#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. Now, please note that in this episode and an episode's sixty three, where we complete part two of this training, when we refer to men and women, were specifically talking about cis gender men and women. There's no refuting that there are some distinct anatomical differences between the two groups, the cis gender 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 one in six CIS gender men are dealing with persistent pain in the pelvis, making chronic pelvic pain syndrome the most common neurological diagnosis in men under fifty. In this two part series, we will learn common pelvic floor diagnoses for men. We'll learn how to properly screen and identify pelvit floor dysfunction and winter 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 Masters of Science and 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 postdoctorate fellowship program teaching physical therapists advanced problem solving and hands on manual therapy skills and is taught continuing education courses to hundreds of physical therapist nationwide. This is a fascinating topic and one that can be incredibly helpful to better understand for your patients. Let's cue the intra 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 public 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 twelve 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 Public 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 about the pelvic floor and integrate both of those. So I do think that we do have some stuff in common that we're going to 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 my certifications for pelvic floor, decided to open up my own practice, and so now today I treat the pelvic floor dysfunctions. It is still a 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 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 win A referral to a public floor physical therabusiness 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 into pelvic floor with stethree that they're 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 and 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 and meant surprisingly enough, the research shows that about one in every sixth man will actually have a pelvic floor dysfunction. We pelic floor therapists think that that number is probably a little bit on the higher end. We think maybe one in four, maybe even one and five men do suffer from a public 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 be like put it on a billboard, let everybody know that we have a public floor dysfunction and paying on ourselves is something that we just accept as common and in 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 position or what so, maybe it's generally about four years until they are referred to a public floor physical therapist. I know that's really astonishing four years for a man to struggle with something that a woman can go to an ob with and say, hey, I have your narring continence and send me tell a public 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, one in six men do suffer from pelvic floor dysfunction. So that's just a little picture showing you really have majority of the superficial muscles of the pelvic floor, and the pelvic floor it is made up of approximately about fourteen muscles. Honestly, it really depends on what textbook that you look in somewhere and say somewhere between fourteen and seventeen muscles make up the pelvic floor. Men and women have very smaller pelvic floors, but you can see they're 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 they'll talk about that. That the pelvic floor is actually collection of muscles, like I just indicated, depends on what anatomy textbook you look at fourteen to seventeen of them muscles that make up the pelvic floor. There are also ligaments, nerves, and connected 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 coxics and at some capacity, either they have direct attachment to the coxics or they attach themselves to other muscles or other connective tissue that also comes in and attaches themselves to the coxics as well. And so that's very very important to kind of think about 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 coxics. 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 podental nerve, and the podental nerve comes from S to S through S four. That's a really cool way to remember. It is S two, S three, S four keeps pm poop off the floor. This nerve here, though the indicated in pelvic health, is probably the nerve that has to take one of the most tumultuous pathways through the pelvis to enervate the pelvic floor. So if you can kind of nerve out with me for just a moment on anatomy, is that the podental nerve is derived, like I said, from the sacred roots of S two S four and as it exits out of the sacrum. But here is a model of the pelvis, and this right here as obviously the sacrum. These are the sacral roots. It's going to come out from the sacrum here and then it's gonna actually dive. One thing you don't see here are two major ligaments between the sacrum and the ilium here, which is the sacral spinus ligament, which is going to go obviously from here to here, and then you have that sacro tubrius ligament. So they kind of have that little criss cross connection like this and that nerve that podental nerve is actually going to pierce through and it's going to go between those two ligaments as it comes into the pelvis here, and then it's going to go through what we call ALCS canal. And then as it dives through ALCS canal, which is inside the pelvis here, it's gonna then branch. And it actually has three branches that's going to go through to the rectum, to the perennial area, and to the also the shaft of the penis. And so you just wanted you to know that there is a major nerve contribution to the pelvic floor and it does come from the podental 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 podendal neuralgia. So we'll go into that just a second. Have you ever thought about teaching or launching a podcast, maybe creating online courses for your patients or a YouTube channel to gain exposure, or maybe you want to pass on your expertise and knowledge to the next generation of healthcare providers, but don't really know where to get started. If this sounds like you, then we would love to have a conversation. Southeast Professional Education Group has helped healthcare providers, national organizations, and product companies create and launch content for the purpose of educating and engaging their target audience. Whether you want to establish your credibility in your hometown as a means to grow your practice, or if you're looking to enter into the exciting world of continuing education, we would love to talk to you. The great W. B. Yeats said, education is not the filling of a pot, but the lighting of a fire. And I guarantee you there's someone out there waiting for you to light that spark. Simply fill out the interest form linked in the show notes and let's have a conversation. Who knows, maybe a few months from now, you're the one that our podcast subscribers are tuning in to learn from. So click the link to request a time to chat. Let's have a conversation and see how we can help you launch something great and also to the pelvic floor is actually divided into three 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 and 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 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 gonna pause here a little bit and then show you this pelvic the deepest layer of the pelvic floor. It doesn't matter whether you're male or female. It is the zac same makeup of muscles when you get here into the third layer. So I'm going to show you the n side here so you can see how these muscles do very much sling back from the frontier of the pubic bone and they go all the way back here towards the tailbone and that sacral coxygeal 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 it changes in both the coxics and the sacrum and kind of pull them more into like an extended while the sacred 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 lore doses and more in achyphotic position. So it can change the orientation of the strong pull from the pelvic floor and how that directly impacts both the coxics, the sacredrum, 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 opturator in turnist 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 operator in turn Well, what does the opturator in turn is having to do with the pelvic floor, because we all know by our anatomy that the opturator in turnus the 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 opturator in turnus sit inside the pelvis, and right in through this area is actually what we call the atla, which is like a ligamentus fibrous band that connect the opturator in turnus to the deep layer we call the vader ani of the pelvic floor muscles. And so oftentimes a problem with the pelvic floor or an issue with the opturator in turnus 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 opturator in turnus. An opturator in turn is generally speaking, it can give rise to many factors of referral patterns. One of the main ones it can cause deep butteck pain. That's one of the primary factors that the operator in turnus. The referral site for a opterator in turnus muscle that may be insfunction is it can refer to deep buttet pain. Oftentimes the patient might say like they feel like they're sitting on like a ball or golf ball or something like on their one side or their butter 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 and really it is the opterator in turnus that is referring pain to the area as well. So those are kind of the three major things that we typically see with the opturator in turnus. I'll add a fourth one on there too, just why I'm thinking about it is also pedental neuralgia because if we look at this here, is that nerve is going to come through here and it has to actually pierce through alcox canal that's opturator. 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 perennial pain, and can also create pain to the shaft of the penis as well. So that's a major factor of that third 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 nineteen sixty where the term Keegel came from, which is a pelvic floor contraction. It was from doctor Keegel, who is an obgi n 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 twenty first century, as 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 three 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 into the pelvic cavity to contract, and that is with two variations, either in isolation with a pelvic floor contraction aka a key goal, 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 transfer subdominus and your gluten max muscles. Your diaphragm also is very important for pelvic floor as well, and so these muscles you can see an isolation of doing a key goal, 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 and the body have a normal resting tone. And normal resting tone is when you're not doing a public 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 bold, which means the pelvic floor needs to be able to relax and go the opposite direction, and so things like pe 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 come being completely on and it's halfway down of being completely off. So if you can just for the sacause 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 it's 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 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 oftentime is that ninety percent scent of the patient population actually have their dimmer switch on, whether that beyond 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 in continence, telbone 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 this 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, to say, hey, I want to refer 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 at the pelvic floor is weak, that must mean that the muscles themselves are in a elongated position and they don't have the the ability to fully contract to stabilize, and so then they go back to this elongated position. But we know ninety percent 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 three 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 p 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 you. So the global system that does have a 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, 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 four 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 hypertinicity and 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 diaformatic breathing. We call it breathing three sixty eight, so good ribcage breathing all the way around, and they're not taking shorts, 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 subdominous muscle. We have done so many AMG studies that indicate that in order to properly recruit and activate the pelvic floor musculature, transverse subdominous activation needs to happen as well, that transverse subdominous activation has a better capacity to build strength within the pelvic floor than just an isolation of keygels only. So we have research that indicates that transverse subdominous helps to strengthen pelvic floor better than just isolation of keegels alone. And then you can look at the backside of this diagram and then you have the multipitous and that is going to round out our container space. And so we know the transverse abdominus comes back, goes into reps around posterially through the thrackle lumber fashion can increase stability or content in the area. And then we know that has an effect great effect on the transverse abdominus and the multipitous coactivation together. So you can see here these four 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 gluten Maximus because of its direct attachment into the coxics into the sacral area. That's can play in big time with the external anal sphincter as well. And then also that optuator in turnus 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 two in episode sixty three, 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 sixty three drops in two 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 course is are released. We've got some exciting new courses in the works, so you'll want to 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. 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