What You Need to Know About the Male Pelvic Floor

Navigate to The Pelvic-Floor Routine

Despite being only in his 30s, Joe Piana felt like an old man. A lifelong athlete, Piana began experiencing persistent bladder-control issues following an injury to his spine. His doctors were stumped.

“I was up a creek without a paddle,” Piana says in a testimonial video for his care provider (Piana is a pseudonym used to protect his privacy). “Nobody could find a solution other than medication just to slow down my bladder. … It kind of felt like they were just throwing darts at a wall.”

Soon, his incontinence was affecting every aspect of his life, including work, athletics, and relationships. Piana noted that it was depressing, especially because he is a relatively young male.

Eventually, he found his way to Mamak Shakib, DC, a chiropractor and physical rehabilitation specialist trained in pelvic floor therapy who focuses on postural neurology and developmental movement. Shakib discovered that the instability in Piana’s lower back had led to dysfunction in his pelvic floor, and that the root of his incontinence lay in these rarely considered muscles.

“For the longest time, they were saying that pelvic-floor issues are female issues,” says Shakib. “And if the problem is in men, it’s in older men.” Both assumptions, she argues, “are far from the truth.”

The pelvic floor — also known as the pelvic diaphragm — is the muscular sheet most commonly associated with the female reproductive system. But it has also been identified as the seat of many urological, reproductive, and orthopedic issues in men, including erectile dysfunction, premature ejaculation, prostatitis, and lower-back pain.

Once Shakib got to the root of Piana’s symptoms, she introduced him to a series of developmental movement exercises designed to strengthen and relax the muscles inside the pelvis, including the pelvic floor, and to refine its ability to function harmoniously with the rest of his pelvis.

“I started feeling relief almost instantly,” says Piana, who adds that he was finally able to restore the life he had before the injury.

A Common Problem

Men experiencing problems like Piana’s may be surprised — and relieved — to learn that an array of treatments is available to help them.

A man’s pelvic floor supports his reproductive organs and is intrinsically linked to sexuality and identity (here’s a quick overview of the bones and muscles that make up the pelvic floor); we often place a lot of value on our sexual function and ability to control elimination of urine and stool. So, troubles with the pelvic floor can be a source of profound embarrassment and frustration — far more so than problems with, say, the knees or hips.

In many respects, though, the pelvic floor is just another set of muscles. Like the biceps or quads, these muscles can weaken with underuse and tire with overuse.

On the other hand, they can grow stronger, more coordinated, and more supple with training and targeted exercises, leading to improved sexual function, better elimination, reduced pain, and improved posture. Even better, many treatment approaches are neither invasive nor painful.

“The old strategy used to be not to talk about it — to suffer in silence,” says Minnesota-based physical therapist Alyssa George, PT, DPT, OCS, a specialist in orthopedic and pelvic conditions. “But that’s changing. There are more male pelvic-floor physical therapists — and more men willing to come to a PT for their pelvic-floor problems as well.”

Pelvic-Floor Anatomy

Part of what makes training the pelvic-floor muscles difficult is that you can’t see them. Like your respiratory muscles, the pelvic diaphragm is internal. So even if you could pretzel your head around to see the underside of your pelvis, you couldn’t observe the small set of muscles — no bigger than a tea saucer — in action.

Feeling them at work is a different story. These are the muscles you contract when you need to stop the flow of urine mid-pee or prevent it when you have a strong urge. Still not clear? Think, lift your testes or squeeze your anus. Bingo — you’ve just activated your pelvic floor.

Several muscles are involved in this simple action. If you could view a model of the pelvis from above, you would see a large opening through its center. The pelvic floor spans this opening like a sheet, fanning out from the tailbone and attaching to the pubic bone in the front and the hip bones along the sides.

“At rest, the pelvic floor forms a kind of hammock structure, hanging downward slightly at its center,” says Adam Gvili, PT, DPT, a New York City–based physical therapist specializing in men’s health and pelvic-floor dysfunction. Contract the muscles, he says, and the hammock pulls taut, like a trampoline.

Like the bottom of a box, these muscles keep the contents of your lower torso — the bladder and intestines, plus the prostate in men and the vagina and uterus in women — in place. They also act as a valve for the urethra and anus, restricting the flow of urine and feces when the muscles contract and allowing their passage when they release.

“The pelvic floor pretty much does all things bladder, bowel, and sexual function,” says Gvili. When your sexual organs function well, and when elimination is smooth, regular, and painless, you have, in part, your pelvic floor to thank for it.

Small and subtle though they are, the muscles of the pelvic floor also play an important role in movement of all kinds, says George.

“How we generate strength from our core has a lot to do with what our pelvic floor is doing,” she explains. If you think of the core as a cylindrical barrel, the pelvic floor provides the base; … the abdominals, obliques, and lower back form the sides; and the respiratory diaphragm — the large, dome-shaped muscle under your rib cage that helps you breathe — provides the top.

All these muscles connect via fascia — an elastic connective tissue made of collagen — so when your core (which encompasses more than just the front of your trunk) works well and is balanced on all sides, the pelvic floor moves subtly in sync with the array of muscles that influence its performance. It contracts whenever you sneeze or perform a heavy lift and relaxes when you’re at rest.

“When you breathe in, your lungs push the abdominal diaphragm downward toward the pelvis,” says Shakib. “That intra-abdominal pressure relaxes the muscles inside the pelvis.” As you breathe out, the opposite action occurs, and the muscles inside the pelvis uniformly contract to initiate the process — a wavelike pattern Shakib calls biological breathing.

“Breathing correctly is a huge player in solving most pelvic-floor dysfunction issues,” Shakib notes.

Like any muscle, the pelvic diaphragm doesn’t just turn on and off. Rather, it contracts and relaxes, to varying degrees, like a light on a dimmer switch.

Max out on the deadlift, for example, and your pelvic floor contracts fully, along with the rest of your core muscles, to support your spine. Take an easy hike, and the pelvic floor contracts gently and relaxes, rising and falling slightly with each step.

Like breathing, these muscular actions are almost entirely unconscious, and we want them to be able to respond appropriately to whatever we’re doing. For that, says George, “we don’t want the muscles to be too tight and we don’t want them to be too weak.”

Causes and Symptoms of Pelvic-Floor Dysfunction

As muscles go, the pelvic floor is uncommonly glitchy. Though this area contains and surrounds some of our most sensitive organs, it can nevertheless become desensitized over time, leading to conditions known as hypertonicity (excessive contraction of muscles) and hypotonicity (excessive relaxation of muscles). Either condition, which can arise from several causes, can cause dysfunction.

Undertraining or Overtraining

Poor fitness can result in pelvic-floor dysfunction (PFD), says George. The glutes weaken due to a lack of exercise and the nearby pelvic floor follows suit.

A lack of coordination in the lower-body musculature, sometimes caused by injury or excessive sitting, is another common culprit. “Your pelvis is the foundation of the structure above,” Shakib explains. “Each body part needs to know how to dance with the rest of the body.” When this stability is in jeopardy, the muscles inside the pelvis pick up the slack.

Ironically, PFD can also arise due to an excessive focus on a central tenet of fitness: bracing the core. “Some people develop pelvic-floor issues because they have learned that a tight core prevents back pain, so they overuse that strategy and lose the ability to fully relax,” George notes.

In trying to resolve one problem by always engaging their abs — even when they’re not lifting something heavy — they can bring about another, she explains.

Additionally, some exercises are notorious for taxing the pelvic floor, especially if those muscles are already weakened, George adds. For instance, running can challenge the pelvic-floor muscles due to the impact of each stride; a suboptimal posture and breathing pattern or weakness in the nearby glutes can further exacerbate these effects.

Similarly, lifting very heavy weights — say, performing deadlifts at weights approaching your max — can also put high load on the pelvic floor and challenge those muscles; again, issues with form, breathing, and preexisting weakness can all contribute to strain.

That’s not to say people should avoid bracing their core, running, doing heavy deadlifts, or performing any other exercise, notes Gvili. By and large, engaging in physical activity and building full-body strength is good for the pelvic floor — and for your overall health. Correct form, proper breathing mechanics, and early intervention as issues crop up can help you get the most out of your workouts without sacrificing fitness gains.

Surgery

The pelvic floor can also be impacted by surgery. An enlarged prostate may compress the urethra and block the flow of urine for weeks or months at a time, explains George, effectively kinking the urinal “hose” and taking over the valve-like function usually served by the pelvic floor, making it difficult to urinate. If the prostate is then surgically removed, the pelvic floor may have forgotten how to close off the flow of urine, like an arm or a leg that atrophies after being immobilized in a cast.

Stress and Trauma

Finally, pelvic-floor issues can be psychological in origin. Along with tension in the jaw and shoulders, pelvic-floor clenching can arise as a habitual response to stress. “The pelvic floor is connected to the autonomic nervous system, which also regulates digestion, breathing, heart rate, and sexual arousal,” says George.

Stress and anxiety can increase activity of the vagus nerve and result in increased muscle tension in the pelvic floor. Tension in one area can exacerbate tension in the others.

Sexual abuse, emotional trauma, and early socialization around toilet training and sexuality can lead us to associate the pelvic region with shame — a way to cope with this may be through dissociation, which results effectively in blunting the sensations that arise in the pelvic area.

Chronic pelvic-floor muscle tension can cause difficulty with relaxing anal sphincters, contributing to constipation; it can cause poor coordination of certain muscles, resulting in premature ejaculation; and it can prevent adequate blood flow to the penis during sexual activity, resulting in erectile dysfunction or impotence.

Orgasms — which are characterized by an involuntary release and contraction of the pelvic-floor muscles — may be less intense and pleasurable. Dysfunction can affect sperm motility, which can make it more difficult to conceive and can be mistaken for infertility.

What You Can Do

Fortunately, solving these problems may not require surgery, medication, or even long-term therapy.

The first line of defense is your doctor. Bacterial and viral infections can cause pelvic-floor issues, as can chronic conditions like type 1 and type 2 diabetes and heart disease — so don’t ignore symptoms if they crop up.

Gvili notes that very few cases of pelvic-floor dysfunction are bacterial. “But get checked out by a urologist or a gastroenterologist just to make sure that there’s nothing more sinister going on.”

Once you’ve secured a clean bill of health, seek out a pelvic-floor specialist. “Male pelvic-floor health has really only become a specialty in the last 10 to 15 years,” he notes. So, you might need to shop around to find a practitioner who specializes in the male pelvic floor. That can take some effort, but the relief, and the freedom from the perceived stigma of PFD, can be well worth it.

Pelvic-floor physical therapy is often educational and collaborative, with the patient playing a proactive role in healing. “[It] doesn’t matter whether you’re going for your knee or your shoulder or your pelvic floor, going to a physical therapist is a learning experience,” he says.

The sessions usually consist of a blend of exercises, neuromuscular reeducation, biofeedback, and manual therapy designed to bring new awareness and sensitivity to areas the patient has been unable to feel — sometimes for years.

Sessions may also include instruction in Kegels — repeated contractions of the pelvic-floor muscles — as well as sessions on the Emsella, a soft chair that stimulates your pelvic floor (while you’re fully clothed) to contract painlessly hundreds of times per minute.

Other treatments can involve a probe or finger inserted anally for clear feedback on the location and degree of any tension — a practice that should be performed with respect and skill. “We always work within the person’s comfort zone,” says Gvili.

Ultimately, the intention of all these treatments is to restore a sense of integration of the pelvic floor into the functioning of the entire body. “What we do is try to teach a person what it feels like for the brain and body to work together,” he says. “Usually, they feel better pretty quickly.”

Gvili notes that regular physical activity is an important component of long-term pelvic-floor care. Targeted exercises can build body awareness and coordination of the pelvic floor with the rest of the body, improve breathing patterns, and they can build balanced strength in weakened muscles around the pelvis, hips, and abdomen.

Physical therapists, like Gvili, also work with patients to address form issues or weaknesses in activities that might contribute to pelvic-floor pain, incontinence, or related concerns. This includes fine-tuning high-impact movements or exercises that require intense intra-abdominal pressure, such as deadlifting, squatting, cycling, jumping, and running, to name a few.

The bottom line: Male pelvic-floor dysfunction is eminently treatable. “Just because you have PFD doesn’t mean you’re broken,” Gvili says. “Sometimes, that’s the most important thing men need to hear.”

The Pelvic-Floor Routine

If you’re experiencing pelvic-floor issues, try the following routine designed by chiropractor Mamak Shakib, DC, who focuses on stabilizing the pelvis when treating patients with pelvic-floor dysfunction.

These moves progressively build stability in different parts of your body. Shakib notes that performing each move with optimal form and maintaining awareness of the pelvic floor is more important than the number of repetitions or the duration of each exercise.