Pelvic Floor Physical Therapy For Men

Pelvic Floor

“I thought only women needed Physical Therapy for the pelvic floor.”

This is a question/declaration I hear almost once a week as a pelvic floor physical therapist. Sometimes it’s from men, sometimes it’s from women, and occasionally it’s from other health care providers.

Men have pelvic floor muscles too. This means that they can suffer from many of the same problems that women experience. Men have incontinence, rectal pain, constipation, ejaculation problems, urinary urgency and frequency issues, and painful intercourse. Many men present with incontinence issues after surgery for prostate removal or treatment for an enlarged prostate.

In fact, pelvic floor dysfunction in males is much more common than once believed. Studies show that 95% of cases of chronic prostatitis in men is nonbacterial, and could indeed have a musculoskeletal origin. Pelvic floor dysfunction and spasm can create symptoms that mimic prostatitis by causing pain and urinary symptoms. Often symptoms are described as pain that is sharp, shooting, stabbing, burning, dull, and/or achy in the area of the genitals, abdomen, back and/or hip region. These symptoms, which are similar to what men describe with type III B prostatitis or non-bacterial prostatitis, are commonly the result of a musculoskeletal disorder.  One reference states “a number of patients who were diagnosed with prostatitis were prescribed antibiotics. After months of this pharmaceutical regimen-and no relief-they were referred for physical therapy and found both an end to their pain and a cure.”

One of the most common reasons men see a pelvic physical therapist is for incontinence and/or pain issues after undergoing a prostatectomy. Studies have shown that one year after surgery, 89-100% of men who had robot assisted laparoscopic prostatectomy are using 0-1 pads for incontinence. Of men who had open radical retropubic prostatectomy, 80-97% are using 0-1 pads for incontinence. Risk for incontinence increases when the man is over 70 years old or has detrusor overactivity (overactive bladder) before surgery. This occurs because the prostate surrounds the urethra and supports it to help control urination. After prostate removal surgery, the pelvic floor muscles have to work harder to make up for the loss of support. If they are not able to do so men can experience incontinence episodes. Coughing, laughing, sneezing, jumping, or getting up from a chair can be especially challenging for the muscles to control. Studies show that pelvic physical therapy before and after surgery can help train the pelvic floor muscles to reduce incontinence. The body is asking the muscles to do something they have never had to do before, so average muscles need conditioning to bulk them up and support the urethra. Strength, endurance, and coordination training for the pelvic floor help prevent leaks. MRI images comparing pelvic muscles before and after recovering from incontinence showed that pelvic muscles were thicker, and the bladder neck was moved higher and forward after they regained continence.

As specialists in the musculoskeletal system, physical therapists treat pelvic floor weakness through strengthening and biofeedback. We also treat hypertonic (increased tone) pelvic floor problems. The increased tone or spasm may result in a reduced range of motion and/or pain in the pelvic region. Because these muscles surround the urethra, anorectal area, and prostate, a dysfunction in these muscles can disrupt normal urinary, bowel, and sexual function.

Physical therapy treatment commonly includes manual therapy, nerve glides, skeletal (structural) alignment, postural re-education, ultrasound, electrical stimulation, biofeedback, behavioral training, and therapeutic exercise.

There are many published cases of success for the male population who sought out the care of a physical therapy for a pelvic issue. A recent case report in the Journal of Women’s Health Physical Therapy outlines management of a 76-year-old male patient with mixed urinary incontinence post prostatectomy 10 years. This case report describes the multifaceted management of a typical patient post radical prostatectomy, which included physical therapy. He reported mixed urinary incontinence symptoms. He used 3-4 adult incontinence pads per day and 1 pad at night. He reported nocturia 3-4 times per night. 2-3 times per week he had large urinary incontinence episodes that soaked through his clothing. He also complained of the inability to delay voiding and having urinary accidents with walking to the bathroom, sit to stand, lifting, coughing, and sneezing.

To address his urge, incontinence symptoms behavioral interventions were utilized. The patient was instructed in and completed pelvic floor muscle contractions to inhibit detrusor contractions and suppress urgency. Educating the patient on correct pelvic floor muscle isolation was a vital component of his treatment. Verbal, digital, and surface electromyography (sEMG) techniques were used to ensure correct PFM contraction and to reduce Valsalva. Clinical decision making for home exercise program utilized dominant PFM fiber types and the patients’ performance on the PERFECT PFM strength testing system described by Laycock. For the home program, the patient completed progressive reps and sets of 10” (targets slow twitch) and 2” (targets fast twitch) PFM isometrics in supine progressing to standing. He was instructed in the use of “the knack” (volitional pelvic floor muscle contraction before and during cough or other physical exertions to prevent accidents. Bladder retraining and lifestyle recommendation were implemented to address those behaviors that were likely contributing to urgency and urge symptoms. Abdominal exercises targeting Transversus Abdominus were also prescribed for their role in core support with pelvic floor muscle contractions. 

The outcome for this patient was extremely positive. In a short period of time (5 visits) he had reduced urinary leakage indicated by reduced undergarment changes and reduced pad usage per day. His pads were less saturated, and he no longer had leakage that spread to his clothing. He had a 50% reduction in UI episodes reported on his bladder diary and a 50% reduction in nocturia from 4 times to 2 times per night. He reported reduced daily urinary frequency from 7 to 5 times per day with no instances of severe urgency. He demonstrated improved PERFECT score of 4, 10, 8, 10 (initially his score was 2, 5, 3, 5) indicating improved PFM strength and endurance. He had improved pelvic muscle coordination and could isolate his contractions without Valsalva or accessory muscle activation. He had one strength grade improvement with abdominal strength. Finally, this patient had improved rating on the outcome questionnaire (International Continence Society Male Short Form (ICSmaleSF)) at discharge indicating improved quality of life. At initial evaluation, this patient rated “a lot” (3 on ICSmaleSF) when asked how much the urinary symptoms interfered with his life, at discharge he reported “not at all” (0 on ICSmaleSF).

One of the most notable aspects of this case is that the patient had surgery 10 years prior but did not participate in physical therapy at that time. While physical therapy is highly recommended as soon as possible after this procedure (and often prior to it), many gains are made even a decade after surgery. 

My average treatment caseload is a 50/50 split between women and men. Often, I find that men needlessly suffer for long periods of time before being seen in Physical Therapy. Most, if not all, report that they wish they had come for treatment sooner.

References

Nickel, J.C. et al. Prevalence of prostatitis-like symptoms in a population based study using the national Institutes of Health chronic prostatitis symptom index.  J Urol, (2001)165: 842.2.

Stein, A.  Heal Pelvic Pain. McGraw-Hill, (2008).  p. 154.

Pacik D and Fedorko M. Literature review of factors affecting continence after radical prostatectomy. Saudi Med J 2-17;38(1):9-17. Doi: 10.15537/smj.2017.1.15293.

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