Hello everyone and welcome back. I am really excited to have a special guest with me today from across the pond. ⁓ He has a lot of different qualifications, but first of all, I want to see welcome, a Umit Erkut.

Umit Erkut, PT, PhD (00:17)
Thank you very much. Thank you.

Dr. Ginger Garner PT, DPT (00:20)
So I want to read a little bit about his background

first, you guys, because there’s just, there’s a lot ⁓ there. He just keeps getting more degrees and education. So here we go. Dr. Erkut is a physiotherapist, osteopath, and ultrasonographist specializing in men’s health, which naturally includes sexual health, dry needling, TMJ dysfunction, and also musculoskeletal ultrasound.

⁓ He completed his osteopathic training in 2014 and holds two international dry needling diplomas. He’s got advanced MSK ultrasound training. Love that. ⁓ Did that in Europe and then teaches pelvic floor and extremity ultrasound courses worldwide. Something that we can all learn more about. He’s the founder and president of the Men’s Health Physiotherapy Association of Turkey and has led men’s health education since 2016. His PhD research, which I can’t wait to dig into,

focuses on male sexual dysfunction and he currently serves as an assistant professor at ⁓ Ramelli University in Istanbul. Welcome.

Umit Erkut, PT, PhD (01:25)
Thank you.

Dr. Ginger Garner PT, DPT (01:27)
All right.

So we spend a lot of time on the vocal pelvic floor talking about pelvic health. Like for example, season four was all about endometriosis, which is by and large generally women’s health. But today, for all you men out there, listen up, this podcast is just for you. So listen in and let’s see how the vocal pelvic floor applies to the other half of the sky.

Umit Erkut, PT, PhD (01:50)
to the

Dr. Ginger Garner PT, DPT (01:51)
So my first question

is, what led you to focus on this for your PhD studies? I want to get to the details of the research in just a second, but just what was your interest in that?

Umit Erkut, PT, PhD (02:04)
Yeah, yeah, you know there are many studies about pelvic pain or urinary incontinence for the male pelvic floor resurgers if you look like mostly focusing on the know after the prostate surgery, prostate surgery, they’re just focusing the urinary incontinence rehabilitation, yeah.

The main pelvic floor is not just urinary incontinence and there is a big, huge topic, the sexual dysfunction. And there are many studies that can prove that the muscles can affect the sexual dysfunction. the other hand, if you look, there are some studies like systematic review studies. They found that, yeah, these muscles can affect the sexuality, but there is no any treatment protocol

And we don’t know how much exercise and, you know, on which patients. And there are many different types of sexual dysfunctions, especially for the premature ejaculation. know, there are four subtitles of the premature ejaculation. And there isn’t any study about these topics. And it was, in our country, if you do PhD, you have to find a new

a new topic, there isn’t any research about any topics you can do on that topics. Otherwise they don’t accept your PhD. say you have to find something new, you know? So, ⁓ it, it was not new for me from 2018. When I started the PhD, it was my plan to, to do on this topic because you know, when I checked all male pelvic floor research,

And I found many things and I said, yeah, this is the topic, but when I treat the patients, I found that it’s not just muscle. So, and you know, I said myself, I can create a, can, I mean, I can do something like the new treatment protocol for these patients. And we focus just on that way. So we,

decided to do this research, my teachers and with my research group friends like that.

Dr. Ginger Garner PT, DPT (04:34)
Yeah, so for ⁓ all of you who may not be familiar with it, I’m just going to read the title for you. And then we’re going to circle back to that in just a second. I have a lot of other questions first before I want to get to that. the title is, so this is your cue listeners to listen to the end, is the effects of diaphragmatic breathing. And he’ll talk about what that is in just a second. ⁓ Diffragmatic breathing exercises on individuals with premature ejaculation.

which was a randomized controlled trial. So first of all, congratulations for getting that published. It was published in the Journal of Sexual Medicine like two minutes ago in August, really recent. ⁓ But my first question based on that is, here’s what surprises me first, constantly surprises me, is that we have so little information and details.

Umit Erkut, PT, PhD (05:18)
based on that.

Dr. Ginger Garner PT, DPT (05:31)
in the realm of sexual health, men’s health, women’s health, for everyone. And that’s just incredibly disappointing. That’s the first point. Second point is really more of a question for you. And that is what surprises you the most about what men misunderstand or are never told about sexual function? And that might be where some of your research focus came from.

Umit Erkut, PT, PhD (06:01)
Yeah, you know, they don’t think about the breathing can affect the duration of the intercourse and how it affected, you know, when I started to treat the these patients, like 2014, I found that they hold their breathing. It was first my finding that

You know, ⁓ they squeeze themselves, the, group of patients, I mean, the premature ejaculation, but there isn’t, there wasn’t any study about the breathing can affect the premature ejaculation or not. Yeah. There are some studies that they found the behavioral therapy and the private rehabilitation. mean, the, ⁓ muscle strengthening can affect the sexuality, but breathing, there isn’t, there wasn’t any study about the breathing. Yeah.

The first thing, if you ask me, the thing which was much more surprised me is after the breathing exercises, you know, the parasympathetic system getting more high. Okay. But we found that a little bit also the sympathetic system increase. It was, you know, for the, when I found these results during the, study,

Dr. Ginger Garner PT, DPT (07:16)
Mm-hmm.

Umit Erkut, PT, PhD (07:23)
There was a doctor in my study. We worked together and he said that I directly called him that I found that the sympathetic system also a little bit increase. He said something wrong with my study. know, he said, no, because there are some studies that waggle nerve also co-activated system. It’s like a balance of the body, you know, this was, yeah.

Dr. Ginger Garner PT, DPT (07:51)
right?

Umit Erkut, PT, PhD (07:53)
much more surprise for me and when I think about it yeah if we give I mean this parasympathetic system we want ⁓ less sympathetic system for the as if the simple extreme higher as you click will be quick okay and also erection will depress the they will lose their erection the quality will less so we want the parasympathetic system if you give ⁓ breathing exercises

thing about it, if the parasympathetic is too high, how can they continue the intercourse so that they can sleep? mean, so this is the balance of the, this is the balance of the body. It also co-activated the sympathetic system. You know, it was a surprise for me. And when I checked the results, I was shocked and I directly called my old friends that is it

Dr. Ginger Garner PT, DPT (08:30)
Mm-hmm. Yeah.

Umit Erkut, PT, PhD (08:52)
Do we did something wrong? you know, can we change something? They said no, it’s the doctor from my study group. And he said, no, there is an animal study on the animals. They found that the high parasympathetic system also increased a little bit sympathetic system. And the breathing also, we found that can affect the strengthening of the pelvic floor muscles.

And also it helps to feeling of the, know, pre-orgasmic sense, feeling so they can control the pre-orgasmic sensation. And it’s important for the premature ejaculation group because they don’t feel the pre-orgasmic sensation and they cannot stop the ejaculation. This is the main problem for them.

Dr. Ginger Garner PT, DPT (09:31)
Mm-hmm.

So they

don’t really perceive like, if I can just kind of encapsulate what you just said and also ask a clarifying question too, is to go back to the vagus nerve, which you mentioned the vagus nerve and there’s so much buzz about the vagus nerve, like no pun intended, ⁓ that we’ve got the parasympathetic system and the sympathetic system and sympathetic would be running from the tiger.

It’s hard to control things if you feel like you’re, you know, under stress and under duress. And the parasympathetic system on one side is more of a rest and digest. It also allows for sexual function. ⁓ So what you’re saying is you actually found some increase in the parasympathetic activity and sympathetic activity of the systems.

Umit Erkut, PT, PhD (10:37)
the dedicated. ⁓

not as much as the parasympathetic but yeah I mean yeah if the parasympathetic getting too high our body make balance and increase a little bit sympathetics yeah it co-activated also sympathetics like this and also there is a study on that but it’s about they did on the animals

Dr. Ginger Garner PT, DPT (10:45)
Right, right, right.

Tee hee.

Umit Erkut, PT, PhD (11:08)
But yeah, you know, we found the same thing. And if you think about it, yeah, because if the person we want person, but the system, if it is much more how they continue with the intercourse, yeah, if the parasymphamatic is too high, they will sleep, you know, so they need also sympathetic a little bit ⁓ to live to, you know, I mean, yeah.

Dr. Ginger Garner PT, DPT (11:13)
Mm-hmm.

It’s going kind of difficult.

Right, to keep things going. So

we need some sympathetic activation to keep things moving and going in the right direction from a sexual function standpoint. But you also have to be, there has to be a, ⁓ you know, like a quantified measure of relaxation at the same time. ⁓ And so that almost feels conflicting, but where it comes down to ⁓ whether or not someone has success,

⁓ in the terms that we’re talking about is a measure of awareness. Because you said also something that kind of piqued my interest in that they’re not aware of that. You said maybe the word was pre-orgasmic, that they’re not aware of what’s happening there. And is it the breath work that’s actually shifting that for them? Like what is changing so that they don’t have premature ejaculation? is that what is happening there?

Umit Erkut, PT, PhD (12:05)
This is a measure of awareness.

Dr. Ginger Garner PT, DPT (12:30)
is awareness changing.

Umit Erkut, PT, PhD (12:31)
I mean,

normally the education, the mechanism, if you look at the mechanism of the education, you know, when you get the stimuli from maybe smell, maybe touching, maybe, you know, imagination, maybe blah, the, sperm starts to move from the epididymis goes with the was deferens and the ejaculated ducts and the seminal vesicle, they open to the prostate. Okay.

and prostate close directly internal and external sphincter and we say this phase the emission phase emission okay but the emission if it starts no one can stop it okay this group of the premature ejaculation i mean premature ejaculation they don’t feel the emission phase or

Dr. Ginger Garner PT, DPT (13:10)
Mm-hmm.

Umit Erkut, PT, PhD (13:29)
They feel late.

Okay, this is our idea that if because their anxiety is high, performance and anxiety and normal anxiety is high. Maybe the sympathetic is high. They cannot focus this feeling and you know, they feel light or they don’t feel. But when breathing, we believe that helps to feel this feeling.

Dr. Ginger Garner PT, DPT (13:43)
Yeah.

Umit Erkut, PT, PhD (14:02)
Because the other group when we check one year later, the other group, without breathing group, just with the behavioral therapy and the exercise group, their intraversional ejaculation latency time decrease one year when we check one year later. But the breathing group, we just ⁓ say then

Dr. Ginger Garner PT, DPT (14:26)
Mm-hmm.

Umit Erkut, PT, PhD (14:31)
We just said them that continued breathing, especially during the intercourse, like keep breathe, but not like, ⁓ you know, not much more breathing, just slow, slow like that. they’re almost same, their introversion and ejaculation, latency time, almost same. It means that their feeling is still continue.

Dr. Ginger Garner PT, DPT (15:00)
you

Umit Erkut, PT, PhD (15:00)
And the

other, just, I mean, if just the behavioral therapy and the exercise group, ⁓ you think that these two techniques help to this feeling, why the other group, introversion, ejaculation, that has time is decreased. So it means breathing help them to feel this feeling and they can manage the ejaculation and they can stop it.

Dr. Ginger Garner PT, DPT (15:25)
Yeah.

Umit Erkut, PT, PhD (15:30)
I mean, maybe they change the position or they stop it, blah, blah. I mean, they will take longer for intercourse.

Dr. Ginger Garner PT, DPT (15:34)
because they…

Yeah, because they

can perceive it now. They have a manner of control, whatever they do to control that, then change through whatever the breathing pieces that you were educating them on, which is that right? Which then brings me to my next question, which is, let’s talk about the study. Can you describe the two groups, the 62, sorry, 62 men, right, were divided up into two groups?

Umit Erkut, PT, PhD (15:56)
Yeah.

Dr. Ginger Garner PT, DPT (16:08)
Can you break that down for us?

Umit Erkut, PT, PhD (16:08)
you

Yeah, 62, 31, 31. And two from the group one, one from the group two, you know, is excluded. And we finished with 59 patients, 29 group one, 30 group two. I mean, group one is with breathing exercise.

Dr. Ginger Garner PT, DPT (16:16)
Mm-hmm.

Okay.

Umit Erkut, PT, PhD (16:36)
Group

2 is without breathing exercise, just behavioral therapy and exercise group.

Dr. Ginger Garner PT, DPT (16:42)
And that’s pelvic floor muscle, just for the listener, that’s pelvic floor muscle stuff, right?

Umit Erkut, PT, PhD (16:48)
yeah just the exercise is just perfect for strengthening for the ⁓ fast twitching and the slow twitch fibers exercises contract all 10 seconds and contract and relax ⁓

Dr. Ginger Garner PT, DPT (16:48)
That’s what’s

Okay, so.

Okay, so for the listener who may not know about fast twitch, slow twitch, pelvic floor, ⁓ muscle physiology, you don’t really have to, just know that if you’re working on fast twitch, it’s more of a contraction of the pelvic floor with an immediate relaxation versus our, which we call quick flicks sometimes. And then the slow twitch muscle fibers, think about those as your marathoners. If your fast twitch muscles are your sprinters,

and your slow twitch muscles are your marathoners, your long distance runners. Those are long holds and you had them hold 10 seconds and then release.

Umit Erkut, PT, PhD (17:43)
Yeah, rather slow.

Dr. Ginger Garner PT, DPT (17:44)
Okay. All right.

For how long? Just to get a little bit into the weeks Eight weeks? Okay.

Umit Erkut, PT, PhD (17:50)
eight weeks

yeah three times a week and ⁓ totally eight weeks and plus

Dr. Ginger Garner PT, DPT (17:57)
And like how many times a day?

Umit Erkut, PT, PhD (18:02)
10 for yeah 10 10

Dr. Ginger Garner PT, DPT (18:07)
Okay, so 10 reps for each one. How many times a day?

Umit Erkut, PT, PhD (18:08)
H1.

⁓ You know, no, I didn’t say, I forgot maybe this is, I think it’s two times a day, three times a day, three times maybe. I I forget it, you know. Yeah. Yeah. They, you know, they published in August, but it’s, it’s not new. It’s old study you know, the duration of the publication is too long. You know that.

Dr. Ginger Garner PT, DPT (18:20)
Two times? Okay. I think I read two times. Yeah, as well. Now, hopefully they did that two times a day. So if you’re talking about…

Yes.

That was like

10 years ago. ⁓ August was 10 years ago. ⁓ So if you’re wondering like, just like how can pelvic floor muscle strengthening change anything? Well, can you explain a little bit of that physiology? Because I don’t think that our listeners probably understand how much pelvic floor muscles actually contribute to sexual function. They’re thinking you just do it if you were leaking or something.

Umit Erkut, PT, PhD (18:41)
Yeah, you know.

Yeah, you know.

Actually, if you ask me, this group, you know, they have tight pelvic floor muscles. It’s not length and weak. Okay. The first thing we try to teach them how to focus these muscles with, you know, inter-rectal palpation. And I choose stop the ring because when you ask them stop the ring, they can stop the ring. So it means to…

to, you know, they can say they can think that if we can stop the rain, we can stop the ejaculation to because both of them in the same canal is, you know, so.

Dr. Ginger Garner PT, DPT (19:45)
So explain that just a little bit more.

You mean stop during urination? Is that what you’re talking about? Right, okay.

Umit Erkut, PT, PhD (19:51)
Yeah. Yeah.

Just, just think, yeah. Stopped urination. Our cue is for the strengthening of the exercise is stopped urination. I chose this cue because of the, they can stop when they contract the muscles, when they stop the urine. So they can, I mean, believe that they can stop the ejaculation too. So because of this, I chose this cue.

If you look many studies, there are many different cruise dates used for the contraction of the pelvic floor, to be honest. don’t know, the culture of the people affected, but there is a study from Australia that stopped, I mean, they found that, you know, shortened the penis. Yeah. Yeah. But if you ask me,

Dr. Ginger Garner PT, DPT (20:27)
Yeah.

That’s a common one.

Umit Erkut, PT, PhD (20:47)
⁓ You know in my country it never worked. I tried one two times Because they have obsession of the penis size and they think that the penis is too short So they don’t do this exit. They say, you know Yeah

Dr. Ginger Garner PT, DPT (20:51)
Really?

They don’t want that key. That key was not flying.

It’s not working.

Umit Erkut, PT, PhD (21:05)
In my country, it never worked. know, I think this study is from 2016. It’s not new from Australia, but it’s a good study actually. you know, in Istanbul, I I tried and I never get any results, you know, so maybe in Dubai, I will try, but I’m not sure that it will work here too. So yeah, because of this, you know, I always, I…

Dr. Ginger Garner PT, DPT (21:13)
Yeah, yeah.

We’ll see what happens in Devise.

Umit Erkut, PT, PhD (21:33)
Much more I use the whole, mean pull your testicles towards the penis head but in this study for the premature ejaculation I use much more stop urination. Okay with this tool to teach them and to be honest You know if there is a tight muscle if you go interrectally also you will release the muscles too

Dr. Ginger Garner PT, DPT (21:46)
Okay. Okay.

True.

Umit Erkut, PT, PhD (22:01)
We didn’t explain this in the study, but if you ask me, it’s a fact, of course. You know, they have too tight or active, I mean, ⁓ or active of these muscles. So, ⁓ I mean, the strength is, it’s better to release and then to focus there and they can control and they can, the range of the movement of the, the ultrasound, when you check.

Dr. Ginger Garner PT, DPT (22:07)
Yeah, yeah.

Right. Right. So.

Umit Erkut, PT, PhD (22:32)
and from the transabdominal you will see they will start to move much more to the right.

Dr. Ginger Garner PT, DPT (22:40)
All right, right. Well, let me summarize this for a second,

because we just went through like a lot of physiology and anatomy stuff. So basically we were talking about fast twitch, slow twitch, we were talking about sprinters and marathoners, and the cue that worked was not shorten the penis, that’s fair. It was stop the flow of urine. Now, did you find,

on either trans abdominal imaging. So this is another question. So for the listener, we were talking about trans abdominal imaging and saying, okay, well, you can see the pelvic floor move better on trans abdominal imaging, which is what many of us, I use it as well in practice, we’ll use to check and see what’s going on, you know, the pelvic floor, the bladder, et cetera.

of my questions would be, ⁓

when you’re doing imaging and you use stop the flow of urine as kind of the cue, whether you’re the long holds for 10 seconds or the quick flicks really short, you know, tightening the public floor and relaxing. Did you find when you did interectal work, which is again for the listener for men’s public health, that’s kind of your only outlet is interectal. So ⁓ that’s what we have to do to see what’s going on there. And yes, you can.

both improve awareness of the muscles in that area, but also facilitate relaxation at the same time, which is important because you’re gonna get better function. So my question for you is this, do you find that both the superficial and the deep layers of the pelvic floor are activated by that one cue of stopping the flow?

Umit Erkut, PT, PhD (24:18)
are activated.

⁓ you know, first, if I go into directly, I explained them to, know, I put my finger. said, if you do correct correct means the first knuckle has to be, you know, towards your. And when, when they try, yeah, this is this one. You will do this exercise from the, the, the ultrasound. ⁓ you know, we didn’t check actually the.

Dr. Ginger Garner PT, DPT (24:37)
Mm-hmm.

Umit Erkut, PT, PhD (24:52)
the which fibers are yeah, but ⁓ I don’t think it will affect much more for the ejaculation reflex, you know, for the education that it’s about to know these muscles and the where is it and how to control these muscles, you know, because it’s getting too tight that, you know, the other things is they

They have, you know, afraid, lose the erection. So they always contract the glutes and it’s better to, to relax the around the glute. mean, the pelvic floor muscles because they always contract it. mean, if they contract the glutes, of course they will ejaculate. If you think about this, you know, if you think like, this is the penis, this is the pelvic floor muscle. If it’s relaxed, the water will not cause.

I was like, if you squeeze your glutes, you know, it will agitate quickly. So it’s the pelvic floor. goal is like to teach them how to control, how to release these muscles, how to control these muscles, how to, you know, there is another study from, laparating. Yeah. You know, there are two types of behavioral therapy techniques and they found that during the, the,

Dr. Ginger Garner PT, DPT (25:56)
Yeah.

Umit Erkut, PT, PhD (26:21)
pre-orgasmic phase, if they control and the, I mean, they contract and the hold and with the breathing, can like, you know, squeeze technique, know, behavioral therapy techniques, there is a squeeze technique. It’s bad, they found that they got ⁓ better results when they do this, better than the, mean, the squeeze technique. So we try to teach.

Dr. Ginger Garner PT, DPT (26:47)
Can you describe that for the listener a little bit more?

Umit Erkut, PT, PhD (26:51)
The squeeze techniques, are two types of the behavioral therapy, like masturbation exercises to teach them pre-orgasmic feeling. So it’s good. know, for the, there are some patients, it’s difficult to teach them this feeling. So the behavioral therapy will help them how to learn the pre-orgasmic, you know, feeling.

so they can stop it or they can change the position or blah, So.

Dr. Ginger Garner PT, DPT (27:25)
Right, so

those behavioral therapy techniques, you’re probably about to say that, sorry. I jumped in too soon. ⁓ So what are the, were both of those techniques discussed in the study? Did you use those in the study? Are those the ones that were used there? Okay.

Umit Erkut, PT, PhD (27:44)
Yeah, they can’t find it in

my study, but it’s a masturbation technique. You wanted me to explain how to do it or I didn’t understand. Yeah, you know, it’s a masturbation technique to do.

Dr. Ginger Garner PT, DPT (27:50)
I am sure the listener would

kind of like, I don’t know how easy it is to describe that because the water bottle for you guys listening on podcasts, you didn’t see him do the water bottle example. So he basically had a water bottle that was partially full and then he squeezed the opposite end where the lid is. And I was like, if you squeeze your glutes, you’re definitely going to have premature ejaculation. So stop doing that. But you guys didn’t get to hear that. You didn’t get to see it because you weren’t watching on YouTube. You’re listening on your podcast.

So there you have the water bottle explanation of why the glutes are like no, no go. If you’re trying to stop premature ejaculation from happening. the second thing would be, yeah, it’s kind of hard to describe on a podcast maybe. But for those of you on YouTube, I don’t know. I don’t know how do you want to describe it. But to the extent that you can in this forum, how do they do these behavioral techniques?

Umit Erkut, PT, PhD (28:46)
Yeah. you know, are different types of the behavioral therapy techniques, but I can explain you start stop techniques that the squeeze techniques, but I don’t prefer the squeeze technique. In the squeeze technique, just during the preorgasmic feeling, they squeeze the frenulum, the head of the glans, I mean, the glans penis down there, the frenulum, the anatomical, they from the up and down, they squeeze like

five, seven or ten seconds when the program is feeling loose and they continue masturbation. Why the masturbation is important? I can start from that because we learn the sexuality first. It doesn’t matter for male and female from the masturbation. know, there are many studies. Some studies, they say that before the marriage, a guy doing between thousand and

one, I mean, yeah, 1000 between 1500 times masturbation. Masturbation is very important for the premature ejaculation. If, you know, if they start during the teenage, if they start to masturbate, you know, quickly, if they don’t focus the feeling, they just focus the result and they don’t learn the pre-orgasmic feeling. So this

Dr. Ginger Garner PT, DPT (30:04)
Mm-hmm.

Yeah, then just

kind of blow by at the whole thing.

Umit Erkut, PT, PhD (30:12)
Yeah, so how can you just contract the muscles you can teach the preorgasmic feeling is I You know, I’m a physio also, but Yeah, I I don’t think with the muscle contraction you cannot teach them any feeling these feelings so behavior and the breathing exercises will help them to you know a guy who don’t feel the preorgasmic or who feel late the preorgasmic feeling so they will

teach them for the start stop technique, you know, the first they get some maybe touching or imagination. start the masturbation. It doesn’t matter. If they feel the preorgasmic feeling, you know, preorgasmic feeling first, you have to teach them that there is a warmness around the adductors and like, you know,

the the anus contraction of the anus we explain them the when these feelings are start stop stop masturbation take deep breath 10 times or eight times you know slowly when you when you lose this feeling do again and four or five times at the five fifth times you can it has to be not long than longer than 30 minutes and

Maximum five times the fact the fifth one will be ejaculate not 30 minutes much more than 30 minutes and this is the the so they they will learn and also for the premature ejaculation, know, the the the inter the sexual intercourse Time is important for them if they have us, you know, say one time a week Intercourse or two week again intercourse

Of course, they will ejaculate early. So with this masterbation techniques, you know, they will ejaculate more than one time. the time of course, of course, they will learn the feeling and the ejaculate will be longer, longer, because when you know, there are many patients when you ask them, do you have premature ejaculation? And they say the first intercourse or the second one, you know, it means they have the

It means they have their premature ejaculation because they don’t accept directly that, yeah, I have premature ejaculation. They don’t say anything about it. And they say the first or the second one. So the second one means they have premature. Of course, the second one will be longer, but sometimes it’s same. Some guys, you know, they ejaculate in eight seconds, even the second one, even the third one. So if you look my study,

We they have the higher level of an anxiety, but please excluded criteria in my study because we use bank bank anxiety bank and anxiety, you know and If it’s lesser than 15 We just excluded the other guys If they have high high high and anxiety sometimes they need medicine So be careful when you when you check my study ⁓

Dr. Ginger Garner PT, DPT (33:30)
Right? Right?

Umit Erkut, PT, PhD (33:35)
careful about the excluding and including criteria. there are some disease also can affect this feeling, preorgasmic feeling and the ejaculation like hypertrite, you know, so be careful when you check my study. The other hand, with the start-stop technique, they will learn how to feel this preorgasmic feeling and when they learn it with the

and the relaxation of these muscles, the pelvic floor muscles. Yeah. With plus breathing exercises. believe that breathing exercise is too important for doing the intercourse if they breathe too much, you know, like if it’s too much, the sympathetic system will, yeah, the sympathetic system will be higher and directly it will ejaculate. So, ⁓

Dr. Ginger Garner PT, DPT (34:16)
Yeah.

Yeah, bad breathing. Yeah.

Mm-hmm. Yeah, so you think about like

almost a seesaw kind of experience for, again, for the listener kind of, it’s easy to kind of…

I lose a little bit of the plot here. So if you think about it as like more of a seesaw, you’re trying to not allow the sympathetic nervous system, which is, you know, that running from the tiger to out to go higher, to be higher than the parasympathetic, which would be rest, digest, sexual function and all that good stuff. So if someone has anxiety, if you know you have an anxiety problem, if you have felt that.

Over here, we use the generalized anxiety disorder scale ⁓ on regular basis. If you score that, you can do it online yourself. ⁓ And you have that issue and you want to go get help for that. I think that could be great. And then the second part is what we’ve been waiting to talk about. That’s the breathing, right? Because if you’ve controlled for that, you’ve controlled for anxiety and you understand the autonomic nervous system.

and parasympathetic versus sympathetic. And of course, we’re greatly simplifying it here because it is complex. Polyvagal theory is a whole thing that we could spend hours talking about. ⁓ And the paradox of the vagus nerve, ⁓ when we think we know it, it’s more complex than that. But at the end of the day, what we do know the literature shows us is that if we engage in any meaningful, good breathing techniques, where you can really shift things.

incredibly, really fast improve things. And so a couple of questions that I have, kind of a two part question here is what were the breathing exercises that you taught? ⁓ And then how did you see that shift things? Because you talked about the one year follow up, which is pretty cool. At a year follow up, those in the breathing group definitely demonstrated something different. So A, what were the breathing exercises and B, how did you see them really shift things?

Umit Erkut, PT, PhD (36:19)
All of us.

Yeah, to be honest, if there is no pelvic pain or other pains, it doesn’t matter just if they control the breathing. I believe that it will affect it. If they have pelvic pain, it depends. mean, I will explain you diaphragmatic breathing exercises, but it doesn’t work in all cases. So, I mean, you know, it depends patient to patient if they have no back pain or pelvic pain or, know, prostatitis or something else.

It will be different. So if you ask me as a researcher and also the clinician If you control the breathing I mean, yeah, we did be diaphragmatic breathing exercises but if they control it if you I mean the apical without apical if they Take breathe both sides. It will affect you but the apical no because they will affect the sympathetic system

but we give them the diaphragmatic breathing exercises to hold breathing on lower ribs.

Dr. Ginger Garner PT, DPT (37:36)
the lower rib cage. So

for the listener for just a second, he said apical breathing. So we’re talking about chest breathing and shallow breathing, breathing that you can see changing, know, the chest rising and all that stuff. Yeah.

Umit Erkut, PT, PhD (37:46)
Yeah, of course, shallow breathing. The other

⁓ main point for the premature is actually shallow breathing. Yeah.

Dr. Ginger Garner PT, DPT (37:53)
Yeah, you’re not

even really getting oxygen down to where you need it. And then you’re like this impotent nervous system is losing its mind and everything, you know, the wheels fall off basically of the wagon. But when you’re doing diaphragmatic breathing.

Umit Erkut, PT, PhD (37:58)
Yeah.

Yeah, the dysfunction

of the breathing about the premature ejaculation, they hold the breathing, they have shallow breathing, know, apical breathing must more the guy with pain, you know, they do the apical, the upper, the breathing, but the mostly the premature ejaculation guy that I saw from the colony, they hold and they do shallow breathing, they hold breathing, you know.

Dr. Ginger Garner PT, DPT (38:16)
Yeah.

Yeah.

breathing and shallow breathing.

Umit Erkut, PT, PhD (38:38)
These two, mean,

like, yeah, I mean, if you like, if I ask you to contract your pelvic floor, you can feel the movement, right? Please take breath and hold it and now contract your pelvic floor. It will not be same. If you hold even during the course, during the intercourse, sorry, during the intercourse, they hold it, they cannot control these muscles.

Dr. Ginger Garner PT, DPT (38:56)
Yeah.

Umit Erkut, PT, PhD (39:09)
to manage the intercourse, so it will affect the ejaculation also. I mean, it will…

Dr. Ginger Garner PT, DPT (39:15)
So it’s really, yeah, it’s important to

know how you breathe. How do you breathe under stress? ⁓ How do you breathe when you’re even completing a task? Because we see patients do this all the time. And if I talk to them about, when have you ever noticed you’re holding your breath? They might notice it even when they’re like standing in the kitchen cooking or opening a can or lifting a box. They’re holding their breath doing that.

And then they’re not putting the two things together like, if I’m holding my breath during everyday tasks when I get stressed, they’re also holding their breath, you know, during sex.

so the question then

would be, can you take the listener through? Can you take us through just that gold standard diaphragmatic breath? If they’re aware of their breath holding, if you’re shallow breathing or chest breathing, I’ll call it mass breathing when you can see the muscles in the neck and the face kind of tighten up. If you’re doing that kind of breathing.

how do they shift it and how quickly can they see results? Like how quickly, and we kind of know where the answer is, where we’re going with that answer is pretty much immediate, but can you take the listener through just a minute or two of what that breathing pattern looks like? ⁓ So they can take that with them.

Umit Erkut, PT, PhD (40:37)
Yeah, normally we ask them to sit and take both hands, the lower ribs, focus here and take breathing towards there, but they can put one hand on the x-ray process, the lower part of the sternum and on the abdominal. They can…

Dr. Ginger Garner PT, DPT (40:58)
the lower part of that. Yeah.

Umit Erkut, PT, PhD (41:04)
take breath towards both hands or the lower part. I use these two in my clinic, but in the study, we just all towards the lower lip and we ask them to take the breathing there, you know, like three seconds inhalation like seven seconds exhilation and like 10 seconds and 10 times.

three times a day. And the main thing is we, you know, the breathing groups, I the breathing group, we ask them to not like this, but as much as like this to keep breathing during the intercourse. not shallow breathing. Yeah. Yeah, of course.

Dr. Ginger Garner PT, DPT (41:54)
so they get their dose response. Yeah.

So three times a day.

Umit Erkut, PT, PhD (42:01)
So, mean, not

like, of course, during the entire course, they, you know, ⁓ they have to do something and, know, ⁓ the breathing, course, a little bit be not like being, ⁓ without intercourse, but we say as much as you can just, ⁓ not too much breathe slow focus on not during the intercourse, but during the exercise focus, the lower ribs.

Take breathing. But three seconds like inhalation seven seconds exhalation And they can do this exercise.

Dr. Ginger Garner PT, DPT (42:41)
Yeah.

Umit Erkut, PT, PhD (42:44)
And sometimes they can, yeah.

Dr. Ginger Garner PT, DPT (42:44)
So I usually.

⁓ well, I usually ⁓ just to recap, three, somewhere around three seconds of inhalation. And I think the most important thing that I’m hearing too is that you want that exhalation to be longer, to slow it down quite a bit, even if you’re not able to take a more, you know, a deep breath, depending on how involved.

how much of an aerobic activity you’ve made it, you might not be able to take much of an inhale, but you can certainly slow down your exhale. And if you can set a timer, maybe they set a timer and practice that throughout the day, just something that pops up, or they start to practice it when they’re feeling moments of stress, because you’re doing the same thing. You’re calling on the parasympathetic nervous system to say, hey, I’ve got to slow things down. I need to relax. And I’m stressed at work.

They can do it at work. can really do it sitting at a stoplight, do it anywhere, but that effect and impact can be immediate. So if you’re a motivated man, and if you’re listening to this, you already are, ⁓ to improve sexual function through pelvic floor therapy, through working the sprint chairs and the marathoners, through those awesome behavioral techniques ⁓ that Umit was describing, through deep dive.

slow breathing. If you’re feeling anxious, stressed, and ashamed about sexual function, this is where it starts. That’s why I love your study so much. This is where it begins. You think about these things that, you know, nobody wants to go into their PCP to talk about, and a lot of men don’t even know what pelvic floor PT does and how much it can actually improve sexual function. So I’m just here to say, y’all, don’t miss this. ⁓ Start your deep breathing now.

start those behavioral techniques ⁓ now and start doing your pelvic floor therapy like at home. You can start doing it now. So.

That’s it. It ⁓ seems so simple, but it’s like a three pronged technique. ⁓ So I just want to thank you so much for taking that on for your PhD work, for doing that study, for bringing stuff out of the shadows that ⁓ men think that there’s no help for or that they’re the only one or they don’t want to talk about it or no one can help them. None of those things are true. It’s common and

especially with our society and stress that can run high so often, I think it’s much, much more common than we think. And ⁓ I love the fact that you did this study to start to dispel that, stress and the anxiety and the shame that’s around it and just get that information out there. So thank you so much.

Umit Erkut, PT, PhD (45:39)
You’re welcome. Can I add something? And yeah, don’t forget that breathing also can ⁓ affect the anxiety and breathing this, I believe that the, the premature ejaculation patient, if they’re not patients, like a behavioral disorder, you know, I don’t say them, don’t want to say them patient. ⁓ But

Dr. Ginger Garner PT, DPT (45:39)
Yeah, thank you so much. Yeah.

Yeah.

Umit Erkut, PT, PhD (46:03)
I believe that all premature ejaculation, the breathing exercises are very important for the premature ejaculation group. if they have like the second one is same, the third intercourse of the ejaculation, it’s same, it’s same, same. It’s better to ask, you know, maybe a neurologist, maybe someone else, medication can help them. But otherwise.

physiotherapy and this breathing exercise is the first step of the treatment because we don’t to prefer them any medicine but some cases even they don’t have an action and they ejaculate and some dynamic cases you know but they have different diseases not just about muscle or dysfunction of some MSK problem but the thing is

Dr. Ginger Garner PT, DPT (46:56)
Right.

Yeah.

Umit Erkut, PT, PhD (47:00)
Physio and breathing, breathing also is part of physio and you know, behavioral therapy and sexual therapy, you know, all of them is the main treatment of these patients.

Dr. Ginger Garner PT, DPT (47:16)
Thank you for adding that ⁓ because there the whole mental health, there’s both mental health and sexual health, which is why I wanted to do a podcast ⁓ a whole season on this is looking at sexual health from the lens or through the lens of it being at the base of that Maslow’s hierarchy of needs and it being a manifestation in a way that we operationalize good mental health ⁓ because people don’t talk about it enough.

So I also want to emphasize too, and I want to get your ⁓ kind of conclusion. If you could give one umbrella concluding statement about your study, what did you learn? That’s point part A. And part B, is it ever too late to do something? Because I’m sure that’s like in the question, that’s in the minds of the listener right now. Like, when is it too late? When is it ever too late? So A, what were the conclusions of your study? And then B, is it ever too late?

Umit Erkut, PT, PhD (48:16)
You can… Primit… premature ejaculation they can manage it. It’s easy. It’s not difficult and Please don’t forget the physiotherapy side of these problems. There are two main things I can prefer them Yeah, these things these two things are important very important for me and yeah, of course we proved that the

Dr. Ginger Garner PT, DPT (48:25)
Hahaha.

That’s right.

Umit Erkut, PT, PhD (48:45)
the physiotherapy and breathing plus a little bit sexual informations they will manage the ejaculation and they will get good results

Dr. Ginger Garner PT, DPT (49:00)
I love a happy ending. That’s great. ⁓ That’s perfect. That’s best way to end. if you are struggling with sexual performance, you know, you can take away these three major pieces of the puzzle and also understand that there could be other underlying issues. So if you try these major pieces of the puzzle that we talked about today and you’re like, I’m just not quite getting where I want.

Umit Erkut, PT, PhD (49:01)
I love how he did it.

Yeah.

on the puzzle that we talked about.

Dr. Ginger Garner PT, DPT (49:29)
Note that there are physiotherapists all over the world that are using ultrasound imaging. They’re using musculoskeletal ultrasound imaging to inform what they do so that it is more diagnostic. The interventions are more specific and individualized to you. So there is so much more that can be done, but this is where it starts because yeah, there’s nothing better than a happy ending.

Thank you so much for joining me today. I just really appreciated this conversation.

Umit Erkut, PT, PhD (49:58)
You’re welcome. Thank you. Thank you

very much. You’re welcome. Thank you for your invitation. Thank you.

Dr. Ginger Garner PT, DPT (50:07)
Absolutely.