Physio and the Male Pelvic Floor

Beyond the SIJ

Irmina Nahon

Damage to the pelvic floor

Direct injury• Groin strains• Bicycle seats• Blunt force trauma• Surgery • Overuse

Indirect injury• Spinal • Pelvic #• PS, SIJ injuries• Abdominal/visceral

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Anatomy of the Pelvic Floor

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Innervation of the pelvic floor

• Peripheral – pelvic parasympathetic nerves– lumbar sympathetic nerves– pudendal nerves

• Autonomic Nervous System– Pelvic parasympathetic nerves: S2-4– Sympathetic nerves:T11 to L2

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Pain in the .......

• Presents as pain in groin, flank, testis, penis, pubic symphysis, SIJ, hip, abdominus, back....

• Can come from all those areas and more

• Information will not necessarily be volunteered. It must be elicited

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Treatment of pelvic pain

Treat the cause of the pain• Trigger points• Down training• Tight structures

– Muscles– Nerves

• Impingement• Exercises

No evidence is currently available

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Incontinence

Clients may not come to see you because of incontinence but it may stop them from doing what you prescribe

• Urgency• Frequency• Stress incontinence

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Causes of incontinence

• Insidious causes: – life habits– Constipation– OAB

• Prostatic causes: – Benign prostatic hypertrophy – Prostate cancer

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Treatment of incontinence

• Refer to continence advisor for insidious causes

• LUTS need to be assessed medically• Pelvic floor exercises for post prostatectomy

incontinence– Strengthening exercises – Functional exercises

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Cues for correct PFMT

• What does it feel like to tighten them– Feel for movement at the base of the penis

towards the body and the testicles rise– Like stopping wind– To stop after the last drop– Pull your balls in, cold air on the gonads– Stop the flow of urine

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PFMT: Evidence

• Cochrane review of 10 RCT’s Hunter ‘09– level 1 strong evidence for positive effect of PFMT

• Recent RCT of 300 patients Filocamo ’05– PFMT vs control group (homogenous grps)– PFMT resulted in earlier return to continence:

• benefit significant at 3/12 (74% cf 30%) and 6/12 (96% cf 64%)• Decreased effect at 12/12 (99% cf 88%)

• Further evidence: Burgio ’06, Sueppel ’01 Bales ’00

• Overall strong support for inclusion of PFMT in Mx of PPI but further RCT’s required

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Erectile dysfunction

• Becoming a bigger issue as more and younger men are diagnosed with prostate cancer

• Can also have other causes• Affects c 1million Australian men of all ages

Andrology Aust, 2003

• Ischiocavernosus and bulbocavernosus are active during erection and ejaculation

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Physio Treatment for ED

• 3 maximum strength contractions • Holding for 10 seconds • Performed in supine lying, sitting and standing • 3 times per day• ‘50%’ contraction while walking• Slow, rhythmic contractions during sexual

activity.Dorey 2006

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ED: Evidence

• Sommer et al ‘02; 124 men, – 3 grps; PFE, Viagra and placebo– At 3/12, PFMT group had improved more than

Viagra• Dorey ‘04; PFMT vs lifestyle changes, at 3/12

PFMT group: 75% cured, 8.3% improved• Glass ‘03; 80% improvement with PFX cf

sildenafil (74%) Control (18%)• Claes & Baert, 1993; Van Kampen et al, 2003

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Conclusion

• Men have muscles in their pelvic floor too• Injury and weakness can cause significant

problems• Physiotherapists have skills and knowledge to

treat these• Pain, incontinence and erectile dysfunction

can all be treated in the male pelvic floor

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