© 1994 by John D. Perry, Ph.D., BCIAC, Psychologist
The treatment of male impotence--both ordinary and post-prostatectomy--may well be the next frontier for EMG perineometry. It is likely that pelvic muscle biofeedback can be as successful in treating impotence as it has been in treating Stress and Urge Incontinence, Fecal Incontinence, and Constipation--in other words, in most cases, surgery will be unnecessary.
Traditionally impotence has been seen as either (1) a psychiatric problem or (2) a plumbing and wiring problem. But new research into the mechanism of erection helps to explain how pelvic muscle contractions could directly influence the physiological process of erection. And a Belgian study published in the British Journal of Urology shows the theory may just work!
Interestingly, exercises help impotence in the same way they cure urge incontinence when caused by a hyper-reflexive bladder-voluntary contractions of the PC cause the inhibition of smooth muscle activation.
For many years it was assumed that PC exercise could only help treat stress incontinence, which is usually caused by muscle weakness. Then in the late 70's, urologists showed that electrical stimulation of the perineum or anus caused the bladder to stop its contractions. The mechanism of action was shown to be an inhibitory reflex arc that operates at the level of S2, S3 & S4.
The final step was to show that most human beings come equipped with their own built-in electric stimulators, called "brains", as eloquently put by Dr. de Groat at the 1988 Concensus Conference. It turns out that voluntary contractions have the same bladder-inhibiting effect as externally-caused contractions, and they are a lot cheaper and easier since you can carry the stimulator with you at all times.
For stress incontinence, PC exercises are prescribed to build up the bulk of the muscles (thus increasing their physical sphinc-teric action), and to teach rapid recruitment to counteract any sudden increases in interabdom-inal pressure. For urge incontinence, building up the muscle may still be helpful, but the primary effect comes from activating the inhibitory reflex and thus calming the bladder.
Most male patients at Continence Clinics present with a combination of "stress", "urge", and just plain "dribbling" incontinence, which began with their surgery and failed to go away spontaneously. The diagnosis isusually "788.3 incontinence of urine" (interestingly listed under 'Symptoms, Signs, and Ill-defined conditions'!), since "625.6 stress incontinence" is specifically limited to "female". Weekly bladder records detailing accidents will suggest the emphasis to be applied during training and later in the generalization of training.
It is important to understand that males are much more severely affected by incontinence than are females, since wearing diapers, no matter what their name, is still associated with women and children.
Bad as it is, most males find it easier to seek help for their incontinence than for their impotence, although the latter is probably even more devastating to the ego.
Most female incontinence is "gradual onset", while most male problems have sudden onset. Formulating a treatment plan for a male patient (P-P) is more difficult, since we usually do not know (1) how much physical material was removed during surgery, and (2) how much damage, if any, was done to nearby nerves. Nevertheless, it is safer (and heuristically better) to assume, for therapy, that any nerve damage was physiological, rather than organic, and therefore, can be overcome by a good biofeedback-assisted exercise program.
A 78 year-old retired truck driver was being treated for urinary incontinence following radical prostatectomy. He made excellent progress because he practiced every night with the Personal Perineometer while watching television. Whenever ads came on screen he would switch on his home trainer and do a few minutes of contractions.
One day he asked "Hey, Doc, do you suppose this will help with my 'other' problem (which he did not name)?"
"We can't promise, but it might!" he was told.
The next visit he reported that the night before, while practicing his exercises, he had gotten "half an erection", for the first time since his operation.
"What did you do then?"
"Well, I watched it for a while and it went away." was his answer.
The bad habit called "Spectatoring" was explained, and he left enthusiastically. The age cohort now getting prostate surgery often does not understand basic sexual function, and may need explicit suggestions.
A rudimentary knowledge of basic sex therapy is helpful, and in some states, more formal training is even required, to treat sexual dysfunctions. For professional collaboration, look for "AASECT Certified Sex Therapist" in yellow page advertisements.
Recently a number of clinics have begun "Before and After" pelvic muscle biofeedback therapy. The patient is trained for several weeks before surgery, as well as after, with the expectation that both problems will be reduced. So far none of these projects has published results, but initial reports are very positive.
At the 1988 AUA meeting, world-famous sexologist Gorm Wagner presented strip-chart recordings of the erection-inhibiting muscle impulses that ordinarily prevent erection. His charts, which showed strong spikes 6 to 10 seconds apart, were obtained from needle electrodes inserted directly into the corpus cavernosum, and fed into a "DC" amplifier and polygraph.
Most of the time these electrical impulses keep the tiny smooth muscles of the penis contacted, thus preventing the inrush of blood. But when sexual arousal occurs, the impulses stop, the smooth muscle relaxes, and the blood begins to flow into the arteries, causing erection. Thus the "normal" state of the penis is engorged; but when inhibited (most of the time), it stays flacid.
The detruser (bladder) works a similar way. One circuit makes it contract, to squeeze urine out. But when that is "inhibited" by other impulses (99% of the day) it relaxes--and the bladder fills. Kegel exercises can inhibit premature contractions of the bladder muscles; they can also quiet the penile muscles, in that case allowing blood to flow in and make an erection. [Return to previous link ]
Medical Tribune - March 11, 1993
"Impotence in some men can be treated with pelvic muscle exercises, according to Belgian scientists. ... In the Belgian study, 150 men who were impotent because of disrupted penile blood flow were treated with Kegel exercises or surgery.
"They were instructed to do the exercises* three to five times a day for 15 minutes.
"Four months after treatment, surgery was found more effective than exercises, but with time the effects of surgery waned in some cases while those of exercise persisted.
One year after treatment, 42% who were treated with exercise said their impotence had been cured, and an additional 15% said that they had improved so much that they no longer wished to undergo surgery, the doctors report in the current issue of the British Journal of Urology.
"Thus, in the long-term, exercises may be better than surgery in treating impotence related to blood-flow problems, said Dr. Hubert Claes of the Catholic University in Leuven, Belgium.
"...Impotence is thought to affect 10 million to 15 million men in the United States, and one in three over age 60. ..." [Return to text link]
* Note: There was no mention of the nature of the instruction; quite possibly, it was simply verbal instruction, as is common in Europe. It is interesting to speculate how much MORE effective the exercise group might have been if EMG biofeedback training had been utilized. -- Webmaster.