Pelvic floor exercises as a treatment for men with erectile dysfunction

Erectile dysfunction was defined by a National Institutes of Health conference in 1993 as 'the inability to achieve or maintain an erection sufficient for satisfactory sexual performance (for both partners)' (National Institutes of Health, 1993). The degree of erectile dysfunction may be graded according to the number of satisfactory attempts out of 10 (mild 7-8, moderate 4-6, and severe 0-3) (Albaugh and Lewis, 1999).

Prevalence of erectile dysfunction
The exact prevalence is unknown. It is recognised to be a common problem that may affect 10 per cent of healthy men and significantly greater numbers of men with co-morbidities such as:

- Hypertension (15 per cent);

- Diabetes (28 per cent);

- Heart disease (39 per cent) (Wagner et al, 1996; Feldman et al, 1994).

The number of men with erectile dysfunction is predicted to increase due to higher life expectancy and a growing population of older people.

Increased public awareness due to the availability of oral therapy has changed society's ability to discuss sexual matters and has resulted in a greater number of men seeking treatment (Krane et al, 2000).

Assessment of erectile dysfunction
The cornerstone of clinical assessment remains a detailed sexual, medical and psychological history together with the identification of the needs of the patient and his partner (Wagner et al, 2002). A testosterone assay is usually performed.

Treatment
Regimes available for treating erectile dysfunction include:

- Oral pharmacological agents;

- Intraurethral therapy;

- Intracavernosal injections;

- Vacuum devices;

- Constriction bands;

- Androgen replacement therapy;

- Psychotherapy;

- Sex therapy;

- Surgery.

The option chosen will depend on the assessment and advice of the clinician, the efficacy of the treatment, and patient and partner preference.

A randomised controlled trial compared outcomes for two groups of men over a three-month period. One group was advised to change lifestyle by:

- Reducing alcohol intake;

- Quitting smoking;

- Reducing weight;

- Getting fit;

- Avoiding saddle pressure.

For this group, erectile function improved only marginally during the trial. The other group performed pelvic floor muscle exercises for the three months and erectile function for these men improved significantly (p<0.001) (Dorey, 2003).

In another study involving 55 men, the results from an assessor who was blinded to the grouping showed that after performing pelvic floor muscle exercises for six months, 22 men (40 per cent) achieved normal function, 19 (34.5 per cent) improved and 14 (25.5 per cent) failed to improve (Dorey, 2003).

The effectiveness of pelvic floor muscle exercises in this sample was comparable with the effectiveness of oral medication in a similar group of men with mixed aetiology (Goldstein et al, 1998).

The treatment regime placed emphasis on the ability to achieve maximum-strength pelvic floor muscle contractions sustained for 10 seconds, with some sub-maximum pelvic floor muscle contractions while walking. The exercise regime is shown in Box 1 and a suggested management pathway for men with erectile dysfunction is shown in Box 2.

Discussion
The results of this research could change practice in a number of ways. Some of these changes will be instigated by professionals and some will be driven by patients.

Urology assessments by all medical practitioners including nurses and physiotherapists could feature a single question: 'Do you have difficulty attaining or maintaining an erection?' This would present an opportunity for medical practitioners to offer the patient the option of performing pelvic floor muscle exercises.

Pelvic floor muscles could be assessed and graded digitally at urology examinations, for example, in prostate clinics, and those men with weak pelvic floor musculature could be offered a strengthening regime. It also seems reasonable to suggest that preventative exercises could be taught to men. Those with weak pelvic floor muscles may be more amenable to an exercise regime once they understand the role of pelvic floor muscles.

Men who are having prostate or abdominal surgery could strengthen their pelvic floor muscles before and after surgery.

Workouts in the gymnasium could include some exercises for the pelvic floor in order to develop all muscles equally and avoid muscle imbalance.

Pelvic floor muscle exercises could be considered as a first-line approach for men seeking long-term resolution of erectile dysfunction. This avoids acute pharmacological and surgical interventions that may have side-effects.

Men receiving other forms of therapy for erectile dysfunction could also be advised to practise pelvic floor muscle exercises in addition to the therapy prescribed.

Resources are available to help educate and support men to perform these exercises. Two examples of these are outlined in Box 3.

Conclusion
Pelvic floor muscle exercises are an effective treatment for men with erectile dysfunction. They are aimed at restoring normal pelvic floor muscle function and may be performed in conjunction with other forms of treatment for erectile dysfunction.

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