Chronic Testes Pain

March 7, 2018

Andrew Siegel MD    3/7/2018

New Jersey is shut down because of the impending Nor’easter, surgery and office hours are cancelled, so I have plenty of free time and am going to post this entry today rather than on Saturday morning.

Orchialgia is medical-speak for chronic testes (ball) pain, defined as constant or intermittent pain perceived in the testicles, lasting for 3 or more months and interfering with one’s quality of life.  It is a not uncommon problem of men of all ages, but is more frequently seen in young adults.  It certainly keeps us busy in the office…some morning sessions seem like “ball clinics”!

Testes 101

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Image above, public domain from Wikipedia

The testes are paired, oval-shaped organs that are housed in the scrotal sac. They have two functions, testosterone and sperm production.  Encased within the tough and protective cover of the testes (tunica albuginea) are tiny tubes called seminiferous tubules which make sperm cells.  The testes also contain specialized cells called Leydig cells that produce testosterone.  Sperm from the testes travels to the epididymis for storage and maturation. The epididymis empties into the vas deferens, which conducts sperm to the ejaculatory ducts.

The testes are suspended in the scrotal sac via the spermatic cord, a “rope” of tissue containing connective tissue, the vas deferens, the testes arteries, veins, lymphatics, and nerves. The spermatic cord is enveloped by tissues that are extensions of the connective tissue coverings of three of the abdominal core muscles. The most important of these coverings surrounding the spermatic cord is the cremaster muscle, which elevates the testes in a northern direction when it contracts.

The scrotal sac has several roles, packaging the testes as well as aiding in their function by regulating their temperature. For optimal sperm production, the testes need to be a few degrees cooler than core temperature.  The dartos muscle within the scrotal wall relaxes or contracts depending on the ambient temperature, allowing the testes to elevate or descend to help maintain this optimal temperature. Under conditions of cold exposure, the dartos contracts, causing the scrotal skin to wrinkle and to bring the testicles closer to the body.  When exposed to heat, dartos relaxation allows the testicles to descend and the scrotal skin to smoothen.

Good news/bad news:

The good news about the testes location dangling between one’s legs is is ready and easy access for examination, unlike the female counterpart (ovaries), which are within the abdomen.  This is one reason why testes cancer is so much easier to diagnose at an early stage than ovarian cancer.

The bad news is that their precarious location dangling between one’s legs as well as their delicate packaging in the thin sac makes them subject to trauma and injury.

Chronic orchialgia

Chronic testes pain can be caused by numerous different conditions and it is important to rule out the following possibilities:

  • Infection: An infection of the testes (orchitis), epididymis (epididymitis), both (epididymo-orchitis), or the spermatic cord (funiculitis). Infections can be bacterial, viral, and at times inflammatory without an actual infection.
  • Tumor: A benign or malignant mass of the testes or epididymis.
  • Groin hernia: A prolapse of intra-abdominal contents through a weakness in the connective tissue support of the groin.
  • Torsion: A twist of the testes or one of the testes or epididymal appendages.
  • Hydrocele: An excess fluid collection in the sac surrounding the testes.
  • Spermatocele: A cyst resulting from a blockage of one of the sperm ducts within the epididymis.
  • Varicocele: Varicose veins of the spermatic cord.
  • Trauma: Injury.
  • Prior operations: Groin hernias are most commonly associated with chronic testes pain; less commonly, vasectomies and any other type of groin or pelvic surgery.
  • Referred pain: Pain perceived in the testes, but originating elsewhere, e.g., a kidney stone that has dropped into the ureter, or a lower spine issue affecting the nerves to the testes.
  • Tendonitis: There are numerous muscles with tendons that insert into the pubic bone region that can be subject to injury and inflammation.
  • Pelvic floor muscle tension myalgia: Excessive muscle tension in these muscles can cause pelvic pain, including pain in the testes.
  • Idiopathic: This fancy medical term means that we are clueless about the origin of the pain. Unfortunately, many men have idiopathic orchialgia, a distressing and frustrating experience for both patient and urologist.

Evaluation

The evaluation of the patient with chronic testes pain includes a detailed history, a careful examination of the scrotal contents, groin and prostate, if necessary, as well as a urinalysis and possibly urine culture. It is helpful to obtain an ultrasound of the scrotum, a study which utilizes sound waves to image the testicle and epididymis. On occasion, it is warranted to obtain imaging studies of the upper urinary tract and pelvis and possibly a CT or MRI of the spine if there is back or hip pain.

Management

The management of chronic testis pain is directed at the underlying cause, although unfortunately this cannot always be precisely determined. Often, a course of antibiotics may prove helpful even if the physical findings are indeterminate.  Anti-inflammatory medications such as Advil and ibuprofen are often useful in the short-term management. Supportive, elastic jockey shorts as well as local application of a heating pad can be helpful. At times, amitriptyline or Neurontin can be helpful for neurologically-derived pain.  If the source of the pain is felt to be tension myalgia, referral to a pelvic floor physical therapist can be beneficial.  A referral to a pain specialist, typically an anesthesiologist who focuses on this discipline, can be advantageous.

An injection of a local anesthetic into the spermatic cord (spermatic cord block) can be a useful diagnostic test and a means of alleviating the pain.  If spermatic cord block proves successful in relieving the pain, it may be necessary to surgically denervate the spermatic cord, a procedure in which the nerve fibers in the spermatic cord are divided.  Under extremely rare circumstances, removal of the epididymis or the testicle is necessary. Often chronic testis pain remains elusive with the source undetermined and is thought to be similar to other chronic inflammatory conditions.

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”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

 

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Nuts and Bolts of Pelvic Floor Muscle Training: Part 4

March 3, 2018

Andrew Siegel MD   3/3/2018

There are few, if any, pelvic programs in existence targeted for specific pelvic floor dysfunctions, as what you will generally find is a “one-size-fits-all” approach.

What follows are focused pelvic training programs, each designed for the nuances of the specific pelvic dysfunction at hand.  I have designed a general program as well as programs for poor pelvic muscle endurance, stress urinary incontinence (SUI), overactive bladder (OAB), pelvic organ prolapse (POP)/vaginal laxity, sexual/orgasm issues, bowel incontinence and pelvic pain. These programs have been carefully crafted based on my specialized training in pelvic medicine and surgery, clinical experience, interactions with physical therapists, exercise/fitness experts, Pilates and yoga instructors, and most importantly, my patients.

 General PFMT Program

The general program is a balanced program that incorporates strength and endurance training.  It is intended for women who are found to have poor PFM strength or poor strength and endurance on the preliminary testing. It is also appropriate for women without specific pelvic issues who wish to pursue a PFM exercise program to make their PFM stronger, more durable and to help prevent the onset of pelvic floor issues.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each week try to step up the intensity of the PFM contractions and duration of the short contractions; allot equal time to relaxing phase as contracting phase; refer back to previous pages if you need a refresher on snaps, shorts and sustained.

 Week 1: snaps x20; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

 Week 2: snaps x30; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

 Week 3: snaps x40; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

 Week 4: snaps x50; 2-5 second shorts x30; 10 second sustained x3 = 1 set 

Week 5 and on: Advance to resistance training. However, if you were severely challenged by this non-resistance program or cannot or prefer not to use resistance—which requires the placement of a device in your vagina—you can continue this as a “maintenance” program, consisting of the Week 4 regimen performed twice weekly (as opposed to every other day).

 PFMT for Poor PFM Endurance

This program is designed for those with satisfactory PFM strength (Oxford grades 3-5), but poor endurance. The number of contractions performed and contraction duration are gradually increased over the course of the training program as adaptation occurs.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; allot equal time to relaxing phase as contracting phase.

 Week 1: snaps x15; 2 second shorts x15; 6 second sustained x1 = 1 set 

 Week 2: snaps x25; 3 second shorts x20; 8 second sustained x2 = 1 set 

 Week 3: snaps x35; 4 second shorts x25; 10 second sustained x3 = 1 set 

 Week 4: snaps x50; 5 second shorts x30; 10 second sustained x4 = 1 set 

 Week 5 and on: Advance to resistance training.  If you found yourself severely challenged by this non-resistance program or cannot/prefer not to use resistance (which requires the placement of a device in your vagina), you can continue this as a “maintenance” program consisting of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for POP/Vaginal Laxity

Endurance training is especially relevant for those with POP and poor vaginal tone. Focusing on sustained contractions will benefit the slow twitch endurance PFM fibers that are the prime contributors to pelvic tone and support. 

 Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each successive week, work on stepping up the intensity of the PFM contractions; allot equal time to relaxing phase as contracting phase.

 Week 1: snaps x20; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

 Week 2: snaps x30; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

 Week 3: snaps x40; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

 Week 4: snaps x50; 2-5 second shorts x30; 10 second sustained x4 = 1 set 

 Week 5 and on: Advance to resistance training.  However, if you were severely challenged by this non-resistance program or cannot or prefer not to use resistance—which requires the placement of a device in your vagina—you can continue using this as a “maintenance” program, which will consist of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for Sexual/Orgasm Issues

The PFM contract intensively at the time of climax with each contraction lasting about 0.8 of a second, about how long snaps last. A series of vigorous snaps is precisely the PFM contraction pattern experienced at the time of orgasm. If you have issues with achieving an orgasm or with orgasm intensity, this natural contraction pattern is replicated in this program, which focuses on high-intensity pulses of the PFM (snaps) that benefit the fast twitch explosive fibers.  Endurance training is also important for sexual function since sustained contractions benefit the slow twitch endurance PFM fibers that contribute to pelvic support and vaginal tone.    

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each week work on stepping up the intensity of the snap PFM contractions; allot equal time to relaxing phase as contracting phase.

Week 1: snaps x30; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

Week 2: snaps x40; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

Week 3: snaps x50; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

Week 4: snaps x60; 2-5 second shorts x30; 10 second sustained x4 = 1 set 

Week 5 and on: Advancing to the resistance training.  However, if you were severely challenged by this non-resistance program or cannot/prefer not to use resistance—which requires the placement of a device in your vagina—you can continue using this as a “maintenance” program, consisting of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for SUI

Strength and power training are critical for managing SUI, with the power element (i.e., how rapidly you can maximally contract your PFM) vital in order to react quickly to SUI triggers.  Focusing on moderate intensity contractions that last for several seconds (shorts) will benefit SUI, as this type of PFM contraction deployed prior to and during any activity that induces the SUI will help prevent its occurrence.  Attention directed to these short contractions will allow earlier activation of the PFM with SUI triggers, as well as increased contraction strength and durability to counteract the sudden increase in abdominal pressure that induces SUI.  Effort applied to sustained contractions is equally important since the slow twitch endurance PFM fibers are prime contributors to pelvic tone and pelvic support of the urethra, which promote urinary continence.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each successive week try to step up the PFM contraction intensity as well as the activation speed (how long it takes to get to peak intensity); allot equal time to relaxing phase as contracting phase.

Week 1: snaps x20; 5 second shorts x15; 10 second sustained x1 = 1 set 

Week 2: snaps x30; 5 second shorts x20; 10 second sustained x2 = 1 set 

Week 3: snaps x40; 5 second shorts x25; 10 second sustained x3 = 1 set 

Week 4: snaps x50; 5 second shorts x30; 10 second sustained x4 = 1 set 

Week 5 and on: Advance to resistance training.  However, if you were severely challenged by this non-resistance program or cannot or prefer not to use resistance—which requires the placement of a device in your vagina—you can continue this as a “maintenance” program, which consists of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for OAB and Urinary/Bowel Incontinence

Focusing on high-intensity pulses of the PFM (snaps) will benefit the fast twitch explosive fibers that are critical for inhibiting urinary and bowel urgency/urgency incontinence. These snaps will generate increased PFM strength and power to enhance the inhibitory reflex between PFM and the bladder/bowel, permitting a speedy reaction to urgency and facilitating the means to counteract urinary and bowel urgency, frequency and incontinence. Of equal importance is endurance training of the slow twitch, fatigue-resistant fibers that contribute to baseline tone of the voluntary urinary and bowel sphincters.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each successive week try to step up the intensity of the PFM contractions; allot equal time to relaxing phase as contracting phase.

Week 1: snaps x20; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

Week 2: snaps x30; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

Week 3: snaps x40; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

Week 4: snaps x50; 2-5 second shorts x30; 10 second sustained x4 = 1 set 

Week 5 and on: Advance to resistance training.  However, if you were severely challenged by this non-resistance program or cannot/prefer not to use resistance (which requires the placement of a device in your vagina), you can continue using this as a “maintenance” program, which will consist of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for Pelvic Pain Due to Tension Myalgia: “Reverse” PFMT

Focusing on the relaxing aspect of the PFM contraction/relaxation cycle is the key to “down-train” the PFM from their over-tensioned, knot-like state. Those with over-contracted and over-toned PFM will not benefit from the typical strengthening PFMT done for most PFM dysfunctions—and can actually worsen their condition—so the emphasis here is on the relaxation phase of the PFM. This is “reverse” PFMT, conscious unclenching of the PFM in which the PFM drop and slacken as opposed to rise and contract. Reverse PFMT strives to stretch, relax, lengthen and increase the flexibility of the PFM. 

“Reverse” Kegels can be a confusing and difficult concept, particularly because these exercises demand conscious relaxation of the PFM, which only occurs subconsciously in real life. Recall that the PFM have a baseline level of tone and that complete PFM relaxation only occurs at the time of urination, bowel movements, passing gas or childbirth. 

To make this easier to understand, think of a PFM contraction on a scale of 0-10, with 0 being complete relaxation and 10 being maximal contraction. I have arbitrarily chosen 2 as the baseline level of PFM tone.  In reverse Kegel exercises you strive to go from 2 to 0 as opposed to standard exercises in which the effort is to go from 2 to 10.  When you urinate, move your bowels or pass gas, the PFM relax to a level of 0, so this is the feeling that you should strive to replicate, while continuing to breathe regularly without straining or pushing.  A deep exhalation of air will facilitate PFM relaxation, as it does for other muscle groups.

Perform the following: A very gentle PFM contraction to initiate PFM engagement, followed by deep relaxation and release of the PFM lasting as long as the contraction; 3 sets; one-minute break between each set; do 3-4 times weekly.

Week 1: reverse snaps x20; reverse 2-5 shorts x15; reverse 10 second sustained x1 = 1 set 

Week 2: reverse snaps x30; reverse 2-5 shorts x20; reverse 10 second sustained x2 = 1 set 

Week 3: reverse snaps x40; reverse 2-5 shorts x25; reverse 10 second sustained x3 = 1 set 

Week 4: reverse snaps x50; reverse 2-5 shorts x30; reverse 10 second sustained x3 = 1 set 

Week 5 and on: There is no role for using resistance exercises for tension myalgia. Continue using this program as a “maintenance” program, consisting of the Week 4 regimen done twice weekly (as opposed to every other day). Make a concerted effort at keeping the PFM relaxed at all times, not just while pursuing the PFMT program.

…To be continued.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (the female version is in the works): PelvicRx

 

When Sex Hurts (and Pain Replaces Pleasure)

February 24, 2018

Andrew Siegel MD    2/24/2018

Sex should be pleasurable and enjoyable, but sadly, that is not always the case.  Dyspareunia is doctor-speak for difficult or painful sexual intercourse, derived from dys, meaning “difficult” and the Greek term pareunos, meaning “lying with.” Although more typically a female complaint, dyspareunia does not spare the male gender.

ouch-147868_1280

Thank you Pixabay for image above

A Mechanistic View of Sexual Intercourse

A mechanical view of sexual intercourse is that it is an activity that involves moving parts that need to be lubricated and fit together properly for optimal function.  The “piston” component of an engine moves up and down within the “cylinder,” requiring appropriate fitting together of these component parts and sufficient lubrication to avoid excessive friction among the moving parts. “Piston clearance” is the clearance or gap between piston and cylinder.  If piston clearance is too small, the piston can “seize” inside the cylinder on expansion. If the pistons fits too tightly within the cylinder, it can result in excessive friction and damage to the cylinder wall.  The bottom line is that problems can arise if the piston does not properly fit the cylinder or if there is inadequate lubrication of contact points.

 Causes of Female Dyspareunia

  • Size discrepancy with partner – The vagina is an incredibly accommodating organ capable of tremendous stretch and expansion—think vaginal delivery of a 10-lb. baby—so this is relatively rare, but a woman with petite anatomy who couples with an outsized male can be a formula for pain. A lengthy penis can strike the cervix or vaginal fornix and a penis with formidable girth may prove excessive for a narrow vagina, resulting in “collision dyspareunia.”
  • Vaginal scarring – Scar tissue from pelvic or vaginal surgery, birth trauma, or poor healing of episiotomies can alter vaginal anatomy and make sexual intercourse painful and challenging.
  • Menopause – Estrogen nourishes and nurtures the genital tissues.  Declining levels of estrogen after menopause cause the vaginal walls to thin, become more fragile and less supple, and the amount of vaginal lubrication to diminish.
  • Infection – Vaginitis (vaginal infections), bacterial cystitis (bladder infection), interstitial cystitis, pelvic inflammatory disease, and infections of the paraurethral (Skene’s glands) can all give rise to pain.
  • Endometriosis –The lining tissue within the uterus called the endometrium can implant outside the uterus, causing painful intercourse.
  • Hypertonic pelvic floor – This is a condition–also called vaginismus– in which the pelvic floor muscles are taut and over-tensioned and fail to relax properly, which can cause painful intercourse, if sex is even possible.
  • Vulvodynia – This is a condition marked by hypersensitive vulvar tissues that are extremely tender to touch.
  • Loss of vaginal lubrication –  This can happen from menopause (natural or from surgery), side effects of medications, breast-feeding, as well as insufficient foreplay.
  • Disuse atrophy – Use it or lose it; if one has not been sexually active for prolonged times, there can be loss of tissue integrity and vaginal atrophy.   Staying sexually active keeps one’s anatomy toned and supple.
  • Urethral diverticulum – This is an acquired outpouching from the urethra channel that can cause a cystic mass in the vagina that can result in pain with sex.
  • Psychological/emotional – “The mind suffers…the body cries out.” Emotionally or physically traumatic sexual experiences can negatively affect future sexual experiences.

Causes of Male Dyspareunia

Urologists sometimes refer to male dysparenuia as “his-pareunia–not a legitimate medical word, but to the point!

  • Infections —Infections of the prostate (prostatitis) and urethra (urethritis) can cause pain with ejaculation.
  • Peyronie’s disease – Scarring of the sheath of the erectile cylinders gives rise to an angulated and often painful penis, particularly so with erections.
  • Phimosis — This is a condition is which the foreskin is tight and cannot be drawn back, leading to inflammation, pain and swelling.
  • Tethered frenulum — The frenulum is a narrow band of tissue that attaches the head of the penis to the shaft; at times it can tear during sexual intercourse, causing bleeding and pain.
  • Penile enlargement procedures – Efforts to “bulk up” the penis with injections of fat, silicone and other tissue or prosthetic grafts can result in an unsightly, lumpy, discolored, and painful penis.
  • Improperly sized penile implants – Penile implants can be lifesavers for the sexually non-functional or poorly functional male, but need to be sized precisely, like shoes for one’s feet.  If too large, they can result in penile pain and pain with sex.
  • Her issues causing his pain – Mesh exposure is a condition in which a mesh implant–used in females to help support dropped pelvic organs and to cure stress urinary incontinence–is “exposed” in the vagina, which feels on contact like sandpaper and can result in both female and male dyspareunia.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, Apple iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

 

The Nuts and Bolts of Pelvic Floor Muscle Training (PFMT): Part 3

February 17, 2018

Andrew Siegel MD   2/17/2018

What follows in this and the next few blog entries are pelvic training programs that I have crafted based on my specialized training in pelvic medicine and surgery; clinical experience; and interactions with physical therapists, exercise/fitness experts, Pilates instructors, yoga instructors and most importantly, my patients. Programs have been designed to treat areas of pelvic floor muscle weakness, e.g., if strength is the issue, emphasis on strength training is in order, whereas if  pelvic stamina is the issue, focus on endurance training is appropriate.

There are few, if any, pelvic programs in existence that are designed for specific pelvic floor dysfunctions, as what is generally out there is a “one-size-fits-all” approach.  I have created “tailored” PFMT exercise routines, customized for the particular pelvic health issue at hand, including stress urinary incontinence (SUI), overactive bladder (OAB), pelvic organ prolapse (POP), sexual/orgasm issues and pelvic pain.

Program Flexibility

These programs are not designed with the intent that they be rigidly adhered to, as they can be customized to make them work for you, recognizing that every woman and every pelvic floor is unique. You can modify the programs and experiment with all variables—intensity, power, contraction and relaxation duration, number of reps and number of sets, with the ultimate objective of challenging the pelvic muscles to make them stronger, better toned, firmer, more flexible and healthier.

Do what feels right and works for you, building to your maximal potential over time. If you feel fatigued before completing the number of reps recommended, do as many quality contractions as you can do.  If you cannot maintain contraction intensity for the duration recommended, do the best you can. Three sets per session are ideal, but if you find this too challenging, you can do two sets, or even just one. If you find that completing 3 sets becomes a simple task, you can do 4 or 5 sets as your PFM become stronger and more durable.

The 3 Types of Pelvic Floor Muscle Contractions

There are three basic types of PFM contractions based upon the duration and intensity of the contraction.  Three “S” words make these contractions easy to remember: Snaps, Shorts and Sustained.

Snaps are rapid, high intensity pulses of the PFM that take less than one second per cycle of contracting and relaxing. These are the type of PFM contractions that occur involuntarily at the time of sexual climax, so should be easy to understand and perform.

Shorts are slower, less intense squeezes of the PFM that can last anywhere from two to five seconds (with equal time allotted to the relaxing phase).

Sustained PFM contractions are less intense squeezes that last ten seconds or longer (with an equal time in the relaxing phase).  These are the type of PFM contractions that you use when you have a strong desire to urinate or move your bowels but do not have access to a bathroom and must apply effort to “hold it in.”

Warming Up

Before starting the PFMT program, I recommend a warm-up week to practice and become familiar with snaps, shorts and sustained contractions. Do not start the formal PFMT until you feel comfortable with all three contractions. Do the Oxford strength and endurance testing to obtain baseline values before you begin the warm-up week.

If your Oxford grade is 0-2, consider yourself to have weak PFM. If you cannot do more than 20 snaps, 15 shorts or one-10 second sustained contraction, consider your endurance poor. If your PFM strength is good, but your endurance is poor, use the program tailored for poor endurance. If you have a specific pelvic dysfunction that you would like to focus on improving, use the program tailored to that specific dysfunction. If you suffer with more than one pelvic floor dysfunction, e.g., both pelvic organ prolapse  and stress urinary incontinence, determine which issue is most compelling and disturbing to you and start with that specific program. If you feel that the problems are equal in degree, complete one program followed in succession by the other.

Warm-Up Week: Do as many good quality snaps as possible until you feel that you can no longer do them with full intensity.  Take a short break and then do as many good quality shorts until you feel that your efforts are diminishing.  Finally, do a sustained contraction for as long as you can until fatigue sets in. After a short break, repeat the sustained contraction.  Do this warm-up every other day for this preliminary week before proceeding with the programs.

…To be continued in 2 weeks.  Next week’s entry will take a break from PFM training to cover “When Sex Hurts and Pain Replaces Pleasure.”

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (the female version is in the works): PelvicRx

 

The Nuts and Bolts of Pelvic Floor Muscle Training (PFMT): Part 2

February 10, 2018

Andrew Siegel MD    2/10/18

This is a continuation of last week’s entry.  Remember, PFMT is equally appropriate for males as well as females –both genders have these important muscles that can benefit from whipping them into shape.

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The basic PFMT programs that follow are “low tech” exercises of the PFM without added resistance.  They can be thought of as PFMT 101, the goal of which is to provide the foundation for pelvic muscle proficiency. After mastery of basic PFMT, progression to the next phase of conditioning—resistance training—is in order.

PFMT is the essence of “functional fitness,” exercises that develop PFM strength, power, stamina and the skillset that can be used to improve and/or prevent specific pelvic functional impairments. PFMT regimens must be flexible and nuanced, designed and customized with particular functional needs in mind, i.e., issues of pelvic support, urinary control, sexual function, pain, etc., as opposed to a one-size-fits-all approach.  An additional consideration is baseline PFM strength and stamina.  After determining an area of weakness, focused effort should be applied to this deficit.

Time to Begin

You do not need to go to a gym, wear athletic clothing, have any special equipment, or dedicate a great deal of time to PFMT. It is vital to do properly performed, quality PFM contractions with the goal of slow and steady progress. Experiencing some aching and soreness as you begin is not uncommon.

If you are pursuing PFMT for specific pelvic issues, expect that it may take a number of weeks or more to see an improvement in your symptoms.  After you have noticed a beneficial effect, the exercise regimen must be maintained, because regression can occur if the pelvic muscles are not consistently exercised…”use it or lose it” applies here.

Basic PFMT exercises can be performed lying down, sitting upright in a comfortable chair with your back straight, or standing. It is best to begin lying down, to minimize gravity, which makes the exercises more challenging. Regardless of position, it is essential to maintain good form, posture and body alignment while doing PFMT. It is important to relax your abdomen, buttocks and thighs. Breathe slowly and do not hold your breath. Even though no muscle group works alone, by trying to isolate the PFM and focusing on squeezing only the PFM, you will make more rapid progress. You should not be grimacing, grunting or sweating, as PFMT is, in part, a meditative pursuit that employs awareness, focus, mindfulness and intention while performing deliberate contractions of the PFM.

Helpful metaphor: “Snap” describes a brief, vigorous, well-executed contraction of the PFM. With increasing PFM command, these pelvic muscles can be “snapped” like your fingers.

There are six variables with respect to PFM contractions:

  1. contraction intensity
  2. contraction duration
  3. relaxation duration
  4. power
  5. repetitions
  6. sets

Contraction intensity refers to the extent that the PFM are squeezed, ranging from a weak flick of the muscles to a robust and vigorous contraction. The contraction duration is the amount of time that the squeeze is sustained, ranging from a “snap”—a rapid pulsing of the PFM, to a “sustained hold”—a long duration contraction. The relaxation duration is the amount of time the PFM are unclenched until the next contraction is performed. Power is a measure of contraction strength and speed, the ability to rapidly achieve a full intensity contraction. Repetitions (reps) are the number of contractions performed in a single set (one unit of exercise).

It is relatively easy to intensively contract your PFM for a brief period, but difficult to maintain that intensity for a longer duration contraction. It is unlikely that you will be able to maintain the intensity of contraction of a sustained hold as you would for a snap.

The better PFMT regimens utilize a combination of snaps, few-second contractions and sustained duration contractions to reap the benefits of both strength and endurance training.

Fact: Short duration, high intensity contractions build strength and power, whereas longer duration, less intense contractions will build endurance, both vital elements of fit PFM.

Incremental change—the gradual and progressive increase in the intensity of contraction, duration of contraction, number of reps and number of sets performed—is the goal.  Performing the program 3-4 times weekly is desirable since recovery days are important for skeletal muscles.

PFMT is not an extreme program; nonetheless, it is by no means an undemanding program, and certainly requires effort and perseverance.  Depending on your level of baseline PFM fitness, you may find the exercises anywhere in the range from relatively easy to quite challenging. Your PFM are unique in terms of their shape, size and strength and consequently expectations regarding results will vary from individual to individual.

After a month or so, you should be on your way to achieving basic conditioning of the PFM. Reassessing the PFM by repeating the Oxford grading and the PFM endurance tests that you measured at baseline should demonstrate objective evidence of progress. More importantly, you should start noticing subjective improvement in many of the domains that PFM fitness can influence.  Once you have mastered non-resistance training, it is time to move on to resistance training, in which you squeeze your PFM against the opposing force of resistance in an effort to accelerate the PFMT.

If you are challenged by the non-resistance PFMT or cannot or prefer not to use resistance—which for women requires the placement of a device in your vagina and for men the ability to achieve a rigid erection—you can continue with the non-resistance training using it as a “maintenance” program.  PFM maintenance training typically requires continuing with the PFMT program, but performing it less frequently, twice weekly usually being sufficient.

To be continued next week…

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, Apple iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

 

The Nuts and Bolts of Pelvic Floor Muscle Training (PFMT): Part 1

February 3, 2018

Andrew Siegel MD  2/3/18

I received intensive exposure to surgical aspects of pelvic health at UCLA School of Medicine, where I spent a year training in pelvic medicine and reconstructive surgery following completion of my urology residency at University of Pennsylvania School of Medicine. This background, coupled with my passion for health, fitness and the benefits of exercise, led to my interest in PFMT as a means of optimizing pelvic health and to avoid, or at times facilitate, surgical management of pelvic floor dysfunctions.  Is it traditional for a pelvic surgeon to espouse non-surgical treatments?  Not at all, but after decades in the urology/gynecology “trenches,” I have concluded that PFMT is a vastly unexploited resource that offers significant benefits.

Photo below: Yours truly on left with Dr. Shlomo Raz (UCLA professor who is “father” of female urology) on right (1988)

shlomo and andy

 

“Strength training improves muscle vitality and function.” These seven words embody a key principle of exercise physiology that is applicable to the PFM.

Introduction

There is little to no consensus regarding the nuances and details of PFMT programs.  There is no agreement on the best position in which to do PFMT; the number of sets to perform; the number of repetitions per set; the intensity of PFM contractions; the duration of PFM contractions; the duration of PFM relaxation; and how often to do PFMT. The particulars of many PFMT routines are arbitrary at best. In fact, Campbell’s Urology—the premier textbook—concludes: “No PFMT regimen has been proven most effective and treatment should be based on the exercise physiology literature.”  

My goal is to take the arbitrary out of PFMT, providing thoughtfully designed, specifically tailored programs crafted in accordance with Dr. Arnold Kegel’s precepts, exercise physiology principles and practical concepts.

Dr. Kegel’s precepts are summarized as follows:

  • Muscle education
  • Feedback
  • Progressive intensity
  • Resistance

Exercise physiology principles as applied to PFMT include the following (note that there is some overlap with Dr. Kegel’s precepts and practical concepts):

  • Adaptation: The process by which muscle growth occurs in response to the demands placed upon the PFM, with adaptive change in proportion to the effort put into the exercises.
  • Progression: The necessity for more challenging exercises in order to continue the process of adaptive change that occurs as “new normal” levels of PFM fitness are established. This translates into slowly and gradually increasing contraction intensity, duration of contractions, number of PFM repetitions and number of sets.
  • Distinguishing strength, power and endurance training: Strength is the maximum amount of force that a muscle can exert; power is a measure of this strength factoring in speed, i.e., a measure of how quickly strength can be expressed. Endurance or stamina is the ability to sustain a PFM contraction for a prolonged time and the ability to perform multiple contractions before fatigue sets in. High intensity PFM contractions build muscle strength, whereas less intensive but more sustained contractions build endurance. Power is fostered by rapidly and explosively contracting the PFM.
  • “Use it or lose it”: The “plasticity” of the PFM—the adaptation in response to the specific demands placed on the muscles—requires continued training, at minimum a “maintenance” program after completion of a course of PFMT.
  • Full range of motion: The goal of PFMT is not only to increase strength, power and endurance, but also flexibility. This is accomplished by bringing the muscle through the full range of motion, which at one extreme is full contraction (muscle shortening), and at the other, complete relaxation (muscle lengthening). The exception to this is for muscles that are already over-tensioned, which need to be relaxed through muscle lengthening exercises.

Practical concepts encompass the following:

  • Initially training the PFM in positions that remove gravity from the picture, then advancing to positions that incorporate gravity.
  • Beginning with the simplest, easiest, briefest PFM contractions, then proceeding with the more challenging, longer duration contractions.
  • Slowly and gradually increasing exercise intensity and degree of difficulty.
  • Aligning the specific pelvic floor dysfunction with the appropriate training program that focuses on improving the area of weakness, since each pelvic floor dysfunction is associated with specific deficits in strength, power and/or endurance.

To be continued….

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (the female version is in the works): PelvicRx

 

 

Viral STI (Sexually Transmitted Infection) Update

January 27, 2018

Andrew Siegel MD   1/27/2018

Sadly, there exist many “creatures” out there that enjoy cohabiting our genitals and bodies. Today’s entry is on the topic of viral STIs– an important subject, since several viral STIs are highly prevalent and many of those who are infected are unaware that they are infected. Viral STIs consist of the four “H’s”: HPV, HIV, herpes and hepatitis as opposed to bacterial STIs (gonorrhea, syphilis, chlamydia), protozoan STIs (trichomoniasis) and other-organism STIs (pubic lice and scabies). This is the 4-H club that you would rather not be a member of. 

Mermin-Quote-Graphic

The format of today’s entry will be a 10-question multiple-choice quiz to test your basic knowledge.  Please try to answer all questions before proceeding to the answers and explanations at the end.

Abbreviation Glossary:

STI: sexually transmitted infections

HAV: hepatitis A virus

HBV: hepatitis B virus

HPV: human papilloma virus

HSV-1: herpes simplex 1

HSV-2: herpes simplex 2

HIV: human immunodeficiency virus

AIDS: acquired immune deficiency syndrome

  1. Which of the following STIs can be prevented by means of vaccination?

a) hepatitis A virus

b) hepatitis B virus

c) human papilloma virus (HPV)

d) all of the above

  1. Natural membrane condoms (lambskins) are effective in preventing STIs.

a) true

b) false

  1. Which of the following is the most common ulcerative STI?

a) genital herpes

b) chancroid

c) syphilis

d) lymphogranuloma venereum

  1. Most genital herpes infections are transmitted by people who are unaware they are infected.

a) true

b) false

  1. What is the most common STI in the United States?

a) chlamydia

b) HPV

c) herpes

d) gonorrhea

  1. Most cases of HPV infections are characterized by which of the following?

a) self-limited

b) asymptomatic

c) unrecognized

d) all of the above

  1.   What areas of the body may HPV infect?

a) genital and anal areas

b) mouth and throat

c) respiratory tract

d) all of the above

  1. Hepatitis B infections can cause which the following problems?

a) permanent liver scarring

b) liver failure

c) liver cancer

d) all of the above

  1. Hepatitis A infections, although usually spread by contaminated food or water can also be spread sexually by the following means:

a) oral-anal contact

b) digital-anal contact

c) penetrative anal sex

d) all of the above

  1. Approximately what percent of persons living with HIV are unaware of their infection?

a) 15%

b) 25%

c) 35%

d) 45%

Answers:

  1. All of the above. There are effective vaccinations available for hepatitis A virus, hepatitis B virus and human papilloma virus (HPV).  These are the only STIs for which vaccination is available for prevention.
  2. False. Natural membrane condoms (lambskins) are NOT effective in preventing STIs. They are made from lamb intestine and have pores that block passage of sperm, but the pores are more than 10 times the diameter of HIV and 25 times the diameter of HBV. Sexual transmission of hepatitis B, HIV and herpes simplex can occur with natural membrane condoms. However, latex condoms are capable of preventing the transmission of these viruses
  3. Genital herpes is the most common STI that can cause ulcerations.  When symptomatic it causes painful, watery blisters that usually erode to form ulcers.
  4. True. Most genital herpes infections are transmitted by people who are unaware that they are infected. In the USA, one in six persons age 15-50 is infected with HSV-2. Most people infected have not been diagnosed and as such, most genital herpes infections are transmitted by people who are unaware they are infected or are asymptomatic. Lesions recur in 80% of those with HSV-2 and 50% of those with HSV-1.
  5. The most common STI in the United States is HPV. The prevalence of genital HPV in adults is approximately 45% in men and 40% in women. All boys and girls 11 to 12 years of age are currently recommended to receive HPV vaccines, prior to the onset of sexual activity and initial exposure to the virus.
  6. All of the above. Most cases of HPV infections are self-limited, asymptomatic and go unrecognized.  When symptomatic, HPV is characterized by genital warts (condyloma) in the anogenital regions.
  7. All of the above. HPV can infect the genital and anal areas, the mouth and throat, and even the respiratory tract.
  8.  All of the above. Hepatitis B infections if left untreated can cause serious liver diseases: permanent liver scarring (cirrhosis), liver failure, liver cancer and death.  HBV is transmitted by exposure to infected blood or body fluids.
  9. All of the above. Hepatitis A infections, although usually spread by contaminated food or water, can also be spread sexually by oral-anal contact, digital-anal contact, and penetrative anal sex. A combined HAV/HBV vaccine is available.
  10. About 15% percent of persons living with HIV are unaware of their infection. It is estimated that in the United States about 1.2 million individuals are living with HIV or acquired immune deficiency syndrome (AIDS). Fortunately, there are effective medications utilized for prevention of HIV infection as well as treatment of HIV infection.  

Bottom Line:  Be smart when choosing your sex partner and practice safe sex. There are many infections that are caused by pathogens (bacteria, viruses, protozoa, etc.) spread person to person by intimate contact. Although some are merely annoying and are easily treated, others can cause significant morbidity; some are associated with the development of cancer, and others, including HIV, are responsible for an epidemic of death. The viral STIs are the 4 “H’s”: HPV (human papilloma virus, responsible for genital warts), HIV (human immunodeficiency virus), hepatitis, and herpes.  Latex condoms are the only widely available proven method for reducing the risk of transmission of HIV and other STIs, but they are certainly not infallible. Strongly consider getting vaccinated to protect against HPV and hepatitis.

Wishing you the best of health!

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (the female version is in the works): PelvicRx

 

 

 

Preparing For Pelvic Floor Muscle Training (PFMT): What You Need To Know (Part 3)

January 20, 2018

Andrew Siegel MD  1/20/18

This entry, written for both women as well as men, is intended to enable one to do a proper contraction of  the pelvic floor muscles (PFM), a task easier said than done.  A means of self-assessment of PFM strength and stamina is offered. 

Image Below: The Pelvic Floor Muscles (Male left; Female right)

1116_Muscle_of_the_Perineum

Attribution: URL: https://cnx.org/contents/FPtK1zmh@8.108:b3YG6PIp@6/Axial-Muscles-of-the-Abdominal
Version 8.25 from the Textbook
OpenStax Anatomy and Physiology
Published May 18, 2016 

Do It Right

PFM exercises (Kegel exercises) must be done properly to reap benefits. Many think they are doing these pelvic contractions correctly, but actually are contracting the wrong muscles, an explanation of why their efforts may have failed to improve their clinical situation. In both women and men, PFM exercises involve pulling inwards and upwards, lifting and elevating.  In females, this will result in tightening the urethral, vaginal and anal openings and in males tightening the anus and if done at the time of an erection, elevating the erect penis.  Proper pelvic contractions are the very opposite of straining. One strains to move their bowels, whereas one “Kegels” to accomplish the opposite—to tighten up the sphincters to NOT move their bowels; in fact, PFM contractions are a means of suppressing bowel urgency (as well as urinary urgency).

How do you know if you are contracting your PFM properly?

For the Ladies: 6 Ways to Know That You Are Properly Contracting Your PFM

  1. When you see the base of your clitoris retract and move inwards towards your pubic bone.
  2. When you see your perineum (area between vagina and anus) move up and in.
  3. When you see the anus contract (“anal wink”) and feel it tighten and pull up and in.
  4. When you can stop your urinary stream completely.
  5. When you place your index and middle fingers on your perineum and you feel the contraction.
  6. When you place a finger in your vagina, you feel the vaginal “grip” tighten.

 

 

For the Gentlemen: 6 Ways to Know That You Are Properly Contracting Your PFM

  1. When you see the base of your penis retract inwards towards the pubic bone and the testes rise up towards the groin.
  2. When you place your index and middle fingers in the midline between the scrotum and anus and you feel the PFM contractions.
  3. When you see the anus contract (“anal wink”) and feel it tighten and pull up and in.
  4. When you get the same feeling as you do when you are ejaculating.
  5. When you touch your erect penis and feel the penile erectile chambers surge with blood and you can make the penis lift upwards when you are in the standing position.
  6. When you can stop your urinary stream completely.

Fact:  Vince Lombardi stated: “Practice doesn’t make perfect, perfect practice makes perfect.”  This is wholly applicable to PFM training. Do it right or don’t do it!

Assessing Your PFM: Note that this is used primarily for women

There are many fancy ways of testing your PFM, but the simplest is by using tools that everyone owns—their fingers.  Digital palpation (a finger in the vagina, or alternatively the anal canal) is the standard means of testing the contraction strength of the PFM. The other methods are visual inspection, electromyography (measuring electrical activity of the PFM), perineometry (measuring PFM contractile strength via a device that is inserted into the vagina or anus) and imaging tests that assess the lifting aspects of the PFM, such as ultrasound and magnetic resonance imaging.

Assessment of your PFM evaluates PFM strength and endurance.  PFM strength can be self-assessed in the supine position (lying down, face up) with your knees bent and parted. Gently place a lubricated finger of one hand in the vagina (or alternatively the anal canal) and contract your PFM, lifting upwards and inwards and squeezing around the finger. Keep your buttocks down in contact with the surface you are lying on. Ensure that you are not contracting your gluteal (butt), rectus (abdomen) or adductor (inner thigh) muscles. Do this by placing your other hand on each of these other muscle groups, in turn, to prove to yourself that these muscles remain relaxed during the PFM contraction.

Rate your PFM strength using the modified Oxford grading scale, giving yourself a grade ranging from 0-5.  Note that the Oxford system is what many physicians use and it is relatively simple when done regularly by those who are experienced performing pelvic exams. Granted that this is not your area of expertise, so you may find this challenging. However, do your best to get a general sense of your baseline PFM strength.

Oxford Grading of PFM Strength

0—complete lack of contraction

1—minor flicker

2—weak squeeze

3—moderate squeeze

4—good squeeze

5—strong squeeze

Next test your PFM endurance. Do as many PFM contractions as possible, pulsing the PFM rapidly until fatigue sets in (the failure point where you cannot do any more contractions).  After you have recovered, contract the PFM for several seconds followed by relaxing them for several seconds, doing as many repetitions until fatigue occurs. Finally, do a single PFM contraction and hold it for as long as you can.

Record your Oxford grade and the maximum number of pulses, maximum number of several second contractions and the duration of the sustained hold as baseline measurements. These will be useful to help assess your progress. Initially, it is likely that your PFM will be weak and lack endurance capacity.

Coming soon…The Nuts and Bolts of Pelvic Floor Muscle Training.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following pelvic floor health books that are available on Amazon, Apple iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

 

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

 

 

 

 

 

Preparing For Pelvic Floor Muscle Training (PFMT): What You Need To Know (Part 2)

January 13, 2018

Andrew Siegel MD    1/13/2018

This entry, written for both males and females, will help you develop pelvic floor muscle (PFM) awareness and build PFM muscle memory.  

Image below: Male PFM (left); Female PFM (right)

 

1116_Muscle_of_the_Perineum

Attribution: URL: https://cnx.org/contents/FPtK1zmh@8.108:b3YG6PIp@6/Axial-Muscles-of-the-Abdominal
Version 8.25 from the Textbook
OpenStax Anatomy and Physiology
Published May 18, 2016

PFM Education and Awareness

Fact: Studies have clearly shown that most women with pelvic issues referred for PFM training are unable to perform a proper PFM contraction. Almost all demonstrate weak PFM strength regardless of age, ethnicity or diagnosis. Most males are clueless about PFM training, many not even realizing that they have this set of important muscles. 

Physical therapists and physical medicine and rehabilitation experts have used functional restoration to effectively manage injured skeletal muscles. This strategy can likewise be applied to weakened and poorly functional PFM. The principles involve segregation, guidance and progression.  Segregation is an awareness of PFM anatomy and function with the ability to isolate the PFM by contracting them independently of other muscles. Guidance refers to the instructions necessary to learn how to properly engage and train the PFM.  Progression refers to the incrementally more challenging exercises over the course of the PFM training regimen that result in PFM growth and improvement.  Again, exercise is about adaptation, so increasing repetitions and intensity is mandatory to achieve results. The goal is for fit PFM—strong, yet flexible, equally capable of powerful contractions as well as full relaxation.

Initially, one must become aware and mindful of the presence, location and nature of the PFM.  A good starting point is what the PFM are not: they are NOT the muscles of the abdomen, thighs or buttocks, but are the saddle of muscles that run from the pubic bone in front to the tailbone in back.

The PFM have a resting tone, even though you are not typically aware of it. They can be contracted and relaxed at will: a voluntary contraction of the PFM will enable interruption of the urinary stream and tightening of the anal canal and an involuntary (reflex) contraction of the PFM occurs, for example, at the time of a cough. Relaxation of the PFM occurs during urination or a bowel movement.

Dr. Arnold Kegel described a PFM contraction as “a squeeze around the pelvic opening with an inward lift.” With a proper PFM contraction, the perineum (the area between vagina and anus in females and scrotum and anus in males) pulls in and lifts in an upwards direction.  This is a “drawing in and up,” which is the very opposite feeling of “bearing down” to move one’s bowels.  For females, one method of getting the feel for doing a proper PFM contraction is to initially tighten the vagina, secondly the anus, and thirdly lift up the perineum.

Fact: Kay Crotty, a pelvic floor physiotherapist in the UK, feels that it is initially easier to learn to contract your PFM by concentrating on just the back PFM (anal sphincter).  She discovered that women who tighten their PFM while focused on both the front PFM (vaginal) and back PFM do better quality PFM contractions than those who tighten their PFM focused on just the front PFM. 

There are many mental images that can be useful in understanding PFM contractions. One is to think of the pubic bone and tailbone moving towards each other. Another helpful picture is to imagine the PFM as an elevator—when the PFM are engaged, the elevator rises upwards to the first floor from the ground floor; with continued training, the elevator rises to the second floor.  Alternatively, for females, envision that you are lifting a ping pong ball with your vagina and pulling it deep inside you. Another means is to mentally visualize that you are removing a tampon from your vagina and as you pull on the string you try to resist and hold the tampon in.

There are simple “biofeedback” techniques that can be helpful as well. After emptying your bladder about halfway, try to interrupt your urinary stream for a few seconds while you focus on the PFM that allow you to do so. Then resume and complete urination.  The feeling should be that of clenching and unclenching the vagina, urethra and anus in females and the anus and urethra in males.  Another method for females is to place a finger in your vagina and contract your PFM: the feeling should be of your vagina having a firm grip around your finger; alternatively, in either gender one can place a finger in the anus and when the PFM are contracted, the feeling should be of the anus having a firm grip around your finger.

Building Muscle Memory

It is important to understand how one becomes adept at using muscles.  This is relevant to gaining competence in any new physical activity and will be applied specifically to acquiring the skills to perform well-executed PFM contractions.

There are four stages of motor learning.  (I learned this as it pertained to the mechanics of a golf swing, but it is equally relevant to mastering contracting the PFM.)

Stage 1. Unconscious/incompetent

There is no awareness of the motion and it cannot be capably performed. It is challenging to make the connection between your brain and your PFM because the PFM under most circumstances are used involuntarily (without conscious awareness). This connection is not intuitive and must be taught.

Fact: The connections between brain and PFM consist of sensory and motor nerves. The PFM contain sensors known as “proprioceptors” that detect stretch, position and motion and convey this information to the brain via sensory nerves. Motor nerves originate in the brain and enable the PFM to contract.

Stage 2. Conscious/incompetent

Awareness of the motion is learned, but the motion cannot be competently performed.

Stage 3. Conscious/competent

Awareness of the motion is established and with sufficient practice the motion can be competently performed.

Stage 4. Unconscious/competent

With continued practice, the brain-PFM connection and muscle memory become well established and the motion can be performed reflexively (without conscious thought or effort).

…To be continued next week with a discussion on the execution of a proper PFM contraction and self-assessment of  your PFM strength and stamina.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, Apple iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

 

 

 

 

 

Preparing For Pelvic Floor Muscle Training (PFMT): What You Need To Know

January 6, 2018

Andrew Siegel MD  1/6/2017

Happy New Year!  At this time, many of us are trying to execute New Year’s resolutions.  Topping the list of most resolutions is getting into good physical shape.  A vital piece of this is pelvic floor fitness; in fact, pelvic floor muscle training was among the top five exercises recommended for general health and fitness in a recent Harvard Medical School report.

The next series of blog entries, written for both men and women, will enable you to achieve pelvic floor fitness.  Remember, Kegels are not just for the ladies!  This first entry discusses the fast and slow twitch muscle fibers that determine pelvic floor muscle (PFM) function, the adaptation principle and the distinction between strength, power and stability.  

Image below: Male PFM (left) and female PFM (right); notice their similarity.

1116_Muscle_of_the_PerineumAttribution: URL: https://cnx.org/contents/FPtK1zmh@8.108:b3YG6PIp@6/Axial-Muscles-of-the-Abdominal  Version 8.25 from the Textbook, OpenStax Anatomy and Physiology, 
Published May 18, 2016

Muscles 101

Muscles provide shape to our bodies and allow for movement, stability and maintenance of posture.  Most skeletal muscles come in pairs and cross bony joints—when one group contracts, it causes bending of that joint and when the opposing group contracts, it causes straightening of that joint (e.g., biceps/triceps).  When each contract equally, the joint is in a neutral position. The human body has three types of muscles—skeletal muscles that provide mobility and stability, smooth muscles that line the arteries, bladder, intestine, etc., and the unique cardiac muscle of the heart.  Muscles are composed of fibers that contract (shorten and tighten) and relax (lengthen and loosen).

The PFM are skeletal muscles that are comprised of fast twitch and slow twitch muscle fibers. Fast twitch fibers predominate in high contractile muscles that fatigue rapidly and are used for fast-paced muscle action, e.g., sprinting.  Slow twitch fibers predominate in endurance muscles, e.g., marathon running. The PFM have a constant tone (low level of involuntary contraction) because of the presence of slow twitch fibers. The fast twitch fibers allow for voluntary contraction. The PFM fibers are 70% slow twitch, fatigue-resistant, endurance muscles to maintain constant muscle tone (e.g., sphincter function and pelvic support) and 30% fast twitch, capable of rapid and powerful contractions (e.g., sexual climax, interrupting the urinary stream and tightening the anus).

Fact:  Aging causes a decline in the function of the fast twitch fibers, but tends to spare the slow twitch fibers.   

Muscle mass is in a dynamic state, a constant balance between growth and breakdown. With aging, muscle fiber wasting occurs as muscle breakdown exceeds muscle growth, adversely affecting function. Strength training reduces muscle wasting by increasing muscle bulk through enlargement of muscle fibers. This is true of all skeletal muscles, the PFM being no exception.

Adaptation Principle

Muscles are remarkably responsive to the stresses placed upon them.  Muscle growth only occurs in the presence of progressive overload, which causes compensatory structural and functional changes, a.k.a. adaptation. This explains why exercises get progressively easier in proportion to the effort put into doing them.  As muscles adapt to the stresses placed upon them, a “new normal” level of fitness is achieved.  Another term for adaptation is plasticity. Skeletal muscles are “plastic,” capable of growth or shrinkage depending on the environment to which they are exposed.

The PFM behave similarly to other skeletal muscles in terms of their response to exercise or lack thereof.  In accordance with the adaptation principle, it is advisable to increase number of repetitions and contraction intensity to build muscle PFM strength, power and endurance.  As much as our muscles adapt positively to resistance, so they will adapt to the absence of stress and resistance, resulting in smaller, weaker and less durable muscles.

Fact: Use It or Lose It. With a conditioning regimen, the PFM will thrive, optimizing their function.  When the PFM are neglected, they will weaken, impairing their function.   

Strength, Power and Stability

The goal of PFM training is to maximize the trio of PFM strength, power and stability. Strength is the maximum amount of force that a muscle can exert. With time and effort, PFM contractions become more robust, helping sexual function and improving one’s ability to neutralize stress urinary incontinence, overactive bladder and pelvic organ prolapse in females.  In males, command of one’s pelvic floor muscles can improve sexual, urinary and prostate health.  Power is a gauge of strength and speed (muscle force multiplied by the contraction speed), a measure of how rapidly strength can be expressed, of great benefit to sexual health and the ability to react rapidly to urinary/bowel urgency and stress urinary incontinence. Stability helps maintain vaginal tone, urinary and bowel sphincter function and pelvic organ support as well as contributing to the “backboard” that helps prevent stress urinary incontinence.

To be continued… Next week’s entry provides information on the process of building muscle PFM memory and how to develop PFM awareness.

Wishing you the best of health!

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx