The prevalence of incontinence in males is estimated to be between 3 to 11 percent. In that patient population, 40 to 80 percent complain of a strong urge to urinate and inability to contain their urine on the way to the restroom. Surprisingly, stress incontinence accounts for less than 10% of cases and is seen most commonly after prostate surgery, trauma and neurological injury. Incontinence in men increases with age, but severe incontinence in 70- to 80-year-old men is about half of that in women.
Men are reluctant to share these problems with their partners and even less with their doctors. They will spend their days scheduling around their bathroom breaks, sometimes voiding every hour during the day and waking several times per night. If left untreated, the problem can eventually contribute to erectile dysfunction and constipation. Physical Therapists, Chiropractors and Athletic Trainers treating male patients are not asking about bladder issues and males are not offering to discuss their problems due to embarrassment and a lack of knowledge of what is available for treatment.
So, the take home message here is that if you treat male patients in a clinic, training room or sideline, you can help them with incontinence, urinary frequency and urgency by being informed or just knowing where to refer them!
Addressing Pelvic Floor Function
Did you know that incontinence, urinary frequency, urgency and even erectile function can be effectively managed and even cured by addressing pelvic floor function? The pelvic floor is responsible for the following:
- Supporting the contents within the abdominal cavity
- Works with the diaphragm for maintaining intra-abdominal pressure during breathing
- Enhancing the local circulation
- Assists to maintain good posture.
- Maintains urinary and fecal continence.
- Gains and maintains penile erection
- Pumps the ejaculate and urine out of urethra.
The pelvic floor muscles are just like every other muscle in our body just in a taboo area that we are not used to talking about. So let’s get acquainted with it!
A healthy pelvic floor is comprised of 70% slow-twitch type 1 fibers (fatigue-resistant fibers that maintain static tone) and 30% are fast-twitch type 2 (fatigue-prone fibers that are capable of active contraction). With increased age, decreased activity and nerve de-innervation, the proportion of fast-twitch and slow-twitch fibers can change causing performance failure. Proper exercise prescription can enhance pelvic floor muscle strength, tone, endurance, and responsiveness, since muscles increase in strength in direct proportion to the demands placed upon them.
To facilitate the discussion, when you think of a specific pathology consider whether the pelvic floor is weak and possibly tight, or strong and fast but lacks endurance. We know from an orthopedic perspective that muscles will develop a compensatory tension or restriction when strength has been compromised and it needs to compensate. The same is true for the pelvic floor. When exercise is prescribed, we need to consider what the patient cannot do to figure out how to fix it! Does the activity require a sustained hold or does it need to react quickly as with a sneeze or cough or with an explosive movement from an athlete?
Typically, in a patient that has stress incontinence, the pelvic floor needs to react quickly and with a considerable force to close the urethra to support a quick movement, sneeze, laugh, or cough. The inability to close in under a second or provide the required force will result in urine loss.
In a patient that senses the urge to urinate after drinking a small glass of water, their muscles may present with a low resting tone that is unable support the bladder and its contents. The decreased support of the pelvic floor will stimulate the stretch receptors in the bladder resulting a sensation to void and warrant a visit to the restroom. If the muscles cannot maintain a static contraction on the way to the bathroom then urine will leak out before it was intended to.
Kegel Exercises
Everyone has heard of Kegel contractions but not many people know that there are different ways to describe and prescribe them! If you find the words urethra and pelvic floor in a comfortable part of your vocabulary then keep reading this article. If not then find a Pelvic Health Physical Therapist in your area to refer to!
When describing a Kegel the proper terminology to use is pretend like you want to stop your urine stream and you will see and feel a small lift of the penis. This is certainly where men have an advantage! The visual biofeedback of seeing a penile lift is assurance that the exercise is being done correctly and that a contraction is being maintained according to the patient’s intention. Once they figure out where their muscles are and can turn them on and off then there is now a program that can be designed to get the desired outcome.
If the patient has leakage with sneezing, coughing, exercise and quick movements, then we are going to give exercises that promote speed and strength. As an added bonus these same exercises will help with erectile dysfunction. Kegel exercises should be performed as a quick contraction 10 times and up to 3-5 times per day. Please stress boundaries to your patients. For you male readers you know what I am talking about. More is not better in this circumstance! More can actually have a negative effect of urinary retention which is a problem for which they will have to end up see a pelvic specialist. Have them start lying down and work their way to sitting and then a standing position. Symptoms should gradually get better with a 4 to 6 week compliance.
If the patient has leakage with a partially full bladder or just has to go to the bathroom frequently with or without urgency, have them perform the same Kegel exercise but instead of contracting the pelvic floor and immediately releasing, have them contract their pelvic floor and hold for 5 seconds and release for 10 seconds. Usually after 5 contractions the pelvic floor muscles will show signs of fatigue on the surface electromyography readings that we use clinically. Have them work up to a 10 second hold starting in a supine position and progressing to standing. This protocol also requires a 4 to 6 week compliance.
Play Your Part with this Patient Population
Please remember with any rehabilitation there is not a one size fits all answer to any problem. There can be comorbidities with any diagnosis and as always following up with a physician to rule out infections or other underlying pathologies is a must in this arena. If you are a clinician looking to expand your horizons with this amazing patient population, Performance Health has been instrumental to my practice having all the tools I need to not only get started but in continuing to grow our Pelvic Health program. Electromyography both hand held and software based systems through Prometheus have increased the efficacy of pelvic health rehabilitation and have demonstrated continued improvement and consistent patient compliance.
Bottom Line – Men do not have live with these issues and the bladder should not run anyone’s life. We have the ability to deal with these issues, and medications should never be the first treatment option. A little exercise has never hurt anyone, right?
About the Author
Tonya Bunner, PT, DPT, WCS, OCS, BCB-PMD
Co-Founder & Women’s Health Residency Director
BODYCENTRAL Physical Therapy
Dr. Tonya Bunner is a physical therapist with over 18 years of experience treating men, women, and children with spine and pelvic health diagnoses. She co-owns a private practice, BODYCENTRAL Physical Therapy, in Tucson, Arizona with eight locations currently. She is a dual Board Certified Clinical Specialist in Women’s Health Physical Therapy and Orthopedic Physical Therapy. Dr. Bunner is also Board Certified in Biofeedback and Electromyography in Pelvic muscle dysfunction. Dr. Bunner is the Women’s Health Residency Director for the BODYCENTRAL Women’s Health Residency and is passionate about the pelvic health of all her patients and the education of aspiring clinicians.
Resources:
Nitti, V. W. (2001). The Prevalence of Urinary Incontinence. Reviews in Urology, 3(Suppl 1), S2–S6.
Berghmans, B., Nieman, F., Leue, C., Weemhoff, M., Breukink, S., & Koeveringe, G. van. (2016). Prevalence and triage of first contact pelvic floor dysfunction complaints in male patients referred to a Pelvic Care Centre. Neurourology and Urodynamics, 35(4), 487–491. https://doi.org/10.1002/nau.22733
Siegel, A. Urology, 2014-07-01, Volume 84, Issue 1, Pages 1-7
Miller J.M., Perucchini D., Carchidi L.T., et al: Pelvic floor muscle contraction during a cough and decreased vesical neck mobility. Obstet Gynecol 2001; 97: pp. 255-260
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