Over the last few years, a growing body of studies has expanded our understanding of male pelvic floor dysfunction and refined the approach to treatment within pelvic rehabilitation. The latest evidence supports a multifaceted, neuro-muscular strategy grounded in early intervention, individualized care, and integration of tools like electrical stimulation and manual therapy. Below, are a few key findings that are reshaping clinical protocols and outcomes in male pelvic rehab.

Post-Prostatectomy Urinary Incontinence
Pelvic floor muscle training (PFMT) remains the first-line therapy for post-prostatectomy incontinence (PPI). A 2022 meta-analysis by Park et al, involving 21 randomized controlled trials, found that PFMT nearly tripled continence rates compared to no PFMT. Patients also showed significant improvements in both objective measures (e.g., pad counts) and subjective continence scores.

While long-term benefits are well established, recent research emphasizes the importance of early initiation. Multiple studies support beginning PFMT preoperatively or immediately postoperatively to optimize outcomes, particularly after nerve-sparing robotic-assisted radical prostatectomy. Timed, progressive PFMT, especially when started early, is essential for maximizing continence recovery, even more so in cases involving nerve-sparing approaches that may affect pelvic floor coordination.

Combining PFMT with Electrical Stimulation
A 2025 meta-analysis by Lunardi et al examined 885 female patients and found that pelvic floor muscle training (PFMT) combined with electrical stimulation significantly outperformed PFMT alone in improving continence, pelvic floor strength, and quality of life. However, these findings are limited to women and do not directly translate to male populations.

In contrast, evidence in male patients, particularly those with post-prostatectomy incontinence, is more mixed. A randomized, placebo-controlled trial by Yamanishi et al. in 2010 that involved 56 men found that PFMT combined with anal electrical stimulation significantly improved continence rates during the early recovery period (1–6 months) compared to “sham” stimulation. However, by 12 months, the difference between groups was no longer statistically significant, suggesting that the benefits may be short-term.

While adjunctive electrical stimulation appears to provide early benefit in some men, especially those with severe leakage or poor initial voluntary contraction, the long-term advantage remains uncertain. Patients with limited neuromuscular control may benefit from neuromuscular electrical stimulation (NMES) to enhance recruitment and early adherence, but expectations should be managed regarding sustained continence outcomes beyond the first 6–12 months.

Pelvic Floor Therapy for Sexual Dysfunction
Emerging literature from Pastore et al. (2021) supports pelvic rehab in the management of erectile dysfunction, premature ejaculation, and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Integration of manual therapy, PFMT, and behavioral retraining has yielded meaningful gains in function and reduction in nociceptive signaling.

A 2024 study utilizing High-Intensity Focused Electromagnetic (HIFEM) therapy further points to new frontiers in non-invasive intervention for erectile dysfunction and male urinary control.

These findings highlight the evolving role of pelvic floor therapy as a cornerstone in the multidisciplinary management of male sexual dysfunction. Whether through traditional rehabilitation approaches—such as PFMT, manual therapy, and behavioral retraining—or through emerging technologies like HIFEM, pelvic health interventions demonstrate tangible benefits in improving sexual function, alleviating pelvic pain, and restoring urinary control.

Clinical Patterns Worth Noting
In clinical practice, several common patterns emerge when treating male pelvic floor dysfunction. Patients with chronic pelvic pain frequently present with pelvic floor overactivity, often accompanied by restrictions in the obturator internus, adductor magnus, and piriformis muscles. This hypertonicity is commonly associated with neural sensitization and can be exacerbated by postural imbalances or stress-related bracing strategies.

Men recovering from prostatectomy may exhibit compensatory recruitment of accessory muscles, such as the gluteal and abdominal muscles, due to impaired pelvic floor motor control. This can reduce the effectiveness of voluntary pelvic floor muscle contractions and contribute to persistent urinary leakage despite exercise adherence. Thorough neuromuscular re-education is often required to facilitate isolated pelvic floor activation and restore continence.

Erectile dysfunction in this population is frequently compounded by contributing factors such as pelvic asymmetry, altered respiratory diaphragm coordination, and increased thoracolumbar tension. These findings emphasize the importance of a whole-body biomechanical and neuro-myofascial assessment, as pelvic floor dysfunction in men rarely presents in isolation. Recognizing and addressing these interrelated impairments is key to achieving lasting functional outcomes.

August Satellite Lab: Pelvic Function Level 2C
Herman & Wallace invites you to refine your clinical reasoning and hands-on skills at the upcoming Pelvic Function Level 2C Satellite Lab Course, held August 16–17.

This intermediate-level course emphasizes:

• Recognizing the key signs and symptoms that lead to impairment, functional limitations, and disabilities in men’s health
• Use of an evaluation/outcome tool relating to patient condition(s)
• Designing a multi-modal plan of care for pelvic rehabilitation
• Performing clinical interventions based on the patient's presentation and goals

Clinical treatment interventions include patient education, neuro re-education, therapeutic exercise, manual therapy, therapeutic activities, instruction in self-care, and recommendations for relevant modalities.

It’s essential that pelvic rehabilitation continues to evolve beyond the historically female-centered framework to address the full spectrum of pelvic dysfunction, including the complex needs of male patients. Evidence indicates that targeted, neuromuscular-driven rehabilitation strategies can significantly improve outcomes for men experiencing urinary, sexual, and pain-related pelvic conditions.

The August course is available in 9 different satellite locations as well as self-hosted. Satellite locations for Pelvic Function Level 2C: Men’s Pelvic Health and Rehabilitation include:

• Columbus OH
• Danvers MA
• Katy TX
• Milwaukee WI
• New Orleans LA
• New York NY
• Palm Beach FL
• Paso Robles CA
• Tacoma WA
• Self-Hosted

References

1. Park JJ, Kwon A, Park JY, Shim SR, Kim JH. Efficacy of Pelvic Floor Exercise for Post-prostatectomy Incontinence: Systematic Review and Meta-analysis. 2022 Oct;168:175-182. doi: 10.1016/j.urology.2022.04.023. Epub 2022 May 5. PMID: 35526757. https://pubmed.ncbi.nlm.nih.gov/35526757/
2. Lunardi AC, Foltran GC, Carro DF, Silveira LTY, Haddad JM, Ferreira EAG. Efficacy of electrical stimulation in comparison to active training of pelvic floor muscles on stress urinary incontinence symptoms in women: a systematic review with meta-analysis. Disabil Rehabil. 2025 Jun;47(13):3256-3267. doi: 10.1080/09638288.2024.2419424. Epub 2024 Oct 28. PMID: 39467254. https://pubmed.ncbi.nlm.nih.gov/39467254/
3. Yamanishi T, Mizuno T, Watanabe M, Honda M, Yoshida K. Randomized, placebo-controlled study of electrical stimulation with pelvic floor muscle training for severe urinary incontinence after radical prostatectomy. J Urol. 2010 Nov;184(5):2007-12. doi: 10.1016/j.juro.2010.06.103. Epub 2010 Sep 20. PMID: 20850831. https://pubmed.ncbi.nlm.nih.gov/20850831/
4. Pastore AL, Palleschi G, Fuschi A, Maggioni C, Rago R, Zucchi A, Costantini E, Carbone A. Pelvic floor muscle rehabilitation for patients with lifelong premature ejaculation: a novel therapeutic approach. Ther Adv Urol. 2014 Jun;6(3):83-8. doi: 10.1177/1756287214523329. PMID: 24883105; PMCID: PMC4003840. https://pmc.ncbi.nlm.nih.gov/articles/PMC4003840/
5. Yaacov D, Nelinger G, Kalichman L. The Effect of Pelvic Floor Rehabilitation on Males with Sexual Dysfunction: A Narrative Review. Sex Med Rev. 2022 Jan;10(1):162-167. doi: 10.1016/j.sxmr.2021.02.001. Epub 2021 Apr 27. PMID: 33931383. https://pubmed.ncbi.nlm.nih.gov/33931383/
6. Brandeis J. Improving Male Pelvic Health: Efficacy of HIFEM Muscle Stimulation for Urinary Function and Sexual Dysfunction in Men. Reproductive System & Sexual Disorders: Current Research. Research Article. 2024; 13(1). ISSN: 2161-038X. https://www.longdom.org/open-access/improving-male-pelvic-health-efficacy-of-hifem-muscle-stimulation-for-urinary-function-and-sexual-dysfunction-in-men-106497.html

Did you know that September is prostate cancer awareness month? As of 2020, prostate cancer is the most common cancer in men worldwide. Prostate cancer accounts for one in every 14 cancer diagnoses globally, and 15% of all cancers in patients born with a prostate. It ranks second in terms of cancer mortality in this population, second only to lung cancer.(1) A recent Lancet Commission on prostate cancer is projecting a significant increase in the number of new cases of prostate cancer annually. They are projecting that the number of new cases will rise from 1.4 million annually worldwide in 2020 to 2.9 million by 2040. This is due to changing age structures within the population and improved life expectancy.(1) This projected rise in prostate cancer cannot be prevented by lifestyle changes or public health interventions. Due to this projected increase in new cases, screening is a must and will be critical to better prognosis and survival for these patients. Along with a rise in prostate cancer, it is expected that other conditions such as diabetes and heart disease will mirror the projected increase in prostate cancer. It is recommended that screening and early diagnosis programs should not only focus on prostate cancer but “men’s health more broadly.”(1)

The Commission also recommended outreach programs to educate the population about prostate cancer. Social media and traditional media were both recommended to be used to reach individuals who may not be accessing medical care as frequently. This is something that we as rehabilitation clinicians can help with! As a rehabilitation clinician, we are expert educators for our patients. So much of what we do with patients is educate them about their bodies and things that can be done to assist in healing. We can take it a step further and educate them to have general health checks that would include screening for prostate cancer, among other screens such as for heart disease, and diabetes. We may also be able to reach other individuals by educating our patients to encourage their family and friends about the importance of general health screens. Many of us are also very adept at using social media to reach the community. Can we post something about Prostate Cancer Awareness Month? How easy is it to post a quick word about the expected rise in prostate cancer diagnoses and encourage patients to see their doctor for their annual health exam? Let’s all try to reach a few additional individuals this month in honor of Prostate Cancer Awareness Month! If we each are able to get a few more individuals in for screening, what impact could we make? This is something we should continue to do over the next several decades to encourage our patients to health screens! Mark your calendars every September to honor this month and educate our patients and their families!

To learn more about prostate cancer and how to treat this population, take Oncology of the Pelvic Floor Level 2A. This is an online course where you can learn specific techniques to help patients who have been diagnosed with pelvic cancers and colorectal cancers. It is offered September 7-8. Register today!

Reference:

1. James N, Tannock I, N’Dow J, et al. (2024). The Lancet Commission on prostate cancer: planning for the surge in cases.  The Lancet Commissions. 403(10437): P1683-1722. DOI:https://doi.org/10.1016/S0140-6736(24)00651-2

AUTHOR BIO:
Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC

Allison Ariail has been a physical therapist since 1999. She graduated with a BS in physical therapy from the University of Florida and earned a Doctor of Physical Therapy from Boston University in 2007. Also in 2007, Dr. Ariail qualified as a Certified Lymphatic Therapist. She became board-certified by the Lymphology Association of North America in 2011 and board-certified in Biofeedback Pelvic Muscle Dysfunction by the Biofeedback Certification International Alliance in 2012. In 2014, Allison earned her board certification as a Pelvic Rehabilitation Practitioner. Allison specializes in the treatment of the pelvic ring and back using manual therapy and ultrasound imaging for instruction in a stabilization program. She also specializes in women’s and men’s health including conditions of chronic pelvic pain, bowel and bladder disorders, and coccyx pain. Lastly, Allison has a passion for helping oncology patients, particularly gynecological, urological, and head and neck cancer patients.

In 2009, Allison collaborated with the Primal Pictures team for the release of the Pelvic Floor Disorders program. Allison's publications include: “The Use of Transabdominal Ultrasound Imaging in Retraining the Pelvic-Floor Muscles of a Woman Postpartum.” Physical Therapy. Vol. 88, No. 10, October 2008, pp 1208-1217. (PMID: 18772276), “Beyond the Abstract” for Urotoday.com in October 2008, “Posters to Go” from APTA combined section meeting poster presentation in February 2009 and 2013. In 2016, Allison co-authored a chapter in “Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies.”

Allison works in the Denver metro area in her practice, Inspire Physical Therapy and Wellness, where she works in a more holistic setting than traditional therapy clinics. In addition to instructing Herman and Wallace on pelvic floor-related topics, Allison lectures nationally on lymphedema, cancer-related changes to the pelvic floor, and the sacroiliac joint. Allison serves as a consultant to medical companies, and physicians.

Outside of work, Allison enjoys spending time with her family, caring for her animals, reading, traveling, and most importantly of all, being a mom! She lives in the Denver metro area with her family.

Holly Tanner is the Director of Education at Herman & Wallace and has curated and instructs the Male Pelvic Floor course. Male Pelvic Floor was first taught in 2008 and has since been expanded to include 22 contact hours. This current content includes 7 pre-recorded lectures and 2 full days of live lectures and labs, allowing more time for hands-on skills in examination and treatment. The schedule covers bladder, prostate, sexual health, and pelvic pain, and further discusses special topics like post-vasectomy syndrome, circumcision, and Peyronie’s disease.

Post-orgasmic illness syndrome (POIS) is a condition that encompasses a cluster of clinical symptoms. The literature most often reports this presentation in men as a response that occurs shortly after ejaculation and that lasts a period of days or even a week or longer. Symptoms may include transient, flu-like symptoms including, but not limited to headache, sore throat, general myalgia, exhaustion, and cognition that is impacted during the reaction. Understandably, people who experience post-orgasm illness often limit sexual encounters, demonstrate avoidance of sexual function, experience interference in relationships with partners, and report lost time from work and other activities. The diagnosis may be primary (occurring from first ejaculation experience) or secondary (acquired later in life.)

Despite the recognition that clinical presentation can be highly variable, diagnostic criteria have been described by Waldinger and colleagues in 2011 (Part 1) and are based on their study of 45 Dutch Caucasian men with POIS.

Preliminary diagnostic criteria for post-orgasmic illness syndrome include 1 or more of the following:

• Flu-like symptoms, fatigue, muscle weakness, feeling feverish, sweating, mood disturbances or irritation, memory and concentration difficulties, nasal congestion, watery nose, and/or itchy eyes.
• Symptoms occur immediately after or within hours after ejaculation
• Symptoms occur almost always, or in more than 90% of ejaculation events
• Symptoms last for 2-7 days
• Symptoms disappear spontaneously

There are various theories postulating the reason for developing POIS including the autoimmune-allergy hypothesis, cytokine and neuroendocrine disruption, and endogenous m-opioid receptors (orgasm uses large quantities of endogenous opioids). One of the primary reasons that immune reaction to a patient’s own semen has been a strong theory is because sexual activities without ejaculation often do not produce the reaction. Hyposensitization with autologous semen has proven beneficial as a desensitization therapy. (Waldinger et al., 2011, Part 2) Other treatments that may be used include antihistamines, SSRIs, benzodiazepines, and NSAIDs. Comorbidities of POIS reported by Natale and colleagues (2020) include erectile dysfunction, allergies, chronic pelvic pain, autoimmune conditions, and depression and anxiety.

From the standpoint of pelvic rehabilitation, there is much to offer to alleviate symptoms and promote function in patients who have POIS. Genitopelvic pain during or after ejaculation, urinary hesitancy, and difficulty with bowel movements can accompany the syndrome - all complaints that warrant evaluation typical of any patient who has abdominopelvic dysfunction. In the men who have presented to me with this diagnosis, a period of sexual dysfunction including premature ejaculation was described prior to developing POIS. One patient, in particular, described a period of a decade or more of suppressing sexual desires, including masturbation, due to beliefs in his community. When he did masturbate for the first time, he developed post-orgasm illness immediately. I have also observed a tendency to report hypersensitivity to touch, with any palpation to the lower abdomen or groin area causing significant discomfort, and even spontaneous erection or orgasm that was difficult for the patient to manage. In the few cases I have seen, abdominal and pelvic muscle dysfunction was present, and patients responded favorably to manual therapy, education, breathing, and self-management with the use of thermal therapies and self-treatment for soft tissues. It is likely that a combination of medical management, as well as rehabilitation efforts, will provide the best recovery, as anyone who develops fear of an activity usually benefits from learning how to prepare for said activity by addressing concerns prior to, during, and after the activity. Addressing the nervous system response to ejaculation can be part of the rehabilitation process, and a referral to a mental health professional may also prove beneficial in managing the anxiety that often accompanies post-orgasm illness syndrome.

References:

1. Abdessater, M., Elias, S., Mikhael, E., Alhammadi, A., & Beley, S. (2019). Post orgasmic illness syndrome: what do we know till now?. Basic and Clinical Andrology, 29(1), 1-6.
2. Le, T. V., Nguyen, H. M. T., & Hellstrom, W. J. (2018). Postorgasmic Illness Syndrome: What do we know so far?. Journal of Rare Diseases Research & Treatment, 3(2).
3. Nguyen, H. M. T., Bala, A., Gabrielson, A. T., & Hellstrom, W. J. (2018). Post-orgasmic illness syndrome: a review. Sexual Medicine Reviews, 6(1), 11-15.
4. Waldinger, M. D., Meinardi, M. M., Zwinderman, A. H., & Schweitzer, D. H. (2011). Postorgasmic illness syndrome (POIS) in 45 Dutch Caucasian males: clinical characteristics and evidence for an immunogenic pathogenesis (part 1). The journal of sexual medicine, 8(4), 1164-1170.
5. Waldinger MD, Meinardi MM, Schweitzer DH. Hyposensitization therapy with autologous semen in two Dutch caucasian males: beneficial effects in Postorgasmic illness syndrome (POIS; part 2). J Sex Med. 2011a;8(4):1171–6
6. Waldinger, M. D., & Schweitzer, D. H. (2002). Postorgasmic illness syndrome: two cases. Journal of Sex &Marital Therapy, 28(3), 251-255.

Price: $695                                            Experience Level: Beginner-Intermediate                                            Contact Hours: 22

Description:  
The course introduces valuable concepts in pelvic health including urinary and prostate function, chronic pelvic pain, and sexual health. For therapists who have taken Pelvic Floor Function, Dysfunction, and Treatment Level 2A, the Men’s Pelvic Health Course expands on the men’s pelvic health topics introduced in Pelvic Floor Level 2A. This continuing education course is also created at an introductory level, covering topics such as internal rectal pelvic muscle examination, so that a therapist who has not taken prior pelvic floor muscle function coursework can attend. It is expected that participants will only register for satellites in which they are within driving distance, and adhere to all state and local COVID guidelines, including wearing a mask at all times during the course.

Urinary dysfunction such as post-prostatectomy incontinence, benign prostatic hypertrophy, urinary retention, and post-micturition dribble are discussed in this class. Because urinary incontinence is a potential consequence following prostate surgery, risk factors, pre-surgical rehabilitation, and post-surgical intervention strategies following prostatectomy are instructed. The medical aspects of prostate cancer testing are also clearly described, including prostate-specific antigen (PSA) testing, Gleason scores, and any recent updates in recommended medical screening.

Although most men diagnosed with prostatitis do not have a true infection, prostatitis remains a common diagnosis within chronic pelvic pain. The Men’s Pelvic Health course explains typical presentations of prostatitis-like pain, evaluation techniques, and evidence-informed intervention techniques. Other pelvic diagnoses are covered, such as Peyronie's Disease, testicular and scrotal pain, penile pain, and pelvic floor muscle-related conditions. Men who experience pelvic muscle dysfunction including pain or weakness are at risk for sexual dysfunction. Participants will be able to describe the relationships between pelvic muscle function and men’s sexual health, including the evidence that demonstrates pelvic muscle rehabilitation's positive impact on erectile function. This continuing education course includes lectures and labs, including external and internal muscle mapping and neuro-myofascial treatment techniques.

Next Course Date: October 22-23, 2022

Satellites:

• Self-Hosted
• Virginia Beach, VA
• Downer's Grove, IL
• Baltimore, MD
• New York City, NY
• Omaha, NE
• Leesburg, FL
• Smyrna, TN