Facts about Symptoms of
Pelvic Floor Dysfunction (PFD)
Definition of Pelvic Floor Dysfunction
Pelvic Floor Dysfunction is used to describe the difficulty of the muscles of the pelvic floor to tighten and relax normally. Pelvic Floor Dysfunction leads to a variety of somtimes strange and debilitating symptoms.
The Wise-Anderson Protocol treatment for
Pelvic Floor Dysfunction
The Wise-Anderson Protocol, developed at the Stanford University Department of Urology, has treated Pelvic Floor Dysfunction (see below for its different names). The results of our treatment protocol have been published in scientific journals and the results have been shown to help a large majority of patients who complied with its regiment (see published research on the Wise-Anderson Protocol). Our website is devoted to a discussion of pelvic floor dysfunction and a thorough reading of it may be greatly informative to anyone suffering from it.
Understanding the Pelvic Floor as a cereal bowl
Why it is easy to get confused: The different names of Pelvic Floor Dysfunction
Pelvic Floor Dysfunction can be devastating - often putting a patient's life on hold.
When people suffer from pelvic pain and go to the doctor, they are often given a variety of diagnoses and treatments. This is confusing both to patients and to doctors. Unless you suffer from Pelvic Floor Dysfunction, it is difficult to understand the profound effect it has on patients’ lives. The impact of Pelvic Floor Dysfunction that is not resolved or healed can be devastating—often putting a patient’s life on hold.
Finding help that restores the pelvic floor muscles to normal is often much harder than finding someone who can make a proper diagnosis. Because Pelvic Floor Dysfunction affects such private parts of patients’ lives, most patients have never met anyone who has the problem.
Different names for Pelvic Floor Dysfunction
- Chronic pelvic pain
- Chronic pelvic pain syndrome
- Levator ani syndrome
- Prostatitis or chronic prostatitis
- Prostatodynia (prostadynia)
- Non-bacterial (abacterial), prostatitis
- Coccydynia or coccygodynia (tail bone pain)
- Myofascial pain symptoms often associated with Interstitial Cystitis
More about Pelvic Floor Dysfunction in which the pelvic muscles are chronically clenched
- The pelvic floor muscles are the muscles you clench to stop yourself from urinating.
- In Pelvic Floor Dysfunction sufferers (the kind of Pelvic Floor Dysfunction the Wise-Anderson Protocol treats), these muscles tend to remain chronically clenched interfering with their normal ability to contract and relax.
- This chronic muscle contraction can cause pain and dysfunction in the basic life functions, such as urination, defecation, sexual activity, sitting, and sleeping
An easy way to understand Pelvic Floor Dysfunction by making a fist
Imagine if you made a tight fist with both hands for 24 hours straight.
Now imagine how painful your hands would feel immediately after this prolonged period of strenuous clenching.
It would be difficult to...
Thread a Needle
Draw very detailed
Play a precise passage on a piano
Just use your hands normally
Why Pelvic Floor Dysfunction becomes chronic:
How Pelvic Floor Dysfunction takes on a life of its own
|Figure 2: In A Headache in the Pelvis describes the Wise-Anderson Protocol for Pelvic Floor Dysfuction|
One of the reasons traditional medicine struggles to treat Pelvic Floor Dysfunction is because it often fails to identify and address the tension-anxiety-pain-protective guarding cycle.
In this cycle, chronic tension has shortened the muscles in the pelvic floor and created an environment in which the pelvic floor is functioning like a clenched fist that cannot properly relax and contract. It is common for Pelvic Floor Dysfunction sufferers to feel that their pelvic muscles are chronically contracted despite their earnest intention to relax them.
How protective guarding perpetuates Pelvic Floor Dysfunction
The pain caused by the chronic contraction of the pelvis triggers a survival instinct in the body to protectively guard itself against the pelvic pain. It is the same instinct that causes the muscles in our body to retract from the pain when we inadvertently touch a hot stove. Similarly, when there is pain in the pelvis, the pelvic muscles tighten up to guard against it.
Unlike the genuine self-protective reflex that causes us to pull our hand away from a hot stove, the reflex to tense up pelvic muscles against pain in the pelvis is dysfunctional because it tightens what is already tight and tends to make the pain worse.
The Tension-Anxiety-Pain-Protective-Guarding Cycle that perpetuates Pelvic Floor Dysfunction
Anxiety tends to make Pelvic Floor Dysfunction worse
The sore and painful pelvis is usually hypersensitive to anxiety. Anxiety tends to produce increased tension, which then produces more pain, which triggers protective guarding, which then produces more anxiety; thus, the cycle perpetuates.s
In the experiments of Gevirtz and Hubbard, who studied the relationship between electrical activity in myofascial tissue and anxiety, they found that when a needle electrode was inserted into an active trigger point, its electrical activity dramatically increased when the subject was stressed. Remarkably, it normalized when the subject practiced relaxation. Anxiety and the symptoms of Pelvic Floor Dysfunction are often inextricably intertwined. It is for this reason that one of the central methods used in the Wise-Anderson Protocol trains patients in Paradoxical Relaxation, which allows patients to reduce their level of nervous system arousal.
Ending the Cycle
Over time, the chronic tension tends to cause the pelvic floor muscles to become short and form trigger points. Once the tension-anxiety-protective-guarding cycle is established, the tension of Pelvic Floor Dysfunction continues even after you attempt to voluntarily relax the pelvic muscles. Unlike unclenching a fist where there is no self-feeding cycle, you have to interrupt the self-feeding cycle of Pelvic Floor Dysfunction in order for the tissue to become normal. This is no small task when the areas to be treated are up inside the pelvis and have to be accessed vaginally or rectally and the cycle has been present for many years.
The therapeutic goal of the Wise-Anderson Protocol is to give patients the ability to stop this cycle. (See Wise-Anderson Protocol treatment for Protocol for Pelvic Floor Dysfunction)
Detailed description of typical symptoms of pelvic floor dysfunction when the muscles are chronically contracted
Below we attempt to describe more fully the symptoms of Pelvic Floor Dysfunction and the experience of having to chronically deal with it. Most patients with PFD have two or more of the following symptoms.
Urinary frequency and urinary urgency (the need to urinate too often and hard to hold urination once urge occurs)
- For patients, urinary frequency can range from being annoying to debilitating
- There is typically a feeling of something always nagging in your bladder/urethra/genitals. Typically after someone urinates, they don’t feel ‘emptied’ and have the feeling of having to urinate again even though there is no urine in the bladder
- The normal relaxation you would feel after urination when you have no pelvic pain is not there
- Frequency/urgency means you have to always be near a bathroom and sometimes can hardly hold in the urge to urinate
- If you are in a movie theatre, sports event etc. you usually look to sit in the aisle seat in case the urge to urinate comes
- Some patients feel that their life revolves around being near a toilet
- Urinary urgency and frequency can deprive people of sleep because of how often they wake up during the night
Dysuria (pain or burning during urination)
- Burning or pain with urination is always disconcerting
- It is often associated with Pelvic Floor Dysfunction
- We have observed when the chronic spasm and myofascial contraction of the pelvic muscles in many of our patients is resolved, dysuria is also resolved
- Sometimes people feel no pain during urination but only after
- Dysuria can be so painful that urination becomes a large ordeal and sets off further pain
Nocturia (frequent urination at night)
- Often this is a major problem because a patient's sleep is so disturbed they are exhausted all the time
- Exhaustion from sleep deprivation tends to feed into the cycle of tension, pain protective guarding and anxiety
Reduced urinary stream and hesitancy of urination
- In men this is an important symptom to medically evaluate to see whether the source of the reduced stream is from prostate enlargement or other other issues
- Hesitancy of initiating urination can be worsened when urine is held in longer than comfortable
- This is sometimes a contributing symptom to low self-esteem and hypochondriasis especially in younger men
- Some of our patients have reported their urinary flow has improved after loosening the pelvic floor
- Some people with muscle based pelvic pain have to wait for a while to get a stream of urine going
Perineal pain (pain between the anus and scrotum in men or anus and vagina in women)
- Perineum is one of the most common sites of pelvic pain, is intimate, can hurt 24/7 and can be very distressing
- The perineum is the place where most muscles of the pelvic floor attach and therefore has many sources of referred pain
- Perineum is often the site of bicycle riding pain
- Perineum pain can be made worse by sitting or standing
- In a 2009 Stanford study of our work published in the Journal of Urology, it was documented that 79% of subjects complained of pain in the perineum
- We documented key abdominal and pelvic muscles that all refer pain to the perineum (rectus abdominus, adductor magnus, and coccygeus)
- The perineum and the anal sphincter is one of the parts of the body where the patients feel the feeling of “sitting on a golf ball”
- Perineal pain is intimate pain and when it doesn’t stop, it is very distressing
Discomfort during or after orgasm
- Increased discomfort hours or the day after sexual activity is common
- Our explanation about why there is often an increase in discomfort during or after sexual activity in men and women with chronic pelvic pain syndromes is as follows:
- Orgasm causes strong contractions of the pelvic, prostate and seminal vesicle muscles lasting about once a second during orgasm.
- There is a significant increase in nervous system arousal during sexual activity.
- The pleasure spasm of orgasm in the form of the increased series of contractions during orgasm will tighten the pelvic muscles further.
- This increased tightening temporarily contracts an already contracted area which doesn’t relax well and it tends to throw the patient further above the symptom threshold
- When our patients learn to release the muscles inside the pelvic floor, they usually can feel this increased muscle contraction
- After a certain time frame (from hours to days), the pelvic muscles relax and return to their baseline level, the normal tightened state of the pelvic floor reasserts itself (which is back to some degree of pain or discomfort when a person has chronic pelvic pain syndrome).
- For this reason we do not recommend increasing sexual activity (as has often been suggested by physicians our male patients have seen) when a person has an increase in symptoms after sex
Dyspareunia (pain with sexual activity in women)
- Sexual activity is painful either during or afterward
- Pain is felt on the outside of the vagina, inside or both
- Pelvic examination in which trigger points are palpated can often recreate symptoms of pain during sex
- Sitting can trigger or exacerbate discomfort/pain/symptoms
- Sitting is one of the great sufferings and scares in pelvic pain and makes all aspects of normal life difficult
- Sitting pain makes one acutely aware of how sitting is the center of social and work life
- Sitting pain usually starts out milder at the morning but after sitting through the day, there is increased discomfort that can last into the night
- Patients often are looking for the padded seats in a restaurant because sitting is so uncomfortable
- It is difficult to fly or drive for any distance without pain
- Sometimes patients have to go on disability if they can not work because they have to sit at their job
- Sitting pain is one of the symptoms that raises the fear that you might not be able to work or function
- Most endure the pain and deal with the buildup of pain during the day
Genital pain (penile pain in men and vaginal pain in women)
- In men, pain at the tip and shaft of the penis is a common symptom
- In men, penile pain is sometimes accompanied with a redness at the tip
- In men, sometimes there is an irritation on the tip so that rubbing against underwear is uncomfortable
- In women, pain inside the vagina, on one side or another is common
- In women, sometimes vulvar pain accompanies pelvic pain
- Genital pain is usually referred from the anterior levator ani muscle
In men, testicle pain or discomfort
- Testicular pain/discomfort is particularly miserable and scary
- Pain/discomfort is felt in one testicle or another
- Sometimes the cremaster muscles pull up the testicles or penis especially when the anal sphincter is sore and this can be very disconcerting
- Patients have come to see us who had their testicle removed and their pain remained unchanged
Suprapubic pain (pain above the pubic bone)
- It is a common symptom
- Suprapubic pain is common with patients who have urinary frequency, urgency, hesitancy and anterior symptoms
- Sometimes pressing on this area can refer into the anorectal (anus and rectal) area and sometimes bladder pain is experienced here
- Pain can be on one side or another or in the middle
Coccygodynia/coccydynia or Coccyx (tailbone) pain
- Tailbone pain is common
- It is often referred pain from the pelvic floor and not from the tailbone itself
- Patients we have seen who had their tailbone removed typically felt no relief
- Coccyx pain is often related to sitting-on-a-golfball feeling, post bowel movement pain, and sitting pain
Low back pain (on one side or both)
- This is common and often confuses patients and practitioners because the symptoms can be referred from the muscles of the pelvic floor, not the low back
- Discomfort can be on one side or another or sometimes migrate from one side to another
Groin pain (on one side or both)
- Groin pain often is confused with a hernia
- We have seen patients who have had hernia repair for their pain that did not resolve their groin pain
- Relief after a bowel movement occurs when the tight pelvic muscles relax
- Discomfort after a bowel movement is a very disconcerting experience because when people have post bowel movement pain, symptoms often begin more strongly for the rest of the day
- Little is written about this symptom when it occurs in the absence of hemorrhoids or anal fissures, but in our experience it is common
- The mechanism of defecation typically involves the filling up of the rectum with stool, which then sends a signal for the internal anal sphincter and puborectalis muscle to relax and triggers the experience of urgency to have a bowel movement
- Once the stool passes through the relaxed anal sphincter and out of the body, the internal anal sphincter reflexively closes.
- When someone has pelvic pain and exacerbation of symptoms after a bowel movement, we propose that the internal anal sphincter tends to ‘over close.’
- That is, it tightens up more than it was tight before the bowel movement and sometimes appears to go into a kind of painful spasm
- Post bowel movement pain appears to occur less frequently when someone is relaxed and not hurried, and whatever contributes to a more relaxed state during a visit to the bathroom may reduce this symptom
- Resolving post bowel movement pain in our patients tends to occur as their entire pelvic muscle tension releases
Symptoms can migrate or change location
- It is not uncommon for symptoms to change location or ‘migrate’
- Sometimes pain or sensation will appear in one part of the pelvis or abdomen and then the next day it is elsewhere
Heat (hot bath or shower, heating pad) helps temporarily
- Hot water or heat often helps temporarily
- Cold weather flares up symptoms in some patients
Benzodiazepines temporarily reduce symptoms when first used
- The family of drugs called benzodiazepines can often relieve symptoms for a few hours and are helpful when used skillfully
- Benzodiazepines are addictive and when used regularly for pelvic pain, they tend to lose their effectiveness when used regularly over time and can cause addiction
- Benzodiazepines typically make the user tired and should not be used when driving or having to be alert
Reduced libido (reduced interest in sex
- Reduced interest in sex is common with pelvic pain
- In pelvic muscle related pelvic pain, there is typically no pathology of the physical structures involved in sexually activity
- Our view is that reduced libido is a mix of anxiety, reduced self-esteem and pelvic pain which all mitigate against sexual arousal and sexual interest and resolution of pain and dysfunction of the pelvic muscles usually resolves reduced libido
Anxiety about having sex and ‘erectile dysfunction’ in men
- Because sex can be painful or painful afterward, there is often a conditioned withdrawal from having sex to avoid pain
- This anxiety can result in difficulty in maintaining an erection which adds to relationship and courting difficulties particularly in younger patients
- Anxiety with having sex, in our view is the major reason for performance anxiety and what is called erectile dysfunction
- When pelvic pain is resolved, erectile dysfunction related to it typically resolves as well
Anxiety and catastrophic thinking
- The scariest part of pelvic pain is the catastrophic thought that it will never go away
- Most patients attention is on their pain most of the time at some level and this focus is most disconcerting
- It is a focus that distracts your attention away from your life and with many patients, paints the picture of an unacceptable future
- When you are in the throes of pelvic pain, the thought that it will never go away prompts depression in many patients
- Where the doctors cannot help you and you see no light at the end of the tunnel, depression and/or and anxious depression is the rule rather than the exception
- Depression involves the feeling of helplessness about doing anything about what you feel is critically wrong in your life
Social withdrawal and difficulty in intimate relations
- This withdrawal that comes from chronic pelvic pain and robs us of any enjoyment of the moment
- There is a major toll that chronic pelvic pain takes on relationships in regard to partners of those in pain. These problems arise from the patient’s withdrawal from activities such as sex, planning trips,parenting, socializing and doing the things of partnership or marriage
- The much needed experience of a partner for the other to be present is often lost due to a patient’s suffering and preoccupation with pain
Impairment of self-esteem
- Self-esteem almost always goes down
- Men and women with chronic pelvic pain almost always worry that no one will want to be with them
- Sleep disturbance is very common
- Patients either to wake from sleep to urinate or because of pain and anxiety
- We have written a paper about the precipitous rise in cortisol in the morning amongst pelvic pain patients
- Many patients wake up anxious, wondering if the pain has gone, disappointed every day that it isn’t
Stress increases pain
- Ordinary stresses as well as extraordinary stress tend to increase symptoms
- When stress has triggered pelvic pain, the stress tends to triggers the tension-anxiety-pain-protective guarding cycle that continues after the stress has gone
Helplessness and hopelessness
- Helplessness and hopelessness is the real suffering with chronic pelvic pain
- The hopelessness and helplessness of pelvic pain steals away your ability to rest or enjoy anything
- Hopelessness in pelvic pain patients arises when they ca not see anything on the horizon that might help them.
The Wise-Anderson Protocol can help Pelvic Floor Dysfunction
The Wise-Anderson Protocol for Pelvic Floor Dysfunction is offered in a monthly 6-day immersion clinic in California (read about our monthly clinic).The therapeutic strategy of the Wise-Anderson Protocol focuses on the breaking tension- anxiety-pain-protective guarding cycle described above. We do this by focusing on both the physical and mental dimensions of Pelvic Floor Dysfunction. Physically we train our patients to restore the ability of the pelvic muscles to relax and contract by teaching them to do trigger point release and myofascial release inside and outside the muscles of the pelvic floor (click here for a description of the methodology). To intervene mentally in this difficult disorder, we train our patients in the practice of Paradoxical Relaxation (click here for a description of Paradoxical Relaxation for pelvic pain).