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. .

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.

What is Levator Ani Syndrome, and What are the Symptoms?

What to Know About Levator Ani Syndrome and its Association with Rectal Pain.

Levator Ani Syndrome is a condition of chronic muscle-based pelvic pain up inside the muscles of the pelvic floor commonly associated with rectal pain . If you are experiencing chronic rectal and/or anal pain, there is a chance you will be diagnosed with Levator Ani Syndrome.

The syndrome was first named by George Thiele, a colorectal surgeon in the 1930s who discovered that patients who came to see him with rectal pain, reported pain when he touched the levator muscle inside the pelvic floor.

Levator Ani Syndrome/spasm can make life very difficult. It tends to be made worse by sitting, bowel movements, sexual activity, and stress. When Levator Ani Syndrome occurs it will often take on a life of its own as the condition forms a self-feeding cycle of tension, anxiety, pain, and protective guarding. This is why drugs, surgery electrical stimulation, or biofeedback have offered little relief from pain with what is diagnosed as Levator Ani Syndrome.

The Wise-Anderson Protocol has helped many patients diagnosed Levator Ani Syndrome with the treatment described in the sixth edition of A Headache in the Pelvis. The Wise-Anderson Protocol for symptoms of Levator Ani Syndrome is offered in a monthly six-day immersion clinic in California. A specific kind of physiotherapy for pelvic pain and relaxation protocol adapted specifically for pelvic muscle pain (called Paradoxical Relaxation) are central parts of the protocol and are aimed at rehabilitating chronically tightened pelvic muscles and reducing anxiety related to this chronically contracted condition of the pelvic floor.

NOTE: While it is our hope that these facts about Levator Ani Syndrome are helpful, this information is not to be misconstrued as medical advice. This should be presented as general information about the disorder.