What is permanent seed brachytherapy?
Permanent seed brachytherapy, also known as low dose-rate (LDR) brachytherapy, is a type of radiotherapy where tiny radioactive seeds are put into your prostate. Each radioactive seed is the size and shape of a grain of rice. The seeds stay in the prostate forever and give a steady dose of radiation over a few months.
The radiation damages the prostate cells and stops them dividing and growing. The cancer cells can't recover from this damage and die. But healthy cells can repair themselves more easily.
The seeds release most of their radiation in the first three months after they’re put into the prostate. After around 8 to 10 months, almost all the radiation has been released. The amount of radiation left in the seeds is so small that it doesn’t have an effect on your body.
Watch Chris' story below for one man's experience of brachytherapy.
Or listen to our audio explanation of brachytherapy.
Who can have permanent seed brachytherapy?
On its own
Permanent seed brachytherapy on its own may be suitable for men with CPG 1 (low risk) localised prostate cancer. This is because the radiation from the radioactive seeds doesn’t travel very far, so will only treat cancer that is still inside the prostate.
It may also be suitable for some men whose cancer have a CPG 2 or CPG 3 (intermediate risk) of spreading.
With other treatments
If you have CPG 4 or CPG 5 (high risk) localised prostate cancer, you may have brachytherapy together with external beam radiotherapy and hormone therapy. This is sometimes called a brachytherapy boost. Having these other treatments at the same time as permanent seed brachytherapy can help make the treatment more effective. But it can also increase the risk of side effects.
Some men with intermediate risk localised prostate cancer or locally advanced prostate cancer may be offered a brachytherapy boost.
When is permanent seed brachytherapy not suitable?
Permanent seed brachytherapy won’t be suitable if your cancer has spread to other parts of your body (advanced prostate cancer).
It may not be suitable if you have a very large prostate. If you do have a large prostate you may be able to have hormone therapy before treatment to shrink your prostate.
It may also not be suitable if you have severe problems urinating, such as those caused by an enlarged prostate or overactive bladder. Permanent seed brachytherapy can make these problems worse. Before you have treatment, your doctor, nurse or radiographer will ask you about any urinary problems, and you may have some tests.
You may not be able to have permanent seed brachytherapy if you have Crohn’s disease or ulcerative colitis. This is because it could make your bowel problems worse. Brachytherapy won’t be suitable if you’ve had surgery to remove your rectum (back passage), because the treatment involves using an ultrasound probe in the back passage to make sure the seeds are put in the right place.
If you’ve recently had surgery to treat an enlarged prostate, called a transurethral resection of the prostate (TURP), you may have to wait three to six months before having permanent seed brachytherapy. Some hospitals don’t offer brachytherapy to men who’ve had a TURP because it can make the treatment more difficult to perform.
You will usually have a general anaesthetic while the brachytherapy seeds are put in place, so you’ll be asleep and won’t feel anything. This means permanent seed brachytherapy may only be an option if you are fit and healthy enough to have an anaesthetic. However, you may be able to have a spinal (epidural) anaesthetic instead. This may depend on what your hospital offers.
Not all hospitals offer permanent seed brachytherapy. If your hospital doesn’t do it, your doctor may refer you to one that does.
What are the advantages and disadvantages?
What may be important to one man might be less important to someone else. Your doctor, nurse or radiographer can help you choose the right treatment for you. There’s usually no rush to make a decision, so give yourself time to think about things.
- Recovery is quick, so most men can return to their normal activities one or two days after treatment.
- It delivers radiation directly into the prostate, so there may be less damage to surrounding healthy tissue, and a lower risk of some side effects.
- You will only be in hospital for one or two days.
- If your cancer comes back, you may be able to have further treatment.
- It can cause side effects such as urinary and erection problems.
- You will usually need a general or spinal anaesthetic, which can have side effects.
- It may be some time before you know whether the treatment has been successful.
- You will need to avoid sitting close to pregnant women or children during the first two months after treatment.
What does treatment involve?
You will be referred to a specialist who treats cancer with radiotherapy, called a clinical oncologist. The treatment itself may be planned and carried out by other specialists including a therapy radiographer, a radiologist, a urologist, a physicist and sometimes a specialist nurse.
Each hospital may do things slightly differently but you will usually have:
- an appointment to check the treatment is suitable for you
- a planning session, to plan the treatment
- the treatment itself.
The planning session and the treatment itself may be on the same day (one-stage procedure), or on two separate hospital visits (two-stage procedure).
Before the planning session, let your specialist know if you are taking any medicines, especially medicines that thin your blood such as aspirin, warfarin or clopidogrel. Don’t stop taking any medicines without speaking to your doctor, nurse or radiographer.
Many hospitals offer treatment in just one visit, where you will have the planning session and the seeds put in at the same time under the same anaesthetic. You may not need to stay in hospital overnight.
You will have had an appointment one or two weeks before your procedure to check that the treatment is suitable for you. At this appointment, you’ll have had an ultrasound scan to check the size of your prostate and work out how many seeds you need. You won’t need an anaesthetic for this scan.
You will have an appointment before your treatment, to check that the treatment is suitable for you. Unlike the one-stage procedure, you won’t have an ultrasound scan at this appointment. Instead, your doctor will wait until your planning session to check the size of your prostate and work out how many seeds you need. The seeds will then be put in on your next visit, two to four weeks after the planning session.
Some men may be offered the two-stage procedure if they need treatment to reduce the size of their prostate before having brachytherapy. Some hospitals only offer the two-stage procedure.
Your planning session
During your planning session, your doctor, radiographer or physicist will use an ultrasound scan to work out how many seeds you need and where to put them.
If you’ve already had an ultrasound to see how many seeds you need, the planning session will be used to work out exactly where to put the seeds to make sure the whole prostate is treated.
A thin tube (catheter) may be passed up your penis into your bladder to drain urine.
You will usually have a general anaesthetic so that you’re asleep during the ultrasound scan. This will be given by a health professional called an anaesthetist. If you can’t have a general anaesthetic for health reasons, you may be able to have a spinal (epidural) anaesthetic. This is where anaesthetic is injected into your spine so that you can’t feel anything in your lower body. In some hospitals, the anaesthetist will talk through the different types of anaesthetic before deciding with you which is the best option.
It’s important that your bowel is empty so the scan shows clear images of your prostate. You may need to take a medicine called a laxative the day before the planning session to empty your bowels. Or you might be given an enema when you arrive at the hospital instead. An enema is a liquid medicine that is put inside your back passage (rectum). Your doctor, nurse or radiographer will give you more information about this.
The planning session is a final check that the treatment is suitable for you. If the scan shows that your prostate is too large, you may be offered hormone therapy for up to six months to shrink your prostate. You’ll then have another planning session before you have the seeds put in. Very occasionally, the scan may show that permanent seed brachytherapy isn’t possible because of the position of your prostate and pelvic bones. If this happens, your specialist will discuss other treatment options with you.
The planning session usually takes about half an hour, as well as the time it takes for you to recover from the anaesthetic. You can go home the same day if you aren’t having the treatment straight away. Ask a friend or family member to take you home, as you shouldn’t drive for 24 to 48 hours after an anaesthetic.
Placing the seeds
The clinical oncologist will put the seeds into your prostate. If you have the treatment on the same day as your planning session, the seeds will be put in straight after the planning scan, under the same anaesthetic.
If you have the treatment on a different day to your planning session, you’ll need another anaesthetic on the day of your treatment. You may also need to take another laxative, or have another enema to empty your bowels for the treatment. You may have a catheter to drain urine from your bladder.
An ultrasound probe is again put inside your back passage to take images of your prostate and make sure the seeds are put in the right place. In some hospitals, the clinical oncologist might put gel into your urethra (the tube you urinate through). This may be used if you don’t have a catheter and helps the doctor see your urethra more clearly so they avoid putting any seeds into it.
The clinical oncologist then puts thin needles through your perineum (the area between the testicles and the back passage), and into your prostate. They pass the radioactive seeds through the needles into the prostate. The needles are then taken out, leaving the seeds behind.
Depending on the size of your prostate, between 60 and 120 seeds are put into the prostate. The seeds can be loose individual seeds or linked together in a chain using material that slowly dissolves. Each hospital is different and the clinical oncologist will decide what type of seeds you will have. Treatment usually takes 45 to 90 minutes.
After your treatment
You’ll wake up from the anaesthetic in the recovery room, before going back to the ward or discharge area. Most men feel fine after a general anaesthetic but a few men feel sick or dizzy. Your nurse may give you an ice pack to put between your legs to help prevent swelling.
If you have a catheter, it will usually be removed before you wake up. Or it may be left in for a few hours until you are fully awake, and taken out before you go home. Having the catheter removed may be uncomfortable, but it shouldn’t be painful.
You can go home when you’ve recovered from the anaesthetic and can urinate. Most men go home on the same day as their treatment. But some men find it difficult to urinate at first, and need to stay in hospital overnight. You shouldn’t drive for 24 to 48 hours after the anaesthetic. Ask a family member or friend to take you home.
Your doctor or nurse will give you any medicines that you need at home. These may include drugs to help you urinate, such as tamsulosin, and antibiotics to prevent infection.
You may have some pain or bleeding from the area where the needles were put in. You can take pain-relieving drugs such as paracetamol for the first few days if you need to.
When to call your doctor, nurse or radiographer
Your doctor, nurse or radiographer will give you a telephone number to call if you have any questions or concerns. Contact them if any of the following things happen.
- If your urine is very bloody or has large clots in it, you may have some bleeding in your prostate. Contact your doctor or nurse as soon as possible.
- If you suddenly and painfully can’t urinate, you may have acute urine retention. Go to your local accident and emergency (A&E) department as this will need treatment as soon as possible. Take information about your cancer treatment with you, if you can.
- If you have a high temperature (more than 38ºC or 101ºF), this may be a sign of infection. Contact your doctor or nurse or go to your local A&E department.
What happens afterwards?
The prostate absorbs most of the radiation, and it’s safe for you to be near other people or pets. But you should avoid sitting closer than 50 cm (20 inches) to pregnant women and children during the first two months after treatment. You can give children a cuddle (at chest level) for a few minutes each day, but avoid having them on your lap. If you have pets, try not to let them sit on your lap for the first two months after treatment. Your doctor or nurse will talk to you about this in more detail.
Although the seeds usually stay in the prostate it is possible, but rare, for seeds to come out in your semen when you ejaculate. To be on the safe side, don’t have sex for a few days after treatment, and use a condom the first five times you ejaculate. Double-wrap used condoms and put them in the bin.
It is also rare for a seed to come out in your urine. If this happens at the hospital, don’t try to pick it up. Leave it where it is and let the hospital staff know straight away. If this happens after you’ve left the hospital, don’t try to pick up the seed. Just flush it down the toilet.
Always tell your doctor, nurse or radiographer if you think you have passed a seed. Your treatment will still work, because there will still be enough radiation left in the prostate to treat your cancer.
It is possible for a seed to move into your bloodstream and travel to another part of your body, but this is rare. This shouldn’t do any harm and will often be picked up when you have a scan at your follow-up appointment. If you have any unusual symptoms, speak to your doctor or nurse.
Your radiographer will give you an advice card that says you’ve had treatment with internal radiation. You should carry this card with you for at least 20 months after your treatment.
If a man dies, for whatever reason, in the first 20 months after having treatment, it won’t be possible to have a cremation because of the radioactive seeds. Speak to your doctor or nurse if you are worried about this. Some men decide not to have permanent seed brachytherapy because of this – for personal or religious reasons.
Going back to normal activities
You should be able to return to your normal activities in a few days. You can go back to work as soon as you feel able. This will depend on how much physical effort your work involves. It’s best to avoid heavy lifting for a few days after having the seeds put in. Speak to your doctor, nurse or radiographer about your own situation.
Remember to take your advice card with you when you travel. The radiation in the seeds can occasionally set off metal or radiation sensors at the airport, train station or cruise port.
Speak to your doctor, nurse or radiographer if you plan to travel anywhere soon after having permanent seed brachytherapy, or if you have any concerns about holidays and travel plans. Read more about travelling with prostate cancer.
Your follow-up appointment
You’ll have an appointment with your doctor, nurse or radiographer a few weeks after your treatment. They will check how well you are recovering, your PSA level, and ask about any side effects you might have.
After your treatment you’ll have a computerised tomography (CT) or magnetic resonance imaging (MRI) scan to check the position of the seeds. This can happen on the same day as your treatment, but it may be up to six weeks after your treatment, depending on your hospital.
Your PSA level should drop to its lowest level (nadir) 18 months to two years after treatment. How quickly this happens, and how low your PSA level falls, varies from man to man, and will depend on how big your prostate is and whether you’re also having hormone therapy. Your PSA level won’t fall to zero as your healthy prostate cells will continue to produce some PSA.
Your PSA level may rise after your treatment, and then fall again. This is called ‘PSA bounce’. It could happen up to three years after treatment. This is more common in younger men and men with a large prostate. It can be worrying but it doesn’t mean your cancer has come back.
If your PSA level rises by 2 ng/ml or more above its lowest level, this could be a sign that your cancer has come back. If this happens, your doctor will talk to you about further tests and treatment options, if you need them.
What are the side effects?
Like all treatments, permanent seed brachytherapy can cause side effects. These will affect each man differently, and you may not get all the possible side effects.
Side effects usually start to appear about a week after treatment, when radiation from the seeds starts to have an effect. They are generally at their worst a few weeks or months after treatment, when the swelling is at its worst and the radiation dose is strongest. They are often worse in men with a large prostate, as more seeds and needles are used during their treatment. Side effects should improve over the following months as the seeds lose their radiation and the swelling goes down.
You might also get more side effects if you had problems before the treatment. For example, if you already had urinary, erection or bowel problems, these may get worse after permanent seed brachytherapy.
After the treatment, you might get some of the following:
- blood-stained urine or rusty or brown-coloured semen for a few days or weeks
- bruising and pain in the area between your testicles and back passage which can spread to your inner thighs and penis – this will disappear in a week or two
- discomfort when you urinate and a need to urinate more often, especially at night, and more urgently.
Some side effects may take several weeks to develop and may last for longer. These may include problems urinating, erection problems, bowel problems and tiredness.
Sometimes bowel, urinary and sexual problems after radiotherapy treatment are called pelvic radiation disease. The Pelvic Radiation Disease Association has more information.
Researchers have been looking at whether smoking increases the chance of having long-term bowel and urinary problems after radiotherapy for prostate cancer. At the moment only a small number of studies have been done, so we need more research into this. If you’re thinking of stopping smoking there’s lots of information and support available on the NHS website.
Permanent seed brachytherapy can irritate the bladder and urethra. You may hear this called radiation cystitis. Symptoms include:
- needing to urinate more often or urgently
- difficulty urinating
- discomfort or a burning feeling when you urinate
- blood in your urine.
In some men, permanent seed brachytherapy can cause the prostate to swell, narrowing the urethra and making it difficult to urinate.
A few men find they suddenly and painfully can’t urinate in the first few days or weeks after treatment. This is called acute urine retention. If this happens, contact your doctor or nurse straight away, or go to your nearest accident and emergency (A&E) department as soon as possible. They may need to put in a catheter to drain the urine. You may need to have the catheter in for several weeks until your symptoms have settled down.
Urinary problems may be worse in the first few weeks after brachytherapy, especially in men with a large prostate, but they usually start to improve after a few months.
Medicines called alpha-blockers may help with problems urinating. You can also help yourself by drinking liquid regularly (two litres or three to four pints a day) and by avoiding drinks that may irritate the bladder, such as alcohol, fizzy drinks, artificial sweeteners, and drinks with caffeine, such as tea and coffee.
Permanent seed brachytherapy can also cause scarring in your urethra, making it narrower over time. This is called a stricture, and can make it difficult to urinate. This is rare and may happen several months or years after treatment. If it happens, you might need an operation to widen your urethra or the opening of the bladder.
Some men leak urine (urinary incontinence) after permanent seed brachytherapy, but this isn’t common. It may be more likely if you’ve previously had surgery to treat an enlarged prostate, called a transurethral resection of the prostate (TURP). Problems with leaking urine may improve with time, and there are ways to manage them.
Your bowel and back passage are close to the prostate. Permanent seed brachytherapy can irritate the lining of the bowel and back passage, which can cause bowel problems. The risk of bowel problems after permanent seed brachytherapy is low. But you're more likely to have problems if you’re also having external beam radiotherapy.
Bowel problems can include:
- loose and watery bowel movements (diarrhoea)
- passing more wind than usual
- needing to empty your bowels more often
- needing to empty your bowels urgently
- bleeding from the back passage
- feeling that you need to empty your bowels but not being able to go.
Bowel problems tend to be mild and are less common than after external beam radiotherapy. They often get better with time but a few men have problems a few years after treatment. Try not to be embarrassed to tell your hospital doctor or your GP about any bowel problems. There are treatments that can help.
A small number of men may have bleeding from the back passage after brachytherapy. This can also be a sign of other problems such as piles (haemorrhoids) or more serious problems such as bowel cancer, so tell your nurse or GP about any bleeding. They may do tests to find out what is causing it. They can also tell you about treatments that can help.
Using a rectal spacer to protect your back passage
Your doctor or radiographer may suggest using a rectal spacer to help protect the inside of your back passage from radiation damage. The spacer is placed between your prostate and your back passage. This means that less radiation reaches your back passage, which may help to lower your risk of bowel problems.
Rectal spacers aren’t commonly used in permanent seed brachytherapy alone. But you may have one if you’re also having external beam radiotherapy. If your hospital doesn’t use rectal spacers, you may be able to have one through private healthcare or a clinical trial. Ask your doctor, nurse or radiographer for more information.
Screening for bowel cancer
If you’re invited to take part in the NHS bowel screening programme soon after having brachytherapy, the test may pick up some blood in your bowel movements, even if you can’t see any blood yourself. Your doctor, nurse or radiographer may suggest that you delay your bowel screening test for a few months if you’ve recently had brachytherapy. This will help to make sure you don’t get incorrect results.
A small number of men get blood in their bowel movements after permanent seed brachytherapy, and this shouldn’t be anything to worry about. But if you notice blood, you should always let your doctor, nurse or radiographer know.
Sexual side effects
Brachytherapy can affect the blood vessels and nerves that control erections. This may cause problems getting or keeping an erection (erectile dysfunction). Erection problems may not happen straight after treatment, but sometimes develop some time afterwards.
The risk of long-term erection problems after brachytherapy varies from man to man. You may be more likely to have problems if you had any erection problems before treatment, or if you are also having hormone therapy or external beam radiotherapy.
If you have anal sex and prefer being the penetrative partner (top) you normally need a strong erection, so erection problems can be a particular issue.
There are ways to manage erection problems, including treatments that may help keep your erection hard enough for anal sex. Ask your doctor or nurse about these, or speak to our Specialist Nurses.
You may produce less semen than before the treatment, or none at all. This can be a permanent side effect of brachytherapy. Your orgasms may feel different or you may get some pain in your penis when you orgasm. You may also notice a small amount of blood in the semen. This usually isn’t a problem, but tell your doctor or nurse if it happens. Some men have weaker orgasms than before treatment, and a small number of men can no longer orgasm afterwards.
If you have anal sex and are the receptive partner (bottom), there’s a risk that your partner might be exposed to some radiation during sex in the first few months after treatment. Your doctor or radiographer may suggest you avoid having anal sex for the first six months. Anal play is unlikely to move the brachytherapy seeds out of the prostate, but ask your doctor, nurse or radiographer for more information about having anal sex after permanent seed brachytherapy. They might be able to give you specific advice about how long to wait before having sex that is tailored to you and your treatment.
If you prefer to be the receptive partner during anal sex, then bowel problems or a sensitive anus after permanent seed brachytherapy may affect your sex life. Even when the risk of radiation to your partner has passed, wait until any bowel problems have improved before trying anal play or sex.
Read more about sexual side effects after prostate cancer treatment. We also have specific information if you're a gay or bisexual man. And there are lots of tips for managing sexual problems in our interactive online guide.
Brachytherapy may make you infertile, which means you may not be able to have children naturally. But some men are still able to make someone pregnant after brachytherapy.
It’s possible that the radiation could change your sperm and this might affect any children you conceive. The risk of this is very low, but use contraception for at least a year after treatment if there’s a chance you could get someone pregnant. Ask your doctor or clinical oncologist for more information.
If you plan to have children in the future, you may be able to store your sperm before you start treatment so that you can use it later for fertility treatment. If this is relevant to you, ask your doctor, nurse or radiographer whether sperm storage is available locally.
You may feel tired for the first few days after treatment as you recover from the anaesthetic. The effect of radiation on the body may make you feel tired for longer, especially if you’re also having external beam radiotherapy or hormone therapy. If you get up a lot during the night to urinate, this can also make you feel tired during the day.
Fatigue is extreme tiredness that can affect your everyday life. It can affect your energy levels, motivation and emotions. Fatigue can continue after the treatment has finished and may last several months.
There are things you can do to help manage fatigue. For example, planning your day to make the most of when you have more energy. Read more about fatigue, or get tips for dealing with fatigue in our interactive online guide. Our Specialist Nurses also offer a fatigue support service that can help you improve your fatigue over time.
Questions to ask your doctor, radiographer or nurse
- Will I have a planning session at a different time to the treatment, or immediately before?
- Will I have external beam radiotherapy or hormone therapy as well?
- What side effects might I get?
- How will we know if the treatment has worked?
- What should my PSA level be after treatment and how often will you test it?
- If my PSA continues to rise, what other treatments are available?
Updated: March 2019 | Due for Review: March 2022
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- Peter Bownes, Deputy Head of Radiotherapy Physics, Head of Brachytherapy and Gamma Knife Physics, Medical Physics & Engineering, St James's University Hospital, Leeds
- Professor Peter Hoskin, Consultant Clinical Oncologist, Mount Vernon Cancer Centre, Northwood
- Phil Reynolds, Consultant Radiographer in Prostate Radiotherapy, The Clatterbridge Cancer Centre NHS Foundation Trust
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