Overactive bladder

Initially, doing pelvic floor exercises can be difficult for men, and the reason it’s difficult is we probably haven’t had to do them before. We’re doing exercises that are new to us and we’re trying to find muscles that maybe we weren’t too sure where they were, or that we even had them in the first place. So when we start the pelvic floor exercises, it’s easier to do the exercises initially in lying, and in lying what we’re really trying to do is just find those muscles and start to do some of the fast contractions, some of the slow contractions. Once we’re happy that we can do them in lying, then we would move to doing them in standing.

We want them to work in standing. We want to train them in standing because it’s in standing and moving that we’re going to have, whether it’s some bowel symptoms or some urinary symptoms. Once we can do them in standing, we’ll make it harder again by maybe doing some squatting, some lunging, adding some resistance.

Men find it really difficult to do pelvic floor exercises, and what you generally find is when they try and do any pelvic floor exercises, they contract everything: buttock muscles, tummy, jaw, sometimes even the hands. So what we’re going to do first of all is just go through what you’re not going to do. We’re going to start in lying because it’s an easier position to find these muscles. Before we do anything, what we’re going to do is just ensure that we’re breathing normally, and when we do the contraction we’re going to keep breathing normally. So I don’t want you to hold your breath, because a common thing people do when they try and contract is they’ll hold their breath.

We’re going to breathe normally, and we’re going to keep the tummy nice and relaxed, so when you do the contractions the tummy is going to stay relaxed. A lot of people will feel that they’ve got to tighten that tummy as hard as possible. We want to keep that relaxed, and we also want to keep the buttock muscles relaxed and keep those knees nice and soft. So just checking: breathing normally, tummy relaxed, buttock muscles relaxed, knees nice and soft. Then what we’re going to do is really focus on the front pelvic floor.

The front pelvic floor helps form that external or outer urethral sphincter valve. That’s what we need to contract around. So I’m going to get you initially to just visualise that you’re passing urine and that you’re going to stop mid-flow. So you’re just going to squeeze at the front as if you’re stopping mid-flow and let go. You’re going to imagine you’re passing urine, so you’re going to squeeze at the front, bit of a lift, imagine that you’re stopping mid-flow, and let go. Let’s just do a few of those initially, so you could do about maybe five or six of those initially just to get that stopping mid-flow sensation.

Next thing we’re going to do is the front squeeze, but this time we’re going to also imagine that we’re lifting the scrotum or testicles up a little bit. The phrase a lot of the men like and can visualise is we’re going to do a “nuts to guts,” so if we imagine we’re lifting up nuts to guts and let go. We’re going to do this big nuts to guts feeling and let go. Squeeze at the front, doing that nuts to guts and let go. What will get those front pelvic floor muscles starting to contract is doing that big scrotum lift, nuts to guts. So where do I feel this? I feel this kind of lower tummy, almost in that triangle below my belt (I’m wearing a belt); I feel it a little bit behind the scrotum. When you’re at home or on your own, if you put your hand in behind the scrotum to that soft area, which is the perineum, when you do the contraction you’ll feel that tighten a little bit and let go.

Initially, you’ll start doing that stopping mid-flow, let go, just to really find that front part. Then you’ll progress to doing the nuts to guts. Nuts to guts is what we want you doing, really. So nuts to guts and relax, but keeping the tummy relaxed, buttock muscles relaxed, breathing normally.

You’re going to now do things a bit more specifically. We want to do some fast pelvic floor contractions and some slow contractions. The fast ones are where I’m going to do a big front lift, nuts to guts lift. I’m going to do it nice and strong and fast. I’m going to nuts to guts, strong squeeze, let go; strong squeeze, let go; strong squeeze, let go. I’m going to try and build up to doing 10 of those.

It’s important when we’re doing all of this that we try and keep the back passage nice and relaxed. Now that’s difficult, but what you definitely don’t want to do is try and actively squeeze or contract. We really want the contraction at the front. If you’ve got urinary leakage, you want those front muscles to get stronger. Whereas if you do lots and lots of back passage contractions, they will almost prevent those front muscles from coming in. So we’re going to do some fast contractions, so that’s big nuts to guts, maximum contraction, let go; maximum contraction, let go. It’s important to relax in between the contractions.

With the slow contractions, we’re just going to do a lighter contraction, about 50–60%, so a little bit less. We’re going to contract a bit lighter at the front, nuts to guts, and we’re aiming to keep breathing and hold for one – 1, 2, 3—up to 10, and let go. That is difficult, so if you can’t hold for 10, that’s okay. You could hold for 5. You could start off doing 5 repetitions for 5 seconds, and once you feel “I can do that,” then you could do 8 for 8 seconds and then 10 for 10 seconds. We want you doing some fast contractions, 10, and then building up to doing 10 slow contractions for 10 seconds. You’re trying to really get to a point where you’re doing that three times per day. Once you can do it three times per day and you feel “I can do this,” then we want you to do them in standing—that’s really important.

It’s very important that if you’re experiencing any changes in urinary function, or changes in bowel function, changes in erectile function, or any pelvic-related pain, that you seek help from your GP. When doing the pelvic floor exercises, these should be comfortable to do and they should not be painful. It’s also important that you don’t overdo it. A lot of men doing pelvic floor exercises may feel that the more they do and the harder they do them, the quicker things will improve, but that tends to make things much worse or cause new problems. So it’s important to do small amounts as advised in the video, and do them gently as advised.

Another top tip is really for the men who’ve got particularly urinary frequency or urgency. So frequency is when I’ve just been to the loo and I feel I could go again. Urgency is where you get this sudden feeling that I need to urinate now, so instead of it being a very slow build-up, you go from not feeling like you need to urinate to suddenly feeling you need to urinate. Sometimes we use a technique called bladder training with those men, but it’s easier to do that if you can measure what your bladder pattern is like, and this is where we get men to fill in a bladder diary. CliniMed has a really good bladder diary that we can signpost you to.

Before we would do anything to try and change that pattern of urination, we get those men to measure it for about 5–7 days. Another good tip is to look at your hydration. It’s quite common that if men have urinary incontinence, or frequency, or urgency, it is intuitive to them to start to drink less. So you can end up that their fluid intake becomes too low, and that then makes things worse. That kind of intuition to drink less is actually making the problem much worse. We look at really what hydration or fluid intake is – how much water people are taking in, but also what people are taking in in terms of things that might irritate the bladder. So how much coffee am I drinking today, how much tea, how many carbonated drinks, how much alcohol – and it’s easier to modify or change that if you also do a hydration diary, which we can also signpost you to on the CliniMed website.

Two things that are going to really help with your pelvic floor exercises, and also whether it’s your urinary control, bowel control, or both. One of those is the Squeezy app for men. So Squeezy app for men is an award-winning NHS app, so it can be found in the Google Store, in the Apple Store, and you download it to your phone or device. It helps you do the fast contractions, it counts one fast contraction, it helps you with the slow contractions, so it’s kind of an aid to doing the exercises, and it also records how often you’ve done them. It helps you build up that you’ve done them twice today or three times. Men love the Squeezy app for men.

The second thing is doing the knack. So most men who’ve either got urinary incontinence or anal incontinence will be able to say, “Well, in these activities I’m leaking,” and the common ones are initially maybe going from sitting to standing, standing to sitting, bending down to the floor, lifting something, a cough or sneeze. What can happen there is the timing of those sphincters is out. If I’m going to cough, sneeze, or lift something heavy, what should happen is before I do that activity, that pelvic floor should contract, close those sphincters, so I can do that activity and I’m not leaking. That timing tends to be out when there is a pelvic floor issue, so what we’re going to get you to do is the knack.

Let’s say that I’m standing and I’m going to bend down to put my shoes back on. What I would do is a nice front contraction – let’s say I’m leaking urine –so I’ll do a nice front contraction, a nuts to guts strong contraction. I’m going to keep that contracted, I’ll bend down to my shoe, maybe tie that up, keep it contracted, and come back up. It may be that it’s when I get out of a chair. I’m sitting watching the TV, I’m fine, but once I get out of the chair I know that I’m going to leak some urine. What I would do is, in sitting, before I get up, contract at the front – a nice big nuts to guts front contraction –keep it contracted, stand up, then relax. You’re not going to need to do that forever—you tend to do that for a few weeks—and then that tends to help that timing so it becomes more automated.

Similarly, with people where they’ve got lack of control of wind, it may be that they pass wind when they cough or sneeze. What they will do is, they feel they’re going to cough or sneeze, they will do a nice squeeze around the back passage, keep that contracted, sneeze, relax. It may be that they feel they’re going to maybe get a little bit of faecal leakage—maybe they’re out playing golf and they feel they’re a bit nervous about bending down into the hole to pick the ball out. What they would do is a nice contraction around the back passage, bend down, and relax. This is really helping that kind of muscle patterning and muscle memory timing. So two things that are worth exploring are the knack, and then what will help you actually do the exercises in a more fun way is the NHS Squeezy app.