UNJ February 03

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 dysfunction dribble and loss of the postvoid milking reflex. Pelvic floor 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 arteries 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 perineum 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. fascia 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 Artery 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 resulting in ejaculation. Ischiocavernosus muscle. Subtunical space The ischiocavernosus muscle arises from the inner surface of Outflow the ischial tuberosity 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 nerve (S 2-4) Outflow Compressed Literature Search Strategy subtunical venule An extensive literature review of existing research findings was undertaken to determine if postmicturition dribble may be associated 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

Load more