The document discusses the role of the male pelvic floor (MPF) in male sexual dysfunction. It begins with an introduction on the prevalence of male sexual dysfunctions like erectile dysfunction (ED), ejaculatory dysfunction (EjD), and chronic pelvic pain/chronic prostatitis (CP/CPPS). It then covers the anatomy and physiology of the MPF, explaining its role in urination, erection, and ejaculation. Subsequent sections discuss how MPF dysfunction may contribute to ED, EjD/orgasmic dysfunction, and CP/CPPS. The document concludes that MPF therapy shows promise in treating some male sexual dysfunctions and more research is still needed.

1. Role of Pelvic Floor in Male
Sexual Dysfunc6on
Ege Can Serefoglu, MD, FECSM
Bagcilar Training & Research Hospital, Istanbul

2. Content
• Introduc@on
• Anatomy and Physiology of the MPF
• ED and the MPF
• Ejaculatory/Orgasmic Dysfunc@on and the MPF
• CP/CPPS and the MPF
• Conclusions

3. Content
• Introduc@on
• Anatomy and Physiology of the MPF
• ED and the MPF
• Ejaculatory/Orgasmic Dysfunc@on and the MPF
• CP/CPPS and the MPF
• Conclusions

4. Introduc6on
• MSDs are highly prevalent in men - increasing with age
• ED
• EjD
• CP/CPPS
• Sexual func@on is a vital and cri@cal part of men’s overall health
Porst et al, Eur Urol, 2007; 51: 816-824
Althof et al, J Urol, 2006; 175: 842

5. Introduc6on
• MSDs are mul@factorial – a variety of psychological and biologic
e@ologies may cause MSDs
• Most of the MSD research focused on hormonal, neurologic, and/or vascular problems
• Biologic rela@onship between MPF and MSD is seldom emphasized.
• This is in contrast to countless pelvic floor studies in FSDs.
• Pelvic floor therapies are successful in the management of FSD.
Lin et al. Cancer Nurs, 2012; 35: 106

6. Introduc6on
MPF is also important in MSD…!!!
• MPF and ED
• MPF and PE
• MPF and CP/CPPS
Rosenbaum TY, J Sex Med, 2007; 4: 4
Shafik A, Arch Androl, 1994; 32: 141
Litwin et al, J Urol, 1999; 162: 369

7. Introduc6on
MPF is also important in MSD…!!!
• MPF and ED
• MPF dysfunc@on has been associated with ED as well as EjD
• MPF muscle training increases penile rigidity and penile hardness in some
men with ED
• MPF dysfunc@on may cause Pudendal Artery Syndrome
• a syndrome characterized by decreased internal pudendal blood flow due to external
compression inside pudendal canal
• MPF and PE
• MPF and CP/CPPS
Rosenbaum TY, J Sex Med, 2007; 4: 4
Shafik A, Arch Androl, 1994; 32: 141
Litwin et al, J Urol, 1999; 162: 369

8. Introduc6on
MPF is also important in MSD…!!!
• MPF and ED
• MPF and PE
• MPF muscle func@on is also involved in coordina@ng ejacula@on
• MPF therapy has been shown to improve control over ejacula@on and
increase IELT
• Strong BS contrac@ons may enhance orgasmic pleasure during ejacula@on.
• Improvements in ejacula@on/orgasm and erec@le func@on have been
demonstrated with MPF therapy.
• MPF and CP/CPPS
Rosenbaum TY, J Sex Med, 2007; 4: 4
Shafik A, Arch Androl, 1994; 32: 141
Litwin et al, J Urol, 1999; 162: 369

9. Introduc6on
MPF is also important in MSD…!!!
• MPF and ED
• MPF and PE
• MPF and CP/CPPS
• Effec@ve management of CP/CPPS has been demonstrated in MPF therapy.
• MPF muscle tone is an important factor in the pathophysiology of CP/CPPS.
• neuromuscular reeduca@on with the guidance of EMG (or other methods of
biofeedback) is beneficial in reducing pain scores.
Rosenbaum TY, J Sex Med, 2007; 4: 4
Shafik A, Arch Androl, 1994; 32: 141
Litwin et al, J Urol, 1999; 162: 369

10. Content
• Introduc@on
• Anatomy and Physiology of the MPF
• ED and the MPF
• Ejaculatory/Orgasmic Dysfunc@on and the MPF
• CP/CPPS and the MPF
• Conclusions

11. Anatomy and Physiology of the MPF
• The ICS has proposed the following
defini@on:
• The pelvic floor is a compound structure
that encloses the bony pelvic outlet,
consis@ng of muscle, fascia, and neural
@ssue.
• The term pelvic floor muscles refers to
the muscular layer of the pelvic floor
• The pelvic floor is made up of muscles
and other @ssues that form a sling
from the pubic bone to the coccyx.
• assist in suppor@ng the abdominal and
pelvic organs
• help to control bladder, bowel and sexual
ac@vity.
Messelink et al, Neurourol Urodyn, 2005; 24: 374

13. Anatomy and Physiology of the MPF
• Physiology of MPF is extremely complex
• One part of the muscle may be contrac@ng while the other is relaxing
• MPF muscles are important in normal urina@on, erec@on and
ejacula@on
• They empty the bulbar urethra by reflex ac@on ajer urina@on.
• They prevent blood reflux during erec@on (by exer@ng pressure on veins)
• They sucks and ejects semen during ejacula@on
Juarez R and Cruz Y, Neurourol Urodyn, 2014; 33: 437
Dorey G, Urol Nurs, 2003;23:42, 48-52

15. Anatomy and Physiology of the MPF
• MPF innerva@on is fundamental
to normal male sexual, urinary,
and bowel func@ons.
• Sympathe@c
• Parasympathe@c
• Soma@c
• Hypogastric n.
• Pudendal n.
• Levator ani n.
Filler AG, Neurosurg Focus, 2009; 26: E9
Nadelhaj I and Booth AM, J Comp Neurol, 1984; 226: 238
Holmes GM and Sachs BD, Physiol Behav, 1994; 55: 255

16. Anatomy and Physiology of the MPF
• Coordinated contrac@on of the
BS and IC muscles are controlled
by pudendal n. (from spinal
nerves S2-4)
• BS contrac@ons à ejacula@on
• BS + IC contrac@ons à erec@on
• A comprehensive understanding
of MPF anatomy and physiology
is crucial to truly understand
male sexual func@on.
Filler AG, Neurosurg Focus, 2009; 26: E9
Nadelhaj I and Booth AM, J Comp Neurol, 1984; 226: 238
Holmes GM and Sachs BD, Physiol Behav, 1994; 55: 255

17. Content
• Introduc@on
• Anatomy and Physiology of the MPF
• ED and the MPF
• Ejaculatory/Orgasmic Dysfunc@on and the MPF
• CP/CPPS and the MPF
• Conclusions

18. ED and the MPF
• Erec@on = pressurized and
closed hydraulic system within
the corpora cavernosa.
• ED = inability to either obtain
and/or maintain that closed
hydraulic system.
• Prevalence of ED range from 9%
to 40% of men by age 40
• increase by 10% in each decade of
life thereajer.
Andersson KE and Wagner G, Physiol Rev, 1995;75: 191
Nicolosi et al, Urology, 2003; 61: 201

19. ED and the MPF
• Contrac@ons of MPF muscles (in par@cular BS
and IC) temporarily increase penile rigidity
• IC à enhances erec@le rigidity by compressing
the roots of the corpora cavernosa
• BS à leads to engorgement of corpus
spongiosum and glans penis
• In ED, MPF muscle func@on may be imparied
• Voluntary MPF muscle ac@va@on is more efficient in
healthy men compare with ED pa@ents
• Rehabilita@on of MPF func@on has long been
suggested for the treatment of ED.
• MPF muscle exercise appears to be especially
beneficial in men with ED due to mild or moderate
VOD
Lavoiser, et al, J Urol, 1986; 136: 936
Wespes et al, Eur Urol, 1990; 18: 45
Claes et al, Int J Impot Res, 1993; 5: 13

20. ED and the MPF
• Abnormally high MPF muscle
tone may also cause ED
• provide extrinsic compression on
lumen of the internal pudendal a and
limit arterial inflow.
• This explains the high prevalence of
ED in CP/CPPS pa@ents.
Tran CN and Shoskes DA, World J Urol, 2013; 31: 741
Siegel, Urology, 2014; 84: 1

21. Content
• Introduc@on
• Anatomy and Physiology of the MPF
• ED and the MPF
• Ejaculatory/Orgasmic Dysfunc@on and the MPF
• CP/CPPS and the MPF
• Conclusions

22. Ejaculatory/Orgasmic Dysfunc6on and the
MPF
• Ejacula@on occurs via simultaneous
• contrac@on of the smooth muscles of the prostate gland,
• contrac@on of the smooth muscles of the bladder neck, and
• relaxa@on of the smooth muscles of the urethral sphincter.
• Rhythmic BS contrac@ons act as a “suc@on-ejec@on pump”
• sucking the semen into the posterior urethra while relaxed
• ejec@ng it into the bulbous urethra upon contrac@on
• Strong BS contrac@ons increase urethral pressure, facilita@ng
expulsion of the semen
• Strong BS contrac@ons may also enhance and intensify
orgasmic pleasure during ejacula@on.
• Therefore, pelvic floor muscle training may act to op@mize
ejaculatory volume, force, and intensity of sexual climax.
Shafik A, Int Urogynecol J Pelvic Floor Dysfunct, 2000; 11: 361
Symonds et al, J Sex Marital Ther, 2003; 29: 361

23. Ejaculatory/Orgasmic Dysfunc6on and the
MPF
• EjDs (especially PE) are the most common MSD (around 30% of men)
• nega@vely affec@ng the sexual sa@sfac@on in many men and their partners.
• The importance of MPF func@on in the treatment of PE is recently
appreciated.
• Inten@onal relaxa@on of the BS + IC muscles may inhibit the ejacula@on reflex
• “Squeeze technique” described by Masters&Johnson uses the BS reflex
• sustained pressure to glans penis à diminished rhythmic BS contrac@on à ejacula@on delays
• “internal squeeze technique” helps control of ejacula@on
• stopping intercourse and performing a sustained contrac@on of the MPF muscles
• MPF therapy improve control over ejacula@on and increase IELT in men with MPF
muscle dysfunc@on.
Porst et al, Eur Urol, 2007; 51: 816
Siegel AL, Urology, 2014; 84: 1
Pastore et al, Int J Androl, 2012; 35: 528

24. Ejaculatory/Orgasmic Dysfunc6on and the
MPF
• MPF therapy for PE seems to be safe and effec@ve.
• How the treatment should be applied???
• Should we improve contrac@ons or relaxa@ons?
• Therefore, current treatment should be tailored to individual
findings.
Porst et al, Eur Urol, 2007; 51: 816
Siegel AL, Urology, 2014; 84: 1
Pastore et al, Int J Androl, 2012; 35: 528

25. Content
• Introduc@on
• Anatomy and Physiology of the MPF
• ED and the MPF
• Ejaculatory/Orgasmic Dysfunc@on and the MPF
• CP/CPPS and the MPF
• Conclusions

26. CP/CPPS and the MPF
• CP/CPPS is characterized by pain in the
pelvis, abdomen, or genitals, and LUTS
without evidence of recurrent UTI
• CP/CPPS is a common and ojen
debilita@ng condi@on that affects millions
of men worldwide (up to 16% of men)
Aubin et al, J Sex Med, 2008; 5: 657
Mehik et al, BJU Int, 2001; 88: 35
Lee et al, Urology, 2008; 71: 79

27. CP/CPPS and the MPF
• The rela@onship among MSD,
pelvic pain, and CP/CPPS is
complex, with the 3 condi@ons
ojen overlapping
Cohen et al, Sex Med Rev, 2016; 4: 53

28. CP/CPPS and the MPF
• Discomfort or pain accompanying
ejacula@on is common à ED and EjD
• Prevalence rates of ED and EjD in these men have been
reported to be as high as 70%
• Presence of sexual MSD is correlated with greater CP/
CPPS symptom severity and worse QoL
• Men with CP/CPPS had greater rates of
depression compared with controls.
• their female partners were also depressed
• Their female partners reported higher rates of
dyspareunia.
Aubin et al, J Sex Med, 2008; 5: 657
Mehik et al, BJU Int, 2001; 88: 35
Lee et al, Urology, 2008; 71: 79

29. CP/CPPS and the MPF
• Correla@on between ED and CP/CPPS may be
explained by a compromise in penile
hemodynamics
• Men with CP/CPPS are more likely to have arterial
s@ffness associated with NO-mediated vascular
endothelial dysfunc@on
• Increased autonomic vascular tone associated with
pain-induced chronic stress may play role in ED
• Vascular endothelial dysfunc@on contributes to the
chronic muscle spasm and pain
• Elevated pelvic floor muscle tone obstructs arterial
inflow to the penis via extrinsic muscular
compression.
Rosenbaum et al, J Sex Med, 2008; 5: 513
Gonen et al, J Androl, 2005; 26: 601
Screponi et al, Urology, 2001; 58: 198
Shoskes et al, J Urol, 2004; 172: 542
CP/CPPS à Pain à Chronic Stress à Autonomic vascular tone é
êé ê
Chronic muscle spasms à arteries compressed à ED

30. CP/CPPS and the MPF
• PE is also commonly associated with CP/CPPS.
• Prevalence PE is greater in men with CP/CPPS
• Prosta@c inflamma@on (56.5%) and chronic prosta@c infec@on
(47.8%) are common among men with PE.
• “Inflamma@on” in prostate may alter sensa@on involved in
the ejaculatory reflex and lead to PE
• Pelvic floor muscle spasms may also impair normal sensory
feedback involved in ejacula@on
• Ejaculatory pain is another common complaint of men with
CP/CPPS.
• The cause of this associa@on is controversial.
• Half of the men with CP/CPPS experience painful ejacula@on.
Inflamma@on and neuromuscular spasm are important sources of
ejaculatory pain.
• The nega@ve impact of CP/CPPS on individuals increase with the
frequency of their ejaculatory pain, and their mental and physical
quality of life decreased.
• Men with CP/CPPS have significantly more tenderness, muscle
spasm, and dysfunc@on throughout the abdomen and pelvis.
Rosenbaum et al, J Sex Med, 2008; 5: 513
Gonen et al, J Androl, 2005; 26: 601
Screponi et al, Urology, 2001; 58: 198
Shoskes et al, J Urol, 2004; 172: 542

31. CP/CPPS and the MPF
• Ejaculatory pain is another common
complaint of men with CP/CPPS.
• The cause of this associa@on is
controversial.
• Half of the men with CP/CPPS experience
painful ejacula@on.
• “Inflamma@on” and “neuromuscular spasm”
are important sources of ejaculatory pain.
• The nega@ve impact of CP/CPPS on
individuals increase with their ejaculatory
pain
• their mental and physical QoL is decreased.
Rosenbaum et al, J Sex Med, 2008; 5: 513
Gonen et al, J Androl, 2005; 26: 601
Screponi et al, Urology, 2001; 58: 198
Shoskes et al, J Urol, 2004; 172: 542

32. Pelvic Floor Treatment Strategies in Men With
CP/CPPS
• Abnormal muscle tone and shortening of
the levator ani and external rotators of
the hips have been iden@fied as possible
culprits in the pathophysiology of CP/
CPPS.
• There is significantly more pelvic floor
muscle spasm and tension in men with
CP/CPPS than in healthy men,
• with up to 50% showing signs of this
musculoskeletal dysfunc@on.
• 88.3% had pathologic tenderness of the
pelvic floor muscle and poor pelvic floor
muscle func@on.
• MPF dysfunc@on associated with CP/CPPS
may indicate that there is a central
nervous system disturbance in regula@on
of the MPF muscles. Hetrick et al, J Urol, 2003; 170: 828
Berger et al, BMC Urol, 2007; 7: 17
Shoskes et al, J Urol, 2008; 179: 556
Doggweiler-Wiygul R, Curr Pain Headache Rep, 2004; 8: 445
Zermann et al, J Urol, 1999; 161: 903

33. Pelvic Floor Treatment Strategies in Men With
CP/CPPS
• Effec@ve management of CP/CPPS seems
possible by MPF treatment programs
• Neuromuscular reeduca@on is the guided
conscious retraining of muscle ac@va@on and
deac@va@on
• It is a component of physical therapy treatments
across many specializa@ons, including pelvic
health.
• With the guidance of EMG (or other methods of
biofeedback), neuromuscular reeduca@on may
reduce baseline tone of the MPF muscles.
• This reduc@on in muscle ac@vity also reduce pain
and improve overall QoL
• Soj- @ssue mobiliza@on, myofascial release,
and connec@ve @ssue manipula@on
techniques may also be used.
Hetrick et al, J Urol, 2003; 170: 828
Berger et al, BMC Urol, 2007; 7: 17
Shoskes et al, J Urol, 2008; 179: 556
Doggweiler-Wiygul R, Curr Pain Headache Rep, 2004; 8: 445
Zermann et al, J Urol, 1999; 161: 903

34. Conclusion
• The role of the pelvic floor in MSD and the importance of MPF
physical therapy are only beginning to be appreciated by the sexual
medicine community.
• Treatment of the MPF has been shown to result in significant
func@onal improvement of sexual health in selected men with sexual
dysfunc@on (especially in the presence of CP/CPPS)
• Addi@onal research is needed
• to bexer understand the anatomy and physiological func@on of the MPF
• to iden@fy which men with MSD will benefit from MPF rehabilita@on

35. THANK YOU
Ege Can Serefoglu, MD, FECSM
egecanserefoglu@hotmail.com