Welcome back to the Healing Pain Podcast with Lance Frank, PT, DPT

Male pelvic health is something that not a lot of people talk about, even in medical circles. A lot of people experiencing male pelvic pain don’t even consult a specialist until it gets unbearable enough that they have no choice. Pelvic health isn’t a female thing. In fact, the male and female pelvic floors are essentially the same structurally, and both are prone to dysfunction. But because of toxic masculinity culture, many men suffering from any disorder related to the pelvic floor feel reluctant to talk about it or seek professional help. In this episode of Healing Pain Podcast, Dr. Joe Tatta talks to a pelvic health specialist to clear things up around this sensitive topic. Lance Frank, PT, DPT, helps us understand the different aspects of pelvic floor dysfunction, how it is related to conditions like male pelvic pain, prostatitis, and erectile dysfunction, and how it can be alleviated with stress management techniques and physical therapy.

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Male Pelvic Pain, Erectile Dysfunction, And Prostatitis With Lance Frank, PT, DPT

In this episode, you will meet Dr. Lance Frank, a physical therapist that specializes in pelvic floor dysfunction in all gender identities. Dr. Frank opened his own practice shortly after graduating from the Doctor of Physical Therapy Program at Emory University in Atlanta, Georgia. Lance is one of a small group of physical therapists that treat male pelvic floor disorders and one of an even smaller group of queer practitioners that work in pelvic health.

He understands people’s awkwardness in the doctor’s office discussing vulnerable issues surrounding their genitals. He also understands how toxic masculinity culture makes it difficult for men to discuss pelvic health and sexual dysfunction. In this episode, we discuss various pelvic floor conditions such as male pelvic pain, erectile dysfunction, urinary dysfunction, prostatitis, and other sexual health concerns. Without further ado, let’s begin and learn about male pelvic health with Dr. Lance Frank.

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Lance, thanks for joining me on this episode.

Thanks for having me. I’m excited to be here.

Me, too. I’m excited to talk about pelvic health in men. It’s not an episode that I did before. We have talked about women’s pelvic health and women’s pelvic pain. I’m excited to dive into this with you. It may be a new topic for some men who are reading to learn the idea that there is pelvic health for men and a lot of these conditions that we will talk about can be effectively treated with pelvic health and physical therapy. A good place to start is to give us an overview of what the pelvic floor is and why it’s important to men’s health.

Whenever people hear pelvic floor or pelvic floor therapy, most people think vaginas, postpartum, or maybe even menopause with prolapse. Aside from two very specific urinary muscles and the vagina versus the penis, all of the muscles on the pelvic floor are exactly the same. They are just oriented a little differently. They all have the same functions like urination and bowel movements. They play a role in sexual function and intimacy. They also play an overall supportive role. They sit inside the pelvis like a hammock or a trampoline. They hold everything in place. In terms of the deepest layer, the external layers are the ones that form the genitalia.

Those are the ones whose orientation differs between the genders. For somebody with a penis, in the clinic, I call them the banana peel muscles because if you look at an anatomy app or a model, they wrap around the shaft of the penis where they come out underneath the pubic bone, similar to the way a banana peel wraps around a banana. Whenever I’m talking about erections or urination with my patients, I refer them to the banana peel muscles. Aside from the orientation, all of those muscles are essentially the same in somebody with a vagina and they have all the same functions.

Essentially, the male pelvic floor and the female pelvic floor are the same.

Correct. The muscles on the outside wrap around the vaginal canal and create a literal canal but for somebody with a penis, as I said, they wrap around the entire thing and they form the shaft of the penis. They don’t go all the way up. They stop about halfway, up the shaft of the penis. The orientation is a little different, but the functionality is exactly the same.

You mentioned the supportive role of these muscles. Tell us what they are supporting.

They support a lot of things, but they are the connection between basically our upper body and lower body. All of the intraabdominal organs sit directly on top of them like the bladder, the prostate, the liver, and the large intestines. They all sit in this hammock that the pelvic four muscles form. Not only do they have a visceral support system, but they also connect all of the bony systems like the pelvis, the SI joints, and the hip rotators. They support the body both from a visceral standpoint and also from an orthopedic standpoint.

A lot of people with SI joint pain, low back pain, or lateral hip pain may come in presenting with what may seem like a torn labrum or a SI joint dysfunction, but it could be coming from the pelvic floor. When we are talking about what all the pelvic floor supports, it’s got this huge network of attachments that it plays. They hold everything together, the upper body and the lower half, and the hips. They are the glue that holds everything together.

Maybe we should go through a small checklist of some of the more common conditions that you see with men’s pelvic health and men’s pelvic pain.

With men’s pelvic pain specifically, and a disclaimer for anybody that’s reading. I always say this. We are talking about men in the context of people with penises and somebody with a penis that has a prostate anatomy from the reproductive standpoint is not going to have the same anatomy as somebody born with a vagina and a uterus.

When I’m talking about men, I’m talking about somebody that has a penis and a prostate. All of that to say, some of the more common diagnoses that I see in men in my clinic is a condition called prostatitis. I won’t go down the rabbit hole of prostatitis, but essentially there are different categories of prostatitis. The most common form of prostatitis is chronic non-bacterial prostatitis. It all means there are no bacteria causing inflammation in the prostate.

For the longest time, people were getting thrown rounds and rounds of antibiotics and high-dose steroids and nothing was happening. It still happens to this day. Sometimes, I will get patients that have seen so many physicians and haven’t gone on so many antibiotics and nothing’s helped them. The nomenclature’s been changed recently from chronic non-bacterial prostatitis to chronic pelvic pain syndrome. They found that most of the patient’s pain, while it presents as inflammation in the prostate, could be created by tension through the pelvic floor musculature.

In terms of pelvic pain, that’s probably the most commonly treated diagnosis that I see in my clinic closely followed by testicular pain. I see a lot of people with testicular pain and some people will think that it’s their testicle or epididymis that hurts. I can see a lot of epididymitis on prescription referral forms but the muscles of the pelvic floor, the hip flexors, the iliopsoas, and even some of the banana peel muscles that I talked about. The bulbospongiosus can refer to pain in the testicle or the scrotum.

A lot of people will go to the urologists and they will have all of these tests and scans done and nothing will come back. That’s usually when they end up in my door because it’s more of a muscular function causing the testicular pain. Prostatitis is the biggest one as testicular pain. Sometimes people will have general pelvic pain like the space between the testicles and the anus or the perineal body. Some people will have pain and tension there.

I always joke with people that it’s the Grand Central Station of the pelvic floor, the perineal body. Everything attaches to that. If your muscles are constantly playing a tug of war with one another, it’s the same. It’s like getting tendonitis. Sometimes people will have general perineal pain. There are a couple of rectal dysfunctions that I treat. One is proctalgia fugax. People will describe it as like a lightning bolt going up their ass and it’s this intense quick spasm of the posterior pelvic floor muscles. That’s a pretty common one that I see as well in men.

I want to hang on to that prostatitis for a moment because you mentioned that in the beginning. I think a lot of people don’t know what the function of their prostate gland is.

I would say that’s a fair assessment.

Tell us what the function of it is because I think when people hear that, they think of an older man’s condition and I’m not quite so sure that’s the message you want to send.

It is not an older man’s condition. Most of the patients that I see in my clinic are in their 20s, 30s, and 40s even. I have a few 50s and 60s patients, but I would say the vast majority of my patients are in the 20 to 40 demographic with prostatitis. The prostate is a gland and its main function is to help secrete seminal fluid and help prepare the sperm to make it from the testicles out of the penis. The prostate sends out the seminal fluid and it coats the sperm that it travels in to help neutralize the pH so that it can enter safely into whatever orifice or into wherever it’s going after it leaves the scrotum.

The prostate when it’s “inflamed” or it has any inflammation to it, they don’t know why it happens. Somebody that has bacterial prostatitis, it’s usually from an STI or a UTI. However, in somebody whose urine and sperm cultures keep coming back negative, generally, even though the prostates are “inflamed,” it’s usually a function of the pelvic floor muscle tension that the muscles are creating.

To your point about it being an older man’s condition, anyone can experience stress, but 9 times out of 10, when people come into my office and they have prostatitis, it’s generally a function of some stress or stressor in their life. That’s usually why I feel like the younger population tends to present with it more frequently because stress is inevitable in our lives and people manage it and lots of different ways. However, when you don’t manage it well, it usually presents somehow in a physical manifestation.

I would say most of my older patients, it’s rare that I have somebody over the age of 50 come in with prostatitis symptoms. Usually, they are more erectile dysfunction or urinary symptoms like urgency or frequency. I’m sure you have heard of BPH or Benign Prostatic Hyperplasia. Somebody’s prostate gets enlarged and it increases urinary and urgency symptoms but it’s rare that I see somebody of that age demographic come in with true chronic pelvic pain syndrome or prostatitis symptoms.

The stress connection is interesting to talk about because I think when people hear it, they can identify that stress might cause neck pain or my cause lower back pain. However, in your patients with more general pelvic pain where they have pain between their scrotum and their anus, are you seeing people with a lot of current stress in life, toxic stress, or post-traumatic stress? What do you think is the root cause of that?

All of the above. My spiel or general explanation for patients is that people fall into 1 of 2 categories when they have pelvic floor dysfunction. It’s usually an underactive pelvic floor or an overactive pelvic floor. Underactive, as I mentioned, think of somebody who’s just given birth or somebody who’s perimenopausal. They need a little bit more strengthening. Somebody with an overactive pelvic floor has a pelvic floor that’s so locked up that it never ever relaxes.

That can happen for a lot of different reasons. Stress, as we talked about, or post-surgical rehabilitation. Somebody who has some trauma or fall or a history of sexual assault or abuse. Stress is such an umbrella word for a lot of different things and a lot of different stressors can be the culprit of somebody’s symptoms.

I have seen people that have a history of sexual assault, even in men that happened in their childhood and they have been dealing with all of these pain symptoms their entire lives, or somebody who fell down the stairs and their tailbone has been impacted. That stress can cause pelvic floor dysfunction, but stress in and of itself, you go to your job, you hate your job, and you have a fight with your boss.

Like me, I identify as somebody like that when I am stressed, pissed, or anxious. Getting into pelvic floor therapy, PT, you learn a lot about yourself. I have an overactive pelvic floor thinking about the different types of symptoms that fall into that category. As I said, when I’m stressed, pissed, anxious, or mad, my pelvic floor’s locked up into my throat. I always joke with people to think of somebody with an overactive pelvic floor. It’s not funny, but it also is. I call them tight asses and those are the people that don’t ever relax. If you don’t ever relax or figure out ways to relax, those symptoms are going to manifest sometimes as pelvic floor dysfunction.

Tight ass is a good metaphor in a way, but as clinicians, it’s interesting to think about how the sympathetic nervous system has an impact on all the organs of your pelvis, people don’t even know necessarily where their organs are and their pelvis. However, making the connection between stress and your pelvic floor is a deep connection. I’d imagine it’s probably an intimate experience to have with a patient and it’s intimate for them to start to explore their own pelvic floor and pelvic health, right?

Yeah, 1,000%. In my little intake spiel, after I have explained what the pelvic floor is, I have talked about its function and correlated it to why they are there. I always try to be real with people. I’m like, “A lot of what I do here is to help people learn how to relax. I teach people how to connect with their bodies, connect with their pelvic floor, understand what’s happening and why it’s happening, and also, figure out ways to help people relax.

Whether that’s through different breathing techniques, different exercises or therapeutic stretches, or different hands-on techniques that I can facilitate with dry needling or shockwave therapy. Whatever it may be, the most basic watered-down explanation that I give people is I teach people and help people learn how to relax. A lot of what I do is get people to get in touch with their sympathetic nervous system and parasympathetic nervous system and learn how to down-regulate themselves so that they can get out of these upregulated flares that they tend to get into.

It’s very intimate work with people. People have to get vulnerable and I try to create a safe space for people to do that. I’m serious and professional, but I try to keep it lighthearted with people and I always tell them. I’m like, “We are going to become best friends by the time we are finished working together. I’m going to learn a lot about you and hopefully if you are honest with me, you are going to share a lot about yourself so that I can help figure out the best way to treat you.” Getting to people’s ability to relax and figure out different coping mechanisms and therapeutic relaxation techniques, or whatever it may be, that’s a lot of what I do with chronic pelvic pain syndrome.

You started to talk about some techniques and treatments. You mentioned dry needling. I’m sure people are wondering how dry needling comes in and where is that used and what part of the body. There will be some visuals happening out there and how effective that can be. I think a good place to probably start before we go into more of those interventions is what does an evaluation look like when they come to see you as a pelvic health therapist?

I can’t speak to everybody. This is what I do with people. I have taken a lot of different training courses through a lot of different institutions. I have blended all of them together but in general, my evaluation for every new patient is 90 minutes. Whenever I’m with people, usually the first half of that, I’m asking questions that people probably haven’t ever been asked before or they have never shared with anybody.

They are sharing details about their very personal lives like whom they have sex with and how they have sex. If it hurts whenever they have sex and different issues with peeing and pooping. 45 minutes of my 90-minute eval is usually spent talking. It’s a lot of history-taking and getting more information about them. Usually, by the time we are done talking, I already have a pretty good sense of what’s going on.

Most of the time, I don’t know if it’s because of the marketing that I have done and the referral networks that I have made, but most of the people that come in to see me have some variation of an overactive pelvic floor. I already have an idea of what’s going on, but when we move into the actual exam component, I always have people do a movement assessment. There are various movement assessments out there and quick mobility screens. I have them do 6 or 7 different movements so I can see where functionally their deficit is. I will move into my orthopedic exam where generally, I tailor it to what they are coming in for but again, it’s a blanket coverage.

I look at the strength of the hip muscles, hip flexors, glute meds, and adductors. I check the range of motion and flexibility of those same muscle groups. I will palpate. I always joke with people that when I’m doing my palpation or a lot of pelvic floor therapies, my specialty is everything above the knees and below the ribs. When I’m doing my palpation exam, I tell them, “If it’s cool with you, I’m going to be feeling for these different muscle groups to see from your ribcage down to your knees if anything is tight, tender, painful, stiff, or restricted.”

Based on that, if I feel it’s necessary or indicated, we will move into the pelvic exam and with the pelvic exam, the first thing that I do is a general breathing observation. We haven’t talked about it, but I almost went down this rabbit hole when we were talking about relaxation techniques, but I will save it and for now, I will just tiptoe around it. The pelvic floor and the diaphragm are best friends. A lot of what I do in talking about helping people relax is to learn how people sync up their breathing for the most optimal pelvic floor relaxation.

I have them for the pelvic exam lay on the table and I’m having them breathe. Patients are always like, “You want me to lay here and breathe?” I’m like, “Yes, I do because I’m assessing what your pelvic floor is doing in response to your breathing.” I will have them lay there. They are usually unclothed if they are cool with it. Having them lay in a butterfly position and I’m observing what their pelvic floor, their perineum is doing in response to their breathing.

Based on what I find, we usually go into how to make that appropriate contract/relax or that appropriate piston mechanism happen. We will do an external palpation exam. I always say, “Imagine a clock is on your pelvic floor or your perineum. 12:00 is the pubic bone and 6:00 is the tailbone. I’m just going to go around the clock and feel for different muscles around this clock to see if anything is tender, tight, or painful.”

Another part of my spiel is that healthy tissue shouldn’t hurt. It shouldn’t be painful. If I’m pressing or poking on anything and it causes you pain or recreates your type of pain, it’s an indicator of what may be impacted or implicated in your symptoms. Generally, I will stop at the external palpation exam unless I feel like it’s indicated on that first visit for them to get an internal pelvic floor exam to understand what’s going on with their symptoms.

Sometimes, I will get through all of that and I will find deficits or I will find restrictions or I will find muscles that may be impacted. For certain diagnoses, usually testicular pain, I will stop at the external palpation exam, but for prostatitis, erectile dysfunction especially proctalgia fugax, I will do an internal exam. With the internal exam, we are reviewing the breathing and pelvic floor relaxation mobility that they hopefully will get once we go through the breathing assessment. Usually, with internal palpation, I’m checking for the pelvic floor. Again, I relate it to a clock.

I go around right to left all around the clock and try to find muscles inside that may be recreating their pain or may be problematic or restricted. After that, we do any other general assessment or physical therapy assessment and plan. I talk about what I found. I tell them what I want them to work on until I can see them again. I tell them what I would like to do the next time I see them, whether that’s exercise or hands-on stuff or revisiting the breathing and relaxation stuff.

I try to get through all of that in 90 minutes. Ninety minutes sounds like a long time, but I don’t always get through everything, especially if somebody has a very extensive history or intake. There are a lot of details they feel like they want to share. That’s usually the first visit. The second and subsequent visits are usually when we get more into actual treatment stuff, different hands-on modalities, or different exercise prescriptions. The first visit is usually a lot of examination stuff.

That’s a great description. I also think it helps people to know that if they are second thinking about coming to pelvic health, it’s good to know that there’s a lot that can be done by going through your history and some basic movement exam-type features to it. It doesn’t necessarily have to involve an internal examination on the first visit. It may be later on, but there are many steps that we can take before to help you with the pain that you are experiencing.

When patients finally do get to me, there’s a lot that patients in terms of their thought processes go through before they even reach out to me.

I was going to ask you about that. If someone’s coming to see an OB-GYN for example, they pretty much know that there’s going to be an internal exam at some point but if you are coming to a pelvic health physical therapist, there’s not always that knowledge base that’s there.

There’s not. I have a group of physicians in the city whom I work very closely with. I have been very intentional about the physicians whom I have built those connections with. I have done a lot of education about what I do and how I do it, but you are right though. If somebody who’s just given birth, they go see their OB-GYN and they are like, “I want to go see a pelvic PT.” They may already know that there may be an internal exam.

However, Joe Schmoe on the street has prostatitis pain that he is too embarrassed to talk to his primary care about. He finally breaks down and or he is probably doing all of his Googling at home, reading all of the terrible things on WebMD about what could be going on, decides to go see a urologist, and his urologist may or may not know about pelvic floor therapy.

If he does know about pelvic floor therapy, will probably refer them, but also have no idea about what it all entails. Most of the time, patients come in and they are like, “What are we doing here?” Whenever a patient reaches out to me, I always assume the worst. I assume that they have no idea about anything that I do because 9.9 times out of 10, they don’t. They have either read about pelvic floor therapy online or they have been referred by a physician that told them that they needed therapy.

I try to do a lot of education before patients even get to the clinic so that they know what to expect and what might happen. My evals are 90 minutes because I wanted to make sure that I allotted enough time to talk to people because a lot of people are telling somebody in the medical profession for the first time about a lot of these symptoms that they have probably never been asked before.

I always make a blanket disclaimer that after the conversation that we have, that will give me a better idea of whether or not I think an internal exam will be beneficial. If it is beneficial or if I do think it would be beneficial, we absolutely do not have to do that now. I realize that this was sprung on you and you probably weren’t expecting to come to a visit now getting a finger up your butt. If at some point I think it will be beneficial, we can explore that in a session or two. There are lots of other things that I can do and we can do together to at least come up with a plan before we even talk about internal exams.

I think that’s important information for people to have. As you mentioned, even some physicians aren’t aware of the services that a pelvic health therapist can provide for their patients, whether they are male or female. Can we talk about erectile dysfunction for a moment?

Yeah.

I think people would like to hear your perspective on treating erectile dysfunction or things they can do to prevent erectile dysfunction instead of relying on medication or being improperly diagnosed at times because it’s another sensitive area for men to have a discussion around.

It is a sensitive discussion. My least favorite phrase in PT school was, “It depends.” When we are talking about ED, it depends on how they are presenting. If they are a young guy, twenty years old coming in with issues getting an erection, my assessment of him is going to be very different from someone who is 45, 50, or 60 years old and has erectile dysfunction. They might fall into the same category, or they might not, and in order to know that, it is one diagnosis that an internal exam would be beneficial.

From a therapeutic standpoint, I’m all about analogies because I feel like when I’m talking to patients, it helps people to conceptualize what might be going on. When we are talking about erectile dysfunction, the best way that I explain it to people or have found to make it make sense for people and I’m going to have you do this with me. I want you to squeeze your fist as hard as you can for a couple of seconds. If somebody’s reading this, also do the same. I want you to let that first go and take a look at your palm. All of the blood that’s rushing back into your hand right now, that vascularity principle can be applied to the pelvic floor.

We talked about that clenched fist pelvic floor, that overactive pelvic floor. If people are constantly staying in that tight ass position, if they are not relaxing enough of the pelvic floor to even allow blood flow into the pelvic floor or the penis, getting an erection is going to be difficult. The 20, 25, or 30-year-olds coming in and they are like, “I can’t get it up for anything.” Those people are going to be the people that I’m looking at how well can you relax a pelvic floor? Do you have that mobility in the pelvic floor muscles to allow blood in?

It’s always where I start with people. If somebody’s coming in and they have seen their urologist. They are on PDE5 inhibitors like Viagra or Cialis and those drugs are working or they may not work very well anymore. If they are in the older demographic, usually, I need to say that erectile dysfunction from a vascular component is one of the first indicators of a heart disease issue.

If somebody’s coming to see me for the first time and their main complaint is ED and they haven’t seen primary care or even their urologist or a cardiologist, I’m always referring them to go get their heart checked because I have a patient whom I’m treating for ED. He started having signs of erectile dysfunction two years before he had a heart attack. It came out of nowhere. He is seemingly healthy and fit. He didn’t have any overt signs of heart disease. Correlation doesn’t necessarily mean causation, but you have to wonder.

Erectile dysfunction should be considered as not a vital sign but as a vital sign. It’s like, “How are your erections?” It’s because it’s one of the first indicators that’s been published and studied of being correlated with some heart dysfunction or disease. If they are an older demographic, if that’s all they are coming in for, and if they don’t have any pelvic pain symptoms or no testicular pain or anything else, urinary symptoms, if it’s only ED, I’m going to make sure that I have a position on my treatment team to make sure that they have had their heart checked.

If that is their main symptom, then I’m also looking at how strong their pelvic floor is, which you are going to be like, “If it’s overactive why and we are working on relaxation, why do they need to make it even stronger?” This is a great thought, but if I have done their internal exam and I have assessed them. I have checked everything that I mentioned before and if people are reading, if they are physical therapists, you know the 0 to 5 grading scale. If I’m doing a pelvic floor exam and I give them a 2+, I’m going to give them some strengthening exercises to help bulk up the pelvic floor tissue.

It’s because of two of the main jobs of those banana peel muscles that I talked about, one of them is ejaculation and one of them is erections. They are from a muscular component. They help those functions happen. If somebody presents with an underactive pelvic floor and they need a little bit more strengthening, then I will give them some strengthening exercises. I will help them with their general hip and pelvic strengthening stability.

However, going back to my twenty-year-old younger guy who’s chronically in a state of overactive tension, I do his internal exam and maybe he has a 3 out of 5 pelvic floor strength. I’m still not going to give him strengthening exercises because if you think of something that’s overactive that doesn’t have that full range of motion to do a contraction, inherently, it’s also weak, but for a different purpose. For that patient, I’m not giving him strengthening stuff. He’s going to be working on relaxation and more flexibility stuff until he gets that full range of motion. We might incorporate pelvic floor strengthening stuff.

In terms of erectile dysfunction in general, if you go on Google or Reddit and you get down these rabbit holes and you think the worst. A lot of my patients come in and they are like, “I don’t want to be on medications. I want my erections back to when I was twenty years old again.” Physical therapy isn’t witchcraft. I don’t have a magic wand that I can wave and magically get you an erection. I’m going to do everything that I can from a physical standpoint to get you to where you should be or the most optimal state to get an erection.

However, if it’s a function of age, hormones, or past medical history like heart disease, I can help you with that to get more physically fit, and your erection may be a byproduct of that. Your erection strength might be a byproduct of getting physically fit. On the medical side of things, if it is a true medical issue, unfortunately, physical therapy, I’m not going to say it’s not beneficial because I feel like everyone can benefit from physical therapy, but it may not be the most optimal route for somebody with an older demographic that has a bunch of past medical history stuff.

My skills are going to be limited in what I can provide. The caveat to that though, there is a technology out on the market right now. It’s been around forever, but shockwave therapy, as I mentioned is a new modality in the terms of pelvic health function and is being used for erectile dysfunction. Again, analogies or watered-down explanations. Shockwave helps to create new vascular supplies to the tissues that you are being treated with.

In the urology realm, a lot of urology physicians are using shockwaves as an alternative to medications that people may not want to take or may not be able to take. I have some patients that are like, “I can’t take Viagra because it gives me this intense migraine, or Cialis at its most potent dose doesn’t do a whole lot.” There are a lot of reasons why that may be. Shockwave therapy is an alternative treatment or method for erectile dysfunction that I have in the clinic that people benefit from and are going to respond to.

I feel this is important to say because if the readers out there are going to be researching shockwave therapy, there are lots of different types of shockwave therapy out there and it may not necessarily be true shockwave therapy depending on the device that the clinic or clinician has. I don’t do any marketing for shockwave. I’m not an ED clinic. That’s not what I want to treat, but there are clinics like that out there that have “shockwave” devices that are marketing themselves at ED clinics and accepting anybody that wants to come.

There’s research that came out in 2022 about shockwave therapy and it’s most beneficial for patients who either don’t need any PDE5 inhibitors like Viagra or Cialis. They don’t need that and can still get an erection, but it’s weak. They are not super satisfied with it. Shockwave therapy would be beneficial for them or patients who still respond to those medications but may not respond all the time or still may not have the best erection quality that they would like, shockwave will be beneficial for them.

The people that shockwave won’t be beneficial for are the people that cannot get an erection with any medication. I talk about Viagra and Cialis, but there are other substances or medications like BiMix or Trimix that are a punch in the face of nitrous oxide to help get patients to get an erection. If they are not responding to that, shockwave isn’t going to do anything for you. The milder to slightly moderate cases of ED are the people who, if they come into my clinic and they are coming in with ED, those are the people that I’m going to give the education of whether or not to pursue treatment.

It’s the same thing with somebody with severe ED. I’m going to educate them. I’m going to tell them, “Studies show that this probably isn’t going to do much for you,” and leave it up to them whether or not they want to go through therapy. At the end of the day, I’m not trying to steal people’s money and if they want to receive treatment, I’m not going to tell them that I won’t do it, but I will make sure that they are informed that they are likely not going to benefit from it. Some people are grasping at straws and want something other than a penile implant or a penis pump for the rest of their lives. Who am I to take that away from them? However, depending on the severity of the ED, shockwave in my experience hasn’t been super beneficial.

Those are all good valid points. As you said, if you go onto the internet and look at the world of erectile dysfunction and potential treatments, there are all sorts of promises, pills, and potions out there. It takes a licensed health professional like you to differentiate, diagnose, and figure out where it’s coming from and how it can be treated. Do you need one form of treatment or maybe you need a couple of different treatments to help treat that and to manage it as best as possible?

You have been very clear about so many aspects of male pelvic health which I think is great. It’s been a pleasure speaking with you, but I wonder if you could give men and women as well because this is a topic of interest to women also. How can they keep their pelvic floor as healthy as possible, which is some basic lifestyle intervention and ways to cope as you get older with your health in general?

I get that question a lot and my best advice for people is to find ways to manage their stress or whatever that looks like for you. Some people enjoy hiking. Some people enjoy walking. Some people enjoy going to yoga. Some people meditate. There are lots of different ways for people to manage their stress. You have to figure out what works best for you. Because most of my patients fall into the overactive category, I’m constantly trying to be creative with patients to figure out what they enjoy and to help them figure out ways to relax and reduce stress and maintain their pelvic health.

I love yoga for people. You are not going to CorePower Yoga and doing their hot yoga class jamming to Beyoncé. The slow controlled static or even dynamic stretch positions are a great way to optimize pelvic health because like every other type of physical therapy, motion is the lotion and movement is medicine. If people are moving, people aren’t staying static. If people are trying to stretch and be active, ultimately, that is going to be the best form of pelvic health than not doing anything.

People always tell me I always hear in various ways, “I shouldn’t be doing 1,000 Kegels a day.” Absolutely not. Please do not do that. On TikTok or Instagram, there are these trends where you do Kegels to the beat based on whatever song it is. I’m like, “Why are we teaching people to do this?” It’s going to be great for my business, but terrible for all these people out there. If you are constantly doing Kegels all day long, please stop. It’s not going to end well for you and you are probably going to need a pelvic PT like myself.

Trying to figure out ways to manage stress or whatever that looks like is priority number one. Two, figure out ways to move your body that are going to be productive, and that promote some movement and flexibility through the pelvis. Of people with penises, there are twelve. Of people with vaginas, there are fourteen. Those muscles are attached all over the hips and pelvis and low back. Trying to get more mobility through those areas is going to be the best way to maintain your pelvic health than doing one million Kegels every day.

Sitting for long periods of time under intense stress is probably the worst thing for going pelvic floor.

It’s probably not great.

Also, your penis for that matter.

Yeah. COVID didn’t do anybody any favors. People who used to get up, travel, move around all day at work, and walk between different offices are now confined to their couches, dining room table, or wherever they may be and they are sitting for eight hours a day. COVID wreaked havoc on a lot of different things, especially people that didn’t know how to manage their stress and then were static for long periods of time did not bode well for their pelvic health. Sitting for a long time and being super stressed is probably not going to end well for you.

It has been great speaking with you. I know everyone’s going to appreciate this episode and all the information you have shared. How can people learn more about you and follow your work?

I’m based out of Atlanta, Georgia. My website is FlexPTATL.com. If people want to learn more about my clinic and learn more about me or schedule a session with me, I’d love that. I do a lot of education online, mostly through social media. Instagram and TikTok are my go-tos. I also have a YouTube channel, but I don’t post much to it. For all of those social media, the handle is @LanceInYourPants or people can email me directly. If you read the blog and want to chat with me directly, my email address is [email protected].

You mentioned online work. Do you work with clients online?

I do virtual coaching. If you are a physical therapist, you know that we have state practice acts and physical therapy can’t cross state lines, but coaching can. I do coaching with people virtually if people want to work with me and they think that I’m the best fit for what they have got going on. I have a guy right now in Ireland. I have another guy in Canada. I have worked with a guy in Australia and one is in Qatar. Yes, I work with people virtually.

Make sure to share this episode with your friends and family on Facebook, LinkedIn, Twitter, or wherever anyone’s talking about male pelvic health or pelvic health physical therapy. I want to thank, Lance, for being here in this episode. We will see you next episode.

Important Links

• Dr. Lance Frank
• FlexPTATL.com
• @LanceInYourPants – Instagram
• YouTube – Lance In Your Pants
• [email protected]

About Dr. Lance Frank

Dr. Lance Frank is a physical therapist that specializes in pelvic floor dysfunction in all gender identities. Shortly after graduating from Emory University in Atlanta, Georgia, Dr. Lance opened his own practice, Flex PT ATL, in Midtown – the gay mecca and heart of Atlanta. Lance is one a small group of penis-having therapists that treat pelvic floor disorders, and one of an even smaller group of queer practitioners that work in pelvic health.

Being in the LGBTQIA+ community himself, Dr. Lance understands the awkwardness that queer people can feel in doctors offices discussing vulnerable issues surrounding their genitals. He also understands the toxic masculinity culture that makes it difficult for those with penises to discuss pelvic health concerns and sexual dysfunction as well.

In his clinic, Lance sees cisgender and transgender men and women with pelvic floor dysfunction; however, most of his caseload consists of people with penises. These patients have a wide range of issues involving the pelvic floor like urinary and bowel dysfunction, sexual health concerns, and pelvic pain.

When Lance isn’t treating in the clinic, he’s likely spending time traveling with his partner, cuddling with their pups, working out, or spending too much time on TikTok.