Male Pelvic Floor: Advanced Massage and Bodywork

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 rigidity, the propulsive force of 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 one's 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, enlightening, 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, Deep Tissue Massage, Trigger Point Release, Swedish Massage, Cross-Fiber Manipulation, Positional Release, elements of 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 employ testing protocols to evaluate pelvic floor strength, endurance, and function—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.

Section links and the topics within are:

External Pelvic Floor Bodywork ♦ The bulbospongiosus muscle ♦ The ischiocavernosus muscles ♦ The superficial transverse 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 smooth muscles of the penis and penile rehabilitation ♦ The penile urethra ♦ The myofascial and neuromuscular tissues of the inguinal, pubic, and groin region ♦ The cremaster muscles ♦ The epididymes and testicles, and blue balls

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 and ♦ The obturator internus muscles

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External Pelvic Floor Bodywork

The external approach engages these muscles in the same way that most other muscles of the body are massaged, mobilized, and stretched: by using pressure and movement on and through the skin. Many pelvic floor muscles can be accessed in this way and a few of them can only be accessed via the external approach (i.e. bulbospongiosus and ischiocavernosus muscles, for example). Several additional myofascial tissues that I discuss below—the suspensory ligaments of the penis, the cremaster muscles, the groin and inguinal tissues, the foreskin, and various other structures—are, as well, only accessible externally.

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 discomfort, pain, and dysfunction; 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 helps facilitate and augment internal pelvic floor work when that is to be 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.

Regardless of the motivation for seeking out my work, I will provide a pelvic floor bodywork session that is seemless and comfortable, 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):

The bulbospongiosus muscle (BS). The BS surrounds 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 coccyx via the anococcygeal ligament) in the back, adheres to the deeper perineal myofascia 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 functional continuum from the tailbone to the tip of the penis. Among other things, 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. Conditions that benefit from specific attention to the BS include penile retraction, tip of the penis or shaft pain, perineal tension and pain, penoscrotodynia, hard flaccid, erectile dysfunction, premature ejaculation, weak ejaculatory propulsion, post-surgical sensory and sexual impairment, 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). These muscles encircle the left and right perineal roots of the penis, within which lie additional erectile chambers. The IC muscles run along the inside surface of the ischial and pubic bones of the pelvis, merge with the bulbospongiosus, and anchor into the main layer of connective tissue 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 IC muscles are relevant to most of the conditions listed in the BS 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 closer 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 of the penis runs close to the IC muscles and within their associated connective tissues, making it susceptible to the effects of excess tension or restriction that can ultimately affect all areas of the penis that the dorsal nerve supplies. 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 bulbospongiosus section. Beyond that, it can improve the health and function of the penis, perineum, and pelvic floor.

The paired superficial transverse perineal muscles (STP). These small muscles anchor into the left and right sit bones (ischial tuberosities) and connect centrally to the perineal body, where they share fibers with the bulbospongiosus, external anal sphincter, deep transverse perineal muscle, and some central fibers of the levator ani group. While rarely problematic by themselves, they are part of the larger whole of the pelvic floor and easily incorporated into external pelvic floor bodywork.

The deep transverse perineal muscle (DTP). The DTP and its associated connective tissues horizontally span almost the entirety of the 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) toward 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), it 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.
It can be engaged from an external and/or internal approach and is accessible externally through 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 external anal sphincter (EAS) and external urethral sphincter (EUS). While parts of the EAS 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 bulbospongiosus 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 much 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 (bottoming).
The main portion of the external urethral sphincter is embedded within the middle layer (DTP) of the pelvic floor, thus making it amenable to work from below (external) and above (internal). External pelvic floor bodywork techniques applied around the periphery of the bulbospongiosus 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. This portion 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 is infuenced by external work through these and other external pelvic floor tissues, it is much more directly accessible via the internal approach as described below.
The LA 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, clearly demonstrating the value and importance of comprehensive pelvic floor bodywork.

The pelvic floor attachments on the inside border of the sit bones. Several pelvic floor muscles and connective tissues come together and anchor into the inside surface of the left and right sit bones (ischial tuberosities), including the ischiocavernosus, the superficial transverse perineal, and the back portion of the deep transverse perineal muscles and their associated connective tissues. In addition, the pudendal nerve and blood vessels course through this area on their way to the perineal and penile tissues. This concentration of structures makes this a useful and rewarding area to incorporate into external pelvic floor bodywork.

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 the pudendal canal that houses the pudendal nerve and blood vessels adheres to and travels along the inner surface of the OI, within its connective tissues and adjacent to the 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 pudendal nerve compromise. Back to top

Several highly relevant pelvic floor structures beyond the main muscles 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 location, 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 this center will distend, or stretch, all the radiating filaments of the web. A very similar effect occurs with pressure on the perineal body, 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 ACL 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 ACL 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 at 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 ligaments. All pelvic floor muscles that end with geus 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 pelvic floor muscles can address 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 ACL and coccyx.

The second chakra or energy center—swadhisthana—is located at the tip of the tailbone where the ACL attaches to it, and is associated with subconscious instinct and expression, pleasure, and all means of gratification, among many other things. The pelvic floor is unique in that it houses two of the seven chakras.

The ischioanal fossa (IAF). The IAF is comprised of two parallel, elongated, three-sided pyramid-shaped spaces whose tips point toward the pubic bone and base faces backward (i.e. two 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 connective tissue and fat, but—importantly—major nerves and blood vessels and their rectal, perineal, and genital branches pass within or 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. Back to top

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 some aspects can be particularly intimate. 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. 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. Using the principles of mechanotransduction, specific manual techniques designed to remodel myofascial tissues can induce changes in their shape, baseline tension level, elasticity, and function—resulting in additional length, width, stretch, and pliability. These techniques are as relevant to the foreskin as they are to other myofascial tissues (including scar tissue, which can be a factor in some foreskin restrictions), and skilled application of these techniques can address such issues. As well, some of these techniques are easily learned and can be done at home for further benefit. Consistency and patience are both 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 without any active associated disease processes.

The smooth muscles and connective tissues of the penis, and penile rehabilitation (PR). Note that smooth muscles differ from striated muscles in that the former is not under voluntary control while the latter is. Both have the usual contractile properties that we associate with muscle actions. 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. Beyond the pelvic floor itself, the rectal walls, the bladder walls, the prostate gland, and the urethra—as well as the erectile chambers of the penis, are all composed of smooth muscles and connective tissues.
I previously mentioned that the BS and IC muscles wrap around the perineal roots of the penis that house the erectile chambers contained within, but these roots—and their associated erectile chambers—come together and extend well beyond the perineum to form the distal shaft of the penis (the visible part that most of us mean when we refer to the penis). The penile smooth muscles are in a mild state if 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. Additional conditions associated with such overcontraction are discomfort or a sense of constriction in the penile tissues, an hourglass shape when generating an erection; hard-flaccid; abnormal, uneven density or tension that pulls or tethers local tissues or creates a minor bend or curve of the penile shaft (penile connective tissues are equally important here); and other manifestations. Manual therapy techniques applied to the smooth muscles of the penis can be a valuable addition to pelvic floor bodywork, when indicated and with permission. I also strongly encourage clients to consider self massage to these tissues and teach them the techniques required.

There are several layers of penile connective tissues including the superficial dartos myofascia, the deep penile fascia, the tunica albuginea, 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 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 conditions mentioned in the previous paragraph.

The penile tissues, as well as those of the pelvic floor and lower abdomen, 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. While it 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. Many traumas result in muscular tension or spasm, reduced vascular function, and some degree of neurapraxia—nerves that are not structurally damaged but have become dormant due to the shock of traumatic events or interventions. Bulbospongiosus, ischiocavernosus, perineal, and penile bodywork 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, improve or resolve neurapraxia, and restore the general health, function, and vitality of the penile and perineal tissues. Appropriate, targeted, bodywork, with particular attention to the aformentioned pelvic floor and penile tissues, can be used as an excellent stand alone treatment approach for penile rehabilitation or as an 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 about the exact causes and mechanisms. Nevertheless, careful manual techniques applied to the glans itself, the tissues along the course of the 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 have the ability to widen (relax), narrow (contract), lose their pliability, or otherwise become problematic. Symptoms—including urethral discomfort, pain, irritation, and/or burning— can be felt anywhere along the course of the penile urethra or at 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 are referred sensations from the pelvic floor or other muscles rather than from the urethra itself. Many men are convinced that they have an infection when urethral burning or irritation symptoms first appear. When a trip to the doctor and medical tests reveal no evidence of infection, however, the myofascial tissues of the pelvic floor and urethra become prime suspects.

The myofascial and neuromuscular tissues 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 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 be a result of, or associated with, acute or chronic myofascial tightness, overactivity, shortness, adhesions, or scar tissue; groin injuries from sports or other activities (groin pull, adductor strain, pubalgia, inguinodynia, and others); vasectomy, herniorrhaphy (hernia surgery), and other surgical procedures (post-vasectomy pain syndrome and chronic postoperative inguinal pain, for example); cremasteric synkinesia (see below); retractile testis, and other causes. Skilled and informed bodywork—targeting the inguinal and pubic muscles, tendons, and ligaments; spermatic cord and cremaster muscles; iliopsoas muscles; lower abdominals; adductor muscles; and pelvic floor— can help speed healing as well as help better manage or resolve dysfunction and pain associated with such conditions.

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 bullet point), among others. Specific bodywork techniques directed at the cremaster and lower abdominal muscles can 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 epididymes and testicles, and blue balls. 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. Other terms that include scrotal pain are post-vasectomy pain, chronic epididymitis, retractile testis, chronic pelvic pain syndrome, chronic prostatitis, scrotodynia or penoscrotodynia, and cremasteric synkinesia. 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 or compression, and fluid sluggishness (stasis) in the glands, ducts, or vascular components of the scrotal contents and spermatic cord. Herein lies the value of light, gentle, 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, and inguinal tissues. In addition, it is important to remember the scrotal contents' close relationship to the lower abdomen (originating there before descending via downward stretch and elongation of the abdominal wall tissues, thus forming the scrotum itself), and that many pelvic floor connective tissues are continuous with those of the scrotum. Further, the adductor muscles of the inner thigh can refer pain to the testicles and scrotum. 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 and orgasm. 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 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.

Skilled external bodywork targeting some or all of the above myofascial tissues and structrures is an excellent way to explore 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 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, thighs, and low back, for example—due to the extensive structural and functional relationships between all of these central 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 unsolicited testimonials from clients describing, in personal terms, the impact and significance of our work together. Back to top

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 in different directions depending upon the target tissues. Placement, pressure, movement, pace, technique, and verbal cues are important factors and should be 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 sphincters (EAS and IAS). These muscles 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, and the rectal wall muscles. Specific bodywork techniques applied to the EAS and IAS can help address several conditions associated with or caused by 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), and chronic proctalgia.
In addition, men for whom receptive anal sex—commonly referred to as bottoming—is challenging or painful can benefit from bodywork aimed toward releasing, relaxing, stretching, and desensitizing 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 sex toys. Anodyspareunia, by the way, is a medical term describing painful anal receptive sex.

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.

The DTP 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 and ischiocavernosus muscles), within (external urinary 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. Among the many bodywork techniques that can be used here, these myofascial structures 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. These mobilizations also positively affect the superficial transverse perineal muscles, the external urethral sphincter, the bulbospongiosus muscle, the anal sphincters, and parts of the levator ani.

The main, circular part of the external urethral sphincter lies within the DTP, 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. 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.

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.
Internal work engages the muscles of the pelvic diaphragm by gently inserting a gloved finger in through the anal canal and applying various techniques to the front, the sides, and the back surfaces of this inner bowl to mobilize, release, and stretch these tissues. 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 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 muscles and connective tissues that attach to the front and sides of the lower sacrum can also be accessed and engaged internally.

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 muscle and connective tissue, within which are embedded glands that produce seminal fluid and ducts that connect these glands to the urethra as it passes through the prostate. 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. 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: improved circulation within and around the prostate, reduced stasis or congestion within its glands and ducts, better drainage and fluid movement, decreased inflammation, diminished pain, reduced muscular tension, and increased pliability—in other words, a healthier, more comfortable, and better functioning prostate. Prostatic massage is easily performed and can be a valuable and rewarding addition to internal pelvic floor bodywork.

Beyond 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 (OI) muscles. 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. Back to top

A Note about Sexual Energy, Erections, and Ejaculation

The pelvic floor muscles are very involved in sexual response and activity, and work here can give rise to sexual energy. For a number of men, this can be a source of anxiety when considering whether to schedule a pelvic floor bodywork session. "What if I get an erection?" some may ask, sometimes leading to another question and perhaps bigger fear: "What if I happen to ejaculate?" The physiology of erection and ejaculation is complex and both of these responses are often outside of our voluntary control—and can occur regardless of intention. I regard erections during a session, if they occur, as a normal response and a non-issue; if a client happens to ejaculate I reassure him that it is OK and is not cause for any shame or embarrassment. Communication and dialogue 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 bodywork is about letting go, opening up, 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, for example, unlock tissues, shift awareness, repattern sensory response, and enhance vitality. As Dean Ornish, MD, founder of the Preventive Medicine Research Institute associated with the University of California–San Francisco medical school, has said: sexual energy is healing energy.

My suggestion to clients is to allow all sensations and responses to happen without worry or censure.

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 legs 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."

"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

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

Pelvic Floor Massage and Bodywork