I first heard of pelvic physical therapy as a urology resident. In fact, a world-renowned pelvic physical therapist worked in our urology clinic. I knew that some of our male patients with post-prostatectomy stress urinary incontinence and patients with interstitial cystitis were referred to her but am embarrassed to say I had very little idea of what she did. Had I known then what I know now I would have shadowed her in clinic, would have taken her for coffee to pick her brain (on multiple occasions) and would have referred many more patients to her for help. After 3 years of being in practice, I am proud to say I now know better and can confidently say that the pelvic physical therapists I have had the privilege of working with during this time have revolutionized the way I care for patients, and as a result, so many of my patients are no longer suffering.

When it comes to multidisciplinary algorithms, we often find a single specialty reporting on the role(s) of other specialties in the care of the mutual patient/symptom. I decided to take a different route–I asked several pelvic physical therapists to share their approach to various pelvic conditions, ultimately in hopes of answering the question, “Which of my patients/conditions can you help me with?” Here is what they said.

–Amy Pearlman

Scrotal Content Pain

Cari Everhart, Amy Little, Mary Hausler and Natalie Kruse

As pelvic physical therapists, we take a whole-person approach to scrotal content pain. After medical diagnoses have been ruled out (eg urinary tract infection, testicular torsion, testicular mass, bacterial orchitis/epididymitis/prostatitis), we focus on the musculoskeletal system as well as the complex way the brain processes pain. Although we are called “pelvic floor physical therapists” and are experts in genital pain, we are often looking for sources of scrotal content pain physically located outside of the pelvis.

Potential musculoskeletal causes of scrotal content pain may include pelvic floor muscles, abdominal muscles, hip joint, thoracolumbar junction, ilioinguinal nerve, genitofemoral nerve, pudendal nerve, and/or scar tissue or fascial restrictions along the abdomen and groin. Taut or irritable bands of muscle in the pelvic floor or abdominal muscles can refer to the testicles.^1,2 Hip joint pain due to arthritis or labral tears can refer to the groin and scrotum.³ The ilioinguinal and genitofemoral nerves exit the spine at the thoracolumbar junction and travel through potentially restricted areas of muscle, fascia and scar tissue. These are all areas that may benefit from a pelvic floor therapist skilled in manual therapy techniques involving this region, as well as home programs for tissue release, hip stretching and strengthening, nerve gliding and body mechanics training.^4,5

In the case of chronic pain (generally defined as greater than 3 months, or beyond expected tissue healing times), there is thought to be a complex interaction between the tissues, nervous system and brain. Research shows that patients who learn about how pain works, along with other therapeutic interventions, are more effective at reducing their pain.^6,7 Physical therapists have the advantage of being able to spend more time with patients and can provide guidance on how to turn the pain “alarms” down through breathing techniques, meditation and reassurance.

Premature Ejaculation (PE)

Jeremy Calame

As a pelvic physical therapist, I first seek to understand symptom onset, latency to ejaculation, symptom presence with penetrative versus nonpenetrative sexual encounters, and any prior treatments, interventions (pharmacological or nonpharmacological) or behavioral modifications.

The examination involves a thorough musculoskeletal assessment of the pelvic region, including the spine and lower extremities, to identify any deficits affecting optimal pelvic floor muscle function. Detailed postural assessment, and range of motion and flexibility testing of the spine and lower extremities are important to identify any compensatory adaptations. Pelvic floor muscle testing should target the contractile strength, tone and performance of the pelvic floor muscles. It is clinically more advantageous to perform the muscle testing through an internal (rectal) assessment to examine the different layers of the pelvic floor musculature, but it is not required if the patient is uncomfortable with this approach. Biofeedback testing can also be beneficial to help assess pelvic floor muscle function.

Research supports pelvic floor muscle rehabilitation for PE with an emphasis on utilizing pelvic floor muscle contractions to help delay the ejaculatory reflex.^8,9 Those with PE should not simply be assumed to have weak pelvic floor muscles and instructed to perform pelvic floor strengthening exercises without being thoroughly examined. For those with shortened pelvic floor muscles, stretching may be more beneficial prior to strengthening. Pelvic floor muscle exercises can be performed in many different positions and settings, and accompanied with electrical modalities. They can also be enhanced during sexual encounters to further promote delaying the ejaculatory reflex. Physical therapists emphasize that improving muscle function takes time and that compliance with exercises is critical to achieving optimal sexual performance.

Erectile Dysfunction (ED)

Beth Shelly

There are many options for the treatment of ED, ranging from pharmacological to surgical, with regenerative therapies gaining popularity. For this reason, very few men will have untreatable ED if seen by appropriate health care providers. As a pelvic physical therapist, however, I wonder if we’ve overlooked a very conservative intervention in the treatment of this condition.

To understand the role of the pelvic physical therapist in the treatment of ED, we must first understand the role of the pelvic floor in the ability to obtain and maintain erections. The ischiocavernosus muscle over the crus of the penis assists with erection by compressing venous return. The bulbospongiosus muscle over the bulb of the penis empties the bulb of the penis of semen and also assists with erection.

When it comes to pelvic floor muscle exercises for men, one must include focused contraction of the anterior pelvic floor musculature. Verbal instruction for activation of the bulbospongiosus muscle includes, “Tighten around the anus” followed by “shorten the penis.”¹⁰

Another explanation for bulbospongiosus contraction is the action of squeezing out the last drops of urine after voiding. It is important to describe the contraction in several different ways and to test the patient’s ability to perform the correct anterior contraction. Imaging ultrasound is the best modality to test the contraction of the anterior pelvic floor muscles in the male. This modality allows the therapist and patient to see elevation of the bulbospongiosus muscle as it compresses the base of the penis.

Though no optimal training protocol has been identified for ED after prostatectomy, studies do show that pelvic floor muscle training is better than nothing.^8,11,12 Pelvic floor muscle training increases ability to maintain an erection, and biofeedback with imaging ultrasound or electromyography (with or without electrical stimulation) may produce the best outcomes in those with venous leakage.¹¹ A recent systematic review also provides evidence that increasing physical activity decreases ED, with recommendations for 40 minutes of moderate to vigorous exercise 4 times per week.¹³ Physical therapists emphasize the importance of overall healthy behaviors, including systematic exercise.

Pelvic physical therapists perform thorough physical examinations, provide critical education and reinforce practical ways of modifying behavior to improve scrotal content pain, PE and ED, among many other conditions.

The most incredible part about this whole topic is that many pelvic physical therapists actually want to treat these conditions–we don’t have to feel bad about making these referrals!

As a result, the more relevant question becomes, “Are there any patients with benign genitourinary conditions/symptoms who should NOT see a pelvic physical therapist, at least as part of a comprehensive treatment approach?” I cannot think of a single one.

–Amy Pearlman