Well after 73 posts I am finally going to address the Elephant in the Room!
Yes, I have been very sexist in my blog writing and have rarely mentioned the poor male of the species. Yes! men do suffer with urinary incontinence, albeit mostly 20-30 years after women are first hit with it and yes! in many ways it is more catastrophic than it can be for women. We women at least have been conditioned to use pads for menstruation from a young age and there is also a narrative that it is manditory that after children incontinence is inevitable. Now after 74 blogs, you are a well informed audience and know this narrative is false and there is much that can be done to combat incontinence ……and prolapse….and pelvic pain….and sexual dysfunction…..and today I am going to go through the strategies to address the incontinence that may follow surgery on the prostate.
The male pelvic floor is different from the female pelvic floor in that it doesn’t have that hernia portal called the vagina. It also isn’t subjected to the stresses and strains that childbirth can inflict- although young men in the gym sometimes have a similar amount of damage from lifting excessively (ridiculously) heavy weights. The other difference is the mechanical advantage created by the longer urethra in men- the pelvic floor muscles sit in a much better position compared to women where the urethra is shorter (only 4 cm).
Illustration from The Pelvic Guru website
Amy Stein: Heal Pelvic Pain (Taken from Internet site 24/3/13)
So how do men find their pelvic floor muscles? The following is taken from the Continence Foundation of Australia Website – the peak organisation for incontinence information and service delivery.
Method 1 – Stopping the flow
When you go to the toilet, try to stop or slow the flow of urine midway through emptying your bladder. If you are able to do this you are squeezing the correct muscles. Do not do this repetitively. This is not an exercise, but a way to identify the correct muscles.
Method 2 – Visualisation
Stand in front of the mirror (with no clothes on) and tighten your pelvic floor muscles. If you are tightening the right muscles, you should see the base of the penis draw in and scrotum lift up. The back passage will tighten too but it is not the focus of the exercise. When you relax your muscles you should feel a sensation of ‘letting go’.
Getting the technique right
Correct technique is very important when doing pelvic floor muscle exercises. You should feel a ‘lift and a squeeze’ inside your pelvis. The lower abdomen may flatten slightly, but try to keep everything above the belly button relaxed, and breathe normally.
Exercising your pelvic floor muscles
Once you master the art of contracting your pelvic floor muscles, try holding the inward squeeze for longer (up to 10 seconds) before relaxing. If you feel comfortable doing this, repeat it up to 10 times. This can be done three times a day. Make sure you continue to breathe normally while you squeeze in.
You can do the exercise lying down, sitting or standing with your legs apart, but make sure your inner thighs and buttock muscles are relaxed.
Some recent work by a researcher at the University of Queensland has looked at the best terminology to get the best contraction from a group of men using an EMG wire and found repeatedly “shorten the penis” gets the best contraction!
So now we know how to find the muscles and do the pelvic floor muscles exercises, once you have had your surgery, there are some critical things which will improve any leakage you have.
1. Do a pre-op bladder diary measuring each individual void (wee) out and every drink in. Remember the normal bladder capacity is 350-500 mls with no residual urine left behind. This gives you an idea of how your bladder is storing before your surgery.
2. Once you are 6 weeks post-op repeat this to see how the storing is going. If you have significant leakage it may be difficult to hold onto too much at all initially- but going frequently with small volumes will increase the likelihood of the bladder muscle (the detrusor) becoming overactive and increasing the risk of long term frequency, urgency, urge incontinence and nocturia.
3. Find the other important muscles, which I call ‘your best friend’ in my Pelvic Floor Recovery books – Transversus Abdominis – the fourth and deepest layer of the abdominal muscles. Think of your pubic hairline, and think about doing up your fly (zipper on your jeans) and so as not to catch your pubic hairs in your zipper, you gently pull in your low tummy. (Another way to do it is to think of that screamingly funny (except if you’re a male) scene from There’s Something About Mary and that’s where you you are gently pulling in your low tummy). We do this because it co-contracts with the pelvic floor muscles and increases your urethral closing pressure.
So your exercise programme now consists of pelvic floor and transversus abdominis exercises daily. But to help maintain continence you must learn to combine these two important muscle groups and brace before and as you move – especially before you go from sit to stand, cough, sneeze, lift or bend- to engage these muscles before the increase in intra-abdominal pressure. This is something that happens automatically prior to your surgery- something you don’t even think about, but after your operation, dependent on how much damage to the nerve or sphincter is forced by the removal of the prostate, this must become a learned knack to continue forever. It will become second nature, just as you learned to cover your mouth with cough or sneeze as a youngster.
4. Go completely decaf! Caffeine is a bladder irritant and in large quantities is a diuretic. Now what you don’t need if your sphincter mechanism is not great, is to challenge your bladder with the irritation of caffeine (and be careful when drinking alcohol – another bladder irritant, diuretic AND muscle relaxant). Aim to drink around 2 litres of fluid if you are not exercising, more if you are. Over-drinking can be a problem.
5. Check out pads before your operation. Assume you will need them initially and if you don’t require them post surgery then throw a party! There are pharmacies which specialise in stocking good ranges of the different pads; go with your partner so they know what there is available and once you know what the situation is, then they can easily and quickly purchased before you come home. You will be seen in hospital by a Continence nurse and they will be able to give you lots of advice as well.
6. Always be on top of your bowels. Check out my blog on All About Bowels to get the hang of the position and dynamics of defaecation – if you are constipated then that added pressure on your bladder will increase the risk of incontinence. Also there is advice in there regarding managing faecal incontinence which can happen during chemotherapy and or radiation treatment later down the track.
Well, this has been a suitably enormous blog for one called There’s an Elephant in the Room– but that’s what happens when you have completely ignored such an important topic for so long. Hopefully, there are plenty of men out there who find it helpful and don’t forget that my book, Pelvic Floor Recovery: A Physiotherapy Guide for Gynaecological Repair Surgery has all the information on normal bladder and bowel function which will be helpful, (just ignore all the pink bits and the references to the vagina!) and when you’ve finished reading it you can gift the book to your partner.
Good luck to all those facing surgery in the future!