Pelvic Pain | Pelvic Pain Help

THE WISE-ANDERSON PROTOCOL CAN SIGNIFICANTLY SYMPTOMS OF CHRONIC PELVIC PAIN SYNDROME IN A MAJORITY OF THOSE WHO PRACTICE IT

by Robert Grahameon 18 October 2023in Pelvic Pain, Prostatitis, Wise-Anderson Protocol

• In this blog, I will explain the Wise-Anderson Protocol and why it helps significantly reduce pain and symptoms, of chronic pelvic floor related pain in majority of men and women who are trained in it.
• I suffered from pelvic floor related pain and symptoms for over 20 years before I had the great fortune, unlike many who suffer from chronic pelvic pain, of resolving it.
• The way that I became symptom free became the basis of what is now called the Wise-Anderson Protocol, a protocol named after myself and Dr. Rodney Anderson, professor of Urology at Stanford University School of Medicine with whom I developed the program.
• I sometimes muse that if the Wise-Anderson Protocol in its current form, had been available when I first started having symptoms when I was 18, back in 1963, many years of my life would have been very different
In a study our team conducted and published in the Journal of Urology, the method we call the Wise-Anderson Protocol used for almost 30 years now, was show to reduce pelvic pain symptoms in a majority of patients who had been trained in it and practiced it. It has given their lives back to many of our patients.
• In a published article in the major urology journal, the Journal of Urology after 6 months, there was a 59% marked to moderate reduction in pain and symptoms.
• In another published article in the Clinical Journal of Pain there was a dramatic reduction in trigger point sensitivity — how much it hurt inside when trigger points were palpated – a drop from 7.5 to 4 after 6 months.
• This occurred when patients who failed at all other treatments who then used our Internal Trigger Point Wand in conjunction with our entire protocol – almost cutting the internal pain/sensitively level in half.
• It has been my observation that the pain level continues to reduce among many of our patients as they continue our protocol after a period of 6 months.
• In the journal of Applied Psychophysiology and Biofeedback, 1/3rd of patients after 6 months voluntarily gave up all medications they were taking in relationship to their symptoms.
• Medication reduction was unsurprisingly associated with a decrease in pain and symptoms

The Wise-Anderson Protocol is now offered to eligible people in a 4 day immersion in-person immersion clinic and home program

The Wise-Anderson Protocol is a protocol we began to develop almost 30 years ago at Stanford University Medical Center in the Department of Urology and since 2003 has been taught to patients in a private multi-day in-person clinic, and more recently is available in a comprehensive home program that can be done without in-person attendance.

How you understand a problem determines how you treat it
In our book, A Headache in the Pelvis, we use the example saying that it isn’t a good idea to treat chest pain with open heart surgery if the problem is heartburn. You don’t want to do exploratory brain surgery when headache is simply caused by stress. Correctly understanding a problem is the key to solving it. This is especially important for pelvic floor pain that you can’t see or detect with any conventional testing.

Here is our understanding as to why pelvic floor related pain becomes chronic and how to resolve it
• Pelvic floor-related pain is invisible to the eye and to conventional medical testing. A person with chronic pelvic pain complains of a variety of peculiar and varied symptoms and yet the doctor or anyone else can’t see evidence of the problem other that the person’s complaints of pain and symptoms.
• Conventional tests and treatment –… conventional tests like CT scans MRI’s Xrays, blood tests etc. can’t detect chronic pelvic pain syndromes. Similarly the conventional treatments of drugs surgery procedures, injections are of little help.
• It turns out that to know what to do with a patient whose symptoms you can’t see or test for, you have to project a concept of the problem on the patient
• If the concept you project on the pelvic pain patient is wrong, your treatment won’t help. This is the case in the current treatment of pelvic pain.
The confusion about how to effectively treat pelvic pain comes from the strange and seemingly unrelated symptoms. Pelvic pain patients have 3 or more of the following symptoms.
• Perineal, anal, rectal pain, genital pain/discomfort/tightness/burning that can be on one side or another, on both sides or in the middle.
• Symptoms can be continual, episodic, at different levels of intensity during the day, can remain in the same place or shift to different places
• Pain or discomfort can worsen with sitting (sometimes feels like a golf ball stuck up inside)
• Pain or discomfort can be relieved or worsened during or after bowel movements (or bowel movements can have no effect on symptoms)
• Pain or discomfort and be felt in the perineum, lower abdomen (on one side or another or in the middle), tailbone, low back, above the pubic bone as well as up inside the pelvis
• Pain or discomfort if often exacerbated during/after sex, sitting or with stress, after a long day at work,
• Urinary urgency, frequency, or discomfort, constipation are common
• Temporary relief sometimes occur with hot baths or valium type drugs
• Symptoms can be constant or wax and wane, often (not always) better in the morning and worsens as day unfolds
• Typically, symptoms flare ups occur (varies from person to person) with stress, sitting, sex, bowel movements
• Occasional anal fissures
• Pelvic pain is accompanied by anxiety, depression, reduction in self esteem
• Significant reduction in quality of life

How can you make sense of these symptoms?
• Pelvic floor pain is typically a quiet and ongoing inner crisis of being in pain, having often chronic weird symptoms, feeling alone, misunderstood and having little help. Even when some things like physical therapy help, symptom relief is typically short-lived. I know this well from my personal experience.
So what is pelvic floor pain. I want to refer to a study we published an article in the Gold Journal of Urology in 2018 called Prostatitis/chronic pelvic pain syndrome as a psychoneuromuscular disorder—a problem of chronically painful, tight pelvic and related muscles that make the pelvis tissue sore – pelvic tissue that has developed painful trigger points occurring as the result of chronic pelvic tension which feed more pelvic tightening, anxiety, and pain … all in an self-feeding cycle.
• This symptoms of a male pelvic floor pain, often confusingly diagnosed as prostatitis/cpps also occur in women. In a study we published in the Journal of Psychophysiology and Biofeedback, we found that our protocol helps women with pelvic floor pain and symptoms to the same degree that it helps men.

• While a small minority of pelvic pain we treat appears to be the result of an insult or injury to the pelvis, most cases of pelvic pain occur as the result of the reaction of the pelvis to chronic, worry that is that prompts an often unconscious habit of protective pelvic muscle tightening.

• Like a dog that pulls in its tail when frightened, pelvic floor pain can be thought of as the human equivalent of a dog pulling its tail in. When upset, the pelvis of the dog contracts to pull in the tail. Chronic worrying in a certain group of people produces chronic pelvic tightening. Not infrequently the tailbone is actually pulled in.

- You can think of pelvic floor pain as the center of the body, the core of the body that is chronically hurting, tensed, triggering anxiety, pain, protective guarding — resulting in ongoing sore pelvic tissue – all part of a self-feeding cycle that has been out of reach of all medical interventions.

So what to do about this peculiar and distressing picture? The Wise-Anderson Protocol addresses this condition directly.

- The aim of the Wise-Anderson Protocol is to stop the cycle of tension, anxiety, pain and chronic tightening of the pelvic and related muscles on a daily basis.
- In the Wise-Anderson Protocol we ask patients to follow a physical and ongoing behavioral program that has to be practiced for an extended period of time to restore the pelvic muscles to a state of not being contracted or in pain.
- I learned that resolving pelvic pain is an inside job. No one could do it for me. Having been through it, I see that stopping the pain and symptoms of chronic pelvic floor pain requires that the person with pelvic pain release the chronic painful guarding in the pelvis, release the painful internal and external trigger points, daily stop anxiety – all in order to help the sore pelvic tissue to heal
- Ultimately no one can stop you from chronically tightening up your pelvic muscles except you
- And here is a key issue that is missed in most attempts to deal with pelvic pain: if the sore pelvic tissue doesn’t heal from its long time of being squeezed, this sore, painful tissue itself triggers a reflex guarding/tightening. Unresolved painful trigger points, chronic muscle guarding, and sore painful tissue all forming a self feeding cycle is what keeps pelvic floor pain chronic.
- Extended Paradoxical Relaxation is based on the pioneering work of my teacher, Edmund Jacobson, considered the father of relaxation therapy in the United States who developed Progressive Relaxation at the turn of the 20^th This method puts the pelvic floor and nervous system into a quiet chamber every day which is not unlike the quiet necessary for someone in a hospital room to heal.

- Extended Paradoxical Relaxation uses the principles of Jacobson’s Progressive Relaxation and has been adapted to be used by the pelvic pain patient who must deal with pain and anxiety. It requires proper instruction and daily practice of at least an hour a day for an extended period of time.
- At this time, conventional medicine has little to offer to release the chronically tightened pelvic floor muscles and to reduce the anxiety of an aroused nervous.
- You would think that a pill could calm down the nervous system. In fact there are no such pills that don’t have serious side effects and the problem of addiction. You would think that someone could simply do physical therapy on you and that would solve the problem of the chronically tightened pelvis.
- Pelvic floor physical therapy, which we pioneered in men 30 years ago and are experts at teach patients, is a necessary but temporary intervention that doesn’t stop the habit of tightening the pelvis under stress that reinvigorates pelvic trigger points.
- Pelvic floor physical therapy that you learn to do yourself can release the chronic guarding that keeps the pelvis too tightened. It must be carefully taught and a effective tool needs to be used and its use taught to the patient. Our FDA approve/cleared Internal Trigger Point Wand for internal trigger point release and our FDA registered Trigger Point Genie are the medical devices we have designed and carefully teach our patients to use.
- Resolving pelvic pain is an inside job. Pills, surgery or procedures don’t work for it. As most of our successful patients have found, no one can do this for yourself except you.

- When our program is successful, it is typically practiced daily for 3 months to a year or more until symptoms abate.

- In summary, the Wise-Anderson Protocol takes on the major task of helping to heal a sore and irritated inner core of the body called the pelvic floor.

- It is a practice that we teach our patients to do using our specialized devices for releasing the chronically painful and tightened pelvic floor and related muscles. This, in combination with Extended Paradoxical Relaxation have the goal of helping to heal the pelvic tissue that became sore from chronic protective guarding
- The Wise-Anderson is not a quick fix. In our experience there are no quick fixes.

It is possible however to skillfully practice a physical and behavioral set of methods that can help to heal the sore and painful pelvis.

How we diagnose pelvic floor pain, pelvic floor dysfunction, (including chronic pelvic pain syndrome, prostatitits/cpps, levator ani syndrome, pudendal neuralgia, coccydynia)

by Robert Grahameon 29 June 2023in Levator Ani Syndrome, Pelvic Floor Dysfunction, Pelvic Pain, Prostatitis, Wise-Anderson Protocol

The Wise-Anderson Protocol treats muscle-based pelvic pain. This typically includes diagnostic categories like pelvic floor dysfunction, chronic pelvic pain syndrome, prostatitis/abacterial prostatitis/non-bacterial prostatitis or sometimes simply diagnosed as prostatitis, levator ani syndrome, pudendal neuralgia, coccydynia, anal and rectal pain, and perineal pain among others.

The way we diagnose muscle-based pelvic pain is straightforward and came from the extensive experience of Tim Sawyer who trained and treated patients with Travell and Simons who introduced trigger points to medicine. Tim is the architect of our physical therapy protocol and our diagnostic method.

In this talk I will discuss the way our group diagnoses muscle based pelvic pain and the understanding and skills and training necessary to make the diagnosis. As I will explain, we diagnose muscle based pelvic floor pain by skillfully palpating the internal muscles of the pelvic floor as well as the external muscles related to the pelvic floor. In locating and palpating these muscle, we determine whether there are painful trigger points in them and whether there is referral from the trigger points to the patients symptoms. We treat pelvic pain with the Wise-Anderson Protocol when there is an absence of any physical pathology, and when trigger points are found in and around the pelvic floor.

It is not easy to find a someone skilled at the diagnosis of muscle based pelvic pain according to our protocol. We have seen and helped many patients over the past almost 30 years who have seen both physicians and therapists who never looked for, or could not find trigger points related to their pelvic pain, in whom we found classic and diagnostically definitive trigger points. Unfortunately the ability to diagnosis of muscle based -pelvic pain is not a commodity – the same everywhere. In our experience it is accurately determined by a doctor or therapist trained, skilled and experienced in trigger point release and diagnosis in general and pelvic floor pain in particular. Absent skilled professionals in their area, many patients have come to see us or travelled to others skilled in this diagnosis just for an hour-long evaluation visit.

What is common to muscle based pelvic pain is an absence of any physical pathology and any significant findings in conventional testing and the pelvic hypertonicity (chronic increased pelvic muscle tension) together with painful trigger points in the pelvic and related muscles. Very often a tendency to chronically worry is present. In our experience, muscle based pelvic pain tends to occur in successful, intelligent, sensitive, ambitious, deeply-felt and often anxious men and women

The method of diagnosis.
External Trigger Point evaluation is typically done on the gluteal muscles including the gluteus minimus, medius and maximus, the hamstrings, the adductors or muscles of the inner thighs, the quadratus lumborum, rectus abdominis and external rectus abdominal obliques, iliopsoas consisting of the psoas and ilacus. These are the muscles that generally go from the breast bone to the thighs. The method is to locate these muscles and press on them to explore if they contain painful trigger points and that tend to refer to the patient’s symptoms.

In working internally, we generally work with patients in the prone position with a cushion, or the lithotomy position, or whatever is most comfortable. The pelvic diaphragm is important and includes: transverse perineal, ischio cavernosus, bulbospongiosus men and the bulbocavernosis women. The practitioner’s gloved and lubricated right hand is used to examine the left side of the pelvic floor and the left hand to the right side of the pelvic floor.

The internal and external muscles are felt and pressed on with a skilled finger using pressure that is neither excessive or not strong enough. This is determined through practice and training. The appropriate level of pressure is gained through the practitioners training and experience. The practitioner also is determining if there is an often felt ‘twitch response’ when pressing on the trigger points.

The internal muscles that are palpated that are known to contain the typical trigger points related to muscle-based pelvic pain are the anterior levator ani muscles in the superior portion, furthest from the opening, the anterior levator ani, middle portion or levator prostatae, the anterior levator ani inferior portion sometimes called the puborectalis, the coccygeus or ischiococcygeus, the anal sphincter, the piriformis internally accessed, the coccyx or tailbone and areas attaching to it.

The external and internal muscles that I have mentioned and where they tend to which they refer pain or sensation, are illustrated in detail in the last Penguin/Random House/ Harmony edition of our book A Headache in the Pelvis; The Definitive Edition

Our understanding of muscle-based pelvic pain
Our group has been treating muscle-based pelvic pain for almost 30 years. It is our view that pelvic floor pain is typically the physical consequence of underlying worry, fear/anxiety/nervous system arousal. Sometimes it is triggered by an intense physical or emotional event. And there are individuals who develop muscle based pelvic pain from a physical trauma.

In many individuals with pelvic floor related pain, there is a tendency, often unconscious, to reflexively and chronically respond to anxiety by tightening up the pelvic muscles. At a certain point the chronically tightened pelvic and related muscles become taut bands that give rise to trigger points — trigger points being the heart of a painfully tightened muscle. In our view the formation of these trigger points and the overly tight bands of pelvic related muscles, fed by heightened nervous arousal, is responsible for pelvic pain and dysfunction.
When someone with muscle based pelvic pain is able to release these muscles back to a normal tone, and is able to regularly reduce autonomic nervous system arousal, in our experience pelvic floor pain significantly reduces or resolves.

Modern medicine is a miracle for diagnosing and treating many illnesses. All doctors want to help their patients and use all of their tools to do so. The problem with diagnosing pelvic floor dysfunction is that it is undetectable with conventional diagnostic protocols. Most medical training does not include the manual evaluation of pelvic tissue for trigger points that in our view is essential to make the diagnosis.

Many patients we have seen have been told by doctors that they can find no reason for their pain. We have had patients whom well-meaning doctors, finding no physical pathology, have referred them to psychiatrists. Many of our patients had gone from one doctor to the next, on a search for a solution. These patients often wander for years in chronic, pain or discomfort, thinking that they suffered from a condition that is unknown, or beyond the power of anyone to diagnose or treat.

In conclusion, making a diagnosis of muscle-based pelvic pain requires that the doctor has the training in locating trigger points and diagnostically palpating them. After taking the patients history and an inventory of trigger points found through the manual evaluation, a diagnosis can typically be made in single visit without any sophisticated devices or methods.

I hope this has been helpful for you.

A disciplined, daily focus for helping to resolve pelvic pain including conditions diagnosed as prostatitis, chronic pelvic pain syndrome, CPPS, pelvic floor dysfunction, levator ani syndrome, pudendal neuralgia, perineal pain among others

by Robert Grahameon 15 May 2023in Levator Ani Syndrome, Paradoxical Relaxation, Pelvic Floor Dysfunction, Pelvic Pain, Prostatitis

Why a disciplined, focused daily program is necessary to have a chance of recovering from pelvic pain (including prostatitis, chronic pelvic pain syndrome, CPPS, pelvic floor dysfunction, levator ani syndrome, pudendal neuralgia, perineal pain among others)
We tell people who do our program that it takes time and diligent practice to have the best chance of a reliable reduction or resolution of pelvic floor related symptoms? Let me summarize what this means. Unflagging daily program over time of myofascial trigger point release and relaxation is the key to helping heal a sore pelvis. If you have pelvic pain, healing pelvic pain needs to be the top priority of everything you are doing using tools that work and a method that cooperates with what the pelvic floor needs in order for it to heal.
In some people, pelvic floor related pain spontaneously and mysteriously goes away with no treatment. Sometimes, it’s a one-time or two-time occurrence, and that’s it. It’s also not uncommon for pelvic pain to reappear later. More often than not, however, pelvic pain becomes chronic and occurs on a daily basis.
Having chronic pelvic pain is typically a very distressing, frustrating, and scary experience. I suffered from pelvic pain for over twenty years. Those were very difficult years. I first developed the method we now use through my experimentation to help myself when I was in a desperate way.
Later, I met with Dr. Rodney Anderson in the Urology department at Stanford University Medical Center with whom I spent eight years. The result of our collaboration was the development of a private immersion clinic that our group has been holding regularly now for twenty years. And significantly, when the normal scheduling of our immersion clinic was curtailed by Covid,-19, a home program was developed not requiring people to come to see us in person. Gratefully we continue to do our in-person clinic 8 times a year.

It’s important to understand that there has never been an effective treatment for muscle-based pelvic floor pain in the history of medicine. In my experience few doctors have an interest in this problem, really understand what it is and what is needed to resolve it. You can’t see pelvic pain like you can a broken bone which includes conditions named prostatitis, chronic pelvic pain syndrome, CPPS, pelvic floor dysfunction, levator ani syndrome, pudendal neuralgia, perineal pain among others)

No visualizing technology like an X-ray, CT scan, MRI, or sonogram can detect it. No blood, urine, or other fluid tests will pick it up. So, pelvic pain is essentially invisible to the doctor. If you are a doctor and a patient complains of pelvic pain and a variety of peculiar symptoms, which you yourself have never experienced, but you can’t detect the problem with your eyes or regular tests, then you have to project a concept of what’s wrong with the patient. If the concept you project is wrong, the solution won’t work. In our book A Headache in the Pelvis we say that open-heart surgery on someone with heartburn isn’t a good idea – you need a correct understanding of the problem to effectively treat it. And if you’ve never suffered from pelvic pain, it is very difficult to understand what it is. Our view of pelvic pain comes from my decades long first-hand experience and of my recovery from it.
Pelvic-floor pain has no conventional recognizable pathology associated with it other than the obvious misery of that the sufferer complains of. It has been clear to me for many years that pelvic floor pain is a stress-related disorder that tends to occur to sensitive, ambitious, successful, conscientious, deeply felt, people who inadvertently and repeatedly tighten their pelvic muscles over years when they get anxious. Over time, this anxiety-driven tightening causes the pelvic muscles to shorten, form painful trigger points, become irritated and remain in a chronically painful and tightened state.
In our program, patients learn to physically release these chronically tightened pelvic muscles themselves by inserting our FDA certified/approved Internal Trigger Point Wand internally and actually press on the painful trigger points in the pelvic floor in order to release them. Our patients use our FDA certified Trigger Point Genie to do external trigger point release of the external muscles that are connected to the painful pelvis. This goal of this treatment is to repeatedly physically restore pelvic muscles to a normal ease and tone. When the pelvic muscles are not chronically tightened, trigger pointed and sore, they don’t hurt.
But the physical untightening, I know from personal experience and the observation of many patients I’ve seen over the past 30 years, is not enough to restore the normal tone and ease of the pelvis. In addition to physically working in the pelvis floor and related muscles, in is generally necessary for most patients to daily reduce the arousal of their nervous system. To this end we teach them a method called Extended Paradoxical Relaxation. Extended Paradoxical Relaxation borrows from my teacher Edmund Jacobson, developer of Progressive Relaxation and who is considered the father of relaxation therapy in the United States.

We originally thought of calling our book TMJ of the Pelvis instead of A Headache in the Pelvis. It is helpful to understand the need for ceasing the anxiety driven clenching of the pelvic floor by seeing that even if you are able to release the shortened contracted muscles of the jaw when you have TMJ, unless you stop clenching your teeth, all of the work of loosening the muscles of the jaw won’t stop the jaw pain.
I suffered with pelvic pain for over twenty years – bumbling through a series of incorrect diagnoses and treatments. From what I learned, I want to discuss the nature of pelvic pain and what I believe are the requirements to resolve it. It has been my experience that it is necessary to have the discipline of doing a daily program to release the painfully tightened and trigger-pointed muscles in and around the pelvic floor alongside a daily program providing significant daily time of significantly reduced or no anxiety if you want to have a chance of resolving the vexing problem of pelvic-floor pain and dysfunction. As it is with stopping teeth grinding/clenching in TMJ to stop jaw pain, so one must stop the ‘grinding’ of the pelvic muscles along with the releasing of the pelvic trigger points in order to stop pelvic pain. This is not a small thing to do. But it is possible.
Said very simply, pelvic floor pain is a condition in which the center of the body chronically, what has been called the ‘core’ of the body, physically tightens and ultimately isn’t able to relax. Again, this is all driven by anxiety. At a certain point, often triggered by intense or prolonged stress, this chronic tightening doesn’t untighten and becomes a chronic painful normal state. This is a different paradigm than is conventionally held of conditions with the names including prostatitis, chronic pelvic pain syndrome, CPPS, pelvic floor dysfunction, levator ani syndrome, pudendal neuralgia, perineal pain among other diagnostic terms.

This pelvic tightening throws a monkey wrench into the normal feeling of ease, and into normal functions that the center of the body is involved in like urination, defecation, sexual arousal and orgasm, balance, and even sitting. This disorder is labeled differently by doctors having different sub-specialties – the names include pelvic floor dysfunction, prostatitis/CPPS, anorectal pain, levator ani syndrome, or pudendal neuralgia among others. In pelvic pain patients, the center of the body is unhappy — the nerves and muscles of the pelvic floor are in a state of what could be called ‘freeze’ in the famous distillation of the stress response as fight, flight, freeze.
The pelvic floor muscles are in a state of freeze. This tightened, painful state becomes the unhappy normal state, and is fed hourly and daily by chronic pelvic tightening fed by pain, anxiety, and sore, irritated tissue. It is further exacerbated by the underlying worry that nobody understands what’s going on, nobody can help, and it will never go away.
This all brings me back to why I am saying here that a prolonged and concerted effort is needed to have the best chance of resolving this problem. In a word, it is a very big deal to change how you hold yourself in the center of your body, and to change the reflexive habit of how you automatically tighten yourself physically up as you worry. In our program, addressing chronic pelvic pain involves the very big job of calming down the body physically as well as mentally and emotionally on a daily basis – a problem that conventional medicine isn’t very helpful with. In my experience, the anxiety driving the protective guarding response of pelvic tightening isn’t resolved through medication. In fact, drugs often worsen someone’s pain as the medication stops being effective, and most typically becomes addictive.
Easing the chronic tightening of the pelvic-floor muscles in the core of the body and the related muscles requires a concerted and long-term daily effort of releasing them and reducing anxiety on a daily basis. There are ups and downs. There are flare-ups. There are periods of great optimism and periods of anxiety related to flare-ups or lack of progress as it appears in the moment. All this needs to be understood and accepted, and the practice of releasing the sore, tightened muscles and quieting the nervous system must nonetheless be doggedly pursued.
In my view, a daily quieting of anxiety and nervous-system arousal must be done. For any long-term resolution of pelvic-floor pain, focusing on only the physical release of the pelvis (which itself requires skill and patience and knowledge) is not enough. Again, pelvic pain is ultimately a stress-related disorder, and addressing the physical pain without providing the pelvis with a stress-free/guarding-free environment every day is like continually cleaning up spilled water from a leaky faucet rather than replacing the leaky faucet.
I myself was dogged in treatment of myself when I was symptomatic because there was really nothing else to do. And gratefully, I now sit here and write this essay without pelvic pain.
Pelvic pain doesn’t occur overnight, even if for some it feels like it does. I like the aphorism, “the fruit falls suddenly, but the ripening takes time”. While there are no studies about this, I believe it takes years of chronic tightening from anxiety to create chronic pelvic pain. Similarly, when pelvic pain heals, it doesn’t heal overnight. Healing pelvic pain takes dedication, trust, and a significant amount of time every day doing what is necessary to address the problem – physically releasing the painfully tightened pelvic muscles, yes, and simultaneously interrupting the habit of chronically tightening the pelvic floor. This means taking the time to give the sore pelvic tissue an opportunity to be free from anxiety, and to heal. This concept applies to conditions including diagnoses of prostatitis, chronic pelvic pain syndrome, CPPS, pelvic floor dysfunction, levator ani syndrome, pudendal neuralgia and perineal pain among others.
There are a number of mainstream treatments for pelvic pain, from taking drugs to undergoing surgery to simply doing physical therapy. However, in my view, the painful pelvis has little chance of healing without the long-term practice of regularly releasing stubborn pelvic floor muscle related trigger points (which is best done by the patient himself or herself), and without the devoted, daily practice of resting in an environment free from the major pelvic irritants.

Relaxation is the healing chamber for chronic pelvic pain after the trigger points have been released

by Robert Grahameon 2 January 2023in Pelvic Pain

Healing pelvic pain means both stopping the local clenched muscular pain in the pelvis and reducing the arousal of the nervous system that is driving the chronic clenching of the pelvic floor.

It is indisputable that when someone has pelvic floor pain, selected muscles inside and outside the pelvis are painful upon palpation (that is when your press on them with an educated finger). The centers of the pain in these painful muscles are called trigger points, which you can think of as rice-grain shaped knots of spasm within a tight muscle. The presence of pain/soreness/discomfort when you press on certain muscle in and around the pelvic floor of the pelvic pain patient, recreating someone’s symptoms, is the definitive criterion we use to determine the appropriateness of our protocol.
As a rule, people who do not have pelvic pain do not have such pain, tenderness and symptom-referral upon palpation in and around the pelvic floor. Furthermore, when the muscles in and around the pelvic floor stop being painful in the person with pelvic pain, it has been our experience over years that pelvic pain has significantly reduced or has gone away.
In order to determine the presence of trigger points and their referral of symptoms upon palpation, one must be skilled at trigger point release, one must understand the location in the pelvis where trigger points reside, and one must be skilled in using correct pressure in pressing on this tissue.
We understand that the overriding question in treating pelvic floor pain is how to ultimately help the pain in the external and internal pelvic tissue go away and, importantly, for it to stay away.
It is important to understand that in general, physical treatment of chronically tightened pelvic and related muscles, while essential in our protocol, is clearly necessary but not sufficient in the long-term resolution of pelvic floor pain. Relief of pain from pelvic floor physical therapy, and sometimes even the flare up of symptoms from pelvic floor physical therapy which is usually indicative of pressing too hard in the pelvis, usually last for a relatively brief period of time.
If, you don’t understand this, then you can get discouraged that the pelvic floor myofascial/trigger point release, sometimes called pelvic floor physical therapy isn’t working. If it affects the pelvis one way or another, it is significant and in our view prognostic. Chronic guarding in the pelvis floor produces pain in the pelvis. My point here is that this ongoing physical release of the pelvic muscles, using myofascial trigger point release, must be combined with stopping the habit of re-tightening these muscles, for any long-term solution.
Said in the simplest terms, the chronically painful muscles in and around the pelvis that are the hallmark of the condition of chronic pelvic pain and occur because the sufferer typically inadvertently and reflexively tightens their pelvis and related muscles all the time, keeping the pelvic floor sore and painful. The inadvertent tightening is fueled largely by the habit of tightening the pelvis under stress and by the sore, painful pelvic floor which tightens on a hair-trigger.
This tightening is ongoing… throughout the day. Pelvic pain is not something that is triggered at one moment in time and mysteriously continues because of this one event. Certainly pelvic floor pain may be set in motion at one moment in time, but it continues as a chronic condition because you are inadvertently fueling it throughout your day in the self-feeding cycle of chronic guarding/tightening, which is potentiated by the hyper-irritable pelvic tissue, which triggers pain, which triggers anxiety, emotional distress and the ruining of any quality of life, leading to more chronic and uncontrolled tightening, pain and anxiety.
Without the regular physical release in these muscles and without the regular and deliberate practice of placing them in in a stress-free environment which is the role of Extended Paradoxical Relaxation, pelvic pain remains chronic. We see relaxation acting like a cast to a broken bone. It provides a healing environment for the healing mechanisms of the body to restore the normality of the sore, chronically tightened pelvic tissue. Extended Paradoxical Relaxation and our training patients to do their own internal and external trigger point release with our FDA approved Wand, is how we help our patients break the pelvic pain cycle. Breaking the cycle of chronically tightening the pelvis, which fuels pain, which trigger anxiety which triggers more pain —breaking this cycle is the whole point of the Wise-Anderson Protocol.
Unfortunately, there is no subspecialty that focuses on both the physical and mental components required to heal a sore pelvic floor. Strangely unless you have suffered from pelvic pain, and have recovered from it, it is difficult to understand what it is and what is necessary to resolve it. Because pelvic pain is invisible and the conventional tests cannot detect it, and the person who never experienced pelvic pain has difficulty in understanding it, the practitioner has to project a concept of what is wrong with the pelvic pain patient to treat him or her. Unfortunately, the current concepts of pelvic pain are either vague or off the mark in my opinion. In my own journey, I had to include, but venture well beyond the existing subspecialties and their ideas for me to get better.
In 2018, we published a meta analysis in the Gold Journal of Urology defining pelvic floor related pain as a psychoneuromuscular disorder—psychoneuromuscular meaning being intimately involved in mind and body. There are few who treat pelvic floor pain as a psychoneuromuscular disorder with a robust program involving both mind, nervous system arousal reduction and the regular releasing the internal and external muscles related to pelvic floor guarding
Extended Paradoxical Relaxation stands on the shoulders of my work with Edmund Jacobson who developed Progressive Relaxation in the beginning of the 20th century, and is the method we have developed over the years aimed at reducing nervous system arousal in someone who is suffering from pelvic pain.
The practice of Extended Paradoxical Relaxation is the method we use to put the pelvic muscles in a regular environment protecting them from having to tighten in response to the stresses of life. Extended Paradoxical Relaxation isn’t an easy or quick method. It must be practiced daily.
This method trains attention to focus on sensation rather than on thought. In the service of calming down an aroused nervous system, it asks those who want to learn how to do it to paradoxically give up attachment to an outcome to achieve the outcome – which is profound relaxation – it is a paradox. It asks to accept tension as the way of relaxing it – another paradox. It asks practitioners to return attention from what distracts them over and over again. Clearly, our method borrows from the storehouse of what all wisdom and meditation traditions that move the body into the relaxation response borrow from.
Extended Paradoxical Relaxation is the practice of effortlessness, the practice of giving the body an opportunity to do nothing while being present in the moment. It is the practice of not thinking, focusing on sensation and away from the movies and words that are the regular narratives of the mind. The instructions we ask patients to follow guide them in resting attention in sensation from moment to moment in order for the body to rest. When attention rests in sensation from moment to moment, thinking reduces, and this practice makes it most likely for the nervous system to shift into the relaxation response. We see this inner quiet as the healing room for the sore pelvis.
It is not well understood that the practice of relaxation or meditation is a profoundly psychological event… for it is the practice of letting go of your own inner defenses. I want to propose what is obvious to me after many years of the practice of relaxation – chronic tension is the expression – usually unconsciously — of not feeling safe and the tension is a primitive way, and not helpful way, of protecting us from harm.
In the lore of yoga, there are energy centers in the body that must remain open to permit the passage of the life force (kundalini) through the body to maintain heath and emotional balance. The centers associated with pelvic pain in the yoga tradition are the first and second chakras. The first chakra has to do with the anorectal area. The second chakra is associated with reproduction and is related to the genitals involving sexuality, creative expression and emotions. Pelvic pain can been seen from a yoga perspective as the blockade of the bodily energy involving the feeling of safety which is the first chakra, and issues around sexuality, which is the 2nd chakra.
When we look at the experience of those with pelvic pain, the issue of existential safety – of feeling safe in life — regularly shows up. The great catastrophic thought of the pelvic pain patient is ‘will I have to live with this pain that I can’t imagine living with’. In my view, the inability to relax is typically related to unconscious concerns about existential safety and survival and the worry that ‘If I relax, I will be vulnerable and can be hurt so I have to keep guarded’. In an upcoming podcast, I will go more deeply into the psychology of the inability to relax and my view of its solution.
Learning to profoundly relax with all of the unconscious inner fears of childhood showing up during relaxation, and in the midst of a world full of scary news and uncertainty is life changing. I say this from my own experience and from my experience working with many patients.
No app or deep breathing reliably brings the nervous system into the relaxation response. There is no royal road to learning to quiet the body and mind. It must be done daily, along with the physical loosening of the body, to have a chance of soothing the nervous system, along with loosening the pelvic floor, to resolve chronic pain and dysfunction in the pelvis.

Understanding the Healing of Prostatitis, CPPS and Pelvic Floor Dysfunction, Levator any Syndrome, and Related Pelvic Pain Conditions, Continued

by Robert Grahameon 17 February 2020in Book "A Headache in the Pelvis", Pelvic Pain, Prostatitis

In my long experience with pelvic pain, before it resolved for me, I had no idea how to stop my pain, it was there, I woke up with it every day, it didn’t go away, some things made it worse sometimes some things made it better or it just got a little better, but it never went away. For years I couldn’t see a way to resolve it. When it finally did resolve, the path of its resolution became clear to me.
We all understand that an intensive care unit in a hospital is a place in which patients who are dangerously ill are kept under constant observation to support their bodies to become well enough to remain alive and healthy without the need for such intensive support. Intensive care is needed to help someone recover their health. The true purpose of an intensive care unit is to support the body’s ability to become well. Let me say that again – the true purpose of an intensive care unit is to support the body’s innate natural ability to become well because the circumstances of someone’s life are jeopardizing and challenging the capacity of the body’s ability to do this.
An intensive care unit is aimed at supporting the body’s ability to heal so that it does not need extraordinary support to remain alive and healthy. Ultimately Intensive care leading to the recovery of someone’s health supports the natural, indigenous ability in the human body to be healthy and alive when it is compromised. We all intuitively understand that we don’t bring germs into an intensive care unit, we don’t play loud music, or we don’t do anything to stress the person who is there. We all understand that undue physical or psychological stress will impair the person’s ability to recover, will impair the body’s ability to restore health. We all understand that undue physical or psychological stress in an intensive care unit is forbidden for good reason. It’s touchy – the body’s ability to recover under certain circumstances, and in order for the body to heal, efforts that are intense and pointed are necessary to kickstart the healing mechanism of the body to be able to support the patients recovery to life and health.

None of us would be surprised in any way if there were a sign that said “quiet” outside an intensive care unit or even to require visitors to put gowns, masks, and gloves on, to not bring in any potential threat to the healing immune compromised person.

In another example, when an injured solder comes back from a war none of us are surprised at the long period of time it takes for the injured soldier to recover. None of us would be surprised that the soldier would be in the sanctuary of a hospital, that the soldier would not be expected to work or do normal duties of life that normally would not stress a healthy person, but would stress someone who is recovering from serious injury or compromise of their body.

When we get the flu most of us know that sleep, rest, liquids are essential to our recovery. We don’t go to work, often staying in the protected environment of bed and rest. What we are doing when we have a cold and take these measures in supporting our body is supporting our own natural healing mechanisms. It’s not the cold medicines that we buy at the pharmacy or the cold medicines that the doctor might give us that do the trick. It’s our body’s amazing ability to recover and heal. And that’s what we do when we protect ourselves in the way that we do when we have a bad flu for instance.

In the intensive care unit the case of an injured soldier who comes home from war or in the case of our battle with the bad flu, we may not recognize it explicitly but we honor and support and cooperate with the healing mechanism of the body to cure itself. In the age of modern medicine, we often forget this. We attribute all kinds of power to the drugs and healing devices that have been invented in modern times, but we forget that those are all just the servants of the healing mechanism of the body. This is what the important thing I’m saying here. Whatever we do in the intensive care unit or the hospital for an injured soldier, or for our own struggle with a bad flu, without the body being able to heal itself, none of our efforts would matter. We serve of the body’s ability to heal in the intensive care unit, the soldier’s hospital stay, or our attempts to heal ourselves of a bad flu.

Now pelvic pain doesn’t seem like a problem that requires healing in the same way as the examples that I’ve just discussed. I believe this is because pelvic pain is invisible, doctors can’t see it, friends can’t see it, doctors can’t find any abnormality either in the normal manual examination of a patient or in all the standard medical tests or standard visualizing tests used in contemporary medicine.
What is typically overlooked in understanding chronic pelvic pain is why the pelvic tissue is sore in the first place. What caused it? Why does it remain sore? It is accepted that chronic pelvic pain tissue is sore, it keeps being sore, and there isn’t much understanding about it.

If you pull a muscle or overdo exercise and your arm or hand or leg or back gets sore, you might baby it, not stress it, in other words, you would cooperate with the mechanism of the body that heals a sore arm, or neck, or back by mobilizing it, not stressing it, not using it so vigorously. You might not think that you are cooperating with the body’s capacity to heal sore, painful tissue, but in fact you are. A splint or brace or even a cast for a broken bone are all efforts to help the body’s natural healing mechanisms heal the problem. Most people don’t explicitly give a lot of credit to the body’s ability to heal but everyone goes to great lengths to support this ability of the body when they are injured or hurt even though they may not explicitly say “I am honoring the body’s ability to heal”.

It is peculiar that conventional thinking of chronic pelvic pain doesn’t recognize the need to support the body’s ability to heal itself. In the Wise Anderson Protocol, we train our patients to be servants of the body’s ability to heal the sore and irritated pelvic tissue. After all, when the sore and irritated pelvic tissue stops being sore and irritated, pelvic pain stops existing. Pelvic pain is essentially sore irritated pelvic tissue that hurts and that interferes with the normal functioning of urination and defecation and sexual activity and sitting and management of stress that otherwise it wouldn’t be affected by. What needs healing is the sore tissue that has occurred typically because chronic tension in the muscles of this tissue has made it sore and this process is invisible, it can’t be seen.
In our Protocol we support the healing of the body in pelvic pain by essentially training our patients in three methods: physical intervention; behavioral and mental intervention, which we call “extended paradoxical relaxation”. And, implicitly, we want to offer a new the viewpoint of what pelvic pain is, what needs to be done for it so that we help head off the normal catastrophizing and fear that people have about this very distressing disorder.
The problem with pelvic pain healing is that for a good part of a person’s day there are things that interfere with the healing up of this tissue, namely urination with some people, defecation with some people, sitting with many people, anxiety, which is a huge exacerbator of this problem. And sexual activity often exacerbates the condition. When somebody is anxious the tissue does not relax. The tissue remains tight and irritated. And the catastrophizing that occurs with many people like “they’re never going to get better, that no one understands, that the doctors can’t help, and woe is me, what am I going to do? What’s the matter with me”?
With some peoples continued activity like bodybuilding, bicycle riding, and other things that stress the pelvic floor are all things that normally don’t have any negative affect on the pelvis and in a pelvis that is not disordered like it is in pelvic floor dysfunction. But it can be a problem when you have pelvic floor tenderness and pain. So, the healing that is required for the sore pelvic floor is typically interrupted all day in the life of the person suffering from chronic pelvic pain. Imagine somebody in the ICU who is carefully monitored and supported in healing at 9:00 in the morning and at 9:00 in the morning has to deal with somebody coming in and saying “ok you have to go to work, get in a car, deal with all the stresses of life, and when you come back at 6:00 in the evening we can again support your healing in the ICU”. This would be a joke. The same would be true in our attempts to support the healing with a bad flu or a soldier recuperating from wounds, we wouldn’t think of doing this.
But in my view, this is what the pelvic pain patient is subject to. So, the two to four hours of self-treatment that we ask our patients to do, a huge requirement, which involves loosening the tightened tissue that needs to be loosened in order for it to heal and then reducing the inner turmoil triggered by an aroused nervous system continually stoked by catastrophizing, and the inherent arousal of the nervous system because of chronic pain, is a minimum time required for healing and this is why the healing takes so long. Because when you’re doing well, you’re moving ahead three steps and you’re moving back two steps in dealing with all of the stresses that continue to irritate the tissue during a normal day.

If you could put someone in an quiet environment protected from the stresses of normal life, supported them emotionally and physically, and this is a big if, I believe pelvic pain would heal up.
Because you can’t see what needs healing in the pelvic floor pain patient and because the pelvic pain patient can work and function, albeit, with a silent, very large cost to the patient, chronic pelvic pain remains chronic. In my view, supporting the healing of the body must be the ultimate focus of someone struggling with pelvic pain. And this is not a small matter. How do you calm a nervous system down and a tightened, painful pelvic floor in a person who has no experience in doing this.

Doing physical therapy to loosen the pelvic floor takes training and the right tool. Loosening the hypertonic pelvic floor has to be taught. You have to learn how to find the tissue, you have to insert a device inside the pelvic floor. It’s a challenge at first. you have to learn how to do it, but in our protocol, it is routinely done. You’re basically going into a sore area and releasing it. And you can’t do it too hard. And you can’t do it too softly. And practicing relaxation and getting very quiet is a life changing practice that requires training and support. It’s a commitment to peace. Many people are not ready to make that commitment. And then the nervous system has got to get used to being quiet, the nervous system used to be vigilant, will often rebel against being quiet, not anxious or fearful.

These are the real obstacles – the absence of an understanding and the creation of an environment – to heal the pain associated with diagnoses like prostatitis, CPPS, levator ani syndrome, and other chronic pelvic pain diagnoses. The healing of the sore and irritated pelvic floor — which is the common thread passing through all of these diagnoses —- requires making the body a regular healing environment. The healing of the painful pelvic floor involves loosening the pelvic floor tissue, releasing related trigger points inside and outside the body related to the pain and creating a healing chamber in which you regularly rest, a healing chamber that is quiet emotionally that peaceful, not guarded. It’s a major event in life to do this. This is why pelvic pain is a major event in life that in the most optimistic viewpoint provides us with the opportunity to be able to find peace inside to allow what is sore and irritate to heal.

You are the environment in which your pelvic pain heals or does not heal

by Robert Grahameon 14 January 2020in Book "A Headache in the Pelvis", Pelvic Pain, Prostatitis

In the original version of our book A Headache in the Pelvis, we described pelvic floor pain as a condition in which the tissue of the pelvic floor is caught in an inhospitable environment of chronic contraction, pain, and tension. We stated simply that our therapeutic approach – called the Stanford Protocol by some, and we call the Wise-Anderson Protocol – aims to turn this unhealthy environment into a hospitable one to permit the healing of sore, tightened tissue.

Many years after we originally wrote that first edition, and after treating several thousand additional patients, many new observations and insights have emerged, and we’ve found different ways to describe the onset and perpetuation of this invisible condition.

If you have pelvic pain, and your pelvic floor muscles are locked in a self-feeding cycle of tension, anxiety, pain, sore tissue, and protective guarding, then it’s an important but often-overlooked observation that you are the environment in which this condition exists. You are the environment in which this sore, painful tissue can or cannot heal. As a result, you needn’t be a passive participant to resolving your condition.

I experienced pelvic pain for over 20 years. Every day, I was in pain, distracted, and living with an underlying feeling of dread that I would never recover my life. Inwardly, I felt like a mess. Doctors had nothing to offer me. They told me that my conditions was related to my prostate gland – something I later discovered was untrue – but they also seemed uninterested in my pain, and more than happy to see me leave their office. Knowing what I do know now, I think my sense about the doctors was correct: they weren’t interested in my situation, they didn’t understand it, and they could do nothing to help. In fact, they offered the faulty diagnosis that somehow this was a prostate-related problem for which there was no solution. When you’re a doctor and someone comes to see you with a condition you don’t understand and can’t help, you naturally withdraw. I still clearly remember the first time I went to see a doctor about my pelvic pain. He talked to me, examined me, and very quickly said to his nurse, “Next patient.”

I went to these doctors as an anxious and frustrated patient. I had the idea that my condition was mysterious and arbitrary – that it had nothing to do with the state I was in. I didn’t understand that my inner state had everything to do with my chronic symptoms. But, no doctor I saw understood this either.

What does it mean that my inner state led to my chronic condition? Consider a more straightforward example: if you tightened your hand into a fist for a year, the tissue of your hand would be sore, irritated, and painful. That’s just common sense. Further, if you kept maintaining a fist, this sore tissue would remain irritated and painful – that pain isn’t going to heal. This continually tightened fist is the environment that the sore, painful hand and fingers exist in.

The same situation exists with pelvic floor pain: the patient’s tightened, anxious, nervous state is the environment that interferes with the healing of the tissue. Furthermore, normal activities of life exacerbate the pain and irritation of sore pelvic tissue. Sitting, walking, lifting, and balancing are all potentially irritating to the already sore pelvic floor. Additionally, a subset of people with pelvic pain have post bowel movement pain, post urination pain, post orgasm pain, and even sitting pain – activities that are part of regular life and normally cause no pain or difficulty. With pelvic floor pain and dysfunction, these activities contribute to the inhospitable environment that interferes with the pelvic floor.

And, of course, there is also anxiety, sleep disturbance, and the deep psychological distress that most people with pelvic pain endure. Anxiety and nervous arousal are a huge exacerbator of pelvic floor pain. Gevirtz and Hubbard demonstrated in a watershed study that relaxation quiets electrical activity in trigger points, while anxiety hugely heightens electrical activity.

All of this is what I mean when I say that you are the environment in which your pelvic floor tissue can heal or remain irritated. Our approach asks a very big sacrifice – that patients devote at least two hours every day to applying competent, self-administered physical release and practicing relaxation.

When I had pelvic pain, I went to the doctor and hoped that the doctor would just fix it. I wanted to simply say, “Here it is doc. It’s your problem, now.” A doctor who understood pelvic floor pain would have replied, “You will have to create an environment inside yourself, every day, to allow the sore and painful tissue to heal.”

It’s true that pelvic floor pain can go away on its own without treatment. There are people who practice no self-treatment and just get better. It’s also true that some patients get better in a variety of ways – from doing physical therapy to changing jobs and other apparent interventions. In my experience, however, those people are a small minority of pelvic pain patients. For the majority of patients, no one else can ultimately fix the problem. It’s like brushing your teeth – yes, someone else can show you how to brush and floss, but ultimately there is no one who can do this for you in your life except you.

We are the environment in which our pelvic pain exists, and in my view this environment in which we exist day-to-day is the central factor that facilitates the healing of pelvic pain. Skillfully loosening the relevant tissue inside and outside physically and providing regular and significant daily time in which the body becomes quiet and relaxed is necessary for most cases of pelvic pain to significantly improve and resolve.

How Plato Inadvertently Points to the Healing of Pelvic Pain

by Robert Grahameon 30 December 2019in Pelvic Pain, Prostatitis

Plato reportedly said, “Be kind, for everyone is fighting a hard battle.” What he meant is that for many people, underneath the surface is a struggle that isn’t visible. Inside each of us is a daily fight to deal with survival and the many obstacles in life, and the unseen interior efforts to overcome them.

My experience with pelvic pain – both professionally and personally – has made clear to me that the battle Plato refers to is more than just psychological, but also physical. It is intuitively obvious that stress can kill you or make you sick. We’re not surprised when an especially stressful event occurs and someone gets sick or even dies from it. There is an indisputable physiological component to stress: major blood vessels constrict, blood pressure elevates, the immune response is weakened or postponed, and adrenaline pumps into the bloodstream. This inward “fight, flight, or freeze” response to stress can take a huge toll on our health.

In my view, pelvic pain typically arises out of this inward battle. When a person is at peace and life is good, the muscles of the pelvic floor are relaxed and perform the functions of urination, defecation, and sexual response easily and comfortably. The pelvic floor feels good. However, when certain people deal with the challenges of life, and anxiety arises – which is just a fancy word for fear, and typically has little to do with actual survival – then the pelvic floor tightens.

Prolonged tightening in the pelvic floor leads to irritation of the pelvic tissue and then pain, setting the pelvic pain cycle in motion that makes pelvic pain chronic. One of the challenges for those suffering from pelvic pain is that there are no outward signs of this inner battle. Some physicians discount the pain that a patient describes because there are no outward symptoms that the physician can detect. The battle inside, however, is real.

So, the injunction to be kind to others because of the battles they deal with inside also speaks to the best treatment for pelvic pain. The Wise-Anderson Protocol is a method that operationalizes kindness to our own inner battle. Through careful instruction in pelvic floor and related physical therapy self-treatment, we teach our patients to gently physically loosen the painful inner and outer knots connected with pelvic floor pain. In order maintain this eased state long enough for the sore pelvic floor to have a chance to heal, we also teach our patients to quiet body and mind using Extended Paradoxical Relaxation.

Plato’s point is an excellent metaphor for thinking about how to heal pelvic floor pain. It’s important we recognize the inner battle fought by the pelvic pain patient, and apply a method to bring kindness and healing to it.

SURGERY IS NOT A GOOD IDEA FOR TREATMENT OF MUSCLE BASED CHRONIC PELVIC PAIN

by Robert Grahameon 4 December 2019in Pelvic Pain

After consulting with my physician colleagues in our program about our experience with many patients who have undergone some surgery or invasive procedure for their pelvic floor related pain, it has been our conclusion that there is no convincing basis for a surgical approach to treating chronic pelvic pain syndromes. While there are obviously circumstances in which surgery is called for related to cancer or pelvic related repair, we have never seen a positive surgical outcome in the 25 years we have treated many patients for idiopathic pelvic floor pain in which no pathology is found. Although ours may not be a representative sample, in our experience the overwhelming majority of patients we have seen have expressed regret about their particular surgical intervention and often found it hurt them.

The pelvic pain symptom complex we treat has been blessed with several descriptive names including pelvic floor dysfunction, chronic pelvic pain syndrome, chronic prostatitis/CPPS, urologic chronic pelvic pain, syndrome, painful bladder syndrome, coccydynia, pudendal neuralgia, chronic proctalgia, levator ani syndrome, pelvic floor dysfunction, pelvic floor myalgia, anorectal pain, dyspareunia, to name a few. The aggravating sensory pain may be associated with several anatomical sites including genitalia (scrotum, penis, and urethra), perineum, anus, groin, suprapubic region, bladder, psoas muscle, and even into the upper thigh. Normal genitourinary and intestinal function may be disturbed at the same time, manifested by urinary frequency, urgency, incontinence, sitting pain, nocturnal voiding (often labeled overactive bladder), bladder pain with filling (often diagnosed as interstitial cystitis), incomplete voiding, erectile dysfunction, painful ejaculation and disturbances in ejaculatory function as well as sexual arousal and orgasm and, of course, irritable bowel syndrome and anorectal pain and dysfunction.

Our experience over a period of twenty five years and treating several thousand patients suggests that some of the unfortunately worst patient cases of recalcitrant chronic pelvic pain have occurred following what we regard as misguided attempts at a surgical cure.

Typical examples of what we believe to be inappropriate and misguided surgical treatments we have documented include:

 Total Prostatectomy

 Transurethral resection of prostate tissue

 Orchiectomy for testicular pain,

 Coccygectomy for tailbone pain,

 Varicocelectomy for penile/testicular pain

 Surgical excision of prostatic calculi

 Ileostomy for post bowel movement pain

 Vascular reconstructive surgery for men with erectile dysfunction

 Hysterectomy for female pelvic pain

 Urethral surgery for slow urinary stream or urinary symptoms related to pelvic pain and no urodynamics documentation

 Pudendal nerve decompression surgery

Scrotal operations to remove epididymis or testis

In our experience, It should be noted that every one of these documented surgical attempts at treatment, failed to alleviate the pelvic pain and, often produced worsening and more complexity of the pain syndrome. Agreeing to failed surgery has typically occurred with anxious and desperate patients seeking relief at any cost while simultaneously not seeing being educated about the risks or reports in the research about poor outcomes.

The choice of surgery misunderstands the nature of chronic, muscle based pelvic pain. It sees the problem of chronic pelvic pain as a condition in which something has gone wrong in the pelvis that must be surgically treated. This viewpoint, in our view, is out of touch with the real nature of this disorder.

Over viewpoint, that comes from many years of treating thousands of patients, and first shaped by my own recovery from chronic pelvic pain after suffering with it for over 20 years bears no resemblance to the view point of those who have advocated surgery. In the viewpoint of those of us who use the Wise-Anderson Protocol, chronic pelvic floor pain occurs because the tissue in the pelvic floor is irritated and sore because the pelvic tissue has been tightened in a posture of chronic muscular guarding. This typically is related to years of anxiety and sometimes in response to an insult or injury to the pelvis.

With people who have pelvic pain, worry tends to show up physically in the muscles of the pelvis, which tighten whenever you get anxious, just like the muscles in the pelvis of a dog tightens to pull the tail between the legs when the dog is frightened. This tightening isn’t debilitating – we’re talking about a slight but noticeable guarding and tension. However, for those who are chronically worried or anxious, over time little knots occur in pelvic muscles that are habitually tightened. We call these knots trigger points and they are sensitive to emotional distress. In a watershed study with hundreds of subjects on the relationship between emotional distress and trigger-point activity, Richard Gevirtz and David Hubbard found that when emotional distress is heightened, trigger-point electrical activity is profoundly heightened as well. This is likely why many pelvic pain patients experience a worsening of symptoms with increased stress.

Other than pelvic floor pain that occurs as the result of an injury or insult to the pelvic floor, pelvic floor related pain is strongly associated with worry-related pelvic tightening over a long period forming trigger points and an inhospitable environment in the pelvic tissue. This worry-triggered tightening produces tissue that becomes uncomfortable, sore and hyper-irritable.

It is overwhelmingly the case that people with pelvic floor pain have sore, irritated, trigger point laden pelvic floor tissue easily detectible by an experienced and skillful practitioner of trigger point release. We have seen many patients who were unaware of their pelvic floor trigger points and areas of restriction until they came to see us and were examined by our doctor and physical therapist. In our book, A Headache in the Pelvis, we have illustrated the different anatomical locations of trigger points in relationship to someone’s symptoms. In 2009, we published an article in the Journal of Urology documenting painful pelvic floor trigger points in relationship to someone’s symptomatic complaints (J Urol. 2009 Dec;182(6):2753-8. doi: 10.1016/j.juro.2009.08.033)

What is not well understood – but becomes obvious when you look at people with pelvic pain – is how irritated, sore and hyper-reactive 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 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, anxiety, pain 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, recently revised and published by Penguin/Random House/Harmony books in a definitive edition. Once established, the sore tissue triggers reflex protective guarding, producing pain and dysfunction, leading to more guarding against the pain, triggering anxiety that profoundly irritates the trigger-pointed pelvic tissue which then leads to more tightening. Once pelvic floor pain occurs, it takes on a life of its own and is generally not responsive to conventional treatment. Surgery for pelvic floor dysfunction in our view, may be among the worst things to do to an already painful, sore and tightened pelvic tissue.

It is the healing of the sore, irritated pelvic tissue that is the answer to pelvic floor pain

It is the support of the natural healing of this sore, irritated tissue that is the answer to pelvic floor dysfunction. Facilitating the healing of this tissue, in our protocol, is the point of treatment. In order for the tissue to heal, the chronically tightened pelvis must be physically loosened and the trigger points and myofascial restriction must be released on an ongoing basis. In the Wise-Anderson Protocol, we loosen the tissue by teaching patients to do their own internal and external trigger point release. This method is described in other writings, podcasts, and in our book, A Headache in the Pelvis. In conjunction with regularly loosening the sore pelvic tissue, an environment that allows the sore tissue to heal must be regularly provided, free from the reflex and default tightening of the sore pelvis in people with painful pelvic tissue. This is why we ask our patients to practice the method of Extended Paradoxical Relaxation, that allows the tissue remain undisturbed by the many stresses and strains of ordinary life that keep the sore pelvic tissue from healing. In our view, surgery has no place in the healing process of hypertonic muscle based pelvic floor pain.

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

by Robert Grahameon 5 November 2019in Pelvic Pain, Prostatitis

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

by Robert Grahameon 20 August 2019in Pelvic Floor Dysfunction, Pelvic Pain, Prostatitis

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 20^th 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.