As many of us reading this blog can attest, pelvic pain can be an issue that leaves us feeling not only physically uncomfortable, but emotionally/mentally drained and isolated. Often, by the time many people get seen by a physical therapist, they have been mismanaged by other providers, leading to increased frustration among other things. Men, in particular, seem to be the population most overlooked or poorly managed by the current healthcare system when dealing with pelvic pain. The most current research on the prevalence of pelvic pain among males reports that 15% of men have dealt with or are currently dealing with pelvic pain at some point in their lives.1 And that is just based on a sample size of men that were actually willing to report whether or not this is something that has been an issue;I tend to think that this number might even be higher. Here is a great blog post on male pelvic pain that Stephanie wrote earlier this year.
Throughout this blog, we have tried to touch on so many of the issues that come up when dealing with pelvic pain, but have never specifically talked about what could be happening on a musculoskeletal level when erections become painful. This is such a common issue that I see men dealing with, so I wanted to spend some time delving into what can be happening to our sexual function when there are myofascial impairments in the pelvic floor musculature.
First, let’s do an anatomy review. My colleague Rachel Gelman, DPT wrote a great post last year detailing the male pelvic anatomy. She explains that “All of the internal muscles that make up the pelvic floor are the same for men and women. The muscles sit in the pelvis like a muscular bowl, providing support to the organs of the pelvis and assisting in bowel, bladder, and sexual function…In men, the pelvic floor supports the prostate as well as the bladder and the colon.”
Taking a closer look at the image below, you will see that the artist has included two different triangles over the pelvic muscle groups. The top outline surrounds the urogenital triangle and the bottom outline identifies the anal triangle. The urogenital triangle muscles (aka urogenital diaphragm) are the most superficial muscles of the pelvic floor, comprised of the bulbospongiosus, ischiocavernosus, transverse perineum and external anal sphincter. These are the muscles that I will be writing about in this blog because they are the most involved muscles during arousal and orgasm.
The penis is an organ that serves both urinary and sexual functions. It is made up of highly vascularized soft tissue that can become erect when there is an increased blood volume in the area . The bulbospongiosus (see on image above) attaches from the transverse perineal muscle to the lower ⅓ of the penis. During arousal blood rushes into the penis and is held in place by a sustained contraction of both the bulbospongiosus and the ischiocavernosus. Orgasm and ejaculation occur when these 2 muscles begin to maximally contract and relax repeatedly.
That is the how the muscle system physiology should work during a typical erection and orgasm/ejaculation. However, what happens if something goes awry? In many cases of pelvic pain and dysfunction, the pelvic floor muscles have been in a long term, shortened position. When they are contracted, tight, they often have trigger points, and they are often tender or painful to the touch. So it can make sense that if the muscles are already in a contracted state, it can be painful when there becomes an increased demand on these structures. We can apply this concept to a similar situation elsewhere on the body;think about if you have ever had a tight calf muscle, it doesn’t take much to put that thing into a full blown charlie horse (anyone ever wake up in the middle of the night with these?). But it is the same idea;calf muscle is tight, we tend to sleep with our feet/ankles in a plantar flexed or pointed position, the muscle gets pushed past its breaking point and we end up with a major cramp.
Here is how PT can help:
Painful erections can be caused by hypertonic pelvic floor muscles and potential trigger points. Think about it, if we need those superficial pelvic floor muscles to contract and maintain a sustained contraction for any length of time, that’s a big deal for those muscles. It’s like a major workout, and if they are already in a tightened state, then getting them to further tighten is going to be a problem. People with tight pelvic floor muscles may often notice difficulty achieving and maintaining an erection or diminished quality of erection. This change often precedes the onset of pelvic pain.
If you are experiencing this issue, consult with your physician and a pelvic floor physical therapist to address potential issues. Painful erections that are occurring due to factors mentioned in this blog are highly treatable with PT intervention. If you need some help finding a pelvic floor specialist in your area, check out some previous posts on this matter here and here.
Because the pelvic floor muscles are so often involved with this issue, it is important to schedule with a pelvic floor physical therapist sooner rather than later. Here are two previous blog posts on what to expect from a good pelvic floor physical therapy session.
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Are you unable to come see us in person? We offer virtual appointments!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
References:
Systematic Review of Acupuncture for Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Qin Z, Wu J, Zhou J, Liu Z. Medicine (Baltimore). 2016 Mar;95(11):e3095.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
Oh thank you so much for this explanation. You explain it so beautiffuly and so everyone can understand this in men.
I sure hope all P.T.’s can read this amd am sure will umderstand as you make your explanations so plain.
You are so helpful in your explanations and speaking of men which is such a common problem and life and relationship problem for us males.
We can only hope more P.T.’s will become more comfortable treating and talking with men about all the problems this disorder does causes.
Thanks again. You are the greatist..
MM
I recently learned about tight pelvic floor muscles and have started going for physical therapy. I finally have some clarity on my frequent urination issues and erectile dysfunction. I am hopeful that over the next few months my stretching and Keigel exercises will help me to regain bladder control and improve my sex life. Thank you for your article. Mark G