Jack, a 66-year-old retired professor, came to therapy for back pain and a history of toileting hourly, feeling urgency sometimes every half hour, occasional leaking before making it to the bathroom and constipation. His primary functional limitation was that he could not golf 18 holes with his friends every week. He filled out a bladder/bowel screening checklist (see box) on his initial visit.

Jack, like many men over 50 years of age, has at least one of five problems related to the urinary and pelvic muscle systems. The diagnoses for these men include urgency and frequency, overactive bladder, urge incontinence, poor urine stream flow and hesitancy with starting urination, constipation, pelvic pain/prostatitis and erectile dysfunction.

The basis for men's bladder and bowel problems is often a combination of changes in the prostate gland, the pelvic muscles and autonomic nervous system.

The Prostate Gland

Surrounding the urethra at the base of the bladder is the prostate gland. It produces fluid that transports sperm and helps with immune function. The prostate is walnut size until a man is 35 years old. Then it gradually enlarges. This is called benign prostate hyperplasia (BPH). It can narrow the urethra so urine flow is constricted and urine remains in the bladder longer. The result can be urgency and frequency, poor urine stream flow, a feeling of incomplete emptying and urge incontinence.

The Pelvic Muscles

The bladder and bowel are supported by the pelvic muscles, also referred to as the pelvic rotator cuff. These muscles form a bowl suspended between two pelvic tendons connected to the obturator internus muscles that attach on the femur at the greater trochanter. The pelvic muscles also attach on the sacrum, coccyx and pubic bones. This bowl of muscles, the pelvic and urogenital diaphragm muscles, exhibit increased resting tone and sometimes spasm when bladder and bowel dysfunction is present. Increased resting tone prevents normal elimination of urine and bowel movements and alters alignment of the sacroiliac and lumbosacral joints. Back pain, poor urine stream flow, a feeling of incomplete emptying, and constipation are common symptoms that can be related to pelvic muscle tone changes.

The Autonomic Nervous System

The autonomic nervous system (ANS) is a common factor in both prostate and pelvic muscle function or dysfunction. The ANS directs activity of smooth muscle and secretory function of the prostate gland and determines pelvic muscle resting tone. High pelvic muscle resting tone can lead to constipation and straining to eliminate bowel movements. High resting tone of the pelvic muscles interrupts urine flow and is a factor in pelvic pain/chronic benign prostatitis and low-back pain.

Elevated prostate smooth muscle resting tone leads to urethral occlusion and interrupted urine flow. It can lead to poor and interrupted urine stream flow and potential urinary retention. Jack's complaint of urgency and frequency and overactive bladder is the result of the bladder, directed by the ANS, trying harder and more frequently to push urine out against a narrowing urethra.

As the bladder tries harder to push urine out, Jack's frustration grows and he decides to drink less and less. Instead of helping solve the problem, this only makes things worse. The decreased fluid intake leads to the bladder getting smaller and holding less urine, and the urine becomes more concentrated with waste products that irritate the bladder. Urgency, frequency, overactive bladder and constipation increase. As a result, Jack cancels his weekly golf outing because of his increasing problems.

What to Do?

There are three easy-to-follow steps to improve male urinary symptoms. These techniques rebalance function of the ANS, pelvic muscle and prostate, smooth muscle resting tone, and restore more normal urine flow and bowel regularity. Jack's therapist recommended all three as a treatment approach.

Step One: Start with the deepest core of control, the autonomic nervous system. Rebalance the neurological messages to the pelvic muscles, bladder, prostate and bowel. The ANS determines the resting tone of all smooth and striated muscles through sympathetic control of the muscle spindle. Physiological quieting techniques of handwarming, diaphragmatic breathing and body-mind quieting can normalize bladder, prostate, bowel and pelvic muscle resting tone so urine flows more effectively and bowel patterns normalize. One of the easiest exercises is diaphragmatic breathing. The key to this exercise is to focus on your breathing, paying attention to its rhythm and location.

Think to yourself: "Slow, low breathing. My abdomen rises with inhale and falls with exhale. Quiet shoulders, quiet chest. Jaw released, teeth apart, tongue at the bottom of my mouth."

In step one, Jack practiced diaphragmatic breathing three to four times a day for 30 to 60 seconds which helped him rebalance the sympathetic and parasympathetic portions of the ANS to return his bladder and bowel to normal function.

Step Two: Focus on the second core level of lifestyle change. Jack focused on sleep, nutrition and exercise as the keys to step two-lifestyle change. He scheduled a bedtime routine so he slept between eight and nine hours a night, He used absorbent continence pads so he would not worry about getting up and toileting more than once a night. He listened to the physiological quieting CD to improve deep sleep during the night.

Jack also changed some basic food and drink habits to improve bladder and bowel control. These included drinking six to eight glasses of water daily, eliminating caffeine and, because constipation is a problem, eating a fresh pear and bright green vegetables like spinach, chard or broccoli daily. Finally, Jack added walking 30 to 60 minutes a day to improve pelvic muscle, bladder and bowel function. Jack changed his food and drink habits and listened to the physiological quieting CD at bedtime to improve his sleep.

Step Three: Finish with the third core level of realigning and reeducating the pelvic muscle system and internal organs.

To realign and reeducate the bladder and bowel in the pelvic cavity, use a Wonder W'edge and incorporate the Roll for Control exercises. Recline on a wedge approximately 6 inches high with hips on the highest end of the wedge and feet on the floor or on a wall. Roll knees and toes out several inches against a resistance band and hold for a count of 10. Rest for a count of 10. Then roll knee and toes in against a ball for a count of 10. Rest for a count of 10. In step three, Jack practiced the Roll for Control exercises, for 10 repetitions three times a day for two weeks.

After incorporating the three core steps for two weeks, Jack told his therapist, "My back pain is gone, my bladder urgency problems are eliminated and I can have a BM without straining. I can play 18 holes of golf without going to the bathroom. Life is good and back to normal."

Resources

1. Hulme, J. Beyond Kegels: Treatment Algorithms and Special Populations. Missoula, MT: Phoenix Publishing.

2. Hulme, J. (2009). Beyond Kegels: Fabulous Four Exercises and More To Prevent and Treat Incontinence, 3rd ed. Missoula, MT: Phoenix Publishing.

3. Hulme, J. (2009). Power Up! Men's Bladder, Bowel, and Sexual Function. Missoula, MT: Phoenix Publishing.

Janet A. Hulme is a physical therapist with more than 35 years of experience. She is an international speaker on abdominal and pelvic muscle function in relation to women's health.

Bladder and Bowel Screening Tool

In the past month you have seen: (Answer yes or no)

• Leaking with physical activity, coughing, sneezing, etc.

• Leaking with sudden uncontrolled urge to go

• Slow and continual leaking

• Difficulty getting to the bathroom in time

• Know where every bathroom is & limit trips

• Feeling of incomplete emptying

• Toileting every one to two hours during the daytime

• Two or fewer hard bowel movements a week

• Straining to eliminate

• Feeling of incomplete emptying of stool

• Frequent passage of unformed soft to liquid stool two or more times/day

• Alternating constipation and diarrhea, bloating, gas

• Staining in underwear with liquid or small pieces of stool

-Janet A. Hulme