Male Pelvic Fitness Optimizing Sexual & urinary HealtH Andrew L. SiegeL, M.d.
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Published by ROGUE WAVE PRESS Copyright Š 2014 by Andrew L. Siegel, M.D. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, distributed or transmitted in any form by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the publisher and copyright holder. Printed in the United States of America First printing 2014 ISBN: 978-0-9830617-3-1 Paperback ISBN: 978-0-9830617-4-8 e-book
To order additional copies of this book: www.MalePelvicFitness.com
DISCLAIMER: This publication contains the opinions, ideas, and biases of the author. There is no intent that any of the information provided should be construed as medical advice or professional medical services. Before adopting any recommendations made in the book, it is imperative that you consult with your own health care provider. The author and publisher disclaim any and all responsibility for any liability or loss incurred as a consequence of the use of any of the information provided.
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This book is dedicated to my patients, many who have opened up their lives and hearts and have shared very personal and intimate details with me. They have been among my most important teachers and have given me a wealth of information that is not to be found in medical textbooks or journals. Meaningful, enjoyable, and rewarding relationships have been developed and nurtured over the years and it has been a privilege and an honor to be entrusted with their urological care. Engaging their confidence and respect through our interactions has proven to be one of the most satisfying and fulfilling aspects of being a physician.
TAbLe of ConTenTS Acknowledgments Author’s Note Foreword by Dr. Grace Dorey
xi xiii xv
Preface
xvii
Introduction
xxi
chapter 1
Marvels of The Penis • the Penis: the Ultimate Multi-tasker • size Matters • erectile Geometry: Up-Right • “Hard Up”: the Male sexual Response
1
chapter 2
The Penis and nether Parts • Genital embryology • comparison of the Genders: Genital anatomy and the Pelvic Floor Muscles • anatomy of the Genital-Urinary tract: What’s Up Down there? • “Hard science”: Mechanics and Biochemistry of erections
chapter 3
Male Sexual dysfunction 37 • Overview • Risk Factors for erectile Dysfunction • causes of erectile Dysfunction: Psychological;vascular; neurologic; endocrine; Medication-induced; systemic Disorders; Peyronie’s Disease; Priapism; Penile trauma/Penile Fracture; Bicycling/Other saddle sports • evaluation of erectile Dysfunction • Management of erectile Dysfunction: Healthy lifestyle; Psychological counseling; Hormone Replacement; Modification/elimination of Medications; Oral Medications;vasodilator injections; Urethral suppositories; constriction Devices;vacuum Devices; Penile Revascularization surgery; Penile implants • Other Problems of Male sexual Dysfunction: ejaculation issues
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viii Male Pelvic Fitness chapter 4
“Member” benefits: Practical Applications of Pelvic floor Muscle fitness • erectile Dysfunction • Diminished ejaculation/Orgasm intensity • Premature ejaculation • stress Urinary incontinence • Overactive Bladder • Post-void Dribbling • Pelvic Pain Due to levator Muscle spasm • Bowel Urgency and incontinence • Perineal Damage from saddle sports • Prostate Health
69
chapter 5
Muscles of Love • core Muscles • external Rotators • Pelvic Floor Muscles
85
chapter 6
The Muscles of Love: origins, insertions and Actions
91
chapter 7
explore That floor: what’s Under The Hood? • Bony landmarks • the Pelvic Floor Muscles • the Penis
99
chapter 8
Pelvic floor Muscle Training: from fringe to Mainstream
chapter 9
basic Training of the Pelvic floor Muscles • no Respect • skeletal Muscle • Muscle contractility • assessing PFM strength • PFM education and awareness • Basic training
chapter 10
Advanced (resistance) Training of the Pelvic floor Muscles • the Resistance Principle • adaptation • stability, strength and Power • applying Resistance training to the Pelvic Floor Muscles
105 111
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table of contents ix
chapter 11
Pilates and Male Pelvic fitness
127
Concluding words
149
references
151
inTrodUCTion
With respect to sexuality, medical publications—and more specifically the urological literature—rarely, if ever, make mention of targeted exercise as a potential means of optimizing function or helping to treat a dysfunction. The preeminent urology textbook, Campbell’s Urology, a 4000 page, 4-volume tome, devotes precisely one paragraph to the utility of pelvic floor muscle exercises in the management of male sexual dysfunction and makes no mention of its use in maximizing sexual function. Despite numerous studies and significant research demonstrating the effectiveness of targeted pelvic exercises, they have been given short shrift. Part of the reason for this is simply that there has never been an easy-to-follow exercise program or well-designed means of facilitating pelvic floor muscle training in men. Instead, there is an emphasis on oral medications, urethral suppositories, penile injections, vacuum devices and penile implants. In the United States, we have a pharmacology-centric medical culture—“a pill for every ill”—with aggressive prescription writing by physicians and a patient population that expects a quick fix. It is shameful that traditionally there has been such little emphasis on lifestyle improvement—healthy diet, weight management, exercising, and avoidance of tobacco, excessive alcohol and stress—as a means of preventing and improving sexual dysfunction. In addition to general lifestyle measures, specific exercises targeted at the pelvic floor can confer great benefits to pelvic health and fitness, an important element of overall health and fitness. The pelvic floor muscles (PFM) are critical to healthy sexual function and achieving fitness in this domain is advantageous on many levels: to enhance sexual health; to maintain sexual health; to help prevent the occurrence of sexual dysfunction in the future; and to aid in the management of sexual dysfunction. PFM exercises should be considered first-line treatment of xxi
xxii Male Pelvic Fitness sexual dysfunction and a safe and natural self-improvement approach ideally suited to the male population, including the baby boomers, generation X, and generation Y. PFM fitness can serve as an effective means to help keep the boomers “booming.” I do not mean to downplay and disparage the role of medications and other options in managing sexual dysfunction. The availability of that magic blue pill in April 1998—Viagra—was a seminal moment in the world of male sexual dysfunction that enabled for the first time a simple and effective means of treating erectile dysfunction (ED). On the polar opposite end of the treatment spectrum—but of no less importance—was the development and refinement of the penile implant, used in severe cases of ED unresponsive to less invasive options. But why should we not initially try to capitalize on simpler, safer, and more natural solutions and consider, for example, using a targeted exercise program or medications in conjunction with a targeted exercise program? Sexual function is all about blood flow to the penis and pelvis. And what better way to enhance blood flow than to exercise? We engage in exercise programs for virtually every other muscle group in the body. Working out our PFM can result in a strong, robust and toned pelvic floor, capable of supporting and sustaining sexual function to the maximum. Physical therapy is a well-accepted discipline that is commonly used for disabilities and rehabilitation after injury or surgery. The goal of a physical therapy regimen is to promote mobility, functional restoration and quality of life. A targeted PFM exercise regimen should be considered the equivalent of genital and pelvic physical therapy with the goal of increasing the bulk, strength, power and function of the PFM. The PFM can be thought of as a vital partner to our sexual organs, whose collaboration is an absolute necessity for optimal sexual functioning, little different than the relationship between the diaphragm muscle and the lungs. The role of the PFM in sexual function has been vastly undervalued and understated. The hard truth is that a well-conditioned pelvic floor that can be vigorously contracted and relaxed at will is often capable of improving sexual prowess and functioning as much as fitness training can enhance athletic performance and endurance. Such targeted exercises confer advantages that go way beyond the sexual domain. These often-neglected muscles are vital to our genitalurinary health and wellness and serve an essential role in urinary function, bowel function and prostate health. Additionally, they are important contributors to lumbar stability, spinal alignment and the prevention of back pain. Specifically, PFM exercises can be beneficial with respect to the following spectrum of issues: erectile dysfunction;
introduction xxiii
orgasmic dysfunction; premature ejaculation; urinary incontinence; overactive bladder; post-void dribbling; pelvic pain due to levator muscle spasm; bowel urgency and incontinence; and in mitigating damage incurred from saddle sports including cycling, motorcycling and horseback riding. The PFM, comprised of muscles that form a muscular shelf that spans the gap between our pelvic bones, form the base of our “core” muscles. Our core muscles are the “barrel” of muscles in our midsection. The top of our core is our diaphragm, the sides are our abdominal, flank, and back muscles, and the bottom of the barrel are our PFM. The core muscles, including the PFM, are not the glitzy muscles of the body—not those muscles that are for show. Our core muscles are often ignored and do not get much respect, as opposed to the external glamour muscles of our body, including the pectorals, biceps, triceps, quadriceps, latissimus, etc. In general, muscles that have such mirror appeal are not those that will help in terms of sexual and urinary function. Our core muscles are the hidden gems that work diligently behind the scenes—the muscles of major function and not so much form— muscles that have a role that goes way beyond movement, which is the cardinal task of a skeletal muscle. On a functional basis, we would be much better off having a “chiseled” core as opposed to having “ripped” external muscles, as there is no benefit to having all “show” and no “go.” The pelvic floor seems to be the lowest caste of the core muscles— the musculus non grata, if you will kindly accept my term. The PFM, however, do deserve serious respect because, although concealed from view, they are responsible for some very powerful and beneficial functions, particularly so when intensified by training. Although the PFM are not muscles of “glamour,” they are our muscles of “amour.” WHO KNEW?
Having “ripped” external glamour muscles might help get your romance going, but having a chiseled core and conditioned PFM will help keep it going . . . and going . . . and going! The female pelvic floor muscles, exercises for which were popularized by gynecologist Dr. Arnold Kegel, have long been recognized as an important structural and functional component of the female pelvis. But who has ever heard of the male pelvic floor? The male pelvic floor has been largely unrecognized and relegated as having far less significance than the female pelvic floor. Yet from a functional standpoint, these muscles are of vital importance, certainly as critical to male genital-urinary health as they are to female genital-urinary health. The PFM, as with other muscles in the body, are subject to the forces
xxiv Male Pelvic Fitness of adaptation. Unused as they are intended, they can suffer from “disuse atrophy.” Used appropriately as designed by nature, they can remain in a healthy structural and functional state. When targeted exercise is applied to them, particularly against the forces of resistance, their structure and function, as that of any other skeletal muscle, can be enhanced. The key responsibility of most of our skeletal muscles is for joint movement and locomotion. The core muscles in general, and the PFM in particular, are exceptions to this rule. Although the core muscles do play a role with respect to movement, of equal importance is their contribution to support, stability, and posture. Consider that the pelvic floor muscles, particularly the superficial PFM, have an essential function in the support, stability and “posture” of the penis. They should be considered the hidden “jewels” of the pelvis. WHO KNEW?
If you want your penis to have “outstanding” posture and stability, you want to make sure that your PFM are kept fit and well-conditioned. The PFM have three main functions that can be summarized by three S’s: support, sphincter, and sex. Support refers to their important role in securing our pelvic organs—the urinary, genital and intestinal tracts—in proper anatomical position. Sphincter function allows us to interrupt our urinary stream and pucker the anus and contributes in a major way to urinary and bowel control. These vital responsibilities are generally taken for granted until something goes awry. With regard to sexual function, the PFM are active during erection and ejaculation. They cause a surge of penile blood flow that helps maintain a rigid penile erection throughout sexual activity and at the time of orgasm, contract rhythmically, enabling ejaculation by propelling semen through the urethra. The PFM can become atrophied, flabby and poorly functional with aging, weight gain, a sedentary lifestyle, saddle sports and other forms of injury and trauma, chronic straining, and surgery. Sexual inactivity can lead to their loss of tone, texture, and function. However, PFM integrity and optimum functioning can be maintained into our golden years with attention to a healthy lifestyle, an active sex life, and PFM training, particularly when such exercises are performed against progressive resistance. The goal of such a regimen is the attainment of broader, thicker and firmer PFM and maintenance and/or restoration of function. The PFM may physically be the bottom of the barrel of our core, but functionally they are furthermost from the bottom of the barrel. For those who are already functioning well, an intensive PFM training program—as with any good fitness regimen—can impart better per-
introduction xxv
formance, increased strength (rigidity), improved endurance (ejaculatory control), and decreased recovery time (the amount of time it takes to achieve another erection). Keeping the PFM supple and healthy can help prevent the typical decline in function that accompanies the aging process. On so many domains, diligently practiced PFM exercises will allow one to reap tangible rewards, as they are the very essence of functional fitness—training one’s body to handle real-life situations and overcome life’s daily obstacles.
1
Marvels Of The Penis • • • •
The Penis: The Ultimate Multi-Tasker size Matters erectile Geometry: Up-right “hard Up”:The Male sexual response
The Penis:The Ultimate Multi-Tasker The penis, when functioning properly, is a proud soldier, a term used when I was a urology resident at University of Pennsylvania and rotating through pediatric urology at Children’s Hospital of Philadelphia (CHOP). Numerous penile reconstructive procedures were performed at CHOP for congenital birth defects that caused the penis to have a disfiguring curvature and an abnormally located urethral opening. The term “proud soldier” was used in the context of the excellent results after repair. I admire that nickname—it signifies a warrior, peacekeeper, man-at-arms, standing tall at attention, saluting, noble, confident and majestic. WHO KNEW?
A sect of wandering, ascetic Hindu holy men of India known as the Sadhu believe that God dwells in the penis.
WHO KNEW?
“Wood in the Womb.” Male fetuses have erections in utero as demonstrated by prenatal ultrasounds. Maybe that “kicking” that brings a smile of baby-pride to pregnant mom’s face is not really kicking at all! Men have a special bond with their most curious appendage—arguably their most precious accessory—which truly is a remarkably versatile organ that adapts to the environment as the situation demands. When we don’t need it, it remains flaccid, out-of-sight, concealed and low in profile. However, on demand, our cooperative friend will readily rise to the occasion and assume the gravity-defying role of proud soldier. There are not many other organs in the body that demonstrate such a 1
2 MALE PELVIC FITNESS great versatility in terms of the physical changes between “inactive” and “active” states. WHO KNEW?
Q. What organ in the body when stimulated will increase its size fourfold? A. If you were thinking the penis, you are going to be very disappointed, but wouldn’t that be nice! The correct answer is the pupil of the eye, which will dilate from 2 millimeters in diameter in bright light to 8 millimeters in dark, as governed by the iris. The penis is an organ of convenience. Like a good friend, it is always there for us—at arm’s length away—and provides us with the luxury of being able to empty our bladders with laser-like precision in the standing position when the need arises. I think it is fair to say that most women are quite envious of our capacity for such a directed urinary stream, which proves to be a very handy benefit that allows us to remain a healthy distance away from the toilet in the circumstance of unpleasant public bathrooms. It also enables us to duck behind a tree and readily empty our bladders on a golf course or on the side of a highway when there is no bathroom available.
WHO KNEW?
Hypospadias is a medical condition in which the urethra does not open at the appropriate place at the tip of the penis, but can open anywhere on the undersurface of the penis. In its most severe form, it can open on the perineum, the area between the scrotum and anus.This condition causes us to lose our competitive gender advantage of “directed” urinating.The good news is that pediatric urologists can repair hypospadias such that the urethral opening is repositioned at its normal location. The penis is an amazingly multifunctional structure—no less so than a Swiss army knife—with an impressive ability to multi-task, having an array of functions, including urinary, sexual and reproductive. Eric Gill, the British sculptor, articulated the multi-tasking function of the penis with the following statement: “The water tap that could turn into a pillar of fire.” The penis wears many “hats” that can be summarized by the four P’s. It permits us to pee with a directed urinary stream. When erect, it enables vaginal penetration and sexual intercourse. Ejaculation deposits semen in the vagina, with the passage of genetic material and ultimately, the perpetuation of the species. What an astonishingly clever biological design in which sexual enjoyment is linked with the act of reproduction. We think we’re pursuing pleasure, but what we are actually getting is reproduction—nature’s ultimate bait and switch scheme that ensures perpetuation of the species.
Marvels of the Penis
3
If sex were not such a pleasurable act, there would be little incentive to have it. In this regard, it is much like eating—under the guise of pleasure and satisfying hunger, we are actually fueling ourselves with nutrition that ensures nature’s endpoint of perpetuation of the individual. WHO KNEW?
“Penile Couture.” Men from the Ketengban tribe in the highlands of New Guinea, who are otherwise naked, wear decorative sheaths on their penises called “phallocarps.” They are made from a variety of different materials, often in vibrant colors, and vary in ornamentation and size, being similar in many respects to our neckties.
size Matters WHO KNEW?
Hung like a horse—forget about it! The blue whale has the mightiest genitals of any animal in the animal kingdom: penis length is 8-10 feet; penis girth is 12-14 inches; ejaculate volume is 4-5 gallons; and testicles are 100-150 pounds. Hung like a whale! Suffice it to say that with all biological parameters, there is a bell curve with a wide range of variance, with most clustered in the middle and outliers at either end. The penis is no exception, with some of us phallically endowed, some phallically challenged, but most of us somewhere towards the center. In a study of 3500 penises published by Alfred Kinsey, the average flaccid length was 8.8 centimeters (3.5 inches). The average erect length ranged between 12.9-15 centimeters (5-6 inches). The average circumference of the erect penis was 12.3 centimeters (4.75 inches).
WHO KNEW?
“Genital Genetics.” As with so many physical traits, penis size is largely determined by genetic and hereditary factors. Blame it on your father (or mother). In actuality, it is the roll of the genetic dice and how the inherited blueprint that determines physical traits interacts with the local hormonal environment. Measuring the penis on its upper side will result in a different measurement than measuring it from the bottom side because of the way the inner (hidden) aspect of the penis is anchored to the pubic bone. The proper means of linear appraisal of the penis is from the glans (head of the penis) to the pubic base on its upper side—this will measure just the pendulous (outer) portion of the penis.
WHO KNEW?
On the subject of penis size, one of my favorite things to do when driving on the highway and seeing some idiot in a Lamborghini driving hazardously from lane to lane at about 95 miles an hour is not to
4 MALE PELVIC FITNESS flash him my middle finger, but to show him my hand with my thumb and index finger separated about one inch apart to indicate to him what I think is the likely size of his penis. “Hard Assets”: Some women prefer men who are formidably hung, just like some men prefer women with large breasts. Whereas men with tiny penises may be less capable of sexually pleasing a woman, men who have huge penises can end up intimidating women and provoking pain and discomfort, particularly if cervical contact occurs. The long and the short of it is summarized in the adage, “It’s not the size of the ship, but the motion of the ocean.” Or even better, as I saw on an airline poster in a gateway while boarding an airplane: “Size should never outrank service.” WHO KNEW?
“Men are from Mars, Women from Venus.” Leonardo Da Vinci had an interesting take on perspectives: “Woman’s desire is the opposite of that of man. She wishes the size of the man’s member to be as large as possible, while the man desires the opposite for the woman’s genital parts.”
WHO KNEW?
“The Book of More-Man” Q: Wouldn’t you like nine inches of throbbing, steel-quality manhood that is always ready to quench the desires of your partner? How about the prospect of precisely controlling the moment of climax at which time you volcanically erupt across the room in a powerful trajectory? A: Well, who wouldn’t? However, it “ain’t gonna happen” by reading this book or any other for that matter. If there were an effective and safe means to increase penile size, you would know about it. Realistic expectations are for you to gain awareness of your anatomy and function and learn to maximize what nature has given you with targeted exercises to optimize your erectile and ejaculatory function.
WHO KNEW?
There are a bunch of “amenities” that accompany the aging process, one of which is “presbyopia” or farsightedness, which demands reading glasses. They are a real nuisance, never around when you need them and always getting lost. But one thing I have observed is that if you forget to take them off when you get up to relieve your full bladder, when you glance down, you see a rather large “member,” thanks to the magic of magnification. I am currently wearing 1.5 power; perhaps it’s time for 2.0!
Marvels of the Penis
5
WHO KNEW?
“Supersize Me.” In order to make their genitals look larger, the Mambas of New Hebrides wrap their penises in many yards of cloth, making them appear massive in length.The Caramoja tribe of Northern Uganda tie weights on the end of their penises in attempts to elongate them.
WHO KNEW?
A female contributor to FHM (For Him Magazine, a U.K. lifestyle magazine), in response to a question about the importance of penis size, wrote the following: “In case you’re one of those guys who’s been mollycoddled by a sympathetic girlfriend, the question ‘does size matter?’ is not up for debate.The jury delivered its verdict on that long ago and yes—it bloody well does. Cocks don’t do handstands, cook gourmet meals or speak Urdu, they go in—out, in—out. Size matters!” As a urologist who examines many patients a day, I can attest to the fact that penises come in all shapes and sizes and that there is no clear cut correlation between ethnicity and penis size. Flaccid length does not necessarily predict erect length and can vary depending upon emotional state and ambient temperature. There are showers and there are growers. Showers have a large flaccid length without significant expansion upon achieving an erection, as opposed to growers who have a relatively compact flaccid penis that expands significantly with erection.
WHO KNEW?
There is no correlation between penis size and shoe size, hand size or nose size.
WHO KNEW?
“Where’s Woody?” Three of the most common words I hear in my urology practice are the following: “Doc, I’m shrinking.”
WHO KNEW?
Part of the problem is the pervasive pornography industry, where many male stars are endowed like the centaur, the mythological creature with the head and torso of man and the lower body of a horse.This has given the average guy a bit of an inferiority complex. Many men complain of “shrinkage,” which is a very real phenomenon predicated on blood flow. The typical circumstances evoking this are exposure to cold weather or cold water, the state of being nervous, and athletic pursuits. The mechanism in all cases involves blood circulation. Cold exposure causes vasoconstriction (narrowing of arterial flow) to the body’s periphery to help maintain core temperature. This is the very reason one places ice on an injury as the vasoconstriction will reduce swelling and inflammation.