REVIEW

The Role of Physical Therapy in Sexual Health in Men and Women:

Evaluation and Treatment
Amy Stein, PT, MPT, DPT, BCB-PMD, IF,1 Sara K. Sauder, PT DPT,2 and Jessica Reale, PT, DPT, WCS3

ABSTRACT

Introduction: Many conditions of pelvic and sexual dysfunction can be addressed successfully through pelvic
floor physical therapy (PFPT) through various manual therapy techniques, neuromuscular reeducation, and
behavioral modifications. The field of pelvic rehabilitation, including sexual health, continues to advance to
modify these techniques according to a biopsychosocial model.
Aim: To provide an update on peer-reviewed literature on the role of PFPT in the evaluation and treatment of
pelvic and sexual dysfunctions in men and women owing to the overactive and the underactive pelvic floor.
Methods: A literature review to provide an update on the advances of a neuromusculoskeletal approach to PFPT
evaluation and treatment.
Main Outcome Measure: The use and advancement of PFPT methods can help in successfully treating pelvic
and sexual disorders.
Results: PFPT for pelvic muscle overactivity and underactivity has been proven to be a successful option for
pelvic and sexual dysfunction. Understanding the role of the organs, nerves, fascia, and musculoskeletal system in
the abdomino-pelvic and lumbo-sacro-hip region and how pelvic floor physical therapists can effectively evaluate
and treat pelvic and sexual health. It is important for the treating practitioner to know when to refer to PFPT.
Conclusion: Neuromusculoskeletal causes of pelvic floor disorders affect a substantial proportion of men,
women, and children and PFPT is a successful and non-invasive option. Pelvic floor examination by healthcare
practitioners is essential in identifying when to refer to PFPT. Use of a biopsychosocial model is important for the
overall well-being of each patient. Further research is needed. Stein A, Sauder SK, Reale J. The role of physical
therapy in sexual health in men and women: Evaluation and treatment. Sex Med Rev 2018;XX:XXXeXXX.
Published by Elsevier Inc. on behalf of the International Society for Sexual Medicine.
Key Words: Vulvodynia; Sexual Pain; Pelvic Floor Physical Therapy; Manual Therapy; Vestibulodynia; Pelvic
Floor Muscle Dysfunction

INTRODUCTION Previous studies have cited time constraints, perceived lack of

Sexual dysfunction affects not only intimacy, but an in-
dividual’s sense of identity and self-worth. Studies indicate that
sexual dysfunction is underreported and inadequately treated.1,2
Those experiencing sexual dysfunction are unlikely to seek
medical help and often find that effective treatment may be
difficult to obtain.1,3 Some healthcare providers also lack confi-
dence and experience in treating individuals with sexual
dysfunction. Others are confused if lab results do not determine
pathology that can be treated with prescription medication.2,3
Received May 12, 2018. Accepted September 16, 2018.
1
Beyond Basics Physical Therapy, LLC, New York, NY, USA;
2
Urology Austin, Austin, TX, USA;
3 significant role in sexual function in both men and women, and
Atlanta PT, Altanta, GA, USA
Published by Elsevier Inc. on behalf of the International Society for Sexual
Medicine.
https://doi.org/10.1016/j.sxmr.2018.09.003
effective therapies, insufficient training, and perceptions
regarding patientephysician gender discordance as factors
contributing to decreased confidence in physicians when man-
aging patients with sexual complaints.4e6 These perceived bar-
riers often lead to those experiencing sexual dysfunction being
inadequately served by healthcare professionals.
Sexual function can often derive from physical, psychological,
sociocultural, and interpersonal factors.3 Therefore, a bio-
psychosocial approach involving a multidisciplinary team is
important in providing optimal treatment for individuals expe-
riencing varying types of sexual dysfunction.3,7e9 It is imperative
to understand the many provider options available and the role
that each provider can play. The pelvic floor muscles play a
thus, physical therapists specializing in evaluation and treatment
of the pelvic floor muscles can be important members of an
interdisciplinary team providing care for men and women

Sex Med Rev 2018;-:1e11 1

2 Stein et al
experiencing sexual dysfunction. We wished to perform a review
of the pertinent literature in this area. This article will review the
major role pelvic floor physical therapy (PFPT) plays in helping
men and women overcome dysfunction and achieve sexual
health.
BACKGROUND
According to Arnouk et al,10 25% of women in the United
States experience some form of pelvic floor dysfunction. Because
sexual health is affected by a variety of variables—desire, arousal,
and pelvic floor function among others—PFPT takes a holistic
approach to care of sexual dysfunction.9 Physical therapy assesses
the body, mind, and habits to achieve changes in both sexual
function and experience.9 Over the last 2 decades, and in
particular, during the past few years, this approach has yielded
positive results.
Research on treatment techniques for sexual health in men
and women has shown that PFPT is an integral treatment for the
musculoskeletal causes of causes of pelvic and sexual pain.11-16
The treatment approach taken by physical therapists to treat
sexual dysfunction has progressed and adapted over the past few
decades to achieve positive results.
In the 1990s, psychologist Dr. Howard Glazer demonstrated
the positive effects of applying surface electromyography
(SEMG) biofeedback to the pelvic floor to treat vulvar pain.15
Patients were able to improve muscle function through aware-
ness of muscle activation and relaxation. Active activation and
active relaxation was practiced through SEMG biofeedback ses-
sions. Dr. Glazer’s research was implemented by physical ther-
apists in providing care for individuals experiencing pelvic floor
dysfunction. The technique has since been modified to include
tactile and verbal feedback as a means of improving proprio-
ceptive and kinesthetic awareness of pelvic floor muscles.15,16
Pelvic floor physical therapists previously treated primarily
symptoms related to pregnancy, but in 1994, The Guide to
Physical Therapist Practice17 included vaginal and rectal assess-
ment and treatment. This allowed the PFPT specialty to evolve
to treat men and women with a broad number of impair-
ments—even those leading to sexual dysfunction.9,17 That action
opened the door to new training courses in PFPT so that today
pelvic floor physical therapists have a plethora of educational
options from which to choose. In 2005, a taskforce created by
the Section on Women’s Health through the American Physical
Therapy Association published guidelines for professional and
postprofessional education for physical therapists in women’s
health, including recommendations regarding the evaluation and
treatment of pelvic floor muscle dysfunction.18 In 2006, the
American Board of Physical Therapy Specialties approved the
development of board certification in the specialty of women’s
health, which included examination, evaluation, and treatment
of urinary, bowel, and sexual dysfunction as well as pelvic pain.
As of 2017, there are almost 400 board-certified specialists in the
United States.19
ANATOMY
The pelvic floor muscles form a hammock that connects the
pubic bone to the coccyx and extends laterally toward each hip,
as shown in Figures 1e4. The muscles, connective tissue, and
ligamentous structures provide support for the bladder, uterus,
prostate, and rectum. Bladder and bowel function, sexual satis-
faction, and lumbopelvic mobility depend on healthy pelvic floor
muscles.9 The muscles are composed of several layers, typically
described in 3 segments from caudal to cranial. The most su-
perficial layer is composed of the bulbospongiosus, ischioca-
vernosus, superficial transverse perineal muscles, and the external
anal sphincter. The bulbospongiosus and ischiocavernosus insert
at the hood of the clitoris in females and play a role in sexual
arousal and orgasm. It is theorized that weakness in these muscles
would likely lead to decreased sexual pleasure owing to these
muscle attachments.20 In males, the same muscles are known to
facilitate penile rigidity through creating increased intra-
cavernosal and intraspongiosal pressures during muscle activa-
tion, and also contribute to ejaculation.21 Although ejaculation is
a neural reflex, it is theorized that improving pelvic floor muscle
control, particularly of the ischiocavernosus and bulbospongio-
sus, could inhibit this reflex through voluntary relaxation.20
These superficial muscles also aid in urinary continence.20,21
The middle layer of the pelvic floor muscles, also known as
the urogenital diaphragm, is composed of the deep transverse
perineal muscles, urethral vaginal sphincter (in females), as well
as the compressor urethrae (in females) and sphincter urethrae.
These structures play a significant role in continence and also
contribute to lumbopelvic stability owing to fascial connections
with the abdominal wall. The most cranial layer, known as the
pelvic diaphragm, includes the pubococcygeus (composed of the
pubourethralis, pubovaginalis in females, and puborectalis) and
iliococcygeus, known as the levator ani, as well as the coccygeus
(previously referred to as ischiococcygeus). The pelvic diaphragm
predominantly provides organ support in males and females and
also contributes to continence and defecation as well as stabili-
zation of the coccyx and sacrum.21e23 Contractions of the
levator ani muscle group are also theorized to contribute to sexual
pleasure during sexual activity.20 Collectively, the pelvic floor
muscles activate synergistically with the respiratory diaphragm,
transverse abdominis, and lumbar multifidus muscles to
contribute to respiration as well as static and dynamic postural
stability.22,24
The pelvic floor muscles are composed of 80% Type I slow-
twitch skeletal fibers and 20% Type II fast-twitch skeletal
fibers. The Type I muscle fibers maintain long-term continence
and structural support whereas the Type II fibers maintain
continence during such short bursts of increased intraabdominal
pressure such as sneezing or coughing. These fast-twitch fibers
aid in orgasm.9
The pelvic floor is predominantly innervated by the pudendal
nerve as well as direct branches from sacral nerve roots S3e5.25
The pudendal nerve is the only pelvic nerve with motor,
Sex Med Rev 2018;-:1e11
Role of Physical Therapy in Sexual Health in Men and Women
Figure 1. Female urogenital system (midsagittal section).
Copyright Amy Stein, DPT.
sensory, and autonomic function. Its 3 branches include the
dorsal, perineal, and inferior rectal branch, which provide inner-
vation to the clitoris, penis, urethral sphincter, perineum, and
external anal sphincter. Impairment of the pudendal nerve can
create pelvic pain. In addition, the ilioguinal, iliohypogastric,
genitofemoral, and posterior femoral cutaneous nerves can also be
the source of sexual dysfunction or genital pain. The ilioinguinal,
iliohypogastric, and genitofemoral nerves derive from the lumbar
plexus and course through the abdominal wall, whereas the pos-
terior femoral cutaneous nerve derives from the lumbosacral plexus
coursing through the greater sciatic foramen. Musculoskeletal
dysfunction within these areas can thus contribute to impairments
at these nerves and result in pain or deficits in sexual function.26
Although not included within the pelvic floor muscles, the
obturator internus, an external rotator of the hip, is also important
to consider. The obturator internus shares an attachment with the
pelvic floor muscles at the arcus tendinous levator ani and extends
laterally to the obturator foramen. Fascia from the obturator
internus composes Alcock’s canal where the pudendal nerve
courses, and thus, restrictions within this muscle can lead to pu-
dendal nerve pathology and contribute to sexual pain.21
CAUSES OF PELVIC FLOOR AND SEXUAL
DYSFUNCTION
According to Arnouk et al,10 pelvic floor dysfunction is present
in most women with bowel, bladder, or sexual dysfunction. A
variety of pelvic floor dysfunctions can result in sexual dysfunction.
It is of vital importance to differentiate each patient’s root cause of
symptoms. Pelvic floor dysfunction can present after significant or
chronic psychological stress, pregnancy and childbirth, traumatic
insult, infection, or bony misalignment.2,9 It can present idio-
pathically or through pathology.
Myofascial pelvic pain encompasses pain in all of the fascia of
the pelvic floor. This in itself can be considered a collection of
symptoms causing pain or it can be related to another diagnosis.2
Sex Med Rev 2018;-:1e11
3
According to Bertotto et al,27 menopause can contribute to
urogenital dysfunctions secondary to vulvar atrophy. This can
contribute to urinary incontinence and increased urinary urgency
and frequency.
Causes of pelvic floor muscle dysfunction may be generalized
into 2 categories—pelvic floor muscle overactivity and under-
activity. It is important to note that the current terminology of
muscle underactivity vs overactivity as defined by the Interna-
tional Continence Society lacks a description for the muscle that
is both underactive and overactive. This is commonly found in
patients with pelvic pain who display pelvic floor muscle weak-
ness upon manual muscle testing and shortened, or contracted,
muscle fibers as a result of a chronic state of increased tone.9
Overactive Pelvic Floor Dysfunction
Pelvic floor muscle overactivity can contribute to or be the sole
cause of pain in the abdomen, pelvis, back, lower extremities, or
genitals with or without sexual activity.2 It can also contribute to
or be the sole cause of dysfunction or pain with urination,
defecation, or sexual activity.2,9 Men with overactive pelvic floor
muscles and myofascial trigger points may report pain in the
testicles, groin, tip of the penis, and abdomen.2 They also may
report inability to achieve an erection, premature ejaculation,
difficulty reaching climax, or postejaculatory pain. Women may
report symptoms of vulvar burning or itching, clitoral pain, and
vaginal pain. In addition, men and women experiencing pelvic
floor dysfunction may report bowel and bladder symptoms not
related to sexual function.2,9 These symptoms can include con-
stipation, particularly outlet dysfunction and dyssynergia, void-
ing dysfunction, urinary urgency and frequency, as well as
urinary and fecal incontinence.
Chronic muscle overactivity can result in shortened or con-
tracted muscle fibers.9 This results in reduced mobility of the
most superficial layer of connective tissue—the pannicular fascia.
Fascia is highly neurogenic and vascular; therefore, limitations of
fascial mobility can create pain. It is essential to assess connective
tissue, among other fascia, when treating muscle overactivity.9
Men can experience sexual dysfunction as a result of muscle
overactivity or connective tissue restrictions even in the absence
of pain. Proper discernment of muscle overactivity vs underac-
tivity is necessary to determine the appropriate plan of care for
men with difficulty achieving or maintaining an erection. Men
with muscle underactivity without shortened muscle fibers might
benefit from pelvic floor muscle strengthening activities; how-
ever, men with muscle overactivity and or shortened fibers
commonly will have exacerbated symptoms if performing these
same activities.
Underactive Pelvic Floor Dysfunction
Pelvic floor muscle underactivity in both men and women can be
the result of weakness and shortened muscle fibers.9 Muscle under-
activity can result from disuse, increased parity, and neuropathy.28
4 Stein et al
Figure 2. Female pelvic floor anatomy. Copyright Amy Stein, DPT.
Muscle weakness, shortening, or poor coordination can decrease
sexual response and performance.
In addition, laxity of connective tissue and pelvic floor muscle
weakness can diminish support of pelvic viscera contributing to
pelvic organ prolapse (POP). Typically, symptoms related to
POP worsen over the course of the day. POP can cause
discomfort and is linked to lower levels of sexual satisfaction and
poor genital body image.29 Although surgical options exist for
POP, they can result in reduced blood flow, decreased genital
sensation, pain, and vaginal adhesions.30,31 This can diminish
arousal and orgasm response and cause dyspareunia. When a
more conservative approach of PFPT intervenes for prolapse,
sexual functioning scores have shown to improve.13
Incontinence of urine, stool, or gas can occur secondary to pelvic
floor muscle underactivity.32 This incontinence can affect men,
women, and children.32 Stress urinary incontinence, in particular,
is a result of increased abdominal pressure from a cough, laugh,
sneeze, or lift and can be associated with underactive pelvic floor
and abdominal wall muscles, respiratory diaphragm impairment,
POP, or prostatectomy.33e35 Stress incontinence can negatively
impact all domains of sexual function including increasing sexual
distress and decreasing desire and orgasm.36
ASSESSMENT
A pelvic floor physical therapist’s assessment starts by
obtaining a detailed history.2 The physical therapist will obtain a
complete picture of the patient’s sexual activities including
quality of desire and arousal, type and quality of orgasm, and any
pain associated with sexual activity. It is necessary for the physical
therapist to be appropriately trained in obtaining a sexual health
and sexual function history.37
Specific assessment is critical in determining the cause of
pelvic floor dysfunction. The physical therapist must assess bony
Figure 3. Male urogenital system (midsagittal section). Copyright
Amy Stein, DPT.
alignment, muscles, tissues, and nerves that contribute to pelvic
floor function.2 Proper function is assessed via strength, endur-
ance, and coordination testing of the pelvic floor, hip, and core
muscles. The pelvic bones allow for a small degree of movement,
therefore misalignment and repetitive microtraumas to these
structures can occur from sitting, standing, daily and recreational
activities, and sleeping habits. Larger traumas such as pelvic
expansion during pregnancy and childbirth can also cause the
pelvis to become misaligned. Without proper symmetrical
alignment, muscles will pull asymmetrically, changing their
ability to contract and relax. This may further irritate nerves and
blood vessels, creating a sequela of what may initially appear to
be unrelated symptoms. Individuals with chronic pelvic pain
have been found to have increased pelvic asymmetries compared
with pain-free control subjects.38
With or without pelvic bony alignment issues, the therapist
must assess the hip joints for proper range of motion, strength,
and pain.9 Hip joint restrictions can lead to a number of muscle
performance and pain complaints—among them, groin, vulvar,
or genital pain.9,39 When the hips do not achieve full and pain-
free joint motion, the body may compensate by creating a pelvic
obliquity or spinal dysfunction.9,40 Without proper hip stabili-
zation, the pelvic floor muscles may compensate by over-
activating.41 This means that the pelvic floor muscles will not
have an opportunity to relax fully after functional activation. Hip
and pelvic floor muscle pain can result from this compensatory
action.9 This can lead to sexual dysfunction characterized by
deep thrusting pain with penetrative intercourse or by post-
orgasmic or ejaculatory pain.
If chronic pain is untreated, a patient may develop central
sensitization.9,24 This is a change in the brain and spinal cord
secondary to increases in nociceptive firing.3 The body’s trauma,
injury, or impairment may resolve, however, in cases of central
sensitization, the nociceptive information to the central nervous
system does not cease, but rather, is augmented and facilitated by
Sex Med Rev 2018;-:1e11
Role of Physical Therapy in Sexual Health in Men and Women
Figure 4. Male pelvic floor anatomy. Copyright Amy Stein, DPT.
ascending and descending pathways.3 The patient continues to
experience pain sensations, even after the underlying cause has
been successfully treated.
Untreated pain also can lead to peripheral sensitization, which
occurs when peripheral nerves interpret non-noxious stimuli as
noxious.3 This is a misreading that lowers the individual’s pain
threshold.3,42,43 Physical therapists can change sensitization
through gentle movement training and by educating the patient
about the body’s response to pain and about how the brain in-
terprets pain. Neurophysiology-based pain education is a fairly new
and growing area of interest for all healthcare providers who address
pelvic and sexual pain.3,42,43
Assessment of pelvic floor muscle activity can be performed by
a pelvic floor physical therapist with or without use of SEMG
biofeedback. SEMG biofeedback gives the patient visual feed-
back of their muscle function through collecting both voluntary
and involuntary muscle activity.18 SEMG biofeedback is
commonly used in clinical practice; however, it has been shown
to be less comprehensive in evaluating pelvic floor muscle
function when compared with a digital vaginal examination.44
SEMG biofeedback also has been shown to have poor reli-
ability when used to make comparisons between subjects or
when used to evaluate progress in the same subject over time.45
Therefore, SEMG biofeedback is most often recommended as a
training tool rather than an examination technique in pelvic floor
muscle rehabilitation.45 Several studies have shown benefits of
using SEMG biofeedback during pelvic floor rehabilitation;46e49
however, studies vary as to whether SEMG biofeedback-assisted
training is superior to pelvic floor muscle training alone.50,51
TREATMENT
Physical therapy focuses on function.9 Treatment is aimed at
correcting impairments that make up the sexual dysfunction
Sex Med Rev 2018;-:1e11
5
specific to each individual.2,9 Although some patients may have
the same symptoms, the causes of those symptoms might differ.
This warrants different treatment approaches. Physical therapists
generally employ multimodal techniques that often include
manual therapy techniques, motor control, and movement
training, as well as patient education. Although quality studies
regarding the efficacy of a multimodal program are often lacking,
several studies have shown benefit to this approach for diagnoses
such as chronic pelvic pain, vestibulodynia, and vaginismus.52e55
Summary of Manual Techniques
Pelvic floor muscle overactivity, fascial, visceral, neural, and
scar tissue restrictions can be assessed and treated through
manual therapy techniques. These interventions aim to increase
range of motion of the tissues and joints, which subsequently can
lead to reduced pain and improve sexual function.9
Trigger point release and paradoxical relaxation treatment can
reduce pelvic pain and improve sexual outcome scores.9,56
According to Travell and Simons, a myofascial trigger point is
“a hyperirritable spot in skeletal muscle that is associated with a
hypersensitive palpable nodule in a taut band” and can result in
shortened tissue (Figure 5).57 Trigger point release techniques
can be performed as intravaginal or intrarectal manual therapy to
address overactive pelvic floor muscles. Overactivity in the pelvic
floor muscles has been shown to correlate with sexual dysfunc-
tion.58 Several studies have found that internal manual therapy
techniques are effective in improving pelvic floor myalgia and
sexual function.11,59e62 Thiele massage is an internal manual
therapy technique performed using sweeping strokes across the
pelvic floor muscles. This technique has been found to improve
pelvic floor myalgia, reduce pain levels, and improve sexual
function in individuals with chronic pelvic pain, interstitial
cystitis, and dyspareunia.11,59,61,63,64 Additionally, Zoorob
et al62 compared intravaginal manual therapy techniques by a
pelvic floor physical therapist with levator ani trigger point in-
jections. Results showed an improvement in pain and sexual
function in both groups, however, the group receiving physical
therapy demonstrated a greater overall improvement in sexual
function.
An additional technique used to treat trigger points in muscles
is dry needling. Dry needling can be performed by physical
therapists in certain parts of the United States. This technique
involves insertion of a monofilament needle into a muscle. This
is a treatment technique intended to reduce the discomfort of a
trigger point and can affect discomfort at locations apart from the
specific treated trigger point through referral patterns.2 Although
the effects of dry needling have been studied in various muscles,
there is only 1 case study published to date regarding dry
needling specific to the pelvic floor musculature.65,66
Intravaginal manual therapy has also been studied in conjunc-
tion with Botox injections. Halder et al67 performed a retrospec-
tive case series of 50 women with chronic pelvic pain, also
complaining of dyspareunia, who had myofascial trigger points on
6 Stein et al
Figure 5. A sample of a self-massage technique to calm an
abdominal trigger point.
examination and had failed another intervention including phys-
ical therapy and oral analgesics. Their results showed that all
participants had a significant difference in pre- and postoperative
pain scores.
Visceral mobilization treats visceral restrictions and adhesions
that cause referred pain.68 This referred visceral pain can extend
to the pelvis and affect sexual function. Wurn, Wurn, and
Roscow69 studied the effects of visceral mobilization techniques
on sexual function in 29 women and found statistically signifi-
cant improvements in Female Sexual Function Index scores in
both the pain and orgasm domains.
Connective tissue manipulation, also termed skin rolling,
lengthens connective tissue and improves circulation to areas
with decreased blood flow, increased mast cell release, and
neurogenic irritation.70 Although this treatment can be uncom-
fortable for patients with connective tissue impairments, it can be
a beneficial component of myofascial therapy. A large random-
ized multicenter trial by FitzGerald60 compared global massage
with myofascial physical therapy for women with interstitial
cystitis/painful bladder syndrome. The myofascial techniques
used included internal and external techniques, including con-
nective tissue mobilization. Results indicated a 60% improve-
ment for women in the treatment group compared with 26% in
the control group.
Scar tissue mobilization is a crucial aspect of physical therapy
treatment for men and women who have undergone abdominal
or pelvic surgery. Scar tissue mobilization can decrease pain,
preserve normal function, and improve mobility, eliminating
adherence to deeper tissues and improving elasticity.2,9 As with
connective tissue and visceral manipulation, scar mobilization
techniques also improve the mobility of the surrounding struc-
tures.71 A case study published in 2015 by Morrison, Spadt, and
Goldstein72 examined the effects of a myofascial physical therapy
approach including scar tissue mobilization at the clitoral pre-
puce for a 41-year-old woman experiencing low back and pelvic
pain as well as dyspareunia and anorgasmia occurring after a
blunt trauma injury to the vulva. The initial examination
identified myofascial impairments as well as clitoral phimosis.
Following 11 treatment sessions over 16 weeks, the patient
demonstrated complete resolution of her symptoms.
Joint mobilization or manipulation of the spine, pelvis, and hip
improve joint function, muscle recruitment, and range of motion
while decreasing pain.2,73 A study by Mieritz et al74 examined
musculoskeletal dysfunction in women with chronic pelvic pain
and suspected endometriosis. 51% of the patients had musculo-
skeletal dysfunction that included deficits in lumbar and sacral
mobility as well as positive pain provocation tests for sacroiliac joint
dysfunction. Thoracolumbar spinal restrictions can lead to irrita-
tion anywhere along the course of the ilioinguinal, iliohypogastric,
and genitofemoral nerves and sacral dysfunctions can cause irri-
tation of the pudendal and posterior femoral cutaneous nerves,
potentially all contributing to pelvic floor dysfunction. Improper
firing of a nerve can affect muscle recruitment, mimic muscle pain,
or limit a joint range of motion from the dermatomal or myotomal
distribution of that specific spinal segment. Additionally, there is a
correlation between lower back pain and breathing disorders with
stress urinary incontinence and decreased automatic muscle
functioning.57 Spine, pelvic, and hip joint dysfunctions can be
sources of sexual dysfunction such as pain at the clitoris, penis,
testicle, vestibule, or deep in the vaginal muscles, resulting in pain
during or after sexual activity. Correcting joint impairments can
address these varied dysfunctions.9
Motor Control and Retraining
Pelvic floor muscle retraining improves motor control to
improve bladder, bowel, and sexual function and to reduce pelvic
pain.75,76 Patients with chronic pelvic pain, dyspareunia, con-
stipation, or urinary dysfunction (including urgency, frequency,
voiding dysfunction, or retention) often present with overactive
pelvic floor muscles.9,16,17,77-79 Pelvic floor muscle overactivity
can be the result of chronic holding patterns or a response to
trauma such as surgery or childbirth.9 Pelvic floor muscle over-
activity can result in shortened muscle fibers, contracted sarco-
meres, ischemia, and poor mobility of muscle, connective, visceral,
and neural tissues.9 Treatment aimed at correcting motor control
and function involves manual lengthening of muscle fibers as
described previously and muscle movement retraining.
In treatment of the overactive pelvic floor muscles, the patient
learns how to downtrain, or actively relax, the muscles.2,3,9
Downtraining also assists in calming the nervous system, and
improving sexual function.3,9,78 Downtraining is accomplished
through specific movement-based exercises, often paired with
active relaxation and diaphragmatic breathing (Figure 6).
Behavioral therapy is incorporated into treatment to make lasting
changes in the patient’s habits.3,9 Individuals with pelvic pain
often contract pelvic floor muscles in anticipation of pain, which
can be especially problematic in cases of dyspareunia.9 Behavioral
reeducation via verbal and tactile cueing improves kinesthetic
and proprioceptive awareness of muscle contraction, active
elongation, and passive relaxation.3,9
Sex Med Rev 2018;-:1e11
Role of Physical Therapy in Sexual Health in Men and Women
Figure 6. Demonstrates a pelvic floor stretch: a sample of a
movement exercise and recommended with diaphragmatic
breathing to further enhance the relaxation.
Another technique, well known via popular media, is the use
of pelvic floor muscle training (PFMT). PFMT is well supported
in the literature as a treatment for urinary incontinence, fecal
incontinence, and POP.80 A Cochrane review published in 2014
recommended PFMT as a first-line treatment for any type of
urinary incontinence.81 Despite the widespread support for this
treatment, it is often underutilized.82 Additionally, only 50% of
individuals perform PFMT correctly.16 PFMT should be taught
and monitored by a physical therapist who can offer tailored
instruction with proper guidance. A review by Ferreira82 pro-
vided Level 2 evidence supporting the effect of PFMT on female
sexual function. Additionally, there is some evidence that PFMT
can improve erectile dysfunction, particularly in cases of mild to
moderate veno-occlusive dysfunction.21,83 A recent study by
Lavoisier84 examined the effects of PFMT on sexual function in
122 men with erectile dysfunction and 108 men with premature
ejaculation. The results indicated significant improvements in
intracavernous pressure and improvements in erectile function.
Although PFMT can improve sexual function including quality
of orgasm in some patient populations, it can induce pain in
others, particularly those with pelvic floor muscle overactivity.9
Bertotto et al27 supported the necessity of proper assessment of
baseline muscle activity before initiating muscle recruitment
activities. Improper PFMT for muscle recruitment can lead to
poor neuromuscular recruitment. Understanding the effects of
Sex Med Rev 2018;-:1e11
7
PFMT on overactive pelvic floor muscle dysfunctions can help
patients avoid creating or worsening pelvic or sexual dysfunction.
Postural and movement dysfunctions also play a role in sexual
impairments. Varying presentations can be observed in patients;
thus, a specific individualized examination is necessary.85 Lee86
identified several subgroups that she termed upper chest grip-
pers, back grippers, and butt grippers. Upper chest grippers
referred to individuals who had overactivity in their external
oblique muscles leading to poor firing of the respiratory dia-
phragm and alterations in intraabdominal pressure. Back grip-
pers referred to individuals with increased activity in thoracic
paraspinals leading to postural-related pain and decreased
abdominal muscle activity. Butt grippers referred to those who
had overactivity at the gluteal muscles leading to a posteriorly
tilted pelvis and flexion at the lumbar curve. Each of these
presentations can lead to alterations in movement as well as in
pelvic floor muscle function, including either overactivity or
underactivity problems.
The physical therapist can apply a range of interventions for
improving movement patterns to achieve long-term resolution of
the impairments. The physical therapist’s intervention seeks to
retrain the patient on how to modify the movement pattern.
This can require manual therapy, specific exercises, and neuro-
muscular reeducation of spinal and hip movement.
Patient Education
Patient education is a vital component of physical therapy
intervention. Men and women experiencing pain and sexual
dysfunction, and women experiencing painful penetration, sec-
ondary to overactive pelvic floor muscles may benefit from dilators
or internal wand use.9 Both can help eliminate myofascial trigger
points and assist in elongating short muscle fibers. An individual
with pain at the vaginal introitus can also passively stretch the tis-
sues at the introitus with a dilator while practicing graded exposure
to an increasing dilator size.9 Anderson et al87 evaluated the benefit
of internal pelvic floor massage with a wand on reduction of
medication use in men and women with chronic pelvic pain. Re-
sults indicated a 22% overall reduction in medication use from
baseline after 6 months. Behavioral modifications in sexual activity
are extremely important in pelvic floor muscle rehabilitation for the
individual with sexual dysfunction.3 Stress management, focused
and intentional diaphragmatic breathing, meditative practices, and
a focus on physiological quieting can enhance relaxation of the
pelvic floor and improve sexual health.9 Examples of other
behavioral modifications, although not an exhaustive list, include
scheduled voiding, urinary urge control strategies, postural
retraining, and pelvic floor muscle relaxation and massage.9 Addi-
tionally, hygiene habits can affect a female’s vaginal flora and thus
sexual satisfaction, so education can be very beneficial.3,9
Ensuring that the patient thoroughly understands the physi-
ological changes of the body during sexual desire and arousal is
another role of the physical therapist. The physical therapist can
8 Stein et al
educate the patient on options for improving desire and arousal,
varying from exploring the senses or discovering film or literature
that might assist in desire and arousal.88,89
CONCLUSION
Although additional high-quality evidence is needed to further
understand the role of physical therapy in the treatment of sexual
dysfunction, current evidence is promising, particularly regarding
sexual pain conditions. Physical therapists take a multifaceted
approach when evaluating and treating pelvic floor muscle
dysfunction, neuralgias, and orthopedic dysfunctions, addressing
both musculoskeletal dysfunction and behavioral contributions.
Healthcare providers should recognize when physical therapy is
indicated in treating sexual dysfunction. Additional research is
needed to further understand the most optimal treatments in a
multidisciplinary model to address specific sexual dysfunctions in
men and women.
Corresponding Author: Amy Stein PT, MPT, DPT, BCB-
PMD, IF, 110 E. 42nd Street, Suite #1504, New York, NY
10017, USA; Tel: 212-354-2622; Fax: 212-354-2752; E-mail:
Amy@beyondbasicspt.com
Conflicts of Interest: The authors report no conflicts of interest.
Funding: None.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Amy Stein; Sara Sauder; Jessica Reale
(b) Acquisition of Data
Amy Stein; Sara Sauder; Jessica Reale
(c) Analysis and Interpretation of Data
Amy Stein; Sara Sauder; Jessica Reale
Category 2
(a) Drafting the Article
Amy Stein; Sara Sauder; Jessica Reale
(b) Revising It for Intellectual Content
Amy Stein; Sara Sauder; Jessica Reale
Category 3
(a) Final Approval of the Completed Article
Amy Stein; Sara Sauder; Jessica Reale
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