PELVIC FLOOR DYSFUNCTION
THE WISE-ANDERSON PROTOCOL TREATMENT FOR PELVIC FLOOR DYSFUNCTION
The Wise-Anderson Protocol, originally developed in the Stanford University Department of Urology, is devoted to the treatment of pelvic floor dysfunction. The results of our treatment protocol have been published in scientific journals and the results have been shown to help a large majority of patients who complied with its regimen.
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WHY IT IS EASY TO GET CONFUSED: DIFFERENT NAMES FOR PELVIC FLOOR DYSFUNCTION ARE GIVEN DEPENDING ON WHETHER IT IS DIAGNOSED BY A UROLOGIST, GASTROENTEROLOGIST, COLORECTAL SURGEON OR GYNECOLOGIST
People suffering from the pelvic pain are often given a variety of diagnoses and treatments depending on the medical subspecialist they see. This is confusing both to patients and to doctors. Some common names for pelvic floor dysfunction are:
- Chronic Pelvic Pain
- Chronic Pelvic Pain Syndrome
- Levator Ani Syndrome
- Coccydynia or Coccygodynia (Tail Bone Pain)/Chronic Rectal Pain
- Chronic Proctaglia
- Prostatitis/Non Bacterial Prostatitis
- Prostatodynia (Prostadynia)
- Interstitial Cystitis
With pelvic floor dysfunction, patients look quite normal and conventional medical imagery and blood test results are typically unremarkable. Thus, patients are often told there is nothing wrong with them by doctors who have little understanding of pain in pelvic floor muscles.
PELVIC FLOOR DYSFUNCTION IS BOTH A LOCAL AND SYSTEMIC DISORDER
Relief from pelvic floor dysfunction, with its often bewildering and troubling symptoms, is what those seeking help from any treatment are looking for when they go to a doctor. Conventional medical treatment, however, almost universally misunderstands pelvic floor dysfunction. The remedies it offers at best are partial and short-termed and at worst, remedies like surgical intervention or certain injections, can exacerbate the problem.
The fundamental error of conventional treatment is that it does not grasp the fact that pelvic floor dysfunction is both a systemic and local problem. It is systemic in that the nervous system is chronically aroused in pelvic pain patients, chronically tightening up the pelvic muscles and blocking the healing of the sore, irritated, painful, chronically tightened pelvic tissue. Chronic worry, anxiety and nervous agitation in pelvic pain patients results in chronically tightened muscles in the pelvis that remain sore, unable to heal. Without regularly reducing anxiety and the up regulated nervous system to enable the sore pelvic tissue to heal, and without doing direct physical treatment of the sore contracted pelvic tissue, pelvic floor dysfunction remains. We train our patients to address both the local and systemic dimension of this problem in our 6 day immersion clinic.
Our 6-day clinic, offered throughout the year, is devoted to resolving both the local and
systemic dimensions of pelvic floor dysfunction by training our patients in the most advanced
internal and external physical therapy self-treatment (local treatment), and practicing our
relaxation protocol, Extended Paradoxical Relaxation, which is aimed at reducing nervous system arousal daily.
WHY PELVIC FLOOR DYSFUNCTION BECOMES CHRONIC
One of the reasons traditional medicine struggles to treat pelvic floor dysfunction is because it often fails to identify and address the tension-anxiety-pain-protective guarding cycle.
The pain caused by the chronic contraction of the pelvis triggers a survival instinct in the body to protectively guard itself against the pelvic pain. It is the same instinct that causes the muscles in our body to retract from the pain when we inadvertently touch a hot stove. Similarly, when there is pain in the pelvis, the pelvic muscles tighten up to guard against it.
Unlike the functional self-protective reflex that causes us to pull our hand away from a hot stove, the reflex to tense up pelvic muscles against pain in the pelvis is dysfunctional because it tightens what is already tight and tends to make the pain worse. The painful and sore pelvis tends to be reactive to anxiety. Anxiety produces increased tension, increases activity in trigger points which then produces more pain, which triggers protective guarding, which then produces more anxiety; thus, the cycle perpetuates.
THE GOAL OF THE WISE-ANDERSON PROTOCOL IS TO GIVE PATIENTS THE ABILITY TO STOP THIS CYCLE
The therapeutic strategy of the Wise-Anderson Protocol focuses on breaking the tension-anxiety—pain-protective guarding cycle described above. We do this by focusing on both the physical and mental dimensions of pelvic floor dysfunction. Physically we train our patients to restore the ability of the pelvic muscles to relax and contract by teaching them to do trigger point release and myofascial release inside and outside the muscles. Mentally we teach patients to calm down their nervous system and relax the pelvic muscles using Extended Paradoxical Relaxation.
THE WISE-ANDERSON PROTOCOL
6-Day Immersion Clinic
We began treating varieties of pelvic floor dysfunctions in patients at Stanford University in 1995 in conventional office visits. In 2003, we reorganized our treatment in a private practice in the form of a 6-day immersion clinic held in Santa Rosa, California. The clinic, limited to 14 patients and offered throughout the year, has evolved to implement the Wise-Anderson Protocol, a treatment to teach patients to rehabilitate the chronically contracted muscles of the pelvic floor and to reduce anxiety daily. The Wise-Anderson Protocol, done daily at home by patients we have trained in self-treatment, has helped to give many their lives back. The purpose of our self-treatment is to help patients become free from having to seek additional professional help. For over a decade, research has documented our results of training patients with self-treatment.
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SYMPTOMS OF PELVIC FLOOR DYSFUNCTION
(Most of our patients have at least two or more symptoms)
- Dysuria can be very painful and thus, urination becomes a large ordeal and sets off further pain
- Burning or pain with urination is often disconcerting and associated with pelvic floor dysfunction
- Sometimes people feel no pain during urination but only after
- When the chronic spasm and myofascial contraction of the pelvic muscles is resolved, in many of our patients, dysuria is also resolved
- Often nocturia is a major problem because a patient’s sleep is so disturbed he or she is exhausted all the time
- Exhaustion from sleep deprivation tends to feed into the cycle of tension, pain, protective guarding and anxiety
- Sitting is one of the great sufferings and scares in pelvic pain and makes all aspects of normal life difficult
- Patients often look for the padded seats in a restaurant because sitting is so uncomfortable
- Sitting pain can make it miserable to sit with friends or family and socialize
- Difficult to fly or drive for any distance without pain
- Sometimes patients have to go on disability because they can’t work because their job is a sitting job
- Sitting can trigger or exacerbate discomfort/pain/symptoms and can hurt in the front, back of the pelvis, or both
- Sitting pain usually starts out milder in the morning but increases after sitting through the day, and can last into the night
- Genital pain is usually referred from the anterior levator ani and one of the easier symptoms to resolve
- In men, pain at the tip and shaft of the penis is a common symptom
- In men, sometimes there is a redness at the tip, which can be accompanied by an irritation so that rubbing against underwear is uncomfortable
- In women, pain inside the vagina, on one side or another is common
- In women, sometimes vulvar pain accompanies pelvic pain
- Relief after a bowel movement occurs when the tight pelvic muscles relax
- Discomfort after a bowel movement can be particularly disconcerting if it triggers symptoms more strongly for the rest of the day
- Little is written about this symptom when it occurs in the absence of hemorrhoids or anal fissures, but in our experience it is common
- The mechanism of defecation typically involves the filling up of the rectum with stool, which then sends a signal for the internal anal sphincter and puborectalis muscle to relax and triggers the experience of urgency to have a bowel movement
- Once the stool passes through the relaxed anal sphincter and out of the body, the internal anal sphincter reflexively closes
- When someone has pelvic pain and exacerbation of symptoms after a bowel movement, we propose that the internal anal sphincter tends to ‘over close’
- That is, it tightens up more than it was tight before the bowel movement and sometimes appears to go into a kind of painful spasm
- Post bowel movement pain appears to occur less frequently when someone is relaxed and not hurried, and whatever contributes to a more relaxed state during a visit to the bathroom may reduce this symptom
- Resolving post bowel movement pain in our patients tends to occur as their entire chronic pelvic muscle tension releases
- Reduced interest in sex is common with pelvic pain
- In muscle related pelvic pain, there is typically no pathology of the physical structures involved in sexually activity
- Our view is that reduced libido is a mix of anxiety, reduced self-esteem and pelvic pain which all mitigate against sexual arousal and sexual interest, and resolution of pain and dysfunction of the pelvic muscles usually resolves reduced libido
- The scariest part of pelvic pain is the catastrophic thought that it will never go away
- It is a focus that distract your attention away from your life and with many patients, paints an unacceptable future
- Sleep disturbance is common
- Many patients wake up anxious, wondering if the pain has gone, disappointed every day that it isn’t
- Patients either wake up to urinate or because of pain and anxiety
- We wrote a paper about precipitous rise in cortisol in the morning amongst pelvic pain patients. Cortisol and Men with Chronic Prostatitis– American Urological Association Poster 2007
- Helplessness and hopelessness is the real suffering with chronic pelvic pain
- Helplessness comes from a patient’s inability to stop pain/discomfort that is draining and scary
- Hopelessness in pelvic pain patients arises when they can’t see anything on the horizon that might help them
- Increased discomfort hours or the day after sexual activity is common in men and women
- Our explanation about why there is often an increase in discomfort during or after sexual activity in men and women with chronic pelvic pain syndromes is as follows:
- There is a significant increase in nervous system arousal during sexual activity
- Orgasm causes strong contractions of the pelvic, prostate and seminal vesicle muscles that last about once a second during orgasm
- The pleasure spasm of orgasm in the form of the increased series of contractions can tighten up the pelvic muscles further
- This increased tightening temporarily contracts an already contracted area that is also contracted initially and this is why orgasm tends to throw the patient further above the symptom threshold
- When our patients learn to release the muscles inside the pelvic floor, they usually can feel this increased muscle contraction
- After a certain time-frame (from hours to days or weeks), the pelvic muscles whose tone is elevated after orgasm relax and return to their baseline levels
- Also the normal default tightened state of the pelvic floor reasserts itself (which is back to some degree of pain or discomfort when a person has chronic pelvic pain syndrome)
- For this reason, we do not recommend increasing sexual activity (as has often been suggested by physicians our male patients have seen) when a person has an increase in symptoms after sex
- Ordinary stresses, as well as extraordinary stress, tend to increase symptoms
- When stress has triggered pelvic pain, the stress also tends to trigger the tension-anxiety-pain-protective guarding cycle that continues after the stress has gone
- Because sex can be painful or painful afterward, there is often a conditioned withdrawal from having sex to avoid pain
- This anxiety in men can result in difficulty in maintaining an erection which adds to relationship or courting difficulties, particularly in younger patients
- Anxiety about having sex, in our view, is the major reason for performance anxiety and what is ‘medicalized’ as erectile dysfunction
- In our experience, when pelvic pain and dysfunction goes away, anxiety and what is called “erectile dysfunction” connected to it tends to go away as well
WHAT TEMPORARILY CAN HELP:
- Hot water or heat often helps temporarily
- Heat sometimes flares up symptoms; patients feel relief using cold packs or ice
- The family of drugs called benzodiazepines can often relieve symptoms for a few hours and are helpful when used skillfully
- Benzodiazepines are addictive and when used regularly for pelvic pain, they can lose their effectiveness
- Benzodiazepines typically make the user tired and should not be used when driving or having to be alert
- Naps, or vacations can sometimes help reduce pain