Postvoid Dribbling

Postvoid dribbling is involuntary leakage of a small amount of urine immediately after finishing micturition, typically after leaving the toilet or on standing. It is one of the post-micturition lower urinary tract symptoms. It differs from stress or urge incontinence and from the continuous dribbling of overflow incontinence.

• Commonest mechanism in men: urine pooled in the bulbar urethra is not expelled because bulbospongiosus contraction is weak, and drains passively afterwards. Contributing causes are benign prostatic enlargement, urethral stricture, weak pelvic floor, age related loss of bulbospongiosus tone, obesity, and a prior radical prostatectomy or pelvic radiotherapy.
• In women the usual cause is vaginal pooling of urine during voiding (labial adhesions, obesity, wide hips, pelvic organ prolapse, voiding with the legs together), or a urethral diverticulum that fills during voiding and empties afterwards.
• Other causes: incomplete bladder emptying with overflow, detrusor underactivity, neurogenic bladder, diabetic neuropathy, urinary tract infection, and drugs that impair detrusor contraction (anticholinergics, opioids, calcium channel blockers).
• Prevalence rises with age; about 1 in 5 men over 40 report it. It is benign but causes embarrassment, skin irritation, and odour.

• A few drops of urine after voiding, with a normal stream in the early phase of micturition in simple cases.
• Ask about stream strength, hesitancy, straining, intermittency, incomplete emptying, nocturia, urgency, urge or stress incontinence, dysuria, haematuria, previous urethral instrumentation, urethritis, pelvic trauma, prostate or pelvic surgery, radiotherapy, neurological symptoms, diabetes, constipation and drug history.
• Red flags: visible haematuria, recurrent urinary infection, palpable bladder, painful retention, perineal or back pain with neurological signs, a tender cystic anterior vaginal wall mass with pus on pressure (diverticulum), poor stream suggestive of stricture.
• Examination: abdomen for a palpable bladder, external genitalia (meatal stenosis, phimosis, balanitis xerotica obliterans), digital rectal examination for prostate size and anal tone, perineal sensation and bulbocavernosus reflex, pelvic examination in women (prolapse, atrophy, urethral mass).

• Clinical. Confirm the pattern with a 3 day frequency volume chart.
• Urinalysis and culture.
• Post-void residual volume by bladder scan: over 100 mL warrants further assessment.
• Uroflowmetry in men: peak flow below 10 mL/s with a prolonged plateau suggests obstruction; a low flat curve suggests stricture.
• Bloods: urea, creatinine and eGFR, glucose or HbA1c, and PSA after counselling in men.
• Urethroscopy or retrograde urethrogram if stricture is suspected; pelvic MRI for urethral diverticulum in women.

• Reassure that it is benign and usually responds to simple measures.
• Urethral milking after voiding (men): after the stream stops, place the fingertips behind the scrotum and press firmly upward and forward along the underside of the penis towards the tip two to three times to expel pooled urine. Wait 10 to 15 seconds after the last drops before leaving the toilet, then repeat.
• Pelvic floor muscle training supervised by a physiotherapist: contraction held 3 to 10 seconds with equal relaxation, 10 repetitions, three times daily for at least 12 weeks. A "squeeze out" contraction at the end of voiding strengthens bulbospongiosus. Evidence supports benefit particularly after prostatectomy.
• Double voiding: wait 30 to 60 seconds, then try again. In women, sit well back on the toilet with the knees apart and lean forward.
• Treat the cause: tamsulosin 400 micrograms orally once daily after food (alfuzosin 10 mg modified release once daily is an alternative) for prostate related obstruction; urethral stricture requires urology (dilatation or urethrotomy); stop or substitute drugs that impair detrusor function; treat constipation; weight loss; vaginal oestrogen for atrophy (estradiol 10 microgram vaginal tablet nightly for 2 weeks then twice weekly).
• Use absorbent pads for protection, with hygiene and a barrier cream (zinc oxide) to prevent dermatitis.
• Avoid anticholinergic drugs if residual volume exceeds 150 mL.
• Refer: suspected stricture, residual over 150 mL, haematuria, urethral diverticulum, neurological disease, failure of 12 weeks of pelvic floor training.