Episode 16 | Ask the Expert | Guest: Diedre, Pelvic Health Physiotherapist
Men’s health, in the medical sense, has nothing to do with the cover of a fitness magazine. It refers to something far more specific – and far less discussed: the health of the pelvic region, and the bladder, bowel, and sexual function it governs.
In this episode of the London Bridge Sports Medicine podcast, Dr Ajai Seth is joined by Diedre, a specialist pelvic health physiotherapist, to explore a topic that affects men of all ages but is rarely talked about openly. The symptoms are often embarrassing. The causes are frequently misunderstood. And the solutions – more often than not – are practical, accessible, and highly effective.
What is the pelvic floor – and why does it matter for men?
The pelvic floor is a group of muscles sitting at the base of the pelvis, through which the urethra, rectum, and in men, the structures involved in sexual function all pass. Most men have either never heard of it, or associate it exclusively with women who have given birth. In Diedre’s experience, the vast majority of male patients she sees have never been taught that these muscles exist – let alone that they can be assessed and treated.
The pelvic floor has three core functions relevant to men’s health:
- Bladder control – managing urinary continence, flow, and urgency
- Bowel control – supporting healthy defecation and preventing leakage
- Sexual function – contributing to erectile strength, maintenance, and pain-free function
Like any muscle group, the pelvic floor can be too weak, too tight, or simply not functioning as it should. Problems in any of those three domains can often be traced back to it.
Sexual dysfunction: more than a psychological issue
When men experience changes in erectile function – reduced strength, difficulty maintaining an erection, pain during erection or ejaculation – the immediate assumption tends to be either psychological or pharmaceutical. Viagra is well advertised. Pelvic floor physiotherapy is not.
But the pelvic floor muscles play a direct role in erectile function. They contribute to blood trapping in the penis, which supports both the strength and duration of an erection. When these muscles are not working properly – either too weak or, importantly, too tight – function is affected.
“If the pelvic floor gets tight, it can get painful – the same way that a tight muscle in your neck or leg can cause pain,” says Diedre. A hypertonic (overactive) pelvic floor can cause pain with erection or ejaculation, and is often entirely overlooked in standard investigations.
The pathway Diedre recommends: see your GP first. Rule out medical causes – vascular issues, diabetes, hormonal factors – and involve a urologist if indicated. But if investigations come back clear and symptoms persist, pelvic floor assessment is a logical and often very productive next step. “If tests are negative and you’re thinking what else is there to look at, then pelvic floor is definite,” she says.
Bladder problems: not just a prostate issue
Most men – and many GPs – associate urinary symptoms in older men with the prostate. That association is well founded and important. But the prostate is not the only explanation, and medication is not the only solution.
Bladder symptoms that can have a pelvic floor component include:
- Leaking urine with coughing, sneezing, or lifting (stress incontinence)
- A sudden, urgent need to reach the toilet – and sometimes not making it in time (urge incontinence)
- Getting up multiple times during the night to urinate
- A reduced or interrupted urine stream, or a feeling of incomplete emptying
NICE guidelines recommend pelvic floor re-education as first-line treatment for urinary symptoms in women. The same logic applies to men – but the clinical pathway hasn’t caught up. “If tests are negative, the sooner you can get those muscles assessed, the better,” says Diedre. “It’s always easier to change muscle behaviour earlier than if you’re four or five years down the line.”
A significant proportion of Diedre’s older male patients come to her post-prostatectomy – following surgical removal of the prostate for cancer – where pelvic floor rehabilitation is an established and important part of recovery. But she also sees younger men, many of them active and physically strong, who have developed pelvic floor dysfunction through heavy weight training or endurance sport.
Cycling is one example: prolonged time in the saddle holds the pelvic floor in an adaptively shortened position. Heavy lifting is another: maximal abdominal pressure during a loaded squat or deadlift places significant demand on the pelvic floor, and in some men this contributes to overstraining over time.
Bowel problems: a muscular explanation
Bowel symptoms are perhaps the most taboo of the three areas – and therefore the most likely to go unaddressed. The anal sphincter is part of the pelvic floor, and its dysfunction can manifest as constipation, difficulty fully emptying, faecal urgency, or occasional leakage.
As with bladder symptoms, the default response is often medical or dietary: laxatives, fibre, hydration. These can all help – but a pelvic floor that is not releasing properly is a muscular problem, not a dietary one, and the solution is different.
Diedre’s most practical tip for constipation: use a small step or footstool under the feet when sitting on the toilet. This changes the angle of the pelvis, moving it into a more natural squatting position and allowing the pelvic floor to relax more fully. It is a simple, immediately accessible intervention that can make a meaningful difference. “Small changes can make quite a big difference,” she says.
How pelvic floor physiotherapy works
Assessment involves an internal rectal examination – which Diedre acknowledges puts some men off, but which most men who have been through the urology pathway will have already experienced. The examination assesses whether the muscles can contract, how long they can sustain that contraction, and critically, whether they can fully release. Trigger points and areas of restriction are also identified.
Treatment depends entirely on what the assessment reveals – and this is an important distinction:
- If the muscles are weak – strengthening exercises, progressed from lying to sitting to standing, are prescribed and built up over time
- If the muscles are too tight – relaxation and downtraining techniques are used, including meditative breathing and, where appropriate, internal massage using a finger or a specific device
Getting this distinction right matters. A man who researches his symptoms and begins doing pelvic floor strengthening exercises without assessment may be doing exactly the wrong thing – if his muscles are already overactive, more strengthening will worsen his symptoms. Assessment is not just helpful; it is essential.
Why this isn’t talked about enough
The gap in awareness around men’s pelvic health is not simply cultural. There is also a genuine shortage of specialist men’s health physiotherapists – even practitioners who work extensively in women’s health do not always extend into men’s. This means the referral pathways are less established, the services are less visible, and men with treatable conditions often cycle through investigations for years without being pointed towards physiotherapy.
“It’s not necessarily that doctors don’t know where to send them,” says Diedre. “It’s that the services aren’t always there.” Dr Seth draws a useful comparison: awareness around testicular cancer has grown significantly over recent years. Men’s pelvic health deserves a similar level of attention. The symptoms may not be life-threatening, but they significantly affect quality of life – and that matters.
The bottom line
If you are a man experiencing any of the symptoms discussed – changes in bladder or bowel function, urinary leakage, urgency, difficulty with sexual function, or pelvic pain – the first step is always your GP, to rule out any underlying medical cause. If investigations come back clear and symptoms persist, pelvic floor physiotherapy is a well-evidenced, practical, and underutilised option that is well worth exploring.
These are not symptoms to be embarrassed about or to manage in silence. They are muscular problems, and like any other muscular problem, they respond to the right assessment and the right treatment.
Diedre is a specialist pelvic health physiotherapist with experience treating men across all ages and presentations, from post-surgical rehabilitation to pelvic pain and bladder dysfunction in active men.
To discuss men’s health concerns with the LBSM team, visit lbsm.co.uk/booking
Listen to the full episode below ↓
