Kim Vopni (00:01.924)
Hi Lance, welcome so much. Let me start that again. Hi Lance, thank you so much for joining me. Welcome to Between Two Lips. I have been watching you on social media for quite some time and I really wanted to have you on the podcast because you speak more to the male population but I get asked all the time from the women in my community, will this work for my husband? Will this work for my partner? And of course, men have pelvic floors too.
And so I really wanted to have you on to address, even though I work in women's health, I'm the vagina coach, I needed to have somebody who was more of the penis coach. And so I wanted that to be you. So welcome. If you can please start out by telling the listeners who you are, what you do, and then we'll jump into a couple of questions I have for you.
Lance Frank (00:31.863)
now.
Lance Frank (00:41.774)
Thank
Lance Frank (00:54.306)
Yeah, perfect. well, first and foremost, thanks for having me. I'm excited to be here. I've been following you for a while too. So whenever this opportunity came up, I was very excited to be asked, I might change my handle to the penis coach now. but no, my name's Lance Frank. I grew up, I'm here in the States in the United States. I grew up originally from Missouri and I moved to Atlanta back in 2014 and
I've been here ever since I went to PT school at Emory University and got my doctorate degree and I decided to stay and after a few years set up my own shop. And so I treat, you know, pelvic floor dysfunction. I'm a pelvic health physical therapist, but my niche within a niche, if you want to call it that is men's pelvic health. so
You know, my whole mantra is that like, feel capable to treat everything that comes in the door, whether it's a penis or a vagina or trans or non-binary person. feel comfortable with all genders, but really my target population is somebody who has a penis or a prostate. And so that's primarily what I treat here in the clinic. I pelvic floor dysfunction and primarily people with penises and everything from
urinary dysfunction, bowel dysfunction, sexual health issues, and just general kind of pain complaints. I dabble in orthopedic, just general kind of orthopedic stuff, hips, knees, shoulders, all that kind of stuff. But most of, I would say 80 % of my caseload, 90 even, is people, are people with different pelvic floor dysfunction issues.
Kim Vopni (02:31.263)
And you're a rare breed. don't know if, and actually I know one in Vancouver where I am, there's one male pelvic floor PT. There are women pelvic floor PT's who do treat men, but there's not a lot of male pelvic floor PT's. So I guess what brought you into wanting to specialize in this area when you were going through PT school?
Lance Frank (02:55.426)
I'm not going to lie. I didn't have any interest in pelvic health when I was going through when I was going through PT school. because in my program and at that time in the part as in part of our curriculum, there was only one lecture and one lab that talked about pelvic floor dysfunction and it was all about postpartum women. And I, you know, I treat that population now even to this day, but that's not what gets me excited about pelvic health. And so in PT school, I was like, if this is all pelvic health is like,
No, thank you. And then it was during my orthopedic rotation where my instructor mentor at the time, she was a dual pelvic ortho sports PT. so half and half of half of her caseload was ortho half of her caseload was pelvic. And so that's really kind of where the seed got planted of pelvic health because she at the end of that clinical
told me after graduation, which was a year later, if I wanted a job, she'd hire me. But she was like, you know, she had just started her own cash practice and she was like, I think that you have what it, you would have the makings of a good pelvic health therapist, but I want to, how would you feel about dabbling in men's pelvic health? There aren't many men that do this work and there are a lot of men that need help. And so like from a marketability standpoint, like you would
have cornered the market essentially. And I was like, I mean, it's not exactly where I saw my career going, but I'm open to it. And so I took the first Herman and Wallace pelvic floor course. And that was really when it solidified. was like, wow, like there's just a lot of people out there that need help. And there aren't many people that look like me in terms of having a penis or identify as man, as a male.
Kim Vopni (04:22.445)
.
Lance Frank (04:49.656)
that are in this field. And so it just felt like a huge barrier gap in healthcare for men that want a male provider. And so that was really kind of what ignited it. And ever since then, I've just kind of furthered down this path and it just keeps getting more and more specific.
Kim Vopni (05:09.185)
Yeah, yeah.
So I guess if we can highlight aside from vagina penis, what are the differences in the male pelvis versus the female and the pelvic floor male versus female?
Lance Frank (05:24.846)
So, I mean, aside from the genitalia themselves, the external genitalia, the pelvic floor musculature itself is pretty similar actually. The bulbocavernosis and the bulbospongiosis and the ischiocavernosis, they're all the same. They're just oriented a little differently. And so rather than the two, you know, bulbospongiosis, ischiocavernosis forming a canal in a vagina,
they wrap around the shaft, the base and a penis. So that's really the only difference. And then a couple, there's like two or three urinary muscles that women have that men don't have because of the extra urethral length that we have. We don't necessarily need extra support, but that's really the only difference. And so whenever I'm having this conversation with patients, and as part of my like initial spiel, I'm always like, you know, people with penises have 12 muscles, people with vaginas have 14.
They play the same function, they're just oriented slightly differently, but we have very similar musculature.
Kim Vopni (06:30.833)
Got it. And the male pelvis is a little narrower and like from a bony perspective, the hips are a little bit higher, so to speak, it orientation compared to female. Is that correct?
Lance Frank (06:43.47)
Yeah, the bones themselves are a little bit more dense. They're not as wide because we obviously don't have the anatomy to bear children. And yeah, they're just a little bit more narrow.
Kim Vopni (06:56.878)
Yep, yep. Okay, so what then in terms of pelvic floor dysfunction in a male population, what are the most common types of pelvic floor dysfunction? And then we'll get into contributing factors after that.
Lance Frank (07:11.566)
I would say the most common diagnosis that I see here in my clinic is one that's called prostatitis. I'll elaborate a little bit more on that, but prostatitis, erectile dysfunction, urinary urgency, frequency, kind of like that overactive bladder presentation. I see a lot of testicular pain.
premature ejaculation is one that I see primarily, but I would say those are the most common diagnosis, diagnoses that I see here in the clinic. Heart flaccid is another common one. but in general, you know, we can have, you know, people with penises can have the same issues as women aside from, you know, postpartum child bearing issues, but you know, urinary urgency, frequency, waking up in the middle of the night to pee.
Kim Vopni (07:56.377)
Yep.
Lance Frank (08:04.238)
pain with urination, dribbling is another common one that I see here in the clinic. Constipation, hemorrhoids, fissures, pain with bowel movements. From the sexual, like health dysfunction issues usually, like I said, erectile dysfunction, pain with erections, pain with ejaculation, premature ejaculation. I worked with a couple guys that have had anorgasmia or delayed ejaculation.
Kim Vopni (08:21.052)
.
Lance Frank (08:33.42)
I also self identify. very open about my sexuality and I identify as gay. And so a good chunk of my caseload is also other gay men that have pain with receptive penetration. But obviously everyone has a rectum regardless of sexuality. And so there are people that I work with regardless of being gay or straight that also have pain with receptive anal penetration. So that's something that I work with. And then the general kind of pelvic pain.
Paraneal pain, low back pain, SI joint pain, outer hip pain, all that kind of pelvic, low back, hip area pain is pretty common too.
Kim Vopni (09:11.562)
Yeah, yeah, there's a lot of similarities and a lot of
a lot of what the female population deals with, the male population deals with as well. Of course, again, you're taking out the pregnancy, childbirth perspective and prolapse is one, there's rectal prolapse, but in terms of the other like cysticel, recticell type things that women, obviously that's not gonna happen. So I wanna dive into a few of those, but what would you say?
Like you've mentioned a lot. So what could be contributing factors to, I mean, we talked about a lot, so there's gonna be a lot of contributing factors, but what do you see? Let's talk about urinary urgency, frequency, kind of the urinary piece first. What are some of the more common contributing factors to that in the male population?
Lance Frank (10:02.862)
I kind of want to come at it from a different approach if you don't mind. Instead of addressing urgency or frequency first, I think just in general, this is again my general spiel to patients when they come in. It's a very watered down explanation, but patients either come in with what we call an underactive pelvic floor or an overactive pelvic floor. You know this, but an underactive pelvic floor, this is typically...
most of the time what patients think of whenever they think of pelvic floor PT. These are the patients that are postpartum. They have a little bit leaking. They might have some sort of organ falling out, like as you mentioned, a prolapse. They just need a little bit more strengthening and coordination with the pelvic musculature. But most of the patients that come into my clinic because of, I would have to assume because of just the male anatomy, come in with an overactive pelvic floor. And so these, most of my guys are just like gripping the hell out of their pelvic floor all day long.
And that in and of itself can just contribute to urinary issues, bowel issues, sexual issues, and just pain complaints. so most people come in with that overactive, just tightly wound pelvic floor. you know, when I'm talking to patients about like, how did, like, because they always ask, well, how did this happen? Like, how did, how did this just like, how did I wake up one day and had pelvic floor dysfunction? Well, you probably didn't. there, you know, lifestyle stress?
I see so many CrossFitters, not to like poop all over CrossFit, but like I see a lot of power lifters that just are so strong in their pelvic floor, but they have no idea how to relax anything. so surgeries, traumas, sexual assaults, you know, there's a huge, I would argue a huge psychosocial aspect to a lot of the patients that I work with and their overactivity.
Kim Vopni (11:33.973)
You
Kim Vopni (11:40.284)
.
Lance Frank (11:56.078)
And so when we're going back to your question about urgency and frequency, you know, a lot of my patients have this like anxious pattern of feeling like the urge that they need to pee, going to the bathroom to get rid of the urge. And then it's this like repetitive cycle of feeling the urge going, feeling the urge going, and not really as you, I don't want to assume what you do and don't know, but as you know, when we, they're not just not giving their bladder time to expand and fill and adapt. And so, um,
Kim Vopni (12:10.603)
.
Lance Frank (12:25.774)
It's just a lot of bladder retraining and kind of calming the nervous system and easing some of that anxiety and just learning better behavioral patterns that aren't serving their symptoms well.
Kim Vopni (12:38.996)
Yeah, and that's so, you could have been talking about the female population and more and more women are also dealing with the same thing with tightness and the afraid of leaking or the vulnerability from prolapse or the over exercising. All of those are very similar contributors. So when you're thinking of that population in terms of down regulating the nervous system and giving them the...
tools to learn how to relax, to trust that the bladder has time to fill and what sort of lifestyle recommendations, posture, pelvic floor cues, what are you giving to them to help them through that process?
Lance Frank (13:20.738)
Yeah, I would say I always joke with my guys. I'm like, it's not mind over matter, it's mind over bladder. And you have to retrain your bladder to do the job that it's meant to do. And so I always use the analogy of a crying kid in a candy store. If you just buy your kid candy, your kid's gonna learn that if it throws a fit, it's gonna get what it wants. And so the bladder is the exact same way. so I have a lot of patients that are
like, well, I heard, thought it was bad to hold your bladder. I thought that was, you you weren't supposed to do that. And to a certain extent, yes, but like, we don't need to go to the bathroom every time we feel the urge because then, you know, it leads to this overactive, overactive bladder condition. so one of the things that I always first teach, I have patients do is a bladder diary and just have them track their symptoms. And so that we can kind of get a, a,
range of normal for them like what a day of their life looks like and then we talk about you know substances or drinks or food that might irritate their bladder bladder irritants and Just I always tell patients, you know I'm not telling you that you can't have your morning cup of coffee or you can't have your your cup of tea at night but maybe Sandwich it with a glass of water before and after or at least after to help dilute it a little bit So it's not as irritating to the bladder
Kim Vopni (14:35.252)
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Lance Frank (14:47.118)
And then we talk about, give them the data that, know, what is quote unquote normal bladder norms for people, you know, six to nine times during waking hours, zero to maybe once an overnight, unless you're over the age of 65 or have some sort of prostate condition. And a two to four hour timeframe between voids is, what I tell them. You know, like if you're going more than two hours, we would consider that, you know,
something is happening with the bladder that needs to be addressed. And if you're going more than four hours, you're probably dehydrated. And so I usually tell them like, we're gonna track your time. I want you to be as detailed as possible, pick two days and just be as diligent as possible with your voids. And so that we can get a snapshot of a day in your life and start to look at different behavioral patterns that you might be doing. Are you going to the bathroom because there's a bathroom nearby? Please don't do that anymore.
Kim Vopni (15:42.35)
Yeah, yeah, 1000%, very aligned in terms of the education and kind of recommendations I'm giving to people. Would there be any
Lance Frank (15:42.7)
Are you going to the bathroom because you're about to leave the gym and you don't want to be in your car and have to go to the bathroom? Please don't do that anymore. So it's this like, I always tell patients, I'm not just telling you to hold it for the sake of holding it. There's science behind it, but you know, we have to start to retrain it and not give in every time we have this urge because that's not going to serve us.
Lance Frank (16:10.83)
See you later.
Kim Vopni (16:12.524)
Like that's kind of responding to the lifestyle component. Would there be anything that you would talk about from a, like are there any exercises you would give somebody to release tension on the pelvic floor?
Lance Frank (16:25.048)
So yeah, I mean, obviously the lifestyle stuff is important and that's a huge, would argue a huge part of somebody's urgency, frequency symptoms. But you know, as physical therapists, my, most common question I get is, what exercises can I do? And so again, going back to the idea that I would argue most of the patients that I work with have a more of an overactive pelvic floor presentation. I don't really want them to do a lot of strengthening work. I want them to do a lot of down training and I want them to learn how to
talk to their pelvic floor and get it to relax. Whether that's with diaphragmatic breathing and what I call pelvic drops, coordinating your breath with pelvic floor relaxation, getting into poses that are really gonna open up the pelvis, happy baby or deep squat or frog position, and then also talking to the pelvic floor in that position and getting it to release and let go through breath work.
Kim Vopni (17:21.133)
.
Lance Frank (17:22.902)
As like a home program, that's typically what I'll give patients. But in real time, when they're out living their life, I always tell them, you know, whenever that urgency symptom comes, I want you to pay attention to where it shows up in your body. And the first thing that I want you to do is just take a deep breath and try to relax your pelvic floor and see what happens. A lot of times the urgency symptom will go away. Sometimes it won't. And if it doesn't after, you know, two or three, five breaths, it doesn't go away. Then, you know, this
feedback loop between the bladder and the brain that's constantly sending signals. And whenever we do quick pelvic floor contractions, sometimes it disrupts that pathway. And so if the deep breaths and the pelvic drops don't work after that first urge hits, I'll tell them, you know, I just want you to squeeze the heart of your pelvic floor rapidly 10 times, but that's it. You're not doing a hundred. You're just doing 10 quick contractions. See what happens. If the urgency symptom is still there, you know,
Kim Vopni (17:57.783)
.
Lance Frank (18:21.144)
count backwards from 100 distraction. power of distraction is huge. And sometimes if you can just think about something else and turn down the dial of the noise that's happening from your bladder in the background, sometimes it just goes away and you don't even think about it anymore. But if after, you know, a couple of minutes, you're still feeling that urge, well, then you probably really have to go. And I want you to just go to the bathroom. So like in real time that those three tactics are what I usually tell people.
Kim Vopni (18:25.242)
.
Lance Frank (18:49.9)
But in terms of like a home program, really exercises and more so stretches, mobility work that's gonna open up the pelvis is what I usually prescribe.
Kim Vopni (18:59.9)
Yeah. You mentioned prostatitis being a very common presentation that's coming that you're dealing with. What is prostatitis? What contributes to it? And what are some of the other...
issues or prostate challenges that men would have and what is it about prostate issues that then contribute to the pelvic floor challenges.
Lance Frank (19:25.624)
very loaded question and so I'm gonna try to break it up into easy digestible chunks. So prostatitis is really just a junk term for you have pain in your pelvis and we don't really know why. There's four categories of prostatitis. Three of them involve a bacterial infection and active bacterial infection and the fourth one doesn't. And the fourth category makes up 95 % of cases. So the non-bacterial chronic prostatitis
Kim Vopni (19:27.271)
Yep.
Kim Vopni (19:48.936)
Hmm.
Lance Frank (19:55.35)
makes up 95 out of 100 people that get diagnosed with prostatitis. And so you don't have a bacterial infection. They can't find anything on any urine cultures, any semen cultures, viral fungal infections all come back negative. But these guys still get put on rounds and rounds and rounds and rounds of antibiotics because there must be an infection in the prostate. When in reality, it's the pelvic floor musculature that's
Kim Vopni (20:11.275)
.
Lance Frank (20:23.458)
Literally strangling the prostate and the urethra that is creating this inflammatory response that feels like What prostatite actual true prostatitis would or UTI would feel like or an STI would feel like and so guys will feel the these Burning with urination pain or burning with ejaculation painful erections Pain with sitting in the perineum or in the perineal body where the prostate really lives
They feel these symptoms and they go tell their urologist and the urologist does a blood test, a urine test, a semen test, and everything comes back negative. And a lot of urologists, if they're not kind of up to date with the recategorization of this fourth category, the AMA changed the nomenclature that what they call prostatitis, the chronic pelvic pain syndrome, because it doesn't involve the prostate at the pelvic floor muscle problem. And so if your urologists are up to date on that,
Kim Vopni (21:09.259)
.
Lance Frank (21:23.416)
Hopefully they'll refer these guys to pelvic PT because that's become the gold standard for that fourth category but a lot of physicians are still old-school and they want to rule out an infection they want to rule out any sort of sinister pathology which I can understand but sometimes even with this fourth category of Non-bacterial prostatitis these guys will get prescribed antibiotics and because antibiotics have an anti-inflammatory component
Kim Vopni (21:41.438)
.
Lance Frank (21:53.612)
It'll help with their symptoms temporarily while they're taking it. But you know, they take, stopped taking it and a couple of days later, a week later, their symptoms come back and it's like, well it must not have killed the infection. So they get prescribed more antibiotics. And so it's this loop that patients get stuck in and until they either do their own Googling or they are on a Reddit thread or they find me on Tik TOK or YouTube, like somehow guys will hopefully come across pelvic PT and start to get some help. But
I see guys that have been suffering for years that keep getting fed different antibiotics and different steroids and keep getting told that they're crazy and you need to see a mental health therapist because this must be in your head. It's infuriating and it's a soap box that I could talk about all day long. so when it comes to prostatitis, it's really just, again, a different type of presentation of this overactive pelvic floor that
Kim Vopni (22:51.476)
.
Lance Frank (22:52.652)
just creates this chronic spasm that mimics symptoms similar to a UTI STI or a prostate infection. And so those symptoms typically show up as just general pain in the pelvis or in the testicles or in the perineum, painful erections, pain with ejaculation. A lot of times there'll be urinary symptoms, urgency, frequency, a lot of dribbling, feeling just like you.
haven't fully emptied, like there's something still in there. I don't see as many like bowel movement issues, but it's generally just urinary sexual issues and just pain symptoms that show up.
Kim Vopni (23:35.824)
Yeah, okay. So what then, from a treatment perspective with, we've talked about the lifestyle and yes, some exercises, but.
When somebody comes in to see you in clinic, different from female, which can be vaginal and or rectal, with male it is rectal in terms of the internal evaluation and assessment. Can you walk me through what happens in that, whether like your first session, somebody coming in, how often is there the internal evaluation on that first time? And what other things are you exploring before you get to the internal?
And then again, I'm asking so many questions in a row, but I want to know what happens with the internal treatment as well.
Lance Frank (24:20.366)
Yeah, that's okay. So day one, just as I'm sure you do this with women, it really just depends on the diagnosis that they're coming in with. But let's say hypothetically speaking, it is a prostate, a prostatitis patient that is coming in. So day one, you know, they're going to come in, we're going to have my evaluations. I have them scheduled for two hours, but really I'm usually done hour 15 hour and a half. But a lot of these guys,
have either never told anybody about these symptoms or they have told so many people and nobody really understands or is able to hear them. So I have a long evaluation slot for new patients so that if they need to talk, they can get it all out. And sometimes these guys will talk and talk and talk and talk. And sometimes even just talking about it can make them feel better to somebody that can like actually help them, but help them understand what's happening to them. But
Kim Vopni (25:13.341)
.
Lance Frank (25:18.68)
So day one, they come in, we have this subjective intake. talk, you know, typically 20, 30, sometimes 45 minutes. And then we move into the actual exam piece. So the first thing that I have them do, have them do what's called a functional movement screen. So I like to say, we're gonna play a little game of Simon Says. I'm gonna have you do seven or eight different movements. I just wanna watch how you move in your body to check for active flexibility, range of motion, strength deficits, imbalances with your movement.
And then we go through what I call my orthopedic exam and that over the years I've sort of refined based on the patient that's coming in. But again, keeping the prostatitis patient in mind, I usually check range of motion, flexibility of their hip joints, their, all of the muscles that attach up into the pelvis, adductors, hamstrings, hip flexors, glutes. I'm checking range of motion and flexibility of those joints and musculature. And then
We move into a palpation exam and so palpation for the listeners just means touch. so I always say, you know, healthy tissue shouldn't hurt healthy tissue. Shouldn't nothing that I touch on you should be painful within reason. Obviously if you're really mashing into somebody, you might cause some pain. Might be tender, but with a mild to moderate amount of palpation pressure, nothing that I touch should be painful. And if it is, you know, it might be pieces of the puzzle that could help me treat you better. And so I start by palpating.
Kim Vopni (26:19.586)
Okay.
Lance Frank (26:43.746)
feeling for muscle tissue in the abdomen, in the front of the pelvis, in the inner thighs. I'll have them flip over onto their stomach and I'll check their glutes and the back of their hips and their low back. Sometimes I'll check spinal mobility. So do some compression to directly to the spine to see if that reproduces anything depending on the diagnosis that's coming in. But after that, generally I'd say, you know, this is when we move into the pelvic exam. So
going to step out while I go jot some notes down about everything that I've checked so far. I'm going to let you get undressed. You can keep your shirt on. You can keep your socks on if you want. Just take pants and underwear off. And then we do what I call breathing observation assessment. And so with that, they're just laying on their back in a butterfly position, knees out to the side. And I always tell them, I'm looking, what I'm looking for is the pelvic floor, the perineum, the space between your testicles and your anus. I'm looking what's happening there while you're, you know,
Kim Vopni (27:29.993)
So,
Lance Frank (27:42.722)
this relationship that exists between the diaphragm and the pelvic floor. If you're looking at somebody breathing in this butterfly position, you should be able to see some degree of movement. And so when I do this assessment, that's what I'm looking for. And depending on what I find, most of the time there's no movement at all, or it's completely reversed. You know, when you inhale, the pelvic floor should lengthen and kind of bulge outward. And when you exhale, should contract and recoil inward. And so a lot of times, especially on my chronic pain guys, there's either no movement or it's just
puckered up in a contracted position and just doesn't ever leave that state. So day one, I always tell them, know, this is Willy Wonka's golden ticket. Like if you take nothing else away from me today and you leave here thinking I'm a quack, this is the one thing that I want to make sure that you go home that you like fully understand because this is going to set the foundation for everything else that we do in therapy. You know, this breathing mechanism of learning how to relax your pelvic floor, you know, this is pelvic floor 101, relaxation 101, like how to relax your pelvic floor, breathing,
Kim Vopni (28:28.02)
.
Lance Frank (28:42.432)
Relaxing the pelvic floor. I always make sure that they've got that, you know, rock solid before they leave here. And I have obviously resources that I send them afterwards and videos of other patients from the waist down going through it so they can see on another patient what it should look like. But that's always where I first start with patients, just that like breathing observation assessment. And so depending on
Kim Vopni (29:02.324)
That's it.
Lance Frank (29:05.1)
how patients are feeling like in real time. You know, if they've got chronic pain and it hurts for me to palpate even down in the perineum, just a light pressure, I'm not going to stick my finger up there. I already know it's going to be painful. It's going to be more uncomfortable for them than it needs to be. And the last thing I want to do is cause more pain to people. So depending on the diagnosis, there sometimes isn't a rectal exam or a pelvic floor exam, internal pelvic floor exam on day one.
Kim Vopni (29:18.363)
.
Lance Frank (29:34.208)
Again, hypothetically speaking, say Joe, his prostate pain, pelvic floor pain isn't, you know, 10 out of 10, he's maybe a two out of 10. I might do an internal exam on him. And so I always tell patients, know, if 12 o'clock is your pew, if you're laying on your back and 12 o'clock is up towards the ceiling and six o'clock is down towards the floor, I'm just going to go around a clock on the outside. I'm going to feel some of these muscles. You know, typically when I'm in the intake and I'm going through my explanation of who I am and what I do and how I think I might be able to help them.
I use an anatomy app on my laptop and I will literally take them muscle by muscle and be like, this is what this does, this is what this does. This group is responsible for peeing, pooping and having sex. And so when I am doing the palpation exam on the outside, I'm telling them, I'm going around a clock and I'm like, okay, remember this muscle that I showed you, this is what I'm feeling for right now. And then so on and so forth, all the way around the clock. And then assuming that I feel like they can tolerate it,
And what if their symptoms, if they're coming in, their diagnosis justifies an internal exam with the internal exam, that breathing technique, that mechanism of relaxing the pelvic floor. That's the first thing I always say, like as you, as I insert my finger, that's the, that's what I'm going to be checking. Like visually I can see that I think you're doing it, but with my finger in there, I'm really going to tell, be able to tell how well you're descending and how much range of motion and flexibility we're getting. So.
Kim Vopni (30:52.681)
.
Lance Frank (31:02.717)
As I'm inserting my finger, that's what I'm checking. And I really want you to try to, you know, practice this lengthening, gently pushing my finger out, trying to push my finger out as I'm inserting it. Once I'm in there, then I'm assuming they're okay and I can visually see that they're not, you know, trying to jump off the table. Then I'll do a palpation, an internal palpation exam. And so again, palpation meaning touch, I'm just going around the clock.
Kim Vopni (31:24.92)
Okay.
Lance Frank (31:28.782)
12 o'clock's the ceiling or the pubic bone, six o'clock's the table or the floor, I'm going around a clock and checking all of the, I start with the prostate and palpate that and then I go all the way around on both sides to see, if anything is painful. I always repeat back to them, even inside the rectum, there might be a little bit of pressure, it might be a little uncomfortable, but nothing that I touch in there should be painful. And if it is,
I want to know that and a home run or you know bonus points if it recreates a familiar pain that you're used to feeling and so a lot of times I'll get over certain muscles and they're like, that's my pain and I don't I don't know how specific you want me to go into like the actual anatomy of the muscles that I'm touching or palpating but a lot of times it's not the prostate that's causing their pain. It's the other surrounding musculature that is
Kim Vopni (32:12.023)
.
Lance Frank (32:27.15)
creating a lot of their discomfort.
Kim Vopni (32:29.267)
Yeah, yeah, so interesting. What queuing, I'm big on visualization and queuing to access this group of muscles given that it's not, you we might externally, if we put a mirror there, as you say, you're looking for a little bit of movement, but not everybody.
sees it and especially if they already are in the hypertonic phase, what cueing do you give specific to men that help them relax but also move the muscles through the range of motion?
Lance Frank (32:57.432)
So I, when I'm going over pelvic floor mobility, I always say, you whenever we're talking about a pelvic floor contraction, this is what most people know of as a Kegel. You know, think about trying to make your penis jump or your penis inside your body. Think about lifting your nuts to your guts. Try to pull your testicles up off the table. Try to hold in a fart. Usually one of those cues.
they'll be able to resonate with and be able to do the up phase. 9.5 times out of 10 people have no problem with up phase. The down phase is where a lot of people really struggle. And as you know, when people are stuck in this overactive state, that phase of eccentric lengthening feels really unfamiliar and uneasy. And so with my guys, I'll say,
Whenever we're doing a pelvic floor lengthening, it's really a three-part movement. You you've got the up phase of a contraction, you've got the down phase, and then you've got a release phase. So I always say contract, relax, release. And that release phase is going to feel, you might have to create a little bit of pressure in your abdomen. And I always joke, you know, have you ever been a little gassy and like, you want to let one slip, but you don't want anybody to know. So you just kind of do a little bit of a push like
Kim Vopni (34:15.189)
Okay.
Lance Frank (34:17.548)
That's what we're trying to do. It's a gentle push without really straining and bearing down. Most of my guys know what I mean by that and so they'll get it. But if they don't, I, know, imagery cues can be really helpful. And so I'll say, think of the external anal sphincter. And I always start with, I always feel so silly when I say these cues, but they're helpful to just paint an image.
You know, think of the external anal sphincter as a mouth yawning or a flower blooming or a jellyfish kind of billowing out that expansion effect. That widening effect is what we're trying to make happen with your anal sphincter. And I would say eight times out of 10 with the little subtle push or the imagery cues. Most patients will get it. have had patients that have struggled to get it though. And
those instances I'll have patients lay on their side and I'll do some tactile cueing I'll literally have them lay on their side and practice the breathing and I'm like, okay I'm gonna separate your glutes and separate the perineum and separate the anal sphincter So you can feel what it should feel like for that lengthening to happen and I want you to try to match what I'm doing try to just You channel your mental energy down there and just do a little bit of an explain Try to get it get it to expand or push out
And most of the time, patients can connect with that. I think I can count on one hand how many patients by the end of the evaluation I haven't been able to get that drop to happen. Or at least have them recognize to some degree what I'm looking for. Unless they're lying to me. But I would say most of the time people, that sequence, patients will get it.
Kim Vopni (36:05.06)
Yeah, yeah, similar to some of the cues that I use as well. I love the kind of blossoming and jellyfish cues. So, prostatitis, we've covered that. There's also people who may have
prostate cancer, who may have radiation treatment, who may even have the removal of the prostate. So what is it that happens, there's scar tissue and radiation, but I guess what are some of the other reasons why that exacerbates some of the symptoms that somebody may have post-prostatectomy or post-radiation?
Lance Frank (36:41.07)
I think I'm a little, I don't fully understand your question. So if somebody who has had prostate cancer, who's had their prostate removed, how that might exacerbate pelvic floor symptoms. Is that your question? Okay, got it. So if somebody's had their prostate removed, I always tell patients the prostate is the floodgate. It's the fail safe for the bladder. And as people with penises, that's how our anatomy works.
Kim Vopni (36:51.269)
Yes.
Lance Frank (37:08.59)
So we don't have as many urinary control muscles as women do. And so when the prostate gets removed, the internal urethral sphincter also gets removed. And the internal urethral sphincter is the one that really closes off the neck of the bladder so that we're not peeing all over ourselves. And so when the prostate gets taken out, a lot of times people really struggle with incontinence and leakage. And so we have to do a lot of work really bulking up and strengthening the external urethral sphincter, which is a part of
Kim Vopni (37:34.432)
Got it.
Lance Frank (37:37.09)
the rest of the pelvic floor so that they regain continence and they're not paying on themselves anymore. With radiation, it's a little bit more tricky and it's really even more tricky if I get them without having any sort of like prehab before their radiation because radiation is really difficult, it's almost impossible to train and strengthen
radiated tissue and so if their prostate has been know fried with radiation and their internal urethral sphincter was also a part of that radiation
they can also experience the same type of leakage as somebody who's had their prostate taken out because the radiation has just zapped the muscles ability to just to contract or relax. And so it's the same sort of principle of working on strengthening and trying to develop the external urethral sphincter and the rest of the pelvic floor to act as that floodgate when the prostate's been compromised.
Kim Vopni (38:41.187)
Got it.
In the female population, there are some treatments, for instance, Bulkamid, which is a bulking agent that can be inserted. Is that, or injected, sorry, is that something that is also used with men?
Lance Frank (39:00.406)
It can be, yeah. They'll do urethral bulking agents to help plump up the urethra if conservative pelvic PT efforts aren't working. Sometimes they'll also do what's called a urethral sling where they just go in and they take a little hammock essentially and kind of lift up the urethra a little bit to help with some of that. I have guys that just have this like slow drip leaky faucet sort of incontinence. It doesn't matter if they're laying down, sitting up.
standing, they're just constantly leaking. And sometimes the urethra might be compromised during surgery and it descends a little bit. Or if they take the prostate out and the sling just inherently helps to lift it up a little bit to help gravity and the pelvic floor musculature kind of act as that fail safe. So I would say between the sling and the urethral, like the bulking agents that you mentioned, I would say those are probably two other kind of medical treatments that patients will undergo if
PT doesn't work.
Kim Vopni (40:02.486)
Yeah, yeah. And you and I are very aligned in terms of I wholeheartedly agree that, or well, I believe that
pelvic floor PT really should be our first line of defense even before we go and see physicians. As you said and have noticed, the referral to pelvic floor PT isn't always happening from the medical community as of yet. Whereas pelvic floor PT is if there is something that's beyond treatment there, it always is being referred on to the medical community afterwards. There was an interesting study that I looked at you may know of and it was, I'm hoping that the same study
or similar will be done with women as well. I believe in if somebody does need a procedure, a bulking agent or a sling surgery or pelvic in my community, prolapse surgery, that we have an element of prehab. And you said with the radiated tissue, unless they have had some sort of radiation, sorry, some sort of prehab, it makes it more difficult afterwards. And so the study was looking at putting the men through a prehab prior to...
their treatment with greater success afterwards. I don't know if you know that study, but I just, think that that is, it's kind of a no-brainer really. And I wish that it would become gold standard common practice for male and female.
Lance Frank (41:25.202)
I do too. Luckily here in Atlanta where I have my practice, I've found physicians in various fields that are very supportive of me and very supportive of pelvic PT, huge proponents, but I still on a weekly basis will get new patients that tell me that their doctors have never heard of pelvic PT. They said that they wanted a referral to it, but told them that it wouldn't do anything.
And it is just, it's really frustrating as a, as you know, as a clinician, I have no question about the things that pelvic PT can and cannot help. And if somebody's not getting better after six weeks of therapy, I'm not going to continue treating them and, you know, spinning my wheels. Like I'm going to send them to somebody that might be able to do some further testing, might be able to do some further imaging in the States. don't know what it's like.
for you guys in Canada, but we can't order imaging and we can't prescribe any sort of medications. so a lot of times patients will come to me without having any sort of imaging or any sort of diagnostic testing done. And most of the time I feel pretty competent in my red flag and clinical screening to know if this is something that I can treat or if this is something that I'm like, no, you need to go see somebody today or tomorrow or next week.
It's just to reiterate my point, it's just really frustrating when I get patients that providers are either not receptive to pelvic PT or have never heard of it. It's just really, really frustrating.
Kim Vopni (43:06.24)
Yeah, yeah, yeah, I agree. Thank you so much for sharing all of your amazing information and thank you for the work that you do. Where can people find you if they wanted to come and work with you or where can they follow you on social media?
Lance Frank (43:20.162)
Yeah. I hopefully, you know, I don't know what's going to happen with this Tik Tok ban, but that's where I'm, that's where I'm most active. my handle is Lance in your pants and then it's the same on Instagram and YouTube. people want to follow along on there on my social media channels. If people want to work with me, I do virtual consults where we just chat about symptoms to see if you're even appropriate for virtual care or pelvic PT in general. and if people are appropriate and they, they do one.
go on and work with me virtually, we can do that. Or if people are stateside or at least in the southeast and want to come see me in person, my Atlanta clinic, FlexPTATL is where they can find me.
Kim Vopni (44:03.16)
Amazing. Thank you so much. And I will put all the links to everything in the show notes so people can find you. yeah, again, thank you so much for your time and for everything that you do.
Lance Frank (44:12.77)
Yeah, thanks for having me.
