How to Treat Men in Pelvic Floor Therapy: An OT's Approach

In this episode:

•  The two groups of male clients who come through the door, and what's happened to them first
•  Why the intimidation factor is mostly in our heads, and what to do on the rare occasion it isn't
•  An anecdotal pattern Celine keeps noticing in her younger male clients
•  What's actually happening in a chronically contracted pelvic floor
•  What changes clinically when you treat movement as an occupation rather than a home program

Lindsey: You've worked in nine practice settings in eight years. ICU, psych, peds, lymphedema, and now pelvic health. How did that happen?

Celine: In OT school I was set on neuro. Give me strokes, give me all the awesome neuro diagnoses. Then I got into the field and there was so much opportunity that I thought, maybe I don't even know what I want to do.

My husband was in the Navy, so we moved every eighteen to twenty-four months. Each time we moved I'd pick a new setting, and I could always work per diem, so sometimes I had two or three positions at once.

A lot of it happened by chance. I was in an acute care hospital and they said, we need someone to cover per diem in our hand clinic in rural Alabama. Sure. I worked at a city hospital that treated inmates from the prison and they said, you seem comfortable with all types of people, we need someone to float to the locked psych unit. Sure.

So some of it was the moving. But a lot of it was being open and curious about how far you can stretch this OT muscle.

Lindsey: Was there a through line? Anything you kept noticing across all of them?

Celine: It sounds cheesy, but the through line was that people want to feel heard.

No matter the setting, there were so many people who felt dismissed by the medical system, or like a number because everywhere is understaffed. In rehab we're in a unique position — we get to spend time with patients that other medical professionals don't have the luxury of spending.

I'd have these really combative, aggressive patients, and when you sat down and got to the meat of what was actually going on, it was: I don't feel heard. You're not helping me. I need this and I can't get it.

Home health, inpatient rehab, pelvic health — same thing. It's one of my favorite parts of this job, getting to validate people, because they've been dismissed or had things normalized or brushed over.

Any age, any gender, any setting. People are looking for help, and for someone to sit and listen to them.

Celine: It was random. I needed CEUs and the deadline was coming, and there was a six-hour course, so I thought: great, take the long one. It happened to be pelvic health.

And it blew my mind. Wait, there's a length-tension relationship? You're not supposed to just do kegels till the cows come home?

It was also divine timing, because I was being diagnosed with endometriosis at the same time. I was literally signing up for my excision surgery. And hearing about pelvic health I thought, wait, there's something I can do about this? I don't have to just live like this?

Lindsey: When there's a personal reason attached to pelvic health — our mom, our sister, ourselves — there's a drive underneath it. For me it was my dad and his cancer. It doesn't have to be that way, but it often is.

Celine: I've found a passion I never knew existed. I'm that person at parties going you need pelvic health, you need pelvic health. It was a series of events that I stumbled into, but it feels like the most natural thing in the world.

Lindsey: Who are the male clients who come to your clinic, and what's already happened to them before they get to you?

Lindsey: Before we recorded, we both talked about the intimidation factor. Not being sure what those sessions would be like. Whether it could get weird or uncomfortable. What's your experience been?

Celine: For the most part, really positive.

Most of the men coming into the clinic are at their wit's end. Anecdotally they've been struggling for two to five years, and the research points to roughly a four-year delay in care from the onset of symptoms.

There's a lot of shame they carry with that. I'll try this, I'll try that. It's fine. And then eventually: all right, I'm just going to go get help.

So for the most part they're very thankful there are people like us who can help them.

There are differences between treating penis owners and vagina owners, for sure. But the muscular system is very similar.

Men are like anyone else seeking care. They have an issue, they're struggling with it, and it's affecting their daily life, their mental health, their relationships. Which is so OT — how all of this bleeds into every aspect of life. And when it's been going on for years, that's genuinely debilitating.

I understand other clinicians' hesitancy. I'm not sure what it looks like to treat men. I'm not comfortable. But my experience has been really rewarding. They're honestly some of my favorite clients.

Celine: There have been a few uncomfortable experiences in the clinic. Comments that were inappropriate. But those are so few and far between, and it's a good lesson in setting boundaries.

No matter what gender someone is, if they're making you uncomfortable, it's a chance to flex that muscle. This is not okay. Here's the expectation.

And the response after setting that boundary is usually very positive. Oh my gosh, I'm so sorry. That's all it needs.

Lindsey: An opportunity to practice boundary setting is genuinely helpful, especially for empaths and people in healthcare. We have big hearts and we want to say yes to everyone, because we know what their journeys have been.

Every time I get the chance to practice it, it reinforces how important it is.

Lindsey: You mentioned an OCD co-diagnosis in some of your clients. Can you talk about what that looks like, and how you started noticing the pattern?

Celine: It's an interesting pattern, and I haven't been able to find any research on it. It's anecdotal, something I've noticed especially in my younger male clients — usually the ones arriving with a hard flaccid diagnosis.

With hard flaccid there's usually some trauma to the penis, and it stays in a semi-contracted state even when flaccid.

Celine: That chain happens with any chronic condition or chronic pain, regardless of gender.

But for some reason I kept seeing these young male clients whose medical intake included an OCD diagnosis. And unpacking that in sessions, I think part of it is being more prone to anxious thoughts, and already having that hypersensitivity of the sympathetic nervous system.

Our thoughts have a big role in what state our nervous system stays in. And for most of these young men, it seemed like they were in a chronic state of activation — from the OCD or otherwise — and that played directly into their resting muscle tone, the contraction through the pelvic floor, and how that affected the neuromuscular structures and blood vessels.

So I've taken a more multidisciplinary approach with those patients. Making sure they have good people supporting them with cognitive behavioral therapy, or whatever is appropriate for them.

We definitely have the scope to address the cognitive, psychosocial and behavioral aspects of some of this. But having another discipline on board who really supports them in that way means we can focus on integrating all of it with their pelvic health care.

Lindsey: A team approach is so vital. A lot of OTs want to take on everything, and I think the best do the basics better.

When we recognize that a team approach means someone is supported in all the areas of their life, we can step more firmly into the role we actually play. It takes the pressure off.

Celine: One of my mentors used to say: Celine, you can't hang the moon. You can do a lot. But you can't do it all.

Lindsey: What changes clinically when you treat movement as an occupation rather than as a home exercise program?

Celine: My undergrad is in exercise physiology, so I came into OT with more of a biomechanical approach.

For pelvic health therapists in particular, understanding the mechanics of the pelvis matters — how it affects length-tension relationships, nerve compression or stretch, how forces through the feet work up the chain and through the pelvis.

And movement was another through line across every setting I worked in. In the ICU, trying to get eye tracking — that's movement. Passive range of motion for contracture prevention — that's movement.

Movement is essential to participating in daily life. There's a spectrum to that, obviously. But the ability to engage comes from movement, and being able to break an activity down into its components is a really important skill. As OTs we're trained in activity analysis.

So when I look at movement, I genuinely believe it's part of daily life. It's an ADL.

Whether that's getting dressed — what components are essential for that, how is it affecting your pelvic health, are there garments specific to your pelvic health, what balance do you need to manage them.

My approach is zooming out and looking at the person, the occupation and the environment, then breaking that down into movement components, to better serve the person in whatever is important to them.

Lindsey: Everyone does need OT.

Celine: Let's get some more OTs into men's pelvic health.