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.
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.
Question from Steve: I suffer from chronic constipation. While that is terrible by itself, I also find that I cannot get fully hard during sex when I am constipated. Am I imagining this, or is there a correlation between constipation and erectile dysfunction?
Answer from Becca: Steve, I wish that more of our patients made this connection between the bowel and sexual function. The organs that sit within the relatively small cavern of the bony pelvis in men are the bladder, prostate, and the end of the colon (rectum). These organs are crammed into a very tight space. Which means that when one of these organ systems is a little bit off, the other systems invariably feel askew as well!
When the bowel is impacted with stool, as it is with constipation, this organ presses on the prostate and then the bladder. Also, the pressure on the perineum (the saddle region we discussed in Marc’s case), is created by too much fecal matter accumulating in the bowel. This excess pressure inhibits a full sexual response and limits full erections in men. The long-term discomfort associated in prolonged constipation can also distance a man from wanting to engage in sex.
The solution: pelvic floor physical therapists treat bowel dysfunction. We educate our patients in how to improve bowel regularity with stretches, exercise and lengthening of the pelvic floor muscles. What we find in treating patients like Steve is that when regular bowel movements are achieved, more satisfactory sex follows!
Question from Chen: I have trouble urinating from time to time. Sometimes, I think I am done peeing, I pull up my pants, and then I dribble urine. I am only 25 years old. Why is this happening and what can help?
Answer from Becca: Chen, I wish that you would start an online social media feed about your problem! Because it is so common and so very easily addressed. Many men come to pelvic floor physical therapy with complaints of leaking after peeing, or what we refer to in our line of work as “the post-void dribble.” Guys think there is something terribly wrong when this occurs, and because they won’t talk about it, they don’t know that many other guys have exactly the same problem!
Many men stand up to pee in urinals. This is the cultural norm in our society. But for men with tight pelvic floor muscles, or even men with moderate anxiety in a public restroom, the bladder cannot completely empty when a guy is in a standing position or when there are other men around him. What happens in this case is that the bladder cannot fully relax and the urine within it will not completely drain from the pelvis. Many guys shake their penises to try to get excess pee out of it. But this technique doesn’t always work to sufficiently drain the bladder. Hence, the dribble occurs after you think you are done peeing, Chen, and so many other men like you leave the bathroom to return to the tavern or sports arena, because they never allowed their bladders to fully empty.
Here is what a pelvic floor physical therapist may tell you, Chen.
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.
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.”