Is there a direct correlation between worsening post-void dribbling (PVD) due to hypertonic pelvic floor and the development of adult nocturnal enuresis?

Relationship Between Hypertonic Pelvic Floor, Post-Void Dribbling, and Adult Bedwetting

There is no established direct correlation between worsening post-void dribbling (PVD) due to hypertonic pelvic floor and the development of adult nocturnal enuresis, though they may share underlying pathophysiological mechanisms.

Understanding Post-Void Dribbling and Hypertonic Pelvic Floor

Post-void dribbling is classified as a post-micturition symptom that describes the involuntary loss of urine immediately after an individual has finished passing urine 1. In men with hypertonic pelvic floor dysfunction, PVD often indicates incomplete bladder emptying.

A hypertonic pelvic floor involves overactive pelvic floor muscles that fail to relax appropriately during voiding, which can lead to:

• Staccato or interrupted urinary flow patterns
• Reduced maximum flow rate
• Incomplete bladder emptying with elevated post-void residual volumes
• Post-void dribbling

Nocturnal Enuresis in Adults

Adult nocturnal enuresis without daytime incontinence is relatively uncommon but clinically significant. When it develops in adults, it often indicates:

• Severe urethral obstruction
• High post-void residual volumes
• Potential upper urinary tract complications 2

In a study of adult-onset nocturnal enuresis, all affected patients were men with severe prostatic or vesical neck obstruction, and many had complications including hydronephrosis (63%), bladder diverticulum (38%), and vesicoureteral reflux (50%) 2.

Connecting Mechanisms

While direct correlation studies are lacking, several shared mechanisms may exist:

1. Incomplete Bladder Emptying: Hypertonic pelvic floor can lead to significant post-void residual volumes, which may contribute to both post-void dribbling and nocturnal enuresis 3, 2.

2. Detrusor Dysfunction: Chronic pelvic floor hypertonicity can eventually lead to detrusor underactivity or decompensation, which may manifest as both PVD and nocturnal enuresis 4, 3.

3. Bladder Overactivity: Pelvic floor spasm can coexist with detrusor overactivity, potentially contributing to both symptoms 5.

4. Abnormal Bladder Emptying During Sleep: Research shows that nocturnal enuresis episodes are frequently incomplete micturitions, suggesting dysfunctional voiding patterns similar to those seen with hypertonic pelvic floor 6.

Diagnostic Considerations

For patients with both PVD and adult nocturnal enuresis, consider:

• Uroflowmetry to identify staccato or interrupted flow patterns 3
• EMG studies to confirm pelvic floor muscle overactivity during voiding 3
• Post-void residual volume measurement (values >200-300 ml indicate significant dysfunction) 3
• Frequency-volume chart to assess voiding patterns 3
• Video urodynamics to distinguish between different causes of voiding dysfunction 5

Management Approach

For patients with hypertonic pelvic floor dysfunction presenting with PVD and/or nocturnal enuresis:

1. Pelvic Floor Physical Therapy: Targeted therapy to address hypertonic pelvic floor muscles 3

2. Voiding Techniques:

   • Proper voiding posture instruction to relax pelvic floor muscles
   • Double voiding to improve bladder emptying
   • Scheduled voiding during daytime 3

3. Fluid Management:

   • Regulate evening fluid intake to minimize nighttime bladder distention
   • Maintain adequate hydration during morning and early afternoon 3

4. Bowel Management: Treat constipation to improve bladder emptying 3

5. Pharmacological Options:

   • Alpha-1 blockers for men with prostatic obstruction
   • Antimuscarinic agents for coexisting detrusor overactivity (only if PVR is low) 3

6. Regular Monitoring:

   • Post-void residual volumes
   • Frequency and severity of leaking episodes
   • Urinary tract infection surveillance 3

Important Considerations

• Adult-onset nocturnal enuresis should be considered a serious symptom warranting thorough urological investigation 2
• The psychological impact of nocturnal enuresis can be severe, making appropriate treatment essential 3
• Patients with significant post-void residual volumes require close monitoring for upper urinary tract complications 2

While the direct correlation between worsening PVD due to hypertonic pelvic floor and adult bedwetting is not firmly established in the literature, addressing the underlying pelvic floor dysfunction may improve both conditions through shared pathophysiological mechanisms.