By Allison Romero
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.
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.