How can Pelvic Floor Physical Therapy help erectile dysfunction?

Jim is a 58-year-old male who has been experiencing a gradual reduction in the time he is able to maintain an erection over the past 3 years. Recently, he has noticed difficulty with achieving a full erection that allows for an enjoyable sexual experience with his wife of 30 years. Jim finally set up an appointment with his doctor with the support of his wife where a thorough medical history was taken and tests were performed, including a blood draw. After reviewing the results, his doctor stated his testosterone levels, among other test results, looked to be within a normal range. Jim was surprised when his doctor recommended pelvic floor physical therapy to assess the muscle function needed for erections. He was a bit hesitant at first but finally called after a few weeks to make an appointment. Jim’s physical therapist (PT) asked thorough questions including the timeline of his symptoms, medications, and medical history. Afterwards, Jim’s PT performed an examination on the muscle function of his spine, hips, legs, and pelvic floor. After the examination, Jim’s PT explained the findings of the examination and recommended a pelvic floor specific strengthening program to improve his erectile function.  

Erectile dysfunction (ED) typically increases during the lifespan with approximately 20% of men experiencing ED before 30 years old and approximately 90% experiencing ED over 70 years old.1 This means that erectile dysfunction affects approximately 52% of men between 40 and 70 years of age.2 ED involves a complex response between multiple factors including blood flow (vascular), nerve function, hormones, partner relationship(s), and mental and emotional well-being. Because most research has focused on the medical treatments of erectile dysfunction (ED) in the past, specifically medications, other avenues of treatment have been under researched and undervalued until recently.  

I find it is most beneficial for my patients to understand the “why” behind what is happening. When discussing erections there are two phases: a vascular phase and a muscular phase. The vascular phase means that blood flow toward the penis needs to occur resulting in an increase in pressure and stretching of the lower abdominal muscle (the TA or transversus abdominis). The muscular phase occurs when the pelvic floor muscles, specifically one called the ischiocavernosus, contracts to maintain the blood in the penis and provide rigidity. This means that more blood is kept in the penis than is being allowed to leave for the erection to be achieved and maintained.3 

The good news is that these muscles can be trained to perform their job more effectively meaning firmer and longer lasting erections if this is a contributing factor to an individual’s ED. A study of 51 men found that 47% regained normal erection function and 24% had improved erection after a pelvic floor muscle training program in addition to biofeedback and electrical stimulation. The greatest improvement occurred in men with venous-occlusive dysfunction meaning that the pelvic floor treatments helped improve erection strength and duration by decreasing the blood flow out of the penis. Improvement in rigidity occurred between week 1 and 6 with the average improvement occurring at 3.4 weeks. Improvement in duration of erection occurred between week 1 and 12 with the average improvement occurring at 3.9 weeks.4 

Another study that was performed looked at 122 men with erectile dysfunction (ED) and 108 men with premature ejaculation (PE) who received 30 minutes of pelvic floor muscle training (contractions) and electrical stimulation that was meant to increase the ischiocavernosus muscle strength over 20 sessions. The pelvic floor muscle training was found to be beneficial for erectile dysfunction because the ischiocavernosus muscle is better able to maintain the blood pressure in the penis leading to and maintaining an erection. The results showed that 87% positive effect on those with erectile dysfunction by increasing the pressure (think blood flow) into the penis and the sustained pressure within the penis by the ischiocavernosus muscle.5  

Keep in mind that the pelvic floor does not work on its own. Your PT may very well incorporate pelvic floor specific strengthening into your program in addition to other exercise. In fact, a variety of exercise can have different beneficial effects. For example, aerobic exercise, such as biking or running, results in vascular adaptations meaning improved blood flow. Resistance training increases testosterone while group and outdoor activities has psychological gains. These benefits can all play a role on ED improvement.1  

Physical activity has been found to reduce the risk of ED as studies have shown that those who are physically active had improved erectile function than those who are less active or inactive. Specifically, 20-30 minutes of moderate or high intensity activity 3-5 days per week over a minimum of 16 weeks is needed to see meaningful physical changes within the body. It assists with addressing many of the contributing factors to ED including increasing nitric oxide, strengthening endothelial function, increasing testosterone, decreasing stress and anxiety, and improving body image. Nitric oxide works as a vasodilator meaning it opens the blood vessels allowing more blood flow to the penis. Endothelial cells line blood vessels and lymph vessels and release nitric oxide.1   

Overall, aerobic training at a moderate, rather than high or low intensity, is recommended to ensure vascular changes by adequately challenging the system but not over training. Additionally, resistance training performed twice a week at a high intensity is considered optimal so as not to over train and to create the most beneficial effects from short term testosterone increase. While there is not a set protocol regarding exercise and improvement in erectile dysfunction, the general guidelines should typically include the World Health Organization’s recommendations of high-intensity whole body resistance training twice a week, moderate-intensity aerobic exercise two days per week and a group-based sport activity 1 day per week.1   

Some key takeaways with regards to erectile dysfunction and its treatment: 

• Erectile dysfunction can have multiple factors including hormones, blood flow, muscle strength and endurance, self-image, and relationship with partner(s). 
• Addressing the body as a whole system is going to create the best outcomes, which includes addressing the blood flow and muscular components. 
• Pelvic floor physical therapy will not create a change overnight! Be patient and consistent as this will create long-lasting changes.  

• Finally, do not be surprised if your pelvic floor PT creates a program for your pelvic floor and includes an exercise program for muscles outside of the pelvic floor. There are benefits to different types of exercise and each has a purpose! 

If you have been experiencing a change in your erectile function and have gone through all the tests and been told “everything looks normal”, please reach out to your local pelvic floor physical therapist for an evaluation to ensure the muscles are not contributing to your symptoms! 

Written by Jordan Schmidt, PT, DPT 

References 

1. Allen, M. (2019). Physical activity as an adjunct treatment for erectile dysfunction. Nature Reviews Urology, 16(9), 553-562. 

1. Ciocanel O, Power K, Eriksen A. Interventions to Treat Erectile Dysfunction and Premature Ejaculation: An Overview of Systematic Reviews. Sex Med. 2019 Sep;7(3):251-269. doi: 10.1016/j.esxm.2019.06.001. Epub 2019 Jul 9. PMID: 31300388; PMCID: PMC6728733. 

1. Lavoisier, P., Roy, P., Dantony, E., Watrelot, A., Ruggeri, J., & Dumoulin, S. (2014). Pelvic-floor muscle rehabilitation in erectile dysfunction and premature ejaculation. Physical therapy, 94(12), 1731–1743. https://doi.org/10.2522/ptj.20130354 

1. Van Kampen, M., De Weerdt, W., Claes, H., Feys, H., De Maeyer, M., & Van Poppel, H. (2003). Treatment of Erectile Dysfunction by Perineal Exercise, Electromyographic Biofeedback, and Electrical Stimulation. Physical Therapy, 83(6), 536-543. 

1. Lavoisier, P., Roy, P., Dantony, E., Watrelot, A., Ruggeri, J., & Dumoulin, S. (2014). Pelvic-floor muscle rehabilitation in erectile dysfunction and premature ejaculation. Physical therapy, 94(12), 1731–1743. https://doi.org/10.2522/ptj.20130354