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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I hope this has been helpful for you.

MUSCLE SORENESS/TENSION AND URINARY FREQUENCY AND URGENCY

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

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

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

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

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

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

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

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

Cause and Effect In Muscle Based Pelvic Pain

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

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

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

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

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

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

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

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

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

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

Cause and Effect In Muscle Based Pelvic Pain

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

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

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

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

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

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

 

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

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

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

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