From heart disease to mental health issues, low testosterone to some medicines — there is a range of physical and psychological factors that contribute to erectile dysfunction in men. One factor that’s often overlooked in men who have difficulty getting or maintaining an erection is the role of pelvic floor muscles and the potential of pelvic floor muscle therapy (PFMT) in treating erectile dysfunction.
What is the male pelvic floor?
We all have a pelvic floor, which is the group of muscles that stretch from the pubic bone at the front of your pelvis to the tailbone at the back. It also stretches side-to-side from one sitting bone to the other. It has a crucial role in supporting your bladder, bowel and sexual function. Pelvic floor problems can occur when the pelvic floor muscles are stretched, weakened or too tight.
“Often men don't even know they have a pelvic floor until something goes wrong and they have an urgent need to quickly upskill,” says men’s health physiotherapist and researcher Dr Jo Milios. “They may have done a Pilates session and heard it mentioned, but generally they wouldn't know where it actually is, what it does and how to contract and relax it.”
Pelvic floor muscles and erectile dysfunction
First, let’s look at how erections happen. When you’re aroused your brain sends messages to the blood vessels in your penis, which relax allowing more blood to flow in. This fills up two tubes of spongy tissue in the penis. The veins running through the outer sheath of the penis are then compressed, which stops the blood from leaving the penis, giving you an erection. When the inflow of blood reduces and the veins open, your erection stops.
Your pelvic floor muscles help manage blood flow to your genitals by compressing the penile veins, trapping blood in the penis, creating an erection. There are two main ways pelvic floor problems can lead to erection issues. If the pelvic floor is weak, the outflow of blood isn’t prevented, and an erection can’t be maintained. A pelvic floor that’s too tight — also called a hypertonic or overactive pelvic floor — has been suggested as a possible cause of erectile dysfunction due to compression of the artery that provides blood to the penis.
Weak pelvic floor
Pelvic floor muscles can be weakened by surgery, constipation, being overweight, persistent heavy lifting, high impact exercise, long-term coughing and ageing1. Aside from erectile dysfunction, if you have a weak pelvic floor, you might also notice symptoms such as leaking urine during activities like running, jumping or sneezing, a sudden and urgent need to urinate, or leaking stool. There also can be incomplete emptying of the bladder and bowel or increased frequency of toilet visits.
Pelvic floor exercises can strengthen your pelvic floor and might have benefits for treating erectile dysfunction2. It’s important to find your pelvic floor muscles in order to exercise them, which can be difficult and take some practice.
“For home practice, I encourage men to stand naked in front of a mirror and to observe their penis retracting and testes rising, without bracing their abdominals,” Dr Milios says. “Doing this action ‘gently’ as opposed to with ‘gusto’ is the key. My favourite cue — which men seem to best relate to — is to think of ‘lifting the nuts to the guts’.”
When you're tightening the right muscles, you should see the base of the penis draw in and the scrotum lift up. If you don't feel a distinct 'squeeze and lift' of your pelvic floor muscles, work with a men’s health physiotherapist. They can tailor an exercise program for you and monitor it to ensure it’s working.
Pelvic floor exercises for a weak pelvic floor
Before you start doing pelvic floor muscle exercises, also called Kegel exercises, there are some important things to remember:
- Do not clench your buttocks when you are doing these exercises
- Keep your legs relaxed
- Keep breathing
- Squeeze and lift rather than tightly clenching.
With those tips in mind, here are the next steps:
- Squeeze and draw in the muscles of the urethra and anus at the same time, whilst you keep breathing. Hold your muscles tight for 3-5 seconds to train the slow twitch ‘endurance' fibres that help gain and maintain an erection. You should feel a tightening and lifting when you squeeze and a feeling of letting the muscles go when you relax them
- Repeat this squeezing motion 10 times. Try to get to 3-5 seconds of lifting and squeezing, and 3-5 seconds of rest between each repetition. If you cannot make it to 3-5 sec, try to hold for as long as you can
- This should also be repeated in a quick action at a rate of 1 second per cycle. This trains the fast twitch pelvic floor muscle fibres that are responsible for orgasm and ejaculatory function
- Try to do three sets of 10 quick squeeze and 10 slow lifts (a total of 60 squeezes) every day.
You can do the exercises lying down, sitting, or standing. Try staying in one position throughout the exercise for best results.
Overactive pelvic floor
An overactive or hypertonic pelvic floor occurs when your pelvic muscles become too tense and can’t relax. You might experience symptoms such as constipation, incomplete emptying of your bowels, straining when emptying your bowels, frequent or urgent urination, urinary incontinence, hesitancy or slow flow of urine, and pelvic pain3. Several activities can lead to an overactive pelvic floor including a history of holding on to your bladder or bowels, intense core training, high levels of stress or anxiety, injury and trauma, and conditions such as chronic prostatitis/chronic pelvic pain syndrome. Treatment for overactive pelvic floor muscles involves strategies to relax the area.
“It's all about learning to let go of any tension in their belly, buttocks and pelvic floor area,” Dr Milos says. “This includes yoga-based stretches of the inner thigh muscles, buttock muscles, hips and lower back to release stiff, tight muscles leading into the pelvis.”
Treatment can also involve breathing and relaxation techniques, manual therapy and myofascial techniques, education and biofeedback.
Relaxation exercises for a tight pelvic floor
A men's health physiotherapist can help diagnose a hypertonic pelvic floor and share techniques to relax your pelvic floor. Here are some pelvic floor relaxation exercises you can try at home:
Body scanning: This technique can help you improve your awareness of muscle tension in the body. Get comfortable lying down or seated and take a few deep breaths. Bring awareness to your feet and pay attention to how they feel. Focus on relaxing the area and visualise any tension leaving it before moving on to the next body part and continue through each part of your body.
Stretching: There is a range of stretches to help relax your pelvic floor (which you can find here). Start with the frog leg stretch by lying flat on your back with the soles of your feet together and knees falling apart. Bring your feet comfortably close to your bottom. Breath into your belly while holding the stretch for 30-90 seconds. Taking 5 seconds to beath in then 5 seconds to breathe out is a soothing cycle to practise.
Breathing exercise: In a seated position place your feet apart on the floor and let your lower jaw hang loose. Let your shoulders drop and your belly relax. Take a breath expanding your waist and focus on letting the pelvic floor muscles soften. Repeat this breathing technique five times.
What to do next
If you’re experiencing erectile dysfunction, chat to your GP first as it’s critical you investigate any underlying health problems that could be causing it. Erectile dysfunction is often a sign of cardiovascular disease and identifying it early can help prevent events like heart attack or stroke.
The benefits of kegel exercises or pelvic floor muscle therapy for erectile dysfunction are that it’s minimally invasive and can be done alongside lifestyle modification and medication. Your GP can help you find a physiotherapist to work with or you can find one here.