Posts Tagged ‘urethra’

Stress Urinary Incontinence (SUI)—Gun and Bullet Analogy

November 18, 2017

Andrew Siegel MD   11/18/17

With all the violence and senseless shootings in the USA, I hate to even mention the words “guns” and “bullets,” but they do offer a convenient metaphor to better understand the concept of stress urinary incontinence

Stress urinary incontinence (SUI) is a spurt-like leakage of urine at the time of a sudden increase in abdominal pressure, such as occurs with sneezing, coughing, jumping, bending and exercising. It is particularly likely to occur when upright and active as opposed to when sitting or lying down, because of the effect of gravity and the particular anatomy of the bladder and urethra. It is common in women following vaginal childbirth, particularly after difficult and prolonged deliveries.  It also can occur in men, generally after prostate surgery for prostate cancer and sometimes after surgical procedures done for benign prostate enlargement. 7. SUIIllustration above by Ashley Halsey from The Kegel Fix

Although not a serious issue like heart disease, cancer, etc., SUI nonetheless can be debilitating, requiring the use of protective pads and often necessitating activity limitations and restrictions of fluid intake in an effort to help manage the problem. It  certainly can impair one’s quality of life.

The root cause of SUI is typically a combination of factors causing damage to the bladder neck and urethra or their support mechanisms.  In females, pelvic birth trauma as well as aging, weight gain, chronic straining and menopausal changes weaken the pelvic muscular and connective tissue support.  In males this can occur after radical prostatectomy, although fortunately with improved techniques and the robotic-assisted laparoscopic  approach, this happens much less frequently than it did in prior years.

An effective means of understanding SUI is to view a bladder x-ray (done in standing upright position) of a person without SUI and compare it to a woman or man with SUI.  The bladder x-ray is performed by instilling contrast into the urinary bladder via a small catheter inserted into the urethra.

A healthy bladder appears oval in shape because the bladder neck (situated at the junction of the bladder and urethra) is competent and closed at all times except when urinating, at which time it relaxes and opens to provide urine flow.  An x-ray of the bladder of a woman or man with SUI will appear oval except for the 6:00 position (the bladder neck) where a small triangle of contrast is present (representing contrast within the bladder neck).  This appears as a “funnel” or a “widow’s peak.” With coughing or straining, there is progressive funneling and leakage.

normal bladder

Above photo is normal oval shape of contrast-filled bladder of person without SUI

female sui relaxAbove photo is typical funneled shape of contrast-filled bladder of female with SUI

male suiAbove photo is typical funneled shape of contrast-filled bladder of male with SUI following a prostatectomy

female sui strainAbove photo shows progressive funneling and urinary leakage in female asked to cough, demonstrating SUI 


The presence of urine within the bladder neck region is analogous to a bullet loaded within the chamber of a gun.  Essentially the bladder is “loaded,” ready to fire at any time when there is a sudden increase in abdominal pressure, which creates a vector of force analogous to firing the gun.

What to do about SUI?

Conservative management options include pelvic floor muscle training to increase the strength and endurance of the muscles that contribute to bladder and urethra support and urinary sphincter control.  Surgical management includes sling procedures (tape-like material surgically implanted under the urethra) to provide sufficient support and compression.  Sling procedures are available to treat SUI in both women and men.  An alternative is urethral bulking agents, injections of materials to bulk up and help close the leaky urethra. On occasion, when the bladder neck is rendered incompetent  resulting in severe urinary incontinence, implantation of an artificial urinary sphincter may be required to cure or vastly improve the problem.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, Apple iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food


These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.




Shy Bladder Syndrome

January 16, 2016

Andrew Siegel MD   1/16/16

charlie pink leaves

The image above is of Charley Morgan, my Springer spaniel, who is standing in a bed of cherry blossoms.  She has the very opposite of shy bladder syndrome, urinating involuntarily whenever people visit!


The following are quotes from patients of mine who suffer with shy bladder syndrome, the difficulty or inability to urinate in a public venue or in the presence of others:

“ I can’t urinate in front of other people.”

 “No way could I ever use a urinal.”

 “No beer for me at the sports arena.”

 “I would die before I ever attempted to urinate into one of those trough urinals they have at some stadiums and gyms.”

 “I need a private stall when in a public restroom.”

In medical speak, the condition “shy bladder syndrome” is known as “paruresis,” although I prefer the term “bashful bladder.” There are an estimated 20 million or so Americans suffering with this social phobia in which even the thought of having to urinate in public causes great distress, making the physical act of urinating impossible. However, those with bashful bladder have no such issues when in a private venue. In its most extreme form, a person with this phobia can only urinate at home when no other family members are present.

This problem occurs in both women and men and often manifests itself in adolescent years. It is a classic example of the mind-body connection in action. Anxiety brought on by the thought of having to pee in public causes the release of adrenaline and other stress chemicals, which cause a host of general effects such as  rapid pulse, shallow breathing, but also specific effects including the clenching of the muscles in the urethra (and male prostate gland). The inability to relax these sphincter muscles make the act of urinating difficult, if not impossible. It is little different than stage fright or the inability to speak in a public setting.

There are a variety of coping measures that people with shy bladder syndrome use, including restricting fluid and caffeine intake, deliberately holding in their urine and avoiding travel and other circumstances that would require the use of public restrooms.

Solutions to Bashful Bladder

The seemingly simple act of urination is actually a very complex event. Effective urination requires a contraction of the bladder muscle with coordinated relaxation of the sphincter muscles that pinch the urethra closed.  In order to improve bashful bladder, efforts need to be directed at general relaxation/anxiety management as well as at relaxing the urethra and sphincter muscles.

  • Relaxation techniques include deep breathing with exhalation to maximally relax the voluntary sphincter when in a public restroom; other methods include meditation and any of the many means of achieving a relaxed state including yoga, massage, tai chi, aromatherapy, hypnosis, etc.
  • Pelvic floor physical therapy to help relax tense pelvic muscles that can contribute to the problem, since they contribute in a major way to the voluntary sphincter muscle.
  • Cognitive behavioral therapy, which aims to retrain the mind to replace dysfunctional thoughts, perceptions and behavior with more realistic or helpful ones in order to modify fear of emptying one’s bladder in public.
  • Medications: Alpha blockers, “anti-adrenaline” agents used to relax the muscles of the urethra and prostate (Flomax, Rapaflo, Uroxatral, etc.);  Anti-anxiety medications can be helpful as well at times.

Bottom Line: Bashful bladder is a not uncommon social phobia that can severely impact one’s quality of life.  The good news is that this is a manageable problem.  For more information visit

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.

Uterine Fibroids And The Bladder

January 9, 2016

Andrew Siegel MD   1/9/16



Fibroids are muscular growths that develop within the womb that can put direct pressure on the next door neighbor of the uterus–the urinary bladder.  This compression can give rise to a host of annoying urinary symptoms including urinary urgency, frequency, urinary leakage and difficulty urinating.  

Although fibroids usually grow within the uterine wall, at times they do so internally into the uterine cavity or, alternatively, externally on the outside of the uterus. They are virtually always benign and much of the time they do not cause symptoms. When symptomatic they may cause the following: heavy uterine bleeding; pelvic pressure; a swollen and distended lower abdomen; urinary and bowel issues; pelvic and lower back pain; pain with sexual intercourse; as well as fertility problems, reproductive issues and complications of pregnancy (breech births, failure of labor to progress, the need for C-section, preterm delivery, and bleeding following delivery).

The most common presenting symptom of uterine fibroids is uterine bleeding, which often begins as prolonged menstruation and can be severe enough to cause a low blood count.  Fibroids are problems of the reproductive years, prevalent in women in their 30s, 40s and 50s. They can be solitary or multiple, range in size from tiny to huge and vary in location within the uterus. The largest fibroids can outgrow their blood supply and undergo degenerative changes. When extremely large, they can distort the lower abdomen, simulating pregnancy. Fibroids are “tumors”–-although benign–- that microscopically consist of interlacing bundles of smooth muscle surrounded by condensed uterine tissue. There is a genetic basis for fibroids with an increased prevalence in women with a family history. Obesity increases one’s risk for fibroids.

The growth of uterine fibroids is largely controlled by estrogen, the key female sex hormone. Fibroids tend to grow rapidly during pregnancy and regress after menopause when estrogen production ceases.

The presence of fibroids may significantly impair one’s quality of life. Because of the pressure they apply against the typically balloon-thin female urinary bladder, they often cause urinary symptoms, much as in pregnancy when an enlarged uterus compresses the bladder. Urinary symptoms most often occur when the fibroids are located closest to the bladder and/or urethra. Typical symptoms include urinary urgency, frequency and stress urinary incontinence (leakage of urine with sneezing, coughing, and exertion). Symptoms are proportionate to the size of the fibroid, with larger fibroids causing more significant symptoms. On occasion, a fibroid can cause an obstruction of the urinary tract, impairing one’s ability to empty their bladder, sometimes requiring the placement of a urinary catheter to alleviate the obstruction.

On pelvic examination, fibroids can often be recognized as pelvic masses. Thye can be further evaluated with imaging studies, including ultrasound, computerized tomography and magnetic resonance imaging. They characteristically cause a “popcorn” appearing calcification on abdominal radiographs.

Those fibroids that do not cause symptoms or bleeding do not require treatment. There are numerous pharmacological options for symptomatic fibroids including medications that lower estrogen levels that cause suppression and shrinkage of the fibroids. Surgery may be required when there is an inadequate response to conservative measures. Surgical options include removing or destroying the uterine lining to control heavy bleeding, deliberately blocking the blood supply to the fibroid, surgical removal of one or more of the fibroids and, at times, removing the entire uterus (hysterectomy).

Bottom Line: As a urologist, I not uncommonly see women with urinary urgency, frequency, incontinence or urinary obstruction caused by one or more uterine fibroids pushing and compressing the bladder or urethra. It is usually very obvious on pelvic ultrasound or cystoscopy (visual inspection of the bladder), where the fibroid can be seen to cause extrinsic compression. The good news is that such fibroids are eminently manageable, which most often resolves the urinary issues.    

Wishing you the best of health and a very happy New Year,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.

Prostate: Bigger Is Not Better

November 24, 2013

Blog #129

The following quote from Gabriel Garcia Marquez’s Love in the Time of Cholera colorfully sums up the aging prostate:

“He was the first man that Fermina Daza heard urinate. She heard him on their wedding night, while she lay prostrate with seasickness
in the stateroom on the ship that was carrying them to France, and
 the sound of his stallion’s stream seemed so potent, so replete with authority, that it increased her terror of the devastation to come. That memory often returned to her as the years weakened the stream, for she never could resign herself to his wetting the rim of the toilet bowl each time he used it. Dr. Urbino tried to convince her, with arguments readily understandable to anyone who wished to understand them, that the mishap was not repeated every day through carelessness on his part, as she insisted, but because of organic reasons: as a young man his stream was so defined and so direct that when he was at school he won contests for marksmanship in filling bottles, but with the ravages of age it was not only decreasing, it was also becoming oblique and scattered, and had at last turned into a fantastic fountain, impossible to control despite his many efforts to direct it. He would say: “The toilet must have been invented by someone who knew nothing about men.” He contributed to domestic peace with a quotidian act that was more humiliating than humble: he wiped the rim of the bowl with toilet paper each time he used it. She knew, but never said anything as long as the ammoniac fumes were not too strong in the bathroom, and then she proclaimed, as if she had uncovered a crime: “This stinks like a rabbit hutch.” On the eve of old age this physical difficulty inspired Dr. Urbino with the ultimate solution: he urinated sitting down, as she did, which kept the bowl clean and him in a state of grace.”

The prostate gland is that mysterious, deep-in-the-pelvis male reproductive organ that can be the source of so much trouble.  It functions to produce prostate fluid, a milky liquid that serves as a nutrient and energy vehicle for sperm. Similar to the breast in many respects, the prostate consists of numerous glands that produce this fluid and ducts that convey the fluid into the urinary channel. At the time of sexual climax, the smooth muscle within the prostate squeezes the fluid out of the glands through the prostate ducts into the urethra (urinary channel that runs from the bladder to the tip of the penis), where it mixes with secretions from the other male reproductive organs to form semen.

The prostate gland completely envelops the urethra, enabling its many ducts to drain into the urethra. However, this necessary anatomical relationship between the prostate and the urethra can potentially be the source of many issues for the aging male. In young men the prostate gland is the size of a walnut; under the influence of three factors—aging, genetics, and adequate levels of the male hormone testosterone—the prostate enlarges, one of the few organs that actually gets bigger with time when there is so much atrophy (shrinkage) and loss of tissue mass going on elsewhere.

Who Knew?  As we age our muscles atrophy, our bones lose mass, our height shrinks and our hairlines and gums recede.  So why is it that our prostates—strategically wrapped around our urinary channels—swell up?

Prostate enlargement can be very variable; it can grow even to the size of a large Florida grapefruit!  As the prostate enlarges, it often—but not always—squeezes the sector of the urethra that runs through it, making urination difficult and resulting in a number of annoying symptoms and sleep disturbance.   It is similar to a hand squeezing a garden hose that affects the flow through the hose. The situation can be anything from a tolerable nuisance to one that has a huge impact on one’s daily activities and quality of life.

The condition of prostate enlargement is known as BPH—benign prostate hyperplasia—one of the most common plagues of aging men. It is important to identify other conditions that can mimic BPH, including urinary infections, prostate cancer, urethral stricture (scar tissue causing obstruction), and impaired bladder contractility (a weak bladder muscle that does not squeeze adequately to empty the bladder).

Although larger prostates tend to cause more “crimping” of urine flow than smaller prostates, the relationship is imprecise and a small prostate can, in fact, cause more symptoms than a large prostate, much as a small hand squeezing a garden hose tightly may affect flow more than a larger hand squeezing gently. The factors of concern are precisely where in the prostate the enlargement is and how tight the squeeze is on the urethra. In other words, prostate enlargement in a location immediately adjacent to the urethra will cause more symptoms
 than prostate enlargement in a more peripheral location. Also, the prostate gland and the urethra contain a generous supply of muscle and, depending upon the muscle tone of the prostate, variable symptoms may result. In fact, the tone of the prostate smooth muscle can change from moment to moment depending upon one’s adrenaline (the stress hormone) level.

Typical symptoms of BPH include an urgency to urinate requiring hurrying to the bathroom that gives rise to frequent urinating day and night and sometimes even urinary leakage before arriving to the bathroom.  As a result of these “irritative” symptoms, some men have to plan their routine based upon the availability of bathrooms, sit on an aisle seat on airplanes and avoid engaging in activities that provide no bathroom access.  One symptom in particular, sleep-time urination—aka nocturia—is particularly irksome because it is sleep-disruptive and the resultant fatigue can make for a very unpleasant existence.

The other symptoms that develop as a result of BPH are “obstructive” as the prostate becomes “welded shut like a lug nut.”  These symptoms include a weak stream that is slow to start, a stopping and starting quality stream, prolonged time to empty, and at times, a stream that is virtually a gravity drip with no force.  One of my patients described the urinary intermittency as “peeing in chapters.”  Many men have to urinate a second or third time to try to empty completely, a task that is often impossible. There may be a good deal of dribbling after urination is completed, known as post-void dribbling.  At times, a man cannot urinate at all and ends up in the emergency room for relief of the problem by the placement of a catheter, a tube that goes in the penis to drain the bladder and bypass the blockage. BPH can be responsible for bleeding, infections, stone formation in the bladder, and on occasion, kidney failure.

Not all men with BPH need to be treated; in fact, many can be observed if the symptoms are tolerable. There are very effective medications for BPH, and surgery is used when appropriate. There are three types of medications used to manage BPH: those that relax the muscle tone of the prostate; others that actually shrink the enlarged prostate gland; and Cialis that has been FDA approved to be used on a daily basis to treat both erectile dysfunction as well as BPH.  There are numerous surgical means of alleviating obstruction and currently the most popular procedure uses laser energy to vaporize a channel through the obstructed prostate gland.

In terms of the three factors that drive prostate growth: aging, genetics and testosterone: There is nothing much we can do about aging; in fact, it is quite desirable to live a long and healthy life!  We cannot do a thing about our inherited genes.  Having adequate levels of testosterone is actually quite desirable in terms of our general health.

So what can we do to maintain prostate health? The short answer is that a healthy lifestyle can lessen one’s risk of BPH.  Regular exercising and maintaining a physically active existence results in increased blood flow to the pelvis, which is prostate-healthy as it reduces inflammation. Sympathetic nervous system tone tends to increase prostate smooth muscle tone, worsening the symptoms of BPH; exercise mitigates sympathetic tone.  Maintaining a healthy weight and avoiding abdominal obesity, will minimize inflammatory chemicals that can worsen BPH.   Vegetables are highly anti-inflammatory and consumption of those that are high in lutein, including kale, spinach, broccoli, and peas as well as those that are high in beta-carotene including carrots, sweet potatoes, and spinach can lower the risk of BPH.  

Bottom Line: BPH is a common problem as one ages, oftentimes negatively impacting quality of life.  There are medications as well as surgery that can help with this issue; however, a healthy lifestyle that includes exercise, avoidance of obesity, and a diet rich in vegetables can actually help lower the risk for developing bothersome prostate symptoms.

Ten Steps To A Healthy Prostate 1. Decrease the amount of animal fat in your diet 2. Eat less meat and dairy 3. Eat more fish 4. Eat more tomatoes 5. Increase the amount of soy in your diet 6. Eat more fruits, veggies, beans, cereals and whole grains 7. Drink a cup of green tea daily 8. Maintain a healthy weight 9. Exercise regularly 10. Manage stress

Andrew Siegel, M.D.

Facebook Page: Our Greatest Wealth Is Health

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Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food:

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in January 2014.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe and receive notifications of new posts in your inbox.  Please feel free to avail yourself of these educational materials and share them with your friends and family.

What The Heck is Urology?

August 24, 2013

Andrew Siegel, MD  Blog #116

“Urology” (uro—urinary tract and logos—study of) is a medical specialty concerned with the study, diagnosis, and treatment of diseases of the urinary tract in females and of the genitourinary tract in males. The organs under the “domain” of urology include the adrenal glands, kidneys, the ureters (tubes connecting the kidneys to the urinary bladder), the urinary bladder and the urethra (the channel that conducts urine from the bladder to the outside).  The male reproductive organs include the testes (i.e., testicles), epididymis (structures above and behind the testicle where sperm mature and are stored), vas deferens (sperm duct), seminal vesicles (the structure that produces the bulk of semen), prostate gland and, of course, the scrotum and penis.  The reproductive and urinary tracts are closely connected, and disorders of one oftentimes affect the other…thus urologists are referred to as  “genitourinary” specialists. Urology involves both medical and surgical strategies to approach a variety of conditions.

Urology has always been on the cutting edge of surgical advancements (no pun intended) and urologists employ minimally invasive technologies including fiber-optic scopes to be able to view the entire inside aspect of the urinary tract, as well as ultrasound, lasers, laparoscopy and robotics.  There is a great deal of overlap in what urologists do with other medical and surgical disciplines, including nephrology (doctors who specialize in medical diseases of the kidney); oncology (cancer specialists); radiation oncologists (radiation cancer specialists); radiology (imaging); gynecology (female specialists); and endocrinology (hormone specialists).

Urologists are the male counterparts to gynecologists and the go-to physicians when it comes to expertise in male pelvic health.  Urologists, in addition to being physicians, are also surgeons who care for serious and potentially life-threatening illnesses, particularly cancers of the genital and urinary tracts.  In terms of new cancer cases per year in American men, prostate cancer is number one accounting for almost 30% of cases; bladder cancer is number four accounting for 6% of cases; and cancer of the kidney and renal pelvis (the inner part of the kidney that collects the urine) are number six accounting for 5% of cases.  Urologists are also the specialists who treat testicular cancer.  Urologists also treat women with kidney and bladder cancer, although the prevalence of these cancers is much less so than in males. 

Very common reasons for a referral to a urologist are the following: blood in the urine, whether it is visible or picked up on a urinalysis done as part of an annual physical; an elevated PSA (Prostate Specific Antigen) or an accelerated increase of PSA over time; prostate enlargement; irregularities of the prostate on examination; urinary difficulties ranging the gamut from urinary incontinence to the inability to urinate (urinary retention).

Urologists manage a variety of non-cancer issues. Kidney stones, which can be extraordinarily painful, keep us very busy, especially in the hot summer months when dehydration (a major risk factor) is more prevalent. Infections are a large part of our practice and can involve the bladder, kidneys, prostate, or the testicles and epididymis.  Urinary infections is one problem that is much more prevalent in women than in men.  Sexual dysfunction is a very prevalent condition that occupies much of the time of the urologist—under this category are problems of erectile dysfunction, problems of ejaculation, and testosterone issues. Urologists treat not only male infertility, but create male infertility when it is desired by performing voluntary male sterilization (vasectomy).   Urologists are responsible for caring for scrotal issues including testicular pain and swelling.   Many referrals are made to urologists for blood in the semen.

Training to become a urologist involves attending 4 years of medical school after college and 1–2 years of general surgery training followed by 4 years of urology residency. Thereafter, many urologists like myself pursue additional sub-specialty training in the form of a fellowship that can last anywhere from 1–3 years.  Urology board certification can be achieved if one graduates from an accredited residency and passes a written exam and an oral exam and has an appropriate log of cases that are reviewed by the board committee.  One must thereafter maintain board certification by participating in continuing medical education and passing a recertification exam every ten years.  Becoming board certified is the equivalent of a lawyer passing the bar exam.

In addition to obtaining board certification in general urology, there are 2 sub-specialties within the scope of urology in which sub-specialty board certification can be obtained—pediatric urology, which is the practice of urology limited to children and female pelvic medicine and reconstructive surgery (FPMRS), which involves female urinary incontinence, pelvic organ prolapse, and other female uro-gynecological issues.  The FPMRS boards were offered for the very first time in June 2013, and I am pleased to announce that I am now board certified in both general urology and FPMRS.  There are approximately 100 or so urologists in the entire country who are board certified in the urology subspecialty of FPMRS.

In terms of the demographics of urology, although urology is largely a male specialty, women have been entering the urological workforce with increasing frequency.  This is because female students now comprise approximately 50% of United States medical school population. There are 10,000 practicing urologists in the USA, of which about 500 are women. Urologists have a median age of 53, so we are not a particularly young specialty. The aging population will demand more urological health services and the Affordable Care Act will result in the dramatic expansion of the number of American citizens with health insurance. These factors combined with the aging of the urological workforce and the contraction due to retirement, all in the face of growing demands, does not augur well for a balance of supply and demand in the forthcoming years.  Hopefully there will be enough of us to provide urological care to those in the population that need it.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food:

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health, in press and available in e-book and paperback formats in the Autumn 2013.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Post-Void Dribbling

May 25, 2013

Post-Void Dribbling (PVD)

Andrew Siegel, MD  Blog #108

Introduction:  Probably the two most common and annoying complaints from my male patients are sleep-disruptive nighttime urination and post-void dribbling. The following is a tiny “taste” of the content of my new book, forthcoming this summer, entitled Male Pelvic Fitness: Optimizing Sexual and Urinary Health.

The Problem: Post-void dribbling is the leakage of urine immediately or shortly after completing the act of urinating. This “after-dribble” is more annoying than serious and can be one of the first manifestations of prostate enlargement.  Although it rarely occurs before age forty, it can happen on occasion to men of any age.

Dorey et al published an article in the British Journal of Urology that demonstrated the effectiveness of pelvic floor muscle (PFM) exercises for erectile dysfunction, but also suggested an association between the occurrence of erectile dysfunction (ED) and post-void dribbling.  How fascinating—ED and PVD are linked and parallel problems, one sexual and the other urinary—both being manifestations of pelvic floor muscle weakness, and both treatable by increasing pelvic floor muscle fitness.

The Science: The urethra has an external portion within the penis, an internal portion that travels in the perineum (the area of the body between the scrotum and the anus), and an innermost portion, which traverses the prostate and enters the bladder.  After urinating, there is always some urine that remains and pools in the internal urethra.  When it drips out of the urethra aided by gravity and movement, it is referred to as PVD.

The Premise: Pelvic floor muscle contractions are the body’s natural mechanism for draining the urethra.  Improving the strength and tone of the PFM will help eject the contents of the inner, deeper portion of the urethra.  When contracted, the bulbocavernosus (BC) muscle compresses this deep portion of the urethra, displacing the urine within further downstream.  A powerful BC muscle will substantially help this process, in much the same way that it facilitates ejaculation. The BC is the body’s natural urethral “stripper”; however, the BC does not surround the entire urethra, so it is likely that a strong BC will improve the PVD, although it is possible to still have some drops remaining in the penile urethra.

The Solution: Try not to rush the act of urination.  The adage “haste makes waste” is absolutely relevant with respect to PVD. When finished urinating, vigorously contract the PFM several times to displace the inner urethra’s contents. If necessary, the urethra of the penis can be further evacuated of urine by manually compressing and stripping it.  To do so, starting where the penis meets the scrotum, compress the urethra between your thumb on top and index and middle fingers on the undersurface and draw them forth towards the penile tip, “milking” out any remaining urine.  To further improve the PVD, gently shake the penis until no more urine drips from the urethra. It is not a bad idea to apply tissue to the tip of the penis to soak up any residual urine—women have the right idea here.


Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food:

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.