By Jandra Mueller
Being a pelvic pain specialist means that I get to talk about sex, or in my patients’ case, reasons why they aren’t having sex. Many of our patients who suffer from pelvic floor dysfunction are unable to engage in satisfying intercourse because of pain, but in some male clients, erectile dysfunction and premature ejaculation are also an issue. It is a touchy subject for most men and they are often embarrassed to talk about these issues; unfortunately, what they are dealing with is quite common with pelvic floor dysfunction.
When I talk to people about what I do, and tell them I work with people that have sexual dysfunction, it is no surprise that I get a lot of confused looks and people asking “physical therapy can help with that?” My answer is of course! The muscles in our pelvis play a critical role in our ability to have sex!
Let’s talk about that – what role does the musculoskeletal system play in erectile dysfunction and premature ejaculation? Often, men who experience pelvic pain are having difficulty in some way with their ability to have sex. They go to the doctor and all their tests come back normal so they are at a loss as to why this is happening to them. Can the musculoskeletal system be causing this? Is this something that PTs can treat? Do I need to take viagra?? This is often the question not just by patients but pelvic floor therapists themselves.
In this week’s blog I’ll be talking about how physical therapy may be able to help these male clients overcome their erectile and premature ejaculation and return to a normal sex life when the musculoskeletal system seems to be the culprit. I also wanted to explain what we do in an evaluation and how we treat men. Many of my male clients tell me after we are done with the evaluation, “I didn’t really know what to expect coming in here today.”
Male sexual dysfunction is complex and most of the research regarding biologic factors has focused on hormonal, neurologic, and/or vascular issues. Male pelvic floor dysfunction has been associated with erectile dysfunction and dysfunction of ejaculation and orgasm1. One of the most common conditions we treat men for is chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS); a condition associated with problems with urination, defecation, and/or sexual activity. Men with CP/CPPS may experience pain constantly or intermittently, and this pain can occur with sitting, standing, routine daily activity, or sexual activity. The relationship among male sexual dysfunction, pelvic pain, and CP/CPPS is complex, with the three conditions often overlapping.
Erectile dysfunction (ED) is defined as the inability to achieve or sustain an erection suitable for sexual intercourse. While there are many definitions of premature ejaculation (PE), I feel this definition best describes this dysfunction on multiple levels: “Premature ejaculation is persistent or recurrent ejaculation with minimal stimulation before, on, or shortly after penetration, and before the person wishes it over which the sufferer has little or no voluntary control which causes the sufferer and/or his partner bother or distress,”2 typically described as ejaculating within one minute of penetration.
Getting an erection is actually quite an involved process, and there are many things that need to go right for this process to happen, which I will summarize shortly. First, I want to familiarize everyone with some key parts of the male anatomy, you can also check out Shannon’s blog here for more details on pelvic floor anatomy.
In the above picture I want to highlight the bulbospongiosus and ischiocavernosus muscles, we will be referring to them when talking about erections and ejaculation. They form part of what we call the urogenital diaphragm of the pelvic floor muscles and are involved with both urinary and sexual functioning.
This photo shows a cross-section of a penis; the corpus cavernosum and spongiosum are erectile tissues and within them is an artery that fills these tissues with blood when stimulated. This will all be described below in a brief summary.
So how does erections and ejaculation work? If you want to hear a great review of all the details and physiology, check out this excellent YouTube video here.
I will just briefly go over some main points, mainly emphasizing the muscle and role of the nervous system – what PTs can treat.
- It starts with stimulation of the genitals, which is picked up by sensory fibers of the pudendal nerve.
- This stimulation then leads to erection via our parasympathetic nervous system (the part of our nervous system that controls ‘rest and digest’) to cause the central artery of the penis to dilate and allow the corpora cavernosa and corpora spongiosum to fill with blood.
- Contraction of ischiocavernosus muscles help to increase the penile erectile rigidity and hardness by compressing the roots of the corpora cavernosa and increasing the pressure.
- Contraction of the bulbospongiosus leads to temporary engorgement of the glans penis and corpus spongiosum.
- At the same time, the dorsal vein of the penis becomes compressed with the engorgement of the corpora cavernosa and spongiosum, and does not allow blood to leave the penis.
- Emission is the first part of ejaculation and is controlled by our sympathetic nervous system (what we know as our ‘fight or flight’ system); it gets the sperm where it needs to be to leave the body.
- Ejaculation is controlled by the pudendal nerve. Impulses begin in the spine and send signals down the pudendal nerve to cause rhythmic contractions of the bulbospongiosus and ischiocavernosus muscles to eject the semen from the body.
In men with pelvic floor dysfunction, they can have various problems with these structures including low tone (too weak) musculature from having age-related changes or a prostatectomy, or high tone (to tight) musculature for a number of reasons, including CP/CPPS and pudendal neuralgia. Both of these very different scenarios can result in TREATABLE erectile dysfunction.
There are a number of medical interventions to treat erectile dysfunction including medications and injections. PHRC friend and colleague, Joshua Gonzalez, MD will be sharing medical interventions in an upcoming blog. But what about the muscles? What about when all your medical tests come back clear and “nothing” is wrong with you? That is where a pelvic floor physical therapist can assess you for a musculoskeletal cause of dysfunction.
It is known that the bulbospongiosus and ischiocavernosus muscles enhance erectile rigidity; they used to be labeled in Gray’s Anatomy as the “erector penis.”3 It has been suggested that in men who show good voluntary contraction of the ischiocavernosus muscle, it may increase pressure enough to establish or maintain penile hardness sufficient for penetration. It has also been thought that spasm of the pelvic floor muscles can provide extrinsic compression that restricts the artery and limits inflow of blood. It’s also hypothesized that high-tone muscles and chronic pain is a distraction to effective and sustained corporal smooth muscle relaxation, and that reducing high pelvic floor muscle tone and eliminating chronic pain may help to normalize this function.
In regards to premature ejaculation, it is the most common male sexual dysfunction with the prevalence found to be 23%.4,5 A quick search on google will bring you to a lot of information regarding delaying the urge or using manual pressure, the two techniques are described below.
- The stop/start technique first introduced by Dr. James Semans (1956), is an alternative treatment option for treating PE. As suggested by the name, this technique involves masturbatory stimulation of the penis until the sensation of heightened arousal is met but prior to the onset of the ejaculatory reflex. The stimulation is then withheld until the sensation resolves. This is repeated until the man reaches the point that extravaginal stimulation occurs without ever reaching the sensation of inevitability.6
- The second technique, the squeeze technique, involves the patient and/or his partner to squeeze the erect penile shaft before the ejaculatory reflex is stimulated. Using this technique, the patient will learn to voluntarily delay ejaculation while maintaining sexual excitation (Masters et al. 1970).6
What can PT do for you? It has been thought that training of the pelvic floor may result in:
- Increasing penile rigidity and hardness in men with ED to facilitate vaginal penetration7
- Improve control over ejaculation and allow for increases in intravaginal ejaculatory latency times in men with premature ejaculation and pelvic floor dysfunction8
- Improved resting tone9-14
You will also find a ton of information telling you to do kegels, and to contract the muscles we discussed above. You may find that following those instructions leads to more dysfunction and potentially even pain – why? This is because you may fall into the category of too-tight muscles, and you may need to do relaxation based exercises to reduce the tone to improve the function of these muscles, this is called a reverse kegel!
So how do you know what type of treatment will help you? Many people think to just do the trial and error method; however, it may not be as simple as that and you may need to get an evaluation from a specialist to have them determine what specifically is going on with the muscles of the pelvic floor. Are they too tight? Too weak? Do they have trigger points that need to be released? This will all determine what type of treatment you may need.
A typical PT evaluation of a male client will include both an internal and external examination of all of the muscles and fascia from the knees to the rib cage, looking for myofascial restrictions and/or muscle trigger points. We will also palpate (feel) externally the ischiocavernosus and bulbospongiosus muscles looking for reproduction of pain and/or tightness. The internal portion of the examination is a rectal exam in which we will palpate the deeper layer of muscles – the levator ani group. We will also assess the tone (low or high) and the motor control – can you squeeze, do you let go after the squeeze and can you bear down. This part is essential and it will determine what will be the best course of treatment for you. To find out more about treatment for male pelvic pain click here.
The treatment will be determined by the findings but will often include up-training (kegel based exercises) if there is low tone and difficulty contracting, down-training which includes relaxation based exercises to relax and release the muscles, or a combination of the two. We will also prescribe home exercises, like stretching, foam rolling, and mindfulness- based exercises, and/or strengthening that you can do to help to make the physical therapy treatment more effective.
As providers who treat males, we understand that this topic may be extremely embarrassing or frustrating to discuss, and we want to help as best we can. We urge you to discuss with your doctor the option of pelvic floor physical therapy if you are suffering with this condition, especially in the absence of any major systemic disease.
- Cohen D, Gonzalez J, Goldstein I. The role of pelvic floor muscles in male sexual dysfunction and pelvic pain. Sex Med Rev 2016; 4:53-62.
- McMahon CG, Abdo C, Incrocci L, et al. Disorders of orgasm and ejaculation in men. J Sex Med 2004; 1(1): 58-65.
- Dorey G. Pelvic dysfunction in men: diagnosis and treatment of male incontinence and erectile dysfunction. 1st ed. Chichester, UK: Wiley; 2006.
- Porst H, Montorsi F, Rosen RC, Gaynor L, Grupe S, Alexander J. The premature ejaculation prevalence and attitudes (PEPA) survey: prevalence, comorbidities, and professional help-seeking. Eur Urol 2007: 51:816; discussion 824.
- Althof SE. Prevalence, characteristics and implications of premature ejaculation/rapid ejaculation. J Urol 2006; 175(3 Pt 1):842.
- Schuster TG. Premature ejaculation. Medscape. http://www.medscape.com/viewarticle/
543996_7. Accessed April 21 2017.
- Rosenbaum TY. Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabilitation in treatment: a literature review. J Sex Med 2007; 4:4.
- La Pera G, Nicastro A. A new treatment for premature ejaculation: the rehabilitation of the pelvic floor. J Sex Marital Ther 1996; 22:22.
- Siegel AL. Pelvic floor muscle training in males: practical applications. Urology 2014; 84:1.
- Segura JW, Opitz JL, Greene LF. Prostatosis, prostatitis or pelvic floor tension myalgia? J Urol 1979; 122:168.
- Cornel EB, Van Haarst EP, Schaarsberg RW, Geels J. The effect of biofeedback physical therapy in men with chronic pelvic pain syndrome type III. Eur Urol 2005; 47:607.
- Clemens JQ, Nadler RB, Schaeffer AJ, Belani J, Albaugh J, Bushman W. Biofeedback, pelvic floor re-education, and bladder training for male chronic pelvic pain syndrome. Urology 2000; 56:951.
- Nadler RB. Bladder training biofeedback and pelvic floor myalgia. Urology 2002; 60(6 Suppl):42; discussion 44.
- Duclos AJ, Lee CT, Shoskes DA. Current treatment options in the management of chronic prostatitis. Ther Clin Risk Manag 2007; 3:507.