[Physio Explained] Men’s pelvic health: practical tips for clinicians with Dr David Cowley

In this episode, we discuss everything about men’s health. We explore: 

• Applications for diagnostic ultrasound in men's pelvic health
• Physiotherapy for post prostatectomy patients
• Role of manual therapy in men’s health
• Upskilling in men’s health physiotherapy

Want to learn more about men’s health? Dr David Cowley recently did a brilliant Masterclass with us called “Pelvic Health in Men: Practical Approaches for Physiotherapists” where he goes into further depth on this topic. 

👉🏻 You can watch his class now with our 7-day free trial https://physio.network/masterclass-cowley

Dr David Cowley is a clinician-researcher specialising in men’s pelvic health. He works as a Postdoctoral Researcher at the University of Queensland and as the Men’s Health Clinical Stream Leader at Active Rehabilitation Physiotherapy. He completed his PhD at the University of Queensland, where his research focused on male pelvic floor biomechanics and their role in urinary continence. Alongside his research and clinical practice, David teaches Men’s Health Physiotherapy across the University of Queensland, Australian Catholic University, and Griffith University.

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Our host is @Sarahyule from Physio Network

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Transcript

SPEAKER_02 0:05

Some really great preliminary research. I'm going to shout them out a lot today. I think I do in the masterclass. But again, my colleagues, Paul Jesus and Ryan Stafford, looked at these different muscles in in great detail in a post-prostatectomy incontinence population, and they found that the guys who had the best striatig urethral sphincter function tended to have the highest probability of recovery of continence after their surgery. And so I think it's the staple patient that the pelvic health clinician will see in a male population will be the post-prostatectomy incontinent patient. The wonderful thing about transparineal ultrasound is it allows us to evaluate the function of that striatig urethal sphincter.

SPEAKER_00 0:45

Welcome to today's episode of Physio Explained. In this episode, we unpack how ultrasound can be used beyond post-prostatectomy incontinence, how manual therapy fits into managing male pelvic pain, and where the future of male pelvic health is heading. To explore all of this, we're joined by David Camley, one of Australia's leading clinicians and researchers in male pelvic floor function. David is a senior physiotherapist and the men's health clinical stream leader at Active Rehabilitation Physiotherapy and a postdoctoral research associate at the University of Queensland. His PhD investigated how body position, breathing, prostatectomy, and electrical stimulation influence pelvic floor muscles in men, and he has published extensively on male pelvic floor biomechanics, neuromuscular control, ultrasound assessment, and EMG. David not only treats men with complex pelvic health conditions day to day, but he has also helped shape clinical guidelines, led service development, collaborated with urologists and surgeons, and presented at major international and national conferences. He's someone who deeply understands both the science and the real-world clinical application, which is exactly why this conversation is so valuable. David has done a fantastic masterclass with Physio Network titled Pelvic Health in Men: Practical Approaches for Physiotherapists, where you can dive much deeper into this area than we were able to do in today's episode. So be sure to click the link in the show notes to watch David's masterclass for free with our seven-day trial. You're going to love today's episode with many practical insights from David. Let's jump into it. I'm Sarah Yule, your co-host, and this is Physio Explained. Welcome, David. Thank you for joining us today.

SPEAKER_02 2:29

Awesome. Thanks so much for having me, Sarah, and big shout out to the whole Physio Network team. You've all been so lovely and kind and helpful in getting a lot of this content over the line. So I'm really excited.

SPEAKER_00 2:39

Marvellous. Well, you've done a tremendous masterclass with us today. So your masterclass is titled Pelvic Health in Men: Practical Approaches for Physiotherapists. So I'm going to dive into the first question, which is what are the under-recognized applications of ultrasound in male pelvic health patients that musk physios should know?

SPEAKER_02 3:01

Yeah, great question, Sarah. I'm not going to hide away from it. I'm a massive ultrasound fan, as I'm sure many musculoskeletal physios are. Look, the applications are varied. And I think what's really cool about ultrasound as a tool is it allows us to provide in a really non-invasive way different perspectives on how the bladder's moving, how the urethra is moving, how the anus and the rectum are moving. And thanks to a lot of the work, a lot of the early work done by my colleagues, especially Paul Hodges and Ryan Stafford, over the last particularly 15 years, we've learned that there are some really, really cool validated measures we can make from ultrasound, particularly transparineal ultrasound, which lets us evaluate the function of three muscles in particular, but the striatage urethral sphincter, bulbocavinosis, and puberectalis. Those are the three kinds of muscles we spend, I spent my whole research career really looking at in particular. But a lot of that was built off the back of some earlier transabdominal ultrasound work that was really still really helpful and foundational and allows us certainly to have a particular view of the bladder that might be helpful in some contexts, but may not provide quite as comprehensive a view as the transpirineal approach. So I guess in terms of underappreciated, I think transpirineal could always be used more broadly. It allows us to evaluate functioning in guys with pain, guys with incontinence, guys with urgency and frequency disorders. And we've been using it a lot more recently in bow patients, especially when we're maybe not thinking so much about classical up training like we might normally in the continence and bladder disorders, but maybe more about downtraining, which is something that's more helpful. We talk about this a lot in the masterclass, but something that's especially helpful in the pain and the constipation, bowel obstruction kind of population. So I'm a massive ultrasound fan, and I guess I think it can be used in any context, but being specific, I think really primarily up training for continence disorders, and then probably down training more in the pelvic pain and bowel population.

SPEAKER_00 4:59

Fantastic. So it sounds like it can help clinicians understand how they recruit or compensate with muscles.

SPEAKER_02 5:06

Exactly, and how certain techniques might be used. So to be provide more specificity, some really great preliminary research. I'm going to shout them out a lot today. I think I do in a masterclass. But again, my colleagues, Paul Loggers and Ryan Stafford, looked at these different muscles in in great detail in a post-prostatectomy incontinence population. And they found that the guys who had the best striatage urethral sphincter function tended to have the highest probability of recovery of continence after their surgery. And so I think it's this the staple patient that the pelvic health clinician will see in a male population will be the post-prostatectomy incontinent patient. The wonderful thing about transpirineal ultrasound is it allows us to evaluate the function of that striatage urethral sphincter. And I think more and more we're seeing clinicians trained. There's more opportunities for training. And so as a result, there's more and more uptake as well. A lot of the early work was also done by a great great physiodist, Sydney called Stuart Paptist, who has even done some research looking at the learning curve and the ability to perform the technique and evaluate some of the measures you're looking at at the same time. So yeah, it's it's a wonderful technique for that staple patient that you're seeing, the post-prostatectomy incontinent patient, but more and more, particularly in our clinic at active rehabilitation and hopefully in some research in the future, we've been using it as a means to evaluate the function of puberctalis. So a common symptom, or how can I say this, a common cause of constipation in everyone, but in males, particularly in our demographic, is guys who have defecatory dysnergia. So they tend to recruit, especially their puberctalis, during attempted defecation rather than relaxing it. So dysynergia meaning kind of discoordinated, inappropriate use of muscles. So normally pubarrectalis should relax to enable defecation. But in some of these men with constipation, they've learned to either maintain or even increase the contraction through that muscle. So we can actually, on ultrasound, teach them how to relax this muscle. And they've got that wonderful kind of visual biofeedback where they can actually see perhaps what they are doing and that dysynergic pattern where the muscle shortens when they try and defecate, and we can show them how to actually lengthen the muscle, which is a habit they can then establish in the long term. And that'll prevent things like hemorrhoids, fissures, and ongoing sequilae of constipation in the long term as well. So yeah, I think it can be used for, like I said, continence or disorders, which is the bulk of what we have seen historically. But as we move more into the space around bowels and maybe pelvic pain even as well, we can use it as a downtraining tool, which I love.

SPEAKER_00 7:37

Sounds like a really powerful biofeedback tool.

SPEAKER_02 7:40

Yeah, yeah, I love it.

SPEAKER_00 7:43

So my next question then is where does manual therapy fit in the mix? Because I know a lot of your research, you've contributed to research on muscle tone, overactivity, electrical stimulation, pelvic pain syndromes. So where does it fit and which presentations respond best? And just talk to the upskilling component from a physio perspective as well in that.

SPEAKER_02 8:07

Yeah, that's so important, isn't it? So again, if we're thinking about disorders in terms of what your goal as a therapist is, what you're trying to achieve with the muscles. So thinking, like I said before, again, your continensaw disorders, you're thinking about up training those pelvic floor muscles. Whereas perhaps with disorders like I've just described, constipation and dysynergia, where there might be either inappropriate or increased muscle tone or activity. Manual therapy, I think, can play a role in the bowel disorders, but also pain. So there was this wonderful study. I talk about it every every presentation I ever do, just about, but I talk about it a lot in the masterclass by Anderson and colleagues. It's not recent, but it was wonderful. 2009, I think it might have been. They examined all these different men who met the criteria for chronic pelvic pain syndrome, and they are able to reproduce symptoms of pain in in different parts of the pelvis, so penis, scrotum, testes, groin, with palpation of different abdominal and pelvic floor muscles. It wasn't an interventional study, it was purely an observational study. It was just to kind of demonstrate that perhaps we can recreate these symptoms through muscle palpation. And then more recently, was very, very lucky to be involved with a systematic review I did last year with a physio from Melbourne called Ryan Homp, who's done some great work with his supervisor, Adam Semchew, looking at physio interventions. I think the paper says conservative interventions, but I think in my mind they're kind of one and the same in Australia for chronic pelvic pain syndrome. And we're actually able to pick out a couple of studies where they kind of did do a classic physio intervention where I don't think there were any which just did manual therapy, but many which did manual therapy and or sorry, a few that did manual therapy and exercise concurrently. And I think we found that there there was significant improvement in the studies where manual therapy and exercise were compared to a control group, which is really, really reassuring. And there hasn't been a lot of manual therapy research in this space. I suspect because, like in all areas of physio, we talk about manual therapy as both a science and an art. So if someone if someone's better at manual therapy than someone else and they're on the same trail, that can definitely influence results. Whereas if someone, as you were kind of alluding to, Sarah, if someone has had that additional training and had those years of experience, perhaps their ability to provide a more targeted, effective intervention is going to be more demonstrative of the effects of the intervention. I think all that is to say is that certainly we're seeing developing evidence for manual therapy in the pelvic pain space, and there's already some evidence appearing. In terms of bowels, there was a systematic review released just this year, which included a meta-analysis where they didn't look so much at manual therapy of the pelvic floor, but there was enough evidence to perform meta-analysis of abdominal massage, which is, I think there's been a lot of research done over the years into abdominal massage and how it can affect constipation. They found some really reassuring improvements. They found that the gut transit time was reduced, they found that defecations per week increased, and they found the overall bowel function improved in response to abdominal massage. So, yeah, so not something that we would necessarily think of as a first-line treatment, but their recommendation in this paper was that, and I talk about this a lot in the masterclass, of course, their recommendation was that the abdominal massage was included as a first-line intervention for constipation, which is really cool because it's a a series of techniques with the right training, as you say. Certainly, physios can affect and use to improve symptoms in this space.

SPEAKER_01 11:42

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SPEAKER_00 12:10

That's fantastic research. Just on that training piece, for the say the new grad physio listening, what do you recommend in the way of upskilling and what that should look like?

SPEAKER_02 12:20

So I'm fortunate enough to teach some of the content at a couple of universities here in Southeast Queensland. And what we aim for at an undergraduate level in the in the male pelvic health space is providing one skill that I think is really helpful that they can apply to different presentations. And that skill is usually transabdominal ultrasound. So as I mentioned before, not as specific, doesn't allow you to see as much as transparental ultrasound, but the learning curve isn't particularly steep. And I think you probably can learn the skill within an one two-hour prack, which is often all we're all we're allotted within the syllabus. So I think as a starting point, my hope is that within the next 10 years, every physiograduate in Australia will have that as a minimum. Beyond that, there's the opportunity to engage in courses. Now, there have been several attempts over the last few years to redesign, and a lot of this is still ongoing. Redesign the Australian Physio Association course. There are a lot of private courses available, more and more private courses, I should say, available in Australia in particular and worldwide as well. America have their wonderful academy within the APTA. So the skills that are learned there are far beyond what I'm capable of. But I would love to do a series of their courses one day in terms of manual therapy. There's no equal for what they're what they're doing over in the States, which is wonderful. But fortunately, a couple of our physios who now reside in Australia are offering courses based on what they've learned in those courses in the American Academy. So I feel fortunate I was trained by a PhD colleague, Rachel Warman, who was one of the trainers for the APTA in America. So she was fortunate enough to train me. So I feel very lucky, but she's now moved back to California from the completion of her PhD, unfortunately. But yeah, there are more and more courses available. And my hope is that there'll be more consensus amount and a clearer pathway among different levels and a kind of a stepwise approach to skill development, is my thinking.

SPEAKER_00 14:13

Yeah, fantastic. So you've alluded to the ultrasound forming a part of our practice from a transabdominal perspective. Are there any other changes that you'd hope to see in the pelvic health space over the next decade?

SPEAKER_02 14:27

Lots. Yeah. So I was quite fortunate last year, briefly, I worked in a Queensland health role. And as far as I know, I think that was the first time there was a male, male pelvic health physiotherapist. And I'm a big believer that irrespective of any gender, anyone can work in this space. But it was nice, I suppose a male pelvic, not male, not me, male as inpatient, pelvic health physio-protected role within the government, which it was only part-time. But certainly these have begun to pop up. There was one available, I think, somewhere in Melbourne. And more recently, there's been some at certain hospitals in Sydney. And so I think that's what I would like to see. Perhaps a bit more mainstream recognition and protected roles within the public sector. Because at this stage, unfortunately, certainly in Queensland, I'll speak to my experience within Queensland. We have lots of wonderful therapists within Brisbane, fortunately. And I think this is true elsewhere in Australia, but most of the most of the game is private, unfortunately, it being prostatectomy, post-prostatectomy patients forming the bulk of the caseload. And these are often done through private hospitals, through private urologists. So unfortunately, it still seems that that's the pathway. But my hope is that as we continue to broaden our scope, I've talked a lot surprisingly today about bowels. I think it's because I feel so passionately about it. My hope is we can treat more and more. We can start treating varieties of bowel conditions, overactive bladder. We can continue and develop our skill set within treating urgency and frequency disorders. A lot of these outpatient screening clinics are popping up around Queensland Health and I'm sure well established elsewhere in the country as well, where we have a physio being the first person to treat a patient presenting with back pain. And certainly in a few hospitals, we're seeing that within a pelvic health space as well. And so I guess my hope is that at an undergraduate level, we develop the skill set to create clinicians who have, like I said, a bare minimum skill set so that if they come across a male pelvic pain patient or male pelvic health patient, they can treat them, scaling all the way up to specialist positions protected at a high level for treating these patients and often being a first contact practitioner within the hospital setting, within the outpatient hospital setting as well. So I dream of growth at all levels from undergraduate up to the pointy end. Those are the changes I hope to see. And your last question was a wonderful segue into this. The way we do that is by developing skill sets at all levels in the undergraduate training, which we're doing more and more and more of, and I'm so grateful for. But also I think just becoming a bit more streamlined with the process of upskilling, because I think we're not there yet, and we can become a lot more consistent. And the stepwise approach to upskilling within the pelvic health space was key to a lot of the changes I've described.

SPEAKER_00 17:13

Well, I think that creates a wonderful segue to me talking about your masterclass. For everyone listening, if you'd like to deepen your understanding and start applying these principles straight away, I think it's crucial that you check out David's Physio Network Masterclass. It distills his research, the clinical frameworks, the assessment tools into a really useful and clinically translatable resource. So, David, thank you so much for this conversation. I think it's such a crucial area, and your work is definitely pushing the field forwards in ways that will hopefully change patient outcomes.

SPEAKER_02 17:47

Thanks so much for your time, Sarah. It's been such a pleasure to talk about this stuff. I could talk about it and monologue and sylloquise forever. So thank you for tolerating all that. I really, really, clearly, really enjoyed it. So thank you.

SPEAKER_00 17:58

We love the passion.