By Becca Ironside, PT
Your urologist has likely performed a digital exam (meaning they inserted a finger) to assess the size of your prostate. It is the test that NOBODY wants from their doctors. But the test is valuable because it can determine if your prostate is enlarged. And you are in good company, Sam, because the chances of having an enlarged prostate are as high as 50% in guys over the age of fifty. This condition is referred to as BPH, or benign prostatic hypertrophy, in the medical world. 
As a pelvic floor physical therapist, I have treated many men with enlarged prostates, or BPH. Their complaints range from difficulty peeing (hesitation, weak stream or dribbling) to the sensation of sitting on a golf ball (or a ping pong ball, if you prefer this sport over golf)! Furthermore, erectile dysfunction can also result from having an enlarged prostate.
While pelvic floor physical therapists cannot shrink enlarged prostates (we are not magicians), we can help with techniques to improve urinary flow, educate on the mechanics of urination to maximize that stream, and even teach men how to perform Kegel exercises to strengthen their pelvic floor muscles. Stronger muscles in the saddle region can lead to better erections.
In response to your question, Sam, having an enlarged prostate is not a huge cause for concern. Remind yourself that roughly half of the guys from your graduating high school class now have the same condition. And if you want to refine what your pelvic floor muscles are doing for you, pelvic floor physical therapy is a nice option to take control of your symptoms and improve the quality of your life.
Question from Lars: I had my appendix removed over 6 months ago. I have noticed that my erections are not the same since my surgery. I spoke about it with my surgeon, who prescribed Cialis. Why is this happening? Is this normal?
Answer from Becca: This is such an interesting question, Lars. Erections are obviously governed by blood flow, which is likely why your doctor prescribed the Cialis. But there is also more involved with arousal than meets the naked eye (please excuse the pun. I just get so enthused when talking about this, I cannot help myself!)
The beginnings of an erection start with blood flow that is shunted to the groin. What makes erections so complex is that once the blood gets into the penis and testicles, it needs to remain there during the arousal process. In order for the blood to remain there, the pelvic floor muscles are required to lengthen to accommodate this new influx of pressure.
If the muscles responsible for containing this blood are too tight, they won’t be able to do their job, which is to act as a water balloon that expands to take in more water. With tight pelvic floor muscles, guys are left with a water balloon with a much smaller reservoir and volume capacity.
Now, let’s add another factor into your specific situation, Lars. The muscles of the core, specifically a deep abdominal muscle known as the transversus abdominus, have a very close relationship with the pelvic floor muscles. When the pelvic floor muscles contract in ejaculation, so does the transversus abdominus; conversely, when the pelvic floor muscles lengthen to accommodate blood in the penis and testicles, the transversus abdominus follows in suit.
Given the location of your appendix and the scar tissue incurred from its removal, there may have been a disruption in the coordination of your pelvic floor and core muscles. Decreased erectile function can certainly happen if these two muscle groups are not communicating in the exquisite and refined manner which they once did.
Pelvic floor physical therapists often hear of decreased quality of sex after abdominal surgeries in their patients. It is often one of the first questions I ask people who report a change in sexual habits. Lucky for you, Lars, and so many others, is that seeing a professional to manually release the scars of your surgical incisions and learning how to breathe properly during very basic life activities can reunite these muscle groups who have parted ways.
As a review, the appendix removal might have caused the abdominal muscles to become bound down and unable to expand. As a result, the pelvic floor muscles might have shortened and less blood was then allowed into the penis and testicles for Lars. There are so many people for whom this is the case. And there is help in pelvic floor physical therapy!
Question from Dave: I have blue veins on one side of my scrotal sack. They have been there for a while. Is this normal? I don’t have any pain or anything, the veins just make my testicles look a little strange.
Answer from Becca: What you have, Dave, is called a varicocele. This is similar to having varicose veins in the legs, only it is happening in your left testicle. Varicose veins occur when the valves of veins get damaged and are not as good as circulating blood back to the rest of the body thereafter. The cause of varicose veins in any part of the body is largely unknown.
Having a varicocele, or a varicose vein in the testicles, is seen in 10-15% of men. Varicoceles usually arise in men around puberty and it is very typical that you see this only on your left testicle, Dave, as they are more prevalent on this side of the scrotum. The awesome news for you is that varicoceles rarely present with any actual symptoms that would impact your sex life or cause pain. If you do have symptoms down the road, they would most likely involve infertility or poor sperm quality. That said, the incidence of this is not common with the presence of a varicocele. And if you did want to get treatment for pain or infertility should they arise, there is surgery available.
Otherwise, my suggestion would be to acknowledge that you are in good company with other men and that your varicocele is not a sign of anything that you did or did not do. The blue veins will remain, but think of them like a cool tattoo that you didn’t have to pay for and carry on with your sex life!
Question from Alex: I am 28 years old and I live in the United States. My parents never had me circumcised, because they didn’t believe in it. Yet I always felt like there was something wrong with me when I took a shower in the locker room after football practice. Many of the women I have slept with have never seen an uncircumcised penis before. What is the point of circumcision and why am I so unusual for not having one?
Answer from Becca: Alex, this question could not be asked at a better time in history. I’ll explain why. The fact that you live in the United States and are not circumcised reveals how we perceive this medical procedure. We live in a country with some of the highest rates of circumcision in the world. Israel’s rates are higher than America’s, which makes sense because the removal of the foreskin is a religious celebration in Jewish culture shortly after the birth of a male child. Men born in Muslim countries are also commonly circumcised, though this usually happens at an older age of approximately ten years. But why are the circumcision rates so high in the United States, if we are not performing this surgery in accordance to religion?
The reason that many cultures have historically embraced circumcision is because it was perceived as keeping the penis “cleaner”. This argument it not scientifically based, because if a young boy learns how to pull back the foreskin of his penis and clean it properly, there aren’t documented increased risks of things becoming dirty or infected. Americans appear to embrace circumcision for their baby boys because of what you mentioned about your locker room experience as a teenager, Alex. Parents believe that circumcision is the social norm, that it is “the right thing to do” to avoid the shame of men later in life.
The purpose of the foreskin is to protect the head of the penis. From an anatomical standpoint, it exists for a reason. When it is surgically removed, as it is in circumcision, this actually decreases sensation to the head of the penis. Imagine a part of your body that is routinely exposed to the outside air and friction against surfaces. Like your hands. Your hands will get dry and cracked in cold weather and your sensitivity to touch will decrease on your fingertips. Wearing gloves would protect your hands and improve the nerve sensation. When the head of the penis is rubbing up against boxers all day, as it will in a circumcised guy, that skin might toughen up with that friction and sensation may decrease. In an uncircumcised man, the head of his penis is protected by the foreskin, thus potentially enhancing the sexual response.
The trend of circumcising boys in America seems to be dropping. The Center for Disease Control reported a steep decline in circumcision rates to merely 30% of male births in 2010. I hope that this trend will dispel the myth that the uncircumcised penis is somehow “unclean” or “unsanitary” and help the next generation feel more confident about being “uncut” down there.
To sum things up, I have a friend who is Hungarian named Katalina. She had her first sexual experiences in Hungary, where the circumcision rate is quite low. When she moved to the U.S. and she saw her first circumcised penis, Katalina thought, “What is this odd-looking thing? Why would anyone allow surgery to his penis? I mean, it is beyond the guy’s control if he got a circumcision as a baby, but STILL!” Hearing Katalina say this in her Hungarian accent was priceless. Let that be a message to you, Alex, and to all the other men out there! This decision was made for you. There is no right or wrong answer to the circumcision question and there is little medical evidence to support the idea that cutting off the foreskin of the male penis has much benefit. Whether you are circumcised or not, rock on with your bad selves! And if you have a baby boy one day, consider all these aspects before you make this decision for him
Question from Juan: I have spasms in my rectum. They are so uncomfortable that I can barely sit. These spasms get worse after I have a bowel movement and last for 2-3 hours. I am at the point where I am severely constipated, because I now avoid going to the bathroom. I have been to a gastroenterologist, who can find nothing wrong in testing. Is there any treatment available for this?
Answer from Becca: Juan, I feel your pain. This is a tough condition, but fortunately for you, you are alive at a time where pelvic floor physical therapy for men is becoming more widely available. The reason that you have rectal spasms is likely because the muscles of your saddle region are too tight. Just like having neck spasms and having difficulty turning your head, spasms in the pelvic floor or saddle region will make it so you cannot open up your rectum to get poop out without discomfort. It is often that simple.
The fact that you are constipated is consistent with the rectal spasms. This is because the human brain is very clever. It wants to protect the body from pain, so your intestines will hold onto that fecal matter to prevent the rectal spasms from overwhelming your nervous system. This contributes to the cycle of pain and spasm and it can become a never-ending loop of constipation.
So, what can be done? A pelvic floor physical therapist can assess your saddle muscles to see how tight they really are. Then, stretching within the rectum can be performed with a gloved finger to allow them to relax. It sounds pretty crazy, I know, but if you can get over the fact that a medical professional is in your bum, you will find that this treatment is extremely beneficial. I have treated many men like you. Once the indignity of the initial exam has been conquered, most patients report a sense of quiet in their pelvises when they are receiving the appropriate treatment. They report decreased pain in the rectum over time and have more regular bowel movements.
The action plan for you, Juan, is to find a pelvic floor physical therapist. I have a good feeling that this will allow your pelvis to return to a calm state and facilitate more consistent and pain-free bathroom relief.
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.
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.”
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.