Welcome back to our blog series on Male Pelvic Health. In part one, Sarah Haag introduced us to the basic issues and common diagnoses experienced by men. In part two, she offered an understanding of how pelvic physical therapy can address pelvic pain when an infection is no longer, or never was, the culprit (often mis-diagnosed as prostatitis or chronic UTIs). Now in part three, I asked Nancy Dowker to talk us through what a pelvic health physical therapy program would look like. She walks us through assessment, typical presentation issues and modifiable contributing factors (fitness, movement and muscular patterns, emotions, etc) to an introduction to treatment ideas and a few take-home tips. Read on…..(printed with permission).
Male Pelvic Health from the Trenches
By Nancy Dowker
When I treat a male with pelvic pain, I start out with a good history. Often he has a long list of issues and an even longer list of interventions that he has already tried, including numerous antibiotics. He likely has seen a long list of Health Care Professionals, and has had as many tests, as well. The phrase ‘chronic prostatitis’ may have been thrown about.
There may be a long or short history of:
- Bladder issues: increased frequency, urgency (can’t wait feeling), increased night-time voiding, difficulty starting or emptying, poor stream, dribbling
- Constipation with hemorrhoids/fissure/abscess or alternating constipation/loose bowels
- Pain/numbness in any number of areas in the genital region/abdomen/low back/groin/hips
- Changes in sexual function: Erectile Dysfunction, pain during or after ejaculation, reduced ejaculatory strength
There is a big emotional piece as well. There is a lot of worry and stress about both his current symptoms and his long-term well-being.
Clinically, from a muscular and structural standpoint, I often find he has a overused, and contracted pelvic floor that is lifted high chronically. There is a tendency to overuse oblique abdominals, and he cannot let the abdominals relax. This creates pressure like crazy into the pelvis. Often he is also holding his diaphragm as tightly as his pelvic floor, which is seen as poor breathing patterns and breath holding for exertion support. The word ‘relax’ is simply not in his vocabulary.
Assessment includes a careful observation and documentation of all of the above, plus:
- Lumbar spine, sacro-iliac and hip joint scans
- Assessment of muscle length, tone and trigger points both externally and internally
- Connective tissue and neural restrictions
- Breathing patterns
Once I have collected enough information, the education can begin. I start with an Anatomy 101 lesson using pictures and models. We discuss the diaphragm, the relationship to the abdominals and how tight abs impede breathing and then the pelvic floor. The pelvic floor can be a hard concept to master. Guys can feel it engaging best in two places – at the anus and in the space between the pubic bone and the base of the penis. When they engage the pelvic floor they should feel the anus close and base of the penis lift!! The engagement should be only the pelvic floor and not the buttocks, thighs, abdominals or the testicles (they move on their own but drawing them up is not the pelvic floor).
Because these guys are often already unknowingly engaging their pelvic floor and it is likely high, they can’t feel any motion with the contraction because the muscles are already engaged fully. This is similar to a bicep curl at the full ‘curl’, elbow bent hand to shoulder, you can’t curl it more. After every bicep curl, you release the muscle and let the elbow straighten. After every pelvic floor engagement you should let go of the pelvic floor muscle and let it release to its ‘baseline’. This baseline is enough to maintain continence. Your body is pretty good at figuring out where that point is, if you will let it. This is hard news to take for the folks who ‘leak’. Squeezing harder is not the way to control the bladder.
Then, I teach the diaphragm/pelvic floor pistoning relationship to help train this idea and the bean lift analogy to help them visualize what they are supposed to do with their pelvic floor. I ask them to start in sitting (no slouching), and imagine drawing a bean up slightly in the anal area. Then I cue them “Now let it drop. Now let it drop some more”. No pushing, just lowering!!! Often they feel a softening at the sit-down bones (ischial tuberosities), deep under their buttocks. Now take a breath in, timed with letting go of your beans, Ahhhhhhhhh. You now have a new, more relaxed place for your body to move from. Every time they use this release, their body remembers – muscle memory is a wonderful thing! The goal, of course, is to have a breath IN and pelvic floor release become one and the same (and automatic).
Quickly we move on to connecting the pelvic floor to the breath and abdominals. With this population, I find one of the best places to feel this connection is on hands and knees. As you breathe in, feel the ribcage expand, let the abdominals RELAX towards the floor and let the pelvic floor relax as well. This position helps to cue release of the abdominals, as gravity helps to pull them. Repetition, time and patience helps to embed this as a pattern!! Learning to time this with their exertions also helps to address their fitness routines. The biggest challenge is to eliminate the ‘bear down’ with exertion and teach them to lift and support instead. Men tend to work with higher forces, be it weights at the gym or work/sporting activities. The opportunities for movement dysfunctions produced by excessive pressure in to the pelvic bowl and held tension in the pelvic floor lurk everywhere. Unfortunately, at the first sign of pelvic floor issues, the diagnosis of ‘prostatitis’ slows down the journey to better pelvic floor mechanics.
Along the way we teach proper toileting, to void (pee) we recommend sitting with legs apart, back straight, lean forward just a little and let that pelvic floor release (the ‘bean drop’ we have been working on). Or for standing, we recommend a relaxed ‘slouch’, that is pelvis forward, arms slightly behind the hips. For BM’s (poops) we recommend sitting with knees raised on a stool to simulate a squat.
As a Pelvic Floor Physiotherapist I also work internally to address issues such as muscular cueing, muscular trigger points, nerve entrapment, and scarringthat may be impeding progress.
It takes gumption to admit to pelvic floor issues, and then to work hard towards relearning ingrained movement patterns. The benefits are immeasurable.
**INDEED! Thanks to both Sarah Haag and Nancy Dowker for sharing such great information! Please leave comments and questions below, including any resources that you are aware of that might be beneficial for men. Below are the websites to help you locate a pelvic health therapist in your area to help you on your path. Thanks for stopping by!**
Find a pelvic health pro here:
USA Physical Therapists
New Zealand Physiotherapists
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