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Original papers
British Journal of General Practice, November 2004 819
Randomised controlled trial of pelvic
floor muscle exercises and manometric
biofeedback for erectile dysfunction
Grace Dorey, Mark Speakman, Roger Feneley, Annette Swinkels, Christopher Dunn and Paul Ewings
Introduction
ERECTILE dysfunction was defined by a National Institute
of Health (NIH) Consensus Development Panel as ‘the
inability to achieve or maintain an erection sufficient for sat-
isfactory sexual performance’ (for both partners).1The exact
prevalence of erectile dysfunction is unknown, although it is
a common problem that may affect 10% of healthy men and
significantly greater numbers of men with existing comor-
bidities such as hypertension (15%), diabetes (28%), and
heart disease (39%).2,3 Men with erectile dysfunction may
suffer from depression and low self-esteem, and experience
difficulties establishing and maintaining relationships.4,5
Treatment regimens currently available for erectile
dysfunction include psychotherapy, sex therapy, oral phar-
macological agents, androgen replacement therapy,
intraurethral therapy, intracavernosal injections, vacuum
devices, and surgery. The pelvic floor muscles play a role
in sexual activity. Contractions of the ischiocavernosus and
bulbocavernosus muscles produce an increase in the
intracavernous pressure and influence penile rigidity. The
bulbocavernosus muscle compresses the deep dorsal vein
of the penis to prevent the outflow of blood from an
engorged penis.
Previous studies using pelvic floor muscle exercises for
erectile dysfunction have been unrandomised or uncon-
trolled.6-11 We carried out the first randomised controlled trial
to examine the effect of pelvic floor muscle exercises
enhanced by manometric biofeedback for men with erectile
dysfunction.
Method
Power calculation
A power calculation could not be performed as there were
no data from similar studies using pelvic floor exercises.
Data from this trial could be used to provide a power cal-
culation for future larger studies.
Ethics approval
Approval was obtained from the West Somerset Local
Research Ethics Committee and the University of the West of
England Ethics Committee.
Sample
Men aged 20 years and over who had experienced erectile
dysfunction for 6 months or more were referred to the phys-
iotherapy department of The Somerset Nuffield Hospital for
treatment by a consultant urologist. Those men with uro-
logical congenital abnormalities, neurological deficits, and
previous urological surgery were excluded from the trial.
G Dorey, PhD, FCSP, consultant physiotherapist, The Somerset
Nuffield Hospital, Taunton. M Speakman, MBBS, FRCSP, MS,
consultant urologist; A Swinkels, PhD, MCSP, senior lecturer, Faculty
of Health and Social Studies, University of the West of England,
Bristol. R Feneley, MBBChir, MA, MChir, FRCS, emeritus consultant
urologist, The Somerset Nuffield Hospital. C Dunn, DSc, PhD, BPharm
(Hons), FIB, FRSM, FRSH, AIBS, professor of social pharmacy, University
of Oslo, Oslo, Norway. P Ewings, PhD, senior statistician, Taunton
and Somerset NHS Trust Hospital, Taunton.
Address for correspondence
Grace Dorey, Old Hill Farm, Portmore, Barnstaple EX32 0HR.
E-mail: grace.dorey@virgin.net
Submitted: 5 January 2004; Editor’s response: 23 April 2004;
final acceptance: 24 May 2004.
©British Journal of General Practice, 2004, 54, 819-825.
SUMMARY
Background: The pelvic floor muscles are active in normal
erectile function. Therefore, it was hypothesised that weak pelvic
floor muscles could be a cause of erectile dysfunction.
Aims: To compare the efficacy of pelvic floor muscle exercises
and manometric biofeedback with lifestyle changes for men with
erectile dysfunction.
Design of study: Randomised controlled trial.
Setting: The Somerset Nuffield Hospital, Taunton, United
Kingdom.
Method: Fifty-five men with erectile dysfunction (median age
59.2 years; range 22–78 years) were enrolled from a local
urology clinic. Of these, 28 participants were randomised to an
intervention group and engaged in pelvic floor exercises, as well
as receiving biofeedback and suggestions for lifestyle changes.
Twenty-seven controls were solely advised on lifestyle changes.
Baseline, 3- and 6-month assessments were: erectile function
domain of International Index of Erectile Function (IIEF),
Partner’s International Index of Erectile Function (PIIEF),
Erectile Dysfunction-Effect on Quality of Life (ED-EQoL), anal
manometry, digital anal measurements, and clinical assessment
by an assessor blind to treatment allocation. After 3 months, the
control group were transferred to the active arm.
Results: At 3 months, compared with controls, men in the
intervention group showed significant mean increases in the
erectile function domain of the IIEF (6.74 points, P = 0.004);
anal pressure (44.16 cmH2O, P<0.001); and digital anal grades
(1.5 grades, P<0.001). All showed further improvement in these
outcomes at 6 months. Similar benefits were seen in men of the
control arm after transfer to active treatment. A total of 22
(40.0%) participants attained normal function, 19 (34.5%)
participants had improved erectile function, and 14 (25.5%)
participants failed to improve.
Conclusion: Pelvic floor muscle exercises and biofeedback are
an effective treatment for men with erectile dysfunction.
Keywords: pelvic floor exercises, biofeedback, erectile
dysfunction.
However, men having undergone transurethral resection of
prostate were included as it was considered that they would
not have neurological impairment. The trial ran from June
2000 to April 2002.
Randomisation and recruitment
A system of random odd- or even-numbered tickets in
sealed envelopes for participant selection was used to
randomise patients into either the intervention or the con-
trol group. Men selected and opened their sealed enve-
lope from a box containing 150 sealed envelopes. Those
who selected tickets with even numbers were placed in
the intervention group. The sample consisted of 55 men
who fulfilled the inclusion criteria and were enrolled into
the trial. Table 1 shows baseline characteristics for both
groups.
Intervention
The flow of participants through the study is shown in Figure
1. All participants underwent a full subjective and objective
clinical assessment by the researcher, who is an experi-
enced physiotherapist. The objective examination was con-
ducted in supine position with knees bent and feet on the
couch. An assessment was made of puborectalis muscle
strength and the length of hold of the contraction in seconds
by digital anal examination graded 0 (nil) to 5 (strong).12
A further assessment was performed using anal manome-
try to test muscle strength; each participant was positioned
supine as before, and with a view of the computer screen for
feedback. The air-filled, sheathed and lubricated anal probe,
with a diameter of 1 cm, was inserted into the anal canal as
far as the probe external position marker (to a depth of 4 cm)
in order to approximate to the puborectalis muscle.
Participants were instructed to voluntarily tighten and lift the
pelvic floor muscles as strongly as possible as if preventing
the flow of urine, and to hold this contraction for 10 seconds.
A scrotal lift and penile retraction was confirmed to ascertain
that the pelvic floor muscles were contracting correctly. The
maximum anal pressure reading achieved from the best of
three pelvic floor muscle contractions (maximum anal pres-
sure) and the lowest pressure obtained while attempting to
maintain a 10-second hold (anal hold pressure) were
recorded in cmH2O. A rest of 10 seconds was given
between each contraction.
Men in the intervention group were educated about the
mechanics of the pelvic floor musculature and individually
taught specific pelvic floor muscle exercises enhanced with
manometric biofeedback for strength and endurance. The
exercise programme (Box 1) included occasionally lifting the
pelvic floor muscles 50% of maximum while walking, and a
post-void ‘squeeze out’ pelvic floor muscle contraction.13
These treatments were given in five 30-minute periods in
consecutive weeks and included advice on lifestyle changes
concerning smoking, alcohol intake, general fitness, a
healthy diet, weight reduction, and saddle pressure. Each
participant in the intervention group was given a list of pelvic
floor muscle exercises to perform at home daily for
6 months.
Men in the control group were given advice on lifestyle
changes only, in five 30-minute periods in consecutive
weeks. Following assessment of outcomes at 3 months,
these men were offered the intervention as described above.
Outcome measures
The primary outcome measure was the validated erectile
function domain of the International Index of Erectile
Function (IIEF),14 which was self-completed at baseline,
3 months, and 6 months. There were six questions relating
to erectile function in this domain (for example, ‘Over the
past 4 weeks, how often were you able to get an erection
during sexual activity?’), and each ranked 0–5 points:
•5 = almost always or always,
•4 = most times (much more than half the time),
•3 = sometimes (about half the time),
•2 = a few times (much less than half the time), and
•1 = almost never or never, and
•0 = no sexual activity.
It has been suggested that an increase in six points in this
domain indicates a clinical improvement.15
Secondary outcome measures were the self-completed
validated Erectile Dysfunction-Effect on Quality of Life (ED-
EQoL),16 which addresses men’s feelings concerning their
erectile difficulties; digital anal measurements; anal mano-
metric measurements; and assessments by a urologist
blind to treatment allocation, to whom participants reported
erectile function status (worse, same, improved, cured).
All men were requested to ask if their partner would like to
complete the Partner’s IIEF (PIIEF) in confidence and unaided.
G Dorey, M Speakman, R Feneley, et al
820 British Journal of General Practice, November 2004
HOW THIS FITS IN
What do we know?
There is a wide range of treatments for
erectile dysfunction. Pelvic floor muscle
exercises are not routinely used to treat erectile
dysfunction and they have not been the subject of a
randomised controlled trial.
What does this paper add?
Pelvic floor muscle exercises are effective in treating men with
erectile dysfunction, and should be the first-line approach to
treat the problem. They may be used in conjunction with other
treatments for erectile dysfunction.
Table 1. Description of subjects at baseline.
Intervention group Control group
median (range) median (range)
Number of subjects 28 27
randomised
Age in years 58 (22–78) 61 (41–72)
Months with erectile 24 (6–360) 54 (6–360)
dysfunction
Body mass index 26 (21–42) 29 (22–38)
Erectile function domain 7.5 (1–28) 7.0 (1–17)
of International Index of
Erectile Function score
Data analysis
All analyses were conducted using SPSS. The main analyses
were based on analysis of covariance examining the differ-
ence between the two trial groups on each clinical outcome
measure at 3 months, while controlling for baseline value of
that same measure. Where parametric analyses were inap-
propriate (for example, for manometry measurements and
digital anal grades), Mann–Whitney tests were conducted
comparing the changes from baseline to 3-month follow-up
between the two groups. The data from the assessor blind to
treatment allocation was on an intention-to-treat basis to
include those who dropped out from the trial.
Results
In total, 28 participants were randomised into the interven-
tion group and 27 into the control group. Data at 3 months
were available on 25 subjects in each group.
Erectile function
At 3 months, the intervention group scored significantly
better than the control group on the primary outcome
measure of erectile function, as assessed by the relevant
domain of the IIEF (Table 2). All other domains showed
weak benefit for the intervention group. The sexual desire
domain (libido) remained constant for both groups.
Of the participants’ partners, 47 (85.5%) were willing to com-
plete the PIIEF at baseline. However this was only completed
by 39 partners. Mean scores for partners (PIIEF) were similar
to those for the subjects (IIEF), and again showed advantage
for the intervention group in most domains (Table 2).
Following assessment at 3 months, the improvement in
erectile function was maintained over the following 3 months
when intervention subjects were advised to continue with the
home-based pelvic floor exercises. The control group also
showed a similar response (and maintenance) when they
underwent the active treatment arm (Figure 2).
Quality of life affected by erectile dysfunction (as mea-
sured by the ED-EQoL) improved slightly in both groups
over the 3 months, more so in the intervention group but not
significantly so (mean difference between groups estimated
as ANCOVA 3.1, 95% confidence interval [CI] = -3.5 to 9.6,
P = 0.35).
Manometry and digital anal measurements
The intervention group showed statistically significant
improvements in manometric and digital anal measure-
ments compared to the control group (Table 3). As with
erectile function, these improvements were largely main-
tained over subsequent months, and the control group fol-
lowed a similar pattern upon introduction of the intervention
at 3 months (Figure 2). Participants in the intervention
British Journal of General Practice, November 2004 821
Original papers
Analysed after a further 3 months: n= 25
Excluded from analysis at 3 months: n= 2
Analysed at 6 months: n= 21
Excluded from analysis at 6 months: n= 4
Analysed at 9 months: n= 16
Excluded from analysis at 9 months: n= 5
Analysed at 3 months: n= 25
Excluded from analysis at 3 months: n= 3
Analysed at 6 months: n= 17
Excluded from analysis at 6 months: n= 8
Allocated to 3 months’ pelvic floor exercises: n= 25
Lifestyle changes: n= 21
Dropped out: n= 4, due to improved (n= 1) and no
improvement (n= 3)
Allocated to 3 months’ pelvic floor exercises: n= 25
Pelvic floor exercises: n= 17
Dropped out: n= 8, due to normal erectile function
(n= 2), improved erectile function (n= 2) and
no improvement (n= 4)
Allocated to 3 months’ control: n= 27
Lifestyle changes: n= 25
Dropped out: n= 2, due to normal erectile function (n=
1) and no improvement (n= 1)
Randomised (n= 55)
Excluded (n= 1, worked abroad)
Assessed for eligibility (n= 56)
Allocated to 3 months’ intervention: n= 28
Pelvic floor exercises and lifestyle changes: n= 25
Dropped out: n= 3, due to normal erectile function
(n= 1) and no improvement (n= 2)
Received further 3 months’ pelvic floor exercises: n= 16
Dropped out: n= 5, due to normal erectile function
(n= 2) and improved erectile function (n= 3)
Figure 1. Algorithm of randomised controlled trial.
group who regained normal function attained anal pressure
measurements of 100 cmH2O and above. However, four
participants failed to achieve anal pressure measurements
in excess of 85 cmH2O and showed no improvement. Anal
manometric measurements were positively correlated with
digital anal scales at baseline, 3 months, and 6 months
(ρ>0.556, P=0.001) in both groups.
Withdrawals
Twenty-two (40%) participants did not remain in the trial for the
intended duration; of these, six (10.9%) participants withdrew
because they had achieved normal erectile function, and
seven (12.7%) participants withdrew following improved erec-
tile function. Nine (16.4%) participants withdrew showing no
improvement. Participants who failed to improve reported
822 British Journal of General Practice, November 2004
G Dorey, M Speakman, R Feneley, et al
1. In standing position
Stand with your feet apart and tighten your pelvic floor muscles as if you were trying to stop the flow of urine and wind escaping. If
you look in a mirror, you should be able to see the base of your penis move nearer to your abdomen and your testicles rise.
Hold the contraction as strongly as you can.
Try to avoid holding your breath, pulling in your abdomen or tensing your buttocks.
Perform 3 maximal contractions in standing in the morning holding for ___ seconds.
Perform 3 maximal contractions in standing in the evening holding for ___ seconds.
2. In sitting position
Sit on a chair with your knees apart and tighten your pelvic floor muscles as if you were lifting your pelvic floor but not your buttocks
off the chair.
Hold the contraction as strongly as you can.
Try to avoid holding your breath, pulling in your abdomen or tensing your buttocks.
Perform 3 maximal contractions in sitting in the morning holding for ___ seconds.
Perform 3 maximal contractions in sitting in the evening holding for ___ seconds.
3. In lying position
Lie on your back with your knees bent and your knees apart. Tighten your pelvic floor and hold the contraction as strongly as you
can.
Try to avoid pulling in your abdomen or tensing your buttocks.
Perform 3 maximal contractions in lying in the morning holding for ___ seconds.
Perform 3 maximal contractions in lying in the evening holding for ___ seconds.
4. While walking
Try lifting your pelvic floor up 50% of maximum when walking.
5. After urinating
After you have voided urine, try tightening your pelvic floor muscles strongly to avoid the after-dribble.
6. During sexual activity
Try tightening your pelvic floor muscles rhythmically to achieve and maintain penile rigidity during sexual activity. Slow thrusting
movements generate higher pressures inside the penis.
7. To delay ejaculation
For men with premature ejaculation, try tightening your pelvic floor muscles to delay ejaculation.
Box 1. Pelvic floor muscle exercises for men.
Table 2. International Index of Erectile Function domain scores in subjects and partners at 3-month follow-up.
Intervention group Control group Corrected difference
mean (SD) (mean SD) (95% CI)aP-valuea
Sample size for analysis
Subjects 25 25 - -
Partners 17 22 - -
Erectile function
Subjects 17.2 (9.7) 8.4 (7.3) 7.0 (2.4 to 11.6) 0.004
Partners 17.4 (10.7) 10.0 (9.6) 6.9 (1.1 to 12.8) 0.02
Intercourse satisfaction
Subjects 7.8 (3.9) 4.6 (4.3) 2.6 (0.5 to 4.7) 0.02
Partners 7.9 (4.3) 4.5 (4.5) 3.3 (0.7 to 6.0) 0.02
Orgasmic function
Subjects 6.7 (3.3) 4.1 (3.7) 2.2 (0.4 to 4.1) 0.02
Partners 6.6 (3.9) 4.1 (3.9) 2.3 (-0.09 to 4.6) 0.06
Sexual desire
Subjects 6.2 (2.3) 5.9 (2.1) 0.4 (-0.5 to 1.4) 0.38
Partners 7.1 (2.0) 4.7 (2.5) 1.7 (0.4 to 3.0) 0.01
Overall satisfaction
Subjects 6.1 (2.3) 4.1 (2.5) 1.8 (0.5 to 3.0) 0.008
Partners 6.9 (5.2) 4.2 (2.9) 2.0 (-0.5 to 4.4) 0.11
aDifference is intervention group minus control group, derived from ANCOVA. SD = standard deviation.
possible reasons for this as testicular pain, severe low back
pain, addiction to alcohol, saddle trauma, cardiac bypass
surgery, cardiovascular problems, pacemaker, diabetes melli-
tus, Peyronie’s disease, and bilateral orchidectomies with
testosterone implants.
Blind assessment
The final analysis from the blind assessments of both groups
combined, including those who withdrew from the trial,
showed that a total of 22 (40.0%) participants attained nor-
mal function, 19 (34.5%) had improved erectile function, and
14 (25.5%) failed to improve.
Discussion
Summary of main findings
With a clinical improvement of 6.74 points on the erectile
function domain of the IIEF, the intervention group showed a
significant improvement (P = 0.004) in erectile function com-
pared with the control group after 3 months. The control
group showed no significant increase in erectile function fol-
lowing lifestyle changes (P = 0.658), but a highly significant
increase following intervention at 6 months (P<0.001). At
6 months, there was clinical improvement of 9.88 points on
the erectile function domain of the IIEF for the intervention
group and 10.94 points for men initially assigned to the con-
trol group. There was, however, no further significant
improvement with the pelvic floor exercises in either the
intervention group (P = 0.108) or control group (P = 0.646).
There was good correlation between the IIEF and the PIIEF.
The ED-EQoL correlated poorly with the erectile function
domain of the IIEF.
Manometric measurements and digital anal measure-
ments showed that both groups improved significantly
(P<0.001) after intervention. Further improvement after
engaging in pelvic floor exercises was not significant.
After 3 months of intervention and 3 months of pelvic floor
exercises, 40.0% of all participants had attained normal
function, 34.5% had improved, and 25.5% failed to improve.
Strengths and limitations of this study
This was the first randomised controlled trial to use a validat-
ed outcome to measure the effectiveness of pelvic floor mus-
cle exercises enhanced by manometric biofeedback. The
anal pressure biofeedback displayed on a computer screen
motivated the subjects to attain a pelvic floor muscle exercise
contraction of maximum strength. The men worked hard to
improve on previous readings. Results are in line with other
non-randomised or uncontrolled trials using similar treatment
modalities.7.9,10,17 Previously, pelvic floor exercises may not
have been routinely given for erectile dysfunction following
these non-randomised or uncontrolled trials due to their
methodological limitations.
It was a limitation of the IIEF that it did not provide any
specific information about the partner relationship or the
non-erectile components of sexual response.14 It would be
useful to have a tool that explored cultural, social, ethnic,
and religious perspectives. Another perceived limitation
was the use of the non-validated PIIEF; however, the inclu-
sion of the PIIEF did involve partners in the research
process and provided reinforcement to the accuracy of the
IIEF responses by the subjects. A validated partner’s ques-
tionnaire in this study may have indicated the different sex-
ual and non-sexual needs of the partners, which could have
been relayed to the men.
The study was limited by the small number of subjects.
Further trials could be multicentred and thereby involve a
larger sample size with an opportunity to investigate a more
heterogeneous sample.
British Journal of General Practice, November 2004 823
Original papers
Table 3. Manometric and digital anal measures at baseline and 3-month follow-up.a
Outcome Intervention group (n= 25) Control group (n= 25) P-valueb
Baseline Follow-up Baseline Follow-up
Maximum anal pressure 96 147 75 75 <0.001
Anal hold pressure 85 130 70 69 <0.001
Digital anal measurements 3 5 3 3 <0.001
aAll values are medians; bMann–Whitney test comparing change in score between the two groups.
Erectile function 6 months
Figure 2. Mean erectile function domain of International Index of
Erectile Function scores for both groups at each assessment.
17 17 17 16 16 1616
40
35
0
30
25
5
10
15
20
Intervention (n)Control (n)
Erectile function baseline
Erectile function 3 months
Erectile function 9 months
**
Significant difference
Pelvic floor exercises
Intervention
Lifestyle changes
*
Mean erectile function domain of
International Index of Erectile Function score
824 British Journal of General Practice, November 2004
G Dorey, M Speakman, R Feneley, et al
Comparison with existing literature
The blind assessment indicated that 40.0% of participants
regained normal erectile function. These results were compa-
rable to previous studies using pelvic floor muscle exercises
which reported that 26–46% of men had regained normal
function following a similar exercise regime.7,9,10,17
The number of participants who withdrew from the trial
was a concern, although a high drop-out rate has been
reported previously in this type of study18 and may reflect
the embarrassment and unease suffered by this cohort of
men or possibly the commitment involved in performing
daily exercises. However, some of the men who withdrew
from the study did so because they had achieved normal
erectile function.
All participants who received the allocated intervention
reported completion of their pelvic floor home exercise
regime. All men were able to achieve a penile retraction and
scrotal lift during training with pelvic floor muscle exercises,
although, initially, this response was often difficult and slow.
As muscle strength improved, this response was initiated at
a faster rate. Examination of individual cases revealed the
return of self-reported nocturnal erections following
1–4 weeks of pelvic floor muscle exercises and prior to
regaining erectile function. Weak evidence showed that
orgasmic and ejaculatory function also improved with pelvic
floor muscle exercises. This improvement was not surprising
as the bulbocavernosus muscle, which is strengthened by
pelvic floor muscle exercises, pumps the ejaculate.19
The erectile function domain of the IIEF showed poor
correlation with the ED-EQoL in both groups. These results
were similar to the findings of MacDonagh et al,16 and
demonstrated a clear reason for the clinical usefulness of
the ED-EQoL to monitor men’s feelings about their erectile
difficulties. The quality of life of some men who experi-
enced severe erectile function was unaffected by their lack
of erectile function while others with less severe symptoms
reported that their quality of life was severely negatively
affected.
This was the first time that anal manometric measurements
have been used as an outcome measure for pelvic floor mus-
cle strength in men with erectile dysfunction. These mea-
sures have previously been shown to have good within-day
and day-to-day intrarater reliability.20 Six participants who
had low anal pressure measurements after intervention failed
to achieve normal function, suggesting that weak pelvic floor
muscles are a risk factor for erectile dysfunction.
In this trial the median age of the participants was
59.2 years and much higher than the subjects in all the other
trials.7-9,17,21 The duration and severity of erectile dysfunction
were not predictors of the results of therapy in this trial.
It was expected that the control group would show
some improvement by reducing alcohol levels, quitting
smoking, increasing fitness levels, losing weight, and
avoiding saddle pressure. This did not seem to be the
case. Although the majority of participants reduced alco-
hol levels, lost some weight, and performed daily exercis-
es such as hill walking and running up and down stairs, no
participant ceased smoking, and two participants
remained addicted to alcohol. It may be that 3 months of
lifestyle changes was too short a time to effect a reversal
of symptoms.
Comparison with sildenafil. The results of this trial were
compared with a large grade II trial using oral sildenafil for
329 participants with similar mixed aetiology.15 Both trials
used the erectile function domain of the IIEF as the main
outcome measure. In the sildenafil trial at 12 weeks, par-
ticipants receiving up to 100 mg sildenafil based on effi-
cacy and tolerance improved by 10 points to attain a
score of 21 points (Figure 3). In our trial, participants in
the intervention group improved at 3 months by eight
points from the overall baseline score to attain a score of
17 points. An increase in six points was considered a clin-
ical improvement as this indicated that the men moved up
a category in each of the erectile function scores, for
example, from ‘almost never’ to ‘a few times’, or from
‘sometimes’ to ‘most times’.
Implications for future research or clinical
practice
Evidence has shown that pelvic floor muscle exercises are
significantly effective for some men with erectile dysfunction.
To obtain a benefit, pelvic floor muscle exercises should
be properly taught and practised for at least 3 months. A
maintenance programme may then be implemented for life.
Not all men with erectile dysfunction may be suitable for
pelvic floor muscle training. Those men with severe arteri-
ogenic and neurological causes may well not benefit. The
results of this trial may have been more impressive if men
with severe low back pain, addiction to alcohol, cardio-
vascular disease, diabetes mellitus, Peyronie’s disease,
Figure 3. Comparison of pelvic floor muscle exercises in our trial
and sildenafil15 at 3 months using the erectile function domain of
the International Index of Erectile Function.
0
30
25
5
10
15
20
Oral sildenafil
Pelvic floor muscle exercises
Significant difference at
0.001 level
Baseline
Control
Intervention
Pelvic floor muscle
exercises
Sildenafil
*
*
*
Mean erectile function domain of
International Index of Erectile Function score
British Journal of General Practice, November 2004 825
Original papers
and bilateral orchidectomies had been excluded in the
first instance.
Pelvic floor muscle exercises could be considered as a
first-line approach for men seeking resolution of erectile
dysfunction without pharmacological and surgical inter-
ventions. Also, men receiving other forms of therapy for
erectile dysfunction could be advised to practise pelvic
floor muscle exercises in addition to the therapy pre-
scribed. Although pelvic floor muscle exercises are more
labour intensive than using a pharmacological agent, men
could be given a choice of treatment. Some men may pre-
fer a more natural approach. Figure 4 details a suggested
management pathway for men with erectile dysfunction.
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Acknowledgements
We thank all the subjects who participated in the trial and The Somerset
Nuffield Hospital, Taunton for their cooperation.
Figure 4. Suggested algorithm for treatment of erectile dysfunction.
Third-line treatment
Vascular surgery
Prosthetic implant
Second-line treatment
Oral pharmacological agents
Vacuum devices
Constriction bands
Counselling/sex therapy
Intracavernous injections
Intraurethral medication
Topical therapy
First-line treatment
Pelvic floor muscle exercises
Diagnosis
Testosterone assay
