Erectile Dysfunction and The Male Pelvic Floor – What’s The Connection?

Introduction to The Male Pelvic Floor

The male pelvic floor is a complex network of muscles, ligaments, nerves, and fascia that stretches from the pubic bone to the tailbone. This structure is vital in several essential functions, including urinary and faecal continence, core stability, and sexual health. The pelvic floor muscles support the pelvic organs, providing control over bladder and bowel movements by ensuring the proper function of sphincters. In addition, these muscles contribute to erectile function, ejaculation, and the overall sexual experience by facilitating adequate blood flow and maintaining the rigidity of erections. Maintaining strength and flexibility in these muscles is critical. Weakness or dysfunction in the pelvic floor can lead to various issues, such as urinary incontinence, bowel dysfunction, pelvic pain, and sexual dysfunction, including erectile dysfunction and premature ejaculation. Strengthening the pelvic floor through targeted exercises can help restore balance and control in these areas. This is especially beneficial post-surgery, such as after prostate removal, where pelvic floor exercises can aid in the recovery of continence and sexual function.

What Are The Male Pelvic Floor Muscles?

The male pelvic floor muscles form a dome-like structure, crucial for maintaining continence, sexual function, and pelvic organ support. These muscles span the pelvis, creating a supportive “hammock” that engages in various bodily functions.

• Superficial Layer: The superficial perineal pouch includes muscles like the bulbospongiosus, ischiocavernosus, superficial transverse perineal, and external anal sphincter. These muscles are essential for ejaculation and both urinary and faecal continence.
• Intermediate Layer: The urogenital diaphragm consists of the deep, transverse perineal muscles, sphincter urethrae, and compressor urethrae. This layer is critical in maintaining urinary continence during increased intra-abdominal pressure, such as coughing or sneezing.
• Deep Layer: The pelvic diaphragm is the deepest layer, composed of muscles like the pubococcygeus, puborectalis, pubourethral, iliococcygeus, and ischiococcygeus. These muscles are primarily responsible for supporting pelvic organs and ensuring continence. The pelvic diaphragm provides structural integrity to the pelvis. It is vital in preventing prolapse and maintaining the proper function of the pelvic organs.

Anatomy of the Prostate Gland

The prostate gland, approximately the size of a walnut, is located in the male pelvis beneath the bladder and surrounds the urethra. Its primary function is to secrete prostatic fluid, a component of semen that nourishes and protects sperm. The prostate is situated just behind the pubic ramus and has critical relationships with nearby structures. A key aspect of prostate anatomy is the presence of a neurovascular bundle on each side, encapsulated within its fascial sheath. These bundles contain nerves essential for erectile function. Damage to these nerves, especially during surgical removal of the prostate (radical prostatectomy), can lead to complications such as erectile dysfunction and incontinence. However, advancements in surgical techniques, pioneered by Walsh and Donker in 1982, introduced nerve-sparing procedures, significantly improving postoperative outcomes. Today, prostatectomy procedures range from non-nerve-sparing to bilateral nerve-sparing, depending on the extent of the cancer.

Additionally, the prostate houses two sphincter muscles: the proximal smooth muscle sphincter and the distal striated muscle sphincter. The proximal sphincter prevents retrograde ejaculation, while the distal sphincter is crucial for maintaining urinary continence. Damage to the latter during surgery can result in incontinence, making the preservation of this muscle group a priority during prostate-related procedures. Understanding the intricate anatomy of the prostate and its surrounding structures is vital for both surgical planning and the management of potential post-surgical complications.

The Nerve Pathway To The Male Pelvic Floor

The male pelvic floor is controlled by parasympathetic, sympathetic, and somatic nerve pathways, providing both involuntary and voluntary regulation. These pathways primarily involve the pudendal, pelvic splanchnic, and presacral nerves, originating from sacral roots S2-S4.

• Pudendal Nerve: This nerve controls somatic functions, such as voluntary contraction of pelvic floor muscles, contributing to urinary continence and ejaculation.

• Pelvic Splanchnic Nerves: These parasympathetic nerves innervate the blood vessels of the penis, playing a pivotal role in erectile function. Damage to these nerves, particularly during procedures like a prostatectomy, can lead to erectile dysfunction.
• Sympathetic Innervation: The sympathetic nervous system contributes to ejaculation and detumescence (the process of the penis returning to a flaccid state after erection). Disruptions in sympathetic pathways can impact these functions.

The Male Pelvic Floor and Erectile Dysfunction

Erections result from a sophisticated interplay between the vascular, parasympathetic, sympathetic, somatic, and central nervous systems, involving hormones and the muscular system. Blood flow to the corpus cavernosa (penile tubes) must outpace venous outflow, creating a closed hydraulic system to maintain rigidity.

Key muscles in the male pelvic floor, specifically the bulbospongiosus and ischiocavernosus, play pivotal roles in achieving and maintaining erections. Pelvic floor muscle training can enhance penile rigidity, positively affecting erectile function. Conversely, spasms or dysfunction in these muscles can limit blood flow, leading to erectile dysfunction. Strengthening these muscles is vital for sexual health and may serve as an adjunct to other erectile dysfunction treatments.

How To Activate The Male Pelvic Floor Muscles

Activating the male pelvic floor muscles correctly involves closing the sphincters and creating a general upward lift of the muscles, akin to pulling the bladder towards the belly button. To better target specific areas of the pelvic floor for continence and sexual function, you can divide the “hammock” into three sections: front, middle, and back. For example, cues like “shorten your penis” and “stop the flow of urine” focus on the anterior and middle sections, aiding in erectile function and urinary control. Meanwhile, cues like “tighten around the anus” can help activate the posterior region, which is crucial for maintaining faecal continence.