Are Erectile and Ejaculatory Dysfunction Associated with Postmicturition Dribble? Grace Dorey

review of existing re- Research findings from two earlier literature reviews were examined to search findings was determine if there may be an association between erectile dysfunction undertaken to deter- and postmicturition dribble. From the review, bulbocavernosus and mine if postmicturition ischiocavernosus muscle dysfunction may be responsible for both Adribble may be associated with erectile and ejaculatory dysfunction, as well as a cause of postmicturi- erectile and ejaculatory dysfunc- tion dribble and loss of the postvoid milking reflex. muscle tion. After reviewing 17 studies, exercises may help to improve these conditions. However, research to the conclusions that may be investigate the conclusions proposed following the literature review is drawn are discussed. Before highlighting the existing research necessary for an association or relationship to be stated conclusively. literature, a review of the defini- tions, prevalence, and etiology of both erectile dysfunction and Prevalence of ED & Grugnetti, 1994; Colpi, Negri, postmicturition dribble are sum- An estimated 152 million men Nappi, & Chinea, 1999; Mamberti- marized. worldwide suffered from ED in Dias, Vasavada, & Bourcier, 1999; 1995, and this figure is projected Van Kampen et al., 1998). Erectile Dysfunction to rise to 322 million men world- Penile erection occurs fol- Erectile dysfunction (ED) was wide in 2025 (Aytac, McKinlay, & lowing a series of integrated vas- defined by a National Institutes of Krane, 1999). Feldman et al. cular events culminating in the Health (NIH) Consensus Develop- (1994) found the problem was accumulation of blood under ment Conference in 1993 as “the strongly age related. They found pressure and end-organ rigidity inability to achieve or maintain that the probable prevalence of (Moncada Iribarren & Sáenz de an erection sufficient for satisfac- complete or partial ED rose from Tejada, 1999) (see Figure 1). This tory sexual performance.” There 40% in 50 year olds to 66% in 70 vascular process can be divided are varying degrees of ED: mild year olds. However, Lewis and into five phases, followed by ED has been described as achiev- Mills (1999) stated that age-related detumescence. ing a satisfactory erection 7 to 8 diseases might be the risk factors 1. Flaccidity. A state of low attempts out of 10; moderate ED for ED, rather than age itself. With flow of blood and low pres- as achieving erection 4 to 6 increased life expectancy and sure exists in the penis. attempts out of 10; and severe ED with a growing population, the 2. Latent or filling phase. When as achieving an erection 0 to 3 out number of men with ED is expect- the erection mechanism is of 10 (Albaugh & Lewis, 1999). ed to increase. initiated by any stimulus, the parasympathetic nervous sys- Etiology of ED tem (S2-4) provides excitatory There are a variety of risk fac- input to the penis. The penile tors which separately or com- smooth arterial muscle then bined may cause erectile dys- relaxes and the cavernosal Grace Dorey, MSc, MCSP, is a function, as shown in Table 1. and helicine dilate, Specialist Continence Physiotherapist, enabling blood to flow into Somerset Nuffield Hospital, Taunton, There is also anecdotal or case Somerset, United Kingdom, and a study information that supports the lacunar spaces. Doctoral Student, University of the West the theory that weakness of the 3. Tumescence. The venous of England, Bristol, UK. bulbocavernosus and ischiocav- outflow is reduced by the ernosus muscles are a risk factor compression of the subtuni- Acknowledgment: The author expresses for ED (Ballard, 1997; Claes & cal venules against the tunica her sincerest thanks to Professor Roger Baert, 1993; Colpi, Negri, Scroppo, albuginea (corporal veno- Feneley for kindly reviewing this article.

42 UROLOGIC NURSING / February 2003 / Volume 23 Number 1 Table 1. neither due to stress inconti- Risk Factors for Erectile Dysfunction nence nor bladder dysfunction (Wille, Mills, & Studer, 2000) and Risk Factor Possible Components should be distinguished from ter- minal dribble, which occurs at Psychogenic Marital conflict the end of micturition (Shah, Depression 1994). The amount can be as Poor body image much as 15 ml. It is a common Performance related problem for men of all ages (Pomfret, 1993), but particularly Vasculogenic Arteriogenic Venogenic troublesome in older men (Paterson, Pinnock, & Marshall, Neurogenic Spinal cord trauma 1997). Multiple sclerosis Spinal tumors Prevalence of Postmicturition Dribble Endocrinologic Hormonal deficiency Malmsten, Milsom, Molander, and Norlen (1997) found the Diabetic Peripheral neuropathy prevalence of PMD to range from Hypertension 29% in men aged 45 years, to Renal failure 36.6% in men aged 90 years or Drug related Antihypertensives older; while Koskimäki, Makama, Psychotropics Huhtala, and Tammela (1998) Hormonal agents found that PMD prevalence did not increase with age. Also Surgical trauma Transurethral prostatectomy Koskimäki et al. (1998) found the Radical prostatectomy prevalence of PMD was much Pelvic surgery higher, with 48% for mild and Pelvic radiotherapy 15% for moderate to severe, mak- ing a total prevalence of 63% for Life-style related Trauma to the Nicotine abuse men from 50 to 70 years of age. Drug abuse There may be many factors pre- Alcohol abuse venting men from acknowledging the problem such as embarrass- Weak perineal musculature Lack of use? ment, a wish to be independent, a Aging? belief that it is part of aging, and lack of knowledge of the effective- ness of available treatment.

occlusive mechanism), caus- tractions of the bulbocaver- Etiology of Postmicturition ing the penis to expand and nosus muscle propel the Dribble elongate, but with scant semen down the urethra Postmicturition dribble is increase in intracavernous resulting in ejaculation. attributed to a failure of the bul- pressure. Detumescence. The sympa- bocavernosus muscle to evacuate 4. Full erection. The intracav- thetic nervous system is respon- the bulbar portion of the urethra ernous pressure rapidly sible for detumescence via spinal (Feneley, 1986; Millard, 1989). increases. cord segments T10-12 and L1-2. This pooling of urine in the bul- 5. Rigidity. The intracavernous Contraction of the penile smooth bar urethra may dribble with pressure rises higher than the muscles and contraction of the movement (see Figure 2). diastolic pressure as blood penile arteries leads to a decrease Bulbocavernosus muscle. inflow occurs with the sys- of blood in the lacunar spaces The bulbocavernosus muscle, tolic phase of the pulse, and the contraction of the also called the bulbospongiosus enabling complete rigidity to smooth trabecular muscle leads muscle, arises from the median occur. Contraction or reflex to their collapse. raphe and the perineal body (see contraction of the ischiocav- Figure 3). The middle fibers ernosus and bulbocaver- Postmicturition Dribble encircle the bulb and corpus nosus muscles produces The symptom postmicturi- spongiosum penis. They assist in increases in the intracav- tion dribble (PMD), also called erection of the corpus spongio- ernous pressure. At peak postvoid dribble or after-dribble, sum penis by compressing the rigidity, there is minimal fur- is the complaint of a dribbling erectile tissue of the bulb. The ther arterial inflow. When loss of urine which occurs after anterior fibers spread out over climax occurs, rhythmic con- voiding (Blaivas et al., 1997). It is the side of the corpus caver-

UROLOGIC NURSING / February 2003 / Volume 23 Number 1 43 nosum, and are attached to the Figure 1. covering the dorsal vessels Veno-Occlusive Mechanism of the penis. They contribute to erection by compressing the deep dorsal vein of the penis. The bul- Outflow Helicine bocavernosus muscle empties FLACCID STATE urine from the bulbar canal of the urethra. The fibers are relaxed Trabecular Inflow through during voiding and come into smooth muscle cavernosal artery action to arrest micturition. Rhythmic contractions propel semen down the urethra result- ing in ejaculation. Ischiocavernosus muscle. Subtunical space The ischiocavernosus muscle arises from the inner surface of Outflow the and pubic ramus. It inserts into an aponeu- rosis into the sides and under the Outflow Dilated helicine artery surface of the crus penis (see Figure 3). Contractions of the Inflow through ischiocavernosus muscles com- Tunica albuginea dilated cavernosal press the crus penis and produce artery an increase in the intracavernous pressure and influence penile rigidity. The ischicoccygeus and ERECT STATE bulbocavernosus muscles are supplied by the perineal branch Lacunar space of the pudendal (S 2-4) Outflow Compressed Literature Search Strategy subtunical venule An extensive literature review of existing research findings was undertaken to determine if post- micturition dribble may be associ- ated with erectile and ejaculatory dysfunction. The search used the Figure 2. following computerized databases Urine Retained in the Bulbar Portion of the from 1980 to 2002: Medline, Urethra after Micturition AAMED (Allied and Alternative Medicine), CINAHL, EMBASE – Rehabilitation and Physical Medicine, and The Cochrane Library Database. The keywords chosen were erectile dysfunction, impotence, conservative treat- Voluntary ment, physical therapy, physio- urinary sphincter therapy, pelvic floor exercises, Urine in bulbar biofeedback, postmicturition drib- urethra ble, postvoid dribble, after-drib- ble, bulbocavernosus muscle, bulbar urethral massage, urethral milking, electrical stimulation, and electrotherapy. A manual search was undertaken of manu- scripts found from the references of this literature. Selection criteria. A study was included if it met the follow- ing criteria: 1. The trial investigated weak pelvic floor muscles as a pos-

44 UROLOGIC NURSING / February 2003 / Volume 23 Number 1 Figure 3. ed seven patients with psy- Male Superficial Pelvic Floor Muscles chogenic ED, age range 28 to 50 years (mean 38.2 years), to mea- sure the intracavernosal pressure during activity of the ischiocaver- nosal muscles. The procedure consisted of simultaneous record- ings of penile circumference from

Bulbocavernosus a strain gauge around the penile muscle shaft; penile rigidity using a Ischiocavernosus muscle penile cuff; and electromyograph- ic (EMG) activity of the perineal Transverse muscles during nocturnal erec- Pelvic floor perineal muscle tions. The EMG surface sensors muscles were placed on the perineal area. Results showed that the contrac- tions of the perineal muscles strongly coincided with changes in penile rigidity during noctur- nal erections, and triggered increases in intracavernous pres- sure (over 300 mmHg). The sible etiology for ED and/or dle EMG; an invasive method of authors suggested that the role of PMD. biofeedback (Claes & Baert, 1993; the perineal muscles caused dras- 2. The trial reported the results Claes et al., 1995; Lavoisier, tic increases in intracavernous of conservative treatment for Courtois, Barres, & Blanchard, pressure, which could never men with ED and/or PMD. 1986); and one trial which mea- exceed systolic blood pressure 3. The treatment under investi- sured pressure from a transducer in alone, even with the venous out- gation included physical the corpus cavernosum (Lavoisier flow completely blocked. They therapy interventions. et al., 1988). stated that ED could be broadly 4. The outcome measures were Another previous literature classified into two broad cate- clinically relevant and reli- search (Dorey, 2001a) revealed gories: dysfunction in penile able for the problem under only five papers investigating tumescence and dysfunction in investigation. PMD. Of these, one paper penile rigidity. Exclusion criteria. Trials were described the action of the bulbo- Lavoisier et al. (1986) studied excluded if they failed to meet the cavernosus muscle during void- nine patients with ED, with an age selection criteria or were not in ing cystourethrograms (Wille et range of 29 to 65 years (mean 41.8 English. al., 2000); one nonrandomized years). Patients with venous occlu- Included and excluded studies. controlled trial (Chang et al., sive dysfunction were excluded. A previous literature search (Dorey, 1998) and two randomized con- An artificial erection was induced 2000 a, b, & c) revealed seven non- trolled trials explored the effect of by injecting physiologic saline, randomized or noncontrolled trials pelvic floor muscle exercises on and the patients were asked to per- investigating pelvic floor muscle PMD (Paterson et al., 1997; Porru form several maximal muscular exercises for ED (Claes, Van et al., 2001); while one paper contractions of the ischiocaver- Kampen, Lysens, & Baert, 1995; investigated the affect of PMD on nosus muscle. The EMG biofeed- Claes, Vandenbroucke, & Baert, sexual dysfunction (Frankel et al., back of the ischiocavernosus mus- 1996; Claes & Baert, 1993; Colpi et 1998). cle was recorded using a needle al., 1994; Colpi et al., 1999; Four further nonrandomized, electrode, and the intracavernosus Mamberti-Dias, & Bonierbale- noncontrolled studies by MacFarlane pressure was recorded using a Branchereau, 1991; Van Kampen et et al. (1996), Yang and Bradley pressure transducer in the corpus al., 1998). Of these, three included (1999; 2000), and Shafik and El- cavernosum. Results showed that biofeedback (Colpi et al., 1994; Sibai (2000) were subsequently increases in the intracavernosus Colpi et al., 1999), and one added found and included in this pressure were significant for all electrical stimulation (Claes et al., review. patients (p<0.01) and were always 1996), while three included Seventeen total studies met in phase with greater ischiocaver- biofeedback and electrical stimula- the broad selection criteria and nosus muscle activity. They tion (Claes et al., 1995; Mamberti- were included in this review. Key hypothesized that ED may some- Dias & Bonierbale-Branchereau, findings will now be discussed. times have a muscular origin, 1991; Van Kampen et al., 1998). which would support the use of Also found were three clinical trials Role of Pelvic Floor Muscles physiotherapy as a treatment for which monitored the activity in the On Penile Rigidity this type of erectile dysfunction. ischiocavernosus muscle using nee- Lavoisier et al. (1988) select- continued on page 48

UROLOGIC NURSING / February 2003 / Volume 23 Number 1 45 Literature Review bulbocavernosus muscle activity. the 15 without this action, 13 continued from page 45 The balloon was then withdrawn (87%) reported PMD. The to lie in the membranous, bul- decrease in rate of milking and Using electromyography bio- bous, and pendulous urethra, increase in the rate of PMD from feedback, Colpi et al. (1999) stud- and the test repeated at each site. before to after surgery was statis- ied the contractile activity of the Distension with 0.5 ml and up to tically significant (p=0.0001 and pelvic floor muscles of 76 sexual- 1.5 ml in only the bulbous area p<0.0001 respectively). Wille et ly potent men aged 18 to 35 caused increased EMG activity of al. (2000) concluded that the nor- years, and 97 age-matched impo- the bulbocavernosus muscle. mal postvoid milk-out is often tent men. Another group of 217 When the bulbous urethra or the absent in the early postoperative older impotent men aged 36 to 75 bulbocavernosus muscle was period after radical prostatecto- years was also studied to verify anesthetized, there was no my, and that this was associated the impact of age on the efficien- response to urethral distension. with PMD. cy of pelvic floor muscle contrac- Yang and Bradley (1999) tion. The average myoelectrical used genitourinary electrodiag- Effect of Pelvic Floor Muscle activity of 24 maximal contrac- nostic testing in 13 healthy male Exercise for PMD tions was measured with an anal volunteers aged 20 to 43 years of In a nonrandomized con- plug sensor. Two surface sensors age. They found that electrical trolled trial, Chang et al. (1998) recorded the myoelectric activity stimulation to the anterior ure- evaluated the effect of pelvic of the antagonist abductors, thra caused a bulbocavernosus floor muscle exercises on fre- glutei and abdominal muscles muscle contraction. quency, postmicturition drib- (position not recorded), and a Yang and Bradley (2000) bling, urinary incontinence, and third grounded sensor was investigated the somatic reflex quality of life in patients follow- placed on the anterior superior innervation of the bulbocaver- ing transurethral resection of iliac spine. The subject was nosus muscle and the role of the prostate. The first 25 consecutive asked to perform an imitation of in bulbocaver- men served as a control group coital thrusts in side-lying posi- nosus contraction. Ten healthy and the next 25 men were given tion to increase penile rigidity, potent men underwent genitouri- pelvic floor muscle exercises and then perform 24 maximal nary electrophysiologic testing. once the catheter was removed. pelvic floor contractions lasting 3 Stimuli were applied to the dor- At 4 weeks, there was a statisti- seconds, with a rest of 6 seconds. sal nerve of the penis at the base cally significant difference in the The myoelectric activity of the of the penis, glans and anterior strength of pelvic floor muscle perineal values were significant- urethra, and the perineal nerve contractions (p<0.05) and PMD ly higher in sexually potent branch to the bulbocavernosus (p<0.05). Prior to pelvic floor young men (20.3V±6.2) com- muscle. EMG responses of the exercises, 20 men in the control pared to impotent young men bulbocavernosus muscle were group and 24 men in the treat- (16.8V±7.2) (p=0.0007). They recorded at baseline and after ment group suffered from PMD, were also significantly higher in anesthetizing the perineal nerve. and after 4 weeks, 10 in the con- younger impotent men than in A reflex contraction of the bulbo- trol group and 3 in the treatment older impotent men (13.5V±6.0). cavernosus muscle initially group experienced PMD. The results showed that perineal elicited from all the stimulation In a randomized controlled contraction was significantly sites was altered when the per- trial, 58 out of 63 consecutive higher (p=0.05) in potent than in ineal nerve was anesthetized. patients were selected to undergo impotent men. In addition, in transurethral resection of the older impotent men the pelvic Role of Bulbocavernosus prostate (Porru et al., 2001). floor muscle efficiency was nega- Muscle in Postvoid Milking Subjects excluded were those tively correlated to age (r=-0.21, Mechanism over 80 years of age and those p=0.002). Wille et al. (2000) performed who had a previous history of voiding cystourethrograms before pelvic surgery, neurogenic blad- Role of the Bulbocavernosus and 10 to 15 days after radical der, or prostate cancer. Thirty Muscle in Ejaculation prostatectomy to correlate with subjects were randomly assigned Shafik and El-Sibai (2000) the presence or absence of PMD. to the treatment group and 28 to investigated the action of the bul- Prior to surgery, they found that the control group. The treatment bocavernosus muscle once semi- 12 of 19 patients (63%) had a group received a preoperative nal fluid had reached the bul- normal postvoid milking reflex treatment session. This included bous urethra. A 10F balloon- action, and none of these patients a digital rectal assessment for tipped catheter was introduced suffered from PMD. Six of the muscle strength on a 0 (none) to into the prostatic urethra of 14 seven patients (86%) without a 4 (strong) scale, and instruction healthy male volunteers (mean postvoid milking mechanism in pelvic floor muscle exercises. age 37 years). It was then filled reported PMD. Postoperatively, Home exercises consisted of 45 with saline in increments of 0.25 only 1 out of 16 patients (6%) contractions a day, divided into ml while needle EMG recorded had a postvoid milking action. Of three sessions of 15 exercises.

48 UROLOGIC NURSING / February 2003 / Volume 23 Number 1 Outcome was measured by the of visits to the therapist was not men reporting less than once a American Urological Association stated. Though not statistically week almost ten times more like- Symptom Score (Barry et al., significant, of the 43 men who ly to be dissatisfied. 1992), and the ICSmale question- completed the program, those naire was used to assess quality who practiced pelvic floor exer- Discussion of Findings of of life (Donovan, Abrams, & cises were twice as likely to have Reviewed Articles Peters, 1996). Patients kept void- reduced urine loss (4.7 g) than the Pelvic floor muscle function. ing diaries to evaluate conti- urethral milking group (2.9 g). Contraction or reflex contraction nence status. At 4 weeks post- However, treatment by either of the ischiocavernosus and bul- surgery, there was a significant method was more effective than bocavernosus muscles produces increase in muscle strength in counseling alone (p=0.01). Sub- an increase in the intracavernous the treatment group, with the jectively, men in the exercise pressure in the tumescent penis average strength score increasing group stated more satisfaction (Lavoisier et al., 1986; Lavoisier from 2.8 to 3.8 (p<0.01). The than the other two groups. et al., 1988; Moncada Iribarren & number of patients with inconti- Sáenz de Tejada, 1999). The bul- nence episodes and PMD were Association Between bocavernosus muscle acts as a comparable in both groups at PMD and ED suction-ejection pump to propel catheter removal. However, it In a study by Frankel et al. the semen down the urethra, was significantly lower in the (1998), the effect of lower urinary resulting in ejaculation (Shafik & treatment group compared to the tract symptoms on sexual dys- El-Sibai, 2000). However, the control group at weeks 1, 2, and 3 function was investigated in 423 number of subjects was small, (p<0.01) with 9 versus 17 at week men over age 40 in Leicestershire, possibly due to the invasive 1, 5 versus 16 at week 2, and 4 UK, and 1,271 urology clinic nature of the studies, which lim- versus 12 at week 3, respectively. attendees over age 45 in 12 coun- ited any strong conclusions. However, the difference was not tries. Men were excluded if they Pelvic floor muscle dysfunc- significant between the two had prostate cancer, an abnormal tion. Erectile dysfunction can be groups at week 4. midstream specimen of urine, caused by the inability to pro- One single-blind randomized neurologic disease, previous pro- duce an increase in the intracav- controlled trial was found in state surgery, or were taking med- ernous pressure (Dorey, 2000a, b, which pelvic floor muscle exer- ication active on the lower urinary & c) due to weakness of the cises were compared to bulbar tract. All men completed the ICS ischiocavernosus and bulbocav- urethral massage. Paterson et al. “BPH” study questionnaire, which ernosus muscle. Similarly, loss of (1997) randomized 49 men (age included the ICSmale and ICSsex ejaculatory force can probably be range 36 to 83) who had not questionnaires (Donovan et al., caused by loss of rhythmic con- undergone previous urologic 1996). Results showed that there tractions of the bulbocavernosus surgery or had a history of was an association between PMD muscle (Shafik & El-Sibai, 2000). urgency or stress incontinence to and sexual dysfunction [reduced Postmicturition dribble was one of three groups. The sample rigidity] 1.68 (p<0.001), reduced attributed to a failure of the bul- received pelvic floor muscle ejaculation 1.79 (p<0.001), and bocavernosus muscle to evacuate exercise, urethral milking, or pain on ejaculation 1.73 (p<0.01)] the bulbar portion of the urethra counseling (toileting habits, use among the clinic sample. The (Feneley, 1986; Millard, 1989). of beverages, dietary advice, study concluded that men with Pelvic floor muscle contrac- bowel habits, and relaxation lower urinary tract symptoms tions associated with increased therapy). Pelvic floor muscle were more likely to suffer sexual intracavernosal pressure. Lavoisier exercises gradually progressed to dysfunction. et al. (1988) showed that the con- a maximum of ten 1-second con- Macfarlane et al. (1996) in- tractions of the pelvic floor mus- tractions and ten 6-second con- volved 2,011 men in a community- cles strongly coincided with tractions. Participants were based study in France. Men increased penile rigidity during instructed to spread exercise ses- between 50 and 80 years complet- nocturnal erections. Increases in sions throughout the day and to ed a self-administered question- the intracavernosal pressure were vary the position from lying, to naire and were interviewed by a always in phase with greater sitting and standing. The number professional interviewer. The ischiocavernosus muscle activity of exercise sessions was not stat- odds ratio of an association for all patients and was significant ed. Subjects were instructed to between PMD and sexual life sat- (p<0.01). tighten and lift as if interrupting isfaction was 1.72 for those men Bulbocavernosus and ischio- the flow of urine, and observe a with moderate PMD, and 2.20 for cavernosus muscles involved in penile and scrotal lift. Individual those with frequent PMD. The normal reflex postvoid milking assessment determined the num- number of times sexual inter- mechanism. Wille et al. (2000) ber of exercises. Treatment lasted course took place during the past used cystourethrograms to demon- for 12 weeks, and urine loss was month was by far the most impor- strate an antegrade wave from the assessed with a 4-hour pad test at tant factor having an influence on external sphincter through the 5, 9, and 13 weeks. The number sexual life satisfaction, with those urethra at the end of voiding,

UROLOGIC NURSING / February 2003 / Volume 23 Number 1 49 sure (Miller, Aston-Miller, & Bulbocavernosus muscle dysfunction may, therefore, DeLancey, 1996). Similarly, in the absence of a urethrocaver- provide the association between erectile dysfunction, nosus reflex and bulbocaver- ejaculatory dysfunction, and postmicturition dribble. nosus reflex, men may be taught to perform a voluntary “squeeze out” muscle contraction to eject the last few drops of urine after which cleared the urethra of ed through the urethrocavernosus voiding (Dorey, 2001b). Indeed, urine. They postulated that the reflex. While this reflex is impor- Strasser et al. (2001), using tran- bulbocavernosus and ischiocav- tant for ejaculation, it may play a srectal ultrasound after trans- ernosus muscles were involved part in eliminating urine follow- urethral resection of prostate or in clearing the urethra at the end ing micturition. radical prostatectomy, detected of normal voiding. The decrease Bulbocavernosus reflex. Yang defects in the rhabdosphincter in rate of milking and increase in and Bradley (1999) found that and postoperative scarring in 7 the rate of PMD from before to electrical stimulation to the ante- out of 12 patients with postoper- after radical prostatectomy was rior urethra caused a bulbocaver- ative stress incontinence. Of statistically significant (p=0.0001 nosus muscle contraction, sug- these men, three patients showed and p<0.0001, respectively). gesting that the somatic afferents areas of muscle thinning, and Wille et al. (2000) stated that the from the anterior urethra were two patients had complete rhab- efferent nerve supply via the involved in the ejaculatory reflex. dosphincter atrophy. It may be to the bulbocav- Yang and Bradley (2000) that lack of use, benign prostatic ernosus and ischiocavernosus recorded three distinct somatic hyperplasia, or surgical interven- muscles was untouched during bulbocavernosus reflexes. Bulbo- tion may cause a level of atrophy radical prostatectomy. A possible cavernosus muscle contraction of the bulbocavernosus muscle. It reason may be due to damage to was elicited after stimulating the would be interesting to investi- the sensory innervation of the dorsal nerve at the glans and gate the integrity of the bulbocav- external urethral sphincter. Re- anterior urethra by flexor ernosus muscle with these new cent investigations have shown a responses of the bulbocaver- imaging techniques. Voluntary decrease in sensitivity in the nosus reflex. Bulbocavernosus muscle strengthening may not membranous urethra after pelvic muscle contraction can also be only serve to strengthen the bul- surgery (Hugonnet, Donuser, induced on stimulating the per- bocavernosus muscle, but corti- Springer, & Struder, 1999). This ineal nerve, which is the path- cal control may have an influ- would indicate the importance of way through which stretch and ence on the autonomic system. It sensory as well as motor innerva- tendon organ reflexes are carried is not known if these reflexes can tion to maintain continence to mediate muscle tone. The bul- be regained. (Wille et al., 2000). However, bocavernosus reflex therefore Pelvic floor muscle strength Wille et al. (2000) examined men depends on sensory afferents associated with ED and aging. following radical prostatectomy, from the dorsal and perineal Colpi et al. (1999) demonstrated when motor nerve damage is , the conus medullaris, that the pelvic floor muscle activ- known to occur either from surgical and motor efferents via the per- ity was significantly higher in trauma or postoperative swelling ineal nerve. Since the motor potent than in impotent men (neuropraxia). Neuropraxia to the innervation of the bulbocaver- (p=0.0007). In addition, in older pudendal nerve would lead to tem- nosus muscle for all reflexes is impotent men, the perineal floor porary paralysis of the bulbocaver- carried through a branch of the efficiency was negatively corre- nosus muscle. Another possibility perineal nerve, these findings lated to age (r=-0.21, p=0.002). is postsurgical pain, which could may be relevant to the evaluation The authors reported that these render this muscle inactive or inef- of ejaculatory disorders and post- results supported the idea that fective. Wille et al. (2000) also sug- micturition dribble. pelvic floor inefficiency may be gested that benign prostatic There may be an analogy related to ED, and that the rein- hyperplasia may be responsible between the loss of the rhab- forcement of the striated muscles for a reduced or absent postvoid dosphincter reflex and the loss of of the penis achieved through milking reflex. urethrocavernosus and bulbocav- physiotherapy, directly or indi- Urethral distension associat- ernosus reflexes. The rhab- rectly, may improve penile erec- ed with bulbocavernosus muscle dosphincter tightens by reflex tion. activity. Shafik and El-Sibai action to prevent urine loss dur- Association between ED and (2000) found that distension of ing increases in intra-abdominal PMD. Frankel et al. (1998) found the bulbous urethra caused pressure. This function can be that in 12 countries, men aged 40 increased EMG activity of the bul- relearned by using “the knack” of years and over showed a signifi- bocavernosus muscle. They con- voluntary tightening the pelvic cant association between PMD cluded that this bulbocavernosus floor muscles during activities and ED (odds ratio 1.68, contraction was probably mediat- that raise intra-abdominal pres- p<0.001). Similarly, Macfarlane

50 UROLOGIC NURSING / February 2003 / Volume 23 Number 1 et al. (1996) studied men between 50 and 80 years of age, To treat men holistically, nurses must investigate the and found the odds ratio of an association between PMD and embarrassing problem of postmicturition dribble when sexual dysfunction was 1.72 for assessing men with ED. moderate dribbling, and 2.20 for frequent dribbling. Pelvic floor muscle exercises for ED. In a review of the litera- with the subjects imitating coital ing men with ED. Equally, men ture of the treatment for ED thrusts. They concluded that the presenting with postmicturition (Dorey, 2000 a, b, &c), seven non- affects of aging might reduce vol- dribble should be asked about randomized or noncontrolled tri- untary contractile capacity. The any difficulties gaining and als advocated pelvic floor muscle tendency to a more sedentary maintaining an erection and exercises (Claes & Baert, 1993; lifestyle and to systemic patholo- about any problems with ejacula- Claes et al., 1995; Claes et al., gies, such as diabetes, hepatopa- tion. 1996; Colpi et al., 1994; Colpi et thy, arteriosclerosis, and neu- Pelvic floor muscle exercises al., 1999; Mamberti-Dias & ropathies may cause decreases in may help to improve each of Bonierbale-Branchereau, 1991; muscle mass. Pelvic floor exer- these conditions. Randomized Van Kampen et al., 1998). cises could be used to prevent or controlled trials with a good sam- In three trials, men were reverse muscle weakness caused ple size are needed to address the encouraged to perform specific by disuse, and may prolong the effect of pelvic floor muscle exer- ischiocavernosus and bulbocav- onset of some pathology. cises on erectile dysfunction, ernosus muscle exercises, as If the activity of the ischio- ejaculatory dysfunction, and opposed to just pelvic floor mus- cavernosus muscles increases postmicturition dribble. The out- cle exercises (Claes & Baert 1993; penile rigidity, then weak muscu- comes of these studies may prove Claes et al., 1995; Van Kampen et lature would produce a decrease or disprove an association al., 1998). In another three stud- in penile rigidity and ED. This between these conditions, due to ies men performed these exercis- links with the work of Colpi et al. weakness of the bulbocavernosus es with an erect penis, showing (1999) who demonstrated that muscle and surrounding pelvic the need for exercising the spe- pelvic floor muscle efficiency floor musculature. • cific muscles concerned with was decreased with aging and penile rigidity (Colpi et al., 1999; with patients suffering from ED References Lavoisier et al., 1986; Wespes, Albaugh, J., & Lewis, J.H. (1999). Insights Conclusion and into the management of erectile dys- Nogueira, Herbaut, Caufriez, & function: Part I. Urologic Nursing, Schulman, 1990). Lavoisier et al. Nursing Implications 19(4), 241-247. (1986) showed that patients with Bulbocavernosus and ischio- Aytac, I.A., McKinlay, J.B., & Krane, R.J. ED, but without venous occlu- cavernosus muscle dysfunction (1999). The likely worldwide in- may contribute to the inability to crease in erectile dysfunction sive dysfunction, gained in- between 1995 and 2025 and some creased intracavernous pressure produce an increase in intracav- possible policy consequences. British when asked to perform maximal ernous pressure and be a cause of Journal of Urology International, 84, voluntary contractions of ischio- erectile dysfunction. They may 50-56. cavernosus muscle with an artifi- also be responsible for a loss of Ballard, D.J. (1997). Treatment of erectile dysfunction: Can pelvic muscle cially induced erection. They the postvoid milking reflex and a exercises improve sexual function? stated that this increase in pres- cause of postmicturition dribble. Journal of Wound Ostomy and sure would not have occurred if Bulbocavernosus muscle dys- Continence Nurses, 24, 255-264. the cavernosal cavities were not function may result in a loss of Barry, M.J., Fowler, F.J., O’Leary, M.P., rhythmic contractions and a loss Bruskewitz, R.C., Holtgrewe, H.L., completely engorged. This Mebust, W.K., & Cockett, A.T. (1992). research would indicate that men of ejaculation force. Bulbo- The American Urological should be advised to use these cavernosus muscle dysfunction Association symptom index for muscles during coitus. During may, therefore, provide the asso- benign prostatic hyperplasia. the thrust phase of coitus, the ciation between erectile dysfunc- Journal of Urology, 148, 1549-1557. Blaivas, J.G., Appell, R.A., Fanti, J.A., pelvic floor muscles and trans- tion, ejaculatory dysfunction, Leach, G., McGuire, E.J., Resnick, versus abdominis work synergi- and postmicturition dribble. N.M., Raz, S., & Wein, A.J. (1997). cally, aided by the larger and Before this statement can be said Definition and classification of urinary stronger gluteus maximus mus- with certainty, research studies incontinence: Recommendations of the designed to specifically address Urodynamic Society. Neurourology cle. This would pose a need for and Urodynamics, 16, 149-151. optimum muscular strength and the relationship must be com- Chang, P.L., Tsai, L.H., Huang, S.T., Wang, endurance and a good level of pleted. T.M., Hsieh, M.L., & Tsui, K.H. cardiovascular fitness. Colpi et To treat men holistically, (1998). The early effect of pelvic al. (1999) monitored the strength nurses must investigate the floor muscle exercise after transurethral prostatectomy. Journal of the pelvic floor muscles with embarrassing problem of post- of Urology, 160(2), 402-405. EMG in right side-lying position micturition dribble when assess-

UROLOGIC NURSING / February 2003 / Volume 23 Number 1 51 Claes, H., & Baert, L. (1993). Pelvic floor sensitivity in the membranous ure- Oxford: Isis Medical Media. exercise versus surgery in the treat- thra after orthotopic ileal bladder National Institutes of Health Consensus ment of Impotence. British Journal substitute. Journal of Urology, Development Panel on Impotence. of Urology, 71, 52-57. 161(2), 418-421. (1993). Impotence. Journal of the Claes, H., Van Kampen, M., Lysens, R., & Koskimäki, J., Makama, M., Huhtala, H., American Medical Association, 270, Baert, L. (1995). Pelvic floor exercis- & Tammela, T.L.J. (1998). Prevalence 83-90. es in the treatment of impotence. of lower urinary tract symptoms in Paterson, J., Pinnock, C.B., & Marshall, European Journal of Physical Finnish men: A population-based V.R. (1997). Pelvic floor exercises as Medicine Rehabilitation, 5, 135-140. study. British Journal of Urology, 81, a treatment for post-micturition Claes, H.I.M., Vandenbroucke, H.B., & 364-369. dribble. British Journal of Urology, 7, Baert, L.V. (1996). Pelvic floor exer- Lavoisier, P., Courtois, F., Barres, D., & 892-897. cise in the treatment of impotence. Blanchard, M. (1986). Correlation Pomfret, I. (1993, March). Male inconti- The Journal of Urology, 157(4 between intracavernous pressure nence. Community Outlook, 45. Suppl.), 786. and contraction of the ischiocaver- Porru, D., Campus, G., Caria, A., Colpi, G.M., Negri, L., Scroppo, F.I., & nosus muscle in man. Journal of Madeddu, G., Cucchi, A., Rovereto, Grugnetti, C. (1994). Perineal floor Urology, 136, 936-939. B., Scarpa, R.M., Pili, P., & Usai, E. rehabilitation: A new treatment for Lavoisier, P., Proulz, J., Courtois, F., De (2001). Impact of early pelvic floor venogenic impotence. Journal of Carufel, F., & Durand, L. (1988). rehabilitation after transurethral Endocrinology Investigation, 17, 34. Relationship between perineal mus- resection of the prostate. Colpi, G.M., Negri, L., Nappi, R.E., & cle contractions, penile tumescence, Neurourology and Urodynamics, 20, Chinea, B. (1999). Perineal floor effi- and penile rigidity during nocturnal 53-59. ciency in sexually potent and impo- erections. Journal of Urology, 139, Shafik, A., & El-Sibai, O. (2000). tent men. International Journal of 176-179. Mechanism of ejection during ejacu- Impotence Research, 11(3), 153-157. Lewis, R.W., & Mills, T.M. (1999). Risk lation: Identification of a urethrocav- Donovan, J.L., Abrams, P., & Peters, T.J. factors for impotence. In C.C. ernosus reflex. Archives of (1996). The ICS-“BPH” Study: The Carson, R.S. Kirby, & I. Goldstein Andrology, 44(1), 77-83. psychometric validity and reliability (Eds.), Textbook of erectile dysfunc- Shah, P.J.R. (1994). The assessment of of the ICS male questionnaire. tion. (pp. 141-148). Oxford: Isis patients with a view to urodynam- British Journal of Urology, 77, 554- Medical Media. ics. In A.R. Mundy, T.P. Stephenson, 562. Macfarlane, G.J., Botto, H., Sagnier, P., & A.J. Wein (Eds.), Urodynamics: Dorey, G. (2000a). Conservative treatment of Teillac, P., Richard, F., & Boyle, P. Principles, practice and application erectile dysfunction 1: Anatomy/phys- (1996). The relationship between (pp. 59). New York: Churchill iology. British Journal of Nursing, sexual life and urinary condition in Livingstone. 9(11), 691-694. the French community. Journal of Strasser, H., Klauser, A., Helweg, G., Dorey, G. (2000b). Conservative treatment Clinical Epidemiology, 49(10), 1171- Frauscher, F., Pallwein, G., & of erectile dysfunction 2: Clinical tri- 1176. Bartsch, G. (2001). Three-dimen- als. British Journal of Nursing, 9(12), Malmsten, U.G.H., Milsom, I., Molander, sional transrectal ultrasound of the 755-762. U., & Norlen, L.J. (1997). Urinary male urethral rhabdosphincter. Dorey, G. (2000c). Conservative treatment incontinence and lower urinary tract Poster presented at the 2nd of erectile dysfunction 3: Literature symptoms: An epidemiological International Consultation on review British Journal of Nursing, study of men aged 45 to 99 years. Incontinence, Paris. 9(13), 859-863. Journal of Urology, 158, 1733-1737. Van Kampen, M., De Weerdt, W., Claes, Dorey, G. (2001a). Prevalence, aetiology, Mamberti-Dias, A., & Bonierbale- H., Feys, H., De Maeyer, M., Van and treatment of post-micturion Branchereau, M. (1991). Therapy for Poppel, H., & Baert, L. (1998). dribble in men: A literature review. dysfunctioning erections: Four years Contribution of the pelvic floor mus- Physiotherapy, 88(4), 219-228. later, how do things stand? cles exercises in the treatment of Dorey, G. (2001b). Conservative treatment Sexologique, 1, 24-25. impotence. Doctoral thesis, of male incontinence and erectile Mamberti-Dias, A., Vasavada, S.P., & Katholieke Universiteit Leuven, dysfunction. London: Whurr Bourcier, A.P. (1999). Pelvic floor Belgium. Publishers, Ltd. dysfunction; Investigations and con- Wespes, E., Nogueira, M.C., Herbaut, Feldman, H.A., Goldstein, I., Hatzichristou, servative treatment. Casa Editrice A.G., Caufriez, M., & Schulman, C.C. D.G., Krane, R.J., McKinlay, J.B. Scientifica Internationale, 303-310. (1990). Role of the bulbocavernosus (1994). Impotence and its medical Millard, R.J. (Ed.) (1989). After-dribble. In muscles on the mechanism of and psychological correlates: Results Bladder control: A simple self-help human erection. European Urology of the Massachusetts Male Ageing guide (pp. 89-90). NSW, Australia: 18, 45-48. Study. Journal of Urology, 151, 54-61. William and Wilkins and Associates Wille, S., Mills, R.D., & Studer, U.E. Feneley, R.C.L. (1986). Post micturition Pty, Ltd. (2000). Absence of urethral post- dribbling. In D. Mandelstam (Ed.,) Miller, J., Aston-Miller, J.A., & DeLancey, void milking: An additional cause Incontinence and its management. J.O.L. (1996). The knack: Use of pre- for incontinence after radical prosta- London: Croom Helm. cisely-timed pelvic muscle contrac- tectomy? European Urology, 37, 665- Frankel, S.J., Donovan, J.L., Peters, T.I., tion can reduce leakage in stress uri- 669. Abrams, P., Dabhoiwala, N.F., nary incontinence. Proceedings of Yang, C.C., & Bradley, W.E. (1999). Osawa, D., & Tong Long Lin, A. the International Continence Somatic innervation of the human (1998). Sexual dysfunction in men Society, Greece, 15(4), 392. bulbocavernosus muscle. Clinical with lower urinary tract symptoms. Moncada Iribarren, I., & Sáenz de Tejada, Neurophysiology, 110(3), 412-418. Journal of Clinical Epidemiology, I. (1999). Vascular physiology of Yang, C.C., & Bradley, W.E. (2000). Reflex 51(8), 677-685. penile erection. In C.C. Carson, R.S. innervation of the bulbocavernosus Hugonnet, C.L., Donuser, H., Springer, Kirby, & I. Goldstein (Eds.), Textbook muscle. British Journal of Urology J.P., & Struder, V.E. (1999). Decreased of erectile dysfunction (pp. 141-148). International, 85(7), 857-865.

52 UROLOGIC NURSING / February 2003 / Volume 23 Number 1