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​Question from Kirk: I am an avid bike guy. I go outdoor trail riding on weekends, over 60 miles, if the weather is good. On my weekdays, I do spin classes to stay in shape. I have begun noticing a dull ache in my testicles that won’t go away, even if I skip a day of riding. I went to my urologist because of my testicular pain. After some tests and an ultrasound, she said there is nothing wrong with my scrotum, but that I should lay off the bike riding. It is my favorite way to blow off steam after a long week at the office. Is bike riding related to my testicular pain? If so, do I have to stop altogether?

Answer from Becca: Kirk, I understand how distressing it is to have undiagnosable pain in your pelvis. While working in a pelvic floor physical therapy clinic, we treat men like you all the time. Your testicular pain may be caused by tension in the small muscles of the saddle region of your body. The nerves and soft tissues of the groin are delicate and often get upset when they are compressed, as they would be during prolonged sitting on your bike seat. In your particular case, these bodily structures are also being jostled around quite a bit, especially during your trail rides on bumpy terrain. Spin classes also present a particular strain on the saddle area, as you are likely raising your butt off the seat for increased resistance and then slamming your body right back down to a sitting position a few moments later.

Bike riding is your passion, and I wouldn’t want to rid you of something you like, especially if it is helping you “blow off steam after a long week at the office”. There are a few modifications that may help ease the pressure off your testicles and decrease your pain. Firstly, buy a seat for your trail bike that is specially designed for people with pelvic pain. There are many from which to choose, and they will often have a hole cut out of the seat, so that your pelvic floor will not be in contact with any surface while you ride. Secondly, when outdoors, try to bike on level surfaces for now. The rugged land of the trails is like riding a Jeep in the jungle. What you want to do to rest your pelvic floor muscles and scrotum is to travel on level terrain (cement), which will feel like riding your grandfather’s Cadillac with superb suspension. I know, it won’t be the same, but bear with me. Your testicles need this rest right now. Thirdly, if you are going to do spin classes, buy your own bike seat designed for pelvic pain sufferers, install it before a class, and avoid the alternating standing/sitting repetitions that spin classes are famous for.

In time, your testicles will heal and you may get back to the point when you can resume trail riding. Also, if you have the time, find a pelvic floor physical therapist. The tight muscles of your pelvic floor can be stretched and any possible soft tissue restrictions within your scrotum can be addressed as well. By doing this, you will be sending your testicles on a much-needed vacation and they will thank you for it in the future.

Question from Lou: My partner and I are fairly certain that we are done having children. I am considering having a vasectomy but am worried that something might go wrong. Can you tell me about this surgery and what I might expect if I get it in the future?

Answer from Becca: I understand that this is a major decision, Lou, and you are not alone in the vast number of men who consider this procedure and are held back by trepidation about what the long-term implications might be. Let’s start with the anatomy or plumbing in how all this works. The sperm of a male is stored in tiny little coil, called the epididymis, that is located directly above each testicle. That sperm waits until it is needed, and then travels from the epididymis down a long tube called the vas deferens. The sperm then mixes with seminal fluid and is ejaculated through the penis. (This is a highly simplified explanation, but you get the idea). The procedure known as the vasectomy entails cutting both of the long tubes that serve as a conduit of the sperm to the ejaculatory fluid.

The surgery involves one or two small incisions in the scrotum. The vas deferens is cut and a small piece may be removed, leaving a gap between the two ends. The physician then sears the ends of the tube, and ties little knots on each end. This is then performed on the opposite vas deferens. Afterwards, there may be one to two small scars on the scrotum which heal rapidly. Then, voila! This surgery is a 99% effective form of birth control.

​The recovery time after a vasectomy is quite short. You will need a few days of rest and some ice on the groin. After undergoing this surgery, many men are satisfied that they 1) no longer have to use condoms if they have a single sex partner and 2) do not have to burden their female partner with the more tricky forms of birth control, which do not offer as high a protection against pregnancy.

​There is a small risk of side-effects for this surgery, including the formation of a granuloma (a small lump of scar tissue where the vas deferens has been cut), though this is often not pain-producing. The sensation and quality of ejaculation will usually remain completely unchanged. I hope that I have answered your questions, Lou, and best of luck in making your decision!

Question from Sergio: I am in my mid-thirties and have a very high-stress corporate job. On the days when I work 12 plus hours, my girlfriend often wants to have sex late at night. I find that I take longer to finish and that my ejaculation is more like a dribble than the forceful explosions that I usually have. Is something wrong? What should I do about this?

​Answer from Becca: Sergio, this is a great question and a common cause of concern for men. It all boils down to the lives that we live today. Many men have high-stress corporate jobs. Which means they are under tremendous pressure for long hours, they are often sitting, and their tension is traveling down to the muscles upon which they sit. This is the perfect description of mild pelvic floor tension. Just as some people carry their muscular tension in their shoulders or low backs, you are storing it in your pelvic floor, Sergio. And these days, with the way that we work and live in our society, your need for increased time to ejaculate and the decreased power of your ejaculation are both incredibly common.

While it wouldn’t hurt to see a urologist to rule out any other problems, these sexual issues are likely caused by tightness in your pelvic floor muscles. In order for arousal to take place, the muscles of the pelvic floor should lengthen and allow blood to pool within the testicles and penis. If these muscles are tight, they may not be allowing enough blood into these tissues and erections may be less rigid. This would cause a delay in ejaculation, resulting in increased time to finish the job. Furthermore, that decreased blood flow into the groin would result in less pressure generated to create the “forceful explosions” that you typically experience, Sergio. A weak dribble of seminal fluid at climax may often result.
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In summary, there doesn’t seem to be anything wrong here, Sergio, except that you are living in the world today. My suggestion would be to practice some form of stress reduction at the end of these long workdays. It could be as simple as listening to some calming music during your commute home. You might want to do some simple stretches on the floor or spend time with your girlfriend without rushing into sex late in the evenings. Finally, you could reschedule sex for early mornings or weekends. This would assist your pelvic floor in being more primed and relaxed to achieve the quality of arousal and ejaculation that you deserve.

​Question from Marc: I have premature ejaculation. It has been part of my life since I was sexually active at 16 years old and I am now 33. Is this something that can be helped by pelvic floor physical therapy?

Answer from Becca: Marc, I would imagine that you may have been treated by psychotherapists for your issue. In the last century, many specialists have placed premature ejaculation into the category of a problem of the brain. However, pelvic floor physical therapists now treat your particular diagnosis in an entirely different manner. What we have discovered in treating men like you, is that those who experience early climax often have tight musculature in their saddle muscles (the muscles of your body that would be in contact with the saddle of a horse, were you seated upon one). In the ideal situation of arousal, these saddle muscles should expand and allow blood to flow into the penis and testicles. This blood should be retained in this saddle area to allow for an adequate time span during arousal and penetrative sex before ejaculation. In the case of premature ejaculation, the muscles of this saddle region are taut and cannot allow accumulation of blood to pool in the testicles and penis, which then creates an emergency expulsion of the seminal fluid from the penis.

This condition of premature ejaculation is treated in pelvic floor physical therapy. We assist men in reaching longer time durations of their erections by teaching them to lengthen their pelvic floor (saddle) muscles. We also instruct patients and their partners to increase the time of arousal and defer climax, thereby encouraging the blood flow necessary to prolong the sexual experience. In answer to your question, Marc, you can find help with a pelvic floor physical therapist.​

Finally, for Chen and the vast number of guys like him, view this PDF for the technique on how to avoid the post-void dribble.

​By Karen Bruno, PT, DPT

According to a recent article published in the American Journal of Physical Therapy, “Research continues to reveal that sleep is not a period of physiologic inactivity; rather, it represents a critical period of recovery that supports cardiovascular, neurologic, and other life functions. Sleep is a basic human need, and recent attention on sleep by researchers and media are changing sleep attitudes and behaviors. Sufficient sleep was often viewed as a luxury, and reduced sleep time was often equated with increased productivity; however, attitudes are shifting to prioritize sufficient quality sleep.  Quality sleep is recognized as a positive health behavior, and it has been recommended to consider sleep as another vital sign,  as sleep can give insight into the functioning and health of the body (3)."

You may have noticed that getting a good night’s sleep helps you to feel better both physically and mentally and this helps you function better during your waking hours.  Basically, getting a good night’s sleep is a game changer that enhances the quality of your life. “Sleep is critical for the proper functioning of the body, including immune function, tissue healing, pain modulation, cardiovascular health, cognitive function, and learning and memory.  Impaired sleep can lead to obesity, mood disorders, constipation and heart disease” (3).

1. https://www.sleepassociation.org/about-sleep/sleep-statistics/​
2. https://academic.oup.com/ptj/article/97/8/826/3831304
3. Siengsukon CF, Al-dughmi M, Stevens S. Sleep health promotion: practical information for physical therapists. Phys Ther. 2017;97(8):826-836. 

 
Tips for Healthy Sleep
There is good news! There are many natural ways to improve the quality of your sleep and restore your sleep health. Scroll through the list below and try one or more of the tips, and see how they work for you.

• Decrease stress - Try diaphragmatic breathing to help you wind down and de-stress. Breathing full breaths in through your nose for 4 seconds and exhaling through your mouth or nose for 8 seconds is calming to the nervous system.
• Create your bedroom space as a peaceful sanctuary - remove electronics, TV’s, exercise equipment and anything that may remind you of any form of work. Reserve your bed for sleeping and intimacy.
• Get to bed in enough time to enable you to get 7+ hours of sleep. Create a relaxing bedtime routine. Read a book or take a bath to help wind down.
• Establish regular sleeping and waking hours
• Avoid light-emitting electronic devices at least 30 minutes to 2 hours before bedtime; use amber glasses at night when watching TV or working on a laptop.
• Find the right temperature for your bedroom. The general recommendation is to keep the bedroom temperature between 60-70 degrees.
• Sleep in complete darkness. Use of an eye mask may be beneficial to keep light out. Use earplugs or a white noise machine to block out noises.
• Consider applying a hot pack to your abdomen. This can be very calming. Keep the hot pack on for no more than 20 minutes. If you tend to have cold feet, wrapping a hot pack around your feet for 10-20 minutes can be warming and relaxing.
• Consider using essential oils. Lavender, Roman Chamomile and Vetiver provide relaxing effects and calm the nervous system. You can diffuse them, put the oils on your pulse point, rub them on the bottom of your feet, lightly spray them on your pillowcase or add them to an Epsom Salt bath and take the bath before bedtime.
• Find a comfortable, supportive, neutral sleep positions. Use of a neck roll or a lumbar roll, or a pillow between your knees when you are on your side as positioning supports.
• Avoid taking naps to catch up on sleep.
• Exercise can have a positive effect on deep sleep. Find the time of day that works best for you. Stretching, strengthening, yoga, aerobics or a combination of activities may be right for you.
• Avoid alcohol, caffeine and other inflammation-causing foods, like sugary snacks, refined carbohydrates, or processed meats, late at night.
• Support through vitamins and supplements may be useful. Please check with your doctor, nutritionist, pharmacist or herbal practitioner for what may be right for you. Some common sleep nutrients include ashwagandha, valerian, chamomile, passion flower, lemon balm, melatonin, L-theanine and 5-HTP or Tryptophan.  GABA is helpful if sleep is disturbed by anxiety. Taurine and phosphatidylserine help to lower cortisol. Magnesium and magnesium glycinate are helpful in insomnia.
• Move your energy through easy Energy Medicine exercises.

Adding fiber too quickly into the diet can cause discomfort, bloating, and abdominal gas. A fine balance is important for people with bowel dysfunction.

Eswaran S, Muir J, Chey WD. Fiber and Functional Gastrointestinal Disorders. Am J Gastroenterol. 2013 Apr:108:718-727.

Experts recommend drinking 1600 mL of liquid (~ 54 oz) every 24 hours, requirements that may vary according to a person’s size and activity level. Water is preferred, with other liquids substituted in moderation. Other signs of dehydration may include: headaches, muscle and joint soreness, dark urine, constipation, and kidney stones.

(The Importance of Water. Wilmette, Illinois: The Simon Foundation for Continence, 2014. Print.)

More than half of women with symptoms of vulvodynia do not seek medical care. Of those that do, less than 2% of them are given an accurate diagnosis.

(Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc. 2003 Spring;58(2):82-8.

Reed BD, Harlow SD, Sen A, Edwards R, Chen D, Haefner HK. Relationship between vulvodynia and chronic comorbid pain conditions. Obstet Gynecol. 2012;120:145-51.)

Thinking of kicking the habit? Women who smoke are three times more likely to have urinary urgency and frequency than women who have never smoked.

(Tahtinen RM et al., “Smoking and bladder symptoms in women”. Obstet Gynecol. 2011 Sep; 118(3): 643-8.)

​The NVA, or National Vulvodynia Association, has a free tutorial for Women with Vulvodynia. It reviews anatomy, normal and abnormal symptoms, and vulvar self-examination, for starters. Check it out at www.nva.org.