Understanding Male Pelvic Health Presented by: Dr. Casey M. Smith, PT, DPT, CSCS Women s Health Physical Therapy and Men s Pelvic Health Richmond, VA Objectives Review male pelvic anatomy/physiology Understand common male pelvic health issues and the role of the pelvic floor muscles Understand physical therapy treatments to address issues Anatomy 1
External Anatomy Penis: superficial muscles & erectile tissue Scrotum: houses the testis, contiguous with abdominal wall & fascia Testis: reproductive organ, makes sperm Dartos: smooth muscle, contracts & elevates testis Cremasteric muscle: comes from internal oblique muscle, involunatry Vas deferens: tube connecting testis to urethra at the ejaculator ducts in the prostrate (anterior to pubis) Suspensory ligaments: pubic symphysis fuses with fascia on the ventral surface of the penis Vascular Anatomy and Nerve Supply Muscular Anatomy 2
One: Endopelvic Fascia Two: Pelvic Diaphragm Three: Urogenital Diaphragm Layers of the Pelvic Floor 1: Endopelvic Fascia Most internal layer Supports and covers organs CANNOT be exercised 2: Pelvic Diaphragm Contents: levator ani (pubococcygeus, puborectalis, iliococcygeus), coccygeus, internal sphincter muscles Function: levator ani spans between the sitting bones and coccyx and pubic bones, lifts the anus it guarantees continence at night, has a high resting tone, when coughing or sneezing a precontraction is required to maintain continence 3
3: Urogenital Diaphragm Outer layer (superficial) Contents: deep transverse perineal, superficial transverse perineal, bulbocavernosus, ischiocavernosus, anal sphincter Function: important for continence, sexual function and supporting the levator ani muscle; does not support the pelvic organs Synergistic Trunk Muscle Function Abdominals (Transverse abdominis) Deep back extensors Diaphragm Pelvic floor muscles Urinary Tract Kidney: produces urine Lower abdomen along posterior abdominal wall Ureter: tract for urine between kidney and bladder Urinary Bladder: reservoir to hold urine Urethra: structure where urine exits the body Proximal urethra surrounded by the prostate gland above and external urethral sphincter & pelvic floor muscles below 4
Urinary Tract Male Urethra 18-20 cm long Extends from the bladder neck through the prostate and penile shaft Divided into sections: Proximal (sphincter) Prostatic extends through prostate gland Membranous lies below prostate and pierces the pelvic floor muscles Distal (conduit) Prostate Gland Small, walnut-shaped fibromuscular gland with ducts at base of bladder surrounding prostatic urethra Not part of urinary tract but can have impact on continence due to anatomy With age, prostate enlarges and can cause urethra obstruction Produces fluid which is a constituent of semen Urinary Tract Pelvic floor muscles surround the urethra to control flow of urine Innervation of the Urinary System S3, S4 and branch of the Pudendal Nerve Levator Ani S4, S5 Coccygeus Both autonomic (smooth muscle) and somatic (skeletal muscle) 5
Continence Mechanism Nervous Nerve Origin Function System Somatic Pudendal N S2-S4 Voluntary contraction of external Urethra Sympathetic Hypogastric N T11-L2 Relaxes Detrusor muscle to allow bladder filling and contracts Internal Sphincter for closure Bowel Tract Bowel Tract Small intestine duodenum, jejunum, ileum (20 ft) Continuous peristalsis 1-2 liters of liquid stool daily Large intestine cecum, ascending colon, transverse colon, descending colon, sigmoid colon (5 ft) Absorbs water, corrects electrolyte imbalance, forms/stores/propels feces Feces change from liquid to solid Rectum continuation of the sigmoid colon Senses fullness/time to empty Internal anal sphincter controlled by Autonomic NS, 80% of resting anal pressure, smooth muscle (involuntary) External anal sphincter controlled by Pudendal N, striated muscle (voluntary) surrounding anal canal Anal canal 6
Normal Defecation Anal canal sampling reflex Internal anal sphincter relaxation External anal sphincter contraction Anorectal angle becomes less acute to allow bowels to empty What does a physical therapist do? Physical therapists are doctors (DPT) trained to be experts in the musculoskeletal system and how the body moves Examination and diagnosis Muscle strength, tone, range of motion Quality of movement, coordination Ligaments, tendons, fascia, bone, nerve, visceral and muscle pain Treatment Exercise, joint mobilization, soft tissue mobilization, neuromuscular re-education, modalities (ultrasound, laser, e-stim, etc) Patient education Give the patient knowledge of the condition, anatomy, behavioral modifications and posture in order to empower them to make informed decisions about health Physical Therapy for Male Pelvic Issues Patient education Bladder/bowel retraining: diary, timed voiding, nutrition, fluids/caffeine Biofeedback train muscles for activation, strength and endurance Manual therapy to muscles, ligaments, fascia, joints, organs to increase mobility and reduce restrictions Muscle strengthening exercises internal and external Ultrasound to increase circulation, speed tissue healing and enable muscle activation Posture, ergonomics, orthotic devices 7
Common Health Issues: Pelvic Pain Can arise from reproductive, digestive, urinary or musculoskeletal systems Inflammation may cause tension and irritability in pelvic floor muscles, ligaments and nerves May ultimately cause dysfunction in neighboring organs and referral pain elsewhere Pelvic Pain Prostatitis Pelvic pain with inflammation or infection of prostate, bacteria enters urethra Pelvic pain, malaise, fever (acute), dysuria, urgency, frequency and obstructive voiding (chronic) Levator Ani Syndrome Anal pain caused by spasm in levator ani muscle Achy, pressure Chronic Pelvic Pain Syndrome or Prostadynia Pelvic pain without inflammation or infection Males 35-45 y/o Proctalgia Fugax Severe, episodic rectal and sacroccygeal pain Episodes of pain last seconds to minutes sharp, cramping, twisting Likely a spasm in levator ani muscles Pelvic Pain Anismus (dyssenergic defecation) Failure of the normal relaxation of pelvic floor muscles during defecation External sphincter contracts t rather than relaxes Pudendal Neuralgia Entrapment of the nerve from the sacral plexus and causes pain in rectum, perineum, scrotum and penis Painful bowel movements, urinary urgency & frequency, painful intercourse, constipation, decreased sitting tolerance Coccydynia Pain in coccyx May occur from traumatic force to tailbone, aging, repetitive strain, infection, cancer Hurts to sit Prostate Cancer Most common cancer among men (after skin) Pain or incontinence with or without surgery 8
Physical therapy for pelvic pain Literature review: physical therapy treatment of pelvic pain is an integral component of the multidisciplinary approach to chronic pelvic pain and associated sexual dysfunction (Rosenbaum TY 2008) Clinical Trial: 33 consecutive males dx with chronic prostatitis or chronic pelvic pain syndrome. All participated in pelvic floor biofeedback re-educating program. Change in symptom index and tone of pelvic floor muscles both were statistically significant (Cornel 2005) Case study analysis: 138 men with CP/CPPS underwent myofascial tigger point assessment and release therapy in combination with paradoxical relaxation therapy. 72% of patients reported moderately or markedly improved pain and urinary symptoms (Anderson 2005) Common Health Issues: Urinary Incontinence Involuntary leakage of urine, control over urinary sphincter is either lost or weakened Stress incontinence leaking with coughing, sneezing, etc Urge incontinence having a strong urge and leaking before you reach the toilet Mixed Incontinence simultaneous occurrence of stress and urge incontinence Others Causes: weak pelvic floor muscles, overactive muscles, prostate enlargement, prostate cancer, nerve damage Occurrence: 1/3 of men ages 30-70 16% of men >18 y/o have overactive bladder 2/3 men ages 30-70 never discuss bladder health with their doctors (main reason to avoid nursing home) Frequent/urgent trips to the bathroom increases fall risk in elderly by 26% and bone fractures by 34% Urinary incontinence in men 9
Physical Therapy for Bladder Dysfunction Current Urology Reports 2013 collective literature indicates that PFMT is effective for incontinence, urgency, frequency and nocturia RCT: 300 male patients with incontinence post-radical retropubic prostatectomy compared structured pelvic floor training prior to discharge to control with no training. i Findings: early PFM training i reduces recovery time (Filocamo, 2005) Tx:19% achieved continence in 1 month, 94.6% after 6 months Control: 8% achieved continence in 1 month, 65% after 6 months RCT: Men with urinary incontience post-prostate surgery, compared pelvic floor muscle training and biofeedback over 3-month period to standard care including information on pelvic floor exercise. Test group was more likely to be doing PF exercises 12 months later but no difference in quality of life. (Glazener 2011) Common Health Issues: Constipation Difficulty emptying the bowels 10-18% of ppl strain with defecation 20% of community dwelling elderly, up to 40% if over 65 May have: pain in abdomen, swelling in abdomen, hard/small stool, straining, vomiting Causes: Diet: lack of fiber or water, too much dairy, eating disorders Medication: narcotics, antidepressents, antacids, iron supplements, overuse of laxatives Other conditions: IBS, Parkinson s, Hypothyroidism, Stress, Inactivity, Colon Cancer Pelvic floor muscles may be too tight puborectalis overactive Common Health Issues: Bowel Dysfunction Fecal incontinence Involuntary or inappropriate passage of feces 0.5-5% of population, incidence as high as 30% in nursing homes, as high as 50% in psych wards Anal incontinence Involuntary loss of flatus, liquid or solid stool, loss of anal sphincter control Causes: lumbosacral trauma, neurological conditions, abdominal surgery, gastrointestinal disorders, congenital anorectal malformation 10
Physical Therapy for Bowel Dysfunction RCT: 60 ppl (male & female) with constipation. Tx was abdominal massage and laxative vs. control of laxative only. Significant changes in massage group in both GI symptoms and increase in bowel movements. (Lamas 2009) Case report:10-minute home abdominal massage resulted in return to normal bowel function in 85 y/o without need to strain or use digital evacuation with no known side effects (Harrington 2006) Clinical study: 10 males & 5 females with idiopathic slow transit constipation. Given low-frequency current stimulation (TENS) to S2-S3 sacral dermatomes, set to 50 Hz with burst intervals of 3 sec and 6 sec for 20 minutes, 3x week for 6 weeks. Findings: statistically significant increase in bowel movements (Kim 2014) Abdominal Massage Common Health Issues: Sexual Dysfunction Pelvic floor disorders may result in pain, weakness, decreased libido, erectile dysfunction (inability to maintain erection) or inability to reach orgasm May be due to pelvic floor muscle weakness, hormone imbalance, stress, medications or pelvic congestion Weak pelvic floor can lead to decreased sensation and staying power Autonomic dysfunction can lead to erectile or ejaculatory problems Heart disease, hypertension and high blood sugar can cause erectile dysfunction Constricted blood flow or nerve damage to penis 11
Treatment 51 men with erectile dysfunction treated with pelvic floor exercises, EMG biofeedback and electrical stimulation. 47% regained normal erection, 24% improved, 18% did not complete the therapy (Van Kampen 2003) The Kegel Pelvic floor exercises Just like every other muscle in your body it takes practice and time to strengthen The Kegel Quick Flick Contractions Front door Like holding back urine Long Hold Contractions Back door Like holding back a bowel movement When do I do these? Several times a day in different positions pick a color you see or with a task/chore 3 Quick or 1 Long Am I doing these correctly? Feel the muscles moving up and in 12
The Kegel Everyone try it! Feel for it. Take Away Messages Many male pelvic conditions (primary or secondary) can be improved or completely healed, not just managed with medication or maintenance Pelvic floor and abdominal muscle training can help with many pelvic conditions Muscles can almost always improve Physical therapy can be a good resource or recommendation for male patients with incontinence, pelvic pain, weakness, constipation, fecal leakage or sexual dysfunction Thank You Dr. Casey Smith, PT, DPT, CSCS Women s Health Physical Therapy and Men s Pelvic Health Drcasey.whpt@gmail.com 804.379.3002 www.obgyn-physicaltherapy.com 13
References Netter F. Atlas of Human Anatomy, third edition. Icon Learning Systems, Teterboro, NJ. 2003 Filocamo M, Li Marzi V et al. Effectiveness of Early Pelvic Floor Rehabilitation Treatment for Post-Prostatectomy Incontinence. European Urology Vol 48, Issue 5, Nov 2005 pp 734-738 Rosenbaum TY and Owens A. The role of pelvic floor physical therapy in the treatment of pelvic and genital pain-related sexual dysfunction. J Sex Med 2008;5:513-523 Cornel E, van Haarst E, et al. The effect of biofeedback physical therapy in men with chronic pelvic pain syndrome type III. European Urology, vol 47, issue 5, maiy 2005, pp 607-611 Anerson R, Wise D, et al. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J of Urology, vol 174, issue 1, july 2005, pp 155-160 Lamas K, Lindholm L et al. Effects of abdominal massage in management of constipation A randomized controlled trial. Intl J of Nursing Studies. Vol 46, issue 6, june 2009, pp 759-767 Kim JS, Yi SJ. Effects of low-frequency current sacral dermatome stimulation on idopathic slow transit constipation. J Phys Ther Sci. 2014 Jun; 26(6): 831-832 14