Reducing Anxiety to Heal Pelvic Pain: The Wise-Anderson Protocol

PART 1 – INTRODUCTION: PELVIC PAIN IS A PSYCHO-PHYSICAL EVENT TO REDUCE ANXIETY

Learn the importance to reduce Psycho-Physical events to help reduce Anxiety. During the writing of the fourth edition of our book, a physical therapy colleague of ours reported an important story that occurred with one of her patients. The patient was a woman with pelvic pain who had experienced an intense flare-up of her symptoms, and she had started seeing our colleague in an attempt to reverse the flare-up. In one of their physical therapy sessions a remarkable event occurred. It was remarkable not because it was uncommon (indeed we see it often in our patients) but because the event was witnessed in a therapeutic setting and the relationship between cause and effect was so clear. While the therapist was pressing on trigger points inside the vagina of her patient, the patient began to talk about a politician she despised. As the woman shared her anger, the therapist felt her finger being crushed in a vise-like grip of the woman’s pelvic muscle contraction.

Emotional upset, anxiety and sympathetic nervous system arousal can trigger clenching, contraction, and spasm in the pelvic muscles

The patient was middle-aged and the physical therapist was amazed at the strength of contraction of the muscles of this woman’s pelvic floor while she shared her upset feelings. The vice-like pelvic contraction appeared suddenly in this patient and the strength of the contraction was intense. The physical therapist shared with us that it felt like her finger was about to be crushed and she felt frightened that she might be injured.

“Did you feel that?” the physical therapist asked her patient.
“Did I feel what?” replied the patient.
“Can’t you feel the spasm that your pelvis has gone into right now while you are talking about your hatred of this man?” asked the physical therapist.
The patient was dumbfounded. “Feel what? I don’t feel anything,” replied the patient.

Almost unbelievably, the patient had no sense of the relationship between her emotions and the reaction of her pelvic muscles. And while this particular example was striking given the setting and acute cause/effect detection of our colleague, we have seen this psycho-physical inner behavior in all of our patients over the last 21 years and believe it to be the primary causative and perpetuating factor in chronic pelvic pain syndromes.

Chronic pelvic pain syndromes represent a psycho-physical event

Indeed, the chronic pelvic pain that we treat is a psycho-physical event. Unfortunately, the historical treatment of pelvic pain has almost entirely been a misdirected physical treatment of the organs of the pelvis such as the prostate or bladder. Indeed, the conventional medical establishment unfortunately continues to place most of the blame for pelvic pain on the pelvic organs, and attempts to throw various pharmaceuticals at the condition, including antibiotics, anti-inflammatories, botox, and other classes of medications, as well as procedures such as nerve blocks and even surgery, all of which have had, at best, mixed results. And, when physical therapy for the pelvic muscles is prescribed, it is almost always prescribed alone, that is, with no accompanying psychological/cognitive support, relaxation training, or self-treatment training.

In our experience, a limited course of solitary physical therapy produces mediocre to poor results in the pelvic pain patient. In our FDA study that led to the approval of our internal trigger point wand, approximately ¼ of our patients had previously undergone some physical therapy and their baseline level of symptoms was no different than those who had received no previous physical therapy. It has been our strong collective experience over the years that simply treating pelvic pain as a physical event and trying to rehabilitate the pelvic muscles to a supple and pain-free state without addressing the psychological environment and inner behavior of the patient is ultimately not helpful and can often result in the patient abandoning his/her treatment regimen.

Of course, we are not saying that the physical therapy aspects of our protocol are not important in recovering from chronic pelvic pain and dysfunction. It is essential to understand, diagnose, evaluate and treat the myofascial trigger points and muscular restriction that has developed inside and around the pelvic floor in muscle based chronic pelvic pain syndromes. We consider ourselves disciples and champions of the work of Drs. Janet Travel and David Simon and their seminal medical textbook Myofascial Pain & Dysfunction. We comprehensively treat our patients for myofascial trigger points, conducting what we believe to be the gold standard evaluation and identification of trigger points, and then we treat them over multiple sessions in our immersion retreats with specific manual trigger point release, myofascial release, skin rolling, and other myofascial trigger techniques. We train our patients extensively in self-treatment of trigger points using our FDA-approved internal trigger point wand, the theracane, trigger point balls, and other tools, and teach specific yoga-type stretches following trigger point self-treatment. We have developed an unrivaled 300 plus page manual regarding physical therapy self-treatment that our patients take home with them, which includes our “Pressure Principle” concept that details how to determine the level of pressure to use in trigger point self-treatment. Thus, as one can see, we have a world class physical aspect of our protocol and continue to enhance and improve it. What sets us apart from most providers, however, is our deep understanding of chronic pelvic pain syndromes as a psycho-physical disorder and that we pair with our physical protocol with a comprehensive and continuing relaxation/behavioral protocol.

Ignoring the psychological environment of muscle based pelvic pain means that it typically sticks around

The psychological environment that perpetuates the physical contraction, irritability, pain and dysfunction of the pelvic floor has simply not been fully addressed in conventional medicine. When the psychological/anxiety environment that regularly tightens up the pelvis is ignored, pelvic pain typically remains a gnawing and ongoing problem. Even if the relationship between anxiety and pelvic floor pain is acknowledged, and drugs, psychotherapy, mindfulness, or breathing exercises are casually or partially suggested, these mechanisms still usually fail, in our opinion, because the practitioner fails in adequately advising and informing the patient of how significant the intervention needs to be in order to profoundly and reliably down-regulate the patient’s sympathetic nervous system and anxiety.

Over the last 20 years of enhancing the Wise-Anderson protocol, we have developed both a strong and substantial behavioral and psychological protocol of intervention to help patients stop their pain and dysfunction. In the psychological area, we have come to an understanding and treatment of anxiety and the nervous environment of the pelvic pain patient that we believe is remarkable and unparalleled. In this essay, we describe in more detail our method of teaching patients to reduce their anxiety and sympathetic nervous system arousal.

PART 2 – THE TENSION-ANXIETY-PAIN-PROTECTIVE GUARDING CYCLE AND THE METHOD OF EXTENDED PARADOXICAL RELAXATION TO BREAK IT

How anxiety keeps the pelvic muscles tight and painful

The typical etiology (the manner of causation) in chronic pelvic pain syndromes we treat is that the muscles of the pelvis in someone with a tendency toward anxiety tighten up in response to their daily anxiety over a long period of time, often months or even years and decades. During this extended period of anxiety-related pelvic muscle contraction, myofascial trigger points form in the chronically contracted muscle tissue and then, often with an intense period of acute stress, these tightened and restricted muscles get pushed over a certain threshold, become painful and produce a variety of physical dysfunctions and pain. When pelvic muscles remain in this chronically squeezed and contracted posture, they become very sore, painful (including all types of pain such as burning, stinging, aching, shooting, piercing, etc), and irritated. In this constricted state blood flow becomes inhibited, range of motion is restricted, and interference occurs with the neurological relationships that allow for normal and symptom-free life functions: urination, defecation, sexual activity, sitting, exercising, and any other movement or function that involves the pelvis.

The Tension-Anxiety-Pain-Protective Guarding Cycle is the heart of the self-feeding vicious cycle of chronic muscle based pelvic pain

The major concept we introduced in the early editions of our book, A Headache in the Pelvis, is the self-feeding vicious cycle of tension-anxiety-pain-protective guarding. This cycle is the causative and perpetuating heart of muscle based chronic pelvic pain disorders, and is the reason why the sore, irritated and painful pelvic muscles cannot achieve the environmental space to heal like other conditions the body heals on its own. The reason for this is the significant multitasking required by the pelvic floor and the normally inaccessible environment of the internal pelvic floor (vs. the shoulder, for example). Immediately below is a helpful graphic demonstrating this vicious cycle:

pelvic pain

The pelvic floor muscles are like a hub of many highways

help with pelvic painThe pelvic floor is like a hub in which many freeways converge and the pelvic floor, like the heart, is almost always moving and called upon for different tasks including key life functions like urination, defecation, sexual function and structural support. Even breathing in and out moves the pelvic floor. Even the most basic full body movements involve the pelvic floor muscles because of their intimate support of the body’s core.

Once the pelvis becomes sore and painful, and normal life functions are disturbed, the pelvis becomes hyper-sensitive to anxiety and/or nervous system arousal, which we refer to herein interchangeably. Indeed, the onset of anxiety can immediately aggravate hyper-irritable pelvic tissue and directly result in the further tightening or “guarding” of the muscles. Beyond this initial reflexive protective clenching that occurs in response to anxiety and nervousness, an additional layer of reflexive tightening can occur in the pelvic pain patient in response to the actual pain, and all of this inner behavior usually occurs outside of a person’s awareness if the patient does not understand and comprehend this cycle.

 

Pelvic pain as a tail-pulled-between-the-legs phenomenon

We have discussed in several previous writings how pelvic pain can be understood biologically and psychologically as a tail-pulled-between-the-legs phenomenon where fear causes a contraction of the pelvic muscles that pull in the mammalian tail as an evolutionary reflexive response to stress and anxiety. There are a number of ways to comprehend the fact that the pelvic floor muscles, once they have become painful and dysfunctional, fail to heal in a way that normally occurs in other, less complex, more easily treatable parts of the body. Indeed, the reflexive and ongoing engagement and clenching in the pelvis interferes with and prevents the kind of rest, relaxation, blood flow and protection from stress that is required to restore the pelvic tissue back to a supple, relaxed, functional, pain-free state.

Anxiety is the fuel to the fire of chronic pelvic pain syndromes

Some level of anxiety or sympathetic nervous system up-regulation is what almost all patients with chronic pelvic pain syndromes live with day in and day out. Anxiety can trigger pelvic contraction and, as Gevirtz and Hubbard demonstrated in their 1995 experiments, electrical activity strongly increases in trigger points with increased anxiety. Anxiety regularly exacerbates the condition and this mental state is further fed by the patient’s catastrophic thinking, the isolation of often being unable to share the feelings and experiences of pelvic pain, and a conventional medical establishment unequipped to provide any significant help or relief to the sufferer. Most pelvic pain patients who have not been trained in our protocol have no way to reduce their level of nervous upset and anxiety other than with drugs, which of course, have their own significant side effects and problems.

In the presence of anxiety and reflexive protective guarding, the sore contracted pelvis cannot find the healing space and environment to restore to a normal, non-symptomatic state. Added to an individual’s anxiety is the puzzlement of the doctors. The doctor is often frustrated about his inability to help the problem and is not infrequently worried that perhaps he has missed something. Doctors are problem solvers. As we have discussed in our book and other essays, certain doctors do not respond well to their own helplessness to solve the problem of chronic pelvic pain syndromes. Any anxiety, uncertainty or helplessness felt by the doctor is almost always communicated to the patient – a communication whose impact can be overwhelmingly upsetting to the patient.

That pelvic pain is hugely affected and perpetuated by anxiety is why the placebo effect reduces the anxiety that helps fuel the condition. This is also why many people have a reduction in symptoms after they read our book. Many of our patients whose symptoms reduce after reading A Headache in the Pelvis report their emotional relief after finally finding something that makes sense about what is going on and offers some intuitively viable solution.

Anxiety, sympathetic nervous system arousal, and reflex guarding is the environment that keep the pelvis painful; the concept of a stopping anxiety and protective guarding to create a “healing environment” for pelvic pain and dysfunction

During our 21 years of treating muscle-based chronic pelvic pain syndromes with the Wise-Anderson Protocol, we have often said that the challenge of healing and rehabilitating the pelvis would be much easier if we could send the pelvis on a long island vacation where it had nothing to do but relax and heal its chronically tightened, sore, irritable and painful state. While meant comically, our saying this acknowledges a very important question in the understanding and treatment of pelvic pain, and one that is rarely discussed in the realm of conventional treatment for pelvic pain: namely, how can we create a healing environment that allows for the sore, contracted and painful pelvic muscles to heal? How can we interrupt the tension-anxiety-pain-protective guarding cycle in a profound enough way to fully permit the pelvic floor muscle irritability to heal, just like other muscle conditions heal?

The inner healing environment of Extended Paradoxical Relaxation

This idea of a “healing environment” to allow physical healing both in terms of an external environment and a “local or internal” environment, is intuitively understandable and practiced in a multitude of medical conditions and treatments, including the following very familiar ones –

  • a cast for a broken bone to ensure bone immobilization and a reliable healing environment for the process of bone healing;
  • a neck brace for the neck after certain types of neck injuries;
  • band-aids and tourniquets along with antiseptic ointments for cuts and wounds to heal;
  • stroke and brain rehabilitation centers for the regaining of function lost in stroke and brain damage disorders;
  • in-patient addiction retreat centers for drug and alcohol users that remove the abuser from the aspects of his/her life that make it difficult to abstain from drugs or alcohol.

As one can see, these examples include both external, social-psychological healing environments (addiction retreat centers, stroke rehab centers, etc.) and local, body-focused healing environments (cast for a broken bone, wound healing, neck brace, etc.). Both of these aspects of the healing environment are crucial in chronic pelvic pain syndromes because the factors of the external, social-psychological healing environment (anxiety, work and family stresses) are so inextricably intertwined with the local function and state of the muscles in and around the pelvis. It is unfortunate that we could prepare an exhaustive and long list of healing environments like those listed above for myriad conditions in conventional medicine yet a similar concept for chronic pelvic pain syndromes has hardly ever been discussed.

When we get a cold, we don’t have to change our environment in order to recover; perhaps we get some extra sleep and stay home for a few days but otherwise we maintain our normal lifestyles of work and relationships. Healing from pelvic pain and other conditions similar to the above examples, however, requires a heightened and more intentional intervention to our normal schedule. Drug rehabilitation is an obvious and well known example where “time away” is almost universally accepted and supported by the entire medical community as well as a patient’s family and friends. This type of caregiver and social support is exactly what the pelvic pain patient needs in attending to his/her recovery as well.

The Wise-Anderson Protocol helps patients create a daily “healing environment”

In our view, when the symptoms of the pelvic pain patient get routinely better, like in the morning, on week-ends, on vacation or in a hot bath, they are in an “inner healing environment.” The muscle tension has eased, the nervous system is quieter. We are convinced that chronically contracted and dysfunctional pelvic muscles need a “healing environment” in order to optimize recovery potential in the patient. In this healing environment the pelvic muscles are not caught in the tension-anxiety-pain-protective guarding cycle. The Wise-Anderson Protocol is focused on helping the patient create this healing environment regularly in order to interrupt the self-feeding cycle that keeps the pelvic muscles sore, irritated and painful.

While we cannot place a literal “cast” on the pelvic muscles, like you can on a broken leg, or send it to a tropical island for an extended healing vacation free from the onslaught of a vigilant and aroused nervous system, we have developed a 2-4 hour daily practice that can help turn off the relentless self-feeling cycle of tension-anxiety-pain-protective guarding. We do this by using the practice of daily Extended Paradoxical Relaxation (EPR). The practice of EPR allows for a profound down-regulation of our sympathetic nervous systems, which in turns stops fueling the fire of pelvic pain and allows the pelvic muscles time to heal.

The concept of taking a significant and continuous 2-4 hour daily break from your normal life in order to heal from pelvic pain (which we mean to include the variety of diagnoses given to pelvic pain including prostatitis, pelvic floor dysfunction, interstitial cystitis, chronic proctalgia, levator ani syndrome, among others) is not something that is part of the current conversation among professionals who treat pelvic pain. While certain conditions like stroke and drug rehabilitation have been treated in month long immersive formats, it is rare for a patient of a functional somatic disorder to be encouraged to do this. In a recent essay we wrote for our blog comparing a locked up computer to the state of a dysfunctional, up-regulated nervous system, we stated:

With regard to people who have chronic pelvic pain, their bodies can be said to be experiencing 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 the demands of our hectic lives, the muscles of the pelvic region have engaged in a pattern of chronic, unyielding protective guarding as a method of coping with and getting through these stresses. These pelvic muscles, normally supple and pain-free and able to relax and contract easily, are rigid and chronically contracted and dysfunctional. In other words, the pelvis has become part of the body’s lock up, just like the locked up computer.

Using an Extended Paradoxical Relaxation retreat to train the patient in EPR and “Kick-Start” their recovery journey

What Extended Paradoxical Relaxation provides is a regular daily hiatus from the tasks, stresses, demands, and pressures that have played a causative and perpetuating role in a patient’s symptoms. When a soldier returns injured from war, or a patient survives a stroke, usually all of the caregivers and family support a comprehensive, immersive, long term treatment program. The physicians, physical therapists, psychologists/counselors, and loved ones of the patient are all on the same team and understand that a sustained, repetitive healing environment will be required for many months or years for the patient to reach his/her full potential of recovery.

We are studying a similar methodology for the functional somatic disorder of chronic pelvic pain where treatment begins with a multi-week, (9-30 days) immersion, in-patient clinic, in which the patient receives all of the training in the physical therapy aspects of our protocol and engages in 4-7 hours of our Extended Paradoxical Relaxation method in order to profoundly intervene in and break the vicious cycle causing and perpetuating their pelvic pain and dysfunction.

This extended, intensive immersion retreat sets the patient on the path to recovery by helping patients regularly turn off the ongoing mental narrative and regular experience of being ‘on’ in order to respond to personal and work demands, and by spending enough sustained hours in a state of Extended Paradoxical Relaxation in order to create the healing cast for the pelvic muscles to return to a supple, relaxed, functional pain free state. Indeed, our goal in conducting research into this extended EPR retreat is to place the patient into an almost permanent “airplane mode” for several weeks and essentially bring the ancient practice of the meditation retreat into the 21st Century as medical treatment for functional somatic disorders like chronic pelvic pain.

PART 3 – BRINING THE TRADITIONAL MEDITATION RETREAT INTO THE 21ST CENTURY TO DOWN-REGULATE THE NERVOUS SYSTEM AND HEAL THE PELVIC FLOOR

For thousands of years, in most spiritual or wisdom traditions, it has been common for those seeking deep inner understanding to spend long periods of time in meditation and contemplation. Innumerable books and texts over the centuries have extensively documented and profiled the concept of the meditation retreat in the Buddhist, Hindu, Judeo-Christian, and Muslim traditions.

Indeed, among other Biblical examples, Jesus was purported to have spent 40 days of contemplation in the desert, and all of the other religious traditions have similar stories in their sacred texts. From Buddha to St. Francis to Hindu sadhus to contemporary meditators like Thomas Merton, quieting the body and mind through meditation has been a lofty practice. Even today, the explosion in popularity in the practice of yoga, including its brief forms of meditation at the end of most hatha yoga classes, demonstrates a collective intuition that quieting down the nervous system through meditation is good for us.

Paradoxical Relaxation practice is a secular form of meditation

My teacher Edmund Jacobson went to great lengths to make a distinction between his protocol, which he called Progressive Relaxation, and many other practices including meditation. He wanted make a distinction between Progressive Relaxation and other practices and phenomena that produced relaxation like meditation, transference in psychoanalysis, spiritualism, yoga, and hypnosis, among others.

Jacobson wanted to identify Progressive Relaxation as a scientific and medical protocol aimed at reducing nervous system arousal that only relied on practitioners following the given instructions during a session. He did numerous scientific experiments with barium and fluoroscopy to demonstrate the scientific efficacy of his method. He worked with Bell labs in the 1940s to invent the electromyography that was able to measure electrical activity in muscles that he used to document the efficacy of his method.

Despite Jacobson’s protests and attempts at drawing clear distinctions between his relaxation method and other practices and phenomena that produced relaxation, contemporary methods of relaxation and ancient methods of meditation have more similarities than differences. Relaxation methods and meditation methods all aim at controlling attention to bring about the quieting of body and mind. While relaxation teachers don’t don robes, light candles or incense, or lecture students on spiritual subjects, the basic principles apply to both the directing attention away from discursive thought and cognitions and back to a focus that allows the reduction of thinking and mental activity. These instructions are the main ingredients in helping reducing sympathetic “fight or flight” nervous system arousal.

Meditation and relaxation methods, from the largest perspective, are essentially the same and both borrow from the universal principles that allow for the nervous system to quiet down. While psycho-physiologists may call the goal of relaxation “stress reduction” and “autonomic down-regulation,” while meditation teachers may call meditation the “practice of inner peace,” there is no essential difference to them on the inside if the practitioners gains entrance to the relaxation response and gains peace and equanimity; in short, it is a healing environment whether the practitioner calls what she did meditation or relaxation.

Brief periods of regular relaxation have been shown to help certain health difficulties and reduce anxiety but the effects of longer periods of relaxation have not been studied

Conventional wisdom in the 21st century easily understands the relationship between stress and illness. In the last few decades, stress reduction has become a subject of much interest not only because the relationship between stress and illness is often reported in the popular media, but many people feel the effects of stress with the increasing non-stop computer culture that routinely bombards one with stimuli, often disturbing, from numerous portals such as email, text, instant message, Twitter, Facebook, etc. The sources of our nervous system stimulation has become endless with the explosion of communication technologies.

Much has been written about the benefits of meditation for stress reduction. As with relaxation methods, such meditation interventions are prescribed in the form of relatively short periods of time – perhaps a ½ hour to an hour a day where one is asked to sit upright and quiet, and direct attention to the breath, a sound or a visual image. Indeed, meditation has been shown to help depression, anxiety disorders, chronic fatigue syndrome, and functional somatic disorders, including irritable bowel syndrome. It has also been shown in helping reduce the symptoms related to heart disease, and in our own work and previous studies, in the reduction of pelvic pain symptoms. These studies, however, typically do not include long, extended periods of relaxation/meditation. They tend to be confined to daily, ½ hr – 1 hour periods. Thus, to be sure, meditation does have the capacity to lower nervous system arousal to some modest degree or another when done regularly and reliably in short periods of time on a once a day basis.

Like these studies, for the past 21 years of our work with pelvic pain, we have asked patients to do short periods of Paradoxical Relaxation, typically between 30 minutes to 50 minutes, twice a day. We have had excellent results with a large number of our patients with this regimen. There are certain patients, however, who seem to require several hours to calm down enough to enter into the healing state of nervous system down-regulation. In recent times, for these patients, we have been recommending significantly longer periods of Extended Paradoxical Relaxation – between 2-4 hours, if not longer, on a daily basis for those whose symptoms continue to be at a plateau.

In the ways we live now, however, long periods of meditation/relxation that range from multiple hours to days (or even weeks or months) do exist but are very uncommon. Modern life, and its demands for real-time access and constant production of content, strongly discourages us from taking that unwired, unconnected sabbatical. Busy is good the society tells us. Taking a hiatius where one is “unwired” and off the communications grid is not on the radar screen of what people think about in the 21st century. Indeed, even a two or three week vacation can cause anxiety in many people for fear that their employer will consider such a break excessive. And while meditation retreats are offered at a few centers in the world, they typically are not done as part of a treatment for a specific medical disorder, as we use in the Wise-Anderson Protocol for chronic pelvic pain syndromes.

The Meditation Retreat as specific medical treatment in the Wise-Anderson Protocol

Little scientific research has been done in terms of documenting the real physiological healing potential of long relaxation retreat periods that give the nervous system a profound rest from the ongoing stimulation of the demands of life. Because meditation retreats are typically done for spiritual reasons and not for medical reasons, and because there appears to be no economic advantage to be gained by a company in investing time and research energy into the benefits of extended periods of nervous system quieting, little reliable data is available on the true, scientific healing potential of such a practice. It may be clear to some that if you were able to calm down and be peaceful for a long period of time it would have the potential to heal your medical condition; however, many people have little exposure to scenarios of recovery outside the conventional medical system and its drugs and procedures.

In the Wise-Anderson Protocol, we are now studying a modern-day, 21st-century version of the meditation retreat done at the same time and in combination with our medical, physical therapy, and psychological protocols. We believe an extended, intensive relaxation retreat combined with our Protocol has huge undiscovered potential in helping even the most refractory chronic pelvic pain patients.

From Spiritual Focused to Medical Focused: Bringing Meditation into the 21st Century

There is little difference between meditation instructions today and meditation instruction given centuries ago. Indeed, in meditation communities there tends to be a reverence toward ancient instructions. The concept exists that somehow ancient instructions have a certain power that should be adhered to up to the present day, and it is heretical to do otherwise. It is not uncommon for meditation instructions to be relatively brief and sparse, done at the beginning of someone’s interest in meditation, and infrequently reiterated or explored as someone continues meditation over their lifetime. One is expected to remember of their own accord the instructions on how to do meditation; for example, in many traditions one is often directed to attend to one’s breath and every time one’s attention wanders away from the sensation of the breath, one should return their attention to it. The meditator, however, is charged with being responsible for these self-instructions and self-motivation themselves.

In the most popular meditation traditions still active today, there are usually some instructions given about what to do when one’s attention is distracted by thinking, but again, the instructions for bringing attention back to focus is very uncommon. The meditator is expected to coach him or herself regarding directing attention on a moment-to-moment basis after the initial instructions are given and no one has truly researched what actually goes on in the mind of the meditator over time. When I first learned meditation, the instructions were given by a relative neophyte and I struggled for many years with the instructions to keep my posture straight and to focus my attention in the lower part of my abdomen. This was often difficult for me to do and at the end of meditations I would notice that, while some inner quieting had occurred, nothing really remarkable occurred in my nervous system.

Simply put, the ancient meditation instructions suffer from the problem of not having the necessary psychological insight to support the patient within the context of the stresses and demands the patient faces in modern times and its particular relation to the patient’s medical symptoms. To sit on a pillow in a cross legged position and keep a straight spine, among other ancient instructions, prove to be very difficult to a symptomatic pelvic pain patient in 2015 in facing the terms of his/her nervous system up-regulation. We do not put counseling and psychotherapy sessions on a recorded CD nor do we rely on ancient texts to determine how we counsel psychology patients in modern times. In Paradoxical Relaxation, we bring the instructions of relaxation practice, and the relationship between instructor and student, into a modern context where all of the nuances and subtleties of a reliable relaxation practice can be addressed and enhanced.

The Evolution of Extended Paradoxical Relaxation

In our experience of teaching Paradoxical Relaxation, instructions and how to focus attention usually can be held in the mind for about 10 to 30 seconds. After that the mind will tend to wander unless someone is very practiced in focusing attention and is good at self-coaching. Paradoxical Relaxation has been informed by the work of Edmond Jacobson and the number of meditation traditions that I have studied over the years. The relaxation method of Paradoxical Relaxation has mostly been informed by my attempt over the years to down-regulate my own sympathetic nervous system, and borrowing from different teachings I have experienced has been helpful to some degree.

Extended Paradoxical Relaxation that is done over a 2-5 hour period daily has evolved over the last 21 years as a relaxation/meditation method that very particularly and specifically bring meditation into the 21st-century. As someone becomes skillful in doing Paradoxical Relaxation over this long period of time daily, we have noticed that there is a qualitative shift in the effectiveness of the methodology.

Chronic pelvic pain is a problem that is fed by nervous system arousal. If someone were able to calm down mentally and emotionally and release the chronic contraction of their pelvic muscles and related areas, their pelvic pain would resolve relatively quickly. The main problem with pelvic pain recovery comes from the pelvis not being given a rest from the onslaught of nervous system stimulation that is relentlessly delivered throughout one’s day by anxiety and the common stresses of modern life.

The purpose of Extended Paradoxical Relaxation, in the form of an “off the grid” relaxation retreat, is to give a hiatus or sabbatical to the nervous system arousal over a period of two or three weeks (or possibly longer) that can initiate the healing of the pelvic muscles from their irritable, sore, dysfunctional and painful state. During the retreat we engage the patient in 4-7 hours of Paradoxical Relaxation sessions. Often times “opening the door” is the hardest process in recovery; once the body’s momentum gets started in a healing direction, the patient usually is easily able to stay reliably committed to the protocol and the healing journey. This is the goal of the intensive, multi-week Extended Paradoxical Relaxation retreat.

Our Methodology

Here are some of the methodologies we are using in Extended Paradoxical Relaxation:

  • Noise canceling headphones to help block out any distracting noise in the environment.
  • A sophisticated, light stopping sleep mask to help keep the light out that can help calm down nervous arousal.
  • We help the patient find the ideal position to rest in during the practice, not based on ancient traditions but what works best for the patient in light of their current physical symptoms.
  • Importantly, we give detailed and optimized instructions to the real live person doing relaxation every 20 or 30 seconds to a minute and we address in our instructions the obstacles to relaxation, for example: (1) the desire to escape from discomfort that is inevitable when you sit down with a condition that involves pain; (2) the desire for pleasure and the avoidance of pain; (3) the desire to reach an ideal outcome instead of staying focused in the present moment which is paradoxically the essential ingredient in shifting a painful and uncomfortable physical state to one that is comfortably pleasurable and provides a healing environment for the pelvic tissues.

Finally, when someone goes home after their relaxation retreat with us we ask them to do what is rarely asked of any patient, which is to take 2 to 3 hours a day to create a hiatus for the nervous system. We ask them to get up early or to somehow create the time that they would take if their pain was some critical condition like a stroke recovery that demanded a certain amount of rehabilitation time. We do this for a very specific, medical reason: we have found in our 21 years of experience that this is the kind of commitment necessary to break the vicious tension-anxiety-pain-protective guarding cycle that forms the causative and perpetuating foundation of pelvic pain and dysfunction.

We have found that the length of the relaxation session is critical to the efficacy of the method in a certain sub-population of our patients. This is the same difference between taking a sub-minimal amount of a drug that doesn’t have enough traction to affect the disorder and increasing the dosage to a dosage that demonstrates efficacy. In a 14 day immersion program we just concluded we found a qualitative difference between a brief Paradoxical Relaxation session and the hours-long session. It is clear that there is a minimum dosage for the efficacy of certain drugs; likewise, we are seeing that for certain patients, there is a minimum “dosage” of relaxation in terms of the time allocated for it. For certain patients, the difference between doing Paradoxical Relaxation for ½ hr/ day and 3 hours per day makes the difference between remaining in pain and resolving the pain.

We are also excited to announce that in conjunction with our research into these longer, multi-week relaxation retreats where we do 4-7 hours a day of Extended Paradoxical Relaxation, we are developing a “take-home kit” that will include a comprehensive book, audio-visual materials, Paradoxical Relaxation recordings, and other support tools. Our goal with this kit is to provide as much environmental support as possible so that the patient can “re-create” the healing environment of the relaxation retreat at home as much as possible. Because of its personal nature with audio-visual recordings, the kit will also reinforce the teacher-student connection that occurred during the relaxation retreat. We will also be exploring the possibility of the kit as a stand-alone product for the treatment of a wide range of anxiety and functional somatic disorders.

Prostatitis as a Tension Disorder

(AN EARLY DISCUSSION OF THE WISE ANDERSON PROTOCOL)

1999 Selected Abstracts from American Urological Association annual meeting

Anyone with prostatitis should be aware of the disagreement among professionals about the cause of prostatitis.

This is especially true if he currently has pain or discomfort:

  • in the penis
  • in the testicles
  • above the pubic bone
  • in the low back, down the leg, in the groin or perineum
  • during or after ejaculation
  • while sitting

The condition often involves:

  • having a sense that there is a golf ball in the rectum that can’t be dislodged
  • urinary frequency and urgency
  • dysuria or burning during or after urination
  • a need to urinate even after one has just urinated
  • some sense of pelvic discomfort
  • no evidence of infection in the urine or prostatic fluid
  • no evidence of disease in the prostate or elsewhere in the pelvic floor

The reason that understanding this lack of agreement about the cause of prostatitis is important, especially for sufferers of the problem, is that the definition of a problem determines what you do about it. If you have chest pain caused by indigestion, you don’t elect to have open heart surgery to correct the pain. Indigestion tells you what to do about your chest pain.

Similarly, if prostatitis is caused by a chronic tension disorder in the pelvic muscles where there is no evidence of infection, you might take pause before you elect to have your prostate removed or take another course of antibiotics or have your prostate gland painfully squeezed and massaged.

There is a genuine controversy about what prostatitis is among urologists and professionals treating this problem. There are three basic views outlined below:

  • Prostatitis is a condition caused by chronic squeezing of the pelvic muscles that, after a while, causes a self-perpetuating and chronic irritation of the contents of the pelvic floor, including irritation of the nerves and other delicate structures involved in urination, ejaculation, and defecation.
  • Prostatitis is caused by a bacteria or unknown microorganism in the prostate gland.
  • Prostatitis is an autoimmune problem.

The majority of urologists tend to propound the second and third theories. Because of this, their treatments tend to focus on the use of antibiotics or pain medications. Sometimes urologists will tell their patients that there may be a microbe responsible for the problem that still has not been identified.

Similarly, prostatitis as a tension disorder sees abacterial prostatitis/prostatodynia essentially as a ‘headache in the pelvis” or “TMJ of the pelvis”. In this view it is a condition usually manifesting itself after years of tensing the pelvic muscles. It usually tends to occurs in men who hold their tension and aggression inside. They squeeze themselves rather than lashing out at others. Often they have work in which they sit for long periods of time and the only way they have found to express their frustration is to tense their pelvic muscles. This tension disorder has become a habit with them. Often they do not know they tense themselves in the pelvic floor.

If in fact abacterial prostatitis/prostatodynia (which happens to make up about 95% of all cases of chronic prostatitis) is a condition of chronic tension disorder in the pelvic floor, one would have to question whether drugs or surgery are a correct treatment. In fact, there is no effective drug regimen or surgical procedure for this condition although at Stanford we have had men consult with us who, in moments of desperation, have had their prostates resectioned or removed and who have taken heroic doses of antibiotics and other drugs. None of these treatments have helped them. Not infrequently, these treatments have made the problem worse or created other problems.

In a pilot study, men with abacterial prostatitis/prostatodynia often are found to have trigger points or “knots” of contracted muscle fiber that are very painful when pressed and refer pain to different places in the pelvic floor. Not infrequently, men will report that pressing on these trigger points recreates the pain that they usually have. From the view of prostatitis as a tension disorder, trigger points and tender points in the pelvic floor come about because of chronically contracted muscles there. To deactivate the trigger points is a method borrowed from physiotherapy called “myofascial release” or “soft tissue mobilization”. This is done inside the pelvis where the therapist pushes against the trigger points, stretching the tender contracted tissue.

After a number of sessions, there is often a significant reduction of symptoms. Frequently, with an extensive course of these treatments, symptoms tend to continue to diminish or disappear but only if the patient learns to stop chronically tensing the pelvic muscles.

Learning to profoundly relax the pelvic muscles is not an easy thing. Chronic pelvic tension has usually been a long-standing habit for many men who have pelvic pain. Learning to relax the pelvic muscles requires a major commitment of time. It involves learning a relaxation method we have developed aimed at stopping this chronic squeezing of the pelvic floor muscles.

Seen this way, prostatitis is a secret language that the body is using to tell the man that he needs to handle his stress in his life differently. In offering a treatment based on the view that abacterial prostatitis is a tension disorder, there has been a difficulty with reimbursement from insurance companies. This makes it very difficult for a patient to follow a minimal protocol of intrapelvic myofascial release and progressive relaxation of the pelvic floor.

Because we who see prostatitis from this viewpoint want to get patients off of drugs, we get no financial support for research from drug companies who are often the major source of research funding. Furthermore, because no surgery is involved and urologists are not extensively trained in looking at conditions which result from the direct interaction between mind and body, there has not been much interest in learning and using this treatment among our colleagues in urology.

I hope that this discussion is useful to the many men who suffer from prostatitis and chronic pelvic tension.

Rectal Pain, Anal Fissures, Hemorrhoids, Constipation and Other Manifestations of Headaches in the Pelvis

Are you experiencing the symptoms of rectal pain, anal fissures, hemorrhoids, or constipation?

It is important to have a clear understanding on symptoms for hemorrhoids, rectal pain, anal fissures and constipation. At some time or another, many people find a little blood in their stool usually after a particularly hard bowel movement and can become confused and upset at such an event. At other times, alarmed individuals go to the doctor complaining of rectal pain after a bowel movement with no apparent blood in the stool. Often the doctor gives the diagnosis of anal fissure or hemorrhoid to these complaints. To most, this can sound foreboding. In fact, an anal fissure is like a paper cut in the internal anal sphincter. Hemorrhoids constitute another condition that is painful and sometimes the source of blood in the stool. A hemorrhoid is a kind of varicose vein in the anus.

One French study showed that one-third of women had hemorrhoids or anal fissures after childbirth. One to ten million people in North America suffers from hemorrhoids symptoms. Both of these conditions are common in both men and women. These conditions are often related to constipation and diarrhea. Constipation has been related to chronic tension in the pelvic muscles in adults and recently in a study at the Mayo Clinic in refractory constipation in children.

The colon and rectum are structures that operate together in the activity of the evacuation of stool. Normal, non constipative bowel function involves the reflex relaxation of the external anal sphincters the pelvic floor muscles (along with sufficient tone in the colon) to allow the reflex of the sense of urgency with the filling of the rectum for fecal matter in the bowel to pass through the anal canal. Chronic tension in the bowel and pelvic floor triggered by anxiety can commonly result in constipation.

It is understood by many of researchers that the anal fissure is what is called an ‘ischemic ulcer’. Ischemia is a condition in which there is a significant reduction in blood flow to an area. The current understanding about anal fissures is that because there is elevated tension, the blood flow in the anal sphincter is reduced, thereby impairing the tissue. It becomes fragile and vulnerable to injury from a hard bowel movement or from the pressure of bearing down during defecation.

Diet has clearly been implicated in the development of the anal fissure. Cow milk consumption has been associated with chronic constipation and anal fissures in infants and children. Interestingly, a shorter duration of breastfeeding and early bottle feeding of cow’s milk are also suspected to play a role in early incidences of anal fissures in infants and young children. A Danish study showed a significant relationship between the absence of raw fruits, vegetables and whole grains and anal fissures. Furthermore, frequent consumption of white bread, sauces thickened with roux, and bacon and sausages increased the risk of anal fissures. British researchers found that hemorrhoids and anal fissures were much more likely to occur when one did not eat breakfast.

While most anal fissures and hemorrhoids resolve themselves after they flare up, some colorectal surgeons lean toward a procedure or surgery. The hope is that they will treat the rectal pain associated with hemorrhoids and anal fissures. We have seen patients who are anxious about their rectal pain easily talked into an aggressive treatment of the fissure or hemorrhoid involving surgery.

It is generally agreed that the source of the anal fissure in large part involves a chronically tightened internal anal sphincter. Surgery, the procedure of stretching or dilating the anal sphincter under anesthesia, and the application of topical agents are all aimed at relaxing the anal sphincter. The concept of surgery for anal fissures is based on the peculiar idea that cutting the sphincter is the best way to reduce the tone, tension, and spasm in the anal sphincter. While surgery is often successful, there is a risk of short term and sometimes long term fecal incontinence.

This conventional medical treatment of rectal pain, anal fissures, hemorrhoids, and constipation tends to ignore the relationship between mind and body. Like the conventional treatment of prostatitis, the relationship of a person’s mindset, level of relaxation during bowel movements, and management of stress is almost entirely ignored in the literature on the anal fissure. Instead, there is a narrow focus on immediately reducing symptoms. Procedures, surgery, laxatives and other medications are the usual options for patients suffering from rectal pain and other conditions. Like in the treatment of prostatitis, there is little literature on the connection or treatment of body and mind in the anal fissure, hemorrhoid or in problems of constipation.

The focus on a surgical intervention for rectal pain, anal fissures, or hemorrhoids is an expression of a viewpoint that sees no value and sees no intelligence in the symptoms of someone with such a condition. Instead of seeing the symptom of an anal fissure, for example, as the way in which one’s body is complaining of the diet, stress, bowel habits and anxiety, conventional treatment sees the symptom of blood in the stool, rectal pain, or abdominal pain as something that needs to be stopped. No regard is shown in the big picture of a person’s life and how symptoms are a response to this big picture. As we have said elsewhere, it is our view that the symptom is the way our bodies are trying to communicate. If we simply try to refuse to understand the message because we don’t understand the body’s language, we needlessly suffer and don’t deal with the root problem prompting the symptom. We continue to suffer.

In the large majority of cases, it is the chronic tension in the pelvic floor, including the anal sphincter, usually combined with diet and anxiety that leads to rectal pain, anal fissures, hemorrhoids, and constipation. In a word, a person’s mind and body and lifestyle are involved in the creation and perpetuation of these conditions.

Squatting vs. sitting during defecation as way of helping the relaxation of the pelvic floor

Most people throughout history have squatted when evacuating their bowels. The modern toilet is relatively new in the history of mankind and has been adopted as a civilized bathroom appliance. The perennial hole in the ground over which one squatted to defecate is universally considered primitive. A website devoted to promoting the advantages of squatting during defecation writes about the history of the modern toilet:

“Human beings have always used the squatting position for elimination. Infants of every culture instinctively adopt this posture to relieve themselves. Although it may seem strange to someone who has spent his entire life deprived of the experience, this is the way the body was designed to function.

The modern chair-like toilet, on the other hand, is a relatively recent innovation. It first became popular in Western Europe less than two centuries ago, largely by coincidence. Invented in England by a cabinet maker and a plumber, neither of whom had any knowledge of physiology, it was installed in the first dwellings to use indoor plumbing. The “porcelain throne” was quickly imitated, as the sitting posture seemed more “dignified” – more suited to aristocrats than the method used by the natives in the colonies.

Two other influences also favored the adoption of this new water closet. One was the headlong rush to modernize all existing sanitation facilities (which were, in fact, non-existent.) The public assumed that all the benefits of modern plumbing required the use of the seat-like toilet since it was the only one having the proper fittings to connect to the pipes. This assumption was incorrect since toilets with all the same flushing capabilities could be (and have since been) designed to be used in the squatting position.

Secondly, in nineteenth-century Britain, any open discussion of this subject was considered most improper. Those who felt uncomfortable using a posture for evacuation that had nothing to do with human anatomy were forced to keep silent. How could they denounce the toilet used by Queen Victoria herself? (Hers was gold-plated.)

So, like the Emperor’s New Clothes, the water closet was tacitly accepted. The general discomfort felt by the population was indicated by the popularity of “squatting stools” sold in the famous Harrods of London. These footstools elevated one’s feet while in the sitting position to bring the knees closer to the chest – a crude attempt to imitate squatting.

The rest of Western Europe, as well as Australia and North America, did not want to appear less civilized than Great Britain, whose vast empire at the time made it the most powerful country on Earth. So, within a few decades, most of the industrialized world had adopted ‘The Emperor’s New Throne.’

A hundred and fifty years ago, no one could have predicted the effect of this change on the health of the population. But today, many physicians blame the modern commode for the high incidence of a number of serious diseases. Compared to the rest of the world, people in westernized countries have much higher rates of appendicitis, hemorrhoids, colon cancer, prostate cancer and inflammatory bowel disease.”

There is compelling evidence that sitting on the toilet to evacuate the bowels is inferior to squatting in a number of ways. Squatting tends to relax the puborectalis muscle which is essential in defecation. It tends to reduce or eliminate the need to strain and bear down. A long study showed improvement or elimination or hemorrhoids as the result of squatting during defecation. Doing the ‘valsalva maneuver’ in which one bears down to initiate defecation while holding one’s breath have been known to cause a fatal heart attack or sometimes episodes of atrial fibrillation because such a maneuver increases pressure in the thorax and interferes with venous blood returning to the heart. The heart rate can significantly drop during this activity. Defecating while squatting can reduce the need to bear down and set this cycle in motion.

The modern toilet makes squatting during defecation a little problematic as it is made for sitting. Nevertheless, with a little innovativeness, it is possible to squat on a toilet. A device is sold that allows one to easily squat during defecation. When pelvic pain also involves rectal pain, anal fissures, hemorrhoids, or constipation, the issue of integrating squatting during defecation might well be considered.

We would like to see research on a non-invasive and self-administered treatment of both anal fissures and hemorrhoids and certain types of chronic constipation following our protocol for pelvic pain with some modifications. This would involve the rehabilitation of a very tight pelvic floor using Trigger Point Release, modifying the habit of tightening the pelvic muscles habitually under stress and during defecation and a focus on reducing anxiety producing thinking that prompts increased and habitual levels of anxiety. Squatting during defecation should strongly be considered as part of the protocol. While there is little research done on the treatment of these kinds of conditions using this perspective, we strongly support an independent study evaluating the efficacy of a modified Stanford protocol for the treatment of rectal pain, anal fissures, hemorrhoids, and certain kinds of constipation.

Facts About Prostatitis and CPPS: How Prostatitis is Often Misdiagnosed

https://www.youtube.com/watch?v=DWNPuQfcEbA

CPPS

Many men diagnosed with prostatitis and CPPS are confused about what the doctor is saying is wrong with them. As we have written about extensively on our website, in our book, A Headache in the Pelvis and in our published research, most men diagnosed with prostatitis and CPPS have no prostate infection or inflammation responsible for their symptoms. Yet most men given the diagnosis don’t understand this and suffer silently when medicines aimed at the prostate fail to help. This is an essay featuring the writing of a renounced physician and expert in prostatitis/chronic pelvic pain syndrome who speaks strongly to doctors to clarify their misunderstandings about prostatitis. In his admonitions to the doctors who treat pelvic pain, he clarifies the issues than many patients are confused about.

Men are typically diagnosed with prostatitis and CPPS and are given antibiotics without any evidence of infection in the prostate.

Today, when a man comes into the physician’s office and complains about the following issues, the doctor often treats the patient as if the cause of the problem is an infected or inflamed prostate gland and routinely gives antibiotics:

  • Pain: pelvic, urinary, rectal, or genital
  • Urinary symptoms such as: frequency, urgency, dysuria (pain during urination), sitting pain, or ejaculatory discomfort

However, there is no evidence of structural disease if one types in ‘prostatitis and CPPS’. If you search these terms on the internet, this misinformation, unfortunately, comes right up from a large number of sources.

Prostatitis, meaning an infection or inflammation of the prostate gland, is often diagnosed without the doctor doing any tests to establish the validity of such a diagnosis. We have seen men who have been given multiple rounds of antibiotics who have had no evidence of infection in the prostate. We do not consider it a good practice without verifying the presence of infection.

Antibiotics are not effective for symptoms diagnosed as prostatitis when the source of symptoms is pelvic muscle dysfunction.

Antibiotic treatment of bacterial prostatitis is an achievement of modern medicine. If you have bacterial prostatitis, antibiotics are a very good treatment—certainly the only treatment. Viewing all conditions of pelvic pain and dysfunction in men, however, as acute or chronic bacterial prostatitis is an error in therapeutic judgment, diagnosis, and treatment. Despite the clear scientific evidence to the contrary, it is shocking that giving antibiotics routinely for nonbacterial prostatitis is common. This is very important to understand, particularly if you have been diagnosed with prostatitis and it has not been determined whether infection or inflammation is present.

Below, Daniel Shoskes, MD, a urologist and expert in the research and treatment of prostatitis, understands this confusion particularly from the physician’s viewpoint. He writes an excellent article that also explains how prostatitis is typically misdiagnosed and treated.

He uses the analogy of Martin Luther who nailed 95 ‘theses’ on the door of a Church in the 16th century protesting the ‘selling of salvation from sins’ where a priest would grant you absolution by giving you a piece of paper called an indulgence if you paid the priest. Luther’s protest was to protest and stop this behavior of the Catholic priests at the time.

If you have been diagnosed with prostatitis, you and your physician can learn from the article below written to physicians.

What is Chronic Pain?

Since the beginning of our work at Stanford, we have held the idea that the prostate gland is not the problem in a very large proportion of men who are diagnosed with prostatitis. Like Martin Luther, Shoskes ‘protests’ against the common confused treatment of prostatitis. If you are a patient, you can learn from his instruction to physicians. If you are physician his article is sure to be enormously instructive. Here is a summary of the theses or points he makes to doctors who treat what is commonly called prostatitis/chronic pelvic pain syndrome. At the bottom of this article is Shoskes article in full. Here are excerpts of Dr. Shoskes advice to physicians diagnosing prostatitis:

In 1517, Martin Luther posted on the local church his 95 theses entitled, “Disputation on the Power and Efficacy of Indulgences.” Luther was outraged that members of the Catholic Church were selling indulgences by telling parishioners that their sins would be absolved following payment. Well, 493 years later patients are coming to the “Church of Urology” with prostatitis and CPPS, and in return for their pieces of silver they are often handed similar pieces of paper (antibiotic prescriptions) and told that they are absolved of their illness.

Although I cannot comment on whether Renaissance-era indulgences bought their holders relief from temporal punishment in purgatory, the modern-day indulgences are not buying our patients chronic pain relief from their punishment on Earth. Based on some published data and the histories of hundreds of patients I have seen with prostatitis and CPPS, I believe that the typical standard of care ignores important published advances in our knowledge of diagnosis, classification, and therapy over the past 15 years. Enough is enough; we need a broad reformation of the medical community’s management of these disorders. Here are my (fewer than 95) theses.

  1. Stop telling everyone that they have prostatitis and CPPS as though it is one disease.
  2. You should not tell a man with pain in between his nipples and knees that he has prostatitis and CPPS without doing a proper history and physical examination.
  3. Prostatitis is the name given to a group of disorders that share surprisingly little in the way of etiology, symptoms, and treatment. Frequently, the diagnosis and management of these conditions is empiric, inadequate, ineffective, and contrary to the published literature of the past 10 years. In the present commentary, 23 “theses” are presented as a plea to physicians managing these patients to modify their ingrained approaches and incorporate simple evidence-based changes that can greatly improve outcomes and patient quality of life.
  4. Do you think that doing a prostate massage and getting some fluid is difficult and time-consuming? It is not. If you cannot do it, get a post-massage urine sample instead.
  5. Just because the patient complains of pain during a rectal exam, it does not mean that they have prostatitis.
  6. While your finger is in the rectum, palpate the muscles to either side of the prostate. If they feel rock hard or if the patient reacts and says, “That is my prostate pain,” then the patient has pelvic floor spasm. At least half of men with category III prostatitis have this condition [3], and it can get better with pelvic floor physiotherapy [4]. This is NOT a subtle finding; if you look for it, you will easily find it.
  7. Not everyone with prostatitis and CPPS needs a cystoscopy. However, if you do a cystoscopy, stop telling patients that their prostate has the “classic appearance of prostatitis.” There is no such thing.
  8. If the patient has true category II chronic bacterial prostatitis, do not give them 5 days of antibiotics. They need 2-4 weeks of antibiotic medication [5]. Advise the patient of potential side effects (e.g., tendinitis with quinolones, sun sensitivity with tetracyclines, diarrhea with any antibiotic).
  9. Do not try to eradicate category II prostatitis with nitrofurantoin. It does not penetrate the prostate [6]
  10. Everyone is busy; many men have a simple urethritis and a few have UTI. It is alright to give a course of antibiotics empirically the first time. However, if it does not work and cultures are negative, STOP GIVING THEM.
  11. Just because a patient feels a bit better on antibiotics and feels worse the day after stopping them does not mean that he has an infection. Quinolones, macrolides, and tetracyclines are powerful anti-inflammatory drugs that block cytokines directly [7]. These antibiotics kill bacteria in the prostate for up to 2 weeks, so if the patient has pain the day after stopping them but does not have a fever, IT IS NOT AN INFECTION.
  12. The normal prostate is not a sterile place. It has been reported that 68% of healthy men have gram-positive bacteri in their prostate fluid, and 8% of healthy men have classic uropathogens [8]. Every bacteria found on culture is not necessarily the cause of symptoms, especially if appropriate treatment does not improve the symptoms.
  13. Do not treat men who have pelvic pain with empiric interstitial cystitis therapies unless their symptoms actually suggest bladder involvement
  14. Do not forget to tell men about simple and often effective supportive measures
  15. Consider using a clinical phenotyping system to stratify patients for therapy, such as the one found at http://www.upointmd.com. This website gives a complete, simple algorithm for the diagnosis and multimodal therapy of chronic pelvic pain syndrome (CPPS) [10].
  16. Learn and use simple and effective therapies for the different clinical domains
  17. Patients with longstanding chronic pain can get depression and feel helpless or hopeless.
  18. Help patients to be optimistic, because most will eventually get better. Do not tell them that this is a condition they will have until the day they die.
  19. Take new symptoms seriously.
  20. In patients without UTI, do not treat an elevated prostate specific antigen (PSA) with antibiotics to see if the PSA will drop. The PSA may drop but the cancer risk does not [15].
  21. Use the NIH Chronic Prostatitis Symptom Index to monitor symptom severity, but NOT to diagnose the condition [16].
  22. Prostate consistency varies among men. Having an isolated finding of a “boggy prostate” is meaningless and does not diagnose prostatitis or any other condition.
  23. Assemble a good referral team.

Full Article

Commentary on Chronic Prostatitis and CPPS: The Status Quo Is Not Good Enough (But It Can Be)

Daniel Shoskes

Department of Urology, Cleveland Clinic, Cleveland, Ohio, USA

Submitted March 5, 2010 – Accepted for Publication April 5, 2010

www.urotodayinternationaljournal.com

Volume 3 – June 2010

COMMENTARY

In 1517, Martin Luther posted on the local church his 95 theses entitled, “Disputation on the Power and Efficacy of Indulgences.” Luther was outraged that members of the Catholic Church were selling indulgences by telling parishioners that their sins would be absolved following payment. Well, 493 years later patients are coming to the “Church of Urology” with prostatitis, and in return for their pieces of silver they are often handed similar pieces of paper (antibiotic prescriptions) and told that they are absolved of their illness. Although I cannot comment on whether Renaissance-era indulgences bought their holders relief from temporal punishment in purgatory, the modern-day indulgences are not buying our patients relief from their punishment on Earth. Based on some published data and the histories of hundreds of patients I have seen with prostatitis, I believe that the typical standard of care ignores important published advances in our knowledge of diagnosis, classification, and therapy over the past 15 years. Enough is enough; we need a broad reformation of the medical community’s management of these disorders. Here are my (fewer than 95) theses.

  1. Stop telling everyone that they have prostatitis as though it is one disease. The National Institutes of Health (NIH) classification may not be perfect, but it is a start and simple to use [1]. Category I is an acute febrile urinary tract infection (UTI). Category II is recurrent UTI with the same bacteria that is recovered from the prostate between acute bladder infections. Category III is persistent pain with or without lower urinary tract symptoms (LUTS) in men without UTI who have no other demonstrable cause. Category IV is asymptomatic and found during semen analysis or prostate biopsy. Stop telling everyone that they have the same condition and treating them all the same.
  2. You should not tell a man with pain between his nipples and knees that he has prostatitis without doing a proper history and physical examination.
  3. Nobody has to do a full Meares-Stamey 4-glass test. Who cares if there is Escherichia coli in VB1 vs VB2? It makes no difference. You should test at least a midstream sample of urine and then obtain a culture of either prostate fluid or post massage urine [2]. Unless you want false negatives, do Prostatitis is the name given to a group of disorders that share surprisingly little in the way of etiology, symptoms, and treatment. Frequently, the diagnosis and management of these conditions is empiric, inadequate, ineffective, and contrary to the published literature of the past 10 years. In the present commentary, 23 “theses” are presented as a plea to physicians managing these patients to modify their ingrained approaches and incorporate simple evidence-based changes that can greatly improve outcomes and patient quality of life.
  4. Do you think that doing a prostate massage and getting some fluid is difficult and time-consuming? It is not. If you cannot do it, get a post massage urine sample instead.
  5. Just because the patient complains of pain during a rectal exam, it does not mean that they have prostatitis.
  6. While your finger is in the rectum, palpate the muscles to either side of the prostate. If they feel rock hard or if the patient reacts and says, “That is my prostate pain,” then the patient has pelvic floor spasm. At least half of men with category III prostatitis have this condition [3], and it can get better with pelvic floor physiotherapy [4]. This is NOT a subtle finding; if you look for it, you will easily find it.
  7. Not everyone with prostatitis needs a cystoscopy. However, if you do a cystoscopy, stop telling patients that their prostate has the “classic appearance of prostatitis.” There is no such thing.
  8. If the patient has true category II chronic bacterial prostatitis, do not give them 5 days of antibiotics. They need 2-4 weeks of antibiotic medication [5]. Advise the patient of potential side effects (eg, tendinitis with quinolones, sun sensitivity with tetracyclines, diarrhea with any antibiotic).
  9. Do not try to eradicate category II prostatitis with nitrofurantoin. It does not penetrate the prostate [6].
  10. Everyone is busy; many men have a simple urethritis and a few have UTI. It is alright to give a course of antibiotics empirically the first time. However, if it does not work and cultures are negative, STOP GIVING THEM.
  11. Just because a patient feels a bit better on antibiotics and feels worse the day after stopping them does not mean that he has an infection. Quinolones, macrolides, and tetracyclines are powerful anti-inflammatory drugs that block cytokines directly [7]. These antibiotics kill bacteria in the prostate for up to 2 weeks, so if the patient has pain the day after stopping them but does not have a fever, IT IS NOT AN INFECTION.
  12. The normal prostate is not a sterile place. It has been reported that 68% of healthy men have gram-positive bacteria in their prostate fluid, and 8% of healthy men have classic uropathogens [8]. Every bacteria found on culture is not necessarily the cause of symptoms, especially if appropriate treatment does not improve the symptoms.
  13. Do not treat men who have pelvic pain with empiric interstitial cystitis therapies unless their symptoms actually suggest bladder involvement (eg, severe refractory frequency; pain that worsens with bladder filling and improves with emptying) [9].
  14. Do not forget to tell men about simple and often effective supportive measures such as sitting on a donut-shaped cushion and avoiding caffeine and spicy foods.
  15. Consider using a clinical phenotyping system to stratify patients for therapy, such as the one found at http://www.upointmd.com. This website gives a complete, simple algorithm for the diagnosis and multimodal therapy of chronic pelvic pain syndrome (CPPS) [10].
  16. Learn and use simple and effective therapies for the different clinical domains: Urinary symptoms: alpha blockers or antimuscarinics. Prostate pain or inflammation: quercetin [11] and cernilton [12]. Systemic neurologic symptoms: pregabalin or amitriptyline [13]. Pelvic floor spasm: pelvic floor physiotherapy myofascial release, NOT Kegel’s) [4].
  17. Patients with longstanding chronic pain can get depression and feel helpless or hopeless. This reaction is called catastrophizing [14]. Find out if they are feeling these emotions with a few simple questions and refer those with symptoms to other professionals for chronic pain treatment or chronic pain medication.
  18. Help patients to be optimistic, because most will eventually get better. Do not tell them that this is a condition they will have until the day they die.
  19. Take new symptoms seriously. Patients with prostatitis also can develop kidney stones and genitourinary (GU) cancers.
  20. In patients without UTI, do not treat an elevated prostatespecific antigen (PSA) with antibiotics to see if the PSA will drop. The PSA may drop but the cancer risk does not [15].
  21. Use the NIH Chronic Prostatitis Symptom Index to monitor symptom severity, but NOT to diagnose the condition [16].
  22. Prostate consistency varies among men. Having an isolated finding of a “boggy prostate” is meaningless and does not diagnose prostatitis or any other condition.
  23. Assemble a good referral team. Urologists cannot be expected to treat the parts of these conditions that do not pertain to the GU system. Team members may include physical therapists who know myofascial release therapy, pain management specialists, and psychologists who have experience with catastrophizing, chronic pain, or stress.

Conflict of Interest: Dr. Shoskes is a paid consultant to Farr

[1] Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999;282(3):236-237.

[2] Nickel JC, Shoskes D, Wang Y, et al. How does the pre massage and post-massage 2-glass test compare to the Meares-Stamey 4-glass test in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol. 2006;176(1):119-124.

[3] Shoskes DA, Berger R, Elmi A, et al. Muscle tenderness in men with chronic prostatitis/chronic pelvic pain syndrome: the chronic prostatitis cohort study. J Urol. 2008;179(2):556-560.

[4] Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155-160.

[5] Bjerklund Johansen TE, Gruneberg RN, Guibert J, et al. The role of antibiotics in the treatment of chronic prostatitis: a consensus statement. Eur Urol. 1998;34(6):457-466.

[6] Gleckman R, Alvarez S, Joubert DW. Drug therapy reviews: nitrofurantoin. Am J Hosp Pharm. 1979;36(3):342-351.

[7] Dalhoff A, Shalit I. Immunomodulatory effects of quinolones. Lancet Infect Dis. 2003;3(6):359-371.

[8] Nickel JC, Alexander RB, Schaeffer AJ, et al. Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls. J Urol. 2003;170(3):818-822.

[9] Forrest JB, Nickel JC, Moldwin RM. Chronic prostatitis/chronic pelvic pain syndrome and male interstitial cystitis: enigmas and opportunities. Urology. 2007;69(Suppl 4):60-63.

[10] Shoskes DA, Nickel JC, Dolinga R, Prots D. Clinical phenotyping of patients with chronic prostatitis/chronic pelvic pain syndrome and correlation with symptom severity. Urology. 2009;73(3):538-543.

[11] Shoskes DA, Zeitlin SI, Shahed A, Rajfer J. Quercetin in men with category III chronic prostatitis: a preliminary prospective, double-blind, placebo-controlled trial. Urology. 1999;54(6):960-963.

[12] Wagenlehner FM, Schneider H, Ludwig M, Schnitker J, Brahler E, Weidner W. A pollen extract (Cernilton) in patients with inflammatory chronic prostatitis-chronic pelvic pain syndrome: a multicentre, randomised, prospective, double-blind, placebo-controlled phase 3 study. Eur Urol. 2009;56(3):544-551.

[13] O’Connor AB, Dworkin RH. Treatment of neuropathic pain: an overview of recent guidelines. Am J Med. 2009;122(Suppl 10):S22-S32.

[14] Nickel JC, Tripp DA, Chuai S, et al. Psychosocial variables affect the quality of life of men diagnosed with chronic prostatitis/chronic pelvic pain syndrome. BJU Int.2008;101(1):59-64.

[15] Shtricker A, Shefi S, Ringel A, Gillon G. PSA levels of 4.0 – 10 ng/mL and negative digital rectal examination. Antibiotic therapy versus immediate prostate biopsy. Int Braz J Urol. 2009;35(5):551-558.

[16] Propert KJ, Litwin MS, Wang Y, et al. Responsiveness of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). Qual Life Res. 2006;15(2):299-305.

©2010 UroToday International Journal / Vol 3 / Iss 3 / June doi:10.3834/uij.1944-5784.2010.06.12

http://www.urotodayinternationaljournal.com

ISSN 1944-5792 (print), ISSN 1944-5784 (online)

Abbreviations and Acronyms

GU = genitourinary

LUTS = lower urinary tract symptoms

NIH = National Institutes of Health

PSA = prostate-specific antigen

UTI = urinary tract infection

ABSTRACT

CORRESPONDENCE: Daniel Shoskes, MD, Department of Urology, Cleveland

Clinic, 9500 Euclid Ave, Desk Q10-1, Cleveland, Ohio, 44195, USA (dshoskes@mac.com).

CITATION: UroToday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.12

The Wise-Anderson Protocol Helps a Large Majority of Men with Prostatitis

Men with ProstatitisMost of the symptoms of pelvic pain or discomfort, urinary frequency and urgency, and pain related to sitting or sexual activity in cases diagnosed as prostatitis are not related to infection. They can be caused by chronically tightened muscles in and around the pelvis. Our natural protective instincts can tighten the pelvic basin, causing pain and other perplexing and distressing symptoms. Stress is intimately involved in creating and continuing these symptoms. Once the condition starts, the symptoms tend to have a life of their own.

And the good news is that it is possible for a large majority of sufferers to reduce and sometimes eliminate symptoms. A Headache in the Pelvis: A New Understanding and Treatment for Prostatitis and Chronic Pelvic Pain Syndromes, now out in the 6th edition, describes how chronic tension in the pelvic muscles can cause many of the bewildering symptoms of prostatitis and chronic pelvic pain syndromes.

In most cases of men with prostatitis, the prostate is not the problem.

In 95% of prostatitis cases, the prostate is not the problem. In the case of men with prostatitis and chronic pelvic pain syndromes, 95% of patients who are diagnosed with prostatitis do not have an infection or inflammation that can account for their symptoms. The prostate is not the issue.

Chronic Nonbacterial Prostatitis represents by far the largest number of cases of men with prostatitis. It has been estimated that this category involves 90-95% of all cases diagnosed as “prostatitis.” Studies have shown that men undergo impairment in their self-esteem and their ability to enjoy life in general because the pain and urinary dysfunction is so profoundly intimate and intrusive.

The effect on a person’s life of nonbacterial prostatitis has been likened to the effects of having a heart attack. This includes chest pain (angina) or having active Crohn’s disease (bleeding/inflammation of the bowel). If nonbacterial prostatitis moves from a mild and intermittent phase to a chronic phase, sufferers tend to have lives of quiet desperation. Having no one to talk to about their problem, usually knowing no one else who has it, and receiving no help from the doctor in its management or cure, they often suffer depression and anxiety. Symptoms may be intermittent or constant. Few sufferers have all of the following symptoms.

In the case of men with prostatitis and chronic pelvic pain syndromes, 95% of men with prostatitis symptoms do not have an infection or inflammation that can account for their symptoms. The evidence is compelling that in these cases, the prostate is not the issue. It is the muscles of the pelvis that have gone into a kind of chronic spasm or charlie horse that is responsible for the symptoms.

The Wise-Anderson Protocol was developed at Stanford University in the Department of Urology specifically to treat what has been diagnosed as prostatitis by relaxing the pelvis and stopping the chronic spasm in the muscles of the pelvic floor. Below is a list of symptoms that the Wise-Anderson Protocol can typically help in selected men with prostatitis:

https://www.youtube.com/watch?v=cE_Uv5h0HRw

Symptoms typically helped by the Wise-Anderson Protocol
NOTE: Most men have 2 or more of these symptoms

  • Urinary frequency (need to urinate often, usually more than once every two hours)
  • Urinary urgency (hard to hold urination once urge occurs)
  • Sitting triggers or exacerbates discomfort/pain/symptoms
  • Pain or discomfort during or after ejaculation
  • Discomfort/aching/pain in the rectum (feels like a “golf ball” in the rectum)
  • Discomfort/pain in the penis (commonly at the tip or shaft)
  • Ache/pain/sensitivity of testicles
  • Suprapubic pain (pain above the pubic bone)
  • Perineal pain (pain between the scrotum and anus)
  • Coccygeal pain (pain in and around the tailbone)
  • Low back pain (on one side or both)
  • Groin pain (on one side or both)
  • Dysuria (pain or burning during urination)
  • Nocturia (frequent urination at night)
  • Reduced urinary stream
  • Sense of incomplete urinating
  • Hesitancy before or during urination
  • Reduced libido (reduced interest in sex)
  • Anxiety about having sex
  • Discomfort or relief after a bowel movement
  • Anxiety and catastrophic thinking
  • Depression
  • Social withdrawal and impairment of intimate relations
  • Impairment of self-esteem

Essays on Pelvic Pain

Essays on Pelvic Pain

WHY INTRAPELVIC BIOFEEDBACK MEASUREMENT IS NOT A RELIABLE INDICATOR OF THE USEFULNESS OF THE STANFORD PROTOCOL AND THE ISSUE OF THE THERAPEUTIC USEFULNESS OF PELVIC FLOOR BIOFEEDBACK

David Wise, PhD

I am responding to a request for a comment about the usefulness of INTRAPELVIC biofeedback measurements in determining if pelvic pain is a tension disorder and appropriate for the Stanford Protocol. My short answer is that electromyographic measurement of the anal sphincter with a biofeedback anal probe, used alone, is an unreliable measure of what is going on inside the pelvic floor. Unremarkable readings of the anal sphincter should not be used to rule out tension disorder prostatitis and pelvic pain nor to dismiss the appropriateness of a treatment of the Stanford protocol.

Here is the longer answer. In my own case, when I was symptomatic, I did an hour or two of pelvic floor biofeedback on a daily basis for a year. After many months of diligent practice, my resting anal sphincter tone was a remarkable zero after about 15 minutes of relaxation. And I was very dismayed to find that I was still in pain at the moment that the anal probe registered zero. I was also disappointed as a clinician experienced in the successful use of biofeedback for other problems. I discovered that the biofeedback measurement seemed to indicate (erroneously) that tension was not a central problem in my pelvic pain.

I did not understand then what I understand now – the electrical activity in the anal sphincter is, for the most part, the only area that the anal biofeedback sensor measures. Often this says very little about what is going on with the other 20 other muscles within the pelvic floor. Furthermore, the biofeedback sensor measures dynamic muscle tension, but not chronically shortened tissue without elevated tone. It is possible to have a relaxed anal sphincter and have pelvic floor trigger points. In this case, elevated tone and active trigger points inside the pelvic floor are not reflected in the anal sphincter measurements.

Shortened contracted tissue inside the pelvic floor, symptom-recreating trigger points when palpated, and a tension-anxiety-pain cycle are the culprits in most people with pelvic pain that we successfully treat (which can sometimes include a chronically tight anal sphincter). We consider these factors criteria for diagnosis. For example, in my experience at Stanford, people with levator ani syndrome almost always have an entirely normal resting anal sphincter tone while palpating the painful trigger points on the levator ani muscle. This is excruciatingly painful. Resolving those trigger points and relaxing the inside of the pelvic floor can resolve this pain without much change in the measurement of the tone of the anal sphincter before or after treatment.

On our website, we have video clips of an important study replicated many times. In it, we demonstrate that at rest, the electrical activity inside a trigger point in the trapezius, monitored by a needle electromyographic electrode, is quite high. At the same time, the electrical activity of the tissue less than an inch away from this elevated electrical activity is essentially electrically silent. If you used a regular biofeedback sensor to measure the general tone of the trapezius, you may well find nothing remarkable. Yet to rely on this information is entirely misleading and would incline you to miss the treatment that could substantially reduce or abate the pain and dysfunction coming from the active trigger point.

The bottom line is that in my experience, electrical measurement of the anal sphincter (or the opening of the vagina) used alone, is often a poor measure of what is going on inside the pelvic floor. While I believe biofeedback is remarkably successful for many other disorders and is one of the treatments of choice for urinary incontinence and vulvar pain, I am unimpressed with the usefulness of biofeedback in treating most male pelvic pain.

The best gauge of the usefulness of the Stanford protocol that treats the pelvic pain of neuromuscular origin is a thorough examination of the pelvic floor for trigger points that recreate symptoms and palpating for tightened and restricted muscles inside the pelvic floor. This must be done by someone with a significant amount of experience and with the kind of myofascial Trigger Point Release that we use. An inexperienced person will miss all this and I have seen many times that even physical therapists who specialize in treating pelvic pain miss trigger points referring the symptoms inside the pelvis. This is one reason why we have offered training for physical therapists who treat male pelvic pain.

We sometimes find it useful when there is a high pelvic floor resting tone because it provides an objective marker that we can compare readings to after the patient has used the Stanford protocol. The idea that pelvic floor biofeedback measurements are a reliable test of whether pelvic pain is a tension disorder represents a misunderstanding of the problem and should not be relied on, especially when the readings are normal. Pelvic floor electromyographic measurement monitoring the anal sphincter is one of those medical tests where a positive finding may mean something and point toward the proper therapy and a negative result doesn’t prove anything.

The Latest CPPS and Wise-Anderson Protocol Research

The Latest CPPS and Wise-Anderson Protocol Research

 

The following are excerpts and abstracts of publications regarding the latest CPPS and Wise-Anderson Protocol research:

The following is an abridged version. For the full version, see the link at the bottom.

CPPS

Department of Urology, School of Medicine, Stanford University, Stanford, California.

PURPOSE: A combination of manual physiotherapy and specific relaxation training effectively treats patients. However, little information exists on myofascial trigger points and specific chronic pelvic pain symptoms. We documented relationships between trigger point sites and pain symptoms in men with chronic prostatitis/chronic pelvic pain syndrome.

MATERIALS AND METHODS: We randomly selected a cohort of 72 men who underwent treatment with physiotherapy and relaxation training from 2005 to 2008. Patients self-reported up to 7 pelvic pain sites before treatment and whether palpation of internal and external muscle trigger points reproduced the pain. Fisher’s exact test was used to compare palpation responses, i.e., referral pain, stratified by the reported pain site.

RESULTS: Pain sensation at each anatomical site was reproduced by palpating at least 2 of 10 designated trigger points. Furthermore, 5 of 7 painful sites could be reproduced at least 50% of the time (p <0.05). The most prevalent pain sites were the penis in 90.3% of men, the perineum in 77.8% and the rectum in 70.8%.

Puborectalis/pubococcygeus and rectus abdominis trigger points reproduced penile pain more than 75% of the time (p <0.01). External oblique muscle palpation elicited suprapubic, testicular and groin pain in at least 80% of the patients at the respective pain sites (p <0.01).

CONCLUSIONS: This report shows relationships between myofascial trigger points and reported painful sites in men with chronic prostatitis/chronic pelvic pain syndrome. Identifying the site of clusters of trigger points inside and outside the pelvic floor may assist in understanding the role of muscles in this disorder and provide focused therapeutic approaches.

PMID: 19837420 [PubMed – indexed for MEDLINE]

Chronic prostatitis chronic pelvic pain syndrome

Department of Urology, Stanford University Schoolof Medicine, Stanford, California.

PURPOSE: Chronic pelvic pain in men has a strong relationship with biopsychosocial stress and central nervous system sensitization may incite or perpetuate the pain syndrome. We evaluated patients and asymptomatic controls for psychological factors and neuroendocrine reactivity under provoked acute stress conditions.

MATERIALS AND METHODS: Men with pain (60) and asymptomatic controls (30) completed psychological questionnaires including the Perceived Stress, Beck Anxiety, Type A behavior and Brief Symptom Inventory for distress from symptoms. Hypothalamic-pituitary-adrenal axis function was measured during the Trier Social Stress Test with serum adrenocorticotropin hormone and cortisol reactivity at precise times, before and during acute stress, which consisted of a speech and mental arithmetic task in front of an audience. The Positive and Negative Affective Scale measured the state of emotions.

RESULTS: Patients with chronic pelvic pain had significantly more anxiety, perceived stress and a higher profile of global distress in all Brief Symptom Inventory domains (p <0.001), scoring in the 94th vs. the 49th percentile for controls (normal population). Patients showed a significantly blunted plasma adrenocorticotropin hormone response curve with a mean total response approximately 30% less vs. controls (p = 0.038) but no differences in any cortisol responses. Patients with pelvic pain had less emotional negativity after the test than controls, suggesting differences in cognitive appraisal.

CONCLUSIONS: Men with pelvic pain have significant disturbances in psychological profiles compared to healthy controls and evidence of altered hypothalamic-pituitary adrenal axis function in response to acute stress. These central nervous system observations may be a consequence of neuropsychological adjustments to chronic pain and modulated by personality.

Chronic prostatitis

Department of Urology, Stanford University School of Medicine, Stanford, California

PURPOSE: The impact of chronic pelvic syndrome on sexual function in men is underestimated. We quantified sexual dysfunction (ejaculatory pain, decreased libido, erectile dysfunction, and ejaculatory difficulties) in men with chronic pelvic pain syndrome assessed the effects of pelvic muscle Trigger Point Release concomitant with paradoxical relaxation training.

MATERIALS AND METHODS: We treated 146 men with a mean age of 42 years who had had refractory chronic pelvic pain syndrome for at least 1 month with Trigger Point Release/paradoxical relaxation training to release trigger points in the pelvic floor musculature. The Pelvic Pain Symptom Survey and National Institutes of Health –Chronic Prostatitis Symptom Index were used to document the severity/ frequency of pain, urinary and sexual symptoms. A global response assessment was done to record patient perceptions of overall therapeutic effects at an average 5-month follow-up.

RESULTS: At baseline 133 men (92%) had sexual dysfunction, including ejaculatory pain in 56%, decreased libido in 66%, and erectile ejaculatory dysfunction in 31%. After Trigger Point Release/paradoxical relaxation training specific Pelvic Pain Symptom survey sexual symptoms improved an average of 77% to 87% in responders that are greater than 50% improvement. Overall a global response assessment of markedly or moderately improved, indicating clinical success, was reported by 70% of patients who had a significant decrease of 9(35%) and 7 points (26%) on the National Institutes of Health- Chronic Prostatitis Symptom Index (p<0.001). Pelvic Pain Symptom Survey sexual scores improved 43% with a markedly improved global response assessment (p<0.001) but only 10% with moderate improvement (p=0.96).

CONCLUSIONS: Sexual dysfunction is common in men with refractory chronic pelvic pain syndrome but it is expected in the mid fifth decade of life. Application of the Trigger Point Release/paradoxical relaxation training protocol was associated with significant improvement in pelvic pain, urinary symptoms, libido, ejaculatory pain and erectile and ejaculatory dysfunction.

PubMed – U.S. National Library of Medicine

Journal of Urology

Abstract
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.

Anderson RU, Wise D, Sawyer T, Chan C.

Department of Urology, Stanford University School of Medicine, Stanford, California, USA. rua@stanford.edu

From the Department of Urology (RUA, CC), Stanford University school of Medicine, Stanford, Sebastopol (DW) and Los Gatos (TS), California.

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 pelvic pain symptom survey (PPSS) and National Institutes of Health-CP Symptom index. Patient response assessment 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 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.

chronic pelvic pain syndrome

PURPOSE: Abnormal regulation of the hypothalamic-pituitary-adrenal-axis and diurnal cortisol rhythms are associated with several pain and chronic inflammatory conditions. Chronic stress may have a role in the disorder of chronic prostatitis/chronic pelvic pain syndrome related to initiation or exacerbation of the syndrome. We tested the hypothesis that men with chronic pelvic pain syndrome have associated disturbances in psychosocial profiles and hypothalamic-pituitary-adrenal-axis function.

MATERIALS AND METHODS: A total of 45 men with CPPS and 20 age-matched, asymptomatic controls completed psychometric self-report questionnaires including the Type A personality test, Perceived Stress Scale, Beck Anxiety Inventory and Brief Symptom Inventory for distress from physical symptoms. Saliva samples were collected on 2 consecutive days at 9 specific times with strict reference to time of morning awakening for evaluation of free cortisol variations, reflecting secretory activity of the hypothalamic-pituitary-adrenal-axis. We quantified cortisol variations as the 2-dat average slope of the awakening cortisol response and the subsequent diurnal levels.

RESULTS: Men with CPPS had more perceived stress and anxiety than controls (p<0.001). Brief Symptom Index scores were significantly increased in all scales (somatization, obsessive/compulsive behavior, depression, anxiety, hostility, interpersonal sensitivity, phobic anxiety, paranoid ideation, psychoticism) for chronic pelvic pain syndrome, and Global Severity Index rank for CPPS was 93rd vs. 48th percentile for controls (p<0.0001). Men with chronic pelvic pain syndrome had significantly increased awakening cortisol responses, mean slope of 0.85 vs. 0.59 for controls (p<0.05).

CONCLUSIONS: Men with CPPS scored exceedingly high on all psychosocial variables and showed evidence of dysfunctional hypothalamic-pituitary-adrenal-axis function reflected in augmented awakening cortisol responses. Observations suggest variables in biopsychosocial interaction that suggest opportunities for neurophysiological study of relationships of stress and chronic pelvic pain syndrome.

pelvic pain syndrome

Below is a summary of the latest research findings about the Stanford Protocol presented at the American Urological Association in San Antonio, Texas, May, 2005

RESULTS: 138 men with refractory CPPS enrolled and treated; average age 40.5 years (range 16-79). Disease duration: median 31 months (range 1-354) 59% (81/138) of patients had clinically meaningful improvements (“>25-100% decreased symptom core) in total pain as reported on Stanford PPSS(table 1)

Of these, 39% of patients achieved “>50%

Symptom improvement Total pain score 69% Urinary sc80%

After a median of five myofascial TrP release treatments , median baseline total pain scores of 13 decreased significantly by 8 points (p<0.001), Stanford PPSS (Table 2)

72% of patients reported GRAs indicating marked (46%) or moderate (26%) improvements in their symptoms.

Both symptom surveys, the NIH-CPSI and the Stanford PPSS, reflected similar levels of symptoms improvement after treatment (fig. 2)

CONCLUSION:

MFRT combined with PRT (treating these patients with the Wise-Anderson Protocol) resulted in moderate to marked improvements in symptoms in 72% of patients.

Treatment is based on the new understanding that certain chronic pelvic pain reflects a self-feeding state of tension in the sore pelvic floor perpetuated by cycles of tension, anxiety and pain. Our premise is that in addition to releasing painful myofascial trigger points, the patient needs to supply the central nervous system with information or awareness to progressively quiet the pelvic floor. The patient moves from being a passive, helpless victim to an active participant/partner in healing.

Contact us for a PDF of the Full Research.

Pelvic Pain Syndrome: An Address to the National Institute of Health

The following is an address by Dr. Wise to the National Institutes of Health

(NOTE: Portions of this transcript have been edited for clarification.) 

The goal of the Wise-Anderson Protocol is to enable the patients to reduce and/or resolve symptoms without dependency on drugs or others to do so for them.

David Wise, PhD
Plenary address to the
National Institutes of Health (NIH)
Scientific Workshop on Prostatitis/Chronic Pelvic Pain Syndromes
Baltimore, Maryland
October 21, 2005

Introduction

Thank you for giving me the opportunity to discuss the Wise-Anderson Protocol at this National Institutes of the 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 syndrome for a period of over twenty years. At one time or another I had almost all of the symptoms you typically hear from patients, and then unrelieved, unrelenting pain 24 hours a day 7 days a week. I had no one to talk to and 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 Wise-Anderson Protocol. I gratefully remain pain and symptom-free. So I speak to you both 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 the pelvic pain syndrome with the experience of resolution.

The development of the Wise-Anderson Protocol.

I also have the unusual fortune of meeting and collaborating with Rodney Anderson at Stanford University, director of the Stanford Pelvic Pain Clinic. He is a remarkable physician to whom I have great gratitude for his big mind and willingness to think outside of the box. I have also collaborated with Tim Sawyer, an extraordinary physical therapist. My purpose in the few minutes is to, as clearly as I can, explain the methodology we developed at Stanford over an eight-year period and which we continue to study and refine.

Paradigm shift: chronic pelvic pain is not an infection, but a tension disorder.

I am aware that the Wise-Anderson Protocol represents a significant paradigm shift. We don’t believe the vast majority of those diagnosed with prostatitis/chronic pelvic pain syndrome suffer from a prostate infection or occult bacteria, an autoimmune disorder or compressed pelvic nerves.

We see the overwhelming majority of cases diagnosed as the result of the overuse of the human reflex to tighten the genitals, rectum, and contents of the pelvis in response to anxiety, pain, or trauma by chronically contracting the pelvic muscles. This tendency becomes exaggerated in predisposed individuals, particularly those with a tendency toward anxiety who respond to stress by habitually and unconsciously tightening their pelvic floor. Such a tendency is invisible. No one can see it. Usually, the person who has such a tendency is unaware of it. And the consequences of this tendency are also invisible except for the complaints of discomfort, pain and urinary dysfunction that the sufferer eventually expresses.

This state of chronic constriction creates pain-referring trigger points in and around the pelvis, which in turn, creates an inhospitable environment for the nerves, muscles, blood vessels, and structures within the pelvic basin. This results in a self-feeding cycle of tension, anxiety, and pain, which has been previously unrecognized and untreated. It is a kind of short circuit. Patients with pelvic pain often wind up in the emergency room when this short circuit gets out of control.

The havoc of chronic tension in the pelvis and the tension-anxiety-pain cycle.

Most people neither appreciate nor understand the havoc that chronic tension plays in the pelvic floor. It is the same havoc that chronic neck and shoulder tension plays in a headache, chronic back tension plays in low back pain, or chronic jaw clenching plays in temperomandibular disorder.

There can be psychological, physical, or social triggers to the chronic tightening of the pelvic floor. Once this cycle begins, it tends to have a life of its own and carries on even when the initiating triggers have passed.

The purpose of the Wise-Anderson Protocol is to break this cycle and to help patients prevent its reoccurrence. The methodology is low tech. The aim is to get patients off of all drugs and to end patient dependency on professional help. The responsibility for the success of the treatment is largely up to the patient’s compliance with the protocol. Patients who look for a quick external fix to their condition tend to lack the motivation that the Wise-Anderson Protocol demands. Such individuals tend not to be good candidates.

The problem in the great quest to restore the pelvis to a relaxed and symptom-free state is that pain, tension, and trigger point activity in the pelvis is intimately tied to emotional reactivity and autonomic arousal. They feed each other. Anxiety is the gasoline on the fire of pelvic pain. This is also why placebo is so influential in this condition. This tie-up with autonomic arousal and pelvic pain has never been addressed and is essential to any effective treatment.

How to understand pelvic pain if you don’t have it.

I want to take a moment to help those of you who have never had pelvic pain syndrome to experientially understand it from my viewpoint. In this way, you have more of an intuitive sense of what we do. If I were to ask you to tighten your pelvic muscles for the next ten seconds as though you were stopping yourself from urinating, most of you could do this. If I ask you to tighten your pelvic muscles for one minute, probably fewer of you would be willing.

Now imagine you were to continually tighten up your pelvic muscles for a half an hour, one hour, twelve hours, twenty-four hours, one month, six months, one year, two years, five years, ten years. Most people consider it inconceivable to be stuck in an activity of such self-abuse and self-inflicted pain. No one here would dare venture voluntarily. I suggest that the consequences of this kind of chronic tension lead to the symptoms of which most patients diagnosed with prostatitis/cpps suffer.

I want to talk about the relationship between anxiety and trigger point activity.

Anxiety makes trigger points hurt more.

Here are pictures of electrical activity in trigger points at baseline, during relaxation and under stress, in a study done by Gevirtz and Hubbard in San Diego. On the left, we see trigger point activity at baseline… notice that the electrical activity in the trigger point is significantly elevated from the electrical activity of the non-tender tissue just 1/4 inch away. Notice now the center reading after the subject has begun relaxation. The electrical activity of the trigger point normalizes. Notice now the electrical activity of the trigger point during a stressor. The electrical activity is significantly activated well beyond baseline readings. These studies have been duplicated hundreds of times and clearly show the strong impact of autonomic arousal on trigger point activity.

The Wise-Anderson Protocol represents an effective and safe non-drug, non-surgical treatment for pelvic pain syndrome. It provides far better outcomes than conventional therapies for most patients with no long term side effects. I will briefly summarize the results of our study published this year in the July issue of Journal of Urology. At Stanford, we studied 138 patients who were referred to us, usually by physicians who could no longer help these patients because they had failed all conventional therapy. We were the court of last resort. After treatment, using the Wise-Anderson Protocol, 72% of these refractory patients reported that they marked moderate improvements in their symptoms as reported on the Global Response Assessment. These responses reported as marked and moderate improvements by patients were commensurate with appreciable (10.5% decrease in marked and a 6.5 % decrease) decreases in the NIH-CPSI scores.

Although we have not systematically studied the numbers, it is my observation that positive results from our protocol improve with the increased competence of the patient in our methodology over time. In other words, in my experience, patients’ symptoms appear to improve the longer they follow our protocol.

The two essential elements: Paradoxical Relaxation and pelvic floor Trigger Point Release.

Let me touch on the Wise-Anderson Protocol Trigger Point Release. Time does not permit any detailed discussion of the Trigger Point Release we use and have developed. Suffice it to say that we work with approximately 40 trigger points related to pelvic pain syndrome. We apply the same principles of Trigger Point Release pioneered by Travell and Simons for external muscles, to the release of the internal muscles. A comprehensive list and detailed illustrations of trigger points related to male pelvic pain syndrome and a detailed description of our method are found in the 3rd edition of our book, A Headache in the Pelvis: A New Understanding and Treatment for Prostatitis and Chronic Pelvic Pain Syndromes.

Wise-Anderson Protocol Trigger Point Release.

Here are some notable aspects of the Trigger Point Release protocol we use.

  • We use primarily Trigger Point Release oriented therapy and not myofascial release therapy. They are not the same.
  • Trigger points that refer pelvic pain exist both inside and outside the pelvic floor.
  • The most common trigger points in male pelvic pain are found in the anterior levator ani, the obturator internus, adductors and surprisingly, in the quadratus lumborum and the psoas. I don’t expect you to take in this list but only to know that we have found there are specific trigger points related to specific pelvic pain symptoms.
  • Trigger points tend to be found anteriorly in patients with more urinary symptoms and posteriorly in patients complaining more of rectal pain.
  • We use a method called pressure release on a trigger point, holding it for 60-90 seconds– this length of time, which is usually difficult for many therapists to routinely hold, is critical to the release of the trigger point.
  • We rarely do trigger point injection, only with stubborn external trigger points. Even then, we never advise the use of botox in such injections. We never do or advise internal injections.
  • The number of treatments varies between 5-40 sessions.
  • We generally discourage kegel exercises and do not use pelvic floor biofeedback or electrical stimulation.
  • Patients are taught external and internal trigger point self-treatment. We have found that patients can do the majority of the Wise-Anderson Protocol physiotherapy themselves once they are shown how to do it.
  • We continue to develop an internal wand which we sometimes prescribe for patients when they have no partner or other resources to work with the internal trigger points at home. This has to be used carefully and only after the patient has been thoroughly instructed in its use.
  • In the Wise-Anderson Protocol, Trigger Point Release is done concomitantly with Paradoxical Relaxation.

A word about using only physiotherapy or Paradoxical Relaxation in treating pelvic pain syndrome.

Both Paradoxical Relaxation and Wise-Anderson Protocol physiotherapy aim to rehabilitate the patient’s pelvic floor and to stop the habit of chronically tightening the pelvic muscles under stress. For most patients, each method is necessary but not sufficient in restoring the pelvis to a symptom-free state. The intrapelvic Trigger Point Release we use rehabilitates the pelvic muscles and allows them to relax. The focus of Paradoxical Relaxation is to allow a rehabilitated pelvis to profoundly relax and to support the healing mechanism of the body with respect to a chronically sore and contracted pelvic floor. Importantly, a central purpose of Paradoxical Relaxation is to modify the habit to unconsciously and habitually tighten the pelvis.

It is tempting to look for a quick fix to the problem of Prostatitis/CPPS. As we know, there are no drugs or surgical procedures that satisfactorily help the pain and dysfunction of Prostatitis/CPPS. There is no quick fix. While physiotherapy is essential to our protocol, it is insufficient to resolve the problem. Most patients who have suffered from this problem and simply do physiotherapy discover this.

Generally, if patients do not learn to voluntarily and regularly relax the pelvic floor and reduce their own nervous system arousal, in the long term, manual physiotherapy efforts at rehabilitating the pelvic floor tend to be short lived. Patients easily go back to the old habits that brought about the condition in the first place. A stressful hour in traffic or a fight with one’s partner after the best of physiotherapy session can easily reactivate the trigger points that the therapist has just deactivated. I have seen this with many patients and know it personally.

Paradoxical Relaxation in the Wise-Anderson Protocol.

Few would disagree with the value of profoundly relaxing a painful pelvis. The question is: how is it done? Consider how difficult it is to relax even you neck muscles in the middle of an ordinary upset in your life. Relaxing tension associated with pelvic pain syndrome and anxiety is more difficult.

Tightening against pelvic pain worsens it.

Paradoxical Relaxation seeks to reverse the dysfunctional reflex to tighten against pelvic pain syndrome and the fear associated with it. We can call this chronic tension dysfunctional protective guarding. This reflexive tightening is dysfunctional because it exacerbates rather than protects against pain and anxiety.

The reaction to tighten the pelvis in response to pain paradoxically exacerbates it. Pain is a stimulus that triggers fight or flight. Pain does not reflexively trigger repose and rest, which is in fact what we ask patients to do. Accepting tension as a way to relax it is counter- intuitive. It is this strategy that can reduce the pain or take it away, and thus, we name our method Paradoxical Relaxation.

Dysfunctional protective guarding is at the heart of other functional disorders.

Dysfunctional protective guarding exists in a number of other functional somatic disorders. They include tension headache, temperomandibular disorder, lower back pain, non-cardiac chest pain, and idiopathic dyspepsia among others.

I think a modified Wise-Anderson Protocol may be useful in some of these disorders as well. The central strategy of Paradoxical Relaxation comes from the insight that accepting tension relaxes it. In Paradoxical Relaxation, the emphasis is on tension and not on pain even though pain is usually perceived peripherally during the relaxation training.

Paradoxical Relaxation is not new. The major insights of this therapeutic strategy derive from the world’s oldest wisdom traditions and practices that focus on quieting the mind and body, and from the methodology of my teacher Edmund Jacobson who developed the technique of progressive relaxation.

The paradox of Paradoxical Relaxation can be expressed in the following ways:

  • That accepting tension relaxes it
  • That accepting what is, is the fastest way to change it
  • That what we resist persists
  • That the requisite for changing something is first accepting it as it is, on its own terms

This happens to apply to stubborn pelvic muscle tension. Remarkably, this insight has the potential to allow patients to dissolve pelvic pain syndrome.

Accepting tension is both counter-intuitive and functional in terms of relaxing stubborn tension associated with functional somatic disorders I have mentioned above. Paradoxical Relaxation is a modern day method to implement this perennial wisdom for ordinary people who have pelvic pain syndrome.

In Paradoxical Relaxation, we ask patients to do an extraordinary thing: to focus on, and then rest with their tension when they are anxious and in pain. Learning to do this requires many hours of practice. For the first 3 months, patients are asked to do 1- 1 1/2 hours of relaxation guided by 1 of a 38 lesson sequenced recorded course. The course consists of over a year of 1-2 daily sessions of relaxation training. This can’t be learned from stand-alone relaxation tapes. Patients must receive many hours of instruction by a teacher competent in the method. The Wise-Anderson Protocol is the slow fix.

Pelvic Pain syndrome is almost always accompanied by a constant level of fear.

Paradoxical Relaxation asks patients to relax while they feel pain and fear. Patients have to be reassured that it won’t hurt them to relax while they experience their fear. It is common for patients to feel that if they accept their tension and fear and pain, that they have given up and that they will never get rid of their condition. These notions are obstructions to learning and must be addressed directly. Here is the paradox again–relaxing with and accepting fear is most likely to dissolve it.

To the novice, relaxing with pelvic pain syndrome, chronic tension, and chronic anxiety is scary.

And so it is, in this context, that we ask people to sit still with it all. Relax with the pain, fear, helplessness, desire for distraction, fear of the method failing, fear that their life is over and that they will have to live in chronic pain until they die, and fear of getting their hopes up. This is scary territory. Teaching patients this relaxation protocol addresses all of these concerns and takes time and many repetitions to gain some degree of competence.

The Wise-Anderson Protocol is done in a 6-day intensive immersion clinic.

The format of the Wise-Anderson Protocol is unusual as it is done in a six-day intensive immersion clinic involving some 30 hours of treatment. At this clinic, patients are trained in Paradoxical Relaxation, receive daily physiotherapy, are trained in self-administered Wise-Anderson Protocol Trigger Point Release, specific stretches, and related physiotherapy techniques. It is the goal of this clinic for the patient to be able to self-administer most of the protocol without reliance on additional treatment.

The goal of the Wise-Anderson Protocol is to enable patients to resolve symptoms without drug dependency.

The Wise-Anderson Protocol represents a very different paradigm from one in which a patient who feels he has no control over his symptoms comes to the doctor to be cured and submits himself passively for the remedy. Our aim is to make patients independent. It is our goal that patients trained in our protocol find themselves in a position to take care of and possibly resolve this condition themselves without dependency on drugs or others to do so for them.

Paradoxical Relaxation: Relieving a Painful Pelvic Floor

 

https://www.youtube.com/watch?v=kBnu9Hl0B1A

Paradoxical Relaxation relaxes the tension and shortened muscles within a painful pelvic floor.

This involves a daily practice of the cultivation of effortlessness in the presence of pain, anxiety, and tension.

Paradoxical Relaxation has two components: The first is a breathing technique used at the beginning of relaxation, a coordination of heart rate and breathing. This reduces respiration to approximately 6 breaths per minute. The second component is the instruction given for the remainder of the session. These direct the patient to focus attention on the effortless letting go of tension in a specified area of the body, accepting residual tension that does not easily release.

b. Patients are asked to listen to approximately 1 hour of recorded relaxation instruction daily. These allow the focus of individual predetermined sites, including frontalis, jaw, neck, shoulders, arms, hands, upper back, chest, stomach pelvis, legs, and feet. Each site is the focus of practice for approximately 2 weeks, and the entire course lasts for approximately a year and two months. Home practice is done daily and includes the use of 46-recorded lessons varying in length from 7 minutes to 45 minutes. The focus on the relaxation of a painful pelvic floor is generally avoided for the first several months of relaxation training. This is because such a focus can exacerbate symptoms until competence in relaxation is gained in neutral, non-painful areas.

c. Relaxation instruction guides the patient to redirect attention away from discursive thinking and daydreaming. The target range of brain wave activity is low-frequency alpha.

d. Catastrophic thoughts that increase sympathetic arousal arising during relaxation are identified. A cognitive therapy protocol is used to help the patient reduce the impact of such thinking.

The process of Paradoxical Relaxation is a slow one.

Respect for and cooperation with this very slow process is essential to success. When the desire of the patient aims to hurry the body’s slow letting go of deeply ingrained tension, they usually fail to relax a painful pelvic floor. In Paradoxical Relaxation, the instruction is given to let go of tension. This effortless relaxation usually occurs in small and unremarkable steps. Recognizing and working with these small gradations of relaxation is essential.

Edmund Jacobson described residual tension in detail in his long career in the development of relaxation therapy, which began in 1908. The patient is instructed to keep attention focused on residual tension without trying to change it. When attention is distracted by visual or conceptual thinking throughout the protocol, the patient is instructed to refocus attention on the remaining tension without aiming to achieve any result. It is essential that the patient understands that deep relaxation occurs when attention rests in sensation and not in thinking.

Instructions alternate between letting go of the tension that easily lets go and effortlessly feeling the remaining tension. The tension that is being focused upon without effort usually abates during this process. The patient is instructed to permit this abatement to occur. Sometimes the tension does not abate or even increases, and the patient is instructed to remain softly focused on the remaining sensation without an intention to change it. The concept underlying this protocol is that one does not relax stubborn, residual tension directly but instead is effortless in remaining continually aware. Relaxation occurs without any effort on the part of the patient. Exerting any effort increases tension. This is because relaxation is identical to effortlessness.

We specifically discourage patients from focusing on the relaxation of a painful pelvic floor for the first 4 months of treatment, as the patient’s attachment to the relief of symptoms tends to interfere with the conscious and simultaneous effortless attention on tension. The focus on the relaxation of the upper body is most easily accomplished and usually results in a reduction of pelvic tone. The focus on the relaxation of the pelvic musculature requires that the patient makes the distinction between pain and tension. The aim of the protocol then becomes directed to the tension and not the pain in the area of a painful pelvis.

https://www.youtube.com/watch?v=ToZQDIq90rs

Learn to profoundly relax pelvic tension in the presence of pain and anxiety.

Pain and anxiety stimulate additional tension and aversion. Without instruction, most patients who are not properly instructed are loathe to sit still in the presence of unresolved pain. The instructions of Paradoxical Relaxation train patients to stop the tension-anxiety-pain cycle by focusing on tiny residual tensions that they can easily relax. At the same time, they can accept the tension and pain that remains. Attention is redirected from negative cognitions and focuses on letting go of tiny and often ignored tensions in the body unconsciously aimed stopping the pain and tension – efforts that only exacerbate symptoms. In the paradoxical acceptance of pain and tension that does not easily relax, the patient learns how to ride the tension down in small steps that require acceptance of what formerly has been unacceptable and frightening.

Chronic pelvic pain syndromes tend to be self-perpetuating disorders in which a patient’s pain causes a reflexive tightening of the pelvic floor, which in most patients, often prompting a flurry of negative thinking. The reflex to contract against pain actually increases pain. Negative and catastrophic thinking fan the fire of the pain by igniting the electrical activity in the trigger points referring pain in the pelvis. The tension-anxiety-pain cycle is a major obstacle to the reduction of a painful pelvic floor. It feeds itself in the moment that a patient is asked to relax the pelvic tension. The disruption of the self-feeding cycle of tension, anxiety, and pain can be accomplished by a select group of patients who become competent in Paradoxical Relaxation.

While we utilize an extensive set of recorded tapes in the Wise-Anderson Protocol relaxation method, instruction is necessary to train patients in the method. Below we discuss the issue of stand-alone relaxation tapes.

Why Paradoxical Relaxation cannot be learned from recorded tapes in the absence of instruction.

(This is part of a response sent to the webmaster of the chronicprostatitis.com website on the issue of stand-alone relaxation tapes.)

As we have discussed, I do not sell the audio Paradoxical Relaxation course on a stand-alone basis. There are numerous relaxation tapes that can be bought from many different sources and people are free to buy them. I could sell the recorded lessons I use on a stand-alone basis – I have certainly had enough requests – but choosing not to do this is neither a casual nor a self-serving decision on my part. I have a short answer and a long answer to explain.

Here is the short answer why.

I have no confidence that someone can learn to relax a painful pelvic floor from a relaxation tape without instruction from someone who is competent in the method and without intrapelvic Trigger Point Release. I do not want to associate myself with making available a half measure that appears to offer something substantial but does not.

When I was symptomatic, I tried many remedies that all seemed reasonable but ultimately failed to help me. They left me hopeful at first, then disappointed, and disheartened. A stand-alone relaxation tape, in my opinion, is a half measure. Half measures give little chance of offering real recovery from chronic pelvic pain syndromes. I have decided that if I am to err, I will err in the direction of not offering anything instead of offering a half measure in which I have no confidence.

Here is the long answer why.

Learning to relax the pelvic muscles and muscle tenstion from a relaxation tape is like learning to play the violin by listening to recorded instructions. In my experience, such an endeavor usually fails; the person gets discouraged and usually gives up. To learn the violin, you need instruction from someone who plays the violin. The more accomplished the player, the better. You want to learn the violin from someone who plays it every day, who is excited about it, and whose expertise is obvious. Imagine learning the violin from someone who does not play it. The obstacles to learning to play the violin and learning to relax deeply are very similar — except learning to deeply relax a painful pelvic floor is harder than playing the violin.

Our instinct is to tighten against pain, not relax. Yet, I found that relaxing with the tension of certain kinds of pelvic pain can dissolve it. Learning to do this is a major event in someone’s life because it is from this place that it can become possible to break the cycle of pain, anxiety, and tension and allow the sore and irritated tissue in the pelvic floor to heal.

There may be some unusual individuals who can deeply relax on a consistent basis by simply using recorded instructions and I applaud them and wish them well. The reason I do not have any faith in this is that to relax a painful pelvic floor and maintain a relaxed pelvic floor over time, (and not everybody can learn how to do this) requires guidance with regard to many issues. Examples of the issues that must be addressed are:

  • What to do with the pain during relaxation
  • How to not add tension the tension of ‘trying’ to relax tension
  • When to use breathing to focus distracted mind and when to cease the breathing technique
  • What to do when emotions arise that the tension in the pelvic floor is suppressing
  • How to accept the resistance to accepting the tension
  • What it means to rest while there is discomfort
  • What to do when a plateau is reached and tension doesn’t reduce
  • What to do when symptoms abate during relaxation and then resume quickly afterward
  • How to relax in the office or on the bus

I have seen many patients distort instructions and become frustrated in their practice of relaxation. A relaxation tape usually addresses none of this and the successful resolution of these issues makes the difference between success and failure.

To learn to relax a painful pelvic floor, especially in the presence of pain, is an enigma and the method to do this is anti-intuitive. It is often frightening for someone with pelvic pain to sit still with their pain and their thoughts without guidance. In my experience, people avoid the kind of relaxation required to relax a tight and painful pelvis if there is no support and the recorded tapes wind up on the shelf.

Few professionals whom I have offered to train in teaching this method have been interested. I think that the reason is that they were not motivated, like my pain motivated me, to spend the time learning to do the relaxation themselves. The best teachers of this method are turning out to be the patients I have trained who are doing well and use it on a daily basis.

The History of the Stanford Protocol and Wise-Anderson Protocol

https://www.youtube.com/watch?v=DCw9LCHKsys

The History of the Wise-Anderson Protocol & Prostatitis Symptoms 

The Wise-Anderson Protocol began with David Wise, PhD, a psychologist in California who had suffered from Chronic Pelvic Pain Syndrome for many years. He contacted several urologists, including Dr. Rodney Anderson, a professor of Urology at Stanford University School of Medicine and leading practitioner and expert in the field of pelvic pain. Dr. Anderson was considered to be the court of last resort for patients with pelvic pain and prostatitis who had not been helped by any other treatment.

Through many years of suffering, David Wise, PhD discovered a way to become free of symptoms.

He reported the method he used to Dr. Anderson, who headed the chronic pelvic pain clinic in the Department of Urology at Stanford University Medical Center. Dr. Wise then began working as a Visiting Research Scholar at Stanford’s Department of Urology alongside Dr. Anderson, treating men and women with a variety of diagnoses. This included chronic pelvic pain, prostatitis, levator ani syndrome, pelvic floor dysfunction, pelvic floor myalgia, interstitial cystitis, and other chronic pelvic pain syndromes. Dr. Wise and Dr. Anderson worked together for eight years at Stanford, treating patients with the protocol that Dr. Wise used in his own recovery. At Stanford, the protocol was administered to patients on an individual basis in a conventional medical format.

During these early years, the results of the Wise-Anderson Protocol were presented at meetings for pelvic pain and to prostatitis researchers at the National Institutes of Health and other scientific meetings. In 2003, Dr. Wise and Dr. Anderson published the first edition of A Headache in the Pelvis, a book that described the new protocol in detail. In the first edition of A Headache in the Pelvis, this protocol was called the Wise-Anderson Protocol. As the protocol became more widely disseminated, those on the internet dubbed it the Stanford Protocol. The term Wise-Anderson Protocol is now again used, although it was popularly called the Stanford Protocol for many years. The Wise-Anderson Protocol is identical in form and substance to what has been called the Stanford Protocol in the public arena.

When Dr. Wise left Stanford he began treating patients using the Wise-Anderson Protocol in a six-day comprehensive clinic in Sonoma County, California. The immersion clinics have been offered in Sonoma County since 2003. Patients come from all around the world to learn the Wise-Anderson Protocol and prostatitis causes.

Competence in self-treatment has produced the best results in patients who have learned the Wise-Anderson Protocol.

The focus of the Wise-Anderson Protocol has evolved over the years to train patients to do the protocol without the assistance of professionals. While the immersion clinics in Sonoma County are not affiliated with Stanford, Dr. Anderson continues to evaluate patients with pelvic pain at Stanford and refer patients to the immersion clinic. Additionally, Dr. Anderson continues conducting and publishing research on the Wise-Anderson Protocol, as well as other medical research on a variety of subjects. From 2003 to the present, Dr. Rodney Anderson, Dr. David Wise and Tim Sawyer (Physical Therapist) have actively and enthusiastically collaborated on research involving patients seen at both clinics.

Since 2003, Anderson, Wise and Sawyer have published a number of articles in the Journal of Urology on data from patients they have collaboratively seen and treated. Abstracts of these articles can be found in the “Latest Published Research” post on this blog. In 2005, Dr. Wise was a plenary speaker at a National Institutes of Health conference on pelvic pain. There he presented research results on the Wise-Anderson Protocol. Dr. Wise presented the protocol to scientific meetings, including those of the International Continence Society. Both Dr. Wise and Dr. Anderson have written chapters in medical textbooks describing the Wise-Anderson Protocol. At the time of writing this section, Dr. Anderson presented a clinical poster at the American Urological Association. A report of Dr. Anderson’s presentation at the American Urological Association was published in Medscape Medical News. It was titled Intensive Therapy Regimen Helps Men With Chronic Pelvic Pain Syndrome.

Tim Sawyer, who is the architect of the physiotherapy program, was chosen to write the pelvic floor section for the new edition of Travell and Simons. It was called Myofascial Pain and Dysfunction: The Trigger Point Manual. This is the authoritative medical textbook on myofascial trigger point therapy. Tim Sawyer trained and treated patients with Dr. Janet Travell and Dr. David Simons, the physicians who introduced trigger point therapy to medicine. Dr. Travell was the White House physician to President John F. Kennedy, and Tim Sawyer is considered one of the top pelvic floor physical therapists in the world.

Recently, Anderson, Sawyer, and Wise published a pioneering article in the Journal of Urology. The article showed the relationship of trigger point location and symptoms in patients with pelvic pain, using the data from the immersion clinics held in Sonoma County. Another article updating these results has been completed and recently submitted for publication. Currently, Anderson, Wise and Sawyer have completed a study on the effectiveness of a new internal trigger point physiotherapy device for the self-treatment of trigger points. The study data on the physiotherapy device is being prepared for publication and will hopefully be published soon.