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, 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.
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 irritated, 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. .