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Erectile Dysfunction Radio Podcast
Jonathan Noury, DPT, joins us to discuss Erectile Dysfunction and the Pelvic Floor. Dr. Noury is a physical therapist in New York.
The Erectile Dysfunction Radio Podcast is dedicated to educating and empowering men to address erectile dysfunction, improve confidence, and enhance the satisfaction in their relationships. This podcast is hosted by certified sex therapist, Mark Goldberg, LCMFT, CST.
Transcript of Episode 27 – Erectile Dysfunction and the Pelvic Floor
Mark: Today we are joined by Dr. Jonathan Noury, who is a doctor of physical therapy. He graduated from New York Medical College and has a specialty in geriatrics. He currently works in oncology rehab and pelvic floor rehab. Two areas that can significantly impact erections and erectile dysfunction.
Can you tell our listeners what the pelvic floor is?
Jonathan Noury, DPT: Sure, so in order to locate the pelvic floor, the best way to think about it is it’s the area that you sit on when you’re sitting in a chair, if you try to sit up nice and tall, your pelvis rocks forward, and If you slouch back in the chair, your pelvis rocks back with you.
The pelvic floor, for the most part, controls urinary function, sexual function, and fecal functions, as well as housing all of those organs inside of the pelvis.
It functions as a part of the core, so you have your abdominals in the front, you have your back muscles, you have your glutes around the back as well, and then underneath is the pelvic floor itself.
There’s a group of muscles there that play an important part in allowing people to urinate, have a bowel movement, erections and so forth.
Mark: Jonathan, can you tell us a little bit more specifically about the role of the pelvic floor when it comes to erections, are there particular muscle groups that are involved? Are there particular areas of the pelvic floor that primarily impact erections?
Jonathan Noury, DPT: I’ll go into some of the muscles and layers, there’s essentially three layers. The first layer and second layer are your more functional muscles, they work to allow you to hold in your urine, hold in your bowel movements, relax to have a bowel movement or urinate, as well as have a role in the erection. For females, it would be very similar.
There’s then the deeper layer of muscles those are referred to usually as Levator ani muscles, their functions more for support and structure of holding up the bladder, prostate and rectum in the male.
Those muscles are not as functional for an erection when it comes to erections or erectile dysfunction, there’s two muscles that we focus on, the first is called the bulbospongiosus and the second is called the ischiocavernosus, they’re essentially between the shaft of the penis toward the scrotum of the testical area, and then the ischiocavernosus comes out from the side of those, so those are usually the muscles that are involved in an erection.
There is a larger nerve supply and blood supply. The pudendal nerve is a nerve that supplies sensation and motor to the pelvic floor, and it actually passes through the piriformis muscle and some of the deeper pelvic muscles that I mentioned.
Sometimes you’ve heard of piriformis syndrome where you get that kind of radiating pain down the back of the leg, and that is the same kind of pain that messes with the sciatic nerve.
The pudendal nerve comes right off of that, it actually leaves the pelvis, wraps back around, connects with the artery in the vein that ends up going towards the penis and scrotum area, and so when blood rushes through these arteries through the bulbocavernosus and into the penis, that’s how you get the erection, the pressure closes off the venous return, and therefore you have a blood-gorged penis.
Mark: So this is actually a really important point that I want to clarify because a lot of what we do touch on on this podcast is about blood flow, and what I’m gathering from what you’re sharing is that the muscles that we’re talking about in the pelvic floor impact the blood flow into the penis. That would create the erection, is that correct?
Jonathan Noury, DPT: Definitely, definitely the muscles are at the base of the penis. They don’t create the erection themselves, so it’s not like if you have a strong bulbocavernosus you have a strong erection, it’s that if those muscles aren’t able to one, support a erection, if they’re not able to bring enough blood supply to that area, that’s how you might have an issue with your erection.
Mark: Okay, I think we got that. Now, what are some of the problems, or perhaps some of the common injuries that people encounter with the pelvic floor or in that region?
Jonathan Noury, DPT: There’s usually two ways it goes, one is either the muscles there are too tight, or it can go the other way, where those muscles are a little too lax, if the muscles are too tight, that restricts more blood flow and the muscles are too lax, then they can’t really be stimulated or engaged enough to maintain that erection, or in the case of an incomplete ejaculation or retrograde ejaculation, they might not have the ability to produce enough ejaculate.
So with the problems that can occur, if you have tightness laxity, those might be secondary to some other injury or painful syndromes that somebody’s going through, it can also be due to bladder issues or constipation, or it could be somebody who has some kind of dysphoria of that area where they are either uncomfortable with their own genitals or they just don’t like to think about their own genitals
Mark: So again, I want to make sure I’m clarifying this for our listeners. So as we’ve mentioned multiple times in this podcast, erections require blood flow into the penis and for it to be contained and not exit as quickly as it flows in, that’s really what creates that erection and what I’m gathering from you is that there’s a particular balance or a certain range of muscle tone that they shouldn’t be too tight as to restrict blood flow in, but also can’t be too loose as to allow the blood to flow right out.
Is that what we’re touching on here?
Jonathan Noury, DPT: Exactly. And tight muscle doesn’t mean that it’s too strong per se, usually things will get tight when they’re actually weaker or when there’s lack of blood flow to an area, it’s going to make that muscle try to almost beg for blood flow.
When you have a tight muscle and you’re getting lack of blood flow, it’s going to be difficult to get enough blood flow for the penis to get erect or stay erect.
Mark: Got it. So I think what’s going to be important for our listeners to understand is, does somebody know that they’re having a pelvic floor issue or a pelvic floor problem?
Jonathan Noury, DPT: Yes and no. I’ve seen patients who’ve come in and their main complaint is that they have erectile dysfunction or retrograde ejaculation, and I can’t say that I fix or work on erections or ejaculation issues, but the issues that come along with that are typically some type of urinary dysfunction, bladder dysfunction, rectal dysfunction, constipation, it could have been a testicular trauma that they had.
Or someone who has some type of nerve damage, say somebody who’s doing the biking class five days a week, 45 minutes a day, and that nerve keeps getting pinched and hurt through that seat of the bicycle, those are kinds of injuries that can occur.
So if somebody is either not able to urinate as well or as fluidly as they used to be, if they’re having a frequent urination issue, if they’re having inability to urinate, those are some things that come up with pelvic floor dysfunctions, same thing with constipation.
If there is a chronic constipation, that could also be a dysfunction of the pelvic floor where they’re unable to actually use muscles to allow for bowel movements to happen.
And then if there are sensory issues, so if the tip of the penis isn’t getting sensory information or the floor muscles aren’t getting enough sensory information, that can also limit an erection or the ability to get the erection.
Mark: Got it. I want to just touch for a moment on the sensory piece, can I ask you to elaborate on that, because that’s a question that does come up quite often about lack of sensation with an erection in various parts of the penis. Does the pelvic floor play some sort of role in that, or the muscle restriction that we were touching on?
Jonathan Noury, DPT: Definitely with any sensation there is going to be a musculoskeletal component to it, there is also probably a psychosomatic part to it as well From a musculoskeletal perspective, I mentioned the pudendal nerve or pudendal neuralgia that can occur where if there is a lack of blood flow to that nerve that does intervene the pelvic floor, that can lead to decrease in sensation anywhere along that pelvic floor including and probably especially to the shaft of the penis or the tip of the penis, which has the most sensory integration, and is a very important piece of erection and ejaculation.
If there is a lack of blood flow to the area, as we said before, that’s a huge problem, and nerves love blood, they really need blood in order to survive, and when they don’t have blood, they tend to die off or scream out for blood, and that creates a whole cascade effect of pain and further damage to the area, and that’s how you would get a poor sensory to that area.
Mark: Okay, thank you for clarifying. And taking another step back to this question as to whether somebody is going to know they have a pelvic floor problem, what I gathered is that there’s a whole slew of medical conditions and symptoms that the pelvic floor can play a pretty significant role in.
However, what I was kind of hearing between all of that is that a patient is not going to be able to readily identify that the pelvic floor weakness or pelvic floor problem is what’s at play… their first stop would probably be, a physician. Is that correct?
Jonathan Noury, DPT: That is correct. We come in when the issue has been looked at from a medical perspective in terms of Pharmacology for increased block flow or increased dilation or restriction constriction of the blood vessels in that area.
If there’s no cardiovascular injury to the area, there could be other medical conditions there that are going on, but once that is all evaluated and assessed that, okay, it’s not a cardiovascular issue, it’s not a severe nerve damage issue, or especially not a neurological issue, like a spinal cord issue, we come in and we assess for the muscles of the pelvic floor, how those muscles are functioning, and whether or not that could contribute to the lack of an erection.
Mark: Got it, okay, thank you very much for clarifying that. So it seems pretty clear that the pelvic floor plays a role in being able to gain and maintain an erection and conversely, a problem or an injury or a weakness in the pelvic floor would seem to contribute potentially to erectile dysfunction, so a question that our listeners are absolutely going to want to know is what can be done, and can the pelvic floor be strengthened or repaired?
Jonathan Noury, DPT: Right. So again, I think the biggest issue that we face sometimes, and this is especially with the female population, because they tend to have more of those urinary effects, like leakage, is people going online or doctor’s telling the patients just do kegels, and while kegels are essentially what we’re trying to teach a patient, sometimes the problem isn’t that they’re too week, is that those muscles are too short or too tight to even perform a kegel.
If they’re already in a shortened position, it’s going to be much harder for them to contract or work in that small position. So sometimes when we have to take patients through is teaching them actually how to relax those muscles and coordinate those muscles a little better before we actually just get them to do the kegels.
Mark: And I want to piggy back on what you’re saying because this is really important, erectile dysfunction and the human body in general is so complex that even in the question that I ask, just assuming that the solution is to strengthen the pelvic floor.
I just appreciate you sharing with our listeners just the complexity, and then sometimes it’s actually not what needs to be done in order to get the desired outcomes and in order to get the pelvic floor working in the way it needs to… So to that end, I’m sure listeners are going to want to know, is there something that they can be doing at home if Dr. Google is not the answer?
Jonathan Noury, DPT: Sure. So the opposite of a kegel would be something that we call bearing down, essentially bearing down is the same movement you would do to pass gas, and when you do that, you’re actually actively relaxing the pelvic floor muscles to allow them to be in their most relaxed state.
And that allows the patient usually to feel where their muscles can go to, so how far they can get. It’s actually one of the harder movements to teach a patient, because most of the patients are so tight or stressed in that area that they don’t know how to relax or how to bring those muscles into their normal range. And so part of what we work with is teaching them how to find those muscles a little bit better.
At home, the idea would be trying to lie on your back or lie on your side, and imagine you’re trying to pass gas, it’s a very subtle movement. But you should feel a kind of relaxing of that public floor.
Mark: Got it. And it sounds somewhat complex to be able to really learn how to get this correct, and I’m sure once people have experienced the technique, I think gonna do a whole lot better job of being able to implement it.
So to that end, would you recommend that a person who is serious about addressing erectile dysfunction and may have some awareness that the pelvic floor already is involved based on some of the other symptoms that we spoke about, would you recommend them going for at least a one-time consult to meet with a pelvic floor specialist to see if that can be something that can be done to facilitate better erections, potentially?
Jonathan Noury, DPT: I definitely would recommend that as long as they’ve been assessed already for any cardiovascular issues or neurological issues that might be playing a part in that, once those are ruled out or either give a medication for… I think there’s still benefit to learning how to use the pelvic floor muscles, how to regain the coordination of those pelvic floor muscles to then last longer with the erection or gain the erection even without medication.
Mark: Thank you for clarifying that. Jonathan, is there anything else that you would add at this time that our listeners might benefit from being aware of?
Jonathan Noury, DPT: I think your background is a psychology background, and we definitely see a lot of patients who come in, again, erectile dysfunction is not their main concern per se, they definitely are concerned about it, but that’s not usually why their doctors send them to us, but there’s always some type of psychological component to the care as well, whether it’s a habit that needs to be changed or an exercise that needs to be modified because of what it’s doing to their psyche of thinking about the pelvic floor.
So those are definitely ways for patients to get a little bit of the psychological realm of things, but also focus on the physical part of it, because I don’t think it can be taken care of with just one aspect.
Mark: Thank you for that, and thank you for highlighting once again the complexity of erectile dysfunction. I believe that the more good information we can bring to men, the better their outcomes are going to be.
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