Pelvic Floor Massage and Bodywork
Massage and bodywork is a wonderful way to more fully connect with your pelvic floor and begin to gain an awareness of its role in your life. It is an essential part of your core musculature and is thus integral to movement, support, and respiration. It also has a very strong influence on the health of the organs it cradles: the prostate, bladder, and rectum—as well as the genitals. Sexual arousal, erectile function, ejaculation, orgasm, urination, and bowel function would be severely compromised without the central role of the pelvic floor. Various emotions such as fear and anger can both originate and become embedded in these muscles, and it is a powerful energy center. This area is rich in nerve endings and thus can be a source of great pleasure—or much pain.
For many men, experiencing pelvic floor bodywork is a journey of discovery, a way to more fully experience and deeply inhabit their body. I strive to create a non-judgemental space in which you feel safe and comfortable, and give you an experience that is warm, engaging, informative, and effective. Working with the male pelvic floor—which is more complex than the female pelvic floor—requires an informed and sensitive touch, a clear understanding of the relevant anatomy, and respect for boundaries.
Techniques I use to mobilize, stretch, release, and improve the function of the muscles, connective tissues, and organs of the pelvic floor are drawn from Neuromuscular Therapy, Myofascial Release, Orthopedic Massage, Sports Massage (I was among the first to become nationally certified in Sports Massage and have worked with athletes at the Olympics, the Boston Marathon, and with the U.S. Olympic Judo team), Deep Tissue Massage, Trigger Point Release, Swedish Massage, Cross-Fiber Manipulation, Positional Release, Trager Bodywork, and other modalities. To help you isolate and feel these muscles I may use Active Engagement techniques, in which I ask for mild contractions followed by full relaxation of the pelvic floor muscles as I gently apply pressure to various myofascial structures. This approach has the added benefit of enhancing tissue release and stretch as well as deepening awareness, connection, and control. In addition, I may include active or passive pelvic and leg movements to further stretch and open muscles and connective tissues that I am working on (often referred to simply as Pin and Stretch Technique, an approach very similar to Active Release Technique). I teach clients how to connect the breath to the pelvic floor and how to use this valuable tool to further stretch, open, and release the pelvic floor and abdominal tissues. When indicated, I assess pelvic floor strength and endurance—and teach clients how to strengthen these muscles if needed.
There are two main approaches to pelvic floor bodywork: external and internal. For some readers the information below may seem a bit overwhelming and too detailed or technical; feel free to scan the topics to get a sense of what pelvic floor bodywork can entail and read only those sections of particular interest. While I often include conditions, pain syndromes, and other dysfunctions that specific muscles or muscle groups are especially relevant to, keep in mind that no muscle operates in isolation and treating the pelvic floor and wider region as an integrated whole ensures better outcomes. Further, pelvic floor bodywork is not only about addressing dys function and pain, and is just as much about improving function and enhancing your ability to inhabit this part of your body with greater comfort, ease, openness, vitality, pleasure, groundedness, and integrity. Explorers and seekers who have no issues with their pelvic floor can benefit from pelvic floor bodywork just as much as those who do. These two groups are not at all mutually exclusive.
Section and subsection links:
External Pelvic Floor Bodywork
♦ The bulbospongiosus muscle ♦ The ischiocavernosus muscles ♦ The superficial transverse perineal muscles ♦ The deep transverse perineal muscle ♦ The external anal sphincter and the external urethral sphincter ♦ The levator ani muscle group ♦ The pelvic floor attachments on the inside border of the sit bones ♦ The obturator internus muscles ♦ The perineal body ♦ The anococcygeal ligament and tailbone ♦ The ischioanal fossa
Closely Associated Muscles, Connective Tissues, and Other Structures
♦ The suspensory ligaments of the penis ♦ The foreskin ♦ The muscles of the penis, and penile rehabilitation ♦ The penile urethra ♦ The muscles and connective tissues of the inguinal, pubic, and groin region ♦ The cremaster muscles ♦ The testicles and epididymes
Internal Pelvic Floor Bodywork
♦ The external and internal anal sphincters ♦ The perineal body, deep transverse perineal muscle, and external urethral sphincter ♦ The levator ani and coccygeus muscles ♦ The anococcygeal ligament and tailbone ♦ The prostate gland and prostate massage ♦ The obturator internus muscles
A Note about Sexual Energy and Erections
External Pelvic Floor Bodywork
The external approach engages these muscles in the same way that most other muscles of the body are massaged, mobilized, stretched, and released: by using pressure and movement on and through the skin. Many pelvic floor muscles can be accessed in this way and external pelvic floor bodywork is by far the most direct and easiest approach for some of them (i.e. bulbospongiosus and ischiocavernosus muscles, for example). Several additional closely associated myofascial tissues—the suspensory ligaments of the penis, the cremaster muscles, the groin and inguinal tissues, the foreskin, and various other structures that I discuss below—can be valuable additions to external pelvic floor bodywork.
External pelvic floor bodywork is the foundation of my pelvic floor approach and is always a logical and practical starting point for several reasons: it directly engages or influences the entire pelvic floor; it is effective in addressing many instances of discomfort, pain, and dysfunction on its own; it is an excellent way for clients to learn about and explore the landscape of their pelvic floor in an experiential, felt-sense way; and it facilitates, complements, and augments internal pelvic floor bodywork when that is included. External work can be deeply relaxing both locally and globally (i.e. to the entire body) via its strong effects on the autonomic nervous system, and is equally useful for those who have specific issues or concerns they want to address as well as for those who simply wish to experience and explore this critical but overlooked part of their bodies in a bodywork context.
Regardless of the motivation for seeking out my work, I will give you a pelvic floor bodywork session that is comfortable, informative, and effective, with the intention of creating an extraordinary experience for each client. Bringing an open mind and a willingness to explore is an excellent way to approach this work.
External pelvic floor bodywork includes all of the following major muscles (see my Anatomy and Function page, especially Figure 4, for illustrations of these muscles). Muscles are in red text; ligaments and other important connective tissues are in green text.
- The bulbospongiosus muscle (BS)
→The bulbospongiosus wraps around the bulb, or central perineal root of the penis and, along with connective tissue layers, encloses the erectile chambers and urethra that lie within it. It connects to and shares fibers with the perineal body and external anal sphincter (which itself connects to the tailbone via the anococcygeal ligament) in the back, adheres to the deeper perineal fascia above it, merges with the paired ischiocavernosus muscles, and anchors into penile connective tissues in the front—thus making it an integral part of a myofascial continuum from the tailbone to the penis. The BS is critical to erectile function and ejaculation, some aspects of urination, and can be a generator or key contributor to many manifestations of pain and dysfunction.
Among the many conditions that benefit from specific attention to the bulbospongiosus are penile retraction; penile tip or shaft pain; perineal tension and pain; cycling-related numbness, pain, or erectile compromise; hard flaccid; erectile dysfunction; premature ejaculation; weak ejaculatory propulsion; post-surgical sensory and sexual impairment; penoscrotodynia; penile and perineal trauma or injury; post-void dribbling; slow or intermittent urinary stream; urethral irritation or pain; and general penile health.
- The paired ischiocavernosus muscles (IC)
→ The ischiocavernosus muscles encircle the left and right perineal roots of the penis, within which lie additional erectile chambers. They run inside and below the ischial and pubic bones of the pelvis, merge with the bulbospongiosus, and with it anchor into the tunica albuginea connective tissue layer within the penile shaft—thereby extending their contractive force as far as the glans. Along with the BS muscle with which they form a functional unit, the IC muscles retract the flaccid penis, generate compressive (squeezing) and tensile (pull-back) forces that pump blood into the penis to help generate and maintain an erection, enhance erectle firmness, and help block blood from draining out—thus being key players in erectile generation, rigidity, endurance, and stability. The IC muscles also lift up, or bounce, the penis when it is erect.
The ischiocavernosus muscles are relevant to most of the conditions listed in the bulbospongiosus section above, including penile retraction, tip of the penis or shaft pain, penoscrotodynia, perineal tension and pain, hard flaccid, erectile dysfunction, premature ejaculation, post-surgical sensory and sexual impairment, and penile or perineal trauma or injury. Urinary issues and ejaculatory propulsion strength are more relevant to the BS muscle given its more direct relationship to the urethra, but the IC muscles form a strong functional unit with the BS and thus play an important role. In addition, the dorsal nerve and blood vessels of the penis runs close to the IC muscles and within their associated connective tissues, making them susceptible to the effects of excess tension or restriction that can ultimately affect all areas of the penis that they supply. Both the IC and the BS can also suffer varying degrees of discomfort, pain, or injury due to sexual activities that exert excessive or unusual forces on the shaft of the erect penis.
Bodywork targeting the IC muscles, the BS, and their connective tissues—in conjunction with the wider pelvic floor—can be an effective treatment for various manifestations of perineal or penile pain, sensation alterations, erectile and ejaculatory dysfunctions, restless genital syndrome, persistent genital arousal disorder, and other dysfunctions and conditions as described in the above paragraphs. Beyond that, it can improve the health and function of the penis, perineum, and pelvic floor.
- The paired superficial transverse perineal muscles (STP)
→ The small STP muscles anchor into the left and right sit bones (ischial tuberosities) and connect centrally to the perineal body, where they share fibers with each other, the bulbospongiosus, external anal sphincter, deep transverse perineal muscle, and some central fibers of the levator ani group. These muscles and their many connections—all of which can contribute to perineal pain and dysfunction—are easily incorporated into external pelvic floor bodywork.
- The deep transverse perineal muscle (DTP)
→ The deep transverse perineal muscle and its associated connective tissues horizontally span almost the entire front half of the pelvic floor and constitute its middle layer (urogenital diaphragm). It connects to the perineal body and external anal sphincter in the back, and attaches to the inner surface of the left and right pelvic bones (ischium and pubis) on each side and towards the front. The DTP has a number of functions: it provides a strong base to which the central root of the penis anchors (including the bulbospongiosus); stablizes and interrelates with the pelvic floor muscles above, below, and behind it; supports the prostate gland that sits upon it and the bulbourethral (Cowper's) glands that are embedded within it; provides an opening for the urethra to pass through; and houses the bulk of the external urethral sphincter.
The DTP can be engaged from an external and/or internal approach and is accessible externally around and between the bulbospongiosus and ischiocavernosus muscles, through the perineal body to which it attaches, and along its back border where the DTP and the STP muscles are clearly felt as the edge of a shelf.
The perineal and penile branches of the pudendal nerve and blood vessels—including the dorsal nerve, arteries, and veins that supply the penis—travel around, though, and between the DTP, the STP, and the IC muscles, making them relevant to any perineal or penile neurovascular compromise.
- The external anal sphincter (EAS) and external urethral sphincter (EUS)
→ While parts of the external anal sphincter closest to the skin at the anal verge can be directly engaged externally, work from within the anal canal—using a glove or cot and lubrication—is a more direct and comprehensive approach. Still, given its strong connections to the anococcygeal ligament in the back and the perineal body, perineal muscles, and bulbosponsiosus in the front, external pelvic floor bodywork targeting these tissues provides additional support and benefit for the EAS. See the first bullet point in the Internal Pelvic Floor Bodywork section below for more information on the external and internal anal sphincters and the benefits of bodywork to address many anal concerns and conditions, including tension, spasm, pain, fissures, difficult bowel movements, and discomfort or pain with receptive anal sex.
The main, circular portion of the external urethral sphincter is embedded within the middle layer of the pelvic floor (DTP, described above), thus making it amenable to work from below (external) and above (internal). Despite being less directly accessible than many other pelvic floor muscles, external bodywork techniques applied around the periphery of the bubospongiosus muscle and into the deeper perineal tissues, through the bulbospongiosus itself, and to the perineal body which directly connects to the EUS are all effective ways to engage this sphincter. See below for internal pelvic floor bodywork approaches to the EUS.
- The levator ani (LA) muscle group: puborectalis, pubococcygeus, and iliococcygeus muscles
→ The back half of the LA can be effectively engaged via the anococcygeal ligament and perineal body to which many of its fibers attach, as well as through the ischioanal fossa which is in direct contact with all of the back half as well as much of the front half of this muscle group. Note that while the front portion of the LA can be influenced by external work through these and other external pelvic floor tissues, it is much more directly accessible via the internal approach as described in that section, below.
The levator ani is often involved in, or central to, many manifestations of pelvic, pelvic floor, and genital tension, pain, and dysfunction—including those associated with sexual function and voiding. These can be felt as a deep, hard-to-place internal pelvic pain; a sense of having a golf ball within the pelvis; pain felt as coming from the prostate; tailbone pain, anal pain, perineal pain, or penile pain; pain with or after ejaculation or defecation; erectile pain; urethral irritation; urinary urgency and frequency; and more.
Many other pelvic floor muscles and tissues can cause or contribute to these same symptoms—often collectively diagnosed as chronic pelvic pain syndrome or chronic prostatitis—clearly demonstrating the value and importance of comprehensive pelvic floor bodywork.
- The pelvic floor tendon attachments on the inside border of the sit bones
→ Several pelvic floor myofascial tissues come together and anchor into the inner surface of the left and right sit bones (ischial tuberosities), including the ischiocavernosus muscles, the superficial transverse perineal muscles, and the back portion of the deep deep transverse perineal muscle— as well as their associated connective tissues. This concentration of tendons can be susceptible to strain and become tender, painful, or otherwise problematic—making this a useful and rewarding area to incorporate into external pelvic floor bodywork. In addition, the pudendal nerve and blood vessels course through here on their way to the perineal and penile tissues, adding to this area's importance.
- The paired obturator internus muscles (OI)
→ These lateral rotators of the hip are also pelvic wall muscles, and are highly relevant to the pelvic floor. They can be engaged or influenced from several angles: through the buttocks (deep to the gluteus maximus and at their attachments to the hip), the external pelvic floor, the internal pelvic floor, and/or via particular pressure applications combined with leg and hip movements.
The OI muscles have special relevance to the pudendal nerve, whose branches supply much of the pelvic floor and genitals as mentioned a few times previously: the pudendal canal that houses the pudendal nerve and blood vessels travels along the inner surface of the OI, within a connective tissue tube between it and the adjacent ischioanal fossa (see below). Pudendal neuralgia and pudendal nerve entrapment (or compression) are two of several diagnostic terms describing pain or sensory alterations due to myofascial tension and compression affecting this canal.
Several highly relevant pelvic floor structures beyond the main muscles described above are also included with external pelvic floor work. Among them:
- The perineal body (PB)
→ This is an important central nexus at and through which many muscles and connective tissues from all three layers of the pelvic floor anchor, meet, intertwine, merge into, and continue with other myofascial structures and organs. In addition to its essential physical aspects, Eastern philosophical and spiritual systems consider this area to be an especially powerful energy center that is critical to vitality, survival, pleasure, security, and many other foundational aspects of ourselves. The perineal body is the physical location or correlate, for example, of the first or root chakra—muladhara—and the seat of ones life force (kundalini)—something many yoga practitioners will be familiar with.
Because of these close associations, mobilizing and treating the PB in various ways directly or indirectly engages multiple pelvic floor muscles and connective tissues, with attendant benefits. One way to visualize this is to imagine the PB as the center of a spider web; pressing on the center will distend, or stretch, all the radiating filaments of the web. A very similar effect occurs when mobilizing the perineal body in various directions, which makes it a very effective vehicle through which to stretch, open, and relax the numerous pelvic floor tissues that meet here.
For more on the PB, which like the anococcygeal ligament can be accessed externally and/or internally, read the relevant section of the internal approach, discussed below.
- The anococcygeal ligament (ACL) and tailbone (coccyx)
→ The anococcygeal ligament connects the external anal sphincter directly to the tail bone and serves as an attachment site for many levator ani muscle fibers. It is continuous with coccygeal, sacral, and vertebral connective tissues and is an important part of the pelvic floor–spinal functional axis. Pelvic floor contractions draw the tailbone forward into flexion via their pull on the ACL and the coccyx itself. The anococcygeal ligament is easily engaged externally and work here affects and benefits all of the structures associated with, or connected to, this ligament.
The tailbone or coccyx is affixed to the bottom of the sacrum and is the 'tail' end of the spinal column. In addition to the ACL which attaches at its tip, many other ligaments and fascias surround and attach to the tailbone on its front, sides, and back to support and stablize it, forming a continuum with other spinal and pelvic connective tissues. All pelvic floor muscles that end with or contain coccygeus attach to the tailbone (pubococcygeus, iliococcygeus, and coccygeus), as do some fibers of the gluteus maximus. Further, several spinal muscles (multifidus, longissimus thoracis, and iliocostalis lumborum) extend down into the sacrum and its connective tissues, thus affecting or influencing the tailbone.
Detailed bodywork directed to the ligaments of the tailbone and sacrum (including the ACL), the sacral and coccygeal attachments of the gluteus maximus, the spinal muscles that anchor into the sacrum, and the relevant pelvic floor muscles can be key to addressing tailbone discomfort and pain. Diagnoses describing tailbone pain can include coccyx pain, coccygeal pain, coccydynia, coccygodynia, and coccalgia. See the internal pelvic floor bodywork section below for more on the anococcygeal ligament and the coccyx.
The physical correlate of the second chakra or energy center—swadhisthana—is near the tip of the tailbone, and is associated with subconscious instinct and expression, pleasure, and all means of gratification, among many other things. The pelvic floor is unusual in that it houses two of the seven chakras.
- The ischioanal fossa (IAF)
→ The ischioanal fossa, also called the ischiorectal fossa, is comprised of two parallel, elongated, three-sided pyramid-shaped spaces whose tips point toward the pubic bone in the front and base faces backward (i.e. two long side-lying pyramids pointing forward). Each fossa is bounded by the levator ani, the obturator internus, the deep transverse perineal myofascia, and in the back by the gluteus maximus muscles and the sacrotuberous ligament. The tissues that make up its contents are largely composed of fat and its associated connective tissues, but—importantly—major nerves and blood vessels and their rectal, perineal, and genital branches pass within and alongside it, including the pudendal nerve, the internal pudendal arteries, and the internal pudendal veins.
While it is rare for the highly mobile IAF to be problematic in and of itself, its position and contents make it an excellent vehicle through which its bordering muscles, connective tissues, and neurovascular structures can be engaged and treated.
Closely associated muscles, connective tissues, and other structures:
Depending upon the issues, concerns, and goals of each client and his level of comfort and trust, external bodywork may include additional pelvic and genital structures, as described below. All of my work is permission-based and every client has the right to determine what is included and what is not; I explain, describe, and discuss all options as part of the informed consent process so that each client fully understands the rationale behind, and value of, each option. For most men, pelvic floor bodywork is new and includes areas that have not been part of previous bodywork sessions. Agency and autonomy are important and boundaries are always respected. Having said that, when permission is given the following muscles, connective tissues, and other structures may be included:
- The suspensory ligaments of the penis
→ Located at the base of the penis where it meets the pubic bone, these ligaments anchor and suspend the penis from the pelvis, stabilize it when erect, and have a close relationship to the central lower abdominal tissues including the linea alba. The main targets here are the suspensory ligament itself, the fundiform ligaments, and associated connective tissues—all of which can be a source of discomfort, pain, tightness, or constriction felt primarily at the penile base and pubic area. In addition, the dorsal nerves and blood vessels of the penis emerge from within the pelvis via a small canal through the suspensory ligaments, and can be compromised when these ligaments narrow this opening or otherwise affect it.
Careful suspensory ligament system work can have multiple benefits by addressing discomfort or pain associated with this area, enhancing penile neurovascular function, giving these tissues and the penis itself more space and ease, and enabling the penis to hang a bit more freely.
- The foreskin (prepuce)
→ The foreskin is largely composed of muscle fibers and connective tissues and is designed to be very elastic so as to cover and protect much or all of the glans when flaccid yet still be flexible enough to accommodate comfortable retraction. In addition, the foreskin has to adapt to the increased size and volume of penile erection and the movements associated with sexual activity. It can, however, be too tight or lack full pliability, thus creating discomfort, restriction, or a lack of mobility. Sometimes it is mobile and retractable when flaccid but not when erect.
Manual techniques designed to remodel myofascial tissues can, via a process called mechanotransduction, induce changes in their shape, baseline tension level, elasticity, and function. When applied to the foreskin, such techniques can increase length, width, stretch, pliability, and ease to address many foreskin restrictions as well as any discomfort or pain. Many of these techniques are easily learned and can be done at home for further benefit, keeping in mind that repetition, consistency and patience are all key to a successful outcome.
Phimosis is generally defined as a condition in which foreskin retraction is limited, difficult, or impossible. Phimosis in children (physiologic) is a natural state before biologic processes loosen and separate the foreskin from the glans, whereas in adults (often classified as acquired, pathologic, or adult), phimosis can be problematic. When considering the use of the above mentioned techniques in cases of phimosis, I am, of course, referring to the adult version.
- The muscles and connective tissues of the penis, and penile rehabilitation (PR)
→ Note that smooth muscles differ from striated muscles in that the former are not under voluntary control while the latter are. Both have the same contractile properties that we associate with muscle function. Most of the main pelvic floor muscles, including the bulbospongiosus and ischiocavernosus, for example, are striated muscles under conscious control. But there are many smooth muscles within the pelvic bowl, highly integrated with the striated pelvic floor muscles, that get far less attention. Several muscles within the pelvic floor itself (not included here), the rectal walls, the bladder walls, the prostate gland, and the urethra—as well as the erectile compartments within the penile shaft and roots—are all largely composed of smooth muscles and connective tissues.
I previously mentioned that the bulbospongiosus and ischiocavernosus muscles wrap around the three perineal roots of the penis that house the erectile chambers contained within. These roots come together and extend well beyond the perineum to help form the distal shaft of the penis—the visible part that hangs down just below the pubic bone. The penile smooth muscles within the shaft and roots are in a normal but mild state of contraction when the penis is flaccid; however, they can become overly contracted or resistant to full relaxation, thus limiting the inflow of blood necessary to create a firm erection. This can affect both penile appearance and erectile mechanics.
Symptoms and conditions associated with such overcontraction include a sense of constriction in the penile tissues; discomfort or pain within the shaft or glans; an hourglass shape when generating an erection; hard-flaccid; altered penile sensations; abnormal, uneven density or tension that pulls or tethers local tissues or creates a minor bend, curve, or hinge within the penile shaft; and other manifestations. Manual therapy techniques applied to the smooth muscles and connective tissues (see next paragraph) of the penis can be a valuable addition to pelvic floor bodywork, when indicated and with permission. I also strongly encourage clients who are experiencing such conditions to perform penile self massage at home and I teach them the techniques required.
There are several layers of penile connective tissues including the superficial dartos myofascia (connective tissue with a high density of muscle fibers), the deep penile fascia, the bilayered tunica albuginea (into which the bulbospongiosus and ischiocavernosus muscles anchor), the urethral walls, and the connective tissues associated with the above-mentioned smooth muscles of the erectile chambers. In many cases the connective tissues are significant contributors to, or primary causes of, constriction, pain, and dysfunction—and deserve as much attention and focus as the muscles themselves. Bodywork techniques targeting the connective tissues of the penis are designed to mobilize, lengthen, realign, reorganize and increase the pliability of these tissues. Such work is applicable and relevant to all of the symptoms and conditions mentioned in the previous paragraph.
The myofascial tissues of the penis, as well as those of the pelvic floor, lower abdomen, and groin can cause or contribute to—via direct effect or referral mechanisms—tension, constriction, pain, burning, irritation, or sensation changes that can be felt anywhere in the penis: base, shaft, glans, tip, or in any segment of the penile urethra. Manual therapy can be an effective way to reduce, better manage, or resolve such issues. Skilled and informed bodywork, as is often the case, is an overlooked or underappreciated treatment approach in such cases.
Penile rehabilitation (PR) is a set of treatment practices intended to restore and maximize natural erectile function after any trauma or injury that degrades or compromises it—as a result of pelvic or urologic surgeries, for example, or any physical (and often emotional or psychologic) trauma. Trauma can involve physical injury, muscular tension or spasm, scar tissue formation, altered nerve function, reduced vascular function, and varying degrees of neurapraxia—nerves that are not structurally damaged but have become dormant due to the shock of traumatic events or experiences. While penile rehabilitation was originally developed in urology to treat men who experienced erectile dysfunction after surgical removal of the prostate (prostatectomy), its uses and applications have broadened considerably in more recent years.
Targeted pelvic floor bodywork, including the bulbospongiosus and ischiocavernosus muscles, the perineal and pelvic floor myofascia, the smooth muscles and connective tissues of the penis, and relevant areas of the groin, inguinal region, pubic area, and lower abdomen can help relieve muscle spasm or tension, prevent erectile chamber atrophy and fibrosis, preserve and enhance connective tissue pliability, increase myofascial function, improve vascular function, enhance tissue oxygenation, re-establish sensory awareness and response, speed the recovery of dormant nerves, and restore the general health, function, and vitality of the penile and perineal tissues.
Bodywork in the context of penile rehabilitation can be applied a an useful stand-alone treatment approach or in addition to the standard panoply of medical PR treatments. Pelvic floor strengthening exercises, when indicated, can also be a component of penile rehabilitation.
Finally, a brief note about soft glans syndrome (also called floppy glans syndrome or cold glans syndrome): While this is thought to be primarily a vascular issue, much is still to be clarified regarding the exact causes and mechanisms involved. Nevertheless, careful manual techniques applied to the glans itself, the tissues along the course of the penile dorsal artery and its branches (its main blood supply), the suspensory ligaments through which the dorsal neurovascular bundle emerges, the corpus spongiosum (the central tube on the underside of the penis, which the glans is an extension of), the bulbospongiosus and ischiocavernosus muscles, and the perineal myofascia may be helpful.
- The penile urethra
→ Most tubes within the body—including the urethra—are composed of connective tissues and smooth muscles, which means they are dynamic and can widen (relax) or narrow (contract) to varying degrees. They can also be the source of unwelcome sensations or otherwise become problematic. Urethral symptoms—including discomfort, pain, irritation, tingling, and/or burning— can be felt anywhere along its course through the perineum, the penile shaft, and/or the penile tip. While we don't usually think of tubes and ducts as logical targets of manual therapy, they—like all other myofascial tissues—can frequently benefit from specific work.
Note that in many cases, urethral irritation, burning, and/or pain can be referred from tense pelvic floor or regional muscles rather than coming from the urethra itself. Many men understandably worry that they have an STD or other infection when urethral burning or irritation symptoms first appear. A trip to the doctor or a clinic is wise in such cases, but if no evidence of infection or other pathology can be found, the myofascial tissues of the urethra itself, the pelvic floor, the groin, and lower abdomen become prime suspects as generators and perpetuators of their complaints.
- The muscles and connective tssues of the inguinal, pubic, and groin regions
→ The region where the upper thigh meets the lower abdomen and pelvic floor contains a multitude of muscles, tendons, ligaments, fascias, blood vessels, and nerves—all of which can be highly relevant to a variety of symptoms and conditions associated with tension, restriction, pain or dysfunction in the front of the hip, inguinal area, groin, pelvic floor, scrotum, penis, pubic area and/or lower abdomen. These conditions can result from, or be associated with, acute or chronic myofascial tightness, overactivity, shortness, adhesions, or scar tissue; groin symptoms from sports injuries or other activities (groin pull, adductor strain, pubalgia, inguinodynia, and others); surgical procedures such as vasectomy or herniorrhaphy (hernia surgery) and chronic pain that can subsequently develop (post-vasectomy pain syndrome, and chronic postoperative inguinal pain, for example); cremasteric synkinesia (see next section); retractile testis; and other causes.
Skillful and informed bodywork targeting the inguinal, pubic, and groin muscles, tendons, and ligaments can help speed healing as well as help better manage or resolve dysfunction and pain associated with the above conditions. This may include the spermatic cord and cremaster muscles, iliopsoas muscles, lower abdominals, adductor muscles of the inner thigh, the pelvic floor, and their associated connective tissues.
- The paired cremaster muscles
→ The cremaster muscles arise from the lower abdomen and are highly integrated with these muscles, especially the internal oblique. They surround the spermatic cord and wrap around, suspend, and support each testicle within the scrotum. Contraction pulls the testicles upward (retraction) and slightly compresses the scrotal contents and spermatic cord, while relaxation allows the testicles to hang lower and the scrotum to be more at ease. Hyperactive, hyperirritable, or overly contracted cremaster muscles can cause intermittent or sustained upward pull on the testicles, often as far as the inguinal region or lower abdomen—bothersome at best and the cause of significant discomfort or pain at worst.
Medical conditions associated with cremaster dysfunction include retractile testis (or testes), cremasteric synkinesia (persistent, involuntary, uncomfortable cremaster contractions triggered by other muscle activity), and any of several scrotal content pain diagnoses (see next section), among others. Bodywork techniques applied to the cremaster and lower abdominal muscles can help re-establish normal baseline function in these tissues and address pain and overactivity.
Note that the corrugated, wrinkly surface of the scrotal skin is caused by the dartos myofascia, not the cremaster muscles—but the two often function together.
- The testicles and epididymes
→ Chronic scrotal content pain (CSCP) is a term that broadly refers to discomfort or pain felt in the testicles, epididymes, other scrotal structures, and/or the spermatic cord. Additional terms that can include scrotal pain are post-vasectomy pain, chronic epididymitis, retractile testis, chronic pelvic pain syndrome, chronic prostatitis, scrotodynia or penoscrotodynia, and cremasteric synkinesia, among others. While there are many possible causes of CSCP, in up to half of all cases no pathology can be identified and no obvious structural abnormalities can be found. Two aspects often overlooked in such cases are the roles of myofascial tension and compression, and fluid sluggishness (stasis). Myofascial tension is a common cause of local or referred discomfort or pain, while stasis can slow or back up fluids within the glands, ducts, or vascular components of the scrotal contents and spermatic cord—also potentially resulting in discomfort or pain.
Herein lies the value of specific massage and bodywork techniques focusing on all the structures that may be causing or contributing to discomfort, pain, or dysfunction: testicles, epididymes, ducts, neurovascular components (including the pampiniform plexus), connective tissue layers, the above-mentioned cremaster muscles, the inguinal tissues, and the lower abdominals and adductor muscles—both of which can be the source of referred pain to the scrotal contents.
It is important to remember the scrotal contents' close structural and functional relationship to the lower abdominal myofascia (originating there before descending via downward stretch and elongation of the abdominal wall tissues, thus forming the scrotum itself), and that many pelvic floor and adductor connective tissues are continuous with those of the scrotum. Further, the nerves that supply the scrotum and its contents travel through the abdominal, inguinal, groin, and pelvic floor myofascia. Because of these relationships, skilled bodywork targeting all these structures can be the key to reducing or resolving scrotal content pain.
Blue balls is defined as scrotal pain after prolonged, intense, or frequent sexual activity unrelieved by ejaculation. Though often ignored in medicine, blue balls is a physiological condition that typically results from an unresolved build up of fluids (vascular and reproductive) coupled with unrelieved myofascial tension (especially in the pelvic floor, scrotal, and inguinal tissues). While it is usually self-limiting—i.e. it eventually goes away on its own—sometimes the system has difficulty resetting back to baseline. In these instances, massage and bodywork targeting the pelvic floor, scrotal and spermatic cord contents (sensitively done), inguinal and groin tissues, and lower abdomen can reset the muscular, vascular, and neurologic drivers of blue balls.
External bodywork targeting some or all of the above myofascial tissues and structures is an excellent way to more fully explore, experience, and inhabit the often ignored yet crucial landscape of the male pelvic floor and pelvic region, and to enhance awareness, control, function, and vitality in these areas. It also is a valuable and effective way to address many symptoms, conditions, dysfunctions, and pain syndromes associated with the pelvic floor, perineum, genitals, groin, inguinal and pubic areas, and lower abdomen, as described above. Moreover, it frequently has positive effects on the wider region—hips and low back, for example—due to the extensive structural and functional relationships between all of these core areas.
Speaking of the core, some readers may wish to look at the information on my companion website coremassage4men.com. My Core Bodywork page on that site lists and describes several categories of men—Explorers, Sufferers, Optimizers, Survivors, Power Users, and Seekers—and how each of these groups can benefit from pelvic floor bodywork by itself or as part of my broader core work. It also includes numerous testimonials from clients describing, in personal terms, the impact and significance of our work together.
Internal Pelvic Floor Bodywork
The internal approach accesses and engages the muscles, connective tissues, and organs discussed below via the anal canal and rectal wall. Gloves or cots are worn, lubrication is used to facilitate entry, and a finger is then gently inserted to varying depths and oriented in different directions depending upon the target tissues. Placement, pressure, movement, pace, technique, and verbal cues are important factors and are employed in a way that enables each client to accommodate the work as comfortably as possible. Maintaining open communication is essential.
- The external and internal anal sphincter muscles (EAS and IAS)
→ The EAS and IAS surround the richly innervated anal canal and govern its function. They have strong connections to, and relationships with, both the wider pelvic floor and the rectum—including the levator ani muscles (especially the puborectalis), the perineal body, the bulbospongiosus, the transverse perineal muscles, the anococcygeal ligament, the coccyx (tailbone), and the rectal wall muscles.
Specific bodywork techniques applied to the EAS and IAS can help address several conditions associated with or caused by anal tension, spasm, hyperactivity, or laxity—including pain with or after bowel movements, anal hypersensitivity, chronic fissures, constipation (when the sphincters are relevant), proctalgia fugax (sharp, episodic, anorectal pain caused by anorectal spasms that last from seconds to minutes), chronic proctalgia, and incontinence.
In addition, men for whom receptive anal sex—often referred to as bottoming—is challenging or painful can benefit from bodywork aimed toward releasing, relaxing, stretching, and retraining the anal sphincters, the anal canal, and the pelvic floor as a whole. Gaining more awareness and control of these muscles is an important step in reeducating and retraining them to more easily and comfortably accommodate penile penetration, digital penetration, or the use of anal sex toys. Anodyspareunia, by the way, is a diagnpostic term describing painful anal receptive sex. Note that research data has clearly shown that receptive anal sex and anal play is more widely practiced than many assume, including among straight men and their partners.
Finally, EAS and IAS work will help facilitate deeper internal pelvic floor work, as described in the following bullet points.
- The perineal body (PB), deep transverse perineal muscle (DTP), and external urethral sphincter (EUS)
→ Directly in front of the anus is a relatively flat, triangular shelf primarily consisting of these three structures and their associated connective tissues.
The perineal body in men is located near the center of the pelvic floor where the urogenital and anal triangles meet, and is a fibromuscular nexus where numerous pelvic floor muscles and connective tissues from both triangles converge, merge, anchor, connect, and continue—making it an especially useful handle through which many pelvic floor muscles can be engaged and treated. Among the many bodywork techniques that can be used here, the perineal body can be mobilized in the same way as described for the anococcygeal ligament and tailbone (see below): by placing the pad of the internal finger on the inner surface, combined with the thumb pad on the external surface, and gently stretching in several directions. Positive effects from these and other bodywork techniques applied to the PB can be felt in the superficial transverse perineal muscles, the deep transverse perineal muscle, the external urethral sphincter, the bulbospongiosus muscle, the anal sphincters, parts of the levator ani, and many pelvic floor connective tissues.
The deep transverse perineal muscle spans the front half of the pelvic floor from side to side, providing a strong platform that helps reinforce, stabilize, and support the muscles above (levator ani), below (bulbospongiosus, ischiocavernosus, and superficial transverse perineal muscles, within (external urethral sphincter), and the structures behind it (perineal body, external anal sphincter, and anococcygeal ligament).
The PB and DTP are thus highly integrated with most other pelvic floor muscles and structures and very deserving of attention both externally (described previously) and internally.
The main, circular part of the external urethral sphincter lies within the deep transverse perineal muscle, upon which the bottom of the prostate gland rests. From this circular part, semicircular fibers rise up like an apron around the front and sides of the lower part of the prostate; these fibers anchor into connective tissues around the sides and in the back of this gland. Careful work directed toward the DTP muscle immediately surrounding the EUS, the connective tissues anchoring the prostate to the DTP, along the sides and back of the prostate gland, and toward the EUS itself are all useful ways to internally engage this sphincter.
Note that the internal urethral sphincter (IUS) is located at the base of the bladder where the bladder outlet meets the top of the prostate. Unlike the external urethral sphincter and the external and internal anal sphincters, the IUS is separate from the pelvic floor and lies above it rather than within it. Several prostate surgical procedures may degrade its ability to function or remove this sphincter altogether; in such cases the external urethral sphincter becomes the sole remaining closure mechanism to prevent urinary leakage and can benefit from strengthening exercises both before and after such surgical procedures.
A dysfunctional or absent internal urethral sphincter also allows ejaculate to travel upward into the bladder—called retrograde ejaculation—rather than down and out through the penis as in normal (antegrade) ejaculation.
- The levator ani (LA) and coccygeus muscles
→ The LA is composed of the puborectalis, pubococcygeus, and iliococcygeus. Together with the coccygeus, these muscles constitute the deepest layer of the pelvic floor and are the only layer that spans the opening at the bottom of the pelvis in its entirety—thus forming the bowl or funnel-shaped pelvic diaphragm. Within and around the pelvic floor, fibers of the LA directly connect to and communicate with the perineal body, the bulbospongiosus, the transverse perineal muscles, the anal sphincters, the anococcygeal ligament, the tailbone, the ischioanal fossa, and the obturator internus. In addition, the levator ani cradles the prostate gland and has many fascial connections to it.
Internal bodywork engages the muscles of the pelvic diaphragm by gently inserting a gloved finger into the anal canal and rectum and applying various techniques to the front, the sides, and the back surfaces of this inner bowl to mobilize, release, stretch, and retrain these tissues and to improve their function. The levator ani group in particular is relevant to a number of manifestations of pelvic pain—levator ani syndrome and chronic prostatitis/chronic pelvic pain syndrome to name just a few—as well as many voiding and sexual dysfunction issues.
- The anococcygeal ligament (ACL) and tailbone (coccyx)
→These have been described in the external section above, and both can be accessed by external and/or internal means. A finger pad on the internal surface of the ACL combined with a thumb pad on its external surface allows for easy, gentle, mobilization and stretch of this ligament and the muscles that directly attach to it (external anal sphincter and levator ani). Likewise, the tailbone itself can be mobilized and gently flexed and extended in the same way, and additional work can be directed toward its associated connective tissues and muscle attachments around its sides, front, and tip.
Attention to all these tissues and structures can help open up this area, address tailbone discomfort or pain, and improve its ease and mobility.
- The prostate gland and prostate massage
→ The prostate gland is an accessory sexual organ that rests upon—and is cradled and supported by—the pelvic floor muscles. It lies below the bladder, in front of the rectum, and behind the pubic bone. The prostate is largely composed of smooth muscles and connective tissues, within which are embedded glands that produce seminal fluid and ducts that connect these glands to the urethra as it passes through the prostate. Immediately surrounding the prostate are multiple nerve bundles that supply the gland itself as well as the penis, perineum, and nearby tissues. During ejaculation, the prostate gland contracts to forcefully express seminal fluid into the urethra where it mixes with fluids from other glands and sperm coming from the testicles to form semen. Due to its rich innervation, it is capable of a range of sensations and responses from significant pain to exquisite pleasure.
Prostate massage was a mainstay of urological practice before the advent of modern pharmaceuticals. Though largely abandoned as standard practice by urologists today, there is general agreement among many experts that this conservative, inexpensive, safe, and non-invasive therapy has multiple potential benefits. Among other things, skilled prostate massage can enhance circulation within and around the prostate, reduce stasis or congestion within its glands and ducts, increase drainage and fluid movement, decrease inflammation, reduce or eliminate sedimentation, alleviate discomfort or pain, address muscular tension, and enhance tissue pliability—in other words, it can play a signifcant role in creating a healthier, more comfortable, and better‐functioning prostate. In addition, prostate massage can have benefits for the prostatic portion of the urethra and the two urinary sphincters (EUS and IUS) that are intimately connected to its bottom and top, thus improving some urinary issues such as, for example, a slow or restricted stream. Prostatic massage is easily performed and can be a valuable and rewarding addition to internal pelvic floor bodywork.
Many men are curious about their prostate, concerned about its health, vaguely aware that it can be a source of pleasure for some men, have heard of or read stories about other's experiences, and/or have questions about it that they are often afraid to ask—but are unsure where to turn for accurate and practical information let alone prostate bodywork. Beyond the benefits for pain and dysfunction, prostate massage in a safe, supportive, and non-judgmental context is an excellent way to learn more about this gland, get a clear, felt sense of its location within your body, explore its sensations and responses, and learn how to differentiate it from nearby structures including the pelvic floor muscles.
Such knowledge and experience can provide a strong foundation from which further exploration in one's personal life can occur.
- The paired obturator internus muscles (OI)
→ As described in the external pelvic floor bodywork section, these pelvic wall and hip muscles have a close relationship to the pelvic floor and to the pudendal canal—through which the pudendal nerve and blood vessels pass on their way to the anus, perineum, and genitals. It can be engaged in several ways, including internally.
A Note about Sexual Energy and Erections
Many of the core muscles and sensory nerves—especially those of the lower abdomen, groin, and pelvic floor—are associated with sexual arousal and response. Thus, working in these areas can give rise to sexual energy in response to physical contact and engagement. This can be a source of anxiety for some men who may wonder: "What if I get an erection?"—which can lead to another question and perhaps bigger fear: "What if I happen to ejaculate?" The physiology of erection and ejaculation is complex and both responses are frequently not within our voluntary control—and can occur regardless of intention. Some men never get erect during a bodywork session, some have intermittent erections, and some are erect for the majority of the time. If and when erections occur, I regard them as a normal response and a non-issue. If a client happens to ejaculate during a session, I allay any feelings of discomfort, embarrassment or shame he may exhibit, and reassure him that he did nothing wrong. Communication, dialogue, and maintaining an open, non-judgemental attitude are essential.
Consider the following two points:
- Worrying about getting an erection or ejaculating will detract from your experience, create tension throughout your body, and make your session less effective and less enjoyable. Pelvic floor and core bodywork is about letting go, opening up, releasing tension, exploring, paying attention to sensations, and allowing the free flow of energy. Worry, anxiety, stress, and fear make it more difficult to experience and embrace these things.
- Sexual energy can be channeled and directed in various ways and used for various purposes. It does not always have to be used for sex. When energy arises (of any sort), it provides an opportunity to work with that energy to unlock tissues, shift awareness, repattern sensory response, enhance vitality, and even heal. Dean Ornish, MD, founder of the Preventive Medicine Research Institute associated with the University of California–San Francisco, for example, states that healing energy and erotic energy are two different forms of the very same thing [1]. I fully agree.
My suggestion to clients is to allow all sensations and responses to happen without worry or censure.
Reference: 1. Ventegodt, S. The Nobel Prize in Medicine Should Go To Dean Ornish. BMJ, 2010;341:c5715
Core Bodywork
'No man is an island' as the saying goes, and this certainly applies to various parts of ourselves including the pelvic floor. It interoperates with and has close relationships to the pelvis as a whole, the thighs and hips, the spine and back, the abdomen and chest, and parts of ourselves beyond these immediate neighbors. Work in these areas benefits the pelvic floor, and vice versa. As noted above, my companion site coremassage4men.com has more details about my core work and how it intersects with pelvic floor bodywork.
Bodyworkers and massage therapists who are interested in adding pelvic floor manual therapy techniques and protocols to their current skill set can contact me about organizing and/or hosting a male pelvic floor training in your city or state. Back to top
Testimonials
"What can I say, you are a good man. I really appreciate all of the information on top of everything we discussed on Thursday. I was really relaxed about my situation on Friday. The fact that I have even discovered the pelvic floor and the fact that it was without doubt the cause of all my issues is huge in itself. So thank you again."
"Your pelvic floor work is way more comprehensive than the two pelvic floor PTs [physical therapists] I have worked with."
"First of all I wanted to thank you for the first treatment we had as I have no pain in my hip as a result of your working that out, honestly thank you. Having never experienced this practice before I am certainly responsive to the therapy and have felt safe in your care. I would like to schedule another session with you [...] and would like to let you guide the session and experience as you wish to, I am totally open to the process."
"There was a lot about it that was so life-changing [...] [the internal pelvic floor and prostate work we did] was transcending."
"Our session was absolutely amazing. Your work is phenomenal, and I love the detail and depth. You have great hands and I trust your touch."
"The pelvic floor massage made me a little nervous at first... but it was total bliss to let go and just relax and enjoy the touch. You are really gifted and you're very gifted in your ability to put people at ease. I could not have gone to the limit of experience today had I not felt the room to go there."
"it was awesome to have the opportunity to work with you via Zoom. I can tell how passionate and knowledgable you are. It would be great to get the opportunity to see you as a client in person someday. Who knows if I will ever get the opportunity, but I appreciate all of the resources and tools to add to the tool box right now. I can't wait to dig in. Thank you again for your time, knowledge, resources, and encouragement. It really means a lot to me."
"Jeff, thank you very much for yesterday. Enormously helpful and encouraging. You are a great teacher—so clear."
"Absolutely amazing. You are a true artist. Life-changing in many ways. Sensations I have never experienced. [...] you elicited feelings I've never had before. [... ] incredible, wonderful, [it] truly was amazing."
"I appreciate the help you've given me over the years. I'd be in pain without it."
"I sense through the work we do together that you are a very giving and generous sort when it comes to your time, thoughtfulness and intention. [...] Also, as always, thank you from the deepest part of me for the work yesterday. It was quite impacting on many different levels."
"That was such a powerful session for me."
"Putting my gratitude in writing feels important. Your intuitive body wisdom, your kindness and care, your patience have all been incredibly supportive for me, both in my life and my spiritual practice. Your skilled bodywork has been an important support over many years. Words, actually, don't fully express the gratitude I feel for you. A deep bow of gratitude."
"You are amazing and you truly have a passion to help people heal their bodies."
"This has been one of the most enlightening conversations I've had in the last ten years."
"Thank you! It was really a pleasure. I already have big improvements from BC [bulbospongiosus muscle] massage. I realize how much hard flaccid I have [been living] with. I sense way more and not so tense. My penis is spongy lol.. more blood flow. Very big difference yet still a long way to go. I am happy about it though."
"It is such a relief from the rectal spasms and I am truly grateful that the treatment with you lessened the frequency of them significantly."
"My utter gratitude to you for the work we did yesterday. I’ve been so contemplative since noon yesterday. I feel that this is just the beginning of a better connectivity between me and my body. Thanks so much! "
"Thank you for the additional information. I learned a lot during our session and I hope to be more conscious of those things in my daily routine. I’ve definitely noticed that my erections are stronger which makes sense. If I come back to SF, I’ll be sure to contact you. Thanks again."
"I felt honored [during our pelvic floor bodywork session] rather than abused [referring to his childhood sexual abuse]."
"I just wanted to let you know that the day after our session I felt a LOT more relaxed and actually had a morning erection ( I rarely have that). But the big thing was I could feel a relaxing buzz in my perineum (maybe near my root chakra?). And I quickly realized if I relaxed enough and focused on the buzzing sensation I could make it feel more pleasurable. The sensation has faded away, but it was definitely a great new feeling."
"Thanks for the masterful massage yesterday Jeff. Truly one of a kind. I enjoyed it very much and was extremely relaxed the entire time." [...] "Can't keep praising your massage enough!"
"Thanks for the resources. [...] Very helpful. Just wanted to say how much I appreciated being heard and validated when I spoke with you. I’ve never had a medical professional ever say anything like that."
"Talking to you has probably been the biggest help, and understanding what I'm going through."
"I would like to be personally evaluated by you, as you've been the most knowledgeable professional I've worked with pertaining to this issue."
"My name is [...]. I was [alerted to] you and your amazing work through taking a male pelvic floor physical therapy course through the APTA. I believe one of the slides had some of your artwork and the instructor gave you credit and mentioned that you were such an amazing resource. I proceeded to look you up and I concur, you are an AMAZING resource!"
"You have such gifted, healing hands and I so appreciate that. Thank you."Back to top
Anatomy man images courtesy of MassageNerd.com. Thanks Ryan!
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