Archive for October, 2014

Male Pelvic Pain: A Charley Horse in the Pelvis

October 25, 2014

Andrew Siegel MD

shutterstock_orange gu tract closeup

Pelvic pain is certainly not a problem unique to males as it can affect both men and women—anyone who has pelvic floor muscles—but the subject of female pelvic pain is a topic for another day.

The term “chronic prostatitis” is a frequent diagnosis tagged to a variety of different conditions having in common discomfort or pain perceived in the pelvic region. It is a wastebasket diagnosis, made after other processes are ruled out, and a term as commonly used by the urologist as “irritable bowel syndrome” is by the gastroenterologist. Traditionally, the prostate has been treated as the source of the pelvic pain, but the truth of the matter is that the prostate is rarely the source.

Ninety-five percent of men diagnosed with “chronic prostatitis” do not have an infected or inflamed prostate gland. What many actually have is tension myalgia of the pelvic floor muscles, a condition of the pelvic floor muscles in which they are tense, spastic and hyper-contractile. Essentially, this is a “headache” of the pelvis driven by spastic pelvic floor muscles.

The pelvis is simply a very bad place for spastic muscles because it is home to urinary, sexual and bowel function. This causes pain and often tenderness to touch, creating the feeling that one’s pelvic muscles are “tied in a knot.” The pain is often perceived in the genitals, lower urinary tract, and rectum/anal areas, and accompanying the pain are often adverse effects on sexual, urinary, and bowel function.

It can be brought on by anxiety, stress and other circumstances and is thought to be an abnormality with the nerve pathway that regulates muscle tone. Characteristically, the pain waxes and wanes in intensity over time and wanders to different locations in the pelvis, possibly involving the lower abdomen, groin, pubic area, penis, scrotum, testicles, perineum, anus, rectum, hips, and lower back.

Patients often have difficulty in articulating the precise symptoms that brought them into the office, although they usually have a long list of issues, lots of prior interventions, and have seen many physicians. The pain is often described as “stabbing” in quality and can be provoked by urination, bowel movements or sexual activity/ejaculation or even driving a car or wearing tight clothing.

After identifying tension myalgia of the pelvic floor muscles in a number of patients, it truly seems to be such an obvious diagnosis. It comes down to a careful history and a physical exam, which includes an evaluation for trigger points of the pelvic floor muscles that, when examined, cause tremendous pain. Most male patients diagnosed with chronic prostatitis and interstitial cystitis probably have tension myalgia of the pelvic floor. In fact, pelvic floor tension myalgia is probably one of the most common problems that urologists see and is likely one of the most misunderstood, misdiagnosed and mistreated conditions in the discipline of medicine.

Tension myalgia is also implicated in voiding difficulties (difficulty starting or emptying, poor quality stream, post-void dribbling), overactive bladder (urgency, frequency, urgency incontinence), erectile dysfunction, ejaculatory dysfunction (premature ejaculation, painful ejaculation, reduced ejaculatory strength), and bowel difficulties (constipation, hemorrhoids, fissure, etc.).

The patient profile of a man with tension myalgia of the pelvic floor is very predictable. A thirty-something or forty-something well-dressed male with excellent posture and a type A personality (competitive, ambitious, organized, impatient, etc.) presents with vague pelvic pain symptoms that he has difficulty in describing. In addition to the pain he often notes urinary, rectal, erectile and ejaculatory issues. He usually has a professional, high-level, stressful occupation and his physical appearance and body language is “tight,” paralleling the tone of his pelvic floor muscles. He tends to be “driven” and seems to have a compulsive, controlling and disciplined personality and typically exercises on a regular basis and is in good physical shape.

He has been to numerous urologists and has been treated with many courses of prolonged antibiotics (to minimal benefit) and has been labeled as having chronic prostatitis. He is miserable and perhaps at wits end because of the negative effects on his quality of life and having endured years of episodic agony. He typically is very worried and emotionally stressed about his pain. It is not uncommon to discover that the pain seemed to be precipitated by a situation deemed to be a personal failure such as involvement in a divorce, loss of a job or other event. On rectal exam, he has very tight tone and has tenderness, spasticity and often knots that can be felt within the levator ani muscles, similar to the tension knots that can develop in one’s back muscles.

It is theorized that this chronically over-contracted group of muscles is a manifestation of stress and anxiety turned inwards, a classic example of the mind-body connection in action. This state of “chronic over-vigilance” of the pelvic floor muscles seemingly serves the purpose of guarding and protecting the genital area. When anxiety expresses itself through tension in the pelvic floor, the physical tension further contributes to the emotional anxiety and stress, which creates a vicious cycle.

In many ways it is similar to tension headaches, a not uncommon response to stress. To use an example from the animal kingdom, tension myalgia of the pelvic floor parallels what a frightened dog does when it pulls its tail between its legs. Sadly, conventional urologic practice is very nuts-and-bolts mechanistic and has been glacially slow to accept the concept that stress and other psychosocial factors can give rise to urological diseases. However, an understanding of this issue is slowly gaining traction and recognition and we are approaching a tipping point in which this type of diagnosis will be made on a more frequent basis in the near future.

To manage tension myalgia, it is necessary to foster relaxation of the spastic pelvic floor muscles and untie the “knot.” There are a variety of means of doing so, including relaxation techniques, stretching, hot baths, massage, and muscle relaxants. Many respond well to physical therapy sessions with skilled pelvic physiotherapists who are capable of trigger point therapy, which involves compressing and massaging the knotted and spastic muscles

Those who are so motivated can treat themselves with a therapeutic internal trigger point release rectal wand that aims to eliminate/mitigate the knots. This treatment is referred to as the Stanford pelvic pain protocol or alternatively, the Wise-Anderson protocol (designed by David Wise, a psychologist, Rodney Anderson, a urologist, and Tim Sawyer, a physiotherapist).

When used judiciously, pelvic floor muscle training programs can be of benefit to pelvic floor muscle tension myalgia. A good program (aside from the emphasis on strength training of the pelvic floor muscles) serves to instill awareness of and develop proficiency in relaxing the pelvic muscles as one cycles through the phases of contraction and relaxation. (The principle is that maximal muscle contraction induces maximal muscle relaxation, a “meditative” state between muscle contractions.) One must be very careful in contracting muscles that are already spastic and hyper-contractile, as pain can potentially be aggravated by such activity.

Bottom Line: When a man presents will pelvic pain, the diagnosis of pelvic floor muscle tension myalgia should be a primary consideration. Physical interventions can be extremely helpful in alleviating the pain and untying the “knot.” By making the proper diagnosis and providing pain relief, the vicious cycle of anxiety/pain can be broken.

For a wonderful reference, consult: Dr. Wise and Anderson’s book, A Headache in the Pelvis: A New Understanding and Treatment for Chronic Pelvic Pain Syndromes.


Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Note: As Arnold Kegel popularized pelvic floor muscle exercises in females in the late 1940’s, so I am working towards the goal of popularizing pelvic floor muscle exercises in males. This year I published a review article in the Gold Journal of Urology entitled Pelvic Floor Muscle Training in Men: Practical Applications to disseminate the importance and applications of these exercises to my urology colleagues. I wrote Male Pelvic Fitness: Optimizing Sexual and Urinary Health, a book intended to educate the non-medical population. I, along with my partner David Mandell and our superb pelvic floor team, co-created the Private Gym male pelvic floor exercise DVD and resistance program.

For more info on the book:

For more info on the Private Gym:


Man’s Motivation for Medical Ministration: His Penis

October 18, 2014

Andrew Siegel MD


shutterstock_side view manjpeg


You—as a man—are a master of denial, who, through a combination of nature and nurture, often play the stoic, tough guy, independent, cool as a cucumber, stubborn, non-demonstrative, too-proud-to-ask-directions act. You typically serve the role of provider, protector, hunter, and warrior as opposed to your nurturing and more emotional female gender mate. Furthermore, you are literally “tainted” by testosterone levels that can biochemically impair your ability to think rationally. Truth is that deep inside, most men are actually weak-kneed milquetoasts who are put to shame by women when it comes to true bravado. Regarding seeking help in the form of medical care, men are much more reluctant to do so than women, particularly preventive health care, and medical care is often not sought until after a problem develops, establishes itself and worsens.

Men’s Health: Facts

  • Men live 6 years less than women on average
  • 36% of men seek medical care only when they become really ill
  • 30% of men defer seeking medical help as long as they can
  • 90 million men have a usual place of medical care, as opposed to 106 million women
  • 30 million men reported no office visits with a physician in the past year, as opposed to 16 million women
  • Men have higher rates of inactivity, poor nutrition, and excessive alcohol consumption than women
  • More than 50% of premature death in men in the USA are result of chronic, but preventable medical conditions

One of the challenges of being a physician is to persuade men to pursue preventive health services. Over the years, however, getting the male patient into the office has actually become much easier, thanks to the emerging field of sexual medicine, the availability of Viagra and other ED drugs, and Big Pharma’s extensive direct-to-consumer advertising.

Viagra was the initial drug in its class that addressed a previously unmet medical need with the collateral effect of being the “carrot” that enticed men to see their doctor. The direct-to-consumer advertising effort has resulted in a change in name of the pejorative term “impotence” into the more euphemistic term “erectile dysfunction,” de-stigmatizing sexual dysfunction, resulting in patients more readily making appointments. Big Pharma has also made the word “testosterone,” previously the domain of endocrinologists and urologists, into a commonly used household word, and numerous patients now appear in the office requesting to know what their “T” is.

Men may be stoic when it comes to their general health but when it comes to their genital health it is a different story. To many, their penis is literally their GPS, and when its function goes south, they become immediately motivated to find medical help! Never mind that they are having chest pain that gets dismissed as indigestion—an episode or two of failure to launch an erection is all it takes for an “emergency” appointment! There is some real truth to the concept that men think with their penises.

What most men do not realize is that they actually have a “canary in their trousers,” analogous to the “canary in the coal mine” carried by mine workers into the mines, the death of which would indicate the presence of dangerous gases. Since the penile arteries are generally rather small (diameter of 1 to 2 millimeters) and the coronary (heart) arteries larger (4 millimeters), it stands to reason that if vascular disease is affecting the tiny penile arteries, it may soon affect the larger coronary arteries as well—if not now, then at some time in the future. In other words, the fatty plaque that compromises blood flow to the smaller vessels of the penis may also do so to the larger vessels of the heart and thus ED may be considered a genital “stress test.” 

In fact, the presence of ED is as much of a predictor of cardiovascular disease as is a strong family history of cardiac problems, tobacco smoking, or elevated cholesterol. The British cardiologist Graham Jackson expanded the initials ED to mean: Endothelial Dysfunction (endothelial cells being the type of cells that line the insides of arteries); Early Detection (of cardiovascular disease); and Early Death (if missed).

Bottom Line: Because many men have an “obsession”—if not a “fascination,” with their penises—a dysfunction in this department is often the motivating factor that drives them to seek medical help, which often uncovers other medical issues. The pharmaceutical companies have developed excellent medications to treat ED and are credited with the name “ED” and for de-stigmatizing sexual issues are also responsible for getting the stoic gender into the physician’s office. So man’s peno-centric focus and Big Pharma are actually beneficial for men’s health.


Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health:

Private Gym:

Kegel Exercises: GET WITH THE PROGRAM!

October 11, 2014

Andrew Siegel, M.D.

The problem with most D.I.Y. (Do It Yourself) pelvic floor exercise regimens is the same issue with any activity done without proper guidance—compliance—sticking with the plan and seeing it through long enough to reap meaningful results. In order to D.I.Y., you need some real sitzfleisch (my new favorite word)—literally “sit on your flesh”—staying power and perseverance. And if your program ain’t working, your sitzfleisch is going to rapidly peter out.

One of the greatest challenges is that there have been no well-designed, easy-to-follow pelvic muscle training programs. Being handed a pamphlet suggesting a several-month program of 10 Kegel muscle contractions squeezing against no resistance three times daily during down times—for example while stopped at a red light in your car—simply does not pass muster! These inadequate programs lack guidance, training, direction and the feedback to confirm the engagement of the proper muscles. It is not surprising that if you undertake one of these ineffective pelvic floor muscle exercise regimens, you will more than likely ultimately abandon them.

The bottom line is that you will be unlikely to commit to an ineffective regimen, and any regimen will be ineffective unless it is a well-designed program that adheres to the tenets promoted by Arnold Kegel, the namesake of pelvic floor muscle training. Kegel’s principles that are imperative to adhere to are the following: muscle education, biofeedback, progressive intensity and resistance.

Muscle education is an understanding of your pelvic floor muscle anatomy and function and precisely where in your body that these muscles are located. This will permit you to develop muscle memory—the development of the nerve pathway from your brain to your pelvic floor muscles, a.k.a. neuromuscular education in medical lingo.

Feedback is a means of confirming to you that the proper muscles are being exercised, important since studies have shown that over 70% of women who think they are doing pelvic floor muscle exercises properly are actually squeezing other muscles, typically the rectus (abs), gluteal (butt) and adductor (thigh) muscles. With respect to the male gender, most men have not a clue as to where their pelvic floor muscles are, but also what their pelvic floor muscles do, how to exercise them, and what benefits they confer. In fact, many men don’t even know that they have pelvic floor muscles.

Progressive intensity is an escalation of the exercise magnitude and degree of difficulty over time. In a graduated fashion, you increase repetition number, intensity of contraction and duration of contraction. This progression is the key to increasing your pelvic floor muscle strength and endurance. Additionally, it allows you to measure and monitor you progress by witnessing your increased capabilities over time.

Resistance adds a new dimension that further challenges the growth of your pelvic floor muscles. Working your pelvic muscles against resistance rapidly escalates their strength and endurance, since muscle growth occurs in direct proportion to the demands and resistances placed upon them, a basic principle of muscle physiology.

Dr. Kegel recognized that the process of pelvic floor muscle strengthening advances in phases starting with awareness of the pelvic muscles and slowly and progressively proceeding to muscle regeneration and ultimately restoration.

As a physician, I see many female patients who have tried Kegel exercises and report that they did not help the problem they were trying to improve. However, on examining them and testing the strength and integrity of their pelvic floor muscles, they are often found to be contracting the wrong muscles! On questioning them on their regimen they often relate that their gynecologist had at some time given them a single page handout detailing how to perform Kegel exercises.

NO, NO, NO!…this simply will not do. One needs to GET WITH THE PROGRAM and receive the proper training to make these exercises meaningful and purposeful. The vast majority of those who try Kegels do not use a program that provides the precise wherewithal to isolate and exercise the pelvic floor muscles in a progressively more challenging fashion. It’s the equivalent of giving someone a set of weights and expecting them to pursue a weight training regimen without giving them the exercise routine and supervision to go along with the hardware, dooming them to failure!

For pelvic floor muscle strengthening to be effective, it is critical to use a well-crafted, progressive instructional routine with the ultimate incorporation of a resistance device. This is now available for men with the release of the Private Gym ( for men, and the program for women is in the works.  Do it right or don’t do it… In order to do it right, you need to get with the program!


Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health:

Private Gym:


New Paradigm: Preventive Kegel Exercises (Pelvic Floor Muscle Training)

October 4, 2014

Andrew Siegel, M.D.

“To guard is better than to heal, the shield is nobler than the spear!”  Oliver Wendell Holmes

“Honor your pelvic floor–it has done a whole lot for you over the years.”

Restoration of the function of injured muscles is well established in the fields of sports medicine, orthopedics, plastic surgery and physical medicine and rehabilitation. A traumatized or injured muscle is treated with early active rehabilitation and muscle training to accelerate tissue healing and restore it back to working order.

Dr. Arnold Kegel popularized the application of this principle to the female pelvic floor muscles to improve muscle integrity and function in women after childbirth. Obstetrical trauma (9 months of pregnancy, labor and delivery of a 9 lb. baby out the vagina) can cause pelvic floor dysfunction. Pelvic floor dysfunction can cause incontinence (urinary and bowel control issues), pelvic relaxation (laxity of the vagina and its support tissues with descent of the pelvic organs including the bladder, uterus and rectum) and altered sexual function.

Likewise, this principle has been effectively applied to men with compromised pelvic floor muscle integrity and function in order to improve urinary, bowel, erectile, and ejaculatory health. Obviously, men do not suffer with the acute pelvic floor muscle trauma of childbirth that women do, but they can develop pelvic floor muscle dysfunction on the basis of aging, weight gain, a sedentary lifestyle, disuse atrophy, etc.

Don’t Allow Function to Become Dysfunction

Why not take a radically different approach and try to prevent pelvic floor dysfunction instead of fixing it? If you pardon the clichés, although “a stitch in time saves nine,” isn’t a better approach “an ounce of prevention is worth a pound of cure?”. Obstacles to implementing this paradigm are our very reactive and repair-oriented medical culture that does a poor job of being proactive and promoting prevention and our patient population that often prefers fixing things that go awry as opposed to making the effort to prevent them from occurring in the first place. The concept of promoting wellness as opposed to treating diseases is one that resonates powerfully with me.

So, if obstetrical trauma to the pelvic floor often brings on pelvic floor muscle dysfunction and its urinary, gynecological and sexual consequences, why not start pelvic floor muscle training well before pregnancy? And if aging and other factors contribute to male pelvic floor muscle dysfunction and its urinary, bowel and sexual consequences, why wait for the system to malfunction? Why not bolster and strengthen the pelvic floor muscles when one is young, hale and hearty to prevent the age-related decline that is so often predictable? Many of us do apply preventive and proactive means to our health through regular exercise—aerobic for cardiovascular health and strength training to maintain muscle tone, integrity and function.

Whether male or female, the new paradigm is preventive pelvic health. The goal is to preclude, delay, or mitigate the decline in pelvic function that accompanies aging and that is accelerated by pelvic muscle trauma and injury, obesity and disuse atrophy.

Maintaining healthy sexual functioning is important because it contributes to masculine and feminine identity and behavior and has an impact that extends way beyond the sexual domain, permeating positively into many areas of life. Sexual dysfunction—at least to some extent—will eventually surface in most of us and the prospect of this is unsettling.

So, why passively accept the seemingly inevitable, when one can be proactive instead of reactive and can address the future problem before it becomes a current problem? Why wait until function becomes dysfunction? This is a commonly practiced approach for general physical fitness. We work out in the gym not only to achieve better fitness, but also to maintain fitness and prevent age-related losses in strength, flexibility, endurance, etc.

In this spirit, I encourage men and women who are enjoying excellent sexual and urinary health to maintain their pelvic health via preventive PFMT. This preemptive strategy is an opportunity for those who are healthy-functioning to continue enjoying their healthy functioning and prevent, delay and/or mitigate the age-related changes as best as they can.

Bottom Line: You have the ability to affect your own health destiny. Don’t be reactive and wait for your pelvic health to go south. Be proactive to ensure your continuing sexual, urinary and bowel health. If you wait for the onset of a dysfunction to motivate you to action, it may possibly be too late. Think about integrating a preventive PFMT program into your exercise regimen—it’s like a vaccine to prevent a disease that you hopefully will never get. As the saying goes: “Prepare and prevent, not repair and repent.”

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Note: As Arnold Kegel popularized pelvic floor muscle exercises in females in the late 1940’s, so I am working towards the goal of popularizing pelvic floor muscle exercises in males. This year I published a review article in the Gold Journal of Urology entitled Pelvic Floor Muscle Training in Men: Practical Applications to disseminate the importance and applications of these exercises to my urology colleagues. I wrote Male Pelvic Fitness: Optimizing Sexual and Urinary Health, a book intended to educate the non-medical population. I, along with my partner David Mandell and our superb pelvic floor team, co-created the Private Gym male pelvic floor exercise DVD and resistance program.

For more info on the book:

For more info on the Private Gym: