49 yr old M. PSA started out at 2.7 when I 33, have been monitoring them every year. They fluctuated up and down for years and they have never been below 1.9.
When I turned 45 I started checking my psa’s every 6 months. October 2023 they reached 4.1, doc said let’s wait 2 months to see if they go down. 2 months later they jumped to 4.71. 12/2023 referred to urologist and he did a DRE and felt a small nodule on left base of prostate.
Doc said let’s do a biopsy. I asked if we could do a MRI first and he said considering my psa’s and nodule via Dre he recommends doing a biopsy. Mid January 2024 biopsy performed no cancer.
Results:
Final Diagnosis A. Prostate, right, core biopsy: Patchy acute and chronic inflammation with atrophic changes No evidence of malignancy B. Prostate, left, core biopsy: Patchy acute and chronic inflammation with atrophic changes No evidence of malignancy
Got another opinion and the other urologist states they should have done a mri first and he suggest considering my psa’s over 4.0 weeks schedule a mri, however since I just did a biopsy we have to wait 2 months due to all the blood around my biopsy. 9 weeks later MPMRI performed (pelvis w/w/o contrast.
Findings: LESION 1: There is a T2 intermediate signal lenticular mass in the right anterior transition zone. This mass demonstrates marked associated restricted diffusion and a diffusion pattern different from the background transition zone. There is associated capsular bulging. Extraprostatic Extension (EPE) Grade: Grade 2, both capsular contact length ? 15 mm and capsular irregularity or bulge. Lesion PI-RADS Category: 5 - Clinically significant cancer is highly likely to be present.
External urethral sphincter: Normal. Seminal vesicles: Unremarkable. Neurovascular bundles: Unremarkable. Lymphadenopathy: There is no lymphadenopathy. Bones:No aggressive osseous lesion. Other pelvic organs: N/A
Scheduled a 2nd biopsy (different type) perineal core sample for 4/8. Insurance denied the biopsy twice, they said they don’t cover investigational procedures. So on Monday we are doing the other biopsy, (standard one) whatever it’s called. Same on I did back in January but this in the transitional zone.
Last week I decided to go get my psa’s checked again out of pocket and my psa’s have dropped to 4.4. Anyone ever had a situation like this specifically in the transitional zone of the prostate? I’ve read that bph can mimic prostate cancer and have also read that only 20 percent of prostate cancer is found in this area. I have also read the the capsular bulging could also be hemorrhaging from the previous biopsy that performed 9 weeks prior and could be mimicking a tumor.
This has been going on for 8 months now and I’m yet to have an accurate diagnoses.

Intro
Firstly, this post will be very long because it is full of advice that I always wanted to share with everyone from the beginning of my prep. I wrote down every single piece of advice that I would give, when my exam was over. Throughout my prep, I have been scouring for any information that may help and I just wanted to give it back by giving my two cents. If this helps just one person, I would be so glad.
My thoughts
I just want to start with my thoughts on this exam.
This exam will be probably the worst exam that you have taken up to date, especially if you're planning to go to medical school straight from graduation. I'm even willing to say that this exam will take years off of your life. YEARS. But with the right schedule and preparation, you CAN do this. You WILL become a physician one day.
I'm a non-trad, been out of school for 5+ years -- working, getting married, just living my life -- until I stumbled on the idea that MAYBE I could be a doctor, I knew what I had to do. Another series of exams until I can become one, and the MCAT is the only beginning.
My Score
My score did not improve until a month before the exam. I've been getting mid-500's until I started using the method below. Then my third AAMC FL increased to 517, fourth to 520. The actual exam ended up being 523 (131/130/131/131). My total prep time was ~2.5 months.
General review/guideline

1. You do NOT need 500 hours of total studying. What do I mean by that? I don't mean to say that you can just study for 10 hours and ace this exam. Not at all. This exam takes patience, knowledge, and the right tactics to succeed. But at the same time, you do not need over-memorization of every fine detail that you see in Kaplan, or whatever content review books you use. In other words, you don't spend 100 extra hours memorizing extra fine details. As the famous saying goes, "MCAT is a mile long, but an inch deep". There may seem an infinite number of things you would have to memorize, but once you've done enough content review, it will come to you.
2. Use AAMC content outline. I was surprised as to how many people do not utilize this. This is like a study guide that you might have seen back in high school. This is telling you what to study. You might look at the list and say, "this is basically everything". I know. But it's giving you the topics and concepts that they will test you on. You have somewhere to start. So look at it, and use it as a checklist to check it off or highlight it once you know that concept.
3. Do NOT waste your time on content review, more than you need to. Sure, you may need content knowledge to some extent. Especially if you're like me, a non-trad who has been out of school for so long. But MCAT is not going to ask you, "What is a Km?" Rather, they will ask you to predict the Km value, based on what type of inhibitor you see in the passage. You will have to extrapolate that information and APPLY it to the question. With that said, you need to get into practice questions ASAP. I cannot emphasize this any stronger. MCAT is 30% content, 70% critical thinking.
4. Get into a routine. Are you a student? Do you have a full-time job? Wherever you are, you need to get into a study routine. Pick a day of the week that you will do a full-length exam. For other weekdays, choose however many hours you are willing to commit and do it. For me, it was Saturdays (I presume this will be the case for a lot of people). I just did a full-length every Saturday, a thorough review on Sunday, and a content review for the following week. Don't just say, "Oh, I will review 2 chapters of chemistry on Monday, 2 chapters of Biochemistry on Tuesday" etc. Pick topics. Say enzymes. Make sure you understand enzymes on Monday, enough of understanding that you can teach this to someone else without looking at your book/notes. More importantly, you need a DAILY task. When I say daily tasks, you need a list of things that you will review every day. For me, it was glycolysis, gluconeogenesis, PPP, amino acids, geometry, developmental stage, and enzyme kinematics. I made a blank note on my iPad and started drawing those every day. By the end of my first two weeks, I was able to draw them without looking at any template. (and this ended up being super helpful on my exam. Those standalone questions...)
5. Study high-yield topics first. Now, I'm not trying to say don't study or pay less attention to low yield stuff because there is no such thing as low yield. Every last information on your prep book is fair game for the exam. But by studying the high-yield topics first, you are building other content knowledge ON TOP OF what you already know based on those high yield topics. It's easier that way. Trust me.
6. Build stamina. This exam is made up of 4 sections, 95 minutes each, besides CARS which is 90 minutes. After you have that routine built, you need to block your study times with 2 hours each. Study straight for 2 hours and rest for 10 minutes. and go back to studying. I don't mean focus for 30 minutes, and scroll through social media for 20 min, and back to studying for 30 minutes. You need intense, focused 2 hours. This way, each section on the exam will not be a problem for you to focus on. You are building stamina in every study block that you're working on. When I first started, I couldn't even sit for 1 hour without touching my phone. By the end of the exam week, I was able to sit for 3.5 hrs without noticing that much time had gone by.
7. Study in a distraction-free zone. This may be hard for some people, especially if you have kids or something. Go to a local library. Go in a quiet room. Isolate yourself from everyone and everything. If you have ADHD like me, you cannot take your phone with you in that room. What I did when I noticed that I could not keep myself from focusing on the material, I bought a phone stand. (The thing that you just prop your phone on) I put my phone there and recorded myself studying with a timelapse function. This way, it saves your storage on your phone but at the same time, it monitors your studying habits. I noticed that I bite my lips a lot and I picked up on those little habits. (NOT that I fixed it anyway lol) Ultimately, it forces you to keep away from your phone because it's recording!
8. Do your diagnostic ASAP. Please don't be scared of diagnostic as I was during the beginning of my prep. This is to see where you are. It doesn't matter if you don't know ANYTHING content-wise. If you decide that you will take the MCAT on whatever date, take a diagnostic test. You can take a half-length one if you want to. This is to see what content area you need to focus on, NOT to stomp on your ego. Your score doesn't matter. Hell, your last full-length exam score doesn't matter either. The only score that matters is what you get on the actual exam. Don't let the score beat you down.
9. Don't give up until the last minute. If you don't get anything out of this post, THIS is your takeaway. Your score can improve until you quit studying. Yes, there may be times when you feel like your brain isn't braining, and there is so much content that you feel overwhelmed and say "screw this". But you don't give up. Just get up and do it. The feelings that you are feeling right now, that goes away. Your knowledge that you gain, doesn't.

How to design your study plan effectively (Resources: Kaplan book set, 1 Diagnostic exam)
Content Review (this will be AFTER you take your diagnostic, but before you review)

1. Chem/Phys: people say this is the hardest section to improve. I disagree. Why? Out of all sections, this section is solely based on recognition. Once you know, you know. Here is what I want you to do. Grab your chem/phys book (this will be 3 books: Gen Chem, O Chem, Physics). Without a pen or a highlighter, just read it, front to back. (I didn't say skim it. Actually read it.) While you're reading, actively engage in what the book is saying. Try to understand it. If you don't understand it, write that concept down. Look it up. Watch videos. This should take you about a day or two. Once you have done that, review that diagnostic. See how many concepts you can recognize. NOT understand, but recognize. Are some things coming to your mind? Good. Once you have recognized some details, make the concepts that you DIDN'T understand into flashcards or ANKI. Review them and if you still don't understand it, look it up. Khan Academy videos, YouTube videos or ask a tutor if you have one handy. This is how you "build" your knowledge. I don't care what anybody says, this method will last. Procrastination will not serve you well in this exam. You need long-term memory. During the rest of the week, go back and re-read all the sections you DIDN'T see on the exam. You're already building the knowledge of the content that you DID see on the exam with videos and flashcards. Keep doing this until you feel confident that you can recognize concepts when you see a passage.
2. CARS: People usually have a hard time increasing their score in this section. I understand why and let me explain this. All of us have different ways of "comprehending" a written passage or article. This is because we all have different habits of reading things that were unconsciously trained over the past 20+ years. All of a sudden, you're trying to either highlight, paraphrase or summarize the entire 5-700 word passage. Of course, you're going to have a hard time. Without practicing these highlighting skills or paraphrasing skills, you're now looking for WHAT to highlight, WHERE to highlight, WHAT keywords you're looking for etc. If these methods are failing, here's my advice. Next time when you practice CARS, try to read the passage with hands-free. No hands on the mouse or keyboard. Just try to read it as if you were just reading a book, newspaper, or an article that was in a magazine that you just picked up. Only after you finished reading the entire passage and before looking at the question, try to regurgitate what the passage said. What did the author talk about? What was he/she trying to say in that passage? What was their tone? Did they agree/disagree? Were they happy/mad/sad about the topic? Asking yourself these questions will help you not only to answer questions but also with the timing as well. I went from reading a passage in 8 minutes to 4 minutes. That gives me 5-6 minutes to answer the questions instead of 1:30 - 2 minutes for 5-7 questions. But the main goal of this section is to improve on accuracy first. Don't worry about timing at first. Focus on accuracy. Try taking as much time as you need for your first set, but record how long it took you to understand and go through the problems. Next time, give yourself 2 minutes less. and another 2 minutes less the next time. Rinse and repeat until you hit 8 minutes with 5 question passage, 9 minutes on 6 question passage, and just under 11 minutes for 7 question passage. You are solid if you are improving on accuracy and timing.
3. Bio/Biochem: This section is all about relationships. It mostly deals with our body, it's applicable and the content just makes sense. There may be some information that you just need to study, then it comes to you. Unfortunately, AAMC knows this. They will give you the most confusing experimental passage so that you will lose focus and panic. You probably will think "Omg, I do not recognize this terminology", or "I do not remember this from my Kaplan book". It's meant to be that way. For you to effectively do the content review in this section is to flowchart. Divide up our body into different sections. Write them out. Which hormone produces thyroid hormone, and what inhibits that? Abundance in which hormone inhibits the release of insulin? Why is glycolysis inhibited? When do we use the pentose phosphate pathway? What kind of characteristics will inhibit charged amino acids? This is the exact "AAMC logic" that the test makers will expect of you. Try to keep this in mind, and use the same method as above. Grab your biology and biochemistry book and read it front to back. Then review your diagnostic.
4. Psych/soc: People put this section off to the last because they think this is the easiest section. I argue to differ. This section is becoming more and more like CARS, with term recognition. You will need to know the terms, and relationships, AND apply them in experiments given in the passage. Please do NOT procrastinate until the last minute to go over psych. For this section, Khan Academy is your main source. As you're aware, Khan Academy has paired with AAMC and they are the go-to resource for MCAT. If you watch their videos and understand your terms and relationships, your only task is to manage through the passage. And what do you do with the passage? Read them through, just like CARS. Lastly, do not rely on 86page or 300page document that you can find. I'm not saying that is not a good resource. But if you're going to use that, make sure you are reinforcing all the terms and understanding it.

Question Bank (Resources: UWorld, AAMC)

1. AAMC: I have seen SO many people saying that they should save this AAMC material to the last. Please do NOT SAVE everything to the last minute. Think about it. They are the test-makers. You want to get your hands on their material as soon as possible. Other companies will try to mimic the "AAMC-Logic" in their tests, but if you can get the real deal, why are you deferring to other companies? Other companies are just meant to supplement!
   1. There are 10 sections in AAMC Q packs. Here is how you should use them (in order)
      1. Biology Question Pack Vol. 1 and 2: This is very content-based. This is nothing like the real exam and you should not use/think of this as the real deal. This is just there to make sure you understand the contents. Go through them, and review them thoroughly. (I'll explain HOW to review thoroughly below)
      2. CARS diagnostic tool: this is probably the only CARS question pack that will give you any kind of detailed explanation in videos. There are approximately 160+ CARS practice questions in this pack, so get used to it. You will have done enough practice with CARS after this tool and CARS pack 1 and 2. Don't go using other sites. Maybe do a Jack Westin here and there but don't rely too much on other companies. This is where your AAMC logic practice comes from. Download the Jack Westin Chrome extension. They have an explanation for every single AAMC question WITH DETAIL.
      3. Chemistry Pack: This is very orgo-heavy. This is not an exhaustive content review tbh. But DO use this pack to solidify your orgo contents. If you can master this content, you should be good on your orgo. Gen chem you will have other resources.
      4. Physics: Also content-heavy just like bio. This is very focused on calculations, and passage-based information extrapolation. This is very similar to your physics course exam in college. Use them, and master all your equations. Don't just memorize them, understand their relationships. For example, don't just memorize PV=nRT. How can you change this equation? What would happen to pressure if temperature was increased? This is the AAMC logic and how they will test you on it. Make sure you can move around those variables.
      5. CARS Vol. 1 and 2: CARS Vol. 1 is EXTREMELY difficult. Don't let it beat you down. 2 is more representative of the real exam. But kudos to you if you're doing well on this section! Try to reason through it, by using the method above. If the method above does not work, you need to find YOUR way. All these CARS practices are for you to figure out how you best comprehend a passage.
      6. Independent pack: this is also subject-based, divided into 6 subjects (25 questions each). This can be pushed off to a later date, but do it before the section bank.
      7. Online practice: This is 30 questions in each section: C/P, CARS, B/B, P/S. Save this to a later date but do it before the section bank.
      8. Section bank: THIS is what people mean when they say save the question bank to the last month. This is the section that is most representative of what the actual exam may look like, and uses the full "AAMC logic". Some flowsheets claim that a certain percentile on the section bank is correlatable to your score, but as I said above, the only score that matters is your real exam score. Nothing else. Don't let it pull you down. Study it carefully.
   2. UWorld
      1. This is probably the next best thing you can ask for, next to AAMC. Their explanation is so detailed and you can make flashcards out of it. I found P/S section to be the most helpful and make connections. Trust me, they are hard. They are MEANT to be hard. Unless you're totally bombing the percentages with <40%, you are okay. Make sure you read through their explanations, and understand them. And if you don't understand something, look it up. Don't just write it down and say "Oh, I'll review that later". You may never get the chance to review that later. Do it now.
      2. Please, please understand that this is to supplement. This will NOT and CANNOT take the place of AAMC. and if you can't afford this, it's okay. There are plenty of free resources out there that you can use to succeed at this exam.
   3. Third-party full length
      1. Blueprint: I liked blueprint, and I used just 2 of their FL to kind of supplement AAMC. I did thorough review of all my FLs.
      2. Kaplan: This is ok, but their explanation is almost nothing. Just like AAMC, they will tell you B is right because it is. Hate their explanation. Use it as a practice for another FL.
      3. TPR: Please be cautious using TPR. Their score is weirdly deflated. I scored 517 on AAMC FL3 but 502 on TPR. If you are planning to use this, don't look at the score but just review it. See the link on how approximate conversions work: https://joel.vg/converting-3rd-party-mcat-scores-to-actual-scores/

What the hell is AAMC Logic?
I'm sure you have seen a lot of people say to understand the AAMC logic, but you still don't get it. Let me try my best to explain this and how I understood it (and it might be completely wrong, but hey, it got me somewhere, right?). So here it is.
AAMC logic is all about Relationships and prediction. Think about it. They are administering an exam that will decide who gets to be the future doctor or not. What the AAMC logic appears to be, is trying to test your ability to understand relationships of factors and how one impacts another. Your job is to predict that change in relationship so that you are able to act correspondingly to that change. For example, knowing your normal glucose value doesn't really help in a clinical setting where your patient comes in with hyperglycemia. What systems are affected by that? How are you going to develop a treatment plan based on this symptom? What other tests are you going to run? The MCAT is basically trying to "train" your ability to understand relationships, make predictions, and act accordingly.
So it only makes sense for them to test you on it. Whenever you study something, try asking yourself: does this affect any other systems? If this changes, how would this affect other systems? What will be the most likely outcome?
ANKI
You all know you should do ANKI daily. I'm just going to say it's not going to end well if you binge ANKI. I'll just leave it at that.
Though, I have seen a lot of questions about which deck to use and which deck is the most comprehensive. Let me just share what I did. At first, I used Kaplan's book and did 3 chapters a day. Once I had done that, I used the Jacksparrow deck to supplement and reinforce what I've learned. I liked Jacksparrow deck because it is divided up into each chapter. I can just select that and go through them. Once I finished all my reviews with Kaplan, I switched over to Miledown. I felt like it was more comprehensive and more of a traditional "flashcard" type of deal. People say Anking is an upgraded version of Miledown but I never had the time to do another deck. But with any pre-made deck, there will be some missing information that you will find. So my suggestion is to use whichever deck you are using and modify them. Add cards, delete cards that you already know, etc.
I really didn't like doing ANKI. The only thing that may have gotten me through this torment was the ANKI clicker thing. I hated doing ANKI with a hunched back and my fingers across 1,2,3,4 and the spacebar. So I just bought this remote and grind through it.
Full Length
I'm sure you've heard to take your full length in a testing condition to simulate what it would feel like on your test day. I feel like so many people have stressed over this, that I don't feel the need to emphasize this anymore. The only extra thing that I did was to buy a mouse. I used to study on my Mac and just needed to simulate the actual testing condition because I have testing anxiety (I mean who doesn't, right?).
Review
Okay. How to review exams. Before I go into what you should be doing, let me start with what you should NOT be doing. You literally cannot just "look at" the questions and answers and say, "oh, I'll get that next time. For sure" and move on. Please do NOT do this, this is just time-killing.
Instead of re-viewing, try re-doing the problems. When you get a question wrong, just think about what concept is being tested in that question. What are the test makers trying to ask? and try to simplify the question into your own words. If you're missing some content, look it up whether it's your Kaplan book, YouTube, or KA. For AAMC material, I made a little flap of paper so that I could block the right answer and redo the problem. Re-read, summarize it in my own words, and figure out what the experiment they're doing, and what the outcome would be. By doing this, you're solidifying. your knowledge on content, and understanding how they ask you a question (a.k.a AAMC logic).
For CARS, you may think that you can't apply this method. Yes you can. Remove all highlights (if you're using highlighter). Re-read the passage. What's the topic? What did the author talk about? What did the author say about the topic? How do they feel? If someone else were to say they oppose, how would the author respond?
Once you have this re-doing strategy down, you can review anything and make it yours.
About making an excel sheet to write down everything you missed, why you missed it, and what you'll do next time. A word of caution: if you are going to do this, please do it briefly. Don't waste your time making it look pretty! That is another trap that a lot of MCAT takers fall into, and I really hope you're not another one that does this. I didn't make the excel sheet--instead, I just kept a piece of paper that I wrote down every concept that I missed and just reinforced them.
Exam itself
The final boss. The reason you've killed your social life for the past couple of months. If you have done enough of practice, you should go into the testing center with the mindset that you can get every question right. But also, more importantly, you need to understand that ALL the questions you will see, is probably the questions you have never seen before. Ironic, but true. But you have the knowledge to navigate your way through the exam. Doesn't matter what they're asking, you already have the strategy to tackle all their questions. What concept is being tested here? That's all.
Another thing to keep in mind. The exam is not over until you see the survey screen. Until you see that screen, you have every possibility/chance to increase your score. Remember how I said your score can increase until you quit? Same thing here. Your score can increase until you see that end screen.
Final note
I feel like I rambled so much and just hope that I got my point across to you. This is by no means the "only right way to study", or "the best way to study" but I REALLY wanted to give it back to the community because you guys helped me so much during my journey to taking the MCAT. Like I said, if this helps at least one person, I would be forever grateful.
I'm going to leave you with a quote that I always had in front of my desk. This is a random quote that I saw on Instagram reels and just stuck with me ever since I started studying for the MCAT.
"The magic you are looking for, is in the works that you are avoiding."
So stop avoiding, turn off Reddit, and go make that increase in your score. Remember, your score can improve until you quit studying.
I love you all. God bless.

I am sharing here for others, as I see soo many post about "what does this mean" This is a very long read. But there was a full tear after 2.5 years of suffering through pain. Ya'll state after 6 months demanding surgery. Imagine what I was enduring. I feel deeply for anyone who has to endure this pain. For information purposes at the time of the injury, I was 58 years old and a female. At the time of surgery, I was 60 years old.
This is my MRI Results that was with contrast.
MRI ARTHROGRAM SHOULDER RIGHT POST INJECTION
IMPRESSION:

1. The supraspinatus tendon demonstrates dominant interstitial tears communicating from the bursal to the articular surfaces with an overall porous appearance of the tendon as contrast is insinuated within the substance of the supraspinatus tendon. This appears to be the source of the subacromial subdeltoid collection of contrast as no discrete full thickness tendon tear is present.
2. Abnormal appearance of the posterior superior labrum which appears to be somewhat denuded and is not identified along the cartilage of the glenoid. Frayed appearance of the superior glenoid labrum along for contrast to permeate into the labral substance.
3. A tear of the posterior band of the inferior glenohumeral ligament is suspected along for contrast to extend along the inframedial humeral neck region.

END OF IMPRESSION:
INDICATION: Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, subsequent encounter Bicipital tendinitis, right shoulder Primary osteoarthritis, right shoulder.
TECHNIQUE: MR imaging of the right shoulder was performed with intra-articular contrast. 13 cc of intra-articular contrast were instilled without complication.
CONTRAST: Arthrography was performed under a separate procedure. Above sequences were performed following injection of dilute Gadavist solution under fluoroscopic guidance.
COMPARISON: None available.
FINDINGS:
Labrum: Contrast is insinuated within the superior labral rim suggesting fraying and tearing. The posterior superior labrum is completely denuded and not identified. A sublabral foramen appears to be present in the anterior superior labrum. A small perilabral sulcus is noted superiorly.
Glenohumeral ligaments: Intact superior and middle glenohumeral ligaments. The inferior glenohumeral ligaments may be torn posteriorly as contrast is extending along the inframedial humeral neck along the posterior margin suggesting a tear of the inferior glenohumeral ligaments.
Cartilage: Intact.
Bones: Normal.
Rotator cuff: The distal supraspinatus tendon is very porous with contrast insinuated throughout the substance of the tendon and multiple interstitial tears and bursal surface fraying. The abnormal appearance extends from the musculotendinous junction to the insertional footprint, approximately 3 cm in total length. There is a prominent amount of contrast extending into the subacromial subdeltoid bursa which appears to be using one of the many interstitial communicating tears of the supraspinatus tendon. The infraspinatus, subscapularis and teres minor are intact.
Biceps tendon: Biceps tendon is intact.
ESTIMATED BLOOD LOSS: None.
SPECIMENS OBTAINED: None.
Here is the Surgery Results:
Pre-op Diagnosis * Traumatic complete tear of right rotator cuff, subsequent encounter [S46.011D] Postoperative diagnosis: High-grade near full-thickness superior lateral corner subscapularis tear long head biceps subluxation, 95% bursal sided supraspinatus cuff tear and subacromial impingement right shoulder Procedure: Arthroscopic right subscapularis and supraspinatus rotator cuff repairs long head biceps tenodesis acromioplasty right shoulder
Anesthesia:General with Interscalene Nerve Block
PROCEDURE NOTE: The patient was placed in the supine position and general anesthesia was instituted. The patient did receive IV antibiotics within 1 hour of surgery. An interscalene block had been instituted by the anesthesia department. TED hose and SCDs were placed on bilateral lower extremities for DVT prophylaxis. The patient was placed in a beachchair position. The head and neck were kept in a neutral position and all pressure points were padded and protected. Exam under anesthesia of the operative RIGHT shoulder showed full passive range of motion and no evidence of instability. The right upper extremity was sterilely prepped with chlorhexidine and ChloraPrep solutions and sterilely draped and a timeout was performed. The ChloraPrep was allowed to sit and become thoroughly dry for 3 minutes prior to drape application. All landmarks were marked on the skin with a surgical marker. #11 scalpel was used to perform the skin incision for a standard posterior portal and the arthroscope was inserted into the glenohumeral joint. An anterior portal was created under spinal needle guidance to lie superior to to the level of the subscapularis and lateral to the glenoid and an 8.25 Arthrex cannula was inserted here over switching stick and cannulated dilator. In a similar fashion an anterior-superior-lateral portal was created lateral in the rotator interval and an 8.25 Arthrex cannula was inserted here over the a switching stick and cannulated dilator. A full diagnostic arthroscopy of the RIGHT shoulder revealed: A small flap articular sided tear of the anterior supraspinatus at the level of the biceps which was lightly debrided with a shaver. A small degenerative flap of the anterior mid equator labrum which was gently debrided with a tomcat shaver. The footprint however the insertion of the supraspinatus infraspinatus and teres minor appeared intact from the articular side however. There is a superior lateral corner of the subscapularis tear and long head the biceps could easily medially subluxed into this tear. There were no labral lesions. The articular cartilage of the humeral head inferiorly showed some stippling otherwise normal cartilage of glenohumeral joint. No loose bodies in the axillary or subcoracoid recesses. Long head biceps tenodesis: The long head of the biceps was secured by passing a BirdBeak with a #2 FiberWire attached through the anterior-superior-lateral cannula to secure the long head of the biceps tendon at the superior level of the biceps groove with a self racking half hitch. Long head of the biceps was then released lateral to the supraglenoid tubercle with a duckbill punch. The long head biceps stump was then debrided with a vapor radiofrequency device back to a smooth and stable border confluent with the superior labrum. The sutures securing the biceps were then placed outside the anterior superior lateral cannula. The long head the biceps would later be tenodesed to the sub-Scapularis repair anchor. There were no subcoracoid spurs thus no Coracoplasty was necessary. Subscapularis rotator cuff repair:The area of the lesser tuberosity's empty footprint at the level of the subscapularis tear was lightly decorticated with a tomcat shaver to encourage healing. An Arthrex lasso was used to shuttle a Nitinol wire through the subscapularis approximately 10 mm medial to the tear. The Arthrex tamp was placed at the lesser tuberosity at the empty footprint at the level of the subscapularis tear in the correct position and angle and was then gently impacted down to its laser line. Next an Arthrex 5.5 FT anchor was placed down to its laser line and flush with the lesser tuberosity. Firm back pressure on the sutures confirmed that the anchor was fully and firmly seated. The Nitinol wire was used to shuttle 2 of the strands of FiberWire attached to the anchor through the subscapularis. The Arthrex lasso was used again 12 mm separated from the first pass to pass another shuttle through the subscapularis. The Nitinol wire was then used again to shuttle the additional 2 strands of FiberWire attached to the anchor through the subscapularis in a double horizontal mattress fashion. The standard arthroscopic knot tying techniques described by Gartsman provided 6 alternating arthroscopic surgical square knots and this fully and firmly delivered the subscapularis back to its anatomic insertion. The sutures from the subscapularis repair anchor were then incorporated with the 2 suture strands of FiberWire securing the long head the biceps with the same arthroscopic knot tying techniques so that the long head of the biceps was tenodesed in an anatomic fashion at the level of the subscapularis repair anchor. There were no other intra-articular abnormalities. #1 PDS was placed with a spinal needle percutaneously through the supraspinatus laterally at the level of the small anterior flap tear which was debrided so that the supraspinatus could be better evaluated on the bursal side. Subacromial space arthroscopic examination: The arthroscope was redirected in the subacromial space. The anterior and anterior superior lateral cannulas were redirected in the subacromial space. The bursal examination of the rotator cuff revealed: An essentially full-thickness tear of the bursal side of the anterior supraspinatus consisting of a 95% tear. The infraspinatus and teres minor were completely intact on the bursal side. Acromioplasty: The undersurface of the anterior acromion was debrided of soft tissue and a prominent type 3 acromial spur became evident. First through a standard lateral portal the acromionizer bur was utilized to perform a standard cutting block acromioplasty from lateral to medial so that the undersurface of the anterior acromion was flush and flat with the undersurface of the posterior acromion. The arthroscope was then switched to the lateral portal and the acromionizer bur was then placed in the posterior portal and the acromioplasty was completed in 2 planes orthogonal to 1 another so that the undersurface of the anterior acromion was flush and flat with the undersurface of the posterior acromion.A bursectomy was performed with a combination of a tomcat shaver and vapor radiofrequency device to clear the bursa from the edges of the cuff tear and for maximal visualization of the cuff tear from the bursal side. This was performed first with the arthroscope in the posterior portal and then eventually the arthroscope was switched to the lateral portal for better visualization of the cuff and an 8.25 cannula was inserted additionally in the posterior portal over a switching stick and cannulated dilator.An accessory anterior superior portal was created lateral to the anterolateral corner of the acromion under spinal needle guidance for anchor placement. At this point the Arthrex 5.5 FT anchos were placed lateral to the cartilage at the level of the empty footprint of the greater tuberosity in the following configuration: With one 5.5 Arthrex FT anchor placed at the central aspect of the empty footprint at the level of the supraspinatus tear. The Express Sew was used to pass all the FiberWire suture strands attached to the anchors from deep to superficial starting posterior and ending anterior in a double horizontal mattress fashion. The same standard arthroscopic knot tying techniques provided 6 alternating arthroscopic surgical square knots and this fully and firmly delivered the cuff back to its anatomic insertion. The quality of the repair could be described as: Good and since this was such a small tear this was repaired as a single row configuration. There were no other abnormalities. The arthroscope was removed. The portals were closed with a 3-0 nylon horizontal mattress suture. Xeroform, copious sterile gauze and 3 sterile ABDs were applied. A fourth ABD was placed in the axilla to protect the skin. Medipore tape was applied gently. The patient was placed in a sling and transferred to the recovery room neurovascularly intact and in stable condition. Plan: The low opioid protocol of minimal Norco along with gabapentin Mobic Zofran was E prescribed to Walmart Shippensburg pharmacy and PDMP showed no discrepancies. Quickly transition to just Tylenol. Follow-up with Dr. Lyons early next week for dressing change. Instruct the patient in the supine passive stretching for full forward elevation and external rotation to be performed self-directed 1 minute every hour while awake. Follow-up with physician assistant at 2 weeks postop for x-rays of the operative shoulder 3 views along with suture removal and check self-directed passive range of motion.

DAY: MARCH 30-31, 2024

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I have received numerous messages about what I did as I approached reapplying into anesthesiology for a second Match after only matching for a transitional year in 2023 so I wanted to make a public post with advice and reflections. If this is your scenario this cycle, I am truly sorry for what you are feeling and still remember all the feelings a year later.
The best thing I was told following Match 2023 - “this result has no bearing on what type of intern, colleague and physician you will be. Only you have the power to control that”
This could not be more true and it is what I gripped onto for the past year. You cannot control this result, but you can control how you react to it and how you move forward.
My Post Match 2023 Reflections on Why I Did Not Match: - USMD Step 2 25x - No home anesthesiology residency program affiliate - Did not do an away rotation as I was told it wasn’t necessary - Research heavy application with mentors that were not affiliated with a residency program (working hard but not for the right people, no connections) - Attending conferences but not networking / no program knew I existed - Did not geographic preference signal and applied to 30 programs (was uneducated about # of programs to apply to and then later found out not geographic preferencing put me at an extreme disadvantage) - Perhaps did not represent my best and truest self on a virtual interview platform - Interviewed at programs that had only a few spots and may have assumed I would match at another program bc of scores/research interests but didn’t have enough pizzazz to match at a top program - Numerous factors all aligning at once and a touch of bad luck
2023 Interview Season Stats: no geo signaling, applied to 30 programs and received 6 interviews (received interviews at ⅕ programs I signaled). Ranked one TY program at the end of my ROL and matched there for one year position. This TY was out of state and had an anesthesiology residency nearby (in contrast to other TYs I interviewed at).
The week after the Match: - Reached out to my TY PD to facilitate an intern year schedule conducive to reapplying (ICU month, EM month, research month / away rotation in anesthesiology, policy about interviews while on required medicine months where most are unable to use vacation days), desire to work toward the strongest letter possible from them - Emailed every program I interviewed with for feedback about my application and things to improve upon for the next cycle. Some programs informed me that they would have a Reserved position or two in the next Match and hoped I would reapply to them - Emailed every program in my home state to see if I could get a visiting student rotation for April or May prior to graduation (secured an away in April, also did 2 week observership beginning of May) - Reached out to a MD/PhD researcher in my TY city that I met at ASA annual meeting the prior fall to see if I could do a research month in the lab, met with her, discussed which months she had availability for me to be a “visitor.” She also looked over my application and couldn’t pinpoint why I didn’t match. - Reached out and met with your feedback on my ERAS app with the PD of the program in my TY city (did not receive an interview with them during Match 2023 cycle, did not signal them)
April - Worked very hard on my away and observership. Met with the PDs, APDs and asked for feedback on my performance while on rotation and on my application. Got involved with research with one of the programs. - - Talked to the residents about which attendings would advocate for me to match there the next cycle. Showed up earlier than everyone to set up their OR for them or help them with it. Prepared daily learning topic related to the case if I knew it ahead of time to discuss with them while in the room when MDA was present. - Asked residents on these rotations for feedback on my app - was told my PS did not talk enough about ME, too much emphasis on storytelling. Did not quantify my impact factor within the experiences section in ERAS despite having strong involvement. - Presented at IARS. Approached attendings/leadership where I was currently rotating while at this conference to show face - If your TY/prelim program has the option for you to leave for a month during intern year in order to rotate as a visiting “resident,” I imagine this would be the month to be setting this up. I did not do this but I was cautioned that it can be difficult with licensing/various privileges if crossing state lines - Started working on my PS but truly could have waited because I talked a lot about my experiences as an intern in my new PS
May - Took a 2 week vacation to Europe and mentally checked out - Attended medical school graduation (first physician in my family, still proud of myself!) - Coached youth soccer as it helped me mentally and physically, played soccer for 13 years growing up and still a favorite hobby of mine - Worked out lifting weights and fitness classes with friends to keep myself feeling physically well - Moved to my TY city - Found a volunteering project that coincided with a “theme” in my application (super passionate about medical education, tutored all years of undergrad and medical school, so I did STEM tutoring for refugee children and teens for which there is a large population of in my TY city)
June - Had fun bonding with my co-interns who became some of my closest friends and biggest supporters. Started beer league volleyball as a distraction from life, they read my PS and gave me feedback, picked up call days during interview season so I could interview (with me paying them back in the coming months post Match 2024) - Start writing your new PS - Tidy up your experiences section - Find a volunteering activity in your new TY/prelim city that you can talk about on your app that you are passionate about. This will set you apart and shows you’re engaging with your new community
July - Focused on absolutely dominating my medicine wards month - Picked out letter writers - my TY PD, TY APD, reused letter from medical school anesthesiology mentor. For my fourth, I used a letter from my away in my home state or a letter written by the physician researcher I got to know through research in my TY city - Advice on letters: I only reused one letter from the previous cycle and it was my mentor who knew me all 4 years of medical school, an anesthesiologist, did research with him. The advice I received was max send 2 anesthesiology letters and the other 2 from other specialties. Your PD letter is the most important letter you’ll send as a reapplicant - make sure you show up & show out. - Rewrote my ERAS experiences to QUANTIFY my impact but kept the activities mostly the same. Actually had to trim them down as the application changed to allow for max 10 activities in Match 2024 cycle. Included new volunteering activity here. - Elected as TY Chief of my class. Talked about this in my application as well. This role also allowed me to work incredibly close with my PD and APD, allowing them to get to know me even more.
August - Anesthesiology rotation with private practice group. Strategized working with younger attendings who still had ties to residency program - they reached out on my behalf but did not write me a formal letter. - Practice interviews with anesthesiologists from my home institution (private practice) who were former PDs for fellowship programs, etc
September - Worked with my APD and PD on another medicine month, met about my letters from them - Submitted ERAS nearly at the last possible minute - Started studying for Step 3
October - ICU month, so busy - Presented poster at ASA annual meeting, snuck into the medical student session that was ticketed this year for residency program meet and greet - Sought out programs I connected with previously - aways, the program in my TY city, programs in major nearby cities - Started interviewing
November - Research elective - Did 11 interviews this month - Took Step 3
DecembeJanuary - Interviewed on non-call days on medicine - Reached out with progress updates to PDs I had met, sharing unique cases I encountered related to anesthesiology blah blah - Sent LOI to the program in my TY city - Did not send multiple LOIs despite receiving this advice
February - Attended one second look while on emergency medicine - Kinda checked out and stopped email communication and networking due to being exhausted - My PD emailed all Reserved programs I interviewed with to match me then made calls to my top 2 programs 2 weeks later
March - Matched Reserved at my #1
Stats in Match 2024 cycle - Applied 157 anesthesiology programs (did not dual apply but debated this heavily) - Received 21 anesthesiology interviews - Received interviews with 14/15 signals - Received interviews in every geographic region despite only being able to geographically preference 3 of them - Cost: ~$4,200 for apps plus additional $330 for ranks beyond 20 in NRMP
Things I’m Glad I Did - Networked - Away/visiting rotation prior to graduation - Worked hard, impressed my PD who got to know me who 1000% went to bat for me and advocated all the way to the finish line - Research month (visibility to the department I just matched with but also was able to complete 11 interviews at my “leisure” and take Step 3) - Taking Step 3 prior to rank lists being due - Used geographic preference signaling, signaled almost all programs in my home region that had an R position if they also had greater than 10 categorical spots - Wrote an “Impactful Experience” that focused on my growth mindset and strong work ethic (later found out this section appears FIRST when PDs and committees view your application) - Applied Reserved, Categorical and Advanced
Signal Advice - Used geographic preference signaling, signaled almost all programs in my home region that had an R position if they also had greater than 10 categorical spots - All program signals should be within your geographic preferences - One geographic region you signal should be your home region - I truly believe applicants, and especially a reapplicant, are at an advantage when they are trying to signal and match close to home. Bottom line programs want a happy resident - Bottom line: signal close to “home” or any place you have strong ties (then talk about the specific tie in last paragraph in your PS)
PS Advice - Start new - Focus on you - As a reapplicant, your second to last paragraph needs to be why you think you didn’t match in a sentence of two with a STRONGER EMPHASIS on all the things you did after to tackle these weaknesses and to be better this cycle - Check out Dr. Michael Hofkamp’s personal statement on MedTwitter / X
Other General Things - You will be asked in almost every interview by every individual interviewer “why do you think you didn’t match the first time” - Dr. Michael Hofkamp has an algorithm/flowsheet for Matching Anesthesiology in the current environment on MedTwitter / X. Check it out to see if you should be dual applying.
You can do this if you absolutely want it, but it was a ton of work. A year later, I’m glad I did not give up. I’m rooting for you!

TLDR: Discworld is awesome. Here's a huge rant about how much I love it.
Halfway through Men at Arms and couldn't wait to come here to express my love. From a young age, I've always been an avid reader, especially of fiction: Harry Potter, Percy Jackson, all them YA dystopias. I read crazy fast and loved all of the stories. Not born in an English-speaking country, but reading so much in English had definitely helped. It's pretty much my native tongue now. In middle school, I sort of just ... stopped. Schoolwork was piling on, social situations, etc etc, reading just wasn't something I'd do voluntarily out of class anymore. I stopped reading (actual reading for myself, not schoolbooks) for three years. In my first year of highschool, I was a lonely kid with no friends and a lot of time to kill. I got back to reading, and rediscovered how awesome it is. Went through some fiction and nonfiction, liked some quite a bit, and started to read routinely again. Heard of Sir PTerry from Good Omens, but haven't touched his stuff.
At the beginning of my second year of high school, a friend suggested "Small Gods" to me after we talked about books and nerding for an hour. Our school library has a pretty complete selection of Discworld, so I checked it out and decided to give it a try.
Best decision ever. Small Gods was fantastic, so I searched a bit on Google and found the flowsheet. Went to Mort, and obliterated the Death series. Even after getting back to reading, Discworld has been the only series that genuinely and continuously sparked joy and empathy in me. The last series that did this for me was Percy Jackson, but Discworld is on a whole other level. Reaper man was so astonishingly beautiful; my favourite moment was when Azrael's giant "YES" was printed on the page. When I flipped the page over, I could actually feel my soul tingle and shake. Every character is so well-written! Death! Susan! Mort! The Librarian. Oh I love Death so much. All of them! And the jokes! The plot! The small phrases! Everything! It blows my mind that someone can write like this.
After I finished the Death books, said friend recommended Guards! Guards!. Absolutely fantastic hell of a book. Jesus Christ. I expected that nothing would top the Death books, but I think every book I read will soon become my favourite. I love Carrot. And Colon. And Nobbs, even. And Vimes. Holy crap, Vimes is going to replace Death as my favourite character. Or can I have two? Or all of them?
Vimes is such a character. He's not your usual pure good hero, I bet no one in Ankh-Morpork is one (maybe except Carrot), but his goodness is so ... violent and angry and stubborn that I just can't help but love him for it. When he drowns himself in alchohol because Vetinari took away his sword and disbanded the Watch? That was absolutely heartbreaking to read. Unfortunately I got spoiled and I know there will be more heartbreak later. I feel for Vimes so much, in more ways that I can currently put into words.
A lot of people, even well-meaning ones, ones that are readers themselves, makes fun of me for reading fantasy like Discworld. I don't understand this at all: if they even bother to read one of these books, they'd realize that it was so, so much more than whatever simple children's fairytale they imagine it to be in their mind. It's so much more, and I love the fact that my brain just starts thinking like crazy when I read these books.
Right now, my biggest fear is that one day, I'd have no more Discworld left to read.

how do students from school of arts check the courses they took already or need to still take to graduate ? for SEAS students there's this flowsheet on seas portal where you get to check your progress current courses your taking , ones you've taken already and what other courses you need to take to graduate . so just wondering for school of arts do ya'll got Something like that too ?

Here are all my thoughts and advice based on my personal experiences, other people’s insight and helpful experiences, and research I have done on and off about pelvic floor issues from the past eight years or so. There is still a lot left to learn, but I am putting everything I know currently here. I am not claiming that any of this is revolutionary, but I hope it can help some of you out there to give you a head start on healing and advance our understanding of these conditions. As I am a 27 year old male with previous major problems with pelvic floor issues and hard flaccid, some of my advice may be biased towards my condition. However, I believe everyone can benefit from a lot of this because I really do think that all of these conditions that I mentioned are linked in at least some way, especially by pelvic floor dysfunction and sex hormone desensitization. I try not to come to these forums because it increases anxiety and negative emotions which leads to worse pelvic floor symptoms, so my apologies if I do not respond to your questions. For hard flaccid and pelvic floor affected people, follow my advice and I am confident you can heal and reach a place where your symptoms barely affect your life, if at all, which is where I am at now. The mentality of trying to find a 100% “magic cure” solution just leads to anxiety and catastrophic thinking if you have a set back which will only worsen your symptoms. You can and will heal. I know this is a lot of information, but try to implement just one or two things at a time. Focus on the present, and take it one day at a time. Don’t get overwhelmed.
Post Finasteride Syndrome (PFS), Post-SSRI Sexual Dysfunction (PSSD), Hard Flaccid Syndrome (HFS), Pelvic Floor Dysfunction, and Chronic Pelvic Pain Syndrome all can have some similar symptoms. I believe that they are all either caused or can be exacerbated by androgen and estrogen receptor insensitivity and are triggered by medication, genital injury, and pelvic floor inflammation and dysfunction. The pelvic floor is rich in androgen receptors and estrogen receptors. However, without proper androgen receptor activation and sensitivity, the pelvic floor muscles don’t have enough DHT which line the tissues of the pelvic floor, genitalia, and lower urinary tract. DHT is vital for healthy sexual functioning in both sexes - it provides an anabolic effect to tissues to provide strength, stability, healing, and relaxation to tissues. As a result of androgen receptor insensitivity and lack of DHT, the pelvic floor can become chronically weakened, tight, and inflamed which reduces blood flow to the region leading to even more androgen receptor insensitivity and thus less DHT. These symptoms can cause psychological stress to the individual which tightens the pelvic floor further leading to more symptoms and less blood flow. One study found that androgen sensitivity has raised the possibility that androgens can be used to rebuild the weakened and/or damaged muscles comprising the pelvic floor - source. Some people may also have normal sex hormone levels in the blood when tested, but these hormones cannot reach or be effective in the pelvic floor tissues or brain due to sex hormone insensitivity and the lack of the blood flow in the region caused by pelvic floor tightness and dysfunction.
Desensitized estrogen receptors leading to decreased estrogen levels in local pelvic floor and genital tissues may be causing a similar mechanism of dysfunction in some people like androgen receptor insensitivity and DHT because estrogen is important for pelvic floor and sexual health in both sexes. This study says that “Estradiol in men is essential for modulating libido, erectile function, and spermatogenesis. Estrogen receptors, as well as aromatase, the enzyme that converts testosterone to estrogen, are abundant in brain, penis, and testis, organs important for sexual function. In the brain, estradiol synthesis is increased in areas related to sexual arousal. In addition, in the penis, estrogen receptors are found throughout the corpus cavernosum with high concentration around neurovascular bundles.” Steroid users report that low estrogen causes decreased or numb penile sensitivity, shrunken flaccid penis, dull orgasm, urinary hesitancy, urinary frequency, low sex drive, and erectile dysfunction. Here is a paper from a PSSD community member that hypothesizes, as do an increasing amount of people, that the main issue of PSSD, PFS, and Post-Retinoid Sexual Dysfunction is estrogen receptor insensitivity. PSSD and PFS sufferers often have similar hard flaccid and pelvic floor issues, so if those conditions are caused by estrogen insensitivity, then perhaps our pelvic floor dysfunction, HFS, and CPPS, is also impacted by a lack of estrogens in the pelvic floor tissues, not just androgens. The most important element to remember to help start the healing process for these disorders is to boost blood flow through supplements, stretches, and exercises which will increase both androgen and estrogen receptor sensitivity over time.
Post Finasteride Syndrome (PFS) caused by Finasteride, a 5-alpha-reductase inhibitor (5-ARI), plummets DHT levels in the body to try to help hair loss causing sexual dysfunction and pelvic floor issues. Androgen receptors that surround the pelvic floor, genitals, and brain become desensitized due to the Finasteride leading to less DHT binding to these receptors causing dysfunction and a tight, weak pelvic floor. The tight, dysfunctional pelvic floor now restricts blood flow which impacts healing and the delivery of testosterone to this area that further exacerbates androgen insensitivity leading to less DHT in these tissues. Since androgen receptors are found in the brain and androgens have neuroprotective effects, this could be one reason why some PFS and PSSD sufferers are also impacted cognitively. An herbal supplement called Saw Palmetto has also been reported to cause a disorder similar to PFS because it is also a 5-ARI that blocks the conversion of testosterone into DHT. Another disorder called Post Accutane Syndrome (PAS) is also similar to PFS and it reduces DHT as well through being a 5-AR.
For Post-SSRI Sexual Dysfunction (PSSD), SSRIs are also known to decrease androgens and down regulate androgen receptors. This study shows that SSRIs can have an anti-estrogenic effect as well and can even reduce the expression of estrogen receptors (ER), including in the hypothalamus.. As androgen and estrogen receptors get desensitized in the pelvic floor, genital region, and brain, it causes localized DHT and estrogen levels in these tissues to decrease causing emotional blunting, sexual dysfunction, pelvic floor issues, hard flaccid syndrome, and more. The pelvic floor dysfunction can then prevent the sex hormone receptors from being reactivated and sensitized in this area due to restricting oxygen and sex hormone rich blood flow to the tissues. SSRIs can cause androgen receptor insensitivity and estrogen receptor insensitivity by severely inhibiting the serotonin transporter (SERT) leading to increased serotonin levels which desensitizes those receptors throughout the body. It is also interesting that some PSSD community members are trying to restore estrogen receptor sensitivity via boosting estrogen in various ways including by taking hops extract which is a potent phytoestrogen. Check out the PSSD Network for more information on this condition as they are helping to give a voice to the unheard..
Hard Flaccid Syndrome (HFS) - There are many men suffering from HFS and pelvic floor issues due to PSSD, PFS, heavy weight lifting, excess kegeling, or in the case I’m presenting here, physical damage to the genitals and/or PF muscles from excessive, vigorous sexual activity (my case) or penis enlargement exercises. When the genitals or surrounding PF muscles get damaged, an inflammatory process starts and the pelvic floor contracts to protect itself. Since the pelvic floor is now in a chronic, contracted state, it limits oxygen and sex hormone rich blood flow to the genitals and pelvic floor which leads to sex hormone insensitivity and negatively impacts healing, muscle relaxation, and DHT production in these tissues. Finasteride, Accutane, and SSRIs also desensitize sex hormone receptors in the genitals and pelvic floor tissues leading to hard flaccid and pelvic floor dysfunction. Since the pelvic floor tightness restricts blood flow, it is difficult for hard flaccid sufferers to reactivate and sensitize their pelvic floor muscle androgen receptors again to regain relaxation and strength in their pelvic floor muscles, including the ischiocavernosus (IC), bulbocavernosus (BC), and pubococcygeus (PC) which are in a contracted state; the IC muscle in particular is thought to be the most implicated in the cause of hard flaccid. We first need to promote relaxation in the pelvic floor by boosting blood flow through supplements and stretches because tight muscles are weak muscles. Once the pelvic floor is in a chronic state of tension, it is hard to heal from pelvic floor issues because you likely already had bad habits such as poor posture, unhealthy sexual practices, stiff muscles, sedentary lifestyle, unchecked anxiety, and other negative lifestyle factors. Along with supplements, exercises, and stretches, correcting these bad habits is necessary to heal to have an even healthier pelvic floor than you ever had before because it likely was already tight and dysfunctional to begin with before developing obvious issues, but it was more subtle and you had no awareness of your pelvic floor muscles until now. You have the potential to now become a much healthier person overall than you ever would have been without being affected by pelvic floor dysfunction and hard flaccid.
What I see in all these conditions is that sex hormone receptors become desensitized in the pelvic floor and genital tissues either from a drug, pelvic tightness, or inflammation from injury leading to less localized sex hormones causing sexual and pelvic floor dysfunction. The pelvic floor now goes into a chronic tightened state as a response, leading to more inflammation and less oxygen and testosterone rich blood flow to the genital and pelvic region which leads to more androgen insensitivity and subsequently less DHT. This all explains why many people who have these conditions are helped by supplements that improve androgen receptor sensitivity and blood flow, and why pelvic floor therapy and exercises are so helpful to many of them. Estrogen receptor insensitivity in the pelvic floor also appears to have a similar mechanical negative effect by leading to less estrogen levels in the pelvic floor and genital tissues. It is also possible that some people with PSSD/PFS may have subtle or no pelvic floor symptoms, but the medication still desensitizes sex hormone sensitivity in their genitals and pelvic floor tissues that is leading to sexual dysfunction.
Another study linking androgens and the pelvic floor: Levator ani and other muscles of the pelvic floor and lower urinary tract are sensitive to the anabolic effects of testosterone. Androgen receptors are also expressed in the pelvic floor and lower urinary tract of both animals and humans. Anabolic effects of androgens may play an important role in the female pelvic-floor and lower-urinary-tract disorders. The action of androgens in the lower urinary tract and pelvic floor is complex and may depend on their anabolic effects, hormonal modulation, receptor expression, interaction with nitric oxide synthase, or a combination of these effects.
My solution to help heal and improve the well-being of people with these issues is to try to improve sex hormone receptor sensitivity and pelvic floor function through supplements, stretches, exercises, and boosting blood flow which will hopefully restore normal levels of estrogens and androgens in pelvic, genital, and brain tissues. The body has a tremendous capability of self-healing, but we need to support it through active recovery methods.
We will first start with supplements (this is not professional medical advice - talk with your doctor before taking):
L-citrulline - This is the precursor to l-arginine, and it will improve blood flow and levels of nitric oxide to help get oxygen and testosterone rich blood to the pelvic floor and genital tissues to increase androgen sensitivity. Nitric oxide can also induce smooth muscle relaxation which is important for relaxing the pelvic floor. Herein we report on a young man affected by PSSD who regained sexual functioning after 3-month treatment with EDOVIS, a dietary supplement containing L-citrulline and other commonly used aphrodisiacs.. I recommend taking at least 6000 mg daily by taking 2000mg three times throughout the day. The max dose is 10,000mg. Even potentially better, people report great results using Cialis to improve blood flow and healing rather than L-citrulline and some doctors will even prescribe it to women if you show them the evidence - talk with your doctor. “Tadalafil (Cialis) reversal of sexual dysfunction caused by serotonin enhancing medications in women”. L-Citrulline and Cialis are not recommended to be taken together.
L-Carnitine - This will improve the number of androgen receptors and their sensitivity to testosterone to increase levels of DHT in the pelvic floor, genital tissues, and brain. Acetyl-L-Carnitine can pass through the blood-brain barrier, while Propionyl-L-carnitine has a high degree of interaction with testosterone. Propionyl may be better for sexual and pelvic floor dysfunction, while Acetyl might help people suffering from the mental effects of PSSD. This study used each at 2000mg daily to improve erectile dysfunction along with Viagra.. I would work up to 2000mg each of Acetyl and Propionyl L-Carnitine along with Cialis instead of Viagra as it lasts in the body for much longer (36 hours) for increased blood flow healing purposes. You can also use L-Citrulline instead of Cialis as mentioned earlier. Discuss with your doctor before taking them.
Vitamin D - This vitamin, which acts more like a hormone, works directly with the endocrine system. It has its own receptors throughout the body and they are often in close proximity to androgen receptors. Deficiency in vitamin D is associated with a stunting of testosterone's effects on androgen receptors and a decline in testosterone levels. Vitamin D will encourage androgen receptor resensitization. One study found that higher vitamin D levels are associated with a decreased risk of pelvic floor disorders in women, and The levator ani and coccygeus muscles are skeletal muscles that are critical components of the pelvic floor and may be affected by vitamin D nutritional status. I recommend 4000IU of vitamin D daily or whatever gets your levels to 60 - 80 ng/ml. I would also take 100mcg of vitamin K2 to ensure that any excess calcium from vitamin D is deposited into the bones and not arteries.
Magnesium Glycinate - This will help relax your pelvic floor muscles to help restore function and blood flow. I recommend starting with 300mg.
If you have inflammatory issues or pain due to pelvic floor dysfunction, I recommend a fish oil supplement daily. I take fish oil, and I find that it helps limit pelvic inflammation. Take quercetin and bromelain as needed if you experience pelvic inflammatory flare ups, pain, and bladder issues, but just be careful as quercetin can also inhibit the production of DHT from testosterone as well. Some say fish oil blocks DHT too, but experiencing chronic pelvic floor pain and inflammation will do more harm to you than minimal DHT blocking.
I also recommend doing some form of yoga or pelvic floor stretches daily to improve blood flow for pelvic floor relaxation and sex hormone receptor sensitivity. You also need to request to see a pelvic floor therapist for an evaluation and treatment. Learn how to do reverse kegels. Doing reverse kegels will be difficult at first because your pelvic floor is tight and you have little to no awareness of these muscles, so just focus on lengthening and relaxing the pelvic floor through stretches for now. Do not do regular kegels for pelvic floor issues. Learn how to diaphragmatically breathe in 360 degrees to create expansion in your rib cage and abdomen to encourage pelvic floor relaxation. Do not breathe through your chest, and “belly breathing” isn’t the right term because the ribs need to expand as well. You can learn how to diaphragmatically breathe through an exercise such as 4-7-8 breathing. Here is a great video on diaphragmatic breathing and another video. Retraining yourself to properly breathe diaphragmatically is the single most important thing that you can do to heal from pelvic floor issues.
Stretches/Yoga poses I recommend:
Hold the Malasana/hindi/yoga squat pose for at least 5-10 minutes at least twice a day, but doing it morning, mid-day, and at night would be the best. Some get great results holding it for 15-20 minutes.This is one of the most important things for your pelvic floor because it will help lengthen and release it. Doing them barefoot is also very beneficial to strengthen your ankles and feet which are connected to your pelvic floor. Again, remember to breathe deeply down into your belly and pelvic floor for all these stretches.
Begin your stretching routine with an Exercise ball ab stretch and Upward-facing dog/cobra pose. This will help stretch your lower abs and psoas muscles so that you can get more breath deeper down into your pelvic floor for the rest of your stretches. Some people say that these types of stretches aren’t great for people who have Anterior Pelvic Tilt, which we should fix, but I still do them as it is important to stretch the lower abs that are hard to get to. You can experiment with doing them sporadically instead of every time you stretch.
This is my current personal complete stretch routine I do in order 3+ days a week:
Myofascial release on my glutes with an orb massage ball but you can use any small hard ball (don’t do this if glutes are currently sore) > Calf stretch against a wall or a yoga block which is what I use > exercise ball ab stretch > upward facing dog > (optional) Do a handful of cat cows > Supine hamstring stretch with yoga strap or an IdealStretch tool which is what I use > Kneeling hip flexor stretch > flat on back supine single knee to chest stretch > then bring knee to opposite shoulder stretch > supine figure four > I do this stretch next right after figure four > Reclined bound angle pose > (optional) butterfly stretch > (optional) A little bit of downward facing dog to stretch the calves > (optional) Lizard Pose) > (optional) Half split stretch/Half monkey pose with yoga blocks > Half-pigeon pose > Child’s pose > Wall quad hip flexor stretch > Wall figure four stretch > Wall straddle pose > Wall happy baby pose > Flat on back while pulling knees apart > kneeling with one leg, other leg out to side for adductors > (optional) Frog pose with feet together > regular Frog pose with feet separated in line with the knees > Yoga squat/malasana > Corpse pose
All these stretches are the ones I found most useful in a routine. See what works for you and develop your own routine. Consistency is the most important. This long stretching routine may not be possible for you to complete regularly so make adjustments, but doing this routine at least 3 days a week is ideal. Stretches such as the yoga squat, supine hamstring stretch, hip flexor stretches, and wall stretches are vital and should be done most days to help relax the pelvic floor. For how long you should hold each stretch, just go by how you and your body feels. Really let go, breathe, and sink into every stretch. On rest days, doing some deep breathing in child’s pose, reclined bound angle pose, flat on back while pulling knees apart, and the happy baby wall pose is really great while trying to do gentle reverse kegels.
You can also work on more individualized stretches for posture to correct anterior pelvic tilt, muscle imbalances, and to release other tight muscles, such as the upper body. Listen to your body if you need to give yourself a rest day from stretching. Adding in a 30-60 minute walk/swim on rest days is incredibly beneficial as well. Eventually, you can also try to learn isometric PNF stretching to incorporate it into some of the stretches such as the kneeling hip flexor stretch and hamstring stretch.
Exercises I recommend:
After working to relax and lengthen your pelvic floor through yoga and stretches, I would begin gentle body strengthening exercises that are pelvic floor safe. The pelvic floor is a master compensator. So, if the glutes, adductors, deep hip rotators, transversus abdominis, and other supportive muscles are weak, then the pelvic floor is in the prime position to pick up the slack which leads to a lot of strain on the pelvic floor which results in tightness and dysfunction. You need to strengthen the surrounding muscles to relieve tightness in the pelvic floor. This is where working with a pelvic floor therapist would be helpful to point out safe individualized exercises for you. Yoga will help strengthen your muscles in a safe way too.
The glutes and transversus abdominis in particular are very important to strengthen. Glute bridge, single glute bridge, side lying leg raises, lateral band walks can help build up glute strength. Deadbugs, Bird Dog, 8- point planks, or planks with pelvic floor-friendly modifications, can help to strengthen the transversus abdominis (TVA). Abdominal work may be triggering to your pelvic floor symptoms, especially the 8 point plank, so you can instead look into hypopressive exercises to work the TVA without overworking the pelvic floor. These exercises will help you bring more awareness to your breathing, diaphragm, TVA, and pelvic floor which are all important for recovery. Here is how to find and become aware of the TVA. Do side planks for your oblique ab muscles.
For hip/abductors do the side lying hip abduction exercise, fire hydrants, and the shinbox lunge. For the adductors, do Copenhagen adductor exercise, cossack squats, and an exercise where you squeeze a soft ball between the knees just don’t do any crunch movements with pelvic floor issues. For hamstrings, Nordic hamstring curl/glute ham raises, and single leg bridge. For the back, do supine pelvic tilt. One person even reported that dorsiflexion exercises and stretches were one important element to solve his pelvic floor issues; this is most likely because the ankle bone, like everything else including even our jaw, is connected to the pelvic floor.
Like with anything, do all these exercises in moderation and stop if you sense your pelvic floor is not responding well to them - do them one at a time to see which ones your pelvic floor can handle for now. Here is an exercise routine from another poster that has helped many people. Just be careful of the ab exercises such as the ab wheel and 5 minute planks with your pelvic floor issues - don’t over do it or avoid it if they cause too many symptoms.
Myofascial release and foam rolling to release trigger points also helps a lot of people to relax their pelvic floor muscles and improve blood flow. The glutes are the most important area to target for pelvic floor issues when foam rolling in my experience if you only had limited time. Using a soft ball to lay on and breathe deeply can help release trigger points in the abdominal muscles and psoas which can help you breathe better and relax the pelvic floor. I haven’t done it, but you can also try out a massage gun for myofascial release; just be careful and don’t use it in sensitive pelvic areas. Some men and women also report success using a therawand to release internal trigger points that are causing them pelvic floor dysfunction symptoms.
Walking and swimming for 30-60 minutes are some of the best exercises to lengthen, relax, stretch, and release your pelvic floor, boost blood flow, and help to retain and build strength in muscles that give support to the pelvic floor. Walk or swim for 5+ days a week for the best results. The breaststroke and freestyle are very helpful for pelvic floor sufferers. Along with swimming, people also use an elliptical at a low resistance to help provide a cardio workout that is safer for your pelvic floor.
Fix your posture. Pelvic floor issues and hard flaccid syndrome are closely associated with Anterior Pelvic Tilt and other postural issues. Get evaluated by a physical therapist so that they can give you exercises and stretches to fix it. You could also look into the Postural Restoration institute and see one of their providers and try to implement some of their exercises. In the meantime, here is one video playlist on how to fix APT. Another video to fix APT says to stretch the hip flexors, lower back, while focusing on strengthening the abs, glutes, and hamstrings. Make sure that you sit and walk with good posture - watch this to learn how to walk correctly - activate your glutes during each step and push off with your back foot!. I also recommend getting a standing desk to try to avoid sitting for long periods of time.
Weight training can be effective for boosting active androgen receptors in the body to increase testosterone and DHT levels. However, you need to make sure that it isn’t making your pelvic floor symptoms worse which defeats the purpose. If you are going to lift weights with pelvic floor issues, don’t lift heavy, do any intensive ab workouts, or any other exercises that can put extra strain on your pelvic floor. Do lifts where you can sit down instead of standing up. Start with yoga, stretching, and gentle body exercises to relax your pelvic floor and strengthen surrounding muscles before incorporating consistent weight training. I highly recommend, however, just sticking with yoga and pelvic floor safe body weight exercises to build strength instead. Remember to see a pelvic floor therapist to get evaluated first before starting any weight lifting.
Work on your mental health. Anxiety can worsen pelvic floor issues. Just as dogs tuck and tense their tails when stressed, we tense our pelvic floors which are directly connected to our tailbone where we used to have tails ourselves in our evolutionary history. As we are impacted by sexual dysfunction and pelvic floor dysfunction symptoms, we become anxious along with other negative emotions which leads to more pelvic floor tension symptoms due to the fight or flight mode response causing even more anxiety leading to more symptoms. It is a vicious cycle that needs to break by not becoming anxious and negative when we experience pelvic floor symptoms or hard flaccid and instead let go, accept, surrender, and realize that it is a normal process when trying to heal because sometimes our muscles that are used to that tightness don't want to let go of the tension we hold in our pelvic floors. Daily yoga, meditation, stretching, and walking will help with anxiety. I would also see a mental health therapist because all of these issues are deeply traumatic, and we cannot go through this alone. We often hold tension in the form of emotions and trauma in our bodies, especially our pelvic floor and genital areas. By openly talking about these issues with a therapist, it will help us process and release our emotions and trauma that we are holding inside our bodies to improve our anxiety, relax our pelvic floor, and to let go of all of our tension. Many people who healed their hard flaccid and pelvic floor issues said that solving their anxiety and negative thoughts by talking to a mental health counselor was vital in recovery. The mind-body connection is so powerful, and it directly impacts our pelvic floor. Those who are stuck in the cycle of experiencing pelvic floor symptoms leading to anxiety and negative thoughts will also benefit from Cognitive Behavioral Therapy you can do by yourself like in this video or preferably with a trained therapist. Here is an informative mini lecture on how stress impacts the pelvic floor.
I would also definitely go on a healthy anti-inflammatory diet. Avoid caffeine, alcohol, marijuana, and other triggering substances. Avoid foods and liquids that can trigger pelvic floor inflammation such as highly acidic fruits and veggies, carbonated beverages, very spicy foods, and artificial sugars. To maintain a healthy gut to reduce inflammation in your body I recommend trying a low-histamine probiotic supplement along with eating healthy. You should also work on preventing or fixing constipation; eat a lot of soluble fiber to not get constipated - take a supplement such as metamucil if you have to. Check the Bristol stool shape chart to identify if you are constipated because even mild constipation can contribute to pelvic floor tension. This is because the constipation leads to a lot of pressure being put on your rectum and pelvic floor leading to the muscles becoming weak and dysfunctional. I am willing to bet many of you are constipated and don’t know it because it isn’t just whether you go regularly, it is also how your stool is shaped. People with pelvic floor disorders are at a high risk of constipation which makes their tension and dysfunction worse which then worsens the constipation, another cycle to fix. I recommend getting a Squatty Potty to reduce strain on the pelvic floor during elimination.
Sexual health advice:
This is a good reddit guide on how to reverse kegel.
However, I will also give a shot at explaining how to reverse kegel because it is one of the most confusing things for people about this healing pelvic floor issues, and many people unfortunately do it wrong. This is why visiting a pelvic floor therapist would be helpful.
If you know how to do a kegel, the reverse kegel is the opposite feeling of that. I describe the kegel as a pull feeling, while the reverse kegel is a pushing out feeling. The reverse kegel helps to lengthen the pelvic floor through the front using the penis (front rk) and the back (back rk) using the perineum behind the testicles near the anus, but not the anus itself. I learned to reverse kegel by diaphragmatically breathing down into the belly and pelvic floor. On the inhale, inflate your diaphragm and belly, breathe down into your pelvic floor area and feel a gentle pushing movement out the front of the penis and out the back of the perineum. You can then gently release this pushing feeling on the exhale. Never force any movements - it should be a gentle process guided by the diaphragmatic breath. You can also try to do the front rk and back rk separately to try to concentrate on each better. To give another perspective, one person described the reverse kegel as like blowing up a balloon in the whole front area between the perineum and pubic bone inside out - so to me this means blowing up the balloon with your diaphragmatic breath into your pelvic floor and making a pushing feeling out the front of the penis and out the back of the perineum. You should also reverse kegel during sexual activities to help keep your pelvic floor relaxed and prevent involuntary kegels that lead to a tight, imbalanced pelvic floor and premature ejaculation. Reverse kegeling when erect may be difficult at first, but it will become easier to understand during sexual stimulation when you get the feeling of wanting to involuntary kegel, but doing the opposite of that and gently doing the push feeling through the front reverse kegel.
I would stay away from regular kegels when dealing with pelvic floor and hard flaccid issues - it will only lead to contraction and tightening. The kegel (BC) muscle works plenty involuntarily on its own without us needing to exercise them. Once again, the reverse kegel helps to counterbalance the pelvic floor that has been overusing regular kegels leading to hypertonic pelvic floor dysfunction. Positions that I am most able to feel the reverse kegel the most in are the wall happy baby pose, lying flat on my back while spreading my knees apart, child’s pose, and the yoga/malasana squat. Do not be discouraged if you have no awareness of your pelvic floor or the concept of reverse kegeling just yet. Your pelvic floor is tight and dysfunctional giving you little to no feeling of the proper movements. Once your pelvic floor becomes relaxed and lengthened through pelvic floor stretches, you will have an easier time gaining awareness. Learning how to reverse kegel is often the hardest part of recovery for men. It may take many months, so have patience with your body while it is healing.
To help heal hard flaccid and pelvic floor issues, never watch pornography again (this is vital). Go on NoFap for 90+ days to help heal your brain and body from any unhealthy pornography and sexual habits you have partaken in. Pornography leads to involuntary kegels, a tight pelvic floor, desensitizes you, and messes up the dopamine and arousal circuitry in your brain. Don’t climax too often. Use lube and a very gentle gliding motion if you are going to self-pleasure, no more tugging on your penis that is then pulling on your pelvic floor muscles, and avoid masturbation positions that puts you into an anterior pelvic tilt - stick to neutral/posterior pelvic tilt positions. Sex is much healthier compared to masturbation for the penis and pelvic floor muscles because the head of the penis is stimulated by the vaginal walls which creates a reflex that helps activate the ischiocavernosus (IC) muscle, which is vital for erection health and is likely in a contracted state causing hard flaccid - thank you to this thread for this information. If you do have a partner, only climax through sex. Make sure you have proper erection quality during sexual activities - take supplements or medications if you have to. Climaxing flaccid or semi-flaccid is what causes many people to develop hard flaccid and pelvic floor issues in the first place. This is likely due to a complicated process of the IC muscle being improperly activated due to flaccidity during climax leading to a cramping of the muscle leading to hard flaccid and causing dysfunction across the pelvic floor muscles causing a cascade of inflammation. Only partake in sexual activities when you have relaxed your pelvic floor enough through stretching and the rest of the techniques. Again, I do recommend abstaining from masturbation as long as possible while healing and preferably after as well.
One interesting and strange thing that I also want to mention is that a person with hard flaccid and pelvic floor issues reported significant improvements after changing the position in which they masturbated and climaxed in to an elevated glute bridge position while reverse kegeling, some commenters also reported improvements - here is the thread. Another post here said that using a squatting position while sitting at the edge of a chaibed with feet flat on the ground and not touching himself during climax helped him. Another reminder, I would only attempt this if you have gotten your pelvic floor to a relaxed state through stretching and learned how to reverse kegel when erect during sexual activities. Going gentle and using lube is necessary. During all sexual activities you should be erect as possible to support proper pelvic floor function.
The reason why masturbating in a posterior pelvic tilt along with glute muscles activated likely worked for them is that we have been masturbating and climaxing in an Anterior Pelvic Tilt (APT) all of our lives. This is unnatural and goes against our evolutionary biology because during sex throughout all of our human history, thrusting and climaxing puts us into more of a posterior pelvic tilt position with a lot of activation of our glutes. Men are often self-pleasuring with an APT while edging for sometimes hours at a time throughout their lives while sitting on a chair, couch, bed, etc. which has put unnatural pressure, or improper activation on their pelvic floors that has likely caused dysfunction with our BC, PC, and especially IC muscles. By switching to more of a natural sex position during masturbation that puts us in a posterior pelvic tilt state, such as during an elevated glute bridge, it is reactivating and counter correcting the function of our pelvic floor muscles, such as the IC muscle in particular, that has been dormant or dysfunctional due to our bad sexual habits. This of course isn’t a miracle cure, but it could be worth a try if you first applied the rest of the recommendations.
You can and will heal. Stay strong and never give up. Thank you for reading.

Here are all my thoughts and advice based on my personal experiences, other people’s insight and helpful experiences, and research I have done on and off about pelvic floor issues from the past eight years or so. There is still a lot left to learn, but I am putting everything I know currently here. I am not claiming that any of this is revolutionary, but I hope it can help some of you out there to give you a headstart on healing and advance our understanding of these conditions. As I am a 27 year old male with previous major problems with pelvic floor issues and hard flaccid, some of my advice may be biased towards my condition. However, I believe everyone can benefit from a lot of this because I really do think that all of these conditions that I mentioned are linked in at least some way, especially by pelvic floor dysfunction and sex hormone desensitization. I try not to come to these forums because it increases anxiety and negative emotions which leads to worse pelvic floor symptoms, so my apologies if I do not respond to your questions. For hard flaccid and pelvic floor affected people, follow my advice and I am confident you can heal and reach a place where your symptoms barely affect your life, if at all, which is where I am at now. The mentality of trying to find a 100% “magic cure” solution just leads to anxiety and catastrophic thinking if you have a set back which will only worsen your symptoms. You can and will heal. I know this is a lot of information, but try to implement just one or two things at a time. Focus on the present, and take it one day at a time. Don’t get overwhelmed.
Post Finasteride Syndrome (PFS), Post-SSRI Sexual Dysfunction (PSSD), Hard Flaccid Syndrome (HFS), Pelvic Floor Dysfunction, and Chronic Pelvic Pain Syndrome all can have some similar symptoms. I believe that they are all either caused or can be exacerbated by androgen and estrogen receptor insensitivity and are triggered by medication, genital injury, and pelvic floor inflammation and dysfunction. The pelvic floor is rich in androgen receptors and estrogen receptors. However, without proper androgen receptor activation and sensitivity, the pelvic floor muscles don’t have enough DHT which line the tissues of the pelvic floor, genitalia, and lower urinary tract. DHT is vital for healthy sexual functioning in both sexes - it provides an anabolic effect to tissues to provide strength, stability, healing, and relaxation to tissues. As a result of androgen receptor insensitivity and lack of DHT, the pelvic floor can become chronically weakened, tight, and inflamed which reduces blood flow to the region leading to even more androgen receptor insensitivity and thus less DHT. These symptoms can cause psychological stress to the individual which tightens the pelvic floor further leading to more symptoms and less blood flow. One study found that androgen sensitivity has raised the possibility that androgens can be used to rebuild the weakened and/or damaged muscles comprising the pelvic floor - source. Some people may also have normal sex hormone levels in the blood when tested, but these hormones cannot reach or be effective in the pelvic floor tissues or brain due to sex hormone insensitivity and the lack of the blood flow in the region caused by pelvic floor tightness and dysfunction.
Desensitized estrogen receptors leading to decreased estrogen levels in local pelvic floor and genital tissues may be causing a similar mechanism of dysfunction in some people like androgen receptor insensitivity and DHT because estrogen is important for pelvic floor and sexual health in both sexes. This study says that “Estradiol in men is essential for modulating libido, erectile function, and spermatogenesis. Estrogen receptors, as well as aromatase, the enzyme that converts testosterone to estrogen, are abundant in brain, penis, and testis, organs important for sexual function. In the brain, estradiol synthesis is increased in areas related to sexual arousal. In addition, in the penis, estrogen receptors are found throughout the corpus cavernosum with high concentration around neurovascular bundles.” Steroid users report that low estrogen causes decreased or numb penile sensitivity, shrunken flaccid penis, dull orgasm, urinary hesitancy, urinary frequency, low sex drive, and erectile dysfunction. Here is a paper from a PSSD community member that hypothesizes, as do an increasing amount of people, that the main issue of PSSD, PFS, and Post-Retinoid Sexual Dysfunction is estrogen receptor insensitivity. PSSD and PFS sufferers often have similar hard flaccid and pelvic floor issues, so if those conditions are caused by estrogen insensitivity, then perhaps our pelvic floor dysfunction, HFS, and CPPS, is also impacted by a lack of estrogens in the pelvic floor tissues, not just androgens. The most important element to remember to help start the healing process for these disorders is to boost blood flow through supplements, stretches, and exercises which will increase both androgen and estrogen receptor sensitivity over time.
Post Finasteride Syndrome (PFS) caused by Finasteride, a 5-alpha-reductase inhibitor (5-ARI), plummets DHT levels in the body to try to help hair loss causing sexual dysfunction and pelvic floor issues. Androgen receptors that surround the pelvic floor, genitals, and brain become desensitized due to the Finasteride leading to less DHT binding to these receptors causing dysfunction and a tight, weak pelvic floor. The tight, dysfunctional pelvic floor now restricts blood flow which impacts healing and the delivery of testosterone to this area that further exacerbates androgen insensitivity leading to less DHT in these tissues. Since androgen receptors are found in the brain and androgens have neuroprotective effects, this could be one reason why some PFS and PSSD sufferers are also impacted cognitively. An herbal supplement called Saw Palmetto has also been reported to cause a disorder similar to PFS because it is also a 5-ARI that blocks the conversion of testosterone into DHT. Another disorder called Post Accutane Syndrome (PAS) is also similar to PFS and it reduces DHT as well through being a 5-AR.
For Post-SSRI Sexual Dysfunction (PSSD), SSRIs are also known to decrease androgens and down regulate androgen receptors. This study shows that SSRIs can have an anti-estrogenic effect as well and can even reduce the expression of estrogen receptors (ER), including in the hypothalamus.. As androgen and estrogen receptors get desensitized in the pelvic floor, genital region, and brain, it causes localized DHT and estrogen levels in these tissues to decrease causing emotional blunting, sexual dysfunction, pelvic floor issues, hard flaccid syndrome, and more. The pelvic floor dysfunction can then prevent the sex hormone receptors from being reactivated and sensitized in this area due to restricting oxygen and sex hormone rich blood flow to the tissues. SSRIs can cause androgen receptor insensitivity and estrogen receptor insensitivity by severely inhibiting the serotonin transporter (SERT) leading to increased serotonin levels which desensitizes those receptors throughout the body. It is also interesting that some PSSD community members are trying to restore estrogen receptor sensitivity via boosting estrogen in various ways including by taking hops extract which is a potent phytoestrogen. Check out the PSSD Network for more information on this condition as they are helping to give a voice to the unheard..
Hard Flaccid Syndrome (HFS) - There are many men suffering from HFS and pelvic floor issues due to PSSD, PFS, heavy weight lifting, excess kegeling, or in the case I’m presenting here, physical damage to the genitals from excessive, vigorous sexual activity (my case) or penis enlargement exercises. When the genitals get damaged, an inflammatory process starts and the pelvic floor contracts to protect itself. Since the pelvic floor is now in a chronic, contracted state, it limits oxygen and sex hormone rich blood flow to the genitals and pelvic floor which leads to sex hormone insensitivity and negatively impacts healing, muscle relaxation, and DHT production in these tissues. Finasteride, Accutane, and SSRIs also desensitize sex hormone receptors in the genitals and pelvic floor tissues leading to hard flaccid and pelvic floor dysfunction. Since the pelvic floor tightness restricts blood flow, it is difficult for hard flaccid sufferers to reactivate and sensitize their pelvic floor muscle androgen receptors again to regain relaxation and strength in their pelvic floor muscles, including the ischiocavernosus (IC), bulbocavernosus (BC), and pubococcygeus (PC) which are in a contracted state; the IC muscle in particular is thought to be the most implicated in the cause of hard flaccid. We first need to promote relaxation in the pelvic floor by boosting blood flow through supplements and stretches because tight muscles are weak muscles. Once the pelvic floor is in a chronic state of tension, it is hard to heal from pelvic floor issues because you likely already had bad habits such as poor posture, unhealthy sexual practices, stiff muscles, sedentary lifestyle, unchecked anxiety, and other negative lifestyle factors. Along with supplements, exercises, and stretches, correcting these bad habits is necessary to heal to have an even healthier pelvic floor than you ever had before because it likely was already tight and dysfunctional to begin with before developing obvious issues, but it was more subtle and you had no awareness of your pelvic floor muscles until now. You have the potential to now become a much healthier person overall than you ever would have been without being affected by pelvic floor dysfunction and hard flaccid.
32% of women will develop a pelvic floor disorder in their lifetime which is double that of men. While childbirth and pregnancy plays a role in this discrepancy, women also have far less testosterone and DHT levels than men which I believe plays a major factor. Since women have less testosterone, their androgen receptors that line the pelvic floor don’t make enough DHT to adequately support these tissues compared to men. This makes them more prone to pelvic floor dysfunction that causes them a disparate amount of pain, tightness, and inflammation. Androgen receptors and their ability to convert testosterone into DHT play such a vital role in pelvic floor health and sexual functioning. This is mentioned in a research study: Prevailing scientific literature has indicated the presence of androgen receptors in the levator ani muscle and pelvic fascia. The existence of androgen receptors in the vaginal wall can play an essential role in the development of pelvic floor disorders in women.Thus, androgen-related disorders may interfere with the function of pelvic floor muscles.. Many people mistakenly believe that androgens are only important for male sexual health: Androgens have a three-fold action on female sexual function. They (1) increase libido by providing the fuel for a woman’s psychosexual stimulation, (2) increase sensitivity and blood flow to the external genitalia, and (3) increase the intensity of sexual gratification..
What I see in all these conditions is that sex hormone receptors become desensitized in the pelvic floor and genital tissues either from a drug, pelvic tightness, or inflammation from injury leading to less localized sex hormones causing sexual and pelvic floor dysfunction. The pelvic floor now goes into a chronic tightened state as a response, leading to more inflammation and less oxygen and testosterone rich blood flow to the genital and pelvic region which leads to more androgen insensitivity and subsequently less DHT. This all explains why many people who have these conditions are helped by supplements that improve androgen receptor sensitivity and blood flow, and why pelvic floor therapy and exercises are so helpful to many of them. Estrogen receptor insensitivity in the pelvic floor also appears to have a similar mechanical negative effect by leading to less estrogen levels in the pelvic floor and genital tissues. It is also possible that some people with PSSD/PFS may have subtle or no pelvic floor symptoms, but the medication still desensitizes sex hormone sensitivity in their genitals and pelvic floor tissues that is leading to sexual dysfunction.
Another study linking androgens and the pelvic floor: Levator ani and other muscles of the pelvic floor and lower urinary tract are sensitive to the anabolic effects of testosterone. Androgen receptors are also expressed in the pelvic floor and lower urinary tract of both animals and humans. Anabolic effects of androgens may play an important role in the female pelvic-floor and lower-urinary-tract disorders. The action of androgens in the lower urinary tract and pelvic floor is complex and may depend on their anabolic effects, hormonal modulation, receptor expression, interaction with nitric oxide synthase, or a combination of these effects.
My solution to help heal and improve the well-being of people with these issues is to try to improve sex hormone receptor sensitivity and pelvic floor function through supplements, stretches, exercises, and boosting blood flow which will hopefully restore normal levels of estrogens and androgens in pelvic, genital, and brain tissues. The body has a tremendous capability of self-healing, but we need to support it through active recovery methods.
We will first start with supplements (this is not professional medical advice - talk with your doctor before taking):
L-citrulline - This is the precursor to l-arginine, and it will improve blood flow and levels of nitric oxide to help get oxygen and testosterone rich blood to the pelvic floor and genital tissues to increase androgen sensitivity. Nitric oxide can also induce smooth muscle relaxation which is important for relaxing the pelvic floor. Herein we report on a young man affected by PSSD who regained sexual functioning after 3-month treatment with EDOVIS, a dietary supplement containing L-citrulline and other commonly used aphrodisiacs.. I recommend taking at least 6000 mg daily by taking 2000mg three times throughout the day. The max dose is 10,000mg. Even potentially better, people report great results using Cialis to improve blood flow and healing rather than L-citrulline and some doctors will even prescribe it to women if you show them the evidence - talk with your doctor. “Tadalafil (Cialis) reversal of sexual dysfunction caused by serotonin enhancing medications in women”. L-Citrulline and Cialis are not recommended to be taken together.
L-Carnitine - This will improve the number of androgen receptors and their sensitivity to testosterone to increase levels of DHT in the pelvic floor, genital tissues, and brain. I recommend taking 2000mg daily. Acetyl-L-Carnitine can pass through the blood-brain barrier, while Propionyl-L-carnitine has a high degree of interaction with testosterone. Propionyl may be better for sexual and pelvic floor dysfunction, while Acetyl might help people suffering from the mental effects of PSSD. This study used each at 2000mg daily to improve erectile dysfunction along with Viagra.. I would work up to 2000mg each of Acetyl and Propionyl L-Carnitine along with Cialis instead of Viagra as it lasts in the body for much longer (36 hours) for increased blood flow healing purposes. You can also use L-Citrulline instead of Cialis as mentioned earlier. Discuss with your doctor before taking them.
Vitamin D - This vitamin, which acts more like a hormone, works directly with the endocrine system. It has its own receptors throughout the body and they are often in close proximity to androgen receptors. Deficiency in vitamin D is associated with a stunting of testosterone's effects on androgen receptors and a decline in testosterone levels. Vitamin D will encourage androgen receptor resensitization. One study found that higher vitamin D levels are associated with a decreased risk of pelvic floor disorders in women, and The levator ani and coccygeus muscles are skeletal muscles that are critical components of the pelvic floor and may be affected by vitamin D nutritional status. I recommend 4000IU of vitamin D daily or whatever gets your levels to 60 - 80 ng/ml. I would also take 100mcg of vitamin K2 to ensure that any excess calcium from vitamin D is deposited into the bones and not arteries.
Magnesium Glycinate - This will help relax your pelvic floor muscles to help restore function and blood flow. I recommend starting with 300mg.
If you have inflammatory issues or pain due to pelvic floor dysfunction, I recommend a fish oil supplement daily. I take fish oil, and I find that it helps limit pelvic inflammation. Take quercetin and bromelain as needed if you experience pelvic inflammatory flare ups, pain, and bladder issues, but just be careful as quercetin can also inhibit the production of DHT from testosterone as well. Some say fish oil blocks DHT too, but experiencing chronic pelvic floor pain and inflammation will do more harm to you than minimal DHT blocking.
I also recommend doing some form of yoga or pelvic floor stretches daily to improve blood flow for pelvic floor relaxation and sex hormone receptor sensitivity. You also need to request to see a pelvic floor therapist for an evaluation and treatment. Learn how to do reverse kegels. Doing reverse kegels will be difficult at first because your pelvic floor is tight and you have little to no awareness of these muscles, so just focus on lengthening and relaxing the pelvic floor through stretches for now. Do not do regular kegels for pelvic floor issues. Learn how to diaphragmatically breathe in 360 degrees to create expansion in your rib cage and abdomen to encourage pelvic floor relaxation. Do not breathe through your chest, and “belly breathing” isn’t the right term because the ribs need to expand as well. You can learn how to diaphragmatically breathe through an exercise such as 4-7-8 breathing. Here is a great video on diaphragmatic breathing and another video. Retraining yourself to properly breathe diaphragmatically is the single most important thing that you can do to heal from pelvic floor issues.
Stretches/Yoga poses I recommend:
Hold the Malasana/hindi/yoga squat pose for at least 5-10 minutes at least twice a day, but doing it morning, mid-day, and at night would be the best. Some get great results holding it for 15-20 minutes.This is one of the most important things for your pelvic floor because it will help lengthen and release it. Doing them barefoot is also very beneficial to strengthen your ankles and feet which are connected to your pelvic floor. Again, remember to breathe deeply down into your belly and pelvic floor for all these stretches.
Begin your stretching routine with an Exercise ball ab stretch and Upward-facing dog/cobra pose. This will help stretch your lower abs and psoas muscles so that you can get more breath deeper down into your pelvic floor for the rest of your stretches. Some people say that these types of stretches aren’t great for people who have Anterior Pelvic Tilt, which we should fix, but I still do them as it is important to stretch the lower abs that are hard to get to. You can experiment with doing them sporadically instead of every time you stretch.
This is my current personal complete stretch routine I do in order 3+ days a week:
Myofascial release on my glutes with an orb massage ball but you can use any small hard ball (don’t do this if glutes are currently sore) > Calf stretch against a wall or a yoga block which is what I use > exercise ball ab stretch > upward facing dog > (optional) Do a handful of cat cows > Supine hamstring stretch with yoga strap or an IdealStretch tool which is what I use > Kneeling hip flexor stretch > flat on back supine single knee to chest stretch > then bring knee to opposite shoulder stretch > supine figure four > I do this stretch next right after figure four > Reclined bound angle pose > (optional) butterfly stretch > (optional) A little bit of downward facing dog to stretch the calves > (optional) Lizard Pose) > (optional) Half split stretch/Half monkey pose with yoga blocks > Half-pigeon pose > Child’s pose > Wall quad hip flexor stretch > Wall figure four stretch > Wall straddle pose > Wall happy baby pose > Flat on back while pulling knees apart > kneeling with one leg, other leg out to side for adductors > (optional) Frog pose with feet together > regular Frog pose with feet separated in line with the knees > Yoga squat/malasana > Corpse pose
All these stretches are the ones I found most useful in a routine. See what works for you and develop your own routine. Consistency is the most important. This long stretching routine may not be possible for you to complete regularly so make adjustments, but doing this routine at least 3 days a week is ideal. Stretches such as the yoga squat, supine hamstring stretch, hip flexor stretches, and wall stretches are vital and should be done most days to help relax the pelvic floor. For how long you should hold each stretch, just go by how you and your body feels. Really let go, breathe, and sink into every stretch. On rest days, doing some deep breathing in child’s pose, reclined bound angle pose, flat on back while pulling knees apart, and the happy baby wall pose is really great while trying to do gentle reverse kegels.
You can also work on more individualized stretches for posture to correct anterior pelvic tilt, muscle imbalances, and to release other tight muscles, such as the upper body. Listen to your body if you need to give yourself a rest day from stretching. Adding in a 30-60 minute walk/swim on rest days is incredibly beneficial as well. Eventually, you can also try to learn isometric PNF stretching to incorporate it into some of the stretches such as the kneeling hip flexor stretch and hamstring stretch.
Exercises I recommend:
After working to relax and lengthen your pelvic floor through yoga and stretches, I would begin gentle body strengthening exercises that are pelvic floor safe. The pelvic floor is a master compensator. So, if the glutes, adductors, deep hip rotators, transversus abdominis, and other supportive muscles are weak, then the pelvic floor is in the prime position to pick up the slack which leads to a lot of strain on the pelvic floor which results in tightness and dysfunction. You need to strengthen the surrounding muscles to relieve tightness in the pelvic floor. This is where working with a pelvic floor therapist would be helpful to point out safe individualized exercises for you. Yoga will help strengthen your muscles in a safe way too.
The glutes and transversus abdominis in particular are very important to strengthen. Glute bridge, single glute bridge, side lying leg raises, lateral band walks can help build up glute strength. Deadbugs, Bird Dog, 8- point planks, or planks with pelvic floor-friendly modifications, can help to strengthen the transversus abdominis (TVA). Abdominal work may be triggering to your pelvic floor symptoms, especially the 8 point plank, so you can instead look into hypopressive exercises to work the TVA without overworking the pelvic floor. These exercises will help you bring more awareness to your breathing, diaphragm, TVA, and pelvic floor which are all important for recovery. Here is how to find and become aware of the TVA. Do side planks for your oblique ab muscles.
For hip/abductors do the side lying hip abduction exercise, fire hydrants, and the shinbox lunge. For the adductors, do Copenhagen adductor exercise, cossack squats, and an exercise where you squeeze a soft ball between the knees just don’t do any crunch movements with pelvic floor issues. For hamstrings, Nordic hamstring curl/glute ham raises, and single leg bridge. For the back, do supine pelvic tilt. One person even reported that dorsiflexion exercises and stretches were one important element to solve his pelvic floor issues; this is most likely because the ankle bone, like everything else including even our jaw, is connected to the pelvic floor.
Like with anything, do all these exercises in moderation and stop if you sense your pelvic floor is not responding well to them - do them one at a time to see which ones your pelvic floor can handle for now. Here is an exercise routine from another poster that has helped many people. Just be careful of the ab exercises such as the ab wheel and 5 minute planks with your pelvic floor issues - don’t over do it or avoid it if they cause too many symptoms.
Myofascial release and foam rolling to release trigger points also helps a lot of people to relax their pelvic floor muscles and improve blood flow. The glutes are the most important area to target for pelvic floor issues when foam rolling in my experience if you only had limited time. Using a soft ball to lay on and breathe deeply can help release trigger points in the abdominal muscles and psoas which can help you breathe better and relax the pelvic floor. I haven’t done it, but you can also try out a massage gun for myofascial release; just be careful and don’t use it in sensitive pelvic areas. Some men and women also report success using a therawand to release internal trigger points that are causing them pelvic floor dysfunction symptoms.
Walking and swimming for 30-60 minutes are some of the best exercises to lengthen, relax, stretch, and release your pelvic floor, boost blood flow, and help to retain and build strength in muscles that give support to the pelvic floor. Walk or swim for 5+ days a week for the best results. The breaststroke and freestyle are very helpful for pelvic floor sufferers. Along with swimming, people also use an elliptical at a low resistance to help provide a cardio workout that is safer for your pelvic floor.
Fix your posture. Pelvic floor issues and hard flaccid syndrome are closely associated with Anterior Pelvic Tilt and other postural issues. Get evaluated by a physical therapist so that they can give you exercises and stretches to fix it. You could also look into the Postural Restoration institute and see one of their providers and try to implement some of their exercises. In the meantime, here is one video playlist on how to fix APT. Another video to fix APT says to stretch the hip flexors, lower back, while focusing on strengthening the abs, glutes, and hamstrings. Make sure that you sit and walk with good posture - watch this to learn how to walk correctly - activate your glutes during each step and push off with your back foot!. I also recommend getting a standing desk to try to avoid sitting for long periods of time.
Weight training can be effective for boosting active androgen receptors in the body to increase testosterone and DHT levels. However, you need to make sure that it isn’t making your pelvic floor symptoms worse which defeats the purpose. If you are going to lift weights with pelvic floor issues, don’t lift heavy, do any intensive ab workouts, or any other exercises that can put extra strain on your pelvic floor. Do lifts where you can sit down instead of standing up. Start with yoga, stretching, and gentle body exercises to relax your pelvic floor and strengthen surrounding muscles before incorporating consistent weight training. I highly recommend, however, just sticking with yoga and pelvic floor safe body weight exercises to build strength instead. Remember to see a pelvic floor therapist to get evaluated first before starting any weight lifting.
Work on your mental health. Anxiety can worsen pelvic floor issues. Just as dogs tuck and tense their tails when stressed, we tense our pelvic floors which are directly connected to our tailbone where we used to have tails ourselves in our evolutionary history. As we are impacted by sexual dysfunction and pelvic floor dysfunction symptoms, we become anxious along with other negative emotions which leads to more pelvic floor tension symptoms due to the fight or flight mode response causing even more anxiety leading to more symptoms. It is a vicious cycle that needs to break by not becoming anxious and negative when we experience pelvic floor symptoms or hard flaccid and instead let go, accept, and realize that it is a normal process when trying to heal because sometimes our muscles that are used to that tightness don't want to let go of the tension we hold in our pelvic floors. Daily yoga, meditation, stretching, and walking will help with anxiety. I would also see a mental health therapist because all of these issues are deeply traumatic and we cannot go through this alone. We often hold tension in the form of emotions and trauma in our bodies, especially our pelvic floor and genital areas. By openly talking about these issues with a therapist, it will help us process and release our emotions and trauma that we are holding inside our bodies to improve our anxiety, relax our pelvic floor, and to let go of all of our tension. Many people who healed their hard flaccid and pelvic floor issues said that solving their anxiety and negative thoughts by talking to a mental health counselor was vital in recovery. The mind-body connection is so powerful, and it directly impacts our pelvic floor. Those who are stuck in the cycle of experiencing pelvic floor symptoms leading to anxiety and negative thoughts will also benefit from Cognitive Behavioral Therapy you can do by yourself like in this video or preferably with a trained therapist. Here is an informative mini lecture on how stress impacts the pelvic floor.
I would also definitely go on a healthy anti-inflammatory diet. Avoid caffeine, alcohol, marijuana, and other substances. Avoid foods and liquids that can trigger pelvic floor inflammation such as highly acidic fruits and veggies, carbonated beverages, very spicy foods, and artificial sugars. To maintain a healthy gut to reduce inflammation in your body I recommend trying a low-histamine probiotic supplement along with eating healthy. You should also work on preventing or fixing constipation; eat a lot of soluble fiber to not get constipated - take a supplement such as metamucil if you have to. Check the Bristol stool shape chart to identify if you are constipated because even mild constipation can contribute to pelvic floor tension. This is because the constipation leads to a lot of pressure being put on your rectum and pelvic floor leading to the muscles becoming weak and dysfunctional. I am willing to bet many of you are constipated and don’t know it because it isn’t just whether you go regularly, it is also how your stool is shaped. People with pelvic floor disorders are at a high risk of constipation which makes their tension and dysfunction worse which then worsens the constipation, another cycle to fix. I recommend getting a Squatty Potty to reduce strain on the pelvic floor during elimination.
Sexual health advice:
This is a good reddit guide on how to reverse kegel.
However, I will also give a shot at explaining how to reverse kegel because it is one of the most confusing things for people about this healing pelvic floor issues, and many people unfortunately do it wrong. This is why visiting a pelvic floor therapist would be helpful.
If you know how to do a kegel, the reverse kegel is the opposite feeling of that. I describe the kegel as a pull feeling, while the reverse kegel is a pushing out feeling. The reverse kegel helps to lengthen the pelvic floor through the front using the penis (front rk) and the back (back rk) using the perineum behind the testicles near the anus, but not the anus itself. I learned to reverse kegel by diaphragmatically breathing down into the belly and pelvic floor. On the inhale, inflate your diaphragm and belly, breathe down into your pelvic floor area and feel a gentle pushing movement out the front of the penis and out the back of the perineum. You can then gently release this pushing feeling on the exhale. Never force any movements - it should be a gentle process guided by the diaphragmatic breath. You can also try to do the front rk and back rk separately to try to concentrate on each better. To give another perspective, one person described the reverse kegel as like blowing up a balloon in the whole front area between the perineum and pubic bone inside out - so to me this means blowing up the balloon with your diaphragmatic breath into your pelvic floor and making a pushing feeling out the front of the penis and out the back of the perineum. You should also reverse kegel during sexual activities to help keep your pelvic floor relaxed and prevent involuntary kegels that lead to a tight, imbalanced pelvic floor and premature ejaculation. Reverse kegeling when erect may be difficult at first, but it will become easier to understand during sexual stimulation when you get the feeling of wanting to involuntary kegel, but doing the opposite of that and gently doing the push feeling through the front reverse kegel.
I would stay away from regular kegels when dealing with pelvic floor and hard flaccid issues - it will only lead to contraction and tightening. The kegel (BC) muscle works plenty involuntarily on its own without us needing to exercise them. Once again, the reverse kegel helps to counterbalance the pelvic floor that has been overusing regular kegels leading to hypertonic pelvic floor dysfunction. Positions that I am most able to feel the reverse kegel the most in are the wall happy baby pose, lying flat on my back while spreading my knees apart, child’s pose, and the yoga/malasana squat. Do not be discouraged if you have no awareness of your pelvic floor or the concept of reverse kegeling just yet. Your pelvic floor is tight and dysfunctional giving you little to no feeling of the proper movements. Once your pelvic floor becomes relaxed and lengthened through pelvic floor stretches, you will have an easier time gaining awareness. Learning how to reverse kegel is often the hardest part of recovery for men. It may take many months, so have patience with your body while it is healing.
To help heal pelvic floor and hard flaccid issues, never watch pornography again (this is vital). Go on NoFap for 90+ days to help heal your brain and body from any unhealthy pornography and sexual habits you have partaken in. Pornography leads to involuntary kegels, a tight pelvic floor, desensitizes you, and messes up the dopamine and arousal circuitry in your brain. Don’t climax too often. Use lube and a very gentle gliding motion if you are going to self-pleasure, no more tugging on your penis that is then pulling on your pelvic floor muscles, and avoid masturbation positions that puts you into an anterior pelvic tilt - stick to neutral/posterior pelvic tilt positions. Sex is much healthier compared to masturbation for the penis and pelvic floor muscles because the head of the penis is stimulated by the vaginal walls which creates a reflex that helps activate the ischiocavernosus (IC) muscle, which is vital for erection health and is likely in a contracted state causing hard flaccid - thank you to this thread for this information. If you do have a partner, only climax through sex. Make sure you have proper erection quality during sexual activities - take supplements or medications if you have to. Climaxing flaccid or semi-flaccid is what causes many people to develop hard flaccid and pelvic floor issues in the first place. This is likely due to a complicated process of the IC muscle being improperly activated due to flaccidity during climax leading to a cramping of the muscle leading to hard flaccid and causing dysfunction across the pelvic floor muscles causing a cascade of inflammation. Only partake in sexual activities when you have relaxed your pelvic floor enough through stretching and the rest of the techniques. Again, I do recommend abstaining from masturbation as long as possible while healing and preferably after as well.
Remember that you are not alone. So many people have pelvic tension, muscle imbalances, sexual deficits, posture issues without realizing it and never will heal due to their lack of awareness. Since we now have the great gift of awareness over our issues, we can start to heal our whole body and minds to become healthier than ever before, including our pelvic floor! Everyone’s journey is different due to our unique bodies and needs so that is why I gave you all the information I had regarding stretching, strengthening, supplements, nutrition, mental health advice, etc. to empower you to form your own plan to heal.
You can and will heal. Stay strong and never give up. Thank you for reading.

Here are all my thoughts and advice based on my personal experiences, other people’s insight and helpful experiences, and research I have done on and off about pelvic floor issues from the past eight years or so. There is still a lot left to learn, but I am putting everything I know currently here. I am not claiming that any of this is revolutionary, but I hope it can help some of you out there to give you a headstart on healing and advance our understanding of these conditions. As I am a 27 year old male with previous major problems with pelvic floor issues and hard flaccid, some of my advice may be biased towards my condition. However, I believe everyone can benefit from a lot of this because I really do think that all of these conditions that I mentioned are linked in at least some way, especially by pelvic floor dysfunction and sex hormone desensitization. I try not to come to these forums because it increases anxiety and negative emotions which leads to worse pelvic floor symptoms, so my apologies if I do not respond to your questions. For hard flaccid and pelvic floor affected people, follow my advice and I am confident you can heal and reach a place where your symptoms barely affect your life, if at all, which is where I am at now. The mentality of trying to find a 100% “magic cure” solution just leads to anxiety and catastrophic thinking if you have a set back which will only worsen your symptoms. You can and will heal. I know this is a lot of information, but try to implement just one or two things at a time. Focus on the present, and take it one day at a time. Don’t get overwhelmed.
Post Finasteride Syndrome (PFS), Post-SSRI Sexual Dysfunction (PSSD), Hard Flaccid Syndrome (HFS), Pelvic Floor Dysfunction, and Chronic Pelvic Pain Syndrome all can have some similar symptoms. I believe that they are all either caused or can be exacerbated by androgen and estrogen receptor insensitivity and are triggered by medication, genital injury, and pelvic floor inflammation and dysfunction. The pelvic floor is rich in androgen receptors and estrogen receptors. However, without proper androgen receptor activation and sensitivity, the pelvic floor muscles don’t have enough DHT which line the tissues of the pelvic floor, genitalia, and lower urinary tract. DHT is vital for healthy sexual functioning in both sexes - it provides an anabolic effect to tissues to provide strength, stability, healing, and relaxation to tissues. As a result of androgen receptor insensitivity and lack of DHT, the pelvic floor can become chronically weakened, tight, and inflamed which reduces blood flow to the region leading to even more androgen receptor insensitivity and thus less DHT. These symptoms can cause psychological stress to the individual which tightens the pelvic floor further leading to more symptoms and less blood flow. One study found that androgen sensitivity has raised the possibility that androgens can be used to rebuild the weakened and/or damaged muscles comprising the pelvic floor - source. Some people may also have normal sex hormone levels in the blood when tested, but these hormones cannot reach or be effective in the pelvic floor tissues or brain due to sex hormone insensitivity and the lack of the blood flow in the region caused by pelvic floor tightness and dysfunction.
Desensitized estrogen receptors leading to decreased estrogen levels in local pelvic floor and genital tissues may be causing a similar mechanism of dysfunction in some people like androgen receptor insensitivity and DHT because estrogen is important for pelvic floor and sexual health in both sexes. This study says that “Estradiol in men is essential for modulating libido, erectile function, and spermatogenesis. Estrogen receptors, as well as aromatase, the enzyme that converts testosterone to estrogen, are abundant in brain, penis, and testis, organs important for sexual function. In the brain, estradiol synthesis is increased in areas related to sexual arousal. In addition, in the penis, estrogen receptors are found throughout the corpus cavernosum with high concentration around neurovascular bundles.” Steroid users report that low estrogen causes decreased or numb penile sensitivity, shrunken flaccid penis, dull orgasm, urinary hesitancy, urinary frequency, low sex drive, and erectile dysfunction. Here is a paper from a PSSD community member that hypothesizes, as do an increasing amount of people, that the main issue of PSSD, PFS, and Post-Retinoid Sexual Dysfunction is estrogen receptor insensitivity. PSSD and PFS sufferers often have similar hard flaccid and pelvic floor issues, so if those conditions are caused by estrogen insensitivity, then perhaps our pelvic floor dysfunction, HFS, and CPPS, is also impacted by a lack of estrogens in the pelvic floor tissues, not just androgens. The most important element to remember to help start the healing process for these disorders is to boost blood flow through supplements, stretches, and exercises which will increase both androgen and estrogen receptor sensitivity over time.
Post Finasteride Syndrome (PFS) caused by Finasteride, a 5-alpha-reductase inhibitor (5-ARI), plummets DHT levels in the body to try to help hair loss causing sexual dysfunction and pelvic floor issues. Androgen receptors that surround the pelvic floor, genitals, and brain become desensitized due to the Finasteride leading to less DHT binding to these receptors causing dysfunction and a tight, weak pelvic floor. The tight, dysfunctional pelvic floor now restricts blood flow which impacts healing and the delivery of testosterone to this area that further exacerbates androgen insensitivity leading to less DHT in these tissues. Since androgen receptors are found in the brain and androgens have neuroprotective effects, this could be one reason why some PFS and PSSD sufferers are also impacted cognitively. An herbal supplement called Saw Palmetto has also been reported to cause a disorder similar to PFS because it is also a 5-ARI that blocks the conversion of testosterone into DHT. Another disorder called Post Accutane Syndrome (PAS) is also similar to PFS and it reduces DHT as well through being a 5-AR.
For Post-SSRI Sexual Dysfunction (PSSD), SSRIs are also known to decrease androgens and down regulate androgen receptors. This study shows that SSRIs can have an anti-estrogenic effect as well and can even reduce the expression of estrogen receptors (ER), including in the hypothalamus.. As androgen and estrogen receptors get desensitized in the pelvic floor, genital region, and brain, it causes localized DHT and estrogen levels in these tissues to decrease causing emotional blunting, sexual dysfunction, pelvic floor issues, hard flaccid syndrome, and more. The pelvic floor dysfunction can then prevent the sex hormone receptors from being reactivated and sensitized in this area due to restricting oxygen and sex hormone rich blood flow to the tissues. SSRIs can cause androgen receptor insensitivity and estrogen receptor insensitivity by severely inhibiting the serotonin transporter (SERT) leading to increased serotonin levels which desensitizes those receptors throughout the body. It is also interesting that some PSSD community members are trying to restore estrogen receptor sensitivity via boosting estrogen in various ways including by taking hops extract which is a potent phytoestrogen. Check out the PSSD Network for more information on this condition as they are helping to give a voice to the unheard..
Hard Flaccid Syndrome (HFS) - There are many men suffering from HFS and pelvic floor issues due to PSSD, PFS, heavy weight lifting, excess kegeling, or in the case I’m presenting here, physical damage to the genitals from excessive, vigorous sexual activity (my case) or penis enlargement exercises. When the genitals get damaged, an inflammatory process starts and the pelvic floor contracts to protect itself. Since the pelvic floor is now in a chronic, contracted state, it limits oxygen and sex hormone rich blood flow to the genitals and pelvic floor which leads to sex hormone insensitivity and negatively impacts healing, muscle relaxation, and DHT production in these tissues. Finasteride, Accutane, and SSRIs also desensitize sex hormone receptors in the genitals and pelvic floor tissues leading to hard flaccid and pelvic floor dysfunction. Since the pelvic floor tightness restricts blood flow, it is difficult for hard flaccid sufferers to reactivate and sensitize their pelvic floor muscle androgen receptors again to regain relaxation and strength in their pelvic floor muscles, including the ischiocavernosus (IC), bulbocavernosus (BC), and pubococcygeus (PC) which are in a contracted state; the IC muscle in particular is thought to be the most implicated in the cause of hard flaccid. We first need to promote relaxation in the pelvic floor by boosting blood flow through supplements and stretches because tight muscles are weak muscles. Once the pelvic floor is in a chronic state of tension, it is hard to heal from pelvic floor issues because you likely already had bad habits such as poor posture, unhealthy sexual practices, stiff muscles, sedentary lifestyle, unchecked anxiety, and other negative lifestyle factors. Along with supplements, exercises, and stretches, correcting these bad habits is necessary to heal to have an even healthier pelvic floor than you ever had before because it likely was already tight and dysfunctional to begin with before developing obvious issues, but it was more subtle and you had no awareness of your pelvic floor muscles until now. You have the potential to now become a much healthier person overall than you ever would have been without being affected by pelvic floor dysfunction and hard flaccid.
What I see in all these conditions is that sex hormone receptors become desensitized in the pelvic floor and genital tissues either from a drug, pelvic tightness, or inflammation from injury leading to less localized sex hormones causing sexual and pelvic floor dysfunction. The pelvic floor now goes into a chronic tightened state as a response, leading to more inflammation and less oxygen and testosterone rich blood flow to the genital and pelvic region which leads to more androgen insensitivity and subsequently less DHT. This all explains why many people who have these conditions are helped by supplements that improve androgen receptor sensitivity and blood flow, and why pelvic floor therapy and exercises are so helpful to many of them. Estrogen receptor insensitivity in the pelvic floor also appears to have a similar mechanical negative effect by leading to less estrogen levels in the pelvic floor and genital tissues. It is also possible that some people with PSSD/PFS may have subtle or no pelvic floor symptoms, but the medication still desensitizes sex hormone sensitivity in their genitals and pelvic floor tissues that is leading to sexual dysfunction.
Another study linking androgens and the pelvic floor: Levator ani and other muscles of the pelvic floor and lower urinary tract are sensitive to the anabolic effects of testosterone. Androgen receptors are also expressed in the pelvic floor and lower urinary tract of both animals and humans. Anabolic effects of androgens may play an important role in the female pelvic-floor and lower-urinary-tract disorders. The action of androgens in the lower urinary tract and pelvic floor is complex and may depend on their anabolic effects, hormonal modulation, receptor expression, interaction with nitric oxide synthase, or a combination of these effects.
My solution to help heal and improve the well-being of people with these issues is to try to improve sex hormone receptor sensitivity and pelvic floor function through supplements, stretches, exercises, and boosting blood flow which will hopefully restore normal levels of estrogens and androgens in pelvic, genital, and brain tissues. The body has a tremendous capability of self-healing, but we need to support it through active recovery methods.
We will first start with supplements (this is not professional medical advice - talk with your doctor before taking):
L-citrulline - This is the precursor to l-arginine, and it will improve blood flow and levels of nitric oxide to help get oxygen and testosterone rich blood to the pelvic floor and genital tissues to increase androgen sensitivity. Nitric oxide can also induce smooth muscle relaxation which is important for relaxing the pelvic floor. Herein we report on a young man affected by PSSD who regained sexual functioning after 3-month treatment with EDOVIS, a dietary supplement containing L-citrulline and other commonly used aphrodisiacs.. I recommend taking at least 6000 mg daily by taking 2000mg three times throughout the day. The max dose is 10,000mg. Even potentially better, people report great results using Cialis to improve blood flow and healing rather than L-citrulline and some doctors will even prescribe it to women if you show them the evidence - talk with your doctor. “Tadalafil (Cialis) reversal of sexual dysfunction caused by serotonin enhancing medications in women”. L-Citrulline and Cialis are not recommended to be taken together.
L-Carnitine - This will improve the number of androgen receptors and their sensitivity to testosterone to increase levels of DHT in the pelvic floor, genital tissues, and brain. I recommend taking 2000mg daily. Acetyl-L-Carnitine can pass through the blood-brain barrier, while Propionyl-L-carnitine has a high degree of interaction with testosterone. Propionyl may be better for sexual and pelvic floor dysfunction, while Acetyl might help people suffering from the mental effects of PSSD. This study used each at 2000mg daily to improve erectile dysfunction along with Viagra.. I would work up to 2000mg each of Acetyl and Propionyl L-Carnitine along with Cialis instead of Viagra as it lasts in the body for much longer (36 hours) for increased blood flow healing purposes. You can also use L-Citrulline instead of Cialis as mentioned earlier. Discuss with your doctor before taking them.
Vitamin D - This vitamin, which acts more like a hormone, works directly with the endocrine system. It has its own receptors throughout the body and they are often in close proximity to androgen receptors. Deficiency in vitamin D is associated with a stunting of testosterone's effects on androgen receptors and a decline in testosterone levels. Vitamin D will encourage androgen receptor resensitization. One study found that higher vitamin D levels are associated with a decreased risk of pelvic floor disorders in women, and The levator ani and coccygeus muscles are skeletal muscles that are critical components of the pelvic floor and may be affected by vitamin D nutritional status. I recommend 4000IU of vitamin D daily or whatever gets your levels to 60 - 80 ng/ml. I would also take 100mcg of vitamin K2 to ensure that any excess calcium from vitamin D is deposited into the bones and not arteries.
Magnesium Glycinate - This will help relax your pelvic floor muscles to help restore function and blood flow. I recommend starting with 300mg.
If you have inflammatory issues or pain due to pelvic floor dysfunction, I recommend a fish oil supplement daily. I take fish oil, and I find that it helps limit pelvic inflammation. Take quercetin and bromelain as needed if you experience pelvic inflammatory flare ups, pain, and bladder issues, but just be careful as quercetin can also inhibit the production of DHT from testosterone as well. Some say fish oil blocks DHT too, but experiencing chronic pelvic floor pain and inflammation will do more harm to you than minimal DHT blocking.
I also recommend doing some form of yoga or pelvic floor stretches daily to improve blood flow for pelvic floor relaxation and sex hormone receptor sensitivity. You also need to request to see a pelvic floor therapist for an evaluation and treatment. Learn how to do reverse kegels. Doing reverse kegels will be difficult at first because your pelvic floor is tight and you have little to no awareness of these muscles, so just focus on lengthening and relaxing the pelvic floor through stretches for now. Do not do regular kegels for pelvic floor issues. Learn how to diaphragmatically breathe in 360 degrees to create expansion in your rib cage and abdomen to encourage pelvic floor relaxation. Do not breathe through your chest, and “belly breathing” isn’t the right term because the ribs need to expand as well. You can learn how to diaphragmatically breathe through an exercise such as 4-7-8 breathing. Here is a great video on diaphragmatic breathing and another video. Retraining yourself to properly breathe diaphragmatically is the single most important thing that you can do to heal from pelvic floor issues.
Stretches/Yoga poses I recommend:
Hold the Malasana/hindi/yoga squat pose for at least 5-10 minutes at least twice a day, but doing it morning, mid-day, and at night would be the best. Some get great results holding it for 15-20 minutes.This is one of the most important things for your pelvic floor because it will help lengthen and release it. Doing them barefoot is also very beneficial to strengthen your ankles and feet which are connected to your pelvic floor. Again, remember to breathe deeply down into your belly and pelvic floor for all these stretches.
Begin your stretching routine with an Exercise ball ab stretch and Upward-facing dog/cobra pose. This will help stretch your lower abs and psoas muscles so that you can get more breath deeper down into your pelvic floor for the rest of your stretches. Some people say that these types of stretches aren’t great for people who have Anterior Pelvic Tilt, which we should fix, but I still do them as it is important to stretch the lower abs that are hard to get to. You can experiment with doing them sporadically instead of every time you stretch.
This is my current personal complete stretch routine I do in order 3+ days a week:
Myofascial release on my glutes with an orb massage ball but you can use any small hard ball (don’t do this if glutes are currently sore) > Calf stretch against a wall or a yoga block which is what I use > exercise ball ab stretch > upward facing dog > (optional) Do a handful of cat cows > Supine hamstring stretch with yoga strap or an IdealStretch tool which is what I use > Kneeling hip flexor stretch > flat on back supine single knee to chest stretch > then bring knee to opposite shoulder stretch > supine figure four > I do this stretch next right after figure four > Reclined bound angle pose > (optional) butterfly stretch > (optional) A little bit of downward facing dog to stretch the calves > (optional) Lizard Pose) > (optional) Half split stretch/Half monkey pose with yoga blocks > Half-pigeon pose > Child’s pose > Wall quad hip flexor stretch > Wall figure four stretch > Wall straddle pose > Wall happy baby pose > Flat on back while pulling knees apart > kneeling with one leg, other leg out to side for adductors > (optional) Frog pose with feet together > regular Frog pose with feet separated in line with the knees > Yoga squat/malasana > Corpse pose
All these stretches are the ones I found most useful in a routine. See what works for you and develop your own routine. Consistency is the most important. This long stretching routine may not be possible for you to complete regularly so make adjustments, but doing this routine at least 3 days a week is ideal. Stretches such as the yoga squat, supine hamstring stretch, hip flexor stretches, and wall stretches are vital and should be done most days to help relax the pelvic floor. For how long you should hold each stretch, just go by how you and your body feels. Really let go, breathe, and sink into every stretch. On rest days, doing some deep breathing in child’s pose, reclined bound angle pose, flat on back while pulling knees apart, and the happy baby wall pose is really great while trying to do gentle reverse kegels.
You can also work on more individualized stretches for posture to correct anterior pelvic tilt, muscle imbalances, and to release other tight muscles, such as the upper body. Listen to your body if you need to give yourself a rest day from stretching. Adding in a 30-60 minute walk/swim on rest days is incredibly beneficial as well. Eventually, you can also try to learn isometric PNF stretching to incorporate it into some of the stretches such as the kneeling hip flexor stretch and hamstring stretch.
Exercises I recommend:
After working to relax and lengthen your pelvic floor through yoga and stretches, I would begin gentle body strengthening exercises that are pelvic floor safe. The pelvic floor is a master compensator. So, if the glutes, adductors, deep hip rotators, transversus abdominis, and other supportive muscles are weak, then the pelvic floor is in the prime position to pick up the slack which leads to a lot of strain on the pelvic floor which results in tightness and dysfunction. You need to strengthen the surrounding muscles to relieve tightness in the pelvic floor. This is where working with a pelvic floor therapist would be helpful to point out safe individualized exercises for you. Yoga will help strengthen your muscles in a safe way too.
The glutes and transversus abdominis in particular are very important to strengthen. Glute bridge, single glute bridge, side lying leg raises, lateral band walks can help build up glute strength. Deadbugs, Bird Dog, 8- point planks, or planks with pelvic floor-friendly modifications, can help to strengthen the transversus abdominis (TVA). Abdominal work may be triggering to your pelvic floor symptoms, especially the 8 point plank, so you can instead look into hypopressive exercises to work the TVA without overworking the pelvic floor. These exercises will help you bring more awareness to your breathing, diaphragm, TVA, and pelvic floor which are all important for recovery. Here is how to find and become aware of the TVA. Do side planks for your oblique ab muscles.
For hip/abductors do the side lying hip abduction exercise, fire hydrants, and the shinbox lunge. For the adductors, do Copenhagen adductor exercise, cossack squats, and an exercise where you squeeze a soft ball between the knees just don’t do any crunch movements with pelvic floor issues. For hamstrings, Nordic hamstring curl/glute ham raises, and single leg bridge. For the back, do supine pelvic tilt. One person even reported that dorsiflexion exercises and stretches were one important element to solve his pelvic floor issues; this is most likely because the ankle bone, like everything else including even our jaw, is connected to the pelvic floor.
Like with anything, do all these exercises in moderation and stop if you sense your pelvic floor is not responding well to them - do them one at a time to see which ones your pelvic floor can handle for now. Here is an exercise routine from another poster that has helped many people. Just be careful of the ab exercises such as the ab wheel and 5 minute planks with your pelvic floor issues - don’t over do it or avoid it if they cause too many symptoms.
Myofascial release and foam rolling to release trigger points also helps a lot of people to relax their pelvic floor muscles and improve blood flow. The glutes are the most important area to target for pelvic floor issues when foam rolling in my experience if you only had limited time. Using a soft ball to lay on and breathe deeply can help release trigger points in the abdominal muscles and psoas which can help you breathe better and relax the pelvic floor. I haven’t done it, but you can also try out a massage gun for myofascial release; just be careful and don’t use it in sensitive pelvic areas. Some men and women also report success using a therawand to release internal trigger points that are causing them pelvic floor dysfunction symptoms.
Walking and swimming for 30-60 minutes are some of the best exercises to lengthen, relax, stretch, and release your pelvic floor, boost blood flow, and help to retain and build strength in muscles that give support to the pelvic floor. Walk or swim for 5+ days a week for the best results. The breaststroke and freestyle are very helpful for pelvic floor sufferers. Along with swimming, people also use an elliptical at a low resistance to help provide a cardio workout that is safer for your pelvic floor.
Fix your posture. Pelvic floor issues and hard flaccid syndrome are closely associated with Anterior Pelvic Tilt and other postural issues. Get evaluated by a physical therapist so that they can give you exercises and stretches to fix it. You could also look into the Postural Restoration institute and see one of their providers and try to implement some of their exercises. In the meantime, here is one video playlist on how to fix APT. Another video to fix APT says to stretch the hip flexors, lower back, while focusing on strengthening the abs, glutes, and hamstrings. Make sure that you sit and walk with good posture - watch this to learn how to walk correctly - activate your glutes during each step and push off with your back foot!. I also recommend getting a standing desk to try to avoid sitting for long periods of time.
Weight training can be effective for boosting active androgen receptors in the body to increase testosterone and DHT levels. However, you need to make sure that it isn’t making your pelvic floor symptoms worse which defeats the purpose. If you are going to lift weights with pelvic floor issues, don’t lift heavy, do any intensive ab workouts, or any other exercises that can put extra strain on your pelvic floor. Do lifts where you can sit down instead of standing up. Start with yoga, stretching, and gentle body exercises to relax your pelvic floor and strengthen surrounding muscles before incorporating consistent weight training. I highly recommend, however, just sticking with yoga and pelvic floor safe body weight exercises to build strength instead. Remember to see a pelvic floor therapist to get evaluated first before starting any weight lifting.
Work on your mental health. Anxiety can worsen pelvic floor issues. Just as dogs tuck and tense their tails when stressed, we tense our pelvic floors which are directly connected to our tailbone where we used to have tails ourselves in our evolutionary history. As we are impacted by sexual dysfunction and pelvic floor dysfunction symptoms, we become anxious along with other negative emotions which leads to more pelvic floor tension symptoms due to the fight or flight mode response causing even more anxiety leading to more symptoms. It is a vicious cycle that needs to break by not becoming anxious and negative when we experience pelvic floor symptoms or hard flaccid and instead let go, accept, and realize that it is a normal process when trying to heal because sometimes our muscles that are used to that tightness don't want to let go of the tension we hold in our pelvic floors. Daily yoga, meditation, stretching, and walking will help with anxiety. I would also see a mental health therapist because all of these issues are deeply traumatic and we cannot go through this alone. We often hold tension in the form of emotions and trauma in our bodies, especially our pelvic floor and genital areas. By openly talking about these issues with a therapist, it will help us process and release our emotions and trauma that we are holding inside our bodies to improve our anxiety, relax our pelvic floor, and to let go of all of our tension. Many people who healed their hard flaccid and pelvic floor issues said that solving their anxiety and negative thoughts by talking to a mental health counselor was vital in recovery. The mind-body connection is so powerful, and it directly impacts our pelvic floor. Those who are stuck in the cycle of experiencing pelvic floor symptoms leading to anxiety and negative thoughts will also benefit from Cognitive Behavioral Therapy you can do by yourself like in this video or preferably with a trained therapist. Here is an informative mini lecture on how stress impacts the pelvic floor.
I would also definitely go on a healthy anti-inflammatory diet. Avoid caffeine, alcohol, marijuana, and other substances. Avoid foods and liquids that can trigger pelvic floor inflammation such as highly acidic fruits and veggies, carbonated beverages, very spicy foods, and artificial sugars. To maintain a healthy gut to reduce inflammation in your body I recommend trying a low-histamine probiotic supplement along with eating healthy. You should also work on preventing or fixing constipation; eat a lot of soluble fiber to not get constipated - take a supplement such as metamucil if you have to. Check the Bristol stool shape chart to identify if you are constipated because even mild constipation can contribute to pelvic floor tension. This is because the constipation leads to a lot of pressure being put on your rectum and pelvic floor leading to the muscles becoming weak and dysfunctional. I am willing to bet many of you are constipated and don’t know it because it isn’t just whether you go regularly, it is also how your stool is shaped. People with pelvic floor disorders are at a high risk of constipation which makes their tension and dysfunction worse which then worsens the constipation, another cycle to fix. I recommend getting a Squatty Potty to reduce strain on the pelvic floor during elimination.
Sexual health advice:
This is a good reddit guide on how to reverse kegel.
However, I will also give a shot at explaining how to reverse kegel because it is one of the most confusing things for people about this healing pelvic floor issues, and many people unfortunately do it wrong. This is why visiting a pelvic floor therapist would be helpful.
If you know how to do a kegel, the reverse kegel is the opposite feeling of that. I describe the kegel as a pull feeling, while the reverse kegel is a pushing out feeling. The reverse kegel helps to lengthen the pelvic floor through the front using the penis (front rk) and the back (back rk) using the perineum behind the testicles near the anus, but not the anus itself. I learned to reverse kegel by diaphragmatically breathing down into the belly and pelvic floor. On the inhale, inflate your diaphragm and belly, breathe down into your pelvic floor area and feel a gentle pushing movement out the front of the penis and out the back of the perineum. You can then gently release this pushing feeling on the exhale. Never force any movements - it should be a gentle process guided by the diaphragmatic breath. You can also try to do the front rk and back rk separately to try to concentrate on each better. To give another perspective, one person described the reverse kegel as like blowing up a balloon in the whole front area between the perineum and pubic bone inside out - so to me this means blowing up the balloon with your diaphragmatic breath into your pelvic floor and making a pushing feeling out the front of the penis and out the back of the perineum. You should also reverse kegel during sexual activities to help keep your pelvic floor relaxed and prevent involuntary kegels that lead to a tight, imbalanced pelvic floor and premature ejaculation. Reverse kegeling when erect may be difficult at first, but it will become easier to understand during sexual stimulation when you get the feeling of wanting to involuntary kegel, but doing the opposite of that and gently doing the push feeling through the front reverse kegel.
I would stay away from regular kegels when dealing with pelvic floor and hard flaccid issues - it will only lead to contraction and tightening. The kegel (BC) muscle works plenty involuntarily on its own without us needing to exercise them. Once again, the reverse kegel helps to counterbalance the pelvic floor that has been overusing regular kegels leading to hypertonic pelvic floor dysfunction. Positions that I am most able to feel the reverse kegel the most in are the wall happy baby pose, lying flat on my back while spreading my knees apart, child’s pose, and the yoga/malasana squat. Do not be discouraged if you have no awareness of your pelvic floor or the concept of reverse kegeling just yet. Your pelvic floor is tight and dysfunctional giving you little to no feeling of the proper movements. Once your pelvic floor becomes relaxed and lengthened through pelvic floor stretches, you will have an easier time gaining awareness. Learning how to reverse kegel is often the hardest part of recovery for men. It may take many months, so have patience with your body while it is healing.
To help heal hard flaccid and pelvic floor issues, never watch pornography again (this is vital). Go on NoFap for 90+ days to help heal your brain and body from any unhealthy pornography and sexual habits you have partaken in. Pornography leads to involuntary kegels, a tight pelvic floor, desensitizes you, and messes up the dopamine and arousal circuitry in your brain. Don’t climax too often. Use lube and a very gentle gliding motion if you are going to self-pleasure, no more tugging on your penis that is then pulling on your pelvic floor muscles, and avoid masturbation positions that puts you into an anterior pelvic tilt - stick to neutral/posterior pelvic tilt positions. Sex is much healthier compared to masturbation for the penis and pelvic floor muscles because the head of the penis is stimulated by the vaginal walls which creates a reflex that helps activate the ischiocavernosus (IC) muscle, which is vital for erection health and is likely in a contracted state causing hard flaccid - thank you to this thread for this information. If you do have a partner, only climax through sex. Make sure you have proper erection quality during sexual activities - take supplements or medications if you have to. Climaxing flaccid or semi-flaccid is what causes many people to develop hard flaccid and pelvic floor issues in the first place. This is likely due to a complicated process of the IC muscle being improperly activated due to flaccidity during climax leading to a cramping of the muscle leading to hard flaccid and causing dysfunction across the pelvic floor muscles causing a cascade of inflammation. Only partake in sexual activities when you have relaxed your pelvic floor enough through stretching and the rest of the techniques. Again, I do recommend abstaining from masturbation as long as possible while healing and preferably after as well.
One interesting and strange thing that I also want to mention is that a person with hard flaccid and pelvic floor issues reported significant improvements after changing the position in which they masturbated and climaxed in to an elevated glute bridge position while reverse kegeling, some commenters also reported improvements - here is the thread. Another post here said that using a squatting position while sitting at the edge of a chaibed with feet flat on the ground and not touching himself during climax helped him. Another reminder, I would only attempt this if you have gotten your pelvic floor to a relaxed state through stretching and learned how to reverse kegel when erect during sexual activities. Going gentle and using lube is necessary. During all sexual activities you should be erect as possible to support proper pelvic floor function.
The reason why masturbating in a posterior pelvic tilt along with glute muscles activated likely worked for them is that we have been masturbating and climaxing in an Anterior Pelvic Tilt (APT) all of our lives. This is unnatural and goes against our evolutionary biology because during sex throughout all of our human history, thrusting and climaxing puts us into more of a posterior pelvic tilt position with a lot of activation of our glutes. Men are often self-pleasuring with an APT while edging for sometimes hours at a time throughout their lives while sitting on a chair, couch, bed, etc. which has put unnatural pressure, or improper activation,on their pelvic floors that has likely caused dysfunction with our BC, PC, and especially IC muscles. By switching to more of a natural sex position during masturbation that puts us in a posterior pelvic tilt state, such as during an elevated glute bridge, it is reactivating and counter correcting the function of our pelvic floor muscles, such as the IC muscle in particular, that has been dormant or dysfunctional due to our bad sexual habits. This of course isn’t a miracle cure, but it could be worth a try if you first applied the rest of the recommendations.
You can and will heal. Stay strong and never give up. Thank you for reading.

I just got off orientation as a new nurse on med/surg floor. I am all sorts of overwhelmed at the moment. Tonight, I started off with 4 patients and knew I was getting my 5th patient an hour after my shift started.
My patients started out fine but then my night got crazy. One of my patient’s had a post surgical issue with their feet so I had to contact provider and do neurovascular checks often. Then my other post op patient had a foley in place that ended up clotting. The doctor had specific orders to keep foley in place until specified. Well…the foley ended up clotting when patient was brought up after surgery. Got a one time order to irrigate the foley by provider at that time. For a couple hours it drained fine after. Then 3 hours later, urine became dark red again. Contacted provider who came to bedside. They irrigated with me there. They then put orders for me to manually irrigate foley every hour….for the next 5 hours of my shift. Mind you, tonight was my first night ever irrigating a foley. I had another nurse teach me the first time around. Also, I had 4 other patients with meds and one of them needed close monitoring as well.
I wanted to cry but I sucked it up and just did it as ordered. I got out of work two hours later since I had to catch up on charting. Am I unreasonable for feeling overwhelmed? My charge and other RNs on my unit said the Q1H irrigation is too much but idk if I’m just dumb and incompetent 😩.

My manager told me that we’re meeting soon with risk management regarding an event that happened with my preceptee. They’re calling it a sentinel event, and I’m just nervous for what that could mean for my job/license.
Long story short, my preceptee straight cathed a patient and when she independently d/ced the cath, she forgot to take out the first cath she missed that went vaginally and day shift discovered it later. The patient is completely fine, no skin breakdown or harm caused. They’re labeling it a sentinel event because it was a “foreign object left in the body.”
My preceptee has more years of experience than I do as a nurse, has straight cathed dozens of times in her career and multiple times with me and I deemed her safe to do so independently. We’re on week 20 something of orientation and at this point I’m instructed to just be a resource to them and they independently care for the patient. This was just an honest mistake, it could only have been prevented by her paying a little more attention. I knew she d/ced the successful catheter bc we talked about it after, there was no reason for me to go behind her and check her work.
Has anyone been in a similar situation before? Having the title of “sentinel event” has scared me and I’m wondering how this investigation will go. Any words of encouragement or advice would help as this meeting is days away and I’ll be an anxious mess until then.
UPDATE: meeting went fine, it was a RCA meeting and they interviewed my preceptee and I separately and got both of our POVs on what happened and suggestions to prevent it from reoccurring. In our flow sheet there’s only a place to document output after a straight cath and nothing else and it’s not protocol for us to write a note, so I suggested adding more info into that flowsheet to further say who performed the straight cath, who assisted if any, if cath was successfully dced, etc. and they thought that was a great thing to add. My manager will let me know if anything else comes of it. Thank you all for your advice on the subject!!

I've browsed this subreddit since I (26) started working and designed my entire budget around the flowsheet. My spouse (26) has also followed my lead putting us in a strong position, but as we explore buying a house I'm trying to figure out what's realistic against what we'll be approved for. Below are budgetary items after tracking 1.5 years of data. Of note, some numbers are rounded slightly to make the math cleaner. My job: $58k/yr, work at university with stable job with ~7% match total (403b/457 + Roth 403b supplemental). I put 11% in pre-tax and $60 post-tax per paycheck ($40 in supplemental, $20 in HSA). Employer also deposits $1500/yr into HSA as I cover both myself and spouse's insurance. Been informed of a promotion in the next month for unknown increase but anticipating around 10% increase based on prior promotion. ~$38k in retirement accounts. Spouse: Estimated $78k/yr. Works "PRN full-time" due to an accepted job offer being rescinded (explored promissory estoppel, wasn't worth pursuing), meaning higher pay rate but no employer retirement or benefits. All W2 employment, but shift availability may drop some later this year. Maxing their Roth IRA before mine while they work in this design until a permanent opportunity arises. ~$15k in retirement accounts. Monthly net: ~$8500 average (may fluctuate with spouse's work) Savings: Currently have $22k E-fund (6mo. expenses with no lifestyle changes), $80k for house down payment, and another $40k that we're planning to move into our HYSA with the other $102k. Hoping to use $5k for a vacation and the other $35k towards the house (~$20k towards House E-fund, rest towards closing). We currently trend at saving 50% of our monthly net income. Debt: None (paying off CC in full each month). Expenses: Excluding housing, ~$2300/mo. Housing: Currently rent 2B/1b 950sqft townhome for $1500/mo. Looking to leave after some terrible experiences and being sick of renting. Initially planned for $450k max budget, more hopeful for $400-425k. I would argue we're in a MCOL area as it is with very limited supply, a lot of poorly made townhomes built lately, and overpriced homes due to a very affluent geriatric population. Also challenging to pull the data as we're in Virginia and cities being separate from counties muddies the waters. Looking for a 3B/2b minimum with more space, a driveway, air conditioning, and having enough distance from neighbors to where we could have a private conversation (many new builds here are patio homes with a wall between back patios).
Target purchase date: 6-12 months from now. Targeting Spring-Summer 2024. Future plans: Starting a family in 3-5 years. Had the opportunity to leave the area earlier this year but we decided against due to enjoying the area, what it offers, and proximity to family.
Am I simply being too cautious to think that a 28% DTI off gross ($3150) is a lot to spent on PITI? Calculators online are saying we'll be approved for $600k+, but even sniffing $3k/mo on a mortgage seems wild and over-leveraged to me. Mainly looking for a reality check to build a more effective plan before we hope to truly hunt in the next year, especially without fully compromising retirement contributions or lifestyle changes. Thanks.