By: Rachel Daof, DPT
People often ask me what symptoms men present with that land them in pelvic floor physical therapy. The truth is, men suffer from similar issues as women when it involves their pelvic floor: bowel, bladder, sexual dysfunction, and/or pain in the pelvic region. Furthermore, it’s not only the elder male population that can experience these things. Young men can experience urinary urgency/frequency, discomfort after ejaculating, etc. Here, I’ll take you through a case of a 33 year old male that was suffering from what he initially thought was a Urinary Tract Infection (UTI).
History:
Chris has a long history of urinary urgency, frequency, and nocturia. He recalls his problems starting two years before coming into pelvic PT where he noticed that if he did not urinate before bedtime, he would have to get up to urinate several times a night. He realized that it was a problem on January 3, 2019 when his urinary urge and frequency increased. It progressed to a point where he felt an “unending urge to urinate that was so bad it became painful,” and he slept on the bathroom floor because he needed to urinate every 15 minutes. Some of the symptoms manifested in his abdomen where he felt what he thought were “GI issues” because he felt abdominal cramping. Also, he noticed an “odd discomfort” associated with ejaculation. It was also unmasked after a couple of treatment sessions that he felt uncomfortable “rectal fullness”.
At this point he went to urgent care to seek results, thinking that he had an unforgiving UTI. Although diagnostic testing revealed he did not have any infection, he was prescribed three rounds of antibiotics to no avail. In search for answers, he found himself in the hands of one of our urology colleagues, who confirmed he did not have an infection and sent him here to the Pelvic Health and Rehabilitation Center.
It is important to note that Chris told me that he is generally an anxious person, and he started seeing a psychologist for this problem around the time he started PT here. He told me that he believes his anxiety manifested itself in his body, and he had physical therapy prior to coming here because he believed his anxiety resulted in numbness throughout his body.
Exam and assessment
- Severe myofascial trigger points on bilateral adductors and throughout abdomen which were very tender to touch.
- Moderate connective tissue restrictions in his bony pelvis, suprapubic region, and abdomen, extremely sensitive.
- Hypertonus (tightness) throughout bilateral PFM with myofascial trigger points in his urogenital diaphragm, obturator internus, bilateral hip external rotators externally, all tender to touch.
- Poor PFM range of motion with poor ability to lengthen pelvic floor voluntarily/paradoxical contraction (contracting PFM when asked to relax).
Given Chris has been being treated for anxiety with a psychologist and his self-reported anxiety related muscle tension, it became apparent that improving muscle guarding and clenching when stressed was contributing to his pelvic muscle dysfunction. As treatment continued, he reported that he did clench his abdomen throughout the day possibly due to stress, and this contributed to his abdominal pains. Given these objective findings, it was no surprise that Chris was experiencing abdominopelvic discomfort. All of this muscle guarding led to feeling urge urination, and when you experience urge it contributes to further muscle guarding. Think about the muscles you activate when you have the urge to urinate and you’re trying not to leak urine. You squeeze your inner thighs, glutes, abdomen, and pelvic floor muscles. Because Chris had urge urination, it is highly likely that he was activating these muscle groups causing them to be dysfunctional. All of these muscle groups were very hypertonic/had myofascial trigger points at this point and extremely sensitive to touch. Furthermore, when they’re in a hypertonic state, they contribute to urinary urgency. Part of the pelvic floor consists of the urogenital diaphragm (the muscles surrounding his penis), and these muscles were also hypertonic and tender to touch. While these muscles contribute to his urinary symptoms, they were also contributing to some of the discomfort associated with ejaculation. During ejaculation, you contract your urogenital triangle muscles; however, if they’re already in a contracted position it becomes uncomfortable or even painful after ejaculating. With all of these muscle restrictions now making him highly uncomfortable to say the least, it can lead to connective tissue changes, and he had connective tissue restrictions throughout his abdomen, bony pelvis, and inner thighs. Connective tissue restrictions accompanied with the tightness of his pelvic floor and obturator internus contributed to the “rectal fullness” sensation.
Plan
My plan was to treat Chris once a week to work on connective tissue mobility, improve hypertonicity and myofascial trigger points, and improve range of his pelvic floor muscles so that he was able to voluntarily lengthen his pelvic floor muscles (perform a pelvic drop). Since I suspected anxiety to be part of the issue, heavy patient education was a part of the plan as well in order for him to understand his condition. This included noticing if he was clenching any of these muscle groups during the day (which we already found out he did) and to perform some diaphragmatic breaths and pelvic floor drops (once he was able to) to relax his body. Seeing a psychologist regarding anxiety/stress helped as well. Performing diaphragmatic breaths also helps reduce stress and anxiety by activating the parasympathetic nervous system, so doing this throughout the day is always a good idea. Explaining my assessment in detail was important in order for Chris to understand how the musculoskeletal system can contribute to his symptoms.
Overview of treatments and changes
The initial treatment cut down Chris’s anxiety over his condition which ultimately contributed to his success. Yay for patient education! Between visits two and three, Chris went on a road trip and had to sit in the car for hours at a time. However, after our talk about how stress/anxiety can perpetually contribute to his lasting urinary urge, he noticed that he had decreased urge on the trip and increased urge when he returned to work. Regardless, he was still urinating two to three times per night at this time and reporting the rectal pressure. Here, we kept on working on myofascial release and improving pelvic floor muscle motor control to further improve his symptoms.
It was not until around week five where he noticed an almost complete resolution of his urinary urge. At this time his pelvic floor muscles were mobile enough and capable of completing a pelvic drop, but there was still hypertonicity throughout PFM limiting full range of motion. This had been a turning point to Chris’s recovery because now he had the ability to voluntarily relax his pelvic floor muscles when he noticed he was clenching during the day. At visits seven and eight, he was reporting that he hadn’t had urge in weeks and was able to hold urine for a normal amount of time. The discomfort associated with ejaculation was fully resolved at this time as well. The motor control of his pelvic floor was also good, and he was fully able to voluntarily perform a pelvic drop.
The last five visits, Chris was feeling so well that we were having monthly appointments as opposed to seeing each other weekly. Even with the appointments spread out, he would come in and report that he was symptom free on the last two visits. If he had noticed a slight flare, it was managed easily by performing HEP: foam rolling (glutes and hip rotators, inner thighs), pelvic drops, stretching (happy baby, deep squat with pelvic drop). Still, Chris has not come in since July of this year, went through a major life change (bought a new home!), and is able to manage his pelvic symptoms. Recently, he had a follow-up visit with his urologist who exclaimed after examination, “You’re cured!”
Here are a few words from Chris:
What were you expecting from PT?
I read a lot about it, so there were no surprises. I was expecting everything that happened with the exception of how painful the skin rolling is *laughs*.
Click here and here to read about what a good pelvic floor PT session looks like.
How do you feel PT treatments helped you?
“Multifaceted. You helped me alleviate a lot of the anxiety which got rid of a lot of the tension. Everything I’ve been holding onto was in my muscles — just generally I became a lot more loose which made me feel better.”
Any additional comments?
I get that there’s a stigma [to internal work] and that it’s emasculating, but you’ll be so happy that you did it. We get that it’s abnormal and unusual and not what you would hope for, but at the end of the day you’ll feel better. I feel better today than the two years before I started therapy.
Additional Resources on Recovering from Male Pelvic Pain:
Our book: Pelvic Pain Explained
Our Male Pelvic Pain Resource Blog that contains podcasts, our male pelvic pain YouTube video, and support group links.
Other Success Stories from our male patients:
Why does the area between my butt and balls hurt?
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
i have read it -i am glad that some one this is helps.I am suffering in 4 years -nobody knows how to help.
Thanks for this information. I’m in desperate need of this therapy.
Hi Andrew,
Have you seen a pelvic floor physical therapist? If not, we can help connect you with one.