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.

When I first co-authored the course Neurologic Conditions and Pelvic Floor Rehab in 2018, the goal was ambitious: help pelvic health clinicians begin to confidently "think neuro." We focused on a deep dive into the pelvic health conditions in people with Parkinson disease, multiple sclerosis, and spinal cord injury. The course was offered in person and then Covid hit in 2020 putting a long pause on general neuro topics. As the stand-alone Parkinson disease and Pelvic Rehabilitation remote on-line live learning course continues to be offered by Herman and Wallace, there have been on-going requests to broaden the neuro course offerings line-up. We are very excited to announce a neuro expert, collaborative effort with the launching of Neurologic Conditions and Pelvic Floor Rehabilitation at the end of June 2026.

There can be a sense of hesitation and uncertainty when a new patient on our schedule has a neurological diagnosis. We may not be confident of where to even begin. Our patients that have been given a neuro diagnosis likely have multiple other comorbidities, are being followed by multiple specialty physicians, and are on many different pharmaceuticals to manage their condition. These patients often present with complex, fluctuating, frequently overlapping symptoms that don't always fit consistently and neatly into traditional evaluation and treatment planning. These patients have often seen multiple therapy providers trying to get help and needing to be understood through a neuro lens.

This course is designed to get you thinking about neuroanatomy and physiology from the ground up and expand on neurologic diagnoses across the lifespan, from pediatrics to adults; from traumatic neurologic injury (such as stroke) to neurodegeneration (such as amyotrophic lateral sclerosis), transient neurologic conditions (such as Lyme disease) to autonomic nervous system dysfunction (such as POTS), and from neurodiversity (such as autism) to pediatric congenital defects (such as cerebral palsy). Our goal is to offer a practical framework you can carry into any pelvic health neurologic evaluation, so when a complex patient walks into your clinic, you feel confident in your clinical reasoning rather than limited by the diagnosis. Instead, we hope you will feel equipped to ask better questions, see patterns others might have otherwise missed, and develop treatment plans that accurately address the neurologic contributions to pelvic function. We also look to strengthen your clinical reasoning and problem-solving ability to adapt and pivot your treatment approaches when patient outcomes do not progress as you intend or expect.

If you've ever felt like, "I have a neuro patient on my schedule tomorrow and I don't even know where to start", "I know there's a neuro component here, but I'm not sure how to assess it" or "This patient doesn't fit the usual presentation", then this course was designed for you. We hope to help you "think neuro" in ways you have not thought about before, refine your assessment and treatment planning with your "neuro brain", and confidently expand into your role as a neuro-informed pelvic health clinician.

A faculty spotlight on Erica Vitek and her upcoming remote course at Herman & Wallace.

Pelvic rehab and neurorehab have traditionally lived in separate clinical silos. Pelvic clinicians manage incontinence, prolapse, and pelvic pain from a primarily musculoskeletal frame. Neuro clinicians work on gait, ADL, and cognition. The patient sitting across from you with multiple sclerosis, spinal cord injury, or Parkinson disease lives at the intersection, and their pelvic floor symptoms are often the ones quietly eroding their quality of life.

Erica Vitek, MOT, OTR, BCB-PMD, PRPC, has spent her career at that intersection. Her two-day remote course at Herman & Wallace, Neurologic Conditions and Pelvic Floor Rehabilitation, returns on June 27 and 28, 2026, and it is the rare course that gives pelvic rehab clinicians a neuroanatomy-forward framework for these patients.

How common is pelvic floor dysfunction in neurologic disease?

Far more common than referral patterns would suggest. In the North American Research Committee on Multiple Sclerosis (NARCOMS) survey of 9,397 patients, moderate-to-severe pelvic floor symptoms were reported by roughly one in three respondents, including 41% with bladder symptoms, 30% with bowel symptoms, and 42% with sexual dysfunction (Browne et al., 2015). Lower urinary tract symptoms in Parkinson disease run between 27 and 80% across studies, driven by dopaminergic degeneration in pathways that govern autonomic and pelvic floor function (Cheng et al., 2023). Spinal cord injury reliably produces neurogenic bladder and bowel patterns that depend on the level and completeness of the lesion.

The clinical gap is wider than the prevalence gap. Most patients with these conditions have never been offered pelvic rehabilitation, and many of the clinicians treating their gait and balance issues have never been trained to evaluate the pelvic floor in a neurologic context.

One in three people with MS reports moderate-to-severe pelvic floor symptoms. Most have never been offered pelvic rehabilitation.

What changes in the nervous system affect the pelvic floor?

The pelvic floor is governed by an unusually long and vulnerable neural chain that runs from cortical micturition centers down through the pontine micturition center, spinal cord, sacral plexus, and pudendal and pelvic nerves. Damage anywhere along that chain produces a different clinical picture. Cortical and subcortical lesions, demyelinating disease, and dopaminergic degeneration each disrupt different aspects of storage, voiding, and pelvic floor coordination.

That is why an orthopedic-style pelvic assessment, on its own, will miss the diagnosis in these populations. A neurogenic bladder is not a tight pelvic floor. A sphincter dyssynergia is not a coordination problem in the conventional sense. The course gives clinicians the neuroanatomy and pathophysiology they need to read the picture correctly before deciding on intervention.

What conditions does this course cover?

The course goes in depth on three conditions and offers a generalizable framework for others:

• Multiple sclerosis. Demyelination across the central nervous system produces a wide range of bladder, bowel, and sexual health patterns. Up to 80% of women with MS experience bladder and sexual dysfunction within ten years of diagnosis.
• Spinal cord injury. Lesion level and completeness determine whether the clinical picture skews toward upper motor neuron, lower motor neuron, or mixed bladder and bowel patterns. The course covers assessment and management for each.
• Parkinson disease. Dopaminergic degeneration drives lower urinary tract symptoms in 27 to 80% of patients, with orthostatic hypotension and constipation often appearing years before the motor diagnosis is made.
• General neurologic considerations. A foundation participants can extend to stroke, traumatic brain injury, and other neurologic populations they may encounter.

What will you learn in this course?

The course runs over two days on Zoom and is built for clinicians with prior pelvic floor coursework or treatment experience. Participants leave with:

• A working knowledge of neuroanatomy and pathophysiology of the central and peripheral nervous system as it relates to pelvic structures
• Assessment frameworks for neurogenic bladder, neurogenic bowel, and neurogenic sexual health considerations
• Pelvic floor external evaluation considerations adapted to neurologic populations
• Treatment planning and intervention strategies for MS, SCI, and Parkinson disease
• Applications of biofeedback and TENS in the neurologic population
• An Ask the Experts Q&A session for problem-solving complex neurologic patient cases

References

Browne, C., Salmon, N., & Kehoe, M. (2015). Pelvic floor disorders and multiple sclerosis: Are patients satisfied with their care? International Journal of MS Care, 17(1), 6 to 12.

Cheng, B., Chen, Z., Yang, K., & colleagues. (2023). Lower urinary tract symptoms in Parkinson disease: Prevalence, mechanisms, and management. Frontiers in Aging Neuroscience.

Tornic, J., & Panicker, J. N. (2018). The management of lower urinary tract dysfunction in multiple sclerosis. Current Neurology and Neuroscience Reports, 18(8), 54.

Parkinson's Foundation. (n.d.). Autonomic dysfunction and orthostatic hypotension in Parkinson disease. Parkinson's Foundation Clinical Resources.