Men's Health Physiotherapy Pelvic Treatment

Original Editor - Stacy Schiurring based on the course by Pierre Roscher
Top Contributors - Stacy Schiurring, Kim Jackson, Lucinda hampton and Jess Bell

This page aims to provide an introductory discussion of men's health physiotherapy assessment techniques. Please note that further training is required through a reputable pelvic health education company before attempting the techniques discussed in this page. See the Resources section at the bottom of this page for links to pelvic and men's health special interest groups.

Clinical Reasoning after Assessment

The physiotherapy assessment is the most critical parts of a therapist's interaction with their patient. Assessment and reassessment occurs every session to develop a detailed clinical picture to guide the creation of a treatment plan of care. Every patient's clinical picture is unique, therefore comprehensive and ongoing assessment will ensure that the patient receives effective and efficient physiotherapy management.

For a review of men's health physiotherapy pelvic assessment, please read this article.

Pelvic Floor Muscle Rehabilitation

Pelvic Floor Muscle Training is the essence of “functional fitness,” training muscles to help in practical life activities. Because of its simplicity, safety, and noninvasiveness, it should be employed as a first-line approach.

Pelvic floor muscle rehabilitation can encompass a variety of issues: muscle overutilisation, muscle weakness, muscle dysfunction and or poor coordination. As when training any muscle group, it is important to properly assess the dysfunction prior to beginning treatment to ensure the patient is receiving the proper therapeutic interventions. A muscle must have the appropriate length, strength, and neuromuscular control to function properly.

Please watch the following short video to learn more about the muscle length-strength relationship.

The muscles of the male pelvic floor are all skeletal muscles and are therefore adaptable. 70% of the pelvic floor muscles are slow-twitch type 1 (fatigue- resistant fibres that maintain static tone) and 30% are fast-twitch type 2 (fatigue-prone fibres that are capable of active contraction). This ratio can change with aging, inactivity, and nerve innervation damage.. To learn more about muscle fibre types, please read this article.

Pelvic Floor Strengthening

When pelvic floor muscle strengthening is indicated, exercises can be performed to improve muscle endurance and or muscle agility. It is important to match the type of muscle strengthening with the patient presented issue.Many patients require a combination of the two types of muscle strengthening. For example: a patient with urinary incontinence. If this patient has an issue with urine leaking throughout the day, this is likely a muscle endurance issue versus a patient who leaks urine with a forced exhalation such as a cough which is likely a muscle quick fire issue.

Pelvic floor exercises are all about technique. With optimal motor learning of the pelvic floor, there is more potential for improved continence and erectile function. When performing pelvic floor muscle strengthening, it is helpful to either palpate the muscle or utilize real-time ultrasound to provide the patient with feedback.

Verbal cues can also affect the degree of observable motion in pelvic floor muscles. Commonly used phrases to help elicit male pelvic floor contractions are “shorten the penis”, “elevate the bladder”, “elevate the scrotum”, “stop the flow of urine” and “tighten the anus.” Stafford et al. conducted a study in asymptomatic participants and in patients suffering from incontinence the cues “shorten the penis” and “stop the flow of urine” were considered the best to target the specific muscles involved in urinary continence. A popular colloquial cue rather than “lift your scrotum” that men seem to respond well to is “nuts to gut.” This cue particularly targets the important lifting action of the pelvic floor.

1. Endurance or slow-twitch fibres: Establish a maximum effort contraction of the pelvic floor muscles. Have the patient hold a 20% max contraction for a set amount of time, such as 4 seconds. Gradually increase the 20%max hold to 6 seconds, 10 seconds, et cetera, allowing the patient to gain control and endurance of the pelvic floor muscles.
2. Agility or fast-twitch fibres: Establish a maximum effort contraction of the pelvic floor muscles. Have the patient hold a 80% max contraction for a set amount of time, such as 4 seconds then relax. Repeat the 80%max hold for 4 seconds for a set amount of repetitions to perform pelvic floor "flicks."
3. Pelvic floor muscle "cross-training": a combination of the above, for example: mix 80%max and 20%max holds for set amounts of time for a set amount of repetitions.

When performing these strengthening exercises, it can be helpful to provide the patient with a chart or graph with the expected %max holds, hold times, and repetitions outlined to service as a guide during the session. This can also be provided as part of the patient's home exercise program.

The following videos are examples of male pelvic floor contractions as viewed via real-time ultrasound. The video on the left is a supra-pubic view, the video on the right is transperineal.

Pelvic Floor Inhibition

Increased pelvic floor tone can be a source of pelvic floor pain and sexual dysfunction.There are multiple techniques that can be used to decrease pelvic floor muscle tone or tightness.

1. Stretching: by rotating the pelvic, one can stretch the muscles of the pelvic floor. Examples include: lunges, bilateral hip external rotation, squatting. Focus on slow and controlled movements.
2. Breathing: slow, deep, diaphragmatic breathing to assist with relaxation.
3. Mindfulness: focus on awareness of the pelvic floor activation and training the muscles to relax.
4. Internal treatments: trigger point release. Patients can be educated on how to perform releases as part of a home exercise program.
5. Hip joint mobility treatments: Maitland or Mulligan mobilisations to improve hip pain and or stiffness can have good carry over to address pelvic floor muscle tone or tightness.

Pelvic Floor Coordination Training

Real-time ultrasound is a good treatment option for patients who present with good pelvic floor muscle strength and length but have coordination issues. Biofeedback alone has been shown to be less effective in retraining the pelvic floor muscles than when biofeedback is used as an adjunct to skilled physiotherapy interventions.

Pain Management

Proper and thorough assessment is critical for proper pain source identification. Utilise the biopsychosocial model as needed for refers to gather more information or if findings are outside of a physiotherapy scope of practice.

Potential treatment approaches for pain conditions may include:

• Pelvic floor muscle relaxation or inhibition
• Internal treatments
• Joint mobilisations of the lumbar spine, sacrum, and or hips
• Neurodynamic treatments to include nerve glides and flossing
• Soft tissue work such as skin rolling, myofascial release, visceral work
• Dry needling
• Patient education on self management techniques

Urinary Incontinence

For more information on male urinary incontinence, please read this article.

When providing treatment for urinary incontinence, the following issues need to be considered and potentially addressed:

• Pelvic floor rehabilitation is not a passive intervention and to see improvements patients need to adhere to the exercises
• Any bowel dysfunction must be managed as this negatively impacts the pelvic floor and bladder
• Any issues of mental health must be addressed
• General exercise is very important and has been shown to improve outcomes
• Weight loss is important in overweight men as obesity has been linked to poorer outcomes

Potential treatment approaches for male urinary incontinence may include:

• Pelvic floor work to improve sphincter control, strongly supported by research
• Use of transperineal ultrasound for visual cues of pelvic floor contractions for improved urethral control
• TENS neuromodulation to stimulate tibial nerve and or around the sacrum can be very effective to treat urge incontinence
• Behavioural management: discussing what to wear such as dark pants to hid leaks, limit fluid intake when away from home, awareness of any foods or drinks that may irritate the bladder
• Bladder training techniques such as stimulating S3-S4 dermatomal levels by doing movements such as rubbing inner thighs, squeeze knees together, push toes into the floor. These activities can override the bladder by challenging the micturition reflex
• Use of male incontinence pads
• Use of penile clamps
• Use of questionnaires and or bladder diary to gather information and track progress

Bowel Issues

Bowel health can have a strong affect on overall pelvic floor functioning. When assessing a patient's bowel habits it is important to ask about toileting position, use of mindful breathing versus Valsalva during voiding. For more information on toileting position and how male anatomy can be affected by it, please read this article.

Men with pelvic pain commonly have a history of constipation and or haemorroids. This is a common symptom for people who must use a large amount of pressure during voiding. A musculoskeletal and breathing assessment would be beneficial for these patients.

Penile Issues

Penile health relies on regular erections (a man will typically have 5-8 nocturnal erections every night). The blood flows into the penis during an erection and encourages mobility of the connective tissue and smooth muscle of the penis.

• Peyronies disease involves a variety of penile symptoms including pain, curvature, shortening, palpable plaque and erectile dysfunction. The development of a plaque within the penis that results in the curvature. Joanne Milios, a physiotherapist in Australia, has found that the use of therapeutic ultrasound as a treatment for Peyronies disease results in reduced penile pain, improved penile deformity and increased erectile function. Extracorporeal Shock Wave Therapy (ESWT) is also gaining acceptance in the treatment of Peyronies disease, a 2021 meta-analysis found that ESWT fails to improve penile curvature or pain, it may reduce plaque size but further research is indicated to confirm these findings. 2022 study found that low-intensity ESWT had a positive impact on patient penile pain, curvature, and plaque size when treated during the acute phase of Peyronies disease.
• Penile shortening is common after a prostatectomy, a patient can expect a one to two centimeter loss in length. Treatment of penile shortening involves patient education on self stretching, skin rolling, encouragement of erections using either a vacuum therapy device or erection medication, and masturbation.
• Painful orgasm is likely due to increased pelvic floor muscle tone or tightness and or pelvic floor pain. Treatment may involve pelvic floor muscle inhibition or relaxation, coordination training, and patient self treatment techniques.
• Erection quality is often due to impaired muscle coordination and or endurance. Treatment may involve pelvic floor strengthening and coordination training. Pelvic floor physiotherapy is an excellent alternative to medication use to achieve quality erections.

Resources

• Siegel AL. Pelvic floor muscle training in males: practical applications. Urology. 2014 Jul 1;84(1):1-7.
• Nahon, I. (2021). Physiotherapy management of incontinence in men. J Physiother, 67(2), 87-94. doi:10.1016/j.jphys.2021.02.010
• Gronski S. Pelvic Pain The Ultimate Cock Block: A no-bullshit guide for men navigating through pelvic pain. Dr. Susie Gronski, Inc., 2020.