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​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.”

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.

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. ​

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.   ​

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.

Patient: 83-year-old female

Chief Complaint: 4/10 R posterior pelvic pain and rectal pain increasing in the evening, that started after hysterectomy 6 years ago

Past Medical History: surgical revision vaginally, local estrogen; gallbladder removal, irritable bowel syndrome

Physical Therapy Treatment: abdominal bowel massage; review of proper bowel evacuation methods and stool formation; manual therapy to gluteal muscles, pelvic floor, and hip adductors; nerve gliding techniques; TENS unit training for home; HEP

Results: 0 out of 10 pelvic and rectal pain after 13 visits

Researchers studied women with the diagnosis of high  pelvic floor tone and interstitial cystitis.  
100% of them had sacroiliac dysfunction. After receiving manual physical therapy, these women 
reported 94% improvement in symptoms.

(The effect of manual physical therapy in patients diagnosed with interstitial cystitis, high tone pelvic floor dysfunction and sacroiliac dysfunction.  Urology 2001; 57(6-Supp. 1):121-122.)