Grace Dorey describes the symptom, prevalence and aetiology of post-micturition dribble in men and explores the literature in order to give guidance on assessment and treatment options.
AUTHOR Grace Dorey, PhD, FCSP, is professor of physiotherapy, University of the West of England, Bristol; consultant physiotherapist, Somerset Nuffield Hospital, Taunton and North Devon District NHST Hospital, Barnstaple.
ABSTRACT Dorey, G. (2008) Post-micturition dribble: aetiology and treatment. Nursing Times; 104: 25, 46-47.
Post-micturition dribble (PMD) is the term used for the symptom when men experience an involuntary loss of urine immediately after they finish passing urine, usually after leaving the toilet (Abrams et al, 2002). It is neither stress dependent (due to exertion) nor due to bladder dysfunction (Wille et al, 2000) and should be distinguished from terminal dribble, which occurs at the end of micturition (Shah, 1994). The condition can be a nuisance and cause embarrassment.
Although PMD is a common problem in all ages including young men (Furuya et al, 1997), Paterson et al (1997) found that it can be particularly troublesome in older men. Its prevalence is reported to range from 11.5% to 63% for men aged 20-70 (Koskim䫩 et al, 1998; Furuya et al, 1997).
Post-micturition dribble is caused by a failure of the bulbocavernosus muscle (which circles the bulbar urethra) to contract by reflex action after micturition and to evacuate urine from this portion of the urethra (Feneley, 1986) (Fig 1). This reflex is known as the urethrocavernosus reflex (Shafik and El-Sibai, 2000). Its failure may occur as a result of surgery, neurological conditions or weak pelvic floor muscles. Urine remaining in the bulbar portion of the urethra will then dribble out on movement.
Rarer organic causes from congenital abnormalities and strictures have also been reported, and these require treatment with surgery (Bullock, 2002).
Wille et al (2000) used cystourethrography to identify reflex activity of the bulbocavernosus muscle after voiding. They identified that a normal urethrocavernosus reflex was absent in the early post-operative period after radical prostatectomy in men who reported PMD.
These authors described an antegrade wave from the external urinary sphincter through the urethra at the end of voiding that cleared the urethra of urine in 63% of pre-operative voiding cystourethrograms. The decrease in rate of urine clearance and increase in the rate of PMD from before to after surgery was statistically significant.
Wille et al (2000) also suggested that benign prostatic hyperplasia may be responsible for a reduced or absent post-void reflex.
Investigations have also shown a decrease in sensitivity in the membranous urethra after pelvic surgery (Hugonnet et al, 1999), which may lead to PMD.
The treatment options for PMD vary and depend on the aetiology of the condition.
Surgery is usually indicated for organic problems such as strictures and congenital diverticuli, while pelvic floor muscle exercises have been found to be significantly effective for problems of a functional nature (Dorey et al, 2004; Paterson
et al, 1997).
Before commencing treatment a full patient assessment, including a digital anal examination
to assess the pelvic floor muscles, should be undertaken. This should be conducted by an experienced healthcare professional.
Pelvic floor exercise regimen
Three trials have aimed to compare the effect of pelvic floor exercises with a control group in men with PMD.
In a non-randomised controlled trial, Chang et al (1998) evaluated the effect of pelvic floor muscle exercises on PMD following transurethral resection of the prostate. After four weeks, there was a statistical significant difference in the increased strength of pelvic floor muscle contractions and a reduction in symptoms in men with PMD compared with the control group.
Paterson et al (1997) conducted a single-blind randomised controlled trial comparing pelvic floor muscle exercises with bulbar urethral massage. This massage, sometimes called urethral milking, is a self-help technique for patients suffering from PMD.
The patient is taught, after urinating, to place his fingers behind the scrotum and gently massage the bulbar urethra in a forwards and upwards direction in order to ‘milk’ the remaining urine from the urethra.
They found that men who practised pelvic floor exercises were almost twice as likely to have reduced urine loss than the urethral milking group and both these interventions were more effective than counselling alone.
Dorey et al (2004) found pelvic floor exercises that included a post-voiding strong pelvic floor contraction were significantly effective in curing PMD in men with erectile dysfunction.
A suggested treatment programme for men with PMD is shown in Box 1. Men with PMD are taught to tighten their pelvic floor muscles strongly after they have completed micturition (Dorey, 2004). This skill may help to evacuate urine from the bulbar urethra and may develop or replace the urethrocavernosus reflex.
In order to achieve full fitness, maximal muscle work should be practised for muscle hypertrophy, together with submaximal contractions for endurance. Men can rehabilitate their pelvic floor muscles for endurance by tightening and lifting their pelvic floor up slightly while walking.
Post-micturition dribble is a common and distressing condition that affects men of all ages. Its overall prevalence remains unknown.
Surgery may be indicated for organic problems, while pelvic floor muscle exercises have been found to be significantly effective for functional problems. Pelvic floor muscle exercises, including a strong post-void muscle contraction, have been shown to be an effective treatment for PMD in men and are superior to bulbar massage.
BOX 1. Pelvic floor muscle exercises for men (Dorey, 2006)
1. In a standing position
Stand with your feet apart and tighten your pelvic floor muscles as if you were trying to avoid breaking wind. If you look in a mirror, you should see the base of your penis move nearer to your abdomen and your testicles rise. Hold the contraction as strongly as you can without holding your breath or tensing your buttocks.
2. In a sitting position
Sit on a chair with your knees apart and tighten your pelvic floor muscles as if you were trying to avoid breaking wind. Hold the contraction as strongly as you can without holding your breath or tensing your buttocks.
3. In a lying position
Lie on your back with your knees bent and your knees apart. Tighten your pelvic floor muscles as if you were trying to avoid breaking wind and hold the contraction as strongly as you can without holding your breath or tensing your buttocks.
4. While walking
Lift your pelvic floor up slightly when walking.
5. After urinating
After you have emptied your bladder, tighten your pelvic floor muscles up strongly to avoid the embarrassing after-dribble.
Abrams, P. et al (2002) The standardisation of terminology of lower urinary tract function: report from the standardisation
sub-committee of the International Continence Society. Neurourology and Urodynamics; 21: 2, 167-178.
Bullock, N. (2002) Letter to the editor: initial investigation of choice should be urethral ultrasound. Urology News; 6: 5, 15.
Chang, P.L. et al (1998) The early effect of pelvic floor muscle exercise after transurethral prostatectomy. Journal of Urology; 160: 2, 402-405.
Dorey, G. (2006) Pelvic Dysfunction In Men: Diagnosis and Treatment of Male Incontinence and Erectile Dysfunction. Chichester: Wiley.
Dorey, G. et al (2004) Randomised controlled trial of pelvic floor muscle exercises and manometric biofeedback for post-micturition dribble. Urologic Nursing; 24: 6, 490-512.
Feneley, R.C.L. (1986) Post micturition dribbling. In: Mandelstam, D. (ed). Incontinence and its Management. London: Croom Helm.
Furuya, S. et al (1997) Incidence of postmicturition dribble in adult males in their twenties through fifties. Acta Urologica Japonica; 43: 6, 407-410 (English abstract).
Hugonnet, C.L. et al (1999) Decreased sensitivity in the membranous urethra after orthotopic ileal bladder substitute. Journal of Urology; 161: 2, 418-421.
Koskim䫩, J. et al (1998) Prevalence of lower urinary tract symptoms in Finnish men: a population-based study. British Journal of Urology; 81: 3, 364-369.
Paterson, J. et al (1997) Pelvic floor exercises as a treatment for post-micturition dribble. British Journal of Urology; 79: 6, 892-897.
Shafik, A., El-Sibai, O. (2000) Mechanism of ejection during ejaculation: identification of a urethrocavernosus reflex. Archives of Andrology; 44: 1, 77-83.
Shah, P.J.R. (1994) The assessment of patients with a view to urodynamics. In: Mundy, A.R. et al. (eds). Urodynamics, Principles, Practice and Application. Edinburgh: Churchill Livingstone.
Wille, S. et al (2000) Absence of urethral post-void milking: an additional cause for incontinence after radical prostatectomy? European Urology; 37: 6, 665-669.