In a male patient with chronic unwanted sexual arousal (hyperstimulation), low libido, poor self‑image and depression, will pelvic‑floor physical therapy restore normal, controllable sexual arousal?

Pelvic Floor Physical Therapy for Chronic Unwanted Arousal and Low Libido in Men

Pelvic floor physical therapy may help restore normal sexual arousal in men with chronic unwanted hyperstimulation and low libido, but it should be combined with testosterone assessment, mental health referral, and medication review for optimal outcomes. 1, 2

Primary Treatment Approach

The initial management should follow this sequence:

1. Measure Morning Testosterone Levels

• Obtain morning serum total testosterone as the first-line laboratory test 2
• If morning total testosterone is <300 ng/dL, diagnose hypogonadism and initiate testosterone replacement therapy (intramuscular, transdermal, or oral formulations) 2
• Testosterone therapy can relieve symptoms of low desire in hypogonadal men 2

2. Review All Current Medications

• Identify and modify any prescription or over-the-counter medications that may suppress sexual desire or contribute to dysfunction 1, 2
• Consider dose adjustment, replacement, or staged cessation of offending medications 1, 2
• Common culprits include hormone therapy, narcotics, and serotonin reuptake inhibitors 1

3. Address Psychological Factors

• Screen for anxiety, depression, relationship issues, and substance use, as these commonly contribute to sexual dysfunction 1, 2
• Refer to a mental health professional with expertise in sexual health for all men with hypoactive sexual desire disorder, as psychotherapy addresses psychological barriers and inhibitions that interfere with sexual excitement 1, 2
• Psycho-behavioral strategies enhance psychosexual arousal and remove barriers to sexual excitement 1

Role of Pelvic Floor Physical Therapy

Evidence for Efficacy

• Pelvic floor physical therapy (pelvic floor muscle training) may improve sexual pain, arousal, lubrication, orgasm, and satisfaction 1
• Many patients with sexual dysfunction have associated pelvic floor dysfunction that can be treated with pelvic physical therapy 1
• A study of 34 gynecologic cancer survivors found that pelvic floor training significantly improved sexual function 1

Important Caveats

The evidence base for pelvic floor therapy in male sexual dysfunction is limited and primarily derived from female populations and cancer survivors 1. The chronic unwanted arousal (hyperstimulation) described in this patient is not a typical indication addressed in the guidelines, which focus more on erectile dysfunction, delayed ejaculation, and orgasmic problems 1, 3.

Behavioral Modifications (Essential for All Patients)

• Smoking cessation 2
• Weight loss if overweight or obese 2
• Regular physical activity and aerobic exercise 2
• Limiting alcohol consumption 2
• Modifying sexual positions or practices to increase arousal may benefit some men 1

Partner Involvement

• Include partners in treatment discussions and therapy, as this is beneficial for outcomes 2
• Encourage ongoing partner communication 1
• Consider couples counseling or sexual therapy referrals 1

Realistic Expectations

The prognosis for sexual desire disorders is generally poorer than for other sexual dysfunctions, with long-term success rates of 40-80% for inhibited male orgasm and the poorest outcomes for sexual desire disorders 4. This patient's presentation—combining chronic unwanted arousal with low libido and poor self-image—represents a complex clinical picture requiring multimodal treatment rather than pelvic floor therapy alone.

The combination of testosterone optimization (if deficient), mental health intervention, medication adjustment, lifestyle modification, and pelvic floor therapy offers the best chance for improvement 1, 2. However, pelvic floor therapy alone is unlikely to resolve the constellation of symptoms described, particularly the psychological components of poor self-image and depression 1.