|David Wise, Ph.D.|
|Rodney Anderson, M.D.|
Facts about Perineum Pain (Perineal Pain)
Symptoms associated with perineum pain
Some people with perineal pain (pain in the perineum) say that they don’t actually feel pain but some variation of discomfort, aching, burning, fullness, squeezing, tightness, sharp or dull sensation. Perineal pain is often exacerbated with sitting and is usually associated with other symptoms. Typical symptoms include one or more of the following:
- Genital pain, anal and rectal pain, suprapubic (above pubic bone) pain, pain in bladder area, tail bone pain, groin pain, low back pain
- Discomfort when sitting (often feels like a golf ball), post bowel movement pain
- Urinary frequency, urgency, hesitancy, burning, frequent night time urination
- Sexual pain including orgasm and post orgasm discomfort (often the next day)
- Anxiety, depression, helplessness regarding symptoms
The understanding and definition of pelvic pain including the common symptoms of genital and perineal pain, as well as its causes, risk factors, diagnostic tests, the understanding of its complications and other relevant matters is currently in transition. The treatment, drugs, lifestyle issues and concepts about home treatment are also in transition. The Wise-Anderson Protocol has often been more effective in the treatment of genital and perineal pain than the conventional treatment of drugs and surgery.
Perineum pain is a central symptom in most muscle based pelvic pain conditions
The Wise-Anderson Protocol, also known as the Stanford Protocol, has been successful in treating genital and perineal pain (pain in the perineum) in selected women and men who suffer with muscle-based pelvic pain conditions.
Both genital and perineal pain typically has its origins in trigger points and areas of muscle restriction inside the pelvic floor. In our 2009 study published in the Journal of Urology, we identified anterior levator ani trigger points that refer genital pain in men. Various other trigger points refer pain to the genital area in men and women.
The perineum is the area located between the anus and the scrotum in the male and between the anus and the vulva (the labial opening to the vagina) in women. The major muscles of the pelvic floor all attach to the perineum and it is one of the most common areas of pain in men and women who suffer from various forms of pelvic pain. Perineal pain makes sitting difficult and is sometimes related to post bowel movement pain.
Because the perineum is so intimately connected to the muscles of the pelvic floor, this symptom tends to be the last to reduce in intensity or the last to be resolved when the Wise-Anderson Protocol is successful in helping patients who have pelvic pain.
Relieving Perineum Pain With
The Wise-Anderson Protocol Developed At Stanford
- Pain in the perineum is commonly the result of trigger points that form in muscles up inside the pelvis
- Trigger points are tight, exquisitely painful bands of muscle tissue that form within chronically tightened muscles
- These trigger points in the perineum can remain in place for years. Their pain can be felt in places relatively far away from them and their pain can be caused by contracted muscles far away from them
- Pain in the perineum, even when it lasts for years, can get better with proper treatment
- A major focus of the Wise-Anderson Protocol is helping to relieve pain in the perineum
- The Wise-Anderson Protocol trains patients to release perineum pain related trigger points and to relax the muscles related to perineum pain.
- A detailed description of the Wise-Anderson Protocol treatment for perineal pain can be found in the sixth edition of A Headache in the Pelvis. Click Here to order A Headache in the Pelvis
Click Here to contact our office for eligibility and treatment information
Below Are Adapted Excerpts From A Headache In The Pelvis On Perineum Pain
“Millions of men and women suffer from pelvic pain, discomfort, or dysfunction. These disorders, which can be called chronic pelvic pain syndromes (CPPS), usually include one or a number of symptoms including rectal, genital, perineal or abdominal discomfort or pain, increased discomfort or pain sitting down, discomfort or pain during or after sexual activity, and often urinary frequency, urgency and hesitancy. Historically, these conditions have been given many different names. As a result, they have been thought to have numerous causes.
In the majority of cases, doctors can find little or no physical basis for the symptoms and most or all tests usually come back normal. In this book, we will demonstrate that there is a simple physical basis for the symptoms and that the seemingly wide array and variability of the symptoms are simply idiosyncratic expressions of the same underlying problem in both men and women. A treatment protocol has been developed, called the Wise-Anderson Protocol. In this methodology, we no longer treat the symptoms; instead we treat what triggers those symptoms. Our approach substantially reduces or abates symptoms in a large majority of qualifying patients who often have symptoms of genital and perineal pain.”
Treatment for Muscle Based Pelvic Pain
|In the latest Stanford study, the global response assessment revealed that 82% of our patients reported improvement (59% marked/moderate, 23% slight). Click to read published research.
READ ABOUT THE SUCCESS OF THE WISE-ANDERSON PROTOCOL
IN PUBLISHED STUDIES
The Journal of Urology
April 2011 Volume 185, Issue 4 p. 1294
RODNEY U. ANDERSON,*,† DAVID WISE, TIMOTHY SAWYER,PATRICIA GLOWE AND ELAINE K. ORENBERG
From the Department of Urology, Stanford University School of Medicine,
Stanford (RUA, PG, EKO) and Sebastopol (DW, TS), California
6-day intensive treatment protocol for refractory chronic prostatitis/chronic pelvic pain syndrome using myofascial release and paradoxical relaxation training.
PURPOSE: Chronic prostatitis/chronic pelvic pain syndrome continues to elude conventional therapy. Evidence supports the concept that phenotypes of pelvic muscular tenderness and psychosocial distress respond to myofascial trigger point release and specific relaxation training. This case series reports long-term outcomes of a 6-day intensive combination of such therapies in refractory cases.
MATERIALS AND METHODS: A total of 200 men with pain for a median of 4.8 years referred themselves to Stanford University Urology for participation in an established protocol. Daily 3 to 5-hour sessions including intrapelvic/extrapelvic physiotherapy, self-treatment training and paradoxical relaxation training provided a solid introduction to facilitate self-management. Subjects answered baseline and followup questionnaires at variable intervals after initiation of therapy including the National Institutes of Health Chronic Prostatitis Symptom Index, global response assessment and a psychological query.
RESULTS: We followed 116 men for a median of 6 months. Baseline total symptom index was 26 out of a maximum 43 points. Scores decreased by 30% (p <0.001) at followup with 60% of subjects demonstrating a 6-point or greater decrease (range 6 to 30). Domains of pain, urinary dysfunction and quality of life showed significant improvement (p <0.001). Global response assessment revealed that 82% of subjects reported improvement (59% marked to moderate, 23% slight).
CONCLUSIONS: Men with chronic pelvic pain refractory to traditional treatment benefit from intensive myofascial trigger point therapy and concomitant paradoxical relaxation training. Education in techniques for self-administered trigger point release and continued pelvic muscle relaxation help patients reduce pain and dysfunction. Refinement of clinical phenotyping and selection of patients with pelvic muscle tenderness should enhance the success rate with this treatment modality.
Clin J Pain. 2011 Nov;27(9):764-8.
Anderson R, Wise D, Sawyer T, Nathanson BH.
Department of Urology, Stanford University, School of Medicine, Stanford, CA.
Safety and effectiveness of an internal pelvic myofascial trigger point wand for urologic chronic pelvic pain syndrome.
OBJECTIVES: Pelvic muscle tenderness occurs often in patients with urologic chronic pelvic pain syndrome; symptoms frequently can be reduced with pelvic myofascial physical therapy. This open-label pilot study evaluated the safety of a personal wand that enables patient's self-treatment of internal myofascial trigger points in the pelvic floor and its effect in reducing pelvic muscle tenderness.
METHODS: A specially designed curved wand served as an extended finger to locate and release painful internal myofascial trigger points; an integrated algometer monitors and guides appropriate applied point pressure. Patients used the wand several times weekly after education and careful supervision. Evaluations for adverse events and assessments of pain sensitivity were conducted at 1 and 6 months after commencing use.
RESULTS: One hundred and thirteen of the enrolled 157 patients completed 6 months of wand use-106 men and 7 women; 44 patients withdrew before study completion but none for adverse events. Median age was 41 years and 93% were male. Baseline median sensitivity visual analog scale score (1 to 10, 10=most sensitive) was 7.5 and decreased significantly at 6 months to 4 (P<0.001, Wilcoxon matched-pairs signed-rank test). Most patients (95.5%) reported the wand as either very or moderately effective in alleviating pain. No serious adverse events occurred.
CONCLUSIONS: A multimodal protocol using an internal pelvic therapeutic wand seems to be a safe, viable treatment option in select refractory patients with pelvic pain.
Nature Reviews Urology
Anderson, R.U. & Nathanson, B.H., Nat.Rev.Urology 8, 236-237 (2011)
Department of Urology, Stanford University School of Medicine, CA 94305-5118,
OptiStatim LCC, P.O. Box 60844, Long Meadow, Mass 01116
Drug Therapies for CP/CPPS: help or hype
A recent network meta-analysis of α-blockers, antibiotics and other drug therapies for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) found that they provided modest-to-no benefit for this condition, confirming previous findings. However, a casual reading of the article may give a false impression of the efficacy and appropriateness of these drugs.
The conundrum of treating CP/CPPS continues to frustrate physicians. Innumerable clinical studies have described the condition and the potential therapeutic options for its management. In an article published in the January issue of JAMA,1 the authors conducted a systematic review and network meta-analysis of clinical studies of the various oral medications used for the management of CP/CPPS, and concluded that “α-blockers, antibiotics, and combinations of these therapies appear to achieve the greatest improvement in clinical symptom scores compared with placebo.”
The title of the article implies a proposal from the American Medical Association for the best management of CP/CPPS. However, after adjusting for publication bias in their direct meta-analysis, there was no clinically or statistically significant treatment benefit associated with α-blockers or antibiotics in terms of reducing either total NIH Chronic Prostatitis Symptom Index (NIH-CPSI) scores or pain, voiding (urinary) and quality-of-life subscores, which should have been a main conclusion. Also, most urologists often find these treatment options to be ineffective, and, unfortunately, the article does a disservice by minimizing the factual evidence from randomized clinical trials that these universally used oral medications fail to help millions of men achieve effective symptom relief. The authors do state that “the total sample sizes [of the studies] are relatively small and the effect sizes are modest and often below the minimal clinically significant difference. Furthermore, even these estimates may be overinflated given the evidence for publication bias,”1 but these points are not adequately emphasized.
Moreover, several methodological issues in this study are worthy of comment. The outcomes of interest were the NIH-CPSI scores or related measures (such as the International Prostate Symptom Score or the Prostatitis Symptom Score Index). The authors note that a reduction of 4 points on the total NIH-CPSI score is necessary to be considered clinically perceptible, and a reduction of >6 points is considered clinically significant. A P-value low enough to signify statistical significance (P <0.05) is misleading if the difference between groups is not clinically meaningful. To prevent this distortion, the analysis should have made the alternative hypothesis state that the significant difference was >4 (the clinically perceptible threshold) and not merely >0, and should have noted where the confidence intervals included this threshold.
The noted heterogeneity of the included studies raises serious methodological issues, particularly for the study’s network (indirect) meta-analysis. A network meta-analysis is a new statistical method that is used to compare multiple therapies when the comparisons were not performed “head to head” in a randomized trial (that is, when trials that directly compare treatment A and treatment B do not exist). The assumptions that are necessary for a valid network meta-analysis are more complex than those for a traditional meta-analysis.2 In short, all the studies analyzed must be homogeneous enough in design, study population and placebo group, both within and among each other, to make the comparisons clinically reasonable, as the exchangeability of results across trials is even more important than in a traditional meta-analysis. We cannot tell from the manuscript whether all these assumptions have been met for each of the studies analyzed. The authors tried to analyze a dichotomous response versus non-response outcome, but the studies’ thresholds were too different (for example, ‘response’ was defined as a 25% decrease in NIH-CPSI score in two studies, and as a 50% decrease in three studies) to make a meta-analysis appropriate.
The story of oral medications for CP/ CPPS has already been told.3 The largest NIH-sponsored randomized controlled trials do not support the use of the α-blockers alfuzosin or tamsulosin, nor the antibiotic ciprofloxacin, either alone or in combination with tamsulosin.4,5 Randomized controlled trials are the gold standard in evidence-based medicine, and this network meta-analysis essentially confirms rather than refutes these previous findings. However, the way the authors present their conclusions, particularly in their abstract, minimizes these facts.
While the ineffectiveness of these drugs is old news to those of us who specialize in treating CP/CPPS, they are still routinely prescribed by most clinicians treating this condition—and patients continue to suffer from CP/CPPS. Underlining the failure of these conventional oral medications should have been the main conclusion of this article. The authors admit that “the reason for the benefit associated with antibiotics is not immediately clear.” Other nonpharmacological therapies for CP/CPPS do exist, however, and the logical trend in the diagnostic evaluation of CP/CPPS is to utilize careful phenotyping in the initial work-up of the suffering patient. This phenotyping approach has recently been proposed and evaluated in a multimodal therapy setting, with excellent results.6 The differences in the management strategies used depend upon recognizing the heterogeneity of the condition and the specificity of symptoms, which are characterized by the six domains of the UPOINT phenotyping system (urinary, psychosocial, organ-specific, infection, neurologic/systemic, and tenderness of skeletal muscles) that are used for focusing treatment. Each of these domains should be treated with state-of-the-art therapy, which might sometimes require more than one treatment modality. Notably, pelvic tension and muscle tenderness make up the majority of the specific symptoms and physical findings in patients with CP/CPPS.
In our personal experience of treating this condition, we have found alternatives to failed oral medications, such as multimodal physical therapy and cognitive behavioral therapy, and suggest that innovative treatment strategies be explored after patients have been carefully phenotyped and once traditional antibiotic or α-blocker therapy of CP/CPPS has been deemed inappropriate.
J Urol. 2005 Jul;174(1):155-60.
Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men.
Department of Urology, Stanford University School of Medicine, Stanford, California, USA. firstname.lastname@example.org
PURPOSE: A perspective on the neurobehavioral component of the etiology of chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS) is emerging. We evaluated a new approach to the treatment of CP/CPPS with the Stanford developed protocol using myofascial trigger point assessment and release therapy (MFRT) in conjunction with paradoxical relaxation therapy (PRT).
MATERIALS AND METHODS: A total of 138 men with CP/CPPS refractory to traditional therapy were treated for at least 1 month with the MFRT/PRT protocol by a team comprising a urologist, physiotherapist and psychologist. Symptoms were assessed with a pelvic pain symptom survey (PPSS) and National Institutes of Health-CP Symptom Index. Patient reported perceptions of overall effects of therapy were documented on a global response assessment questionnaire.
RESULTS: Global response assessments of moderately improved or markedly improved, considered clinical successes, were reported by 72% of patients. More than half of patients treated with the MFRT/PRT protocol had a 25% or greater decrease in pain and urinary symptom scores, as assessed by the PPSS. In those at the 50% or greater improvement level median scores decreased 69% and 80% for pain and urinary symptoms, respectively. The 2 scores decreased significantly by a median of 8 points when the 25% or greater improvement was first observed, that is after a median of 5 therapy sessions. PPSS and National Institutes of Health-CP Symptom Index showed similar levels of improvement after MFRT/PRT protocol therapy.
CONCLUSIONS: This case study analysis indicates that MFRT combined with PRT represents an effective therapeutic approach for the management of CP/CPPS, providing pain and urinary symptom relief superior to that of traditional therapy
“The goal of the Stanford Protocol is to enable the patients to reduce and/or resolve their symptoms without dependency on drugs or others to do so for them.”
David Wise, Ph.D.
Plenary address to the
National Institutes of Health (NIH)
Scientific Workshop on Prostatitis/Chronic Pelvic Pain Syndromes
October 21, 2005
Thank you for giving me the opportunity to discuss the Stanford Protocol at this National Institutes of Health sponsored scientific meeting on Prostatitis/Chronic Pelvic Pain Syndrome.
How I became involved in treating chronic pelvic pain syndrome
I happened to have had the unusual experience of the slow motion nightmare of chronic pelvic pain for a period of over twenty years– at one time or another having had almost all of the symptoms you typically hear from patients, and then unrelieved, unrelenting pain 24 hours a day 7 days a week …and no one to talk to or no one to help me --- and then around ten years ago, I had the fortune of experiencing the resolution of my own symptoms by finding and implementing the elements of what is now called the Stanford Protocol that I am going to discuss. I gratefully remain pain and symptom free. So I speak to you both someone who understands this problem as a clinician who has seen many, many patients with pelvic pain over the past years, and as someone who has had the direct experience of pelvic pain of long duration and then the experience of the resolution of the pain.
Rodney U. Anderson MD,1 David Wise PhD,2 Timothy Sawyer PT2 and Brian Nathanson PhD3
1Department of Urology, School of Medicine, Stanford University, Stanford, CA, 2Sebastopol, CA and 3Longmeadow, MA
SAFETY AND EFFECTIVENESS OF AN INTERNAL PELVIC MYOFASCIAL TRIGGER POINT WAND FOR UROLOGICAL CHRONIC PELVIC PAIN SYNDROME (UCPPS)