Explore insights and strategies for navigating pelvic floor dysfunction in males with Meri Sehat. Gain expert guidance for improved well-being.

Pelvic Floor Dysfunction In Males

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Ismail Munir

Overview

Pelvic floor dysfunction in men is the inability to control &ndash; relax and coordinate &ndash; the muscles of the pelvic floor to urinate or have a bowel movement. 
&nbsp;

The pelvic floor stretches from the coccyx or tailbone at the back to the pubic bone at the front, with its muscles being in a complex connection with the surrounding fascia, nerves, ligaments, and bony pelvis.

In men, the pelvic floor supports the rectum, bladder, and prostate while maintaining continence and sexual function. They also help stabilize the trunk and hips, particularly while standing and walking.

Even though pelvic floor dysfunction is more common in females, many men also have difficulty controlling their pelvic floor muscles. The condition is associated with social isolation, depression, anxiety, and reduced quality of life.

According to a study, 16% of men have pelvic floor disorders, including sexual problems, lower urinary tract symptoms, genital-pelvic pain, and defecation disorders<a href="#accordion">[1]</a>. However, these figures may be misleading since the condition is highly under-reported and hard to diagnose. 
&nbsp;

These include<a href="#accordion">[7]</a>: 
&nbsp;

<ul>
	<li>
	<h5>Obstructed Defecation</h5>
	</li>
</ul>

This refers to difficulty getting bowel movements out of the body. The stool reaches the rectum but doesn&rsquo;t pass out. Consequently, the patient often goes to the bathroom to relieve this sensation. This type of pelvic floor dysfunction may be caused by either abnormal function of pain muscles or pelvic floor prolapse. 
&nbsp;

<ul>
	<li>
	<h5>Pelvic Floor Prolapse</h5>
	</li>
</ul>

This means a pelvic organ (bladder, rectum, and small and large intestines) has moved out of place. In males, it&rsquo;s usually a rectal prolapse wherein part of the end of the large intestine (rectum) bulges into the anus. Stretching of the pelvic floor can occur as part of natural aging or collagen disorders.

Although extremely rare, men may have small bowel prolapse (enterocele) and prolapse of the bladder (cystocele)<a href="#accordion">[5][6]</a>. Symptoms include pressure in the pelvis, difficulty emptying during defecation or urination, and incontinence. 
&nbsp;

<ul>
	<li>
	<h5>Levator Ani Syndrome</h5>
	</li>
</ul>

Patients with this condition experience abnormal spasms of the pelvic floor muscles, sometimes after a bowel movement. They&rsquo;ll have a dull or vague pressure high in the rectum for a long time, which worsens when they lie down or sit. The condition is less common in men compared to women. 
&nbsp;

<ul>
	<li>
	<h5>Paradoxical Puborectalis Syndrome</h5>
	</li>
</ul>

The puborectalis muscle is supposed to relax during a bowel movement to allow it to pass. It can become painful when the muscles don&rsquo;t contract or relax as usual. 
&nbsp;

<ul>
	<li>
	<h5>Coccydynia</h5>
	</li>
</ul>

This is the pain of the tailbone or coccyx. The pain worsens after defecation or with movement. It usually occurs due to trauma or a fall that affects the coccyx. However, there is no known cause in almost a third of patients. 
&nbsp;

<ul>
	<li>
	<h5>Pudendal Neuralgia</h5>
	</li>
</ul>

This is chronic pain related to the irritation of the pudendal nerve, the main sensory nerve in the pelvis providing information about pain, pleasure, temperature, and touch to the penis or perineum. The nerve is also responsible for the movement of the anal and urethral sphincter muscles. 
&nbsp;

<ul>
	<li>
	<h5>Proctalgia Fugax</h5>
	</li>
</ul>

The person feels a sudden searing pain in the rectum or coccyx. It may last for a brief period only, and while an episode frequently wakes the individual from sleep, it can occur any time of the day. This condition is more common in men compared to women. 
&nbsp;

<ul>
	<li>
	<h5>Genitofemoral Neuralgia</h5>
	</li>
</ul>

This nerve provides sensation to the upper half of the penis, part of the scrotum, and the top of the groin and the thighs. The individual experiences pain in all these parts when this nerve is irritated due to trauma to the abdomen, tight abdominal muscles, poor spinal mobility, and back pain. 
&nbsp;

Signs and Symptoms

Symptoms depend on the type of disorder. 
These include: 
&nbsp;

<ul>
	<li>Unexplained pain in the pelvic region, rectum, or genitals with or without a bowel movement</li>
	<li>Pressure in the pelvic region or rectum</li>
	<li>Prolapse or bulge in the lower pelvic region</li>
	<li>Lower back pain with no known cause</li>
	<li>Painful urination</li>
	<li>Frequently feeling the urge to go to the bathroom</li>
	<li>Muscle spasms in the pelvis</li>
	<li>Constipation or straining during bowel movement</li>
	<li>Discontinuous urination and difficulty emptying bowels</li>
	<li>Recurrent UTIs</li>
	<li>Premature or painful ejaculation</li>
	<li>Pain during intercourse</li>
	<li>Stress incontinence, i.e., leaking urine during activities like laughing, coughing, or running</li>
	<li>Bowel incontinence, i.e., accidental leakage of feces and difficulty with controlling wind</li>
	<li>Post-micturition, i.e., leakage of a few drops of urine after you&rsquo;ve finished passing urine 
	&nbsp;</li>
</ul>

According to a study, some men may not present with any symptoms despite having a certain degree of muscle dysfunction. 
&nbsp;

Note: Do not self-diagnose your symptoms. Always consult a doctor if you experience any of the aforementioned symptoms because they can occur due to underlying serious conditions. 
&nbsp;

Causes

These include:

<ul>
	<li>Obesity</li>
	<li>Nerve damage</li>
	<li>Pelvic surgery</li>
	<li>Chronic cough</li>
	<li>Systemic diseases</li>
	<li>Collagen disorder</li>
	<li>Traumatic injury to the pelvic region, like a car accident</li>
	<li>Overusing the pelvic muscles, like pushing too hard 
	&nbsp;</li>
</ul>

Diagnosis

The doctor reviews the medical history of the patient and observes their symptoms. They also perform a physical evaluation to check for muscle knots, spasms, and muscle weakness.

The doctor may place a perineometer into the rectum for an internal exam to check the pelvic muscle contractions and control.

Alternatively, they may place surface electrodes on the perineum (the area between the anus and scrotum) or the sacrum. It is a less invasive technique to determine if the patient can control &ndash; contract or relax &ndash; their pelvic muscles. 
&nbsp;

The doctor may order further tests that are not painful. These include:

<ul>
	<li>Anorectal Manometry &ndash; This tests pressure, strength, and coordination of the anal sphincters.</li>
	<li>Uroflow Test &ndash; This test checks how well patients can empty their bladder. If they have to stop and restart while urinating, or if the urine flow is weak, it can indicate pelvic floor dysfunction.</li>
	<li>Defecating Proctogram &ndash; The patient is given an enema of thick liquid that shows up on an X-ray. During the test, a video X-ray monitors the movement of the muscles during a bowel movement. 
	&nbsp;</li>
</ul>

It&rsquo;s often difficult to diagnose pelvic floor dysfunction given that it can co-exist with multiple conditions, including:

<ul>
	<li>Prostatitis &ndash; The symptoms of pelvic floor dysfunction and prostatitis are similar. However, prostatitis is an inflammation or infection of the prostate that occurs due to bacteria, trauma to the nervous system, or sexually-transmitted infection. It affects 10-15% of US men and is one of the most common diagnoses for men under 502.</li>
	<li>Erectile Dysfunction &ndash; This implies the individual cannot get or maintain an erection. It is a complex condition that may occur due to pelvic pain or pelvic muscle tension. 
	&nbsp;</li>
</ul>

Treatment

The aim is to relax the pelvic floor muscles and provide more control to the individual. Treatment options include: 
&nbsp;

<ul>
	<li>
	<h5>Biofeedback</h5>
	</li>
</ul>

This is the most common option and requires the assistance of a physical therapist. It has a success rate of 75% in people with pelvic floor dysfunction<a href="#accordion">[3]</a>. It involves ultrasound therapy, electrical stimulation, or pelvic floor muscle massage to improve rectal sensation and contraction. 
&nbsp;

<ul>
	<li>
	<h5>Medication</h5>
	</li>
</ul>

Some medications can help keep bowel movements soft and regular. A stool softener may be available over the counter, but it&rsquo;s always best to consult a gastroenterologist or a primary care doctor. Drug therapy is more effective when combined with other strategies like lifestyle changes and pelvic floor exercises. 
&nbsp;

<ul>
	<li>
	<h5>Self-Care</h5>
	</li>
</ul>

This involves dietary changes, like drinking more fluids and eating more fiber, and other relaxation techniques, like warm baths, meditation, acupuncture, and yoga. 
&nbsp;

<ul>
	<li>
	<h5>Physiotherapy</h5>
	</li>
</ul>

According to studies, 66% of men are clueless that pelvic floor muscle training is for males, too, to strengthen and minimize the risk of unwanted symptoms, usually urinary stress incontinence after prostate surgery<a href="#accordion">[4]</a>. 
&nbsp;

Pelvic therapy is an individualized care plan for each patient, including:

<ol>
	<li>Electrical Muscle Stimulation &ndash; EMS uses electrical impulses to contract the pelvic floor muscles, strengthening them and relieving feelings of urgency and pelvic pain</li>
	<li>Percutaneous Tibial Nerve Stimulation &ndash; A low-risk treatment providing indirect electrical stimulation to the nerves responsible for pelvic floor and bladder function.</li>
	<li>Hypopressive Exercises &ndash; These combine specific breathing techniques and postures to prevent prolapse and urinary incontinence. They strengthen the pelvic floor muscles by helping contract the abdominal and pelvic muscles. Further, they help improve general posture. 
	&nbsp;</li>
</ol>

<ul>
	<li>
	<h5>Kegels</h5>
	</li>
</ul>

Kegels for men are different than for women. The exercises are divided into short-hold and long-hold contractions, both equally vital for the optimal function of the pelvic floor muscle. The training should be done as frequently as possible every day.

Before starting the training, though, it&rsquo;s important to identify the muscles to train. Finding the pelvic floor muscles is difficult and takes practice to squeeze the right set of muscles in the right manner. There are several ways to do it while standing, sitting, or lying down; it&rsquo;s recommended that the patient should try and see which one suits them. 
&nbsp;

Follow these steps:

<ol>
	<li>Empty the bladder.</li>
	<li>Tighten the pelvic muscles. Count to 10.</li>
	<li>Relax the muscles completely. Count to 10.</li>
	<li>Repeat 10x, 3-5 times a day. 
	&nbsp;</li>
</ol>

While training the pelvic floor muscle, it&rsquo;s essential to:

<ol>
	<li>Keep breathing</li>
	<li>Only squeeze and lift</li>
	<li>Keep the thighs relaxed</li>
	<li>DO NOT tighten the buttocks</li>
</ol>

Also, over-exercising can increase urine leakage and muscle fatigue, so avoid that<a href="#accordion">[8]</a>. 
&nbsp;

<ul>
	<li>
	<h5>Surgery</h5>
	</li>
</ul>

This is only recommended when other strategies fail. The procedure depends on the specific condition of the patient. Prolapse and incontinence, for instance, may be reasons to insert synthetic mesh slings. Bulking agents may treat stress incontinence, while Botox injections may treat urge incontinence. 
&nbsp;

Important!

Most cases of pelvic floor dysfunction are treatable. Symptoms worsen when they&rsquo;re treated. Physical therapy, biofeedback, and medications can help relieve pain and discomfort.

However, it takes time before symptoms improve. Skipping physical therapy appointments or forgetting to take medications while increasing tension in the pelvic floor muscles as prescribed by the doctor slow healing. 
&nbsp;

Strong pelvic floor muscles are involved when an individual laughs, coughs, sneezes, and even during lifting activities, adding extra support to the pelvic floor and abdomen. Muscles that are weak, overly stretched, or not working effectively increase pressure in the pelvic region.

Under-reporting due to stigma or embarrassment and a lack of research can prove detrimental for men with poor bladder control or other issues associated with pelvic floor dysfunction. The condition leads to discomfort, infection, and long-term colon damage. 
&nbsp;

According to a study, pelvic floor problems are expected to increase by 35% between 2010 and 2030<a href="#accordion">[4]</a>. These include: 
&nbsp;

<ul>
	<li>Advancing age&nbsp;</li>
	<li>Genetics causing weaker muscles and connective tissue and obesity (BMI over 25)</li>
	<li>Underlying health issues like Parkinson&rsquo;s</li>
	<li>Occupations that require repeated heavy lifting</li>
	<li>Prolonged vigorous physical exertion, like athletes engaging in high-impact sports (e.g., gymnastics, running, etc.)</li>
	<li>History of low back pain</li>
	<li>Prostate surgery; nearly 89% of men suffer as the prostate is removed, and the urinary sphincter nerves and cavernous nerves may be damaged in the process</li>
	<li>Previous trauma to the pelvic region, like pelvic radiotherapy or fall, especially if they are not physically active; makes them susceptible to urinary incontinence and erectile impairment</li>
	<li>Increased abdominal pressure due to frequent sneezing and chronic coughing (a symptom of hay fever, chronic lung disease, etc.) 
	&nbsp;</li>
</ul>

Pelvic floor dysfunction usually occurs due to strain, whether from a particular incident or over time. This means that, sometimes, it may not be possible to prevent it.

However, in other situations, pelvic floor disorders can be prevented by:

<ul>
	<li>Maintaining a healthy weight</li>
	<li>Lifting the right way; avoiding the abdomen or back muscles while lifting heavy items</li>
	<li>Preventing constipation</li>
	<li>Exercising and strengthening the pelvic muscles 
	&nbsp;</li>
</ul>

Keeping a bladder diary can also help assess if the lifestyle can be improved to reduce triggers and enhance the quality of life. For instance, daily logs of how caffeine intake affect fluid volume can help. 
&nbsp;

A recent review of contemporary data to examine how pelvic therapy can help relieve male sexual dysfunctions, including dysfunction of ejaculation and orgasm and erectile dysfunction, shows that it is indeed a useful tool for men with these conditions.

Male pelvic floor muscle training, including myofascial release, soft-tissue mobilization, and connective tissue manipulation, increases penile hardness and rigidity in some men with erectile dysfunction. It also enhances control over ejaculation since the pelvic floor muscle is involved in coordinating ejaculation. Further, it helps effectively manage chronic prostatitis/chronic pelvic pain syndrome<a href="#accordion">[9]</a>. 
&nbsp;

Key Points

<ul>
	<li>Pelvic floor dysfunction refers to the abnormal function of the pelvic organs, leading to problems with sex, urination, and defecation.</li>
	<li>Symptoms include painful urination, urinary or fecal incontinence, unexplained lower back pain, and erectile dysfunction.</li>
	<li>It may be caused due to genetics, aging, and pelvic injury.</li>
	<li>Kegel exercises, dietary changes, and medication may help treat an overactive bladder, prolapse, and fecal incontinence. Surgical intervention may be recommended in some cases. 
	&nbsp;</li>
</ul>

[1] Grimes WR, Stratton M. Pelvic Floor Dysfunction. [Updated 2023 May 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

[2] Prostatitis: Inflammation of the prostate - NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases.

[3] Pelvic floor dysfunction: Symptoms, causes &amp; treatment. Cleveland Clinic.

[4] Pelvic floor dysfunction. Physiopedia

[5] Asai M, Wood E, Reickert CA. Extraperineal enterocele in male: A case report and literature review. Int J Surg Case Rep. 2020;72:524-527. doi:10.1016/j.ijscr.2020.06.023