January 2, 2019

Pelvic floor physical therapy (or “rehab”) can help men recover from incontinence after prostate surgery, and from pelvic pain.


Pelvic floor physical therapy is usually prescribed for women who, after a few pregnancies, tend to leak urine.

But men can leak, too, especially after surgery for prostate cancer. Men can also suffer from chronic pelvic pain. Physical therapy specific to the pelvic floor muscles can provide relief.

Vanderbilt Urology and Vanderbilt Physical Therapy and Rehabilitation specialists work with men who are dealing with these problems. Urologist Roger Dmochowski, M.D., and pelvic floor physical therapist Nicole Motzny, PT, DPT, explain common male pelvic symptoms and what men can expect from pelvic floor physical therapy.


What is the pelvic floor?

The pelvic floor comprises muscles and connective tissue that support abdominal organs, control the bowels and bladder and are involved in sexual function.


What pelvic-related problems are typical for men?

The two main symptoms that send men to pelvic floor physical therapy are incontinence (inability to control urination) and pelvic pain.

Incontinence typically stems from problems with a man’s prostate gland. If he has an enlarged prostate – a common condition as men age – the prostate can pinch the urethra. Then the bladder has to work harder to push urine out when it needs to empty, Dmochowski said, and the bladder muscles thicken and become overactive. The result: leaking urine.

Men who have had surgery for prostate cancer have incontinence at least temporarily after their surgery. Some men who receive radiation therapy for prostate cancer can also experience incontinence, Dmochowski said.

“Somewhere between half and two-thirds of the control mechanism for urination is lost as part of (prostate removal) — basically all men will have some degree of incontinence for a period of time after removal of the prostate,” Dmochowski said. But they can regain control with physical therapy. “It has become evident from a lot of very well-done studies that the earlier we get men into therapy, the quicker their continence or urinary control returns.” Better surgical techniques, including robotic surgery, and earlier use of physical therapy mean that today, about 90 percent of men regain control over urination after prostate removal, he said.

Another common pelvic problem for men is chronic (ongoing) pelvic pain. Pain can come from the bladder, rectum or prostate (the latter is sometimes called prostatitis). Pain tends to make muscles tighten up, like a constant cramp, and this becomes an uncomfortable cycle: pain leads to muscle tension, which causes more pain.

“The problem with male pelvic pain is that it’s often misdiagnosed,” Motzny said. “These men have these symptoms and no one knows what to do with them. They often get treated with antibiotics but don’t improve.  Sometimes they see multiple specialists before they get diagnosed with pelvic pain and receive comprehensive treatment including PT.”

The antibiotics are meant to treat an infection that might be causing the pain. But if there’s no actual infection, “nothing seems to really make them better, or they’re only transiently better on antibiotics. So they get these very sensitive pelvic organs,” Dmochowski said.


What is pelvic floor physical therapy like?

There are many aspects to pelvic floor rehab:

Education and a frank conversation. The therapist gives men a basic education about their pelvic floor, an often mysterious part of anatomy.

“Men don’t tend to think about their pelvic floor,” Dmochowski pointed out, “whereas women know a lot about their pelvic floor.” By the time a woman sees a urologist due to incontinence, she’s probably had several children and her obstetrician has recommended pelvic floor exercise. “Men simply don’t have that experience.”

On the first visit, the physical therapist has a discussion with men: “We ask about their pain symptoms — what their urination is like, what their bowel movements are like, what their sexual activity is like,” Motzny said. “Because all of those things can be affected by pelvic floor symptoms.”

Men with questions about any part of pelvic floor rehab can call or email the physical therapist before the first visit to talk through any concerns.

A physical check. The therapist will check strength, flexibility and range of motion in the back, pelvis and hips.

An internal exam. Often the therapist will do a rectal exam with a gloved finger, to feel whether the muscles are weak or in spasm, or have some other dysfunction. Rehab may also involve massaging certain muscles.

Exercises targeting the right muscles. For incontinence, pelvic floor rehab aims to strengthen the muscles controlling urination. For pelvic pain, the aim is coaxing tight muscles to relax. Both will involve exercises that, with practice, will retrain pelvic floor muscles to function properly.

Kegel contractions, for example, retrain muscles after prostate surgery. Imagine stopping the flow of urine mid-stream: that’s a Kegel contraction. Therapy will include a quick series of these contractions – to strengthen the “fast-twitch” muscle fibers – and learning to hold a contraction for a longer period of time, to strengthen “slow-twitch” fibers. The fast- and slow-firing muscle fibers must coordinate correctly to control urination, Motzny said.

There are other exercises beyond Kegels that a therapist will teach men so they can target pelvic floor muscles.


How long do most men need to go to pelvic floor rehab?

Regular sessions for about 20 weeks – sometimes longer – can help men dramatically strengthen control over urination. If prostate surgery goes smoothly, regular physical therapy can resolve incontinence. If surgery had complications, therapy may not completely “cure” incontinence but can improve it significantly, Motzny said.

Pelvic pain can have many factors, so resolving it may take six months or longer, Motzny said. Behavioral, lifestyle or emotional challenges are often part of the problem, and men may need to tackle one or more of those issues in addition to getting physical therapy. For example, Motzny said, a type-A personality with a high-stress life may need to make life changes and learn to manage stress in addition to getting physical therapy, to prevent pain flare-ups.

The frequency of in-person visits to the therapist tapers off as the patient makes progress, especially if he is consistently doing his exercises at home between visits.

“It’s like training for a marathon,” Dmochowski said. “Just like you want to run every day to keep the musculature of your lower extremities up, it’s the same thing for the pelvic floor. … It’s a continuous training of those muscles to keep them either contracting or relaxing.”


What would you say to men who dread discussing urination, bowel movements or sex with a doctor?

“You have to take care of yourself,” Dmochowski said. “Don’t ignore your symptoms, because urinary symptoms are very common in men, and they could be quite problematic later on,” he said.

“If you have symptoms that just don’t seem to go away and the simple stuff (i.e., antibiotics) doesn’t seem to be doing what it should,” talk to a doctor, he said. Men should mention these symptoms during a regular physical, at least. A referral for pelvic floor physical therapy can help.

Talk to your primary care doctor or a urologist about getting a referral for pelvic floor physical therapy. If you’ve had a concerning PSA test or have symptoms of prostate cancer or an enlarged prostate, Vanderbilt Urology offers diagnoses and a wide range of treatment options, including referrals for pelvic floor rehab. Call for an appointment: 615-322-2880.

Roger R. Dmochowski, M.D., M.M.H.C., is professor of urologic surgery, associate surgeon in chief, associate chief of staff and vice chair for faculty affairs at Vanderbilt University Medical Center.