#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 twenty twenty four that they've certainly kept me busy. Now, in today's episode, we're going to pick back up with Part two of our series titled Let's Hear It for the Boys Pelvic floor dysfunction Diagnosis and Treatment Options for men with Britney Saidbrook, a fellowship trained orthopedic manual physical therapist. Please note that in this episode, as in part one, when we refer to men and women, we are referring to cis gender men and women. Now today we will dive deeper into the important role of proper breathing mechanics and 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 or that can impact the pelvic floor or what are some of the common pelvic floor diagnoses and so some of the most common pelot floor diagnoses that we see and men are listed here for you. Urinary and continence. Yes, this is a thing men can suffer from. Urinary and continence. The second thing is constipation. Constipation is one of the major factors actually two urinary and continence. And so if a patient is suffering from constipation and they are 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 exterior to the bladder, that can create issues. Too much content into the rectum can push antier onto the bladder, and also inter 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 a rectile dysfunction. So we often see a rectile 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 prostate itis. That's another common thing that we typically see podendal neuralgia. So we talked about that early our at length, about the podental nerve and that tumultuous path that the podental 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 cyclist and cyclists that they're sitting on their cycle seat or their bike seat for prolonged period 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 issue two rossi's are a little bit closer together, and so sitting on the bike seat, when they sit on there can compress where the pidental nerve comes down through and it can create compression and the area. So cyclists often have podental 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, they can create opt greater in turn is issues pdindal problem printed on neuralgia, So those types of things. Another one is psiatica. Psiatica could be more of driven from a lumbbar issue of 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 the having a history of low back pain, that ninety percent 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 an orthopedics. It seemed like with my low back pain patients, I could get them maybe ninety ninety five percent 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 works contributing factors to their low back pain. So I would say probably low back pain should be almost an immediate referral to a 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, inter social systitis 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 i 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 ninety person scent of patient population of flow back pain also have a pelvic floor issue hip ostarthritis. Something that I would also classify into hip ost arthritis would also be label tears just because of that close association of the obturator internus. Any type of hip issue, whether that be OA of the hip, a labral any type of limited mobility and the hip just because of its association with the opturator internus. The second one or like another one that I would discuss would be also growing pain. Growing pain could be from the adductors. It could also be from the pelvic floor. Also to sometimes growing pain could be in combination with scrotal pain. And if that is the case, scrotal pain definitely referring to pelic floor PT that can be coming specifically from the pelvic floor itself, can also be coming from the passoas muscle nerves that surround the pelvic floor that could be producing growing pain or scrotal pain. And then also that thoracic lumbard junction so all of those areas can produce the growing pain are also the scrotal pain. Hamstring strains that's another one that could often be the opterator in turnus. 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. Umbilica hernia is another one because that's a pressure management problem. M Bilica 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 more a little larger and decided to lose a little bit of weight pretty rapidly, they can develop diastasis rectie. Too much pressure being displaced on the linea alba very rapid weight loss. It can create issues. So mbilicahernia diastasis rectie is a pressure management issue and also a global problem. But definitely referral to pellet floor PT to look at the pelvic floor is warranted as well. And then also patients with psoas strained, because oftentimes those can be a referral from the pelvic floor, So pelvic floor dysfunction can refer to the passois 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 pellet for therapist, I never really asked these questions. It never really dawned on me in a patient what is 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 urineary 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, growing 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 telbone. Remember back earlier we talked about all the muscles that attached 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 if even if there's a fall as a child, a fall in a telebone is definitely warranted for further investigation. If your patient is complaining of pain and their general area, the perennial area, their pelvic area, bladder area, or also have pain with urine nation, 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 is another big indicator that there's a too much tension in the pelvic floor system and that is what's striving those things. Post void dribble. Also difficulty initiating a bowel movement or incomplete emptying of the bowels, are 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 Cozine Pelvic Floor screening tool. There are actually ten 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 go ahead, fill it out and if they indicate three or more, So if they put checks on three 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. 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 end's men's health, and where do we go without. 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 and 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 four 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, and it's really ultimately going to be a better recovery for the patient. And so I truly feel like it is a central for 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 assessment as long as the patient is comfortable, for 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 as 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 therapists found at the local level and how you can work together at a global level. Because there are many factors that affect the pelvic floor, even down to the foot affects the pelvic floor. The striking of the foot and how the forces are transmitted from the foot and angle 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. At Southeast Professional Education Group, we are incredibly selective about the courses we host on our online learning platform. We only want to offer our students the best, most dynamic, evidence based courses, and because of this, we only launch a few new courses each year. We are what I like to consider unapologetically selective. 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Back to the show and that it 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, okay, right away. Are there any specific sports that you find I know you mentioned ling is sometimes something that can contribute to pelvic floor dysfunction and 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 pelvot floor dysfunction? Yeah, great question. The answer that is yes, we see a lot of it. And body builders are men who are lifting very very heavy that have an increase of intrabdominal pressure, so they're descending 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 intrabdominal pressure, they're holding it for thirty seconds. I mean for the course of their lifting, and they've been lifting for five, six, seven years. This way can contribute to the increased tension of pelvic floor issues. So we typically see that more and like bodybuilders or physique patients who are doing like were physique type of building. But anytime there's an increase in inter abdominal pressure, it's going to directly unpack the public 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 public 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 psiatica, 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 psiotica or for low back pain. It's not going to be on the forefront. It may now be on the front forefront that there might be a public 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, three, four or five sessions, and you're going to 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 let 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, ninety percent 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 four or five, six 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 ten five percent 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 public health specialist, and let's let them take a look at you and let's see if we can't resolve that last ten or fifteen percent 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, because really we're after this hundred percent, so we want one hundred percent improvement. So I think that's really it. I think, honestly, is the best policy here. Right. You just got to 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 and take a look at but you guys co collaborating on this, I think is the best practice here. Absolutely, And often times 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 sure 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. 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 going to have to go through a rectal exam? Right? Doing a vaginal exam is that's common, right, We know that happens all of the time, and that's acceptable and that's okay, But it comes to rectal exam. Sorry to say this quote unquote, but we kind of puck her 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 a external assessment, so we will look externally at the musculature, so we will pow pate externally. We can just do that with the first layer, but their possibility could be an internal examined. 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 tool. Said 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 yea or nay to an internal assessment. Right. There are other strategies that we look at. We look at breathing strategies, will 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. Wererant it, 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 toolbacks 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 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 what we do here and kind of in my experience is typically at a billicahernia, 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 are 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 umbilicahernia, and so you have to fix the problem I feel personally at firsthand. So I would say a referral to public floor pt looking at pelvic floor, looking at the system of how they are using their intra abdominal pressure, changing the way that they're using their intrabdominal 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 six, eight, twelve 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 than beiligahernia. There is it an issue with function for that reasons, So I'm definitely more on the conservative method of doing trying this first and then if it is needed, let's do it. Kind of problem with that absolutely, and I would venture to say that most of our audience is 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 pelvot 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? Yes. The answer to both of those questions yes, absolutely. One is going to be an interup. Both of them can actually be inter abdominal pressure. It's just where are you're putting that pressure. So whether that pressure goes enter 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 to a pelvic floor dysfunction. So both 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 sort of 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 public 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 stem 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 interdigital biofeedback. So we try to teach the patient how to relax and let go of those muscles. A lot of that is an 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 sact depending on the practitioner, may not have. So that's a different tool set that we have because we do have the ability to go in internally and trarectily 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 help, even maybe so much 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 kind of like more accepted for us, but with men it's not right. And men is supposed to be able to have intercourse with their significant other, 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 bow or bladder. When a man is losing the ability to have control of their bow or bladder, that hugely impacts their world. The fact that they potentially have to wear a diaper right or a pat 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. 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 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 going to find internally. 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 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 that autonomic nervous system downregulation, looking at the t L junction, so thoracic lumbard junction, because we know those nerves they do have an association with the lumbar spine, with the podental nerve. Those sorts of things that helped to downrate 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 ribcage 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 for us to work together on. 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 it? Yeah? Absolutely, and so I am here at Empower Pelvic Health. We are located in Webster, Texas, Nasau Bay Area, so we are located at eleven twenty NASA Parkway. And the best way if you're interested in sending a patient our way, we could do it by two ways. Can either call us, so our phone number is three four six six seven seven zero one five zero. Also you can email us and that email addresses info at Empower Pelvic Health all one word Empower Pelvic Health the dot com and that way you can refer a patient over you can give the patient the information when you download the file of the co Scene 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 facts. One thing that we do have I'll share really quickly with you and that typically we see our evaluations are actually ninety minutes in duration and then our treatment follow up sessions are sixty minutes. Those are for our patients who were local. We also have an out of town program because pelvic floor are there's not many of us, and they're also not very many of us that do men's health as well, so not every peblvic floor therapist does men's health. So you definitely want to make sure if you're going to send a man to a public 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 two 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 at empower pelvic health dot 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 low 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 to 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. Good to 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. That's it for today's episode. 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