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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I hope this has been helpful for you.