The healing of pelvic floor pain is easy to understand

Pelvic pain is invisible. It can’t be seen, it can’t be visualized with fancy technologies, there are no fluid tests for it; it’s a difficult phenomenon to understand if you’ve never had it. I want to use a metaphor here that I’m hoping is easy to understand, to understand the less easily understood phenomenon of muscle-based pelvic pain.

 

The metaphor of the sore arm

Imagine that you’ve had an accident and you’ve fallen down on your side and as a reflex you put your arm out to protect yourself. You certainly survive, everything is basically ok and nothing is broken, but your hand and wrist hurt and your shoulder has a big bump on it and is very painful. Your whole arm is sore and you’re miserable. You go to the doctor, who says that you’re fine, just take care of it, let it rest and it will heal up. Its all intuitive, it all makes sense.

 

Healing the sore arm

So, the doctor suggests that to help things heal faster and for you to be more comfortable, you put your arm in a sling. In the sling your arm can relax and will be protected from movement and the bumps and grinds of life. It isn’t hard to understand that if your arm gets bumped, it will hurt.   When you see your affectionate aunt who wants to hug you, you say, “Wait,” and you give her a peck on the cheek and tell her you hurt your arm and she shouldn’t grab you and squeeze you like she usually does. You don’t want her to irritate your arm’s healing.

 

Protective guarding and the sore arm

Drawing away from what might hurt your arm is a reflex; you want to protect your arm against what might jar it because you know it will hurt if something does bump against it and irritate what is already sore and irritated. You go around with pain in your wrist and arm and shoulder feeling vulnerable. You notice you protectively guard your arm and shoulder, especially in public, during this period while they are healing up. Guarding means tightening up, tensing it up, being on alert for anything that might hurt it.

 

You notice that if you put it in a certain position or inadvertently bump it against something, you tighten up. In other words, any increased pain makes you tighten up to protect your arm. Let’s call this protective guarding; you guard to protect. This means the muscles tighten up to protect and this is instinctive. You notice you are doing this self-protective guarding without even being conscious of it, it just happens out of awareness. It’s just a reflex of the body to protect itself from being hurt more, when a certain part of the body has been injured or hurt.

 

If you keep it protected over time, it heals. If you don’t protect it, it likely will continue to hurt. If you do take care of it, you stop being so guarded, and eventually you forget about it and you go back to the way you’ve been in the world, not thinking about your shoulder, not tightening it up, not protecting it, not pulling it away from what might hurt it. So the sore arm and shoulder that got hurt, then got better.

 

Comparing the painful pelvis to the sore arm

Now I want to talk about a situation in which the pelvis hurts and is sore, irritated, and increases in pain when you do certain things that are just normal, everyday activities that everyone does. For some people with muscle-based pelvic pain, sitting down hurts. Other people aggravate the pain in the pelvis when they have a bowel movement. Or conversely, sometimes a bowel movement helps. Sometimes urination makes it feel better, sometimes it makes it feel worse. Or when trigger points, which we have extensively discussed elsewhere are in a certain location, for some people orgasm can irritate pelvic pain and make it feel worse. Stresses in life and anxiety can make the pelvis hurt a lot more. Again, all of these things we have explained elsewhere. But these are things that are not a the normal kind of bump, like the bump against your sore shoulder or arm. There are these other things in life that flare up pain in a sore pelvis but they are distressing because they don’t seem to make sense and don’t feel normal.

 

Unlike a shoulder and wrist that were injured when you fell on them, then healed when you rested and took care of them, chronic pelvic pain most simply called pelvic floor dysfunction doesn’t heal up. Why?

 

The relationship between protective guarding in the sore pelvic and the sore arm

In the pelvis something different occurs in response to pain that doesn’t seem to occur in other parts of the body quite like it does in the pelvis. What occurs in the pelvis, different from what occurs in the sore arm, is an instinctive, very sensitive reflexive tightening against anything that feels strange or uncomfortable. This is what I refer to as the reflex-guarding of the pelvic tissue against its own sensation of pain. In other words, when you tighten up the pelvis when you’re anxious, and it stays tight for a long period of time and the muscles become sore, that sore irritated tissue in the pelvis tightens up protectively as a defense against its own pain. It’s not a very good design. Where the instinct to protect a sore arm and shoulder helps healing and is protective, I’ve often thought the reflex guarding of the pelvis against soreness generated by its own chronic tightening is a kind of flaw in the human design because the guarding against the pain makes it worse.

 

Physical bumps cause protective guarding in the arm; anxiety and an aroused nervous system ‘bumps’ the sore pelvis

So, either through chronic anxiety and worry (which again, we have discussed elsewhere) or through injury, the tissue of the pelvis involves the tightening up of certain kinds of muscles and parts of the pelvic floor. It involves a tightening up of the muscles around the genitals and anus, often including the internal pelvic floor muscles called the piriformis, the obturator internus, the levator ani muscles, the coccygeal, levator ani, puborectalis and related internal muscles. The muscles of the lower abdomen are often also involved including the rectus abdominus, and suprapubic muscles. Other muscles including the quadratus lumborum, the iliacus, the psoas get into the act. Many of these muscles can tighten up in concert and remain tight and can feed into the internal muscle hypertonicity and pain. In our experience, when you have pelvic pain all of these muscles have to be dealt with when they are part of the ‘fist’ of muscles that has chronically tightened up if you want to heal the sore pelvis. These muscles tighten up and become painful. They often refer pain and sensation back inside the pelvis and are all part of a complex of tightening and protective guarding against the pain in the pelvis.

 

 

Unlike the arm, pelvic pain and protective guarding is strongly provoked and perpetuated by anxiety and the arousal of your nervous system. Anxiety and nervous arousal that irritate, perpetuate and increases pelvic pain are equivalent to ‘bumping the arm’ when the pelvic floor muscles are irritated and tight, except you don’t even have to move or be bumped to have the pain in the pelvis exacerbated by anxiety. Anxiety and nervous arousal are themselves the bump. While anxiety and nervous arousal may slightly increase the discomfort of a sore arm or shoulder, anxiety and nervous arousal strongly increase the pain, protective guarding and tightening in the pelvis. And people who chronic pelvic pain often catastrophize and worry constantly. The relationship between anxiety and pelvic pain is not at first intuitively obvious.

 

One way to understand pelvic pain is to look at, for instance, a frightened dog who pulls its tail in. The pelvic floor tightens up in a dog to pull the tail in. Similarly, when a certain group people are chronically anxious, their ‘tail’ pulls in.

 

Pelvis pain can be seen as a condition of a tail chronically pulled between the legs

In the case of a human being, pulling the tail in means the tailbone is pulled forward when the pelvic floor tightens. The arm heals relatively quickly when more or less left alone. What is important to understand is that pelvic floor muscles don’t get a chance to heal up because they are continually irritated and held in a guarded, tense and protected state, by all kinds of activities that are just normal activities of life; activities like defecation, urination, sexual activity, sitting, the normal stresses of life, and sometimes even certain kinds of physical activities. Intimately involved, in addition to the activities of life, the formation of knots inside the muscles called trigger points. These knots form and remain irritated and perpetuating pain until they release and go away. Once formed however, for the most part, they stick around unless they’re specifically treated to release.

 

The self feeding cycle of protective muscle guarding and a sore pelvis

So, you have a whole series of factors that bear down on the poor, painful pelvis and stop the painful tissue from healing. What needs to heal is not serious or pathological. But it is sore and painful. In our book at A Headache in the Pelvis and in our other writings, we have talked about the self-perpetuating pelvic pain cycle; a cycle that once it gets going, takes on a life of its own. Sore pelvic tissue triggers its own tightening and protective guarding, which triggers more pain, which triggers anxiety and worry about whether it will ever go away, which is variously aggravated by going to the bathroom, not being able to sleep through the night, sitting down, sex and the stresses of life. These stresses represent an onslaught of perpetuating factors that keep pelvic pain going and give it a life of its own.

 

When you have pelvic pain, like I did for over 20 years, there’s not a lot more to do sometimes than to try and figure this out, and I don’t think that most people don’t figure it out. How you deal with pelvic pain is daunting. If you search the internet, and look at the research on it, there are a lot of ideas about what pelvic pain is how you treat it. But most of what I read on the internet is off the mark. Pelvic floor pain i hard to understand if you have never had it and watched the process of it resolving.

 

Temporarily loosening the sore pelvic contraction vs. healing the sore pelvic contraction

Our protocol was formed by my own experience in conjunction with the remarkable expertise of the folks I work. We have developed a careful, skillful program to physically loosen the tightened tissue in the pelvis. But, as we have said in our book and in a number of podcasts, physical therapy (though we are pioneers in using it and are strong proponents of necessity teaching patients how to self-treat all aspects of it) is a temporary fix for pelvic pain. Unless the tissue is healed to a state of normal tissue like the sore arm or shoulder, even if its loosened in one moment, and the pain is temporarily absent, the tissue s ready to be aggravated, irritated and tightened up again in the next moment by the activities and stresses of life.

 

Putting a sore arm in a ‘sling’ to help it heal; putting the sore pelvis in a sling to help it heal

That is why I suggest here that, like the sore arm, the pelvis needs to be put into a kind of ‘sling’ to prevent aggravation and irritation and allow the healing mechanisms of the body to heal the tissue. Unless you do that, temporarily loosening the tissue through physical therapy and other physical methods, is a temporary (though critical and necessary) intervention and usually not sufficient to heal the pelvic floor. We’ve come to see that the physical loosening of the sore pelvis has to be done repetitively and as we’ve learned, it is best done by the person with pelvic pain themselves. If you have pelvic pain, you really need to learn how to do the loosening yourself.

 

Extended Paradoxical Relaxation is the ‘Sling’ that Allows Tissue of the Pelvis to Heal

 

We teach our patients how to loosen all of this tissue (from the knees to the sternum) themselves physically, and then we teach them how to put this loosened, relaxed tissue into a sort of ‘sling’ to allow its healing.

 

What does it mean to put the pelvis in a sling? It means resting the pelvis in a way wherein it is not being assaulted by anything that tightens it up, so that the mechanisms of the body can heal it and allow it to operate it and work the way it is meant to. In our protocol, the ‘sling’ for the pelvis is called Extended Paradoxical Relaxation. I have written a book about this method and we talk about it extensively in A Headache in the Pelvis.

 

The method we train our patients to do is basically a method to askes us to say to all the stresses that interfere with the healing of the pelvic floor, “Stay out of the room and leave me alone for now. Let me rest.” It’s a method of allowing the pelvic floor to be quiet and be free of the stresses that irritate it and interfere with its healing. Extended Paradoxical Relaxation requires daily practice and we ask our patients to do both the physical loosening and the relaxation components together for at least 2 hours a day. This is a big thing to ask of anyone but most of the people who agree to do this do it because they feel the possibility of their condition healing up. When you suffer from \ pelvic pain for a long time, you often reach a point (as I did) where you say “If I have to go to Mongolia and eat cow dung, tell me when the next plane is.” When you are suffering from pelvic pain that doesn’t heal, it becomes the bane of your existence and you become willing to do whatever it takes to get it to go away.

 

Healing a sore pelvis requires an inner environment in which it can heal

Pelvic pain is peculiar in that we have to deal with the reflex that tightens the pelvis in response to the slightest amount of pain. Many different factors have caused the pelvis to tighten and hurt, and the normal stresses of life trigger the reflex guarding of the sore pelvis which keeps it in pain and not able to heal the way a sore arm will when it’s put in a protected healing environment. I hope that this metaphor is helpful. Like a sore shoulder, you need to provide an environment in which the body can heal itself and return itself to normal. The ‘sling’ for pelvic pain that allows this healing is just a bit different from that of a sore arm and wrist. The sling involves regular physical loosening , inner quiet, and a psycho physical internal environment free from the bumps of everyday life.

 

 

 

 

Why all physical treatment for pelvic pain is not the same

The word commodity comes originally from the Latin commodus meaning ‘a useful or valuable thing’. By the early 15th century commodity was being used in English to refer to “an article of merchandise, anything movable of value that can be bought or sold.” Implicit in this definition is that a commodity is the same anywhere it is found. A commodity is something of value that is the same everywhere. It is like a package of M&Ms: if you buy a package of M&Ms in New York, or San Francisco or Hong Kong, the M&Ms will taste the same. M&Ms are the same everywhere and you can expect and count on that same flavor, shape, quality, size, no matter where they are bought. Similarly, in medicine, some procedures and treatments have been standardized and could be called commodities.

In the world of pelvic pain, only in the last 10-20 years, some physicians treating patients with pelvic pain refer them to physical therapists. I believe these physicians assume that physical therapy for pelvic pain is a commodity…. the same everywhere and any physical therapist will be able to treat the pelvic pain patient in some standardized and successful manner.

In our experience of treating many patients with pelvic pain and hearing their reports , this is simply not so. There is a very wide variety of what is done in the name of physical therapy in the treatment for pelvic pain. There is no standardize physical therapy for pelvic pain. In fact there are a number of treatments done in the world of physical therapy that our patients undergone. Those treatments that were not successful tended not include trigger point therapy. The point here is that physical therapy for pelvic pain is not standardized from therapist to therapist.

We are very specific in terms of what physical therapy for pelvic pain is therapeutic and offers the best chance of helping pelvic pain. In our experience, a physical therapy treatment for pelvic pain in which both myofascial release and trigger point release is done, is the most effective treatment. In another essay, I have discussed the difference between myofascial release and trigger point release and the necessity of doing both. We propose that external as well as internal myofascial trigger point release should be done. In our book we discuss why pelvic floor biofeedback, pilates or kegel exercises are not helpful, nor have we found much use in electrical stimulation either inside or outside of the pelvis.

 

Self-Treatment vs. Treatment by Others

Then there is the subject of self-treatment vs. treatment from a therapist or physician. Over the years, for a number of reasons, we have come to see that self-treatment (externally and internally) in the treatment of muscle based pelvic pain, is far superior and effective in offering the possibility of reduction or resolution of this kind of pelvic pain.

We are strong advocates of teaching our patients how to do their own trigger point release to become their own best therapist. They learn what is going on in their body and tissue, they learn how hard to press and how to locate trigger points easily and certainly they can do treatment far more frequently and conveniently than one could do it if having to go to a physical therapist for treatment. Being able to treat oneself allows for trigger point release to be done more often, at the exact time/location that is most convenient for the person, and after being trained in self-treatment with the proper tools, without the need to travel to and from a physical therapist’s office with the advantage of not cost for a self-treatment.  Physical therapy treatment can be hugely important in conjunction with and in supervising self treatment. 

The Internal Trigger Point Wand

 

The Wise-Anderson Protocol developed the only FDA approved Internal Trigger Point Wand that has been vetted through a rigorous clinical trial for safety and efficacy. But just like a Stradivarius violin, unless you know how to play it, it doesn’t matter if it’s the greatest violin in the world or not. In the same way, if you have the greatest tool for doing trigger point release unless you know how to use it, its not going to help you which is why the focus of our treatment is in the careful training and supervision of our patients doing internal and external physical therapy self treatment.

 

The Issue Of How Hard And Long To Press And How To Find The Trigger Points

 

A number of years ago we articulated what we call the Wise-Anderson Pressure Principle which has to do with how much pressure one should exert on a trigger point. If one exerts too much pressure and there is jumping-out-of-your-skin pain, the whole area can tighten up protectively and cancel anything therapeutic you are trying to accomplish. It is like putting on the gas and the brake pedal at the same time. Too vigorous pressure can actually aggravate the situation. We don’t believe in doing trigger point release that simply flares up symptoms. Of course, there are times where one will be sore after trigger point release and even stay sore for a day or so, but the whole point of doing trigger point release is to loosen the tissue and not cause it to protectively guard. The idea of no pain, no gain does not apply to trigger point release. The idea that if some is good, more is better is the wrong idea with trigger point release.

 

Our Internal Trigger Point Wand is the only device I know of that can measure pressure exerted on trigger points internally. It is very important for the user to be able to have a sense of pressure objectively so that they can pair their internal pressure and the sensation of the pressure on trigger points, and an objective measure.

 

Physical therapists cannot objectively measure the pressure they exert on trigger points internally (and externally) unless they use an algometer, of which none to my knowledge, other than on our device, currently exists in conventional pelvic floor trigger point release. We have had many patients complain that before they came to see us, physical therapy was tortuous, painful, and ultimately unhelpful. It is my guess that especially less experienced physical therapists overdo the amount of pressure they exert on trigger points internally because they want to have an impact on someone’s symptoms. They do not understand that the process of deactivating trigger points is a long one and pressure internally needs to be carefully and sensitively applied so as not to flare up someone’s symptoms unduly. Working internally requires an especially sensitive and delicate hand. Again, if too much pressure is used, symptoms can flare up and the pelvic floor can reflexively tighten up, detracting from instead of promoting the healing of the sore tissue. Internally trigger point release is an art and requires an extensive knowledge of trigger point behavior, of the appropriate pressure to be exerted especially inside and importantly, an understanding of the slow arc of improvement that occurs when a sore pelvic heals. Additionally, as I discuss, trigger point release done skillfully must be paired with regular time for the tissue to recover and heal. And in our view this is all best done by the patient him/herself.

Trigger Point Genie

 

In the last number of years, we have developed and are now using a remarkable tool for external trigger point release called the trigger point Genie. You can find more information about this device at www.triggerpointgenie.com. The trigger point Genie allows someone to comfortably, on a soft surface to perform external trigger point release on almost every part of the body, including the gluteal muscles, TFL muscles, iliotibial band, the adductors on the inside of the thigh, the abdominals, the quadratus lumborum, the rectus abdominus and other places that are implicated in pelvic floor dysfunction. The trigger point Genie, along with the Internal Trigger Point Wand, gives a patient the freedom to treat themselves and to seek out professional help when they need consultation in their self-treatment.

To summarize, physical therapy for pelvic pain is not a commodity. All physical therapy done for pelvic pain is not the same. In our view one way of doing pelvic pain physical therapy can offer little help, can flare up symptoms, or can move the pelvic pain patient in the direction of healing and resolution of symptoms.

In our protocol we have seen people for whom therapists have not been able to even locate trigger points, then we have examined them and found a treasure trove of trigger points. There have also been many people who have just been flared up by physical therapy and had no release of tension or pain prior to doing our protocol, but once they have learned to do their own therapy it has opened the door to their own healing.

Finally, when physical therapy for pelvic pain is done without a dedicated program to reduce anxiety and nervous arousal, in our view the likelihood of real resolution of symptoms is remote. Physical therapy does not offer a permanent rehabilitation of the sore pelvis. The pelvic tissue that is painful and chronically tightened, is human tissue that needs time to heal after it is released and an environment in which it is not tightened in the way that got it in trouble in the first place. Physical therapy is a temporary release of the tissue that can easily return to its pre-treatment state upon leaving the therapists office and getting into traffic.

Being able to do external and internal physical therapy in the comfort of your own home and then putting the pelvis in the healing mode of a long relaxation session to allow the released tissue to recover and rest, in our view is critically important. We have had patients who drove 5 hours to a physical therapist for pelvic floor physical therapy and then found their symptoms flaring back up and whatever therapeutic effect of the physical therapy being undone by having to get into a car and drive back 5 hours. Pelvic floor related pain is essentially a stress related condition that comes about in the body as the result of dealing with the stresses of life. Healing a painful pelvis is an inside job. In our view, when someone has pelvic pain, they must regularly loosen and release the sore pelvis physically, regularly lower anxiety and the arousal of the nervous system in order to have a chance for the sore pelvis to heal and the pain and symptoms to go away.

 

I hope this discussion about the physical treatment of pelvic pain is helpful

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.

MUSCLE SORENESS/TENSION AND URINARY FREQUENCY AND URGENCY

In our experience, and that reported by other centers and physicians who have worked in this field, it is quite common for both men and women who develop a chronic pelvic pain condition also exhibit urinary dysfunction.  Urinary frequency and urgency is one of the most common symptoms of patients who come to our 6 day immersion clinics. It has been well reported that approximately 71% of men experience symptoms such as urinary frequency, urgency, nocturia, poor urinary flow and even pain in the bladder upon filling.  In most of the male patients, there is little to no laboratory or imaging evidence to incriminate the prostate as the source of this pain and urinary symptomatology.

There are women as well suffering chronic pelvic pain with no bladder or organ pathology who have symptoms of urinary frequency and urgency. Both women and men typically have sore and painful anterior (which means located toward the front) musculature within the pelvis floor that refer sensations of urinary frequency and urgency when certain trigger points in the front of the pelvic are palpated. With almost all of the men and women with urinary frequency and urgency and no evidence of organ or related physical pathology, we find trigger points in the pelvic floor and related areas that tend to refer sensations of urinary frequency.

The relationship between sore, painful pelvic floor muscles and urinary frequency is not intuitively clear. Indeed how is it that one has urinary frequency and urgency but with no pathology, infection in or of the organs of the urogenital tract.

When I first had pelvic symptoms, I just had urinary frequency with no pain other than the uncomfortable symptoms you have with urinary frequency and urgency. As time went on, I had most of the symptoms we describe in our book including urinary frequency and urgency, sometimes in the extreme. The doctor could find no physical pathology. Nevertheless I suffered with sometimes extreme urgency, voiding little, never feeling emptied or relaxed the way urination feels in someone without pelvic pain. As I recovered, I went from sometimes feeling that I had to void every 15- 30 minutes to feeling normal in this area and noticing I went 3-5 hours with no undue distress. When I had urinary symptoms, I remember when I went to a movie, I always sat in an aisle seat at in a movie theatre because I could never sit through a whole movie without having to get up to go to the bathroom in the middle of the movie. I experienced a difficult to describe, gnawing, aching irritated feeling in and around the bladder. After my recovery, my urinary frequency and urgency disappeared and urination disappeared.

When someone is suffering from urinary frequency and urgency with no known physical pathology, they feel uncomfortable in and around the bladder, they feel like they need to urinate, often urinating small amounts which don’t resolve the feeling of having to urinate the way one normally feels resolved after a trip to the bathroom. When you have urinary symptoms related to pelvic floor pain and dysfunction, the sensation in and around the bladder simply doesn’t feel normal. So what is going on here? This is a question I believe some people suffering from pelvic pain are baffled by. Being able to easily wait to go to the bathroom is important in many situations in modern life including work, social and recreation related situations. That there is gnawing, uncomfortable feeling in the bladder and urinary tract can be very distressing as it persists without resolution.

So here are thoughts I share with you about the phenomenon of urinary frequency and urgency arising when someone has pelvic pain and subsiding or disappearing with the subsidence of pelvic pain. I would like to propose that afferent (sensory) nerves associated with the bladder or a neighboring receptor in the pelvic neural network may be affected by the tension, discomfort and anxiety originating within the pelvic muscles.  This afferent plexus, or branching network of intersecting nerves of the lower urinary tract is complex and responsive to a variety of different kinds of stimulation including stress and anxiety and pain. Many of us have experienced the need to urinary under circumstances of extreme anxiety or stress.  The theory I propose is that pain and anxiety triggers the branch of the autonomic nervous system related to bladder relaxation – bladder relaxation that is felt as the need to urinate. Absent pain in the pelvis using our protocol, we have often seen someone’s urinary frequency and urgency reduce or entirely go away without any drugs or other interventions.

We all know of the colloquial term to be so scared you pee in your pants. This colloquialism refers to a moment of urinary urgency occurring under conditions of extreme fear or stress. In my personal journey with pelvic pain, I thought that the pain in my pelvis was something that my brain confused with the discomfort of a full bladder that urination would relieve. In a person without pelvic pain, you feel relaxed after urination. My sense when I was symptomatic was that somehow my brain confused the discomfort in my pelvis with the discomfort of a full bladder that is relieved with urination. What is clear is that urinary frequency and urgency is often present when someone has pelvic floor pain and no other physical findings, and the urinary frequency and urgency can disappear once the pelvic pain resolves.

I hope this is a helpful essay about this interesting subject.

Escaping the fight, flight, freeze cycle in the healing of pelvic pain

In the 1920s, a well-known physiologist at Harvard named Walter Cannon introduced the concept of fight, flight, freeze. Coincidentally, Walter Cannon was a teacher of my relaxation teacher, Edmund Jacobsen. Commonly, the term Cannon coined is called “fight or flight.” This means that in the presence of something threatening, you either fight it to get rid of it or run away from it. However, the full term is actually “fight, flight, or freeze,” because the biological response to a threat can also be to freeze up, as a way of hiding from the threat, or indicating you offer no threat to what is chasing you. The phrase a deer in the headlights is an example of freeze. Fight, flight, and freeze are terms that make intuitive sense – we all easily understand how we either run away from, fight against, or freeze up in the presence of a threat. How the freeze response is centrally related to pelvic floor pain is a bit less obvious, but I’d like to explain it now.

Pelvic floor pain is associated with muscles in the pelvic floor being overly tightened on an ongoing basis. I’ve described this previously as a charley horse in the pelvic floor perpetuated by anxiety and protective guarding, and unhealing, sore pelvic tissue. Pelvic floor pain takes on a life of its own and remains painfully present on an ongoing basis.

Once we understand that pelvic pain represents a condition of biological “freeze” in the center of the body, we have a path to the solution: unfreezing the chronically frozen pelvis, I suggest, is the remedy for the disorder. While easier said than done, I can tell you from my own personal and professional experience that it is possible.

So, the question is, “How do you unfreeze a chronically tightened pelvic floor?” In the Wise-Anderson Protocol, we recognize that doing this is a psycho-physical task. It requires intervention in both mind and body.

Over the past 25 years we have carefully developed a method to release painful, frozen pelvic tissue. Our FDA approved Internal Trigger Point Wand, in our protocol, is a necessary tool that can enable the unfreezing the pelvis, because it centrally assists internal trigger point release. Trigger point release is a manual method of skillfully pressing on tight bands that form when muscles are held in an extended or intensely contracted state. We teach our patients to use this wand alongside our new external Trigger Point Genie, specific stretches, and other physical methods to loosen the inside of the body.

However, it is also necessary to provide an environment in which the sore tissue of a chronically tight pelvis can heal up from its tendency to freeze (hypertonia). Loosening the inside of the body without this, in our experience, will not provide long-lasting relief, because whatever triggers reflexive muscle freezing will simply cause the pelvic floor to freeze again even if the tightening has been temporarily released physically. Tissue that is sore and irritated is primed to tighten back up with little provocation. This is why most physical intervention that does not reduce nervous arousal at best provides only temporary relief for pelvic floor pain – the state of freeze prevents the healing of the sore tissue in the pelvic floor. Healing this sore tissue is essential to any real, lasting resolution

The pelvic floor in its normal state is soft and responsive, able to easily relax and tighten as the body needs. In the Wise-Anderson Protocol, we teach our patients how to physically loosen the external and internal tissue, interrupting the frozen state of the pelvic floor while reducing the nervous arousal that keeps the pelvic floor irritated and ready to jump back into a state of freeze.

Cause and Effect In Muscle Based Pelvic Pain

What makes a difference in the journey of healing pelvic pain is seeing when you are doing something that reliably helps your symptoms. When I was symptomatic, I tried all kinds of things: acupuncture, supplements, reflexology, medications, considered surgical procedures which I gratefully didn’t pursue. My symptoms waxed and waned, often inexplicably. At that time, if you asked me if those things helped, I’d have said I didn’t really know. I’ve come to understand that if the answer to the question “Is something helping your symptoms?” is, “I don’t really know,” then it probably is not helping. Anyone with chronic pelvic pain really does know when something is reliably helping.

When I was in pain, I dreaded trying something new to help myself because I had had the experience of trying new things and being disappointed when they ultimately failed to help me, which was most things I tried. I think that disappointment is an underrated suffering. In myself and in my patients, I see that feeling hope of help and then being disappointed at the failure of what you have hoped would help you is a feeling that many people avoid after a number of failures, by being very reluctant to do new treatments and be hopeful about them. Often that reluctance to be hopeful about a new treatment is justified.

When our patients experience improvement, they dance; they say ‘Wow. Gosh. Amazing!” They are genuinely surprised that something worked. Their energy changes. And they move around and exclaim, ‘I feel better’. You know when something helps. The mental and emotional space around someone who has had pelvic pain and experiences something they have done has helped them resolve it is wonderful to be around.

Our patients tend to be intelligent, conscientious and accomplished, keen to find the relationship between their symptoms and the real cause of their symptoms. Not infrequently our patients are scientifically inclined, who sometimes keep charts and records of any relationship between their symptoms and what they eat, when they void, when they go to sleep and a variety of different things. Yet most people fail to helpfully identify the factors that really move the needle in improving the problem. They will look for some kind of food, activity, supplement or something that correlates to their flare-up of symptoms.   Most importantly, they find little that really helps in the direction of resolving their condition.

Not being able to see cause and effect has large consequence psychologically. It is greatly distressing not being able to find a relationship between what really helps a condition that goes on and on. A large part of the suffering of pelvic floor dysfunction comes out of this uncertainty of and helplessness about what the problem is, of often not being able to see a relationship between something that makes it worse or makes it better. In a word the distress comes from the helplessness of really understanding why the problem exists or what to do about it.

It is from this helplessness and inability to see the cause and effect that people catastrophize, that they feel lost, worrying that they will never get better, that their pain is out of their control.

But when you do find a relationship between cause and effect, especially when you see yourself being able to do something that routinely helps you, it’s a game-changer in your life. Not surprisingly, such a discovery tends to stops the catastrophic thinking. I’ve always said that being able to help yourself is the great antidote to catastrophic thinking.

What is the cause and remedy for pelvic pain in the view of those of us who train patients in the Wise-Anderson Protocol? We know it isn’t drugs, or surgery or procedures or supplements. We published an article in the Gold Journal of Urology stating that prostatitis in men, which we are clear is mostly pelvic floor dysfunction, a psychoneuromuscular disorder, involving sore an irritated pelvic floor tissue, the result of anxiety related chronic guarding in the pelvic muscles, held in the grip of chronic reflex guarding that prevents the sore tissue from healing. Our view is that supporting the healing of the pelvic tissue is the answer to this disorder.

The methods of the Wise-Anderson Protocol for pelvic floor related pain are, and are not intuitively obvious. We teach our patients treat how to repetitively loosen the sore, tightened tissue between the breast bone and the knees while practicing daily a method to allow the sore tissue to rest and heal. One of our early patients said that the most memorable moment in his recovery from pelvic pain was not when every little sensation of discomfort finally disappeared but when the pain would flare up and he would not be at all concerned about it because he knew he had the ability to calm down the flare up. Having the ability to do something that regularly is able to reduce or stop symptoms and move in the direction of no symptoms is a major moment in life for the patients we have treated who have such an experience.

It is hard to see the relationship between cause and effect until you practice a method that allows the sore pelvic tissue to heal. I came upon it after many years of experimentation and failure. This method is not intuitively obvious and confidence in it is really only available by practicing it and seeing the results. Our method has helped many of our patients (not everyone) out of pain. It is what I did to resolve my own pain when I was lost in the wilderness of chronic pelvic pain – the wilderness that most pelvic pain patients find themselves in. While our mantra is self-treatment, the methods of self-treatment require in person training. Our 6 day program is not an easy one and at the same time we consider by far it offers the best chance, when done competently and practiced earnestly, when done competently and practiced earnestly to help end chronic muscle based pain.

Cause and Effect In Muscle Based Pelvic Pain

What makes a difference in the journey of healing pelvic pain is seeing when you are doing something that reliably helps your symptoms. When I was symptomatic, I tried all kinds of things: acupuncture, supplements, reflexology, medications, considered surgical procedures which I gratefully didn’t pursue.  My symptoms waxed and waned, often inexplicably.  At that time, if you asked me if those things helped, I’d have said I didn’t really know. I’ve come to understand that if the answer to the question “Is something helping your symptoms?” is, “I don’t really know,” then it probably is not helping. Anyone with chronic pelvic pain really does know when something is reliably helping.

When I was in pain, I dreaded trying something new to help myself because I had had the experience of trying new things and being disappointed when they ultimately failed to help me, which was most things I tried.  I think that disappointment is an underrated suffering. In myself and in my patients, I see that feeling hope of help and then being disappointed at the failure of what you have hoped would help you is a feeling that many people avoid after a number of failures,  by being very reluctant to do new treatments and  be hopeful about them.  Often that reluctance to be hopeful about a new treatment is justified.

When our patients experience improvement, they dance; they say ‘Wow. Gosh. Amazing!” They are genuinely surprised that something worked.  Their energy changes.  And they move around and exclaim, ‘I feel better’. You know when something helps. The mental and emotional space around someone who has had pelvic pain and experiences something they have done has helped them resolve it is wonderful to be around.

Our patients tend to be intelligent, conscientious and accomplished, keen to find the relationship between their symptoms and the real cause of their symptoms. Not infrequently our patients are scientifically inclined, who sometimes keep charts and records of any relationship between their symptoms and what they eat, when they void, when they go to sleep and a variety of different things. Yet most people fail to helpfully identify the factors that really move the needle in improving the problem. They will look for some kind of food, activity, supplement or something that correlates to their flare-up of symptoms.   Most importantly, they find little that really helps in the direction of resolving their condition.

Not being able to see cause and effect has large consequence psychologically. It is greatly distressing not being able to find a relationship between what really helps a condition that goes on and on.  A large part of the suffering of pelvic floor dysfunction comes out of this uncertainty of and helplessness about what the problem is, of often not being able to see a relationship between something that makes it worse or makes it better. In a word the distress comes from the helplessness of really understanding why the problem exists or what to do about it.

It is from this helplessness and inability to see the cause and effect that people catastrophize, that they feel lost, worrying that they will never get better, that their pain is out of their control.

 

But when you do find a relationship between cause and effect, especially when you see yourself being able to do something that routinely helps you, it’s a game-changer in your life. Not surprisingly, such a discovery tends to stops the catastrophic thinking.  I’ve always said that being able to help yourself is the great antidote to catastrophic thinking.

What is the cause and remedy for pelvic pain in the view of those of us who train patients in the Wise-Anderson Protocol?  We know it isn’t drugs, or surgery or procedures or supplements.  We published an article in the Gold Journal of Urology stating that prostatitis in men, which we are clear is mostly pelvic floor dysfunction, a psychoneuromuscular disorder, involving  sore an irritated pelvic floor tissue, the result of anxiety related chronic guarding in the pelvic muscles, held in the grip of chronic reflex guarding that prevents the sore tissue from healing.  Our view is that supporting the healing of the pelvic tissue is the answer to this disorder.

The methods of the Wise-Anderson Protocol for pelvic floor related pain are, and are not intuitively obvious.  We teach our patients treat how to repetitively loosen the sore, tightened tissue between the breast bone and the knees while practicing daily a method to allow the sore tissue to rest and heal.  One of our early patients said that the most memorable moment in his recovery from pelvic pain was not when every little sensation of discomfort finally disappeared but when the pain would flare up and he would not be at all concerned about it because he knew he had the ability to calm down the flare up.  Having the ability to do something that regularly is able to reduce or stop symptoms and move in the direction of no symptoms is a major moment in life for the patients we have treated who have such an experience.

It is hard to see the relationship between cause and effect until you practice a method that allows the sore pelvic tissue to heal. I came upon it after many years of experimentation and failure.   This method is not intuitively obvious and confidence in it is really only available by practicing it and seeing the results.  Our method has helped many of our patients (not everyone) out of pain.  It is what I did to resolve my own pain when I was lost in the wilderness of chronic pelvic pain – the wilderness that most pelvic pain patients find themselves in. While our mantra is self-treatment, the methods of self-treatment require in person training.   Our 6 day program is not an easy one and at the same time we consider by far it offers the best chance, when done competently and practiced earnestly, when done competently and practiced earnestly to help end chronic muscle based pain.

Symptoms and Treatments in Pelvic Pain: Using Modern Terms to Explain Nervous System Arousal

Pelvic Pain Symptoms and Treatments: Using Modern Terms to Explain Nervous System Arousal

Airplane mode, in fact, is an excellent metaphor in terms of describing the pelvic pain symptoms and treatments of the pelvic pain sufferer.

Using the term “airplane mode” to explain the nervous system of the pelvic pain sufferer.

“Airplane mode” consists of two elements:

  1. Setting aside enough sacrosanct, uninterrupted time and space for Paradoxical Relaxation sessions (which we discuss as carving out 2-3 hours a day);
  2. Doing the mental practice of Paradoxical Relaxation during this uninterrupted time and space that allows the nervous system to “down regulate”, reduce its frenetic activity, and cease prompting the squirting of adrenaline into the bloodstream with every thought that worsens the chronic pelvic floor contraction and the feeding of the tension-anxiety-pain-protective guarding cycle.

 

The meaning of airplane mode

To be sure, the technological revolution of the past 20 years has given us not only the ability to be electronically connected at all times but has also provided a new vocabulary to describe our new behavioral world of texting, instant messaging, emailing, and twittering. For example, the term airplane mode is a new concept that has come about to address the idea of temporarily disabling our communication devices from the information and connectivity superhighway. As we know, airplane mode is used when someone is on an airplane or other situation where sending or receiving communications and data are disallowed. In airplane mode, our phone or tablet assumes an unresponsive state where it is not vulnerable to the dings and rings of incoming calls, texts, emails, and other data.

Indeed, when your phone is on airplane mode, you essentially resume the situation humankind was in before the advent of cellular communication systems. You are alone, and unless someone actually engages you in person, you are not vulnerable to being disturbed or prompted. The situation is not unlike the old context of placing a “do not disturb” sign on your hotel room door – you are creating an environment where you cannot be disturbed by the world nor it by you.

A frozen, locked-up computer

Anyone who has ever worked with a computer has experienced the frustrating situation of the computer “freezing up” or “locking up” and having to be manually re-set. Many times we intuitively attribute the freeze to requiring the computer to do too much too quickly. Overwhelmed, it simply stops working properly and ceases to fulfill our processing demands. One perspective is that the computer has simply gotten too far away from its default modes, and the complexity of processing so many demands in a matter of seconds has interfered with basic functions. Interestingly, despite all of the advances in technology, a standard method for fixing the freeze is to manually reset the computer by holding down the power button. By turning the power off and then back on again, we reset the original default modes. This almost always results in the computer resuming its proper functioning.

An analogy can be drawn between our intuition about why computers freeze up and why Colin Powell’s observation that “things always look better in the morning” is intuitively correct. It is also why we have a sense that a good night’s sleep makes everything better. Once locked up elements of body and mind come back into full function. This is also true of going away on vacation. After several days on the beach, away from the demands of business and life, our system is renewed.

With regard to the symptoms and treatments of chronic pelvic pain, a person experiences a similar overwhelm to that of the frozen, locked-up computer. Too many tasks, stresses, demands, and pressures have accumulated over time and the body has found itself in a distant place from its homeostatic, healthy, default mode. In response to a hectic life, the muscles of the pelvic region have engaged in a pattern of chronic, unyielding protective guarding to cope. These pelvic muscles, normally pain-free and able to relax and contract easily, are rigid and chronically contracted and dysfunctional.

Just like the number of programs running on a computer when it freezes up, pelvic pain patients cannot ignore the circumstances of their lives. In our patients, we often see that a vicious, self-feeding cycle has developed in the patient that looks like this:

Even in the face of significant pelvic pain and muscle dysfunction, fear, and anxiety, many of our patients continue to meet the demands in their lives without being able to reset. Typically each day the patient tightens up the pelvic muscles as a coping mechanism to the pressures of life. As the pelvic muscles get more restricted and painful, function deteriorates. In many patients, the pelvic muscles become so contracted that basic functions such as urination, defecation, sitting, and sex become very difficult and painful.

Resetting the default mode of the pelvis by resetting the nervous system

In order to restore the nervous system and the pelvic floor that it controls to a healthy default mode, we propose that the body requires a regular “airplane mode”. This frees the nervous system from stress, demands, pressure, expectations, and requirements. You can have a safe zone protected from disturbance or stimulation. The pelvic floor needs time to ease painful hypertonus and myofascial restriction and be free of any stressful or taxing input from the nervous system. By practicing long hours of airplane mode through the use of our method of Paradoxical Relaxation, the quieted nervous system allows the pelvic floor to “let down its guard” and heal from the effects of the chronically upregulated and aroused nervous system. Through this practice (and along with our trigger point physical therapy regimen), the pelvic muscles are led back to their natural default mode of supple and functional myofascial tissue.

Man as a response animal

Indeed, we can look at the human being as a “response” organism, constantly adjusting to our various issues. Most important is the survival instinct, and while we no longer face the reality of wild animals or food scavenging, the nervous system equates many non-survival issues to survival. This is especially true when the nervous system is hypersensitive to stress in the form of an email, text, or task at work.

We have all experienced that domino effect of catastrophic thinking where one largely insignificant email can be turned into a disastrous conclusion by a fearful mind. When catastrophizing is a common event in someone’s thinking, the pelvic muscles typically contract and often out of a person’s awareness. In the 6th edition of our book, A Headache in the Pelvis, we discuss the remarkable story of a middle-aged woman who was in the middle of an internal myofascial trigger point session with an experienced physical therapist. While the physical therapist had a finger inside her vagina, pressing on an internal trigger point, the woman began to talk about a politician she loathed. Our colleague, the physical therapist, reported that as her patient expressed rage about this politician, her pelvic muscles tightened around our colleague’s finger to a point where our colleague was afraid her finger would be injured. When our colleague said to her patient, “can you feel that?”, referring to the astonishing tightening of her pelvic floor muscles, her patient said back to her “Feel what?” Our colleague’s patient tightened her pelvic muscles ferociously and didn’t even know it!

When you switch to airplane mode and step beyond the world’s ability to stimulate you, you are actually saying: “You can rest. All is calm, everything is okay.” You are giving yourself permission to relax. We tell our patients that this is the environment we want to create for the practice of Paradoxical Relaxation, one of the key methods of the Wise-Anderson Protocol. Spending enough time in this airplane mode, while doing Paradoxical Relaxation (and in conjunction with our physical therapy protocol), may be the most powerful way to break the cycles of protective muscle guarding and to assume a posture of the deepest and most profound relaxation. The muscle tension physiologically returns to a normal, homeostatic state and the organism can take a much-needed break from survival responses.

The problem of treating pelvic pain as solely a physical problem

The vast majority of articles written in medical literature about the kind of pelvic pain we treat focuses solely on the physical dimensions of this condition and the traditional treatment of drugs and procedures, injections, nerve blocks, and sometimes surgery. Recently, there has been interest in the psychological/behavioral dimension of pelvic pain, discussing patients who suffer from trauma, anxiety, or other forms of emotional disturbance. And yet these discussions usually only address what we consider to be paltry and not commensurate with the enormity of the problem being addressed, believing that small doses of cognitive therapy, mindfulness meditation or breathing exercises mixed in with traditional treatments could be helpful. We see these overtures as merely “half-measures”. In our experience with thousands of patients over the years, these minor interventions have had little effect on long-standing, chronic symptoms. While we welcome discussions of the psychological/behavioral aspects of chronic pelvic pain, and believe that cognitive therapy and mindfulness are legitimate and important treatments for certain conditions, our work with patients who have suffered from chronic pelvic pain for many, many years has led us to believe that only more profound nervous system intervention has a chance of any real traction.

The engine of muscle based pelvic pain is chronic anxiety and an upregulated nervous system

In our two decades of treating this condition, we see that the engine of muscle related pelvic pain is an upregulated nervous system acting on a chronically shortened and trigger pointed, myofascially restricted pelvis. What we mean by “upregulated nervous system” is this that the human computer – the mind and central nervous system – is running much faster and processing more stimuli than is healthy. We propose that the pelvic floor is in dire need of a break, in dire need of airplane mode for long periods of time every day. All of the wisdom and spiritual traditions in the world have a concept of “Sabbath” where rest is not only allowed but understood as absolutely critical for health and well-being.

We see pelvic pain as a functional disorder. It generates a self-feeding cycle of tension and the resulting formation of pain. Treating the muscles with a specific method of trigger point physical therapy is essential. However, our experience has shown us that the great perpetuating factor of this condition, indeed the foundation of it, is an upregulated nervous system generating unhealthy amounts of pelvic floor tension. Pelvic floor tension that is constant and unrelenting and from which there is no adequate amount of airplane mode, no Sabbath. This reflects our current societal predicament of a 24/7 society where few if any days are held sacrosanct, where there is little or no time off, and no airplane mode. Patients who commit wholeheartedly to reducing their nervous arousal and anxiety do far better than patients simply focusing on the physical state of their pelvic muscles.

It is essential to commit enough time to airplane mode

We have found that most of our patients require a good 2-3 hours of airplane mode daily in order to create the environment of healing necessary for the rehabilitation of the pelvic muscles. If you are “on” all day, the sore pelvis is continually being contracted and irritated by the avalanche of stimuli agitating the nervous system. The researchers Gevirtz and Hubbard have shown that even the slightest increase in nervous arousal is immediately reflected in increased electrical activity of painful trigger points. Their studies on electromyographic monitoring of their patients’ trigger points demonstrate this dramatically.

Symptoms and treatments in pelvic pain: 2-3 hours of paradoxical relaxation per day

It is important to say that airplane mode is an inner state as well as an outer space where stimuli from the outside do not intrude. Paradoxical Relaxation is airplane mode for the mind and body and involves engaging the will to practice doing nothing, practicing effortlessness, of not judging, guarding, tightening, resisting, trying, accomplishing, or any other activity that requires effort and nervous system upregulation. For many of our patients, we have observed that it is not enough to practice Paradoxical Relaxation for short, half hour or even one hour lessons. Symptoms and treatments of pelvic pain at small intervals, in patients who are chronically hyper-aroused whether they realize it or not, simply do not allow enough time on airplane mode to quiet down the roaring nervous system. A significant number of our patients do far better with 2-3 hours of Paradoxical Relaxation daily to release the pelvic muscles from their chronic guarding and contraction.  In airplane mode you are free, and you can take a sigh of relief. Your body is in a position to reset the default mode of the nervous system that then permits the pelvic floor muscles to return to normal.

In our Paradoxical Relaxation lessons, these instructions are reiterated every 30 seconds or so to help our patients let go of any effort and rest solely in sensation. In the state of resting attention in sensation, the nervous system is put in airplane mode and the pelvic floor can release.

On its face, a daily practice of 2-3 hours of uninterrupted time to do Paradoxical Relaxation may seem daunting. Most pelvic pain patients are busy. Sparing any time can be a challenge. Because of this, we always say that our prescription is not for everyone. Indeed, our patient feedback reminds us that the patients who do the best with our protocol are the ones who decide that they will do whatever it takes to end their suffering.

Truth be told, if one’s pelvic pain doesn’t hurt enough, if the dysfunction isn’t bad enough, if there is a way to decently cope and avoid facing the music of a full measure treatment for pelvic pain, then contemplating 2-3 hours of airplane mode Paradoxical Relaxation a day is not going to be seriously considered, let alone completed. For those, however, who are ready to do whatever it takes, airplane mode will be done without hesitation, and once done, enjoyed beyond measure as the pelvic floor muscles are placed in an extended environment of healing.

Successfully Treating the Stress Dimension of Pelvic Pain Syndromes

There are a growing number of scientific articles on stress and pelvic pain syndromes. 

There have been a growing number of articles appearing in the major journals like the Journal of Urology and World Urology that point out the significant association between stress and prostatitis and related pelvic pain syndromes. This is a new phenomenon because, in the past, urology has largely been uninterested in the psychological aspects that are related to chronic pelvic pain syndromes.

[embed]https://www.youtube.com/watch?v=82OmQa_KrWg[/embed]

What does psychological support for those with pelvic pain syndromes mean?

In an article written recently in the January/February edition of Rev Med Brux, (Rev Med Brux. 2013 Jan-Feb;34(1):29-37), a Belgian medical journal, the authors, Issa, Roumeguere and Bossche, talk about the essential role of psychological support: “the role of psychological support remains essential.” This kind of discussion about chronic pelvic pain syndromes and their proper treatment is new in medical discourse.

Unfortunately, even though the role of stress is finally being acknowledged after many years of being completely ignored, the understanding of the psychophysical relationship between stress and pelvic pain and prostatitis is not well understood. To talk about psychological support for those suffering from chronic pelvic pain syndromes misses the point if you have an interest in offering any substantial help to these people.

Conventional psychological support does very little for pelvic pain.

Psychological support in the conventional sense of a psychologist/counselor who offers insights and cognitive strategies to deal with dysfunctional thinking, in my view, does very little to help those who have chronic pelvic pain syndromes. In my experience, a psychologist/counselor can spend a day with people who have chronic pelvic pain, give them the experience of being heard, and deal with their cognitive distortions, and it will make very little difference to their symptoms or to their life. I say this as a psychologist who has been in practice for 40 years and who has done tens of thousands of hours of psychotherapy and who had chronic pelvic pain himself for many years. Psychological support in the normally understood sense is NOT significant in helping the stress component of chronic pelvic pain syndromes, prostatitis, pelvic floor dysfunction, interstitial cystitis, etc.

It is the basic fear that the pain will never go away that drives the psychological component of these disorders.

Lack of psychological support is not the problem that needs to be solved for people who have chronic pelvic pain syndromes. Offering support without giving them the tools to reduce their pain, in my many years of experience, does essentially nothing to help. When you have aching, burning tightness in the area of your pelvis and genitals and you have pain with sex and you cannot sit down, these symptoms fundamentally impair your life. They impair the basic building blocks of life – of urination, of defecation, of orgasm, of being able to sit and sometimes even being able to stand. Reassurances and psychological support alone will do little to help these symptoms.

Empowering the patient to reduce his or her own pain is the best psychological support you can offer.

What calms anxiety and catastrophic thinking is the experience of being able to reduce your own pain yourself. When you are able to put a finger on your own pain, or put an instrument on your own pain, and work on it, this is life-changing. This is essentially the antidote to the thought that the pain will never go away. This also increases your quality of life.

Data from our Internal Trigger Point Wand Study

In another essay in this blog, I have discussed the essential unhelpfulness of psychological intervention in which the patient is not empowered to help and release his own symptoms. During the years of the clinical trial for our Internal Trigger Point Wand, we saw that emotional distress is directly related to the reduction of symptoms. When people’s symptoms do not get better, their emotional distress generally does not get better, unless they have glimpses of their ability to reduce their own pain themselves.

While our study did not distinguish between cause and effect and which came first, it is my observation that what comes first is the ability to reduce symptoms, leading to or causing a reduction in emotional distress and anxiety. This positively feeds into the reduction of the pain and psychological distress. If tension, anxiety, pain, and protective guarding is a description of the downward cycle which perpetuates chronic pelvic pain syndromes, then the ability to reduce your own pain increases empowerment. You will be entered into a new self-feeding cycle of emotionally feeling better, physically feeling better, emotionally feeling better, physically feeling better.

What is real psychological support – what does that really mean?

Simple manipulation of thinking through cognitive therapy strategies is not very helpful. The core catastrophic thought that triggers emotional distress in folks with pelvic pain is, “I am never going to get better and I am doomed to never be able to relax and have any kind of quality of life.” Yes, that is the villainous thought. Simply identifying it without being able to reduce the pelvic pain symptoms does very little. Simply intervening with words in an attempt to stop cognitive distortion has little traction.

Learning how to be “off” as a stress reduction strategy.

Stress reduction in general, and in pelvic pain syndromes including prostatitis in particular, requires learning how to be “off” rather than “on”. In our experience, working with many people with pelvic pain over the years, the major help that is offered by our behavioral psychological intervention has to do with teaching someone to cease efforting. The deepest relaxation occurs when all of the muscles are “off” and there is no guarding or protecting against something bad happening. My teacher, Edmund Jacobson, who taught me relaxation said, “Turn the power off,” which was his way of guiding me toward becoming effortless.

Being “on”.

We all know what it means to have to be “on”. Being “on” means that I have to be ready to respond to others. I cannot just drop my guard or take my attention off of being responsive. When you are in the work mode, and often when you are not in the work mode, you are always ready to respond, always ready to kick in. Being “off,” sort of like being “off duty,” means that you do not have to be watching the environment to be responsive to it. It means being able to let your attention come into yourself and not have to be out in the world, responding and adjusting to the changing conditions of the world.

When I do a pelvic pain clinic I am “on” for 5 days. From the beginning of the clinic to the end of the clinic I am there responsive to other people. I cannot just wander off by myself, being in my own thoughts, being in my own body, being in my own experience. My attention is out in the clinic, responding to the needs of others and to the environment.

Being “off” means your nervous system can heal and regroup.

When the clinic is over, I usually feel exhilarated and I typically utter a sigh of relief. My life is my own again. I am not “on” anymore. I can be “off duty.” We ask people in our clinic to do Paradoxical Relaxation – which means that you must be “off”. This is the reason why we ask parents to ask their spouse to take care of their children, to turn their phone off, to keep pets away, so they do not attend to anything in their environment outside of the instructions that allow them to release their guarding. Creating a space for an hour or an hour and a half to be “off duty” allows the muscles to rest and the nervous system to down-regulate or calm down. And giving yourself the space to be “off” is all important in giving the nervous system an opportunity to down-regulate.

Anger and the response of the pelvic floor.

When you become sensitive to what is going on in your pelvis, you will often notice how the pelvic muscles tighten up and become more irritated and painful when you are anxious, stressed or pushed in some way. A dramatic example of this is something we discussed in our book, A Headache in the Pelvis. A middle-aged woman was seeing a colleague of ours who was an experienced physical therapist in New York. While our colleague had her finger inside the woman’s vagina doing Trigger Point Release, this woman started talking about something that was going on politically that she had a very strong reaction to. As she spoke about this politician she hated, the muscles in the woman’s pelvic floor began to tighten around our colleague’s fingers and our colleague reported that she was afraid that her fingers were going to be crushed. Now, this is particularly unusual because the pelvic muscles of a middle-aged woman are not known to be particularly strong. However, the physical reaction in the pelvis, which was part of her angry response, was unmistakable and dramatic. When our colleague said to her patient, “Can you feel what is going on in your pelvis as you are talking about the politician that you hate?” the woman said, “Feel what?” She was not aware of it at all.

The pelvic muscles tend to overreact to stress in those who have pelvic pain.

The pelvic muscles in those with chronic pelvic pain tend to tighten up to stressful events. While there has been very little or no research has been done on this, it has been my own personal and professional experience that people who have pelvic pain become sensitive to the tissue down there and see a close connection between pain and stress. Some people experience it remarkably strongly and clearly, and actually, that experience of the direct connection between stress and increased pain is a blessing because it makes a concept a clear experience. It validates the fact that there is a psychophysical one.

In muscle based prostatitis, pelvic floor dysfunction and other pelvic pain syndromes, the most effective stress reduction empowers patients to reduce their own pain. Paradoxical Relaxation is the practice of effortlessness, of letting go. While interpersonal support is mildly helpful, it does not go very far. I often say to patients, “My reassurance will probably last about 10 minutes and then you will get back into your scary thinking.”

Effectively dealing with stress related to pelvic pain is giving patients the tools to be able to turn “off” their own fearful contracted pelvic reaction regularly. Give a man a fish, he eats for a day. Teaching a man to fish, he eats for a lifetime. Reassurance and interpersonal support may help for a small amount of time. On the other hand, giving someone the ability to reduce pain and, in the psychological domain, reduce fearful guarding, gives a person a lifelong ability to manage stress and release themselves from the effect of pelvic pain.

Taking Hot Baths to Alleviate Chronic Pain in the Pelvis

Symptoms of prostatitis and pain in the pelvis typically don’t respond to conventional medical treatment.

Traditionally, when men have complained to their doctor about pain in the pelvis, anus or genitals, urinary frequency and urgency, post-ejaculatory discomfort, or sitting pain or the sensation of a ‘golf ball’ in the rectum, they are usually diagnosed with prostatitis. With this diagnosis, they are given antibiotics and told to avoid caffeine, alcohol and spicy foods, ejaculate more frequently, and take hot baths.

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Most conventional advice about treating prostatitis, including diet modification and increasing sexual activity, is confusing and sometimes makes symptoms worse.

Most of our patients report to us that the dietary advice they have been given about caffeine, alcohol, spicy foods is confusing as they did not understand its basis. Furthermore, following this kind of dietary advice has little effect on their symptoms. In fact, many men who have come to see us for the Wise-Anderson Protocol for prostatitis have reported that alcohol often improves their symptoms and does not hurt them.

To add to the confusion, increasing sexual activity makes symptoms worse in a large majority of men. We have described the post-ejaculatory discomfort as a ‘pleasure spasm’ in our book, A Headache in the Pelvis. When a man’s pelvis is chronically constricted, instead of orgasm relaxing the pelvis, it actually increases its tension level and causes significant discomfort or pain in the pelvis that can last from a few hours to weeks.

Hot baths can temporarily relieve the symptoms of prostatitis.

One piece of conventional wisdom given to men diagnosed with prostatitis is to take hot baths. Most men report that hot baths temporarily relieve their symptoms. Hedelin and Jonsson in the Scandinavian Journal of Urology and Nephrology report that cold tends to aggravate symptoms of prostatitis and heat tends to ameliorate it (Scand J Urol Nephrol. 2007;41(6):516-20). This is common knowledge among urologists and is quickly learned by patients.

Regular baths tend to be more effective than sitz baths for prostatitis.

Patients are often told to take a sitz bath, a bath in which only the buttocks and hips are immersed in water. Patients have reported to us that taking a regular hot bath is more effective than simply immersing the pelvic area in a small tub of hot water. The sitz bath is often uncomfortable and does not allow for the kind of relaxation of the muscles of the pelvis and the reduction of the arousal of the nervous system that a regular hot bath affords. It is the central reduction of nervous arousal as well as the local relaxation of the pelvic muscles that is therapeutic for those suffering from what is diagnosed as prostatitis.

The heat of the hot water (and not what is put into the bath’s hot water) is what relaxes pelvic muscles.

We often hear of men putting Epsom salts or other bath salts into the bath water in an attempt to help calm down their symptoms. In our view, it is the heat of the bath that is therapeutic and not what is put into the bath. Saunas, steam baths, and hot showers help calm symptoms as well. Most cases of prostatitis, as we have discussed extensively in our research and in our book, are caused by chronically tightened pelvic muscles and not a prostate infection, inflammation, or prostate pathology. Getting into a hot bath is a remarkably fast reducer of muscle tension in the pelvis as well as a strong reducer of anxiety and autonomic nervous system arousal. We have often said that if there were a medication that offered the side-effect free benefit of hot water, it would be a major drug used in medicine.

Hot baths help symptoms of prostatitis but offer no permanent solution.

Heat and hot baths are palliative and can make the very distressing symptoms of what is diagnosed as prostatitis momentarily more tolerable. However, the hot water does not offer a permanent solution to these symptoms. Men will typically report that their symptoms feel better when they are in the hot bath but the effects of the hot water fade soon after they get out. Nevertheless, hot baths are a gift to those suffering from pain in the pelvis as the reduction of symptoms for any length of time is very welcomed by patients.

Hot baths help because most cases of prostatitis are caused by muscle contraction in the pelvis, and not by prostate pathology.

In our experience, most men diagnosed with prostatitis do not suffer from a pathology of the prostate gland but from chronically contracted muscles of the pelvic floor that form a cycle of tension, anxiety, pain in the pelvis, and protective guarding. This is the focus of our book, A Headache in the Pelvis. Once initiated, this cycle has a life of its own.

The Wise-Anderson Protocol (popularly known as the Stanford Protocol) has been developed to teach patients to effectively rehabilitate chronic pelvic floor contraction and lower the nervous arousal that feeds it. The success of our protocol in doing this has been documented to significantly reduce the symptoms of those whom we have treated who were diagnosed with prostatitis. Hot baths can help take the edge off of the pain in the process of this rehabilitation.