Release Pelvic Pain in 2-3 months with Pelvic Floor Physical Therapy

March 25th, 2014 by Evelyn Hecht

male-pelvic-painMany evidence based studies prove that pelvic floor physical therapy is an effective treatment approach for men and women suffering from pelvic pain caused by tight muscles and restricted tissues. The pelvic floor muscles, namely the levator ani, coccygeus and obturator internus can develop adhesions, tension or trigger points which restrict movement and cause pain. Trigger points are palpable spasms/knots within muscle tissue and can occur in pelvic floor muscles. Trigger points can lead to adhesions of fascia/connective tissue of the abdomen, groin, pelvic floor and even restrict the viscera (colon, uterus, bladder, prostate gland) within the pelvic bowl.

The pudendal nerves and its branches, traveling from the sacrum (back of the pelvis) and running all through the pelvic floor region innervates the vaginal/penile and rectal areas. The nerves can become squeezed as it travels through tight muscles and fascia, which then decreases optimum pelvic floor function and increases pain.

The pelvic floor muscles are located INSIDE our bodies, in women the muscles are approximately 1-2 inches up from the vaginal/rectal region and in men, the muscles are approximately 1-2 inches up from the base of the penis/rectal region.

The pelvic floor muscles are key for four functions of the body:

1) lower back/core stabilization; 2) normal urinary function; 3) good bowel function; 4) satisfying sexual function.

As a core stabilizer, the pelvic floor works with 3 other core muscles, the Transversus Abdominus (deepest stomach muscle), Multifidus- (deep low back extensor muscle), and deep fibers of the Iliopsoas (hip flexor muscle). These 4 muscles work together to keep our core strong, flexible and prevents lower back pain. If one of the 4 core stabilizer muscles becomes weak or injured, then the other 3 muscles have to work harder to compensate. Over time this puts great strain on the whole core, which leads to back pain/stiffness/weakness.

The pelvic floor muscles are directly involved with three bodily functions, urinary, bowel and sexual.

For functional urination, the pelvic floor muscles surround the urethral opening and should relax when you are voiding and maintain closure or tension when you are not voiding. If the muscles are in spasm, urinary symptoms such as leaking, or feeling a strong urge to void, or having to go to the bathroom multiple times a day (called urinary frequency) and/or being awoken at night to void more than once (called nocturia), can occur. Women using public restrooms should not “hover” over the toilet, as this sustained half squat creates tension in the pelvis and does not allow full relaxation of the sphincters around the urethra to allow full urination. Best to use the protective toilet seat covers and sit comfortably.

For normal bowel movements, the pelvic floor muscles should be able to open and widen to allow the full passage of stool. When not having a BM, the pelvic floor maintains tension at the rectal opening to prevent leakage. If the pelvic floor is weak, leakage can occur. If the pelvic floor is tight, constipation resulting in sitting too long at the toilet, straining to defecate can occur. Toileting should take no longer than 5 minutes following the urge to void. Even though you may not feel completely empty, it’s better to stand and leave the bathroom versus continue to sit and strain. Constant straining can result in hemorrhoids and/or the development of a rectocele, which further impedes good function.

For satisfying sexual function, the toned and flexible pelvic floor allows for more intense orgasms in men and women. A fully relaxed pelvic floor helps women experience pain free intercourse with their male partners. Many patients who are experiencing sexual pain may experience difficulty with partner relationships or even avoid them due feeling of shame or inadequacy.

Pelvic pain due to restricted muscles can be released and return to normal function, no matter how long a person has been experiencing symptoms.

Physical therapists trained and mentored in pelvic floor work can:

  • apply targeted manual therapies to rid muscles of trigger points
  • utilize biofeedback therapy to help patients learn how to either downtrain (relax) their pelvic floor or to uptrain (strengthen) the pelvic floor
  • perform visceral mobilization to improve the mobility of organs lying within the pelvic bowl
  • mobilize and teach a patient self-connective tissue (skin rolling) techniques to abolish tight skin and fascia of the inner thighs and abdomen
  • teach patients gentle stretching techniques with foam rollers, tennis balls, knobbles, Theracane, S –wands and dilators
  • educate in exercises for a strong core
  • teach diaphragmatic breathing and visualization to help lower tension of the pelvis and to increase oxygenation to the body and decreased stress
  • guidance in cardiovascular exercise to pump more oxygen and nutrients to the tissues
  • teach proper bladder and bowel techniques and habits

Most people start to feel better after 2 months of consistent, twice a week therapy which incorporates many of the above techniques. Some reach goals sooner; others may take up to 3 months. By attending regular pelvic floor physical therapy and performing all the home exercises, faulty pattern are reversed and many people are pain free within 2-3 months.


As the owner of EMH Physical Therapy, Evelyn Hecht oversees all patients who are referred to the practice. She meets regularly with each staff licensed Doctor of Physical  Therapy (DPT ) to discuss plan of care and treatment options, she reads  every evaluation report prior to it being sent to your referring doctor and ensures that all patients attain optimum results in their recovery.

Solo Sex

March 10th, 2014 by Paul Nelson

do not disturbOne of the most common responses we see from men when they face sexual or erectile difficulties is simply avoidance. It makes sense. If sex has become frustrating, challenging, embarrassing, or humiliating, then why in the world would anyone continue trying to be sexual? Avoid all that pain by simply avoiding sex. It’s simple!

While it is an understandable feeling and a logical response, it might be compared to someone who has a leg injury who decides to simply give up on walking. It certainly is one answer, but it’s probably not the best answer. It is not in the best interests of anyone to go through life denying their human sexuality.

It remains a basic human need to be sexual. Even though sex may not be working the way we’re used to, or the way we’d like it to, we all still need to maintain both a solo sex life and an intimacy with our partners. It’s good for our mental health. It’s good for our physical health. It’s sort of like that not-walking choice. Eventually, it will lead to further complications and problems.

The first place to start is to think about solo sex. The great thing about solo sex is that you can try things out all by yourself to see how they work, how they feel, and how you respond. Every time I talk about a new technique or therapy with a man, I always caution him to try it out in private and solitude. For example, I hear stories about men who got their penis pump in the mail and are so excited to try it out, that they call in their partner to witness the resurrection of their penis – only to witness a DOA. Well, when things go badly, the letdown makes hope seem more far-off than ever.

No matter what, guys need to remain connected to their penis in more than just a flesh and blood relationship. Even if it’s not working right, even if it’s not feeling right, even if it bears no resemblance to the penis you used to have, you still need to have fun with it.

Many guys don’t realize they can still ejaculate and orgasm with a flaccid penis just as they can with an erect one. Yes, masturbation techniques may change, but the outcome should not. Lots of lubricant, patience, and an exploring spirit can result in some pretty rewarding moments of pleasure.

In addition to adjustments in technique, men may have to find erogenous areas of their bodies they’ve never had to pay much attention to. The perineum, testes, nipples, thighs, anus and groin can all provide some very intriguing sensations. It might take some bravery and a sense of fun adventure, but the rewards are worth it.

Be a pioneer. Be an explorer. The voyage of sexual self discovery is one that has no final destination – but it’s one heck of a journey!

Sexual Aids for Men

January 29th, 2014 by Paul Nelson

Browser bewareSexual aids for men have always had a troubled existence. For decades, they have been associated with lurid porn shops in seedy parts of town. Often, the items just look scary as their specific use remains somewhat of a mystery. Even the packaging can create some unease. Sex toys and porn have been inextricably linked for far too long.

The reality is that marital aids, as they are clinically called, can be a very valuable tool in helping restore and improve sexual performance in men. It is true that the penis needs regular cycles of tumescence for optimal health. If the penis is not experiencing erections during the sleeping cycle, it is really helpful to create erections during waking moments. Use of sexual aids can help create erections which bring in fresh blood and will keep penile tissue healthy.

In the absence of a partner, or if intercourse needs to be avoided for a time, sexual aids can provide a stimulatory outlet that can create great pleasure while maintaining safety and intimacy. I know of one couple where she packs him a surprise sex toy in his suitcase while he is on the road for business. When he gets to his destination, the fun of discovering it is a game that brings them closer even though they are continents apart. When he gets home, telling her about how he enjoyed using it is part of the plan.

Incorporating sex toys into the relationship can provide a sense of fun, excitement and adventure while preserving privacy. Not every couple can create a romantic weekend or plan an erotic setting when the kids are around. But slipping a small, new toy under the pillow shortly before bed can provide a sense of surprise and adventure.

One couple that had been trying to conceive found that sex on demand and on schedule was becoming a point of stress for them. I urged them to bring some toys into their lives. They bought a simple vibrator for her and a vibrating constriction ring for him. They told me that sex to get pregnant became a lot more fun when they had toys to distract them from the pressure of conception.

Go online and take a look at the dizzying array of toys. Think about what might be fun for you. Think about what might feel good. Think about what turns you on. Read reviews. Make an investment and have some fun!



Sex Hormone Binding Globulin

December 16th, 2013 by Nick Cannone, FNP

confused-man-old-funnyJim, a 70 year old man, comes in with significant symptoms of low testosterone including low libido, decreased energy and decreased concentration.  He reports having his testosterone levels checked with is internist.  He was told they were around 700ng/ml which is normal.

After a thorough history and physical, his hormone panel was repeated.

His total testosterone levels were 700ng/ml.  However, his sex hormone binding globulin was 80nmol/L.  Thus, his free androgen index was low.  Treatment with testosterone replacement was started and his symptoms improved.

Total testosterone provides a look at the total amount of testosterone circulating in the bloodstream.  However, 98% of testosterone is bound by proteins, only 2% is free in the bloodstream.  In order for cells to utilize testosterone, it must be free or not attached to proteins.    About 40% of testosterone is bound to SHBG and 55% to albumin or other proteins.

The problem with SHBG is once testosterone is bound to it, it is irreversible.  Testosterone bound to albumin and other proteins can be freed and then utilized.

Thus, if your SHBG levels are high, there is less testosterone available for use.

In Jim’s case, his internist only looked at the total testosterone level and not what was available for his cells to use.  We aimed for Jim to get to 1100ng/ml with his total testosterone.  As his testosterone levels increased, more was available for use and his symptoms resolved.

Some conditions that lead to elevated SHBG levels include aging, chronic liver disease, hyperthyroidism and certain medications.

It is important to have a complete hormone panel done in order to identify all possible causes.


Yours, Mine, Ours

October 15th, 2013 by Paul Nelson


Men love toys. As boys, they love boy toys. As men, they love man toys. Men often have special places where they play with their toys – the garage, the basement, the shed, the man cave. We men usually need to collect more toys to work on our toys. Some people might call them tools. But the fact is, there is often very little distinction between a tool and a toy for many men. Tools are simply toys used to work on other toys.

Men tend to take pride in their toys. Maintaining a classic car can make a guy feel like a brilliant engineer. Any guy that can handle a chainsaw feels like a stud. Keeping the boat afloat and in pristine condition makes him captain of his domain. Fixing a computer can make him feel like a genius.

When it comes to sex toys, men are no different.  Many times just a sex partner is a great toy! That’s great! Bodies are very cool toys! But, having other toys to use on your partner  is even cooler. Many men get their hands on a sex toy and they tend to work on their partner much as they would their Porsche. They get the engine warmed up, then revved up. They check fluid levels and oil. They check the clutch – of course it’s a stick shift. They take it for a spin. The test drive is a success. They are clearly master mechanics.

In my work with men, I often ask men if they ever use the toys on themselves. I usually get a blank stare. Clearly I don’t get it. Tools, or toys, are meant to be used on the other person, right? That’s just how it works. Well, not exactly. Remember those childhood lessons on sharing? It applies to sex and sex toys too. When men hand over the toys to their partner and lets her use the toys on him – the new playground rules can be pretty fun!

Some men might consider it an abdication of power and duty to turn over the control of toys to their partner. After all, isn’t it the man’s job to wear the tool belt?  But, that’s exactly what a lot of men need to do. Guys tend to be big into control. It can be scary to let go and…well…let go. The change in roles can be exhilarating. Some of the most powerful sexual moments happen when the man relinquishes all control and turns over the control of the situation to their partners.

So, everything you learned in kindergarten applies here as well: Be nice to each other, take turns and share your toys.

End The Confusion: Testosterone Replacement Options Explained

September 13th, 2013 by Nick Cannone, FNP

Over the past few years, the FDA (Federal Drug Administration) has approved several new testosterone replacement therapy (TRT) products.  Patients now have several options to choose from.   Treatment can be applied to the skin via a gel or patch, injected into a muscle, placed in the mouth and allowed to absorb through the gums or inserted under the skin by their provider.

There is no right or wrong choice.  TRT modalities are numerous, and all have advantages and disadvantages in terms of safety, convenience, efficacy, ability to mimic physiologic levels, and adverse effects. Choice of treatment must take into account the patient’s age, existing medical conditions, previous and current response to treatment, and preference, as well as cost.

Topical Therapy:  The topical class is the one we typically start patients on.  They are easy to use and the dosage can be adjusted easily to reach goal levels.  There are 4 approved agents in this class.   There is similar efficacy between the products.  The differences between products is where and how much to apply.    All products need to be applied daily.  We find that about 20% of patients will not get good testosterone levels with the topicals due to absorption problems, no matter which of the 4 products is used.   These patients will need to use another delivery system to reach goal levels.  One of the risks of the topical medications is the accidental transfer of the medication to partner or child.  It is important to wash the area before having skin to skin contact with anyone.

A patch, which has been approved for years, is also available.  It is applied daily to the body.   There is no risk of transfer with the patch however some patients will experience a rash.  The patch needs to be applied daily as well.

Testosterone injections have been around for years.  The medication is injected deep into a muscle where it gets absorbed.   The medication is injected once a week or once every two weeks.  In order to monitor levels, patients will typically have their levels checked between injections.   Injections provide  a bolus of medication and thus patients will typically feel better after an injection but may become symptomatic a day or two before their next dose.  There is also an increased risk of polycythemia (an increased hematocrit level which can increase your risk for blood clots).

Testosterone pellets get inserted under the skin during an office procedure.  The pellets get absorbed over the course of 3-4 months.   There is no risk of transfer and absorption of the medication is good.  Testosterone pellets are a good option for patients who have difficulty reaching goal levels with the topical products, are tired or are poor at applying a medication daily or patients who want to decrease the risk of transferring the product to their partner or child.  There is a chance of pellet extrusion or infection although these risks are low.  Also, you cannot make quick changes to dose.

A buccal formulation exists.  It adheres to the gum tissue above the incisors, transbuccal testosterone is absorbed slowly, as it is hydrated by the buccal mucosa.   It is taken twice a day.  Associated adverse effects are mild to moderate and include gum or mouth irritation or tenderness and bitter taste. Other potential concerns include inadvertent swallowing of the tablet resulting in decreased blood levels of testosterone and transfer of salivary testosterone to the partner.

It is important you work with someone who is knowledgeable with all treatment options as this will give you the best chance of success.


ED under 50? Call your doctor now!

September 3rd, 2013 by Paul Nelson

It has been known for several years now, that erectile dysfunction (ED) is often a harbinger of serious medical issues for men.  But in the Mayo Clinic Olmstead County Study published in the American Heart Journal (August 2012), it was found that men with ED, aged 40-49, were fifty times more likely to have a heart attack than their peers who had no ED.

FIFTY times! That’s incredible! This means that having ED figures more into the risk of heart failure than obesity, smoking, cholesterol and family history! In other words, the younger you are, if you have ED, the greater the need for you to go to your doctor.

The problem is, you still have a major hurdle to overcome: Your doctor. Believe it or not, 86% of doctors never ask their patients about their erections. Many doctors are simply uncomfortable with the topic themselves – remember, they are just people too.

So, there you are, in the doctor’s office. You’re there for a physical – or some made up excuse since you did not want to tell the receptionist why you were really there. As the doctor leaves, you mention “things aren’t going so well in the bedroom.”  Whether or not this person remains your doctor is going to be decided in the response. If he says, “At your age? You’re working too hard. You’re stressed out. Take some Viagra,” you really need to think about looking for a new doctor.

The doctor you want to work with should say something like, “At your age? We need to talk.” He then should ask you a whole bunch of questions and then schedule you for some blood tests, listen to your heart, listen to your lungs, and ask even more questions. If your internist can’t figure out the problem, he should send you to a urologist who specializes in sexual medicine. Eventually, you should have an answer to your ED and a plan of action to work on it.

Older men were let off the hook in this study. The Olmstead County Study found that as men age, ED becomes less of an indicator of heart disease.  So, if a 75 year old man has ED, it could be from a number of different causes – heart disease is simply part of that mix.

There are several red flags that every man needs to recognize. Erectile Dysfunction is a big red flag that should motivate a man to seek medical help. It can save his life (and his sex life too)!


Low “T”- What Does It Mean?

August 2nd, 2013 by Nick Cannone, FNP

confused-black-man-green-shirt-400x295[1]As low “T” commercials become more common and more men are having their levels tested, a frequent question asked is:  “Is my testosterone level normal?”  Truth be told, there is no correct answer for this.  Normal for you may be different than normal for me.  However, we have enough experience to know what these results mean.

A typical normal male testosterone level range given is 260 -1080 ng/dl as (which corresponds to about 8.8 – 36.7 nmol/l).  However this is a very large range that is probably too low.  Most medical providers agree that total testosterone levels <300ng/ml are low.  In fact, the endocrine society, which has guidelines on hypogonadism, uses 300ng/ml as the threshold for low testosterone.However, what if your levels are greater than 300ng/ml but you have significant symptoms?  These symptoms include:  low libido, low energy, decrease in strength, erection difficulties, and feeling sad among others.

First, testosterone levels should be checked in the morning (8-10am) for men <45 years of age.   Young men have significant variability in their levels as the day progresses.  For men>45 years old, levels can be checked up until early evening (6pm).   Testosterone variability decreases as we age.   In either case, if your original testosterone level is low, a second should be repeated.

You should also have your LH/FSH, estrogen, sex hormone binding globulin level and free androgen index checked.  This provides a complete look at the hormone panel.  If your levels are between 300-400ng/ml, treatment should be considered based upon your symptomatology.  Thus, men who are consistently at 350ng/ml with symptoms of low testosterone should be treated with testosterone replacement therapy.   There are a couple of validated questionnaires that are used to help identify patients at risk for low testosterone.  We use the ADAM (Androgen Deficiency in Aging Males) questionnaire.

If your total testosterone is consistently >400ng/ml with a normal free androgen index, a thorough evaluation should be undertaken to identify other causes of your symptoms as testosterone is most likely not a significant factor.

Remember, each person is different.  Make sure you work with a provider who is knowledgeable with testosterone replacement therapy.

Steroids: No Turning Back

July 11th, 2013 by Paul Nelson

Bradley_Wiggins_Mark_Cavendish_-_2012_Tour_de_FranceWith the Tour de France underway, talk about doping in sports is again in the news with sportscasters rehashing Lance Armstrong’s admission that he had, indeed, been doping for years and that everybody was doing it.  I cringe when I hear this because the culture of altering body chemistry pervades even the youngest levels of sports.

I have been working with several young men who started using steroids in high school to bulk up and gain a competitive edge athletically.  Sadly, these guys had no idea that using steroids was going to be a decision which haunted them for the rest of their lives.

What nobody tells these athletes is that once you start taking steroids to boost testosterone you might never be able to turn back. When you artificially boost testosterone, your testicles stop making it. The testicles shut down. The testicles shrink, sperm production stops, and if this goes on long enough, even your penis stops working.  These effects are often irreversible.

I was working with a doctor in St. Louis who was inventing a new form of an erectile dysfunction (ED) drug. He had made videos of men using the drug and then showed the results. One could not help but notice that all of these guys were young men in incredible physical shape. I asked the doctor who they were and how he found them.  Apparently they were all male models who had used steroids to get and maintain their physique. These guys were in their 20s and 30s and had complete erectile dysfunction from steroid use.

He said that seeing these young men with complete ED was simply tragic. Their sex lives were changed forever. No one had ever told them that steroid use could, and eventually would, make them both sterile and impotent. These guys paid too high a price for muscle definition.

So next time you hear moralists rail against the scandals of doping in sports, remind the young men in your life that morals have nothing to do with it. Steroids destroy lives.

Testosterone and the Hypothalmus- How It Works

June 11th, 2013 by Nick Cannone, FNP

TestosteroneTestosterone levels in your body are controlled by a complex system that includes your brain, testes, and several different hormones.

Testosterone levels begin to increase in males during puberty.  Men reach peak levels during adolescence and young adulthood.  At about age 30, men start to drop their testosterone by about 1% per year.

The hypothalamus, which is located in the brain, secretes hormones that pulse throughout the day.  The release of these hormones is controlled by a negative feedback loop.  When adequate levels of hormones are reached, a signal is sent to the brain to slow down production.


If you are diagnosed with low testosterone, blood tests can help identify the cause of the low testosterone.  Men are usually diagnosed with either primary hypogonadsim or secondary hypogonadism.  This diagnosis depends on laboratory results.

Primary hypogonadism is a problem with the testes.  In secondary hypogonadism, the problem is with the hypothalamus or pituitary.  Identifying the cause of hypogonadism is important as treatment options may be different.

Testosterone treatment can be complex.  It is important to see someone experienced in treatment as the evaluation and treatment options may affect future issues.