Pelvic pain is invisible. It can’t be seen, it can’t be visualized with fancy technologies, there are no fluid tests for it; it’s a difficult phenomenon to understand if you’ve never had it. I want to use a metaphor here that I’m hoping is easy to understand, to understand the less easily understood phenomenon of muscle-based pelvic pain.

The metaphor of the sore arm

Imagine that you’ve had an accident and you’ve fallen down on your side and as a reflex you put your arm out to protect yourself. You certainly survive, everything is basically ok and nothing is broken, but your hand and wrist hurt and your shoulder has a big bump on it and is very painful. Your whole arm is sore and you’re miserable. You go to the doctor, who says that you’re fine, just take care of it, let it rest and it will heal up. Its all intuitive, it all makes sense.

Healing the sore arm

So, the doctor suggests that to help things heal faster and for you to be more comfortable, you put your arm in a sling. In the sling your arm can relax and will be protected from movement and the bumps and grinds of life. It isn’t hard to understand that if your arm gets bumped, it will hurt.   When you see your affectionate aunt who wants to hug you, you say, “Wait,” and you give her a peck on the cheek and tell her you hurt your arm and she shouldn’t grab you and squeeze you like she usually does. You don’t want her to irritate your arm’s healing.

Protective guarding and the sore arm

Drawing away from what might hurt your arm is a reflex; you want to protect your arm against what might jar it because you know it will hurt if something does bump against it and irritate what is already sore and irritated. You go around with pain in your wrist and arm and shoulder feeling vulnerable. You notice you protectively guard your arm and shoulder, especially in public, during this period while they are healing up. Guarding means tightening up, tensing it up, being on alert for anything that might hurt it.

You notice that if you put it in a certain position or inadvertently bump it against something, you tighten up. In other words, any increased pain makes you tighten up to protect your arm. Let’s call this protective guarding; you guard to protect. This means the muscles tighten up to protect and this is instinctive. You notice you are doing this self-protective guarding without even being conscious of it, it just happens out of awareness. It’s just a reflex of the body to protect itself from being hurt more, when a certain part of the body has been injured or hurt.

If you keep it protected over time, it heals. If you don’t protect it, it likely will continue to hurt. If you do take care of it, you stop being so guarded, and eventually you forget about it and you go back to the way you’ve been in the world, not thinking about your shoulder, not tightening it up, not protecting it, not pulling it away from what might hurt it. So the sore arm and shoulder that got hurt, then got better.

Comparing the painful pelvis to the sore arm

Now I want to talk about a situation in which the pelvis hurts and is sore, irritated, and increases in pain when you do certain things that are just normal, everyday activities that everyone does. For some people with muscle-based pelvic pain, sitting down hurts. Other people aggravate the pain in the pelvis when they have a bowel movement. Or conversely, sometimes a bowel movement helps. Sometimes urination makes it feel better, sometimes it makes it feel worse. Or when trigger points, which we have extensively discussed elsewhere are in a certain location, for some people orgasm can irritate pelvic pain and make it feel worse. Stresses in life and anxiety can make the pelvis hurt a lot more. Again, all of these things we have explained elsewhere. But these are things that are not a the normal kind of bump, like the bump against your sore shoulder or arm. There are these other things in life that flare up pain in a sore pelvis but they are distressing because they don’t seem to make sense and don’t feel normal.

Unlike a shoulder and wrist that were injured when you fell on them, then healed when you rested and took care of them, chronic pelvic pain most simply called pelvic floor dysfunction doesn’t heal up. Why?

The relationship between protective guarding in the sore pelvic and the sore arm

In the pelvis something different occurs in response to pain that doesn’t seem to occur in other parts of the body quite like it does in the pelvis. What occurs in the pelvis, different from what occurs in the sore arm, is an instinctive, very sensitive reflexive tightening against anything that feels strange or uncomfortable. This is what I refer to as the reflex-guarding of the pelvic tissue against its own sensation of pain. In other words, when you tighten up the pelvis when you’re anxious, and it stays tight for a long period of time and the muscles become sore, that sore irritated tissue in the pelvis tightens up protectively as a defense against its own pain. It’s not a very good design. Where the instinct to protect a sore arm and shoulder helps healing and is protective, I’ve often thought the reflex guarding of the pelvis against soreness generated by its own chronic tightening is a kind of flaw in the human design because the guarding against the pain makes it worse.

Physical bumps cause protective guarding in the arm; anxiety and an aroused nervous system ‘bumps’ the sore pelvis

So, either through chronic anxiety and worry (which again, we have discussed elsewhere) or through injury, the tissue of the pelvis involves the tightening up of certain kinds of muscles and parts of the pelvic floor. It involves a tightening up of the muscles around the genitals and anus, often including the internal pelvic floor muscles called the piriformis, the obturator internus, the levator ani muscles, the coccygeal, levator ani, puborectalis and related internal muscles. The muscles of the lower abdomen are often also involved including the rectus abdominus, and suprapubic muscles. Other muscles including the quadratus lumborum, the iliacus, the psoas get into the act. Many of these muscles can tighten up in concert and remain tight and can feed into the internal muscle hypertonicity and pain. In our experience, when you have pelvic pain all of these muscles have to be dealt with when they are part of the ‘fist’ of muscles that has chronically tightened up if you want to heal the sore pelvis. These muscles tighten up and become painful. They often refer pain and sensation back inside the pelvis and are all part of a complex of tightening and protective guarding against the pain in the pelvis.

Unlike the arm, pelvic pain and protective guarding is strongly provoked and perpetuated by anxiety and the arousal of your nervous system. Anxiety and nervous arousal that irritate, perpetuate and increases pelvic pain are equivalent to ‘bumping the arm’ when the pelvic floor muscles are irritated and tight, except you don’t even have to move or be bumped to have the pain in the pelvis exacerbated by anxiety. Anxiety and nervous arousal are themselves the bump. While anxiety and nervous arousal may slightly increase the discomfort of a sore arm or shoulder, anxiety and nervous arousal strongly increase the pain, protective guarding and tightening in the pelvis. And people who chronic pelvic pain often catastrophize and worry constantly. The relationship between anxiety and pelvic pain is not at first intuitively obvious.

One way to understand pelvic pain is to look at, for instance, a frightened dog who pulls its tail in. The pelvic floor tightens up in a dog to pull the tail in. Similarly, when a certain group people are chronically anxious, their ‘tail’ pulls in.

Pelvis pain can be seen as a condition of a tail chronically pulled between the legs

In the case of a human being, pulling the tail in means the tailbone is pulled forward when the pelvic floor tightens. The arm heals relatively quickly when more or less left alone. What is important to understand is that pelvic floor muscles don’t get a chance to heal up because they are continually irritated and held in a guarded, tense and protected state, by all kinds of activities that are just normal activities of life; activities like defecation, urination, sexual activity, sitting, the normal stresses of life, and sometimes even certain kinds of physical activities. Intimately involved, in addition to the activities of life, the formation of knots inside the muscles called trigger points. These knots form and remain irritated and perpetuating pain until they release and go away. Once formed however, for the most part, they stick around unless they’re specifically treated to release.

The self feeding cycle of protective muscle guarding and a sore pelvis

So, you have a whole series of factors that bear down on the poor, painful pelvis and stop the painful tissue from healing. What needs to heal is not serious or pathological. But it is sore and painful. In our book at A Headache in the Pelvis and in our other writings, we have talked about the self-perpetuating pelvic pain cycle; a cycle that once it gets going, takes on a life of its own. Sore pelvic tissue triggers its own tightening and protective guarding, which triggers more pain, which triggers anxiety and worry about whether it will ever go away, which is variously aggravated by going to the bathroom, not being able to sleep through the night, sitting down, sex and the stresses of life. These stresses represent an onslaught of perpetuating factors that keep pelvic pain going and give it a life of its own.

When you have pelvic pain, like I did for over 20 years, there’s not a lot more to do sometimes than to try and figure this out, and I don’t think that most people don’t figure it out. How you deal with pelvic pain is daunting. If you search the internet, and look at the research on it, there are a lot of ideas about what pelvic pain is how you treat it. But most of what I read on the internet is off the mark. Pelvic floor pain i hard to understand if you have never had it and watched the process of it resolving.

Temporarily loosening the sore pelvic contraction vs. healing the sore pelvic contraction

Our protocol was formed by my own experience in conjunction with the remarkable expertise of the folks I work. We have developed a careful, skillful program to physically loosen the tightened tissue in the pelvis. But, as we have said in our book and in a number of podcasts, physical therapy (though we are pioneers in using it and are strong proponents of necessity teaching patients how to self-treat all aspects of it) is a temporary fix for pelvic pain. Unless the tissue is healed to a state of normal tissue like the sore arm or shoulder, even if its loosened in one moment, and the pain is temporarily absent, the tissue s ready to be aggravated, irritated and tightened up again in the next moment by the activities and stresses of life.

Putting a sore arm in a ‘sling’ to help it heal; putting the sore pelvis in a sling to help it heal

That is why I suggest here that, like the sore arm, the pelvis needs to be put into a kind of ‘sling’ to prevent aggravation and irritation and allow the healing mechanisms of the body to heal the tissue. Unless you do that, temporarily loosening the tissue through physical therapy and other physical methods, is a temporary (though critical and necessary) intervention and usually not sufficient to heal the pelvic floor. We’ve come to see that the physical loosening of the sore pelvis has to be done repetitively and as we’ve learned, it is best done by the person with pelvic pain themselves. If you have pelvic pain, you really need to learn how to do the loosening yourself.

Extended Paradoxical Relaxation is the ‘Sling’ that Allows Tissue of the Pelvis to Heal

We teach our patients how to loosen all of this tissue (from the knees to the sternum) themselves physically, and then we teach them how to put this loosened, relaxed tissue into a sort of ‘sling’ to allow its healing.

What does it mean to put the pelvis in a sling? It means resting the pelvis in a way wherein it is not being assaulted by anything that tightens it up, so that the mechanisms of the body can heal it and allow it to operate it and work the way it is meant to. In our protocol, the ‘sling’ for the pelvis is called Extended Paradoxical Relaxation. I have written a book about this method and we talk about it extensively in A Headache in the Pelvis.

The method we train our patients to do is basically a method to askes us to say to all the stresses that interfere with the healing of the pelvic floor, “Stay out of the room and leave me alone for now. Let me rest.” It’s a method of allowing the pelvic floor to be quiet and be free of the stresses that irritate it and interfere with its healing. Extended Paradoxical Relaxation requires daily practice and we ask our patients to do both the physical loosening and the relaxation components together for at least 2 hours a day. This is a big thing to ask of anyone but most of the people who agree to do this do it because they feel the possibility of their condition healing up. When you suffer from \ pelvic pain for a long time, you often reach a point (as I did) where you say “If I have to go to Mongolia and eat cow dung, tell me when the next plane is.” When you are suffering from pelvic pain that doesn’t heal, it becomes the bane of your existence and you become willing to do whatever it takes to get it to go away.

Healing a sore pelvis requires an inner environment in which it can heal

Pelvic pain is peculiar in that we have to deal with the reflex that tightens the pelvis in response to the slightest amount of pain. Many different factors have caused the pelvis to tighten and hurt, and the normal stresses of life trigger the reflex guarding of the sore pelvis which keeps it in pain and not able to heal the way a sore arm will when it’s put in a protected healing environment. I hope that this metaphor is helpful. Like a sore shoulder, you need to provide an environment in which the body can heal itself and return itself to normal. The ‘sling’ for pelvic pain that allows this healing is just a bit different from that of a sore arm and wrist. The sling involves regular physical loosening , inner quiet, and a psycho physical internal environment free from the bumps of everyday life.