A solution to pelvic pain

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Millions of men and women suffer from pelvic pain, discomfort or dysfunction that drugs, surgery and conventional treatment do not help. If you’re one of them, you may have experienced rectal, genital or abdominal discomfort or pain, increased discomfort or pain sitting down, discomfort or pain during or after sexual activity, or urinary frequency, urgency and hesitancy.

You’ve probably gone to a doctor or even many doctors who found little or no physical basis for your symptoms. Your tests came back normal. You may have been diagnosed with pelvic floor dysfunction, prostatitis, chronic pelvic pain syndrome, levator ani syndrome, pundendal neuralgia, coccydynia (tailbone pain), chronic proctalgia, proctalgia fugax, pelvic floor myalgia, piriformis syndrome, interstitial cystitis, urethral syndrome or other related diagnoses, but found no relief. All of these different diagnoses are essentially different names for the same problem, a problem we refer to as a ‘headache in the pelvis.’

The resolution to the kind of pelvic pain that we routinely treat has eluded the best medical minds. Conventional or not, for the most part, there is very little that has helped pelvic floor-related pain and dysfunction.

An intimate look at pelvic pain

The major contributing factor involves a chronically knotted up, contracted pelvis – typically a physical response to years of worry – that leads to tight, irritated pelvic floor tissue, leading to a reflex response in the pelvic tissue of protective guarding, which creates a self-feeding cycle that gives pelvic pain a life of its own. Sore pelvic floor tissue, once established, doesn’t have a chance to heal the way other human tissue heals. You can think about the ongoing reflex protective guarding of irritated, sore pelvic tissue as a kind of ongoing pelvic charley horse.

This chronic charley horse keeps the pelvic tissue irritated, preventing its natural healing. Ongoing pain from this sore tissue leads to protective pelvic muscle guarding, anxiety and chronic painful tissue irritation.

There is a simple psychophysical basis for chronic pelvic pain symptoms.

Whether you’re a man or a woman, the stressors that cause the pelvic floor to chronically tighten can be psychological or physical. What typically triggers symptoms of pelvic pain is the result of long-standing worry, in which the pelvic floor is chronically tightened up. At times, pelvic floor dysfunction can occur as the result of an intense physical or emotional trauma or a series of traumatic mental or physical stresses.

Once set off, protective pelvic guarding/bracing aggravates already sore, painful pelvic floor muscles, and a self-perpetuating cycle begins.

The reason that chronic pain and dysfunction resist a simple mechanical fix is because the irritated pelvic muscles not only require release from contraction, but an ongoing quiet nervous system environment to allow the sore and irritated tissue to heal. The pelvic floor muscles are unique in that they are engaged much of the time and participate centrally in the normal daily functions of life, including urination, defecation, support and balance of the body, lifting, walking, sitting and sexual activity.

Without releasing the chronic contraction of the pelvic muscles and placing them in a daily and extended healing environment, the daily activities of life prevent the healing of the irritated pelvic muscle tissue.

We use a three-part system: rehabilitation through the release of pelvic floor-related trigger points by internally and externally stretching the myofascial tissue that has been constricted, a special form of relaxation that regularly reduces anxiety and nervous system arousal, and a change of mindset among the patients about their condition.

Step 1: De-activating internal and external trigger points

Most of the patients we see with chronic pelvic pain syndromes have sore, tightened tissue containing trigger points in their pelvis and related muscles.

A trigger point is a taut band within a muscle that is painful either spontaneously or when touched, and that creates pain at the site being touched or refers pain to a site remote from it.

Trigger points are exquisitely sensitive, and it is not uncommon for the patient to jump when the trigger point is pressed. We determine the presence of internal trigger points through a digital rectal or digital vaginal examination, where the doctor inserts a finger inside the rectum or vagina and presses on the muscles to assess the tissue and find trigger points.

A 1994 study sheds much light on the relationship between trigger points and stress. Walter McNulty of the California School of Professional Psychology, in San Diego, California, and his colleagues inserted a needle electrode directly into a trigger point and monitored its electrical activity with a machine called an electromyograph. The higher the electrical activity in a trigger point, the higher the level of pain.

When the study participants were given the stressful task of doing mental arithmetic, the electrical activity of the trigger points increased, while the adjacent, non-trigger point tissue remained essentially electrically unresponsive.1

This kind of experiment has been replicated hundreds of times. These findings are remarkable. They suggest that in some way the nervous system that is connected to the stress of emotional activity and arousal is selectively connected to trigger points and not to non-trigger point tissue in the muscle.

It may seem like a challenge for most people to gently reach inside the pelvic floor with a gloved, lubricated finger, rectally or vaginally, in order to release pelvic pain-related trigger points, spasm and areas of restriction. In fact, it is relatively easy to do once one’s initial reluctance and awkwardness are overcome, and we have demonstrated its effectiveness scientifically.2

Trigger point release, especially at the beginning of therapy, is relatively easily done and unremarkable, but does require some level of instruction from an experienced practitioner.

Step 2: Extended Paradoxical Relaxation

The purpose of Extended Paradoxical Relaxation (EPR) is to offer a daily nervous system environment that will provide a regular healing setting for the sore trigger points and contracted tissue in and around the pelvic floor.

A way to describe relaxation at the deepest level is resting with what is. It includes acceptance of your aches and pains, your tension,
your fidgetiness, and your resistance to letting go.

The paradox is that when you give up trying to make something positive happen, that is when it is most likely to happen for you.

• Relaxation needs to be done without distractions, but the most important thing is that you practice it regularly, even if the circumstances aren’t ideal.

• A darkened room is easy to relax in. It is often helpful to use an eye pillow, which has the advantage of dimming the field of vision, even in a room with a lot of light. Phones are turned off, and the expectations are set with others in the household for you not to be disturbed during the relaxation time.

• Extended Paradoxical Relaxation is the cultivation of effortlessness, not doing anything, including not exerting effort to breathe any particular way. It is resting in the present moment and just ‘being’ at the most granular level.

• It is sometimes helpful to have a pen and a piece of paper nearby – a pressing thought can be written down so as to get on with the relaxation, undisturbed by trying to remember what the thought requires to be done.

• It can be done sitting or lying down. The tongue should be comfortable without any attempt to control it.

• Breathing should be easy and uncontrolled. Generally, we don’t ask our patients to pay attention to the breath or control it. This is in contrast to other relaxation or meditation methods that focus on deep breathing or controlled breathing in order to relax.

• If one feels like moving or fussing while doing relaxation, we suggest you simply move or fuss. Eventually, the mind and body quiet down from such irritations.

• In Extended Paradoxical Relaxation, we focus on the slight, subtle sensation that occurs when one asks oneself to relax. With great patience, perseverance, and earnestness, we ask our patients to devote themselves to remaining focused.

• The best time to do Extended Paradoxical Relaxation is when you have the most energy. People usually find that they have this kind of energy in the morning. EPR requires energy because paying attention requires energy.

• It is best to regularly do EPR so the body gets used to a regular time of quiet. We advise people to do Extended Paradoxical Relaxation at least once a day for an extended period of time whenever possible.

• Practice relaxation every day. If a session is missed, it can simply be made up. Hot baths, sauna, or other ways of warming the body are remarkable means of significantly reducing anxiety and nervous system arousal on a temporary basis.

Noting sensations

One of the essential instructions in EPR is to be okay with the sensation you’ve chosen to focus on, whether it’s painful or pleasurable. How do you do that? Being okay with a sensation, especially if it contains tension, requires your willingness to tell yourself that something is okay and to want to believe it.

When you accept whatever sensation is inside you, you simply feel it and make a moment-to-moment choice to do nothing about it. The sensations that appear outside your control, that are often unpleasant, that won’t relax readily no matter how strong or subtle, bring on the tension that you have to work with and accept. In accepting this residual tension and the discomfort it causes, we are also letting go of the desire in this moment to be more relaxed and to feel more at ease or more whole.

Step 3: Your attitude affects your condition

Pelvic pain usually does not occur in someone who feels balanced, relaxed and happy. It tends to be the expression of what is out of balance, fearful and out of sorts. Your pelvic pain and dysfunction, viewed this way, can be considered an intimate adviser about your life. Pelvic pain is not your enemy. In fact, it is helpful to consider that pelvic pain is part of the main curriculum of your life.

The pain is not the deepest source of suffering when someone struggles with chronic pelvic pain syndrome. If we knew for sure that we were going to get better, most pelvic pain and discomfort, while not being something we would choose, would be okay.

Catastrophic thinking, doubt, and fear are usually the worst of the sufferings in dealing with pelvic pain.

It is the meaning you give to the symptoms that causes the real suffering. Indeed, the catastrophic meaning you give to the symptoms and the impact of this meaning on the pain and tension are what make dealing with pelvic pain so difficult.

Consider the following young man, who called us in a state of great anxiety about his condition. He was handsome, accomplished, wealthy and admired by his peers. Women fell in love with him regularly. His friends loved him. He was successful in his profession. He had it all.

For three years, he had experienced pain at the tip of his penis along with some postejaculatory discomfort and problems with urinary frequency and urgency. The doctors he saw told him that they could find nothing wrong, and there was nothing to worry about. He believed them. He characterized these symptoms to himself as an insignificant annoyance and went on with his life with little concern.

He then happened to go on the internet and started reading the scary stories of those who suffer from pelvic pain, which offered no light at the end of the tunnel. His pain became much worse quickly, and he spiraled into a dark and deeply upset state. His sleep became disturbed. He withdrew socially. He began to worry about others abandoning him because of his condition. His pain escalated from being a minor annoyance to becoming sometimes unbearable. His life became a hell.

This went on for quite some time. When we began our protocol, he became clear about what was wrong with both him and his symptoms, and his condition improved dramatically.

He began having days of no symptoms. Instead of taking a negative spiral downward, he began a positive spiral out of his hole. He stopped his catastrophic thinking and saw the possibility of becoming free of symptoms.

Think your pain away

There is scientific evidence demonstrating that your perspective directly affects your pain. Dr Richard Gevirtz, McNulty’s colleague and one of the investigators who discovered that stress increases the level of electrical activity (and pain) in trigger points, described it this way: “Where people have a clear-cut model of what is wrong with them and understand that there is something they can do to help themselves, they decatastrophize what is going on within them. This changed view may physically lower their pain by reducing the effects of sympathetic nervous system arousal inside their trigger
points.”

Common symptoms in men and women

Below is a list of the most common symptoms we see in the patients we have been able to help. Most experience several to many of the symptoms, but rarely all of them.

• Frequency and urgency

• Nocturia (frequent nighttime urination)

• Reduced urinary stream and hesitancy of urination

• Sitting pain

• Perineal discomfort (pain between the scrotum and anus or vagina and anus)

• Discomfort or relief after a bowel movement

• Genital pain

• Pain above the pubic bone (suprapubic pain)

• Coccyx (tailbone) pain (coccygodynia/coccydynia)

• Low back pain (on one or both sides)

• Groin pain (on one or both sides)

• Dyspareunia (pain with sexual activity)

• Sexual dysfunction

The Wise-Anderson pressure principle

Some pelvic tissue triggers dysfunctional protective guarding. Indeed, especially in the first months of doing the protocol, the internal tissue tends to continue to be very sore and tender, and sometimes any contact with the tissue may temporarily increase discomfort. Thus, the goal is to find a ‘sweet spot’ pressure level in each patient that allows for a gentle, competent palpation of the restricted tissue while avoiding being overly aggressive in a way that could be irritating to the tissue.

Once the patient has gently inserted a generously lubricated gloved finger, the finger simply rests inside without pressing on any tissue. The patient just feels the presence of the finger inside the anal sphincter or vaginal opening while applying no pressure. This gentle, stress-free time is to help the pelvic floor and internal anal sphincter or vaginal opening adapt to having the finger there.

From this neutral position, the tip of the finger is then pressed against a specific restricted area of tissue. Pressure with the finger stops at the moment that one begins to experience an intimation of pain or discomfort.

We usually recommend maintaining this minimal static pressure against the tissue for 30-90 seconds, depending upon the circumstances of each patient.

When the patient is ready to move on to another trigger point or area of tenderness, we first suggest that the finger rest inside for a moment in the neutral position, not pressing in any direction.

Over time, as the trigger point and restricted tissue resolves its irritability, more pressure is typically required to elicit the same pain or discomfort on tender, contracted internal tissue.

Techniques used inside the pelvic floor

The most common of our techniques, the Pressure/Release Technique, has also been called the technique of ischemic compression.

You will understand this method if you apply pressure to the back of your left hand with your right index finger. When you press on the back of your hand and then release it, a little white spot is temporarily created where the blood was momentarily pushed out by the finger pressure. This is what we do inside the pelvic floor.

We feel for the typical ‘taut band’ characteristic of the trigger point and apply pressure to it to help release it. We hold this pressure for approximately 15-90 seconds, while always staying in communication with our patient about his or her level of discomfort.

Pressing on trigger points like this, especially at first, can be quite uncomfortable. The tolerance patients have for pressure release of trigger points is improved to the extent to which they feel they can control the duration and intensity of the pressure. We proceed systematically throughout the pelvic floor, applying this pressure release technique.

It is important to relax while doing trigger point release so that the tissue is not tightening up against the pressure that aims to lengthen and release it.

After a patient is instructed in how to carry out his or her trigger point release with a finger, the discomfort of both the external and internal trigger points tends to diminish, and we are left with certain remaining and often stubborn, sore trigger points. We ask patients, when it is possible for them, to take hot baths before a self-treatment session as a way of helping to loosen muscles that are tight and constricted. We often suggest a warm compress to patients or ask them to take a warm bath after treatment as well.

This internal trigger point work is done in conjunction with more traditional external trigger point massage around the legs and hips (see diagrams below), if pain is felt in those areas.

External trigger points to relieve pain