VOL: 99, ISSUE: 29, PAGE NO: 56
Ian J. Pomfret, RGN, NDNCert, PWT, is district continence adviser, Continence Advisory Service, Chorley and South Ribble Primary Care Trust, Lancashire
Post-micturition dribble (PMD) is a small, usually passive leakage of urine, following voiding. It may occur in women but is more common in men.
Men of any age can have PMD which may result from pooling of urine in the bulbar urethra following micturition (Fig 1) (Winder, 1996). Feneley (1986) suggests the problem results from failure of the bulbospongiosum muscle (which assists in emptying the bladder at the end of voiding) to evacuate the bulbar urethra, although the reason is not clear.
Post-micturition dribble is rare in women, but may be due to urine being trapped in a urethral diverticulum (a pouch-like herniation in the urethral wall). Also, urine can occasionally pool in the vagina during micturition and dribble out following voiding (Feneley, 1986). This can be a problem for some women with learning and/or physical disabilities who are unable to sit upright on a toilet, or those with deformities of the genitalia.
Male continence problems
While women are twice as likely as men to suffer from urinary incontinence (RCPL, 1995), many men suffer from PMD. Although men are often reluctant to seek help (Denning, 1986), more products are available on the drug tariff for managing male continence problems than for female.
Symptoms of PMD
Men with PMD can usually pass urine normally. However, despite shaking the penis to evacuate residual urine, leakage of urine retained in the bulbar urethra may occur for several minutes.
Usually no other signs of urinary dysfunction are present, although some patients have symptoms such as urgency, frequency, hesitancy and straining. Older men may experience PMD following a prostatectomy, and may have associated urinary symptoms.
Health professionals often view PMD as an inconvenience or nuisance to patients rather than a symptom of an underlying urinary problem that may require further investigation. Men with PMD should be assessed to determine the need for further investigations to exclude obstruction or incomplete bladder emptying. This is particularly important if there are symptoms of urine obstruction, such as hesitancy or straining to void. A simple bladder ultrasound can be used to exclude a post-micturition residual volume of urine in the bladder.
Bulbar urethral massage
The patient can be taught bulbar urethral massage, also known as bulbar urethral elevation or urethral milking. The patient is taught to place his fingers behind his scrotum after voiding and to gently massage his bulbar urethra in a forwards and upwards direction. This ‘milks’ the urine retained in the bulbar urethra out of the urethra. Teaching the patient to tighten his pelvic floor muscles prior to undertaking bulbar urethral massage may help to prevent further leakage (Dorey, 2000).
The patient should practise the procedure, which can be performed discreetly through clothing when in public lavatories. It is important to allow time to completely empty the urethra. Some men prefer to sit on the toilet, rather than stand.
A diagram of the relevant anatomy is useful when teaching bulbar urethral massage, to show the patient where to place his fingers and the direction in which to massage (Fig 1). At Chorley and South Ribble Primary Care Trust, this information has been incorporated into a leaflet which also covers pelvic floor exercises, as these are often taught at the same time as bulbar urethral massage.
If bulbar urethral massage is not successful a wide range of incontinence aids is available to help manage PMD. However, although these products are valuable in the management of PMD because they absorb or collect the urine, they do not address the underlying problem.
These are designed to absorb, contain, conceal and manage urine leakage and promote the dignity and confidence of the user. Those suitable for patients with PMD are small, discreet, low-capacity aids that are worn on the body, for example dribble appliances. They are available as disposable and reusable (washable) products.
Disposable absorbent aids can be purchased from chemists, supermarkets and by mail order. There may be problems with storage and disposal of these aids, especially as there are no sanitary disposal bins in male toilets. Also, even if the pad is not wet, it will deteriorate with wear and require regular changing.
Reusable aids are more expensive to buy but may be more economical in the long term. It is important to advise patients on the most appropriate reusable product to avoid expensive mistakes.
Modern reusable aids are available in a wide range of styles, with Y-front briefs for men and attractive briefs for women in a range of colours. Many of these types of aids are indistinguishable from normal underwear. However, it is acknowledged that many men do not like using absorbent aids, as they often associate them with nappies and worry that they are noticeable through clothing.
Urine collection aids
These collect and contain urine. External aids - for example, urinary sheaths, pubic pressure urinals or flanges, and dribble appliances - are available for men with PMD.
A major advantage of these aids is that they collect and store urine away from the body, unlike absorbent aids, which store it next to the patient’s skin.
Collection aids, especially urinary sheaths, are similar to condoms and have a masculine image, which may be more attractive to some men.
These work by occluding the urethra and restoring the storage function of the patient’s bladder. External occlusive aids for men apply pressure on the penis. An example is the Cunningham Clamp, which can be prescribed by a consultant. The clamp is placed over the penis and applies pressure directly on the anterior urethra, mechanically preventing PMD.
Occlusion aids are not used as widely as absorbent and collection aids, but are a useful alternative method of management for some patients. They should only be used following specialist medical or nursing advice.
It is important to remember that some patients may buy aids from abroad via the internet. Nurses should be aware that patients may be using devices not available in the UK.
Post-micturition dribble is a distressing condition that is more common in men than women. Nurses should be aware of the prevalence of this condition and the treatment and management methods available, as they are the health care professionals who are most likely to identify patients with PMD.