Treating Male Pelvic Floor Dysfunction: The What, How, and Why

Feb 8

Pelvic health physical therapy is fire. (for those not in Gen Z, that means pelvic health physical therapy is “The new hotness; something remarkable, interesting, fun or amusing”. You’d have to be under a rock over the past 5 years not to notice the raging popularity the pelvic floor has become over all forms of social media, mom groups, fitness trainers, etc.

While this is fantastic and, even better, more and more PTs are seeking education and training in this ever-exciting specialty, the focus tends to be on women’s (people with a vulva) pelvic health. There are now more PTs being trained to treat pelvic conditions for all genders, however, the number of providers, and therefore access to care, continues to be significantly limited for male (people with a penis) pelvic health conditions.

male-pelvic-floor-pain-tailbone-coccydynia-physical-therapy

doctor-of-physical-therapy-bethany-hansen-pelvic-floor — Graduation from Northwestern University - Doctor of Physical Therapy!!

I do treat every gender for pelvic health conditions, but that wasn’t always the case. Let’s back this story up. Many years ago, when I was a “baby PT” and first introduced to pelvic health, it was called “Women’s Health” and I had no idea what the pelvic floor was. I quickly found out and felt very passionate about learning as much as I could to best serve this patient population. The pelvic PTs at the outpatient hospital-based rehab clinic where I worked received referrals from Urogyne and OBGYN, so everyone who came to see us had a vulva. It was an excellent experience with very knowledgeable mentors - and I learned a lot!

Fast forward 2 jobs later when I interviewed with a private practice owner who owned a pelvic health specialty clinic. When considered hiring me, she said, “You know, 40% of our patients are men, so if you want to work here, I’m going to need you to be on board with seeing any type of patient seeking care here”. I must have looked surprised because the thought of treating people with a penis hadn’t even crossed my mind.

Looking back, I know I felt awkward about the idea because I was just starting to feel confident treating women’s (people with a vulva) pelvic problems and didn’t want to look like an idiot. So, I went to my first male pelvic health course, came back, and treated my very first patient with a penis. I was very nervous but he was so kind and desperate for any help I could give him, that I felt at ease very quickly and had a great experience working with him. Since then I have taken other “male-centric” courses, webinars, lectures, etc. and just like any area in pelvic health, I’m never “done” learning (that also means it never gets boring)!

So let’s get into the “what” - what diagnoses do people with a penis get that leads them to seek out the help of a pelvic health PT?

Bladder issues: incontinence, urinary urgency, frequency, hesitancy, slow flow, incomplete emptying, post-void dribble, benign prostatic hyperplasia
Bowel issues: constipation, hemorrhoids, anal fissure, fecal incontinence, dyssynergia, non-relaxing pelvic floor muscles
Pain: pudendal neuralgia, painful bladder or urethral syndrome, post-hernia repair pain, penile, scrotal, or testicular pain, anorectal pain, perineal pain
Orthopedic pain: low back, hip, groin, SIJ, coccyx, sciatica
Sexual Health Issues: erectile dysfunction, premature ejaculation, painful ejaculation, hard-flaccid syndrome, Peyronie’s Disease

Intake forms, questionnaires, good subjective
External exam: spine, pelvis, ROM, flexibility, strength, muscle recruitment, joint mobility, palpation of back, hips, glutes, legs, perineum, external genitalia
Internal exam: pelvic floor muscle assessment transrectally - palpation, strength, relaxation, coordination, etc.
Manual therapy: deep tissue or joint mobilization, trigger point release, myofascial release, dry needling, scar massage
Education: bladder and bowel re-training, breathing re-training, muscle re-education, pain neuroscience education, body mechanics, posture, exercise, stretching, home exercise program, activity progression, lifestyle changes, pain management, sexual health education
Modality Considerations: biofeedback, e-stim, pulse wave therapy, rectal balloon training

Now for the “how” - how do pelvic health PTs evaluate and treat these dysfunctions?

Etc. (I’m probably forgetting things, so think of this as a general list)

Now for the “why”. Why is talking about male - specific pelvic health important?

Aren’t women (people with a vulva) the ones who have been under-researched, under-treated, dismissed, not believed, gaslit, and medically harmed over centuries? This is true, but also…

According to the National Library of Medicine (from 2022), there are 12,443 articles for women’s pelvic health and 2,974 articles for women’s pelvic physical therapy, compared to 80 articles for men’s pelvic health and only 22 articles for men’s pelvic physical therapy. There is even fewer research data for the transgender community, bringing in only 55 research articles for transgender pelvic health and only six articles for transgender pelvic physical therapy. Following this trend, there is also a shortage of pelvic health PTs who are comfortable, willing, and available to treat people of all genders, which leaves this group lacking when it comes to access to care.

It has been remarkable - thanks to social media, pelvic health awareness has exploded across the general public. Patients are seeking out pelvic health specialists on their own accord, rather than waiting for their doctors to wise up and refer them. But it doesn’t do a guy much good when he learns on his Reddit threads that pelvic floor PT can help him with his pelvic pain, and when he calls clinics, they only have PTs who treat “women’s pelvic health”.

For the most part, introductory pelvic health PT training has had women’s (people with a vulva) pelvic floor as the default, or, the “norm”. This may be changing, but historically it would require taking additional “male-centric” pelvic courses (more $$$, time) to be proficient.

Some explanations for limited interest in the penis population that have been given to me by other PTs have sounded like this:

male-pelvic-floor-physical-therapy-erectile-dysfunction

They don’t want to discuss sexual function with someone of the opposite sex
Feeling intimidated or insecure about what they have learned in women’s pelvic health - adding in men would be even more overwhelming
Concerns about inappropriate behavior - physical or verbal
Having a history of trauma or physical, verbal, or sexual assault from someone with a penis

Yes, it is awkward to talk about sexual function when you’re not used to it. If you’ve been treating people with a vulva, think about how you felt the first time you asked questions about your patient’s sexual health. I bumbled through terribly, but over time, it became smoother and easier. It was the same when I started treating people with a penis.

Afraid of not “knowing everything” or being able to answer all of their questions, especially if you own different anatomy? Fear not! In the beginning (and it still happens quite frequently) I got questions from patients that I just didn’t know the answer to. I would give my opinion but tell them I want to be 100% confident in my answer and I would get back to them after consulting with colleagues and doing research. I would do the research/inquiry and at their next visit, discuss what I found. People love this! They hate to be told something only to find out it was BS and they feel so heard and validated when you take the time to investigate something and then get back to them with the answer. You will gain so much respect from your patients when you do this!

Other concerns: When working with patients in pelvic health, inappropriate behavior and/or potential trauma is a risk. I’ve been lucky to only have experienced very mild incidents that were quickly resolved, but I have heard stories from other providers, and these occur with patients of all genders, not just the penis population. As pelvic PTs we are solo, one-on-one, in an isolated treatment room, working in a vulnerable and sensitive area (pelvis, genitals). While I don’t believe that working in the pelvic health specialty is right for every PT, to me, the reward of helping the majority of these patients get back to doing the things they love significantly outweighs the very rare negative experiences.

Here are some things I have picked up that may be helpful:

Pre-plan - create boundary rules, your language for explaining it, and what happens if it’s not respected. Do this in advance and keep it handy. This idea came from Sarah Prestergard, DPT, @pelvismatters, a fantastic pelvic PT friend of mine.
Create a personalized definition of the professional provider/patient therapeutic relationship and have your patients read and sign it before their first visit.
At the beginning of their first visit, describe in detail how the session will go with clear boundaries. For example, verbalize how you would like them to be dressed/undressed and covered before leaving the treatment room for them to change.

These are just a few - there are many more things people can do to set clear boundaries and have a plan. The overwhelming majority of people coming in for pelvic floor problems are desperate to get help and grateful for the care we can provide. This work can be so rewarding, so please don’t let these concerns hold you back!

If you’re interested in learning more about pelvic health for people with a penis, here are some resources to look into:

Courses/Webinars/Mentoring:

Integrated Pelvic Care

Mentorship for Professionals with Dr. Susie Gronski, PT, DPT

Jo Milios, PhD, BSc, YA: Men’s Health in Prostate Cancer: A Clinical and Research Perspective (Recorded Webinar)

Male Pelvic Health Courses through myPFM Academy

Prostatitis and Pelvic Pain: Evaluation and Treatment Techniques with Jake Bartholomy through Pelvic Floor University

1:1 Mentoring with Dr. Sarah Prestergard, PT, DTP

Books:

Pelvic Pain: The Ultimate Cock Block, by Susie Gronski, PT, DPT

Prostate Recovery Map: Men’s Action Plan by Craig Allingham

Keep it Healthy: The Prostate Playbook by Craig Allingham