Pelvic Floor Exercises for Men: A Focus on Prostate Cancer
Pelvic floor exercises are routinely accepted in women’s health domains, but until recently men weren’t even aware they had a pelvic floor. But then along came prostate cancer, PSA checks and enlarged prostates…. With better access to tests, improved diagnostic tools and more optimistic treatment for prostate cancer, a surge in diagnosis has occurred since the beginning of the 21st century.
Today, across the globe, every year, more men are diagnosed with prostate cancer at a rate of 1 in 6 men than women with breast cancer (1 in 8)1. The expected side effects from most forms of treatment include urinary incontinence and erectile dysfunction and this hardly seems a fair reward for the clearance of cancer. But the good news is that pelvic floor muscles (PFM), which support the abdominal cavity, also play a pivotal role in not only preventing these side effects, if commenced prior to treatment, but will almost certainly help the restoration of function following treatment. It is also never too late to start working on your pelvic floor as, like most other skeletal muscles in the body, will adapt to training and usually take between 6 and 12 weeks to strengthen up.
THE PELVIC FLOOR MUSCLE (PFM):
The PFM is made up of two types of muscle fibres and each is responsible for different functions. Slow twitch (type 1) endurance fibres make up approx. 80% of the PFM , and are responsible for ‘’holding’’ the bladder and bowel to control continence. In sexual function these fibres assist with blood flow and maintenance of an erection and also prevent muscle fatigue. The remaining 20%-are composed of fast twitch (type 2) fibres and are responsible for preventing urinary leakage when ‘fast’’ reactions are needed during actions such as in cough, sneeze, sit to stand and squatting. Post-void dribble can also be resolved by performing 4-5 fast PFM contractions at the end of each bladder empty. These fast twitch fibres are also responsible for the sexual functions of orgasm and ejaculation, and in some cases, such as climacturia, can be strengthened to prevent urine loss during climax. This is a very common side effect following treatment for prostate cancer and is usually easily resolved with a few weeks of PFM training.
Where do I start?
The most important thing to know is where the PFM are located, so that the contractions are performed correctly. Depending on the problem needing treatment, different components of the pelvic floor need to be targeted. In post-prostatectomy incontinence (PPI) for e.g., it is essential that the urinary sphincter is localised as it more important to lift this area than the rectal passage. Positioning is also important as most men usually only leak when they move or perform activities such as prolonged standing, walking or when intra-abdominal pressure rises such as in getting in and out of a car or in sneezing.. So, although PFM exercises can be performed in any position, for maximum benefit it is best to do most sets in standing, as it more closely aligned to symptoms. The benefits also increase if you perform the contractions whilst walking or squatting. Lying and sitting positions are ok, but few men leak in these positions, as essentially the pelvic floor are muscles of posture. A common scenario is to be ‘dry’’ all night then ‘’leaking like a tap’’ as soon as you are ‘’upright’’ and worsening over the duration of a day. This is just the PFM fatiguing as it adjusts to its new job, following removal or treatment to the prostate. In the early weeks of recovery having a midday rest for 1- 2 hours is also essential to ‘recharge the PFM.!
Self-tests of the Pelvic Floor:
To get to know where the muscles are located and to perform the exercises correctly, the best place to start is standing naked in front of a mirror and to think of what it feels like to ‘’stop the flow of urine.’’ Whilst relaxing the abdominals and maintaining normal breathing, simply lift the base of the penis and testicles ‘’up’’, as if lifting your ‘nuts to your guts’ or ‘shortening the penis’’. You should see a slight retraction of the penis and lifting of the testes, but definitely no hip, shoulder or buttock movements and definitely no sucking in of the abdominals are allowed. This is a gentle exercise! Holding the breath only increases the downward pressure onto the pelvic floor, thereby ‘weakening’’ the structures that need strengthening.
Another easy self-test is to place one of your fingers immediately behind your scrotum and on the skin in front of your anus. Push up and you will feel it is a soft, slightly ‘’squishy ‘’ tissue. Now lift ‘nuts to guts’’ as described above and feel a very slight firming of this area as the PFM contracts, then let go to feel the softness again. Repeat a few times to become more aware of the difference between contraction and relaxation states.
A quick test to try is to simply stop the flow of urine midway through a bladder void. Rather than repeating this, however, it is best to try when initially learning how to connect your ‘’brain to your bladder’’, then maybe once/week after that. Repeated stop/start contractions are not recommended.
How many Pelvic Floor Exercises should I do?
This is a very individual situation. Every man will have a different level of general fitness leading into treatment for prostate cancer. Patients who are physically fitter, walk a lot or are more physical in their work or activities generally have a stronger pelvic floor than men who are more sedentary. It is therefore recommended that a baseline is reached first, based on how easily it feels to ‘’lift’’, ‘’hold’’ and ‘drop’’ the pelvic floor muscles. For e.g., is a good idea to start with 5-10 ‘quick’’ PFM contractions, making them as brisk as possible. You may notice that the more you do, the weaker the contraction becomes and this is a great indicator of individual strength or ‘’resting tone’’. Start with 5 , then gradually build up to 10. Each quick PFM contraction should take 1 sec or less to perform and with each full contraction, there must a subsequent full relaxation. ‘’Butterfly kisses’’ are not allowed as these do little to build the closing pressure required to stop the urethral sphincter from leaking urine.
Go gently…….
Next, it is wise to start with a 2-3 second duration for the slow ‘holding” PFM exercises, with each long held followed by a ‘’let go’’ to full relaxation and ‘’rest’’ of equal duration of 2-3 sec. These too, can be gradually built up to a maximum of 10 seconds. But be warned: doing too much can sometimes lead to fatigued muscles which may either cause pain in the perineal region (some men describe this as feeling like a haemorrhoid has developed) or cause increased urinary frequency and leakage. Each set of 10 quick and 10 slow PFM exercises should be done a minimum of 3 x/day and a maximum of 6 sets/day whilst in the training.
Nb: If you are still experiencing difficulty in ‘feeling’ the pelvic floor contract and relax, it may be worthwhile to lie down on your back with knees bent gently to 90 degrees, whereby the effect of zero gravity will be the easiest position of all. Do this for both fast and slow contractions.
Can I over-train the pelvic floor muscles?
Absolutely! The PFM should be able to both contract and relax with ease. However, sometimes due to fatigue or over-training, the PFM can become too tight or ‘overactive’ which may result in pain and dysfunction in the urinary, bowel and sexual organs. If you are unable to feel your PFMs relax after contracting you may need to take a complete break from pelvic floor exercises for a day or two or seek the help of a physiotherapist specialising in pelvic health. Sometimes gentle breathing and ‘letting go’ of the PFM also helps reduce tension. This is best done in a lying down position which will be less fatiguing than upright positions such as standing which require a certain amount of tension.
