Healing What is Diagnosed as Prostatitis/CPPS And Pelvic Floor Pain Is Hidden In Plain Sight

Hidden in plain sight is an oxymoron: a figure of speech in which apparently contradictory terms appear together in a phrase yet both are true. When something is hidden you can’t see it, but when something is in plain sight, you can. How peculiar! Yet in my view, this figure of speech clearly illustrates the lack of understanding about pelvic floor dysfunction throughout the history of the treatment of pelvic pain. I am using this figure of speech in this podcast to emphasize the point that, what lies at the center of the resolution of what is diagnosed as prostatitis, chronic prostatitis/chronic pelvic pain is, at the same time, both obvious and often completely disregarded.

To explain: There is no professional nor patient dispute or controversy about the fact that when someone diagnosed with prostatitis/chronic pelvic pain syndrome, the tissue in and around the pelvic floor is painful when pressed on. In fact, this is one of the major criteria we use to determine eligibility in our program; whether we can find tenderness, pain, and/or discomfort in palpating certain key areas in and around the pelvic floor. We have found over the years that palpation related pain in and around the pelvis floor are always associated with complaints of pelvic floor dysfunction.

Said simply, when men diagnosed with prostatitis/chronic pelvic pain syndrome, or with men and women diagnosed with pelvic floor dysfunction, the tissue inside the pelvis is painful or tender upon palpation. This is one of the hallmarks of a trigger point; that is to say, when someone has a trigger point and you press on it, it is exquisitely tender. When you press on an area that is not painful or tender at all, there is no trigger point there.

While there have been some exceptions, which is beyond the scope of this discussion, when we have been able to help a patient heal the soreness and irritation in the pelvic floor and related muscles, with most patients we have seen, there is huge improvement or resolution of symptoms. So again, clearly, the goal of any treatment needs to be to resolve the soreness of the pelvic muscles. How do you do this?

Freeing the pelvic floor and related areas of pain and soreness happens to be the essential goal of the Wise-Anderson Protocol. A number of years ago, we published an article in the Clinical Journal of Pain that documents the significant reduction of pelvic floor tissue pain after 6 months. The entire thrust of our program is to help resolve pelvic floor pain. To do this requires a physical and behavioral methodology.

If resolving the pain in the pelvic floor-related tissue is the goal, then the very simple question that will occur to all patients becomes, ‘How do you get this painful tissue not to be painful?’ I will repeat, ‘How do you get this painful tissue, that can occur from the belly button all the way down to the knees, in the front, back and sides of the body, or throughout this area of the body, to stop being painful?’

I’d like to talk about how the tissue inside the pelvic floor is different from other bodily tissue

The miracle of the healing mechanism of the body is that painful tissue heals. If you have a sore, irritated arm or leg, in the right circumstances this tissue heals. While there are differences, painful tissue inside and outside the pelvic floor associated with pelvic floor pain is no different from other tissue in the body capable of healing? The tissue inside the pelvic floor is sensitive. Tissue inside the vagina or anus or inside the pelvic floor is covered with a mucosal membrane and generally more sensitive than, for instance, the muscles in your arm or leg. Certain pelvic tissue is also connected with specialized nerves in order to cooperate with other parts of the body and respond to other parts of the body involved in urination, defecation, sexual activity and exercise.

For instance, the muscles of the anal canal are normally closed to allow us to remain continent and when a neurological signal is sent from the rectum above the anal canal indicating that stool has distended or expanded the rectum, the anal canal relaxes to permit the stool to pass through, and we feel the urge to have a bowel movement.

The urinary sphincter, which is a continuation of the detrusor muscle, is smooth muscle, and is normally closed enabling us to remain continent. When the bladder stretches as urine collects in it, at a certain point the signal is sent to the urinary sphincter to relax and we feel the urge to urinate. The muscles of the pelvic floor, particularly in men, contract every second when a certain kind of stimulation occurs that we know as orgasm. Other muscle groups in the body do not have these neurologic interconnections. These are some of the ways the muscles in and around the pelvic floor are different from other muscles.

How the pelvic tissue is the same as in other muscles

The muscles of the urogenital tract and anorectal area all tighten and relax like other muscles in the body do. As with other muscles, these muscles also can develop painful knots that form in them called trigger points. Trigger points in and around the pelvic floor (as with trigger points in other muscles) can refer sensation to places remote from them, so that where pain is felt is often not where the source of the pain is.

If there is an injury or irritation in the muscles in and around the pelvic floor, does this require different circumstances and treatments in order to heal? Any muscle that’s sore, irritated, or injured, tends not to heal properly if it is stressed, unduly squeezed, infected, unclean or having to deal with a significant reduction of blood flow among other factors. We want to avoid aggravating and stressing any part of the body that is sore, irritated, or painful. There is no controversy here.

The peculiar circumstance of the pelvic floor during pelvic pain continually irritates and inhibits the healing of the tissue

Once sore pelvic tissue forms in the pelvic floor, there is a reflex in the tissue itself to tighten against its own pain. That is why often people with pelvic pain feel like they’re clenching down in their pelvis all day. There is a reflex to tighten against what is sore, painful or feels unusual in the pelvic floor. Once this soreness in the pelvic floor tissue is initiated and trigger points form, this area becomes hypersensitive to the stimulations of anxiety, sitting, defecation (sometimes people have post-bowel movement or post-urinary pain), sexual activity and orgasm, and the general stresses of life. In other words, when someone has pelvic pain, a cycle that we have called the pelvic pain cycle begins and seems to take on a life of its own. This cycle stops the tissue hourly and daily (even during sleep) from healing up the way other tissue in the body that is irritated can heal.

The Wise-Anderson Protocol’s answer to what is hidden in plain sight

Our program is devoted to training our patients to loosen the contracted tissue that has inhibited blood flow and increased pain, using a specialized self-treatment program of internal and external physical therapy (with our Trigger Point Genie and FDA-approved Internal Trigger Point Wand). It is not well understood that myofascial trigger point release internally and externally in the pelvic floor has only a temporary effect. Doing myofascial trigger point release inside and outside the pelvic floor temporarily, I stress temporarily loosens the tissue.

Pelvic floor physical therapy is not like freeing a rusting nut from a rusty bolt using WD-40. Physical therapy intervention for pelvic pain is essential in our view, but it is modest and usually short term in its effect. When it is sore and irritated, the tissue typically tightens back up after the physical therapy intervention. We have had patients who would drive many hours to see someone for myofascial trigger point release, only to have the treatment undone on the drive home. At Stanford we were among the first to introduce pelvic floor physical therapy for men in the middle 1990’s and I believe we currently are among the best at training our patients how to do it expertly themselves. Training our patients to do internal and external physical therapy is a central part of our program. Even expert physical therapy, done every other day as we recommend is not enough to help heal pelvic floor pain. Unless the tissue is given a chance while in its loosened state to undergo the body’s mechanisms that heal muscle soreness, the pelvic contraction and irritation will tend to reassert itself. 

Cooperating with the body’s healing apparatus is the secret to healing pelvic pain that has been hidden in plain sight  

Thinking that simply loosening the tissue physically is the answer to pelvic floor dysfunction is a misunderstanding that pervades conventional understanding about treating pelvic pain. Often, when doctors (who typically know little about myofascial trigger point release) can’t help their patients with their pelvic pain, they will simply refer them to a physical therapist somehow thinking that physical therapy will somehow take away the pelvic pain. This is a wrong understanding in my view. Yes, physical therapy is essential in the resolution of pelvic pain, but only when done frequently enough and used in conjunction with a method that provides the tissue with an environment in which the body’s mechanism of muscle-healing can take place. Simply applying physical therapy techniques to sore pelvic tissue without a central emphasis on the healing of the tissue is like cleaning up spilled water from a leaky faucet, instead of fixing the leak in the faucet itself.

Our program focuses on supporting the natural healing mechanisms of the body to restore the painful pelvic tissue to a state that it was in before it became sore, painful, and caught in the pelvic pain cycle. The body’s ability to heal sore tissue is the secret that is hidden in plain sight.

In our view, any treatment that aims to resolve pelvic pain must indeed first regularly loosen the tissue with skillful myofascial trigger point release, but this must be done in conjunction with cooperating and becoming friends with the healing mechanisms of the body that heal sore tissue in and around the pelvis (or sore muscle tissue in any other part of the body).

The method we use is called Extended Paradoxical Relaxation, described extensively in our book A Headache in the Pelvis. Relaxing the body when one is in pain and anxious is not simple and most relaxation methods do not in any way address this circumstance. We spend many hours in training our patients who are in pain and anxious how to do Extended Paradoxical Relaxation particularly in dealing with the difficult emotional circumstance of dealing with the anxiety, pain, and general emotional distress that pelvic pain patients generally find themselves in. In using this approach, I am clear that the sore and painful tissue in the pelvis has the best chance of healing and the pain and symptoms going away.

Healing Pelvic Pain (in men called Prostatitis/CPPS) is Simply Repetitively Returning to Your Natural State

It’s easy to medicalize pelvic pain; to view it as a purely physical disease or disorder instead of a stress response tied to chronically tighten up the pelvic floor. In seeing it simply as a physical pathology and a medical problem, you miss out in understanding what pelvic pain in fact is and what it needs to heal. As we wrote in our Gold Urology Journal publication recently, pelvic floor pain, sometimes called prostatitis/CPPS in men, is psycho-neuromuscular state. To say that pelvic pain is psycho-neuromuscular means that it affects muscles, nerves and mind which interact with each other. It is not simply some physical event like a broken bone or a cold. Mind and body do meet in the pelvic floor.

Most important, only treating pelvic floor related physically typically doesn’t resolve it. While physically loosening of a chronically tightened pelvic floor can bring some short term reduction in pain, and is central in its effective treatment, the experience of the vast majority of sufferers we have seen who have been diagnosed with prostatitis or chronic pelvic pain syndrome, is that there is typically no enduring resolution of symptoms by only treating it physically. In only treating it physically, there is no opportunity given to the sore, tightened, irritated pelvic tissue, to have a chance to heal. Anxiety strongly interacts with the pelvic floor related pain, tightens it up, activates the electrical activity of related trigger points and perpetuates its sore irritation-related pain. The sore irritated tissue of the pelvis intimately aggravates a person’s thinking and emotional state as part of a self-feeding cycle of pain, chronic tension, anxiety and sore, irritated pelvic tissue. The sufferer of pelvic floor related pain knows all too well that this condition somehow takes on a life of its own.

Repetitively returning to one’s natural state makes the resolution of pelvic pain possible

When we were in our happy natural state as children, we didn’t have pelvic pain. Absence of pelvic pain reflects a certain kind of ease in the body and mind, one where the pelvic floor muscles are not chronically tightened, irritated and sore, and are not being targeted by, and does not bear the brunt of the stresses of life.

Over the years I have come to see with myself when I was symptomatic and with patients I have seen that returning the pelvic tissue to a quiet, undisturbed state is what is necessary to stop the chronicity of pelvic floor pain. Our natural state is one in which there is an ability to relax, to experience peace and pleasure. It is a state in which the pelvis is not irritated and on a hair trigger to protectively guard, flaring up pain and contraction prompted by many triggers including the heightened the survival alarms of the nervous system in a person living with a chronically painful pelvis.

The question is, how do you return yourself to the own natural state of the body when you have pelvic pain? We have designed our protocol, we aim to help patients return themselves to the state they were in before their pelvis started hurting. We are of the necessity to give control over the restoration of this state to the patient. Healing pelvic pain is an inside job. Ultimately no one can do it for you.

Self-treatment is something we have written about extensively. Physically, we train our patients to regularly loosen up the knotted-up tissue that has become their default state in response to the stresses of life. We do this by teaching our patients physical therapy self-treatment, both externally trigger point release with our Trigger Point Genie and the Theracane and internally by training patients to use our FDA approved Internal Trigger Point Wand to restore the internal pelvic floor tissue to a state of ease and relaxation.

The external and internal physical therapy must be done repetitively to have a chance to release the automatic, default contraction of muscles in and around the pelvis. Typically the stresses of life have been intimately connected to tightening the body for a long time. In most of our patients, the body habitually has been overly tightened for a very strong lock-down. This lock down ultimately hurts the pelvic muscles. If we made a fist day and night for months or years, our fisted hand would soon hurt. We have to repetitively release this lock-down of pelvic floor fist. This is the physical intervention we train our patients to do.

Extended Paradoxical Relaxation is the relaxation method we have published studies on. It is aimed to free the irritated pelvic tissue from its protective guarding for regular, extended periods of time. It is a practice of shifting focus away from thinking, bringing ourselves into a state of effortlessness. It is a practice of stopping the chronic guarding and squeezing that tends to be ongoing in the pelvis pain patient. Learning how to do this at first is not easy when one is anxious and in pain. It requires practice. It is doable with enough practice and intention. This state of not exerting any effort, of not activating any tension in yourself, of resting attention outside of the mental narrative that usually consumes our attention, is the essence of the method.

Babies know how to be in the natural state of ease without any training at all. When you observe a sleeping baby or a happy baby just hanging out, you can see that the baby is not worried about anything. They have (unbeknownst to the baby) outsourced their survival to their parents and the baby’s body is working well and happily and all systems are at ease. The baby doesn’t protectively guard itself. Happy babies trust that they will be protected and taken care of. The pelvis is relaxed. That state is what we want to enter regularly in the journey of healing pelvic pain.

In summary, what I understand about healing pelvic pain is that nothing has to be added to the body, nothing has to be taken away, no drugs need to be given for it to heal. In the restoration of the natural state of the pelvis, we want to repetitively return our body and mind to its natural, undisturbed state on a regular basis by loosening it and controlling our attention in a way that allows the tissue in our body to quiet down and heal. This is our aim at the Wise-Anderson Protocol. This is something you have to practice and get good at.

The sore pelvic tissue present in pelvic pain yearns to be loosened and released and then needs to rest in this state over and over again. This provides the very best chance of providing an environment in which the sore and tender pelvic tissue can heal.

Healing prostatitis, chronic pelvic pain syndrome, pelvic floor dysfunction and the vital medicine of regular, profound relaxation

The concept of intense and relaxation practice as a necessary therapy for the resolution of what is diagnosed as prostatitis, chronic pelvic pain syndrome, pelvic floor dysfunction among other diagnoses, may well produce a head scratch to the casual observer. What does relaxation have to do with pelvic pain?   In this essay, I want to discuss why the practice of profound relaxation is essential to the healing of pelvic-floor pain.

 

There are, certainly, some people whose pelvic pain gets better spontaneously without doing anything. And then there are those who plug away at many, many different treatments but their pelvic pain remains. In general, however someone whose pelvic pain has become chronic and is not able to calm down in deep relaxation regularly, I think the likelihood of really recovering from pelvic-floor muscle-related pain is small. I realize this is quite a strong statement. I say it because of how I see pelvic pain from the inside after my own person al experience with pelvic pain of 22 years, my continued state of being pain free and my ongoing relaxation practice.

 

Why is regular quieting of the body necessary for the healing of pelvic floor related pain and dysfunction? After all, people without pelvic pain don’t need to do any kind of relaxation in order to remain pain-free – but, people without pelvic pain also don’t have sore pelvic-floor tissue that needs to heal. When you have sore, tightened pelvic muscles that are continually re-irritated by the normal functions of life (including urination, defecation, sexual activity, daily stresses, and even sitting), irritated pelvic tissue is unlikely to heal without the ongoing environment provided by the regular practice of relaxation. As I’ve discussed in other podcasts and as we discuss in our book A Headache in the Pelvis, sore pelvic tissue needs a regular sanctuary – a healing chamber, free from the activities and stresses of life that keep it from healing. In our protocol, regular relaxation, done for two-to-four hours each day in an environment that gives the natural mechanisms of the body a chance to let sore pelvic tissue heal, is necessary for the possibility of any real healing to occur.

 

So, how do you put the sore pelvis into a healing chamber? How do you put up a sign that says to the brain, and to the world, “Do Not Disturb” when you are suffering from prostatitis/chronic pelvic pain syndrome, pelvic floor dysfunction and related conditions? Being able to become deeply quiet and serene in the midst of a crazy world and a demanding life isn’t simple, but it is doable to the person who says, ‘however high I have to jump, I will’.

 

There are several steps in learning how to profoundly relax. The first is understanding that relaxation is a skill which takes ongoing practice. Like learning to play the violin or to fly an airplane, or any skill of value, you have to put the time in. There are relaxation apps, and relaxation lessons to buy, but I don’t personally think much of them. In my experience, quick fixes, simple breathing methods, and other gimmicks always wind up on the shelf. We all know that there’s no quick way to become skilled at playing the violin. In exactly the same way, there’s no quick method to being able to quiet the body and mind – especially when someone is anxious and experiencing chronic pelvic pain.

 

It took me years to learn. I was a student of Edmund Jacobsen, the father of relaxation therapy in the United States. He developed a method called progressive relaxation and began practicing it in the early 20th century, writing a book in 1929, later edited in 1939, called Progressive Relaxation. He was one of the first physicians to treat what we would now call “stress-related disorders” like headache, idiopathic dyspepsia, stomach and digestive problems like esophageal spasm and IBS, hypertension, back pain, and constipation. It took me many years, both at the feet of the master and then on my own after his passing, to really “get” what relaxation is and what is necessary to regularly enter its state.

 

We all can recall “feeling relaxed.” When we talk about being relaxed, in a way even the word trivializes the experience. In my view, being relaxed is a holy, profound state. It is a state in which life has meaning, and we enjoy things, and we have the experience of just being – being able to delight in the present, in the things that have meaning to us, in our love for others, in the food we eat… in the many things that bring us joy. In the state of real relaxation, the sense of separation between people and the world dissolves.

 

Relaxation isn’t about breathing exercises. It’s not about visualizing a sun-drenched desert island or some ideal home. Relaxation is about the experience of effortlessness. The idea that breathing exercises are a method of relaxation, in my view, is a misunderstanding by people who don’t know how to do it themselves. When you’ve been relaxed, I doubt you got there through breathing exercises. The sleeping child who is deeply relaxed didn’t need to do anything. Rather, relaxation is the voluntary shifting of the nervous system from sympathetic dominance to parasympathetic dominance. And what does that mean, exactly? Well, physiologically speaking, relaxation is a state in which one of the parts of the autonomic nervous system, called the parasympathetic division, is dominant – as opposed to the sympathetic division. The parasympathetic division has been called the rest-digest-recuperate aspect of the nervous system, while the sympathetic division is involved in activity, nervousness, focus, and anxiety and is often called the fight-flight aspect.

 

I’m going to do my best to explain how the divisions of the autonomic nervous system work and relate it to the condition that is typically diagnosed as prostatitis/CPPS or pelvic floor dysfunction. You can think of the human body as a computer that comes hard-wired from the factory with two automatic computer programs that are generally not under the owner’s control. These programs refer to the activity of either the sympathetic and parasympathetic divisions of the nervous system. Neither is under much conscious control unless you make effort to learn to control them – which is what we do in the relaxation protocol that is a central part of our program. Generally, these two aspects of the autonomic nervous system work automatically reciprocally: when one is on, the other is off.

 

The activation of the sympathetic system can be thought of as what happens to a car when you press on the gas pedal, and the activation of the parasympathetic system is what happens when you take your foot off if the gas pedal. When one system is operating, the other isn’t. The balanced system is meant to preserve survival – it allows us to respond to danger, to flee, fight or freeze, or to rest, digest and rejuvenate when danger has passed. As a survival mechanism, the body postpones recuperative tasks when there’s an emergency. The parasympathetic system has to wait until it feels safe from danger before it can fully activate`. This is important.

 

We’re often unaware of the autonomic nervous system because it functions involuntarily and automatically. For instance, we generally don’t notice changes in the size of blood vessels or the rate of our heart, because those are automatically regulated by the nervous system. The parasympathetic division of the nervous system is the part that allows recuperation, but it has to be patient… it waits for the right time to do its work. If there’s an emergency, the parasympathetic system waits to rest, digest, or recuperate, for its immune function to fight off infection, or to do the other tasks it performs. However, you can’t postpone parasympathetic functions indefinitely. You can only ignore your body for so long without paying a price.

 

Back to cars… you can run your car at 100 miles per hour all day, but if you keep doing it you’ll be in for a trip to the mechanic. Arousal of the sympathetic nervous system postpones parasympathetic response, and you can’t postpone it forever without something breaking down. Chronic pelvic pain, in my view, is one consequence of ongoing parasympathetic postponement, where the normal relaxation required to heal sore, irritated pelvic-floor muscles doesn’t occur. The pelvic-pain cycle is a sequence of tension leading to anxiety, leading to a sore pelvic floor, leading to a protective guarding that causes more tension and anxiety and pain. This cycle is basically what happens when the sympathetic nervous system goes into overdrive and doesn’t get a chance to turn off.

 

When a person is healthy, these two systems are reciprocal, shifting back and forth depending on the body’s activity at the time. We can tell which system is dominant through certain physiological signs. For instance, sympathetic dominance in its extreme, involves sweaty palms, narrow pupils, muscle tension, dry mouth, and increased blood pressure or heart rate. The parasympathetic response is very different. In a book called The Relaxation Response, Dr. Herbert Benson discusses the “relaxed state,” which is essentially parasympathetic dominance. This is the state in which we sigh deeply and say, “Ah, I feel so good.” Nobody feels relaxed and not good – the experience of parasympathetic dominance is relaxation and pleasure.

 

Sympathetic arousal is certainly not always a negative thing. Sympathetic dominance is about alertness, activity, focus, and getting things done. When someone is “on the case” about something, being attentive and productive, the sympathetic nervous system is on.. Conversely, the parasympathetic nervous system supports rest, rejuvenation, and rehabilitation. It’s the state of ease and unguardedness, of being unconcerned about survival, of not being vigilant but instead feeling safe and open. We know that we’re in a parasympathetic mode before going to sleep, when we feel tired and are just looking forward to nodding off. When people can’t drift off and instead just lie awake, it’s because their sympathetic nervous system is still activated and they are not able to shift into parasympathetic mode to relax.

 

So, I repeat, what does any of this have to do with pelvic pain? As we discuss in A Headache in the Pelvis and in previous podcasts and articles, pelvic pain results from sore pelvic tissue put in an inhospitable environment of contraction and anxiety, when sympathetic dominance of the nervous system doesn’t support healing of this tissue for the soreness to go away. An unfortunate dilemma with pelvic pain is that pain makes you anxious and anxiety puts you in heightened “survival mode” where sympathetic dominance is the rule.

 

This creates an environment unsupportive of healing because the survival state focuses on in-the-moment-action and not long-term health. Sympathetic dominance tells the body to put aside all functions not immediately related to survival. When your house is on fire, you don’t start doing the laundry or washing dishes – the maintenance functions that keep things happy and nice in your house are put aside as you run for your life. The same thing happens in the body when the sympathetic nervous system is perpetually activated – the body never gets the opportunity to do the maintenance functions necessary for pelvic-floor tissue to rest and heal.

 

And that is why relaxation is so important for healing pelvic pain. Relaxation addresses the inhospitable environment that sore pelvic tissue finds itself in. By creating a hospitable, healing environment, relaxation reduces the anxiety that is such a central component of pelvic pain.

 

In another podcast, I’ll discuss the principles of taking control of the body and mind to move from sympathetic to parasympathetic dominance.

Who gets prostatitis/CPPS and why

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. And these men share the common characteristic of worrying. 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 sigmoidoscopy 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. In the same way you may not see the effect of the stresses the pelvis is exposed to until it becomes painful. The “listening” of the pelvis happens deep inside—the physical inner core of a pelvic-pain patient deeply hears and responds to 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 and aims to release the sensitive inner core of the pelvic pain patient from its worried, irritated constriction. We teach our patients to regularly physically release the trigger points, muscle constriction and guarding inside the pelvic floor. Equally important we teach our patients to mentally/behaviorally, to practice a method called Extended Paradoxical Relaxation, whose aim is to regularly bring sore pelvic tissue into a healing inner environment in which the nervous system has shifted to the relaxed parasympathetic activation. In patients we treat whose pelvic pain significantly reduces or resolves entirely, the ongoing practice of Extended Paradoxical Relaxation cannot be avoided in order 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.

 

The resolution of pelvic floor pain and dysfunction is both physical and mental and has to do with changing one’s way of dealing with a body and mind that is sensitive in which anxiety is easily turned 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.

Why Pelvic Floor Dysfunction (Often Confused As Prostatitis) Takes Time to Develop 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.