Symptoms and Treatments in Pelvic Pain: Using Modern Terms to Explain Nervous System Arousal

Pelvic Pain Symptoms and Treatments: Using Modern Terms to Explain Nervous System Arousal

Airplane mode, in fact, is an excellent metaphor in terms of describing the pelvic pain symptoms and treatments of the pelvic pain sufferer.

Using the term “airplane mode” to explain the nervous system of the pelvic pain sufferer.

“Airplane mode” consists of two elements:

  1. Setting aside enough sacrosanct, uninterrupted time and space for Paradoxical Relaxation sessions (which we discuss as carving out 2-3 hours a day);
  2. Doing the mental practice of Paradoxical Relaxation during this uninterrupted time and space that allows the nervous system to “down regulate”, reduce its frenetic activity, and cease prompting the squirting of adrenaline into the bloodstream with every thought that worsens the chronic pelvic floor contraction and the feeding of the tension-anxiety-pain-protective guarding cycle.

 

The meaning of airplane mode

To be sure, the technological revolution of the past 20 years has given us not only the ability to be electronically connected at all times but has also provided a new vocabulary to describe our new behavioral world of texting, instant messaging, emailing, and twittering. For example, the term airplane mode is a new concept that has come about to address the idea of temporarily disabling our communication devices from the information and connectivity superhighway. As we know, airplane mode is used when someone is on an airplane or other situation where sending or receiving communications and data are disallowed. In airplane mode, our phone or tablet assumes an unresponsive state where it is not vulnerable to the dings and rings of incoming calls, texts, emails, and other data.

Indeed, when your phone is on airplane mode, you essentially resume the situation humankind was in before the advent of cellular communication systems. You are alone, and unless someone actually engages you in person, you are not vulnerable to being disturbed or prompted. The situation is not unlike the old context of placing a “do not disturb” sign on your hotel room door – you are creating an environment where you cannot be disturbed by the world nor it by you.

A frozen, locked-up computer

Anyone who has ever worked with a computer has experienced the frustrating situation of the computer “freezing up” or “locking up” and having to be manually re-set. Many times we intuitively attribute the freeze to requiring the computer to do too much too quickly. Overwhelmed, it simply stops working properly and ceases to fulfill our processing demands. One perspective is that the computer has simply gotten too far away from its default modes, and the complexity of processing so many demands in a matter of seconds has interfered with basic functions. Interestingly, despite all of the advances in technology, a standard method for fixing the freeze is to manually reset the computer by holding down the power button. By turning the power off and then back on again, we reset the original default modes. This almost always results in the computer resuming its proper functioning.

An analogy can be drawn between our intuition about why computers freeze up and why Colin Powell’s observation that “things always look better in the morning” is intuitively correct. It is also why we have a sense that a good night’s sleep makes everything better. Once locked up elements of body and mind come back into full function. This is also true of going away on vacation. After several days on the beach, away from the demands of business and life, our system is renewed.

With regard to the symptoms and treatments of chronic pelvic pain, a person experiences a similar overwhelm to that of the frozen, locked-up computer. Too many tasks, stresses, demands, and pressures have accumulated over time and the body has found itself in a distant place from its homeostatic, healthy, default mode. In response to a hectic life, the muscles of the pelvic region have engaged in a pattern of chronic, unyielding protective guarding to cope. These pelvic muscles, normally pain-free and able to relax and contract easily, are rigid and chronically contracted and dysfunctional.

Just like the number of programs running on a computer when it freezes up, pelvic pain patients cannot ignore the circumstances of their lives. In our patients, we often see that a vicious, self-feeding cycle has developed in the patient that looks like this:

Even in the face of significant pelvic pain and muscle dysfunction, fear, and anxiety, many of our patients continue to meet the demands in their lives without being able to reset. Typically each day the patient tightens up the pelvic muscles as a coping mechanism to the pressures of life. As the pelvic muscles get more restricted and painful, function deteriorates. In many patients, the pelvic muscles become so contracted that basic functions such as urination, defecation, sitting, and sex become very difficult and painful.

Resetting the default mode of the pelvis by resetting the nervous system

In order to restore the nervous system and the pelvic floor that it controls to a healthy default mode, we propose that the body requires a regular “airplane mode”. This frees the nervous system from stress, demands, pressure, expectations, and requirements. You can have a safe zone protected from disturbance or stimulation. The pelvic floor needs time to ease painful hypertonus and myofascial restriction and be free of any stressful or taxing input from the nervous system. By practicing long hours of airplane mode through the use of our method of Paradoxical Relaxation, the quieted nervous system allows the pelvic floor to “let down its guard” and heal from the effects of the chronically upregulated and aroused nervous system. Through this practice (and along with our trigger point physical therapy regimen), the pelvic muscles are led back to their natural default mode of supple and functional myofascial tissue.

Man as a response animal

Indeed, we can look at the human being as a “response” organism, constantly adjusting to our various issues. Most important is the survival instinct, and while we no longer face the reality of wild animals or food scavenging, the nervous system equates many non-survival issues to survival. This is especially true when the nervous system is hypersensitive to stress in the form of an email, text, or task at work.

We have all experienced that domino effect of catastrophic thinking where one largely insignificant email can be turned into a disastrous conclusion by a fearful mind. When catastrophizing is a common event in someone’s thinking, the pelvic muscles typically contract and often out of a person’s awareness. In the 6th edition of our book, A Headache in the Pelvis, we discuss the remarkable story of a middle-aged woman who was in the middle of an internal myofascial trigger point session with an experienced physical therapist. While the physical therapist had a finger inside her vagina, pressing on an internal trigger point, the woman began to talk about a politician she loathed. Our colleague, the physical therapist, reported that as her patient expressed rage about this politician, her pelvic muscles tightened around our colleague’s finger to a point where our colleague was afraid her finger would be injured. When our colleague said to her patient, “can you feel that?”, referring to the astonishing tightening of her pelvic floor muscles, her patient said back to her “Feel what?” Our colleague’s patient tightened her pelvic muscles ferociously and didn’t even know it!

When you switch to airplane mode and step beyond the world’s ability to stimulate you, you are actually saying: “You can rest. All is calm, everything is okay.” You are giving yourself permission to relax. We tell our patients that this is the environment we want to create for the practice of Paradoxical Relaxation, one of the key methods of the Wise-Anderson Protocol. Spending enough time in this airplane mode, while doing Paradoxical Relaxation (and in conjunction with our physical therapy protocol), may be the most powerful way to break the cycles of protective muscle guarding and to assume a posture of the deepest and most profound relaxation. The muscle tension physiologically returns to a normal, homeostatic state and the organism can take a much-needed break from survival responses.

The problem of treating pelvic pain as solely a physical problem

The vast majority of articles written in medical literature about the kind of pelvic pain we treat focuses solely on the physical dimensions of this condition and the traditional treatment of drugs and procedures, injections, nerve blocks, and sometimes surgery. Recently, there has been interest in the psychological/behavioral dimension of pelvic pain, discussing patients who suffer from trauma, anxiety, or other forms of emotional disturbance. And yet these discussions usually only address what we consider to be paltry and not commensurate with the enormity of the problem being addressed, believing that small doses of cognitive therapy, mindfulness meditation or breathing exercises mixed in with traditional treatments could be helpful. We see these overtures as merely “half-measures”. In our experience with thousands of patients over the years, these minor interventions have had little effect on long-standing, chronic symptoms. While we welcome discussions of the psychological/behavioral aspects of chronic pelvic pain, and believe that cognitive therapy and mindfulness are legitimate and important treatments for certain conditions, our work with patients who have suffered from chronic pelvic pain for many, many years has led us to believe that only more profound nervous system intervention has a chance of any real traction.

The engine of muscle based pelvic pain is chronic anxiety and an upregulated nervous system

In our two decades of treating this condition, we see that the engine of muscle related pelvic pain is an upregulated nervous system acting on a chronically shortened and trigger pointed, myofascially restricted pelvis. What we mean by “upregulated nervous system” is this that the human computer – the mind and central nervous system – is running much faster and processing more stimuli than is healthy. We propose that the pelvic floor is in dire need of a break, in dire need of airplane mode for long periods of time every day. All of the wisdom and spiritual traditions in the world have a concept of “Sabbath” where rest is not only allowed but understood as absolutely critical for health and well-being.

We see pelvic pain as a functional disorder. It generates a self-feeding cycle of tension and the resulting formation of pain. Treating the muscles with a specific method of trigger point physical therapy is essential. However, our experience has shown us that the great perpetuating factor of this condition, indeed the foundation of it, is an upregulated nervous system generating unhealthy amounts of pelvic floor tension. Pelvic floor tension that is constant and unrelenting and from which there is no adequate amount of airplane mode, no Sabbath. This reflects our current societal predicament of a 24/7 society where few if any days are held sacrosanct, where there is little or no time off, and no airplane mode. Patients who commit wholeheartedly to reducing their nervous arousal and anxiety do far better than patients simply focusing on the physical state of their pelvic muscles.

It is essential to commit enough time to airplane mode

We have found that most of our patients require a good 2-3 hours of airplane mode daily in order to create the environment of healing necessary for the rehabilitation of the pelvic muscles. If you are “on” all day, the sore pelvis is continually being contracted and irritated by the avalanche of stimuli agitating the nervous system. The researchers Gevirtz and Hubbard have shown that even the slightest increase in nervous arousal is immediately reflected in increased electrical activity of painful trigger points. Their studies on electromyographic monitoring of their patients’ trigger points demonstrate this dramatically.

Symptoms and treatments in pelvic pain: 2-3 hours of paradoxical relaxation per day

It is important to say that airplane mode is an inner state as well as an outer space where stimuli from the outside do not intrude. Paradoxical Relaxation is airplane mode for the mind and body and involves engaging the will to practice doing nothing, practicing effortlessness, of not judging, guarding, tightening, resisting, trying, accomplishing, or any other activity that requires effort and nervous system upregulation. For many of our patients, we have observed that it is not enough to practice Paradoxical Relaxation for short, half hour or even one hour lessons. Symptoms and treatments of pelvic pain at small intervals, in patients who are chronically hyper-aroused whether they realize it or not, simply do not allow enough time on airplane mode to quiet down the roaring nervous system. A significant number of our patients do far better with 2-3 hours of Paradoxical Relaxation daily to release the pelvic muscles from their chronic guarding and contraction.  In airplane mode you are free, and you can take a sigh of relief. Your body is in a position to reset the default mode of the nervous system that then permits the pelvic floor muscles to return to normal.

In our Paradoxical Relaxation lessons, these instructions are reiterated every 30 seconds or so to help our patients let go of any effort and rest solely in sensation. In the state of resting attention in sensation, the nervous system is put in airplane mode and the pelvic floor can release.

On its face, a daily practice of 2-3 hours of uninterrupted time to do Paradoxical Relaxation may seem daunting. Most pelvic pain patients are busy. Sparing any time can be a challenge. Because of this, we always say that our prescription is not for everyone. Indeed, our patient feedback reminds us that the patients who do the best with our protocol are the ones who decide that they will do whatever it takes to end their suffering.

Truth be told, if one’s pelvic pain doesn’t hurt enough, if the dysfunction isn’t bad enough, if there is a way to decently cope and avoid facing the music of a full measure treatment for pelvic pain, then contemplating 2-3 hours of airplane mode Paradoxical Relaxation a day is not going to be seriously considered, let alone completed. For those, however, who are ready to do whatever it takes, airplane mode will be done without hesitation, and once done, enjoyed beyond measure as the pelvic floor muscles are placed in an extended environment of healing.

Chronic Pelvic Pain: Reduce Medication Use With Internal Trigger Point Wand

Abstract
Appl Psychophysiol Biofeedback DOI 10.1007/s10484-015-9273-1
February 2015

Chronic Pelvic Pain Syndrome: Reduction of Medication Use After Pelvic Floor Physical Therapy with an Internal Myofascial Trigger Point Wand

R. U. Anderson Stanford University School of Medicine, Stanford, CA 94305, USA e-mail: [email protected]: R. H. Harvey Department of Health Education, San Francisco State University, San Francisco, CA, USA D. Wise _ T. Sawyer National Center for Pelvic Pain Research, Sebastopol, CA, USA; J. Nevin Smith Sonoma, CA, USA; B. H. Nathanson OptiStatim, LLC, Longmeadow, MA, USA_

This study documents the voluntary reduction in medication use in patients with refractory chronic pelvic pain syndrome utilizing a protocol of pelvic floor myofascial trigger point release with an FDA approved internal trigger point wand and paradoxical relaxation therapy. Self-referred patients were enrolled in a 6-day training clinic from October, 2008 to May, 2011 and followed the protocol for 6 months. Medication usage and symptom scores on a 1–10 scale (10 = most severe) were collected at baseline, and 1 and 6 months. All changes inmedication use were at the patient’s discretion. Changes in medication use were assessed by McNemar’s test in both complete case and modified intention to treat (mITT) analyses. 374 out of 396 patients met inclusion criteria; 79.7 % were male, median age of 43 years and median symptom duration of 5 years. In the complete case analysis, the percent of patients using medications at baseline was 63.6 %. After 6 months of treatment the percentage was 40.1 %, a 36.9 % reduction (p\0.001). In the mITT analysis, there was a 22.7 % overall reduction from baseline (p\0.001). Medication cessation at 6 months was significantly associated with a reduction in total symptoms (p = 0.03).

Successfully Treating the Stress Dimension of Pelvic Pain Syndromes

There are a growing number of scientific articles on stress and pelvic pain syndromes. 

There have been a growing number of articles appearing in the major journals like the Journal of Urology and World Urology that point out the significant association between stress and prostatitis and related pelvic pain syndromes. This is a new phenomenon because, in the past, urology has largely been uninterested in the psychological aspects that are related to chronic pelvic pain syndromes.

[embed]https://www.youtube.com/watch?v=82OmQa_KrWg[/embed]

What does psychological support for those with pelvic pain syndromes mean?

In an article written recently in the January/February edition of Rev Med Brux, (Rev Med Brux. 2013 Jan-Feb;34(1):29-37), a Belgian medical journal, the authors, Issa, Roumeguere and Bossche, talk about the essential role of psychological support: “the role of psychological support remains essential.” This kind of discussion about chronic pelvic pain syndromes and their proper treatment is new in medical discourse.

Unfortunately, even though the role of stress is finally being acknowledged after many years of being completely ignored, the understanding of the psychophysical relationship between stress and pelvic pain and prostatitis is not well understood. To talk about psychological support for those suffering from chronic pelvic pain syndromes misses the point if you have an interest in offering any substantial help to these people.

Conventional psychological support does very little for pelvic pain.

Psychological support in the conventional sense of a psychologist/counselor who offers insights and cognitive strategies to deal with dysfunctional thinking, in my view, does very little to help those who have chronic pelvic pain syndromes. In my experience, a psychologist/counselor can spend a day with people who have chronic pelvic pain, give them the experience of being heard, and deal with their cognitive distortions, and it will make very little difference to their symptoms or to their life. I say this as a psychologist who has been in practice for 40 years and who has done tens of thousands of hours of psychotherapy and who had chronic pelvic pain himself for many years. Psychological support in the normally understood sense is NOT significant in helping the stress component of chronic pelvic pain syndromes, prostatitis, pelvic floor dysfunction, interstitial cystitis, etc.

It is the basic fear that the pain will never go away that drives the psychological component of these disorders.

Lack of psychological support is not the problem that needs to be solved for people who have chronic pelvic pain syndromes. Offering support without giving them the tools to reduce their pain, in my many years of experience, does essentially nothing to help. When you have aching, burning tightness in the area of your pelvis and genitals and you have pain with sex and you cannot sit down, these symptoms fundamentally impair your life. They impair the basic building blocks of life – of urination, of defecation, of orgasm, of being able to sit and sometimes even being able to stand. Reassurances and psychological support alone will do little to help these symptoms.

Empowering the patient to reduce his or her own pain is the best psychological support you can offer.

What calms anxiety and catastrophic thinking is the experience of being able to reduce your own pain yourself. When you are able to put a finger on your own pain, or put an instrument on your own pain, and work on it, this is life-changing. This is essentially the antidote to the thought that the pain will never go away. This also increases your quality of life.

Data from our Internal Trigger Point Wand Study

In another essay in this blog, I have discussed the essential unhelpfulness of psychological intervention in which the patient is not empowered to help and release his own symptoms. During the years of the clinical trial for our Internal Trigger Point Wand, we saw that emotional distress is directly related to the reduction of symptoms. When people’s symptoms do not get better, their emotional distress generally does not get better, unless they have glimpses of their ability to reduce their own pain themselves.

While our study did not distinguish between cause and effect and which came first, it is my observation that what comes first is the ability to reduce symptoms, leading to or causing a reduction in emotional distress and anxiety. This positively feeds into the reduction of the pain and psychological distress. If tension, anxiety, pain, and protective guarding is a description of the downward cycle which perpetuates chronic pelvic pain syndromes, then the ability to reduce your own pain increases empowerment. You will be entered into a new self-feeding cycle of emotionally feeling better, physically feeling better, emotionally feeling better, physically feeling better.

What is real psychological support – what does that really mean?

Simple manipulation of thinking through cognitive therapy strategies is not very helpful. The core catastrophic thought that triggers emotional distress in folks with pelvic pain is, “I am never going to get better and I am doomed to never be able to relax and have any kind of quality of life.” Yes, that is the villainous thought. Simply identifying it without being able to reduce the pelvic pain symptoms does very little. Simply intervening with words in an attempt to stop cognitive distortion has little traction.

Learning how to be “off” as a stress reduction strategy.

Stress reduction in general, and in pelvic pain syndromes including prostatitis in particular, requires learning how to be “off” rather than “on”. In our experience, working with many people with pelvic pain over the years, the major help that is offered by our behavioral psychological intervention has to do with teaching someone to cease efforting. The deepest relaxation occurs when all of the muscles are “off” and there is no guarding or protecting against something bad happening. My teacher, Edmund Jacobson, who taught me relaxation said, “Turn the power off,” which was his way of guiding me toward becoming effortless.

Being “on”.

We all know what it means to have to be “on”. Being “on” means that I have to be ready to respond to others. I cannot just drop my guard or take my attention off of being responsive. When you are in the work mode, and often when you are not in the work mode, you are always ready to respond, always ready to kick in. Being “off,” sort of like being “off duty,” means that you do not have to be watching the environment to be responsive to it. It means being able to let your attention come into yourself and not have to be out in the world, responding and adjusting to the changing conditions of the world.

When I do a pelvic pain clinic I am “on” for 5 days. From the beginning of the clinic to the end of the clinic I am there responsive to other people. I cannot just wander off by myself, being in my own thoughts, being in my own body, being in my own experience. My attention is out in the clinic, responding to the needs of others and to the environment.

Being “off” means your nervous system can heal and regroup.

When the clinic is over, I usually feel exhilarated and I typically utter a sigh of relief. My life is my own again. I am not “on” anymore. I can be “off duty.” We ask people in our clinic to do Paradoxical Relaxation – which means that you must be “off”. This is the reason why we ask parents to ask their spouse to take care of their children, to turn their phone off, to keep pets away, so they do not attend to anything in their environment outside of the instructions that allow them to release their guarding. Creating a space for an hour or an hour and a half to be “off duty” allows the muscles to rest and the nervous system to down-regulate or calm down. And giving yourself the space to be “off” is all important in giving the nervous system an opportunity to down-regulate.

Anger and the response of the pelvic floor.

When you become sensitive to what is going on in your pelvis, you will often notice how the pelvic muscles tighten up and become more irritated and painful when you are anxious, stressed or pushed in some way. A dramatic example of this is something we discussed in our book, A Headache in the Pelvis. A middle-aged woman was seeing a colleague of ours who was an experienced physical therapist in New York. While our colleague had her finger inside the woman’s vagina doing Trigger Point Release, this woman started talking about something that was going on politically that she had a very strong reaction to. As she spoke about this politician she hated, the muscles in the woman’s pelvic floor began to tighten around our colleague’s fingers and our colleague reported that she was afraid that her fingers were going to be crushed. Now, this is particularly unusual because the pelvic muscles of a middle-aged woman are not known to be particularly strong. However, the physical reaction in the pelvis, which was part of her angry response, was unmistakable and dramatic. When our colleague said to her patient, “Can you feel what is going on in your pelvis as you are talking about the politician that you hate?” the woman said, “Feel what?” She was not aware of it at all.

The pelvic muscles tend to overreact to stress in those who have pelvic pain.

The pelvic muscles in those with chronic pelvic pain tend to tighten up to stressful events. While there has been very little or no research has been done on this, it has been my own personal and professional experience that people who have pelvic pain become sensitive to the tissue down there and see a close connection between pain and stress. Some people experience it remarkably strongly and clearly, and actually, that experience of the direct connection between stress and increased pain is a blessing because it makes a concept a clear experience. It validates the fact that there is a psychophysical one.

In muscle based prostatitis, pelvic floor dysfunction and other pelvic pain syndromes, the most effective stress reduction empowers patients to reduce their own pain. Paradoxical Relaxation is the practice of effortlessness, of letting go. While interpersonal support is mildly helpful, it does not go very far. I often say to patients, “My reassurance will probably last about 10 minutes and then you will get back into your scary thinking.”

Effectively dealing with stress related to pelvic pain is giving patients the tools to be able to turn “off” their own fearful contracted pelvic reaction regularly. Give a man a fish, he eats for a day. Teaching a man to fish, he eats for a lifetime. Reassurance and interpersonal support may help for a small amount of time. On the other hand, giving someone the ability to reduce pain and, in the psychological domain, reduce fearful guarding, gives a person a lifelong ability to manage stress and release themselves from the effect of pelvic pain.

Taking Hot Baths to Alleviate Chronic Pain in the Pelvis

Symptoms of prostatitis and pain in the pelvis typically don’t respond to conventional medical treatment.

Traditionally, when men have complained to their doctor about pain in the pelvis, anus or genitals, urinary frequency and urgency, post-ejaculatory discomfort, or sitting pain or the sensation of a ‘golf ball’ in the rectum, they are usually diagnosed with prostatitis. With this diagnosis, they are given antibiotics and told to avoid caffeine, alcohol and spicy foods, ejaculate more frequently, and take hot baths.

[embed]https://www.youtube.com/watch?v=QVTrStQTjh8[/embed]

Most conventional advice about treating prostatitis, including diet modification and increasing sexual activity, is confusing and sometimes makes symptoms worse.

Most of our patients report to us that the dietary advice they have been given about caffeine, alcohol, spicy foods is confusing as they did not understand its basis. Furthermore, following this kind of dietary advice has little effect on their symptoms. In fact, many men who have come to see us for the Wise-Anderson Protocol for prostatitis have reported that alcohol often improves their symptoms and does not hurt them.

To add to the confusion, increasing sexual activity makes symptoms worse in a large majority of men. We have described the post-ejaculatory discomfort as a ‘pleasure spasm’ in our book, A Headache in the Pelvis. When a man’s pelvis is chronically constricted, instead of orgasm relaxing the pelvis, it actually increases its tension level and causes significant discomfort or pain in the pelvis that can last from a few hours to weeks.

Hot baths can temporarily relieve the symptoms of prostatitis.

One piece of conventional wisdom given to men diagnosed with prostatitis is to take hot baths. Most men report that hot baths temporarily relieve their symptoms. Hedelin and Jonsson in the Scandinavian Journal of Urology and Nephrology report that cold tends to aggravate symptoms of prostatitis and heat tends to ameliorate it (Scand J Urol Nephrol. 2007;41(6):516-20). This is common knowledge among urologists and is quickly learned by patients.

Regular baths tend to be more effective than sitz baths for prostatitis.

Patients are often told to take a sitz bath, a bath in which only the buttocks and hips are immersed in water. Patients have reported to us that taking a regular hot bath is more effective than simply immersing the pelvic area in a small tub of hot water. The sitz bath is often uncomfortable and does not allow for the kind of relaxation of the muscles of the pelvis and the reduction of the arousal of the nervous system that a regular hot bath affords. It is the central reduction of nervous arousal as well as the local relaxation of the pelvic muscles that is therapeutic for those suffering from what is diagnosed as prostatitis.

The heat of the hot water (and not what is put into the bath’s hot water) is what relaxes pelvic muscles.

We often hear of men putting Epsom salts or other bath salts into the bath water in an attempt to help calm down their symptoms. In our view, it is the heat of the bath that is therapeutic and not what is put into the bath. Saunas, steam baths, and hot showers help calm symptoms as well. Most cases of prostatitis, as we have discussed extensively in our research and in our book, are caused by chronically tightened pelvic muscles and not a prostate infection, inflammation, or prostate pathology. Getting into a hot bath is a remarkably fast reducer of muscle tension in the pelvis as well as a strong reducer of anxiety and autonomic nervous system arousal. We have often said that if there were a medication that offered the side-effect free benefit of hot water, it would be a major drug used in medicine.

Hot baths help symptoms of prostatitis but offer no permanent solution.

Heat and hot baths are palliative and can make the very distressing symptoms of what is diagnosed as prostatitis momentarily more tolerable. However, the hot water does not offer a permanent solution to these symptoms. Men will typically report that their symptoms feel better when they are in the hot bath but the effects of the hot water fade soon after they get out. Nevertheless, hot baths are a gift to those suffering from pain in the pelvis as the reduction of symptoms for any length of time is very welcomed by patients.

Hot baths help because most cases of prostatitis are caused by muscle contraction in the pelvis, and not by prostate pathology.

In our experience, most men diagnosed with prostatitis do not suffer from a pathology of the prostate gland but from chronically contracted muscles of the pelvic floor that form a cycle of tension, anxiety, pain in the pelvis, and protective guarding. This is the focus of our book, A Headache in the Pelvis. Once initiated, this cycle has a life of its own.

The Wise-Anderson Protocol (popularly known as the Stanford Protocol) has been developed to teach patients to effectively rehabilitate chronic pelvic floor contraction and lower the nervous arousal that feeds it. The success of our protocol in doing this has been documented to significantly reduce the symptoms of those whom we have treated who were diagnosed with prostatitis. Hot baths can help take the edge off of the pain in the process of this rehabilitation.

Treating Chronic Prostatitis and Chronic Pelvic Pain: The Meeting of Mind and Body in the Pelvic Floor

Treating chronic prostatitis and chronic pelvic pain: their relationship to mind and body

We are often asked whether the physical or behavioral parts of the Wise-Anderson Protocol for treating chronic prostatitis and chronic pelvic pain is more important for its connection to the relationship to the Mind and body. This is a major issue for patients, researchers and doctors alike because it determines the course of the prostatitis treatment and the outcome of treatment.

[embed]https://www.youtube.com/watch?v=dG_LXnnMsDE[/embed]

Over the years we have anecdotally noticed that a small group of our patients have significant improvement in their symptoms with what appears to be our physical treatment alone. On the other end of the spectrum, another small group of our patients appears to do very well with only the behavior component. The large majority of our patients, however, appear to require both the physical treatment which focuses on directly loosening the muscles of the pelvic floor and the behavioral treatment which focuses on helping patients reduce their anxiety daily in the service of releasing the chronic contraction of the muscles of the pelvic floor.

Those practitioners involved in treating chronic prostatitis and chronic pelvic pain rarely converse.

The health specialties in treating chronic prostatitis based on muscle dysfunction and related disorders are usually confined in their own relatively narrow orientations of focusing on either the physical or behavioral/psychological but not both. Historically the subspecialties like urology, colo-rectal surgery, gynecology, pain management, physical therapy, osteopathy on the one hand, and psychology and psychiatry on the other rarely talk to each other. Even when the physically-oriented practitioner recognizes the importance of the behavioral/psychological dimension, or vice-versa, rarely are the physical and behavioral/psychological treatments coordinated or specifically geared to the patient with a pelvic pain disorder. Psychologists and psychiatrists often have little training in the physical components nor do the physically oriented practitioners have training in the mind related dimension of the treatment of the problem.

Successfully treating chronic prostatitis and pelvic pain in terms of mind and body.

Mind and body meet in the pelvic floor in those who suffer from muscle-based chronic prostatitis and chronic pelvic pain. In our book, A Headache in the Pelvis, we discuss the centrality of the tension-anxiety-pain-protective guarding cycle and how this cycle takes on a life of its own no matter what triggers it. The large majority of our patients come to us with years of chronic pelvic contraction that is the way in which they have expressed their anxiety physically. Simply loosening and releasing the chronic contraction of the pelvic floor tends to be short-lived if this loosening is not done repetitively and accompanied by a daily program of relaxing the pelvis and calming down the arousal of the nervous system. All of this is not a small task and is usually undertaken only by those who are in great and ongoing suffering. Yet for those who understand the necessity of this mind and body treatment and diligently pursue it, they have the possibility of real help in a way that it has never been possible in the past.

Ischemic Pressure Followed by Sustained Stretch for Treatment of Myofascial Trigger Points

In an article in 2000 in Physical Therapy, investigators found that teaching patients to do ischemic compression (pressure on Myofascial trigger points) in the neck and upper back was effective in reducing pain and sensitivity. We are gratified to see some studies showing the efficacy of physical therapy self-treatment for myofascial pain. We have found that self-treatment for patients with pelvic pain is by far the most effective treatment in reducing or resolving their symptoms. It goes without saying that self-treatment is the most cost-effective of methods, empowering to one’s self-esteem and in our experience the best therapy for dealing with the catastrophic thinking that comes out of the powerlessness of the pelvic pain patient to do anything about his/her pain.

[embed]https://www.youtube.com/watch?v=P86VrOz_DcU[/embed]

While learning self-treatment inside and outside the pelvic floor for pelvic pain patients diagnosed with pelvic floor dysfunction, non-bacterial prostatitis, levator ani syndrome and pain related to muscle dysfunction in patients diagnosed with interstitial cystitis and other muscle based pelvic pain diagnoses has huge advantages in the physical and psychological dimensions of pelvic floor dysfunction, it requires careful and competent training.  Over the period of our 6-day clinic we teach patients to use the theracane, a tennis or lacrosse ball, their fingers and hands to do trigger point release abdominally, in the area of quadratus lumborum, adductors, obliques, and abdominals.  We also teach them with their fingers and our newly FDA approved internal trigger point wand to do internal trigger point release.  These are skills that can be learned and can be done with more and more skill over months of doing these skills but the initial training has to be competent.

Below is the 2000 study on teaching patients how to do the trigger point release themselves on areas of pain in their neck and upper back.

Ischemic Pressure Followed by Sustained Stretch for Treatment of Myofascial Trigger Points

Abstract

Background and Purpose. Myofascial trigger points (TPs) are found among patients who have neck and upper back pain. The purpose of this study was to determine the effectiveness of a home program of ischemic pressure followed by sustained stretching for the treatment of myofascial TPs.

Subjects. Forty adults (17 male, 23 female), aged 23 to 58 years (X?=30.6, SD=9.3), with one or more TPs in the neck or upper back participated in this study.

Methods. Subjects were randomly divided into 2 groups receiving a 5-day home program of either ischemic pressure followed by general sustained stretching of the neck and upper back musculature or a control treatment of active range of motion. Measurements were obtained before the subjects received the home program instruction and on the third day after they discontinued treatment. Trigger point sensitivity was measured with a pressure algometer as pressure pain threshold (PPT). Average pain intensity for a 24-hour period was scored on a visual analog scale (VAS). Subjects also reported the percentage of time in pain over a 24-hour period. A multivariate analysis of covariance, with the pretests as the covariates, was performed and followed by 3 analyses of covariance, 1 for each variable.

Results. Differences were found between the treatment and control groups for VAS scores and PPT. No difference was found between the groups for the percentage of time in pain.

Conclusion and Discussion. A home program, consisting of ischemic pressure and sustained stretching, was shown to be effective in reducing TP sensitivity and pain intensity in individuals with neck and upper back pain. The results of this study indicate that clinicians can treat myofascial TPs through monitoring of a home program of ischemic pressure and stretching.

  1. William P Hanten,
  2. Sharon L Olson,
  3. Nicole L Butts and
  4. Aimee L Nowicki

Author Affiliations

  1. WP Hanten, PT, EdD, is Professor, School of Physical Therapy, Texas Woman’s University, 1130 MD Anderson Blvd, Houston, TX 77030 (USA) ([email protected]). Address all correspondence to Dr Hanten
  2. SL Olson, PT, PhD, is Associate Professor, School of Physical Therapy, Texas Woman’s University
  3. NL Butts, PT, MS, is a student, School of Physical Therapy, Texas Woman’s University
  4. AL Nowicki, PT, MS, is a student, School of Physical Therapy, Texas Woman’s University

Paradoxical Relaxation and the Treatment of Chronic Pelvic Pain Syndrome

Paradoxical Relaxation and the Treatment of Chronic Pelvic Pain Syndrome

In a recent New York Times article (see excerpt below), the usefulness of concentration as an integral part of a discussion of mindfulness is discussed. The ability to concentrate is not a subject that is often discussed in the psychological literature on pain reduction; thus, this article is a welcome addition to the narrative of what we consider a critical issue in dealing successfully with chronic pelvic pain.

[embed]https://www.youtube.com/watch?v=0tWwgnT_8x8[/embed]

It has become clear over the last decade that nervous system arousal is a central issue to treat in those suffering from chronic pelvic pain syndromes. Gevirtz and Hubbard have convincingly shown emotional arousal raises the level of electrical activity in pain referring trigger points in those with myofascial-related pain. There have been recent studies evaluating the usefulness of hypnosis and cognitive therapy to deal with nervous system arousal, but it has been our observation that psychotherapy by itself has little effect on modulating or reducing chronic pelvic pain. Traditional methods of cognitive therapy help patients recognize their dysfunctional thinking and analyze distorted thoughts in order to discard them. In our work using the Wise-Anderson Protocol over the last 18 years, we have observed that these methods are not greatly helpful when patients’ pain goes on unabated and they remain helpless to do anything about it.

The method of Paradoxical Relaxation used in the Wise-Anderson Protocol is one of the main ingredients we use to help those with pelvic pain lower their autonomic nervous system arousal. Many of our patients who become competent in this methodology commonly report that they can significantly reduce their pain using this relaxation method.

Paradoxical Relaxation is the practice of focusing attention on sensation rather than mental thought. The aim is to take attention away from all thought—not analyze any of it. While it is sometimes useful to analyze dysfunctional thinking, that is not the aim of Paradoxical Relaxation. If someone is helpless to stop their chronic pain, it doesn’t matter how much analysis of dysfunctional thinking is done because the inability to affect the pain is the main driver of the sense of helplessness and disempowerment.

In the Paradoxical Relaxation session, the nervous system is deliberately deprived of the symbolic stimuli that cause it to become aroused. This break in arousal can help break a flare up of symptoms and moves in the direction of downwardly resetting the nervous system ‘idle speed.’

The most profound relaxation occurs when attention is controlled and kept focused in sensation. Just as the deepest sleep is dreamless (non-REM) sleep, relaxation that is void of thinking produces the deepest level of relaxation. This type of deep relaxation allows for an up-regulated nervous system to quiet down. The idea of relaxation depending on the control of attention rather than the releasing of such control is counter-intuitive, yet over the years patients using Paradoxical Relaxation in the Wise-Anderson Protocol have experienced the ability to control attention, to reduce pain, and ‘down regulate’ the nervous system.

Training attention to stay focused is a discipline that, as the New York Times article we quote below understands, has many benefits. In our work with pelvic pain, calming down nervous arousal to reduce pain is the most important of these benefits.

Excerpt from “The Power of Concentration” by Maria Konnikova in the New York Times on December 16, 2012.

The Power of Concentration

By MARIA KONNIKOVA

December 16, 2012

“MEDITATION and mindfulness: the words conjure images of yoga retreats and Buddhist monks. But perhaps they should evoke a very different picture: a man in a deerstalker, puffing away at a curved pipe, Mr. Sherlock Holmes himself. The world’s greatest fictional detective is someone who knows the value of concentration, of “throwing his brain out of action,” as Dr. Watson puts it. He is the quintessential unitasker in a multitasking world…

In 2011, researchers from the University of Wisconsin demonstrated that daily meditation-like thought could shift frontal brain activity toward a pattern that is associated with what cognitive scientists call positive, approach-oriented emotional states — states that make us more likely to engage the world rather than to withdraw from it.

Participants were instructed to relax with their eyes closed, focus on their breathing, and acknowledge and release any random thoughts that might arise. Then they had the option of receiving nine 30-minute meditation training sessions over the next five weeks. When they were tested a second time, their neural activation patterns had undergone a striking leftward shift in frontal asymmetry — even when their practice and training averaged only 5 to 16 minutes a day.

…But mindfulness goes beyond improving emotion regulation.”

Read the rest of the article here.

The Invisible Patient: The Symptoms of Chronic Prostatitis and Chronic Pelvic Pain Patients

Pain Blog – The Invisible Patient: The Symptoms of Chronic Prostatitis and Chronic Pelvic Pain Patients

Our Pain Blog covers research on chronic prostatitis and chronic pelvic pain.

A recent article in the Korean Journal of Urology (see below) documented that men diagnosed with chronic prostatitis/chronic pelvic pain syndrome (chronic prostatitis, chronic pelvic pain syndrome) were significantly more stressed than control groups. The report showed that higher levels of depression, anxiety, and perceptions of stress were closely related to increased levels of pain and decreased the quality of life levels.

[embed]https://www.youtube.com/watch?v=EFryUqNCJf0[/embed]

The symptoms of chronic prostatitis, chronic pelvic pain are invisible to the eye and x-ray. 

Many of our patients have reported their distress in hearing from bosses, friends, or family members that they looked fine. The fact is that the greatly distressing symptoms of chronic prostatitis —urinary frequency and urgency, genital and rectal pain, pain associated with sex, and sitting discomfort among others—are neither visible to the eye nor any imaging technology that currently exists. It is for this reason that examining physicians will often scratch their heads and tell the patient that there is nothing wrong with him, and perhaps his problem is psychiatric. This experience has left more than a few of our patients describing their time with the doctor as one of the most upsetting in memory. To be told that there is nothing wrong with you and that you don’t look like you have a problem when you’re suffering greatly, often leaves the patient feeling frightened, lost with nowhere to go and catastrophizing about the future.

While the eye can’t see the problem, a physician or physiotherapist experienced in treating prostatitis, chronic pelvic pain can detect the disorder with an educated finger.

Many patients have undergone expensive, high-tech evaluations complete with blood, urine, and other testing that yielded no useful information. When a physician is familiar with muscle-based pelvic pain and has been trained to evaluate trigger point and myofascial constriction inside and outside the pelvis, the problem of prostatitis and most causes of pelvic pain can be easily diagnosed within the time frame of a conventional medical appointment. More important, this diagnosis can point in the direction of a real solution to the problem. Unfortunately, many urologists who are consulted for chronic pelvic pain are not trained to evaluate the presence of trigger points and myofascial constriction in the pelvic muscles. Their focus typically remains on the organs.

The Wise-Anderson Protocol has pioneered a new understanding that many cases are caused by an ongoing charley horse in the muscles of the pelvis.

The Wise-Anderson Clinical Protocol was developed and researched at Stanford University between 1995 and 2003 and continues to be offered monthly in a 6-day immersion clinic in Santa Rosa, California. A number of research articles have documented its effectiveness. This protocol represents a new and pioneering understanding of symptoms typically diagnosed as prostatitis. It focuses on teaching men to release the chronic spasm in the pelvic muscles and calm the nervous arousal that perpetuates their symptoms. A popular book called “A Headache in the Pelvis,” now in its 6th edition, offers the most detail of this new understanding and treatment.

In reviewing the data from an ongoing study we are conducting, we find that men and women who have undergone the Wise-Anderson Protocol experience a significant reduction in their emotional distress when they are able to reduce the symptoms of chronic prostatitis by virtue of their own trained self-treatment.

Korean J Urol. 2012 Sep;53(9):643-8. doi: 10.4111/kju.2012.53.9.643. Epub 2012 Sep 19.

Depression, anxiety, stress perception, and coping strategies in Korean military patients with chronic prostatitis/chronic pelvic pain syndrome.

Ahn SG, Kim SH, Chung KI, Park KS, Cho SY, Kim HW.

Source

Department of Urology, St. Paul’s Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea.

Abstract

PURPOSE:

The objective of this study was to examine the psychological features and coping strategies of patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

MATERIALS AND METHODS:

The participants consisted of 55 military personnel suffering from CP/CPPS and 58 military personnel without CP/CPPS symptoms working at the Military Capital Hospital. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) was used to assess CP/CPPS symptoms. The Responses to Hospital Anxiety and Depression (HAD) scale, Social Readjustment Rating Scale, and Global Assessment of Recent Stress (GARS) scale were compared between the two groups. The Weisman Coping Strategy Scale was used to assess coping ability with CP/CPPS.

RESULTS:

The NIH-CPSI score of the CP/CPPS group was significantly higher than that of the control group for all domains including pain, urinary symptoms, quality of life, and summed score. The Anxiety and Depression domain of the HAD showed significant differences between the two groups. There were no significant differences in the Social Readjustment Rating Scale between the two groups, but the sum of the GARS score was higher in the CP/CPPS group than in the control group. These were correlated with the pain, quality of life, and sum domains of the NIH-CPSI. The Weisman Coping Strategy Scale showed that intellectualization, redefinition, and flexibility were higher in frequency in descending order, and that fatalism, externalization, and self-pity were lower in frequency.

BLOG ABOUT PELVIC PAIN – CONCLUSIONS:

The CP/CPPS patients had depression, anxiety, and higher perception of stress. In particular, these were closely related to the pain and quality of life of the patients

New Findings About Emotional Brain Changes in Prostatitis: What to do About it

New Findings About Emotional Brain Changes in Prostatitis: What to do About it

Swiss researchers looking into brain activity in men with prostatitis, chronic pelvic pain syndrome report that in a small group of men there is a reduction in relative gray matter volume in a part of the cortex.

A new article written in the October 2012 Journal of Urology identifies some changes in the anterior cingulate part of the brain in men suffering from prostatitis, chronic pelvic pain syndrome. The anterior cingulate cortex and other related parts of the brain, comprising part of the limbic system, are known to be connected with the perception of pain and emotion. The Swiss researchers’ observations of changes in this area of the brain may support the idea that when one has changes in prostatitis, chronic pelvic pain, the chronic anxiety fed by catastrophic thoughts that the pain will never go away is reflected in some changes in the brain.

[embed]https://www.youtube.com/watch?v=_ayvQIfLoTc[/embed]

That chronic pelvic pain and emotions are intimately connected and probably affect the brain is no surprise to any of us who have been treating chronic pelvic pain over the years. Many of our patients agree that the feelings of helplessness, hopelessness, and fear can be worse than the actual physical pain.

As with all the research that documents certain relationships, the “elephant in the room” type of question, in this case, is if pain and emotions are strong enough to affect the brain in the way the Swiss researchers have recently documented, what does it mean and what can be done about it? Over the years, our answer has been simple: empower patients to reduce or stop their physical pain and help them reduce their emotional distress.

Wise-Anderson Physical Therapy Self-Treatment and Paradoxical Relaxation

In our latest review of data from patients we have seen in the last four years, we discovered—not surprisingly—that when you give patients the ability to reduce their pain, their emotional distress calms down. In the Wise-Anderson Protocol, the two major methods we use are focused on reducing pelvic pain mentally and physically. We have documented (see 2011 articles in the Journal of Urology and the Clinical Journal of Pain) that physical therapy self-treatment in combination with Paradoxical Relaxation significantly reduces pelvic muscle sensitivity/pain. In additional data, we found that this reduction in pain is associated with a significant reduction in emotional distress. More information on treatment here

In future research, it would be interesting to observe whether the reduction or resolution of symptoms of prostatitis and related pelvic pain syndromes, as experienced after doing our protocol for 6 months, reverses the brain changes this recent study found.

 

Below are articles on the subject of brain changes related to changes in prostatitis, chronic pelvic pain syndromes.

1. Chronic Pelvic Pain Syndrome in Men is Associated with Reduction of Relative Gray Matter Volume in the Anterior Cingulate Cortex Compared to Healthy Controls.

Mordasini L, Weisstanner C, Rummel C, Thalmann GN, Verma RK, Wiest R, Kessler TM.

J Urol. 2012 Oct 18. pii: S0022-5347(12)04500-4. doi: 10.1016/j.juro.2012.08.043.

Source

Department of Urology, University of Bern, Bern, Switzerland.

Abstract

PURPOSE:

Although chronic pelvic pain syndrome impairs the life of millions of people worldwide, the exact pathomechanisms involved remain to be elucidated. As with other chronic pain syndromes, the central nervous system may have an important role in chronic pelvic pain syndrome. Thus, we assessed brain alterations associated with abnormal pain processing in patients with chronic pelvic pain syndrome.

MATERIALS AND METHODS:

Using brain morphology assessment applying structural magnetic resonance imaging, we prospectively investigated a consecutive series of 20 men with refractory chronic pelvic pain syndrome, and compared these patients to 20 gender and age matched healthy controls. Between group differences in relative gray matter volume and the association with bother of chronic pelvic pain syndrome were assessed using whole brain covariate analysis.

RESULTS:

Patients with chronic pelvic pain syndrome had a mean (±SD) age of 40 (±14) years, a mean NIH-CPSI (National Institutes of Health Chronic Prostatitis Symptom Index) total score of 28 (±6) and a mean pain subscale of 14 (±3). In patients with chronic pelvic pain syndrome compared to healthy controls there was a significant reduction in relative gray matter volume in the anterior cingulate cortex of the dominant hemisphere. This finding correlated with the NIH-CPSI total score (r = 0.57) and pain subscale (r = 0.51).

CONCLUSIONS:

Reduction in relative gray matter volume in the anterior cingulate cortex and correlation with bother of chronic pelvic pain syndrome suggest an essential role for the anterior cingulate cortex in chronic pelvic pain syndrome. Since this area is a core structure of emotional pain processing, central pathomechanisms of chronic pelvic pain syndrome may be considered a promising therapeutic target and may explain the often unsatisfactory results of treatments focusing on peripheral dysfunction

2. Limbic associated pelvic pain: a hypothesis to explain the diagnostic relationships and features of patients with chronic pelvic pain.

Fenton BW.

Med Hypotheses. 2007;69(2):282-6. Epub 2007 Feb 9.

Source

Summa Health System, Department of Obstetrics and Gynecology, MED-2, 525 E Market St., Akron, OH 44303-2090, United States. [email protected]

Abstract

Limbic associated pelvic pain is a proposed pathophysiology designed to explain features commonly encountered in patients with chronic pelvic pain, including the presence of multiple pain diagnoses, the frequency of previous abuse, the minimal or discordant pathologic changes of the involved organs, the paradoxical effectiveness of many treatments, and the recurrent nature of the condition. These conditions include endometriosis, interstitial cystitis, irritable bowel syndrome, levator ani syndrome, pelvic floor tension myalgia, vulvar vestibulitis, and vulvodynia. The hypothesis is based on recent improvements in the understanding of pain processing pathways in the central nervous system, and in particular the role of limbic structures, especially the anterior cingulate cortex, hippocampus and amygdala, in chronic and affective pain perception. Limbic associated pelvic pain is hypothesized to occur in patients with chronic pelvic pain out of proportion to any demonstrable pathology (hyperalgesia), and with more than one demonstrable pain generator (allodynia), and who are susceptible to development of the syndrome. This most likely occurs as a result of childhood sexual abuse but may include other painful pelvic events or stressors, which lead to limbic dysfunction. This limbic dysfunction is manifest both as an increased sensitivity to pain afferents from pelvic organs, and as an abnormal efferent innervation of pelvic musculature, both visceral and somatic. The pelvic musculature undergoes tonic contraction as a result of limbic efferent stimulation, which produces the minimal changes found on pathological examination, and generates a further sensation of pain. The pain afferents from these pelvic organs then follow the medial pain pathway back to the sensitized, hypervigilant limbic system. Chronic stimulation of the limbic system by pelvic pain afferents again produces an efferent contraction of the pelvic muscles, thus perpetuating the cycle. This cycle is susceptible to disruption through blocking afferent signals from pelvic organs, either through anesthesia or muscle manipulation. Disruption of limbic perception with psychiatric medication similarly produces relief. Without a full disruption of both the central hypervigilance and pelvic organ dysfunction, pain recurs. To prevent recurrence, clinicians will need to include some form of therapy, either medical or cognitive, targeted at the underlying limbic hypervigilance. Further research into novel, limbic targeted therapies can hopefully be stimulated by explicitly stating the role of the limbic system in chronic pain. This hypothesis provides a framework for clinicians to rationally approach some of the most challenging patients in medicine, and can potentially improve outcomes by including management of limbic dysfunction in their treatment

3. Amitriptyline reduces rectal pain related activation of the anterior cingulate cortex in patients with irritable bowel syndrome.

Morgan V, Pickens D, Gautam S, Kessler R, Mertz H.

Gut. 2005 May;54(5):601-7.

Source

Department of Radiology and Radiological Scienes, Vanderbilt University, Nashville, TN 37205, USA.

Abstract

BACKGROUND AND AIMS:

Irritable bowel syndrome (IBS) is a disorder of intestinal hypersensitivity and altered motility, exacerbated by stress. Functional magnetic resonance imaging (fMRI) during painful rectal distension in IBS has demonstrated greater activation of the anterior cingulate cortex (ACC), an area relevant to pain and emotions. Tricyclic antidepressants are effective for IBS. The aim of this study was to determine if low dose amitriptyline reduces ACC activation during painful rectal distension in IBS to confer clinical benefits. Secondary aims were to identify other brain regions altered by amitriptyline, and to determine if reductions in cerebral activation are greater during mental stress.

METHODS:

Nineteen women with painful IBS were randomised to amitriptyline 50 mg or placebo for one month and then crossed over to the alternate treatment after washout. Cerebral activation during rectal distension was compared between placebo and amitriptyline groups by fMRI. Distensions were performed alternately during auditory stress and relaxing music.

RESULTS:

Rectal pain induced significant activation of the perigenual ACC, right insula, and right prefrontal cortex. Amitriptyline was associated with reduced pain related cerebral activations in the perigenual ACC and the left posterior parietal cortex, but only during stress.

CONCLUSIONS:

The tricyclic antidepressant amitriptyline reduces brain activation during pain in the perigenual (limbic) anterior cingulated cortex and parietal association cortex. These reductions are only seen during stress. Amitriptyline is likely to work in the central nervous system rather than peripherally to blunt pain and other symptoms exacerbated by stress in IBS.

Reflections on Prostatitis and Chronic Pelvic Pain Treatment

Reflections on The  Prostatitis and Chronic Pelvic Pain Treatment and the path to Recovery

By David Wise, PhD

This paper is about sharing my observations about healing my own pelvic pain and my road to recovery.

Millions of men suffer from urinary frequency, urgency, pain with sitting, pain after sex, genital pain and pelvic pain and other symptoms called prostatitis/chronic pelvic pain syndrome. I suffered for over 20 years from what was is now diagnosed as prostatitis/chronic pelvic pain syndrome. This diagnosis is confusing to patients and doctors alike, and the story about this confusion surrounding the treatment of the condition remains to be told to a large audience.

Today, gratefully, my pain is gone and I have become an expert in a field I never wanted to be an expert in. As I think about it now, I can’t imagine the devastation of my life had I continued to be in pain. I always feel grateful. I hope this article can help clarify the confusion, misdiagnosis, and ineffective treatment of what is diagnosed as prostatitis in men and help many silently suffering men find a way back to having a life again.

I observed my own slow and awkward healing.

I am someone who has been interested in my internal life and its process, whether it is related to pelvic pain or to my interpersonal relationships. Naturally, over the years, I observed with great interest the mental and physical happenings in my body through the process of the resolution of my pelvic symptoms. In this essay, I want to share my experience of coming out of pain and what I have observed and learned about this experience in the hope that it can offer a roadmap to others.

When I was a young man experiencing the symptoms our patients come to see us with, I dutifully and sincerely went to the urologist trusting he would help me. I saw him for many years and was never helped by his methods. I was told that I had ‘prostatosis’. The doctor explained, as best he could, that what I had was like prostatitis, except there was no inflammation or infection. He said my prostate was ‘boggy’.

I never quite understood what he was saying. In retrospect, I can’t imagine he understood his explanation either even though he was a kind and intelligent man. It was clear he was telling me that my prostate gland was my problem except for the peculiar explanation that there was no problem with it except it was ‘boggy’. To me ‘boggy’ means soft or spongy. I didn’t understand how something spongy could cause me the pain and symptoms I had, but he was the doctor and I trusted him. Gratefully he told me that my symptoms would get better as I got older (he was wrong) but I appreciated that he gave me the hope that somehow, at some time, my symptoms would get better. As the doctor couldn’t help me, I lost faith seeing doctors. I had nowhere to go and no one to help me. People have asked me how I dealt with my symptoms for over two decades. My answer is that there was nothing heroic about it. I muddled through my life dealing with the symptoms day by day, as all of our patients do.

I took the insights of my recovery to Stanford.

After doing a version of the protocol we now offer, my pain went away in the 1990’s. Excitedly, I called Dr. Rodney Anderson, one of the world experts in prostatitis and pelvic pain and the head of the Pelvic Pain Clinic at Stanford University Medical Center in the Department of Urology, and shared my experience with him. For many years at Stanford Dr. Anderson worked closely with Dr. Thomas Stamey, who co-invented the test for bacterial prostatitis. Dr. Anderson finally came to the conclusion that what was typically diagnosed as prostatitis was not a prostate condition but a condition of the contracted muscles of the pelvic floor and as such was not helped by the conventional standard of treatment using antibiotics and anti-inflammatories.

My call to him that day in 1995, sharing my recovery, found him open to listening about my experience. Gratefully, he recognized the importance of what I told him about how I got out of pain after 22 years of suffering.

From that time Dr. Anderson and I immediately began working together at Stanford. At Stanford was where we saw pelvic pain patients and developed the Wise-Anderson Protocol (popularly called the “Stanford Protocol” in internet discussions) detailed in the first edition of our book, A Headache in the Pelvis. In our protocol, we saw and treated the muscles of the pelvis as the sources of what are commonly diagnosed as prostatitis symptoms and anxiety that inflamed them. We began treating the pelvic muscles and emotions of men’s anxiety related to them, as the key treatment for prostatitis with typical symptoms of prostatitis—not their prostates. I worked with Dr. Anderson as a Research Scholar at Stanford for 8 years.

Later, after I left Stanford, Dr. Anderson and I, along with Tim Sawyer, our senior physical therapist, continued our close collaboration and research into our protocol. The form of treatment changed from a conventional weekly visit format, to what has evolved into a 6 day monthly immersion clinic. In total, I have spent 18 years treating patients with the Wise-Anderson Protocol. We have published a number of papers and have presented our work in major scientific meetings in the US and internationally.

Getting to the top of the mountain to see below: how the discovery of San Francisco Bay is similar to finding the route out of pelvic pain.

When someone’s prostatitis symptoms go away, what happens? How does this healing occur? Here is an analogy that is helpful to me in explaining why conventional medical treatment has been unsuccessful in finding a prostatitis cure: Many years ago, European explorers sailed up and down the coast of California, yet from the ocean they could not see San Francisco Bay. Then, in 1769 Spanish explorer Gaspar de Portola set out for the port at Monterey. Believing he had missed the port, he continued sailing north up the coast. After a time at sea, short on food and water, Portola sent an expedition ashore. They landed in what is today known as Pacifica, and it was looking out from a ridge that they finally saw the San Francisco Bay.

The pathway out of symptoms diagnosed as prostatitis has not been visible from the ‘ocean’ of the conventional medical perspective, or even any common sense perspective. The symptoms are, frankly, weird, and only if you have experienced them can you really understand them. Just like de Portola, after many years of experimentation, blind alleys, hit and miss attempts and trying different ways to stop my pain, I too found the ‘ridge’ of understanding; that my pelvic pain was not an infection or problem with my prostate gland, as my urologists had told me, but was in fact a problem of chronically tightened muscles inside my pelvic floor. This chronic tightening in my pelvis was where I held my anxiety. Some people would call it me being “anal,” and that’s probably true.

I found relief when placing a finger inside, I pressed on these tightened muscles and stretched them or relaxed them. I noticed stress made my symptoms worse and alternatively I felt some temporary relief from a hot bath, a good night’s sleep or the resolution of some worry. I came to see that what made my symptoms better or worse was the tightening or relaxation of my pelvic muscles. While that might seem easy to fix, I found that the fix was neither easy nor obvious.

Why pelvic pain symptoms do not act like other symptoms.

Symptoms commonly diagnosed as prostatitis rarely respond to the normal treatments for pain. One of the reasons that these symptoms have fooled conventional medicine is that they are referred from places in the pelvic floor that are remote from the pain. For example, the cause of pain in the penis is typically found inside the pelvic floor, 10 inches away from where the pain is felt, on the anterior portion of the levator muscles. The cause of muscle based testicular pain can be muscle restriction and trigger points in the quadratus lumborum, an external muscle a good foot away from the testicles. Abdominal pain, urinary frequency and urgency, sexual pain, post-bowel movement pain, and other associated pain are typically caused by tenderness in the muscles inside and outside the pelvic floor.

Most doctors treating pelvic pain do not examine the muscles of the pelvic floor and related areas. In not examining these muscles, they fail to see that the symptoms of what is called nonbacterial prostatitis in the vast majority of cases can be recreated by pressing on specific muscles inside and outside the pelvic floor. Most importantly, when these sore and tender areas of muscle are loosened and what are called trigger points released, done in conjunction with reducing the anxiety that typically flares them up, symptoms diagnosed as prostatitis can reduce or go away.

Doctors typically treat men with prostatitis with medications. The National Institutes of Health have has done an exhaustive, careful study of antibiotics, alpha blockers and anti-inflammatories—the most commonly used drugs for pelvic pain in men diagnosed as prostatitis—and the conclusion of this and other studies was that these medications do not help. While surgery was never suggested to me when I was in pain, in hearing the reports of many patients I have treated who had surgery, I have concluded that surgery, another common ‘solution,’ is a bad idea. It almost always complicates the symptoms or makes them worse. I have never heard patients report that a nerve block or any surgery, including pudendal nerve or prostate resection surgery, resolved prostatitis symptoms. Exploratory procedures, CAT scans and other high tech imaging tests typically cannot find anything wrong. Blood and urine tests are typically normal. The conventional ways of diagnosing and treating what is diagnosed as nonbacterial prostatitis do not help. All of the men (and women) who have come to see us for treatment have been refractorily unhelped by all of their prior drug and surgical treatments.

A heart transplant won’t stop heartburn: treating the prostate will not help the chronic contraction of the pelvic muscles.

I’ve come to understand the importance of the insight that, how you look at a problem determines the method you use to fix it. My view that I had a muscle problem and not a prostate problem changed everything for me. When I witness the suffering of our patients, I see myself before I changed my viewpoint about my problem. Most men we see continue to think in some way that they have a prostate-related problem. Below are my thoughts about the confusion in the diagnosis and treatment of prostatitis.

A heart transplant is a wrong the treatment for heartburn. Cutting down pine trees doesn’t get rid of poison oak rashes. You have to be able to make a differential diagnosis to distinguish reflux pain in the esophagus from pain coming from the heart muscle. You have to distinguish poison oak from pine trees. My experience with men diagnosed with prostatitis over the years is that conventional medicine has erred in its differential diagnosis of their symptoms as pelvic pain. Most of our patients have reported that their doctor never did a culture for infection before prescribing antibiotics. Just as you have to know the difference between pain from a heart attack and pain from acid in the esophagus, so must you differentiate between pain coming from an infected or inflamed prostate gland and pain coming from the muscles inside and outside the pelvic floor. The distinction must be made between symptoms of prostatitis caused by prostate infection, which occurs in a tiny proportion of men diagnosed with prostatitis, and symptoms that are caused by a chronically tightened pelvis, which occur in the large majority of men. This is one of our original contributions to prostatitis treatment.

The misdiagnosis of chronic prostatitis.

All too often we see patients whose doctors ignorantly recommended they undergo invasive surgeries and treatments. All of them which failed to end the symptoms. A doctor who saw one of our patients for testicle pain recommended that he have the offending testicle removed. The patient gladly agreed to surgery with the hope it would end his pain. When surgery didn’t end the pain, the doctor told him they must’ve removed the wrong testicle. Tragically, the surgery to remove the second testicle also failed to stop the pain.

To my great dismay, we’ve seen men who’ve had their prostate glands removed, re-sectioned, and “roto-rootered.” We’ve seen men and women who’ve had their anal sphincters cut. One man elected to have a colostomy with the hope that not having bowel movements would cause his pain to stop. It never did. We have seen many patients addicted to narcotics and other medications that did little good for them and whose efficacy wore off.

In our practice, we’ve seen three women who had their bladders removed and many who’ve undergone hysterectomies, laparoscopies, and urethral dilations. None of it helped. Of course, we’ve seen a number of people who’ve had the pudendal nerve surgery, in which the ligaments that stabilize the pelvis are cut—and we have never seen any resolution of symptoms from this surgery or any surgery. From Botox and electrical stimulation to acupuncture and faith healing, nothing has been effective if the spasticity of the muscles and arousal of the nervous system is not addressed.

The patients who have done best in our program took ownership of their own healing

As the doctors couldn’t help me, I lost faith in them. I had nowhere to go and no one to help me, but I believed the doctor who told me my problem was related to my prostate gland. For years I went along in pain not knowing what to do and inadvertently experimenting with different methods of treatment.

One of the many difficulties of someone diagnosed with prostatitis or chronic pelvic pain syndrome is moving into the position of being your own researcher and doctor. It is not easy or comfortable for many people to abandon trust in the conventional viewpoints in favor of their own research and intuitive judgment. The most common form of muscle based pelvic pain in men is incorrectly named ‘prostatitis’ and both urologists and family practitioners continue to treat it as if it is a prostate problem rather than a problem of the pelvic muscles. I see now that healing muscle based pelvic pain in most of our patients required a journey away from this idea and the authority of the doctors who treat it with this conventional wisdom. This is not easy for many people.

I never wanted to know anything about the pelvis. When I first started having my problem, I wanted to go into the doctor and have him fix it and send me on my merry way. No patient wants to have to learn about this area of the body or its treatment. If you were to ask any pelvic pain patient whether they want to learn to be their own doctor, they would all say, “Don’t call me, I’ll call you.” But, the pelvic pain patient who is able to find a solution to their own pain is the patient who becomes their own researcher and ultimately relies on their own intuitions on what to do and who to believe.

This is a difficult situation for most of us. The patients I have seen who insist on listening to their doctors about this problem, remain in pain or in some cases get into trouble with surgery, narcotic medications and other drugs.

The maddening refusal of conventional doctors to understand most pelvic pain is a muscle-based problem and not an infection or inflammation based problem.

Despite the decision of the National Institutes of Health to change the name of nonbacterial prostatitis—by far the largest category of pain in men—to chronic pelvic pain syndrome, men who seek chronic pelvic pain treatment are routinely treated as if their problem comes from their prostate gland. When I was at the National Institutes of Health (NIH) meeting on prostatitis in 1999, it became very clear that there was only a handful of us who understood the majority of prostatitis cases to be the misdiagnosis of conditions unconnected to the prostate.

When Leroy Nyberg, then head of the section of the NIH covering prostatitis, was asked about the urology community’s refusal to shift paradigms about prostatitis from a prostate infection model to a pelvic floor muscle pain model, he said, “It doesn’t go over well when a big organization loses a disorder.” What was left unsaid was the ideological and economic disincentive of shifting perspectives. Unfortunately, the person who suffers from this is the patient.

Why healing muscle-based pain follows a circuitous route.

As I see it now, several major systems of the body converge in the precipitation and perpetuation of symptoms diagnosed as prostatitis. There is tender pelvic tissue that one cannot see, is hard to reach and is usually in motion. You also typically have to deal with what turns out to be a typical chronic prostatitis patient’s long-standing habit of catastrophic thinking and anxiety. (Elsewhere I’ve discussed literature that documents the relationship between anxiety, emotional distress, family dysfunction and pelvic pain). And then, of course, there is the unfortunate, dysfunctional tendency of the pelvic muscles to reflexively tighten against the pain, which instead of protecting the individual exacerbates the problem. I discuss this cycle in detail below.

One of the problems of conventional medical treatment for pelvic pain is that healing requires the expertise of a number of sub-specialties that do not talk to each other.

Pelvic pain tends to be treated by a variety of different medical sub-specialties—urology, gynecology, colo-rectal surgery, chiropractic, physical therapy, and psychology/psychiatry. The lack of communication between these subspecialties around pelvic pain leads to a piecemeal treatment of the problem. This is especially true in the treatment of the physical and mental aspects of the disorder, which are intimately intertwined. Finally, as is the theme of our program, the concept of teaching patients how to treat themselves is not the major focus of any of these subspecialties. As far as I’m concerned, the aspect of self-treatment as a therapeutic regimen is critical for most pelvic pain patients to get better.

The huge stress-related dimension of muscle-based pelvic pain is only recently being recognized and treated.

The stress/psychological dimension of pelvic pain wasn’t recognized for many years. Even today, many urologists not only have little understanding of the psychological dimension of pelvic pain, but they continue to look for its origin in men in the prostate gland. This completely ignores the central focus of the problem, which is in the muscles of the pelvis. Physical therapists who have somehow established themselves as those who can enter inside the pelvis to do physical treatment have little training in urology or psychology, and physical therapy treatment tends to focus on the treatment of myofascial tissue. Each medical subspecialty has its own strengths and limitations. I am clear that the skills that are required to treat pelvic pain are cross-disciplinary, and all of them cannot be found in any one specialty.

When someone is scared, frightened, or stressed the core of the body tightens in a guarded posture.

As I became aware of the continual muscle tension in my pelvis and began to work with it, I saw how difficult it was to relax. I didn’t understand then, as I do now, that muscles that have become shortened and developed the taut bands called trigger points cannot relax until the trigger points are physically released. This was a huge insight and explained a lot to me. It convinced me that treatment for prostatitis has to be cross-disciplinary and must go beyond the limited skill and understanding of conventional treatment. I understand now that chronically tightened pelvic muscles get stuck in that state and at a certain point begin to cause pain, which triggers a self-perpetuating cycle that has a life of its own even after the precipitating stress goes away.

Someone with pelvic pain typically walks around guarded and tight in the pelvis. ‘Girding your loins,’ a biblical euphemism, describes the tightening, guarding or protecting of the genitals. When we are not stressed, it’s difficult to appreciate the strength this physical contraction has, but muscle tightening in periods of ongoing stress can be profound.

The painful pelvic muscles have shortened, predisposing them to pain and dysfunction.

For years I meditated on and observed my symptoms, but never understood why I could do nothing about them. As I visualize it in my mind now, once pelvic muscle tightening occurs for a certain period of time, I imagine that the microscopic distance between the muscle tissues reduce, creating less air and less space in between these muscle fibers. After a while, taut bands of muscle called trigger points form. These trigger points can refer pain to other places in the pelvis. We illustrate and describe these trigger points and the areas to which they refer pain in our book A Headache in the Pelvis. These trigger points are pivotal in creating, “an inhospitable environment for the muscles, nerves, and structures within the pelvic basin.”

It’s clear to me that the tension-anxiety-pain-protective guarding cycle is the major obstacle to healing muscle based prostatitis.

The Tension-Anxiety-Pain-Protective Guarding Cycle

Chronic Pelvic Pain Treatment

For many years I experienced the tension-anxiety-pain-protective guarding cycle, but it wasn’t until we wrote A Headache in the Pelvis that I put it into words. This cycle is what I believe is at the heart of muscle based prostatitis symptoms. This cycle is the meeting of body and mind within the pelvic floor. I lived within the grip of this cycle for many years.

Men with chronic muscle based prostatitis are caught in the tension-anxiety-pain-protective guarding cycle, in which the pelvic muscles causing the pain can no long relax. They remain tense and sore making them subject to a reflexive protective guarding that makes the pain worse.

Protective guarding occurs as a reflex when we pull our hand away from a hot stove, when our eye flinches after something gets in it, or when we tighten up and withdraw from something that causes us pain. This reflex to tighten and pull away is very important for our survival and indeed it usually protects us.

The instinct to tighten up against pelvic pain diagnosed as prostatitis is dysfunctional because instead of helping, it makes the pain worse. Protective guarding against sore pelvic muscles further tightens them up. This dysfunctional protective guarding is intimately connected to the chronicity and perpetuation of chronic pelvic pain. This is why studies have shown that the muscle tone in the pelvic floor tends to be abnormally high in sufferers of chronic pelvic pain syndromes.

When I gave a talk at the National Institutes of Health, I asked participants to tighten up their pelvic muscles for a minute. I speculated that few would be willing to tighten up like this for the entire minute. I told them that if I asked everyone in the audience to tighten up the pelvic muscles for an hour no one would be surprised if there wasn’t anyone willing to do this. I then took them on an imaginary journey of tightening up their pelvic muscles for a whole day, and then a week, and then a month, and then a year. To someone without pelvic pain, such chronic contraction would be unimaginable.

Those who have symptoms diagnosed as prostatitis and chronic pelvic pain syndrome, experience this dysfunctional protective guarding for months and years. This is why many patients report that when they follow the instructions in our book to do “moment to moment relaxation of the pelvis,” their pelvic muscles invariably tighten up immediately after they stop. It was only after my pain went away that I stopped protectively guarding in the way that I had when I was symptomatic.

Pain prompts protective guarding which increases the pain, which then triggers catastrophic thinking and anxiety. Anxiety feeds into the pain and increases it as Gevirtz and Hubbard have demonstrated in many experiments showing trigger point activity increasing with anxiety. The tension-anxiety-pain-protective guarding cycle has resisted all conventional attempts at resolution.

The challenge of repetitively rehabilitating painful pelvic tissue. The necessity of repetitive loosening of the pelvic floor and of the anxiety related to it. Teaching our patients to do their own internal and external trigger point release.

We begin our treatment by teaching patients how to soften and release the trigger points of contracted pelvic tissue. This means identifying the sore trigger points and palpating them in specific ways for a certain period of time. (see article on physical therapy for pelvic pain)

Using our internal trigger point wand.internal trigger point wand.

To treat the hard-to-reach internal muscles, we developed an internal trigger point wand, which we have been using as part of a treatment study for the past four years. Our clinical study found that patients who did our protocol using the wand for six months saw their median level of pain/sensitivity in the trigger points in the pelvic floor muscles decrease from 7.5 to a 4 (on a scale of 1-10).

It’s clear to me now that repetitively loosening and softening the pelvic floor muscles is central to healing muscle based pelvic pain.

Restoring the pelvic muscles to a normal length and pain-free state requires repetitive, ongoing physical therapy self-treatment. Just as you would change any bad habit, repetition is key. You must repeatedly restore the tissue to a normal state until you over-ride its conditioned tendency to remain contracted. In the book Blink, author Malcom Gladwell restated an observation that a number of researchers have made, which is that mastery requires 10,000 hours of repetition. While 10,000 hours of repetition is not required to loosen a painful pelvis, repetitive physical loosening and relaxation are necessary for my experience of pelvic pain healing.

Along with releasing the tissue physically, I experienced daily the necessity of calming my nervous system down. If I didn’t, my symptoms seemed to stick around. I will discuss the focus on the nervous system below.

Not too much or too little pressure.

When I treated myself physically, I learned that I had to be careful about the level of pressure I used to working with my painful muscles.

I found that when one does myofascial/trigger point release on muscles inside and outside the pelvic floor, chronically tight pelvic muscles have to be rehabilitated within certain specific parameters of pressure and within certain time frames. Too much pressure created a flare-up and caused my pelvic tissue to guard; too little pressure did little good; stretching the tissue for too little time did not seem to give the tissue a chance to lengthen; stretching the tissue too long tended to create guarding and continuing soreness

I have noticed over the years that extremely sore and sensitive tissue in patients can be, as our senior physical therapist Tim Sawyer calls it, “hyperirritable.” Tim says that hyperirritable trigger points and pelvic tissue must be treated like you would hold a wounded dove in your hands. If you physically treat hyperirritable tissue with inappropriate pressure, you can cause long flare-ups of pain and increase anxiety. We have developed a guideline that pelvic floor trigger points and areas of sore muscle restriction should at first not be pressed beyond a 3 on a 0 to 10 pain scale. We then suggest increasing the pressure up to 7 on the 0 to 10 scale as long as the area doesn’t flare-up unduly. If there is a flare-up that continues for more than 24 hours, we believe too much pressure has been applied and it has to be reduced. When patients are treating themselves we ask them to stop their own physical therapy self-treatment for several days to allow the flare-up to calm down. Eventually, as trigger point sensitivity reduces, pressure can be increased to 7 on the 0-10 scale as long as there is a little flare-up of symptoms. If a sore tissue is properly palpated, the trigger point sensitivity and pain can significantly reduce or go away.

Unless we train our patients otherwise, some treat their sore pelvis roughly like a piece of meat; distancing themselves from it and using undue pressure. We train them to feel their pelvic muscles as they treat these muscles so that they do not flare themselves up from self-treatment.

Showing the pelvis unconditional kindness.

In my journey of healing my pelvic pain, I made a choice to listen to my pelvis. I adopted an attitude of kindness and unconditionality in which I came to understand that my pelvis did not want to hurt. I saw that my pelvis reacted to my impatience or negativity like I would react to someone else’s impatience or negativity. Absent words, the only way my pelvis spoke to me when it was not happy was with pain. In my own journey, I had to say, “I’ll do whatever it takes to help myself out of pain.” I’ve noticed that people who assume this attitude tend to do better because they’re forced to give up their own agenda and become interested in what it takes for their pelvis to calm down.

God heals and the physician collects the fee: learning to be kind to your own physician?

The body has a miraculous capacity to heal, and it is possible to recover from pelvic pain. During our body’s noble journey, however, we must consistently act in a way that helps the pelvis to heal and resist doing what interferes with its healing. In short, we have to be mindful of creating an environment that is hospitable for the sore contracted pelvic tissue to become normal.

Changing your attitude toward your pelvic pain.

At the end of our clinics, I do a process with our patients called, “talking to your pelvis.” I have patients feel their painful pelvis while I ask it questions. It is not uncommon for my patients to say, “I can’t believe how I’ve hated my pelvis” or “How unkind I’ve been to my pelvis.” Some have said, “Every time my pelvis hurts, I become frightened or angry or feel dread.” Others have said, “I felt that my pelvic pain was a way in which God was punishing me.” Patients attribute all kinds of motives and attributes to a sore, painful pelvis. They can assume different attitudes toward it that are often hateful, frightened, angry or frustrated. These kinds of attitudes toward the pelvis only tighten the pelvis, increase anxiety and nervous system arousal, and make things worse. When I speak to my pelvis now and ask it if it has anything to say to me, it says ‘Thank you.’

Calming down emotionally.

My journey with relaxation has been long. If I could have found a teacher like the one I am today when I was symptomatic, my journey would have been immeasurably easier. Relaxation did not come easily to me then, despite the fact that I had studied with Edmond Jacobson, who is considered the father of relaxation therapy. I tried to relax for many years, but I failed. Finally, I applied to my relaxation practice the principles I learned from Jacobson as well as those from my own spiritual exploration; to accept what is, to stop resisting the experience within that I couldn’t change, to let go of effort and of trying to achieve something with my relaxation, and to accept my pain and anxiety instead of fighting them. In my book Paradoxical Relaxation, I describe this method.

I have observed that it takes dozens of hours of Paradoxical Relaxation practice for people to begin to learn how to calm down the nervous system, especially when they’re in pain and anxious. Reducing emotional arousal and managing anxiety are the key issues addressed by our Paradoxical Relaxation method.

Becoming emotionally intelligent: managing the tendency to get lost in catastrophic thinking.

When I was beginning to do relaxation for my pain, I came to see that there was always the issue of my pain, and then there was the issue of my attitude toward my pain. They were two different things. As I was able to work with my pain physically and reduce my symptoms, I slowly stopped catastrophizing each flare-up because I came to see that I could reliably calm them down myself.

I’ve observed that for most of our patients, despair, anxiety, and pain tend to be waiting in the wings and ready to pounce when one begins treatment. It is important for patients using our protocol to be able to witness their catastrophic thinking so that they can release it instead of allowing it to sabotage their treatment. I often say to patients that they don’t have to believe everything they think, and that when they catastrophize they will typically confuse their thinking for reality.

Not being scared by a flare-up of symptoms.

In my journey, I had many symptom flare-ups. I would have periods of time during which I was pain-free for days or weeks. Then, something would happen and my symptoms would flare up as badly as they ever were. When my symptoms disappeared I thought my recovery was a done deal, and when they flared up, I sank down into despondency. When I went through this cycle of symptom improvement and then flare-up many times, I became less and less afraid of the symptoms flaring up because I knew I could resolve them with my own self-treatment.

Ending flare-ups through skilled self-treatment.

The majority of our patients who do our protocol consistently do get better. We have patients who were in chronic pain for many years who are now pain-free for the most part. Most have learned not to be afraid of symptom flare-ups, as they are more able to effectively resolve them. For this reason, we ask our patients to do a 52 week recorded course in Paradoxical Relaxation to begin to take the edge off emotional agitation that’s gone on for many years.

An emotional release often accompanies the physical.

The phenomenon of somato-emotional release is common when a certain group of pelvic pain patients who do myofascial trigger point release, especially inside the pelvis. For example, a woman we treated with pelvic pain who was repeatedly sexually abused, wept regularly both when we instructed her on internal trigger point release and when she began doing it herself. Constricted tissue and pain is often connected to the emotional environment in which it began. Understanding and allowing emotional expression of grief, fear, or anger during treatment and giving it space to emerge and be released is essential in pelvic healing.

Controlling the tendency to be ‘anal’.

Those who get pelvic pain tend to be what, in the vernacular, would be called ‘anal.’ The colloquial use of ‘anal’ means to be obsessive, devoted to detail and perfectionistic and also to have obsessive thinking. It’s associated with a tightening of the anus, and in fact, there is some truth in this pejorative colloquialism.

Managing the pelvic pain patient’s tendency toward perfectionism, obsessive-compulsive behavior, and compulsive working is a lifestyle and psychological change that needs to be modified.

Paradoxical Relaxation helps to stop compulsive doing.

Paradoxical Relaxation is the behavioral method we use to help our patients learn to, “stop compulsively doing.” The pelvic pain patient tends to rarely, if ever, relax. In the moment of relaxation, it’s necessary that you stop all doing; this means you stop trying to achieve, get somewhere, or accomplish something. In the state of not doing, the pelvic muscles can relax.

In my book Paradoxical Relaxation, I’ve discussed extensively the importance of training attention to rest in sensation outside of thinking because resting attention is what can help someone who is a compulsive doer to relax.

After patients do a full session of internal and external physical therapy, we encourage them to do half an hour to an hour of Paradoxical Relaxation. The reason I ask people to do this is that I see the importance in disengaging the muscles of the pelvis from activity after they’ve been lengthened in order to allow the sore, tightened, painful tissue to get used to being at a normal length.

Moving from doing to being.

I learned in my own recovery that I had to regularly stop and call a timeout in my life. I had to be able to profoundly relax to calm down my over active nervous system. In a large sense, I have learned that one of the essential components in healing pelvic pain is learning to, at some time during the day, move out of the doing mode and into the being mode.

The mantra that self-treatment is the way.

When I was symptomatic, the most important element of my suffering was the fact that I felt helpless about doing anything about my pain. As I recovered from my own symptoms and felt confidence in helping myself, everything got better. I have come to believe that the most important part of treating pelvic pain is giving patients the ability to reduce or stop their own pain and symptoms both physically and mentally. Doing this dispels anxiety and helplessness which in my view are the most debilitating symptoms among all the symptoms of chronic prostatitis. Chronic prostatitis or chronic pelvic pain syndrome tends to recur under stress, and the most important thing I believe we can do for a patient with symptoms diagnosed as prostatitis is to help him reduce or stop his symptoms by his own efforts.

Summary

In summary, here is what I have learned:

  • When men come to see us with symptoms diagnosed as chronic prostatitis, drug and surgical treatment has failed to help them
  • Men we see who have symptoms diagnosed as chronic prostatitis almost always have painful pelvic muscles and trigger points can be found related to symptoms. Anxiety and stress generally tends to makes them hurt more
  • Symptoms of what is diagnosed as chronic prostatitis occur as the result of chronic tightening of the pelvic muscles over many years, even though symptoms may appear to begin suddenly. The phrase “the fruit falls suddenly but the ripening takes time” reflects this phenomenon
  • When you are suffering from pain with no foreseeable end in sight, it is easy to get lost and caught up in negativity, catastrophic thinking and the anxiety and depression related to it. Anxiety and worry about symptoms makes them worse
  • These emotions can be exacerbated by feelings of helplessness when doctors are unable to successfully treat symptoms
  • We have been dismayed that most doctors who provide chronic pelvic pain treatment do not appear interested in looking beyond the assumed causes of chronic prostatitis because these symptoms are not responsive to drugs or surgery, the main tools of conventional medicine
  • It is possible for most men with symptoms diagnosed as nonbacterial chronic prostatitis to significantly reduce their pain or stop it through their own efforts when they are properly instructed
  • Resolving symptoms diagnosed as nonbacterial chronic prostatitis means relaxing the core physical part of us. While there are methods for strengthening the core, relaxing and loosening our core is harder and more complicated to do—but it is doable
  • Patients who take ownership of their own problem and ultimately use their own intuition to determine what to do seem to do best
  • I am convinced that patients who learn to treat all of their symptoms themselves do best; self-treatment is the way

At this time in history, someone who has pelvic pain is best served by taking responsibility for his or her own welfare and seeking out treatment that makes most intuitive sense to them.