Have a penis? Read this
Many of my patients come in saying, “I didn’t know Pelvic Floor Physical Therapy was a thing,” and the only reason they found out was because something was wrong “down there.” Did you know 16% of cisgender males report having pelvic floor issues and in a recent study, 94.1% of transgender men on hormone therapy also reported having pelvic floor issues.
Let’s start with what explaining what pelvic floor is and its role. All humans have one. Basically, it’s a hammock of muscles in our pelvis that physically support the bladder, bowels, and other abdominal organs, as well as provide sexual function, including erections, orgasms, and clitoral engorgement. Basically, it allows us all to poop, pee, and have sex- the fun things in life! That is, unless the pelvic floor is not working the way it should. We call this pelvic floor dysfunction, and in men, this can include:
- difficulty or pain with erections and/or ejaculation
- constipation
- urinary or bowel leakage
- weak urine stream
- numbness, tingling or pain in and around the pelvis
- difficulty holding back gas
- anal spasm
- chronic prostatitis symptoms with negative lab values
PSA: Pelvic Floor Physical Therapy can help EVERYONE, not just women, and here’s how.
What does the pelvic floor have to do with Erectile Dysfunction?
Let’s talk about it! To initiate an erection, the muscles in the shaft of the penis must relax and allow adequate blood flow to sustain the erection, while inhibiting the return of blood flow through the venous system to return to the rest of the body. It is estimated that between 30 to 50 million men in the United States and 150 million men worldwide experience erectile dysfunction (ED)!
There are a lot of factors that can contribute to the impediment of blood flow, ultimately resulting in ED including lifestyle (diet, exercise, hydration etc), vascular and neurological conditions, stress, mood disorders, and pelvic floor dysfunction. If the pelvic floor is too tense, it can restrict blood flow into the shaft and/or compress nerves that allow for arousal. In contrast, if the pelvic floor is too weak, the blood that enters the shaft cannot be maintained, thus interfering with quality and force of ejaculation.
Why am I constipated?
This is probably the most common condition we see here in the clinic among all ages and genders, but overwhelmingly in men. Constipation is typically classified as having 3 or fewer bowel movements each week, which usually occurs with straining, pain, or incomplete evacuation.
From a mechanical standpoint, the most common culprit is the puborectalis (PR). No, it’s not a virus, it’s a muscle in the pelvic floor. It’s a unique sling-like muscle that, along with our anal sphincter muscles, helps control bowel movements. When it is too tense and tight, it’s unable to relax which is why people have to strain really hard to pass a bowel movement.
Many causes of this excessive tension on the PR are emotional and physical stress, limited hip mobility, poor bowel mechanics (yes, there is a proper way to poop!), prolonged sitting, and faulty weight lifting mechanics. We spend a lot of time in PT helping our patients learn how to relax and stretch this muscle to improve bowel movement frequency and quality.
Jeez. My bowel and bladder have a mind of their own. Why am I having accidents?
First, Incontinence, which is the lack of voluntary control of the bowel or bladder, happens both in women and men, and of all ages. It has been estimated that 5 million American men experience urinary incontinence and 1 in 12 adults experience fecal incontinence.
There are a variety of reasons why this happens in men, with some of the following mechanical reasons involving:
- an enlarged prostate
- injury to bladder or digestive system
- chronic or severe constipation
- pelvic floor weakness and/or tightness
- poor regulation of intra-abdominal pressure
The prostate sits directly underneath the bladder and surrounds the urethra, and acts as the urethra’s support system. Therefore, if the prostate is enlarged it can compress the bladder and urethra so that urine may be impeded so the bladder may not fully empty and cause delayed leakage, or it can cause increased urination at night after pressure decreases from the prostate. And guess what’s under the prostate? The pelvic floor! Typically we also see the pelvic floor get tighter and weaker as the prostate enlarges, and that pelvic floor tension and weakness can contribute to & increase your symptoms. We will work with our patients with benign prostatic hyperplasia to help them reduce their symptoms without surgery, help them prepare for prostate surgery, and help our patients recover after surgery.
Next reason…constipation. It may sound contradictory but it’s more common than you think! With bowel impaction (when stool gets stuck somewhere along the intestinal tract), water is reabsorbed from the stool the longer it remains in our digestive tract, making movement to the rectum even more difficult. Now think of a hose where you place your thumb over the end, your thumb can block some of the water from passing but inevitably pressure builds and water sprays past your thumb at a higher pressure. In this metaphor, the old stool is your thumb and prevents newer waste higher in your colon and rectum from passing through. When the digestive tract cannot sustain this pressure anymore, the looser and newer stool will bypass the old stool out of the rectum.
And finally, let’s talk about breathing (it isn’t as simple as it sounds). Our diaphragm is a large dome shaped muscle that sits beneath our lungs. The diaphragm contracts and lifts upward as we exhale and relaxes downward as we inhale. The pelvic floor is synchronized with the diaphragm’s movement to control the pressure in our abdomen. When we hold our breath, like when we lift something heavy, or due to stress, this regulation of pressure is thrown off and leads to excessive pressure on the pelvic floor, whose job is to support our bladder and bowels. When the pressure is greater than the pelvic floor can sustain and manage, accidents happen.
Pelvic pain explained
There are a multitude of causes for pelvic pain. There can be inflammation of the prostate gland as a result of cancer, bacterial infections, benign growth, or poorly understood mechanisms for chronic prostatitis. Other contributing conditions to pelvic pain include: hernias, sexually transmitted infections, kidney stones, urinary tract infections, or digestive tract distress. While these conditions on their own can be responsible for pelvic pain, they also cause irritation of the local nerves and increase muscle tension which can lead to persistent pain after the condition has been adequately addressed.
However, plenty of people experience pelvic pain who do not have any of these conditions. This is where we can look to the pelvic floor as the primary source of pain. Excessive pelvic floor tension is a huge reason for this. Are you sensing a common theme? To reiterate, when the pelvic floor is tight, this can lead to compressed nerves involved with erection and sensation to the genitals, constipation that can cause painful straining with bowel movements, and preventing the bladder and urethra to fully relax when you pee.
How Can Pelvic Floor Physical Therapy Treat These Conditions?
- Manual Therapy: A Pelvic Floor Physical Therapist (PFPT) can release pelvic floor muscle tension directly through a rectal examination. I know this can sound intimidating, however with the right provider and the right technique it is tolerable. Ultimately, it is the most effective way your provider can fully assess which specific muscles are limiting blood circulation and compressing nerves. Other techniques involve releasing tension in the abdomen, hips, back, or glutes for the same reason. We often get asked if patients “have to have an internal exam” and our answer is always that it is up to you, our patient. You will never be pressured to do anything you’re not comfortable with!
- Strengthening Exercises: A PFPT can also assess the strength of your pelvic floor directly through a rectal exam. Like any other muscle, these muscles can be weak AND tight. Remember, the pelvic floor must be strong enough to sustain blood engorgement in the shaft for an erection and support the bladder and rectal control. The PFPT will instruct you on how to properly strengthen the pelvic floor with not only the infamous Kegels, aka pelvic floor contractions, along with core and hip strengthening exercises to augment strength. Diaphragmatic breathing is also extremely important to regulate pressure on the pelvic floor and is usually incorporated into these strengthening exercises to coordinate control of pelvic floor relaxation and contraction required in healthy erections, fully emptying the bladder. Specifically for healthy bowel movements, the puborectalis, the muscle that wraps around the rectum, must be able to relax.
- Stretching: Pelvic floor tension correlates with the muscles and connective tissue surrounding our pelvis. Stretches that can decrease this tension include stretches for the groin, hip flexors, glutes, abdomen, and diaphragm region.
- Lifestyle Modifications: The pelvic floor’s arch-nemesis is stress! In a study with 108 participants, there was a strong correlation between the severity of pelvic floor dysfunction and severity of anxiety and depression. Therefore, stress management is crucial. In a systematic review of 10 articles, the general recommendation of physical activity to reduce ED consists of 40 minutes of moderate to intense aerobic activity at least 4 times a week. Another large contributing factor involves excessive sitting. Many of us have to sit all day at work, or we love to sit on the couch and watch our favorite shows, or we love long bike rides. Unfortunately, this can place excessive pressure on the pelvic floor muscles and compress the more superficial nerves which can lead to PFD. It’s not realistic to avoid these situations, but just goes to show moderation is the key for everything.
So fellas, there is a solution for your pelvic floor issues. In a recent survey, 65% of men reported waiting as long as possible to seek medical attention! Our goal here at Hey Babe Physical Therapy is to create a safe space for everyone, including men, and to allow them to feel comfortable to seek attention for commonly “taboo” topics. You don’t have to suffer in silence anymore, there are many things a Pelvic Floor Physical Therapist can help with so you can poop, pee, and have sex in peace.
Works Cited
https://pubmed.ncbi.nlm.nih.gov/38662108/
https://www.ncbi.nlm.nih.gov/books/NBK562253/
https://pmc.ncbi.nlm.nih.gov/articles/PMC5960035/
https://www.ncbi.nlm.nih.gov/books/NBK513291/
