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