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Medical Forum / Diseases and Disorders / Prostate Cancer / February 2005

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Revisionary Kegel Theory and Practice 101; the "Tdub" sphincter exercise

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Tdub - 27 Jan 2005 04:22 GMT
The following are two great sphincter exercises, in order of
effectiveness, IMO, which worked for me - it took me 18 mos. from RRP
to get continent (only slight leaking even standing/walking), where
normal Kegels were a dismal failure - I'm certain that if I did the
following instead of Kegels I would have regained continence a lot
sooner; Kegels just didn't work for me:

1) There are two parts to this first exercise. THE FIRST PART: in the
evening when you are relaxing after a long day, and sitting or lying
around, drink 3 or 4,  8 oz. glasses of any liquid during a period of
fifteen minutes or so. I like to drink soy milk, but regular milk, like
chocolate milk, would do; juices would be fine too. Better to do this
when your bladder is already near your current bladder capacity (i.e.,
you haven't pee'd in awhile). After drinking the 24-32 oz., don't get
up until you can't stand the pressure anymore and you absolutely have
to go. You should be able to hold out for at least an hour before
getting up and going to the bathroom, but this depends on your current
state of progress. B4 you pee you'll feel the pressure from the
increase in bladder size, and your sphincters natually clamping down
harder to hold back the flow. Then go pee when you can't take it
anymore. THE SECOND PART: in the morning, when you get up, don't just
run to the bathroom without thinking. First, sit on the edge of the bed
and concentrate on how the muscle contractions feel naturally holding
back the urine flow. Then gently stand up and try to maintain the same
feeling (i.e., try not to cause a change in the natural muscle
contraction). Stay standing for a minute or so and concentrate on, and
feel, the natural pressure/muscle contraction. Then walk to the
bathroom trying to maintain the same pressure/muscle contraction. You
can add to the natural contraction a little, but don't do anything
major. As a result of doing this exercise even once you may notice a
big improvement within a day or so. What you have just done is increase
the strength of the specific/exact muscles you need to get stronger
(they got stronger overnight after the first part of the exercise) and,
with the second part, you have trained them to contract naturally, and
thus work effectively, when you are standing up and walking. I would do
this exercise up to 2 or 3 times a week perhaps, but you can benefit
from it if you only did it a couple times a month.

2) When you are sitting and lying around, at a time when you can
concentrate, and aren't generally exposed to distractions, and
particularly when you haven't peed in awhile, apply a very gentle and
slight contraction of the sphincter muscle, and hold it this way for as
long as you can concentrate on it. I say "very gentle" and "slight"
because if you overdo it you will wear out the muscle and regress
instead of make progress. It's good to do this after you feel the
muscles naturally contracting a bit because then you will know the
exact muscles to apply pressure to. I think this type of exercise is
better than Kegels because it is closer to what you want the muscles to
do (stay steady) and you are getting closer to the exact muscles that
need to get stronger. IMO, Kegels are generally too vague in terms of
the particular muscles applied and strengthened to be of any value, and
can often interfere with the strengthening of the precise/specific
muscles needed for sphincter control. I know this is similar to the
start and stop while you are peeing routine, but I didn't find that to
help for some reason.
A Sherman - 31 Jan 2005 00:56 GMT
There has been a lot of incontinence discussion lately.  Everyone is different
but here's my experience:

I had previously tried both Kegels and interrupting the stream, I had major
setbacks. This could possibly result from too much stress on the sphincter.
My urologist seemed to take a skeptical attitude toward exercise, and
indicated that the problem would likely resolve itself given time.

At about 9 months post RRP, I suddenly stopped almost all leaking.  I have
gone from significant intermittent leaking to occasional spurts and rare
dribbling.  This improvement has only been for a couple of weeks.  Usually
posting a success story here is the precursor to a setback, but this time I
think it is different.  I have not needed a pad at night and the pad stays
nearly dry throughout the day.  For me this was a dramatic change that came on
with surprising suddenness.  There is hope!

My uro seems to think that the healing and recovery time is likely to be
related to the amount of disruption caused by the surgery.  He says there was
more than the usual amount of trauma in my case because it was very difficult
for him to remove my 150 gram prostate due to its large size.

Al

----- Original Message -----
From: "Tdub" <gripshift5@email.com>
Newsgroups: alt.support.cancer.prostate
Sent: Wednesday, January 26, 2005 11:22 PM
Subject: Revisionary Kegel Theory and Practice 101; the "Tdub" sphincter
exercise

> The following are two great sphincter exercises, in order of
> effectiveness, IMO, which worked for me - it took me 18 mos. from RRP
[quoted text clipped - 3 lines]
> sooner; Kegels just didn't work for me:
>    ....<snip>....

Earlier postings:
"Tdub" <gripshift5@email.com> wrote on 12/09/04:
> Three weeks ago (17 mos. post RRP) I was 2-3 pads a day, I am today
> down to one or none. Had a couple of experiences that gave me an idea.
[quoted text clipped - 23 lines]
> a couple times a month. Good luck and godspeed! Yours truly, (today) a
> (very) happy camper.

"Tdub" <gripshift5@email.com> wrote on 1/16/05:
>I found Kegels to be rather dangerous, they didn't seem to help me for
> 10 months after RRP, then I became virtually continent (< 1 pad/day)
[quoted text clipped - 15 lines]
> bladder gets fuller, and "adding to" the natural contraction for
> improvement.
Tdub - 31 Jan 2005 16:08 GMT
Mr. Sherman's experience supports my view that there are problems with
the traditional Kegel view - that the jerking back and forth of the
sphincter via overly foreced contractions is in some cases
counterproductive, that it is better to be more sensitive to the
natural function of the sphincter in its trying to hold back flow while
sitting or lying down, and instead try to amplify/enhance this by just
adding to the natural contraction, and do this quite mildly in order to
avoid overworking the delicate muscle. I have found that the occasional
squirts and missteps are reduced by a mild but concentrated and
consistent (not short and hard as with Kegel exercises) slight
contraction of the sphincter - this is most easily done while lying or
sitting around (when you can concentrate on it), what I referred to as
my second exercise in the orginal post at the beginning of this thread.
It's only been a matter of a few days since the original post, and it
is working - daily improvements, and big improvements from week to
week. Whoever thought up Kegels (i.e., Mr. Kegel) probably didn't have
an RRP himself, and didn't have to figure out how to recover from long
term incontinence resulting from the RRP. It was probably an untested
theory that survived over a long period time because of our tendancy to
give credence to the conventional wisdom, IMO.
I.P. Freely - 03 Feb 2005 02:22 GMT
I was ready to try this aproach this evening, but closer examination puzzles
me. You say we should feel the natural contractions that stop the flow when
we fill our bladders to the brim or when we get up in the morning, then
learn to mimic and strengthen that feeling.

Problem: I've never perceived that contraction. All I've ever perceived is a
Kegel, and I could shut off a full-bladder firehose or stay dry in a sneeze
or cough with Kegels the day my catheter came out. I find Kegels of use only
to preempt leakage when I anticipate physical exertion. I don't feel
dribbles until they're past the Kegel chokepoint, so all a Kegel contributes
to a dribble is distance (maybe altitude someday, if my potence returns).

You can actually FEEL the autonomic/automatic (the Kegels require conscious
effort) sphincter contract? Can any of the rest of you?

I.P.

> Two great sphincter exercises:
snip
> . . .  B4 you pee you'll feel the pressure from the
> increase in bladder size, and your sphincters natually
> clamping down harder to hold back the flow.
Tdub - 03 Feb 2005 05:22 GMT
2 points. 1) there have been a lot of complaints in this forum about
inability to control flow while standing, when sitting and lying down
control is ok. I had the same problem. I largely fixed it by retaining
the natural muscle contraction from the sitting/lying down position to
the standing position. In other words, you don't jump up and run to the
bathroom without thinking. If you do this your nerves/muscles will
think that the thing to do is to flow as soon as you stand up. If
instead you carefully stand up, and be conscious of the
contraction/pressure feeling incident to retaining fluid, and try to
maintain this (easy, boy!) while standing you can make substantial
progress. There will still be some leaking standing/walking, but if you
practice and gradually increase the load it will work. It takes time
but you have to notice the subtle day to day or week to week
improvements to stay on course.           2) My theory is that instead
of Kegels for general improvement, it is better to apply a very mild
and consistent contraction, and do this when you can really concentrate
on it (it does require concentration, you can't do it while your busy).
This way the muscle won't get burned out from overexertion, the nerves
will get the message that a constant contraction is the way to go, not
the jerking back and forth of Kegels, and the muscles will become
stronger over time, but it does take time.         As far as "do I
actually feel the autonomic/automatic" response? "Yes", if my bladder
has filled up enough to feel the pressure from the natural contraction,
"no" if I have recently peed. In the former case you can add slightly
to the natural contraction, in the latter case you can just gently and
lightly add a little contraction even though you don't feel anything
"autonomic/automatic" because your bladder has (relatively) nothing in
it. I haven't experienced what you have. You have been relatively
continent but appear to have long term inconvenient (and minor)
dribbles, etc. I would just suggest that you try not doing the hard,
jerk-like contractions of a Kegel, and just add a dose of deliberate,
mild contraction which might do two things: increase the muscle
strength, and most importantly, train the nerves that they should
generally contract the muscle until you tell them to relax when you are
peeing. I think you just have to listen to your body and try things.
Keep an open mind.
I.P. Freely - 03 Feb 2005 07:19 GMT
Much of your post rings true for me. I've been almost bone dry sleeping and
sitting since I left the hospital three months ago, and don't have to rush
to the bathroom even if my bladder is full, but can overflow 3-4-5 big
Depends pants in several hours on my feet, particularly doing anything
physical. I'm completely relaxed sitting or lying even if my bladder is
really full, yet dribble and squirt much of the time on my feet, often
without feeling it especially if distracted, even minutes after a thorough
void.

It sounds like you're advising maintaining a slight Kegel every upright
moment, with the goal being to train the Kegel muscles to subconsciously
keep us dry while upright. That's not something I recall hearing/reading
before, and it sounds worth trying. The problem is that not only am I very
much mentally and physically preoccupied while upright, I'm very often also
physically active, sometimes extremely so. My only physical constraint since
a month post-op has been tennis elbow, and I've got a ton of hard labor --
building a deck, landscaping, setting up a new garage -- facing me before my
sports season consumes me starting in 6-8 weeks. If I'm still flowing freely
by then, well, I guess I'll just leave a trail behind me. I'm not letting
wet shorts -- or pants, or floor -- get in the way of my life, because it is
probably shortened dramatically now despite my very healthy lifestyle.

My primary prostate surgeon is astounded I'm not dry by now, and insists
that I perform ten full-effort, 10-second Kegel contractions every waking
hour. That advice comes straight from the authors of "PC for Dummies", but
I'm leaning more towards about a fourth of that level of effort, more in
line with most other advice I read, plus lower-level Kegels the rest of the
day, as you're advising. He's going to be ticked next week that I'm not
doing 160 max-effort, 10-second contractions daily.

In all my reading, I've never read why I'm as dry as a bone and as relaxed
as a wet sock while sitting or sleeping, even with a full bladder, yet
dribble and squirt freely just because I'm standing up. Add physical
exertion and distraction and I'm completely filling a big Depends in an
hour, and I haven't even begun my garage/yard/deck work yet. I guess the
neighbors will just have to get used to their dogs following me around the
yard, 'cause I'm not waiting much longer to get back to my projects. I'm
tired of paying others to do things I could do myself.

I'd trained myself to subconsciously tense one muscle or another every
waking hour several times in my life. I had to change my walk because I kept
kicking one ankle as a kid, taught myself to retain a military posture every
waking moment for its many health benefits, even learned to subconsciously
control how my feet strike the ground after countless ankle sprains, many
severe. I guess I can train my freaking Kegel muscles to perform every
upright moment, subconsciously, if that's what it takes.

So why haven't my docs, or any of the books, suggested that? What am I/are
we missing, considering that the guy who chopped up my crotch is stunned
that I'm not dry as a bone?

Thanks for the advice. I'm going to change my strategy from occasional,
deliberate, frequent crotch isometrics to full-time (while standing) subtle
and subconscious mild restraint.

I.P.

> 2 points. 1) there have been a lot of complaints in this forum about
> inability to control flow while standing, when sitting and lying down
[quoted text clipped - 32 lines]
> peeing. I think you just have to listen to your body and try things.
> Keep an open mind.
Tdub - 03 Feb 2005 15:59 GMT
Well, I don't have all the answers but I know the doctors don't either
about this, or I'd be completely dry by now (18 mos. post RRP) given
all the Kegel effort I put in during the first 10 months. The "soft"
and "conscious" approach I have used since 10 mos. has given me lots
more progress than I saw using the "hard" and "laissez-faire" approach
in accord with the conventional wisdom. I also am very physically
active, at 55, and I found that walking never helped. I had done tons
of this B4 RRP. In fact, long periods upright seemed to actually harm
progress, and I think this is because the muscle/nerves then get the
idea that it is OK just to "flow" unrestricted. If you gradually
increase the amount your bladder can retain standing up, making a
smoother transition from sitting to standing, and not going to the
bathroom right away (let it drip some, you're muscles are also learning
to retain standing up) you'll see progress. I think we need to coax our
bodies into doing what we want the mechanism to do naturally, and this
includes just not peeing as often. I think the "convenient" but
"unnecessary" peeing, when our bladders are only a little full, is
counterproductive - you are then training your mechanism to go more
often, which you don't want it to do. I think the doctors that say it
is dangerous to try to get your bladder to hold more are wrong - after
an RP, particularly if you had BPH B4 the RP, your bladder is
substantially shrunk and thick, and the only way to get it to reverse
this is to deliberately try to get it to hold more, and pee less often.
I went from only being able to hold 1/4 cup or so (during the first 10
mos.) to now being able to hold well over a cup and a half in my
bladder. This I did using the dring 3 or 4 glasses when your bladder is
already at least somewhat full routine, and waiting at least another
hour B4 going. I only did this once every few weeks. Some on the forum
said they felt "OUCH", I only felt a wonderful new sensation, of a
(true, genuine) strengthining of the sphincter muscles that I hadn't
felt during the first 10 months post RRP following the myopic Kegel
conventional wisdom.
 
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