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).
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.
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*.
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
Other Success Stories from our male patients: