft urethroplasty in post radiation female urethral stricture: a technical appraisal with outcomes. Urology. 2021;156:321. doi:10.1016/j.urology.2021.06.006. PMID 34157343

24. Adams E, Boulton MG, Horne A, et al. The effects of pelvic radiotherapy on cancer survivors: symptom profile, psychological morbidity and quality of life. Clin Oncol (R Coll Radiol). 2014;26(1):10–17. doi:10.1016/j.clon.2013.08.003. PMID 23992740

25. Lee JY, Spratt DE, Liss AL, McLaughlin PW. Vessel-sparing radiation and functional anatomy-based preservation for erectile function after prostate radiotherapy. Lancet Oncol. 2016;17(5):e198–e208. doi:10.1016/s1470-2045(16)00063-2. PMID 27301047

26. Eigner EB, Freiha FS. "The fate of the remaining bladder following supravesical diversion." J Urol. 1990;144(1):31-3. doi:10.1016/s0022-5347(17)39358-8

27. Fazili T, Bhat TR, Masood S, Palmer JH, Mufti GR. "Fate of the leftover bladder after supravesical urinary diversion for benign disease." J Urol. 2006;176(2):620-1. doi:10.1016/j.juro.2006.03.056

28. Morgan TM, Boorjian SA, Buyyounouski MK, et al. Salvage Therapy for Prostate Cancer: AUA/ASTRO/SUO Guideline Part I: Introduction and Treatment Decision-Making at the Time of Suspected Biochemical Recurrence after Radical Prostatectomy. J Urol. 2024;211(4):509-517. doi:10.1097/JU.0000000000003892

29. Rourke K, Gelman J. "Anastomotic urethroplasty is associated with a lower risk of stricture recurrence compared with buccal mucosa graft onlay after reconstruction for radiation-induced bulbomembranous urethral stenosis." J Urol. Published online August 26, 2026. doi:10.1097/JU.0000000000005279

30. Spratt DE, Lee JY, Dess RT, et al. "Vessel-sparing radiotherapy for localized prostate cancer to preserve erectile function: a single-arm phase 2 trial." Eur Urol. 2017;72(4):617–624. doi:10.1016/j.eururo.2017.02.007

31. Zhang E, Ruth KJ, Buyyounouski MK, et al. "Long-term results of a phase 3 randomized prospective trial of erectile tissue-sparing intensity-modulated radiation therapy for men with clinically localized prostate cancer." Int J Radiat Oncol Biol Phys. 2023;115(5):1074–1084. doi:10.1016/j.ijrobp.2022.12.008

32. Vetterlein MW, Kluth LA, Zumstein V, et al. "Buccal mucosal graft urethroplasty for radiation-induced urethral strictures: an evaluation using the extended Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM)." World J Urol. 2020;38(11):2863–2872. doi:10.1007/s00345-020-03102-5

33. Ravi R, Dewan AK, Pandey KK. "Transverse colon conduit urinary diversion in patients treated with very high dose pelvic irradiation." Br J Urol. 1994;73(1):51-54. doi:10.1111/j.1464-410x.1994.tb07455.x

34. Patel N, Mehawed G, Dunglison N, et al. "Uro-symphyseal Fistula: A Systematic Review to Inform a Contemporary, Evidence-based Management Framework." Urology. 2023;178:1-8. doi:10.1016/j.urology.2023.05.002

35. European Association of Urology. EAU Guidelines on Sexual and Reproductive Health. 2026, §5.6. Full guideline.