Posts Tagged ‘urinary incontinence’

Artificial Urinary Sphincter (AUS): What You Need To Know

May 12, 2018

Andrew Siegel MD   5/12/2018

Severe involuntary leakage of urine following prostate surgery is a rare event, occurring in less than 5% of men following prostatectomy for prostate cancer, and in an even smaller percentage of men who have undergone prostate surgery for a benign process.  Following prostatectomy, it most often results from scarring of the bladder neck sphincter.  Severe incontinence can be devastating to one’s quality of life, affecting psychological, emotional, and sexual well-being and often causing loss of self-esteem, depression, and avoiding a healthy, productive, and active lifestyle.

Fortunately, for the small percentage of men rendered severely incontinent after prostatectomy, the AUS offers a great opportunity for cure and in significantly improving quality of life. It functions as a mechanical compression device of the urethra that is under the patient’s control, providing simple and discreet control over bladder storage and emptying.  Implanted entirely within the body, the device mimics the function of a healthy sphincter muscle by keeping the urethra closed until the patient desires to urinate.

The AUS prosthesis is a saline fluid-filled device composed of solid silicone elastomer consisting of three interconnected components: a cuff implanted around the urethra, a pressure-regulating balloon reservoir implanted behind the pubic bone, adjacent to the bladder, and a control pump implanted in the scrotum.  The cuff gently squeezes the urethra closed, preventing urine from passing.  When one wants to urinate, he simply squeezes and releases the control pump that is situated in the scrotum, temporarily transferring fluid from the cuff to the pressure regulating balloon.  The cuff opens, allowing urine to flow through the urethra.  Within several minutes, the pressure regulating balloon automatically returns the fluid to the cuff to once again pinch the urethra closed.


The AUS, first developed in 1972, has been used successfully for over 45 years and has been implanted in more than 150,000 men. Over the years, biomedical engineering refinements have further improved the AUS.  About two thirds of men will be completely continent after an AUS implant, and the other one third will experience only minor incontinence, requiring one or two small pads per day. The overall patient satisfaction rate exceeds 90%.

In order to be an appropriate candidate for the AUS, incontinence needs to be on the basis of a weakened or damaged sphincter and not due to bladder over-activity.  Additionally,  bladder capacity needs to be adequate and urinary flow rate sufficient to empty the bladder. The incontinence should be present for a minimum of 6 months before considering the AUS, since spontaneous improvement occurs for some time after prostatectomy. One obviously need to be sufficiently motivated to receive an implant, and its use demands manual dexterity in order to operate the control pump.

Implantation of the Artificial Urinary Sphincter

Implantation of the AUS is a one hour or so outpatient surgical procedure done under anesthesia.  The conventional operation is performed with one’s legs in stirrups and requires one incision in the abdomen and the other in the perineum (area between scrotum and anus).  In 2003, Dr. Steve Wilson and I devised an innovative technique for AUS implantation via a single scrotal incision. The advantages of the scrotal technique are a single incision, the fact that it can be done supine (lying on one’s back versus legs up in stirrups), faster operative time, ease of doing the procedure and decreased patient discomfort.  In either case, the control pump is one-size fits all, but the cuff is precisely measured to your anatomy and the pressure-regulating balloon reservoir is usually chosen to be 61-70 cm water pressure.

It is important to know that the AUS will not be activated– and thus will not be functional– for about a 6-week period of time to allow for healing of tissues. Activation is a simple process that is done in the office, involving minimal discomfort.

It is advisable to order and wear a MedicAlert bracelet ( to inform health care personnel that you have an AUS implant in the event of a medical emergency. If you were rendered unconscious or unable to communicate, this bracelet will inform emergency medical staff that you have an AUS, because if there is ever a need for a urethral catheter, it is imperative that the AUS be deactivated prior to catheter placement in order to avoid damaging the urethra.


Who manufactures the AUS?

American Medical Systems Men’s Health Division of Boston Scientific, Inc.

Will insurance cover the AUS?

Medicare has a coverage policy for incontinence control devices, which includes the AUS.  Most commercial health insurers also cover the AUS when deemed medically necessary for the patient.

How effective is the AUS?

More than 90% of patients with the AUS have greatly improved continence, many of whom achieve complete urinary control with no need for pads and the remainder of whom have occasional, minor stress incontinence with vigorous activities, typically requiring one or two small pads per day.  The 61-70 cm pressure regulating balloon provides 61-70 cm of pressure around the urethra, which is sufficient closure for most of the activities of daily living.

Does the AUS need to be measured to my body?

The control pump is “one size fits all”, but the cuff is sized to the circumference of your urethra to achieve a proper fit.  The reservoir comes in a variety of pressures.  The higher the pressure of the reservoir, the tighter the closure of the urethra. The tighter the closure of the urethra, the better is the continence, but also the greater the chance of urethral damage from the higher pressures. A balance must be achieved in order to achieve the necessary pressure to achieve continence while minimizing potential damage to the urethra. In practical terms, this translates into a 61-70 cm. pressure reservoir for most men.

Can I have an AUS if I underwent surgery followed by radiation therapy?

Yes, but radiation therapy increases the  potential risk for complications because of tissue damage, scarring, decreased blood flow and less optimal wound healing.

What are alternatives to the AUS, assuming that behavioral techniques and pelvic floor muscle exercises have failed?

  1. Absorbent pads and garments
  2. Penile compression clamps
  3. External collecting devices
  4. Urethral bulking agents
  5. The male sling

The first three are external, bulky, mechanical means of coping with–not treating–the problem.  Urethral bulking agents have fared poorly and the male sling is a possibility, although it is indicated for lesser degrees of incontinence and achieves results far inferior to those possible with the AUS.

Who should not have an AUS prosthesis?

The AUS is not appropriate for a man with an obstructed lower urinary tract. It also should not be used for those with bladder-related incontinence (overactive bladder or a small-capacity, scarred bladder) as it is indicated only for those with sphincter-related incontinence. It cannot be effectively used in those with compromised dexterity or mental acuity.

What are the potential risks and complications associated with AUS implantation?

Infection   As with any surgery, an infection can develop after an AUS implant.  Every step is taken to reduce the likelihood of an infection, including intravenous antibiotics, an antiseptic scrub of the surgical site on the operating table followed by the application of an chlorhexidine and alcohol skin antiseptic immediately prior to the operation, double-gloving, meticulous surgical technique with the procedure done as quickly as possible, topical antibiotics to flush the surgical site, and minimizing operating room traffic. Antibiotic ointment is placed on the surgical incision prior to placing the surgical dressing. Patients are sent home with oral antibiotics.

Two of the three components of the AUS–the cuff and pump–are coated with an antibiotic combination called InhibiZone, which consists of rifampin and minocycline.  If an infection occurs and does not respond to antibiotics, it may be necessary to remove the AUS, an extremely rare occurrence.

MH AMS 800 urinary sphincter product

Image above: AUS with inhibiZone coating of control pump and cuff


Erosion   This is a breakdown of the urethral tissues that lie beneath the cuff.   It is generally treated with cuff removal to allow for urethral healing prior to consideration for cuff replacement at a later date.  Erosion can occur when a catheter is placed into the urinary bladder by health care personnel uninformed that the AUS device is in place. The delicate urethra, pinched closed by the inflated cuff surrounding it, is traumatized and damaged by catheter placement.  This situation can be avoided by deactivating the AUS prior to catheterization.  This is one of the reasons that a MedicAlert card and bracelet are useful considerations. Erosion of the other AUS components can also occur on a rare basis. The control pump can potentially erode through the scrotal skin and the pressure-regulating balloon reservoir into the urinary bladder.

Mechanical Malfunction   The AUS is effective and reliable, but it is a mechanical device that can ultimately malfunction. It is not possible to predict how long an AUS will function in an individual patient.  As with any biomedical prosthesis, this device is subject to wear, component disconnection, component leakage, and other mechanical problems that may lead to the device not functioning as intended and may ultimately require additional surgery to replace the device. The median durability of the device is about 7.5 years, although I have patients who still have a functional AUS 20 years after implantation.

Urethral Tissue Atrophy   This can result from the long-term pressure effect of the cuff on the urethra.  Essentially, the urethra shrinks down from being squeezed by the cuff, resulting in worsening of urinary control.  When this happens, it generally requires repositioning of the cuff to a new urethral location or the use of a smaller cuff or, on rare occasion, placement of a second cuff (tandem cuff).

Pain    Discomfort in the groin, penis, and scrotum is expected immediately after surgery and during the period when the device is first used. It is very rare to experience chronic pain from an implantation of an AUS.

Migration and Extrusion  Migration is the movement or displacement of components within the body space in which they were originally implanted.  Extrusion occurs when a component moves to an abnormal location outside of the body.  These are both extremely rare occurrences

Bottom Line: The artificial urinary sphincter (AUS) is an effective, safe and reliable implantable medical prosthesis to restore urinary control in men with severe, refractory stress urinary incontinence.  Although there is no means of totally replacing our natural sphincter system, the AUS is the only device that simulates normal sphincter function by opening and closing the urethra at the will of the patient. It provides consistent results in the treatment of incontinence following prostatectomy and is considered to be the “gold standard” in the management of this problem. Many patients report that the AUS is nothing short of “life changing,” converting men who are bladder “cripples” back to normal function and restoring their quality of life. 

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, 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.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx


Menopause: Impact on Nether Regions

September 23, 2017

Andrew Siegel MD  9/23/17


Image above by Mikael Häggström (Own work) [CC0], via Wikimedia Commons

Menopause is the cessation of estrogen production by the ovaries.  It typically occurs at about age 51-years-old, so most women can expect to live another thirty or more years following this event. Many bodily changes occur with menopause, with the urinary and genital systems undergoing sudden and, at times, dramatic changes due to the absence of estrogen stimulation.

The constellation of symptoms related to menopause used to be referred to as “atrophic vaginitis” or “vulvo-vaginal atrophy.” However, these terms were considered disparaging, hurtful and cruel, especially the words “atrophic” and “atrophy,” which imply wasting away through lack of nourishment. Also, the “-itis” designation incorrectly implied inflammation or infection. A more politically correct, medically accurate, less embarrassing and more acceptable term was proposed by the International Society for the Study of Women’s Sexual Health and the North American Menopause Society: “Genitourinary Syndrome of Menopause (GSM).”

“Genitourinary Syndrome of Menopause”–  I don’t particularly care for this term because of its length, the fact that it sounds way too clinical, and implication that menopause causes a medical “syndrome” or “disease” as opposed to a natural, physiological, age-appropriate, virtually universal situation.  Why not label the constellation of symptoms related to menopause as “menopausal symptoms and signs”?

The female hormone (estrogen)-stimulated vagina of a young adult female has a very different appearance from that of a female after menopause. The vestibule, vagina, urethra and base of the urinary bladder have abundant estrogen receptors that are no longer stimulated after menopause, resulting in diminished tissue elasticity and integrity.  Age-related changes of the vulva and vagina can lead to dry, thinned and brittle tissues with loss of vaginal length and width, lubrication potential and expansive ability. Considering that nature’s ultimate purpose of sex is for reproduction, perhaps it is not surprising that when the body is no longer capable of producing offspring, changes occur that affect the anatomy and function of the genital organs.

Symptoms and Signs of Menopause


  • Hot flashes
  • Night sweats
  • Sleep disturbances
  • Mood changes and fluctuations


  • Thinning/loss of elasticity of labia and underlying fatty tissues
  • Diminished tissue sensitivity
  • Paler, thinner and more fragile vulvar skin
  • Increase in vulvar skin issues and vulvar pain, burning, itching and irritation


  • Thinning of the vaginal wall
  • Loss of vaginal ruffles and ridges
  • Shortened vaginal dimensions
  • Looseness of  the vaginal opening
  • Increased vaginal pH (less acid environment)
  • Increased vaginal colonization by colon bacteria and more frequent vaginal infections


  • Diminished sex drive
  • Vaginal dryness
  • Diminished arousal
  • Diminished lubrication
  • Diminished ability to achieve orgasm
  • Tendency for painful sexual intercourse


  • Thinning of the urethral wall and tissues adjacent to the urethra
  • Urinary infections: Before menopause, healthy bacteria reside in the vagina; after menopause, the vaginal bacterial ecosystem changes to colon bacteria, which can predispose to infections.
  • Overactive bladder symptoms: urinary urgency, frequency, urgency incontinence
  • Stress urinary incontinence (urinary leakage with sneezing, coughing, exercise and exertion)
  • Urethral caruncles (benign fleshy outgrowths at the urethral opening)

What to do?

If the symptoms and signs of menopause are not bothersome, nothing need be done. In fact, many women relish not having menstrual periods and tolerate menopause uneventfully.  However, if one’s quality of life is adversely affected, consideration can be made for hormone replacement therapy, particularly if the menopausal symptoms are disruptive and debilitating.

Hormone Replacement

Systemic hormone therapy is available in the form of pills, skin patches, sprays, creams and gels. It can be effective in managing bothersome menopausal symptoms when used for the short-term. Estrogen alone is used in women who have had a hysterectomy, whereas estrogen and progesterone in those who have a uterus. The potential side effects of systemic therapy include an increased risk for heart disease, breast cancer and stroke.

Vaginal hormone therapy is available in creams, rings and tablets. The advantage of  locally-applied estrogen is that it can help manage menopausal pelvic floor issues with minimal absorption into the body and minimal potential systemic effects, as would be expected from oral hormone replacement therapy. It can be helpful for painful intercourse, overactive bladder, stress urinary incontinence, pelvic organ prolapse and recurrent urinary tract infections. Additionally, because estrogen restores suppleness to the vaginal tissues, it can be very useful both before and after vaginal surgical procedures (most commonly for stress urinary incontinence and pelvic organ prolapse).

Note: I commonly prescribe topical estrogen therapy, typically a small dab applied vaginally prior to sleep three times weekly.  It has proven helpful and effective in a variety of circumstances.

Kegel Exercises

Clinical studies have demonstrated that Kegel exercises can effectively improve certain domains of sexual function, particularly arousal, orgasm and satisfaction. This is not surprising given that the pelvic floor muscles are essential to arousal and orgasm, with weakness in these muscles resulting in reduced pelvic and vaginal blood flow and lack of adequate lubrication, painful intercourse and difficulty achieving climax.  Furthermore, Kegel exercises can be effective in the management of overactive bladder, stress urinary incontinence, and pelvic organ prolapse.

Stay Sexually Active: Use it or Lose it

Sexual intercourse can be painful after menopause because of anatomical and functional changes that result in difficulty in accommodating a penis.  This is particularly the case if one has not been sexually active on a regular basis.  Sexual activity is vital for maintaining the ability to have ongoing satisfactory sexual intercourse. Vaginal penetration increases pelvic and vaginal blood flow, optimizing lubrication and elasticity, while orgasms tone and strengthen the pelvic floor muscles that support vaginal functionLubricants can be used for women experiencing vaginal dryness and painful intercourse.

Lifestyle Modification

Pursuing a healthy lifestyle can provide some degree of relief from menopausal symptoms. These measures include a maintaining a healthy weight, a diet emphasizing plant-based proteins, fruits and vegetables, moderate exercise, sufficient quantity and quality of sleep, caffeine reduction, tobacco cessation and alcohol in moderation.

Bottom Line: Menopause is an inevitable part of the aging process with the absence of menstrual periods a welcome change for many women.  However, the cessation of estrogen production can cause a host of symptoms and consequences, particularly affecting the urinary and genital organs.  If symptoms are bothersome, there are numerous means by which to improve them. 

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”:

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as 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 that is in such dire need of bridging.


Female Bladder Works

February 11, 2017

Andrew Siegel MD   2/11/17

This entry is a brief overview of bladder anatomy and function to help you better understand the two most common forms of urinary leakage—stress urinary incontinence and overactive bladder— topics for entries that will follow for the next few weeks.  Having a working knowledge of the properties of the bladder will serve you well in being able to understand when things go awry. 

                          6. bladder

                             Drawing of the bladder and urethra by Ashley Halsey from “The Kegel Fix:                           Recharging Female Pelvic, Sexual and Urinary Health”

The bladder is a muscular balloon that has two functions—storage and emptying of urine. The stem of the bladder balloon is the urethra, the tube that conducts urine from the bladder during urination and helps store urine at all other times. The urethra runs from the bladder neck (where the urinary bladder and urethra join) to the urethral meatus, the external opening located just above the vagina.

Bladder Control Issues—More Than Just a Physical Problem

Urinary incontinence is an involuntary leakage of urine. Although not life threatening, it can be life altering and life disrupting. Many resort to absorbent pads to help deal with this debilitating, yet manageable problem. It is more than just a medical problem, often affecting emotional, psychological, social and financial wellbeing (the cumulative cost of pads can be significant). Many are reluctant to participate in activities that provoke the incontinence, resulting in social isolation, loss of self-esteem and, at times, depression. Since exercise is a common trigger, many avoid it, which can lead to weight gain and a decline in fitness. Sufferers often feel “imprisoned” by their bladders, which have taken control over their lives, impacting not only activities, but also clothing choices, travel plans and relationships.

Bladder Function 101

Healthy bladder functioning depends upon properties of the bladder and urethra. Bladder control issues arise when one or more of these go awry:


The average adult has a bladder that holds about 12 ounces before a significant urge to urinate occurs. Problem: The most common capacity issue is when the capacity is too small, causing urinary frequency.


The bladder is stretchy like a balloon and as it fills up there is a minimal increase in bladder pressure because of this expansion. Low-pressure storage is desirable, as the less pressure in the bladder, the less likelihood for leakage issues. Problem: The bladder is inelastic or less elastic and stores urine at high pressures, a setup for urinary leakage.


There is an increasing feeling of urgency as the urine volume in the bladder increases. Problem: The most common sensation issue is heightened sensation creating a sense of urgency before the bladder is full, giving rise to the frequent need to urinate. Less commonly there exists a situation in which there is little to no sensation even when the bladder is quite full (and little warning that the bladder is full), sometimes causing the bladder to overflow.


After the bladder fills and the desire to urinate is sensed, a voluntary bladder contraction occurs, which increases the pressure within the bladder in order to generate the power to urinate. Problem: The bladder is “under-active” and cannot generate enough pressure to empty effectively, which may cause it to overflow when large volumes of urine remain in the bladder.


A bladder contraction should only occur after the bladder is reasonably full and the “owner” of the bladder makes a conscious decision to empty the bladder. Problem: The bladder is “overactive” and squeezes prematurely (involuntary bladder contraction) causing sudden urgency with the possibility of urinary leakage occurring en route to the bathroom.

Anatomical Position

The bladder and urethra are maintained in proper anatomical position in the pelvis because of the pelvic floor muscles and connective tissue support. Problem: A weakened support system can cause urinary leakage with sudden increases in abdominal pressure, such as occurs with sneezing, coughing and/or exercising.


In cross-section, the urethra has infoldings of its inner layer that give it a “snowflake” appearance. This inner layer is surrounded by rich spongy tissue containing an abundance of blood vessels, creating a cushion around the urethra that permits a watertight seal similar to a washer in a sink. The female hormone estrogen nourishes the urethra and helps maintain the seal. Problem: With declining levels of estrogen at the time of menopause, the urethra loses tone and suppleness, analogous to a washer in a sink becoming brittle, potentially causing leakage issues.


The urinary sphincters, located at the bladder neck and mid-urethra, are specialized muscles that provide urinary control by pinching the urethra closed during storage and allowing the urethra to open during emptying. The main sphincter (a.k.a. the internal sphincter) is located at the bladder neck and is composed of smooth muscle designed for involuntary, sustained control. The auxiliary sphincter (a.k.a. the external sphincter), located further downstream and comprised of skeletal muscle contributed to by the pelvic floor muscles, is designed for voluntary, emergency control. Problem: Damage to or weakness of the sphincters adversely affects urinary control.

The main sphincter is similar to the brakes of a car—frequently used, efficient and effective. The auxiliary sphincter is similar to the emergency brake—much less frequently used, less efficient, but effective in a pinch. The pelvic floor muscles are intimately involved with the function of the “emergency brake.”


The seemingly “simple” act of urination is actually a highly complex event requiring a functional nervous system providing sensation of filling, contraction of the bladder muscle and the coordinated relaxation of the sphincters. Problem: Any neurological problem can adversely affect urination, causing bladder control issues.

Bladder Reflexes

A reflex is an automatic response to a stimulus, an action that occurs without conscious thought. There are three reflexes that are vital to bladder control:

Guarding Reflex: During bladder filling, the “guarding” (against leakage) pelvic floor muscles contract in increasing magnitude in proportion to the volume of urine in the bladder; this provides resistance that helps prevent leakage as the bladder becomes fuller.

Cough Reflex: With a cough, there is a reflex contraction of the pelvic floor muscles, which helps prevent leakage with sudden increases in abdominal pressure.

Pelvic Floor Muscle-Bladder Reflex: When the pelvic floor muscles are voluntarily contracted, there is a reflex relaxation of the bladder. This powerful reflex can be tapped into for those who have involuntary bladder contractions that cause urgency and urgency leakage.

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”:

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery. Much of the content of this entry was excerpted from his recently published book The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health:

He is also the author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Loose (Vaginal) Lips Sink Ships

September 17, 2016

Andrew Siegel MD 9/17/2016


“Loose lips sink ships.” These four words convey the warning “be very cautious of unguarded talk.” Dating back to WWII, this phrase appeared on posters created by the War Advertising Council to advise the public to be discreet with conversation, since information in the wrong hands could have disastrous consequences.

In the context of pelvic health—the topic that I often write about—“loose lips sink ships” has an entirely different meaning. When I use the term “loose lips,” I mean the literal term “loose lips,” referring to sagging and lax female genital anatomy that is a not uncommon occurrence after multiple vaginal births and other promoting factors. When I use the term “sink ships,” I refer to a variety of pelvic problems that can occur in women with “loose lips,” including urinary, bowel and sexual issues (that can affect the partner as well ).

Obstetrical Factors Can CauseLoose Lips”

Genital anatomy, particularly the all-important structural supportive muscles of the pelvis–the pelvic floor muscles (PFM)–take a beating from pregnancy, labor and vaginal delivery. Pregnancy incurs maternal weight gain, a change in body posture, pregnancy-related hormonal changes, the pressure of a growing uterus and fetal weight, all of which may reduce the supportive and sphincter (urinary and bowel control) functions of the PFM.

Labor is called so for a genuine reason…the hours one spends pushing and straining are often unkind to the PFM. Elective Caesarian section avoids labor and affords some protection to the PFM, but prolonged labor culminating in an emergency C-section is equally as potentially damaging to the PFM as is vaginal delivery.

Vaginal delivery is the ultimate PFM traumatic event. The soft tissues of the pelvis (including the PFM) get crushed in the “vise” between baby’s bony skull and mother’s bony pelvis and are simply no match for the inflexibility of these bones. The PFM and connective tissues are frequently stretched, if not torn, from their attachments to the pubic bone and pelvic sidewalls, and the nerves to the pelvic floor are often affected as well. The undesirable consequences of this obstetric “trauma” include altered PFM anatomy with loss of vaginal tone and function, a.k.a. birth-related laxity (“loose lips”).

Studies measuring PFM strength before and after first delivery show a decrease in PFM strength in about 50% of women. Vaginal delivery is much more likely to reduce PFM strength than C-section delivery. Not surprisingly, following delivery, the larger the measured diameter of the vaginal opening, the weaker the vaginal strength.

Although the process of childbirth will not inevitably change one’s vaginal and pelvic anatomy and function, it does so commonly enough. After a vaginal delivery, the vagina becomes looser and more exposed, the vaginal lining becomes dryer, and hormonal-related pigmentation changes often cause a darker appearance to the vulva.

Beyond childbirth, the PFM can also become weakened, flabby and poorly functional with menopause, weight gain, a sedentary lifestyle, poor posture, sports injuries, pelvic trauma, chronic straining, pelvic surgery, diabetes, tobacco use, steroid use, and disuse atrophy (not exercising the PFM). Sexual inactivity can lead to their loss of tone, texture and function. With aging there is a decline in the muscle mass and contractile abilities of the PFM, often resulting in PFM dysfunction.

“Sink Ships”

 As a urologist who cares for many female patients, my clinical sessions bear witness to common pelvic floor complaints that can be classified under the category of “loose lips”:

 “My vagina is just not the same as it was before I had my kids. It’s loose to the extent that I can’t keep a tampon in.”

–Allyson, age 38

“Sex is so different now. I don’t get easily aroused the way I did when I was younger. Intercourse doesn’t feel like it used to and I don’t climax as often or as intensively as I did before having my three children. My husband now seems to get ‘lost’ in my vagina. I worry about satisfying him.”

–Leah, age 43

 “When I bent over to pick up my granddaughter, I felt a strange sensation between my legs, as if something gave way. I rushed to the bathroom and used a hand mirror and saw a bulge coming out of my vagina. It looked like a pink ball and I felt like all my insides were falling out.”

–Karen, age 66

 “Every time I go on the trampoline with my daughter, my bladder leaks. The same thing happens when I jump rope with her.”

–Brittany, age 29

How “Loose Lips” Affect You and Your Partner

Weakness in the PFM cause the following anatomical changes: a wider and looser vaginal opening, decreased distance between the vagina and anus, and a change in the vaginal orientation such that the vagina assumes a more upwards orientation as opposed to its normal downwards angulation towards the sacral bones.

“Loose lips” are not caused by an intrinsic problem with the vagina, but by the extrinsic weakened PFM that no longer provide optimal vaginal support.

Women with this issue who are sexually active may complain of a loose or gaping vagina, making intercourse less satisfying for themselves and their partners. This may lead to difficulty achieving climax, difficulty retaining tampons, difficulty retaining the penis with vaginal intercourse, the vagina filling up with water while bathing and vaginal flatulence (passage of air). The perception of having a loose vagina can lead to self-esteem issues.

 Women with “loose lips” often have difficulty in “accommodating” the penis properly, resulting in the vagina “surrounding” the penis rather than firmly “squeezing” it, with the end result being diminished sensation for both partners. Under normal circumstances, sexual intercourse results in indirect clitoral stimulation. The clitoral shaft moves rhythmically with penile thrusting by virtue of penile traction on the inner vaginal lips, which join together to form the hood of the clitoris. However, if the vaginal opening is too wide to permit the penis to put enough traction on the inner vaginal lips, there will be limited clitoral stimulation and less satisfaction in the bedroom.

Da Vinci made an interesting observation on perspectives: “Women’s desire is the opposite of that of man. She wishes the size of the man’s member to be as large as possible, while the man desires the opposite for the woman’s genital parts.

Bottom Line: “Loose lips” (literally) can sink “ships” (figuratively), causing a number of pelvic floor dysfunctions including pelvic organ prolapse and urinary and bowel control issues. Furthermore, “loose lips” can sink your partner’s “ship,” making sexual intercourse challenging at times and less pleasurable for both parties. If your partner has compromised erections because of aging or other causes, “loose lips” can aggravate his problem by not providing sufficient stimulation to keep his penis erect. Help keep the anatomy and function of your female parts in good working order by participating in a PFM training program (Kegel pelvic exercises).

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 THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at

Author page on Amazon:

Apple iBook:

Trailer for The Kegel Fix: 

Co-creator of the comprehensive, interactive, FDA-registered Private Gym/PelvicRx, a male pelvic floor muscle training program built upon the foundational work of renowned Dr. Arnold Kegel. The program empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance weights, this program helps to improve sexual function and to prevent urinary incontinence: or Amazon.  

In the works is the female PelvicRx DVD pelvic floor muscle training for women.

Pelvic Rx can be obtained at, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 


Pelvic Injuries From Childbirth

September 10, 2016

Andrew Siegel MD  9/10/2016  


Image above: William Smellie (1697-1763): A Set of Anatomical Tables with Explanations and an Abridgement of the Practice of Midwifery, 1754.

The female bony pelvis provides the infrastructure to support the pelvic organs and to allow childbirth. Adequate “closure” is needed for pelvic organ support, yet sufficient “opening” is necessary to permit vaginal delivery. The female pelvis evolved as a compromise between these two important, but opposing functions. Unfortunately, the process of childbirth has the potential for damaging the “closure” mechanism of the pelvis, which can result in permanent childbirth injuries that are often suffered in silence.

Obscured in the magic of delivering a human being through the birth canal are the lasting physical effects that can occur from the birth process. The average birth weight of a newborn is 7.5 pounds, a considerable load to push (and pull) through the vaginal canal. It is a popular misconception that pelvic anatomy rapidly returns to its pre-pregnancy status. Some women do come through the process relatively unscathed with minimal physical changes, whereas others sustain significant pelvic trauma from the process. Potential long-term ramifications may include the following: urinary and fecal incontinence (leakage); vaginal laxity (looseness); pelvic organ prolapse (descent of one or more of the pelvic organs into the vaginal space and at times outside the vaginal opening); vaginal pain with sexual intercourse; and chronic back pain.

The risk factors for childbirth injuries are larger babies, prolonged labor, narrow vaginal anatomy and the need for tools to help deliver the baby, e.g., forceps. Vaginal injuries may involve lacerations, pelvic bone fractures, pelvic floor muscle tears, etc. Although vaginal delivery is the ultimate traumatic event, pregnancy and labor are important factors as well. Accompanying pregnancy is maternal weight gain, a change in body posture, hormonal changes and the pressure of a growing uterus and fetal weight. Labor is an appropriate term for the tough work a mother has to do to push out a baby’s head. The more hours spent pushing and straining, the greater the potential trauma to pelvic anatomy. During the process of vaginal delivery, the soft tissues of the pelvis get “crushed” in the “vise” between the baby’s bony skull and the mother’s bony pelvis. The pelvic muscles and connective tissues are frequently stretched, if not torn, from their attachments to the pubic bone and pelvic sidewalls, and the nerves to the pelvic floor are often equally affected. Although more than half of women who deliver vaginally sustain small tears, only 10% or so suffer a severe pelvic muscle tear or pelvic bone fracture.

The most extreme form of birth trauma is obstetric fistula, a not uncommon, horrific problem often occurring in poverty-stricken countries where pregnant women have poor access to obstetric care. It happens after enduring days of “obstructed” labor, with the baby’s head persistently pushing against the mother’s pelvic bones during contractions. This prevents pelvic blood flow and causes tissue death, resulting in a hole called a “fistula” between the vagina and the bladder and/or vagina and rectum. When birth finally occurs, the baby is often stillborn. The long-term consequences for the mother are severe urinary and bowel incontinence, shame and social isolation.

The human body has a remarkable ability to heal and repair itself, and given time, nature and patience, many women will recover their anatomy and function. However, a subset of women will have lasting effects from birth trauma, referred to by the term pelvic floor dysfunction.  This can result in urinary or bowel leakage with sneezing, coughing and exertion, pooching of one or more of the pelvic organs into the vaginal canal and at times beyond, a loose vagina that may adversely affect sexual relations and pelvic pain with sexual intercourse.

What to do to prepare?

  • Prenatal education: Knowledge is power–the more you know about the expectations of the pregnancy and childbirth process, the better prepared you will be.
  • Maintain a healthy weight and general fitness: A healthy lifestyle will go a long way in making the process of pregnancy, labor and delivery as easy as possible.
  • Pelvic floor muscle exercises (Kegels) starting prenatally: Realistically, this will not prevent pelvic floor issues in everyone, since obstetrical trauma can and will give rise to problems whether the pelvic muscles are fit or not! However, even if a pelvic exercise regimen does not prevent all forms of pelvic floor dysfunction, it will certainly have a positive impact, lessening the degree of the dysfunction and accelerating the healing process. Furthermore, mastering such exercises before pregnancy will make carrying the pregnancy easier and will facilitate labor and delivery and the effortless resumption of the exercises in the post-partum period, as the exercises were learned under ideal circumstances, prior to the injury. 

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 THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo; paperback edition available at

Author page on Amazon:

Apple iBook:

Trailer for The Kegel Fix:

Co-creator of the comprehensive, interactive, FDA-registered Private Gym/PelvicRx, a male pelvic floor muscle training program built upon the foundational work of renowned Dr. Arnold Kegel. The program empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance weights, this program helps to improve sexual function and to prevent urinary incontinence: or Amazon.  

In the works is the female PelvicRx DVD pelvic floor muscle training for women.

Pelvic Rx can be obtained at, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 

Female Sex-Related Urinary Leakage

April 29, 2016

Andrew Siegel MD 4/30/16







I have previously written on the topic of male urinary leakage during sexual excitement and climax:  This entry covers the issue in females.

“Coital incontinence” is the medical term for leakage of urine that occurs during sexual intercourse. This involuntary loss of urine can occur either at the time of vaginal penetration, during the act of intercourse itself or during orgasm. It can be a devastating problem that affects one’s emotional, psychological, and social well being. This is not a topic that many women feel comfortable discussing with their physicians and therefore is under-reported and under-studied. It is important to know that coital incontinence is a manageable situation. 

A healthy sexual response involves being “in the moment,” free of concerns and worries. Women who develop coital incontinence often become mentally distracted during sexual activity, preoccupied with their lack of control over their problem, fear of leakage during intercourse and concerns about what consequences this might have on their partner’s sexual experience. This can cause a feeling of being unattractive and unsexy and an overall negative perception of body image, which can affect sex drive, arousal, sexual fulfillment and ability to orgasm. In addition to being embarrassing, it often results in women withdrawing from participating in sexually intimate situations, which can have a harmful effect on relationships.

There are two distinct forms of coital incontinence: leakage with penetration/intercourse and leakage with climax.

Leakage With Vaginal Penetration or During Intercourse

Leakage with penetration typically occurs in women with weakened pelvic support, often in women with a condition known as a cystocele (a.k.a. dropped bladder), in which the bladder sags to a variable extent through a weakness in its structural support such that the it enters into the vaginal space and at times can emerge outside the vaginal opening. This condition often causes an anatomical kink, resulting in symptoms of urinary obstruction including a weak, slow, intermittent stream and incomplete bladder emptying. Many women with dropped bladders need to use their fingers to manually push the bladder back into its normal anatomical position in order to straighten out the kink to be able to urinate effectively. What happens at the time of penetration is that the penis displaces the bladder back into its normal anatomic position and “unkinks” the urethra, resulting in a gush of urinary leakage.  Urinary leakage can also occur for the same underlying reason after penetration–during the act of intercourse itself– as penile thrusting shifts the bladder position and straightens out the urethra.  Either situation does not make for a happy couple.

Leakage With Sexual Climax

Leakage with sexual climax usually happens because of an involuntary contraction of the bladder that occurs along with the contraction of the other pelvic muscles during orgasm. With climax, there is a rhythmic contraction of the pelvic floor muscles, anal sphincter, urethral sphincter and several of the core muscles. This form of urinary leakage–often with large volumes of urinary incontinence– in many cases is due to an overactive bladder, a bladder that “contracts without its owner’s permission” causing symptoms including urinary urgency, frequent urinating and urgency incontinence.

Who Knew? “Squirting.” At the time of climax, some women are capable of “ejaculating” fluid. The nature of this fluid has been controversial, thought by some to be excess lubrication and others to be  glandular secretions (from Bartholin’s and/or Skene’s glands). There are certain women who “ejaculate” very large volumes of fluid at climax and scientific studies have shown this to be urine released because of an involuntary bladder contraction that accompanies orgasm.

How To Prevent Coital Incontinence:

  • Empty your bladder as completely as possible before sex.
  • If you have a dropped bladder, manually push the bladder back in to optimize your bladder emptying before sex.
  • Decrease fluid and caffeine intake for several hours prior to sex.
  • Experiment with sexual positions that put less pressure on the bladder.
  • Do pelvic floor muscle exercises (Kegels) on a regular basis to strengthen the voluntary urethral sphincter muscle; additionally, pelvic floor training can benefit cystoceles and overactive bladders.
  • Get in the best physical shape possible and exercise regularly (Pilates and yoga emphasize core strength and can be particularly helpful).
  • Medications: two classes of bladder relaxant medications used for overactive bladder can be helpful for incontinence that occurs with climax.

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 THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health– newly available on Amazon Kindle, Apple iBooks, B&N Nook and Kobo (paperback edition will be available May 2016).

Author page on Amazon:

Trailer for The Kegel Fix:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health and Promiscuous Eating: Understanding Our Self-Destructive Relationship With Food   

Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.  In the works is the female PelvicRx pelvic floor muscle training DVD. 

Pelvic Rx can be obtained at, an online store home to quality urology products for men and women. Use promo code “UROLOGY10” at checkout for 10% discount. 

A Brief History of Kegel Exercises

April 16, 2016

Andrew Siegel MD  4/16/16

This first piece (of a two-part entry) reviews the history of pelvic floor training from antiquity up to 2015. The second piece (the 4/23/16 entry) is a discussion of the Kegel “renaissance” and “revolution” that is underway. This “sea change” in pelvic floor medicine that is currently evolving in the urology/gynecology medical community will most certainly permeate into the mainstream in the near future.


His and hers pelvic floor muscles (Dr. Henry Gray, Gray’s Anatomy, 1918, public domain)

The pelvic floor muscles have long been recognized as instrumental for their roles in  pelvic organ support, healthy sexual functioning and for their contribution to urinary and bowel control. They also contribute to core stability and postural support. The pelvic muscles anatomically and functionally link the female pelvic organs—the vagina, uterus, bladder and rectum—and also affect the independent function of each. Pelvic muscle “dysfunction” (when the pelvic muscles are impaired and not functioning properly) in females can contribute to pelvic organ prolapse and vaginal looseness, urinary and bowel control problems, sexual issues and pelvic pain (tension myalgia). Pelvic floor dysfunction in males can play a role in the urinary incontinence that follows prostate cancer surgery, dribbling of urine after the completion of urination, erectile dysfunction, ejaculation issues and pelvic pain.

Pelvic floor muscle fitness is vital to healthy pelvic functioning and pelvic muscle training therefore plays an important role in the management of many pelvic conditions. Pelvic muscle training has the potential of not only treating pelvic floor dysfunction, but also delaying and preventing its onset.

Pelvic floor exercises date back over 6000 years ago to Chinese Taoism. The Yogis of ancient India practiced pelvic exercises, performing rhythmic contractions of the anal sphincter muscle (one of the pelvic floor muscles). Hippocrates and Galen described pelvic exercises in ancient Greece and Rome, respectively, where they were performed in the baths and gymnasiums and were thought to promote longevity as well as general health, sexual health and spiritual health.

However, for millennia thereafter, pelvic floor exercises fell into the “dark.” Fast-forward to the 1930s when Margaret Morris, a British physical therapist, described pelvic exercises as a means of preventing and treating urinary and bowel control issues. In the 1940s, the seminal work of Dr. Arnold Kegel resulted in pelvic floor exercises achieving the stature and acclaim that they deserved. Dr. Kegel wrote four classic articles that put the pelvic floor muscles and the concept of training them to achieve pelvic fitness “on the map.” Kegel’s legacy is the actual name that many use to refer to pelvic exercises—“Kegels” or “Kegel exercises.” Kegel determined that a successful program must include four elements: muscle education, feedback, resistance, and progressive intensity. He stressed the need for pelvic floor muscle training as opposed to casual exercises, emphasizing the importance of a diligently performed routine performed with the aid of an intra-vaginal device known as a perineometer to provide both resistance (something to squeeze against) and biofeedback (to ensure that the exercises were being done properly).

Despite Kegel’s pelvic regimen proving effective for many female pelvic issues, what is currently referred to as Kegel exercises bears little resemblance to what he so brilliantly described in his classic series of medical articles sixty-five years ago. His regimen incorporated a critical focus and intensity that are unfortunately not upheld in most of today’s programs.

In the post-Kegel era, we have experienced a regression to the Dark Ages with respect to pelvic training. Easy-to-follow pelvic exercise programs or well-designed means of enabling pelvic exercises to improve pelvic floor health have been sorely lacking in availability. The programs that are out there typically involve vague verbal instructions and a pamphlet suggesting a several month regimen of ten or so pelvic contractions squeezing against no resistance, to be done several times daily during “down” times. These static programs typically do not offer more challenging exercises over time. Such Kegel “knockoffs” and watered-down, adulterated versions—even those publicized by esteemed medical institutions—are lacking in guidance, feedback and rigor, demand little time and effort and often ignore the benefit of resistance, thus accounting for their ineffectiveness. With women often unable to identify their pelvic muscles or properly perform the training, outcomes are less than favorable and the frustration level and high abandonment rate with these regimens is hardly surprising.

Bottom Line: In the post-Kegel era, pelvic floor muscle training has been an often ignored, neglected, misunderstood, under-respected and under-exploited resource.

Coming next week: The Kegel Revolution

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 The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health– newly available on Amazon Kindle (paperback and Apple iBooks, B&N Nook and Kobo editions will be available in May 2016).

Author page on Amazon:

Trailer for The Kegel Fix:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health and Promiscuous Eating: Understanding Our Self-Destructive Relationship With Food   

Co-creator of Private Gym and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.  In the works is the female PelvicRx.

Pelvic Rx can be obtained at, an online store home to quality urology products for men and women.   Use code UROLOGY10 at checkout for 10% discount. 

How to Best Prepare For And Recover From Prostate Cancer Surgery: What You Need to Know

July 11, 2015

Andrew Siegel, MD  7/11/15

shutterstock_orange gu tract

Having your prostate removed is an effective means of curing prostate cancer. Unfortunately, because of the prostate’s “precarious” location – – at the crossroads of the urinary and genital tracts, connected to the bladder on one end, the urethra on the other, touching upon the rectum, and nestled behind the pubic bone in a well-protected nook of the body – – it’s removal has the potential for causing unwanted and undesirable side effects.

By strengthening the all-important pelvic floor muscles prior to and after surgery, patients can reduce the negative effects of the surgery with respect to urinary control and sexual function. 

Side Effects of Prostate Cancer Surgery

Trauma to nerves, blood vessels, and muscular tissue during surgery can compromise sexual function and urinary control. A small percentage of men will experience significant urinary incontinence, whereas most men will experience mild leakage initially, which will gradually improve over time. Many note a decline in their ability to obtain and maintain an erection after the surgery, particularly during the initial healing phase.

Additional sexual-related side effects that may occur include urinary leakage with foreplay and arousal; ejaculation of urine at the time of sexual climax; less intense orgasms and possibly pain with climax; a change in penile size with a decrease in length,  and girth; and possibly a penile deformity.

The Importance of Strengthening the Pelvic Floor Muscles

Numerous studies have shown the benefits of pelvic floor muscle training after prostate surgery in terms of a hastening the recovery of urinary control and significantly improving the severity of the incontinence.  Studies have also demonstrated the beneficial impact of such training on the recovery of erectile function with respect to how long the ED lasts and how severe it is.

Because of the potential urinary and sexual side effects of radical prostatectomy, it is prudent to commit to a program of Kegel pelvic floor exercises both before and after the prostate surgery. It makes sense to become proficient in these exercises proactively – – before the trauma of surgery – – so you go into the operation armed with precise knowledge and awareness of the pelvic floor muscles as well as with their strength, power and endurance optimized.

The Principles of Arnold Kegel

A quality pelvic floor muscle training program should adhere to the 4 principles promoted by Arnold Kegel, the namesake of pelvic floor muscle training:

  1. Muscle education
  2. Biofeedback
  3. Progressive intensity 
  4. Resistance

1. Muscle education is an understanding of your pelvic floor muscle anatomy and function.  Most men are clueless as to where their pelvic floor muscles are, what they do, how to exercise them, and what benefits they confer. In fact, many men don’t even know that they have pelvic floor muscles!  Muscle education will give you the wherewithal to develop muscle memory—the development of the nerve pathway from your brain to your pelvic floor muscles.

2. Feedback is a means of confirming that you are exercising the proper muscles.

3. Progressive intensity. Over the course of time, you gradually increase reps (number of repetitions), intensity of contraction and duration of contraction. Progression is the key to increasing your pelvic floor muscle strength and endurance. Additionally, it allows you to measure and monitor you progress and witness your increased capabilities over time.

4. Resistance adds a dimension that further challenges the growth of your pelvic floor muscles. Working your pelvic muscles against resistance rapidly escalates their strength and endurance, since muscle growth occurs in direct proportion to the demands and resistances placed upon them, a basic principle of muscle physiology.  It is similar to the difference between doing arm curls without weights versus with weights.

How To Strengthen the Pelvic Floor Muscles

D.I.Y.: One possibility is a D.I.Y. (Do It Yourself) program, but the problem lies in sticking with it and seeing it through in order to reap meaningful results.  D.I.Y. Kegels lack the foundational background and means of isolating and exercising the PFM in a progressively more challenging fashion. It is like handing someone a set of weights and expecting them to engage in a program without the essential knowledge and principles of anatomy and function, specific exercise routine and supervision to go along with the equipment, dooming them to most certain failure.

Physical Therapy: Pelvic floor physical therapy is the other extreme from D.I.Y.  This involves using the services of a physical therapist who specializes in the pelvic floor. I liken the pelvic floor physiotherapist to a “personal trainer” for the pelvic floor muscles. Pelvic floor physiotherapists have the training, tools and wherewithal to educate and instruct those in need. The down side is that physical therapy usually has to be done onsite at a physical therapy center and is both time-consuming and expensive with variable insurance coverage, depending on the carrier.

The “Private Gym” Pelvic Floor Muscle Training Program: This program gives one the advantages and benefits of pelvic floor physical therapy training, but in a D.I.Y. environment.  In many ways, it is like the highly successful P90X home training program, which I am a big fan of.  The Private Gym is the go-to means of gaining pelvic floor muscle proficiency for men who are scheduled for prostate cancer surgery and wish to train in a comfortable home environment with minimal expense.  It is a comprehensive, interactive, easy-to-use, medically sanctioned and FDA registered follow-along exercise program that builds upon the foundational work of Dr. Kegel. The Basic Training program strengthens the pelvic floor muscles with a series of progressive “Kegel” exercises, while the Complete Training program provides maximum opportunity for gains via resistance equipment.

It is recommended that the Complete Training program be used in preparation for prostate surgery because of the importance of using resistance to maximize the strength of the pelvic floor muscles. The Basic Training program can be started once sufficiently healed from surgery, with gradual progression to Complete Training at the appropriate time.

A clinical trial of the Private Gym program showed dramatic increases in the magnitude of pelvic floor muscle contractions, vastly exceeding measurements in the control group. The study demonstrated better quality erections, orgasms, ejaculatory control and sexual pleasure with a striking improvement in sexual confidence in virtually all participants. The study not only proved improved erectile function in men with mild ED, but it also showed enhanced erections and ejaculation in men without ED, with the resistance program expediting the results beyond the capacity of the non-resistance program. For more details about the results of the clinical trial please visit:

Bottom Line:  “Failure to prepare is preparing to fail.”  Before embarking on prostate surgery, make every effort to get in the best general physical shape as well as achieve the best pelvic fitness possible. Yet another reason to exercise, eat properly, and maintain a healthy lifestyle are the advantages that accrue when you get ill and need surgery. A prepared pelvic floor will do wonders in helping to recover erections and urinary control.

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 (Kindle, iBooks, Nook, Kobo) and paperback:  In the works is The Kegel Fix: Recharging Female Sexual, Urinary and Pelvic Health.

Private Gym: -available on Amazon as well as Private Gym website

5 Things You Can Do To Cure Post-Void Dribbling (PVD)

March 20, 2015

Andrew Siegel MD 3/21/15

“No matter how much you shake and dance,

The last few drops end up in your pants.


PVD is “after-dribbling” of urine that is more annoying and embarrassing than serious. Although it commonly occurs after age forty, it can happen to men at any age.  Immediately or shortly after completing urination, urine that remains pooled in the urethra (tubular channel that conducts urine) drips out, aided by gravity and movement.

One specific pelvic floor muscle (PFM) is responsible for ejecting the contents of the urethra, whether it is urine after completing urination or semen at the time of sexual climax. With aging and loss of PFM strength and tone, both PVD and ejaculatory dysfunction may occur. The specific muscle responsible for ejecting the contents of the urethra is the bulbocavernosus muscle, which compresses the deep, inner portion of the urethra to function as the “urethral stripper.” In fact, the 1909 Gray’s Anatomy textbook referred to this muscle as the “ejaculator urine.”

Factoid: Dr. Grace Dorey published the landmark article in the British Journal of Urology that proved the effectiveness of PFM exercises for erectile dysfunction (ED), but also demonstrated an association between the occurrence of ED and PVD. She essentially showed that ED and PVD are linked and parallel issues, one sexual and the other urinary—both manifestations of PFM weakness, and both treatable by PFM exercises.

Factoid: Dr. Grace Dorey wrote the foreword to my book, Male Pelvic Fitness: Optimizing Sexual and Urinary Health. She also serves as a board member at Private Gym and helped design the Private Gym male pelvic floor training program for men.

What To Do About PVD?

  • PFM training has been proven to be an effective remedy for PVD, with the premise that a more powerful BC muscle will help the process of ejecting the contents of the urethra. Not only will PFM training optimize emptying the urethra, but it also has collateral benefits of improving erections and ejaculation.
  • Try not to rush urination. Urologists interpret “Haste makes waste” as “Haste makes PVD.”
  • When you are finished urinating, vigorously contract your PFMs to displace the inner urethra’s contents. By actively squeezing the PFM by using the Private Gym “rapid flex” technique—3-5 quick pulsations—the last few drops will be directed into the toilet and not your pants.
  • If necessary, PFM contractions can be supplemented with manually compressing and stripping the urethra, but this is usually unnecessary since the PFM—particularly when conditioned—are eminently capable of expelling the urethral contents. To strip the urethra, starting where the penis meets the scrotum, compress the urethra between your thumb on top of the penis and index and middle fingers on the undersurface and draw your fingers towards the penile tip, “milking” out any remaining urine.
  • Gently shake the penis until no more urine drips from the urethra. Apply a tissue to the tip of the penis to soak up any residual urine.

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 (Kindle, iBooks, Nook, Kobo) and paperback:

Co-creator of Private Gym pelvic floor muscle training program for men Gym-available on Amazon as well as Private Gym website

The Private Gym is a comprehensive, interactive, follow-along exercise program that provides the resources to strengthen the pelvic floor muscles that are vital to sexual and urinary health. The program builds upon the foundational work of Dr. Arnold Kegel, who popularized exercises for women to increase pelvic strength and tone. This FDA registered program is effective, safe and easy-to-use: The “Basic Training” program strengthens the pelvic floor muscles with a series of progressive “Kegel” exercises and the “Complete Program” provides maximum opportunity for gains through its patented resistance equipment.


March 22, 2014

Blog # 146  Andrew Siegel, MD

As I defined it in the urban dictionary, “urgasm” is when urine is ejaculated at the time of the male sexual climax.

The penis has a dual role as a urinary organ allowing “directed” urination that permits men to stand to urinate, and a sexual and reproductive organ that, when erect, allows the penis to penetrate the vagina and release semen. Although urinary and sexual functions are discrete and separate, their interplay is complex and treatment for prostate cancer with surgery or radiation can muddle the distinction.

Semen or seminal fluid is what comprises the ejaculate.  Less than 5% of the volume is actually sperm and the other 95+% is a cocktail of genital secretions that helps provide nourishment, support and chemical safekeeping for sperm cells. About 70% of the volume comes from the seminal vesicles, which secrete a thick, viscous fluid and 25% from the prostate gland, which produces a milky-white fluid. A negligible amount is from the bulbo-urethral glands, which release a clear viscous fluid that has a lubrication function. The average ejaculate volume is 2-5 milliliters (one teaspoon is the equivalent of 5 milliliters).

“Climacturia” is the medical term for leakage of urine during orgasm, but I much prefer the term that I have coined, a combination of the words “urine” and “orgasm” into “urgasm.” What happens is that urine is “ejaculated” instead of semen. This is a not uncommon occurrence in men treated for prostate cancer with radical prostatectomy, which removes those organs largely responsible for semen production, the prostate and the seminal vesicles. It also can occur after radiation as a treatment for prostate cancer. Even though it is urine that is ejaculated and not semen, the sensation usually remains the same. Urine is generally sterile, so there is limited potential for spreading an infection to a partner.

Urinary incontinence (the inadvertent) leakage of urine, often associated with exertional activities, is commonly present in men complaining of urgasm. After radical prostatectomy, it is typically stress incontinence, leakage with exercise, coughing, bending over, sudden movements, etc. The presence of stress incontinence is a key risk factor for the occurrence of urgasm. However, some men have stress incontinence in the absence of urgasms and other men have urgasms in the absence of stress incontinence.

Urgasm can be quite distressing to the man who experiences it, as well as his partner, who might not appreciate the “golden shower.” Urinating immediately prior to engaging in sexual activity can be very helpful, it being imperative to empty the bladder as completely as possible. Pelvic floor exercises—aka Kegels—very helpful in the management of stress incontinence—may prove helpful in terms of improving urgasm.  Pelvic floor muscle contractions are the body’s natural mechanism to facilitate expelling the urethral contents. When contracted, the bulbocavernosus muscle (BC)—the body’s urethral “stripper”—compresses the deep, internal aspect of the urethra, displacing the urine within outwards. The 1909 Gray’s Anatomy refers to the BC muscle the “ejaculator urine.” Pelvic floor muscle training can foster a powerful BC muscle to help increase the capability to empty the urethra. If you are experiencing urgasm, vigorously contract the BC muscle several times after completing urination in order to empty the urethra. If necessary, this can be supplemented by manual compression and milking of the urethra in an effort to get every drop out before engaging in sexual intercourse.

Bottom LineEjaculation of urine is a not uncommon occurrence following treatment for prostate cancer, particularly removal of the prostate gland. It can be a vexing problem to the patient and partner, but can be improved with simple measures, focusing on gaining facility of the bulbocavernosus muscle, one of the important pelvic floor muscles.

Andrew Siegel, M.D.

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

Trailer for new book:

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

Available on Amazon in Kindle edition

Author of Finding Your Own Fountain of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity  (free electronic download)

Amazon page:

For more info on Dr. Siegel: