Fiona McMahon PT, DPT
I was walking north up Park Avenue in New York City on a snowy morning last December, tip-tapping away on my phone responding to a friend and fellow physical therapist (PT) who had sent me an article outlining what pelvic floor dysfunction is and how to set about treating it. The article proposed Kegels as a great start to treating the pelvic floor on your own. My friend, who does not practice pelvic floor PT texted, “Wow! What a great article!”. I texted back that I didn’t think the article was so good. She was confused by my response and thought I would be pleased to see an article in such a prestigious publication spreading awareness of pelvic floor dysfunction. Although I was pleased about that, (because let’s face it, pelvic floor dysfunction needs all the awareness it can get), whenever I see Kegels presented as a blanket cure for pelvic floor dysfunction my blood begins to boil. Text messaging is not the ideal place to present your opposition to blanket recommendations of starting a Kegel program, so I hope to do so in this article.
“Why are you so anti kegel, Fiona?” You may be asking while you’re reading this. The truth is I’m not, but Kegels are not appropriate for everyone, and in my almost decade at Beyond Basics Physical Therapy, I can honestly tell you that with at least 90% percent of my patients Kegels would also actually delay and/or harm their progress. When an article presents Kegels as a cure-all for incontinence, pain, and other pelvic floor issues it is clear to me that the author truly does not understand the physiology of the pelvic floor, and a good signal to take the information presented in that article with a New York City pretzel sized grain of salt.
Kegels certainly have their place in a rehab paradigm and if they have worked for you, excellent! They can do so much, but like the adage goes in medicine, “ a cure for everything, is a cure for nothing”. So let’s jump into what Kegels are and how you, no matter what gender you are, can find out if they could be helpful to you.
Important Note:For the purposes of this article, we will be discussing pelvic floor dysfunction for individuals with penises using the term men to describe folks with male anatomy. We do acknowledge not all men have penises. Anyone of any gender or anatomy can experience pelvic floor dysfunction.
What is the Pelvic Floor?
The pelvic floor is the group of muscles that lives between your pubic bone and tailbone. Another way to think of the pelvic floor is the area that would make contact with your bicycle seat. These muscles are, in a word, AMAZING. They have many important jobs in the body. The pelvic floor muscles are responsible for keeping us continent, supporting our pelvic organs, maintaining sexual function (erection and ejaculation), stabilizing the spine, and helping to return blood and lymphatic flow back into the body so it doesn’t stagnate in the pelvis and/or lower extremities. When things go wrong with your pelvic floor, you may see symptoms in the aforementioned functions.
What are Symptoms of Pelvic Floor Dysfunction in Men
Since the pelvic floor performs so many functions, you can see many different symptoms when something goes wrong with the pelvic floor. The following is a non-exhaustive list of symptoms and conditions you may experience when something goes wrong with the pelvic floor.
Prostatitis and Chronic Pelvic Pain Syndrome
In my experience, prostatitis is one of the single most common things I treat at Beyond Basics. It’s an extremely common condition. It is estimated that 35-50% of men will experience prostatitis symptoms in their lifetime (Rees). Symptoms include:
- The sensation of having a golf ball stuck in the rectum
- Hesitant urinary stream (having trouble getting the urine to start flowing)
- Post void dribble (spotting of urine on underwear following voiding)
- Pain that radiates into the abdomen (this is one of the differences from symptoms of benign prostatic hyperplasia)
- Erectile dysfunction and decreased libido
- Painful ejaculation
- Painful or burning urination
- Genital pain: penile, testicular, groin, and perineal pain
Prostatitis can be caused by infection, inflammation, and most commonly, (90-95% of cases) problems within the pelvic floor, (which can be treated by physical therapy).
In cases that are caused by infection, your doctor may prescribe antibiotics to treat the infection. For nonbacterial prostatitis physical therapy can be an excellent place to start! Clinical Professor of Urology, R.U. Anderson and his colleagues described the relationship between the presence of myofascial trigger points, (which are highly irritable bands of muscle knots) and symptomatic prostatitis. They also showed that physical therapy intervention, including manual release of these trigger points was effective in reducing symptoms of prostatitis. The benefit of physical therapy was shown again to be more effective than placebo in a 2011 paper by a Clinical Researcher and Urologist J. Curtis Nickel. In addition to treating the trigger points themselves, PT’s work to determine what lead up to the formation of the trigger points in the first place, whether that be poor habitual posture, poor strength, or tight muscles in other parts of the body. They also teach patients how to avoid clenching their pelvic floor to prevent exacerbating symptoms. This type of therapeutic approach was found to be effective in reducing pain in 72% of participants in a study conducted by Anderson and colleagues in 2005. The therapists at Beyond Basics Physical Therapy work to go beyond simple treatment of the trigger points themselves. We develop plans and treatments to prevent their recurrence in the future. Some other effective physical therapy techniques that we use include but are not limited to, joint mobilization to assist proper structural alignment, therapeutic exercise, postural and neuromuscular re-education, and a detailed and individualized home exercise program.
Urinary dysfunction can occur with or without pain. Either way, issues with urination can be incredibly disruptive. Common urinary problems we see at BBPT in People of all genders are
- Difficulty voiding
Let’s dive a little deeper into each of these types of urinary dysfunction.
Incontinence can take many different forms. Stress incontinence occurs when one leaks a little urine with activities like jumping, running, coughing, and or sneezing. Typically stress incontinence occurs when the muscles of the pelvic floor can’t quite counteract the downward pressure on the bladder caused by these activities. Though Kegels may help, they aren’t always the solution if you have a tight and weak pelvic floor. You may also need additional training to move a bit more efficiently, with added shock absorption to reduce the pressure on your pelvic floor.
You may also experience post-void dribbling. Typically post-void dribbling is seen by slight leakage after peeing. You may notice a damp spot on the outside of your trousers after going to the bathroom. This often happens because the muscles that surround the urethra get tight and act almost like a foot on a garden hose, sometimes making it harder to pee and causing pee to get caught in the urethra only to dribble out at inopportune times.
You may also find that you have difficulty voiding when you have a tight pelvic floor. Tight pelvic floor muscles can make the muscles of the bladder work less effectively, and make the outlet through which pee has to get out, smaller and tighter. You may notice difficulty starting your urinary stream, start and stop urination, and splayed urinary stream with pelvic floor dysfunction.
Urge incontinence occurs, as the name implies when you get a sudden urge to urinate and cannot hold back the flow of urine. Commonly, urge incontinence occurs when nearing home, rounding the block to your apartment, at the sound of running water, or while waiting in line to use the loo. A physical therapist can be instrumental in helping you to train your bladder to react less to these triggers and improve your ability to delay urination when required.
Bladder training and pelvic floor physical therapy can also help with issues like frequency. Normal bladder frequency occurs approximately every 2-3 hours during the day and 0 times at night if you are under 65 and one time at night if you are over 65.
Bladder pain can come in many different forms. You can have pain with bladder filling, active urination, or immediately thereafter. Oftentimes, pelvic floor tightness can play a key role in bladder pain. In addition to treating tight pelvic floors, a pelvic floor PT can also guide you through lifestyle and behavioral modifications that can further reduce your pain.
Ways you can help your bladder right now
- If you don’t have pain, try lengthening the time between “goes” 10-15 minutes at a time and practice deep diaphragmatic breathing in the interim.
- If you experience sudden urge, DON’T PANIC! Rushing often makes it worse. Breathe slowly and calmly make your way to the toilet.
- When hesitancy strikes, breath deeply. Try sitting on the toilet to relax the pelvic floor and make peeing easier.
- Avoid drinking water 2 hours before bedtime if you are experiencing frequency at night.
- If you are constipated, work on managing that problem. The bladder lives right in front of the rectum. A large backup of stool will press on the bladder, irritating it and reducing its holding capacity.
Erectile dysfunction (ED) can be an extremely frustrating condition. ED can be an important indicator that some other component of your health, whether it be your heart, your mental health, physical activity, or muscles may need a little extra attention. New-onset ED should be checked out by a healthcare provider to rule out any cardiac contributors to your erectile dysfunction.
What do muscles have to do with erections? A lot. The muscles of the pelvic floor play a vital role in the sexual function of all genders, and as we will explore, there is a considerable amount of muscular coordination required for erection and orgasm. The pelvic floor muscles have to relax enough to let blood into the penis to allow for erection, but then contract to allow the blood pressure in the penis to remain high enough for penetration.
Physical therapy can help to improve the function of the muscles that are responsible for erection, ejaculation and orgasm. As we described earlier, the pelvic floor muscles play an integral role in male sexual function, from erection to ejaculation. When men come into physical therapy after complaining of erectile dysfunction, a pelvic floor physical therapist will examine the muscles of and surrounding the pelvic floor to see if they are too tight or weak to generate enough force to maintain adequate blood pressure in the penis, examine bony malalignments which may be impairing the full function of the muscles and nerves of the pelvic floor, as well as many other things that may be impacting the full function of the pelvic floor.
The effects of physical therapy on erectile dysfunction have been illustrated in many studies. In a 2014 study, Professor of Sexology, Pierre Lavoisier and colleagues examined the effects of a program of pelvic floor physical therapy on erectile function of 108 men suffering from erectile dysfunction. The men in this study had no neurological conditions that could affect their erectile function. In this study, the participants were given 20 sessions of physical therapy which included muscle strengthening and electrical stimulation of the muscles of the pelvic floor. At the end of the study, Lavoisier and colleagues found that physical therapy was effective in strengthening the muscles of the pelvic floor, specifically the ischiocavernosus, which is a major component of being able to achieve erections. In another study by Dorey and colleagues in 2005, men were given either pelvic floor physical therapy exercises or lifestyle changes to treat their erectile dysfunction. The men in the study who were given pelvic floor physical therapy did significantly better than men who performed lifestyle changes alone.
In all genders, pelvic floor dysfunction can affect your ability to have and expel a bowel movement. Dysfunction of the pelvic floor can result in both constipation and bowel incontinence in addition to abdominal discomfort and bloating. Skilled PT can work with you to help you improve the health of your pelvic floor, visceral mobility, and lifestyle habits and reduce your symptoms.
One usually thinks that weak pelvic floors cause bowel issues, which is true in some cases, but oftentimes, pelvic floors that are too tight can lack the strength to hold in a bowel movement, or the ability to feel that stool is building in the rectum. We often see a phenomenon called paradoxical contraction. When paradoxical contraction occurs, the pelvic floor will squeeze instead of open. It is easy to see how paradoxical contraction could very easily worsen constipation.
Hopefully, this article has provided you with a little reassurance that common pelvic ailments of folks with male anatomy can be treated by a skilled pelvic floor physical therapist. Pelvic floor dysfunction is an extremely common occurrence. Skilled physical therapists can work with you to both treat out your symptoms and the cause of your pelvic floor dysfunction. At physical therapy, your pelvic floor physical therapist will construct an individualized program tailored to your specific needs and goals. Pelvic floor dysfunction is by no means a life sentence and through teamwork with your pelvic floor PT, you can begin to feel a lot better!
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Get help now from a pelvic floor therapist on how to treat pelvic floor dysfunction.