What is Pelvic Floor Physical Therapy

marigold-2117436_960_720By Amy Stein, DPT and Fiona McMahon, DPT

As physical therapists who specialize in abdomino-pelvic pain disorders, one of the toughest parts of the job is meeting men and women who have suffered with pelvic pain for years, only to be told by their doctors/healthcare providers that there is no help for them. It is not uncommon to meet a patient who has suffered for 5- 10 years without help before finding us. Musculoskeletal causes of abdomino-pelvic pain are treatable conditions and often times we can start to improve a patient’s symptoms within just a few visits. Please read on to see how we can help you with your pain.

What do pelvic floor physical therapists actually do? Why do they do what they do? What can you expect from your first physical therapy visit?

Physical therapists (PTs) are experts in movement and function, which sounds like a pretty broad topic to be an expert in, and it is. After physical therapists graduate PT school (now-a-days at the doctoral level), they find their niche and specialize. You can find PTs working with high-level athletes, children, infants, people who are recovering from injuries, people with neurological conditions and many other types of clients.

Pelvic floor physical therapists specialize in the muscles, nerves and connective tissues that live between your legs, also known as the pelvic floor. They gain their expertise through a series of post-graduate continuing education classes, certifications, and training. Their training allows them to perform both internal and external pelvic exams, and broadens their knowledge of conditions which affect the pelvic floor. Sometimes, people who specialize in modalities like biofeedback or dilator therapy, advertise themselves as pelvic floor therapists, but don’t have any hands on experience treating the sensitive and often reactive muscles of the pelvic floor. If you are seeking pelvic floor physical therapy, it is important to enquire about the experience and level of training your potential physical therapist has had in this specialty.

What is the pelvic floor and what is pelvic floor dysfunction?

Who needs pelvic floor PT? The pelvis performs many important functions of the body. The muscles, nerves, connective tissues and skeletal structures of the pelvic floor help to keep us continent, aid in sexual performance and function, and assist in core stability.

When some or all of these structures of the pelvic floor are not functioning properly, they can cause a multitude of different symptoms. People who are suffering from bowel, bladder, and or sexual problems, as well as those who are suffering from pain in the pelvis, upper legs, abdomen or buttocks most likely have pelvic floor impairments contributing to their pain.

Issues with the pelvic floor can arise from a multitude of reasons. Infections, previous surgeries, childbirth, postural and lifting problems, and trips and falls can all bring on pelvic floor dysfunction. Pelvic floor pain can persist well after the cause of it has been removed. So it is entirely possible to feel the effects of an old infection, surgery or injury, days to years after they occur. Anyone who has had long standing abdomino-pelvic pain, or pain that they can’t seem to get rid of after seeking the help of medical doctors or other healthcare providers is a good candidate for a pelvic floor physical therapy evaluation and possible curative treatment.

What is Pelvic Floor Physical therapy?

Physical therapy is a practice of healing that restores function and reduces pain through the use of techniques to improve bony alignment, reduce trigger points, and improve muscle coordination and strength. Pelvic floor physical therapy is a branch of physical therapy and is built upon these same principles.

What sets pelvic floor physical therapists apart is their in depth understanding of the muscles and surrounding structures of the pelvic floor, beyond what was taught in physical therapy graduate school. What that means for a patient who is seeking the help of a pelvic floor physical therapist, is that his or her pelvic floor issues will be examined and treated comprehensively with both internal and external treatment, provide them with lifestyle modifications to help remove any triggers, and receive specific exercises and treatment to help prevent the reoccurrence of pain once he or she has been successfully treated.

What exactly do Pelvic Floor Physical Therapists Do?

The elephant in the room with pelvic floor physical therapy is the internal exam/ treatment. It can seem a little daunting, especially if you have pelvic floor pain, but pelvic floor therapists are trained to be as thorough as possible while minimizing discomfort.

During the internal exam, your physical therapist will place a gloved finger into your vagina or rectum to assess the tone, strength, and irritability of your pelvic floor muscles and tissues. Internal exams and internal treatment are invaluable tools that are taught to pelvic floor physical therapists. It can tell us if there are trigger points (painful spots, with a referral pattern or local); muscle/tissue shortening; nerve irritation and/or bony malalignment that could be causing your pain directly or inhibiting the full function of your pelvic floor muscles. We can also determine if your pelvic floor has good coordination during the exam. A pelvic floor without good coordination, may not open and close appropriately for activities such as going to the bathroom, supporting our pelvis and trunk, sexual activity, and keeping us continent.

It is essential that we, as pelvic floor physical therapists, also include other assessments when we are examining our patients for the very first time. We employ the tried and true physical therapy exam practices to determine if there is an underlying condition elsewhere in your body, such as a strength deficit or alignment issue that could be affecting your pelvic floor. It’s wild to think of it, but something as seemingly unrelated as a flat foot or a hip injury can be enough to set off pelvic and abdominal pain!

Some pelvic floor physical therapists may have the opportunity of getting a lot of time to speak one-on-one with a patient to determine possible causes of his or her symptoms, educate the patient and to guide them to other practitioners who may optimize their physical therapy results if necessary. We truly can find out so much by just listening to what our patients have to say. A fall, or infection can be significant as well as a patient’s feelings and knowledge about their current condition.

Once we determine the cause of our patient’s pelvic floor dysfunction, we design a plan tailored to the patient’s needs. At Beyond Basics, we have a diverse crew of physical therapists who bring their own training and background into each treatment. What is really beautiful about that, is that all teach and help each other grow as practitioners. It will be difficult to go over every single type of treatment in one blog post, but we will review some of the main staples of pelvic floor rehab.

Manual Techniques

As physical therapists, are our hands are amazing gifts and phenomenal diagnostic tools that we can use to assess restrictions, tender points, swelling, muscle guarding, atrophy, nerve irritation and skeletal malalignment. We also use our hands to treat out these problems, provide feedback to the muscles, and facilitate the activation of certain muscle groups. There have been a great number of manual techniques that have evolved over the course of physical therapy’s history. Let’s go over a few.

Myofascial Release

Myofascial release was developed by John Barnes to evaluate and treat the myo-fascia throughout the body. The myofascial system is the connective tissue that coats our muscles, nerves, blood vessels, and bones, and runs throughout our bodies. Any tightness or dysfunction in the myofascial system can affect the aforementioned structures and result in pain and or movement dysfunction. By treating the fascia directly, therapists can improve their patient’s range of motion, reduce pain, and improve a patient’s structure and movement patterns.

Myofascial release is a more gentle technique that can be useful in cases where a patient is already experiencing a great deal of pain. The therapist will hold gentle pressure at the barrier of the tissue (the point where resistance is felt) for a short period of time, usually less than 2 minutes until the therapist feels the tissue release on its own. The therapist does not force the barrier.

Scar Tissue Manipulation

Scars are almost always a fact of life. From surgeries, to accidents, to conditions like endometriosis, or certain STI’s, almost everybody has one. What doesn’t have to be a fact of life are the muscle, nerve and skin restrictions and overactivity that they can cause. By releasing scar tissue in physical therapy, it has been shown that the surrounding restrictions also decrease their resistance and adherence to the deeper tissues and surrounding organs.

Myofascial Trigger Point Release

Discussed extensively in Travel and Simon’s two volume series, trigger points are taut (firm) points in the muscle that have a consistent referral pattern (they transmit pain to the another part of the body). Trigger points are not only important because they cause pain, they also can affect how the muscle works. This is one of the main reasons our therapists at Beyond Basics are fastidious about ensuring all trigger points are released in the abdomen, back, legs and pelvic floor before transitioning to any core stabiltiy or strengthening exercises that can re activate a trigger point.

People with trigger points in their pelvic floor and surrounding areas can experience pain in the rectum, anus, coccyx, sacrum, abdomen, groin and back and can cause bladder, bowel, and sexual dysfunction. When physical therapists find a trigger point they work to eliminate it and lengthen it through a myriad of techniques. Recent literature has found that trigger point release alone can achieve an 83% reduction in symptoms.

Connective Tissue Manipulation

Skin rolling, ie. rolling of the skin over another layer helps to improve the movement of those two layers and reduce the tension and pulling between them. It feels like a scratch or ‘nails’, and in cases where a patient has more restrictions, the sensation may be more amplified.

One of the great benefits to skin rolling is it increases the circulation in the area to which it was applied. Often times, areas that are tight or restricted are receiving reduced blood flow and oxygen. By bringing blood flow to the area, toxins can be cleared and the healing contents of the blood are brought to the injured area. Skin rolling can also restore the mobility of surrounding joints and nerves, which can help to restore normal function. By allowing the skin to move more freely, pelvic congestion, heaviness and aching can be effectively treated.

Neural, Visceral, and Joint Mobilization

Nerves, organs, and joints can lose their natural mobility over time and cause a whole host of symptoms from pain, to loss of range of motion, and poor functioning of the bodily symptoms. Skilled and specialized therapists can use a variety of active techniques (patient assisted) and passive techniques to free up restrictions in these tissues and organs and improve overall function.

Neural mobilization as the name implies, involves the restoration of neural structures back to their normal mobility: to glide and slide. Neural structures that cannot move properly can cause pain that can radiate down an extremity or into the trunk and can give the sensation of burning, zinging, and stabbing. Some orthopedic therapists practice this type of mobilization; common examples include the sciatic nerve in the leg and the ulnar nerve in the arm. Pelvic floor PTs focus on these nerves when they cause issues, but they also pay attention to nerves that innervate the perineum and genital region (bicycle seat area), such as the pudendal, iliohypogastric, obturator, ilioinguinal, genitofemoral and the femoral cutaneous nerves. By allowing these nerves to move freely, symptoms such as vulvovaginal, penile, rectal, clitoral and testicular pain, itching and burning can be greatly improved.

Visceral mobilization restores movement to the viscera or organs. As elucidated earlier in our blog, the viscera can affect a host of things even including how well the abdominal muscles reunite following pregnancy or any abdominal surgery. Visceral mobilization aids in relieving constipation/IBS symptoms, bladder symptoms, digestive issues like reflux, as well as sexual pain. Visceral mobilization can facilitate blood supply to aid in their function, allow organs to do their job by ensuring they have the mobility to move in the way they are required to perform their function, and to allow them to reside in the correct place in their body cavity. Evidence is beginning to emerge to demonstrate how visceral mobilization can even aid in fertility problems.

Joint mobilization is a common and favorite tool of most orthopedic physical therapists. We love it so much because it can have so many different benefits depending on the type of technique used. Maitland describes types of joint mobilization on a scale between 1 and 5. Grade 1 and 2 mobilizations are applied to a joint to help to lessen pain and spasm. These types of mobilizations are typically used when a patient is in a lot of pain and to help break the pain cycle. On a non-painful joint, grade 3, 4, and 5 (grade 5 requires post graduate training) mobilizations can be used to help restore full range of motion. By restoring full range of motion within a restricted joint, it is possible to lessen the burden on that and surrounding joints, thereby alleviating pain and improving function.

Neuro-education of the Pelvic Floor and Surrounding Structures

The muscles of the pelvic floor must work together and in coordination to perform specific tasks. The pelvic floor has to contract, elongate and relax in very precise ways to perform basic functions like urination, defecation, support the pelvis and organs, and sexual function and pleasure. If your pelvic floor muscles and/or nerves fail to do what they are supposed to do at the right time, problems like painful sex, erectile dysfunction, constipation, and incontinence can occur.

Biofeedback is a modality that allows you to learn how to better control your muscles for optimal function. Biofeedback shows you what your muscles are doing in-real time. It is helpful to teach patients to lengthen and relax the pelvic floor for issues like general pelvic pain, painful sexual activity and constipation or to contract the pelvic floor in order to prevent leakage with activities like coughing, laughing, lifting, running or moving heavy objects. However, biofeedback does not demonstrate shortened muscles and tissues; therefore, in certain cases the biofeedback may seem to be within normal limits but yet the patient has 10/10 pain. In these incidences, manual palpation is more appropriate to identify restricted and shortened tissues and muscles, and myofascial trigger points.

HEP: Home Exercise Program

 

Home exercise programs are essential for each patient. In the case of weakness, a patient will require more pelvic floor, core and functional strengthening and stability exercises. For overactive and pain conditions, the HEP typically consists of relaxation techniques, self-massages (both external and internal), gentle stretching, cardiovascular fitness as tolerated, and eventually pain-free core stability exercises. Both require postural and behavioral modifications and self-care strategies. For more information and detail, check out the book: Heal Pelvic Pain, by Amy Stein or her DVD: Healing Pelvic and Abdominal Pain here.

Conclusion

As you can now see, there is so much out there that can be done for people suffering with pelvic floor dysfunction. This blog is by no means extensive, and there are even more options you and your physical therapist can explore to help manage your pain or other pelvic issues. Pelvic floor dysfunction requires a multidisciplinary approach for most of our patients. Hopefully, this blog helped to paint a picture of what you will experience with a pelvic floor physical therapist. We advise that you seek out an expert and experienced pelvic floor physical therapist in order to help better your life and improve your function.

Sources

FitzGerald M, Kotarinos R. Rehabilitation of the short pelvic floor I. Background and patient evaluation.

Padoa A, Rosenbaum T. The Overactive Pelvic Floor. Springer. 2016

Simons DG, Travell JG, Simons LS. Travell and Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Volume 1 Upper Half of Body. 2nd ed. Baltimore, MD: Williams & Wilkins; 1999.

Stein, Amy. Heal Pelvic Pain. McGraw-Hill. 2008

Stein, Amy. Healing Pelvic and Abdominal Pain. Video: www.healingpelvicandabdominalpain.com 2013

Travell, Janet G. and Simons, David G., MYOFASCIAL PAIN AND DYSFUNCTION. THE TRIGGER POINT MANUAL, Volume 2, The Lower Extremities, Williams & Wilkins, Baltimore, 1992.

Valovska A. Pelvic Pain Management. Oxford University Press. 2016

Weiss J. Chronic pelvic pain and myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001; 166(6) 2226-31

PH101: Does My Diet Really Matter?

Fiona McMahon, DPT

Gluten free, soy free, low FODMAP. It’s amazing how many diets there are out there that really can  provide people with symptom relief. If you are suffering with chronic pain you may be confused on where to start, or what is right for you. You also may have tried out a bunch of different ways of eating, not seen results and have gotten really frustrated. If this is the case for you, I highly encourage you to come to our next pelvic health seminar on October 9th at 7pm, “Does my diet really matter”.

jessica-drummond-headshot-197x300This seminar will be hosted by a special guest speaker, nutritionist Jessica Drummond. Jessica Drummond is a former pelvic floor physical therapist who now specializes in nutrition for those suffering with pelvic floor dysfunction. This seminar was a hit last year and is a great starting point for those considering adding nutrition as part of their healing journey.

Register at pelvichealth-101.eventbrite.com  today.

 

 

Location

110 East 42nd Street, Suite 1504

New York, NY

10017

Pelvic Health 101 Flyer-jpeg

Pelvic Health 101 is back! Come to Our First Class on September 18th

 

On September 18th, at 7pm we will be kicking off our fall semester of pelvic health education class, we call Pelvic Health 101 (PH101). In our first class we will be introducing you to the pelvic floor muscles, where they are, what they do, and how they relate to the health and function of your bowel, bladder, and sexual functioning. We will also be covering how things such as alignment, posture, muscle tone and nerves can affect your symptoms. This course is a great starting point to help you understand your pelvic floor and pelvic floor symptoms.

Please join us at our office at:

110 East 42nd Street, Suite 1504

New York, NY 10017
Register at: pelvichealth101.eventbrite.com

Here is our line up of this and future classes

Pelvic Health 101 Flyer-jpeg

 

What is Neater than your Peter? A Guide to Penile Health and Function Part 1: Premature Ejaculation

blur-blurry-burst-666013

Fiona McMahon PT, DPT

Ladies and Gentlemen, it is finally time to go for this blog and go on a deep dive to discuss at length (pun not intended), the physiology, health, and function of an amazing organ, the penis! A couple years ago we talked about testicles in our blog, All About Testicles, which remains one of our most popular blogs. Now it is time to travel north and talk about how people with penises can best care for them and how to address things that may go wrong from time to time. This blog will periodically cover different issues that can (ahem) arise with penises. Today we will go over premature ejaculation. But before we can do all that, lets review how the penis works.

As an organ, a healthy penis is an amazingly complex organ despite it’s seemingly simple exterior. It is the tail end of the urinary system, provides amazing sensation, carries sperm to the outside world, delivers a substance that can neutralize the acidity of the vagina in order to make it more hospitable to sperm, and is able to use the muscles around it to raise the blood pressure in the penis higher than that of the outside body, in order to maintain erection.

The penis is not one tissue all the way through. It has what’s called the tunica albuginea which is the wrapping for the erectile parts of the penis. This guy is really important because it closes off the vein returning blood flow from the penis to keep the penis erect during arousal. Inside the tunica albuginea is the corpus carvernosum and corpus spongiosum. No, these two tissues are not Harry Potter spells, but critical parts of penile infrastructure. The corpus cavernosum fills with blood during erection and helps make the penis hard. The corpus spongiosum keeps the urethra from getting clamped shut during erection so the sperm can get out.

How Does The Penis Get Hard?

Usually, in response to sexual stimulation, the smooth muscles (the involuntary ones, not the pelvic floor) will relax allowing the small blood vessels within the penis to fill with blood, the result is the tunica albuginea ( the wrapping of the erectile parts of the penis) will compress on the veins of the penis, thus preventing the blood returning back to the body. The trapped blood in the penis will cause the penis to get hard and stand up. The lovely muscles of the pelvic floor, specifically the ischiocavernosus will contract to further increase the blood pressure within the penis and keep the penis erect.

What Happens with Ejaculation?

Ejaculation occurs with orgasm. It is possible to have an orgasm without ejaculation if you have had a procedure like a prostatectomy. For a normally functioning penis, ejaculation occurs with orgasm and is what carries the sperm and other fluids to the outside world. The contractions felt in orgasm are what propel the sperm through the penis and to the outside world. The bulbospongiosus is responsible for these contractions and is part of the pelvic floor.

Premature Ejaculation

Here is where I would normally supply you a pithy little statistic like “ 1 in 4 men will experience premature ejaculation in their lifetime”. Unfortunately, I cannot provide any such statistic for this subject because so few people talk about this problem. The clinical definition of premature ejaculation is a little wonky too, and has not consistently been used in research, therefore prevalence data are likely inaccurate. The International Society for Sexual Medicine (ISSM) , in an attempt to improve the medical definition of premature ejaculation defines it as:

  • Ejaculation that always or nearly always occurs within about 1 minute of vaginal penetration from the first sexual experience (Defined as lifelong premature ejaculation)
    • OR
  • A clinically significant reduction in latency time, often to about 3 minutes or less (defined as acquired premature ejaculation)
  • Inability to delay ejaculation on all or nearly all vaginal penetrations; and
  • Negative personal consequences, such as distress, bother, frustration, and/or avoidance of sexual intimacy (Althof 2014)

If you are a gay or bi-man, or a man who does not have vaginal intercourse you are probably well aware how problematic this definition is. Currently, it is the ISSM’s stance that there is insufficient evidence to draw up criteria for men who have sex in ways other than vaginal intercourse.

As you can tell by the definition, premature ejaculation is divided up into 2 subgroups, lifelong and acquired. The distinction is relatively new in the research and can help patients find better ways to treat their premature ejaculation.

Potential causes of premature ejaculation include:

  • Hypersensitivity of the glans( head) of the penis
  • Issues with serotonin
  • Erectile dysfunction*
  • Either stopping or starting drugs
  • Chronic pelvic pain syndrome*
  • History of rushing early sexual encounters
  • Prostatitis*

*These are conditions treated at Beyond Basics Physical Therapy

What to do about premature ejaculation?

Don’t ignore it. Performance anxiety and premature ejaculation can often become a vicious cycle, where one will promote the other. Regardless of how your symptoms started, there is a lot that can be done to improve your sex life.

If you have prostatitis or chronic pelvic pain come to physical therapy. Did you know 90-95 percent of cases of “prostatitis”/chronic pelvic pain are musculoskeletal in nature… ahem… this is one of the most common conditions we treat at Beyond Basics. Overactive muscles, those in the abdomen, legs and pelvis can contribute to symptoms of prostatitis/chronic pelvic pain, (i.e. burning urination, painful ejaculation, sitting pain, genital pain, defecatory pain, urinary or bowel frequency, urgency, retention, incomplete emptying, etc.,.). Physical therapy can go a long way to treating and curing these symptoms by relaxing and lengthening your overactive muscles and strengthening weaker muscles. Prostatitis is a vast subject that requires its own blog. Luckily for you, I already wrote one. Check it out here.

If you are experiencing erectile dysfunction along with premature ejaculation, get thee to a doctor. I already explained to you how amazing the penis is as an organ. Its function is reliant on blood flow, thus problems with erection, especially in younger people may be an early sign that something may be up with your vascular system. Once systemic causes have been ruled out, get thee to physical therapy. We spoke earlier about how the penis requires blood flow and muscles to work properly; pelvic floor physical therapy can restore the function and improve the vascular health of the muscles vital to erection. Erectile dysfunction is yet another subject that could use its own blog. Again, luckily for you, I already wrote one. Check it out here.

If you don’t think erectile dysfunction, prostatitis, or chronic pelvic pain is causing your premature ejaculation, there is still a lot you and your urologist can do. There is new work revealing that certain medications and psychotherapy can really help reduce premature ejaculation. You are not alone in this and you deserve to start feeling better.

Thank you so much for reading our blog, if you think physical therapy can help you. Please give us a call at either our midtown location 212-354-2622 or our downtown location 212-267-0240. We are offering free phone consultations at both offices for a short period!

fiona2018

Fiona McMahon PT, DPT is currently practicing from our midtown location

Check out our other Neater Than Your Peter Blog:

What’s Neater Than Your Peter (a series on male sexual dysfunction): A Bend in the Road: Peyronie’s Disease

 

 

Althof S, McMahon C, Waldinger M, et al. An Update of the International Society of Sexual Medicine’s Guidelines for the Diagnosis and Treatment of Premature Ejaculation (PE). Sex Med. 2014; 2(2) 60-90

Anderson R, Sawyer T, Wise D. Painful myofascial trigger points and pain site in men with chronic prostatitis/ Chronic Pelvic Pain Syndrome. J Urol. 2009;182(6): 2753-8

Anderson R, Wise D, Sawyer T. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155-60

Chronic nonbacterial prostatitis (chronic pelvic pain syndrome). Harvard Health Publications. Harvard Medical School. 2007. http://www.health.harvard.edu/newsletter_article/chronic-nonbacterial-prostatitis-chronic-pelvic-pain-syndrome. Accessed December 11, 2016

Dean R, Lue T. Physiology of Penile Erection and Pathophysiology of Erectile Dysfunction. Urpl Clin North Am. 2005; 32(4): 379-v

Herman H. “Male and Female Health Wellness and Sexual Function”. New York. 19-20 May 2018

Quinn P. A Multinational Population Survey of Intravaginal Ejaculation Latency Time. J Sex Med. 2005; 2(4) 492-497

The Hard Truth on Erectile Dysfunction

By Fiona McMahon, DPT

 

bananas basket blur close up
Photo by Pixabay on Pexels.com

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.

What’s Normal?

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:

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.

Emotional

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.

Musculature

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.

Prevention:

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

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.

Medicine

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.

Other Options:

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.

Conclusion:

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.

 

Resources:

Smoking Cessation:

American Cancer Society’s Guide to quitting smoking:

http://www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/index

 

NYC Quits:

NYC Quits provides free coaching and a starter pack of quit-smoking medications

http://www.nyc.gov/html/doh/html/living/nycquits.shtml

Call 311 or 1-866-NY-Quits

 

 

Sources:

 

American Cancer Society. Guide to Quitting Smoking. Accessed December 31, 2015

Arackal B, Benegal A. Prevalence of sexual dysfunction in male subjects with alcohol dependence. Indian J Psychiatry. 2007; 49(2):109-112

Aguilar M, Bhuket T, Torres S. Prevalence of metabolic syndrome in the United States 2003-2012. 2015;13(9)

Bang-Ping, Jiann. Sexual Dysfunction in Men Who Abuse Illicit drugs: A preliminary report. J. Sex. Med. 2009. Apr; 6(4):1070-80. Epub 2007 Dec 18

Brown University Health Promotion. Alcohol and Sex. http://brown.edu/Student_Services/Health_Services/Health_Education/alcohol,_tobacco,_&_other_drugs/alcohol/alcohol_&_sex.php.  Accessed December 23 2015

Centers for Disease Control and Prevention. Quitting smoking. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm#benefits. Accessed December 31 2015

Derby C, Mohr B, Goldstein I, et al. Modifiable risk factors and erectile dysfunction: can lifestyle modify risk. Urology. 2000; 56(2): 302-06

Dorey G, Speakman MJ, Feneley RC, et al. Pelvic floor exercises for erectile dysfunction. BIJU Int. 2005 Sep;96(4):595-7

Gareri P, Castagna A, Francomano D. Erectile dysfunction in the elderly: an old widespread issue with novel treatment perspectives. Int J Endcorinol. 2014 (2014)

Grover S, Mattoo S, Pendharkar S, et al. Sexual dysfunction in patients with alcohol and opiod dependence. Indian J Psycho Med. 2014; 36(4): 355-365

Kaya E, Sikka S, and Gur S. A comprehensive review of metabolic syndrome affecting erectile dysfunction. J Sex Med. 2015;12:856-875

Lavoisier P, Roy P, Dantony E, et al. Pelvic-floor muscle rehabilitation in erectile dysfunction and premature ejaculation. Phys Ther. 2014;94:12: 1731-43

Mayo Clinic: Diseases and Conditions: Erectile Dysfunction. Mayo Clinic Staff. http://www.mayoclinic.org/diseases-conditions/erectile-dysfunction/basics/causes/con-20034244. Accessed December 5,2015

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

Photo source: http://globalcomment.com/wp-content/uploads/2008/09/istock_000005072697xsmall.jpg

 

Do You Speak Pelvic Floor? Guide to Antatomy Part 2: Male Genital Anatomy

woman wearing white high top shoes
Photo by Du01b0u01a1ng Nhu00e2n on Pexels.com

Fiona McMahon PT, DPT (Pronouns: She, Her, Hers)

Hello again and welcome to part two of the “Do you Speak Pelvic Floor Series”. In the first part, we described the most common clinical language we use to describe the genitalia of those with female anatomy. In part two we will look a little more closely at the male anatomy. The male anatomy goes beyond the ‘ol twig and berries and there are specific names for the specific parts. Many folks, when they think of about pelvic floor physical therapy, think of it only as a women’s specialty. Beyond Basics Physical Therapy has been treating male pelvic disorders since 2003! In this blog, we will discuss the structures of the male external genitalia as well as some of the conditions that can affect this anatomy. Let’s read on!

Penis– The penis is one of the male sex organs and it has some pretty cool capabilities. The penis has individual compartments in it called the corpus cavernosus which fills with blood to keep the penis hard during erection. The corpus spongiousus helps to keep the urethra from collapsing upon itself during erection. We can see many issues concerning the pelvic floor muscles, surrounding tissues, and nerves that can affect the penis. Peyronies disease occurs when the penis bends, which can be uncomfortable and painful. We have a whole blog which takes a deep dive into the causes of Peyronie’s as well as treatments. You can read more about it here.

Glans- The glans is also known as the head of the penis. The glans is highly sensitive and provides a good deal of sexual sensation during sexual activities. The glans resembles an acorn. The word glans actually means acorn in Latin. The glans is often a place that will be painful with pelvic floor dysfunction. Tight and restricted muscles of the pelvic floor often refer to this area.

Foreskin- Foreskin is a really interesting structure, (stay with me, folks). Foreskin has cultural and religious importance. Many Abrahamic religions, (Jews, Muslims, and some but not all Christians) may practice circumcision as part of their faith tradition. Whether or not someone has had a circumcision is also linked to where someone lives. In the USA circumcision is extremely common, however in many countries across the pond in Europe, circumcision is much less commonly practiced. Whether or not to circumcise is a deeply personal choice that can be affected by your religion and your nationality. There are trade-offs to being circumcised and being uncircumcised and many doctors recommend that the decision is made by the family of the child.

Urethra- The urethra transports semen and urine to the outside world. Did you know that when the penis is fully erect, only semen can travel through the urethra? This prevents urination during intercourse. Men with poor pelvic floor function may experience leakage secondary to poor closure of the urinary tract into the urethra.

Testes- I have a blog all about testicles. In fact, that’s what it is called, All About Testicles. You can read about it here. Testicles create sperm. Did you know problems with muscles and nerve irritation can cause pain in the testicles, as well other serious and non-serious conditions? Read more about testicular conditions in the blog I linked above..

Scrotum- The scrotum is the sack that contains the testicles. The skin on the scrotum can get tight and restricted and sometimes cause pain in the scrotum and penis. Skilled physical therapists can teach you how to gently mobilize this tissue to treat your pain.

 

If you are having pain in any one of these areas, physical therapy may help.

Give us a call at 212-354-2622 to schedule a free consult for those living in the Tri-State Area to find out if PT is right for you.

Fiona McMahon PT, DPT practices at our Midtown Location

fiona2018

 

 

Yeast the Inflammation Beast

 

bake-baker-bakery-1251179

Fiona McMahon DPT, PT

You are what you eat. Trash in equals trash out. You can’t exercise yourself away from an unhealthy diet. These adages are often on my mind as I make my food choices because of the myriad health professionals who have taken time to come to our practice to tell us how we can improve our own and our patients’ health by taking more time to look at what we are consuming in our diet. Lately, many of these clinicians have been focusing on candida overgrowth and diet, which can contribute to pain and inflammation conditions.

What we eat can directly affect the bacterial and fungal makeup of the gut, AKA the gut microbiome. The gut requires a certain level of good bacteria to help us digest what we eat. Over time a poor gut microbiome can affect how efficiently the gut works. The function of the gut goes beyond just digesting food but also is vitally important for the production of neurotransmitters, which help to spread messages within the brain and throughout the whole body.  The microbiome also plays an important role in our hormones and immune system. When the microbiome of the gut is not balanced, it is called dysbiosis.

One of the most common culprits in gut microbiota dysbiosis is candida, (Yeast!). Candida is a naturally occurring inhabitant of the body and when it’s at appropriate levels, it doesn’t tend to be noticed, but anyone who has experienced a yeast infection knows that if this little guy is allowed to go unchecked, it can do a lot to make you miserable. Besides plaguing women with itching, burning vulvas, a yeast overgrowth may cause many other ailments.

Science has pointed to the role candida can play in contributing to chronic and inflammatory conditions. In one study by Kumamoto in 2011, candida overgrowth was associated with delayed healing of inflammatory lesions and was associated with pro-inflammatory cytokines (chemicals) and increased incidence of inflammatory bowel disease like ulcerative colitis and Crohn’s disease.

Yeast overgrowth can also affect the bladder along with over colonization of Saccharomyces (another form of fungus). In fact, yeast and Saccharomyces were found to be higher in women during a flare of interstitial cystitis than when their symptoms were low.

Yeast is not the only organism that can get out of balance and affect our bodies in harmful ways. There are many other players that can get out of balance. Some signs of an altered gut microbiome is a history of allergies, eczema, or repeated fungal infection.

 

What to do?

It all seems pretty dire, right. How do you control who is colonizing your gut, when you barely have enough time to make it to the gym after work? There are a few simple steps you can start with.

Avoid antibiotics, unless your doctor thinks you need them.

capsules-chemistry-coated-143654

The medical community has become a lot more aware of the dangers of over-prescribing antibiotics from their perspective, but it is important to keep in mind that a powerful antibiotic can wipe out good bacteria and bad bacteria in one fell swoop. If the good guys in your gut are reduced, the bad bacteria have a better chance of taking over. Take antibiotics only when recommended. Keep in mind antibiotics will not help treat viruses like the flu, they can only treat bacterial infections.

Modify your diet

close-up-cooking-cuisine-629093.jpgIncrease your consumption of good fats (omega 3’s) to help reduce inflammation.

Food high in omega 3’s includes flax and hemp seed/oils, fish (the fishier the fish, usually means more omega 3’s, for example, herring is higher in omega 3 than a milder fish like snapper). Also, reduce your consumption of processed foods which can increase inflammation levels and eliminate simple sugars and fried foods. If this is only minimally successful, try a gluten and dairy free diet.  

If simple changes are not helping consider seeing a professional

Find a naturopath, functional or integrated MD, or nutritionist who can investigate more fully whether or not you have SIBO (Small intestinal bacterial overgrowth), candida overgrowth, or other gut microbiome disorder. Or perhaps you are lacking certain ingredients, vitamins or mineral.  These professionals can tailor a diet and medication regimen to help return your gut microbiome to tip-top shape.

fiona2018

Fiona McMahon is currently seeing patients at our Midtown Location

 

If you have questions about orthopedic, pelvic, or sports physical therapy, BBPT is offering free phone consults to those living in the greater NYC area for a limited amount of time!

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)

 

 

Sources:

Kamamoto C. Inflammation and gastrointestinal candida colonization. Cur Opin Microbiol. 2011;14(40): 386-391