Facts About Chronic Prostatitis and Pelvic Pain Syndrome

Facts About Chronic Prostatitis and Pelvic Pain Syndrome

  • While prostatitis* means an inflammation or infection of the prostate gland, most men diagnosed with prostatitis do not have a prostate infection or inflammation.
  • Prostatitis is a condition that can confuse both doctors and patients.
  • Approximately ninety-five percent (95%) of what is called prostatitis is not related to a prostate infection. Most cases diagnosed as prostatitis have no pathology of the prostate gland that can account for symptoms of urinary frequency, sexual and sitting pain, and internal pelvic pain among other symptoms.
  • Major studies have shown that treating the prostate gland with anti-inflammatory drugs and antibiotics fails to help the symptoms of prostatitis in the long term.
  • Symptoms of prostatitis can become chronic and very distressing.
  • In 1995, the National Institutes of Health, in a consensus conference on prostatitis, acknowledged that the terms chronic nonbacterial prostatitis and prostatodynia neither explained nor were even related to the symptoms. They recommended a new name that was adopted for this condition: chronic pelvic pain syndrome (CPPS). In changing the name of the most common disorder seen by urologists, there was the clear implication that the prostate may not be the cause of this disorder.
  • Studies have shown that men undergo severe impairment in their self-esteem and their ability to enjoy life in general because the pain and urinary dysfunction is so profoundly intimate and intrusive. The effect of nonbacterial prostatitis on a man’s life has been likened to the effects of having a heart attack, having chest pain (angina), or active Crohn’s disease (bleeding/inflammation of the bowel). If nonbacterial prostatitis moves from a mild and intermittent phase to a chronic phase, sufferers tend to live lives of quiet desperation. Having no one to talk to about their problem, usually knowing no one else who has it, and receiving no help from the doctor in its management or cure, they often suffer depression and anxiety.

*Prostatitis (National Institutes of Health categories)

I Acute bacterial prostatitis

II Chronic bacterial prostatitis

IIIA CPPS nonbacterial inflammatory prostatitis

IIIB CPPS nonbacterial non-inflammatory prostatitis

IV Asymptomatic inflammatory prostatitis

Cutting edge treatment of the symptoms of prostatitis focuses on the muscles of the pelvis and not the prostate gland. Treating chronically contracted pelvic muscles associated with the symptoms of prostatitis can significantly reduce or resolve these symptoms in a majority of men. Those who are seeking facts about Chronic Prostatitis should ultimately learn about the Wise-Anderson Protocol. This is a pioneering treatment that has been shown in studies to help reduce the symptoms in a majority of men diagnosed with chronic prostatitis.

NOTE: While it is our hope that these facts about Chronic Prostatitis are helpful, this information is not to be misconstrued as medical advice. This should be presented as general information about the disorder.

The Issue of Healing and the Resolution of Symptoms of Prostatitis and CPPS

Chronic Prostatitis Symptoms

In this essay I want to address the issue of the validity of many speculative theories on the internet about chronic  prostatitis symptoms and CPPS symptoms and our view of the issue of the healing of the pelvic floor and the resolution of symptoms of prostatitis and chronic pelvic pain syndromes.

What causes the symptoms of prostatitis and chronic pelvic pain syndromes?

There are numerous ideas on the internet about what causes symptoms of prostatitis and chronic pelvic pain syndromes. For example, a few people propose that prostatitis and CPPS may be related to reflex sympathetic dystrophy. Attempts to make a case for pelvic pain as reflex sympathetic dystrophy are not new. While I am not an expert in RSD this is what I do know. It is generally agreed among clinicians and researchers that RSD is a condition that is complex and has features that are perplexing and poorly understood. It is characterized by regional pain, often in the hands or feet, autonomic, tissue and vasomotor changes, disorders of movement, muscle atrophy, and almost always psychological and social disturbance. Part of the controversy about RSD is whether the psychosocial disturbances and suffering are causative or at the effect of other factors – an issue of the chicken or the egg. The controversy about RSD reached a point where the name was changed to regional pain syndrome to eliminate the implication of agreement about the mechanism of the disorder. In a discussion I had with our senior physical therapist, in his experience RSD is an entirely different problem from one involving myofascial/trigger point pain. Your reader is correct that Trigger Point Release is not indicated with RSD although in some cases a patient originally diagnosed with RSD may simply have a hyper irritable myofascial pain syndrome and the diagnosis of RSD may have been incorrect.

Diagnostic criteria have been proposed for RSD by an international organization but these criteria are not universally accepted. Bottom line here is that this is a poorly understood and controversial condition that has no effective treatment.

RSD, as a general rule, does not respond to Trigger Point Release therapy. Furthermore, muscle atrophy, edema or swelling or disorders of movement are not prominent features in the pelvic pain we treat. What is telling for me is the fact that many patients with pelvic pain have responded favorably to our protocol whose physiotherapy component involves myofascial Trigger Point Release where RSD does not respond to this methodology. All of this makes the RSD/CPPS hypothesis dubious.

So pelvic pain as RSD is a speculation with little supporting evidence … a speculation that is no different from the speculation that pelvic pain is the result of an occult bacteria or is an autoimmune disease. At this point this idea offers no course of treatment or action that helps or protects someone, it offers no definitive evidence and importantly it tends to promote fear and helplessness in many who suffer from pelvic pain. I take the view that pelvic pain as RSD is an idea with little foundation that I choose to ignore until there is some compelling reason to entertain it.

In our book, A Headache in the Pelvis, we address a very important issue related to the question I am discussing here. This is the question of what to do with speculative theories about pelvic pain like the one that it may be related to RSD – theories that offer no treatment and serve to scare the reader. I quote our book below:

“We are often asked about other theories regarding the nature of chronic pelvic pain from people suffering with pelvic pain, a subject we touched upon earlier. Many of these individuals are already in an anxiety state and are looking for some kind of reassurance or guidance as to the nature of their condition and the best course of treatment. When they go on the internet, they read about various theories contending that chronic pelvic pain may be an auto-immune disorder, a condition in which occult bacteria are yet to be discovered, or a deteriorating neurological pelvic condition.

These theories do what we have described earlier. They tend to promote fear and helplessness in the sufferer.

When you have pelvic pain, it is deeply disturbing to read theories which promote fear, helplessness, and confusion or hear stories of people who are not doing well with their pain or dysfunction. When you have pain and dysfunction, you usually feel some degree of anxiety and helplessness which is often exacerbated by these kinds of theories. Some of our patients have asked us whether they should ignore the ideas that they read on the web or simply avoid the internet websites devoted to pelvic pain. Others have asked us if there is some way to find out if in fact they have the problem that these theories purport.

If a theory or an idea about your condition carries some course of action or treatment to help you without unacceptable risks, then it may be an idea that merits your careful consideration. You may wish to investigate the efficacy of such a course of treatment along with the risks and costs.

If the theory, on the other hands, carries with it (a) no course of treatment or action to be done to help or protect you, or if its treatment carries dangers you are not willing to risk, or (b) it offers some non-definitive evidence, and (c) it only helps to create fear, doubt, and disempowerment in your life, we suggest you tell yourself the following: “This is someone’s theory. There is no definitive proof for it. It offers nothing to help me or protect me. What it offers carries unacceptable risks. It creates fear and doubt in me. It is okay for me to disregard it as somebody’s unproven idea which I will consider if there emerges substantial evidence and/or something to do about it. Therefore I can ignore it as simply someone’s unproven idea. This kind of self-talk … is particularly important because anxiety tends to increase symptoms.”

A person who wrote about RSD and whether it is related to pelvic pain was obviously distressed that his symptoms of prostatitis did not improve with Trigger Point Release that was aggressive, and he was looking for some other answer to his difficulties. In my response to the description of his treatment, let me say that we at Stanford do not advocate aggressive physiotherapy in our protocol but a very specific method aimed at locating and deactivating trigger points inside and outside of the pelvic floor that tend to recreate symptoms of prostatitis as well as methods that systematically stretch the shortened and contracted pelvic tissue. It is common that the in beginning stages of treatment, temporary flare-ups occur. It is the normal course that the discomfort diminishes over time during and after physiotherapy. If it doesn’t, in my experience, the problem is often that the physical therapist is missing something.

In my view the whole issue we are dealing with about treatment for pelvic pain is simply this–how to allow the body to heal itself? I think contemporary medicine tends to forget that it is almost always the case that ‘the body heals itself and the doctor collects the fee.’ In the National Library of Medicine today, I found there were 3743 research articles listed on prostatitis and the symptoms of prostatitis. An infinitesimal 7 articles even contained the word healing. My view about treatment for pelvic pain is that we want to optimize the circumstances for the body to heal itself, we want to get out of the way of the healing of prostatitis, the tissues, muscles, and structures inside the pelvic floor. Healing is what we want as well as prostatitis relief. In my own case, when I began thinking this way, my condition began to resolve.

The Wise-Anderson Protocol is about healing. It is about creating a hospitable environment for the restoration of normal happy tissue inside the pelvic floor. The relaxation protocol allows the nervous system to quiet down so that the irritated tissues can heal and can stop being squeezed into an irritated state… a squeezing that in most people who have pelvic pain has become habitual and chronic. The relaxation protocol aims to change the habit of tightening the pelvic muscles under stress. The physiotherapy we do stretches and lengthens the pelvic tissue and deactivates trigger points to make room for a healthy life in the pelvic floor.

https://www.youtube.com/watch?v=yyDIcyk4Uwc

The idea of RSD as it is understood today, at least as I read it, implies a condition where healing is remote. I balk at theories that imply healing isn’t possible because of my personal experience and others who have gotten better with this problem. Healing is possible. The patients I have seen who have done the worst – especially those who have suffered from unwise medical interventions, have given the entire responsibility for curing their condition to someone or something outside them. They come to the doctor and say “fix me doc”. Any treatment for the kind of pelvic pain we treat needs to be the servant of the body’s healing mechanisms. This requires the intimate and whole hearted participation of the patient.

Physiotherapy alone, while an essential component, is usually inadequate to resolve symptoms because it alone cannot make this healing occur. I understand this experientially. It is tempting for someone to think that physiotherapy, this outside procedure, will fix them. In my experience, this person will be disappointed as I was. I had over 50 physiotherapy treatments and at the end of them all, I was still symptomatic and in pain. It was only after I saw that my problem came from my chronic tension, anxiety and habitually squeezing my pelvis – and particularly when I began the relaxation protocol in earnest, often up to 2 hours a day for over two years and doing moment-to-moment pelvic relaxation throughout the day, that my symptoms began to resolve. The pelvic pain of those we help is not simply a mechanistic problem that can be fixed from the outside with a physical therapist’s finger. The habit of tightening the pelvic floor is usually decades old and has been practiced thousands of times. It is part of a coping repertoire. Tightening their pelvic floor under stress is the default mode and keeps the tissue of the pelvic floor irritated and shortened.

Consider that there are 168 hours in a week. Let us say that a person goes to see the physical therapist 2 times a week. That quite a bit of physiotherapy. In the physiotherapy session, after a person takes off their clothes, gives the PT a report on their week and begins the physiotherapy itself, at the most there is probably 30-45 minutes of hands-on treatment. After the treatment, the tissue is lengthened (although sometimes temporarily irritated in the process). That is between 1 hour and 1.5 hours of therapeutic treatment per week. In a good pelvic floor physiotherapy session, the pelvic floor tissue has been lengthened and life has been made more livable for it. But after physiotherapy, there are 167-166 hours per week to live. The old habit of going 100 miles an hour in one’s life and tightening up the pelvis regularly and squeezing and shortening the irritated tissue can easily and quickly undo the therapeutic impact of the physiotherapy session. It makes no sense to think that a physical treatment that lasts less that .023% of your life can work if the old, symptom provoking habits go on unabated. In my view, the resolution of the kind of pelvic pain we treat is an inside job of cooperating with the healing mechanism of the body in the short run and the long run.

We have received hundreds of emails from people telling us that our theory described in A Headache in the Pelvis is the first one that makes sense to them. While I appreciate these comments, I am unmoved by them. I am moved when someone’s symptoms improve or go away. I am moved when the body responds to treatment with a big ‘yes’. Theories are cheap and yet to the lay person, they can sound convincing and formidable. In my view, a theory about pelvic pain is only as good as the efficacy of the treatment that it informs and serves the healing of the body. In other words, the most important issue is results — i.e., does the method that derives from the theory help the body’s healing thereby reducing or resolving symptoms? We do not help everyone who comes to see us. But if they do fit into a certain profile, they must do the entire protocol properly before making a judgment about its efficacy. They must participate and support their own healing. Results are what counts. Results mean that the patient has helped rally his or her body in healing itself.

Sincerely,

David Wise, PhD

Prostatitis as a Tension Disorder

(AN EARLY DISCUSSION OF THE WISE ANDERSON PROTOCOL)

1999 Selected Abstracts from American Urological Association annual meeting

Anyone with prostatitis should be aware of the disagreement among professionals about the cause of prostatitis.

This is especially true if he currently has pain or discomfort:

  • in the penis
  • in the testicles
  • above the pubic bone
  • in the low back, down the leg, in the groin or perineum
  • during or after ejaculation
  • while sitting

The condition often involves:

  • having a sense that there is a golf ball in the rectum that can’t be dislodged
  • urinary frequency and urgency
  • dysuria or burning during or after urination
  • a need to urinate even after one has just urinated
  • some sense of pelvic discomfort
  • no evidence of infection in the urine or prostatic fluid
  • no evidence of disease in the prostate or elsewhere in the pelvic floor

The reason that understanding this lack of agreement about the cause of prostatitis is important, especially for sufferers of the problem, is that the definition of a problem determines what you do about it. If you have chest pain caused by indigestion, you don’t elect to have open heart surgery to correct the pain. Indigestion tells you what to do about your chest pain.

Similarly, if prostatitis is caused by a chronic tension disorder in the pelvic muscles where there is no evidence of infection, you might take pause before you elect to have your prostate removed or take another course of antibiotics or have your prostate gland painfully squeezed and massaged.

There is a genuine controversy about what prostatitis is among urologists and professionals treating this problem. There are three basic views outlined below:

  • Prostatitis is a condition caused by chronic squeezing of the pelvic muscles that, after a while, causes a self-perpetuating and chronic irritation of the contents of the pelvic floor, including irritation of the nerves and other delicate structures involved in urination, ejaculation, and defecation.
  • Prostatitis is caused by a bacteria or unknown microorganism in the prostate gland.
  • Prostatitis is an autoimmune problem.

The majority of urologists tend to propound the second and third theories. Because of this, their treatments tend to focus on the use of antibiotics or pain medications. Sometimes urologists will tell their patients that there may be a microbe responsible for the problem that still has not been identified.

Similarly, prostatitis as a tension disorder sees abacterial prostatitis/prostatodynia essentially as a ‘headache in the pelvis” or “TMJ of the pelvis”. In this view it is a condition usually manifesting itself after years of tensing the pelvic muscles. It usually tends to occurs in men who hold their tension and aggression inside. They squeeze themselves rather than lashing out at others. Often they have work in which they sit for long periods of time and the only way they have found to express their frustration is to tense their pelvic muscles. This tension disorder has become a habit with them. Often they do not know they tense themselves in the pelvic floor.

If in fact abacterial prostatitis/prostatodynia (which happens to make up about 95% of all cases of chronic prostatitis) is a condition of chronic tension disorder in the pelvic floor, one would have to question whether drugs or surgery are a correct treatment. In fact, there is no effective drug regimen or surgical procedure for this condition although at Stanford we have had men consult with us who, in moments of desperation, have had their prostates resectioned or removed and who have taken heroic doses of antibiotics and other drugs. None of these treatments have helped them. Not infrequently, these treatments have made the problem worse or created other problems.

In a pilot study, men with abacterial prostatitis/prostatodynia often are found to have trigger points or “knots” of contracted muscle fiber that are very painful when pressed and refer pain to different places in the pelvic floor. Not infrequently, men will report that pressing on these trigger points recreates the pain that they usually have. From the view of prostatitis as a tension disorder, trigger points and tender points in the pelvic floor come about because of chronically contracted muscles there. To deactivate the trigger points is a method borrowed from physiotherapy called “myofascial release” or “soft tissue mobilization”. This is done inside the pelvis where the therapist pushes against the trigger points, stretching the tender contracted tissue.

After a number of sessions, there is often a significant reduction of symptoms. Frequently, with an extensive course of these treatments, symptoms tend to continue to diminish or disappear but only if the patient learns to stop chronically tensing the pelvic muscles.

Learning to profoundly relax the pelvic muscles is not an easy thing. Chronic pelvic tension has usually been a long-standing habit for many men who have pelvic pain. Learning to relax the pelvic muscles requires a major commitment of time. It involves learning a relaxation method we have developed aimed at stopping this chronic squeezing of the pelvic floor muscles.

Seen this way, prostatitis is a secret language that the body is using to tell the man that he needs to handle his stress in his life differently. In offering a treatment based on the view that abacterial prostatitis is a tension disorder, there has been a difficulty with reimbursement from insurance companies. This makes it very difficult for a patient to follow a minimal protocol of intrapelvic myofascial release and progressive relaxation of the pelvic floor.

Because we who see prostatitis from this viewpoint want to get patients off of drugs, we get no financial support for research from drug companies who are often the major source of research funding. Furthermore, because no surgery is involved and urologists are not extensively trained in looking at conditions which result from the direct interaction between mind and body, there has not been much interest in learning and using this treatment among our colleagues in urology.

I hope that this discussion is useful to the many men who suffer from prostatitis and chronic pelvic tension.

Rectal Pain, Anal Fissures, Hemorrhoids, Constipation and Other Manifestations of Headaches in the Pelvis

Are you experiencing the symptoms of rectal pain, anal fissures, hemorrhoids, or constipation?

It is important to have a clear understanding on symptoms for hemorrhoids, rectal pain, anal fissures and constipation. At some time or another, many people find a little blood in their stool usually after a particularly hard bowel movement and can become confused and upset at such an event. At other times, alarmed individuals go to the doctor complaining of rectal pain after a bowel movement with no apparent blood in the stool. Often the doctor gives the diagnosis of anal fissure or hemorrhoid to these complaints. To most, this can sound foreboding. In fact, an anal fissure is like a paper cut in the internal anal sphincter. Hemorrhoids constitute another condition that is painful and sometimes the source of blood in the stool. A hemorrhoid is a kind of varicose vein in the anus.

One French study showed that one-third of women had hemorrhoids or anal fissures after childbirth. One to ten million people in North America suffers from hemorrhoids symptoms. Both of these conditions are common in both men and women. These conditions are often related to constipation and diarrhea. Constipation has been related to chronic tension in the pelvic muscles in adults and recently in a study at the Mayo Clinic in refractory constipation in children.

The colon and rectum are structures that operate together in the activity of the evacuation of stool. Normal, non constipative bowel function involves the reflex relaxation of the external anal sphincters the pelvic floor muscles (along with sufficient tone in the colon) to allow the reflex of the sense of urgency with the filling of the rectum for fecal matter in the bowel to pass through the anal canal. Chronic tension in the bowel and pelvic floor triggered by anxiety can commonly result in constipation.

It is understood by many of researchers that the anal fissure is what is called an ‘ischemic ulcer’. Ischemia is a condition in which there is a significant reduction in blood flow to an area. The current understanding about anal fissures is that because there is elevated tension, the blood flow in the anal sphincter is reduced, thereby impairing the tissue. It becomes fragile and vulnerable to injury from a hard bowel movement or from the pressure of bearing down during defecation.

Diet has clearly been implicated in the development of the anal fissure. Cow milk consumption has been associated with chronic constipation and anal fissures in infants and children. Interestingly, a shorter duration of breastfeeding and early bottle feeding of cow’s milk are also suspected to play a role in early incidences of anal fissures in infants and young children. A Danish study showed a significant relationship between the absence of raw fruits, vegetables and whole grains and anal fissures. Furthermore, frequent consumption of white bread, sauces thickened with roux, and bacon and sausages increased the risk of anal fissures. British researchers found that hemorrhoids and anal fissures were much more likely to occur when one did not eat breakfast.

While most anal fissures and hemorrhoids resolve themselves after they flare up, some colorectal surgeons lean toward a procedure or surgery. The hope is that they will treat the rectal pain associated with hemorrhoids and anal fissures. We have seen patients who are anxious about their rectal pain easily talked into an aggressive treatment of the fissure or hemorrhoid involving surgery.

It is generally agreed that the source of the anal fissure in large part involves a chronically tightened internal anal sphincter. Surgery, the procedure of stretching or dilating the anal sphincter under anesthesia, and the application of topical agents are all aimed at relaxing the anal sphincter. The concept of surgery for anal fissures is based on the peculiar idea that cutting the sphincter is the best way to reduce the tone, tension, and spasm in the anal sphincter. While surgery is often successful, there is a risk of short term and sometimes long term fecal incontinence.

This conventional medical treatment of rectal pain, anal fissures, hemorrhoids, and constipation tends to ignore the relationship between mind and body. Like the conventional treatment of prostatitis, the relationship of a person’s mindset, level of relaxation during bowel movements, and management of stress is almost entirely ignored in the literature on the anal fissure. Instead, there is a narrow focus on immediately reducing symptoms. Procedures, surgery, laxatives and other medications are the usual options for patients suffering from rectal pain and other conditions. Like in the treatment of prostatitis, there is little literature on the connection or treatment of body and mind in the anal fissure, hemorrhoid or in problems of constipation.

The focus on a surgical intervention for rectal pain, anal fissures, or hemorrhoids is an expression of a viewpoint that sees no value and sees no intelligence in the symptoms of someone with such a condition. Instead of seeing the symptom of an anal fissure, for example, as the way in which one’s body is complaining of the diet, stress, bowel habits and anxiety, conventional treatment sees the symptom of blood in the stool, rectal pain, or abdominal pain as something that needs to be stopped. No regard is shown in the big picture of a person’s life and how symptoms are a response to this big picture. As we have said elsewhere, it is our view that the symptom is the way our bodies are trying to communicate. If we simply try to refuse to understand the message because we don’t understand the body’s language, we needlessly suffer and don’t deal with the root problem prompting the symptom. We continue to suffer.

In the large majority of cases, it is the chronic tension in the pelvic floor, including the anal sphincter, usually combined with diet and anxiety that leads to rectal pain, anal fissures, hemorrhoids, and constipation. In a word, a person’s mind and body and lifestyle are involved in the creation and perpetuation of these conditions.

Squatting vs. sitting during defecation as way of helping the relaxation of the pelvic floor

Most people throughout history have squatted when evacuating their bowels. The modern toilet is relatively new in the history of mankind and has been adopted as a civilized bathroom appliance. The perennial hole in the ground over which one squatted to defecate is universally considered primitive. A website devoted to promoting the advantages of squatting during defecation writes about the history of the modern toilet:

“Human beings have always used the squatting position for elimination. Infants of every culture instinctively adopt this posture to relieve themselves. Although it may seem strange to someone who has spent his entire life deprived of the experience, this is the way the body was designed to function.

The modern chair-like toilet, on the other hand, is a relatively recent innovation. It first became popular in Western Europe less than two centuries ago, largely by coincidence. Invented in England by a cabinet maker and a plumber, neither of whom had any knowledge of physiology, it was installed in the first dwellings to use indoor plumbing. The “porcelain throne” was quickly imitated, as the sitting posture seemed more “dignified” – more suited to aristocrats than the method used by the natives in the colonies.

Two other influences also favored the adoption of this new water closet. One was the headlong rush to modernize all existing sanitation facilities (which were, in fact, non-existent.) The public assumed that all the benefits of modern plumbing required the use of the seat-like toilet since it was the only one having the proper fittings to connect to the pipes. This assumption was incorrect since toilets with all the same flushing capabilities could be (and have since been) designed to be used in the squatting position.

Secondly, in nineteenth-century Britain, any open discussion of this subject was considered most improper. Those who felt uncomfortable using a posture for evacuation that had nothing to do with human anatomy were forced to keep silent. How could they denounce the toilet used by Queen Victoria herself? (Hers was gold-plated.)

So, like the Emperor’s New Clothes, the water closet was tacitly accepted. The general discomfort felt by the population was indicated by the popularity of “squatting stools” sold in the famous Harrods of London. These footstools elevated one’s feet while in the sitting position to bring the knees closer to the chest – a crude attempt to imitate squatting.

The rest of Western Europe, as well as Australia and North America, did not want to appear less civilized than Great Britain, whose vast empire at the time made it the most powerful country on Earth. So, within a few decades, most of the industrialized world had adopted ‘The Emperor’s New Throne.’

A hundred and fifty years ago, no one could have predicted the effect of this change on the health of the population. But today, many physicians blame the modern commode for the high incidence of a number of serious diseases. Compared to the rest of the world, people in westernized countries have much higher rates of appendicitis, hemorrhoids, colon cancer, prostate cancer and inflammatory bowel disease.”

There is compelling evidence that sitting on the toilet to evacuate the bowels is inferior to squatting in a number of ways. Squatting tends to relax the puborectalis muscle which is essential in defecation. It tends to reduce or eliminate the need to strain and bear down. A long study showed improvement or elimination or hemorrhoids as the result of squatting during defecation. Doing the ‘valsalva maneuver’ in which one bears down to initiate defecation while holding one’s breath have been known to cause a fatal heart attack or sometimes episodes of atrial fibrillation because such a maneuver increases pressure in the thorax and interferes with venous blood returning to the heart. The heart rate can significantly drop during this activity. Defecating while squatting can reduce the need to bear down and set this cycle in motion.

The modern toilet makes squatting during defecation a little problematic as it is made for sitting. Nevertheless, with a little innovativeness, it is possible to squat on a toilet. A device is sold that allows one to easily squat during defecation. When pelvic pain also involves rectal pain, anal fissures, hemorrhoids, or constipation, the issue of integrating squatting during defecation might well be considered.

We would like to see research on a non-invasive and self-administered treatment of both anal fissures and hemorrhoids and certain types of chronic constipation following our protocol for pelvic pain with some modifications. This would involve the rehabilitation of a very tight pelvic floor using Trigger Point Release, modifying the habit of tightening the pelvic muscles habitually under stress and during defecation and a focus on reducing anxiety producing thinking that prompts increased and habitual levels of anxiety. Squatting during defecation should strongly be considered as part of the protocol. While there is little research done on the treatment of these kinds of conditions using this perspective, we strongly support an independent study evaluating the efficacy of a modified Stanford protocol for the treatment of rectal pain, anal fissures, hemorrhoids, and certain kinds of constipation.

Facts About Prostatitis and CPPS: How Prostatitis is Often Misdiagnosed

https://www.youtube.com/watch?v=DWNPuQfcEbA

CPPS

Many men diagnosed with prostatitis and CPPS are confused about what the doctor is saying is wrong with them. As we have written about extensively on our website, in our book, A Headache in the Pelvis and in our published research, most men diagnosed with prostatitis and CPPS have no prostate infection or inflammation responsible for their symptoms. Yet most men given the diagnosis don’t understand this and suffer silently when medicines aimed at the prostate fail to help. This is an essay featuring the writing of a renounced physician and expert in prostatitis/chronic pelvic pain syndrome who speaks strongly to doctors to clarify their misunderstandings about prostatitis. In his admonitions to the doctors who treat pelvic pain, he clarifies the issues than many patients are confused about.

Men are typically diagnosed with prostatitis and CPPS and are given antibiotics without any evidence of infection in the prostate.

Today, when a man comes into the physician’s office and complains about the following issues, the doctor often treats the patient as if the cause of the problem is an infected or inflamed prostate gland and routinely gives antibiotics:

  • Pain: pelvic, urinary, rectal, or genital
  • Urinary symptoms such as: frequency, urgency, dysuria (pain during urination), sitting pain, or ejaculatory discomfort

However, there is no evidence of structural disease if one types in ‘prostatitis and CPPS’. If you search these terms on the internet, this misinformation, unfortunately, comes right up from a large number of sources.

Prostatitis, meaning an infection or inflammation of the prostate gland, is often diagnosed without the doctor doing any tests to establish the validity of such a diagnosis. We have seen men who have been given multiple rounds of antibiotics who have had no evidence of infection in the prostate. We do not consider it a good practice without verifying the presence of infection.

Antibiotics are not effective for symptoms diagnosed as prostatitis when the source of symptoms is pelvic muscle dysfunction.

Antibiotic treatment of bacterial prostatitis is an achievement of modern medicine. If you have bacterial prostatitis, antibiotics are a very good treatment—certainly the only treatment. Viewing all conditions of pelvic pain and dysfunction in men, however, as acute or chronic bacterial prostatitis is an error in therapeutic judgment, diagnosis, and treatment. Despite the clear scientific evidence to the contrary, it is shocking that giving antibiotics routinely for nonbacterial prostatitis is common. This is very important to understand, particularly if you have been diagnosed with prostatitis and it has not been determined whether infection or inflammation is present.

Below, Daniel Shoskes, MD, a urologist and expert in the research and treatment of prostatitis, understands this confusion particularly from the physician’s viewpoint. He writes an excellent article that also explains how prostatitis is typically misdiagnosed and treated.

He uses the analogy of Martin Luther who nailed 95 ‘theses’ on the door of a Church in the 16th century protesting the ‘selling of salvation from sins’ where a priest would grant you absolution by giving you a piece of paper called an indulgence if you paid the priest. Luther’s protest was to protest and stop this behavior of the Catholic priests at the time.

If you have been diagnosed with prostatitis, you and your physician can learn from the article below written to physicians.

What is Chronic Pain?

Since the beginning of our work at Stanford, we have held the idea that the prostate gland is not the problem in a very large proportion of men who are diagnosed with prostatitis. Like Martin Luther, Shoskes ‘protests’ against the common confused treatment of prostatitis. If you are a patient, you can learn from his instruction to physicians. If you are physician his article is sure to be enormously instructive. Here is a summary of the theses or points he makes to doctors who treat what is commonly called prostatitis/chronic pelvic pain syndrome. At the bottom of this article is Shoskes article in full. Here are excerpts of Dr. Shoskes advice to physicians diagnosing prostatitis:

In 1517, Martin Luther posted on the local church his 95 theses entitled, “Disputation on the Power and Efficacy of Indulgences.” Luther was outraged that members of the Catholic Church were selling indulgences by telling parishioners that their sins would be absolved following payment. Well, 493 years later patients are coming to the “Church of Urology” with prostatitis and CPPS, and in return for their pieces of silver they are often handed similar pieces of paper (antibiotic prescriptions) and told that they are absolved of their illness.

Although I cannot comment on whether Renaissance-era indulgences bought their holders relief from temporal punishment in purgatory, the modern-day indulgences are not buying our patients chronic pain relief from their punishment on Earth. Based on some published data and the histories of hundreds of patients I have seen with prostatitis and CPPS, I believe that the typical standard of care ignores important published advances in our knowledge of diagnosis, classification, and therapy over the past 15 years. Enough is enough; we need a broad reformation of the medical community’s management of these disorders. Here are my (fewer than 95) theses.

  1. Stop telling everyone that they have prostatitis and CPPS as though it is one disease.
  2. You should not tell a man with pain in between his nipples and knees that he has prostatitis and CPPS without doing a proper history and physical examination.
  3. Prostatitis is the name given to a group of disorders that share surprisingly little in the way of etiology, symptoms, and treatment. Frequently, the diagnosis and management of these conditions is empiric, inadequate, ineffective, and contrary to the published literature of the past 10 years. In the present commentary, 23 “theses” are presented as a plea to physicians managing these patients to modify their ingrained approaches and incorporate simple evidence-based changes that can greatly improve outcomes and patient quality of life.
  4. Do you think that doing a prostate massage and getting some fluid is difficult and time-consuming? It is not. If you cannot do it, get a post-massage urine sample instead.
  5. Just because the patient complains of pain during a rectal exam, it does not mean that they have prostatitis.
  6. While your finger is in the rectum, palpate the muscles to either side of the prostate. If they feel rock hard or if the patient reacts and says, “That is my prostate pain,” then the patient has pelvic floor spasm. At least half of men with category III prostatitis have this condition [3], and it can get better with pelvic floor physiotherapy [4]. This is NOT a subtle finding; if you look for it, you will easily find it.
  7. Not everyone with prostatitis and CPPS needs a cystoscopy. However, if you do a cystoscopy, stop telling patients that their prostate has the “classic appearance of prostatitis.” There is no such thing.
  8. If the patient has true category II chronic bacterial prostatitis, do not give them 5 days of antibiotics. They need 2-4 weeks of antibiotic medication [5]. Advise the patient of potential side effects (e.g., tendinitis with quinolones, sun sensitivity with tetracyclines, diarrhea with any antibiotic).
  9. Do not try to eradicate category II prostatitis with nitrofurantoin. It does not penetrate the prostate [6]
  10. Everyone is busy; many men have a simple urethritis and a few have UTI. It is alright to give a course of antibiotics empirically the first time. However, if it does not work and cultures are negative, STOP GIVING THEM.
  11. Just because a patient feels a bit better on antibiotics and feels worse the day after stopping them does not mean that he has an infection. Quinolones, macrolides, and tetracyclines are powerful anti-inflammatory drugs that block cytokines directly [7]. These antibiotics kill bacteria in the prostate for up to 2 weeks, so if the patient has pain the day after stopping them but does not have a fever, IT IS NOT AN INFECTION.
  12. The normal prostate is not a sterile place. It has been reported that 68% of healthy men have gram-positive bacteri in their prostate fluid, and 8% of healthy men have classic uropathogens [8]. Every bacteria found on culture is not necessarily the cause of symptoms, especially if appropriate treatment does not improve the symptoms.
  13. Do not treat men who have pelvic pain with empiric interstitial cystitis therapies unless their symptoms actually suggest bladder involvement
  14. Do not forget to tell men about simple and often effective supportive measures
  15. Consider using a clinical phenotyping system to stratify patients for therapy, such as the one found at https://www.upointmd.com. This website gives a complete, simple algorithm for the diagnosis and multimodal therapy of chronic pelvic pain syndrome (CPPS) [10].
  16. Learn and use simple and effective therapies for the different clinical domains
  17. Patients with longstanding chronic pain can get depression and feel helpless or hopeless.
  18. Help patients to be optimistic, because most will eventually get better. Do not tell them that this is a condition they will have until the day they die.
  19. Take new symptoms seriously.
  20. In patients without UTI, do not treat an elevated prostate specific antigen (PSA) with antibiotics to see if the PSA will drop. The PSA may drop but the cancer risk does not [15].
  21. Use the NIH Chronic Prostatitis Symptom Index to monitor symptom severity, but NOT to diagnose the condition [16].
  22. Prostate consistency varies among men. Having an isolated finding of a “boggy prostate” is meaningless and does not diagnose prostatitis or any other condition.
  23. Assemble a good referral team.

Full Article

Commentary on Chronic Prostatitis and CPPS: The Status Quo Is Not Good Enough (But It Can Be)

Daniel Shoskes

Department of Urology, Cleveland Clinic, Cleveland, Ohio, USA

Submitted March 5, 2010 – Accepted for Publication April 5, 2010

www.urotodayinternationaljournal.com

Volume 3 – June 2010

COMMENTARY

In 1517, Martin Luther posted on the local church his 95 theses entitled, “Disputation on the Power and Efficacy of Indulgences.” Luther was outraged that members of the Catholic Church were selling indulgences by telling parishioners that their sins would be absolved following payment. Well, 493 years later patients are coming to the “Church of Urology” with prostatitis, and in return for their pieces of silver they are often handed similar pieces of paper (antibiotic prescriptions) and told that they are absolved of their illness. Although I cannot comment on whether Renaissance-era indulgences bought their holders relief from temporal punishment in purgatory, the modern-day indulgences are not buying our patients relief from their punishment on Earth. Based on some published data and the histories of hundreds of patients I have seen with prostatitis, I believe that the typical standard of care ignores important published advances in our knowledge of diagnosis, classification, and therapy over the past 15 years. Enough is enough; we need a broad reformation of the medical community’s management of these disorders. Here are my (fewer than 95) theses.

  1. Stop telling everyone that they have prostatitis as though it is one disease. The National Institutes of Health (NIH) classification may not be perfect, but it is a start and simple to use [1]. Category I is an acute febrile urinary tract infection (UTI). Category II is recurrent UTI with the same bacteria that is recovered from the prostate between acute bladder infections. Category III is persistent pain with or without lower urinary tract symptoms (LUTS) in men without UTI who have no other demonstrable cause. Category IV is asymptomatic and found during semen analysis or prostate biopsy. Stop telling everyone that they have the same condition and treating them all the same.
  2. You should not tell a man with pain between his nipples and knees that he has prostatitis without doing a proper history and physical examination.
  3. Nobody has to do a full Meares-Stamey 4-glass test. Who cares if there is Escherichia coli in VB1 vs VB2? It makes no difference. You should test at least a midstream sample of urine and then obtain a culture of either prostate fluid or post massage urine [2]. Unless you want false negatives, do Prostatitis is the name given to a group of disorders that share surprisingly little in the way of etiology, symptoms, and treatment. Frequently, the diagnosis and management of these conditions is empiric, inadequate, ineffective, and contrary to the published literature of the past 10 years. In the present commentary, 23 “theses” are presented as a plea to physicians managing these patients to modify their ingrained approaches and incorporate simple evidence-based changes that can greatly improve outcomes and patient quality of life.
  4. Do you think that doing a prostate massage and getting some fluid is difficult and time-consuming? It is not. If you cannot do it, get a post massage urine sample instead.
  5. Just because the patient complains of pain during a rectal exam, it does not mean that they have prostatitis.
  6. While your finger is in the rectum, palpate the muscles to either side of the prostate. If they feel rock hard or if the patient reacts and says, “That is my prostate pain,” then the patient has pelvic floor spasm. At least half of men with category III prostatitis have this condition [3], and it can get better with pelvic floor physiotherapy [4]. This is NOT a subtle finding; if you look for it, you will easily find it.
  7. Not everyone with prostatitis needs a cystoscopy. However, if you do a cystoscopy, stop telling patients that their prostate has the “classic appearance of prostatitis.” There is no such thing.
  8. If the patient has true category II chronic bacterial prostatitis, do not give them 5 days of antibiotics. They need 2-4 weeks of antibiotic medication [5]. Advise the patient of potential side effects (eg, tendinitis with quinolones, sun sensitivity with tetracyclines, diarrhea with any antibiotic).
  9. Do not try to eradicate category II prostatitis with nitrofurantoin. It does not penetrate the prostate [6].
  10. Everyone is busy; many men have a simple urethritis and a few have UTI. It is alright to give a course of antibiotics empirically the first time. However, if it does not work and cultures are negative, STOP GIVING THEM.
  11. Just because a patient feels a bit better on antibiotics and feels worse the day after stopping them does not mean that he has an infection. Quinolones, macrolides, and tetracyclines are powerful anti-inflammatory drugs that block cytokines directly [7]. These antibiotics kill bacteria in the prostate for up to 2 weeks, so if the patient has pain the day after stopping them but does not have a fever, IT IS NOT AN INFECTION.
  12. The normal prostate is not a sterile place. It has been reported that 68% of healthy men have gram-positive bacteria in their prostate fluid, and 8% of healthy men have classic uropathogens [8]. Every bacteria found on culture is not necessarily the cause of symptoms, especially if appropriate treatment does not improve the symptoms.
  13. Do not treat men who have pelvic pain with empiric interstitial cystitis therapies unless their symptoms actually suggest bladder involvement (eg, severe refractory frequency; pain that worsens with bladder filling and improves with emptying) [9].
  14. Do not forget to tell men about simple and often effective supportive measures such as sitting on a donut-shaped cushion and avoiding caffeine and spicy foods.
  15. Consider using a clinical phenotyping system to stratify patients for therapy, such as the one found at https://www.upointmd.com. This website gives a complete, simple algorithm for the diagnosis and multimodal therapy of chronic pelvic pain syndrome (CPPS) [10].
  16. Learn and use simple and effective therapies for the different clinical domains: Urinary symptoms: alpha blockers or antimuscarinics. Prostate pain or inflammation: quercetin [11] and cernilton [12]. Systemic neurologic symptoms: pregabalin or amitriptyline [13]. Pelvic floor spasm: pelvic floor physiotherapy myofascial release, NOT Kegel’s) [4].
  17. Patients with longstanding chronic pain can get depression and feel helpless or hopeless. This reaction is called catastrophizing [14]. Find out if they are feeling these emotions with a few simple questions and refer those with symptoms to other professionals for chronic pain treatment or chronic pain medication.
  18. Help patients to be optimistic, because most will eventually get better. Do not tell them that this is a condition they will have until the day they die.
  19. Take new symptoms seriously. Patients with prostatitis also can develop kidney stones and genitourinary (GU) cancers.
  20. In patients without UTI, do not treat an elevated prostatespecific antigen (PSA) with antibiotics to see if the PSA will drop. The PSA may drop but the cancer risk does not [15].
  21. Use the NIH Chronic Prostatitis Symptom Index to monitor symptom severity, but NOT to diagnose the condition [16].
  22. Prostate consistency varies among men. Having an isolated finding of a “boggy prostate” is meaningless and does not diagnose prostatitis or any other condition.
  23. Assemble a good referral team. Urologists cannot be expected to treat the parts of these conditions that do not pertain to the GU system. Team members may include physical therapists who know myofascial release therapy, pain management specialists, and psychologists who have experience with catastrophizing, chronic pain, or stress.

Conflict of Interest: Dr. Shoskes is a paid consultant to Farr

[1] Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999;282(3):236-237.

[2] Nickel JC, Shoskes D, Wang Y, et al. How does the pre massage and post-massage 2-glass test compare to the Meares-Stamey 4-glass test in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol. 2006;176(1):119-124.

[3] Shoskes DA, Berger R, Elmi A, et al. Muscle tenderness in men with chronic prostatitis/chronic pelvic pain syndrome: the chronic prostatitis cohort study. J Urol. 2008;179(2):556-560.

[4] Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155-160.

[5] Bjerklund Johansen TE, Gruneberg RN, Guibert J, et al. The role of antibiotics in the treatment of chronic prostatitis: a consensus statement. Eur Urol. 1998;34(6):457-466.

[6] Gleckman R, Alvarez S, Joubert DW. Drug therapy reviews: nitrofurantoin. Am J Hosp Pharm. 1979;36(3):342-351.

[7] Dalhoff A, Shalit I. Immunomodulatory effects of quinolones. Lancet Infect Dis. 2003;3(6):359-371.

[8] Nickel JC, Alexander RB, Schaeffer AJ, et al. Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls. J Urol. 2003;170(3):818-822.

[9] Forrest JB, Nickel JC, Moldwin RM. Chronic prostatitis/chronic pelvic pain syndrome and male interstitial cystitis: enigmas and opportunities. Urology. 2007;69(Suppl 4):60-63.

[10] Shoskes DA, Nickel JC, Dolinga R, Prots D. Clinical phenotyping of patients with chronic prostatitis/chronic pelvic pain syndrome and correlation with symptom severity. Urology. 2009;73(3):538-543.

[11] Shoskes DA, Zeitlin SI, Shahed A, Rajfer J. Quercetin in men with category III chronic prostatitis: a preliminary prospective, double-blind, placebo-controlled trial. Urology. 1999;54(6):960-963.

[12] Wagenlehner FM, Schneider H, Ludwig M, Schnitker J, Brahler E, Weidner W. A pollen extract (Cernilton) in patients with inflammatory chronic prostatitis-chronic pelvic pain syndrome: a multicentre, randomised, prospective, double-blind, placebo-controlled phase 3 study. Eur Urol. 2009;56(3):544-551.

[13] O’Connor AB, Dworkin RH. Treatment of neuropathic pain: an overview of recent guidelines. Am J Med. 2009;122(Suppl 10):S22-S32.

[14] Nickel JC, Tripp DA, Chuai S, et al. Psychosocial variables affect the quality of life of men diagnosed with chronic prostatitis/chronic pelvic pain syndrome. BJU Int.2008;101(1):59-64.

[15] Shtricker A, Shefi S, Ringel A, Gillon G. PSA levels of 4.0 – 10 ng/mL and negative digital rectal examination. Antibiotic therapy versus immediate prostate biopsy. Int Braz J Urol. 2009;35(5):551-558.

[16] Propert KJ, Litwin MS, Wang Y, et al. Responsiveness of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). Qual Life Res. 2006;15(2):299-305.

©2010 UroToday International Journal / Vol 3 / Iss 3 / June doi:10.3834/uij.1944-5784.2010.06.12

https://www.urotodayinternationaljournal.com

ISSN 1944-5792 (print), ISSN 1944-5784 (online)

Abbreviations and Acronyms

GU = genitourinary

LUTS = lower urinary tract symptoms

NIH = National Institutes of Health

PSA = prostate-specific antigen

UTI = urinary tract infection

ABSTRACT

CORRESPONDENCE: Daniel Shoskes, MD, Department of Urology, Cleveland

Clinic, 9500 Euclid Ave, Desk Q10-1, Cleveland, Ohio, 44195, USA (dshoskes@mac.com).

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.12

The Wise-Anderson Protocol Helps a Large Majority of Men with Prostatitis

Men with ProstatitisMost of the symptoms of pelvic pain or discomfort, urinary frequency and urgency, and pain related to sitting or sexual activity in cases diagnosed as prostatitis are not related to infection. They can be caused by chronically tightened muscles in and around the pelvis. Our natural protective instincts can tighten the pelvic basin, causing pain and other perplexing and distressing symptoms. Stress is intimately involved in creating and continuing these symptoms. Once the condition starts, the symptoms tend to have a life of their own.

And the good news is that it is possible for a large majority of sufferers to reduce and sometimes eliminate symptoms. A Headache in the Pelvis: A New Understanding and Treatment for Prostatitis and Chronic Pelvic Pain Syndromes, now out in the 6th edition, describes how chronic tension in the pelvic muscles can cause many of the bewildering symptoms of prostatitis and chronic pelvic pain syndromes.

In most cases of men with prostatitis, the prostate is not the problem.

In 95% of prostatitis cases, the prostate is not the problem. In the case of men with prostatitis and chronic pelvic pain syndromes, 95% of patients who are diagnosed with prostatitis do not have an infection or inflammation that can account for their symptoms. The prostate is not the issue.

Chronic Nonbacterial Prostatitis represents by far the largest number of cases of men with prostatitis. It has been estimated that this category involves 90-95% of all cases diagnosed as “prostatitis.” Studies have shown that men undergo impairment in their self-esteem and their ability to enjoy life in general because the pain and urinary dysfunction is so profoundly intimate and intrusive.

The effect on a person’s life of nonbacterial prostatitis has been likened to the effects of having a heart attack. This includes chest pain (angina) or having active Crohn’s disease (bleeding/inflammation of the bowel). If nonbacterial prostatitis moves from a mild and intermittent phase to a chronic phase, sufferers tend to have lives of quiet desperation. Having no one to talk to about their problem, usually knowing no one else who has it, and receiving no help from the doctor in its management or cure, they often suffer depression and anxiety. Symptoms may be intermittent or constant. Few sufferers have all of the following symptoms.

In the case of men with prostatitis and chronic pelvic pain syndromes, 95% of men with prostatitis symptoms do not have an infection or inflammation that can account for their symptoms. The evidence is compelling that in these cases, the prostate is not the issue. It is the muscles of the pelvis that have gone into a kind of chronic spasm or charlie horse that is responsible for the symptoms.

The Wise-Anderson Protocol was developed at Stanford University in the Department of Urology specifically to treat what has been diagnosed as prostatitis by relaxing the pelvis and stopping the chronic spasm in the muscles of the pelvic floor. Below is a list of symptoms that the Wise-Anderson Protocol can typically help in selected men with prostatitis:

https://www.youtube.com/watch?v=cE_Uv5h0HRw

Symptoms typically helped by the Wise-Anderson Protocol
NOTE: Most men have 2 or more of these symptoms

  • Urinary frequency (need to urinate often, usually more than once every two hours)
  • Urinary urgency (hard to hold urination once urge occurs)
  • Sitting triggers or exacerbates discomfort/pain/symptoms
  • Pain or discomfort during or after ejaculation
  • Discomfort/aching/pain in the rectum (feels like a “golf ball” in the rectum)
  • Discomfort/pain in the penis (commonly at the tip or shaft)
  • Ache/pain/sensitivity of testicles
  • Suprapubic pain (pain above the pubic bone)
  • Perineal pain (pain between the scrotum and anus)
  • Coccygeal pain (pain in and around the tailbone)
  • Low back pain (on one side or both)
  • Groin pain (on one side or both)
  • Dysuria (pain or burning during urination)
  • Nocturia (frequent urination at night)
  • Reduced urinary stream
  • Sense of incomplete urinating
  • Hesitancy before or during urination
  • Reduced libido (reduced interest in sex)
  • Anxiety about having sex
  • Discomfort or relief after a bowel movement
  • Anxiety and catastrophic thinking
  • Depression
  • Social withdrawal and impairment of intimate relations
  • Impairment of self-esteem

Essays on Pelvic Pain

Essays on Pelvic Pain

WHY INTRAPELVIC BIOFEEDBACK MEASUREMENT IS NOT A RELIABLE INDICATOR OF THE USEFULNESS OF THE STANFORD PROTOCOL AND THE ISSUE OF THE THERAPEUTIC USEFULNESS OF PELVIC FLOOR BIOFEEDBACK

David Wise, PhD

I am responding to a request for a comment about the usefulness of INTRAPELVIC biofeedback measurements in determining if pelvic pain is a tension disorder and appropriate for the Stanford Protocol. My short answer is that electromyographic measurement of the anal sphincter with a biofeedback anal probe, used alone, is an unreliable measure of what is going on inside the pelvic floor. Unremarkable readings of the anal sphincter should not be used to rule out tension disorder prostatitis and pelvic pain nor to dismiss the appropriateness of a treatment of the Stanford protocol.

Here is the longer answer. In my own case, when I was symptomatic, I did an hour or two of pelvic floor biofeedback on a daily basis for a year. After many months of diligent practice, my resting anal sphincter tone was a remarkable zero after about 15 minutes of relaxation. And I was very dismayed to find that I was still in pain at the moment that the anal probe registered zero. I was also disappointed as a clinician experienced in the successful use of biofeedback for other problems. I discovered that the biofeedback measurement seemed to indicate (erroneously) that tension was not a central problem in my pelvic pain.

I did not understand then what I understand now – the electrical activity in the anal sphincter is, for the most part, the only area that the anal biofeedback sensor measures. Often this says very little about what is going on with the other 20 other muscles within the pelvic floor. Furthermore, the biofeedback sensor measures dynamic muscle tension, but not chronically shortened tissue without elevated tone. It is possible to have a relaxed anal sphincter and have pelvic floor trigger points. In this case, elevated tone and active trigger points inside the pelvic floor are not reflected in the anal sphincter measurements.

Shortened contracted tissue inside the pelvic floor, symptom-recreating trigger points when palpated, and a tension-anxiety-pain cycle are the culprits in most people with pelvic pain that we successfully treat (which can sometimes include a chronically tight anal sphincter). We consider these factors criteria for diagnosis. For example, in my experience at Stanford, people with levator ani syndrome almost always have an entirely normal resting anal sphincter tone while palpating the painful trigger points on the levator ani muscle. This is excruciatingly painful. Resolving those trigger points and relaxing the inside of the pelvic floor can resolve this pain without much change in the measurement of the tone of the anal sphincter before or after treatment.

On our website, we have video clips of an important study replicated many times. In it, we demonstrate that at rest, the electrical activity inside a trigger point in the trapezius, monitored by a needle electromyographic electrode, is quite high. At the same time, the electrical activity of the tissue less than an inch away from this elevated electrical activity is essentially electrically silent. If you used a regular biofeedback sensor to measure the general tone of the trapezius, you may well find nothing remarkable. Yet to rely on this information is entirely misleading and would incline you to miss the treatment that could substantially reduce or abate the pain and dysfunction coming from the active trigger point.

The bottom line is that in my experience, electrical measurement of the anal sphincter (or the opening of the vagina) used alone, is often a poor measure of what is going on inside the pelvic floor. While I believe biofeedback is remarkably successful for many other disorders and is one of the treatments of choice for urinary incontinence and vulvar pain, I am unimpressed with the usefulness of biofeedback in treating most male pelvic pain.

The best gauge of the usefulness of the Stanford protocol that treats the pelvic pain of neuromuscular origin is a thorough examination of the pelvic floor for trigger points that recreate symptoms and palpating for tightened and restricted muscles inside the pelvic floor. This must be done by someone with a significant amount of experience and with the kind of myofascial Trigger Point Release that we use. An inexperienced person will miss all this and I have seen many times that even physical therapists who specialize in treating pelvic pain miss trigger points referring the symptoms inside the pelvis. This is one reason why we have offered training for physical therapists who treat male pelvic pain.

We sometimes find it useful when there is a high pelvic floor resting tone because it provides an objective marker that we can compare readings to after the patient has used the Stanford protocol. The idea that pelvic floor biofeedback measurements are a reliable test of whether pelvic pain is a tension disorder represents a misunderstanding of the problem and should not be relied on, especially when the readings are normal. Pelvic floor electromyographic measurement monitoring the anal sphincter is one of those medical tests where a positive finding may mean something and point toward the proper therapy and a negative result doesn’t prove anything.

The Latest CPPS and Wise-Anderson Protocol Research

The Latest CPPS and Wise-Anderson Protocol Research

 

The following are excerpts and abstracts of publications regarding the latest CPPS and Wise-Anderson Protocol research:

The following is an abridged version. For the full version, see the link at the bottom.

CPPS

Department of Urology, School of Medicine, Stanford University, Stanford, California.

PURPOSE: A combination of manual physiotherapy and specific relaxation training effectively treats patients. However, little information exists on myofascial trigger points and specific chronic pelvic pain symptoms. We documented relationships between trigger point sites and pain symptoms in men with chronic prostatitis/chronic pelvic pain syndrome.

MATERIALS AND METHODS: We randomly selected a cohort of 72 men who underwent treatment with physiotherapy and relaxation training from 2005 to 2008. Patients self-reported up to 7 pelvic pain sites before treatment and whether palpation of internal and external muscle trigger points reproduced the pain. Fisher’s exact test was used to compare palpation responses, i.e., referral pain, stratified by the reported pain site.

RESULTS: Pain sensation at each anatomical site was reproduced by palpating at least 2 of 10 designated trigger points. Furthermore, 5 of 7 painful sites could be reproduced at least 50% of the time (p <0.05). The most prevalent pain sites were the penis in 90.3% of men, the perineum in 77.8% and the rectum in 70.8%.

Puborectalis/pubococcygeus and rectus abdominis trigger points reproduced penile pain more than 75% of the time (p <0.01). External oblique muscle palpation elicited suprapubic, testicular and groin pain in at least 80% of the patients at the respective pain sites (p <0.01).

CONCLUSIONS: This report shows relationships between myofascial trigger points and reported painful sites in men with chronic prostatitis/chronic pelvic pain syndrome. Identifying the site of clusters of trigger points inside and outside the pelvic floor may assist in understanding the role of muscles in this disorder and provide focused therapeutic approaches.

PMID: 19837420 [PubMed – indexed for MEDLINE]

Chronic prostatitis chronic pelvic pain syndrome

Department of Urology, Stanford University Schoolof Medicine, Stanford, California.

PURPOSE: Chronic pelvic pain in men has a strong relationship with biopsychosocial stress and central nervous system sensitization may incite or perpetuate the pain syndrome. We evaluated patients and asymptomatic controls for psychological factors and neuroendocrine reactivity under provoked acute stress conditions.

MATERIALS AND METHODS: Men with pain (60) and asymptomatic controls (30) completed psychological questionnaires including the Perceived Stress, Beck Anxiety, Type A behavior and Brief Symptom Inventory for distress from symptoms. Hypothalamic-pituitary-adrenal axis function was measured during the Trier Social Stress Test with serum adrenocorticotropin hormone and cortisol reactivity at precise times, before and during acute stress, which consisted of a speech and mental arithmetic task in front of an audience. The Positive and Negative Affective Scale measured the state of emotions.

RESULTS: Patients with chronic pelvic pain had significantly more anxiety, perceived stress and a higher profile of global distress in all Brief Symptom Inventory domains (p <0.001), scoring in the 94th vs. the 49th percentile for controls (normal population). Patients showed a significantly blunted plasma adrenocorticotropin hormone response curve with a mean total response approximately 30% less vs. controls (p = 0.038) but no differences in any cortisol responses. Patients with pelvic pain had less emotional negativity after the test than controls, suggesting differences in cognitive appraisal.

CONCLUSIONS: Men with pelvic pain have significant disturbances in psychological profiles compared to healthy controls and evidence of altered hypothalamic-pituitary adrenal axis function in response to acute stress. These central nervous system observations may be a consequence of neuropsychological adjustments to chronic pain and modulated by personality.

Chronic prostatitis

Department of Urology, Stanford University School of Medicine, Stanford, California

PURPOSE: The impact of chronic pelvic syndrome on sexual function in men is underestimated. We quantified sexual dysfunction (ejaculatory pain, decreased libido, erectile dysfunction, and ejaculatory difficulties) in men with chronic pelvic pain syndrome assessed the effects of pelvic muscle Trigger Point Release concomitant with paradoxical relaxation training.

MATERIALS AND METHODS: We treated 146 men with a mean age of 42 years who had had refractory chronic pelvic pain syndrome for at least 1 month with Trigger Point Release/paradoxical relaxation training to release trigger points in the pelvic floor musculature. The Pelvic Pain Symptom Survey and National Institutes of Health –Chronic Prostatitis Symptom Index were used to document the severity/ frequency of pain, urinary and sexual symptoms. A global response assessment was done to record patient perceptions of overall therapeutic effects at an average 5-month follow-up.

RESULTS: At baseline 133 men (92%) had sexual dysfunction, including ejaculatory pain in 56%, decreased libido in 66%, and erectile ejaculatory dysfunction in 31%. After Trigger Point Release/paradoxical relaxation training specific Pelvic Pain Symptom survey sexual symptoms improved an average of 77% to 87% in responders that are greater than 50% improvement. Overall a global response assessment of markedly or moderately improved, indicating clinical success, was reported by 70% of patients who had a significant decrease of 9(35%) and 7 points (26%) on the National Institutes of Health- Chronic Prostatitis Symptom Index (p<0.001). Pelvic Pain Symptom Survey sexual scores improved 43% with a markedly improved global response assessment (p<0.001) but only 10% with moderate improvement (p=0.96).

CONCLUSIONS: Sexual dysfunction is common in men with refractory chronic pelvic pain syndrome but it is expected in the mid fifth decade of life. Application of the Trigger Point Release/paradoxical relaxation training protocol was associated with significant improvement in pelvic pain, urinary symptoms, libido, ejaculatory pain and erectile and ejaculatory dysfunction.

PubMed – U.S. National Library of Medicine

Journal of Urology

Abstract
J Urol. 2005 Jul;174(1):155-60.

Integration of myofascial trigger point release and Paradoxical Relaxation training treatment of chronic pelvic pain in men.

Anderson RU, Wise D, Sawyer T, Chan C.

Department of Urology, Stanford University School of Medicine, Stanford, California, USA. rua@stanford.edu

From the Department of Urology (RUA, CC), Stanford University school of Medicine, Stanford, Sebastopol (DW) and Los Gatos (TS), California.

PURPOSE: A perspective on the neurobehavioral component of the etiology of chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS) is emerging. We evaluated a new approach to the treatment of CP/CPPS with the Stanford developed protocol using myofascial trigger point assessment and release therapy (MFRT) in conjunction with paradoxical relaxation therapy (PRT).

MATERIALS AND METHODS: A total of 138 men with CP/CPPS refractory to traditional therapy were treated for at least 1 month with the MFRT/PRT protocol by a team comprising a urologist, physiotherapist and psychologist. Symptoms were assessed with pelvic pain symptom survey (PPSS) and National Institutes of Health-CP Symptom index. Patient response assessment perceptions of overall effects of therapy were documented on a global response assessment questionnaire.

RESULTS: Global response assessments of moderately improved or markedly improved, considered clinical successes, were reported by 72% of patients. More than half of patients treated with the MFRT/PRT protocol had a 25% or greater decrease in pain and urinary symptoms, respectively. The 2 scores decreased significantly by a median of 8 points when the 25% or greater improvement was first observed, that is after a median of 5 therapy sessions. PPSS and National Institutes of Health-CP Symptom Index showed similar levels of improvement after MFRT/PRT protocol therapy.

CONCLUSIONS: This case study analysis indicates that MFRT combined with PRT represents an effective therapeutic approach for the management of CP/CPPS, providing pain and urinary symptom relief superior to that of traditional therapy.

chronic pelvic pain syndrome

PURPOSE: Abnormal regulation of the hypothalamic-pituitary-adrenal-axis and diurnal cortisol rhythms are associated with several pain and chronic inflammatory conditions. Chronic stress may have a role in the disorder of chronic prostatitis/chronic pelvic pain syndrome related to initiation or exacerbation of the syndrome. We tested the hypothesis that men with chronic pelvic pain syndrome have associated disturbances in psychosocial profiles and hypothalamic-pituitary-adrenal-axis function.

MATERIALS AND METHODS: A total of 45 men with CPPS and 20 age-matched, asymptomatic controls completed psychometric self-report questionnaires including the Type A personality test, Perceived Stress Scale, Beck Anxiety Inventory and Brief Symptom Inventory for distress from physical symptoms. Saliva samples were collected on 2 consecutive days at 9 specific times with strict reference to time of morning awakening for evaluation of free cortisol variations, reflecting secretory activity of the hypothalamic-pituitary-adrenal-axis. We quantified cortisol variations as the 2-dat average slope of the awakening cortisol response and the subsequent diurnal levels.

RESULTS: Men with CPPS had more perceived stress and anxiety than controls (p<0.001). Brief Symptom Index scores were significantly increased in all scales (somatization, obsessive/compulsive behavior, depression, anxiety, hostility, interpersonal sensitivity, phobic anxiety, paranoid ideation, psychoticism) for chronic pelvic pain syndrome, and Global Severity Index rank for CPPS was 93rd vs. 48th percentile for controls (p<0.0001). Men with chronic pelvic pain syndrome had significantly increased awakening cortisol responses, mean slope of 0.85 vs. 0.59 for controls (p<0.05).

CONCLUSIONS: Men with CPPS scored exceedingly high on all psychosocial variables and showed evidence of dysfunctional hypothalamic-pituitary-adrenal-axis function reflected in augmented awakening cortisol responses. Observations suggest variables in biopsychosocial interaction that suggest opportunities for neurophysiological study of relationships of stress and chronic pelvic pain syndrome.

pelvic pain syndrome

Below is a summary of the latest research findings about the Stanford Protocol presented at the American Urological Association in San Antonio, Texas, May, 2005

RESULTS: 138 men with refractory CPPS enrolled and treated; average age 40.5 years (range 16-79). Disease duration: median 31 months (range 1-354) 59% (81/138) of patients had clinically meaningful improvements (“>25-100% decreased symptom core) in total pain as reported on Stanford PPSS(table 1)

Of these, 39% of patients achieved “>50%

Symptom improvement Total pain score 69% Urinary sc80%

After a median of five myofascial TrP release treatments , median baseline total pain scores of 13 decreased significantly by 8 points (p<0.001), Stanford PPSS (Table 2)

72% of patients reported GRAs indicating marked (46%) or moderate (26%) improvements in their symptoms.

Both symptom surveys, the NIH-CPSI and the Stanford PPSS, reflected similar levels of symptoms improvement after treatment (fig. 2)

CONCLUSION:

MFRT combined with PRT (treating these patients with the Wise-Anderson Protocol) resulted in moderate to marked improvements in symptoms in 72% of patients.

Treatment is based on the new understanding that certain chronic pelvic pain reflects a self-feeding state of tension in the sore pelvic floor perpetuated by cycles of tension, anxiety and pain. Our premise is that in addition to releasing painful myofascial trigger points, the patient needs to supply the central nervous system with information or awareness to progressively quiet the pelvic floor. The patient moves from being a passive, helpless victim to an active participant/partner in healing.

Contact us for a PDF of the Full Research.

Pelvic Pain Syndrome: An Address to the National Institute of Health

The following is an address by Dr. Wise to the National Institutes of Health

(NOTE: Portions of this transcript have been edited for clarification.) 

The goal of the Wise-Anderson Protocol is to enable the patients to reduce and/or resolve symptoms without dependency on drugs or others to do so for them.

David Wise, PhD
Plenary address to the
National Institutes of Health (NIH)
Scientific Workshop on Prostatitis/Chronic Pelvic Pain Syndromes
Baltimore, Maryland
October 21, 2005

Introduction

Thank you for giving me the opportunity to discuss the Wise-Anderson Protocol at this National Institutes of the Health-sponsored scientific meeting on Prostatitis/Chronic Pelvic Pain Syndrome.

How I became involved in treating chronic pelvic pain syndrome.

I happened to have had the unusual experience of the slow motion nightmare of chronic pelvic pain syndrome for a period of over twenty years. At one time or another I had almost all of the symptoms you typically hear from patients, and then unrelieved, unrelenting pain 24 hours a day 7 days a week. I had no one to talk to and no one to help me — and then around ten years ago, I had the fortune of experiencing the resolution of my own symptoms by finding and implementing the elements of what is now called the Wise-Anderson Protocol. I gratefully remain pain and symptom-free. So I speak to you both as a clinician who has seen many, many patients with pelvic pain over the past years, and as someone who has had the direct experience of the pelvic pain syndrome with the experience of resolution.

The development of the Wise-Anderson Protocol.

I also have the unusual fortune of meeting and collaborating with Rodney Anderson at Stanford University, director of the Stanford Pelvic Pain Clinic. He is a remarkable physician to whom I have great gratitude for his big mind and willingness to think outside of the box. I have also collaborated with Tim Sawyer, an extraordinary physical therapist. My purpose in the few minutes is to, as clearly as I can, explain the methodology we developed at Stanford over an eight-year period and which we continue to study and refine.

Paradigm shift: chronic pelvic pain is not an infection, but a tension disorder.

I am aware that the Wise-Anderson Protocol represents a significant paradigm shift. We don’t believe the vast majority of those diagnosed with prostatitis/chronic pelvic pain syndrome suffer from a prostate infection or occult bacteria, an autoimmune disorder or compressed pelvic nerves.

We see the overwhelming majority of cases diagnosed as the result of the overuse of the human reflex to tighten the genitals, rectum, and contents of the pelvis in response to anxiety, pain, or trauma by chronically contracting the pelvic muscles. This tendency becomes exaggerated in predisposed individuals, particularly those with a tendency toward anxiety who respond to stress by habitually and unconsciously tightening their pelvic floor. Such a tendency is invisible. No one can see it. Usually, the person who has such a tendency is unaware of it. And the consequences of this tendency are also invisible except for the complaints of discomfort, pain and urinary dysfunction that the sufferer eventually expresses.

This state of chronic constriction creates pain-referring trigger points in and around the pelvis, which in turn, creates an inhospitable environment for the nerves, muscles, blood vessels, and structures within the pelvic basin. This results in a self-feeding cycle of tension, anxiety, and pain, which has been previously unrecognized and untreated. It is a kind of short circuit. Patients with pelvic pain often wind up in the emergency room when this short circuit gets out of control.

The havoc of chronic tension in the pelvis and the tension-anxiety-pain cycle.

Most people neither appreciate nor understand the havoc that chronic tension plays in the pelvic floor. It is the same havoc that chronic neck and shoulder tension plays in a headache, chronic back tension plays in low back pain, or chronic jaw clenching plays in temperomandibular disorder.

There can be psychological, physical, or social triggers to the chronic tightening of the pelvic floor. Once this cycle begins, it tends to have a life of its own and carries on even when the initiating triggers have passed.

The purpose of the Wise-Anderson Protocol is to break this cycle and to help patients prevent its reoccurrence. The methodology is low tech. The aim is to get patients off of all drugs and to end patient dependency on professional help. The responsibility for the success of the treatment is largely up to the patient’s compliance with the protocol. Patients who look for a quick external fix to their condition tend to lack the motivation that the Wise-Anderson Protocol demands. Such individuals tend not to be good candidates.

The problem in the great quest to restore the pelvis to a relaxed and symptom-free state is that pain, tension, and trigger point activity in the pelvis is intimately tied to emotional reactivity and autonomic arousal. They feed each other. Anxiety is the gasoline on the fire of pelvic pain. This is also why placebo is so influential in this condition. This tie-up with autonomic arousal and pelvic pain has never been addressed and is essential to any effective treatment.

How to understand pelvic pain if you don’t have it.

I want to take a moment to help those of you who have never had pelvic pain syndrome to experientially understand it from my viewpoint. In this way, you have more of an intuitive sense of what we do. If I were to ask you to tighten your pelvic muscles for the next ten seconds as though you were stopping yourself from urinating, most of you could do this. If I ask you to tighten your pelvic muscles for one minute, probably fewer of you would be willing.

Now imagine you were to continually tighten up your pelvic muscles for a half an hour, one hour, twelve hours, twenty-four hours, one month, six months, one year, two years, five years, ten years. Most people consider it inconceivable to be stuck in an activity of such self-abuse and self-inflicted pain. No one here would dare venture voluntarily. I suggest that the consequences of this kind of chronic tension lead to the symptoms of which most patients diagnosed with prostatitis/cpps suffer.

I want to talk about the relationship between anxiety and trigger point activity.

Anxiety makes trigger points hurt more.

Here are pictures of electrical activity in trigger points at baseline, during relaxation and under stress, in a study done by Gevirtz and Hubbard in San Diego. On the left, we see trigger point activity at baseline… notice that the electrical activity in the trigger point is significantly elevated from the electrical activity of the non-tender tissue just 1/4 inch away. Notice now the center reading after the subject has begun relaxation. The electrical activity of the trigger point normalizes. Notice now the electrical activity of the trigger point during a stressor. The electrical activity is significantly activated well beyond baseline readings. These studies have been duplicated hundreds of times and clearly show the strong impact of autonomic arousal on trigger point activity.

The Wise-Anderson Protocol represents an effective and safe non-drug, non-surgical treatment for pelvic pain syndrome. It provides far better outcomes than conventional therapies for most patients with no long term side effects. I will briefly summarize the results of our study published this year in the July issue of Journal of Urology. At Stanford, we studied 138 patients who were referred to us, usually by physicians who could no longer help these patients because they had failed all conventional therapy. We were the court of last resort. After treatment, using the Wise-Anderson Protocol, 72% of these refractory patients reported that they marked moderate improvements in their symptoms as reported on the Global Response Assessment. These responses reported as marked and moderate improvements by patients were commensurate with appreciable (10.5% decrease in marked and a 6.5 % decrease) decreases in the NIH-CPSI scores.

Although we have not systematically studied the numbers, it is my observation that positive results from our protocol improve with the increased competence of the patient in our methodology over time. In other words, in my experience, patients’ symptoms appear to improve the longer they follow our protocol.

The two essential elements: Paradoxical Relaxation and pelvic floor Trigger Point Release.

Let me touch on the Wise-Anderson Protocol Trigger Point Release. Time does not permit any detailed discussion of the Trigger Point Release we use and have developed. Suffice it to say that we work with approximately 40 trigger points related to pelvic pain syndrome. We apply the same principles of Trigger Point Release pioneered by Travell and Simons for external muscles, to the release of the internal muscles. A comprehensive list and detailed illustrations of trigger points related to male pelvic pain syndrome and a detailed description of our method are found in the 3rd edition of our book, A Headache in the Pelvis: A New Understanding and Treatment for Prostatitis and Chronic Pelvic Pain Syndromes.

Wise-Anderson Protocol Trigger Point Release.

Here are some notable aspects of the Trigger Point Release protocol we use.

  • We use primarily Trigger Point Release oriented therapy and not myofascial release therapy. They are not the same.
  • Trigger points that refer pelvic pain exist both inside and outside the pelvic floor.
  • The most common trigger points in male pelvic pain are found in the anterior levator ani, the obturator internus, adductors and surprisingly, in the quadratus lumborum and the psoas. I don’t expect you to take in this list but only to know that we have found there are specific trigger points related to specific pelvic pain symptoms.
  • Trigger points tend to be found anteriorly in patients with more urinary symptoms and posteriorly in patients complaining more of rectal pain.
  • We use a method called pressure release on a trigger point, holding it for 60-90 seconds– this length of time, which is usually difficult for many therapists to routinely hold, is critical to the release of the trigger point.
  • We rarely do trigger point injection, only with stubborn external trigger points. Even then, we never advise the use of botox in such injections. We never do or advise internal injections.
  • The number of treatments varies between 5-40 sessions.
  • We generally discourage kegel exercises and do not use pelvic floor biofeedback or electrical stimulation.
  • Patients are taught external and internal trigger point self-treatment. We have found that patients can do the majority of the Wise-Anderson Protocol physiotherapy themselves once they are shown how to do it.
  • We continue to develop an internal wand which we sometimes prescribe for patients when they have no partner or other resources to work with the internal trigger points at home. This has to be used carefully and only after the patient has been thoroughly instructed in its use.
  • In the Wise-Anderson Protocol, Trigger Point Release is done concomitantly with Paradoxical Relaxation.

A word about using only physiotherapy or Paradoxical Relaxation in treating pelvic pain syndrome.

Both Paradoxical Relaxation and Wise-Anderson Protocol physiotherapy aim to rehabilitate the patient’s pelvic floor and to stop the habit of chronically tightening the pelvic muscles under stress. For most patients, each method is necessary but not sufficient in restoring the pelvis to a symptom-free state. The intrapelvic Trigger Point Release we use rehabilitates the pelvic muscles and allows them to relax. The focus of Paradoxical Relaxation is to allow a rehabilitated pelvis to profoundly relax and to support the healing mechanism of the body with respect to a chronically sore and contracted pelvic floor. Importantly, a central purpose of Paradoxical Relaxation is to modify the habit to unconsciously and habitually tighten the pelvis.

It is tempting to look for a quick fix to the problem of Prostatitis/CPPS. As we know, there are no drugs or surgical procedures that satisfactorily help the pain and dysfunction of Prostatitis/CPPS. There is no quick fix. While physiotherapy is essential to our protocol, it is insufficient to resolve the problem. Most patients who have suffered from this problem and simply do physiotherapy discover this.

Generally, if patients do not learn to voluntarily and regularly relax the pelvic floor and reduce their own nervous system arousal, in the long term, manual physiotherapy efforts at rehabilitating the pelvic floor tend to be short lived. Patients easily go back to the old habits that brought about the condition in the first place. A stressful hour in traffic or a fight with one’s partner after the best of physiotherapy session can easily reactivate the trigger points that the therapist has just deactivated. I have seen this with many patients and know it personally.

Paradoxical Relaxation in the Wise-Anderson Protocol.

Few would disagree with the value of profoundly relaxing a painful pelvis. The question is: how is it done? Consider how difficult it is to relax even you neck muscles in the middle of an ordinary upset in your life. Relaxing tension associated with pelvic pain syndrome and anxiety is more difficult.

Tightening against pelvic pain worsens it.

Paradoxical Relaxation seeks to reverse the dysfunctional reflex to tighten against pelvic pain syndrome and the fear associated with it. We can call this chronic tension dysfunctional protective guarding. This reflexive tightening is dysfunctional because it exacerbates rather than protects against pain and anxiety.

The reaction to tighten the pelvis in response to pain paradoxically exacerbates it. Pain is a stimulus that triggers fight or flight. Pain does not reflexively trigger repose and rest, which is in fact what we ask patients to do. Accepting tension as a way to relax it is counter- intuitive. It is this strategy that can reduce the pain or take it away, and thus, we name our method Paradoxical Relaxation.

Dysfunctional protective guarding is at the heart of other functional disorders.

Dysfunctional protective guarding exists in a number of other functional somatic disorders. They include tension headache, temperomandibular disorder, lower back pain, non-cardiac chest pain, and idiopathic dyspepsia among others.

I think a modified Wise-Anderson Protocol may be useful in some of these disorders as well. The central strategy of Paradoxical Relaxation comes from the insight that accepting tension relaxes it. In Paradoxical Relaxation, the emphasis is on tension and not on pain even though pain is usually perceived peripherally during the relaxation training.

Paradoxical Relaxation is not new. The major insights of this therapeutic strategy derive from the world’s oldest wisdom traditions and practices that focus on quieting the mind and body, and from the methodology of my teacher Edmund Jacobson who developed the technique of progressive relaxation.

The paradox of Paradoxical Relaxation can be expressed in the following ways:

  • That accepting tension relaxes it
  • That accepting what is, is the fastest way to change it
  • That what we resist persists
  • That the requisite for changing something is first accepting it as it is, on its own terms

This happens to apply to stubborn pelvic muscle tension. Remarkably, this insight has the potential to allow patients to dissolve pelvic pain syndrome.

Accepting tension is both counter-intuitive and functional in terms of relaxing stubborn tension associated with functional somatic disorders I have mentioned above. Paradoxical Relaxation is a modern day method to implement this perennial wisdom for ordinary people who have pelvic pain syndrome.

In Paradoxical Relaxation, we ask patients to do an extraordinary thing: to focus on, and then rest with their tension when they are anxious and in pain. Learning to do this requires many hours of practice. For the first 3 months, patients are asked to do 1- 1 1/2 hours of relaxation guided by 1 of a 38 lesson sequenced recorded course. The course consists of over a year of 1-2 daily sessions of relaxation training. This can’t be learned from stand-alone relaxation tapes. Patients must receive many hours of instruction by a teacher competent in the method. The Wise-Anderson Protocol is the slow fix.

Pelvic Pain syndrome is almost always accompanied by a constant level of fear.

Paradoxical Relaxation asks patients to relax while they feel pain and fear. Patients have to be reassured that it won’t hurt them to relax while they experience their fear. It is common for patients to feel that if they accept their tension and fear and pain, that they have given up and that they will never get rid of their condition. These notions are obstructions to learning and must be addressed directly. Here is the paradox again–relaxing with and accepting fear is most likely to dissolve it.

To the novice, relaxing with pelvic pain syndrome, chronic tension, and chronic anxiety is scary.

And so it is, in this context, that we ask people to sit still with it all. Relax with the pain, fear, helplessness, desire for distraction, fear of the method failing, fear that their life is over and that they will have to live in chronic pain until they die, and fear of getting their hopes up. This is scary territory. Teaching patients this relaxation protocol addresses all of these concerns and takes time and many repetitions to gain some degree of competence.

The Wise-Anderson Protocol is done in a 6-day intensive immersion clinic.

The format of the Wise-Anderson Protocol is unusual as it is done in a six-day intensive immersion clinic involving some 30 hours of treatment. At this clinic, patients are trained in Paradoxical Relaxation, receive daily physiotherapy, are trained in self-administered Wise-Anderson Protocol Trigger Point Release, specific stretches, and related physiotherapy techniques. It is the goal of this clinic for the patient to be able to self-administer most of the protocol without reliance on additional treatment.

The goal of the Wise-Anderson Protocol is to enable patients to resolve symptoms without drug dependency.

The Wise-Anderson Protocol represents a very different paradigm from one in which a patient who feels he has no control over his symptoms comes to the doctor to be cured and submits himself passively for the remedy. Our aim is to make patients independent. It is our goal that patients trained in our protocol find themselves in a position to take care of and possibly resolve this condition themselves without dependency on drugs or others to do so for them.

Paradoxical Relaxation: Relieving a Painful Pelvic Floor

 

https://www.youtube.com/watch?v=kBnu9Hl0B1A

Paradoxical Relaxation relaxes the tension and shortened muscles within a painful pelvic floor.

This involves a daily practice of the cultivation of effortlessness in the presence of pain, anxiety, and tension.

Paradoxical Relaxation has two components: The first is a breathing technique used at the beginning of relaxation, a coordination of heart rate and breathing. This reduces respiration to approximately 6 breaths per minute. The second component is the instruction given for the remainder of the session. These direct the patient to focus attention on the effortless letting go of tension in a specified area of the body, accepting residual tension that does not easily release.

b. Patients are asked to listen to approximately 1 hour of recorded relaxation instruction daily. These allow the focus of individual predetermined sites, including frontalis, jaw, neck, shoulders, arms, hands, upper back, chest, stomach pelvis, legs, and feet. Each site is the focus of practice for approximately 2 weeks, and the entire course lasts for approximately a year and two months. Home practice is done daily and includes the use of 46-recorded lessons varying in length from 7 minutes to 45 minutes. The focus on the relaxation of a painful pelvic floor is generally avoided for the first several months of relaxation training. This is because such a focus can exacerbate symptoms until competence in relaxation is gained in neutral, non-painful areas.

c. Relaxation instruction guides the patient to redirect attention away from discursive thinking and daydreaming. The target range of brain wave activity is low-frequency alpha.

d. Catastrophic thoughts that increase sympathetic arousal arising during relaxation are identified. A cognitive therapy protocol is used to help the patient reduce the impact of such thinking.

The process of Paradoxical Relaxation is a slow one.

Respect for and cooperation with this very slow process is essential to success. When the desire of the patient aims to hurry the body’s slow letting go of deeply ingrained tension, they usually fail to relax a painful pelvic floor. In Paradoxical Relaxation, the instruction is given to let go of tension. This effortless relaxation usually occurs in small and unremarkable steps. Recognizing and working with these small gradations of relaxation is essential.

Edmund Jacobson described residual tension in detail in his long career in the development of relaxation therapy, which began in 1908. The patient is instructed to keep attention focused on residual tension without trying to change it. When attention is distracted by visual or conceptual thinking throughout the protocol, the patient is instructed to refocus attention on the remaining tension without aiming to achieve any result. It is essential that the patient understands that deep relaxation occurs when attention rests in sensation and not in thinking.

Instructions alternate between letting go of the tension that easily lets go and effortlessly feeling the remaining tension. The tension that is being focused upon without effort usually abates during this process. The patient is instructed to permit this abatement to occur. Sometimes the tension does not abate or even increases, and the patient is instructed to remain softly focused on the remaining sensation without an intention to change it. The concept underlying this protocol is that one does not relax stubborn, residual tension directly but instead is effortless in remaining continually aware. Relaxation occurs without any effort on the part of the patient. Exerting any effort increases tension. This is because relaxation is identical to effortlessness.

We specifically discourage patients from focusing on the relaxation of a painful pelvic floor for the first 4 months of treatment, as the patient’s attachment to the relief of symptoms tends to interfere with the conscious and simultaneous effortless attention on tension. The focus on the relaxation of the upper body is most easily accomplished and usually results in a reduction of pelvic tone. The focus on the relaxation of the pelvic musculature requires that the patient makes the distinction between pain and tension. The aim of the protocol then becomes directed to the tension and not the pain in the area of a painful pelvis.

https://www.youtube.com/watch?v=ToZQDIq90rs

Learn to profoundly relax pelvic tension in the presence of pain and anxiety.

Pain and anxiety stimulate additional tension and aversion. Without instruction, most patients who are not properly instructed are loathe to sit still in the presence of unresolved pain. The instructions of Paradoxical Relaxation train patients to stop the tension-anxiety-pain cycle by focusing on tiny residual tensions that they can easily relax. At the same time, they can accept the tension and pain that remains. Attention is redirected from negative cognitions and focuses on letting go of tiny and often ignored tensions in the body unconsciously aimed stopping the pain and tension – efforts that only exacerbate symptoms. In the paradoxical acceptance of pain and tension that does not easily relax, the patient learns how to ride the tension down in small steps that require acceptance of what formerly has been unacceptable and frightening.

Chronic pelvic pain syndromes tend to be self-perpetuating disorders in which a patient’s pain causes a reflexive tightening of the pelvic floor, which in most patients, often prompting a flurry of negative thinking. The reflex to contract against pain actually increases pain. Negative and catastrophic thinking fan the fire of the pain by igniting the electrical activity in the trigger points referring pain in the pelvis. The tension-anxiety-pain cycle is a major obstacle to the reduction of a painful pelvic floor. It feeds itself in the moment that a patient is asked to relax the pelvic tension. The disruption of the self-feeding cycle of tension, anxiety, and pain can be accomplished by a select group of patients who become competent in Paradoxical Relaxation.

While we utilize an extensive set of recorded tapes in the Wise-Anderson Protocol relaxation method, instruction is necessary to train patients in the method. Below we discuss the issue of stand-alone relaxation tapes.

Why Paradoxical Relaxation cannot be learned from recorded tapes in the absence of instruction.

(This is part of a response sent to the webmaster of the chronicprostatitis.com website on the issue of stand-alone relaxation tapes.)

As we have discussed, I do not sell the audio Paradoxical Relaxation course on a stand-alone basis. There are numerous relaxation tapes that can be bought from many different sources and people are free to buy them. I could sell the recorded lessons I use on a stand-alone basis – I have certainly had enough requests – but choosing not to do this is neither a casual nor a self-serving decision on my part. I have a short answer and a long answer to explain.

Here is the short answer why.

I have no confidence that someone can learn to relax a painful pelvic floor from a relaxation tape without instruction from someone who is competent in the method and without intrapelvic Trigger Point Release. I do not want to associate myself with making available a half measure that appears to offer something substantial but does not.

When I was symptomatic, I tried many remedies that all seemed reasonable but ultimately failed to help me. They left me hopeful at first, then disappointed, and disheartened. A stand-alone relaxation tape, in my opinion, is a half measure. Half measures give little chance of offering real recovery from chronic pelvic pain syndromes. I have decided that if I am to err, I will err in the direction of not offering anything instead of offering a half measure in which I have no confidence.

Here is the long answer why.

Learning to relax the pelvic muscles and muscle tenstion from a relaxation tape is like learning to play the violin by listening to recorded instructions. In my experience, such an endeavor usually fails; the person gets discouraged and usually gives up. To learn the violin, you need instruction from someone who plays the violin. The more accomplished the player, the better. You want to learn the violin from someone who plays it every day, who is excited about it, and whose expertise is obvious. Imagine learning the violin from someone who does not play it. The obstacles to learning to play the violin and learning to relax deeply are very similar — except learning to deeply relax a painful pelvic floor is harder than playing the violin.

Our instinct is to tighten against pain, not relax. Yet, I found that relaxing with the tension of certain kinds of pelvic pain can dissolve it. Learning to do this is a major event in someone’s life because it is from this place that it can become possible to break the cycle of pain, anxiety, and tension and allow the sore and irritated tissue in the pelvic floor to heal.

There may be some unusual individuals who can deeply relax on a consistent basis by simply using recorded instructions and I applaud them and wish them well. The reason I do not have any faith in this is that to relax a painful pelvic floor and maintain a relaxed pelvic floor over time, (and not everybody can learn how to do this) requires guidance with regard to many issues. Examples of the issues that must be addressed are:

  • What to do with the pain during relaxation
  • How to not add tension the tension of ‘trying’ to relax tension
  • When to use breathing to focus distracted mind and when to cease the breathing technique
  • What to do when emotions arise that the tension in the pelvic floor is suppressing
  • How to accept the resistance to accepting the tension
  • What it means to rest while there is discomfort
  • What to do when a plateau is reached and tension doesn’t reduce
  • What to do when symptoms abate during relaxation and then resume quickly afterward
  • How to relax in the office or on the bus

I have seen many patients distort instructions and become frustrated in their practice of relaxation. A relaxation tape usually addresses none of this and the successful resolution of these issues makes the difference between success and failure.

To learn to relax a painful pelvic floor, especially in the presence of pain, is an enigma and the method to do this is anti-intuitive. It is often frightening for someone with pelvic pain to sit still with their pain and their thoughts without guidance. In my experience, people avoid the kind of relaxation required to relax a tight and painful pelvis if there is no support and the recorded tapes wind up on the shelf.

Few professionals whom I have offered to train in teaching this method have been interested. I think that the reason is that they were not motivated, like my pain motivated me, to spend the time learning to do the relaxation themselves. The best teachers of this method are turning out to be the patients I have trained who are doing well and use it on a daily basis.