Should Masturbation Be Discontinued Until After Pelvic‑Floor Physical Therapy?
No—masturbation does not need to be discontinued during pelvic‑floor physical therapy for chronic pelvic‑floor hypertonicity and post‑fistulotomy pain; instead, the patient should begin immediate supervised pelvic‑floor therapy focused on relaxation training (not strengthening), continue for at least 3 months, and may resume sexual activity as tolerated once therapy teaches proper pelvic‑floor relaxation techniques.
Rationale for Continuing Sexual Activity During Therapy
Pelvic‑floor physical therapy is the gold‑standard first‑line treatment for pelvic‑floor hypertonicity and dyssynergia, achieving success rates exceeding 70 % when applied correctly 1, 2.
Sexual activity—including masturbation—is not contraindicated during pelvic‑floor therapy; rather, the therapeutic goal is to restore coordinated pelvic‑floor relaxation that will ultimately improve sexual function 3, 2.
Restricting sexual activity offers no therapeutic benefit and may worsen anxiety, which is an independent predictor of poorer biofeedback outcomes 1.
The American Cancer Society and American Urological Association guidelines emphasize discussing sexual function openly with patients and addressing dysfunction through rehabilitation rather than avoidance 4.
Immediate Treatment Protocol: Relaxation‑Focused Pelvic‑Floor Therapy
Core Therapeutic Principle
The pathology in chronic pelvic‑floor hypertonicity is paradoxical pelvic‑floor contraction (dyssynergia), not weakness—therefore, relaxation training is the primary goal, not strengthening exercises 1, 5.
Traditional Kegel exercises (strengthening) are contraindicated in patients with pelvic‑floor hypertonicity because they worsen symptoms 5.
Supervised Biofeedback Component (In‑Clinic)
Initiate supervised pelvic‑floor physical therapy with biofeedback using anorectal or perineal probes that provide real‑time visual feedback of pelvic‑floor muscle activity 1, 5.
Biofeedback sessions should occur 1–2 times per week during the initial 4 weeks, then every 2 weeks through week 12, followed by monthly or as‑needed visits 1, 5.
The therapist must be trained in anorectal physiology and have access to specialized biofeedback equipment; most general pelvic‑floor therapists lack this training, so referral to a gastroenterology‑affiliated pelvic‑floor center or specialized urogynecology practice is advised 1.
Home Exercise Protocol
Perform daily home relaxation exercises focusing on isolated pelvic‑floor muscle contractions held for 6–8 seconds with 6‑second rest periods, repeated 15 times per session, twice daily for approximately 15 minutes each session 1, 6, 5.
Maintain normal breathing throughout exercises—never hold your breath or strain to avoid the Valsalva maneuver 6, 5.
Isolate only the pelvic‑floor muscles without contracting the abdomen, glutes, or thighs 6.
Continue this home exercise program indefinitely; long‑term adherence sustains therapeutic benefits, and programs that mandate home exercises achieve success rates of 90–100 %, whereas omission of home training markedly reduces long‑term success 1, 5.
Adjunctive Measures to Support Therapy
Constipation Management (Critical)
Aggressive management of constipation is essential throughout therapy because ongoing straining reinforces dyssynergic patterns that impair pelvic‑floor relaxation 1, 5.
Constipation treatment may need to be maintained for many months before the patient regains bowel motility and rectal perception; discontinuing treatment too early is a common pitfall 5.
Ensure adequate fluid intake and dietary fiber to support overall pelvic‑floor function 1.
Toilet Posture and Lifestyle
- Adopt proper toilet posture with foot support and comfortable hip abduction to reduce inadvertent pelvic‑floor co‑contraction during voiding or defecation 1, 5.
Topical Therapies for Perianal Pain
Use topical lidocaine for persistent perianal pain or discomfort; this can be applied as needed without interfering with pelvic‑floor therapy 4, 5.
Vaginal moisturizers and topical vitamin E may address concurrent dryness or irritation that exacerbates sensory changes 1.
Sexual Function Considerations
Expected Improvements
Pelvic‑floor physical therapy that incorporates sensory retraining can restore altered pelvic sensation and improve sexual arousal, achieving success rates exceeding 70 % when applied correctly 1.
In patients with pelvic‑floor dysfunction, pelvic‑floor physical therapy improves sexual pain, arousal, lubrication, orgasm, and overall satisfaction 1.
The National Comprehensive Cancer Network explicitly recommends pelvic physical therapy for male cancer survivors experiencing orgasmic difficulties (including reduced intensity and difficulty achieving orgasm) 1.
Counseling on Sexual Activity
Patients should be counseled that sexual activity—including masturbation—can be resumed as tolerated once therapy teaches proper pelvic‑floor relaxation techniques 4.
Sexual intimacy should be encouraged; couples should be instructed to discuss their sexual intimacy and referred to counseling or support services as appropriate 4.
If erectile dysfunction persists despite successful sensory restoration through pelvic‑floor therapy, the addition of phosphodiesterase‑5 inhibitors (e.g., sildenafil, tadalafil) is advised as a secondary intervention after a minimum 3‑month trial of sensory‑retraining biofeedback with documented adherence 1.
Alertness for Night Driving
Pelvic‑floor physical therapy does not impair alertness or cognitive function and is safe for patients who need to maintain alertness for night driving 1, 5.
Avoid anticholinergic medications (e.g., oxybutynin) for urgency symptoms until after pelvic‑floor physical therapy has been attempted, as anticholinergics can cause sedation and impair driving safety 5.
If pharmacologic therapy becomes necessary after failed conservative management, selective serotonin reuptake inhibitors or gabapentin may offer symptom relief with less sedation than anticholinergics, though these are not FDA‑approved for pelvic‑floor dysfunction 4.
Predictors of Success and When to Escalate
Favorable Prognostic Indicators
Patients with less severe baseline dysfunction tend to respond more favorably to sensory‑retraining biofeedback 1.
Intact continence (preserved sphincter function) predicts favorable outcomes 5.
Patient willingness to engage in therapy is associated with higher success rates 5.
Poor Prognostic Indicators
Depression is an independent predictor of poorer biofeedback efficacy; concurrent treatment of mood disorders improves outcomes 1.
An elevated first rectal sensory threshold volume is an independent predictor of reduced efficacy of sensory‑retraining biofeedback therapy 1.
Escalation Criteria (After Full 3‑Month Trial with Documented Adherence)
If symptoms do not improve after ≥ 6 months of supervised pelvic‑floor physical therapy with documented adherence, consider additional interventions 4, 5:
- Topical lidocaine for persistent pain or dyspareunia 4, 5
- Cognitive‑behavioral therapy to manage anxiety or other psychological components 4, 5
- Vaginal dilators if penetration remains painful 4, 5
- Low‑dose vaginal estrogen in postmenopausal patients with atrophic changes contributing to altered sensation 4
Surgical or invasive procedures should not be pursued before completing an adequate trial of pelvic‑floor physical therapy with sensory retraining; conservative therapy is the first‑line recommendation, with surgery reserved only for structural complications unresponsive to biofeedback 1.
Common Pitfalls to Avoid
Do not prescribe traditional Kegel strengthening exercises for pelvic‑floor hypertonicity; this worsens symptoms 5.
Do not discontinue constipation management prematurely; treatment may need to be maintained for many months 5.
Do not refer to a general pelvic‑floor therapist who lacks specialized biofeedback equipment and training in anorectal physiology; outcomes will be suboptimal 1.
Do not advise sexual abstinence; this offers no therapeutic benefit and may worsen anxiety 1.
Do not prescribe anticholinergic medications before attempting pelvic‑floor physical therapy; these agents mask urgency symptoms but do not treat the underlying pelvic‑floor muscle hypertonicity and can impair alertness for driving 5.