Ahmed Albakr: Thanks a lot, Dr. Wein. It's a great pleasure for me to be with you today. We are going to speak about post-micturition dribble in men and our work in a systematic review and meta-analysis on the management of this issue. And this was presented in the ICS-EUS 2025. The ICS defines the post-micturition dribble as the involuntary leakage of urine that happens immediately after men leave the bathroom and after cessation of urination. This usually occurs in males after they leave the bathroom. In females, usually it happens after they just stand up from the toilet. This definition differentiates between the post-micturition dribble and what we call a terminal dribble, which is the slowing of the end of stream at the end of micturition. While the etiology of post-micturition dribble is still not clear, some work by Bader and Wille suspected that the reason behind it is the dysfunction in the bulbospongiosus and ischiocavernosus muscles that impairs the milk in and milk out that clears the urethra from urine at the end of micturition. And they found that this happens in both people without any urethral surgeries, and as it happens in males after BPH surgery and urethroplasty. We refer to the patients without previous surgery as primary PMD in this article. So, PMD is prevalent with a study showing that it's there up to 9% to 60% of males across different age groups, and it's quite bothersome in most of these patients. The caveat is that many symptom assessment/symptom scoring in lower urinary tract symptoms usually do not have any item that refers to post-micturition dribble, even the prevalent IPSS score.
But recently a five-item score, called the Hallym Post-Micturition Dribble Questionnaire, has been validated in multiple languages, evaluating the frequency, volume, bothersome, quality of life, and response to treatment for patients with post-micturition dribble. Our search was a systematic search on the different databases over the management of post-micturition dribble. We include all the original articles published in English that evaluated adult males with no previous urologic intervention. We evaluated the quality of the studies there and tried to do a narrative review when the data were heterogeneous, and a meta-analysis whenever possible. Our search came out with around 240 articles. Out of these, we managed to find four articles that went with the criteria of our inclusion criteria. Those articles were two RCTs that evaluated the effect of behavioral modification and pelvic floor exercises on PMD and two articles that evaluated the effect of PDE5 inhibitors on PMD. In Paterson study, it was a three-arm study that compared between counseling versus pelvic floor exercises and urethral milking, while Dorey evaluated the pelvic floor exercises versus counseling. The two other studies with the medications, they evaluated the effect of tadalafil and udenafil daily usage on post-micturition dribble. The follow-up period was between 12 weeks to 13 weeks, while six months in Dorey study.
So, you can see how heterogeneous the outcome measures between the studies are, as Paterson evaluated the four-hour pad weight test as the primary outcome, then evaluated the pelvic muscle strength at the end of exercises. On the other hand, you can see Dorey evaluated the self-reported complaint of post-micturition dribble through a questionnaire that was developed inside the study, and they dropped actually the 24-hour pad weight test, which was initially planned, when they found that this was not practical to use. Then, in the PDE5 inhibitor studies, these were a little bit less heterogeneous as they evaluated the symptom scoring using the Hallym Post-Micturition Dribble Score as the primary outcome. Then they evaluated the level of the volume of incontinence, the amount of the erectile function, as secondary outcomes. Here, when we tried to assess the outcomes, you can see that, in Paterson, the pelvic floor exercises were effective in improving the patient, the volume of leakage in those patients, actually, with more improvement than those patients who had urethral milking, and both items were better than those who went just with counseling and lifestyle advice. On the other hand, Dorey had much improvement with the pelvic floor muscle exercises in patient complaints. The PDE5 inhibitors, when you did a meta-analysis for the effect of therapy, we noticed that there was a significant decrease in the overall score of the Hallym Post-Micturition Dribble Score with the use of udenafil and tadalafil. In addition, the post-micturition dribble volume decrease was significant with both medications. So, in summary, despite the high prevalence of post-micturition dribble, it's still understudied with a thin body of evidence. And overall, we see that pelvic floor muscle exercises and urethral milking help those patients. The use of PDE5 inhibitors, on daily use in low doses, tadalafil, five milligrams, and udenafil, 75 milligrams.
And it's worth to note that the udenafil is not available in the US, although it's available in some more Eastern countries. The use of these medications may help reducing the post-micturition dribble volume and symptom bother, and more research is needed for post-micturition dribble. Our take-home message is that PMD needs more research. PMD improves with pelvic floor exercise and urethral milking. The evaluation of the severity of symptoms using the validated questionnaires may be helpful for those patients for diagnosis and management and follow-up of the response to therapy. Then the sexual history is very important for those patients, as at some point, they have an association between the post-micturition dribble and erectile dysfunction. And in such group of patients, we think that the PDE5 inhibitors may be useful. Thanks.
Alan Wein: Thanks so much for that really informative discussion about a very common problem. The first question that I'm interested in is, does an outlet-reducing procedure, like TUR prostate or whatever, enucleation, et cetera, does that predispose to a post-micturition dribble?
Ahmed Albakr: Yes. The body of evidence that we have sees that most patients after urethral intervention for surgery for BPH, some surgeries for urethroplasty in particular, and those who have urethral grafting, at some point, those patients have more incidents of post-micturition dribble than in patients without previous surgeries, in males without previous surgeries.
Alan Wein: Can you describe for the audience what urethral milking really is? In other words, when you talk to a patient and you say, "Hey, let me tell you how to do something that may significantly help this," exactly what do you tell them?
Ahmed Albakr: Yeah, so I used to have a lot of those patients in my clinic. Usually, we advise those patients, if they have bothersome leakage after voiding, advise them to try to void sitting rather than standing. And after they void, they do milking from the root of the penis outside, trying to clear all what's there entrapped inside the urethra, before they leave the bathroom. This was really helpful in much of those patients. And this was the same that Paterson used in his study, and it was quite useful. But I would say that as long as this can usually help with a fast response, so they start to notice less leakage after this, they need to keep doing this practice to avoid having the leakage again. On the contrary, they found that those patients who continued to start to do the pelvic floor exercises, although they get the result in a later time period, they tend to have it more sustainable.
Alan Wein: So, if I want to send a patient for, let's say, pelvic physiotherapy, do I just put down the indication post-micturition dribble? They understand what that means, and they know what type of pelvic physiotherapy to give to the patient?
Ahmed Albakr: I would say it's quite similar to the pelvic floor exercises that you refer your patients after radical prostatectomy, too, usually.
Alan Wein: Oh, Okay.
Ahmed Albakr: So, it's quite a similar exercise, trying to grab the pelvis and contract the pelvic floor muscles in order to make it stronger. They tend to do this at least five times a day instead of 10, and try to keep this. The recommendations were to increase the time of the contraction, with each time trying to. So, starting to contract and hold for around 10 seconds up to 30 seconds, and make it higher, and try to cycle between the fast twitches and the strong maintained contractions in order to help with the fast- and slow-twitch muscles in the pelvis to improve the power of the pelvic floor muscles.
Alan Wein: Why do you think the phosphodiesterase inhibitors are effective? I mean, what's the mechanism?
Ahmed Albakr: Well, Dr. Wein, this is actually very interesting. When you see that some studies have noticed that there is an association between post-micturition dribble and erectile dysfunction in this group of patients. And you can notice, recently, how the tadalafil, five milligrams, has been included in the guidelines for the management of male lower urinary tract symptoms, and it seems to be quite helpful, especially those males with problem with erection. This actually put more hand on that the pelvic floor dysfunction with the ischiocavernosus and bulbocavernosus muscles can be involved in the situation, and having these muscles more stronger may help this group of patients.
Alan Wein: Gotcha. Yeah. The ICIQ-Male LUTS Questionnaire actually does have a question about post-micturition dribble and how bothersome it is. As I recall, it's only one question, but the AUA Symptom Score has zero questions about that.
Ahmed Albakr: Exactly.
Alan Wein: So, you get a full picture. Well, that was really informative, and I think the audience now has a better picture of the prevalence, the annoyance, and also some great hints on how to fix it. So, listen. Thanks very much, and I hope you continue your studies in other possible ways to manage this because I know it's really bothersome to a lot of men. So, listen. Thanks so much.
Ahmed Albakr: Thanks a lot, Dr. Wein. Thank you.