After consulting with my physician colleagues in our program about our experience with many patients who have undergone some surgery or invasive procedure for their pelvic floor related pain, it has been our conclusion that there is no convincing basis for a surgical approach to treating chronic pelvic pain syndromes. While there are obviously circumstances in which surgery is called for related to cancer or pelvic related repair, we have never seen a positive surgical outcome in the 25 years we have treated many patients for idiopathic pelvic floor pain in which no pathology is found. Although ours may not be a representative sample, in our experience the overwhelming majority of patients we have seen have expressed regret about their particular surgical intervention and often found it hurt them.
The pelvic pain symptom complex we treat has been blessed with several descriptive names including pelvic floor dysfunction, chronic pelvic pain syndrome, chronic prostatitis/CPPS, urologic chronic pelvic pain, syndrome, painful bladder syndrome, coccydynia, pudendal neuralgia, chronic proctalgia, levator ani syndrome, pelvic floor dysfunction, pelvic floor myalgia, anorectal pain, dyspareunia, to name a few. The aggravating sensory pain may be associated with several anatomical sites including genitalia (scrotum, penis, and urethra), perineum, anus, groin, suprapubic region, bladder, psoas muscle, and even into the upper thigh. Normal genitourinary and intestinal function may be disturbed at the same time, manifested by urinary frequency, urgency, incontinence, sitting pain, nocturnal voiding (often labeled overactive bladder), bladder pain with filling (often diagnosed as interstitial cystitis), incomplete voiding, erectile dysfunction, painful ejaculation and disturbances in ejaculatory function as well as sexual arousal and orgasm and, of course, irritable bowel syndrome and anorectal pain and dysfunction.
Our experience over a period of twenty five years and treating several thousand patients suggests that some of the unfortunately worst patient cases of recalcitrant chronic pelvic pain have occurred following what we regard as misguided attempts at a surgical cure.
Typical examples of what we believe to be inappropriate and misguided surgical treatments we have documented include:
Transurethral resection of prostate tissue
Orchiectomy for testicular pain,
Coccygectomy for tailbone pain,
Varicocelectomy for penile/testicular pain
Surgical excision of prostatic calculi
Ileostomy for post bowel movement pain
Vascular reconstructive surgery for men with erectile dysfunction
Hysterectomy for female pelvic pain
Urethral surgery for slow urinary stream or urinary symptoms related to pelvic pain and no urodynamics documentation
Pudendal nerve decompression surgery
Scrotal operations to remove epididymis or testis
In our experience, It should be noted that every one of these documented surgical attempts at treatment, failed to alleviate the pelvic pain and, often produced worsening and more complexity of the pain syndrome. Agreeing to failed surgery has typically occurred with anxious and desperate patients seeking relief at any cost while simultaneously not seeing being educated about the risks or reports in the research about poor outcomes.
The choice of surgery misunderstands the nature of chronic, muscle based pelvic pain. It sees the problem of chronic pelvic pain as a condition in which something has gone wrong in the pelvis that must be surgically treated. This viewpoint, in our view, is out of touch with the real nature of this disorder.
Over viewpoint, that comes from many years of treating thousands of patients, and first shaped by my own recovery from chronic pelvic pain after suffering with it for over 20 years bears no resemblance to the view point of those who have advocated surgery. In the viewpoint of those of us who use the Wise-Anderson Protocol, chronic pelvic floor pain occurs because the tissue in the pelvic floor is irritated and sore because the pelvic tissue has been tightened in a posture of chronic muscular guarding. This typically is related to years of anxiety and sometimes in response to an insult or injury to the pelvis.
With people who have pelvic pain, worry tends to show up physically in the muscles of the pelvis, which tighten whenever you get anxious, just like the muscles in the pelvis of a dog tightens to pull the tail between the legs when the dog is frightened. This tightening isn’t debilitating – we’re talking about a slight but noticeable guarding and tension. However, for those who are chronically worried or anxious, over time little knots occur in pelvic muscles that are habitually tightened. We call these knots trigger points and they are sensitive to emotional distress. In a watershed study with hundreds of subjects on the relationship between emotional distress and trigger-point activity, Richard Gevirtz and David Hubbard found that when emotional distress is heightened, trigger-point electrical activity is profoundly heightened as well. This is likely why many pelvic pain patients experience a worsening of symptoms with increased stress.
Other than pelvic floor pain that occurs as the result of an injury or insult to the pelvic floor, pelvic floor related pain is strongly associated with worry-related pelvic tightening over a long period forming trigger points and an inhospitable environment in the pelvic tissue. This worry-triggered tightening produces tissue that becomes uncomfortable, sore and hyper-irritable.
It is overwhelmingly the case that people with pelvic floor pain have sore, irritated, trigger point laden pelvic floor tissue easily detectible by an experienced and skillful practitioner of trigger point release. We have seen many patients who were unaware of their pelvic floor trigger points and areas of restriction until they came to see us and were examined by our doctor and physical therapist. In our book, A Headache in the Pelvis, we have illustrated the different anatomical locations of trigger points in relationship to someone’s symptoms. In 2009, we published an article in the Journal of Urology documenting painful pelvic floor trigger points in relationship to someone’s symptomatic complaints (J Urol. 2009 Dec;182(6):2753-8. doi: 10.1016/j.juro.2009.08.033)
What is not well understood – but becomes obvious when you look at people with pelvic pain – is how irritated, sore and hyper-reactive pelvic tissue reflexively tightens up against its own pain. This is one of the strange phenomena in pelvic floor dysfunction: the pain inside the pelvis triggers a guarding or protective reaction in the pelvis that then makes the pain worse. This leads to a cycle of pain in the pelvis, where pain triggers reflexive tightening, anxiety, pain which increases anxiety which leads to further trigger-point activity and pain. We call this the “pelvic pain cycle,” and we’ve written about it extensively in our book A Headache in the Pelvis, recently revised and published by Penguin/Random House/Harmony books in a definitive edition. Once established, the sore tissue triggers reflex protective guarding, producing pain and dysfunction, leading to more guarding against the pain, triggering anxiety that profoundly irritates the trigger-pointed pelvic tissue which then leads to more tightening. Once pelvic floor pain occurs, it takes on a life of its own and is generally not responsive to conventional treatment. Surgery for pelvic floor dysfunction in our view, may be among the worst things to do to an already painful, sore and tightened pelvic tissue.
It is the healing of the sore, irritated pelvic tissue that is the answer to pelvic floor pain
It is the support of the natural healing of this sore, irritated tissue that is the answer to pelvic floor dysfunction. Facilitating the healing of this tissue, in our protocol, is the point of treatment. In order for the tissue to heal, the chronically tightened pelvis must be physically loosened and the trigger points and myofascial restriction must be released on an ongoing basis. In the Wise-Anderson Protocol, we loosen the tissue by teaching patients to do their own internal and external trigger point release. This method is described in other writings, podcasts, and in our book, A Headache in the Pelvis. In conjunction with regularly loosening the sore pelvic tissue, an environment that allows the sore tissue to heal must be regularly provided, free from the reflex and default tightening of the sore pelvis in people with painful pelvic tissue. This is why we ask our patients to practice the method of Extended Paradoxical Relaxation, that allows the tissue remain undisturbed by the many stresses and strains of ordinary life that keep the sore pelvic tissue from healing. In our view, surgery has no place in the healing process of hypertonic muscle based pelvic floor pain.