Pubococcygeus muscle. The pubococcygeus muscle arises from the back of the pubic bone and the anterior part of the obturator fascia and inserts into a fibromuscular layer between the anal canal and the coccyx. In animals, the pubococcygeus draws the tail under the body.

Iliococcygeus muscle. The iliococcygeus muscle arises from the ischial spine and from the arcus tendineus of the pelvic fascia and is attached to the coccyx and the median raphe. In animals, the iliococcygeus wags the tail.

Ischiococcygeus muscle. The ischiococcygeus arises from the pelvic surface of the ischial spine and is inserted into the side of the coccyx and lower sacrum. It is responsible for pulling the coccyx forward after defecation.

Puborectalis muscle. The puborectalis muscle arises from the pelvic surface of the pubic bone, blends with the levator ani and is inserted into the muscle from the other side, posterior to the rectum, at the anorectal flexure. It can be considered part of the pubococcygeus muscle. It helps maintain fecal continence by maintaining the anorectal angle.

Rhabdosphincter. The intrinsic striated muscle of the external urethral sphincter mechanism in the urethra is called the rhabdosphincter [Dixon and Gosling 1994]. It surrounds the membranous urethra and lies deep to the urogenital diaphragm. It is postulated that it receives triple innervation from the sympathetic, parasympathetic, and somatic nervous systems [Gray 1998]. The superficial muscle fibers arise from the transverse perineal ligament and surrounding fascia and insert into the perineal body. The deep fibers form a continuous circular formation around the membranous urethra. The muscles from both sides together form a sphincter compressing the membranous urethra and assisting in the maintenance of urinary continence.

The continence mechanism in men consists of the continuous smooth-muscular structure of the bladder base, the bladder neck, and the proximal urethra, supplemented by the striated muscle fibers of the horseshoe-shaped rhabdosphincter [Elbadawi 1995]. It was Elbadawi who led thinking away from the previous concept of a separate internal and external sphincter, describing instead a “continuous” continence mechanism.

Anal sphincter. The anal sphincter consists of elliptical muscle fibers on each side of the anal canal, attached to the tip of the coccyx posteriorly and inserted into the perineal body anteriorly. Inferiorly, it blends with the skin surrounding the anus; superiorly, it forms a complete sphincter and blends with the puborectalis muscle. The anal sphincter is in a normal state of tonic contraction, but can provide greater occlusion of the anal aperture when needing to contain feces and flatus.

The pelvic floor muscles are supplied by nerve roots S2, S3, and S4.

Bladder storage. Urinary continence relies on three mechanisms: an anatomically intact urinary system; integration of neural modulatory structures in the brain, spinal cord and peripheral nervous system; and a competent urethral sphincter mechanism [Gray 1992, Park et al. 1997]. Maintenance of urinary continence is multifactorial and depends on detrusor control and urethral closure function [Bernstein 1997]. Passive urethral closure is enhanced by the activity of the rhabdosphincter muscle and the use of the pelvic floor muscles, particularly during increased intra-abdominal pressure.

The urine produced by the kidneys is propelled along the ureters into the bladder by peristaltic activity of the smooth ureteric muscle. The viscoelastic bladder is compliant to the volume of urine produced, so that the bladder pressure remains at zero. When the bladder fills to 350–500 mL, the intravesical stretch receptors are stimulated via S2–S4 and trigger a detrusor muscle contraction and a strong desire to void. The first sensation of filling is usually at approximately 200 mL. This initial desire to void can be normally controlled. Voiding will usually take place later, following a stronger desire to void.

Elimination of Urine and Feces

Micturition. The external urethral sphincter is relaxed during micturition. At the end of micturition, the sphincter contracts and together with the bulbocavernosus muscle ejects the last few drops of urine.

Voiding is initiated by the relaxation of the striated pelvic floor musculature under voluntary control, and voiding is completed by reflex action. The detrusor muscle contracts, increasing the internal pressure in the bladder. Urine passes through the relaxed involuntary and voluntary muscle of the urethra. Voiding occurs at approximately 15 mL/s in males (20 mL/s in females), although it is faster in young men. Maximum flow rates are obtained at volumes of 300– 400 mL in normal men. Flow rate is improved by a standing position in men [Berger 1995]. Normally, the bladder empties completely.

After micturition, the external urethral sphincter muscles and the pelvic floor muscles (including the bulbocavernosus muscles) contract, while the detrusor muscle relaxes, enabling the bladder to refill, thus repeating the micturition cycle.

Defecation. The external anal sphincter and pelvic floor muscles relax, while the abdominal muscles contract to eliminate feces.

Neurological control of the bladder. The neurological control of the bladder is a complex subject, and the local interactions between neurologic modulators of the urethra and detrusor are less clear [Gray 1992]. The detrusor muscle is under neurological control from the brain, the spinal cord, the peripheral nerves, and the neurotransmitters of the lower urinary tract [Gray 1998].

Sexual Function

The two muscles that have an important role in sexual function are the bulbocavernosus and the ischiocavernosus muscles.

Ischiocavernosus muscle. The ischiocavernosus muscle arises from the inner surface of the ischial tuberosity and pubic ramus and inserts into an aponeurosis into the sides and under surface of the crus penis. Contractions of the ischio-cavernosus muscles produce an increase in the intracavernous pressure and influence penile rigidity.

Prostate Conditions

Prostate gland. The prostate gland is a small, walnut-shaped, fibromuscular gland with ducts situated at the base of the bladder surrounding the prostatic urethra. The young adult prostate is about 4 × 3 × 2 cm in size and weighs about 20 g, but the size increases with age [Neal 1997]. The prostate gland produces fluid that provides one of the constituents of semen. The fluid contains nutrients, such as zinc (antibacterial factor) and citrate (sperm transport), enabling sperm motility and mobility [Sant and Long 1994]. Prostate-specific antigen (PSA), a protein secreted by the prostate gland, may be found in the bloodstream. During ejaculation, the smooth muscle of the bladder neck contracts to prevent urine escaping and semen entering the bladder.

Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is a condition that includes benign prostatic enlargement due to a multiplication of normal cells, lower urinary tract symptoms, and bladder outlet obstruction. The prevalence of benign prostatic enlargement increases with age. However, there is no significant relationship between prostate size and symptoms [Simpson et al. 1996].

Pathologic BPH is divided into two stages: microscopic and macroscopic [Sant and Long 1994]. The earliest microscopic nodules of BPH develop in men between 30 and 50 years of age in the periurethral zone and may infiltrate the transitional zone. The etiology of BPH is imprecisely defined. Aging and the presence of androgens, especially dihydrotestosterone, are essential factors for the development of BPH.

Blockage to the prostatic urethra causes voiding symptoms of hesitancy, weak stream, straining, intermittency, incomplete emptying, and terminal dribble. Severe blockage may cause acute retention of urine and the need for immediate surgery.

Intervention for BPH. Transurethral resection of the prostate (TURP) is the most frequently performed operation for BPH and is carried out using a resectoscope with a cutting loop and coagulating electrode. In all forms of prostatectomy, the bladder neck is resected, rendering the closure mechanism incompetent. Postoperatively, continence relies on the strength and integrity of the external urinary sphincter. Men can experience retrograde ejaculation after prostatectomy. During normal ejaculation, closure of the bladder neck prevents seminal fluid from entering the bladder. However, after surgery, seminal fluid may enter the bladder on ejaculation and is voided during the next micturition.

A retropubic or suprapubic prostatectomy is occasionally carried out for greatly enlarged prostates with BPH. The procedure is carried out through a lower abdominal incision.

The range of minimally invasive treatments for men with BPH has steadily expanded during the last decade. The energy sources range from microwaves and radiofrequency waves to high-intensity focused ultrasound, laser vaporization, coagulation, and resection, and electrosurgical techniques [Djavan et al. 1999]. However, TURP is still regarded as the gold standard surgical option.

As an alternative to surgery, other treatments such as drug therapy and stents may be advised. Patients will be guided by their urologist to make an informed choice from the different treatments available.

There are two drug therapy treatments available for the reduction of urinary symptoms caused by benign prostatic enlargement. Drug therapy using 5a-reductase inhibitors reduces the size of the prostate by inhibiting the enzyme necessary for testosterone metabolism. However, if the medication is withdrawn, the prostate gland will return to pretreatment size or rebound with an increase in size. This medication acts by androgen deprivation and may be responsible for loss of libido in some men.

For men with retention who are unfit for surgery, wire or silicone mesh stents can be positioned inside the restricted prostatic urethra to allow the free flow of urine. Unfortunately, various problems can arise with the use of stents. They can cause infection and are prone to encrustation or even migration into the bladder.

Prostate Cancer

Prostate cancer is the second commonest cancer in men in the United Kingdom, after lung cancer [National Statistics Office 2000], and it is the third most common cancer globally after lung and stomach cancer [World Health Organization 2003].

Prostate cancer occurs as the result of primary tumors in the majority of cases [Gray 1992]. Prostate cancer is caused by a multiplication of abnormal cells and is associated with loss of apoptotic potential and uncontrolled proliferation [Denmeade et al. 1996]. Prostate adenocarcinomas originate within the stroma (cortex) of the gland, with a firm, single or multifocal nodule. As the tumor volume increases, it causes enlargement of the prostate gland, which may give rise to symptoms of bladder outlet obstruction. The cause of prostate adenocarcinoma remains unclear, but genetic, racial, viral, and dietary factors have been suggested.

Benign prostatic hyperplasia and prostate cancer are two separate entities. One does not lead to the other, although they may coexist. Prostate cancer may be slow-growing in the elderly, who may die “with” rather than “of” the disease.

Intervention for prostate cancer. Men with prostate cancer may be given the choice of a radical prostatectomy, radiotherapy (known as brachy-therapy if radioactive seeds are used), antiandrogen treatment, or more rarely now orchidectomy. Endocrine therapy includes gonadotropin-releasing hormone antagonists or antiandrogen drug treatment as a treatment for prostate cancer. Side effects include gynecomastia, loss of libido, and erectile dysfunction. Shared decision-making is now considered to be an integral part of gaining informed consent from patients for most urological surgery. Radical prostatectomy is becoming increasingly preferred for localized disease, particularly now that nerve-sparing techniques can help preserve potency and continence [Resnick 1991].

Urethral Stricture

Urethral stricture occurs when scar tissue narrows the urethra following surgery, urethritis, or trauma. It may occur at any part of the urethra, from the external meatus to the prostatic urethra. At the penoscrotal junction, strictures may form from traumatic catheterization [Denning 1996].

Treatment of a stricture consists of dilation under anesthetic or surgical division by urethrotomy. Maintenance treatment may consist of regular dilation by intermittent self-catheterization [Lawrence and MacDonagh 1988].

Prostatitis

Prostatitis may cause considerable rectal and suprapubic discomfort (see pelvic pain, below).

Male Incontinence

Prevalence of urinary incontinence in men. The prevalence of urinary incontinence in men increases with age and ranges from 3.6% in men 45 years old to 28.2% in men 90 years of age or older [Thomas et al. 1980, Britton et al. 1990, Brocklehurst 1993, Malmsten et al. 1997]. The prevalence of reported urinary incontinence in men also varies with the definition of incontinence and the threshold of incontinence used.

The prevalence of urinary incontinence 3 months after transurethral resection of the prostate is about 6% [Emberton et al. 1996, Neal 1997].

The prevalence of urinary incontinence 1 year after radical prostatectomy ranges from 14% to 16% [Davidson et al. 1996, Donnellan et al. 1997].

Classification of incontinence. Incontinence may be classified into stress urinary incontinence, urge urinary incontinence, mixed incontinence, postmicturition dribble, continual incontinence, overflow incontinence, extraurethral incontinence, and functional incontinence.

Extraurethral Incontinence

Extraurethral incontinence occurs rarely when leakage occurs as a result of an ectopic ureter or from a fistula.

Functional Incontinence

Functional incontinence occurs when men are unable to get to the bathroom in time due to problems of poor mobility and dexterity.

Assessment of Male Incontinence

Before a diagnosis can be made, and before treatment can be commenced, a subjective and objective assessment is required [Dorey 2001a].

Subjective Assessment

The subjective assessment is based on the patient’s account of his symptoms and should include questions in the following categories:

• Patient’s age, occupation, hobbies, and activities
  
• Chief complaint and other symptoms
  
• Duration and severity of symptoms
  
• Amount of leakage
  
• Frequency of leakage
  
• Urine stop test (this question provides an opportunity to explain that this exercise can lead to retention of urine, counteracts the normal micturition reflexes, and therefore should not be practiced)
  
• Bowel activity
  
• Diet
  
• Surgical history (dates of transurethral resection of prostate, radical prostatectomy, abdominal surgery, spinal surgery)
  
• Medical history (including prostatitis, diabetes, latex allergy, metal implants, medications, radiotherapy, neurological problem)
  
• Previous treatment
  
• Body mass index
  
• Sexual problems (difficulty achieving or maintaining penile erection or premature ejaculation)
  
• Functional factors (mobility and dexterity)
  
• Motivation
  
• Medical investigations (urinalysis of midstream urine, uroflow, ultrasound postvoid residual, blood test for prostate specific antigen, urodynamics, cystoscopy, 24-h pad test, frequency/volume chart.

Objective Assessment

The objective assessment includes an abdominal, perineal, neurological, and digital anal examination. The objective assessment can be undertaken by a physiotherapist or nurse with specialist training. The specialist training should include the theory of the assessment and a practical examination of a plastic male model under supervision.

The patient should be given an opportunity to be chaperoned either by a partner or friend or by a member of staff.

The objective assessment should always begin with an explanation of the reasons for needing a digital anal examination. It can be explained that it is necessary to know whether the muscles that help to control continence are working. The strength and endurance of these muscles can be assessed best by feeling them, the method of exercising can be checked, and the correct amount of exercise can be given. The skin sensation can also be checked. If the patient is unhappy about a digital anal examination, he may allow a perineal examination, but he should not be persuaded against his wishes.

Following this detailed explanation, the patient must give informed consent to the objective examination and the consent must be entered in the patient’s notes. At this stage, he should be given the opportunity to visit the lavatory.

For the objective examination, the patient should be lying on his back with two pillows under his head, with his knees bent and his feet on the plinth (the crook-lying position), without his underwear but with a sheet or paper sheet over his pelvis. He may retain his sheath and drainage system if he has one.

Abdominal Examination

Perineal Examination

Initially, it is necessary to observe the pelvic area in the crook-lying position for congenital abnormalities such as hypospadias, in which the urethral meatus opens on the underside of the penis. At this stage, an enlarged testis, warts, hemorrhoids, and tumors may be identified. The skin condition should be examined for evidence of redness, infection, and excoriation in the penile, perineal, scrotal, and anal areas.

The patient may then be asked to tighten the anus as if to prevent wind escaping, while the anal wink is observed. Then he can be asked to tighten at the front as if to prevent the flow of urine and feel a scrotal lift and the base of the penis pull back toward the abdomen. After this, he is asked to give an unguarded cough, which may provide evidence of leakage. He is then requested to cough while he is tightening his pelvic floor muscles to prevent leakage, which may provide evidence of urinary control.

The patient should be informed of the findings from the digital anal examination. The pelvic floor strength (0—6), the length of hold up to 10 s (endurance), the number of repeats, and the ability to perform a fast contraction should be discussed and recorded.

After the subjective and objective assessment, it is possible to make a problem list (multiple diagnoses), detail the aims of treatment, list the treatment modalities to be used, make a note of any advice to be given, and form a treatment plan.

Intervention for Male Incontinence

Biofeedback is a mechanism by which the patient is more aware of pelvic floor muscle activity and encourages greater muscular effort [Burgio et al. 1989, Knight and Laycock 1994, Jackson et al. 1996, Van Kampen 2003]. Many patients are unable to contract the pelvic floor, or do not understand the maximum effort needed. Biofeedback can often provide the necessary awareness for muscle reeducation. There are three recognized methods of biofeedback: digital, manometric (pressure), and electromyographic [Bump et al. 1991, Haslam 1999]. The three biofeedback methods have been studied and compared, and they appeared to correlate with each other well [Haslam 1999].

Digital anal biofeedback. A lubricated and gloved index finger can be used during a digital anal examination to monitor the strength and endurance of the external anal sphincter and the puborectalis muscle. This information can then be communicated to the patient in order to provide feedback and encouragement.

Manometric biofeedback. An anal pressure probe can be used to monitor muscle activity and provide manometric biofeedback. The anal probe can be attached to a manometer with a visual display. Sophisticated computerized equipment with a colored visual display screen, audible feedback, a variety of work and rest programs, and a printer is considered the gold standard by many therapists. This equipment can also be used for electromyographic biofeedback and electrical stimulation. The patient should be placed in the crook-lying position with the knees bent and apart, with a sheet or paper sheet over his pelvis. He should be able to see and hear the monitor screen. The probe should be covered with a condom, lubricated with gel, and approximated to the patient’s anus. The patient is then asked to bear down as if releasing flatus, while the probe is gently inserted. The probe needs to be held in a position that records maximal readings and prevents it from slipping out.

The manometric pressure is usually measured in bars or numerical units using anal perineometry, or by centimeters of water (cmH₂O) or millimeters of mercury (mmHg) using more sophisticated computerized equipment.

Electromyographic biofeedback. Electromyography (EMG) is the study of minute electrical potentials produced by depolarization of the muscle membrane [Siroky 1996]. Bioelectric activity of the muscles can be recorded using either a needle sensor, an anal probe, or surface sensors. The bioelectric activity is measured in units of microvolts (mV).

The anal probe is easier to apply using lubricating gel whilst the patient bears down as if to release wind, but most probes need to be held by the therapist to prevent slippage. New-shaped anal electrodes fit snugly into position and allow ambulatory use. Anal probes are strictly for single-patient use. The anal probes are attached to a computerized biofeedback machine, which monitors the bioelectric activity of the muscles by EMG biofeedback and provides a colored visual display and sometimes an audible signal to encourage greater effort.

Surface skin sensors may be used on the perineum. They can be used to monitor the activity of the pubococcygeus and the ischiococcygeus muscles. The skin needs to be cleansed with an alcohol swab to remove any oils that may prevent good contact. It may be necessary to shave the area. Better contact is made by using new surface sensors for each treatment. Two small, sticky surface sensors can be placed longitudinally over the pubococcygeus and the ischiococcygeus muscle to be monitored by EMG and can be placed 1 cm lateral to the midline. A third sensor can be placed over a bony point such as the sacrum or coccyx, to act as a reference (grounding) to cut out extraneous “noise” from the electrical activity of other muscles in the area. However, some EMG equipment uses a triangular arrangement for all three sensors, with the two active sensors longitudinal to the muscle fibers. One of the benefits of EMG is its use in functional positions. Problems associated with the use of EMG may be due to the size of the sensor pad or probe, which may pick up electrical activity from the surrounding muscles. Surface EMG is noninvasive, painless, and can also be used as an initiator of cerebral control, a tool of assessment, a motivator, and a method of recording; it can be used both to encourage and challenge the patient [Haslam 1998]. Manometric or EMG biofeedback is a useful adjunct to pelvic floor muscle reeducation to stimulate greater patient effort.

Electrical stimulation has been used for men with stress urinary incontinence postprostatectomy [Sotiropoulos et al. 1976, Kraus and Lilien 1981, Hirakawa et al. 1993, Bennett et al. 1997, Moore et al. 1999].

Maximal electrical stimulation can be applied pulsed at the maximum intensity tolerable for short periods of 20 min at a frequency of about 30–50 Hz to produce a tetanic contraction. The pulse train off-time should exceed the on-time in order to prevent muscle fatigue. Knight and Laycock [1994] stated that a pulse width of 200 ms produced excitation at relatively low current intensity and was more comfortable than shorter pulse widths. They suggested that acute maximal electrical stimulation may benefit patients with very weak pelvic floor muscles.

Bladder training for urge urinary incontinence. Bladder training [Frewen 1979] or urge suppression is a method of consciously suppressing the urge to void in order to delay micturition and increase functional bladder capacity [Wells 1988]. Deferment techniques to delay voiding can be taught with strategies such as keeping calm, sitting on a hard surface, standing still, waiting for 1 min for the urge to disappear, and distraction. Once the urge has abated, men will be able to continue their activities, thus allowing their bladder to stretch and fill further. If they wish to visit the bathroom, they should never dash mid-urge. Patients undergoing bladder training need considerable encouragement, motivation, and determination to succeed.

Fluid intake. Guyton [1986] stated that normal fluid intake averages 2300 mL per day, two-thirds of which (1518 mL) is direct fluid, while the remainder is a product of food synthesis. It may be more helpful to monitor the 24-h urine output, which should be about 1000–1500 mL. Normal intake should be increased during hot weather, with strenuous activity, and when eating salty foods. No one should ever be thirsty. If the urine is dark, the patient should be encouraged to drink more fluid. Water is the best thirst quencher.

Diuretics. Natural diuretics are commonly xanthines, such as caffeine and theobromine, occurring primarily in beverages, which act chemically in the body to increase urine production. Caffeine occurs naturally in about 60 species of plants, most commonly in coffee beans, tea leaves, cocoa seeds, and the cola nut [Moore 1990]. Caffeine is also added to several over-the-counter medicines, to counteract the drowsiness that the drug produces as a side effect or to enhance analgesic absorption [Wells 1988]. Caffeine is a bladder irritant and stimulant, with a diuretic effect. It can cause the detrusor muscle to contract, with implications of nocturia, frequency, urgency, and urge urinary incontinence [Addison 1997]. Caffeine should be reduced slowly over a 3-week period in order to prevent withdrawal symptoms of headaches or drowsiness.

Cranberry juice. In the 19th century, the North American Indians used crushed cranberries as a herbal remedy for the treatment of urinary tract infections [Bodel et al. 1959, Moen 1962]. It is also believed that cranberry juice has a bacteriostatic effect by affecting the adherence of certain organisms, particularly Escherichia coli, to the lining of the bladder [Beachy 1981].

Addison [1997] recommended cranberry juice for patients with a high risk of urinary tract infection, those with cystitis from E. coli, patients with indwelling catheters, those undertaking intermittent self-catheterization, and those using sheath drainage. He considered that the recommendation of cranberry juice should be supported by written patient information and be monitored and recorded with dosage, patient instructions, contraindications, side effects, and expected outcomes. There is controversy regarding the drinking of cranberry juice, as drinking in excess of 1 L a day over a prolonged period may increase the risk of uric stone formation [Rogers 1991]. Other side effects include gastritis, increased joint pain for rheumatoid arthritis sufferers [Addison 1997], and diarrhea in patients with irritable bowel syndrome [Leaver 1996].

Medication for urge urinary incontinence. For men with severe urge urinary incontinence and men with nocturnal enuresis, anticholinergic medication may be helpful whilst they are receiving conservative treatment. The side effects include a dry mouth, drowsiness, constipation, and vision accommodation difficulties.

Postprostatectomy Incontinence

Postprostatectomy incontinence should be treated according to the presenting symptoms. Following TURP and radical prostatectomy, patients may have stress urinary incontinence due to sphincter damage, urge urinary incontinence, or a combination of both types. The internal urethral sphincter at the bladder neck is damaged in all forms of prostatectomy and continence relies on a competent external urethral sphincter, reinforced by the pelvic floor musculature.

Preprostatectomy intervention. It would be useful for patients to receive pelvic floor muscle exercise education when they are fit before prostate surgery. They could then increase the strength and endurance of the pelvic floor muscles to help prevent or reduce incontinence postsurgery [Porru et al. 2001].

Postprostatectomy intervention. After TURP and after radical prostatectomy, patients can carry out pelvic floor muscle exercises when the catheter has been removed. Some consultants allow gentle pelvic floor exercises whilst the catheter is in place. After surgery, patients may have iatrogenic stress urinary incontinence due to sphincter damage, or urge urinary incontinence, or a combination of the two types. Symptoms of frequency, nocturia, urgency, urge urinary incontinence, stress urinary incontinence, and postmicturition dribble can be treated conservatively. Treatment modalities include pelvic floor muscle exercises, biofeedback, electrical treatment, lifestylechanges, and bladder retraining. “The knack” of tightening at times of increased intra-abdominal pressure should be taught, to help patients cope with activities such as moving from sitting to standing and with coughing and sneezing [Ashton-Miller and DeLancey 1996].

Postmicturition Dribble

Research has shown that pelvic floor muscle exercises are extremely effective for postmicturition dribble and should be advised in preference to bulbar urethral massage (urethral milking) [Dorey 2003]. In a randomized single-blind trial to test the efficacy of urethral milking, Paterson et al. [1997] found that pelvic floor muscle exercises were almost twice as effective as urethral milking, and the authors recommended pelvic floor exercises as a treatment for this condition. Contracting the pelvic floor muscles after voiding may facilitate a contraction of the bulbocavernosus muscle, which acts to eliminate urine from the bulbar portion of the urethra. This technique is termed a “squeeze-out” pelvic floor muscle contraction [Dorey 2003].

Overflow Incontinence

Clean intermittent self-catheterization is used for patients with incomplete emptying due to detrusor underactivity or detrusor–sphincter dyssynergia. Detrusor underactivity occurs when the smooth detrusor muscle fails to contract, due to either lack of neurological control or overstretching. Overstretching may also cause pelvic nerve compression. The detrusor contraction may not be strong enough to empty the bladder completely. Detrusor–sphincter dyssynergia is due to neurological impairment and occurs when the detrusor muscle and sphincter contract simultaneously whilst voiding. This can result in retention of urine in the bladder.

Neurological Detrusor Overactivity Incontinence

This is the result of a neurological condition. The bladder fills and empties automatically by detrusor overactivity. The treatment of this type of incontinence consists of clean intermittent self-catheterization, a sheath drainage system, or—as a last resort—an indwelling catheter. For patients who are permanently catheterized, a suprapubic catheter is more acceptable. Medication, in the form of anticholinergic drugs, or surgery, such as a clam ileocystoplasty, sphincterotomy for detrusor dyssynergia, or sacral root stimulation by neuromodulation, may be necessary.

Extraurethral Incontinence

Extraurethral incontinence occurs when the distal end of the ureter opens into a place other than the bladder, such as the rectum or perineum. A fistula—a passageway connecting the bladder to the bowel, resulting from trauma or infection following surgery—will also cause extraurethral incontinence. Patients with extraurethral incontinence need to be referred for surgery.

Functional Incontinence

Functional incontinence is incontinence that is caused by problems of poor mobility and dexterity. Patients may find it difficult to reach the toilet in time, due to physical and environmental factors. Functional incontinence should be treated by improving the patient’s environment, by social care and aids, and by lifestyle and clothing adaptations.

Treatment Outcomes

Treatment aims to achieve urinary control, continence, and confidence by conservative measures. However, it is not always possible to achieve this outcome, and patients may need help with managing their condition. It is important to set realistic goals.

Pelvic Pain

Orchialgia

Orchialgia is pain in one or both testicles. Hayden [1993] and Holland et al. [1994] treated orchialgia with transcutaneous electrical nerve stimulation (TENS) and considered the treatment beneficial.

Penile Pain

Penile pain may be caused by penile prosthesis surgery, intracavernosal injections and circumcision, and may have a psychological aspect [Wesselmann et al. 1997]. There have not been any psychological studies of penile pain independently of other urogenital pain disorders. Causative conditions are paraphimosis, Peyronie’s disease, priapism, and herpes genitalis. Penile pain may be relieved if the underlying cause is treated [Gee et al. 1990].

Prostatitis

Prostatitis occurs as a result of inflammation of the glandular portion of the prostate [Gray 1992], causing discomfort in the rectal and suprapubic areas. The semen may be yellow or blood-stained. There are four types of prostatitis: acute bacterial, chronic bacterial, nonbacterial (prostatosis) and nonbacterial prostatodynia. Acute and chronic bacterial prostatitis occur as a result of bacteria ascending via the urethra. The causal agents in nonbacterial prostatitis and prostatodynia have not been identified.

The symptoms of prostatitis may be malaise and fever in the acute stage before the onset of dysuria, urgency, frequency, and obstructive voiding. In both the acute and chronic stages, there may be pelvic pain.

Treatment for both bacterial and nonbacterial prostatitis is modestly effective. Antibiotics are used for bacterial prostatitis. Nonbacterial prostatitis has been treated with pulsed short-wave therapy [Singh et al. 1997]. However, pseudodyssynergia has been misdiagnosed as chronic prostatitis [Kaplan et al. 1997].

Prostatodynia

Prostatodynia is nonbacterial inflammation of the prostate and urethra. Pelvic floor relaxation techniques and short-wave therapy have been used for men with prostatodynia [Segura et al. 1979, Singh et al. 1997].

Perineal Pain

Perineal pain may be present in patients with orchialgia and prostatodynia [Wesselmann et al. 1997]. Myofascial release may help in the management of pain from pelvic dysfunction.

Cancer Pain

It is important to note that there are no symptoms with prostate and bladder cancer in the early stages. The first sign of bladder cancer is hematuria. No two cancers are the same. In the later stages of prostate cancer, there are symptoms of hip, leg, and back pain, which may be mistaken for arthritis.

Proctalgia Fugax

Proctalgia fugax causes anal pain due to spasm of the anal sphincter. This can sometimes be alleviated by sitting on the toilet and bearing down as if voiding feces, thereby relaxing the anal sphincter.

Erectile Dysfunction

Introduction

Definition. Erectile dysfunction was defined by a National Institutes of Health Consensus Development Conference in 1993 as “the inability to achieve or maintain an erection sufficient for satisfactory sexual performance” [National Institutes of Health 1993].

Severity. There are varying degrees of erectile dysfunction; mild erectile dysfunction has been described as achieving a satisfactory erection in seven or eight attempts out of 10; moderate erectile dysfunction as achieving erection in four to six attempts out of 10; and severe erectile dysfunction as achieving an erection in zero to three attempts out of 10 [Albaugh and Lewis 1999].

Causes of erectile dysfunction. Erectile dysfunction may have arteriogenic, venogenic, diabetic, neurological, psychological, drug-induced, and trauma-related causes. Risk factors include accidental trauma, trauma from surgery, and radiation therapy [Lewis and Mills 1999]. Lifestyle-related factors include cigarette smoking [Dorey 2001b], chronic obstructive lung disease, alcohol abuse [Gambert 1997, O’Farrell et al. 1998, Tan and Philip 1999], drug abuse [Benet and Melman 1995], bicycling [Andersen and Bovim 1997, Nayal et al. 1999], and horse riding [Albaugh and Lewis 1999].

Erectile dysfunction always has a psychological component in addition to the underlying cause [Intili and Nier 1998].

Research has shown that erectile dysfunction can be caused by weakness of the bulbocavernosus and ischiocavernosus muscles [Claes and Baert 1993, Colpi et al. 1994, Ballard 1997, Van Kampen 2003, Colpi et al. 1999, Mamberti-Dias et al. 1999, Dorey 2003].

Anatomy of the penis. The penis consists of three cylindrical erectile bodies: dorsally, the two corpora cavernosa communicate with each other for three-quarters of their length, and ventrally the corpus spongiosum surrounds the penile portion of the urethra. The proximal end of the corpus spongiosum forms a bulb attached to the urogenital diaphragm and at the distal end expands to form the glans penis [Kirby et al. 1999].

Muscles associated with penile rigidity. The muscles influencing penile rigidity are the ischiocavernosus and the bulbocavernosus muscles. The ischiocavernosus muscle is a paired muscle that arises from the medial aspect of the ischial tuberosity and inserts into the medial and inferior surface of the corporal bodies. The bulbocavernosus muscle originates from the central perineal tendon and attaches to the dorsal surface of the corpus spongiosum and to the fascia surrounding the corpora cavernosa that covers the deep dorsal vein of the penis. Contractions of the ischiocavernosus and bulbocavernosus muscles produce an increase in the intracavernous pressure. Rhythmic contraction of the bulbocavernosus muscle propels the semen down the urethra, resulting in ejaculation. Both muscles are supplied by the perineal branch of the pudendal nerve (S3-S4).

Mechanism of erection. Penile erection occurs following a series of integrated vascular events, culminating in the accumulation of blood under pressure and end-organ rigidity [Moncada Iribarren and Saenz de Tejada 1999]. This vascular process can be divided into five phases:

• Flaccidity. A state of low flow of blood and low pressure exists in the penis.
  
• Latent or filling phase. When the erection mechanism is initiated by any stimulus, the penile smooth arterial muscle relaxes and the cavernosal and helicine arteries dilate, enabling blood to flow into the lacunar spaces.
  
• Tumescence. The venous outflow is reduced by the compression of the subtunical venules against the tunica albuginea (corporal venoocclusive mechanism), causing the penis to expand and elongate, but with a scant increase in intracavernous pressure.
  
• Full erection. The intracavernous pressure rapidly increases.
  
• Rigidity. The intracavernous pressure rises higher than the diastolic pressure and blood inflow occurs with the systolic phase of the pulse, enabling complete rigidity to occur. Contraction or reflex contraction of the ischiocavernosus and bulbocavernosus muscles produces changes in the intracavernous pressure. No arterial flow occurs.
  
• Detumescence. Contraction of the penile smooth muscles and contraction of the penile arteries leads to a decrease of blood in the lacunar spaces, and the contraction of the smooth trabecular muscle leads to a collapse of the lacunar spaces.

Treatment of Erectile Dysfunction