Pelvic Floor Muscle vs. Sphincter

I've been trying to build a well-rounded understanding of how this part of the body works, based on info I've gotten from my surgeon (minimal) and pelvic floor-focused physical therapist (much more). Some of what I've been told is leading me to more questions, the more I think about it, and I thought someone here might have a better understanding than I do.

So here's what I THINK I know to be true:
1. In healthy men, the sphincter at the bottom of the bladder is what does the primary work of shutting off the flow of urine.
2. Women don't have this sphincter, so they use the pelvic floor muscle to pinch the urethra to shut off flow.
3. During RP surgery, every effort is made to preserve the sphincter, and this usually is achieved.

So here's where I get foggy:
I assume that the sphincter doesn't work so well for a while after surgery because it's been traumatized. Also, it's been stretched (along with the urethra) for a week or two by the Foley catheter, and it takes it a while to get back to a normal size and shape so it can begin to work properly.

The main question:
If the above is correct (and I know that I may have it all wrong) why the big focus on doing Kegels to build up the pelvic floor muscle? Is it so we can use the female method to assist with shut-off in case the sphincter doesn't recover fully (or at all)? Or is it just to give us an interim method of shutting off until the sphincter does recover, so we can be continent sooner?

I do get the impression from all that I've read that it's not as simple as just waiting for the sphincter to recover, and then all is well. It does seem like a significant percentage of patients have much more complicated outcomes.

Andrewski
Currently six weeks post-surgery/one month post-catheter.
Leaking into pads 60 to 175 ml per day, depending on activity level. Leakage trend has been more or less steadily downward.

Andrewski, From what I understand, you are (mostly) right. Men at birth have two sphincters. One at the bottom of the bladder above the prostate, and one below the prostate. This double valve system allows the prostate to provide seminal fluid for ejaculation and shut off the potential for urine to escape during ejaculation. RP surgery removes the lower sphincter along with the prostate.

As far as the question about voluntary control goes, that also sounds right. We learn as boys how to use our pelvic floor muscles....whenever you learned how to 'hold' it, you were using your pelvic floor muscles, you just didn't know what they were.

On a slightly related note, maybe you can clear something up for me while you're deep in the pelvis!

During orgasm... what's doing the squeezing... (and is it still there after RP, does it still squeeze, and what does it squeeze on, air?)

The whole valving arrangement you describe makes sense and explains why some men dribble during the warm up act I imagine.

Paul, again, this is how I understand things....

The clear fluid that sometimes drips during foreplay comes from the Cowper's glands, and may still be present after RP.

The system down there is pretty darned complex, to be sure. The nerves that run alongside the Prostate (that are frequently damaged during PC treatment) are the nerves that stimulate the valves in the veins that drain the penis, which leads to erection. The nerves that create the sensations that ultimately lead to orgasm are different, the run up through the penis, and are concentrated at the head. Which is why some men who are totally impotent after PC treatment can still have the sensations and even something that feels like orgasm without anything resembling an erection.

I think the pulsations are muscular, and are related to the pelvic floor muscles, which are triggered by the sensory nerves in the penis as opposed to the nerves that trigger erection. To answer the question, yes they are pulsating on 'air' if there is no prostate present.

All this is why, for example, a man can be trained to delay ejaculation by learning how to use the pelvic floor muscles..just as a woman can use her pelvic floor muscles to tighten her 'grip' so to speak during intercourse.

Interesting. According to that drawing, the "external sphincter" appears to just be where the urethra passes through the pelvic floor muscle. I wonder if it's a true sphincter at all, or just an area that gets squeezed by that muscle. I was under the impression that the upper sphincter, at the bladder was typically preserved during surgery, or at least often is. Maybe not, and it's the lower one they talk about being preserved. Anybody know?

For some reason, on my computer, the posts in this thread are stretched wider than the window and I must scroll left to right to read. Odd. I hope it was not the link I copied causing that? Who knows?

www.drcatalona.com/quest/quest_spring03_2.htm

Somebody said...
He explained that it is important to know the anatomy in the area of the operation and to be gentle so as to prevent as much trauma and bleeding as possible.

Bleeding makes it hard for a surgeon to see what he's doing. When a surgeon has a good view, he can be precise, meticulous and dissect in exactly the right place.

"Most important is not to injure the muscle fibers of the external sphincter," Dr. Catalona said. "I call it the 'no touch technique'. Do your best to leave them the way God made them."
"The fear far outweighs the reality."

He explained that temporary incontinence is usually (although not always) a component of post surgery recovery. Bladder control starts improving soon after the catheter is removed, but it could take six to 18 months for the complete return of continence in some patients. After that time period, little improvement is expected.

While incontinence seems to have several definitions, Dr. Catalona uses only one: "If men have to wear any kind of protection at all, they are incontinent."

Using that definition, five and a half percent of his patients have a very mild incontinence 18 months after surgery and one and a half percent have severe incontinence. Age figures strongly into these outcomes and so does the fact that some men go into the surgery with previous incontinence..............................................

In addition, the internal sphincter muscle, the muscle that involuntarily controls bladder output, is removed with the prostate.

After the operation, men who had three layers for holding back urine – the internal sphincter muscle, the prostate lobes pressing against each other, and an external sphincter muscle – have only one, the external sphincter.

"The external sphincter can do all the necessary work to hold in the urine, but it has to be strong. That's why the Kegel exercises, both before and after surgery, are so important," Dr. Catalona said.

He explained why procedures during the surgical removal of the prostate cause temporary incontinence and how time and the healing process usually fix the situation.

The bladder and the urethra must be connected to each other but if they were just sewn together, postoperative swelling of the tissues would close the opening for the urine to pass through. Temporarily, they need a stent to preserve the opening, and that stent is the catheter.

The bladder is always being emptied by the catheter. The bladder isn't holding urine and therefore doesn't expand as long as the catheter is in place. When the catheter is removed, the bladder is a shrunken version of itself.

"Over weeks and months, the bladder expands again and, most often, returns to normal size and normal function," Dr. Catalona said.

Good article, BB. I had it backwards.