The Hard Truth on Erectile Dysfunction

By Fiona McMahon, DPT

 

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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

 

September is Sexual Health Awareness Month!

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Fiona McMahon DPT, PT

September is here and we at Beyond Basics are taking some time to observe sexual health awareness month. We take pride in our role of providing our patients with treatments to make sex comfortable and pleasurable as well as in our role as sexual health educators. Sexual health is comprised of many factors beyond just your ability to have sex. This article, by no means, exhausts all factors but is a good starting point to learn more about increasing your health as well as your enjoyment when it comes to sex. We will be expanding on some of the conditions featured in this blog in future posts, so stay tuned.

What is Sex

Sex is not a one-size fits all activity and can come in many different forms. Even between straight couples penetrative sex may not be the standard. In fact there are many couples that can not engage in penetrative intercourse for a variety of reasons. This may be because of an injury, medical condition, or simply because intercourse is not gratifying for the couple or there is some other act that is more gratifying. It’s really up to the couple’s choice and preference. A term for sexual activity that is not penetrative is called outercourse.  One type is not necessarily better than another. It’s all about what works for you and your partner’s bodies and desires.

Emotional Health and Sex

Sex is more than how it makes you feel physically, it is about how it makes you feel emotionally. Many things can influence how we feel about sex and how sex makes us feel about ourselves. If sex is making you feel unhappy or anxious it is important to get to the root of the cause, in order to maximize not only your pleasure but also, your well being. Common issues, to name a few, that can negatively affect sexual experiences are listed here:

 

  • Trauma
  • Mismatch between your sexuality and culture
  • Issues with your partner
  • Issues with consent: Consent is a hot button issue in today’s media and on college campuses. Although consent is a broad and important topic, it can be boiled down to a few key points:
  1. Consent can never be assumed, regardless of dating status or previous sexual activity. For consent to be given, it must be given with an affirmative “yes” answer.
  2. Consent can not be given if someone is high on drugs, underage, or drunk
  3. Consent must be given with every sexual encounter and can be withdrawn at any time.

If emotional issues are contributing to a lack of enjoyment with sex, it may be time to reach out to a certified sex therapist.

 

Sexually Transmitted Infections (STIs/STDs) and Safer Sex

Sexually transmitted infections also known as sexually transmitted diseases can have a huge impact on your well being. Up until recently, sexually transmitted infections (STI’s) have been known as sexually transmitted diseases. There was a change in the nomenclature of these infections, because many of them can be asymptomatic and a person may carry and transmit them without knowing they have been infected.

STI’s unfortunately sometimes carry a moral connotation, in that blame is often put on the person who has it. STIs are simply an infection with a bacterial, fungal, or viral pathogen and have absolutely no bearing on the moral character of those infected. They can be transmitted sexually but they can also be spread through the childbirth process, dirty needles, or a tainted blood infusion.

All STI’s are not created equal. For some there are excellent screening tests and treatment, yet for others, treatment or screening or both may not be fully effective yet. Some may be obvious to those infected, while others may go undetected for years. Common symptoms of symptomatic STI’s include:

  • Sores and bumps around the genital and rectal area
  • Painful urination
  • Penile discharge
  • Irregular vaginal bleeding
  • Foul vaginal odor
  • Painful sex
  • Fever
  • Swollen lymph nodes in and around the lower extremities, which may also be present in the upper body as well.
  • It is important to remember these symptoms are non-specific and can be related to a number of other conditions that are not solely related to STI.

STI Complications

  • Pelvic pain
  • Eye inflammation
  • Pregnancy complication
  • Infertility
  • Pelvic Inflammatory Disease
  • Certain types of cancers associated with Human Papilloma Virus (HPV)

Risk Reduction

Because not all STI’s can be cured, (although many can be effectively managed) and the impact to one’s health can be so large, it is imperative to safeguard your health and fertility. Steps you can take to reduce your risk of STI infection include:

  • Abstaining from sex: abstinence is the most effective way to reduce your risk of STI; however, with most adults, this is not an acceptable option.
  • Using a barrier to reduce contact with bodily fluids. Using condoms for penetrative sex (vaginal, oral, and anal) or a dental dam for vaginal oral sex, can help to reduce your risk.
  • Keeping your number of sexual partners low: long term monogamous coupling is associated with a lower incidence of STI
  • Regular screening: Because many STI’s can be asymptomatic, regular screening is key to catching an STI early, treating the infection, and preventing damage to your own body as well as transmission to others,
    • Herpes: Recommended for those at risk for herpes (people having unprotected sex, have had sex with someone who is infected, or people experiencing symptoms such as sores)
    • Chlamydia:  men who have sex with men, as well as women who are under 25 have a greater risk of contracting chlamydia and should be tested for it
    • Gonorrhea: men who have sex with men, as well as women who are under 25 have a greater risk of contracting gonnorrhea and should be tested for it
    • Human Immunodeficiency Virus (HIV): It is suggested that everyone between the ages of 13 and 64 be tested for HIV. If you do have HIV, it is imperative to be regularly screened for other STI’s as it is easier to contract them with an HIV infection
    • People born between 1945-1965: should be tested for hepatitis C as there is a high incidence in this population.
    • New Partners: Before having sex with a new partner, both people should be tested for STI to prevent transmission of new infections
    • HPV: Females should be screened for HPV at least every 3 years if they are 21 to 30.  It is recommended to be tested at least every 5 years for sexually active women over 30. There is currently no HPV screening for males.
      • Two vaccines are now available to help prevent two types of HPV associated cancer. The current recommendation is that both boys and girls receive the vaccine between the ages of 11 and 12 years old. Boys can receive that vaccine between 13 and 21 and girls between 13 and 26 as a catch up period.
    • Truvada: Truvada is a drug that is now available to help prevent transmission of HIV and indicated for use in high-risk populations.

 

When Genital Pain Limits Sex

Both men and women can have pain that is so severe that it limits their enjoyment of sex, or prevents sexual pleasure completely. There are many syndromes and diseases that can cause pain with sex. As we covered earlier, STI’s can influence pain, as well as other conditions such as non-bacterial prostatitis, vulvodynia, vaginismus, pudendal neuralgia, as well as many more. These diseases and conditions can be influenced by poorly functioning pelvic floor muscles and vice versa. Keep an eye out for future blog posts devoted entirely to these conditions.  It is possible to have tight and tender pelvic floor muscles as a result of an infective process, injury, or they may arise on their own idiopathically.

 

What to do if you have pain

First off, don’t panic.  Pelvic pain is relatively common, some studies estimate chronic pelvic pain rates being higher than 25%. You are not alone. It is important, though, to act swiftly to identify the culprit. The majority of pelvic pain is treatable, but the process is much easier when started earlier on in the pain cycle.

Go to your doctor to rule out any infective or disease process that may be causing your pain. The best case scenario is that a short course of treatment will do the trick. Unfortunately, often times the root cause is not identified on the first trip to the doctor and your results may come back negative for any infectious agent or systemic condition. This is common for many of the patients we see at Beyond Basics. If this happens to you, consider going to a pelvic pain specialist, whether physician or pelvic floor physical therapist, for more precise testing.

It is important to remember not all physicians are trained to recognize dysfunction of the musculoskeletal system, although the number of those who are trained is growing. Indications of musculoskeletal dysfunction are: pain that changes with changes in activity or position, pain that does not go away once the original disease or infection is treated or cured, or pain that can not be correlated to a specific systemic dysfunction. It is important to remember that musculoskeletal dysfunction in the pelvis can mimic, or be the cause of, bladder, bowel and sexual dysfunction.

If you believe your pain is musculoskeletal in nature or even think it might be, it is important to be examined by a skilled pelvic floor physical therapist and not all pelvic floor physical therapists are well trained. Pelvic floor physical therapists can determine if muscles and/or nerves are playing a role in your pain, and then treat the dysfunctional muscles and tissues to allow you to return to your old activities. When looking for a pelvic floor physical therapist, it is important to inquire whether or not they do internal work, both vaginally and rectally, and to ask about their training and experience.

At Beyond Basics we are experts at treating sexual pain as well as screening our patients and referring them on to the correct physicians to help treat any systemic causes of pain. We value a holistic approach to treating sexual pain, and strive to provide our patients with the best care possible. If you are in the New York area, another state, or even abroad and are suffering from sexual pain, please consider starting your healing journey with us.  We have an extensive ‘out of town’ program:  URL for program.

 

Resources:

STI Awareness and Counselling Services

American Sexual Health Association: http://www.ashasexualhealth.org/

Planned Parenthood: www.plannedparenthood.org

 

  • Services provided
    • STI screening/counseling
    • HPV vaccine
    • Male reproductive health exams
    • Pregnancy tests and counseling
    • Health insurance screening and enrollment

NYC STI Clinics and Services: http://www1.nyc.gov/site/doh/services/clinics.page

 

Sexual Assault Counseling:

 

RAINN: Rape Assault Incest National Network: https://centers.rainn.org/

-800.656.HOPE

  • Services provided (free or low cost):
    • Counseling
    • Medical Attention/ Hospital Accompaniment
    • Victim assistance/ advocacy
    • Legal/ Justice System advocacy
    • Emergency Shelter

Pelvic Pain Resources:

International Pelvic Pain Society: www.pelvicpain.org

 

International Society of the Study of Women’s Sexual Health: www.isswsh.org

www.pelvicpain.org

 

Heal Pelvic Pain

By: Amy Stein DPT

http://www.healpelvicpain.com/

Healing Pelvic and Abdominal Pain DVD

By: Amy Stein DPT

http://www.healingpelvicandabdominalpain.com/

 

Explain Pain

By: David Butler

https://www.amazon.com/Explain-Pain-David-Butler/dp/0987342665?ie=UTF8&hvadid=49868747328&hvdev=c&hvexid=&hvnetw=g&hvpone=&hvpos=1t1&hvptwo=&hvqmt=b&hvrand=9859257768995611935&ref=pd_sl_1tz644lwle_b&tag=googhydr-20

Healing Painful Sex

By:   Deborah Coady, MD and Nancy Fish, PhD

 

The Pain No One Wants to Talk About

https://beyondbasicsptblog.com/2015/05/13/the-pain-no-one-wants-to-talk-about/ When

When Sex Hurts

By: Andrew Goldstein, MD and Caroline Pukall, PhD

 

Sources:

 

International Pelvic Pain Society:  www.pelvicpain.org

 

International Society of the Study of Women’s Sexual Health:  www.isswsh.org (confirm url)

 

Ahangari A. Prevalence of Chronic Pelvic Pain Among Women: An Updated Review. Pain Physician. 2014;17(2) E141-7

 

Barrow R, Berkel C, Brooks L. Traditionally Sexually Transmitted Disease Prevention and Control Strategies: Tailoring for African American Communities.  Sex Transm Dis. 2008 Dec; 35 (12 sUPPL): s30-9

 

Katz A, Lee M, Wasserman G, et al. Sexually Transmitted Disease (STD): A Review of the CDC 2010 STD Treatment Guidlines and Epidemiologic Trends of Commone STDs in Hawai’i. Hawaii J Med Public Health. 2012 Mar; 71(3): 68-73

Mayo Clinci Staff. Sexually Transmitted Diseases (STDs). http://www.mayoclinic.org/diseases-conditions/sexually-transmitted-diseases-stds/home/ovc-20180594. [Accesses August 17, 2016]

 

 

 

Exercise, The Female Athlete, and the Pelvic Floor

active-image

Fiona McMahon PT, DPT

In honor of National Women’s Health and Fitness Day ,September  28, we are exploring the benefits of regular exercise for women as well as addressing some pitfalls (pelvic floor included), that female athletes can fall into too. It is far too often that women find themselves sidelined from their favorite sports and fitness routines secondary to issues like orthopedic or sports-related pain or incontinence. Although all the issues outlined in this blog can occur to both genders, many of these conditions are more likely to happen to females, secondary to their pelvic structure and physiology.

 

Exercise and Its Benefits

heart-health

 

The benefits of exercise are too numerous to discuss every single one here and span the physical to the emotional. There are a number of conditions that have profound effects on the health of women nationwide. Let’s explore some of exercise’s specific benefits for these conditions together.

Heart Disease

According to the American Heart Association, Heart disease is the number one killer of women in the US and is responsible for 1 in 3 female deaths.  Exercise and a healthy lifestyle have been shown to reduce the risk of heart disease by 80%. The American Heart Association recommends 150 minutes of moderate activity or 75 minutes of vigorous activity to stave off heart disease.

Osteoporosis

Osteoporosis is unfortunately a common affliction among white and asian urban dwelling females.  It is characterized by reduced bone density, which causes bones to be fragile and increases the risk of fracture in individuals that have osteoporosis. Exercise has been shown to be helpful in both reducing the risk of osteoporosis as well as improving the bone mineral density of those who already have osteoporosis.

Other benefits of regular exercise include:

  • Reduced risk of diabetes
  • Reduced risk of colon cancer
  • Improved psychological well being
  • Maintenance of healthy body weight

Remember, it is important to consult with a trained healthcare professional before commencing a new fitness routine.

 

The Female Athlete Triad- Aka the Downside

All things in moderation. Although exercise is beneficial it is easy to over do it. It becomes easier to slip into an unhealthy relationship with exercise, especially in women who are training at elite levels, have eating disorders, or body dysmorphia issues.

The  female athlete triad consists of three disorders that can have severe health consequences in both the near and long term. The three disorders that compose the female athlete triad are:femaletriad

  1. Disordered Eating
  2. Ammenorrhea (absent periods or periods that are irregular)
  3. Osteoporosis

The female athlete triad is often attributed to the expectation that women keep a slender appearance. Girls and women who have body image issues may be at greater risk. The female athlete triad is dangerous and has the potential to be deadly. Osteoporosis can result  in fractures and eating disorders can seriously impact fertility, or even throw off the delicate balance of electrolytes in their system, putting them at serious risk for a cardiac event.

Warning signs of the female athlete triad include:

  • Yellowing of skin
  • Stress fractures
  • Rapid fluctuations in weight
  • Development of baby hair over skin
  • Daily vigorous exercise to an excessive level

 

The female athlete triad requires a multidisciplinary approach from medical, to psychological to nutrition.  It is important for someone who is suffering from the female athlete triad to seek help in order to safeguard their health and emotional well being.

 

Athletics and The Pelvic Floor

d14e2-tipsforahappyandhealthyvaginaLike any muscle, the pelvic floor can get fatigued, strained, or even go into a painful muscle spasm. The thing about the pelvic floor muscles, is that they have to work in almost every athletic pursuit. They work in partnership with the multifidus of the back, the transverse abdominus of the belly, and the diaphragm to stabilize and protect your spine. They also contract with every step during running activities to prevent your pelvic organs from dropping down in your pelvic cavity and to prevent urinary and or fecal leakage. Things can go wrong when the pelvic floor or other core muscles don’t function properly. Athletes’ pelvic floors can become tight and restricted, preventing closure of sphincters and support of pelvic organs. They may go into spasm from working too hard to stabilize the spine, if one of the other core muscles is failing to pull its weight.

Recently there has been more work to investigate the link between athletes and pelvic floor dysfunction. A recent study found that self identified female triathletes suffer from urinary and fecal incontinence at rates as high as 37.4% and 28.0%, respectively. Similar results were also found on a group of runners. Of the triathletes studied, nearly a quarter of them fit the criteria for female athlete triad, discussed earlier in this post.

Does this mean you have to give up your penchant for running? NO! (hellooooooo the author of this post is a runner), but if you find yourself experiencing incontinence, pain, constipation, and or painful sex, something is wrong and you must intervene in order to protect your long term health and your ability to participate in your favorite sport. At Beyond Basics Physical Therapy we combine orthopedic and pelvic expertise to help return athletes to their sports in a more functional and less painful condition. We relax tight muscles of the pelvic floor, train the core, including the pelvic floor if needed, to do its fair share, and return normal postural and structural alignment to our patients. We work one on one with you to develop a home exercise plan to help you reach your goals and prevent a reoccurrence of your pelvic floor or core disorder.

 

Please come see us so you can return to your sport in a better and more optimal condition than when you started: http://www.beyondbasicsphysicaltherapy.com/

 

 

Sources

American College of Sports Medicine. Information on … the female athlete triad. https://www.acsm.org/docs/brochures/the-female-athlete-triad.pdf. Accessed September 19, 2016

 

American Heart Association. Facts About Heart Disease in Women.  2016. https://www.goredforwomen.org/home/about-heart-disease-in-women/facts-about-heart-disease/. Accessed: September 6, 2016

 

Bø, K. Urinary incontinence, pelvic floor dysfunction, exercise and sport. Sports Medicine, 34(7), 451-464. 2004.

 

Illinois Department of Public Health: Women’s Health. Facts about  women’s wellness exercise . http://www.idph.state.il.us/about/womenshealth/factsheets/exer.htm Accessed: September 13 2016

 

Loyola University Health System. “Female triathletes at higher risk for pelvic floor disorders.” ScienceDaily. ScienceDaily, 23 August 2016. <www.sciencedaily.com/releases/2016/08/160823165743.htm>.

 

Stampfer M, Hu F, Manson J, et al. Primary prevention of coronary heart disease in women through diet and lifestyle. The New England Journal of Medicine. 2000; 343(1). 16- 22
Todd J, Robinson R. Osteoporosis and exercise. Postgrad Med J. 2003; 79:320-23

Pelvic Health 101: Pain & Sexuality: Is it all in My Head?

By Fiona McMahon, DPT

Sex should feel good… really, really good. But when it doesn’t, you may start to wonder, what’s wrong with me? Am I broken? Am I a prude? Am I frigid? Painful sex isn’t something we talk about. No one would look at you twice if you walked into work complaining of pain in your elbow, but if you walk into work complaining about pain in you vagina or penis, you may end up having a meeting with HR.

On April 7th at 7pm, we at Beyond Basics are breaking down those taboos and having an educational seminar, followed by an optional question and answer session at the end. The event will be hosted by one of our therapists, Stephanie Stamas, DPT, ATC. Stephanie will give a detailed seminar about pelvic health and take time to clear up some common misconceptions many people have concerning their bodies and sexual function. Be sure to sign up at pelvichealth101.eventbrite.com to reserve your spot!

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Multiple Sclerosis Awareness Week

By Fiona McMahon, DPT

MS Awareness Week 2012

The week of March 7 through March 13 is recognized as Multiple Sclerosis (MS) Awareness Week. In an effort to help raise awareness for this condition we wanted to dedicate one of our blog posts to the subject of MS, how it affects people with the disease and how we at Beyond Basics Physical Therapy work with patients with MS.

MS is reported to affect 2.3 million people worldwide. Multiple sclerosis is an autoimmune disease that affects the ability of the nerves to send messages to the body. The typical age of onset for MS is between 20-40, however there are known cases where MS can arise later or in childhood. The immune system of people with MS begins to attack the fatty covering or insulation of the nerve cells, over time the covering of nerve cells scars down, which slows or impedes the messages sent to the body from the brain. The reason why the immune system turns on its own body is unknown and is one of the major areas of research into MS.

The symptoms of MS are variable and some are more common than others. Not everyone presents with the same systems, which is why it can take some time for someone with MS to be properly diagnosed. Common symptoms of MS include, fatigue, tingling in the arms and legs, vision issues, difficulty walking, sexual issues, and issues with bladder and bowel function. There are other symptoms associated with MS and these symptoms can change over time. What is difficult and frustrating for patients with MS as well as their health care providers, is that these symptoms are nonspecific and don’t necessarily rule out or rule in anyone specific disease, whether it be MS or something else. There is no one lab test to diagnose MS, but MRI (magnetic resonance imaging) as well as clinical findings may lead to a diagnosis of MS.

As of now, there is no cure for MS. But fortunately there are a lot of resources that can help people with MS lessen the disability caused by MS. Medicine has come a long way to alter the course of MS with disease modifying agents. Drugs now exist which can slow the progression of the disease, manage relapse, and help correct specific symptoms like depression, fatigue, and pain.

Physical therapy can help a multitude of symptoms associated with MS. Most general physical therapists are qualified to help patients with MS walk more efficiently, manage fatigue, and improve their daily function. Pelvic floor physical therapists can also help to manage specific issues such as urinary issues, bowel issues and bladder issues, as well as the symptoms mentioned above. We at Beyond Basics Physical Therapy are skilled at treating both the orthopedic and pelvic health aspects of MS. We encourage prospective patients to call our office to speak to a physical therapist if they have any questions.

Although MS is manageable, there is still a lot of work that needs to be done. A single test to diagnose MS is still not available, nor is there a cure for this disease. The National Multiple Sclerosis Society is an excellent resource if you want to learn more about MS, donate to research, participate in fundraising, or find support in your area.

 

Sources:

National Multiple Sclerosis Society. http://www.nationalmssociety.org [Accessed March 5, 2016]

Sex After Pregnancy

By Fiona McMahon, DPT

Edited by Amy Stein, DPT

It’s cliché to say the arrival of a new child is one of life’s most joyful events. It certainly can be. It can also be one of life’s most stressful events. According to the Homes and Rahe Stress Scale, pregnancy is one of life’s most stressful events falling just after having an ill family member. Sexual difficulties and arrival of a new family member are ranked just after pregnancy. It is little wonder that among the joy and excitement that comes along with a new baby, there is also stress and anxiety. Childbirth can have a profound effect on a couple’s sexual intimacy. Understanding a little bit about the physical and emotional factors that can affect post pregnancy sexuality can go a long way to reducing stress and beginning to start a new sexual relationship with your partner after the arrival of your child.

The causes of sexual dysfunction postpartum can be multifactorial and varied. They can occur simply because of the sleep deprivation and lifestyle upheaval a new baby can bring to a family dynamic. They can be hormonal. They can also be caused by postpartum depression, which can have a profound effect on one’s sexual desire. There are also physical factors such as dyspareunia, the technical term for painful vaginal intercourse. Rarely one single factor is the culprit. Post pregnancy sexual dysfunction is usually caused by several factors acting in concert.

Dyspareunia or painful sexual intercourse is fairly common after the birth of a child. Between 4 and 58% of women experience painful intercourse after vaginal delivery. Painful sexual intercourse in women after the birth of their first child was examined by Chaychinda and Ungkanungedcha in a 2015 article in the Journal of Sexual Medicine. The authors of this study found no correlation between painful intercourse and the birth weight of the child, newborn head circumference, or whether or not the mother had a history of pre-pregnancy dyspareunia.

In another study by Signorello and colleagues, the relationship of sexual functioning after childbirth was compared to the degree of birth trauma experienced by the mother during delivery.  The authors of this study classified participants into groups that included, the intact group (no vaginal tearing or episiotomy), women with first degree perineal tearing (tears to the vaginal mucosa only), second degree tearing (tears extending to the perineum and perineal muscles), third degree tearing (involving the external anal sphincter), and fourth degree tearing (involving the anal sphincter and surrounding rectal mucosa). The authors of this study found that women who do not experience any tearing or episiotomy tended to be younger and heavier.  Signorello found that all women, regardless of degree of birth trauma, resumed intercourse by 6 months after the delivery of their child. Most of the women experienced pain when they resumed sexual intercourse with the degree of pain dependent on the degree of perineal tearing. Dyspareunia was found in 33% of the intact group, 48% of the second-degree group, and 68% of the third and fourth degree group. The study also found that degree of birth trauma and maternal age were independent predictors of return to sexual functioning.

Overall sexual functioning after childbirth was examined by Khajehi and colleagues in an article to appear in the Journal of Sexual Medicine this year. In this study, overall sexual functioning was examined after childbirth. Khajehi found evidence supporting the work by Signorello that most women do not return to sexual functioning until 6 months after childbirth. Factors that influence return to sexual intercourse included return of genitals to pre-childbirth state, whether or not there is prolonged lochia (bleeding after childbirth) and perineal pain.

The authors also cited research that women having their first baby are more likely to experience sexual dysfunction than those who have already had a child, with sexual dysfunction significantly higher in women who had just given birth to their first baby at 8 and 16 weeks after delivery. The authors also looked at emotional factors that can affect return to sexuality and cited research that, emotional disturbance, fear of another baby, and well-being of the newborn as well as relationship dissatisfaction are correlated with sexual dysfunction, regardless of the sexual orientation of the couple.

New moms are not to be blamed for any type of sexual dysfunction following childbirth. In our society words like “frigid” get thrown around to describe women who cannot or do not want to engage in sex. It is important to remember that your body has gone through a tremendous change and produced something truly incredible. It is okay to allow yourself some time to recover and to return to sex slowly.

The Mayo Clinic has proposed some guidelines on return to sexual function after childbirth. They advise that new mothers wait 4-6 weeks after delivery to have sex regardless of whether they delivered vaginally or by c-section. Using a personal lubricant can help reduce pain and is particularly helpful because hormonal fluctuations can leave the vagina dry and tender, especially in breastfeeding mothers.

Physical exercise can be key in managing stress, improving body image, and helping to normalize sleeping patterns, which can all contribute to sexual dysfunction after pregnancy. Try to get 150 minutes of moderate exercise in a week to improve overall health. It does not all have to be at once, but adding in short 10-minute bouts of exercise in the morning or at lunch can easily add up to the 150-minute recommendation over the course of a week.

If you are not experiencing any pain or discomfort and you have not noticed any changes in bladder and bowel function, then you can do specific exercises for your vagina to increase blood flow and pleasure during sex. Pelvic floor exercises (Kegels) are contractions of your pelvic floor muscles. You perform Kegels by squeezing and drawing up your rectum and your vagina, like you were trying to stop gas or the flow of urine. If you were sitting on a hard chair while performing a correct Kegel you can actually feel the area between your vagina and anus lift up off of the chair. The best part of Kegels is you can do them anywhere and no one knows you are actually doing them! Keep your Kegels to a contraction of about 1-2 seconds and start off slow building to 100-200 contractions broken up over the course of the day. If you feel any pain with the exercises or notice any changes in bladder or bowel health, then stop doing the Kegels. This could be an indication that certain pelvic floor muscles are in spasm or there may be scar tissue that is causing the discomfort, and it is recommended to see a pelvic floor physical therapist.

Remember to take it slow to returning to sex. Start off with kissing and light touching. If anything hurts it is perfectly okay to put it on the back burner and return to it later. Be willing to explore. You might actually come up with new activities to add to your repertoire while you are waiting to recover. If you find that you are still troubled by sexual dysfunction months after childbirth, consider seeing a pelvic floor physical therapist for guidance in your recover. A pelvic floor physical therapist will be able to loosen and free up scar tissue, and treat any tightness and/or weakness, and teach you about more gentle sexual positions and activities to help you return to full sexual function. Just like any other injury, the sooner the problem is identified and treatment begins, the better; however, most conditions can be relieved many years, or even decades, later.

Sources

Chayachinda C, Titapant V, Ungkanungedcha A. Dyspareunia and sexual dysfunction after vaginal delivery in thai primiparous women with episiotomy. J Sex Med. 2015;12:1275-82

Khajehei M, Doherty M, Tilley M et al. Prevalence and Risk Factors of Sexual Dysfucntion ln Postpartum Australian Women. J Sex Med. 2015 [Epub ahead of print]

Mayo Clinic Staff. Sex after pregnancy: set your own timeline.[accessed May 2015] http://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/sex-after-pregnancy/art-20045669

Signorello L, Harlow B, Chekos Am, et al. Postpartum sexual functioning and its relationship to  perineal trauma: A retrospective cohort study of primiparous women. Am J Obstet Gynecol 2001; 184: 881-90

Love in Health

By Riva Preil

April marks Sexually Transmitted Infection (STI) Awareness Month. STI, a broader term for what has previously been referred to as sexually transmitted disease (STD) or venereal disease (VD), refers to a class of infections that can be spread from one individual to another via vaginal intercourse, oral sex, and anal sex.  In addition, the infections can be spread through non-sexual practices that involve transmission of bodily fluids from one person to another (ex. blood transfusion, sharing of injection needles, sharing of tattoo needles, needle-stick injuries, and childbirth or breastfeeding. Individuals may have received the infection without demonstrating symptoms of disease (hence the recent increased usage of the term “infection” in place of the previously used term “disease”), and in fact, sometimes the infection manifests as pelvic inflammatory disease (PID) and/or pelvic pain. A pelvic floor physical therapist can help treat the symptoms of PID and the associated pain.

There are many different causes of infection.  Several of these include viral infection (ex. ex. viral hepatitis/Hepatitis B virus, herpes simplex, human immunodeficiency virus/HIV, and human papillomavirus/HPV), bacterial infection (ex. chlamydia, gonorrhea, and syphilis), fungal infection (ex. candidiasis, or yeast infection), and protozoal infection (ex. trichomoniasis).

The statistics about STIs are alarming- in 1996, the World Health Organization estimated that approximately 1 million individuals became infected on a daily basis.  In general, of those who become infected, approximately 30% are younger than twenty years old.  STIs are found in teenage girls aged 14-19 on a 2 to 1 ratio compared to teenage boys of similar age, and approximately 25% of female teenagers in the United States have an STD according to the CDC.  Furthermore, AIDS is the biggest cause of mortality in Sub-Saharan Africa, and approximately two billion people worldwide have been infected with Hepatitis B.  Considering these frightening statistics, prevention is of the utmost importance.  This includes vaccination for Hepatitis A and B as well as for some forms of HPV.  In addition, proper condom usage is key.  This involves maintaining proper 1.5 cm (3/4 inch) space at the tip to provide room for ejaculate.  It is also important to use latex, polyisoprene, or polyurethane materials (to protect against HIV) and to avoid using oil as a lubricant due to the fact that it can create holes in the condom thereby rendering it ineffective.