#62 - Pelvic Floor Health and Dysfunction in Men, Part 1

Hi guys, welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thank you for listening. Today I'm actually recording from Tokyo, Japan. On the final leg of an amazing trip working with the Japan Chiropractic Association. So I apologize if my audio is a little less than perfect. Travel microphones don't always have quite the same studio sound quality that you may be used to. Today we kick off a new training called Let's Hear It for the Boys: Pelvic Floor Dysfunction Diagnosis and Treatment Options for Men with Brittany Sudbrook, a fellowship-trained orthopedic manual physical therapist.

Hi, everybody.

Now, please note that in this episode and in episode 63, where we complete part 2 of this training, when we refer to men and women, we're specifically talking about cisgender men and women. There's no refuting that there are some distinct anatomical differences between the 2 groups, the cisgender men and women, but there hasn't been a great deal of public awareness brought to the fact that both groups can actually develop Pelvic pain. Usually when you hear about pelvic pain or pelvic floor dysfunction specifically, it often surrounds postpartum or post-hysterectomy care. But studies have found that at least 1 in 6 cisgender men are dealing with persistent pain in the pelvis, making chronic pelvic pain syndrome the most common urological diagnosis in men under 50. In this 2-part series, we will learn common pelvic floor diagnoses for men. We'll learn how to properly screen and identify pelvic floor dysfunction, and when to refer to a pelvic floor physical therapist. We'll also talk about why it is important to establish a mutual relationship with a pelvic floor physical therapist and how it can benefit your patients. Our featured instructor is Brittany Sudbrook. Owner of Empower Pelvic Health, a practice based in Southeast Houston, Texas. Brittany received her Master's of Science in Physical Therapy at Texas State University, then went on to complete a fellowship in orthopedic manual therapy. She's a faculty member of the Manual Therapy Institute, a post-doctorate fellowship program teaching physical therapists advanced problem-solving and hands-on manual therapy skills. And has taught continuing education courses to hundreds of physical therapists nationwide. This is a fascinating topic and one that can be incredibly helpful to better understand for your patients. Let's cue the intro music and get started.

Thank you. Thank you so much, Jessica. And thank you to all of you who have made time to Be on this webinar with me today. I'm super excited to present with you about pelvic floor, and more importantly, pelvic floor in men. Let me go ahead and give you a little background information on myself and kind of how I got here into pelvic health. I actually have originally started in orthopedics physical therapy, and I was doing this for about 12 years, and I had nothing to do with pelvic floor. At that time, and it wasn't until the birth of my daughter about four years ago that I experienced for the first hand of having my own pelvic floor dysfunction. And I thought, oh my goodness! What am I going to do about this? Went to pelvic floor PT, and it was fantastic. It was great, but it was definitely more looking at like the local segment versus kind of global and what was going on both locally and globally. So I decided to bridge the gap between my orthopedic knowledge and learn more. More about the pelvic floor and integrate both of those. So I do think that we do have some stuff in common that we're gonna be able to talk about today of both local factors and then global factors that influence pelvic floor. And what are some red flags that you can look for when you were with a patient that may be having more global things going on, but not recognizing that they may be impacting the pelvic floor? And so went to, got all of my certifications for pelvic floor, decided to open up my own practice. And so now today I treat pelvic floor dysfunctions. It is still very much a topic that is generally not discussed. It's not something that's on the forefront. Definitely is for more women than it is for men. But men's health, I definitely feel like it's on the rise. And men are definitely getting more attention in this area that is, is needed. And so I'm going to be with you today to share with you Some things that you could be looking at in your own patients to help you to recognize when a referral to a pelvic floor physical therapist is indicated, and then ask, and also how you can help those patients as well. So during this topic here, we're going to have some objectives that I'm going to try to stick by, teach a little bit of things, but try to stick by these things because this is why you're here. So what is the pelvic floor? I know when I went to PT school many, many, many moons ago, It was like a special topic that we could do in PT school. It wasn't really like an area like orthopedics or neuro that we really just took a lot of time and discussed the pelvic floor. If you were interested in the pelvic floor, it was definitely either a subspecialty or you could do a clinical rotation in it. So not a lot of information was given at that time. What is its function and what is its impact on my patients? We're going to discuss the most common pelvic floor dysfunctions in men. Men do carry a lot of common pelvic floor dysfunctions, just like women do, but then there are some differences as well. So we'll discuss those. We're going to also learn how to properly screen your patient and identify when a pelvic floor dysfunction is present, and then how to refer that patient to a pelvic floor therapist. And then why is it essential to be able to establish a mutual relationship? between both a pelvic floor physical therapist and yourself, and how does that ultimately benefit the patient? So we're going to do a little bit of an overview here. So pelvic floor dysfunction is actually quite prevalent in men. Surprisingly enough, the research shows that about 1 in every 6 men will actually have pelvic floor dysfunction. We pelvic floor therapists think that that number is probably a little bit on the higher end. We think maybe like 1 in 4, maybe even 1 in 5 men do suffer from pelvic floor dysfunction. Fortunately, for men, it's not necessarily a topic that they can go to the bar and like discuss with their buddies, right? Not like us women, right? We would like put it on a billboard to let everybody know that we have pelvic floor dysfunction and peeing on ourselves is something that We just accept as common and normal. But men don't often talk about these issues. And so they kind of let it go for months, for years. And then finally, when they've had enough, and it really has to be a bigger driver, right? It's changing their, their life in some capacity for them really to seek care. And by that time, by the time they do actually make it to a physician or what, what so may be, it's generally about 4 years until they are referred to a pelvic floor physical therapist. I know that's really astonishing, 4 years for a man to struggle with something that a woman can go to an OB with and say, hey, I have urinary incontinence, and send me to a pelvic floor PT. But it definitely is something that I think is on the rise. So more and more help is going to be on the way, but definitely 1 in 6 men do suffer from pelvic floor dysfunction. So that's just a little picture showing you really a majority of the superficial muscles of the pelvic floor. And the pelvic floor, it is made up of approximately about 14 muscles. Honestly, it really depends on what textbook that you look in. Somewhere in, say, somewhere between 14 and 17 muscles make up the pelvic floor. Men and women have very similar pelvic floors, but you can see there the picture of the pelvic floor muscles. Majority of these that are shown here are going to be the superficial layer of the pelvic floor. So let's still talk about that, that the pelvic floor is actually a collection of muscles like I just indicated. Depends on what anatomy textbook you look at, 14 to 17 of them, muscles that make up the pelvic floor. There are also ligaments, nerves, and connective tissue that creates a natural hammock that attaches the front of the pelvis to the back of the pelvis. So majority of these muscles do run from the pubic bone and they sling all the way back to the coccyx. And at some capacity, either they have direct attachment to the coccyx, or they attach themselves to other muscles or other connective tissue that also comes in and attaches themselves to the coccyx as well. And so that's very, very important to kind of think of in the forefront as we work through this module here, of how can that impact my patients because of the pelvic floor attaching back to the coccyx. So we'll get through that here in just a second. And then there are major nerve contributions to the pelvic floor, and that's derived from the pudendal nerve. And the pudendal nerve comes from S2 through S4. That's a really cool way to remember it is S2, S3, S4 keeps pee and poop off the floor. This nerve here, though, we indicated in pelvic health is probably the nerve that has to take One of the most tumultuous pathways through the pelvis to innervate the pelvic floor. So if you can kind of nerd out with me for just a moment on anatomy, is that the pudendal nerve is derived, like I said, from the sacral roots of S2-S4. And as it exits out of the sacrum— but here is a model of the pelvis, and this right here is obviously the sacrum. These are the sacral roots. It's going to come out from the sacrum here. And then it's going to actually dive. One thing you don't see here are 2 major ligaments between the sacrum and the ilium here, which is the sacrospinous ligament, which is going to go obviously from here to here. And then you have that sacrotuberous ligament. So they kind of have that little crisscross connection like this. And that nerve, that pudendal nerve, is actually going to pierce through, and it's going to go between those 2 ligaments. As it comes into the pelvis here, and then it's going to go through what we call Alcock's canal. And then as it dives through Alcock's canal, which is inside the pelvis here, it's going to then branch, and it actually has 3 branches that's going to go through to the rectum, to the perineal area, and to the— also the shaft of the penis. And so he just wanted you to know that there is a major nerve contribution to the pelvic floor, and it does come from the pudendal nerve. And we'll talk a little bit here, a little bit more about what does that mean for my patients and how do I know if my patient is potentially suffering from pudendal neuralgia. So we'll go into that in just a second.

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And also too, the pelvic floor is actually divided into 3 layers. There's a superficial layer, there is a middle layer or intermediate layer, and then there is a deep layer. The first layer is primarily for sexual function, and it allows for the penis to achieve full erection. The second layer in the pelvis is for sphincter control, right, to start and stop the flow of urine or also for bowels. And the third layer is to help to stabilize the pelvis. the low back and the hips. And so what I'm going to do is I do feel like we'll talk a little bit about the first and second layer and how that affects your patients. But I think for the majority of who is on this webinar here, we really would like to stop and talk more about the third layer because I think the third layer has probably a bigger impact for the types of patients that you see in your clinic. And that could be suffering from a pelvic floor dysfunction. So I'm going to pause here a little bit and then show you this pelvis. The deepest layer of the pelvic floor, it doesn't matter whether you're male or female, it is the exact same makeup of muscles when you get here into the third layer. So I'm going to show you the inside here so you can see how these muscles do very much sling back from the front here of the pubic bone, and they go all the way back here towards the tailbone and that sacrococcygeal area. So they do sling back like that natural hammock. And so you could see where if you were treating a patient that had something going on with a tighter pelvic floor, the contributions could be that the pull of these muscles here could create changes in both the coccyx and the sacrum and kind of pull them more into like an extended— well, the sacrum would go into extended position. So the pelvis gets tucked up underneath you. And it can also change how the lumbar spine is in maybe potentially less lordosis and more in a kyphotic position. So it can change the orientation of the strong pull from the pelvic floor and how that directly impacts both the coccyx, the sacrum, and also the lumbar spine. Another really cool thing that is just quite fascinating in pelvic floor every time that I treat this, and I promise you, every time someone will come in with symptoms and I'm like, oh, I know exactly what that is. That is this. And it happens to be this darn obturator internus. So I'm going to put my finger right here just laterally. So you can see this right here. This particular muscle is actually the obturator internus. Well, what does the obturator internus have to do with the pelvic floor? Because we all know by our anatomy that the obturator internus muscle is actually a muscle of the hip. It helps to externally rotate the femur. The really cool thing though is anteriorly here, the fibers of the obturator internus sit inside the pelvis. And right in through this area is actually what we call the ATL, which is like a ligamentous fibrous band. That connects the obturator internus to the deep layer we call the levator ani of the pelvic floor muscles. And so oftentimes a problem with the pelvic floor or an issue with the obturator internus can create pelvic floor issues one way or another. They are married together. And so oftentimes pelvic floor problems can also create issues with the obturator internus. An obturator internus, generally speaking, it can give rise to many factors of referral patterns. One of the main ones, it can cause deep buttock pain. That's one of the primary factors that the obturator internus, the referral site for an obturator internus muscle that may be in dysfunction, is it can refer to deep buttock pain. Oftentimes the patient might say like they feel like they're sitting on like a ball or golf ball or something like on the, on the one side of their butt, or even honestly into the rectum. This can refer into the rectum as well. Another thing that we normally see that you're going to have to use your differential diagnosis with is also hamstring insertional tendinopathy. Is that it looks like, smells like, acts like insertional hamstring tendinopathy, when in really it is the obturator internus that is referring pain to this area as well. So those are kind of the 3 major things that we typically see with the obturator internus. I'll add a 4th one on there too, just while I'm thinking about it, is also pudendal neuralgia. Because if we look at this here, is that That nerve is going to come through here, and it has to actually pierce through Alcock's canal. That's obturator. This is pelvic floor. So a little bit of increased tone or tension in this area is going to tug on that nerve, and that can also create rectal pain. It can create perineal pain, and it can also create pain to the shaft of the penis as well. So that's a major factor of that 3rd layer of the pelvic floor. And how does that impact the patients that you particularly see? And that's the importance of this third layer is to help to stabilize both the pelvis, the hip, and also the low back. Awesome. And so we're going to move away for just a second of kind of talking about the anatomy and really talking about the function of the pelvic floor. I love to use this analogy with my patients when talking about the pelvic floor. Because in general, first off, when we think about pelvic floor, the first thing we think about is a postpartum woman, right? Let's be honest. That's kind of honestly how this all got started. We're back in the 1960s where the term Kegel came from, which is a pelvic floor contraction. It was from Dr. Kegel, who is an OB-GYN physician that termed this as a pelvic floor contraction. And so that's the first thing that we think about with pelvic floor dysfunction is someone who has given birth. We know now if you come up to the 21st century is that everyone has a pelvic floor and there is a function of the pelvic floor. So in general, the pelvic floor needs to be able to do 3 things. The first thing that it needs to be able to do is it needs to be able to contract. So these muscles do need to be able to pull up. Up into the pelvic cavity to contract. And that is with 2 variations, either in isolation with a pelvic floor contraction, AKA a Kegel, or these muscles need to be able to also function with what we call global muscles that are also associated with the pelvic floor, like your transverse abdominis and your glute max muscles, Your diaphragm also is very important for pelvic floor as well, and so these muscles you can see in isolation of doing a Kegel, or they need to be able to contract with utilization of global muscles as well. The next thing that the pelvic floor needs to be able to do is it actually needs to be able to rest. We know that this theory that all muscles in the body have a normal resting. Tone, and normal resting tone is when you're not doing a pelvic floor contraction or you're not doing a global activation of other muscles that influence the pelvic floor. Just naturally, the pelvic floor should have what we call resting tone. That's its baseline. And then what happens from there is whether it goes up and contracts, but then comes back down to that resting tone. Or the third thing is that pelvic floor actually needs to be able to bulge, which means the pelvic floor needs to be able to relax and go the opposite direction. And so things like pee and poop can come out. I love this little diagram here of what we call a dimmer switch. I always give my patient the dimmer switch analogy. And so if you can look at the dimmer switch here, don't worry about the little button. And the dimmer switch is actually perfect because it's halfway up. Of being completely on, and it's halfway down of being completely off. So if you can just, for the sake of this example, just think about if the dimmer switch was all the way to the bottom, it's completely off. That means that's resting tone for the pelvic floor. That's its natural baseline resting, nothing's happening. And then what happens if you decide to do a pelvic floor contraction or use your global muscles? That dimmer switch needs to rise to the on button, right? So it starts to rise, it gets brighter, it gets brighter, it gets brighter. We've got full contraction. And then it needs to be also be able to do the opposite of that and come down and go back to the resting baseline of what is normal for that tension or tone of that muscle. The issues that happen oftentimes is that 90% of the patient population Actually have their dimmer switch on, whether that be on a quarter of the way, whether that be on halfway. Regardless of that, there's too much tone in the system, which can drive to have other issues like urinary incontinence, tailbone pain, low back pain, hip pain. And so when that dimmer switch stays on, that muscle only has a small available range. To be able to contract. And we know that when muscles are contracted in a shortened range, eventually in that short range, they are weak and no longer able to do their job and to stabilize the pelvis as they should. So they get stuck more in the on portion of the dimmer switch instead of allowing the dimmer switch to come back down. And be at its resting baseline and tone. And so that is a great example. If you're trying to tell your patients a little bit about the pelvic floor, just say, hey, I want to refer you over to pelvic floor, and this is kind of what I'm thinking. You're more than welcome to use the dimmer switch analogies just so people can wrap their brains around, like, what does that mean? Because ultimately, we always thought that when you have a pelvic floor issue, dysfunction, That the pelvic floor is weak. And if the pelvic floor is weak, that must mean that the muscles themselves are in an elongated position and they don't have the ability to fully contract to stabilize. And so then they go back to this elongated position, but we know 90% of the time, that's not really true. We actually have too much tension in the system. We lose the ability for that muscle to go through its full range of available motion. And something that is shortened only has a smaller range, therefore creates weakness too. So you can give your patient that analogy as well. So that is in a nutshell, so to speak, is that is the 3 things that the pelvic floor needs to be able to do: contract, live in its resting position, and be able to bulge down to allow pee and poop to come out. So that's the local level. So now what we're going to look at is a little bit more on a global level, and I think this is super important to understand because this is where we can really help our patients who may not be presenting with you with a direct pelvic floor problem, but could be having a pelvic floor issue that is not resolving the reason that the patient is coming in to see So the global system that does have an effect of the pelvic floor is going to be the pelvic floor itself, which we've already just talked about. That, that's the bottom of the hammock. You can see here on the diagram, if you look down, it says muscles of the pelvic floor. So that's the bottom of what we call the container. Oftentimes you might hear this terminology of these 4 muscles as the piston. But you have the pelvic floor on the bottom. On the top of that, you have the diaphragm. The diaphragm is a muscle that really does play well with the pelvic floor if the diaphragm is working in its full capacity. And so when you breathe in, so the diaphragm is the major muscle for inspiration. So when you take a breath in, that diaphragm is going to contract. When the diaphragm contracts, it is going to push down upon the container space, and the pelvic floor is going to naturally expand and open. So this is one thing that you can work with your patients if you're suspecting a little bit of high tone or hypertonicity in the pelvic floor, is just generally breathing, or maybe looking at the way they are breathing and making sure they're getting that really good diaphragmatic breathing. We call it breathing 360. So good rib cage breathing all the way around, and they're not taking short shallow breaths or breathing up into their shoulders this way, because if that's the case, that's going to create more tone into the pelvic floor. So the diaphragm and the pelvic floor work hand in hand. Another muscle that works hand in hand with the pelvic floor is the transverse abdominis muscle. We have done so many EMG studies that indicate that in order to properly recruit and activate the pelvic floor musculature, transverse abdominis activation needs to happen as well. That transverse abdominis activation has a better capacity to build strength within the pelvic floor than just an isolation of Kegels only. So we have research that indicates that transverse abdominis helps to strengthen pelvic floor. Better than just isolation of Kegels alone. And then you can look at the backside of this diagram, and then you have the multifidus, and that is going to round out our container space. And so we know the transverse abdominis comes back, goes anterior, wraps around posteriorly through the thoracolumbar fascia, can increase stability or content in that area. And then we know that has an effect, great effect, on the transverse abdominis. And the multifidus coactivation together. So you can see here, these 4 muscles work hand in hand with the pelvic floor. Those are more of the global system. Some of the other associated muscles that can also have an effect of the pelvic floor are going to be the glute maximus because of its direct attachment into the coccyx, into like the sacral area. That can play in big time with the external anal sphincter as well. And then also that obturator internus, or your hip external rotators, can affect the pelvic floor as well.

That's it for today's episode. Be sure to tune in for part 2 in episode 63, where we will continue this discussion and dive deeper into the important role of proper breathing mechanics in correcting pelvic floor dysfunction. We will also touch on the impact these conditions can have on the mental health of your patients, as well as best practices for collaborating with other healthcare providers. You won't want to miss it. Episode 63 drops in 2 weeks. And be sure to visit our show notes where you'll find a link to a free— yes, I said free— online course, the link to the full recorded webinar replay from this episode, as well as a link to sign up to get notified when new courses are released. We've got some exciting new courses in the works, so you'll wanna be sure to do that. Plus, you'll receive a free gift just for getting on the list. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Give us a five-star rating to help us grow the show. Every little bit helps. We'll see you next time.

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