Male Pelvic Floor: Advanced Massage and Bodywork for Tension, Dysfunction, and Pain

Creating and Maintaining a Healthy Pelvic Floor
/ Complimentary Therapies

Introduction

Hover your cursor over citation numbers to view the source in a pop-up text box or scroll to the bottom of the page for the full list. At the end of each section on the right is a "back to top" link to return to the main menu.

Awareness

The very first step for anyone wishing to engage the pelvic floor is awareness. If you don't know where your pelvic floor is and cannot feel it, actions you take to support the pelvic floor will be less successful or not successful at all. Massage and bodywork can be invaluable in this regard. Once you understand exactly where your pelvic floor is, as well as how to fully relax and fully contract it, you are well on your way being able to use those self-help approaches you wish to explore. "The greatest changes in the physical body occur when there are corresponding changes in awareness and attitude." writes Ken Dychtwald in his book Bodymind [21]

Pelvic Floor Exercises

Like any other muscle group, these muscles benefit from specific exercises to improve strength, tone, circulation, and nerve function. This translates into better core support, improved function of the genitourinary and sexual systems, and greater awareness and better transmission of sensation - including pleasure. The pelvic floor can become weak from a variety of life circumstances and tends to lose tone as we age - a process that we are not usually conscious of.

Pelvic floor massage and bodywork is an excellent way to identify these important muscles and learn how to contract them in isolation - a necessary first step in any exercise program. I can then give you an exercise protocol you can do at home to build strength and improve function. Once you become familiar with how to contract these muscles, pelvic floor exercises are easy to do and can be done in any position: standing, lying, or sitting. They can be integrated into other exercise programs (see the Physical Activity section below) and can even be done on the sly at work - no one will know! Another way to integrate them into your daily routine is to do a few strong, deliberate contractions at the end of voiding during each visit to the bathroom.

Note that if you currently have pelvic floor pain, these exercises are not appropriate until pain issues are resolved.

Several authors have described stand-alone pelvic floor exercises in their books, including Dorey [1], Stein [2], Franklin [3], Sommer [4], Morin [5], and Liebenson [6].Back to top

Stress Management / Relaxation

For men experiencing pain, such as from Chronic Prostatitis / Chronic Pelvic Pain Syndrome (CP/CPPS), stress management is essential. Various studies have reported an association between high levels of stress and CPPS. Jantos writes that "...it is evident that enhanced pain perception, greater emotional response and increased autonomic reactivity [nervous system response] are closely related to measures of anxiety." [7]. Potts states that "as with other chronic pain conditions, chronic nonbacterial prostatitis [CPPS] patients respond very well to non-specific modalities that act to reduce stress and/or muscle tension." [8]. She believes that these modalities, including massage, aerobic activity, and progressive relaxation, "are incredibly empowering to patients and therefore therapeutic." Ullrich and colleagues found that greater perceived stress was associated with greater pain intensity in men with CPPS [9]. In an interesting study from 1988 on treatment for what the authors called "stress prostatitis", the results were instructive: "With nothing but stress management therapy 110 patients (86%) reported that they were 'better', 'much better', or 'cured'." [10].

Tim Parks has written an excellent book on his years-long quest for relief from chronic pelvic pain. Getting no acceptable answers from the medical profession (and facing surgery) he ultimately charts his own course and, to his great surprise, finds relief through progressive relaxation, bodywork, and meditation. It is well written, engaging, and at times very funny - and speaks to the profound role stress can play in creating tight muscles and pelvic pain [11].

Stress management can take the form of progressive muscle relaxation (based on the work of Edmund Jacobson), meditation, full-body massage, stretching, aerobic exercise (not pelvic floor muscle exercises), yoga, Tai Chi or other martial arts, breath work, visualization and imagery, and similar approaches. Psychotherapy, including Cognitive-Behavioral Therapy, can be helpful in developing better coping strategies, altering pain beliefs, reducing helplessness and depression, and enhancing perceived control in chronic pain situations.Back to top

Aerobic Exercise / Physical Activity

When healthy, the pelvic floor muscles most often function automatically, though conscious control is always an option. When we engage in any physical activity they contract and relax when and to the degree that they should, in conjuntion with other muscles. Physical activity, including aerobic exercise, maintains strength, increases respiration, and enhances circulation, all of which helps keep these muscles in good shape and able to function well. It also improves mood.

Even when pain is present, physical activity can make a difference. In a study from Italy, the authors state that "physical exercise can lead to improvements in pain sensitivity" among other positive outcomes in men with CP/CPPS [12]. They conclude that "Improvements in the aerobic exercise group were significantly superior compared to those in the placebo/stretching and motion exercises group. Aerobic exercise represents a valid treatment option." Potts and Decker, also referring to men with CP/CPPS, note that "men with an exercise regimen at the time of diagnosis were more likely to improve more quickly than men who were sedentary." [13].

Some exercise programs encourage conscious engagement of the muscles of the pelvic floor. For example, in Pilates the pelvic floor is part of the "powerhouse" of core muscles and proper contraction is integral to any exercise in which the powerhouse is engaged. The Elevator is a Pilates exercise that specifically targets the pelvic floor muscles. Many martial arts practices will direct attention to the pelvic floor to engage and transform the energy in the meridian channels and points located there (See my Emotional and Energetic Aspects page for more on these). German urologist Frank Sommer integrates pelvic floor muscle training into his exercise program to increase potency and core fitness in his book VigorRobic [4]. The translation from the original German is not perfect, but the many illustrations are clear. For Yoga practices that specifically target the pelvic floor, see the separate section below.Back to top

Stretching

Though the joints within the pelvic girdle are designed more for stability than for movement, they do allow for subtle motion (large movements come from the hip joints and lumbar vertebrae). An exception to this is the coccyx or tail bone which normally has about 30 degrees of movement at its joint with the sacrum. Significantly, several of the pelvic floor muscles as well as some fibers of the Gluteus Maximus attach to the coccyx.

Positions such as squatting or child's pose in yoga can help to open up the pelvic floor. Lowering your perineum / pelvic floor gently onto a rolled up towel or mat, small soft ball, or other appropriate object and letting the pressure slowly stretch the muscles can be helpful. Care must be taken, especially for those in pain, not to overdo and thus aggravate your symptoms. Using full breaths to slowly, gently, and rhythmically 'bulge' the pelvic floor muscles downward and outward on the inhale can also help open this area up. You must be sure to let the breath do the stretching and resist any urge to assist by straining.

Another strategy is to use the various movements of the hip joint to affect the pelvic floor. The muscles of the inner thigh in particular have fascial (connective tissue) connections to the pelvic floor, and it is through this mechanism as well as subtle pelvic bone movements that a gentle stretch can occur. Both Eric Franklin and Amy Stein have numerous stretching exercises for the pelvic floor in their books [3], [2].

By far the most direct and most effective approach to stretching these muscles is through focused massage and bodywork from a skilled practitioner or from a specially trained physical therapist.Back to top

Yoga

Yoga can have a positive effect on the pelvic floor both as a result of its overall actions and from practices specifically targeting this area. Ripoll and Mahowald write that "Yoga is a useful complimentary therapy in the treatment of chronic urological conditions. Regular practice of yoga has been shown to increase endorphin release, resulting in improved pain control and stress reduction." [14]. They list hatha yoga asanas (postures) that address both pelvic floor hypotonicity (low tone) and hypertonicity (high tone).

The yogic practice of moola bandha (sometimes spelled mula bandha) specifically targets the perineum. "Seen physically, moola bandha is the conscious, willful contraction of the perineum." writes Swami Buddhananda in his book on the subject [15].

Moola bandha is immensely powerful in affecting the nervous and endocrine systems he says, but "its main effect is on the energy systems." He adds that "Though it appears to be a simple muscular contraction, the real work is psychic." It can create a deep sense of mental relaxation, and lead to increased sexual energy. The author also suggests the practices of ashwini mudra and vajroli mudra, which target other areas of the pelvic floor, namely the anal and the urogenital muscles. All three practices are well described in this book.

Another yoga practice that involves the pelvic floor is agni sara. The focus here is on the lower abdomen as well as the pelvic floor, and powerfully recruits the muscles of both areas [16]. Note that there are direct fascial connections between these two groups of muscles.

Craig Liebenson, in his textbook Rehabilitation of the Spine, describes three yoga-based exercises, specifically targeting the front, middle, and back portions of the pelvic floor [6].Back to top

Acupuncture

Lee and Lee did a 2011 review of clinical research on acupuncture's role in treating CP/CPPS. They write that "Recently, there is increasing evidence that acupuncture therapy could benefit men with CP/CPPS", especially in the realm of pain relief [17]. Their conclusion: "Our review finds that acupuncture could be a safe and effective treatment in managing CP/CPPS. In particular, there seems to be good evidence that acupuncture relieves pain-related CP/CPPS more than urinary symptoms or quality of life." Other researchers have found some CP/CPPS symptom improvement using acupuncture but concede that better-designed studies are needed [18] [19]. Back to top

Behavior Modification

For those in pain, behavioral changes can be useful. When sitting for a long time, for example, a donut-shaped cushion can help. Warm baths can relax the body and decrease pain. You may also want to avoid or limit food triggers such as caffeine, spicy foods, acidic foods and fruit juices, and alcohol. One study from Italy found that men with Chronic Prostatitis / Chronic Pelvic Pain Syndrome had a lower intake of fruits and vegetables and higher intake of carbohydrates and dairy products compared to healthy controls, suggesting a possible benefit from increasing the former and reducing the latter [20]. Given the research implicating bicycle seats in pain and dysfunction of the pelvic floor and genitourinary system, it is appropriate to examine saddle options (see my page on Sports / Cycling). Weight-lifting, sports, or other intense physical activities should be limited or avoided if they cause an increase in symptoms. As referenced above in the Stress Management section, Cognitive-Behavioral Therapy can be helpful in indentifying beliefs and behaviors that can magnify pain. Once identified, they can be modified to reduce pain perception and increase the effectiveness of coping mechanisms.

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References

Books are in bold regular text and journal articles are in bold italic text

[1] Dorey G. Pelvic Floor Exercises for Erectile Dysfunction. Whurr Publishers, 2004.

[2] Stein, Amy. Heal Pelvic Pain. McGraw-Hill, 2009.

[3] Franklin, Eric. Pelvic Power. Elysian Editions, Princeton Book Company, 2002, 2003.

[4] Sommer F. VigorRobic: Increased Potency Through Specific Fitness Training. Meyer and Meyer Sport, 2002

[5] Morin J. Anal Pleasure and Health. Down There Press, 2010.

[6] Liebenson, Craig. Rehabilitation of the Spine: A Practitioner's Manual. Lippincott Williams and Wilkins, 2007.

[7] Jantos M. Understanding Chronic Pelvic Pain. Pelviperineology 2007; 26: 66-69.

[8] Potts JM. Alternative Approaches to the Management of Prostatitis: Biofeedback, Progressive Relaxation and the Concept of Functional Somatic Syndromes. European Urology Supplements 2003; 2: 34-37.

[9] Ullrich PM et al. Stress is Associated With Subsequent Pain and Disability Among Men With Nonbacterial Prostatitis / Pelvic Pain. Annals of Behavioural Medicine 2005; 30(2): 112-118.

[10] Miller HC. Stress Prostatitis. Urology 1988; 23(6): 507-510.

[11] Parks T. Teach Us to Sit Still: A Skeptic's Search for Health and Healing. Rodale, 2011.

[12] Giubilei G et al. Physical Activity of Men With Chronic Prostatitis / Chronic Pelvic Pain Syndrome Not Satisfied With Conventional Treatments - Could it Represent a Valid Option? The Physical Activity and Male Pelvic Pain Trial: A Double-Blind, Randomized Study. Journal of Urology 2007; 177: 159-165.

[13] Potts J and Decker S. Specialized Physiotherapy for Sexual Discomfort and Dysorgasmia Associated with Urological Chronic Pelvic Pain Syndrome (UCPPS). Journal of Men's Health 2010; 7(3). ISMH World Congress 2010 Abstract 122.

[14] Ripoll EA and Mahowald DR. Hatha Yoga Therapy Management of Urologic Disorders. World Journal of Urology 2002; 20(5): 306-309.

[15] Swami Buddhananda. Moola Bandha: The Master Key. Yoga Publications Trust, 1978, 1996.

[16] For a good overview of agni sara, see http://www.himalayaninstitute.org/yoga-international-magazine/asana-articles/agni-sara/

[17] Lee SH and Lee BC. Use of Acupuncture as a Treatment Method for Chronic Prostatitis / Chronic Pelvic Pain Syndromes. Current Urology Reports 2011; 12: 288-296.

[18] Tugcu et al. Effectiveness of Acupuncture in Patients with Category IIIB Chronic Pelvic Pain Syndrome: A Report of 97 Patients. Pain Medicine. 2010; 11: 518-523.

[19] Chen R and Nickel JC. Acupuncture Ameliorates Symptoms in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Urology. 2003 June; 61 (6):1156-1159.

[20] Bartoletti et al. Prevalence, Incidence Estimation, Risk Factors and Characterization of Chronic Prostatitis / Chronic Pelvic Pain Syndrome in Urological Hospital Outpatients in Italy: Results of a Multicenter Case-Control Observational Study. Journal of Urology 2007; 178: 2411-2415.

[21] Dychtwald, K. Bodymind. Tarcher, Putnam, 1986. Quoted in: Heller and Henkin Bodywise: An Introduction to Hellerwork for Regaining Flexibility and Well-Being. North Atlantic Books, 1986, 1991, 2004.

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