As a 93-year-old physician, I am well acquainted with the ravages of aging and the continuous adaptations we all must make to accommodate its increasing demands. One area that is particularly troublesome is nocturia with repeated, late-night calls to the toilet. This is not only an issue of disturbed sleep, but also of safety. Nocturia involves leaving my bed, turning on a light, and making my way to the bathroom, activities that all increase the risk of a fall.

My own symptoms of urinary hesitancy and frequency led me to explore simple ways to decrease this risk. The goal was simple: initiate and complete voiding while remaining safely in bed using a urinal. The answer lay not in pharmacology, but in an underrecognized trivia of neuroanatomy.

The anatomical insight

The key was to stimulate directly a reflex arc that I knew was functionally connected to the bladder and involves the perineal branch of the pudendal nerve originating from S2-4. This nerve provides both motor control and autonomic functions to the pelvic area including the posterior skin of the scrotum. My goal was not to bypass the entire system, but to manually “wake up” this nerve; thereby, helping to initiate the normal neurological pathways required for successful micturition.

The technique I use every night

The method, which can complement the Crede maneuver, has not failed me once in five years. It is remarkably simple and can be performed while lying in bed or standing up:

• Place the urinal receptacle in position.
• Begin gentle manual stimulation across the infero-posterior skin of the scrotum. The maneuver targets the perineal branch of the pudendal nerve, which governs sensory input from this area only and critically, controls the urethral sphincter. The rest of the scrotum is enervated by a different branch and is not effective.
• Start with a soft rubbing or a pill-rolling motion over the infero-posterior part of the scrotum, varying the pressure or intensity (sometimes requiring sharp pinches to the skin) until urine flow begins, usually within a few seconds.

It is best to continue this intermittent stimulation until the bladder feels empty. This maneuver is usually accompanied by the expulsion of flatus, which serves as a physiological marker. It is explained by the perineal branch’s role in controlling the relaxation of both anal and bladder sphincters.

This maneuver is usually adequate on its own. The addition of using the Crede pressure before starting usually makes this method even more effective.

For five years, this technique has consistently provided control over my urination by day and night, and its effectiveness has not declined. The novelty is precisely its simplicity: unlike the extensive studies on electrical stimulation of the pelvic plexus, pudendal, or tibial nerves found in the literature, this is an innocuous and accessible bedside method.

A piece of clinical wisdom

As physicians, we often focus on complex interventions, but the most profound needs of our geriatric patients (like safely sleeping through the night) can sometimes be solved by simple, low-tech approaches. The relief I found in this “new” reflex is a tremendous moral boost; being old should not confine one to the scrap heap.

This simple, free technique could be an invaluable, low-stakes tool for primary care physicians, internists, and geriatricians to suggest to their male patients dealing with nocturia. The cost of one serious fall far outweighs the value of this simple anatomical pearl. I encourage my colleagues to explore and share this observation.

Neil R. M. Buist is a pediatrician.