By Bryn Zolty, PT
As rehabilitation therapists we all learn techniques to evaluate and treat patients. Often we refer to all these techniques as tools in our toolbox. Like a good carpenter, we strive to have a toolbox full of techniques so that we can provide the best care for each patient. We all have our favorite tools. With clinical experience and evidence based research, therapists may pick one tool more often for the job than another. However, I feel strongly that a tool will work better if you have been properly trained and had lots of practice with that tool. This applies to the use of biofeedback, specifically in this case, for pelvic muscle dysfunction. It is a tool in our toolbox. Not the only one, but one of my favorites. And a tool supported by medical evidence.
Through the mentoring process I learned many more uses for biofeedback for pelvic floor dysfunction. I learned to teach the patient how to use their muscles during tasks, functional movements, strengthening, coordinating a bowel movement breath, and more! These are things I have always taught, but now the patient and I could actually observe the muscle recruitment during the teaching. I could adjust my cueing and teaching to fit that person.
Not many patients walk into the office complaining that they have problems with their pelvic floor just laying in bed. But lying on your back is the only position many therapists use the biofeedback in. I use the biofeedback in a toileting position, during the movement that makes them leak urine, and in poses to relax or strengthen. It helps patients find out what their body is doing during the task that is most meaningful to them. Again, this is patient-centered care.
What is biofeedback?
Biofeedback is a tool to help a patient change behaviors or responses. More technically, it is electromyography, EMG. It measures muscle recruitment. That means if done correctly, it measures a targeted muscle when you activate it. If I put the surface electrodes (small stickers) on a muscle and ask you to squeeze or contract, the graph on the computer will show if you are able to contract the muscle. In pelvic floor biofeedback we have the option of surface electrodes or internal sensors. This is always a discussion with the patient to find out what method they are most comfortable with.
Am I appropriate for biofeedback?
Often a patient is told at a doctors appointment that they need biofeedback. I receive many scripts that request biofeedback for muscle training. The doctor may have concerns about the patient performing the correct program. Also, many gastrointestinal doctors have done testing that shows that there is incoordination of the pelvic floor during attempted bowel movements. This means the patient squeezes their muscles when they should relax, making it difficult to evacuate stool.
Your first visit with a therapist is an evaluation. One of the many things we look for is your ability to coordinate your muscles. This means we have you contract, relax, and isolate muscles. If you are having difficulty with verbal and physical cueing, you may be appropriate.
Research shows that almost half of patients being told to kegel will actually push and bear down instead of squeezing and lifting. It is also common that patients will contract their abdomen at the same time and have difficulty isolating the pelvic floor. Also, a cause of constipation can be pelvic floor activation when the muscles should be relaxing.
A pelvic physical therapist has special training to perform internal pelvic floor evaluations. This internal evaluation provides us with valuable information to help you with your dysfunction. However, it is so important for a therapist to present all the options for evaluation and treatment. Not everyone needs or is comfortable with internal vaginal or rectal muscle evaluation. I like to inform each patient of all the information I can gather from each technique and let them decide. It is their care, their body, and their decision. Surface EMG can offer the patient and therapist a look at activation and coordination and help their symptoms without any internal contact. Some patient populations that may benefit from biofeedback because internal contact isn’t possible include:
Pelvic floor therapists need to be incredibly sensitive. Our patients share with us things their family may not even know. We need to build trust before many patients feel comfortable, if ever, with internal evaluation. This does not mean they do not get therapy! I see a huge relief in many of my patients when I explain that they do not ever need to have internal treatment. I tell them what I could do instead, and the pros/cons. Many of them choose biofeedback.
What is a session like?
Prior to the biofeedback session, I discuss all the options. First we discuss sensor options. Most of my patients choose the surface electrodes, but internal sensors are an option that can then be used for biofeedback and if stimulation is part of their plan of care. If you are a child or have severe internal pain, the surface electrodes are used. These are placed peri-anally. That means on either side of the anus.
I usually have my patient put their pants back on, or a gown if they prefer for the session. We move around and the more comfortable a patient is the better the session. I will cue the patient through long or short squeezes, coughing, relaxation, bowel movement breathing, or whatever it is that we identified in the evaluation or we find on the biofeedback that needs to be addressed. I try different cues, screens or tones to get the desired outcome. I often find that the patient can achieve the goal on their own by monitoring the screen. If you figure out a problem on your own, you usually remember it better! Many patients need just one session to get started, some patients require more. It all depends on the patient because patient-centered care is so important.
Are there side effects? Can I get hurt?
Patients need to know that the biofeedback detects your muscles’ activity. No electrical charge goes into you during biofeedback. The machine will not hurt you. Squeezing muscles repeatedly can create muscle soreness. Just like after a workout at the gym. If increased resting tension is seen on the biofeedback and pain is associated with kegels, then I focus on muscle relaxation, physiological quieting, body scans, posture, etc. But it is possible that you are sore from exercising the muscles.
Courses and certification
There are several organizations that offer coursework for therapists. My path took me to Herman and Wallace for most of my pelvic floor training. I recently took a more biofeedback focused course from Biofeedback Training and Incontinence Solutions. I have been fullfilling my mentoring requirements through Tiffany Lee from Biofeedback Training and Incontinence Solutions. For information on coursework and mentoring, visit www.pelvicfloorbiofeedback.com. The BCIA offers certifications in different fields of biofeedback including pelvic muscle dysfunction. They require didactic course completion, mentoring, certification exams, and hours. Their website includes information for therapists hoping to become certified, as well as a board certified practitioner database for patients to locate certified therapists at www.BCIA.org.
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.
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.
Foye: I think that the biggest problem is that the vast majority of physicians unfortunately have a huge blind spot when it comes to understanding coccyx [tailbone] pain. We learned almost nothing about the coccyx in medical school. This leads to four main problems.
Dela Rosa: Your book Tailbone Pain Relief Now! describes the many reasons why people end up with tailbone pain. Are there 1 or 2 causes of tailbone pain that are more common than others?
Foye: Great question! By far the most common cause coccyx pain is when there is an unstable joint between the bones of the coccyx. Many medical textbooks and websites incorrectly state that the coccyx is a single fused bone. But that is rarely true. In the vast majority of humans, there are 3 to 5 individual coccygeal bones, with variability in whether there is fusion between any of those bones. Most people have at least a few coccygeal joints. And most people with coccyx pain have joint hypermobility (excessive movement) as the source of their pain.
The second most common cause of coccyx pain is a "bone spur"; extending from the lowest tip of the coccyx. When this happens at the bottom of the coccyx, there is thickening of the bone that projects backwards, often coming to a sharp focal point. It’s almost like a tiny icicle made of bone. This bone spur pinches the skin between the spur and the chair where the patient sits, and especially when they sit leaning partly backwards.
Dela Rosa: Thank you for clarifying the common causes of tailbone pain. In your book, you detail some of the seat cushions and medications that may help. People ask about injections for pain. As a pain management doctor, would injections be helpful for these causes and if so, could you describe how and what kind?
Foye: Sure it's a great question. Medications by mouth have a couple of big problems with them, which is why a lot of times medication given focally by a small local injection could be superior.
When medications are given by mouth, number one they go through multiple places throughout the body. If you're taking medication by mouth, they can cause side effects in the stomach, the intestines, the liver, and the kidneys, so the side effects can be quite limiting.
The second problem with medications by mouth is that because the medicine travels throughout the entire body, it gets diluted out. So only a minuscule amount of the medication actually makes it to the tailbone where the patient needs it the most. Many of these patients do respond to medication given locally at the site. Typically, that's done under fluoroscopic guidance. Fluoroscopy is like x-ray up on a computer screen, and using fluoroscopy we can target a specific location at the tailbone. I'm generally opposed to blind injections, which is where injections are done without any image guidance because 1) you can't guarantee where the medication is going to go and whether it's actually given at a place where it's going to be helpful, and 2) you also can get into problems if it's given in the wrong place - it can cause side effects.
So back to your question, which was about the diagnoses like hypermobility or a bone spur... Absolutely those can respond very, very well to placing medication locally at the spot under image guidance. Often that's a combination of steroid which helps to fight inflammation, and also local anesthetic which can be given as a nerve block and can be very helpful when there's hyperactivity or hyperirritability of the nerves.
Dela Rosa: How is the x-ray your center performs different than how many other facilities perform the test?
Foye: Here at the Coccyx Pain Center, the biggest difference is that we take coccyx x-rays while the patient is sitting down, since that is when tailbone pain hurts the most. I have trained the radiology technicians here regarding how to properly perform this technique, which was first developed in France. Very few places in the United States have ever heard of this approach and even fewer are experienced at doing these x-rays properly. We have evaluated and treated thousands of patients with tailbone pain, many of whom fly in from around the country and internationally. And it is extremely common that patients had previous imaging studies that were read as being normal. But then they come here and our seated x-rays show that when the person sits down and leans backwards (putting their body weight onto the coccyx) they often have very dramatic dislocations or other abnormalities that would be completely undetected if the x-rays had not been done while the patient was sitting. It is a huge relief for patients to finally have an answer as to what is causing their pain. Then, when we have identified a specific cause for their pain, we can provide treatments for that specific cause, which is much more likely to be helpful than generic treatments done blindly without a diagnosis.
Foye: A lot of this goes back to and starts with the general lack of awareness that physicians, radiologists and radiology technicians have about tailbone pain. Frequently, they lump it all in with low back pain. Lumbosacral pain is thousands of times more common than tailbone pain. A lot of the automatic checkoff boxes that people have on their radiology x-ray or MRI forms will have a box to check off for lumbar spine or lumbosacral spine, but they will not have a box to check off for the coccyx or tailbone just because it is thousands of times less common. So what happens is that the primary care doctor, or the orthopedic surgeon, or the pain management doctor, will check off the box and order lumbar or lumbosacral x-rays or MRI, and then that doesn't even include the tailbone at all.
The next problem then is that the study gets done and the patient is told that there's nothing wrong, and that there's no explanation for their pain when really the images did not even include the symptomatic area, or worse yet, it shows an incidental finding of the lumbar spine that may not be causing any symptoms at all. But now they start down the treatment path of epidural injections, and even spine surgery and other things for a part of the body that wasn't even causing the problem. So basically back to your question about what the patient can do: 1) look at the orders, look at the x-ray or MRI orders, make sure that the ordering physician has specifically explicitly requested imaging of the coccyx, and 2) when you go into the radiology center, make a point of talking to the radiology technician and being crystal clear with them that this is not your lumbar spine, that this is not up in the small of your back at the belt line, that the pain is specifically down at the coccyx, and make sure that the radiology technician is going to include that part of the anatomy within the study. It really does require a certain amount of self-advocacy by the patient unfortunately to fight this uphill battle against the ignorance that's out there.
Dela Rosa: I'm just curious, have people come to you from outside of the US? Or are you mostly seeing people domestically?
Foye: Most of my patients travel in from out-of-state and about a third of my patients fly in. It's maybe 5% or less that are international. Within the last six to 12 months, I've had patients from Japan, Sweden, Africa, the UK, New Zealand, and I think two from Australia. Which really just gets back to that there's this unmet need out there and patients who are not able to find local clinicians who will either take them seriously or that know the appropriate testing and treatments to provide.
Dela Rosa: How do you work with pelvic floor physical therapists in the treatment of tailbone pain?
Foye: As a physician specializing in Physical Medicine and Rehabilitation (PM&R), I'm a strong advocate for the role of physical therapists in treating patients who are suffering from painful musculoskeletal conditions. Historically, a big problem was that very few physical therapists were comfortable or experienced in treating pelvic floor problems. Fortunately, that has been improving in recent years.
The pelvic floor is often described as being like a muscular sling, or hammock, which supports and holds up the pelvic organs. The back end of that sling has attachments to the coccyx. Pelvic floor physical therapists and I often collaborate on figuring out the "chicken and the egg" phenomenon. By that I mean that we assess whether a patient is having tailbone pain due to pulling and tugging onto the tailbone caused by tightness and spasms of the muscles that attach to the coccyx. Or, sometimes it could be just the reverse: a painful condition at the coccyx itself might be causing reactive muscle spasm and guarding of the pelvic floor. If evaluation and treatment at one location is not providing adequate relief, then it often makes sense to collaborate and to consult each other, to help the patients find the answers and relief that they deserve.
By Bryn Zolty, PT, DPT
*This article is based on Return to running postnatal-guidelines for medical, health and fitness professionals managing this population. Tom Groom, Grainne Donnelly and Emma Brockwell
Most orthopedic injuries have protocols after surgery for rehabilitation prior to returning to sport. However, there is not a set protocol for women after giving birth to return to their prior level of activity safely. Many women have very limited knowledge of their pelvic floor or ability to strengthen the muscles to support their organs and keep them from leaking urine or bowel movements. Very frequently, women are not even aware of pelvic organ prolapse (POP). POP occurs when the pelvic floor muscles are weakened and the bladder, uterus, or rectum can start to press into or drop out of the vagina.
The research shows that women should wait until 3-6 months postpartum to return to running. For women anxious to return to running, that seems forever! The reason to wait is based on healing time. For vaginal births, the pelvic floor muscles are stretched greatly, and the levator hiatus (pictured below) can take as long as 12 months to become closer to baseline. In addition, the pelvic floor muscles, connective tissue and nerve healing is maximized by 4-6 months (Staer-Jensen et al. 2015). That means that women should seek a pelvic floor physical therapist after vaginal births as soon as they are cleared in order to maximize their ability to heal these tissues.
In both cases, vaginal or cesarean, the recommendation is to have a pelvic health physical therapist evaluate the pelvic floor and abdomen prior to returning to high impact exercise. High impact exercise in female athletes was found to have a 4.59 fold increase in risk of developing pelvic floor dysfunction compared to low impact (De Mattos Lorenco et al 2018). Running has been associated with a rise in intra-abdominal pressure and increased ground reaction force between 1.6 and 2.5 times bodyweight when running at a moderate pace (Gottschall and Kram 2005). These statistics are not to show that women should avoid high impact exercise, but should make sure women are physically prepared to return to sport.
The article concluded that return to running should occur 3-6 months postpartum in the absence of the following symptoms:
Other symptoms in addition to those listed above, that if experienced a woman should seek out a physical therapist include:
In addition, there are recommendations on the amount of strength and endurance in the pelvic floor and fascial support that should be present for running to prevent pelvic floor dysfunction. These measurements can be evaluated by a pelvic floor physical therapist.
The full article can be found for free here.
Goom, Tom & Donnelly, Grainne & Brockwell, Emma. (2019). Returning to running postnatal – guideline for medical, health and fitness professionals managing this population.
Is what you are eating contributing to your pain? Can the choice of food you eat actually help to relieve pain? Can nutritional interventions ease your pain? The answer is that nutritional interventions are often effective in reversing chronic pain. Simple dietary changes that remove inflammatory foods and replace it with better choices can help to reverse chronic pain conditions. Pain conditions are often due to an imbalance in the body’s chemistry. This can be due to many factors, such as a lack of nutrients in your diet, stress overload, lack of exercise, increased inflammation, insulin resistance and environmental factors. Nutritional interventions can be one element for shifting the chronic pain response.
In the links below, Joe Tatta, PT, DPT, addresses components of various anti-inflammatory diets and their benefits. Dr. Tatta is a physical therapist and Founder of the Integrative Pain Science Institute, an education company that supports practitioners as they explore integrative models for pain. In these blogs, there is a review of the current literature of the types of foods and diet that can ease the pain associated with various health conditions.
These are some general guidelines. There is not a “one-size fits all” eating plan as you are unique and complex. Start by making a few changes in your diet and notice how you feel. For example, you can eliminate sugar and processed foods. Making limited changes will assist in recognizing how those particular foods impact you. Is there a relationship between food and pain? Going slowly and changing one or two things at a time is recommended so that you can identify whether a particular modification had an effect.
What happens if you eat a dessert or two, have some alcohol or coffee, or eat some other food that is generally considered inflammation provoking? By all means - enjoy it and savor the experience! There will be more on that in an upcoming blog. Resume the low inflammation regimen when you can and just move forward.
What you choose to eat has an influence on your overall health and resolving pain. Nutrition and diet affect both the physical and psychological processes that impact chronic pain, and good nutrition can be a pivotal component to attain and sustain optimal function and quality of life.
Making delicious and nutritious meals and desserts can be simple. Here is a simple 3 ingredient treat to get you started.
Blueberry Banana Muffins
For reference, check out the Integrative Pain Science Institute.
Question from Don:
“I am 32 years old and have no difficulty with sex. I do find that it is hard for me to pee after ejaculation. Is this normal? And should I be forcing out pee after sex?”
Answer from Becca:
“What you are describing is very normal. The muscles of your pelvic floor that allow you to maintain an erection and expel semen during ejaculation are in a shortened position during sex. These same muscles must be completely relaxed and elongated to allow urine to exit the urethra. Asking your body to pee immediately after having sex is like decelerating a car from 90 mph to a full stop. The pelvic floor muscles are too revved up after climax to stretch and relax. Instead of ‘forcing out pee after sex’, try sitting on the toilet and taking some deep breaths. This will allow whatever is within the bladder to naturally come out of your penis. And if you do not have the urge to pee after sex, you needn’t try this at all.”
Question from Gary:
“I am 53 years old and in pretty good shape. I have diabetes and my erections are not as strong as they used to be. My doctor has tried to give me Cialis; it works only some of the time, and it is very expensive. Are there any tips that you could offer as a pelvic floor physical therapist to improve my erections?”
Answer from Becca:
“Erectile dysfunction and diabetes are often linked. This is because having high blood sugar in the body alters circulation of blood and leads to nerve damage over time. The good news is that this type of erectile dysfunction can be reversed with good lifestyle choices. Maintaining a good diet for stable blood sugar, regular exercise and stress reduction can all help to improve your sexual response. From a physical therapy perspective, we can teach you how to isolate and contract your pelvic floor muscles during sex (also known as Kegel exercises), and improve your core strength. This will allow for increased rigidity of erections. You are one of so many men with exactly the same problem; there is help in pelvic floor physical therapy for a better sex life.”
Question from Pedro:
“I am 28 and began having groin pain over one year ago. I have penile pain along my shaft and up towards the tip, both during and after sex. It helps when I masturbate versus have sex with someone else, because I can avoid the tip of my penis and ejaculate with much less pain. I am not having sex with anyone at the moment, but I am worried because I used to get morning erections and now I don’t. Is this normal? I can’t exactly ask my friends.”
Answer from Becca:
“This is a multi-pronged question, so I want to be careful that I address each part of it. First, a great place for you to start if you have penile pain would be to go to a physician. There may be an infection under your foreskin (known as Balanitis), certain cancers or scar tissue development within the penis (also named Peyronie’s disease. You may have seen commercials on television about this diagnosis). Once your physician has ruled out any medical cause for the pain in your penis, a pelvic floor physical therapist can assess the musculature of your pelvis to determine if there are any imbalances or muscle tension that may be driving your pain.
“Second, having pain in the penis is one of the symptoms of Chronic Male Pelvic Pain Syndrome. That is not to say you have this diagnosis, Pedro. But this description of your problem is more common than you know. In pelvic floor physical therapy, we treat many men with penile, testicular, perineal and rectal pain. The causation of this pain is often tight musculature in the saddle area. Relaxation of these muscles can do wonders, but it is often difficult for guys to learn how to relax this region of the body without some guidance.
“Thirdly, many men with such symptoms tend to prefer masturbation to sex with a partner, especially when they are having a flare-up of pain. This is because, just as you mentioned, only you know what hurts and how to avoid pain during sex. Your partner will have a more challenging time working around your specific pain. That said, once your symptoms are decreasing in severity, the reintroduction of sex with a partner can be a creative and exciting learning curve. Physical therapists can help with this area of problem-solving with both partners.
“Lastly, morning erections are the body’s natural response from overflow of the parasympathetic nerves in your spine. In other words, the nerves are sending calming signals to the pelvis during sleep. This explains why having erections in the middle of the night or first thing in the morning is not a result of having erotic dreams or a person feeling aroused, per se; rather, the body is in a calm state and the testicles and penis become engorged with blood during sleep. Your lack of morning erections is consistent with your penile pain. This is because your pelvis is not relaxing appropriately during the sleep cycle to facilitate those erections. Many men with pelvic pain find that their morning erections return once their symptoms of pain are better managed. This is a good sign that the muscles of the pelvis are relaxing and allowing the return of painfree arousal and improved sex.”
By Bryn Zolty, PT, DPT
However, there is research that suggests that women who have painful penetration and have not yet had children, three maximum Kegels can significantly lower vaginal resting pressure and surface EMG(1). Lower resting pressure and surface EMG, or biofeedback, translates to lower muscle tension, improved function, and less pain.
Biofeedback can be a very helpful tool to determine if this type of treatment is right for you. Small electrodes (stickers) are placed on either side of the anus. These electrodes connect to a computer that measures the muscle activity in the pelvic floor. As you watch the computer, a therapist will guide you through how to contract and relax your pelvic floor and try the three maximal contractions. If the tension in the pelvis is reduced, the therapist will provide you with your home exercise program that includes the three maximal contractions.
Can maximal voluntary pelvic floor muscle contraction reduce vaginal resting pressure and resting EMG activity? Naess, I. & Bø, K. Int Urogynecol J (2018) 29: 1623.
A lot of people ask us about the practice of physiatry. Some people know how it's pain management, but they don't really know how it's different than seeing their gynecologist or their urologist in the way they would treat their pelvic pain. So, can you give me a general overview to describe physiatry and how it treats pelvic pain differently than their gynecologist or their urologist.
Dr. Shrikande: Sure, thank you so much for having me, Michelle, this is great. For a physiatrist treating pelvic pain, we help the other doctors treat the muscles, the nerves, and the joints of the pelvis in a non-operative approach.
Michelle: How would that be different--can you give me examples of treatments that people may not see with their doctor that they're already seeing?
Dr. Shrikande: Essentially, we want to look at it from more of a sports medicine approach, seeing if the pelvic pain is coming from the pelvic floor musculature. Are the muscles in spasm and potentially irritating the nerves of the pelvis, causing some pain? So that's where we would come in when we're evaluating patients. Is there a pelvic floor muscle spasm, which we call pelvic floor hypertonia and can cause pain in patients. And we're really trying to evaluate why this is happening and is there anything from the sports medicine standpoint where we can identify a cause and help to find a proper diagnosis and treatment.
Michelle: I was lucky enough to be able to shadow you for an afternoon and I noticed that while you were treating patients, you were interested in not just recognizing that there was spasm, but like you said, what else could be contributing to it. So what other things do you look for that could be contributing to pelvic spasm?
Dr. Shrikande: From the musculoskeletal or the sports medicine standpoint, you want to see if there's anything going on in the lumbar spine that can cause pelvic floor dysfunction. Or is there anything going on in the sacroiliac joint? Or you want to consider the hips--are the hips working, functioning well? And is there any underlying pathology in the hips as well as what we call the pubic symphysis, which is the joint in the anterior aspect of the pelvis. In addition, is there anything going on from the other specialties as well that could be causing this secondary guarding of the pelvic floor muscles? So is there a gynecological reason if it's a female, or urological reason if you're male or female, or maybe from the GI system, etc? But you really want to say, 'Is there anything else going on here that's causing these muscles to go into this guarding state where it's really not letting go very well?'
Michelle: This is interesting because so many of my patients say they've gotten a diagnosis of pelvic spasm, but they didn't really get checked out. As a physiatrist, you are doing a pelvic exam?
Dr. Shrikande: When you see us, we would do a full exam--again looking at your back, your hips, etc--but we do end the exam evaluating your pelvic floor both externally and internally. So we do an internal exam. I always tell our patients that we're not gynecologists, so we're really looking at the muscles and distribution of the nerves internally. But we would do an internal exam and it does not require a speculum. It would be similar to an internal exam of a pelvic floor physical therapist--we really look at the tone of the muscles, the strength, and the lift of the pelvic floor, and follow the nerve distribution internally to see if there's any increased sensitivity or pain internally.
Michelle: Wonderful, we have such a growing population of men coming to see us for pelvic pain as well. And they're always curious how your exam would be different or how you would be able to help them because they're hearing that a lot of these treatments are for women. Would they be able to access you and what would you be able to offer them?
Dr. Shrikande: We see a lot of men here at Pelvic Rehabilitation Medicine, about equal amounts of men and women. From the muscle, nerve and joint standpoint, the anatomy is actually the same. For us, evaluating men and women, it is a similar approach. For the men, we do look at your lumbar spine, hips, and abdomen, any concern for underlying hernias that could have been missed. But then we do an internal pelvic floor exam as well--it would be internal rectally, also evaluating the muscle's tone and lift and any nerve tenderness internally. With men it would be a similar approach trying to see if there is any possible underlying cause for pelvic floor guarding. And then it's a full body treatment approach where we really can--we call it down-regulate--or calm down the nerves, of both the central and peripheral nervous system and increase blood flow to your muscles, and get the muscles longer and stronger to rehabilitate the pelvic floor.
Michelle: Many of our patients have been seeing multiple providers. And I noticed that in your practice, you seem to be a gateway to many of the other providers, sort of--coordinating care. Is that part of your model of care and how would you say your practice runs differently than other practices that treat pelvic pain?
Dr. Shrikande: Definitely. We see ourselves as the quarterback here, because as rehabilitation doctors, we really are trained from the beginning to look at the whole body and the interplay between multiple organ systems. So quite often, we are talking to a patient, and in our minds, thinking if there's any other specialist that we would need to bring into the picture to help us get this patient better. We work closely with specialists who are excellent in treating the pelvic pain from their angle. But we do see ourselves as the quarterback kind of sending as needed, as well as working closely with pelvic floor physical therapy, to figure out how to get our patients better and what other specialty is needed to calm down their muscles and their nerves.
Michelle: Some of our patients have been getting injections for their pelvic floor and they've been given an option for steroid. I know that you have other options, and also, can you touch upon the imaging that you use to guide you through the injections--if injections are necessary.
Dr. Shrikande: The way we do our injections, or treatments as we like to say…everything is external, nothing is internal. So it's all external, along the sling of the pelvic floor, and they're ultrasound guided. Patients call them their butt injections, that's kind of what it feels like--it's not internal, it's external. The idea behind the guidance is like internal eyes so you can see where you're going. And in addition, it allows us to do a hydrodissection technique, where we can really open up the fascial planes and create space where there is restriction, particularly where the nerves want to flow. What we're using to supplement for a steroid, is something called Traumeel, which is a homeopathic medicine, so it's derived from plants. The main ingredient is arnica--a lot of people have heard of arnica cream like topical arnica--but this is an injectable form of arnica and in combination with echinacea. So it's a nice way to promote healing in addition to decreasing inflammation, which is why we love it. I really used it more in my plastic surgery rotation. Post-operatively we would give it out after a surgery so that patients wouldn't become as bruised and swollen. It would decrease inflammation and promote a faster healing topically. So that's where the idea kind of came from.
Michelle: I know that one of the positions that you hold is that you're the Chair of the Medical Education Committee for the International Pelvic Pain Society. How do you feel that the position helps to shape what you do in your practice and helps shape how pelvic medicine is moving for the future?
Dr. Shrikande: We're actually lucky enough to be surrounded by amazing, intelligent, pelvic health practitioners who constantly push me to really think about things and learn more. The mission of what we do is educate the future of pelvic health from the medical practitioner standpoint--from both the residency program and urology, as well as gynecology and physiatry and any pelvic floor physical therapist who's had training there--just to try and increase awareness for the people who are training, that the pelvic floor itself is its own distinct entity. And although it does not show up in imaging, we really should not ignore it, particularly when the workup is normal and the patient symptoms persist. So we're really trying to raise awareness and at an earlier stage in physician's medical careers, in hopes of getting all our patients recognition earlier and treatment earlier. Because we really believe that is the key--early recognition and early treatment, to squashing it early and getting patients better.
Michelle: What's the range of people that you see in terms of how long patients have had pelvic pain for prior to seeing you? Is there a range?
Dr. Shrikande: It's getting better by the day. But still at this point, the average is six months to 25/30 years worth of symptoms. Even six months is rarest. It's really along the lines of 1.5 years to 25 years.
Michelle: Hmm, yeah. So, both of us are working on that.
Dr. Shrikande: We have to work together.
By Bryn Zolty, PT
How do men Kegel? In the literature, the phrase that was found to be most associated with stopping urine leakage was, “Shorten the penis.” This simple cueing creates the greatest displacement of the muscles that close the urethra. Other cues like “lift the bladder” were not as effective and increased pressure in the abdomen and pushed down on the pelvic floor. (1) It is important to be aware that you are not contracting other muscles in the legs, buttocks, and abdomen when isolating the pelvic muscles.
Every Kegel or pelvic floor strengthening program should be customized to each person. In the clinic, we work on endurance and quick contractions. For example, a home exercise program may include:
Some men lose large amounts of urine after prostate surgery, which can have a huge impact on normal daily activities. It may take time for kegels to make a difference in symptoms. A penis clamp may be an appropriate option to stop large leaks. The clamp places gentle pressure on the urethra to block urine loss. It may not stop all leakage but can significantly reduce it. When the clamp is removed, the release of pressure allows for normal urination. The amount of time recommended for wearing the clamp is variable between different devices. If you have any interest in a using a clamp, contact your physician or pelvic physical therapist to see if you are a good candidate.
According to the Journal of Neurourology and Urodynamics, men " found the device easy to use, felt more confident wearing the device, and had increased levels of physical activity with device in situ." They had significantly improved urinary incontinence symptoms per the Incontinence Impact Questionnaire. (2)
If you are going to have a prostatectomy or already have, ask your physician for a referral to a pelvic physical therapist. They can guide you through your pre- and post-surgical rehabilitation and reduce urinary incontinence.
(1) Stafford, R. E., Ashton‐Miller, J. A., Constantinou, C. , Coughlin, G. , Lutton, N. J. and Hodges, P. W. (2016), Pattern of activation of pelvic floor muscles in men differs with verbal instructions. Neurourol. Urodynam., 35: 457-463.
(2) Barnard, J. and Westenberg, A. M. (2015), The penile clamp: Medieval pain or makeshift gain? Neurourol. Urodynam., 34: 115-116.
By Becca Ironside, PT
I have been working as a pelvic floor physical therapist for a few years now. As with many people with hold this job title, we were often met with confused looks, raised eyebrows and a generalized misunderstanding as to what physical therapy of the pelvic floor could possibly entail. This is entirely understandable, as I had been a physical therapist for sixteen years before taking the dive into getting my pelvic floor specialty.
Why did I change paths and redirect my craft towards the pelvis? In part, because I had become a little bored with the other facets of physical therapy I had worked within and wanted a new challenge. But the larger reason why I felt compelled to undergo this very specific training for the pelvic floor is because I suffered from pelvic pain. It was unpredictable pain, which manifested itself in odd and various ways. I went to so many different physicians, yet none of these specialists I went to for treatment could help me with my symptoms.
Fast forward, five years later: I have a very gratifying job treating the pelvic floor muscles of both women and men. The demand for this work is enormous, as there are not enough pelvic floor therapists to treat the vast number of people who have discovered its importance. Women come to our clinic and the ability to help others who have the nebulous and seemingly inexplicable symptoms that I once did is a splendid feeling. Secondly, I no longer experience pelvic pain. This is because I can utilize the techniques and knowledge that I use with my patients on myself; I also have a great bunch of coworkers who can treat me when I cannot fix the problem and need another mind or another set of eyes and hands to brainstorm and palpate the causation of it. Lastly, there is a show featured on HBO which is all about a woman with pelvic floor dysfunction. Finally, the world is being educated on a grand scale about the importance of pelvic health! The show is entitled Camping.
In watching the show Camping, we learn that Kathryn has undergone a hysterectomy. The loss of her uterus and ovaries has led to other losses. For instance, Kathryn and her husband have not had sex in two years. We are led to the conclusion, by her husband’s discussion with his fishing buddies, and Kathryn’s own overt disgust and refusal of sex, that it is chronic pelvic pain that seems to be driving the boat in their marriage.
Let’s go back to what pelvic floor dysfunction really means. Some women, like Kathryn, have had pelvic surgeries which can lead to scar tissue formation. Other women have constant burning and discomfort with urination, all due to muscular imbalances. What will that lead to? Sex can often become painful and many women brace themselves before each sexual encounter, in fear of the discomfort that will ensue.
The show Camping does a fair job in unveiling how a relationship can be eroded by pelvic pain and the lack of intimacy that often accompanies it. This is a finding often seen in the pelvic pain population. Pain alters how the brain processes information. It effects our ability to be active listeners, to take care of others, either in the bedroom or out of it. But when the pain is so directed in the perineum, sex is often one of the first leisure activities to take a backseat in the relationship. That makes sense, right?
There are other manifestations to having this condition. Many people with chronic pain find themselves more withdrawn than they might have been without it and more apt to find solitude. Their threshold for chaos can often run thin. And because women are often called upon in society to act “motherly” and to be “nurturers”, many of them living with chronic pain will simply put their chins up and bear it. Even though depression and anxiety might be creeping up their backs like a snake. Lots of them soldier on, push down the pain and are reluctant to make their diagnosis public.
Obviously, this does not represent all women with chronic pelvic pain. When we are introduced to Kathryn, the main character in Camping, we get quite a different profile of how this pain can affect people. The actress Jennifer Garner plays the role of Kathryn, and Ms.Garner uses her elan in this performance to show us a woman who is highly obsessive, erratic in thought and speech and has great difficulty maintaining relationships with others. Kathryn is described as “bitter” and “angry” behind her back and she hits her husband when he attempts to initiate sex.
This characterization of a woman with pelvic pain may be what the writer of the series felt if she had similar pain. Or the character may be based on a Type A Helicopter Mom to make the series more amusing, as this series is a sitcom. But the reality of this portrayal of Kathryn as a woman suffering from pelvic floor dysfunction is that she does not represent the typical sufferer. Because this is the first exposure that the general public has had in mainstream television to the pelvic floor, it may render women less willing to acknowledge or seek help for their diagnosis, as they may not want to align themselves with the behaviors of Kathryn.
In fact, the portrayal of women in this light can seem reminiscent of the 1950’s. The term “hysterical” was used in the past as an actual psychiatric diagnosis used to label women for being overly dramatic and prone to bouts of insane behavior. The medical operation known as a hysterectomy was named because it was believed that if a physician removed a woman’s female parts, he would eradicate her insanity.
I am reluctant to bring these facts from the past for women into the cold light of today. This is what the world of pelvic floor physical therapy is trying to reverse – the notion that women with feminine troubles are irrational and unable to be around without great unpleasantness. While it is encouraging that a cable network has named pelvic floor dysfunction, it would be far more helpful in the future if women were represented as emboldened by the power to take back their own pelvic health. Because that is precisely the image of the women who come to us: bold, unashamed and ready to use available resources to uproot outmoded theories of how they should feel and who they should be.
So, where do we go from here?
Written by Becca Ironside, PT
Vincent found our clinic by chance. He scoured the Internet, looking for a reason to explain the confounding pain in his pelvis. Vincent had a high-stress, corporate job wherein he sat all day long. He began to notice pain in his perineum while sitting. The longer he sat, the worse the pain became.
The final symptom which prompted Vincent to become desperate for help was testicular and penile pain during arousal. Vincent could no longer have intercourse with his wife without searing pain. He called a urologist and a gastroenterologist. He scheduled appointments for both specialists around his busy schedule.
The urologist prescribed a pharmaceutical named Flomax to improve Vincent’s ease in urination. The gastroenterologist recommended Miralax, a bowel aide which allows water to be retained in the stool, thereby promoting softer stool and more frequent bowel movements. Both of these agents helped Vincent with about one-third of his overall complaints; but he was still unable to sit at his desk without pain, and his sex life had taken a turn for the worse. Vincent’s wife was unhappy, though not as unhappy as Vincent. There has to be something out there to help me, he wondered. But what?
This was when Vincent initiated his full-throttle search on the Internet. He looked for stories of men with similar complaints. Vincent lives in Central New Jersey. There came a day when he found Connect PT online. The office was merely 14 miles from his home! He booked an appointment for the following week and crossed his fingers as he paced around his office, trying to stop the throbbing in his pelvis by willpower alone.
Upon his initial Pelvic Floor physical therapy evaluation, Vincent told his entire history to his evaluating therapist. She sat and nodded, and then proceeded to ask him a series of questions about his symptoms. To every one of the questions, Vincent longed to shout: YES! I have trouble maintaining a urinary stream! I have severe constipation! I cannot sit without pain! I cannot have sex anymore, because the discomfort is not worth the release!
The PT gave Vincent some relaxation exercises, a home program to stretch his own pelvic floor and even a link to a seat cushion which Vincent could use to take the pressure off of his perineum, rectum and tailbone. This would allow him to sit for longer periods of time with less pain, the PT said. Within a few months, Vincent was able to urinate more freely, have more consistent bowel movements, and was able to return to having sex with his wife.
How had all of this happened? Was it magic? No. But it seemed that way to Vincent. Vincent’s recovery had everything to do with his willingness to seek treatment and the newfound availability of Pelvic Floor physical therapy. His symptoms were far more common than he knew. Now, Vincent writes blogs about pelvic pain in order to share his experience with other men who may be suffering from similar complaints.
The greatest outcome of Vincent’s recovery was his decision to retire from his high-stress, corporate job. He still uses the special seat cushion which takes pressure off of his pelvic floor to drive across the country in an RV. Vincent and his wife have seen Yellowstone National Park, and they even take their English bulldog named Lola along for the ride. In sum, everyone is happier. Vincent, his wife and Lola. All because of one fortuitous Internet search and the prevalence of Pelvic Floor physical therapy.
“Looking back, I see that my symptoms really began to change when I began talking about this,” Vincent says. “Giving a voice to the pain, isolation and embarrassment has changed everything. I just want more people to know that they are not alone.”
Written by former staff physical therapist, Aisling Linehan, PT
Pelvic health therapists are sometimes known as women’s health therapists; however, it’s important to note many of them also treat men. Our pelvic floor therapists treat men as well as women. Pelvic therapy is effective and often life-changing for both genders.
Let’s use male pelvic pain as an example. When pelvic pain strikes, males often wait a few months for it to go away on its own. They finally visit their primary care doctor who commonly refers them to a urologist. Urologists do their best to work up patients for any harmful pathology like infection and cancer. For males with non-bacterial prostatitis, the tests for infection will be negative, and frequently prescribed antibiotics like Cipro may not help. Unfortunately, many men will continue to take it in hopes of future relief all whilst suffering from its many side effects. When urologists have sufficiently ruled out pathology but the pain remains, the patient is left wondering where to turn next. Many males turn to the internet to find that there are other people like them, in pain, alone and suffering but have found relief with pelvic floor therapy. Urologists are so effective at ruling out pathology that almost every male who ends up in a pelvic PTs office is suffering from a musculoskeletal issue.
Pelvic floor tone is assessed digitally through the rectum and electronically with biofeedback. It is important to note that a high tone pelvic floor can cause any combination of the following symptoms: urinary urgency, urinary frequency, constipation, penile pain, and testicular pain/pulling/burning/retraction. Many of these symptoms can be relieved with PT interventions that may include: soft tissue release for pelvis and hips, breath training, rib/diaphragm mobility, internal pelvic floor trigger point and myofascial therapy, perineal mobility, light stretching, and gentle core strengthening.
Pelvic floor therapy is a safe space. It is not scary or threatening. Many patients feel immediate relief knowing that we have treated and helped patients just like them. We are here to educate and make space for the healing to happen. Knowledge is power and the more you know about your body they better you can treat it. If you’re looking for help and education regarding pelvic pain, contact your local pelvic floor physical therapist for an evaluation today.
Written by Becca Ironside, PT. Becca is also a published Author of Fiction.
I met a woman named Eva* at the Pelvic Floor clinic. She came for physical therapy to address urinary leakage, which she has endured for over ten years. I had to glance at her date of birth to make sure of her age. Eva is 85 years old, and she looks spectacular. “What is your secret to looking so young and vibrant?” I asked her. “Maybe it is having good friends. Wonderful children and grandchildren. Or maybe it is just my good Danish genes,” she replied.
Eva told me that she began leaking urine several years ago, but her condition is getting worse. She told me that she cannot go to the beach anymore at Point Pleasant, which is her favorite thing to do. In her medical history, I learned that Eva had had three pregnancies with vaginal births. She does not drink enough water, mostly in fear of losing even more urine. Based on her age and prior history of childbearing, I was working under the assumption that Eva had weakness in her pelvic floor muscles. Maybe a little prolapse of the bladder.
“A lot of young women come here with complaints of pain with sex,” I told her. Eva’s eyes opened wide. “Do you mean to tell me that there is treatment for that? I had two husbands and sex was awful with both of them. The pain was unbearable. I never understood what the big fuss about sex was all about.”
Here was a woman in her eighties who had lived with pelvic floor dysfunction her entire life. The painful intercourse made sense, given how much tension she was holding in her musculature. I devised a treatment program for Eva to allow the muscles of her pelvic floor to elongate. She was given a home program of self-stretching, diaphragmatic breathing exercises, and an activity known as the pelvic floor drop, which is the opposite of the famed Kegels we have all read about in McCall’s Magazine.
Eva has returned several times to our clinic. She has far less urinary leakage, is drinking more water (she has retrained her bladder to accommodate this), and practices yoga and deep breathing. She is planning a month-long trip to Florida, wherein she will be able to go to the beach in a bathing suit encasing her lithe body without fear.
I learned something wonderful during my treatment of Eva. I rejoice in living in a time when help is now possible for these things that have plagued women for centuries. I also learned that it is never too late to change. Eva is 85. And if she responded so readily to this therapy, then anything is possible.
*The name and some personal details of this patient have been changed, according to the laws of the Health Care Portability and Accountability Act. But the symptoms of Eva and the outcome of her treatment are true. Pelvic Floor Physical Therapy works!
Patient: 66-year- old female with mesh repair of rectal and bladder prolapse 10 years ago.
Chief Complaint: “Knife-like” pelvic pain 10/10 with physical activity the following year, pelvic pain with urinary urgency, 6 voids at night.
Past Medical History: Diagnosis of interstitial cystitis 2 years ago, lumbar arthritis, thyroid condition.
Physical Therapy Treatment: Education on lifestyle modification for prolapse; breathing exercises; bladder retraining; manual release to pelvic floor and restricted internal scars; stretches for pelvis, hips, and low back; gentle core strengthening exercises.
Results: Pelvic pain 1/10 with physical activity, 0 discomfort with 2-hour drive, and 3 voids at night in 17 visits!
A new website called “Take the Floor: Voices for PFD” [pelvic floor dysfunction] has been developed by the American Urogynecologic Society (AUGS) and the AUGS Foundation. People can find educational information on bladder and bowel dysfunction that includes: definitions, symptoms, treatment, and prevention. For more inforamation, go to www.voicesforpfd.org.
Connect PT recommends the New Dawn Pilates DVD for people with pelvic pain.
This series of gentle exercises was created by Jenny Buttacio, an occupational therapist and Pilates instructor who was diagnosed with interstitial cystitis in 2005. The DVD contains short segments to allow people with pain to customize a workout according to their needs.