13 November 2020: Here’s how real time ultrasound biofeedback is helping me fine tune my urine control and penile rehab programme after prostate cancer surgery.

It’s hard to keep on board with all the rehab activities after prostate surgery. My recovery from erectile dysfunction (ED) has slowed down in the last couple of months. Doubts have crept in about the effectiveness of pelvic floor physiotherapy to support erectile function. I also still dribble urine every now and then.

Too many people simply tell prostate cancer survivors “remember to do your Kegels.” It’s time to fine tune that with the aid of real time ultrasound biofeedback driven by an expert physiotherapist. After experiencing this amazing technology today, I am much better educated about just how to “do those Kegels.” Just as importantly, my enthusiasm for pelvic floor exercises to support penile rehabilitation is revitalised.

The benefit of biofeedback using ultrasound

This weekend I had two wonderful privileges. Firstly, we travelled to Durban to celebrate Diwali in Chatsworth with family. Secondly, I got two in-person sessions with specialist pelvic floor physiotherapist Pierre Röscher. He really helped connect me with the realities of my pelvic floor muscles through instant visual feedback as I did the various exercises. This approach, supported by recent research, involves using an ultrasound machine similar to those used in pregnancy scans, but this time for men recovering from prostate cancer.

Here’s a brief clip from our session together. The key place to watch is near the bottom of the screen, where pelvic floor muscles help close the bladder control valve.

Pierre got me on his table and instructed me to go through my pelvic floor exercises famously described by Jo Milios as “nuts to guts.” Meanwhile he used ultrasound to display on screen the actual muscles moving inside my body. He quickly taught me to “read” the screen and identify the key muscles. I saw how the “middle” muscles of the pelvic floor can consciously and intentionally squeeze to support urine control.

It was amazing. I tried different kinds of muscle squeeze, twitch and hold. Each time I saw the impact deep inside my own body on screen in real time. He very quickly guided me to correct my practice to be more beneficial. This is way beyond the casual injunction to “do your Kegels.”

It really helped me to distinguish firmly between the muscles that support urine control and those at the base of the penis that support erections. Now I can exercise them separately.

Role of pelvic floor muscles in erectile function

Working with a male physio somehow made it easier for me to be more direct about my number one concern: erectile function. Standard medical wisdom is that erections are primarily “a vascular event” driven by blood flow. This in turn is automatically controlled by our autonomic nervous system. Therefore it is out of conscious control – except indirectly, via sexual arousal which occurs primarily in the brain.

Pierre convinced me that there is also direct, conscious muscle control that contributes to erectile function. These muscles can be enhanced through physiotherapy and fine tuning of pelvic floor exercises. I am receptive to this because of the “hinge effect” that results from erections induced by a Vacuum Erectile Device (VED). In such situations one has a swollen penis but it flops around out of control. He taught me to exercise separately the bulbospongiousus and ischiocavernosus muscles, and why this helps with erectile function.

Ultrasound biofeedback aids male pelvic floor recovery

Male pelvic floor muscles. Source: https://pubs.rsna.org/doi/full/10.1148/rg.2019190064

Fine tuning my penile rehab exercises

Exercising the front muscles that support erections feels weird. It is a bit like “willing” an erection to happen. I feel the sensation along the axis of my penis, from inside my groin to about halfway along the external shaft.

Pierre shocked me by reminding me of the way young men can twitch their semi-erect penises, for example while standing in the shower. I blithely told him “Of course I can still do that.”

But last night when I went home and tried, I found this “cock twitching” was another erection-related function I had lost. Now I will regularly exercise the relevant muscles to restore that base strength.

Building strength and resilience in these “base” muscles quite literally supports better erections.

The transparent perspex of my Vacurect VED also enables me to see what helps my erections grow. More biofeedback as I watch the swelling impact of consciously squeezing my bulbospongiosus muscle. I can literally drive more blood into the erectile tissues. This alone is not enough to create “normal” erections. But it supports my penile rehab process and definitely gets more blood flow into the affected area without taking any drugs.

Yoga for the penis: mindful practice supports lovemaking

It’s paradoxical to pay attention to these medical and muscular details when the goal is to support sexual function.

Real sex involves filling heart and mind and body with love and erotic arousal, not medical science and muscle control. Yet I am now convinced that this kind of “yoga for the penis” is a useful mindful practice. Regular conscious exercises get our bodies more ready and able for the joyous abandon of love making.

And, like Hester, Pierre’s parting challenge to me is this: practice your pelvic floor rehabilitation exercises while you have at least a partial erection. But where do I find this erection while suffering from ED? I’ll keep you posted on progress.

[See also Yoga for the Penis, Part 1 – Penile rehabilitation and Part 3: Integration of exercise and arousal and Pierre Röscher’s research study invitation to South African prostate cancer survivors]