Andrew Siegel MD 4/4/20 *This entry is relevant for prostate cancer patients as well as any patient, male or female.
Interview with the “average Joe”:
Have you heard of Kegel exercises? “I think so…they’re for women after childbirth, right?”
Do you know how to Kegel? “No, I didn’t even know men have those muscles.”
Do you know why to Kegel? “Not a clue.”
Do you know the benefits of Kegels-on-demand? “No, I never heard of this.”
Even if you’re one of those rare men who know about your pelvic floor muscles, how to exercise them and the benefits accrued, it is unlikely that you know how to Kegel-on-demand. Truth be told, Kegel exercises–like any form of physical training that doesn’t involve sports and an element of fun–are BORING. DULL. TIRESOME. TEDIOUS. MONOTONOUS. However, Kegels-on-demand–the applied, practical and utilitarian form of Kegels–can be helpful and capable of lifting your spirits. Read on.
Pelvic floor muscle training is a first-line, simple and conservative approach to help resume bladder control (and erections) following radical prostatectomy. Stress urinary incontinence—leakage with sports, coughing, sneezing, bending and other high impact activities—is a common occurrence immediately following surgery. Contracting one’s pelvic floor muscles “on-demand” (Kegels-on-demand)– briskly engaging the pelvic floor muscles immediately prior to any activity that triggers the incontinence –can effectively improve or eradicate the problem.
TIP OF THE DAY (for men and women):
If you have every experienced urinary or bowel urgency (the unanticipated and strong desire to hustle to the restroom), the following advice is worthwhile. When you feel the sudden and urgent need to urinate or move your bowels, snap your pelvic floor muscles briskly four or five times, briefly but intensively (another form of Kegels-on-demand). When these muscles are so engaged, the bladder and bowel muscle reflexively relax and the feeling of intense urgency should disappear, at least for a while. Understand that this is most effective when the bladder or bowels are not full, but when the urgency is caused by the bladder or bowels are contracting involuntarily.
Bonus of the day from article hot off the press: Use Kegels to help eliminate knee pain while running.
Pelvic Floor Muscles (PFM)
The PFM are skeletal muscles comprised of both fast twitch and slow twitch muscle fibers. Fast twitch fibers predominate in high contractile muscles that fatigue rapidly and are used for fast-paced muscle action, e.g., sprinting. Slow twitch fibers predominate in endurance muscles, e.g., marathon running. The pelvic floor muscles have a baseline tone because of the presence of slow twitch fibers. The presence of fast twitch fibers allows their capacity for voluntary contraction. The PFM fibers are 70% slow twitch, fatigue-resistant, endurance muscles to maintain constant muscle tone (e.g., sphincter function and pelvic support) and 30% fast twitch, capable of rapid and powerful contractions (e.g., sexual climax, interrupting the urinary stream and tightening the anus). Aging causes a decline in the function of the fast twitch fibers but tends to spare the slow twitch fibers.
The deep pelvic floor muscle—a.k.a. levator ani (“lift the anus”)—forms the bottom of the “core” group of muscles and comprises the floor of the pelvis. This muscle helps support the pelvic organs, reinforces the external sphincter and, in conjunction with the sphincters, plays an important role in maintaining urinary control.
Male pelvic floor muscles including superficial (ischiocavernosus, bulbocavernosus, transverse perineal muscles, external anal sphincter) and deep (levator ani) components, Attribution of this image: Openstax / CC BY (https://creativecommons.org/licenses/by/3.0)
When the internal sphincter is damaged, the bladder neck is often left in a scarred, fixed open position, similar to a brittle “washer” in a faucet that no longer has the elasticity and suppleness to provide closure. Under this circumstance, continence becomes largely dependent upon the external sphincter. The external sphincter is not designed for sustained contraction, as is the internal sphincter. Even though the external sphincter has a steady state level of tone to it, it can only be intensively contracted for a brief period of time on demand. A well-functioning external sphincter, in the face of a poorly functional internal sphincter—although helpful in combatting stress incontinence—does not provide sufficient “endurance” of closure to keep one completely dry. For this reason, men with stress urinary incontinence often report that the incontinence is better in the morning but becomes worse in the later afternoon hours, on the basis of external sphincter fatigue.
Pelvic Floor Muscle Training
Since the external sphincter is a voluntary skeletal muscle that is contributed to by the levator ani, PFM training has the potential to increase its tone, strength, power and endurance. When this muscle complex is trained, the sphincter will become more robust and will be better able to maintain continence. PFM conditioning will hone the ability to produce a voluntary, sustained and powerful contraction to offset stress urinary incontinence.
Numerous clinical studies have shown the benefit of PFM training to facilitate an early return of urinary continence following radical prostatectomy. In addition to hastening recovery of urinary control, pelvic training has also been shown to improve the degree of incontinence and the severity of other lower urinary tract symptoms.
To reiterate about Kegels-on-demand– Be attentive to the specific triggers that provoke the incontinence. By intensively contracting the pelvic floor muscles immediately prior to trigger exposure, the incontinence can be prevented, if not made less severe. For example, if the transition from sitting to standing is what brings about the leakage, a brisk and sustained pelvic muscle contraction immediately prior to standing up can help control the problem. This maneuver—engaging the pelvic floor muscles immediately before an activity that might provoke the problem—can be a highly effective means of managing stress incontinence and when practiced diligently, can ultimately become an automatic behavior that does not require conscious thought. This Kegel-on-demand effectively accomplishes pinching your urethra closed from the inside, similar to the effect of pinching your penis closed with your fingers.
The following exercise program is highly recommended as the most expedient means of achieving pelvic floor muscle conditioning, (disclaimer: I am co-creator of the program): PelvicRx (www.PelvicRx.com). It is a nicely-designed, easy to use, follow-along and interactive 4-week pelvic training DVD that offers strengthening and endurance pelvic floor exercises. It provides education, guidance, training, and feedback to confirm the engagement of the proper muscles. It is structured so that repetitions, contraction intensity and contraction duration are gradually increased over the course of the program. This gradual progression is the key to optimizing pelvic strength and endurance in order to address urinary (as well as sexual) issues following prostate cancer treatment. The ideal time to learn pelvic floor muscles is prior to surgery.
The reader is also referred to a book I wrote on the topic of male pelvic floor training: MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health.
10 Ways to Ensure That You Are Properly Contracting Your Pelvic Floor Muscles
- Gaze down: The base of your penis retracts inwards towards the pubic bone as you contract your PFM.
- Gaze down: The testes rise towards the groin as you contract your PFM.
- When you place your index and middle fingers in the midline between the scrotum and anus you feel the PFM tighten as you contract them.
- You can pucker your anus as you contract your PFM. The anus tightens and pulls up and in, known as the “anal wink.”
- You get a similar feeling as when ejaculating when you contract your PFM rhythmically.
- When you touch your erect penis, you feel the erectile chambers surge with blood as you contract your PFM.
- You can make your erect penis elevate (lift and point) as you contract your PFM.
- You can stop your urinary stream completely when you contract your PFM.
- You can push out the last few drops of urine that remain after completing urination when you contract your PFM.
- After pursuing PFM training you notice better urinary control (and the bonus of improved erections and ejaculation).
It is important to know that PFM conditioning is beneficial to any man (and woman for that matter) and not just those men who have been treated for prostate cancer. The PFM are vital to genital and urinary health and serve an essential role in sexual, urinary and bowel wellness in both genders. A fit and trained pelvic floor in men can help improve/prevent erectile dysfunction, ejaculation issues, stress urinary incontinence, overactive bladder, urinary after-dribbling and bowel urgency and incontinence.
Biofeedback
Biofeedback is an adjunct to PFM training that can be helpful in men who have difficulty in gaining an understanding of their PFM. Special sensors are used to relay auditory and visual feedback information about the quality and magnitude of one’s PFM contractions. The intent of biofeedback is to enhance awareness of the PFM, ensure contraction of the proper muscles, and to optimize control over PFM function.
Pelvic Floor Physical Therapy
Physical therapy is commonly used to help rehabilitate injured muscles and joints prior to surgery, following surgery and as an alternative to surgery. Pelvic floor physical therapy is a niche and growing sub-specialty of physical therapy that can be of benefit to men with urinary control and other pelvic issues. I liken pelvic floor physical therapists to personal trainers for the PFM, but they are so much more and serve a vital role in the rehabilitative process. Patients are taught to coordinate the use of their PFM with functional activities including exercise, sitting, standing, home and daily activities, sexual intercourse, etc.
Bottom Line: A fit and toned pelvic floor is beneficial from bathroom to bedroom and can help prevent or improve many issues, including stress urinary incontinence, overactive bladder, post-void dribbling, erectile dysfunction, ejaculation problems and bowel issues. Master your pelvic floor and learn to Kegel-on-demand–you will not regret the effort.
Wishing you the best of health,
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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. He is a urologist at New Jersey Urology, the largest urology practice in the United States.
The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Prostate Cancer 20/20 on Apple iBooks
PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now on sale at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours).
Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Tags: Andrew Siegel MD, levator ani, Male Pelvic Fitness: Optimizing Sexual and Urinary Health; targeted exercise, pelvic floor muscle training, pelvic floor muscles, PelvicRx, post-prostatectomy urinary incontinence, Prostate Cancer 20/20, stress urinary incontinence, urinary sphincter
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