Erectile dysfunction (ED) affects an estimated 30 million men in the United States and becomes increasingly prevalent with age. Yet despite its frequency, treatment conversations often begin, and end, with a prescription.

While phosphodiesterase-5 (PDE5) inhibitors have transformed the management of erectile dysfunction, medication is only one piece of a much larger clinical puzzle. Successful treatment requires understanding the complex interaction between the vascular, neurologic, hormonal, musculoskeletal, and psychosocial systems that make healthy sexual function possible.

Commonly prescribed PDE5 inhibitors include sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®/Staxyn®), and avanafil (Stendra®). Importantly, these medications do not directly cause an erection. Instead, they enhance the nitric oxide (NO)-cyclic guanosine monophosphate (cGMP) pathway, improving blood flow to the penis in response to sexual stimulation. Sexual arousal is still required for these medications to be effective.

For rehabilitation professionals, understanding the neurovascular, musculoskeletal, hormonal, and psychosocial contributors to erectile dysfunction creates opportunities to improve outcomes beyond symptom management. Pelvic health physical therapists are uniquely positioned to contribute to the conservative management of erectile dysfunction through comprehensive evaluation, patient education, movement-based rehabilitation, and interdisciplinary collaboration.

The goal isn't simply to restore erections. It's to restore healthy sexual function by optimizing the systems that make erections possible.

Erections Are a Systems Problem

An erection requires coordinated function across multiple body systems. Successful erectile function depends on the coordinated interaction of multiple physiologic systems, including:

• Healthy arterial inflow
• Efficient venous occlusion
• Intact autonomic and somatic neural pathways
• Responsive pelvic floor musculature
• Hormonal balance
• Psychological safety
• Cardiovascular health

When one, or several, of these systems becomes impaired, erectile dysfunction can develop. This is why ED should rarely be viewed as an isolated diagnosis. Instead, it should prompt clinicians to ask: What system isn't functioning optimally?

Your ED Toolbox

1. Patient Education

Education remains one of the most underutilized interventions. Helping patients understand normal erectile physiology, age-related hormonal changes, cardiovascular influences, medication effects, and nervous system regulation are key components for clinical education.

Knowledge reduces threat, and reducing threat improves nervous system performance. Helping patients understand the "why" behind their symptoms often reduces fear, improves treatment adherence, and empowers them to actively participate in their rehabilitation.

2. Pelvic Floor Rehabilitation

The pelvic floor contributes directly to erectile rigidity, orgasm, and ejaculation. Muscles including the bulbospongiosus, ischiocavernosus, and superficial transverse perineal muscles help compress venous outflow and improve rigidity. Appropriately prescribed pelvic floor muscle coordination should be considered a first-line conservative intervention for many patients.

Beyond the pelvic floor muscles themselves, pelvic health clinicians should evaluate breathing mechanics, pressure management, scar mobility, hip mobility, lumbar spine function, abdominal wall coordination, bowel and bladder health, and movement patterns that influence pelvic floor performance. Successful rehabilitation often requires addressing the entire lumbopelvic system rather than focusing solely on isolated muscle activation or inhibition. Assessment should always guide intervention, recognizing that pelvic floor dysfunction may be a primary contributor in some patients and a secondary adaptation in others.

3. Nervous System Regulation

An erection is ultimately a parasympathetic event. Patients frequently associate erectile dysfunction with performance anxiety, but nervous system dysregulation extends far beyond psychological stress. Persistent pain, chronic inflammation, sleep deprivation, metabolic disease, and ongoing sympathetic activation can all influence erectile physiology.

Additionally, a person's experiences, beliefs, and learned messages about sexuality can shape their ability to experience arousal and intimacy. Individuals who were raised in sex-negative households, taught that sexuality was shameful, or influenced by cultural or religious beliefs that discouraged open conversations about sex may carry those messages into adulthood.

Relationship challenges, performance anxiety, previous sexual experiences, trauma, or fear of disappointing a partner can further contribute to a heightened threat response that interferes with normal sexual function. These factors do not suggest that erectile dysfunction is "all in someone's head." Rather, they highlight the powerful interaction between the brain, nervous system, emotions, and physiology.

Recognizing these influences allows clinicians to approach erectile dysfunction with greater empathy, curiosity, and clinical reasoning, ultimately leading to more individualized and effective care.

Helping patients regulate the autonomic nervous system through breathing strategies, exercise, pain management, stress reduction, improved sleep, and, when appropriate, referral to a mental health or sex therapy professional may improve erectile function while supporting overall health and well-being.

4. Dry Needling & Neuromodulation

Dry needling should never be viewed as a protocol. Rather, it is a neuromodulatory tool that may influence pelvic floor muscle tone, pudendal nerve sensitivity, lumbosacral neuromotor control, pain processing, and autonomic regulation.

Clinical decision-making should guide the selection of tissues to treat. A thorough subjective examination, comprehensive movement assessment, and skilled palpation are essential to identifying the structures contributing to a patient's symptoms. Rather than asking, "What muscles should I needle for erectile dysfunction?" clinicians should ask, "What impairments are contributing to this patient's presentation?"

Depending on the individual, dry needling may be directed toward the pelvic floor, abdominal wall, hip musculature, lumbopelvic stabilizers, or other tissues that influence movement, load transfer, and neuromuscular function. The goal is not simply to reduce tissue sensitivity or muscle tension, but to create an opportunity for improved movement quality, motor control, pain modulation, and functional performance.

Dry needling should also be viewed as a window of opportunity rather than a stand-alone intervention. Changes in tissue sensitivity or neuromuscular performance should be reinforced through movement, progressive loading, breathing strategies, and patient-specific exercise to promote lasting adaptation.

Like every intervention, dry needling works best when integrated into a comprehensive rehabilitation plan that includes patient education, exercise, behavioral strategies, and interdisciplinary collaboration when appropriate.

5. Medical Optimization

Successful management of erectile dysfunction often extends beyond the pelvic floor. Because erectile function relies on healthy vascular, neurologic, endocrine, and metabolic systems, optimizing overall health is an essential component of treatment. In many cases, erectile dysfunction may serve as an early clinical indicator of broader cardiometabolic or endocrine dysfunction, making timely referral and medical evaluation essential.

Clinicians should consider factors such as:

• testosterone deficiency and other hormonal disorders
• thyroid dysfunction
• hypertension
• diabetes and insulin resistance
• obesity
• smoking
• sedentary lifestyle
• poor sleep quality

Exercise remains one of the most effective interventions clinicians can recommend. Strength training, aerobic conditioning, nutrition, weight management, and sleep optimization all support endothelial function, nitric oxide production, cardiovascular health, and sexual function.

When indicated, medical management also plays an important role. Common treatment options include phosphodiesterase-5 (PDE5) inhibitors such as sildenafil, tadalafil, vardenafil, and avanafil, as well as vacuum erection devices, intracavernosal injections, penile prostheses, and hormone replacement therapy for appropriately selected patients.

Rehabilitation does not replace medical management. It complements it.

6. Interdisciplinary Collaboration

Erectile dysfunction is rarely the result of dysfunction within a single body system, and its management rarely falls within the expertise of a single healthcare provider. Optimal patient outcomes often require collaboration among:

• Primary care physicians
• Urologists
• Pelvic health physical therapists
• Endocrinologists
• Cardiologists
• Mental health professionals
• Sex therapists

Successful treatment is rooted in coordinated, patient-centered care rather than isolated interventions. No single provider has every tool, but together, the healthcare team can help patients achieve better outcomes.

The Best Toolbox Is Individualized

No two patients present with erectile dysfunction for the same reason. Clinical reasoning, not protocols, determines which tools belong in each patient's plan of care.

Beyond Erectile Dysfunction

Erectile dysfunction should never be dismissed as "just" a sexual health issue. It is often an early indicator of broader dysfunction involving vascular health, nervous system regulation, hormonal balance, movement quality, and psychosocial wellbeing. As rehabilitation professionals, we have an opportunity to contribute meaningful, evidence-informed care that extends well beyond symptom management.

The question isn't simply: 'How do we improve erections?' The better question is: 'How do we optimize the systems that make healthy sexual function possible?' Because when we optimize the systems that support sexual health, we often improve overall health in the process.

Continue Expanding Your Clinical Toolbox

Pelvic health professionals play an important role in the conservative management of erectile dysfunction, but successful care requires more than mastering individual techniques. It requires understanding the interaction between the nervous system, pelvic floor, hormones, vascular health, movement, and patient education.

At Professional Pelvic Health Consultants, we believe the most effective clinicians aren't defined by the number of techniques they know. They're defined by their clinical reasoning.

Our goal is to bridge current evidence with practical application, helping clinicians understand not only what interventions to use, but when, why, and for whom they are most appropriate.

Because the best toolbox isn't the one with the most tools. It's the one guided by thoughtful clinical decision-making. And that is exactly what transforms good clinicians into exceptional ones.

What Is Dry Needling in Pelvic Health?

Dry needling in pelvic health is the use of thin filiform needles by licensed rehabilitation clinicians to treat the pelvic floor musculature and its associated neuroanatomical structures, including the lumbosacral spine, abdomen, pelvis, and hip joint complex. Pelvic health specialists use dry needling to address lumbopelvic pain, urinary incontinence, voiding dysfunction, and sexual pain or dysfunction, reaching tissue at depths and with a specificity that manual techniques cannot always achieve.

Why Does Dry Needling Belong in Pelvic Practice?

Dry needling belongs in pelvic practice because pelvic floor dysfunction rarely lives in the pelvic floor alone. The lumbosacral spine, abdomen, hips, and trunk all participate in the patterns that produce pelvic pain, urgency, leakage, and pain with intimacy, and dry needling allows the skilled clinician to treat both the pelvic floor musculature itself and the surrounding structures that keep dysfunction in place.

For clinicians already practicing orthopedic dry needling, the pelvic application is a natural and career-differentiating extension. For pelvic specialists who have not yet added needling to their practice, the Herman & Wallace series provides the anatomy review, safety framework, and supervised lab time to build genuine competence rather than familiarity.

What Does Each Course in the Series Cover?

Dry Needling and Pelvic Health: Foundational Concepts and Techniques is the entry point to the series. This lab intensive course teaches the application of dry needling to the female pelvic floor musculature and the associated structures of the lumbosacral spine, abdomen, pelvis, and hip joint complex, framed around the presentations pelvic providers see daily: lumbopelvic pain, incontinence, voiding dysfunction, and sexual pain or dysfunction.

Dry Needling and Pelvic Health Level 2: Advanced Concepts and Neuromodulation builds on that foundation for clinicians with prior dry needling experience. Participants advance to needling male and female pelvic floor musculature and structures across the thoracolumbar spine, trunk, abdomen, pelvis, and hip, and integrate neuromodulation concepts and techniques into clinical reasoning. The course combines pre-recorded lecture with two days of live labs, with a strong emphasis on safety, precautions, and clinical integration.

Dry Needling and Pelvic Health: Pregnancy and Postpartum Considerations addresses the perinatal population specifically. The course covers the physiologic changes of pregnancy and the neuromusculoskeletal conditions common to the pregnancy and postpartum periods, giving providers who treat perinatal patients a safe, evidence-informed framework for needling in this population.

Upcoming Dry Needling Courses in 2026

Dry Needling and Pelvic Health Level 2 - Houston, Texas - August 29-30, 2026
Dry Needling and Pelvic Health - Lubbock, Texas - September 26-27, 2026
Dry Needling and Pelvic Health: Pregnancy - Omaha, Nebraska - October 17-18, 2026
Dry Needling and Pelvic Health - Washington, DC - December 5-6, 2026
Dry Needling and Pelvic Health Level 2 - Seattle, Washington - December 11-13, 2026

About the Instructors

Tina Anderson, MS, PT is a physical therapist and educator practicing in Aspen, Colorado. She received her Master of Science in Physical Therapy from Grand Valley State University and owns and operates a private physical therapy practice.

Kelly Sammis, PT, OCS, CLT, AFDN-S is a physical therapist, board certified in orthopedics, with additional certifications in lymphedema, Pilates, pregnancy and postpartum corrective exercise, and advanced dry needling. She practices in Parker, Colorado and serves as lead faculty developing and teaching dry needling and pelvic health courses nationwide. Together, Tina and Kelly co-instruct the Herman & Wallace Pelvic Rehabilitation Institute dry needling series.

As pelvic rehabilitation continues to evolve, so does our understanding of how to access and modulate the intricate neuromuscular systems that govern pelvic floor function.

Dry needling — long employed in orthopedic and sports medicine settings — is now emerging as a potent tool in the pelvic health therapist’s repertoire. Its precise application can yield neurophysiologic effects far beyond simple trigger point release, particularly when integrated with a broader neuromodulation framework.

The Rationale for Dry Needling in Pelvic Health
Dry needling involves the insertion of a monofilament needle into myofascial, peri-neural, or connective tissues to elicit a therapeutic response. In the pelvic region — where layered dysfunction may involve somatic, autonomic, and visceral pathways — dry needling offers:

• Direct modulation of overactive or inhibited pelvic floor muscles
• Reduction of peripheral nociceptive input from sensitized tissues
• Central downregulation of pain pathways through segmental and supraspinal mechanisms
• Neurovascular and neuroimmune effects that influence tissue health and pelvic organ function

Beyond Trigger Points: Neuromodulatory Targets
While trigger point deactivation is often cited as the primary mechanism, advanced practitioners now utilize dry needling to target peripheral nerves, spinal segmental reflex arcs, and viscerosomatic convergence zones relevant to pelvic dysfunction.

Key neuromodulatory targets include

• Obturator internus and levator ani — often hypertonic in cases of dyspareunia, pudendal neuralgia, or levator ani syndrome. Precise needling can reduce motor overactivity and pain referral.
• Sacral multifidi and paraspinals (S2–S4) — modulate pelvic floor reflex activity and impact bladder and bowel control.
• Gluteus maximus and piriformis — indirectly influence pudendal nerve path and pelvic floor muscle tone.
• Tibial nerve (posterior medial leg) — part of the sacral micturition reflex; targeted in dry needling or electroacupuncture for urge incontinence or bladder pain syndrome.
• Adductor group and iliopsoas — affect pelvic floor positioning and contribute to postural-driven pelvic dysfunction.

Additionally, cutaneous neurogenic zones, such as the sacral dermatomes and perineal region, may respond to superficial needling for neurosensory desensitization.

Application to Common Conditions
Pelvic Pain
Chronic pelvic pain involves peripheral tissue dysfunction, central sensitization, and autonomic dysregulation. Dry needling can:

• Interrupt pain-spasm-pain cycles
• Reduce afferent signaling from hyperactive pelvic muscles
• Decrease neuroinflammation via neuromodulation of spinal circuits
• Be combined with breathing techniques or down-training for improved autonomic regulation

Incontinence and Voiding Dysfunction
In urge incontinence, overactive detrusor activity may be linked to sacral reflex hyperexcitability. Dry needling — particularly of the posterior tibial nerve or S2–S4 paraspinals — may:

• Normalize afferent signaling to the pontine micturition center
• Restore motor balance between detrusor and external sphincter
• Improve pelvic floor muscle recruitment patterns when combined with EMG biofeedback

Sexual Pain or Dysfunction
In cases of vaginismus, vestibulodynia, or erectile dysfunction with pelvic myalgia, dry needling can:

• Reduce hypertonicity in the deep pelvic bowl (e.g., obturator internus, pubococcygeus)
• Increase local blood flow and nitric oxide release
• Support somatosensory reintegration, especially when layered with trauma-informed approaches

Integrating Dry Needling with Broader Neuromodulation Techniques
To fully leverage dry needling’s neuromodulatory capacity, it should be part of a multimodal care plan that may include:

• Electrical stimulation (e.g., intramuscular or percutaneous tibial nerve stimulation)
• Neurodynamic mobilization (e.g., pudendal nerve glide protocols)
• Manual therapy for visceral and connective tissue tension
• Somatic-based interventions for nervous system regulation and interoceptive awareness
• Behavioral strategies such as urge suppression techniques, pacing, and pelvic mapping

Safety and Clinical Reasoning

When applied near sensitive neurovascular and visceral structures, dry needling requires precise anatomical knowledge, informed consent, and advanced training. Ethical practice includes:

• Always using non-threatening, anatomically accurate language
• Avoiding direct needling of internal pelvic structures unless well-trained and permitted by state practice acts
• Employing real-time patient feedback and graded exposure techniques to minimize reactivity and optimize nervous system response

Clinical Pearls

• Always assess for central sensitization — if present, reduce peripheral input gradually and combine with education and graded sensory integration.
• Use ultrasound guidance or EMG if available for difficult-to-access muscles or when precision is paramount.
• Needle outside the pelvic floor (glutes, paraspinals, tibial nerve) when internal work is contraindicated, poorly tolerated, or not functionally required.
• Watch for signs of autonomic shift during or after treatment — sweating, dizziness, nausea — and manage with pacing and grounding techniques.

Dry needling is more than a mechanical intervention — it is a powerful interface with the nervous system. When skillfully applied, it opens new doors in the treatment of complex pelvic floor dysfunctions, especially those involving pain, inhibition, and neuromotor disruption. For advanced pelvic rehabilitation therapists, dry needling represents an opportunity not just to treat, but to modulate — to recalibrate the body’s own self-regulating systems toward a state of ease, control, and embodied safety.

Recommended Continuing Education:
Dry Needling and Pelvic Health: Foundational Concepts and Techniques — SOLD OUT
This course is the first in our pelvic health dry needling series. Designed for pelvic health practitioners, it teaches foundational dry needling techniques for treating pelvic floor and neuromusculoskeletal conditions such as lumbopelvic pain, incontinence, voiding issues, and sexual dysfunction. Participants will learn safe and effective needling for the female pelvic floor, as well as related areas including the spine, abdomen, pelvis, and hips. The course includes anatomy review, safety guidelines, plenty of lab practice, and clinical integration strategies.

Dry Needling and Pelvic Health Level 2: Advanced Concepts and Neuromodulation – August 2-3 in Duluth, MN
This advanced dry needling course offers a specialized approach to treating pelvic floor dysfunction related to pelvic pain, incontinence, voiding issues, and sexual pain. Participants will learn to apply dry needling techniques to both male and female pelvic floor muscles, as well as related areas like the spine, abdomen, pelvis, and hips. The course also covers neuromodulation concepts and techniques. Emphasis will be placed on anatomy review, safety, clinical reasoning, and hands-on lab practice to ensure confident and effective application in clinical settings.

Dry Needling and Pelvic Health: Pregnancy and Postpartum Considerations – August 23-24 in Lemont, IL
This course offers a specialized dry needling approach for treating neuromusculoskeletal conditions during pregnancy and postpartum. Topics include pelvic pain, carpal tunnel, plantar fasciitis, peripheral neuropathy, postural changes, and headaches. Participants will learn safe and effective needling techniques for the extremities, spine, and pelvic floor, with a focus on anatomy, safety, clinical application, and hands-on lab practice.

Resources:

• Dommerholt J, Fernández-de-las-Peñas C. Trigger Point Dry Needling: An Evidence and Clinical-Based Approach. 2nd ed. Churchill Livingstone; 2018.
• Kalichman L, Vulfsons S. "Dry Needling in the Management of Musculoskeletal Pain." J Am Board Fam Med. 2010;23(5):640–46.
• Young JL, Snodgrass SJ, Cleland JA, Rhon DI. “The Role of Dry Needling in Musculoskeletal Dysfunction: An Evidence-Informed Perspective.” Phys Ther. in Sport. 2019; 39:139–49.
• Asavasopon S, et al. “Brain Activity Associated with Pain in Female Pelvic Floor Muscles: A Functional MRI Study.” Neurourology and Urodynamics. 2014; 33(5):7.

Constipation, which includes rectal evacuation disorders, slow transit constipation, and IBS to name a few is one of the most common gastrointestinal disorders worldwide (1,2). The complexity of constipation and its impact on a person’s health and quality of life is often misunderstood and common treatment strategies such as diet, exercise, hydration, and stress management can be an oversimplification of what is necessary to effectively manage the disorder (1). From a rehabilitation lens, it is pivotal to prioritize the function of the nervous system when developing a treatment strategy for constipation, considering the nervous system is the central control mechanism of all functions and processes in the human body.

Dry needling, specifically, dry needling with electrical stimulation, is one of the most impactful tools we have in rehabilitation to improve the health and function of the nervous system. Dry needling has evolved from a procedure that utilizes a monofilament needle to deliver mechanical input into “trigger points” in muscle tissue to include the use of a monofilament needle for the delivery of electrical stimulation, which is often described as percutaneous electrical stimulation or neuromodulation. The use of electrical stimulation with dry needling can have a profound effect on improving the healing capacity of tissues and the overall functional recovery of the human body primarily due to the impact it has on the nervous system. Therefore, we must have a sound understanding of the neuroanatomy and physiology of any region of the body and the associated dysfunction to effectively develop and implement a treatment plan.

The gastrointestinal system is considered the most complicated system in our body in terms of the number of structures involved in function and regulation and the enormity of neurons that innervate the gastrointestinal tract, and it is yet to be fully understood (3). The enteric nervous system, which is commonly considered the third branch of the autonomic nervous system, is at the center of regulatory control of the gastrointestinal (GI) tract and precisely coordinates the function of GI neurons, glial cells, macrophages, interstitial cells, and enteroendocrine cells which drives gut motility and secretions (3). It is interesting to note that the sophistication of the enteric nervous system allows the GI tract to be able to function independently of any neural inputs from the central nervous system (3,4). However, normal physiologic functioning of the GI tract is influenced by bidirectional neuronal connections between the enteric and central nervous systems which is known as the “brain-gut-axis” (3).

Embedded in the walls of the GI tract are the myenteric and submucosal plexuses of the enteric nervous system, which innervate the GI tract and uniquely provide both excitatory and inhibitory motor neurons (4). The myenteric plexus lies between the longitudinal and circular muscle layers of the GI tract and coordinates smooth muscle movements or gut propulsions (“motility”) while the submucosal plexus is found within the connective tissues of the submucosa and regulates secretion, absorption, and blood flow in the GI tract (3,4).

The sympathetic and parasympathetic nervous systems influence the function of the GI tract primarily through integrated neuronal activity with the enteric nervous system versus direct innervation to the wall of the gut, with the exception of blood vessels and sphincters which receive direct sympathetic innervation (3).

Sympathetic inputs to the GI tract regulate secretion and motility and parasympathetic inputs to the distal colon are important for colonic motility and defecation (3).

The function of the somatic nervous system innervating key structures involved with defecation should be equally prioritized to comprehensively evaluate factors contributing to constipation. This may include spinal nerves from the thoracolumbar and sacral vertebral segments, the iliohypogastric and ilioinguinal nerves, the pudendal nerve, the levator ani nerve, and even the phrenic nerve if we are considering the innervation and function of the diaphragm and the importance of breathing mechanics and control of intraabdominal pressure during voiding.

From a treatment perspective, the most impactful window of access to modulate activity in the gastrointestinal tract using dry needling with electrical stimulation is targeting spinal nerves and associated peripheral nerves and their target organs (primarily muscle tissue) that converge with our autonomic nervous system innervating the gut (5). Additionally, electrical stimulation applied directly over the involved target tissue in the GI tract can help facilitate changes in GI function because the enteric nervous system is embedded in the wall of the GI lumen. The rationale for the use of neuromodulation to impact the function of the gastrointestinal tract is that our system is a bioelectric system, therefore, the application of electrical stimulation can have a profound impact on neuromuscular function which is interrelated with neurovascular, neuroimmune function, neuroinflammatory function, neuroendocrine function and so on (5, 6, 7). There is even evidence that electrical stimulation can impact the concentration of bacterial populations in the GI tract which can influence the overall function of the gut. Lastly, ongoing dysfunction in gastrointestinal tissue or any visceral tissue can create neuromotor dysfunction in associated somatic tissues that may include pain, tissue sensitization, abnormal muscle tone, and abnormal motor control strategies which can be effectively and efficiently treated with dry needling and electrical stimulation.

In conclusion, dry needling with electrical stimulation is one the best tools used in conjunction with traditional rehabilitation strategies to create meaningful, sustainable improvements in the function of the human body. If you want to learn more about the implementation of dry needling into your practice as it relates to constipation or gastrointestinal disorders, join us on an upcoming course!

Dry Needling and Pelvic Health: Foundational Concepts and Techniques 

• Galloway NJ - March 21 - 23 2025
  
• Atlanta GA - June 21-22, 2025
• Dayton OH - September 13-14, 2025

Dry Needling and Pelvic Health 2: Advanced Concepts and Neuromodulation

• Seattle WA - May 17-18, 2025

Dry Needling and Pelvic Health: Pregnancy and Postpartum Considerations

References

1. Forootan M, Bagheri N, Darvishi M. Chronic constipation: A review of literature. Medicine (Baltimore). 2018;97(20):e10631. doi:10.1097/MD.0000000000010631
2. Black CJ, Ford AC. Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management. Med J Aust. 2018;209(2):86-91. doi:10.5694/mja18.00241
3. Sharkey KA, Mawe GM. The enteric nervous system. Physiol Rev. 2023;103(2):1487-1564. doi:10.1152/physrev.00018.2022
4. Spencer NJ, Hu H. Enteric nervous system: sensory transduction, neural circuits and gastrointestinal motility. Nat Rev Gastroenterol Hepatol. 2020;17(6):338-351. doi:10.1038/s41575-020-0271-2
5. Larauche M, Wang Y, Wang PM, et al. The effect of colonic tissue electrical stimulation and celiac branch of the abdominal vagus nerve neuromodulation on colonic motility in anesthetized pigs. Neurogastroenterol Motil. 2020;32(11):e13925. doi:10.1111/nmo.13925
6. Zhang C, Chen T, Fan M, et al. Electroacupuncture improves gastrointestinal motility through a central-cholinergic pathway-mediated GDNF releasing from intestinal glial cells to protect intestinal neurons in Parkinson's disease rats. Neurotherapeutics. 2024;21(4):e00369.
7. Jacobson A, Yang D, Vella M, Chiu IM. The intestinal neuro-immune axis: crosstalk between neurons, immune cells, and microbes. Mucosal Immunol. 2021;14(3):555-565. doi:10.1038/s41385-020-00368-1

AUTHOR BIO:
Tina Anderson, MS PT

Tina Anderson (she/her) received her Master of Science in Physical Therapy in 2001 from Grand Valley State University located in Grand Rapids, Michigan. She graduated from Michigan State University in 1996 with a Bachelor of Science in Kinesiology. Tina specializes in treating patients with complex neuromusculoskeletal dysfunction including dysfunctions of the pelvic floor. Tina earned her dry-needling certification in 2006 and has been teaching dry-needling nationwide since 2008. Tina was integral in pioneering dry-needling techniques for the pelvic floor and surrounding neuroanatomical structures. She currently owns and operates a private physical therapy practice in Aspen, Colorado. Tina and her family, including their new “fur” child Beatrice, love living and playing in the Rocky Mountains!

Kelly Sammis, PT, OCS, CLT, AFDN-S is a physical therapist, educator of dry needling and all things pelvic, Pilates instructor, wife, and mama living and working in Parker, Colorado. She specializes in the treatment of male and female pelvic floor dysfunction, athletic injury/return to sport, sports performance, and persistent pain. Her formal education took place at Ohio University (2007) and The University of St Augustine for Health Sciences (2010). Kelly serves as the lead faculty developing and teaching dry needling and pelvic health courses nationwide. Kelly co-instructs the Herman & Wallace Dry Needling courses along with site fellow faculty member Tina Anderson, MS PT.

Urinary incontinence (UI) is defined as ‘any complaint of involuntary leakage or urine’ that has several different subtypes based on when this leakage occurs¹.  UI is a common and relevant condition that has a profound influence on well-being and quality of life of many patients worldwide.  Millions of men and women throughout the world are affected.  According to our body of evidence, UI can affect anywhere between 5-70% of the female population^2-4 and 11-32% of the male population^5,6, contributing to decreased participation in preferred daily, work and recreational activities alongside an immense economic burden for some of those affected.^1-7These symptoms have not only been shown to have a significant impact on a person’s quality of life, but also on their mental health status.⁷

While UI is both common and very bothersome, it is also very treatable. I would love nothing more than to see our society and healthcare continuum recognize that UI is something that is ABNORMAL versus the typical categorization that it is a normal part of the aging, postpartum or postoperative experience.

Common, not normal.  Common, but treatable.
UI can be treated with lifestyle and behavioral interventions, bladder training, electrical stimulation, pelvic floor muscle training (PFMT) with or without biofeedback, physical therapy, neuromodulation, periurethral injections and, in some cases, surgical intervention. ^5,8

Understanding the continence mechanism
In a well-functioning pelvic floor, the connective tissue of the ligaments and fascia act together with the pelvic floor musculature to counteract the impact of any increase in intra-abdominal pressure and ground reaction forces, helping to maintain our continence.^8-10 This is an automatic function, requiring no need to think about voluntary contraction of the pelvic floor musculature. ⁸ When this mechanism is not working adequately, which can undoubtedly be multifactorial, urinary incontinence may occur.

The external urethral sphincter mechanism is a complex system of striated muscle which includes fiber blends from the urogenital triangle musculature and the anterior muscle bundle of the levator ani. ¹¹ The good news here is that we, as rehabilitative clinicians, have many different tissue targets for treatment of UI.

Dry Needling and UI
Dry needling (DN) encompasses the insertion of solid filament, non-injectate needles into, alongside or around muscles, nerves or connective tissues with or without mechanical and/or electrical stimulation for the management of pain and dysfunction in neuromusculoskeletal conditions. DN is both effective and efficient in modulating the central and peripheral nervous systems as well as the somatic tissues, including the pelvic floor.

There is a growing body of evidence that has provided us with an understanding on how to best utilize this technique in our clinical practice as it relates to UI.^12-17 With the external urethral sphincter and associated tissues being a main player in our urinary continence mechanism, it provides a road map on how we can utilize DN to treat UI. This boils down to two things: (1) tissue specificity and (2) utilization of electrical stimulation. DN provides us with an avenue to directly influence a specific tissue as we are able to use an indwelling needle electrode placed strategically into a muscular or perineural tissue target. Using that tactically placed indwelling electrode we can then precisely deliver electrical stimulation, essentially speaking the language of the neuromotor system, making this technique one of the most effective tools we have as rehabilitative clinicians to treat UI.

Ultimately, we are able to stimulate the pudendal nerve alongside the targeted tissues. This can help to improve electric activation, proprioception and coordination in pelvic floor contraction during situations that contribute to UI.^18,19,22 Additionally, the pudendal nerve is an efferent nerve for the external urethral sphincter, so this treatment is capable of increasing the pressure of urethral closure, improving UI. Another important factor is that electrical stimulation has been shown to increase blood flow to the urethra and pelvic floor musculature, lending towards improvements in neuromuscular connections, muscle fiber function and genital atrophy, all leading to improvements in the mechanism of urethral closure. ^19-22

The power of the tissue reset that DN provides has changed clinical outcomes for the better. It has, and will continue to, positively impact and change the lives of many patients through facilitating a more balanced homeostatic baseline within the tissues, healthier motor recruitment patterns and optimal neuromuscular utility to re-establish function.  Want to add this tool to your clinical practice? Check out our Dry Needling course offerings with Herman & Wallace!

 References:

1. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/ International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010;21:5–26
2. Milson I and Gyhagen M. The prevalence of urinary incontinence. Climacteric. 2019;22(3):217-222
3. Carryer, J, Weststrate, J, Yeung, P et al. Prevalence of key care indicators of pressure injuries, incontinence, malnutrition, and falls among older adults living in nursing homes in New Zealand. Research In nursing & Health. 2017;40(6):555–563
4. Damian, J, Pastor-Barriuso, R, Garcia Lopez, FJ et al. Urinary incontinence and mortality among older adults residing in care homes. Journal of Advanced Nursing. 2017;73(3):688–699
5. Gacci M, Sakalis VI, Karavitakis M et al. European Association of Urology guidelines on male urinary incontinence. European Urology. 2022;82:387-398
6. Cao C, Zhang C, Sriskandarajah C et al. Trends and racial disparities in the prevalence of urinary incontinence among men in the USA, 2001-2020. European Urology Focus. 2022; https://doi.org/10.1016/j.euf.2022.04.015
7. Krhut J, Gartner M, Mokris J et al. Effect of severity of urinary incontinence on quality of life in women. Neurourol Urodyn. 2018;37:1925–1930
8. Bo K. Physiotherapy management of urinary incontinence in females. Journal of Physiotherapy. 2020;
9. Ashton-Miller J, DeLancey JOL. Functional anatomy of the female pelvic floor. In: Bø K, Berghmans B, Van Kampen M, Mørkved S, eds. Evidence based physical therapy for the pelvic floor. Bridging science and clinical practice. Chapter 3. Edinburgh: Elsevier; 2015:19–34
10. DeLancey JOL, Low LK, Miller JM et al. Graphic integration of causal factors of pelvic floor disorders: an integrated life span model. Am J Obstet Gynecol. 2008;199:610.e1–610.e5
11. Suriyut J, Muro S, Baramee P et al. Various significant connections of the male pelvic floor muscles with special reference to the anal and urethral sphincter muscles. Anatomincal Science Internatiional. 2020;95:305-312
12. Feng X, Lv J, Li M et al. Short-term efficacy and mechanism of electric pudendal nerve stimulation versus pelvic floor muscle training plus transanal electrical stimulation in treating post-radical prostatectomy urinary incontinence. Oncology. 2022;160:168-175
13. Wang S, Zhang S. Simultaneous perineal ultrasound and vaginal pressure measurement prove the action of electrical pudendal nerve stimulation in treating female stress incontinence. BJU Int. 2012;110:1338–1343
14. Wang S, Lv J, Feng X, Wang G, Lv T. Efficacy of electrical pudendal nerve stimulation in treating female stress incontinence. Urology. 2016;91:64–69
15. Wang S, Lv J, Feng X, Lv T. Efficacy of electrical pudendal nerve stimulation versus transvaginal electrical stimulation in treating female idiopathic urgency urinary incontinence. J Urology. 2017;197:1496–1501
16. Wang S, Zhang S, Zhao L. Long-term efficacy of electric pudendal nerve stimulation for urgency-frequency syndrome in women. International Urogynecology Journal. 2014;25:397-402.
17. Li T, Feng X, Lv J et al. Short-term clinical efficacy of electric pudendal nerve stimulation of neurogenic lower urinary tract disease: a pilot research. Urology. 2018;112:69-73
18. Monga AK, Tracey MR, Subbaroyan J. A systematic review of clinical studies of electrical stimulation for treatment of lower urinary tract dysfunction. Int Urogynecol J. 2002;23:993–1005
19. Chai TC, Steers WD. Neurophysiology of micturition and continence in women. Int Urogynecol Urol. 1997;8:85–97
20. Spruijt J, Vierhout M, Verstraeten R, et al. Vaginal electrical stimulation of the pelvic floor: a randomized feasibility study in urinary incontinent elderly women. Acta Obstet Gynecol Scand. 2003;82:1043–8
21. Balcom AH, Wiatrak M, Biefeld T et al. Initial experience with home therapeutic electrical stimulation for continence in myelomenin-gocele population. J Urol. 1997;158:1272–6
22. Correia GN, Pereira VS, Hirakawa HS et al. Effects of surface and intravaginal electrical stimulation in the treatment of women with stress urinary incontinence: randomized controlled trial. Euro J of Ob & Gyn and Reproductive Bio. 2014;173:113-118

Dry Needling and Pelvic Health - Live Course

Course Dates:
Worcester, MA - November 12-13, 2022
Katy, TX - January 21-22, 2023
Birmingham, AL - September 16-17, 2023

Price: $995
Experience Level: Beginner
Contact Hours: 26

Description: This is the foundational dry needling course in our three course pelvic health series. Practitioners will learn an innovative approach to treating clients with pelvic floor and neuromusculoskeletal dysfunction commonly associated with lumbopelvic pain, incontinence, voiding dysfunction and/or sexual pain or dysfunction. This foundational dry needling course will instruct participants in the application of dry needling to female pelvic floor musculature and associated neuroanatomical structures including the lumbosacral spine, abdomen, pelvis, and hip joint complex. This course will provide a comprehensive review of anatomy, a strong emphasis on safety and precautions, ample lab time to optimize dry needling techniques, as well as dialogue surrounding clinical integration and relevant evidence.

Dry Needling and Pelvic Health: Advanced Concepts and Neuromodulation - Live Course

Course Dates:
Salt Lake City, UT - November 5-6, 2022

Price: $995
Experience Level: Advanced
Contact Hours: 26

Description: Dry Needling and Pelvic Health: Advanced Concepts and Neuromodulation is a lab intensive, hybrid course designed with the pelvic health practitioner in mind. This course is an innovative approach to treating clients with pelvic floor dysfunction commonly associated with pelvic pain, incontinence, voiding dysfunction and/or sexual pain or dysfunction. This advanced dry needling course will instruct participants in the application of dry needling to female and male pelvic floor musculature and associated neuroanatomical structures including the thoracolumbar spine, trunk, abdomen, pelvis and hip joint complex. This course will also discuss and integrate the concept of and techniques associated with neuromodulation. Additionally, there will be a comprehensive review of anatomy, a strong emphasis on safety and precautions, ample lab time to optimize dry needling techniques, as well as dialogue surrounding clinical integration and relevant evidence.

Kelly Sammis, PT, OCS, CLT, AFDN-S is a physical therapist, educator of dry needling and all things pelvic, Pilates instructor, wife, and mama living and working in Parker, Colorado. She specializes in the treatment of male and female pelvic floor dysfunction, athletic injury/return to sport, sports performance, and persistent pain. Her formal education took place at Ohio University (2007) and The University of St Augustine for Health Sciences (2010). Kelly serves as the lead faculty developing and teaching dry needling and pelvic health courses nationwide. Kelly co-instructs the Herman & Wallace Dry Needling courses along with fellow faculty member Tina Anderson, MS PT.

Pelvic floor dysfunction (PFD) is a common and relevant condition that affects many patients worldwide.  According to our evidence, PFD can affect approximately 20-25% of women and men in the United States¹, contributing to decreased participation in preferred daily, work and recreational activities due to high incidences of lumbopelvic pain, abdominopelvic pain, incontinence, prolapse, and/or other urologic and urogynecologic symptoms.²  These symptoms have a significant impact on a person’s quality of life and mental health status.²

While PFD is common, the general public has not been fully educated that these dysfunctions are not normal.  As clinicians, we have a duty to educate our patient population that PFD is not a normal, nor acceptable, part of the postpartum experience or aging process.  These dysfunctions are very debilitating but are also very treatable.

Common, not normal.  Common, but treatable.

Pelvic floor pathology comes to us as clinicians in a variety of diagnoses, etiologies, and presentations². Patients are often referred to physical therapy with medical diagnoses such as chronic pelvic pain syndrome (CPPS), interstitial cystitis, irritable bowel syndrome, endometriosis, dyspareunia, pudendal neuralgia, bowel and urinary incontinence, and chronic prostatitis.^3-5 Symptom presentation is quite varied but often will include bowel, bladder, and sexual dysfunctions. That being said, a multidisciplinary approach is crucial to tailor treatment specific to each patient’s pathology, symptomatology, and clinical presentation.⁶  Many of these patients have seen a variety of gynecologists, urologists, and gastroenterologists without successful symptom mitigation and are being referred to pelvic health practitioners as a last resort. This is unfortunate, as a primary contributor to these symptoms is the neuromusculoskeletal system…and who better to treat the neuromusculoskeletal system than rehabilitative clinicians?!

Multimodal practice is key.

A well-rounded, multimodal treatment approach that is tailored to meet the patient’s specific goals is an important step in successfully treating PFD.  Patient education can be a very powerful modality, which many clinicians tend to overlook. Research suggests education may help to address central nervous system upregulation and may help to retrain the brain in how it is processing input.^7,8 While it is incredibly powerful to be able to influence pain processing, it doesn't stop with education.  As clinicians, we also need to provide non-threatening, nourishing input to the tissues.

Manual therapies may help to desensitize the peripheral nervous system and surrounding soft tissues by providing neural input to alter the source of the pain and disruption.^9,10 These techniques, including joint mobilization, soft tissue release, myofascial techniques, tool-assisted therapies, or any other manual approach, are likely addressing local tissue issues that may be perpetuating chronic pain or tissue dysfunction.

Dry needling is another effective and efficient technique that pelvic health practitioners can utilize to modulate the central nervous system, peripheral nervous systems and local tissues, including the pelvic floor directly.¹⁰  Dry needling encompasses the insertion of solid filament, non-injectate needles into, alongside or around muscles, nerves or connective tissues with or without mechanical and/or electrical stimulation for the management of pain and dysfunction in neuromusculoskeletal conditions.

While the detailed mechanisms of dry needling are not well known, we have seen more and more evidence that has provided us with an understanding on how to best utilize this technique in our clinical practice. Overall, it is thought that dry needling may address hypersensitive neural structures and spinal segments⁵, enhance treatment of myofascial pain and trigger points in the pelvic floor and surrounding musculature, and assist in the facilitation and/or inhibition of abnormal muscle tone and motor recruitment patterns.^10-23 Dry needling has the ability to assist in addressing bladder, bowel, and sexual dysfunction alongside addressing pain syndromes in our patient population that is impacted by PFD.

Dry needling is one of the most effective tools we have as rehabilitative practitioners to reset dysfunctional tissue, providing effective and efficient functional changes for our patients.  Ultimately, we are able to facilitate a more balanced resting tone, healthy motor recruitment patterns, and optimal neuromuscular utility to re-establish ideal function in our patients. The power of the tissue reset that dry needling provides has changed my clinical outcomes for the better and has also positively impacted and changed the lives of many of my clients. Want to add this tool to your clinical practice? Check out our course offerings with Herman & Wallace:

• Dry Needling and Pelvic Health - Waco, TX - June 11-12, 2022
  Dry Needling and Pelvic Health - Milwaukee, WI - September 17-18, 2022
  Dry Needling and Pelvic Health - Hatfield, PA - October 1-2, 2022
  Dry Needling and Pelvic Health - Madison Heights, MI - October 8-9, 2022
  Dry Needling and Pelvic Health - Worcester, MA - November 12-13, 2022
• Dry Needling and Pelvic Health: Advanced Concepts and Neuromodulation - Salt Lake City UT - November 5-6 2022

References:

1. Hallock JK. The epidemiology of pelvic floor disorders and childbirth: an update. Obstet Gynecol Clin North Am. 2016 March;43(1):1-13

2. Messelink et al. Standardization of Terminology of Pelvic Floor Muscle Function and Dysfunction: Report from the Pelvic Floor Clinical Assessment Group of the International Continence Society. Neurology and Urodynamics. 2005;24:374-380

3. Anderson R, Sawyer T, Wise D, Morey A and Nathanson B. Painful Myofascial Trigger Points and Pain Sites in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome. The Journal of Urology. 2009;182:2753-2758

4. Hahn L. Chronic Pelvic Pain in Women. Lakartidningen. 2001;98:1780-5

5. Kotarinos R. Myofascial Pelvic Pain. Curr Pain Headache Rep. 2012;16:433.438

6. Srinivasan A, Kaye J, Moldwin R. Myofascial Dysfunction Associated with Chronic Pelvic Floor Pain: Management Strategies. Current Pain and Headache Reports. 2007;11:359-364

7. Moseley G. Widespread Brain Activity During An Abdominal Task Markedly Reduced After Pain Physiology Eduction: fMRI Evaluation of a Single Patient with Chronic Low Back Pain. Australian Journal of Physiotherapy. 2005;51(1):49-52

8. Moseley G. A Pain Neuromatrix Approach to Patients with Chronic Pain. Manual Therapy. Aug 2003;8(3):130-140

9. Baron et al. Peripheral Input and Its Importance for Central Sensitization. Ann Neurol. 2013;74(5):630-6
10. Chou L, Kao M, Lin J. Probably Mechanisms of Needling Therapies for Myofascial Pain Control. Evidence-Based Complimentary and Alternative Medicine. 2012;11

11. Chen J, Chen S, Kuan T, et al. Phentolamine Effect on the Spontaneous Electrical Activity of Active Loci in a Myofascial Trigger Spot of Rabbit Skeletal Muscle. Archives of Physical Medicine and Rehabilitation. 1998;79(7):790-4

12. Cummings T and White A. Needling Therapies in the Management of Myofascial Trigger Point Pain: A Systematic Review. Archives of Physical Medicine and Rehabilitation. 2001;82(7):986-992

13. Gerber L, Shah J, Rosenberger W et al. Dry Needling Alters Triggers Points in the Upper Trapezius Muscle and Reduces Pain in Subjects with Chronic Myofascial Pain. Physical Medicine and Rehabilitation. 2015;7(7):711-718

14. Gunn C, Milbrandt W, Little A et al. Dry Needling of Muscle Motor Points for Chronic Low Back Pain: A Randomized Clinical Trial with Long-Term Follow-Up. Spine. 1980;5(3):279-291

15. Hsieh Y et al. Dry Needling to a Key Myofascial Trigger Point May Reduce Irritability of Satellite MTrPs. American Journal of Physical Medicine and Rehabilitation. 2007;86(5):397-403

16. Lewit K. The Needle Effect in the Relief of Myofascial Pain. Pain. 1979;6(1):83-90

17. Shah J. Uncovering the Biochemical Milieu of Myofascial Trigger Points Using In Vivo Microdialysis. Journal of Musculoskeletal Pain. 2008;16(1-2):17-20

18. Shah J, Danoff J, Desai M et al. Biochemicals Associated with Pain and Inflammation are Elevated in Sites Near to and Remote from Active Myofascial Trigger Points. Archives of Physical Medicine and Rehabilitation. 2008;89(1):16-23

19. Sterling M, Valentin S, Vicenzino B, et al. Dry Needling and Exercise for Chronic Whiplash - A Randomized Controlled Trial. BMC Musculskeletal Disorders. 2009;10:160

20. Tough E, White A, Cummings T, et al. Acupuncture and Dry Needling in the Management of Myofascial Trigger Point Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. European Journal of Pain. 2009;13(1):3-10

21. Tuzun E, Gildir S, Angın E, et al. Effectiveness of Dry Needling Versus a Classical Physiotherapy Program in Patients with Chronic Low-Back Pain: A Single-Blind, Randomized, Controlled Trial. Journal of Physical Therapy Science. 2017;29(9):1502-1509

22. Hong C and Torigoe Y. Electrophysiological Characteristics of Localized Twitch Responses in Responsive Taut Bands of Rabbit Skeletal Muscle Fibers. Journal of Musculoskeletal Pain. 1994;2(2):17-43

23. Puentedura E, Buckingham S, Morton D, et al. Immediate Changes in Resting and Contracted Thickness of Transversus Abdominis After Dry Needling of Lumbar Multifidus in Healthy Participants: A Randomized Controlled Crossover Trial. Journal of Manipulative and Physiological Therapeutics. 2017;40(8):615-623