Often pelvic floor therapists see men for post-prostatectomy urinary leakage. However, at least for me, that quickly led to seeing male patients for pelvic pain and sexual dysfunction. Male sexual dysfunction is a broad category and can consist of erectile dysfunction (ED), ejaculation disorders including premature ejaculation (PE), and low libido -- often there is a pelvic floor muscle (PFM) dysfunction component. Conservative treatment frequently consists of pharmacological and lifestyle changes for this population.
In normal sexual function, the male superficial pelvic floor musculature (bulbocavernosus and ischiocavernosus) work together to create increased intracavernosus pressure by limiting venous return, resulting in an erection. Ejaculation is created by rhythmic contractions of the bulbocavernosus muscle.
The authors of this systematic review were curious if pelvic floor muscle training was effective for treating erectile dysfunction and premature ejaculation diagnoses, and if so to determine whether there is a treatment protocol. Ten studies were found that met the inclusion criteria, five that focused on ED and five that focused on PE. In total, there were 668 participants ranging in age from 30-59 years old. Studies were excluded if participants were post-prostatectomy and/or had a neurological diagnosis. The intervention was a pelvic floor program, and pelvic floor muscle contractions were either taught or supervised. Studies also included supportive treatment including biofeedback, lifestyle changes, and electrical stimulation.
The studies focused on erectile dysfunction listed a combination of hormonal, psychogenic, arteriogenic, and venogenic causes. The pelvic floor training ranged from 5-20 visits over 3-4 months and included a home exercise program. Pelvic floor training was similar in all studies and consisted of maximal quick contractions over one second and submaximal endurance holds over 6-10 seconds. Compliance to home exercise program was not assessed. Between 35% and 47% of participants reported a full resolution of symptoms. Subjective improvements were supported by improved maximal anal pressure and intracavernosus pressure. One study used the International Index of Erectile Function (IIEF) and showed significant improvement (p<0.05).
The studies focused on premature ejaculation noted participants had either lifelong or secondary PE. The pelvic floor training in these studies ranged from 12-20 sessions over 1-3 months. All studies used electrical stimulation as part of the pelvic floor muscle training. Four studies also used biofeedback. Only one study listed a home exercise program but did not report on compliance. The pelvic floor muscle training was compared to nothing in three studies, and to a selective serotonin reuptake inhibitor (SSRI) in the other two studies. Patient reported full resolution of symptoms was 55-83% in two studies, and there was a significant improvement in delay in heterosexual penetrative ejaculation (p<0.05) in three studies.
For both erectile dysfunction and premature ejaculation, pelvic floor muscle exercise prescription was 2-3 times per week with pelvic floor muscle contractions both maximal quick contractions and submaximal endurance holds. Significant results were shown with participants who were taught pelvic floor muscle contractions through a combination of verbal and physical means (typically biofeedback). Specific verbal cues were not reported. The authors suggest that electrical stimulation was helpful for training recruitment patterns; however, there was not a significant difference in outcomes for those with ED when using electrical stimulation. The authors suggest that pelvic floor muscle training can be part of a conservative treatment. It may be used with oral pharmacology for quick results, and may be beneficial with electrical stimulation and biofeedback, though more research is indicated.
If you are interested in learning more about treating male patients, consider attending Male Pelvic Floor: Function, Dysfunction, and Treatment!
Myers, C., Smith, M. “Pelvic floor muscle training improves erectile dysfunction and premature ejaculation: a systematic review” Physiotherapy 105 (2019) 235–243
When reading published research on a subject matter directly relating to what we do in our career, we may need to remember the expression, “Don’t throw the baby out with the bathwater.” Sometimes the test results for a promising hypothesis are not statistically significant, and we can close our minds to the concept entirely. If we skim the abstract and hone in on the “results” or “conclusion” rather than reading the whole article, particularly a study’s limitations, we may drop a sound clinical pearl down the drain.
A research article published in May 2017 by Amorim et al., looked at the force generation and maintenance of the pelvic floor muscles when combined with hip adduction or abduction contractions. They hypothesized that pelvic floor muscle (PFM) contraction combined with hip abduction contraction (rather than adduction) should produce a greater PFM contraction because of the myofascial connection of the obturator internus to the levator ani muscle. The study included 20 nulliparous women without pelvic floor dysfunction. The pelvic floor muscle contraction was measured in isolation, with 30% and 50% maximum hip adduction contraction, and with 30% and 50% maximum hip abduction contraction. The forces were measured with a cylindrical, intravaginal strain-gauge for PFM and another strain-gauge around the hips for adduction/abduction force generation. The women were given visual feedback to help them obtain the required hip contraction force. An average of 3 contractions (10 seconds each with a 1 minute rest) was used for each condition. This was all performed again 4 weeks later.
The results of this study by Amorim et al.2017 did not support the hypothesis. No statistically significant difference was found among any of the conditions measured. The intravaginal PFM force generation was not different when combined with hip abduction versus hip adduction contraction. Neither hip adduction nor abduction made a significant change in force of the PFM contraction compared to isolated PFM contraction. The authors had to conclude there is no evidence to support the efficacy of combining PFM training with contraction of the hip abductors or adductors.
Even Amorim et al., admitted the study had limitations, and the benefit of PFM training combined with the hip contractions could exist under more “chronic” conditions rather than the brief testing period used in the research. They also used healthy women who had no children, which could make for a different outcome than if they used women with pelvic dysfunction. The specificity of the strain-gauges and the feedback given was not flawless. The authors encouraged further study on the subject. Perhaps there could be an important correlation between PFM and hip abduction contraction not yet found.
Reading research is an integral part of being a responsible healthcare professional, but without solid discernment, we could be entranced or blinded by bubbles as the “baby” escapes us. Taking a course (online or in person) that enhances overall understanding of a subject matter such as the correlation between the lumbopelvic region and the hip can equip the practitioner with a broader foundation upon which clinical decisions can be made. Recognize what concepts to keep and which to wash away, and realize one patient may benefit from what a randomized controlled trial could not cleanly prove to work.
Amorim, A. C., Cacciari, L. P., Passaro, A. C., Silveira, S. R. B., Amorim, C. F., Loss, J. F., & Sacco, I. C. N. (2017). Effect of combined actions of hip adduction/abduction on the force generation and maintenance of pelvic floor muscles in healthy women. PLoS ONE, 12(5), e0177575. http://doi.org/10.1371/journal.pone.0177575