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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

Who gets prostatitis/CPPS and why

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

 

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

 

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

 

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

 

Pelvic Pain is a Squeezing in the Core of the Body

 

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

 

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

 

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

 

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

 

The solution we offer to the sensitive person suffering from chronic pelvic pain is both physical and mental and aims to release the sensitive inner core of the pelvic pain patient from its worried, irritated constriction. We teach our patients to regularly physically release the trigger points, muscle constriction and guarding inside the pelvic floor. Equally important we teach our patients to mentally/behaviorally, to practice a method called Extended Paradoxical Relaxation, whose aim is to regularly bring sore pelvic tissue into a healing inner environment in which the nervous system has shifted to the relaxed parasympathetic activation. In patients we treat whose pelvic pain significantly reduces or resolves entirely, the ongoing practice of Extended Paradoxical Relaxation cannot be avoided in order to allow the pelvis to remain relaxed and pain-free in the midst of often-stressful lives. While I don’t have pelvic pain anymore, I practice Extended Paradoxical Relaxation daily and love doing it. If I did not manage my type A personality and tendency toward anxiety by doing this, I think I very well might become symptomatic again.

 

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

Why Pelvic Floor Dysfunction (Often Confused As Prostatitis) Takes Time to Develop and Takes Time To Heal

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Pleasure Anxiety

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

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

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

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

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

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

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

 

When pelvic pain goes away, the sore pelvic tissue heals

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

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

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

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

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

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

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

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

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

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

Reducing nervous arousal to heal pelvic pain

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

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

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

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

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

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

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

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

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

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

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

 

Pelvic Pain is a Squeezing in the Core of the Body

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

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

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

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

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

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