Case Study: Male Pelvic Pain and Erectile Dysfunction

Our Patient

A male cyclist came to us with erectile dysfunction and pelvic pain. He was being treated elsewhere with manual therapy, with no signs of improvement.

The Challenge

The therapist who had been treating the patient was using internal manual therapy to address tight pelvic floor muscles, when in fact the muscle tension was a symptom secondary to the actual mechanism of injury.

Our Diagnostic Approach

After a thorough health history and clinical exam, we used diagnostic ultrasonography to visualize the structures of the patient’s pelvis. We discovered that the pudendal nerve had been injured by repetitive trauma related to the patient’s cycling activity.

Our Treatment Approach

To promote healing of the injured nerve, we applied nano-energy focused shockwaves along the course of the pudendal nerve where it comes in contact with the bicycle seat.

Our Results

After just seven shockwave sessions once a week, our patient showed a 90% improvement in his erectile dysfunction.



Contrary to current treatment trends, not all pelvic pain and dysfunction is related to pelvic muscle tension. Unless there is a specific mechanism of injury, nearly all pelvic issues are multifactorial. Most physical therapists address pelvic pain from inside the pelvic floor, when in fact pelvic pain is most often secondary to other issues that originate above or below the pelvic floor.


Pelvic pain often arises from dysfunctional breathing, spinal instability, hip dysfunction, foot problems, fascia dysfunction, autonomic dysregulation, nerve entrapment and other issues that have been ongoing, and eventually spread to the pelvic floor. Prior to treating tight pelvic floor muscles, practitioners should seek to diagnose other issues that eventually lead to pelvic pain, and address them.

Related Research


Lee, K. C. J., et al. “Extracorporeal Shockwave Therapy of the Perineum for male patients with chronic pelvic pain syndrome: A Pilot Study.” Prostate International (2023).



In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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