#63 - Pelvic Floor Health and Dysfunction in Men, Part 2

Hi guys, welcome to another 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 am recording back at our headquarters in Houston, Texas. As many of you may have heard on our last episode, we were in Japan and visited Tokyo, Osaka, and Kyoto for a number of weeks. It was an incredible experience, and while I'm sad to say that it's come to an end, I was very excited to get back home and back to work. Our team has so many exciting things in the works for 2024 that they've certainly kept me busy. Now, in today's episode, we're going to pick back up with part 2 of our series titled 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. Please note that in this episode, as in part 1, when we refer to men and women, we are referring to cisgender men and women. Now, today we will 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 and cover best practices for collaborating with other healthcare providers. So, pull up a chair, open the Notes app on your phone, and get ready. Today's episode is full of great information that you can implement into practice immediately. Let's get started.

So the next thing that we're going to look at, now that we have covered a little bit of the anatomy of the pelvic floor, we've talked about the local structures of the pelvic floor, and then global structures of the pelvic floor that are— that can impact the pelvic floor. Or what are some of the common pelvic floor diagnoses? And so the, some of the most common pelvic floor diagnoses that we see in men are listed here for you. Urinary incontinence. Yes, this is a thing. Men can suffer from urinary incontinence. The second thing is constipation. Constipation is one of the major factors actually to urinary incontinence. And so if a patient is suffering from constipation and they're able to list that on their medical intake form, that is definitely something, a question that I would lead with next is asking them if they've ever had any issues with loss of bladder. With the rectum just being posterior to the bladder, that can create issues, too much content into the rectum. Can push anterior onto the bladder and also intra-abdominal pressure can create a little bit of leakage. So that's a question that I would ask. The one that's the probably the most common, I think, that is out there and just like in general in terms of the world is erectile dysfunction. So we often see erectile dysfunction and that can be just with pelvic floor muscles being too tight is that creates issues with the muscles And can create those problems. Also prostatitis, that's another common thing that we typically see. Pedendal neuralgia. So we talked about that earlier at length about the pedendal nerve and that tumultuous path that the pedendal nerve has to go through to make itself into the pelvic cavity. One of the things that I would also indicate with this one is that you, if you treat a lot of men, who are cyclists, and cyclists that they're sitting on their cycle seat or their bike seat for prolonged periods of time. That is a huge differential diagnosis for that patient population. Men's pelvises are a little bit more narrow in stature than females are. So the ischial tuberosities are a little bit closer together. And so sitting on the bike seat When they sit on there can compress where that pudendal nerve comes down through, and it can create compression in the area. So cyclists often have pudendal nerve problems. Also levator ani syndrome. Levator ani syndrome is just another word for that third layer of the pelvic floor having too much tone in it. That can create pelvic floor problems, like, so pelvic pain. It can create obturator internus issues, pudendal problem, pudendal neuralgia. So those types of things. Another one is sciatica. Sciatica could be more driven from a lumbar issue, a spinal issue. And the research does show— I'm going to get a little ahead of myself for a second, but the research does show that having a history of low back pain That 90% of patients with history of low back pain also have a pelvic floor dysfunction. So definitely keep that in mind when you are treating your low back pain patients. This is something that I saw when I was just specifically in orthopedics. It seemed like with my low back pain patients, I could get them maybe 90, 95% better. And then that's pretty much it. I really wish I had the capacity that I have now. to go in and look at the pelvic floor internally and see what the pelvic floor was doing and see if those were some contributing factors to their low back pain. So I would say probably low back pain should be almost an immediate referral to pelvic floor, but we'll talk about that and a couple of other associated factors that would also refer to pelvic floor PT. Another one is chronic pelvic pain syndrome. So this can be chronic prostatitis, interstitial cystitis for men, bladder pain syndrome, where a patient feels like they have to urinate constantly. They can never get any relief. Even when they try to urinate, they just have this constant, like, pressure or urge or burning sensation before urination, during urination, or after urination. And those also would warrant further investigation from pelvic floor PT. Other associated pelvic floor dysfunctions besides the ones that we just discussed. Number one was the low back pain. We already talked about that. 90% of patient population of low back pain also have a pelvic floor issue. Hip osteoarthritis, something that I would also classify into hip osteoarthritis would also be labral tears. Just because of that close association of the obturator internus Any type of hip issue, whether that be OA of the hip, labral, any type of limited mobility in the hip, just because of its association with the obturator internus. The second one, or like another one that I would discuss, would be also groin pain. Groin pain could be from the adductors. It could also be from the pelvic floor. Also too, sometimes groin pain could be In combination with scrotal pain. And if that is the case, scrotal pain definitely referring to pelvic floor PT. That can be coming specifically from the pelvic floor itself. It could also be coming from the psoas muscle, nerves that surround the pelvic floor that could be producing growing pain or scrotal pain. And then also that thoracic lumbar junction. So all of those areas can produce the growing pain or also the scrotal pain. Hamstring strains. That's another one that could often be the obturator internus. So if you have a hamstring strain that's just not getting better, maybe not getting better as fast as you would like it to, that would be another reason for referral to pelvic floor PT. Umbilical hernia is another one because that's a pressure management problem. Umbilical hernias can happen for various reasons. It can be with or without association with diastasis recti. I know diastasis recti tends to be one of those key terms that we only think women can have diastasis recti. That is not true. Men can have it too, especially if men were a little larger and decided to, to lose a little bit of weight pretty rapidly. They can develop diastasis recti, too much pressure being displaced on the linea alba, very rapid weight loss. It can create issues. So umbilical hernia, diastasis recti is a pressure management issue and also a global problem, but definitely referral to pelvic floor PT to look at the pelvic floor is warranted as well. And then also patients with psoas strains, because oftentimes those can be a referral from the pelvic floor. So pelvic floor dysfunction can refer to the psoas area. And create those types of issues. So here are some examination questions that you may be wanting to ask yourself. I feel like at one point before I became a pelvic floor therapist, I never really asked these questions. It never really dawned on me. A patient was there for low back pain or for hip pain. I never once thought about asking these questions, and I think that these questions are phenomenal questions if you've never had. The opportunity, or maybe even uncomfortable to talk about sexual dysfunction, to talk about urinary issues or bowel issues. If you feel like you're uncomfortable, these questions here are good questions to ask. And on the next slide, in just a second, we actually have a screening protocol that you can give your patients and have them answer the questions and then kind of go from there. But we'll talk about those. So, one of the questions. For your patient is, is there a history of low back pain, hip pain, groin pain, or sciatica? With those, it's typically also there's a prevalence of pelvic floor dysfunction. And so with that, you can send your patient to pelvic floor PT so that you guys can co-treat those patients together. Another one is a fall on the tailbone. Remember back earlier, we talked about all the muscles that attach to the tailbone and the pelvic floor, which are pretty much all of them or have some type of associated pathway to attach to the tailbone. So even if there's a fall as a child, a fall on the tailbone is definitely warranted for further investigation. If your patient is complaining of pain in their genital area, their perineal area, their pelvic area, bladder area, or also have pain with urination, that's another referral to pelvic floor PT. Also loss of urine. Difficulty starting Or stopping the urine, or the inability to completely evacuate the bowels or bladder. Oftentimes, this is another big indicator that there's too much tension in the pelvic floor system, and that is what's driving those things. Post-void dribble, also difficulty initiating a bowel movement, or incomplete emptying of the bowels, or also straining to have a bowel movement. Pain with intercourse, difficulty in maintaining and/or achieving erection. Prolonged sitting may increase your symptoms as well. And so these are good questions. So, on the next slide, Jessica is going to go ahead and give you guys this tool. This is the Cozene pelvic floor screening tool. There are actually 10 questions. And so, if you're not comfortable asking your patients some of these, Questions about their sexual health or about having bowel movements or urinary function. This is a great screening tool to have into your clinic. Ask the patient to, to go ahead, fill it out. And if they indicate 3 or more, so if they put checks on 3 or more of these, then that is a highly likelihood that there's a pelvic floor dysfunction and a pelvic floor referral to pelvic floor PT would be indicated. Would be indicated. So go ahead, take a look at that and download that and use that into your, your clinic. So we've covered a lot of information about what is the pelvic floor, what is its function, what are some common diagnoses that we may see in men's health, and where do we go with that? What do we do with that? I truly believe that a better recovery really starts with gaining a great relationship between you as the healthcare practitioner whether you be a PT, an OT, a chiropractor, whatever that may be, is you recognizing that there is an issue firsthand, especially in men's health. Remember I'd mentioned earlier on that men typically go 4 years before getting to the right place to help them with their pelvic floor dysfunction. And so being able to screen these patients better, And sending them over to a pelvic floor therapist is really ultimately going to be a better recovery for the patient. And so I truly feel like it is essential for a referral to a pelvic floor PT if you suspect that there is a pelvic floor dysfunction. We've talked at length so far about different things that can create pelvic floor dysfunction, about common diagnoses to look at, how to screen your patient for those, a screening tool. And then a pelvic floor PT can help look at the pelvic floor from a local area. So they locally can assess, address, and treat the pelvic floor internally. So we do, do internal assessments as long as the patient is comfortable for that. That is how we gain our information of the overall health and success. Of the pelvic floor is internally. Also the PT. So some things that you should be able to get on your end is the PT. So if you refer that patient to a PT, the PT should communicate with you as well about their findings. And how do you both work together with the findings that the therapist found at the local level and how you can work together at a global level? Because there are many factors.

Mm-hmm.

That affect the pelvic floor. Even the down to the foot affects the pelvic floor. The striking of the foot and how the forces are transmitted from the foot and ankle to the knee to the pelvis has an impact on the function of the pelvic floor. So you both should be working hand in hand together for the overall better improvement of this patient. So, Together, it would be best if you both can come up with a plan to help that patient, the pelvic floor PT internally, the other healthcare professional externally, and a global plan together to ultimate success for your patients.

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And that concludes this module here about pelvic floor men's health. What are some common factors, some diagnosis? And how do you assess and be able to refer your patients to pelvic floor physical therapy? I think at this time, we're going to go ahead and open it up to any questions that you may have.

Awesome. Thank you so much. I do have a few questions that have come in here. We'll kind of dive into those right away. Are there any specific sports that you find I know you mentioned cycling is sometimes something that can contribute to pelvic floor dysfunction in men. Are there any other sports such as bodybuilding, any extreme sports that would be very likely to cause injuries that may kind of start a cascade of unfortunate events to cause pelvic floor dysfunction?

Yeah, great question. The answer to that is yes. We see a lot of it in bodybuilders or men who are lifting very, very heavy that have an increase of intra-abdominal pressure. So they're distending that pressure either anterior onto the abdominals or downwards onto the pelvic floor for prolonged periods of time. When I say prolonged periods of time, I don't mean like in time of their like intra-abdominal pressure, they're holding it for 30 seconds. I mean for the course of their lifting, and they've been lifting for 5, 6, 7 years this way, can contribute to the increased tension of pelvic floor. So we typically see that more in like bodybuilders or physique patients who are doing like more physique type of building. But anytime there's an increase in intra-abdominal pressure, it's going to directly impact the pelvic floor.

Absolutely. That definitely makes total sense. When it comes to having this discussion with your male patients, let's say I'm a practitioner, I'm seeing some of these red flags, I've given them the assessment that you provided, and it looks like it's time to refer out. for pelvic floor PT. How do you begin to have that conversation when maybe your patient just thought they were having low back pain and you're a chiropractor, you should be able to fix my low back pain, or I come into PT because I have sciatica, that's not what this is. How do you have that conversation in a gentle way that helps them understand that it affects so much more than just their low back pain?

We get that all of the time, and to answer it is When a patient's coming to see you for sciatica or for low back pain, it's not going to be on the forefront. It may now be on the forefront that heck, there might be a pelvic floor dysfunction going on. But that's not generally what's on the forefront of your mind as the practitioner. And so I definitely think what you do is you actually treat that patient for a bit, right? 3, 4, 5 sessions, and you're gonna see improvement, but it could be where you're not kind of getting to the end, like the end game. Of what you were hoping to see very quickly with just like something simple as low back pain. So it is something where you would want to screen your patient, tell them, say, hey, the research shows that with low back pain, 90% of the patients have a pelvic floor dysfunction. Look, we've been after this thing for a couple of sessions now. We've been doing it 4, 5, 6 sessions. I've given you the screening tool. That does indicate that there is a pelvic floor dysfunction going on. And I think that's what's going to take care of the last 10-15% of your pain that you are having, that I do think that is actually referral pain coming from your pelvic floor. And there's no longer really an issue with the low back. So let's go ahead and get you over to a colleague of mine, whoever that may be, that's a pelvic health specialist. And let, let's let them take a look at you and let's see if we can't resolve that last 10 or 15% of your symptoms. They'll evaluate you, they'll connect with me, we'll talk about it, and we'll make a good game plan going from there. 'Cause really we're after this 100%. So we want 100% improvement. So I think that's really it. I think honesty is the best policy here, right? You just gotta tell them what you think. They came to you because you're the doctor. And they have full confidence in you, and there is a skill or a subset that you just may not have, and referring them over to another healthcare practitioner to take a look at. But you guys co-collaborating on this, I think, is the best practice here.

Absolutely. And oftentimes, I would imagine when you have those conversations, the patient may have questions about what is that going to look like from an assessment standpoint? I'd imagine that a lot of alarms go off if any discussion of internal exams go on. How do you handle that in a delicate way if the next question is, okay, doc, so I'm willing to go see this person. What are they going to do with me? What is that going to look like? Just so that they have a better comfort level with knowing that this is something that's necessary, but there is a much better outcome as the end goal for them.

Right. Right. I think the first thing is just like you said, is that you have to educate your patient on what is the best thing for them. And that's why another reason why I think there's so many dysfunctions in men's health is because the idea of like, what, I'm gonna have to go through a rectal exam, right? Doing a vaginal exam is, we, we, that's common, right? We know that happens all of the time and that's acceptable and that's okay. But when it comes to a rectal exam, sorry to say this, quote unquote, but we kind of pucker up a little bit, right? Who wants to do a rectal exam? And so I think that you just have to tell your patient that they're— what they'll do is first an external assessment. So we will look externally at the musculature. So we will palpate externally. We can just do that with the first layer. But their possibility could be an internal exam. And this is how they get to those muscles by doing that. Just like I can get to your bicep by having you bend your elbow and I can poke on your bicep here. We just don't have that same toolset when it comes to the pelvic floor. And the best practice is to go into rectally. But I would call a local pelvic floor physical therapist and then see what is their best practice. We always tell our patients what they're going to expect on their first visit. But at the end of the day, they can say yay or nay to an internal assessment, right? There are other strategies that we look at. We look at breathing strategies. We'll look at pelvic alignment issues, and we can kind of already say, okay, this person has a hypertonic pelvic floor. This person has this, and so not necessarily do we have to do a rectal exam, but it is highly, highly indicated, warranted. But I definitely think you should just tell your patients like this is a possibility. Just go see what they have to say, and then we have tools in our toolbox to get the patient comfortable with that if that's what they choose to do.

Another question that we had here was related to the umbilical hernias. Obviously these are things that are somewhat common, but we hear more about hernias when it comes to men, and specifically the umbilical hernia. Do you find that it's better for that to be addressed First surgically before doing pelvic floor work, or do you do pelvic floor work first, or is it a chicken or egg type situation?

So it's a chicken or egg type situation. And let me tell you a little bit about— and, and, and what we do here and kind of in my experience is typically an umbilical hernia, it can be repaired surgically or not. And either most of the time it's an aesthetic issue, right? That the gentleman doesn't like the way that it bulges or the way that it looks, right? So that is where the firsthand most of the time says, go to a surgeon, get that repaired. But the underlying problem never was fixed. And so that can create another umbilical hernia. And so you have to fix the problem, I feel personally, at Firsthand, so I would say a referral to pelvic floor PT, looking at pelvic floor, looking at the the system of how they are using their intra-abdominal pressure, changing the way that they're using their intra-abdominal pressure, trying to strengthen up the system around it, changing the way that they move, changing the way that they function to help decrease and offload the tendency for that pressure to go anterior. Onto the abdominal system. I think that is the best practice. And then within the course of 6, 8, 12 weeks, if things haven't changed, and then we go potentially down the surgical route. But I definitely think at first it is better to figure out why is the umbilical hernia there? Is it an issue with function for that reason? So I'm definitely more on the conservative method of doing— trying this first, and then if it is needed, Let's do it. I got no problem with that.

Absolutely. And I would venture to say that most of our audience is of the same mindset and that we try a conservative approach first before we go to surgery for many things. Along that same vein, and this could be an anecdotal response based upon your experience or something that you know from the research statistically speaking, does umbilical hernia oftentimes indicate pelvic floor dysfunction? And then the second part of that question was the same for erectile dysfunction. Does erectile dysfunction typically point to a pelvic floor dysfunction issue?

Yes, the answers to both of those questions is yes, absolutely. One is going to be an intra-abdominal— both of them can actually be intra-abdominal pressure. It's just where are you putting that pressure. So whether that pressure goes anterior onto the linea alba, creating a thinning of the linea alba to allow the hernia to protrude through, or also for the rectum as well, that pressure can go down and create also pelvic floor dysfunction. So, to answer both of them, yes.

Wonderful. The next question talks a little bit more about treatments. And with you being very specialized and being able to do specific internal assessments that are often outside of scope of practice of many of the practitioners that are listening today, We always like to take a peek behind the curtain and say, okay, what kind of tools does she have in her toolbox? Are there specific devices you use? Is a lot of your treatment exercise-based? Is a lot of it retraining breathing patterns? What are some of your go-to treatment approaches that you typically will utilize in treating men's pelvic floor?

One of several tools that we have, and honestly, it just depends on the practitioner. I am more of an exercise-based practitioner than I am with someone who is going to stick you on e-stim and do more biofeedback. We do hear more of intradigital, so using obviously one finger into the rectum to assess the pelvic floor. And then from there, we do intradigital biofeedback. So we try to teach the patient how to relax and let go of those muscles. A lot of that is in association with breathing techniques, helping them learn how to use their diaphragm correctly, being able to expand the rib cage, allow the diaphragm to come down. A lot of it may be looking at hip mobility as well. Externally, that has a major factor of pelvic floor issues. While we are in rectally, we can do a little bit of soft tissue work for those pelvic floor muscles. We could do a little bit of contract-relax, PNF, those types of things, fascial stacking to the pelvic floor directly. That has a huge impact to the pelvic floor of associated tools that most of the practice act, depending on the practitioner, may not have. So that's a different toolset that we have because we do have the ability to go in internally, intra-rectally, to help change the tissue function.

A lot of our discussion in some of our previous trainings, and I think a lot of the discussion now within several professional circles within healthcare, involves the biopsychosocial aspect of different conditions or different symptoms patients may be experiencing. What are you finding in terms of the impact a lot of these dysfunction components may have on patients' mental and emotional health, even maybe so much their, their social life? Like, how does this transform their lives in a negative way when they have it? And then how have you seen that improve their lives after things improve?

This is something that we see daily across the board. I definitely feel like it affects men mostly, I think a little bit more than it does women, just because it's It's kind of like more accepted for us, but with men it's not, right? A man is supposed to be able to have intercourse with their significant other, be able to please their significant other. And when that is taken away from them, that really impacts a man, that really impacts the man, the man's ego. So we see a lot of mental health issues with that. When you're even talking about more just on the terms of incontinence, whether that be bowel or bladder. When a man is losing the ability to have control of their bowel or bladder, that hugely impacts their world. The fact that they potentially have to wear a diaper, right, or a pad or something because of incontinence, it really does— honestly, it just takes the carpet right underneath the man's feet and it impacts them greatly. Um, and so we see a huge association with pelvic health And being able also to refer to a mental health specialist just because of the impact directly that it does have on the mental health.

Absolutely. I can certainly see that being the case. Finally, the final question we had here was talking about co-managing with a pelvic floor specialist. What type of relationship do you prefer to have with practitioners that you co-manage care with? What should they be prepared to provide you? As far as information about the patient and their history and what they've done so far? And then how does that communication go while you're both co-managing that case?

I like to have a direct one-on-one relationship with my other practitioners. I like to see notes because typically these patients are seeing you before they're seeing me. I'd like to see what's been going on, what globally has been done. That gives me a zest of potentially what I'm gonna find in terms And then when I find something internally, I also want to discuss those things with the other healthcare practitioner more on the realm of like I know about pelvic floor and how can we work together to help with this pelvic floor more common like we've talked about is a pelvic floor that has too much tension in it and so how are we going to be able to work together? I'm going to do my internal things that I'm going to do here. And then I'm going to look to you to do external things. And those external things maybe depends on what that person specializes in, right? Looking at manipulations of the thoracic spine, trying to get at that autonomic nervous system downregulation, looking at the TL junction. So thoracic lumbar junction, because we know those nerves, they do have an association with the lumbar spine, with the pudendal nerve, those sorts of things that help to downregulate the pelvic floor as well, maybe some visceral mobilizations, if that is what the healthcare provider is known for, mobilizing the diaphragm, helping to improve the diaphragm mobility, trying to improve how the rib cage moves. So those are some techniques and some things that I would look for, for the healthcare provider to work hand in hand, because that's what is going to help to downregulate and improve the function of the pelvic floor. So that's something that I look at.

Absolutely. That sounds wonderful. Well, thank you so much today. This has been great information, a very interesting topic, and I think definitely has been eye-opening for many of our practitioners about some things to look for. And Brittany, tell us a little bit about your practice, where you're located, and if someone was in Texas and wanted to refer someone to you, how would they go about doing that?

Yeah, absolutely. And so I am here at Empower Pelvic Health. Pelvic Health. We are located in Webster, Texas, Nassau Bay area. So we are located at 1120 Nassau Parkway. And the best way, if you're interested in sending a patient our way, we could do it by 2 ways. You can either call us. So our phone number is 346-677-0150. Also, you can email us, and that email address is info@empowerpelvichealth, all one word, empowerpelvichealth.com. And that way you can refer a patient over, you can give the patient the information. When you download the file of the CoScene screening tool, on the very bottom of that, it has our clinic information. So you all, if you're downloading that, you'll all have that clinic information and ways to communicate with us. Whether that be phone or also by fax. One thing that we do have, I'll share really quickly with you, is that typically we see our evaluations are actually 90 minutes in duration, and then our treatment follow-up sessions are 60 minutes. Those are for our patients who are local. We also have an out-of-town program because pelvic floor are— there's not many of us, and there are also not very many of us that do men's health as well. So not every pelvic therapist does men's health. So you definitely want to make sure if you're going to send a man to a pelvic floor therapist, you want to make sure that they do men's health. But we also have an out-of-town program and we have 2-hour availabilities for those patients who are traveling a longer distance to come and see us. So there's some information, and then you're also more than welcome to contact me directly. And my email address is brittany@empowerpelvichealth.com. And I'll be more than happy to answer any questions or help you with getting patients, even if you're not in this area of Houston, Texas, and you are in a different state. I do have many colleagues in pelvic health that I can also get you connected with and help you get your patient over to them.

All right. That's another great question, actually. If they are looking for someone in their local area develop a relationship with a pelvic floor specialist, is there a certain national organization or credentialing body? What is the best resource for them to look to if they're trying to establish that referral relationship in their area?

Yeah, so you can go to the International Pelvic Pain Society, you can type in your zip code, and they will connect you with a practitioner in your area. Again, I want to emphasize the fact that if that's what you choose to do, that you are asking if they treat men's health.

Wonderful. That's definitely important information to have. Thank you again. We do appreciate you.

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