In Part One we discussed how pelvic floor physical therapy can help men facing pelvic discomfort, urinary urgency or leakage (including during sex), and other concerns that can interfere with daily life. We spoke about why pelvic floor weakness is not always the reason for the problem, why strengthening exercises are not always the answer, and how a full assessment can help understand what is the best way to proceed. We also spoke about the importance of a medical assessment for specific or persistent issues.
In Part 2 we examine two challenging topics for men and the reasons why they can be difficult to discuss: pelvic pain and sexual function. Pelvic pain and sexual function can be uncomfortable, embarrassing, and may prompt a range of concerns about activity, relationships, rest, fitness, and sleep. Men might wait months or even years before speaking to anyone about it, unsure if their concerns are normal or where to seek help.
At Tokyo Rehab, we believe that understanding potential causes is the first step towards resolving the issue. Pelvic pain and sexual function are both complex activities that involve a range of possible contributing factors. We do not always automatically assume that the issue is muscular in nature.
When assessing a patient’s concerns, we take a close look at four pillars of pelvic floor physical therapy: the neurological, the spinal, the muscular, and the tissue contributors. The four pillars can help us understand what a potential diagnosis might be, what areas we should pay closer attention to, and whether we should request a medical assessment.
The neurological system includes the brain, nerves, and spinal cord. It controls a range of basic functions from muscle movement to bladder and bowel control. It also plays a key role in sexual function. When these nerves become compressed, irritated, or injured, symptoms can manifest in various ways in the pelvis and perineal area.
A patient may notice pain, burning, tingling, numbness, or altered sensitivity in the perineum, genitals, or surrounding areas. They may also notice increased sensitivity or pain after sitting for a long time, bicycling, or engaging in a similar sustained activity. Patients usually report that these sensations are different from the feeling of sore muscles and that the pain is not always predictable.
The location of these symptoms can help us identify the potential cause, but a patient should not assume that a particular syndrome is the cause of their discomfort solely based on the location of their symptoms.
Symptoms of these neurological problems can also be found in other areas of the body depending on the individual’s presentation. For example, a patient may find that their lower back discomfort contributes to their pelvic pain, or that the pain radiates down their legs.
Sexual function involves the entire body and is controlled by the brain, nervous system, hormones, muscles, and blood flow, among other factors. Sexual function problems can be neurological in nature, or they can have vascular, hormonal, pharmacological, or psychological causes.
Pain is also a significant factor: when a patient experiences pain in or around the pelvis, they may find that their sexual function is compromised, either due to their perception of it or through muscular compensation.
Sexual activity can sometimes aggravate a patient’s pain symptoms, leading to a cycle of increased pain and reduced sexual function. Similarly, pain and discomfort can lead to tension in the pelvic floor musculature (including the muscles in the penis and scrotum) and trigger sexual avoidance.
At Tokyo Rehab, we take the patient’s neurological history, symptoms, movement patterns, and physical assessment into account when determining whether their sexual function symptoms can be attributed to the neurological system. We also consider whether an individual’s presentation requires neurological investigation by a physician or another specialist.
Physical therapy can play a role in reducing the effects of certain contributing factors for patients with sexual function concerns, but it is not a substitute for a neurological assessment by a specialist and should not be considered a complete solution.
A new loss of sensation in the genital or saddle region, or symptoms such as loss of bladder or bowel control with back discomfort or weakness in one or both legs, require emergency medical care and must be evaluated immediately. Sexual symptoms that are new or persisting, including painful ejaculation, should also be assessed by the appropriate medical professional to determine their cause.
The bones of the spine and spinal cord provide protection and support for the body, including the pelvic region. A range of movement-related conditions can affect the spine, including arthritis and other degenerative conditions. Lumbar spine conditions can be particularly relevant to sexual function and pelvic pain, as the spine is mechanically connected to the pelvis.
Spinal mobility limitations can be aggravated by prolonged sitting, exercise, twisting movements, and other activities that affect the pelvis or lower back region. Symptoms can arise independently or alongside other symptoms, and back pain is not mandatory for a spine-related diagnosis.
The challenge with assessing spinal mobility conditions is that the symptoms often overlap with other potential causes, such as pelvic floor dysfunction, and individual presentations can differ significantly.
At Tokyo Rehab we assess the spinal pillar when a patient’s history and presentation suggest that restricted spinal movement or load bearing could be contributing to their symptoms.
Depending on the findings and presentation, this can involve a physical assessment and discussion of the patient’s history to identify contributing factors. We examine spinal and hip mobility and assess how the patient’s symptoms are affected by different movements or positions.
The purpose of the assessment is to understand whether the symptoms are connected to the spine, how they might interact with other structures, and whether there are additional contributing factors that need to be considered. Patients often expect the assessment to identify a singular cause, but the findings are used to develop a diagnosis that considers the patient’s presentation as a whole.
For example, a patient who has developed symptoms after prolonged sitting may have several potential contributing factors, including reduced mobility, increased pressure on certain tissues, or a range of other issues. The findings would inform the next steps of the treatment, but they would not necessarily dictate a particular treatment based on the location of the pain.
Sexual function can be impacted by restricted movement, including limited ranges of motion, stiffness, or spinal mobility limitations. However, sexual function issues have many potential causes beyond the musculoskeletal system, and movement restrictions should not be assumed to be the sole contributing factor.
Physical therapy can be helpful in identifying and addressing musculoskeletal contributors to sexual function concerns, but these should be considered alongside potential alternative diagnoses by a medical physician or specialist.
The muscles of the pelvic floor run from the base of the pelvis downwards and inwards. They help to support a range of functions, including control over the bladder and bowels, and they work in coordination with the muscles of the abdomen, hips, and thighs.
Muscle function is complex: while muscles need to have sufficient strength, they also need to be able to release tension and coordinate with other structures in order to have an effective role in movement and general function.
This is one reason why men with pelvic pain are sometimes told to perform strengthening exercises for the pelvic floor muscles when there is no evidence that the issue is related to pelvic floor strength.
Men often report that their pelvic pain symptoms are aggravated by sitting, strenuous movement, or other activities that require them to hold tension in their muscles for prolonged periods of time.
Other pelvic pain symptoms can include discomfort during or after ejaculation, perineal pain, and difficulty relaxing the pelvic region.
In some of these cases, the root cause of these symptoms can be related to pelvic muscle tension or poor coordination.
However, these symptoms are not exclusive to pelvic muscle dysfunction, and a physical assessment is required to confirm a diagnosis.
At Tokyo Rehabilitation, we assess the muscular pillar without automatically assuming that the issue is related to strengthening or relaxation.
Depending on the findings, we might recommend breathing, relaxation, and coordination exercises, or a program of activity modification, or strengthening if weakness is confirmed.
The pelvic muscles play a significant role in sexual health, including the ability to fully engage the muscles of the pelvic floor during ejaculation. Pain and tension can impact coordination and, in some cases, contribute to erectile dysfunction. Weakness or poor coordination can have a similar effect.
A man who finds that he experiences pain during or after ejaculation may benefit from a full assessment to identify whether pelvic floor muscle function is a contributing factor. However, these symptoms can also have a number of alternative causes, including generalized medical concerns that require investigation.
Erectile dysfunction is a separate concern: while pelvic floor rehabilitation can play a role in some cases, erectile dysfunction can also be caused by vascular and neurological conditions and should be investigated by a medical professional.
The goal of treatment for sexual health concerns is to find the most appropriate solution for each individual. We do not always recommend strengthening exercises as the solution to pelvic floor issues, and we do not always recommend the same program to every male patient. Some individuals benefit from improving coordination, others need to reduce tension, and some may have additional contributors that need to be addressed.
The fourth pillar of pelvic floor physical therapy involves the tissues that surround the pelvis and can contribute to pelvic pain symptoms, including connective tissue, tendons, and other structures.
Tissues can be affected by a number of different factors, including trauma, restricted mobility, and mechanical stress. Conditions such as inflammation or hypersensitivity can also alter the role of connective tissues.
Pelvic pain can occur during exercise or prolonged sitting or occur independently. There is no typical presentation for tissue-related pelvic pain symptoms, but the location and aggravating factors can be useful in assessment.
Pain around the pelvis and perineum can occur for a wide range of reasons, some of which require medical investigation. Tissues are not always the sole cause of pelvic pain symptoms, and patients should not assume that tissue damage is always the cause of their discomfort.
A number of musculoskeletal and movement-related conditions can also contribute to pelvic pain.
Cycling-related discomfort can be a good example: it can be due to sustained pressure on the perineum, but it can also be attributed to other causes. Surgery and tissue damage can also impact tissue function and contribute to pelvic pain symptoms, but other causes need to be ruled out in each individual case.
Sexual activity involves a range of pressures on the tissues of the perineum and genital region. If an individual has hypersensitive tissues, these can be aggravated by movement, pressure, and other factors that are a normal part of sexual activity. Patients may find that they experience pain during or after sexual activity, or that certain sexual positions aggravate their pelvic pain symptoms.
Depending on the nature of the symptoms, tissue sensitivity can impact both pain and sexual function. Persistent pain such as burning or discomfort after ejaculation can have a number of alternative causes. Painful ejaculation needs to be differentiated from other potential causes, including infection or other conditions, but it can also be a sign of tissue hypersensitivity.
Patients may also notice genital pain after sexual activity or discomfort during erection. Swelling, unusual skin sensations or appearance, or unexplained symptoms should not be dismissed as pelvic floor problems but discussed with an appropriate medical professional.
If a musculoskeletal contributor to tissue pain is identified, a physical therapist can help to develop a program of progressive mobility and activity modification. However, we do not always recommend physical therapy as the sole solution for tissue pain, and we always take the findings of the assessment into account.
We do not always recommend physical therapy as the sole solution for tissue pain.
The four pillars of pelvic floor physical therapy help us assess a range of contributing factors for pelvic pain and related concerns. However, they should not be used in isolation: a patient’s symptoms may have multiple causes or potential contributors.
An individual might experience discomfort after prolonged sitting, but their symptoms might be attributed to connective tissue, pelvic muscle tension, restricted spinal mobility, and/or nerve irritation, among other potential contributors.
Similarly, a man might experience painful ejaculation as a result of pelvic muscle dysfunction, but there are a number of alternative causes that need to be ruled out.
At Tokyo Rehab, we assess each of the four pillars to develop an appropriate diagnosis and treatment plan.
Neurological: Could the individual’s symptoms be related to spinal or nerve irritation?
Spinal: Could the individual’s symptoms be related to restricted mobility or spinal mechanics?
Muscular: Does the individual have symptoms that are commonly associated with pelvic muscle coordination problems (such as weakness or excessive tension)?
Tissue: Does the individual have tissue-related symptoms or conditions that require further investigation?
The four pillars help us identify potential contributors to the individual’s symptoms and potential limitations to a pelvic floor physical therapy assessment. We also know when to refer an individual for a medical assessment if their symptoms are associated with a condition that cannot be resolved through physical therapy.
Men often find that pelvic pain or discomfort in the perineum is inconvenient, embarrassing, or challenging to discuss. They might feel like it is a condition they have to live with, without solutions, or that it is an issue they cannot openly discuss.
Both beliefs are understandable, but they should not prevent men from seeking the assessment and treatment that they need. Persistent pain and changes in sexual function impact a man’s lifestyle in numerous ways, and it is never too early to seek a physical therapist’s opinion.
At Tokyo Rehab, we begin the assessment process by listening to our patient’s concerns and discussing their symptoms. We conduct a thorough assessment to understand the contributing factors, and we consider all four pillars of pelvic floor physical therapy before developing a treatment plan. We consider the neurological, spinal, muscular, and tissue contributors to the individual’s symptoms.
Physical therapy can be an appropriate solution for a range of conditions involving pelvic floor dysfunction. However, it is not always a complete solution, and it should not be dismissed by a patient who feels that their symptoms are a normal part of life. It can also play a supportive role alongside a medical evaluation to better address an individual’s needs.
If pelvic pain, pelvic discomfort, or related concerns are impacting your life, contact Tokyo Rehab for an assessment, and ask whether an English language assessment is available for your needs. The first step is to understand what is happening, and the most important step is to not assume that you know what is happening.
Founded by Mari Gish, PT, Tokyo Rehabilitation has served the English-speaking community in Japan for over 40 years. With state-of-the-art clinics in Shirokane, Minato-ku (Tokyo) and Kadena (Okinawa), our team of U.S.- and Japan-licensed physical therapists, osteopaths, and Pilates specialists provides compassionate, 1-on-1 rehabilitation and holistic wellness support.
We specialize in orthopedic and sports rehabilitation, Men and Women’s Pelvic Health, pre- and postnatal care, pediatric physical therapy, neurological recovery, specialized manual care, osteopathic techniques, and sympathetic nervous system downregulation. We accept international insurance policies and serve as an overseas Tricare provider.
Navigating a foreign healthcare system doesn’t have to mean compromising on the quality or style of your recovery. While Japanese National Health Insurance clinics offer an accessible option for quick, passive relief, private 1-on-1 physical therapy/physio bridges the cultural and linguistic gap for foreign residents who need comprehensive, active rehabilitation. By understanding how both models operate, you can confidently choose the pathway that best fits your specific injury, lifestyle goals, and peace of mind. If you are ready to tackle pain at its root with personalized, English-speaking care in Tokyo or Okinawa, reaching out to a dedicated physical therapy team is your best first step toward living fully and pain-free in Japan.
If you missed part 1, please read it here: Pelvic Floor Physical Therapy for Men: Tokyo Guide
