Why Pelvic-Floor Dysfunction Takes Time Occur and Takes Time to Heal

I’d like to talk about the length of time it can take for pelvic-floor pain and symptoms to significantly improve or resolve when they do using the Wise-Anderson Protocol. Typically when an injury or illness happens – when people get a cold, cut themselves, break a bone, or have some kind of illness – over time, they get better. They take their medicine or they rest properly and the condition gets better and goes away.

Then there are peculiar conditions where instead of going away over time the symptoms just hang on and on. The symptoms don’t kill you. They generally don’t even disable you, although occasionally they can. But, they continue on and on and people don’t know why and suffer more and more silently. Pelvic-floor pain, often called chronic pelvic pain, is such a condition – where pain and dysfunction goes on and on. I personally suffered with pelvic-floor pain for over 20 years before I recovered. For most pelvic-pain patients, the condition is a mystery that cumulatively causes distress and confusion. Why is there pain? And why don’t the symptoms simply go away like other maladies once they’ve run their course?

In other writings and podcasts, I’ve discussed that chronic pelvic-floor pain is an invisible condition: it can’t be detected by conventional medical testing, and it can’t be seen by the eye or heard by the ear. It’s beyond the ability of a doctor’s senses to perceive the problem. As a result, sometimes a particularly insensitive doctor will dismiss the complaints of pelvic-pain sufferers because no symptom can be objectively documented by current medical testing. Sometimes the doctor sends these patients to a psychiatrist, a particularly useless thing to do.

When you’re the one with chronic pelvic pain, this problem is difficult to understand as well. Sufferers of pelvic-floor pain are often very intelligent and systematic. Many of the patients who have come to our clinic had tried to make sense of their symptoms by diligently documenting their pain – keeping journals and pain diaries noting what they eat or drink, what happens in their lives, their sleep patterns. However, these attempts to figure out pelvic pain for the most part result with no answers and the sufferer is left in frustration and bafflement.

Furthermore, when pelvic pain goes away spontaneously – as it sometimes does for a lucky few patients – the reason is usually just as mysterious as its arrival in the first place. The length of time it takes to go away is often mysterious as well. Sometimes, the symptoms simply peter out and one forgets about them.

As someone who experienced pelvic pain for many years, I’d like to share with you my own perspective about why the Anderson-Wise Protocol it often takes a good year or longer to show significant and reliable results in reducing or resolving pelvic pain. The typical course of a patients who successfully use our protocol begins with windows of relief… an few hours, an afternoon a day, several days or longer where there is a substantial reduction or an absence of symptoms. Then flare ups tend to occur mingled with longer and better windows of relief. When symptoms resolve with our protocol, the patient tends to forget about the condition over time as they learn what to do to help the sore pelvis heal.

Over the years, I’ve spent a lot of time observing the issue of the length of time it takes. As I’ve discussed recently and will share with you here, even though sometimes it feels like pelvic-floor pain occurs overnight, in my view this is very rare unless some kind of trauma or injury to the pelvis sets it off. Rather, chronic pelvic-floor pain occurs because the tissue in the pelvic floor has become irritated and sore over time. The pelvic floor becomes painful because the tissue has been abnormally tightened for a long period of time – typically tightened as physical part of an ongoing response of anxiety and fear as I discuss now.

Anxiety is not only a mental phenomenon – it’s a mental and physical event. Anxiety is a survival response to a perceived threat, and the body itself tightens up protectively as part of worry, fear, and apprehension. This tightening typically goes unrecognized but it is clear when the anxious person pays attention to his/her state of tension. The anxious person is usually aware that they have had always had a difficult time relaxing. With people who have pelvic pain, worry shows up physically in the muscles of the pelvis. This tightening isn’t debilitating – I’m talking about a slight but noticeable guarding and tension when you pay attention to it. My relaxation teacher, Edmund Jacobson referred to this tension as ‘residual tension’, tension that remains after you have attempted to consciously relax.

However, for those who are chronically worried or anxious, that is to say for those whose normal mental state is regularly fearful and worried, over time knots occur in pelvic muscles (and often elsewhere) that are habitually tightened in their typically anxious state. We call these knots trigger points, (we discuss trigger points extensively in our book, A Headache in the Pelvis) and it turns out that trigger points are mysteriously connected to nervous system arousal….they’re very sensitive to emotional distress. In a remarkable set of studies with hundreds of subjects examining the relationship between emotional distress and trigger-point activity, Drs. Richard Gewirtz and David Hubbard found that when emotional distress is heightened, trigger-point electrical activity is profoundly heightened as well. This is a central reason as their pelvic floor related trigger points increase in activity and the referral of pain .

I’m suggesting, then, that pelvic-floor pain not related to an injury or physical insult, is a consequence of worry-related pelvic muscle tightening over a long period forming trigger points and an inhospitable environment in the pelvic tissue. This is a central tenet of our book, A Headache in the Pelvis.

Now, somethings that’s not well understood – but becomes obvious when you examine people with pelvic pain – is how irritated and sore pelvic tissue reflexively tightens up against its own pain. This is one of the strange phenomena in pelvic-floor dysfunction: the pain inside the pelvis triggers a heightened guarding or protective reaction in the pelvis that then makes the pain worse. This leads to a cycle of pain in the pelvis, where pain triggers reflexive tightening which increases anxiety which leads to further trigger-point activity and pain. We call this the “pelvic pain cycle,” and we’ve written about it extensively in our book A Headache in the Pelvis.

The Wise-Anderson Protocol is a methodology whose goal is the help our patients free themselves from the cycle of chronically irritated, tightened pelvic-floor muscles – allowing the sore pelvic muscles to heal as they normally would in other places in the body. We’ve developed specific physical self-treatment methods to help our patients loosen the chronically sore and tightened pelvic tissue, including the use of our FDA approved Internal Trigger-Point Wand and our new Trigger-Point Genie, to release these trigger points and areas of sore and restricted muscle. These devices and the techniques we teach our patients that are required for their effective use, in our protocol are central to restoring sore tissue to a healthy state and to stopping the pain.

As we have repeatedly emphasized, physical intervention while essential to our protocol’s ability to help the patient heal, when used alone is limited and inadequate for the resolution of the condition of chronic pelvic floor pain. The reason is that no matter how skillful physical intervention is, it offers the tightened pelvic tissue a temporary respite from its tightened, painful condition because once the pelvic pain patient re-enters the stresses of life, the temporarily loosened pelvic muscles the pelvic pain cycle is triggered without placing it regularly in an internally quiet place.

So, in my view, the missing piece in the conventional understanding and remedy of the problem of pelvic floor muscle pain is that the sore pelvic tissue is not allowed to routinely relax and heal in conjunction with its physical loosening we teach our patients to do. In my broken bone analogy from other blogs and podcasts, I’ve noted that if you have a broken leg, you can’t walk on it once it’s been put in a cast and expect the bone to heal. Obviously, walking on a broken leg would sabotage the healing of the bone.

The principle of putting a broken limb in a cast to support its healing applies to the healing of painful pelvis
You give the broken limb the rest it needs so that the bone can heal without stressing and reinjuring it. The same principle applies to a sore, irritated pelvic floor. The healing of both a broken bone and of a sore pelvis takes time. The process of healing sore pelvic tissue involves both competently and regularly physically loosening the sore muscles of the pelvic basin, and regularly putting them in a stress-free environment that allows the tissue to remain loose and heal. This simply means regularly removing the sore tissue from the stresses that cause it to tighten up, from everything that bothers it. While this cannot be done 24 hours a day in normal life that requires many activities that aggravate a sore pelvis, in the Wise-Anderson Protocol it means resting the pelvis in an internal and external quiet place for a significant period of time every day. When someone is sick in the hospital, it’s not uncommon to see a sign up outside the room that says “Do Not Disturb.” Why? Because the patient needs time and rest without aggravating his condition so that the body’s healing mechanism can work.

In a certain sense, with the Wise-Anderson Protocol we teach our patients to regularly put up a “Do Not Disturb” sign in their life. This is what is done in the quiet environment required by the method we’ve developed over many years called Extended Paradoxical Relaxation . In order to practice this technique properly, you have to set aside considerable time every day, remove yourself from the normal responsibilities and physical and psychological stresses of life, and practice the vital skill of becoming quiet inside. In practicing Extended Paradoxical Relaxation , you learn to quiet mental activity. This kind of inner quiet, in which you have set time up not to be disturbed by things outside or by your own internal thoughts and emotions, allows a relaxed pelvic floor to heal. This is not a simple endeavor. I deeply understand this and lived it in my own recovery.

Entering into profound relaxation in modern life isn’t common or easy. I’ve said elsewhere that if you could take the pelvis and send it to Tahiti where it could relax in a little hut, undisturbed by the stresses of life for a month or two, then it would heal right up. In the reality of daily human life, what we ask our patients to do is find the time to allow ourselves to heal – to take time off every day so that that broken leg so the sore pelvis can heal.

All of this takes time. It takes patience, and sometimes the sacrifice of valuable time that would be put to other ends. In that sense, healing the pelvic floor is truly two steps forward and one step back. But, the goal is to come out in front of the stresses that promote the chronicity of the condition, to where the healing actually does get ahead of the stresses that interfere with its resolution.

While this is not hard and fast, and patients differ, we suggest a time from of about a year in doing our protocol diligently to allow the healing of the pelvis to significantly and reliably reduce symptoms or resolve. For those who are successful in our program, sometimes it takes longer and sometimes it takes less time, but it’s the creation of a practice of taking time that allows the tissue in the pelvic floor to heal up. This includes regularly physical loosening the tissue, and then hanging up that “Do not disturb” sign internally and externally. The Wise-Anderson Protocol requires time, patience, and tolerance of inconvenience and discomfort about how much time this takes out of a normal, active daily life. In my own experience, once I saw the light at the end of the tunnel, once I experienced my symptoms reducing from my own efforts, I stopped being concerned about how long the process of healing was going to take.

The practice of the methods we train our patients in occurs amidst the stresses of their lives and the necessity of continuing to function in all of the aspects of life. It is possible to continue to work and function while regularly providing the pelvis with a healing environment. The time this takes to do this is best acknowledged and honored. Healing of pelvic pain takes time. And, as I experienced, when the pelvic floor does begin to heal, the time it takes typically no longer feels onerous because the joy of the easing of pain through your own efforts, and knowing that you’re going in the right direction tends to remove the concern about the inconvenience, difficulty and time taken in one’s own healing.

Pleasure Anxiety

In this essay I want to discuss an invisible source of the creation and perpetuation of pelvic floor pain. It is the issue I’m calling pleasure anxiety. This is something we’ve discussed in our book A Headache in the Pelvis and it’s not something, to my knowledge, that has ever been discussed in the research on or in the general discussion of, pelvic floor pain. Pleasure anxiety refers to an aversion toward pleasure because it triggers an unconscious fear that something bad might happen if someone is happy and unprepared for danger. Pleasure anxiety is often seen in individuals who have suffered some life-changing trauma like the death of a parent, or some other kind of traumatic painful experience that occurred when they were ‘unprepared’ for such an experience. I have also observed that it is present in individuals who have not suffered any discernable trauma.

Pleasure anxiety can reach a level of distress in some individuals and Extended Paradoxical Relaxation, the relaxation protocol that we teach our patients to help them heal their sore pelvic floor, sometimes needs to be modified to help someone through this anxiety. This is because EPR helps our patients un-defend themselves. Someone who deals with pleasure anxiety can feel vulnerable and anxious as they un-defend themselves by letting go of their vigilance and physical guarding in the pelvis. Sometimes there is what is called a somato-emotional release during EPR or during the physical therapy trigger point release our patients practice. Occasionally, as people with pleasure anxiety follow our relaxation instructions and their nervous systems begins to quiet down, their heartbeat might increase, their palms begin to sweat and to their distress, they feel more anxious doing relaxation. This reaction occurs because the relaxation is challenging a default psychological defense that says it’s not safe to let down one’s guard and vigilance. With the patients motivation and proper guidance, this reaction can disappear.

Pleasure anxiety is the fear that being unguarded and not defending yourself, leaves you vulnerable and unprepared for bad things.

Here is an example of pleasure anxiety that one of our patients with pelvic pain experienced: A patient experienced the suicide of her mother at a time in her life when she was carefree and happy. The news of her mother’s death occurred suddenly and shocked her. From the time of her mother’s death she began unconsciously to tightened up physically and began walking around in her life nervous and wary. In her mind the experience of being happy and carefree was somehow connected to a terrible thing happening for which she was unprepared. This is the reason I believe she complained that she never could relax.

During therapy with a psychotherapist she noticed that as she grew older and explored her life, she seemed to feel uncomfortable feeling good for very long. She reported that invariably when she felt a sense of contentment, negative thoughts and worries about bad things that might happen in the future would come to her mind and her good mood would evaporate. She reported that she felt strangely naked during the brief moments when her pelvic pain would subside. With practice at having more and more periods of the subsidence of the pain, she learned to tolerate being un-defended during relaxation.

The core of our treatment for pelvic pain is training our patients to profoundly relax their pelvic muscles and calm down their guarded and worried nervous system to provide an environment for the sore and chronically contracted pelvic muscles to heal back to normal. You can’t relax the pelvic muscles without relaxing elsewhere in the body. In practicing EPR, you un-defend yourself; you allow yourself to be at ease and feel good; you let go of vigilance and allow yourself to feel pleasure by both by relaxing muscular guarding and by learning to release the compulsion of ongoing worry. Pleasure anxiety represents an unconscious, if not dysfunctional and unworkable existential strategy for survival. Practicing letting go of guarding both physically and mentally using the Wise-Anderson Protocol can bring you right up against the fear that being unguarded for any period of time is unsafe and to be avoided.

Slowly letting go, further and further into being unguarded for longer periods of time is the key to becoming free from the worry that being unguarded is unsafe. This takes time, intention and trust one’s teacher and the method used. The watchword of pleasure anxiety is ‘It’s not safe to feel safe.’ The result of such an attitude is that the whole body tightens up. In people who have pelvic pain, the pelvic floor is one of the central locations that remains chronically tightened and vigilant. It is loosening and releasing oneself from this guarded state, in which one is protecting oneself from the being open and relaxed in life, that the sore and irritated pelvic floor has the possibility to heal.

 

When pelvic pain goes away, the sore pelvic tissue heals

There is a large and growing body of literature documenting how emotional arousal interferes with the body’s ability to heal. Wounds are typically slower to heal in the presence of anxiety; the area of medicine called psychoneuroimmunology has much literature to show how one’s troubled psychological state negatively affects the immune system. In this talk I want to discuss the body’s healing mechanisms and how pain goes away in the case of pelvic floor related pain.

One of the Wise-Anderson Protocol’s major contributions to the field of pelvic pain treatment is the understanding that in chronic pelvic pain syndromes, the center of the body becomes sore and painful because it has been squeezed tight for a long period of time. This inner squeezing is usually an anxiety response much like a dog tightens its pelvis muscles to pull in its tail when it is threatened. In pelvic pain syndromes, the tail is chronically pulled up.

When the pelvic tissue has become chronically tight and painful, there is a primitive reflex inside the pelvis to guard against pain. It is not unlike an amoeba that sucks in if pricked with a pin to protect itself. So, when the tissue of the pelvis becomes sore and irritated, a primitive reflex occurs wherein the pelvis tightens up even more to guard against pain from this sore tissue. This reflex guarding traps and interferes with the sore pelvic tissue healing up, the way other sore tissue can easily heal up. We experience many small injuries to our bodies, where maybe we scrape ourselves or overuse muscles and they become painful, but they readily heal up because nothing interferes with their healing. When the tissue inside the pelvis becomes painful, the tissue tightens against its own soreness and interferes with its own healing.

It is helpful to talk about the phenomenon chronic pelvic pain by comparing it to what would happen if you’re walking around on a broken leg. The break in the bone would not be given a chance to heal up because what it needs for healing — namely a protected environment to allow break in the bone to heal. In the same way we need to provide an environment in which the sore pelvic tissue to heal up as sore tissue in other parts of the body need such protection.

But in the pelvis of those with chronic pelvic pain, there is a self-feeding cycle that interferes with the healing up of the sore pelvic tissue. Combined with normal activities and stresses of life (that normally don’t cause those without pelvic pain to experience any tightening or distress) like sitting or sexual activity or urination/defecation, the sore tissue of the pelvis in those with chronic pelvic pain remains unhealed. The typical life of the pelvic pain patient creates a unwitting situation in which they are continuously ‘walking on the broken leg’ of pelvic pain.

Once one has pelvic pain, the nervous system is necessarily aroused. Glomieski et al demonstrated this in the Journal Pain in 2015

Pain. 2015 Mar;156(3):547-54. doi: 10.1097/01.j.pain.0000460329.48633.ce.

Do patients with chronic pain show autonomic arousal when confronted with feared movements? An experimental investigation of the fear-avoidance model.   Glombiewski JA1, et. al

The nervous system becomes activated and the neurons that flow in the nervous system move quickly and are more reactive. It is like a car that is idling at too high of a speed. Our nervous system becomes ‘jumpy’ when we are in chronic pain. Because pain itself increases the responsiveness of the nervous system, the pelvic pain patient feels in a trap that keeps the symptoms chronic because the arousal inhibits the healing of the sore tissue. The pain and subsequent up-regulated nervous system causes one to be more reactive.

How do you turn down the nervous system activity and free up the pelvic floor from its chronically tightened, healing-inhibited state to allow it to heal? Over the past 25 years we’ve come to see that the treatment must include a physical component, a behavioral component and a psychological/mental component. There must be extended periods of time in which nervous arousal is turned down. The mind and body components are not separate from each other.

Reducing nervous arousal to heal pelvic pain

We teach our patients to regularly loosen the tissue that is in a knot. The physical component of our program includes training in the use of our internal trigger point wand, our trigger point genie, the use of hands finger as well as other methods to loosen the chronically tight tissue between the knees and the sternum. This is not a simple matter but it is doable with the right skilled instruction and regular practice. We teach patients to implement the physical loosening of the tissue using myofascial/trigger point release methodology that we’ve developed, researched, and reported on over the years.

The physical release of the tightened pelvic tissue is essential. Equally important we have found that it is not enough to resolve chronic pelvic pain. If we do only the physical part of the loosening of the tissue of the pelvic floor and we don’t address the environment that is perpetuating this irritated and painful tissue, it is like dealing with a leaky water faucet by just cleaning up the spilled water from the faucet but never finding and fixing the leak in the faucet itself. The leak in the faucet of pelvic pain is the aroused nervous system keeping the pelvic floor tight and the nervous system inhospitable to what is needed for the healing of the sore pelvis.

When you’re relaxed and you were to say to yourself “relax” relaxation is easy. If you’re relaxed you can drift off into sleep, you can let go and just enjoy music or lie in the sun, watch a movie, just let go and enjoy yourself. If you are tense, anxious, worried or in pain and you were to say to yourself, “relax”, relaxation is difficult. Drugs, alcohol, and a variety of addictive behavior are the ways in which tense human beings relax. Without substances, most people have little ability in calming down when they’re anxious and nervous.

In a way, our nervous system has a life of its own. Imagine that you are relaxed and you’re about to go to sleep and inadvertently you drink a strong cup of coffee. You well might find yourself very awake, while the caffeine circulates in your body not allowing you to calm down to be able to sleep. The typically upregulated nervous system is the dilemma of the pelvic pain patient in learning to calm down their nervous system to allow the healing of the sore tissue in the pelvic floor.

Our program is focused on both helping our patients reduce their pain by learning to loosen the pelvic tissue physically and simultaneously reducing the nervous system arousal that arises from and is perpetuated by the anxiety, worry, fear associated with the pain.

We have developed a relaxation methodology for reducing the ongoing state of nervous arousal. Learning to do this was essential to me personally, in overcoming my pelvic pain. This reduction in nervous arousal is a central aspect of what we teach in the Wise-Anderson Protocol.

Why Men Diagnosed with Prostatitis Tend to Be Intelligent, Successful, Ambitious, Conscientious, Accomplished, Type-A Worriers

Men who suffer from pelvic floor pain, whether it’s called prostatitis or pelvic floor dysfunction, tend to be intelligent, successful, ambitious, conscientious, and accomplished type-A personalities who worry. Pelvic floor dysfunction related to pelvic pain often occurs in men who work too much, care too much, want too much, desire to be appreciated, and strongly aim for success—and underlying all of that, who worry too much and have too little faith that things will turn out well.

Indeed, what we see in our practice is that men with pelvic pain tend to be intelligent, ambitious, thorough, and accomplished. Now, what do these characteristics have to do with pelvic floor pain? Underlying all these positive attributes is a worry about life—a sense of not trusting that the outcome of life will be favorable. It is my hypothesis in understanding this phenomenon, that this underlying unease leads these men to the stress response of tightening their pelvic floor. Really, they often tighten their whole body, but the focus shows up in the pelvic floor.

This highlights the larger picture of pelvic pain—like other parts of the body that bear the brunt of the stresses of life, the pelvic floor is a physical place people react to when they worry. The vernacular expression that someone is “anal” in what they do reflects an attitude of needing to get everything right and not make a mistake. This perfectionistic attitude is a way of guarding against something bad happening if you’re not very careful and not doing things correctly. There is an upside to wanting to do things right and caring about the outcome of what you do. These tendencies move men to be successful in their careers. At our clinic we often say that if we started a new business we’d want to hire many of our patients, because these men are typically very responsible, conscientious, thoughtful, creative, and intelligent.

However, there can be a downside to these tendencies, because often under this conscientiousness, care, and perfectionism is fear. Indeed, muscle-based pelvic pain is, in a certain sense, part of the physical expression of fear that leads to symptoms in a certain group of people. It’s a physiological response to the worry that somehow something bad will happen.

 

Pelvic Pain is a Squeezing in the Core of the Body

People who don’t care about outcomes, who don’t care about being conscientious, generally don’t suffer from pelvic pain. There isn’t that pressure to “do things right” and an underlying mistrust about the future and one’s safety. The physical consequence of this habitual worry is an ongoing squeezing in the core of the body, and this habitual squeezing is a big contributor to pelvic pain.

We use colloquial language to describe this chronic inner squeezing, such as gut-wrenching or a gut-response or being punched in the gut. These terms reflect a physical reaction that occurs in the sensitive inner core of the body. The “gut,” which colloquially refers to the colon, and in real life involves the pelvic floor muscles, is a Geiger counter for what’s going on in our lives. In our book A Headache in the Pelvis, we share an anecdote about doctors in the 1950’s examining army recruits with a sigmoidoscope to observe the behavior of the colon in relation to stress. When a doctor said, deliberately within earshot of the patient whose colon they were examining, “Look at that cancer,” the distressed patient’s colon would immediately go into spasm. And when the doctor said, “We were just doing an experiment to see the response of your gut to this kind of news,” the gut spasm reversed. Our gut is instantly responsive to things that frighten or stress us. Many people who have pelvic floor pain also suffer from irritable bowel syndrome, which used to be called a “spastic colon.” The gut and pelvic floor are not in separate rooms, and typically respond together to fear or stress.

In addition to all these tendencies, a person with pelvic pain tends to feel things deeply, even if outwardly this sensitivity is not obvious. There’s a Stephen Sondheim song that says “Children may not obey but children will listen,” meaning that though you might not see the effect of what you’re saying on your children (or really on any individual), they nonetheless hear it. The “listening” can happen deep inside—the inner core of a pelvic-pain patient deeply hears the stresses of life.

I know this subject well because I myself suffered with pelvic pain for a long time, until recovered after I spending several years undertaking a rudimentary version of the protocol we teach our patients. In my view, the answer to being someone with pelvic pain who inwardly is sensitive, caring, and easily responsive to the slings and arrows of life is to regularly practice a method for relaxing the inner core and releasing it from ongoing, irritated contraction.

The solution we offer to the sensitive person suffering from chronic pelvic pain is both physical and mental. We teach our patients to physically release the trigger points and muscle constrictions inside the pelvic floor and, mentally/behaviorally, to practice our relaxation method called Extended Paradoxical Relaxation, whose aim is to regularly bring sore pelvic tissue into a healing environment. In patients we treat whose pelvic pain significantly reduces or even resolves entirely, the ongoing practice of Extended Paradoxical Relaxation is necessary to allow the pelvis to remain relaxed and pain-free in the midst of often-stressful lives. While I don’t have pelvic pain anymore, I practice Extended Paradoxical Relaxation daily and love doing it. If I did not manage my type A personality and tendency toward anxiety by doing this, I think I very well might become symptomatic again.

In our view, the management and resolution of pelvic pain is both physical and mental and has to do with changing one’s way of dealing with a body and mind that tends to be sensitive and to turn anxiety into physical symptoms. In my view, only through daily practice of methods that releases the automatic, frightened physical guarding and tightening, can the pelvis have a real chance to heal and remain pain-free.

 

Different names for pelvic pain are given to describe the same problem

There’s an ancient parable about ten blind men who come upon an elephant. One touches the elephant’s leg and says, “Oh, this is a tree trunk.” Another finds himself under the elephant’s stomach,Prostatitis pushes up and says, “No, this is a soft ceiling.” A third one pulls the elephant’s tail and says, “You’re both wrong; it’s a rope connected to a tree.” All the others report their own perceptions and conclusions, all completely different. Of course all of them were right, but they were also wrong; they all came to different conclusions because each of them had limited information. No one saw the whole elephant.

Similarly, there’s a wide range of misunderstanding about chronic pelvic pain, for both patients and the doctors who treat them.

With the benefit of our 25 years treating several thousand pelvic pain sufferers, we’ve gained fundamental insights into this condition. One of the major insights which I will discuss here, is that whether someone has pelvic pain — whether it is sitting pain, rectal pain, genital pain, pain above the pubic bone, urinary frequency and urgency, pain with sex, pain on one side of the pelvis, both sides or pain in the middle, whether the pain moves from one place to another and other symptoms, the common thread for all of these symptoms is a sore and knotted up pelvis. Skillfully press inside and outside the pelvic floor of the pelvic pain sufferer and you will find pain that does not exist with someone who does not have pelvic pain. The sore, knotted up pelvis and its related trigger points are what need to be addressed for the possibility of the pain going away (wherever it is felt) and the symptoms resolving.

Let me explain it this way. Imagine 100 people holding one of their hands in a fist for a month with no break. Your hand would be painful if you did this. It would not be surprising if some of this group of 100 developed pain in the thumb, some of this group developed pain in the little finger, and others in the palm or the forearm….. Apparently different symptoms of pain location but same cause… which is a hand that has been held in a fist for a long time.

You wouldn’t fundamentally treat this problem of a sore hand differently if someone had a sore thumb or sore pinkie. Yes you may work with the thumb or the pinkie locally to loosen and relieve their particular tissue contraction and pain, but the most important treatment would be to unclench the fist and attend to the sore hand to restore its relaxation and ease whether the soreness is felt in the finger or the thumb.

So it is with the varied and seemingly unrelated symptoms of pelvic floor pain. Whether someone has urinary frequency or urgency, pain with sitting, perineal pain, pain with sex, pain after a bowel movement, or pain during or after urination, pain on one side or another or in the middle—all of these apparently different symptoms originate from a chronically tightened pelvic floor and then perpetuated from the pain, anxiety and guarding that follows. The different pelvic symptoms typically are related to the locations of trigger points that form in the pelvis when the pelvis is held tight for a long period of time. Urinary frequency might be thought of as a painful thumb in the clenched fist metaphor while pain with sitting or with sex might be thought of as pain in the little finger.

We have found that specific trigger points within the pelvic floor are related to specific symptoms. We originally published these findings in 2009, in the Journal of Urology ( J Urol. 2009 Dec;182(6):2753-8. doi: 10.1016/j.juro.2009.08.033. Epub 2009 Oct 17.)

Different names, same condition

It turns out that various medical specialists treat the same condition of a chronically clenched pelvis, but they give this condition different names, based on the specific symptoms I have just listed. For example, gastroenterologists and colorectal surgeons typically treat patients with posterior (or rear) pelvic pain symptoms such as ano-rectal pain, post-bowel-movement pain, tailbone pain, and anal fissures. Urologists treat patients with anterior (or front) symptoms, including urinary frequency and urgency, genital pain, testicular pain, painful sex, sexual dysfunction, gynecologists treat genital pain and pain with sex, and so on.

Again, my point here is that whether one is having genital pain and urinary frequency or tailbone and ano-rectal pain, these symptoms all derive from a chronically tightened pelvis. The only difference in these symptoms is where the pain is felt and the specific trigger points that are related to the symptoms.

All the different names for pelvic pain—prostatitis/CPPS, chronic pelvic pain syndrome, pelvic floor dysfunction, dyspareunia, levator ani syndrome, pudendal neuralgia, anal fissures, and chronic proctalgia—are essentially the same condition, even though they’re treated by different specialists and often given different names. This is confusing to the patient and I think it is also confusing to many doctors.

What is of interest is that different symptoms tend to be related to the location of the trigger points are found in different specific locations inside and outside the pelvis.

In other words, whether someone has anterior or front symptoms, posterior or back symptoms, or both, their condition has produced trigger points in related anterior, posterior or anterior and posterior locations. This is an important fact for our therapist clinically locating the offending trigger points and drawing a map of the trigger points a patient must work with and release with our internal trigger point wand and trigger point genie. While the symptoms may make it seem like the patient suffering from sitting pain has a different problem than the patient suffering from urinary frequency/urgency, the problem is the same and the treatment for both of these symptom complexes is essentially the same.

Pelvic pain is invisible and the best diagnostic tool is an educated finger

It’s difficult for most medical professionals to detect the cause of pelvic pain because there’s no objective test for it. It doesn’t show up in X-rays or MRIs. The way we make the diagnosis of pelvic floor related pain we treat, is for a skilled specialist to palpate the tissue inside and outside the pelvic floor. We make the diagnosis of pelvic floor related pain when we discover trigger points and areas of restriction upon palpation in and around the pelvic floor. We typically recreate or intensify a patients symptoms when we press in certain areas, and we consider it diagnostic when we are able to recreate or intensify someone’s pelvic pain symptoms upon palpation.

In a paper we published in the Gold journal of Urology, we explain that pelvic floor pain is in fact a psycho-neuromuscular disorder.

(https://www.goldjournal.net/article/S0090-4295(18)30775-1/pdf)

 

Given that it’s the same disorder, whether symptoms are experienced in the front or back or both, the diagnostic terms used for these symptoms by different doctors can be confusing because the healing pelvic painirritated, hypertonic pelvis can create the same variety of different symptoms. These symptoms are:

  • Genital pain in men and women, or testicular pain in men
  • Urinary frequency and/or urgency, urinary hesitancy, post-urinary dribbling, waking up at night to go to the bathroom, or painful urination
  • suprapubic pain
  • Painful intercourse, or post-orgasm pain
  • Anal sphincter pain
  • Posterior perineal pain
  • Anal fissures
  • Pain with sitting
  • tailbone pain
  • low back pain

The wide variety of symptoms people complain about, and the different diagnoses given to these symptoms when the cause of the symptoms is the same, is why we named our book, “A Headache in the Pelvis.” The Wise-Anderson Protocol we first worked with at Stanford for treating pelvic floor pain and dysfunction is what we use whether the symptoms are felt in the front of the pelvis, the back of the pelvis or both. .

Why drugs don’t cure pelvic floor pain

I’d like to talk about the opioid epidemic that has been in the news the past several years in relationship to the inside job of healing pelvic pain that is outside the reach of all drugs. In recent years, there is what is now called an opioid epidemic has been in the news. Opioid addiction has often begun with the legal prescription of opioids, often after surgery or some procedure. Some group of patients using opioids in this context continued to use them and subsequently became addicted. When I discuss opioids here, I am also including the use of benzodiazepines, like Valium, Xanex, Ativan and clonapin that are used for pain and, like opioids, are also addicting with ongoing use.

There are many people with chronic pelvic pain who have become addicted to opioids and benzodiazepines. These pain medications were probably the only way many doctors felt they had to help these patients with their pain. As we have discovered in our clinical practice with patients who have become dependent on opioids and benzodiazepines, these drugs can work well in the beginning and then progressively diminish in their ability to reduce pain. Also, the pain threshold drops so what didn’t hurt before, hurts with continual opioid use.

The benzodiazepines, we have seen, can be used skillfully to periodically help with pelvic pain when not used regularly, which then helps avoid addiction.   When used occasionally in this way, the benzodiazepines can help someone over the hump of certain flare-ups while not causing addiction. With continued and regular use of opioids or benzodiazepines, however, a higher dosage typically has to be used, to achieve the initial levels of pain relief. After continued regular use, the effectiveness of opioids diminishes in helping pain.

 

Opioid were primarily used in the past to treat terminal, end-of-life pain. Then, for reasons that are beyond the scope of this discussion, these drugs more and more were prescribed for patients who had chronic, non-end-of-life pain. Our society has painfully learned, that the benefit of pain reduction with the regular use opioids and benzodiazepines comes with what could be called a back-end price… namely after extended, continual use, patients both suffer from addiction to the drug, and a diminishing ability of the drug to help their pain. And then there is the issue of opioid deaths. In 2017 a staggering 47000 overdose deaths were recorded in the United States. I doubt any of this.

It is certainly possible to withdraw from opioid use but it isn’t easy or pleasant. Withdrawal from opioids is a major challenge if the opioids have been used for a long time to deal with chronic pelvic pain. Even if there were no issues of pain, opioid withdrawal is difficult. Significantly, added to the issues of withdrawal, the patient taking opioids suffering from chronic pelvic pain has to deal with the huge challenge of how to deal with their chronic pelvic pain if the opioid is taken away. It is not a small problem when you finally try to stop taking the opioids and you have nothing to help you with the pain.

The Wise-Anderson Protocol for pelvic pain is a non-drug method to stop the pain. In 2015, we published a medical article in which we showed that after 6 months of consistently practicing the Wise-Anderson Protocol, 1/3 of our patients, who had been using different kinds of medications, including some with a current or prior history of using narcotics, had stopped the use of all medication.

Our protocol can help reduce or stop the chronic pelvic pain without drugs because it is aimed at eliminating the cause of the problem.

To be clear, our protocol is based on the understanding that the cause of chronic pelvic pain is sore pelvic floor tissue which continues to be irritated by protective muscle guarding and the irritation of nervous arousal. This protective guarding is a reflex to tighten inside the pelvic floor, whose purpose is to protect against anxiety, but in fact the protective guarding exacerbates it. The normal stresses and functions of life also add to the tissue irritation of the painful pelvic tightening. Our focus is to provide a method to heal this sore tissue by providing a healing environment through the core methods we train our patients in. These include a physical method as well as a behavioral method to calm down the aroused nervous system that aggravates the painful pelvis and interferes with the healing of the sore tissue of pelvic floor.

When someone is taking narcotics or benzodiazepines or other drugs, we advise them to not consider going off of their medications, which we ask patients to get medical help with, until they begin to reduce their pain with our method. It is not uncommon for patients to regularly practice our method for months before they feel comfortable in reducing their medications.

With or without the opioid epidemic, we have found that there are no effective drugs for resolving pelvic pain. Resolving the symptoms of pelvic pain is an inside job of healing the sore, tightened tissue of the pelvic floor. This is something one must do oneself, for oneself. We know of no drugs that are able to do this. Opioids and benzodiazepines can temporarily reduce the pain but does little to the underlying cause of the pain. The Wise-Anderson Protocol is designed to give patients the tools that can allow the possibility of carrying out the inside job of healing a sore and tightened inner core.

 

The healing of pelvic floor pain is easy to understand

Pelvic pain is invisible. It can’t be seen, it can’t be visualized with fancy technologies, there are no fluid tests for it; it’s a difficult phenomenon to understand if you’ve never had it. I want to use a metaphor here that I’m hoping is easy to understand, to understand the less easily understood phenomenon of muscle-based pelvic pain.

 

The metaphor of the sore arm

Imagine that you’ve had an accident and you’ve fallen down on your side and as a reflex you put your arm out to protect yourself. You certainly survive, everything is basically ok and nothing is broken, but your hand and wrist hurt and your shoulder has a big bump on it and is very painful. Your whole arm is sore and you’re miserable. You go to the doctor, who says that you’re fine, just take care of it, let it rest and it will heal up. Its all intuitive, it all makes sense.

 

Healing the sore arm

So, the doctor suggests that to help things heal faster and for you to be more comfortable, you put your arm in a sling. In the sling your arm can relax and will be protected from movement and the bumps and grinds of life. It isn’t hard to understand that if your arm gets bumped, it will hurt.   When you see your affectionate aunt who wants to hug you, you say, “Wait,” and you give her a peck on the cheek and tell her you hurt your arm and she shouldn’t grab you and squeeze you like she usually does. You don’t want her to irritate your arm’s healing.

 

Protective guarding and the sore arm

Drawing away from what might hurt your arm is a reflex; you want to protect your arm against what might jar it because you know it will hurt if something does bump against it and irritate what is already sore and irritated. You go around with pain in your wrist and arm and shoulder feeling vulnerable. You notice you protectively guard your arm and shoulder, especially in public, during this period while they are healing up. Guarding means tightening up, tensing it up, being on alert for anything that might hurt it.

 

You notice that if you put it in a certain position or inadvertently bump it against something, you tighten up. In other words, any increased pain makes you tighten up to protect your arm. Let’s call this protective guarding; you guard to protect. This means the muscles tighten up to protect and this is instinctive. You notice you are doing this self-protective guarding without even being conscious of it, it just happens out of awareness. It’s just a reflex of the body to protect itself from being hurt more, when a certain part of the body has been injured or hurt.

 

If you keep it protected over time, it heals. If you don’t protect it, it likely will continue to hurt. If you do take care of it, you stop being so guarded, and eventually you forget about it and you go back to the way you’ve been in the world, not thinking about your shoulder, not tightening it up, not protecting it, not pulling it away from what might hurt it. So the sore arm and shoulder that got hurt, then got better.

 

Comparing the painful pelvis to the sore arm

Now I want to talk about a situation in which the pelvis hurts and is sore, irritated, and increases in pain when you do certain things that are just normal, everyday activities that everyone does. For some people with muscle-based pelvic pain, sitting down hurts. Other people aggravate the pain in the pelvis when they have a bowel movement. Or conversely, sometimes a bowel movement helps. Sometimes urination makes it feel better, sometimes it makes it feel worse. Or when trigger points, which we have extensively discussed elsewhere are in a certain location, for some people orgasm can irritate pelvic pain and make it feel worse. Stresses in life and anxiety can make the pelvis hurt a lot more. Again, all of these things we have explained elsewhere. But these are things that are not a the normal kind of bump, like the bump against your sore shoulder or arm. There are these other things in life that flare up pain in a sore pelvis but they are distressing because they don’t seem to make sense and don’t feel normal.

 

Unlike a shoulder and wrist that were injured when you fell on them, then healed when you rested and took care of them, chronic pelvic pain most simply called pelvic floor dysfunction doesn’t heal up. Why?

 

The relationship between protective guarding in the sore pelvic and the sore arm

In the pelvis something different occurs in response to pain that doesn’t seem to occur in other parts of the body quite like it does in the pelvis. What occurs in the pelvis, different from what occurs in the sore arm, is an instinctive, very sensitive reflexive tightening against anything that feels strange or uncomfortable. This is what I refer to as the reflex-guarding of the pelvic tissue against its own sensation of pain. In other words, when you tighten up the pelvis when you’re anxious, and it stays tight for a long period of time and the muscles become sore, that sore irritated tissue in the pelvis tightens up protectively as a defense against its own pain. It’s not a very good design. Where the instinct to protect a sore arm and shoulder helps healing and is protective, I’ve often thought the reflex guarding of the pelvis against soreness generated by its own chronic tightening is a kind of flaw in the human design because the guarding against the pain makes it worse.

 

Physical bumps cause protective guarding in the arm; anxiety and an aroused nervous system ‘bumps’ the sore pelvis

So, either through chronic anxiety and worry (which again, we have discussed elsewhere) or through injury, the tissue of the pelvis involves the tightening up of certain kinds of muscles and parts of the pelvic floor. It involves a tightening up of the muscles around the genitals and anus, often including the internal pelvic floor muscles called the piriformis, the obturator internus, the levator ani muscles, the coccygeal, levator ani, puborectalis and related internal muscles. The muscles of the lower abdomen are often also involved including the rectus abdominus, and suprapubic muscles. Other muscles including the quadratus lumborum, the iliacus, the psoas get into the act. Many of these muscles can tighten up in concert and remain tight and can feed into the internal muscle hypertonicity and pain. In our experience, when you have pelvic pain all of these muscles have to be dealt with when they are part of the ‘fist’ of muscles that has chronically tightened up if you want to heal the sore pelvis. These muscles tighten up and become painful. They often refer pain and sensation back inside the pelvis and are all part of a complex of tightening and protective guarding against the pain in the pelvis.

 

 

Unlike the arm, pelvic pain and protective guarding is strongly provoked and perpetuated by anxiety and the arousal of your nervous system. Anxiety and nervous arousal that irritate, perpetuate and increases pelvic pain are equivalent to ‘bumping the arm’ when the pelvic floor muscles are irritated and tight, except you don’t even have to move or be bumped to have the pain in the pelvis exacerbated by anxiety. Anxiety and nervous arousal are themselves the bump. While anxiety and nervous arousal may slightly increase the discomfort of a sore arm or shoulder, anxiety and nervous arousal strongly increase the pain, protective guarding and tightening in the pelvis. And people who chronic pelvic pain often catastrophize and worry constantly. The relationship between anxiety and pelvic pain is not at first intuitively obvious.

 

One way to understand pelvic pain is to look at, for instance, a frightened dog who pulls its tail in. The pelvic floor tightens up in a dog to pull the tail in. Similarly, when a certain group people are chronically anxious, their ‘tail’ pulls in.

 

Pelvis pain can be seen as a condition of a tail chronically pulled between the legs

In the case of a human being, pulling the tail in means the tailbone is pulled forward when the pelvic floor tightens. The arm heals relatively quickly when more or less left alone. What is important to understand is that pelvic floor muscles don’t get a chance to heal up because they are continually irritated and held in a guarded, tense and protected state, by all kinds of activities that are just normal activities of life; activities like defecation, urination, sexual activity, sitting, the normal stresses of life, and sometimes even certain kinds of physical activities. Intimately involved, in addition to the activities of life, the formation of knots inside the muscles called trigger points. These knots form and remain irritated and perpetuating pain until they release and go away. Once formed however, for the most part, they stick around unless they’re specifically treated to release.

 

The self feeding cycle of protective muscle guarding and a sore pelvis

So, you have a whole series of factors that bear down on the poor, painful pelvis and stop the painful tissue from healing. What needs to heal is not serious or pathological. But it is sore and painful. In our book at A Headache in the Pelvis and in our other writings, we have talked about the self-perpetuating pelvic pain cycle; a cycle that once it gets going, takes on a life of its own. Sore pelvic tissue triggers its own tightening and protective guarding, which triggers more pain, which triggers anxiety and worry about whether it will ever go away, which is variously aggravated by going to the bathroom, not being able to sleep through the night, sitting down, sex and the stresses of life. These stresses represent an onslaught of perpetuating factors that keep pelvic pain going and give it a life of its own.

 

When you have pelvic pain, like I did for over 20 years, there’s not a lot more to do sometimes than to try and figure this out, and I don’t think that most people don’t figure it out. How you deal with pelvic pain is daunting. If you search the internet, and look at the research on it, there are a lot of ideas about what pelvic pain is how you treat it. But most of what I read on the internet is off the mark. Pelvic floor pain i hard to understand if you have never had it and watched the process of it resolving.

 

Temporarily loosening the sore pelvic contraction vs. healing the sore pelvic contraction

Our protocol was formed by my own experience in conjunction with the remarkable expertise of the folks I work. We have developed a careful, skillful program to physically loosen the tightened tissue in the pelvis. But, as we have said in our book and in a number of podcasts, physical therapy (though we are pioneers in using it and are strong proponents of necessity teaching patients how to self-treat all aspects of it) is a temporary fix for pelvic pain. Unless the tissue is healed to a state of normal tissue like the sore arm or shoulder, even if its loosened in one moment, and the pain is temporarily absent, the tissue s ready to be aggravated, irritated and tightened up again in the next moment by the activities and stresses of life.

 

Putting a sore arm in a ‘sling’ to help it heal; putting the sore pelvis in a sling to help it heal

That is why I suggest here that, like the sore arm, the pelvis needs to be put into a kind of ‘sling’ to prevent aggravation and irritation and allow the healing mechanisms of the body to heal the tissue. Unless you do that, temporarily loosening the tissue through physical therapy and other physical methods, is a temporary (though critical and necessary) intervention and usually not sufficient to heal the pelvic floor. We’ve come to see that the physical loosening of the sore pelvis has to be done repetitively and as we’ve learned, it is best done by the person with pelvic pain themselves. If you have pelvic pain, you really need to learn how to do the loosening yourself.

 

Extended Paradoxical Relaxation is the ‘Sling’ that Allows Tissue of the Pelvis to Heal

 

We teach our patients how to loosen all of this tissue (from the knees to the sternum) themselves physically, and then we teach them how to put this loosened, relaxed tissue into a sort of ‘sling’ to allow its healing.

 

What does it mean to put the pelvis in a sling? It means resting the pelvis in a way wherein it is not being assaulted by anything that tightens it up, so that the mechanisms of the body can heal it and allow it to operate it and work the way it is meant to. In our protocol, the ‘sling’ for the pelvis is called Extended Paradoxical Relaxation. I have written a book about this method and we talk about it extensively in A Headache in the Pelvis.

 

The method we train our patients to do is basically a method to askes us to say to all the stresses that interfere with the healing of the pelvic floor, “Stay out of the room and leave me alone for now. Let me rest.” It’s a method of allowing the pelvic floor to be quiet and be free of the stresses that irritate it and interfere with its healing. Extended Paradoxical Relaxation requires daily practice and we ask our patients to do both the physical loosening and the relaxation components together for at least 2 hours a day. This is a big thing to ask of anyone but most of the people who agree to do this do it because they feel the possibility of their condition healing up. When you suffer from \ pelvic pain for a long time, you often reach a point (as I did) where you say “If I have to go to Mongolia and eat cow dung, tell me when the next plane is.” When you are suffering from pelvic pain that doesn’t heal, it becomes the bane of your existence and you become willing to do whatever it takes to get it to go away.

 

Healing a sore pelvis requires an inner environment in which it can heal

Pelvic pain is peculiar in that we have to deal with the reflex that tightens the pelvis in response to the slightest amount of pain. Many different factors have caused the pelvis to tighten and hurt, and the normal stresses of life trigger the reflex guarding of the sore pelvis which keeps it in pain and not able to heal the way a sore arm will when it’s put in a protected healing environment. I hope that this metaphor is helpful. Like a sore shoulder, you need to provide an environment in which the body can heal itself and return itself to normal. The ‘sling’ for pelvic pain that allows this healing is just a bit different from that of a sore arm and wrist. The sling involves regular physical loosening , inner quiet, and a psycho physical internal environment free from the bumps of everyday life.

 

 

 

 

Why all physical treatment for pelvic pain is not the same

The word commodity comes originally from the Latin commodus meaning ‘a useful or valuable thing’. By the early 15th century commodity was being used in English to refer to “an article of merchandise, anything movable of value that can be bought or sold.” Implicit in this definition is that a commodity is the same anywhere it is found. A commodity is something of value that is the same everywhere. It is like a package of M&Ms: if you buy a package of M&Ms in New York, or San Francisco or Hong Kong, the M&Ms will taste the same. M&Ms are the same everywhere and you can expect and count on that same flavor, shape, quality, size, no matter where they are bought. Similarly, in medicine, some procedures and treatments have been standardized and could be called commodities.

In the world of pelvic pain, only in the last 10-20 years, some physicians treating patients with pelvic pain refer them to physical therapists. I believe these physicians assume that physical therapy for pelvic pain is a commodity…. the same everywhere and any physical therapist will be able to treat the pelvic pain patient in some standardized and successful manner.

In our experience of treating many patients with pelvic pain and hearing their reports , this is simply not so. There is a very wide variety of what is done in the name of physical therapy in the treatment for pelvic pain. There is no standardize physical therapy for pelvic pain. In fact there are a number of treatments done in the world of physical therapy that our patients undergone. Those treatments that were not successful tended not include trigger point therapy. The point here is that physical therapy for pelvic pain is not standardized from therapist to therapist.

We are very specific in terms of what physical therapy for pelvic pain is therapeutic and offers the best chance of helping pelvic pain. In our experience, a physical therapy treatment for pelvic pain in which both myofascial release and trigger point release is done, is the most effective treatment. In another essay, I have discussed the difference between myofascial release and trigger point release and the necessity of doing both. We propose that external as well as internal myofascial trigger point release should be done. In our book we discuss why pelvic floor biofeedback, pilates or kegel exercises are not helpful, nor have we found much use in electrical stimulation either inside or outside of the pelvis.

 

Self-Treatment vs. Treatment by Others

Then there is the subject of self-treatment vs. treatment from a therapist or physician. Over the years, for a number of reasons, we have come to see that self-treatment (externally and internally) in the treatment of muscle based pelvic pain, is far superior and effective in offering the possibility of reduction or resolution of this kind of pelvic pain.

We are strong advocates of teaching our patients how to do their own trigger point release to become their own best therapist. They learn what is going on in their body and tissue, they learn how hard to press and how to locate trigger points easily and certainly they can do treatment far more frequently and conveniently than one could do it if having to go to a physical therapist for treatment. Being able to treat oneself allows for trigger point release to be done more often, at the exact time/location that is most convenient for the person, and after being trained in self-treatment with the proper tools, without the need to travel to and from a physical therapist’s office with the advantage of not cost for a self-treatment.  Physical therapy treatment can be hugely important in conjunction with and in supervising self treatment. 

The Internal Trigger Point Wand

 

The Wise-Anderson Protocol developed the only FDA approved Internal Trigger Point Wand that has been vetted through a rigorous clinical trial for safety and efficacy. But just like a Stradivarius violin, unless you know how to play it, it doesn’t matter if it’s the greatest violin in the world or not. In the same way, if you have the greatest tool for doing trigger point release unless you know how to use it, its not going to help you which is why the focus of our treatment is in the careful training and supervision of our patients doing internal and external physical therapy self treatment.

 

The Issue Of How Hard And Long To Press And How To Find The Trigger Points

 

A number of years ago we articulated what we call the Wise-Anderson Pressure Principle which has to do with how much pressure one should exert on a trigger point. If one exerts too much pressure and there is jumping-out-of-your-skin pain, the whole area can tighten up protectively and cancel anything therapeutic you are trying to accomplish. It is like putting on the gas and the brake pedal at the same time. Too vigorous pressure can actually aggravate the situation. We don’t believe in doing trigger point release that simply flares up symptoms. Of course, there are times where one will be sore after trigger point release and even stay sore for a day or so, but the whole point of doing trigger point release is to loosen the tissue and not cause it to protectively guard. The idea of no pain, no gain does not apply to trigger point release. The idea that if some is good, more is better is the wrong idea with trigger point release.

 

Our Internal Trigger Point Wand is the only device I know of that can measure pressure exerted on trigger points internally. It is very important for the user to be able to have a sense of pressure objectively so that they can pair their internal pressure and the sensation of the pressure on trigger points, and an objective measure.

 

Physical therapists cannot objectively measure the pressure they exert on trigger points internally (and externally) unless they use an algometer, of which none to my knowledge, other than on our device, currently exists in conventional pelvic floor trigger point release. We have had many patients complain that before they came to see us, physical therapy was tortuous, painful, and ultimately unhelpful. It is my guess that especially less experienced physical therapists overdo the amount of pressure they exert on trigger points internally because they want to have an impact on someone’s symptoms. They do not understand that the process of deactivating trigger points is a long one and pressure internally needs to be carefully and sensitively applied so as not to flare up someone’s symptoms unduly. Working internally requires an especially sensitive and delicate hand. Again, if too much pressure is used, symptoms can flare up and the pelvic floor can reflexively tighten up, detracting from instead of promoting the healing of the sore tissue. Internally trigger point release is an art and requires an extensive knowledge of trigger point behavior, of the appropriate pressure to be exerted especially inside and importantly, an understanding of the slow arc of improvement that occurs when a sore pelvic heals. Additionally, as I discuss, trigger point release done skillfully must be paired with regular time for the tissue to recover and heal. And in our view this is all best done by the patient him/herself.

Trigger Point Genie

 

In the last number of years, we have developed and are now using a remarkable tool for external trigger point release called the trigger point Genie. You can find more information about this device at www.triggerpointgenie.com. The trigger point Genie allows someone to comfortably, on a soft surface to perform external trigger point release on almost every part of the body, including the gluteal muscles, TFL muscles, iliotibial band, the adductors on the inside of the thigh, the abdominals, the quadratus lumborum, the rectus abdominus and other places that are implicated in pelvic floor dysfunction. The trigger point Genie, along with the Internal Trigger Point Wand, gives a patient the freedom to treat themselves and to seek out professional help when they need consultation in their self-treatment.

To summarize, physical therapy for pelvic pain is not a commodity. All physical therapy done for pelvic pain is not the same. In our view one way of doing pelvic pain physical therapy can offer little help, can flare up symptoms, or can move the pelvic pain patient in the direction of healing and resolution of symptoms.

In our protocol we have seen people for whom therapists have not been able to even locate trigger points, then we have examined them and found a treasure trove of trigger points. There have also been many people who have just been flared up by physical therapy and had no release of tension or pain prior to doing our protocol, but once they have learned to do their own therapy it has opened the door to their own healing.

Finally, when physical therapy for pelvic pain is done without a dedicated program to reduce anxiety and nervous arousal, in our view the likelihood of real resolution of symptoms is remote. Physical therapy does not offer a permanent rehabilitation of the sore pelvis. The pelvic tissue that is painful and chronically tightened, is human tissue that needs time to heal after it is released and an environment in which it is not tightened in the way that got it in trouble in the first place. Physical therapy is a temporary release of the tissue that can easily return to its pre-treatment state upon leaving the therapists office and getting into traffic.

Being able to do external and internal physical therapy in the comfort of your own home and then putting the pelvis in the healing mode of a long relaxation session to allow the released tissue to recover and rest, in our view is critically important. We have had patients who drove 5 hours to a physical therapist for pelvic floor physical therapy and then found their symptoms flaring back up and whatever therapeutic effect of the physical therapy being undone by having to get into a car and drive back 5 hours. Pelvic floor related pain is essentially a stress related condition that comes about in the body as the result of dealing with the stresses of life. Healing a painful pelvis is an inside job. In our view, when someone has pelvic pain, they must regularly loosen and release the sore pelvis physically, regularly lower anxiety and the arousal of the nervous system in order to have a chance for the sore pelvis to heal and the pain and symptoms to go away.

 

I hope this discussion about the physical treatment of pelvic pain is helpful

When pelvic pain goes away, the sore pelvic tissue heals

There is a large and growing body of literature documenting how emotional arousal interferes with the body’s ability to heal. Wounds are typically slower to heal in the presence of anxiety; the area of medicine called psychoneuroimmunology has much literature to show how one’s troubled psychological state negatively affects the immune system. In this talk I want to discuss the body’s healing mechanisms and how pain goes away in the case of pelvic floor related pain.

One of the Wise-Anderson Protocol’s major contributions to the field of pelvic pain treatment is the understanding that in chronic pelvic pain syndromes, the center of the body becomes sore and painful because it has been squeezed tight for a long period of time. This inner squeezing is usually an anxiety response much like a dog tightens its pelvis muscles to pull in its tail when it is threatened. In pelvic pain syndromes, the tail is chronically pulled up.

When the pelvic tissue has become chronically tight and painful, there is a primitive reflex inside the pelvis to guard against pain. It is not unlike an amoeba that sucks in if pricked with a pin to protect itself. So, when the tissue of the pelvis becomes sore and irritated, a primitive reflex occurs wherein the pelvis tightens up even more to guard against pain from this sore tissue. This reflex guarding traps and interferes with the sore pelvic tissue healing up, the way other sore tissue can easily heal up. We experience many small injuries to our bodies, where maybe we scrape ourselves or overuse muscles and they become painful, but they readily heal up because nothing interferes with their healing. When the tissue inside the pelvis becomes painful, the tissue tightens against its own soreness and interferes with its own healing.

It is helpful to talk about the phenomenon chronic pelvic pain by comparing it to what would happen if you’re walking around on a broken leg. The break in the bone would not be given a chance to heal up because what it needs for healing — namely a protected environment to allow break in the bone to heal. In the same way we need to provide an environment in which the sore pelvic tissue to heal up as sore tissue in other parts of the body need such protection.

But in the pelvis of those with chronic pelvic pain, there is a self-feeding cycle that interferes with the healing up of the sore pelvic tissue. Combined with normal activities and stresses of life (that normally don’t cause those without pelvic pain to experience any tightening or distress) like sitting or sexual activity or urination/defecation, the sore tissue of the pelvis in those with chronic pelvic pain remains unhealed. The typical life of the pelvic pain patient creates a unwitting situation in which they are continuously ‘walking on the broken leg’ of pelvic pain.

Once one has pelvic pain, the nervous system is necessarily aroused. Glomieski et al demonstrated this in the Journal Pain in 2015

Pain. 2015 Mar;156(3):547-54. doi: 10.1097/01.j.pain.0000460329.48633.ce.

Do patients with chronic pain show autonomic arousal when confronted with feared movements? An experimental investigation of the fear-avoidance model.   Glombiewski JA1, et. al

The nervous system becomes activated and the neurons that flow in the nervous system move quickly and are more reactive. It is like a car that is idling at too high of a speed. Our nervous system becomes ‘jumpy’ when we are in chronic pain. Because pain itself increases the responsiveness of the nervous system, the pelvic pain patient feels in a trap that keeps the symptoms chronic because the arousal inhibits the healing of the sore tissue. The pain and subsequent up-regulated nervous system causes one to be more reactive.

How do you turn down the nervous system activity and free up the pelvic floor from its chronically tightened, healing-inhibited state to allow it to heal? Over the past 25 years we’ve come to see that the treatment must include a physical component, a behavioral component and a psychological/mental component. There must be extended periods of time in which nervous arousal is turned down. The mind and body components are not separate from each other.

Reducing nervous arousal to heal pelvic pain

We teach our patients to regularly loosen the tissue that is in a knot. The physical component of our program includes training in the use of our internal trigger point wand, our trigger point genie, the use of hands finger as well as other methods to loosen the chronically tight tissue between the knees and the sternum. This is not a simple matter but it is doable with the right skilled instruction and regular practice. We teach patients to implement the physical loosening of the tissue using myofascial/trigger point release methodology that we’ve developed, researched, and reported on over the years.

The physical release of the tightened pelvic tissue is essential. Equally important we have found that it is not enough to resolve chronic pelvic pain. If we do only the physical part of the loosening of the tissue of the pelvic floor and we don’t address the environment that is perpetuating this irritated and painful tissue, it is like dealing with a leaky water faucet by just cleaning up the spilled water from the faucet but never finding and fixing the leak in the faucet itself. The leak in the faucet of pelvic pain is the aroused nervous system keeping the pelvic floor tight and the nervous system inhospitable to what is needed for the healing of the sore pelvis.

When you’re relaxed and you were to say to yourself “relax” relaxation is easy. If you’re relaxed you can drift off into sleep, you can let go and just enjoy music or lie in the sun, watch a movie, just let go and enjoy yourself. If you are tense, anxious, worried or in pain and you were to say to yourself, “relax”, relaxation is difficult. Drugs, alcohol, and a variety of addictive behavior are the ways in which tense human beings relax. Without substances, most people have little ability in calming down when they’re anxious and nervous.

In a way, our nervous system has a life of its own. Imagine that you are relaxed and you’re about to go to sleep and inadvertently you drink a strong cup of coffee. You well might find yourself very awake, while the caffeine circulates in your body not allowing you to calm down to be able to sleep. The typically upregulated nervous system is the dilemma of the pelvic pain patient in learning to calm down their nervous system to allow the healing of the sore tissue in the pelvic floor.

Our program is focused on both helping our patients reduce their pain by learning to loosen the pelvic tissue physically and simultaneously reducing the nervous system arousal that arises from and is perpetuated by the anxiety, worry, fear associated with the pain.

We have developed a relaxation methodology for reducing the ongoing state of nervous arousal. Learning to do this was essential to me personally, in overcoming my pelvic pain. This reduction in nervous arousal is a central aspect of what we teach in the Wise-Anderson Protocol.

MUSCLE SORENESS/TENSION AND URINARY FREQUENCY AND URGENCY

In our experience, and that reported by other centers and physicians who have worked in this field, it is quite common for both men and women who develop a chronic pelvic pain condition also exhibit urinary dysfunction.  Urinary frequency and urgency is one of the most common symptoms of patients who come to our 6 day immersion clinics. It has been well reported that approximately 71% of men experience symptoms such as urinary frequency, urgency, nocturia, poor urinary flow and even pain in the bladder upon filling.  In most of the male patients, there is little to no laboratory or imaging evidence to incriminate the prostate as the source of this pain and urinary symptomatology.

There are women as well suffering chronic pelvic pain with no bladder or organ pathology who have symptoms of urinary frequency and urgency. Both women and men typically have sore and painful anterior (which means located toward the front) musculature within the pelvis floor that refer sensations of urinary frequency and urgency when certain trigger points in the front of the pelvic are palpated. With almost all of the men and women with urinary frequency and urgency and no evidence of organ or related physical pathology, we find trigger points in the pelvic floor and related areas that tend to refer sensations of urinary frequency.

The relationship between sore, painful pelvic floor muscles and urinary frequency is not intuitively clear. Indeed how is it that one has urinary frequency and urgency but with no pathology, infection in or of the organs of the urogenital tract.

When I first had pelvic symptoms, I just had urinary frequency with no pain other than the uncomfortable symptoms you have with urinary frequency and urgency. As time went on, I had most of the symptoms we describe in our book including urinary frequency and urgency, sometimes in the extreme. The doctor could find no physical pathology. Nevertheless I suffered with sometimes extreme urgency, voiding little, never feeling emptied or relaxed the way urination feels in someone without pelvic pain. As I recovered, I went from sometimes feeling that I had to void every 15- 30 minutes to feeling normal in this area and noticing I went 3-5 hours with no undue distress. When I had urinary symptoms, I remember when I went to a movie, I always sat in an aisle seat at in a movie theatre because I could never sit through a whole movie without having to get up to go to the bathroom in the middle of the movie. I experienced a difficult to describe, gnawing, aching irritated feeling in and around the bladder. After my recovery, my urinary frequency and urgency disappeared and urination disappeared.

When someone is suffering from urinary frequency and urgency with no known physical pathology, they feel uncomfortable in and around the bladder, they feel like they need to urinate, often urinating small amounts which don’t resolve the feeling of having to urinate the way one normally feels resolved after a trip to the bathroom. When you have urinary symptoms related to pelvic floor pain and dysfunction, the sensation in and around the bladder simply doesn’t feel normal. So what is going on here? This is a question I believe some people suffering from pelvic pain are baffled by. Being able to easily wait to go to the bathroom is important in many situations in modern life including work, social and recreation related situations. That there is gnawing, uncomfortable feeling in the bladder and urinary tract can be very distressing as it persists without resolution.

So here are thoughts I share with you about the phenomenon of urinary frequency and urgency arising when someone has pelvic pain and subsiding or disappearing with the subsidence of pelvic pain. I would like to propose that afferent (sensory) nerves associated with the bladder or a neighboring receptor in the pelvic neural network may be affected by the tension, discomfort and anxiety originating within the pelvic muscles.  This afferent plexus, or branching network of intersecting nerves of the lower urinary tract is complex and responsive to a variety of different kinds of stimulation including stress and anxiety and pain. Many of us have experienced the need to urinary under circumstances of extreme anxiety or stress.  The theory I propose is that pain and anxiety triggers the branch of the autonomic nervous system related to bladder relaxation – bladder relaxation that is felt as the need to urinate. Absent pain in the pelvis using our protocol, we have often seen someone’s urinary frequency and urgency reduce or entirely go away without any drugs or other interventions.

We all know of the colloquial term to be so scared you pee in your pants. This colloquialism refers to a moment of urinary urgency occurring under conditions of extreme fear or stress. In my personal journey with pelvic pain, I thought that the pain in my pelvis was something that my brain confused with the discomfort of a full bladder that urination would relieve. In a person without pelvic pain, you feel relaxed after urination. My sense when I was symptomatic was that somehow my brain confused the discomfort in my pelvis with the discomfort of a full bladder that is relieved with urination. What is clear is that urinary frequency and urgency is often present when someone has pelvic floor pain and no other physical findings, and the urinary frequency and urgency can disappear once the pelvic pain resolves.

I hope this is a helpful essay about this interesting subject.