The Male Pelvic Floor
Most men have never heard of the pelvic floor (women tend to be more in tune with it due to issues following childbirth). However, it is a muscle that is worth taking notice of, particularly from middle age onwards when men may start to experience symptoms. In men the pelvic floor muscle is concerned with urinary and faecal continence, sexual function and core stability. Whilst it performs its tasks silently and subconsciously, most men have the further ability to consciously switch it on and off by voluntarily contracting it. And yet it is often ignored. Fortunately, awareness is growing, as well as the number of pelvic floor physiotherapists who are trained in this area. The workload for the pelvic floor physiotherapist falls into several areas:
- Following prostate surgery that may have produced incontinence and erectile dysfunction.
- Dribble urinary incontinence.
- Erectile dysfunction of unknown cause.
- Chronic pelvic pain syndrome.
If you fit the picture for any one of the situations listed above, it may be worth reading further. Included are short sections for each of the situations on how pelvic floor physiotherapy may be able to help you.
Firstly there is a section describing the pelvic floor:
Where is the male pelvic floor situated?
The pelvic floor as the name suggest, makes up the floor of the pelvis. It stretches from front to back and side to side of the “pudding basin” like bony pelvis to form a shelf. The bladder and top half of the rectum sit on this shelf. There are openings in the pelvic floor shelf for the urethra (front passage), and the rectum (back passage) to pass through. Any naturally occurring gaps are filled in with soft tissue to complete the shelf. The pelvic floor is situated immediately below the prostate gland.
How does the pelvic floor muscle work?
Although arranged in a complex fashion, the pelvic floor is essentially a shelf and a sling. It wraps right around the rectum and has loops around the urethra. The pelvic floor is constantly active, even at rest so that in can constantly support the pelvic organs. During times of extra physical stress such as when moving around, or coughing or sneezing it further contracts sub-consciously to maintain support and compression. When the sling shaped muscle contracts it pulls the rectum and urethra upwards and forwards. This action compresses the urethra and rectum helping to keep them closed in order to prevent leakage. The smaller muscles of the pelvic floor assist in erectile function. One of these muscles compresses the base of the penis to keep blood inside and help with rigidity. Another acts like guy ropes to support the penis.
The enlarging prostate and pelvic floor muscle training
Benign Prostatic Hyperplasia (prostate enlargement) is present in 60% of men in their forties. This figure rises to almost 90% of men in their seventies. Some men may have no symptoms whilst others may have difficulty/hesitancy in initiating micturition (difficulty in starting to pee) and find that they have they have nocturia (getting up in the night to pee). If symptoms exist management may take the form of medication to reduce the size of the prostate or surgical or laser resection of the prostate gland. Other men may have to undergo more radical surgery if they are found to have prostate cancer. Prostate cancer is the commonest of all cancers in men with more than 40,000 new cases each year. Treatment may involve complete removal and/or radiotherapy and/or hormone therapy. Urinary incontinence is common following prostate surgery. This may be due to damage to nerves (although nerve sparing techniques during surgery limit this to a degree) and/or damage to the sphincter/valve and pelvic floor muscle. The sphincter/valve may also be weakened due to disuse when the sphincter was compressed by the large prostate. Following prostate surgery men may experience urinary symptoms such as constant seepage; stress urinary incontinence (leak on cough/sneeze etc); leak on change of position, urge incontinence: an urgent desire to urinate resulting in leakage before there is time to reach a bathroom; and/or post micturition dribble (loss of a few drops of water after passing water). Erectile dysfunction may also be present following prostate surgery. Expert pelvic floor muscle training is proven to be helpful in the management of urinary incontinence following prostate surgery. There is also some evidence to support the use of pelvic floor muscles for erectile dysfunction following prostate surgery although pelvic floor muscle training for erectile dysfunction is more successful for idiopathic erectile dysfunction (see below) than iatrogenic (caused by surgery). Physiotherapy management starts with a rectal examination of the pelvic floor to assess ability to correctly contract the pelvic floor muscles and the tone, strength and endurance of the muscles. A bladder diary is usually completed that will provide important information about fluid input and output, and urinary frequency and urgency. Spinal and muscle imbalance assessment is included if indicated by symptoms. Following assessment an individualised home pelvic floor muscle training programme is set in place and bladder training to help reduce frequency and urgency if required. The aims of pelvic floor muscle training are to make the muscles stronger and stiffer so that they can best perform their functions for continence and erectile function. The mainstay of treatment is an individualised home exercise programme supplemented by regular sessions to progress the programme. The physiotherapist is also able to offer support and advice with respect to questions and issues that may arise. The number of sessions that an individual will need varies widely and is very dependent on severity of symptoms and assessment findings.
The ageing process and pelvic floor muscle training
All skeletal muscle loses strength with age, including the pelvic floor. A common symptom is post micturition dribble (dribbling urine after finishing in the bathroom). This can be improved by strengthening the pelvic floor by doing regular exercises. A few strong pelvic floor contractions performed when still at the toilet bowl/ urinal after urine flow has stopped are often sufficient to squeeze out the last few drops of urine that would otherwise leak. Other men may lose urine at other times and this too can be helped with pelvic floor muscle exercises to improve support to the bladder. When urgency to get to the bathroom is a symptom, physiotherapy in the form of bladder training may also help. Physiotherapy assessment and management for the ageing pelvic floor follows a similar pathway as per post prostate surgery (see above).
Idiopathic erectile dysfunction and pelvic floor muscle training
Erectile function is complex issue that involves psychological as well as physiological processes. For idiopathic erectile dysfunction (dysfunction of no apparent cause), pelvic floor muscle exercises may be helpful. One UK study has found exercise to be as effective as Viagra. It is believed that improved muscle strength as a result of training helps to keep blood in the penis and thus improve rigidity. Physiotherapy assessment for idiopathic erectile dysfunction follows the same pathway as per post prostate surgery (see above). The mainstay of management is a progressive pelvic floor muscle exercise programme.
Chronic pelvic pain
Chronic pelvic floor is not often talked about but is becoming more widely recognised. Men may experience unremitting pain in the genitalia the groin and/or deep inside the pelvis. In most men the cause of chronic pain is unknown whilst some may be able to pinpoint a particular event that may have started it. Commonly this may be a urinary tract or prostate infection; following a long period of sitting on a bicycle saddle; or after an emotionally stressful life event. It is an extremely distressing condition that often has a profound impact emotionally as well as physically. Physiotherapy management is tailored individually as there is a wide spectrum of possible findings on assessment that require differing interventions. Assessment includes examination of the pelvic floor muscle to check for increased muscle tone or weakness and for painful trigger points; spinal assessment to see if the pain may be referred from the spine; muscle imbalance to check for shortened and/or weak muscle groups in the trunk and lower limbs; and external trigger points that may be contributing to the pain. Management may include, trigger point massage; relaxation techniques; spinal and pelvic mobilisation; stretching and strengthening and acupuncture.
Frequently asked questions
Q: Can you tell me over the phone whether physiotherapy will help me?
A: The only valid way to be able to tell you whether you will benefit is to have an assessment so telephone calls are not usually very helpful. However it is likely that if you have any one of the conditions listed above that you will benefit from physiotherapy. The best thing to do is book an assessment. Alternately you may wish to book a telephone consultation which although cannot provide physical assessment, may help you develop your management pathway.
Q: I have a pelvic floor problem and was given a leaflet about pelvic floor exercises by my doctor. They don’t seem to be helping. Could physiotherapy help me?
A: Yes, patients usually do better with face to face training than with a leaflet. The most common outcome following an assessment is increased confidence and reassurance, as your physiotherapist will be able to answer questions that you may have.
Q: How many sessions will I need?
A: This is very much based on your condition and assessment findings after which the frequency of follow up is discussed and agreed. Some patients are limited by distance, work or family commitments etc and may opt to attend every other month, whilst others may opt to start on a weekly or fortnightly basis for a few sessions and then reduce to monthly. Some patients may attend for as long as two years but may have 6 month follow up in the latter half of their programme. Regardless, your programme will always be tailored around your individual set of circumstances.
Q: If I am given a pelvic floor exercise programme how often do I need to do it?
A: Usually the programme is performed three times per day although many patients decide to do them more often. Each session only takes about five minutes at a time. Once you have fitted them into your routine you should not find them too onerous. Once the exercise routine is well established you will be taught how to use your pelvic floor during every day life as well as just during prescribed exercise sessions.
Q: How soon will I see improvement?
A: Often improvement may be seen within the first two weeks, followed by a plateau in improvement whilst the muscle strengthens. This is potentially discouraging, but the knowledge that this plateau in progress is normal is motivation in itself to continue a training programme. It takes at least three months to see decent improvement and so patience is required.
Q: How long do I have to do the exercises for?
A: Pelvic floor exercises are for life. It is a case of “use it or lose it”. However, after an intensive period of exercising over several months, you will be able to reduce the frequency of exercises to maintain the strength you have gained.
Q: I am having prostate surgery next month. Should I start pelvic floor exercises now?
A: Yes. There is some evidence to suggest that getting going prior to your surgery will help you in the long run.
Q: Should all men be doing pelvic floor exercises?
A: Yes. Pelvic floor exercises are involved in many pelvic functions and are implicated in core stability and back pain. They should be exercised just as any other muscle is throughout your lifetime.
Trying exercises at home first
Not everyone can get to see an expert physiotherapist, and may wish to try exercises on their own. For this reason some tips on how to get started appear below.
Squeeze and lift from your back passage as if stopping the escape of wind, then let go. Then do the same thing but this time using the muscles at the front that you use to stop the flow of urine. Now try lifting the front and back together so that you are lifting up completely underneath. Not sure if you are doing it correctly? Stand in front of a full length mirror. As you squeeze and lift your pelvic floor you should see your testicles lift and draw in slightly. If you are still not sure that you are doing it correctly, you may wish get expert advice from a physiotherapist.
Once you get the hang of this basic instruction you can start exercising regularly. Do three clusters of exercises each day. Each cluster should comprise 10 lifts held for 10 seconds each with a 5 second break between each lift. Make each lift as strong as you can. Finish with 10 fast, rhythmic lifts with no break between each lift. You can also try gently lifting/engaging your pelvic floor and holding on for as long as possible as you go about your daily activities. Try to engage it as often as possible, especially during periods of increased physical stress such as when bending or lifting or when at the gym. Don’t worry if you soon realize that you have let go. Simply re engage. Finally, in order to stabilise your pelvic organs during times of increased physical stress,get used to pulling up your pelvic floor quickly whenever you cough, sneeze, laugh, jump etc.
The male pelvic organs in cross section: note the pelvic floor muscle is unlabelled but is illustrated as the approximately horizontal structure that runs front to back immediately underneath the prostate