The following blog is a repost of Ashley Brichter’s original blog post. Ashley is a birth educator, birth and post-partum doula, lactation counselor, and friend of the practice. She hosts many classes on childbirth, lactation, and much more. We will provide more information at the end of the post on how you can get in touch with Ashely and how you can sign up for her excellent classes.
Originally posted: January 22, 2019
Hollywood misrepresents a great deal about the childbirth process, but the fact that they show everyone delivering babies while lying on their backs in a hospital bed is accurate. As Ross clearly demonstrates above, lying down with knees apart is the most common way for someone in the United States to deliver. Here’s why you may want to question this:
A baby’s job in labor is to rotate and descend through the pelvis. If we can maximize the amount of space a baby has within the pelvis, we can not only speed this process along but minimize the stress on muscles and tissues within the pelvic bowl (and therefore minimize the risk injury).
How do you maximize the space in your pelvis to encourage the baby’s rotation and descent? The pelvis has four boney landmarks that determine the maximum circumference a baby has to fit through: the pubic bone at the front, tail bone or coccyx at the back, and two sitz bones at the bottom. Let me walk you through two very simple movements to see how you can create the most space between the pubic bone and tail bone and two sitz bones.
If you’re in a location where feeling around on your pelvis would be immodest, make a commitment to try it the next time you’re in the bathroom or back at home.
First, find the space between your pubic bone and tail bone:
Place one hand on your pubic bone (it’s very low down under the belly, right between your legs. Isn’t it wide!?). Place your other hand on your tail bone. To find your tail bone, invite your hand to feel between the crease of your behind. It is often higher up than most people realize. You can walk your fingers all the way down the bottom of your spine until you reach the end – and/or lean back on your fingers in order to feel it more.
Once you have fingers on the pubic bone and fingers on the tail bone, lean forward and feel the space between your fingers. Then lean back. In which direction to you have the most space between your fingers, between your pubic bone and tail bone? When you are leaning forward or leaning back? Try this a few time before you move on.
Then, find the space between your sitz bones:
This is best done sitting down on the edge of a chair. Place your hands underneath your bum and your should feel your sitz bones protruding down. If you don’t feel them right away wiggle side to side a bit. You should feel boney points digging into your hands.
Now, spread your knees out wide (like you’re having a baby!). Feel the space between your fingers. Then, bring your knees in close together (keeping your feet fairly separated). In which position do you have more space between your sitz bones? With your knees together, feet apart, or your knees and feet wide?
Hopefully when you tried it you were able to feel that there is more space in your pelvis when you are leaning forward and that there is more space in the pelvis when your knees are closer together than your feet.
WAIT. What? That’s right. I said it.
Most people deliver their babies on their backs with their knees spread wide because this is the most convenient position for hospital staff. If you’re thinking about a physiological birth, looking for ways to possibly shorten your labor, or looking for ways to reduce the risk of tearing, give some serious through to positions that lend themselves to forward leaning and keeping feet wider than knees!
Let’s take one more look at the tail bone specifically: leaning backwards makes the tailbone stick in. It limits the amount of space a baby has to rotate and it asks your body to push a baby uphill! Upright and forward leaning positions will allow the tailbone to get out of the way. Granted, you have to deliver with a provider and in a location that is supportive of this. But that’s for another post!
Having a baby is exciting, fascinating, and nerve-wracking. If you have never been through the process before, chances are you have a lot of questions and concerns about what changes your body will go through during your pregnancy, what the birthing process entails, and how your recovery will go once you’ve had your baby.
Join us and childbirth specialist, Ashley Brichter, in our Pelvic Health class to discuss the ins and outs of having a child.
The penis is kind of like a canary in a coal mine for the male body. A penis that isn’t quite working the way it used to is something that should not be ignored. Erectile dysfunction (ED) can have devastating effects on the psyche of the person experiencing it. ED can be an important indicator that some other component of your health, whether it be your heart, your weight, your mental health, physical activity, or muscles may need a little extra attention. In this blog we will discuss some of the common contributors to ED as well as steps you can take to prevent and or treat it.
Erectile dysfunction is the term given to a condition in which a person is unable to maintain an erection to complete sexual intercourse. Erectile dysfunction affects many people. It is considered the most common chronic condition affecting person. The lifetime prevalence (your chance of experiencing ED at least once in your life) is about 50% (Kaya 2015).
It is a sad but true fact that as you age, your risk for ED increases. This is because the penis relies on a mixture or hormonal, musculature, vasculature, and neural inputs for full function. As we age these systems can be impacted by diseases of old-age, medications used to manage these diseases, as well as general inactivity.
Men who are under 40 also may experience erectile dysfunction. The old dogma was that men who were experiencing erectile dysfunction under the age of 40 did so entirely because of mental health conditions like anxiety. This is no longer the belief. We know that certain other health conditions like pelvic floor dysfunction, diabetes, high blood pressure, and obesity can wreak havoc on a man’s sexual function
Although your chances of experiencing ED increase with age, it is certainly not inevitable and we are fortunate to live in an era of effective diagnostics as to the cause of your ED as well as treatment and prevention.
How is a Normal Erection Achieved?
The physiology of the penis is fascinating. It’s like a symphony of different systems that come together to produce one result. In order to achieve an erection your muscular, vascular, neurological, and hormonal systems must all be functioning properly. We can divide erection into two phases; a vascular phase and a muscular phase. The vascular phase relies on the heart and blood vessels to bring blood to the penis and allow it to become stiff. The muscular phase relies on the muscles of the pelvic floor (the bicycle seat area of your body). These muscles work by contracting to increase the pressure of the blood within the penis. Hormones and the nervous system also help to regulate drive, sensation, and the response of your muscles and arteries to sexual stimulation. As we will see, there are many different things that can disrupt these processes and cause difficulty with erection.
Causes of Erectile Dysfunction:
Metabolic syndrome is an increasingly common syndrome in the United States that is currently affecting 35% percent of all adults and is hitting our elders particularly hard, with an estimated 50% of all adults over age 60 meeting the clinical definitions of metabolic syndrome.
Metabolic syndrome is defined as having 3 or more of the following conditions: waist circumference of 102 centimeters or more ( about 47 inches) for men, and 88 cm ( about 35.5 inches) for women, serum triglycerides of 150 mg/dl or greater, high density lipoprotein (HDL, the good cholesterol) of less than 40 mg/dl in men and 50 mg/dl in women, blood pressure of over 130/85 mm/hg or needing to take blood pressure medications, fasting blood glucose of 100mg/dl or greater, or if you are currently taking diabetes medications.
The link to ED and metabolic syndrome and other disorders associated with it (diabetes, obesity, and heart disease) is well established. In a 2015 article, Kaya and colleagues found that men with erectile dysfunction are 3 times more likely to also have metabolic syndrome. The group also found that 79% of men with ED have a BMI of over 25 (overweight) and that men with a BMI of 30 (obese) have a 3 times increased incidence of ED.
You are probably well aware that the above conditions are definitely not good for your health and can put you at risk for heart attack, stroke, and diabetes, but how does metabolic syndrome affect your penis? Metabolic syndrome can have a profound effect on your hormones, sex drive and blood flow, which are important components of maintaining a healthy erection.
Metabolic syndrome is associated with an increase in adipose (fatty tissue) around the waist. Fatty tissue has a strong interaction with the hormones estrogen and testosterone. Testosterone is the hormone of desire and is needed for proper sexual function in both males and females. Obesity can lower the amount of serum testosterone someone has, which can actually increase the amount of fat you store. As the balance between estrogen and testosterone shifts within your body, it becomes harder to lose weight and with increasing fatty tissue your testosterone continues to lower over time making the situation worse.
Metabolic syndrome also affects the delicate and complex arterial system that goes to the penis. Just like plaque in your arteries can cause heart disease and heart attacks, it can also clog up the vasculature in your penis making it difficult or impossible to achieve an erection. This makes the loss of erectile function a serious issue, besides the obvious effect on your sex life, because it is an important indicator of how well your cardiovascular system is working and may indicate a potentially serious buildup of plaque in other vital arteries. The loss of potency certainly warrants further investigation by your primary care provider.
Drug and Alcohol Use
Sometimes drugs and alcohol are used as an aphrodisiac to help dampen inhibitions and fuel the passion between a couple. However, there have been many studies that show that long-term and sometimes short-term use of drugs and alcohol can have a negative effect on a man’s ability to achieve and erection.
Alcohol has long been considered a social lubricant. It factors into our sexual imagery with images of couples sipping a sexy glass of champagne before getting down to business on TV and in movies. But too much alcohol can easily ruin your ability to enjoy an intimate night with your partner.
There are many different ways alcohol can affect erection and sexual potency. In the short term, alcohol is a central nervous system depressant. What that means is that it can slow down the systems that are vital to your erection like respiration, circulation, and nerve sensitivity.
As anyone who has woken up from a night of heavy drinking can tell you, alcohol can be very dehydrating. Dehydration affects your ability to achieve an erection by lowering your blood volume, therefore allowing less blood to get to the penis (a requirement for a rigid erection). Dehydration also increases the amount of angiotensin circulating in the blood. Increased angiotensin is associated with erectile dysfunction.
Long term alcohol use can also wreak havoc on your erectile and sexual function. In a 2007 study by Arackal and Benegal, 100 subjects between 20-50 who had been to a rehabilitation facility for alcohol withdrawal were surveyed for their level of sexual function. The average length of alcohol use for the patient’s surveyed was about 8.59 years. Out of the 100 men surveyed 72% reported sexual dysfunction including low desire, premature ejaculation, and erectile dysfunction. Chronic and heavy alcohol consumption can damage the cardiovascular system, limiting the blood flow available to the penis. Other drugs like opiates, amphetamines, and designer drugs have been found to negatively affect the quality of erections in long term users versus their age matched counterparts who are not using drugs. It is advisable to abstain from drug and excessive alcohol use for many reasons but also for health of your sexual systems.
It has long been the dogma in male sexual health that difficulty in erection in young men is solely attributable to psychogenic or emotional causes. As you have seen in the previous sections there are many different factors that can impair your sexual functioning.
Erections can occur in response to touch, but they can also occur in response to visual stimulus or fantasy. The mind is a powerful sexual organ and disorders that disrupt its function can also disrupt your ability to achieve an erection.
During erection, your brain sends signals to the penis via neurotransmitters (chemical messengers). These messengers cause the release of cyclic guanosine phosphate (cGMP) at the penis to allow the capillaries in the penis to dilate and the penis to engorge. The brain must send continuous messages via these neurotransmitters to keep the supply of cGMP steady throughout intercourse or during sexual play to ensure that your erection is maintained throughout.
Emotional issues affecting erection can range from guilt, anxiety, grief and stress. Anxiety about achieving an erection can make impotence worse, thus creating a vicious cycle. Being able to achieve an erection with masturbation or in the morning (“morning wood”) but not during intercourse, is an important clue that there may be an emotional component to your erectile dysfunction.
What do muscles have to do with my penis? A lot. The muscles of the pelvic floor play a vital role in the sexual function of both genders, and as we will explore, there is a considerable amount of muscular coordination required for erection and orgasm.
The pelvic floor is the region of muscles that reside in the bicycle seat or crotch area. The muscles of the pelvic floor have a lot of work to do for your body. The pelvic floor is divided into 3 layers. The deepest layer provides the supportive function of the pelvis. It supports your pelvic organs like the bladder, rectum, and prostate. It also provides support to the bones of the pelvis. The middle layer provides the sphincteric function of the bladder and is responsible for closing down the openings that allow urine and feces to leave the body and provides us with continence. The last layer is responsible for the sexual functioning of the body. These muscles are amazing. They have to relax enough to let blood into the penis to allow for erection, but then contract to allow the blood pressure in the penis to remain high enough for penetration.
Just like any other muscles in the body the muscles of the pelvic floor can be subject to dysfunction. Injury can occur suddenly from the result of a hard fall on the bottom, sports injury, or operation and it can also occur gradually over a long period of time from chronic stress and muscle holding, poor sitting posture, repetitive stress, or infectious process.
When something goes wrong with the pelvic floor we call it pelvic floor dysfunction. Other symptoms of pelvic floor dysfunction can include pain, urinary issues, and defecation (pooping) issues. Luckily, like other muscles of the body, the pelvic floor can be rehabbed and made to function properly with the help of physical therapy. Treatment:
Society places a lot of weight on a male’s ability to perform sexually and it can be easy to feel a lot of shame and distress when that ability is compromised. As we have explored there are a multitude of physiological and psychological reasons that can affect your penis that have nothing to do with your manhood, your love of your partner, or your sexual skill.
Changes in your erection are potentially serious and may indicate a larger disease process at work. If you find you are unable to maintain an erection, you should make an appointment with your doctor to determine the appropriate treatment.
Once you are cleared by your doctor, physical therapy can help to ensure your muscles are in working order to achieve an erection. Physical therapy can also address other aches and pains that may be preventing you from being active enough to maintain a healthy body.
Now is the time to make healthy lifestyle changes, regardless of whether you are currently experiencing erectile dysfunction or not. Studies looking at the effects of lifestyle changes and the benefit of erectile function find that the earlier in life one makes healthy changes the more effective those changes are at warding off erectile dysfunction.
If you smoke, stop. It is common knowledge that smoking pushes you closer to the grave, but it also affects the blood flow to your penis. It’s no small task to quit smoking. At the bottom of this page you will find links to resources to help you quit smoking. Some of the long-term benefits of quitting include: reduced lung cancer risk, reduced risk of heart disease and stroke. You can even see results right away. Within 20 minutes of quitting, your heart rate and blood pressure drops, and as early as 2 weeks circulation improves helping to restore proper blood flow to your penis.
Aside from smoking, adopting healthier habits overall, can improve your sexual as well as overall function. Getting regular exercise helps to improve many of the conditions associated with metabolic syndrome. Exercise also gets the heart pumping ensuring adequate blood flow to the penis. The CDC suggest that people aged 18 and over get at least 2 hours and 30 minutes of moderate-intensity aerobic activity (brisk walking) and muscle strengthening of all major muscle groups during the week.
Diet is another important component of proper erectile function. A general rule of thumb is to eat a diet that would generally be considered good for your heart. Reducing your alcohol, fat, sugar, and salt intake while increasing your intake of whole grains, vegetables and lean meat is a good place to start. Consulting with a registered dietitian can help to give you more specific advice for your personal goals.
Physical therapy can help to improve the function of the muscles that are responsible for erection, ejaculation and orgasm. As we described earlier, the pelvic floor muscles play in integral role in male sexual function, from erection to ejaculation. When men come into physical therapy after complaining of erectile dysfunction, a pelvic floor physical therapist will examine the muscles of and surrounding the pelvic floor to see if they are too tight or weak to generate enough force to maintain adequate blood pressure in the penis, examine bony malalignments which may be impairing the full function of the muscles and nerves of the pelvic floor, as well as many other things that may be impacting the full function of the pelvic floor.
Pelvic floor physical therapists treat their patients, employing a multitude of techniques individually selected for each patient. Treatments may utilize soft tissue techniques to reduce tightness of the pelvic floor and surrounding fascia to improve muscle function and blood flow. A therapist may guide his or her patient through a series of exercises to strengthen weak muscles. Other techniques include postural correction, biofeedback and much more.
The effects of physical therapy on erectile dysfunction have been illustrated in many studies. In a 2014 study, Lavoisier and colleagues examined the effects of a program of pelvic floor physical therapy on erectile function of 108 men suffering from erectile dysfunction. The men in this study had no neurological conditions that could affect their erectile function. In this study, the participants were given 20 sessions of physical therapy which included muscle strengthening and electrical stimulation of the muscles of the pelvic floor. At the end of the study, Lavoisier and colleagues found that that physical therapy was effective in strengthening the muscles of the pelvic floor, specifically the ischiocavernosus, which is a major component of being able to achieve erections.
In another study by Dorey and colleagues in 2005, men were given either pelvic floor physical therapy exercises or lifestyle changes to treat their erectile dysfunction. The men in the study who were given pelvic floor physical therapy did significantly better than men who performed lifestyle changes alone.
Most of us are aware of Viagra and Cialis; Viagra, most memorably being brought to our collective cultural awareness by former presidential candidate, Bob Dole. These drugs have quite the interesting history. Viagra as an erectile dysfunction drug was actually discovered by accident. Viagra (sildenafil) was originally designed for treatment of heart conditions. It was found that treatment with Viagra improved the erection of those taking it. Conversely it was not effective for its original purpose, the relief of angina (chest pain). It works by relaxing the blood vessels of the penis to allow for blood flow and erection. Viagra does not cause people to have erections, it allows people to respond to sexual stimulation with an erection. It is not an aphrodisiac and taking it recreationally does not change sexual performance of people without erectile dysfunction. Cialis (tadalafil) works in much the same way as Viagra by increasing the blood flow to the penis via dilation of the penile blood supply. Even with the use of Viagra or Cialis, it is important to discuss with your doctor, what the underlying cause of your erectile dysfunction is, and what other steps you can take to improve your overall health and prevent further impacts on your quality of life.
There are other options to treat ED in more advanced cases. There are pumps that can be used to allow blood to be drawn into the penis to maintain erection. Pumps should be prescribed by your doctor to ensure effectiveness and safety.
Implants are another available option, but require surgery. There are two main types: rigid and inflatable. Inflatable implants allow for erection by transferring saline into two semi rigid rods on either side of the penis. This allows for the ability to have a flaccid penis when desired. Rigid implants consist of rods that you adjust to have an erection. The penis will remain firm but you can bend it to conceal it as desired.
Erectile dysfunction is a devastating condition that can have a profound effect on your quality of life. The health of your erection is an important indicator of your overall health. Maintaining an active and healthy lifestyle goes a long way towards staving off erectile problems in the future. If you find yourself troubled by erectile dysfunction, see your doctor. There are many treatments options, including physical therapy that can help you return to living your life fully.
American Cancer Society’s Guide to quitting smoking:
Rajiah K, Veettil S, Kumar S et al. Psychological impotence:psychological erectile dysfunction and erectile dysfunction causes, diagnostic methods and management options. Scientific Research and Essays Vol. 2012; 7(4): 446-52
By: Fiona McMahon, DPT
Hey Ladies!!! In the next installment of our Pelvic Health 101 course, we are hosting a women’s only session to allow for a safe and non-threatening place to discuss many issues that can affect the health of your pelvic floor. This class one of Stephanie Stamas’s (the founder of PH101’s ) favorites and is definitely not to be missed. Hear more about it in her video below! Join us at 7pm on April 23. Please register at pelvichealth101.eventbrite.com
Set Up: Stand with one foot on the carriage and one foot on the platform with weight distributed evenly between both legs. Slightly turn out your legs to help engage outer rotators and glutes. Lighter spring setting will focus on adductors (insides of legs) while a heavier spring setting focuses on abductors (outsides of legs).
Execution: The breath for this exercise changes based on adductor or abductor focus. For adductors- inhale to push carriage away from the platform and exhale to pull carriage back in. For abductors- exhale to push carriage away and inhale to control the carriage back in. Move the carriage out only as far as you can go while maintaining good form, as soon as neutral pelvis shifts to a tilt or a tuck, you’ve gone too far.
Focus: Be sure to keep the integrity of your form throughout the entire exercise. Keep a tall, stacked spine with ribcage over hips, neutral pelvis, and lifted arches. Think of a string lifting you up from the crown of your head. It’s common for the arches of your feet to drop, causing pronation. Keep that pinky toe connected to the machine. This will also keep the knees in correct alignment.
Importance: Great postural exercise. It’s meant to focus on either adductor or abductor strengthening depending on desired resistance. As a whole, it draws attention to weight placement and how that affects your alignment while standing.
Modifications: If you are apprehensive about balance, grab a pole or a long dowel and place that on the floor right in front of you while standing on the machine. If this exercise bothers your knees, keep a slight bend in them the whole time.
On April 16th at 7pm we will be hosting our “Men’s Only Seminar”. Join Sarah Paplanus, DPT as discusses how pelvic floor dysfunction affects the male pelvic floor. Learn how your sex life can be improved by pelvic floor treatment, how to regain function after prostatectomy, and how to rid yourself of the pain of prostatitis, and avoid antibiotics for the most common type of prostatitis. This seminar is not to be missed!
For more reading on men’s pelvic health topics, check out:
Beyond Basics Physical Therapy has some exciting news. We are running the New York City Marathon for the third year in a row with Team Tisch MS. What makes it doubly exciting is that for the first time ever not one but two physical therapists will be running! Both Molly Caughlan and I will be running to raise $5,000 each, for a total of $10,000 dollars to directly support the work of Tisch MS Research Center of New York to help END multiple sclerosis.
Over the course of the next 7 or so months, you will see blogs documenting our progress towards our goal as well as blogs highlighting the work Molly will be doing with her amazing physical therapist, Tina Cardenia, and Myself, and my awesome physical therapist, Jessica Babich. Molly will soon introduce herself and say why she is working with our girl, Tina. But for now, let me explain why I am so excited to return to work with Coach Jess, ( yes, I am calling her coach Jess now, it’s a thing).
In 2017, together, Jessica and I managed to shave off 17 whole minutes from my last NYC Marathon. My dream of all dreams would be to seek out a BQ (Boston Qualifying time), which would require another time shave of about 13 minutes… and 2 seconds to be precise. Which… is a lot (like, a lot a lot). But shoot for the stars, as they say.
So why did I chose Jess to help me with this lofty goal? Because she is a jack of all trades. In 2017 she was able to tie in visceral (organ based) approaches, with orthopedic and pelvic approaches. She is thorough from checking my sneakers to my head and neck control while running. Working with her two years ago, made me feel like I had a new body.
Working with Jess was a commitment, but one that I saw pay dividends in the end. I won’t lie there were definitely times I wished I could sleep in an extra hour rather than come into PT early, but the thing is, that extra physical therapy kept me injury free and helped me maximize my training. You can have the highest VO2max in the world (a measure of cardiovascular fitness) but if something is keeping you from running efficiently, you won’t be running at your top times. You just won’t. Jess has no tolerance for inefficiency and can spot it with a laser focus and then work her magic to correct it.
Jess has been nerding out lately about new ways to facilitate or wake up the core for efficiency. She’s almost always playing with new techniques when she has the time to do it. Literally, she is always in the clinic gym playing with techniques. This is a major reason I love working with Jess: for her, it’s not just work it’s a passion.
Stay tuned for more from Jessica, Tina, Molly, and Me as we work our way towards Marathon Sunday.
Click here to Donate to myself or Molly. We’re competing to see who can raise the most… so if you’re team me or team Molly, make your donation count