Different names for pelvic pain are given to describe the same problem

There’s an ancient parable about ten blind men who come upon an elephant. One touches the elephant’s leg and says, “Oh, this is a tree trunk.” Another finds himself under the elephant’s stomach,Prostatitis pushes up and says, “No, this is a soft ceiling.” A third one pulls the elephant’s tail and says, “You’re both wrong; it’s a rope connected to a tree.” All the others report their own perceptions and conclusions, all completely different. Of course all of them were right, but they were also wrong; they all came to different conclusions because each of them had limited information. No one saw the whole elephant.

Similarly, there’s a wide range of misunderstanding about chronic pelvic pain, for both patients and the doctors who treat them.

With the benefit of our 25 years treating several thousand pelvic pain sufferers, we’ve gained fundamental insights into this condition. One of the major insights which I will discuss here, is that whether someone has pelvic pain — whether it is sitting pain, rectal pain, genital pain, pain above the pubic bone, urinary frequency and urgency, pain with sex, pain on one side of the pelvis, both sides or pain in the middle, whether the pain moves from one place to another and other symptoms, the common thread for all of these symptoms is a sore and knotted up pelvis. Skillfully press inside and outside the pelvic floor of the pelvic pain sufferer and you will find pain that does not exist with someone who does not have pelvic pain. The sore, knotted up pelvis and its related trigger points are what need to be addressed for the possibility of the pain going away (wherever it is felt) and the symptoms resolving.

Let me explain it this way. Imagine 100 people holding one of their hands in a fist for a month with no break. Your hand would be painful if you did this. It would not be surprising if some of this group of 100 developed pain in the thumb, some of this group developed pain in the little finger, and others in the palm or the forearm….. Apparently different symptoms of pain location but same cause… which is a hand that has been held in a fist for a long time.

You wouldn’t fundamentally treat this problem of a sore hand differently if someone had a sore thumb or sore pinkie. Yes you may work with the thumb or the pinkie locally to loosen and relieve their particular tissue contraction and pain, but the most important treatment would be to unclench the fist and attend to the sore hand to restore its relaxation and ease whether the soreness is felt in the finger or the thumb.

So it is with the varied and seemingly unrelated symptoms of pelvic floor pain. Whether someone has urinary frequency or urgency, pain with sitting, perineal pain, pain with sex, pain after a bowel movement, or pain during or after urination, pain on one side or another or in the middle—all of these apparently different symptoms originate from a chronically tightened pelvic floor and then perpetuated from the pain, anxiety and guarding that follows. The different pelvic symptoms typically are related to the locations of trigger points that form in the pelvis when the pelvis is held tight for a long period of time. Urinary frequency might be thought of as a painful thumb in the clenched fist metaphor while pain with sitting or with sex might be thought of as pain in the little finger.

We have found that specific trigger points within the pelvic floor are related to specific symptoms. We originally published these findings in 2009, in the Journal of Urology ( J Urol. 2009 Dec;182(6):2753-8. doi: 10.1016/j.juro.2009.08.033. Epub 2009 Oct 17.)

Different names, same condition

It turns out that various medical specialists treat the same condition of a chronically clenched pelvis, but they give this condition different names, based on the specific symptoms I have just listed. For example, gastroenterologists and colorectal surgeons typically treat patients with posterior (or rear) pelvic pain symptoms such as ano-rectal pain, post-bowel-movement pain, tailbone pain, and anal fissures. Urologists treat patients with anterior (or front) symptoms, including urinary frequency and urgency, genital pain, testicular pain, painful sex, sexual dysfunction, gynecologists treat genital pain and pain with sex, and so on.

Again, my point here is that whether one is having genital pain and urinary frequency or tailbone and ano-rectal pain, these symptoms all derive from a chronically tightened pelvis. The only difference in these symptoms is where the pain is felt and the specific trigger points that are related to the symptoms.

All the different names for pelvic pain—prostatitis/CPPS, chronic pelvic pain syndrome, pelvic floor dysfunction, dyspareunia, levator ani syndrome, pudendal neuralgia, anal fissures, and chronic proctalgia—are essentially the same condition, even though they’re treated by different specialists and often given different names. This is confusing to the patient and I think it is also confusing to many doctors.

What is of interest is that different symptoms tend to be related to the location of the trigger points are found in different specific locations inside and outside the pelvis.

In other words, whether someone has anterior or front symptoms, posterior or back symptoms, or both, their condition has produced trigger points in related anterior, posterior or anterior and posterior locations. This is an important fact for our therapist clinically locating the offending trigger points and drawing a map of the trigger points a patient must work with and release with our internal trigger point wand and trigger point genie. While the symptoms may make it seem like the patient suffering from sitting pain has a different problem than the patient suffering from urinary frequency/urgency, the problem is the same and the treatment for both of these symptom complexes is essentially the same.

Pelvic pain is invisible and the best diagnostic tool is an educated finger

It’s difficult for most medical professionals to detect the cause of pelvic pain because there’s no objective test for it. It doesn’t show up in X-rays or MRIs. The way we make the diagnosis of pelvic floor related pain we treat, is for a skilled specialist to palpate the tissue inside and outside the pelvic floor. We make the diagnosis of pelvic floor related pain when we discover trigger points and areas of restriction upon palpation in and around the pelvic floor. We typically recreate or intensify a patients symptoms when we press in certain areas, and we consider it diagnostic when we are able to recreate or intensify someone’s pelvic pain symptoms upon palpation.

In a paper we published in the Gold journal of Urology, we explain that pelvic floor pain is in fact a psycho-neuromuscular disorder.



Given that it’s the same disorder, whether symptoms are experienced in the front or back or both, the diagnostic terms used for these symptoms by different doctors can be confusing because the healing pelvic painirritated, hypertonic pelvis can create the same variety of different symptoms. These symptoms are:

  • Genital pain in men and women, or testicular pain in men
  • Urinary frequency and/or urgency, urinary hesitancy, post-urinary dribbling, waking up at night to go to the bathroom, or painful urination
  • suprapubic pain
  • Painful intercourse, or post-orgasm pain
  • Anal sphincter pain
  • Posterior perineal pain
  • Anal fissures
  • Pain with sitting
  • tailbone pain
  • low back pain

The wide variety of symptoms people complain about, and the different diagnoses given to these symptoms when the cause of the symptoms is the same, is why we named our book, “A Headache in the Pelvis.” The Wise-Anderson Protocol we first worked with at Stanford for treating pelvic floor pain and dysfunction is what we use whether the symptoms are felt in the front of the pelvis, the back of the pelvis or both. .

Why drugs don’t cure pelvic floor pain

I’d like to talk about the opioid epidemic that has been in the news the past several years in relationship to the inside job of healing pelvic pain that is outside the reach of all drugs. In recent years, there is what is now called an opioid epidemic has been in the news. Opioid addiction has often begun with the legal prescription of opioids, often after surgery or some procedure. Some group of patients using opioids in this context continued to use them and subsequently became addicted. When I discuss opioids here, I am also including the use of benzodiazepines, like Valium, Xanex, Ativan and clonapin that are used for pain and, like opioids, are also addicting with ongoing use.

There are many people with chronic pelvic pain who have become addicted to opioids and benzodiazepines. These pain medications were probably the only way many doctors felt they had to help these patients with their pain. As we have discovered in our clinical practice with patients who have become dependent on opioids and benzodiazepines, these drugs can work well in the beginning and then progressively diminish in their ability to reduce pain. Also, the pain threshold drops so what didn’t hurt before, hurts with continual opioid use.

The benzodiazepines, we have seen, can be used skillfully to periodically help with pelvic pain when not used regularly, which then helps avoid addiction.   When used occasionally in this way, the benzodiazepines can help someone over the hump of certain flare-ups while not causing addiction. With continued and regular use of opioids or benzodiazepines, however, a higher dosage typically has to be used, to achieve the initial levels of pain relief. After continued regular use, the effectiveness of opioids diminishes in helping pain.


Opioid were primarily used in the past to treat terminal, end-of-life pain. Then, for reasons that are beyond the scope of this discussion, these drugs more and more were prescribed for patients who had chronic, non-end-of-life pain. Our society has painfully learned, that the benefit of pain reduction with the regular use opioids and benzodiazepines comes with what could be called a back-end price… namely after extended, continual use, patients both suffer from addiction to the drug, and a diminishing ability of the drug to help their pain. And then there is the issue of opioid deaths. In 2017 a staggering 47000 overdose deaths were recorded in the United States. I doubt any of this.

It is certainly possible to withdraw from opioid use but it isn’t easy or pleasant. Withdrawal from opioids is a major challenge if the opioids have been used for a long time to deal with chronic pelvic pain. Even if there were no issues of pain, opioid withdrawal is difficult. Significantly, added to the issues of withdrawal, the patient taking opioids suffering from chronic pelvic pain has to deal with the huge challenge of how to deal with their chronic pelvic pain if the opioid is taken away. It is not a small problem when you finally try to stop taking the opioids and you have nothing to help you with the pain.

The Wise-Anderson Protocol for pelvic pain is a non-drug method to stop the pain. In 2015, we published a medical article in which we showed that after 6 months of consistently practicing the Wise-Anderson Protocol, 1/3 of our patients, who had been using different kinds of medications, including some with a current or prior history of using narcotics, had stopped the use of all medication.

Our protocol can help reduce or stop the chronic pelvic pain without drugs because it is aimed at eliminating the cause of the problem.

To be clear, our protocol is based on the understanding that the cause of chronic pelvic pain is sore pelvic floor tissue which continues to be irritated by protective muscle guarding and the irritation of nervous arousal. This protective guarding is a reflex to tighten inside the pelvic floor, whose purpose is to protect against anxiety, but in fact the protective guarding exacerbates it. The normal stresses and functions of life also add to the tissue irritation of the painful pelvic tightening. Our focus is to provide a method to heal this sore tissue by providing a healing environment through the core methods we train our patients in. These include a physical method as well as a behavioral method to calm down the aroused nervous system that aggravates the painful pelvis and interferes with the healing of the sore tissue of pelvic floor.

When someone is taking narcotics or benzodiazepines or other drugs, we advise them to not consider going off of their medications, which we ask patients to get medical help with, until they begin to reduce their pain with our method. It is not uncommon for patients to regularly practice our method for months before they feel comfortable in reducing their medications.

With or without the opioid epidemic, we have found that there are no effective drugs for resolving pelvic pain. Resolving the symptoms of pelvic pain is an inside job of healing the sore, tightened tissue of the pelvic floor. This is something one must do oneself, for oneself. We know of no drugs that are able to do this. Opioids and benzodiazepines can temporarily reduce the pain but does little to the underlying cause of the pain. The Wise-Anderson Protocol is designed to give patients the tools that can allow the possibility of carrying out the inside job of healing a sore and tightened inner core.


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.


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.

Treating Chronic Prostatitis and Chronic Pelvic Pain: The Meeting of Mind and Body in the Pelvic Floor

Treating chronic prostatitis and chronic pelvic pain: their relationship to mind and body

We are often asked whether the physical or behavioral parts of the Wise-Anderson Protocol for treating chronic prostatitis and chronic pelvic pain is more important for its connection to the relationship to the Mind and body. This is a major issue for patients, researchers and doctors alike because it determines the course of the prostatitis treatment and the outcome of treatment.


Over the years we have anecdotally noticed that a small group of our patients have significant improvement in their symptoms with what appears to be our physical treatment alone. On the other end of the spectrum, another small group of our patients appears to do very well with only the behavior component. The large majority of our patients, however, appear to require both the physical treatment which focuses on directly loosening the muscles of the pelvic floor and the behavioral treatment which focuses on helping patients reduce their anxiety daily in the service of releasing the chronic contraction of the muscles of the pelvic floor.

Those practitioners involved in treating chronic prostatitis and chronic pelvic pain rarely converse.

The health specialties in treating chronic prostatitis based on muscle dysfunction and related disorders are usually confined in their own relatively narrow orientations of focusing on either the physical or behavioral/psychological but not both. Historically the subspecialties like urology, colo-rectal surgery, gynecology, pain management, physical therapy, osteopathy on the one hand, and psychology and psychiatry on the other rarely talk to each other. Even when the physically-oriented practitioner recognizes the importance of the behavioral/psychological dimension, or vice-versa, rarely are the physical and behavioral/psychological treatments coordinated or specifically geared to the patient with a pelvic pain disorder. Psychologists and psychiatrists often have little training in the physical components nor do the physically oriented practitioners have training in the mind related dimension of the treatment of the problem.

Successfully treating chronic prostatitis and pelvic pain in terms of mind and body.

Mind and body meet in the pelvic floor in those who suffer from muscle-based chronic prostatitis and chronic pelvic pain. In our book, A Headache in the Pelvis, we discuss the centrality of the tension-anxiety-pain-protective guarding cycle and how this cycle takes on a life of its own no matter what triggers it. The large majority of our patients come to us with years of chronic pelvic contraction that is the way in which they have expressed their anxiety physically. Simply loosening and releasing the chronic contraction of the pelvic floor tends to be short-lived if this loosening is not done repetitively and accompanied by a daily program of relaxing the pelvis and calming down the arousal of the nervous system. All of this is not a small task and is usually undertaken only by those who are in great and ongoing suffering. Yet for those who understand the necessity of this mind and body treatment and diligently pursue it, they have the possibility of real help in a way that it has never been possible in the past.

New Findings About Emotional Brain Changes in Prostatitis: What to do About it

New Findings About Emotional Brain Changes in Prostatitis: What to do About it

Swiss researchers looking into brain activity in men with prostatitis, chronic pelvic pain syndrome report that in a small group of men there is a reduction in relative gray matter volume in a part of the cortex.

A new article written in the October 2012 Journal of Urology identifies some changes in the anterior cingulate part of the brain in men suffering from prostatitis, chronic pelvic pain syndrome. The anterior cingulate cortex and other related parts of the brain, comprising part of the limbic system, are known to be connected with the perception of pain and emotion. The Swiss researchers’ observations of changes in this area of the brain may support the idea that when one has changes in prostatitis, chronic pelvic pain, the chronic anxiety fed by catastrophic thoughts that the pain will never go away is reflected in some changes in the brain.


That chronic pelvic pain and emotions are intimately connected and probably affect the brain is no surprise to any of us who have been treating chronic pelvic pain over the years. Many of our patients agree that the feelings of helplessness, hopelessness, and fear can be worse than the actual physical pain.

As with all the research that documents certain relationships, the “elephant in the room” type of question, in this case, is if pain and emotions are strong enough to affect the brain in the way the Swiss researchers have recently documented, what does it mean and what can be done about it? Over the years, our answer has been simple: empower patients to reduce or stop their physical pain and help them reduce their emotional distress.

Wise-Anderson Physical Therapy Self-Treatment and Paradoxical Relaxation

In our latest review of data from patients we have seen in the last four years, we discovered—not surprisingly—that when you give patients the ability to reduce their pain, their emotional distress calms down. In the Wise-Anderson Protocol, the two major methods we use are focused on reducing pelvic pain mentally and physically. We have documented (see 2011 articles in the Journal of Urology and the Clinical Journal of Pain) that physical therapy self-treatment in combination with Paradoxical Relaxation significantly reduces pelvic muscle sensitivity/pain. In additional data, we found that this reduction in pain is associated with a significant reduction in emotional distress. More information on treatment here

In future research, it would be interesting to observe whether the reduction or resolution of symptoms of prostatitis and related pelvic pain syndromes, as experienced after doing our protocol for 6 months, reverses the brain changes this recent study found.


Below are articles on the subject of brain changes related to changes in prostatitis, chronic pelvic pain syndromes.

1. Chronic Pelvic Pain Syndrome in Men is Associated with Reduction of Relative Gray Matter Volume in the Anterior Cingulate Cortex Compared to Healthy Controls.

Mordasini L, Weisstanner C, Rummel C, Thalmann GN, Verma RK, Wiest R, Kessler TM.

J Urol. 2012 Oct 18. pii: S0022-5347(12)04500-4. doi: 10.1016/j.juro.2012.08.043.


Department of Urology, University of Bern, Bern, Switzerland.



Although chronic pelvic pain syndrome impairs the life of millions of people worldwide, the exact pathomechanisms involved remain to be elucidated. As with other chronic pain syndromes, the central nervous system may have an important role in chronic pelvic pain syndrome. Thus, we assessed brain alterations associated with abnormal pain processing in patients with chronic pelvic pain syndrome.


Using brain morphology assessment applying structural magnetic resonance imaging, we prospectively investigated a consecutive series of 20 men with refractory chronic pelvic pain syndrome, and compared these patients to 20 gender and age matched healthy controls. Between group differences in relative gray matter volume and the association with bother of chronic pelvic pain syndrome were assessed using whole brain covariate analysis.


Patients with chronic pelvic pain syndrome had a mean (±SD) age of 40 (±14) years, a mean NIH-CPSI (National Institutes of Health Chronic Prostatitis Symptom Index) total score of 28 (±6) and a mean pain subscale of 14 (±3). In patients with chronic pelvic pain syndrome compared to healthy controls there was a significant reduction in relative gray matter volume in the anterior cingulate cortex of the dominant hemisphere. This finding correlated with the NIH-CPSI total score (r = 0.57) and pain subscale (r = 0.51).


Reduction in relative gray matter volume in the anterior cingulate cortex and correlation with bother of chronic pelvic pain syndrome suggest an essential role for the anterior cingulate cortex in chronic pelvic pain syndrome. Since this area is a core structure of emotional pain processing, central pathomechanisms of chronic pelvic pain syndrome may be considered a promising therapeutic target and may explain the often unsatisfactory results of treatments focusing on peripheral dysfunction

2. Limbic associated pelvic pain: a hypothesis to explain the diagnostic relationships and features of patients with chronic pelvic pain.

Fenton BW.

Med Hypotheses. 2007;69(2):282-6. Epub 2007 Feb 9.


Summa Health System, Department of Obstetrics and Gynecology, MED-2, 525 E Market St., Akron, OH 44303-2090, United States. fentonb@summa-health.org


Limbic associated pelvic pain is a proposed pathophysiology designed to explain features commonly encountered in patients with chronic pelvic pain, including the presence of multiple pain diagnoses, the frequency of previous abuse, the minimal or discordant pathologic changes of the involved organs, the paradoxical effectiveness of many treatments, and the recurrent nature of the condition. These conditions include endometriosis, interstitial cystitis, irritable bowel syndrome, levator ani syndrome, pelvic floor tension myalgia, vulvar vestibulitis, and vulvodynia. The hypothesis is based on recent improvements in the understanding of pain processing pathways in the central nervous system, and in particular the role of limbic structures, especially the anterior cingulate cortex, hippocampus and amygdala, in chronic and affective pain perception. Limbic associated pelvic pain is hypothesized to occur in patients with chronic pelvic pain out of proportion to any demonstrable pathology (hyperalgesia), and with more than one demonstrable pain generator (allodynia), and who are susceptible to development of the syndrome. This most likely occurs as a result of childhood sexual abuse but may include other painful pelvic events or stressors, which lead to limbic dysfunction. This limbic dysfunction is manifest both as an increased sensitivity to pain afferents from pelvic organs, and as an abnormal efferent innervation of pelvic musculature, both visceral and somatic. The pelvic musculature undergoes tonic contraction as a result of limbic efferent stimulation, which produces the minimal changes found on pathological examination, and generates a further sensation of pain. The pain afferents from these pelvic organs then follow the medial pain pathway back to the sensitized, hypervigilant limbic system. Chronic stimulation of the limbic system by pelvic pain afferents again produces an efferent contraction of the pelvic muscles, thus perpetuating the cycle. This cycle is susceptible to disruption through blocking afferent signals from pelvic organs, either through anesthesia or muscle manipulation. Disruption of limbic perception with psychiatric medication similarly produces relief. Without a full disruption of both the central hypervigilance and pelvic organ dysfunction, pain recurs. To prevent recurrence, clinicians will need to include some form of therapy, either medical or cognitive, targeted at the underlying limbic hypervigilance. Further research into novel, limbic targeted therapies can hopefully be stimulated by explicitly stating the role of the limbic system in chronic pain. This hypothesis provides a framework for clinicians to rationally approach some of the most challenging patients in medicine, and can potentially improve outcomes by including management of limbic dysfunction in their treatment

3. Amitriptyline reduces rectal pain related activation of the anterior cingulate cortex in patients with irritable bowel syndrome.

Morgan V, Pickens D, Gautam S, Kessler R, Mertz H.

Gut. 2005 May;54(5):601-7.


Department of Radiology and Radiological Scienes, Vanderbilt University, Nashville, TN 37205, USA.



Irritable bowel syndrome (IBS) is a disorder of intestinal hypersensitivity and altered motility, exacerbated by stress. Functional magnetic resonance imaging (fMRI) during painful rectal distension in IBS has demonstrated greater activation of the anterior cingulate cortex (ACC), an area relevant to pain and emotions. Tricyclic antidepressants are effective for IBS. The aim of this study was to determine if low dose amitriptyline reduces ACC activation during painful rectal distension in IBS to confer clinical benefits. Secondary aims were to identify other brain regions altered by amitriptyline, and to determine if reductions in cerebral activation are greater during mental stress.


Nineteen women with painful IBS were randomised to amitriptyline 50 mg or placebo for one month and then crossed over to the alternate treatment after washout. Cerebral activation during rectal distension was compared between placebo and amitriptyline groups by fMRI. Distensions were performed alternately during auditory stress and relaxing music.


Rectal pain induced significant activation of the perigenual ACC, right insula, and right prefrontal cortex. Amitriptyline was associated with reduced pain related cerebral activations in the perigenual ACC and the left posterior parietal cortex, but only during stress.


The tricyclic antidepressant amitriptyline reduces brain activation during pain in the perigenual (limbic) anterior cingulated cortex and parietal association cortex. These reductions are only seen during stress. Amitriptyline is likely to work in the central nervous system rather than peripherally to blunt pain and other symptoms exacerbated by stress in IBS.

Reflections on Prostatitis and Chronic Pelvic Pain Treatment

Reflections on The  Prostatitis and Chronic Pelvic Pain Treatment and the path to Recovery

By David Wise, PhD

This paper is about sharing my observations about healing my own pelvic pain and my road to recovery.

Millions of men suffer from urinary frequency, urgency, pain with sitting, pain after sex, genital pain and pelvic pain and other symptoms called prostatitis/chronic pelvic pain syndrome. I suffered for over 20 years from what was is now diagnosed as prostatitis/chronic pelvic pain syndrome. This diagnosis is confusing to patients and doctors alike, and the story about this confusion surrounding the treatment of the condition remains to be told to a large audience.

Today, gratefully, my pain is gone and I have become an expert in a field I never wanted to be an expert in. As I think about it now, I can’t imagine the devastation of my life had I continued to be in pain. I always feel grateful. I hope this article can help clarify the confusion, misdiagnosis, and ineffective treatment of what is diagnosed as prostatitis in men and help many silently suffering men find a way back to having a life again.

I observed my own slow and awkward healing.

I am someone who has been interested in my internal life and its process, whether it is related to pelvic pain or to my interpersonal relationships. Naturally, over the years, I observed with great interest the mental and physical happenings in my body through the process of the resolution of my pelvic symptoms. In this essay, I want to share my experience of coming out of pain and what I have observed and learned about this experience in the hope that it can offer a roadmap to others.

When I was a young man experiencing the symptoms our patients come to see us with, I dutifully and sincerely went to the urologist trusting he would help me. I saw him for many years and was never helped by his methods. I was told that I had ‘prostatosis’. The doctor explained, as best he could, that what I had was like prostatitis, except there was no inflammation or infection. He said my prostate was ‘boggy’.

I never quite understood what he was saying. In retrospect, I can’t imagine he understood his explanation either even though he was a kind and intelligent man. It was clear he was telling me that my prostate gland was my problem except for the peculiar explanation that there was no problem with it except it was ‘boggy’. To me ‘boggy’ means soft or spongy. I didn’t understand how something spongy could cause me the pain and symptoms I had, but he was the doctor and I trusted him. Gratefully he told me that my symptoms would get better as I got older (he was wrong) but I appreciated that he gave me the hope that somehow, at some time, my symptoms would get better. As the doctor couldn’t help me, I lost faith seeing doctors. I had nowhere to go and no one to help me. People have asked me how I dealt with my symptoms for over two decades. My answer is that there was nothing heroic about it. I muddled through my life dealing with the symptoms day by day, as all of our patients do.

I took the insights of my recovery to Stanford.

After doing a version of the protocol we now offer, my pain went away in the 1990’s. Excitedly, I called Dr. Rodney Anderson, one of the world experts in prostatitis and pelvic pain and the head of the Pelvic Pain Clinic at Stanford University Medical Center in the Department of Urology, and shared my experience with him. For many years at Stanford Dr. Anderson worked closely with Dr. Thomas Stamey, who co-invented the test for bacterial prostatitis. Dr. Anderson finally came to the conclusion that what was typically diagnosed as prostatitis was not a prostate condition but a condition of the contracted muscles of the pelvic floor and as such was not helped by the conventional standard of treatment using antibiotics and anti-inflammatories.

My call to him that day in 1995, sharing my recovery, found him open to listening about my experience. Gratefully, he recognized the importance of what I told him about how I got out of pain after 22 years of suffering.

From that time Dr. Anderson and I immediately began working together at Stanford. At Stanford was where we saw pelvic pain patients and developed the Wise-Anderson Protocol (popularly called the “Stanford Protocol” in internet discussions) detailed in the first edition of our book, A Headache in the Pelvis. In our protocol, we saw and treated the muscles of the pelvis as the sources of what are commonly diagnosed as prostatitis symptoms and anxiety that inflamed them. We began treating the pelvic muscles and emotions of men’s anxiety related to them, as the key treatment for prostatitis with typical symptoms of prostatitis—not their prostates. I worked with Dr. Anderson as a Research Scholar at Stanford for 8 years.

Later, after I left Stanford, Dr. Anderson and I, along with Tim Sawyer, our senior physical therapist, continued our close collaboration and research into our protocol. The form of treatment changed from a conventional weekly visit format, to what has evolved into a 6 day monthly immersion clinic. In total, I have spent 18 years treating patients with the Wise-Anderson Protocol. We have published a number of papers and have presented our work in major scientific meetings in the US and internationally.

Getting to the top of the mountain to see below: how the discovery of San Francisco Bay is similar to finding the route out of pelvic pain.

When someone’s prostatitis symptoms go away, what happens? How does this healing occur? Here is an analogy that is helpful to me in explaining why conventional medical treatment has been unsuccessful in finding a prostatitis cure: Many years ago, European explorers sailed up and down the coast of California, yet from the ocean they could not see San Francisco Bay. Then, in 1769 Spanish explorer Gaspar de Portola set out for the port at Monterey. Believing he had missed the port, he continued sailing north up the coast. After a time at sea, short on food and water, Portola sent an expedition ashore. They landed in what is today known as Pacifica, and it was looking out from a ridge that they finally saw the San Francisco Bay.

The pathway out of symptoms diagnosed as prostatitis has not been visible from the ‘ocean’ of the conventional medical perspective, or even any common sense perspective. The symptoms are, frankly, weird, and only if you have experienced them can you really understand them. Just like de Portola, after many years of experimentation, blind alleys, hit and miss attempts and trying different ways to stop my pain, I too found the ‘ridge’ of understanding; that my pelvic pain was not an infection or problem with my prostate gland, as my urologists had told me, but was in fact a problem of chronically tightened muscles inside my pelvic floor. This chronic tightening in my pelvis was where I held my anxiety. Some people would call it me being “anal,” and that’s probably true.

I found relief when placing a finger inside, I pressed on these tightened muscles and stretched them or relaxed them. I noticed stress made my symptoms worse and alternatively I felt some temporary relief from a hot bath, a good night’s sleep or the resolution of some worry. I came to see that what made my symptoms better or worse was the tightening or relaxation of my pelvic muscles. While that might seem easy to fix, I found that the fix was neither easy nor obvious.

Why pelvic pain symptoms do not act like other symptoms.

Symptoms commonly diagnosed as prostatitis rarely respond to the normal treatments for pain. One of the reasons that these symptoms have fooled conventional medicine is that they are referred from places in the pelvic floor that are remote from the pain. For example, the cause of pain in the penis is typically found inside the pelvic floor, 10 inches away from where the pain is felt, on the anterior portion of the levator muscles. The cause of muscle based testicular pain can be muscle restriction and trigger points in the quadratus lumborum, an external muscle a good foot away from the testicles. Abdominal pain, urinary frequency and urgency, sexual pain, post-bowel movement pain, and other associated pain are typically caused by tenderness in the muscles inside and outside the pelvic floor.

Most doctors treating pelvic pain do not examine the muscles of the pelvic floor and related areas. In not examining these muscles, they fail to see that the symptoms of what is called nonbacterial prostatitis in the vast majority of cases can be recreated by pressing on specific muscles inside and outside the pelvic floor. Most importantly, when these sore and tender areas of muscle are loosened and what are called trigger points released, done in conjunction with reducing the anxiety that typically flares them up, symptoms diagnosed as prostatitis can reduce or go away.

Doctors typically treat men with prostatitis with medications. The National Institutes of Health have has done an exhaustive, careful study of antibiotics, alpha blockers and anti-inflammatories—the most commonly used drugs for pelvic pain in men diagnosed as prostatitis—and the conclusion of this and other studies was that these medications do not help. While surgery was never suggested to me when I was in pain, in hearing the reports of many patients I have treated who had surgery, I have concluded that surgery, another common ‘solution,’ is a bad idea. It almost always complicates the symptoms or makes them worse. I have never heard patients report that a nerve block or any surgery, including pudendal nerve or prostate resection surgery, resolved prostatitis symptoms. Exploratory procedures, CAT scans and other high tech imaging tests typically cannot find anything wrong. Blood and urine tests are typically normal. The conventional ways of diagnosing and treating what is diagnosed as nonbacterial prostatitis do not help. All of the men (and women) who have come to see us for treatment have been refractorily unhelped by all of their prior drug and surgical treatments.

A heart transplant won’t stop heartburn: treating the prostate will not help the chronic contraction of the pelvic muscles.

I’ve come to understand the importance of the insight that, how you look at a problem determines the method you use to fix it. My view that I had a muscle problem and not a prostate problem changed everything for me. When I witness the suffering of our patients, I see myself before I changed my viewpoint about my problem. Most men we see continue to think in some way that they have a prostate-related problem. Below are my thoughts about the confusion in the diagnosis and treatment of prostatitis.

A heart transplant is a wrong the treatment for heartburn. Cutting down pine trees doesn’t get rid of poison oak rashes. You have to be able to make a differential diagnosis to distinguish reflux pain in the esophagus from pain coming from the heart muscle. You have to distinguish poison oak from pine trees. My experience with men diagnosed with prostatitis over the years is that conventional medicine has erred in its differential diagnosis of their symptoms as pelvic pain. Most of our patients have reported that their doctor never did a culture for infection before prescribing antibiotics. Just as you have to know the difference between pain from a heart attack and pain from acid in the esophagus, so must you differentiate between pain coming from an infected or inflamed prostate gland and pain coming from the muscles inside and outside the pelvic floor. The distinction must be made between symptoms of prostatitis caused by prostate infection, which occurs in a tiny proportion of men diagnosed with prostatitis, and symptoms that are caused by a chronically tightened pelvis, which occur in the large majority of men. This is one of our original contributions to prostatitis treatment.

The misdiagnosis of chronic prostatitis.

All too often we see patients whose doctors ignorantly recommended they undergo invasive surgeries and treatments. All of them which failed to end the symptoms. A doctor who saw one of our patients for testicle pain recommended that he have the offending testicle removed. The patient gladly agreed to surgery with the hope it would end his pain. When surgery didn’t end the pain, the doctor told him they must’ve removed the wrong testicle. Tragically, the surgery to remove the second testicle also failed to stop the pain.

To my great dismay, we’ve seen men who’ve had their prostate glands removed, re-sectioned, and “roto-rootered.” We’ve seen men and women who’ve had their anal sphincters cut. One man elected to have a colostomy with the hope that not having bowel movements would cause his pain to stop. It never did. We have seen many patients addicted to narcotics and other medications that did little good for them and whose efficacy wore off.

In our practice, we’ve seen three women who had their bladders removed and many who’ve undergone hysterectomies, laparoscopies, and urethral dilations. None of it helped. Of course, we’ve seen a number of people who’ve had the pudendal nerve surgery, in which the ligaments that stabilize the pelvis are cut—and we have never seen any resolution of symptoms from this surgery or any surgery. From Botox and electrical stimulation to acupuncture and faith healing, nothing has been effective if the spasticity of the muscles and arousal of the nervous system is not addressed.

The patients who have done best in our program took ownership of their own healing

As the doctors couldn’t help me, I lost faith in them. I had nowhere to go and no one to help me, but I believed the doctor who told me my problem was related to my prostate gland. For years I went along in pain not knowing what to do and inadvertently experimenting with different methods of treatment.

One of the many difficulties of someone diagnosed with prostatitis or chronic pelvic pain syndrome is moving into the position of being your own researcher and doctor. It is not easy or comfortable for many people to abandon trust in the conventional viewpoints in favor of their own research and intuitive judgment. The most common form of muscle based pelvic pain in men is incorrectly named ‘prostatitis’ and both urologists and family practitioners continue to treat it as if it is a prostate problem rather than a problem of the pelvic muscles. I see now that healing muscle based pelvic pain in most of our patients required a journey away from this idea and the authority of the doctors who treat it with this conventional wisdom. This is not easy for many people.

I never wanted to know anything about the pelvis. When I first started having my problem, I wanted to go into the doctor and have him fix it and send me on my merry way. No patient wants to have to learn about this area of the body or its treatment. If you were to ask any pelvic pain patient whether they want to learn to be their own doctor, they would all say, “Don’t call me, I’ll call you.” But, the pelvic pain patient who is able to find a solution to their own pain is the patient who becomes their own researcher and ultimately relies on their own intuitions on what to do and who to believe.

This is a difficult situation for most of us. The patients I have seen who insist on listening to their doctors about this problem, remain in pain or in some cases get into trouble with surgery, narcotic medications and other drugs.

The maddening refusal of conventional doctors to understand most pelvic pain is a muscle-based problem and not an infection or inflammation based problem.

Despite the decision of the National Institutes of Health to change the name of nonbacterial prostatitis—by far the largest category of pain in men—to chronic pelvic pain syndrome, men who seek chronic pelvic pain treatment are routinely treated as if their problem comes from their prostate gland. When I was at the National Institutes of Health (NIH) meeting on prostatitis in 1999, it became very clear that there was only a handful of us who understood the majority of prostatitis cases to be the misdiagnosis of conditions unconnected to the prostate.

When Leroy Nyberg, then head of the section of the NIH covering prostatitis, was asked about the urology community’s refusal to shift paradigms about prostatitis from a prostate infection model to a pelvic floor muscle pain model, he said, “It doesn’t go over well when a big organization loses a disorder.” What was left unsaid was the ideological and economic disincentive of shifting perspectives. Unfortunately, the person who suffers from this is the patient.

Why healing muscle-based pain follows a circuitous route.

As I see it now, several major systems of the body converge in the precipitation and perpetuation of symptoms diagnosed as prostatitis. There is tender pelvic tissue that one cannot see, is hard to reach and is usually in motion. You also typically have to deal with what turns out to be a typical chronic prostatitis patient’s long-standing habit of catastrophic thinking and anxiety. (Elsewhere I’ve discussed literature that documents the relationship between anxiety, emotional distress, family dysfunction and pelvic pain). And then, of course, there is the unfortunate, dysfunctional tendency of the pelvic muscles to reflexively tighten against the pain, which instead of protecting the individual exacerbates the problem. I discuss this cycle in detail below.

One of the problems of conventional medical treatment for pelvic pain is that healing requires the expertise of a number of sub-specialties that do not talk to each other.

Pelvic pain tends to be treated by a variety of different medical sub-specialties—urology, gynecology, colo-rectal surgery, chiropractic, physical therapy, and psychology/psychiatry. The lack of communication between these subspecialties around pelvic pain leads to a piecemeal treatment of the problem. This is especially true in the treatment of the physical and mental aspects of the disorder, which are intimately intertwined. Finally, as is the theme of our program, the concept of teaching patients how to treat themselves is not the major focus of any of these subspecialties. As far as I’m concerned, the aspect of self-treatment as a therapeutic regimen is critical for most pelvic pain patients to get better.

The huge stress-related dimension of muscle-based pelvic pain is only recently being recognized and treated.

The stress/psychological dimension of pelvic pain wasn’t recognized for many years. Even today, many urologists not only have little understanding of the psychological dimension of pelvic pain, but they continue to look for its origin in men in the prostate gland. This completely ignores the central focus of the problem, which is in the muscles of the pelvis. Physical therapists who have somehow established themselves as those who can enter inside the pelvis to do physical treatment have little training in urology or psychology, and physical therapy treatment tends to focus on the treatment of myofascial tissue. Each medical subspecialty has its own strengths and limitations. I am clear that the skills that are required to treat pelvic pain are cross-disciplinary, and all of them cannot be found in any one specialty.

When someone is scared, frightened, or stressed the core of the body tightens in a guarded posture.

As I became aware of the continual muscle tension in my pelvis and began to work with it, I saw how difficult it was to relax. I didn’t understand then, as I do now, that muscles that have become shortened and developed the taut bands called trigger points cannot relax until the trigger points are physically released. This was a huge insight and explained a lot to me. It convinced me that treatment for prostatitis has to be cross-disciplinary and must go beyond the limited skill and understanding of conventional treatment. I understand now that chronically tightened pelvic muscles get stuck in that state and at a certain point begin to cause pain, which triggers a self-perpetuating cycle that has a life of its own even after the precipitating stress goes away.

Someone with pelvic pain typically walks around guarded and tight in the pelvis. ‘Girding your loins,’ a biblical euphemism, describes the tightening, guarding or protecting of the genitals. When we are not stressed, it’s difficult to appreciate the strength this physical contraction has, but muscle tightening in periods of ongoing stress can be profound.

The painful pelvic muscles have shortened, predisposing them to pain and dysfunction.

For years I meditated on and observed my symptoms, but never understood why I could do nothing about them. As I visualize it in my mind now, once pelvic muscle tightening occurs for a certain period of time, I imagine that the microscopic distance between the muscle tissues reduce, creating less air and less space in between these muscle fibers. After a while, taut bands of muscle called trigger points form. These trigger points can refer pain to other places in the pelvis. We illustrate and describe these trigger points and the areas to which they refer pain in our book A Headache in the Pelvis. These trigger points are pivotal in creating, “an inhospitable environment for the muscles, nerves, and structures within the pelvic basin.”

It’s clear to me that the tension-anxiety-pain-protective guarding cycle is the major obstacle to healing muscle based prostatitis.

The Tension-Anxiety-Pain-Protective Guarding Cycle

Chronic Pelvic Pain Treatment

For many years I experienced the tension-anxiety-pain-protective guarding cycle, but it wasn’t until we wrote A Headache in the Pelvis that I put it into words. This cycle is what I believe is at the heart of muscle based prostatitis symptoms. This cycle is the meeting of body and mind within the pelvic floor. I lived within the grip of this cycle for many years.

Men with chronic muscle based prostatitis are caught in the tension-anxiety-pain-protective guarding cycle, in which the pelvic muscles causing the pain can no long relax. They remain tense and sore making them subject to a reflexive protective guarding that makes the pain worse.

Protective guarding occurs as a reflex when we pull our hand away from a hot stove, when our eye flinches after something gets in it, or when we tighten up and withdraw from something that causes us pain. This reflex to tighten and pull away is very important for our survival and indeed it usually protects us.

The instinct to tighten up against pelvic pain diagnosed as prostatitis is dysfunctional because instead of helping, it makes the pain worse. Protective guarding against sore pelvic muscles further tightens them up. This dysfunctional protective guarding is intimately connected to the chronicity and perpetuation of chronic pelvic pain. This is why studies have shown that the muscle tone in the pelvic floor tends to be abnormally high in sufferers of chronic pelvic pain syndromes.

When I gave a talk at the National Institutes of Health, I asked participants to tighten up their pelvic muscles for a minute. I speculated that few would be willing to tighten up like this for the entire minute. I told them that if I asked everyone in the audience to tighten up the pelvic muscles for an hour no one would be surprised if there wasn’t anyone willing to do this. I then took them on an imaginary journey of tightening up their pelvic muscles for a whole day, and then a week, and then a month, and then a year. To someone without pelvic pain, such chronic contraction would be unimaginable.

Those who have symptoms diagnosed as prostatitis and chronic pelvic pain syndrome, experience this dysfunctional protective guarding for months and years. This is why many patients report that when they follow the instructions in our book to do “moment to moment relaxation of the pelvis,” their pelvic muscles invariably tighten up immediately after they stop. It was only after my pain went away that I stopped protectively guarding in the way that I had when I was symptomatic.

Pain prompts protective guarding which increases the pain, which then triggers catastrophic thinking and anxiety. Anxiety feeds into the pain and increases it as Gevirtz and Hubbard have demonstrated in many experiments showing trigger point activity increasing with anxiety. The tension-anxiety-pain-protective guarding cycle has resisted all conventional attempts at resolution.

The challenge of repetitively rehabilitating painful pelvic tissue. The necessity of repetitive loosening of the pelvic floor and of the anxiety related to it. Teaching our patients to do their own internal and external trigger point release.

We begin our treatment by teaching patients how to soften and release the trigger points of contracted pelvic tissue. This means identifying the sore trigger points and palpating them in specific ways for a certain period of time. (see article on physical therapy for pelvic pain)

Using our internal trigger point wand.internal trigger point wand.

To treat the hard-to-reach internal muscles, we developed an internal trigger point wand, which we have been using as part of a treatment study for the past four years. Our clinical study found that patients who did our protocol using the wand for six months saw their median level of pain/sensitivity in the trigger points in the pelvic floor muscles decrease from 7.5 to a 4 (on a scale of 1-10).

It’s clear to me now that repetitively loosening and softening the pelvic floor muscles is central to healing muscle based pelvic pain.

Restoring the pelvic muscles to a normal length and pain-free state requires repetitive, ongoing physical therapy self-treatment. Just as you would change any bad habit, repetition is key. You must repeatedly restore the tissue to a normal state until you over-ride its conditioned tendency to remain contracted. In the book Blink, author Malcom Gladwell restated an observation that a number of researchers have made, which is that mastery requires 10,000 hours of repetition. While 10,000 hours of repetition is not required to loosen a painful pelvis, repetitive physical loosening and relaxation are necessary for my experience of pelvic pain healing.

Along with releasing the tissue physically, I experienced daily the necessity of calming my nervous system down. If I didn’t, my symptoms seemed to stick around. I will discuss the focus on the nervous system below.

Not too much or too little pressure.

When I treated myself physically, I learned that I had to be careful about the level of pressure I used to working with my painful muscles.

I found that when one does myofascial/trigger point release on muscles inside and outside the pelvic floor, chronically tight pelvic muscles have to be rehabilitated within certain specific parameters of pressure and within certain time frames. Too much pressure created a flare-up and caused my pelvic tissue to guard; too little pressure did little good; stretching the tissue for too little time did not seem to give the tissue a chance to lengthen; stretching the tissue too long tended to create guarding and continuing soreness

I have noticed over the years that extremely sore and sensitive tissue in patients can be, as our senior physical therapist Tim Sawyer calls it, “hyperirritable.” Tim says that hyperirritable trigger points and pelvic tissue must be treated like you would hold a wounded dove in your hands. If you physically treat hyperirritable tissue with inappropriate pressure, you can cause long flare-ups of pain and increase anxiety. We have developed a guideline that pelvic floor trigger points and areas of sore muscle restriction should at first not be pressed beyond a 3 on a 0 to 10 pain scale. We then suggest increasing the pressure up to 7 on the 0 to 10 scale as long as the area doesn’t flare-up unduly. If there is a flare-up that continues for more than 24 hours, we believe too much pressure has been applied and it has to be reduced. When patients are treating themselves we ask them to stop their own physical therapy self-treatment for several days to allow the flare-up to calm down. Eventually, as trigger point sensitivity reduces, pressure can be increased to 7 on the 0-10 scale as long as there is a little flare-up of symptoms. If a sore tissue is properly palpated, the trigger point sensitivity and pain can significantly reduce or go away.

Unless we train our patients otherwise, some treat their sore pelvis roughly like a piece of meat; distancing themselves from it and using undue pressure. We train them to feel their pelvic muscles as they treat these muscles so that they do not flare themselves up from self-treatment.

Showing the pelvis unconditional kindness.

In my journey of healing my pelvic pain, I made a choice to listen to my pelvis. I adopted an attitude of kindness and unconditionality in which I came to understand that my pelvis did not want to hurt. I saw that my pelvis reacted to my impatience or negativity like I would react to someone else’s impatience or negativity. Absent words, the only way my pelvis spoke to me when it was not happy was with pain. In my own journey, I had to say, “I’ll do whatever it takes to help myself out of pain.” I’ve noticed that people who assume this attitude tend to do better because they’re forced to give up their own agenda and become interested in what it takes for their pelvis to calm down.

God heals and the physician collects the fee: learning to be kind to your own physician?

The body has a miraculous capacity to heal, and it is possible to recover from pelvic pain. During our body’s noble journey, however, we must consistently act in a way that helps the pelvis to heal and resist doing what interferes with its healing. In short, we have to be mindful of creating an environment that is hospitable for the sore contracted pelvic tissue to become normal.

Changing your attitude toward your pelvic pain.

At the end of our clinics, I do a process with our patients called, “talking to your pelvis.” I have patients feel their painful pelvis while I ask it questions. It is not uncommon for my patients to say, “I can’t believe how I’ve hated my pelvis” or “How unkind I’ve been to my pelvis.” Some have said, “Every time my pelvis hurts, I become frightened or angry or feel dread.” Others have said, “I felt that my pelvic pain was a way in which God was punishing me.” Patients attribute all kinds of motives and attributes to a sore, painful pelvis. They can assume different attitudes toward it that are often hateful, frightened, angry or frustrated. These kinds of attitudes toward the pelvis only tighten the pelvis, increase anxiety and nervous system arousal, and make things worse. When I speak to my pelvis now and ask it if it has anything to say to me, it says ‘Thank you.’

Calming down emotionally.

My journey with relaxation has been long. If I could have found a teacher like the one I am today when I was symptomatic, my journey would have been immeasurably easier. Relaxation did not come easily to me then, despite the fact that I had studied with Edmond Jacobson, who is considered the father of relaxation therapy. I tried to relax for many years, but I failed. Finally, I applied to my relaxation practice the principles I learned from Jacobson as well as those from my own spiritual exploration; to accept what is, to stop resisting the experience within that I couldn’t change, to let go of effort and of trying to achieve something with my relaxation, and to accept my pain and anxiety instead of fighting them. In my book Paradoxical Relaxation, I describe this method.

I have observed that it takes dozens of hours of Paradoxical Relaxation practice for people to begin to learn how to calm down the nervous system, especially when they’re in pain and anxious. Reducing emotional arousal and managing anxiety are the key issues addressed by our Paradoxical Relaxation method.

Becoming emotionally intelligent: managing the tendency to get lost in catastrophic thinking.

When I was beginning to do relaxation for my pain, I came to see that there was always the issue of my pain, and then there was the issue of my attitude toward my pain. They were two different things. As I was able to work with my pain physically and reduce my symptoms, I slowly stopped catastrophizing each flare-up because I came to see that I could reliably calm them down myself.

I’ve observed that for most of our patients, despair, anxiety, and pain tend to be waiting in the wings and ready to pounce when one begins treatment. It is important for patients using our protocol to be able to witness their catastrophic thinking so that they can release it instead of allowing it to sabotage their treatment. I often say to patients that they don’t have to believe everything they think, and that when they catastrophize they will typically confuse their thinking for reality.

Not being scared by a flare-up of symptoms.

In my journey, I had many symptom flare-ups. I would have periods of time during which I was pain-free for days or weeks. Then, something would happen and my symptoms would flare up as badly as they ever were. When my symptoms disappeared I thought my recovery was a done deal, and when they flared up, I sank down into despondency. When I went through this cycle of symptom improvement and then flare-up many times, I became less and less afraid of the symptoms flaring up because I knew I could resolve them with my own self-treatment.

Ending flare-ups through skilled self-treatment.

The majority of our patients who do our protocol consistently do get better. We have patients who were in chronic pain for many years who are now pain-free for the most part. Most have learned not to be afraid of symptom flare-ups, as they are more able to effectively resolve them. For this reason, we ask our patients to do a 52 week recorded course in Paradoxical Relaxation to begin to take the edge off emotional agitation that’s gone on for many years.

An emotional release often accompanies the physical.

The phenomenon of somato-emotional release is common when a certain group of pelvic pain patients who do myofascial trigger point release, especially inside the pelvis. For example, a woman we treated with pelvic pain who was repeatedly sexually abused, wept regularly both when we instructed her on internal trigger point release and when she began doing it herself. Constricted tissue and pain is often connected to the emotional environment in which it began. Understanding and allowing emotional expression of grief, fear, or anger during treatment and giving it space to emerge and be released is essential in pelvic healing.

Controlling the tendency to be ‘anal’.

Those who get pelvic pain tend to be what, in the vernacular, would be called ‘anal.’ The colloquial use of ‘anal’ means to be obsessive, devoted to detail and perfectionistic and also to have obsessive thinking. It’s associated with a tightening of the anus, and in fact, there is some truth in this pejorative colloquialism.

Managing the pelvic pain patient’s tendency toward perfectionism, obsessive-compulsive behavior, and compulsive working is a lifestyle and psychological change that needs to be modified.

Paradoxical Relaxation helps to stop compulsive doing.

Paradoxical Relaxation is the behavioral method we use to help our patients learn to, “stop compulsively doing.” The pelvic pain patient tends to rarely, if ever, relax. In the moment of relaxation, it’s necessary that you stop all doing; this means you stop trying to achieve, get somewhere, or accomplish something. In the state of not doing, the pelvic muscles can relax.

In my book Paradoxical Relaxation, I’ve discussed extensively the importance of training attention to rest in sensation outside of thinking because resting attention is what can help someone who is a compulsive doer to relax.

After patients do a full session of internal and external physical therapy, we encourage them to do half an hour to an hour of Paradoxical Relaxation. The reason I ask people to do this is that I see the importance in disengaging the muscles of the pelvis from activity after they’ve been lengthened in order to allow the sore, tightened, painful tissue to get used to being at a normal length.

Moving from doing to being.

I learned in my own recovery that I had to regularly stop and call a timeout in my life. I had to be able to profoundly relax to calm down my over active nervous system. In a large sense, I have learned that one of the essential components in healing pelvic pain is learning to, at some time during the day, move out of the doing mode and into the being mode.

The mantra that self-treatment is the way.

When I was symptomatic, the most important element of my suffering was the fact that I felt helpless about doing anything about my pain. As I recovered from my own symptoms and felt confidence in helping myself, everything got better. I have come to believe that the most important part of treating pelvic pain is giving patients the ability to reduce or stop their own pain and symptoms both physically and mentally. Doing this dispels anxiety and helplessness which in my view are the most debilitating symptoms among all the symptoms of chronic prostatitis. Chronic prostatitis or chronic pelvic pain syndrome tends to recur under stress, and the most important thing I believe we can do for a patient with symptoms diagnosed as prostatitis is to help him reduce or stop his symptoms by his own efforts.


In summary, here is what I have learned:

  • When men come to see us with symptoms diagnosed as chronic prostatitis, drug and surgical treatment has failed to help them
  • Men we see who have symptoms diagnosed as chronic prostatitis almost always have painful pelvic muscles and trigger points can be found related to symptoms. Anxiety and stress generally tends to makes them hurt more
  • Symptoms of what is diagnosed as chronic prostatitis occur as the result of chronic tightening of the pelvic muscles over many years, even though symptoms may appear to begin suddenly. The phrase “the fruit falls suddenly but the ripening takes time” reflects this phenomenon
  • When you are suffering from pain with no foreseeable end in sight, it is easy to get lost and caught up in negativity, catastrophic thinking and the anxiety and depression related to it. Anxiety and worry about symptoms makes them worse
  • These emotions can be exacerbated by feelings of helplessness when doctors are unable to successfully treat symptoms
  • We have been dismayed that most doctors who provide chronic pelvic pain treatment do not appear interested in looking beyond the assumed causes of chronic prostatitis because these symptoms are not responsive to drugs or surgery, the main tools of conventional medicine
  • It is possible for most men with symptoms diagnosed as nonbacterial chronic prostatitis to significantly reduce their pain or stop it through their own efforts when they are properly instructed
  • Resolving symptoms diagnosed as nonbacterial chronic prostatitis means relaxing the core physical part of us. While there are methods for strengthening the core, relaxing and loosening our core is harder and more complicated to do—but it is doable
  • Patients who take ownership of their own problem and ultimately use their own intuition to determine what to do seem to do best
  • I am convinced that patients who learn to treat all of their symptoms themselves do best; self-treatment is the way

At this time in history, someone who has pelvic pain is best served by taking responsibility for his or her own welfare and seeking out treatment that makes most intuitive sense to them.