Symptoms and Treatments in Pelvic Pain: Using Modern Terms to Explain Nervous System Arousal

Pelvic Pain Symptoms and Treatments: Using Modern Terms to Explain Nervous System Arousal

Airplane mode, in fact, is an excellent metaphor in terms of describing the pelvic pain symptoms and treatments of the pelvic pain sufferer.

Using the term “airplane mode” to explain the nervous system of the pelvic pain sufferer.

“Airplane mode” consists of two elements:

  1. Setting aside enough sacrosanct, uninterrupted time and space for Paradoxical Relaxation sessions (which we discuss as carving out 2-3 hours a day);
  2. Doing the mental practice of Paradoxical Relaxation during this uninterrupted time and space that allows the nervous system to “down regulate”, reduce its frenetic activity, and cease prompting the squirting of adrenaline into the bloodstream with every thought that worsens the chronic pelvic floor contraction and the feeding of the tension-anxiety-pain-protective guarding cycle.


The meaning of airplane mode

To be sure, the technological revolution of the past 20 years has given us not only the ability to be electronically connected at all times but has also provided a new vocabulary to describe our new behavioral world of texting, instant messaging, emailing, and twittering. For example, the term airplane mode is a new concept that has come about to address the idea of temporarily disabling our communication devices from the information and connectivity superhighway. As we know, airplane mode is used when someone is on an airplane or other situation where sending or receiving communications and data are disallowed. In airplane mode, our phone or tablet assumes an unresponsive state where it is not vulnerable to the dings and rings of incoming calls, texts, emails, and other data.

Indeed, when your phone is on airplane mode, you essentially resume the situation humankind was in before the advent of cellular communication systems. You are alone, and unless someone actually engages you in person, you are not vulnerable to being disturbed or prompted. The situation is not unlike the old context of placing a “do not disturb” sign on your hotel room door – you are creating an environment where you cannot be disturbed by the world nor it by you.

A frozen, locked-up computer

Anyone who has ever worked with a computer has experienced the frustrating situation of the computer “freezing up” or “locking up” and having to be manually re-set. Many times we intuitively attribute the freeze to requiring the computer to do too much too quickly. Overwhelmed, it simply stops working properly and ceases to fulfill our processing demands. One perspective is that the computer has simply gotten too far away from its default modes, and the complexity of processing so many demands in a matter of seconds has interfered with basic functions. Interestingly, despite all of the advances in technology, a standard method for fixing the freeze is to manually reset the computer by holding down the power button. By turning the power off and then back on again, we reset the original default modes. This almost always results in the computer resuming its proper functioning.

An analogy can be drawn between our intuition about why computers freeze up and why Colin Powell’s observation that “things always look better in the morning” is intuitively correct. It is also why we have a sense that a good night’s sleep makes everything better. Once locked up elements of body and mind come back into full function. This is also true of going away on vacation. After several days on the beach, away from the demands of business and life, our system is renewed.

With regard to the symptoms and treatments of chronic pelvic pain, a person experiences 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 a hectic life, the muscles of the pelvic region have engaged in a pattern of chronic, unyielding protective guarding to cope. These pelvic muscles, normally pain-free and able to relax and contract easily, are rigid and chronically contracted and dysfunctional.

Just like the number of programs running on a computer when it freezes up, pelvic pain patients cannot ignore the circumstances of their lives. In our patients, we often see that a vicious, self-feeding cycle has developed in the patient that looks like this:

Even in the face of significant pelvic pain and muscle dysfunction, fear, and anxiety, many of our patients continue to meet the demands in their lives without being able to reset. Typically each day the patient tightens up the pelvic muscles as a coping mechanism to the pressures of life. As the pelvic muscles get more restricted and painful, function deteriorates. In many patients, the pelvic muscles become so contracted that basic functions such as urination, defecation, sitting, and sex become very difficult and painful.

Resetting the default mode of the pelvis by resetting the nervous system

In order to restore the nervous system and the pelvic floor that it controls to a healthy default mode, we propose that the body requires a regular “airplane mode”. This frees the nervous system from stress, demands, pressure, expectations, and requirements. You can have a safe zone protected from disturbance or stimulation. The pelvic floor needs time to ease painful hypertonus and myofascial restriction and be free of any stressful or taxing input from the nervous system. By practicing long hours of airplane mode through the use of our method of Paradoxical Relaxation, the quieted nervous system allows the pelvic floor to “let down its guard” and heal from the effects of the chronically upregulated and aroused nervous system. Through this practice (and along with our trigger point physical therapy regimen), the pelvic muscles are led back to their natural default mode of supple and functional myofascial tissue.

Man as a response animal

Indeed, we can look at the human being as a “response” organism, constantly adjusting to our various issues. Most important is the survival instinct, and while we no longer face the reality of wild animals or food scavenging, the nervous system equates many non-survival issues to survival. This is especially true when the nervous system is hypersensitive to stress in the form of an email, text, or task at work.

We have all experienced that domino effect of catastrophic thinking where one largely insignificant email can be turned into a disastrous conclusion by a fearful mind. When catastrophizing is a common event in someone’s thinking, the pelvic muscles typically contract and often out of a person’s awareness. In the 6th edition of our book, A Headache in the Pelvis, we discuss the remarkable story of a middle-aged woman who was in the middle of an internal myofascial trigger point session with an experienced physical therapist. While the physical therapist had a finger inside her vagina, pressing on an internal trigger point, the woman began to talk about a politician she loathed. Our colleague, the physical therapist, reported that as her patient expressed rage about this politician, her pelvic muscles tightened around our colleague’s finger to a point where our colleague was afraid her finger would be injured. When our colleague said to her patient, “can you feel that?”, referring to the astonishing tightening of her pelvic floor muscles, her patient said back to her “Feel what?” Our colleague’s patient tightened her pelvic muscles ferociously and didn’t even know it!

When you switch to airplane mode and step beyond the world’s ability to stimulate you, you are actually saying: “You can rest. All is calm, everything is okay.” You are giving yourself permission to relax. We tell our patients that this is the environment we want to create for the practice of Paradoxical Relaxation, one of the key methods of the Wise-Anderson Protocol. Spending enough time in this airplane mode, while doing Paradoxical Relaxation (and in conjunction with our physical therapy protocol), may be the most powerful way to break the cycles of protective muscle guarding and to assume a posture of the deepest and most profound relaxation. The muscle tension physiologically returns to a normal, homeostatic state and the organism can take a much-needed break from survival responses.

The problem of treating pelvic pain as solely a physical problem

The vast majority of articles written in medical literature about the kind of pelvic pain we treat focuses solely on the physical dimensions of this condition and the traditional treatment of drugs and procedures, injections, nerve blocks, and sometimes surgery. Recently, there has been interest in the psychological/behavioral dimension of pelvic pain, discussing patients who suffer from trauma, anxiety, or other forms of emotional disturbance. And yet these discussions usually only address what we consider to be paltry and not commensurate with the enormity of the problem being addressed, believing that small doses of cognitive therapy, mindfulness meditation or breathing exercises mixed in with traditional treatments could be helpful. We see these overtures as merely “half-measures”. In our experience with thousands of patients over the years, these minor interventions have had little effect on long-standing, chronic symptoms. While we welcome discussions of the psychological/behavioral aspects of chronic pelvic pain, and believe that cognitive therapy and mindfulness are legitimate and important treatments for certain conditions, our work with patients who have suffered from chronic pelvic pain for many, many years has led us to believe that only more profound nervous system intervention has a chance of any real traction.

The engine of muscle based pelvic pain is chronic anxiety and an upregulated nervous system

In our two decades of treating this condition, we see that the engine of muscle related pelvic pain is an upregulated nervous system acting on a chronically shortened and trigger pointed, myofascially restricted pelvis. What we mean by “upregulated nervous system” is this that the human computer – the mind and central nervous system – is running much faster and processing more stimuli than is healthy. We propose that the pelvic floor is in dire need of a break, in dire need of airplane mode for long periods of time every day. All of the wisdom and spiritual traditions in the world have a concept of “Sabbath” where rest is not only allowed but understood as absolutely critical for health and well-being.

We see pelvic pain as a functional disorder. It generates a self-feeding cycle of tension and the resulting formation of pain. Treating the muscles with a specific method of trigger point physical therapy is essential. However, our experience has shown us that the great perpetuating factor of this condition, indeed the foundation of it, is an upregulated nervous system generating unhealthy amounts of pelvic floor tension. Pelvic floor tension that is constant and unrelenting and from which there is no adequate amount of airplane mode, no Sabbath. This reflects our current societal predicament of a 24/7 society where few if any days are held sacrosanct, where there is little or no time off, and no airplane mode. Patients who commit wholeheartedly to reducing their nervous arousal and anxiety do far better than patients simply focusing on the physical state of their pelvic muscles.

It is essential to commit enough time to airplane mode

We have found that most of our patients require a good 2-3 hours of airplane mode daily in order to create the environment of healing necessary for the rehabilitation of the pelvic muscles. If you are “on” all day, the sore pelvis is continually being contracted and irritated by the avalanche of stimuli agitating the nervous system. The researchers Gevirtz and Hubbard have shown that even the slightest increase in nervous arousal is immediately reflected in increased electrical activity of painful trigger points. Their studies on electromyographic monitoring of their patients’ trigger points demonstrate this dramatically.

Symptoms and treatments in pelvic pain: 2-3 hours of paradoxical relaxation per day

It is important to say that airplane mode is an inner state as well as an outer space where stimuli from the outside do not intrude. Paradoxical Relaxation is airplane mode for the mind and body and involves engaging the will to practice doing nothing, practicing effortlessness, of not judging, guarding, tightening, resisting, trying, accomplishing, or any other activity that requires effort and nervous system upregulation. For many of our patients, we have observed that it is not enough to practice Paradoxical Relaxation for short, half hour or even one hour lessons. Symptoms and treatments of pelvic pain at small intervals, in patients who are chronically hyper-aroused whether they realize it or not, simply do not allow enough time on airplane mode to quiet down the roaring nervous system. A significant number of our patients do far better with 2-3 hours of Paradoxical Relaxation daily to release the pelvic muscles from their chronic guarding and contraction.  In airplane mode you are free, and you can take a sigh of relief. Your body is in a position to reset the default mode of the nervous system that then permits the pelvic floor muscles to return to normal.

In our Paradoxical Relaxation lessons, these instructions are reiterated every 30 seconds or so to help our patients let go of any effort and rest solely in sensation. In the state of resting attention in sensation, the nervous system is put in airplane mode and the pelvic floor can release.

On its face, a daily practice of 2-3 hours of uninterrupted time to do Paradoxical Relaxation may seem daunting. Most pelvic pain patients are busy. Sparing any time can be a challenge. Because of this, we always say that our prescription is not for everyone. Indeed, our patient feedback reminds us that the patients who do the best with our protocol are the ones who decide that they will do whatever it takes to end their suffering.

Truth be told, if one’s pelvic pain doesn’t hurt enough, if the dysfunction isn’t bad enough, if there is a way to decently cope and avoid facing the music of a full measure treatment for pelvic pain, then contemplating 2-3 hours of airplane mode Paradoxical Relaxation a day is not going to be seriously considered, let alone completed. For those, however, who are ready to do whatever it takes, airplane mode will be done without hesitation, and once done, enjoyed beyond measure as the pelvic floor muscles are placed in an extended environment of healing.

Successfully Treating the Stress Dimension of Pelvic Pain Syndromes

There are a growing number of scientific articles on stress and pelvic pain syndromes. 

There have been a growing number of articles appearing in the major journals like the Journal of Urology and World Urology that point out the significant association between stress and prostatitis and related pelvic pain syndromes. This is a new phenomenon because, in the past, urology has largely been uninterested in the psychological aspects that are related to chronic pelvic pain syndromes.


What does psychological support for those with pelvic pain syndromes mean?

In an article written recently in the January/February edition of Rev Med Brux, (Rev Med Brux. 2013 Jan-Feb;34(1):29-37), a Belgian medical journal, the authors, Issa, Roumeguere and Bossche, talk about the essential role of psychological support: “the role of psychological support remains essential.” This kind of discussion about chronic pelvic pain syndromes and their proper treatment is new in medical discourse.

Unfortunately, even though the role of stress is finally being acknowledged after many years of being completely ignored, the understanding of the psychophysical relationship between stress and pelvic pain and prostatitis is not well understood. To talk about psychological support for those suffering from chronic pelvic pain syndromes misses the point if you have an interest in offering any substantial help to these people.

Conventional psychological support does very little for pelvic pain.

Psychological support in the conventional sense of a psychologist/counselor who offers insights and cognitive strategies to deal with dysfunctional thinking, in my view, does very little to help those who have chronic pelvic pain syndromes. In my experience, a psychologist/counselor can spend a day with people who have chronic pelvic pain, give them the experience of being heard, and deal with their cognitive distortions, and it will make very little difference to their symptoms or to their life. I say this as a psychologist who has been in practice for 40 years and who has done tens of thousands of hours of psychotherapy and who had chronic pelvic pain himself for many years. Psychological support in the normally understood sense is NOT significant in helping the stress component of chronic pelvic pain syndromes, prostatitis, pelvic floor dysfunction, interstitial cystitis, etc.

It is the basic fear that the pain will never go away that drives the psychological component of these disorders.

Lack of psychological support is not the problem that needs to be solved for people who have chronic pelvic pain syndromes. Offering support without giving them the tools to reduce their pain, in my many years of experience, does essentially nothing to help. When you have aching, burning tightness in the area of your pelvis and genitals and you have pain with sex and you cannot sit down, these symptoms fundamentally impair your life. They impair the basic building blocks of life – of urination, of defecation, of orgasm, of being able to sit and sometimes even being able to stand. Reassurances and psychological support alone will do little to help these symptoms.

Empowering the patient to reduce his or her own pain is the best psychological support you can offer.

What calms anxiety and catastrophic thinking is the experience of being able to reduce your own pain yourself. When you are able to put a finger on your own pain, or put an instrument on your own pain, and work on it, this is life-changing. This is essentially the antidote to the thought that the pain will never go away. This also increases your quality of life.

Data from our Internal Trigger Point Wand Study

In another essay in this blog, I have discussed the essential unhelpfulness of psychological intervention in which the patient is not empowered to help and release his own symptoms. During the years of the clinical trial for our Internal Trigger Point Wand, we saw that emotional distress is directly related to the reduction of symptoms. When people’s symptoms do not get better, their emotional distress generally does not get better, unless they have glimpses of their ability to reduce their own pain themselves.

While our study did not distinguish between cause and effect and which came first, it is my observation that what comes first is the ability to reduce symptoms, leading to or causing a reduction in emotional distress and anxiety. This positively feeds into the reduction of the pain and psychological distress. If tension, anxiety, pain, and protective guarding is a description of the downward cycle which perpetuates chronic pelvic pain syndromes, then the ability to reduce your own pain increases empowerment. You will be entered into a new self-feeding cycle of emotionally feeling better, physically feeling better, emotionally feeling better, physically feeling better.

What is real psychological support – what does that really mean?

Simple manipulation of thinking through cognitive therapy strategies is not very helpful. The core catastrophic thought that triggers emotional distress in folks with pelvic pain is, “I am never going to get better and I am doomed to never be able to relax and have any kind of quality of life.” Yes, that is the villainous thought. Simply identifying it without being able to reduce the pelvic pain symptoms does very little. Simply intervening with words in an attempt to stop cognitive distortion has little traction.

Learning how to be “off” as a stress reduction strategy.

Stress reduction in general, and in pelvic pain syndromes including prostatitis in particular, requires learning how to be “off” rather than “on”. In our experience, working with many people with pelvic pain over the years, the major help that is offered by our behavioral psychological intervention has to do with teaching someone to cease efforting. The deepest relaxation occurs when all of the muscles are “off” and there is no guarding or protecting against something bad happening. My teacher, Edmund Jacobson, who taught me relaxation said, “Turn the power off,” which was his way of guiding me toward becoming effortless.

Being “on”.

We all know what it means to have to be “on”. Being “on” means that I have to be ready to respond to others. I cannot just drop my guard or take my attention off of being responsive. When you are in the work mode, and often when you are not in the work mode, you are always ready to respond, always ready to kick in. Being “off,” sort of like being “off duty,” means that you do not have to be watching the environment to be responsive to it. It means being able to let your attention come into yourself and not have to be out in the world, responding and adjusting to the changing conditions of the world.

When I do a pelvic pain clinic I am “on” for 5 days. From the beginning of the clinic to the end of the clinic I am there responsive to other people. I cannot just wander off by myself, being in my own thoughts, being in my own body, being in my own experience. My attention is out in the clinic, responding to the needs of others and to the environment.

Being “off” means your nervous system can heal and regroup.

When the clinic is over, I usually feel exhilarated and I typically utter a sigh of relief. My life is my own again. I am not “on” anymore. I can be “off duty.” We ask people in our clinic to do Paradoxical Relaxation – which means that you must be “off”. This is the reason why we ask parents to ask their spouse to take care of their children, to turn their phone off, to keep pets away, so they do not attend to anything in their environment outside of the instructions that allow them to release their guarding. Creating a space for an hour or an hour and a half to be “off duty” allows the muscles to rest and the nervous system to down-regulate or calm down. And giving yourself the space to be “off” is all important in giving the nervous system an opportunity to down-regulate.

Anger and the response of the pelvic floor.

When you become sensitive to what is going on in your pelvis, you will often notice how the pelvic muscles tighten up and become more irritated and painful when you are anxious, stressed or pushed in some way. A dramatic example of this is something we discussed in our book, A Headache in the Pelvis. A middle-aged woman was seeing a colleague of ours who was an experienced physical therapist in New York. While our colleague had her finger inside the woman’s vagina doing Trigger Point Release, this woman started talking about something that was going on politically that she had a very strong reaction to. As she spoke about this politician she hated, the muscles in the woman’s pelvic floor began to tighten around our colleague’s fingers and our colleague reported that she was afraid that her fingers were going to be crushed. Now, this is particularly unusual because the pelvic muscles of a middle-aged woman are not known to be particularly strong. However, the physical reaction in the pelvis, which was part of her angry response, was unmistakable and dramatic. When our colleague said to her patient, “Can you feel what is going on in your pelvis as you are talking about the politician that you hate?” the woman said, “Feel what?” She was not aware of it at all.

The pelvic muscles tend to overreact to stress in those who have pelvic pain.

The pelvic muscles in those with chronic pelvic pain tend to tighten up to stressful events. While there has been very little or no research has been done on this, it has been my own personal and professional experience that people who have pelvic pain become sensitive to the tissue down there and see a close connection between pain and stress. Some people experience it remarkably strongly and clearly, and actually, that experience of the direct connection between stress and increased pain is a blessing because it makes a concept a clear experience. It validates the fact that there is a psychophysical one.

In muscle based prostatitis, pelvic floor dysfunction and other pelvic pain syndromes, the most effective stress reduction empowers patients to reduce their own pain. Paradoxical Relaxation is the practice of effortlessness, of letting go. While interpersonal support is mildly helpful, it does not go very far. I often say to patients, “My reassurance will probably last about 10 minutes and then you will get back into your scary thinking.”

Effectively dealing with stress related to pelvic pain is giving patients the tools to be able to turn “off” their own fearful contracted pelvic reaction regularly. Give a man a fish, he eats for a day. Teaching a man to fish, he eats for a lifetime. Reassurance and interpersonal support may help for a small amount of time. On the other hand, giving someone the ability to reduce pain and, in the psychological domain, reduce fearful guarding, gives a person a lifelong ability to manage stress and release themselves from the effect of pelvic pain.

Taking Hot Baths to Alleviate Chronic Pain in the Pelvis

Symptoms of prostatitis and pain in the pelvis typically don’t respond to conventional medical treatment.

Traditionally, when men have complained to their doctor about pain in the pelvis, anus or genitals, urinary frequency and urgency, post-ejaculatory discomfort, or sitting pain or the sensation of a ‘golf ball’ in the rectum, they are usually diagnosed with prostatitis. With this diagnosis, they are given antibiotics and told to avoid caffeine, alcohol and spicy foods, ejaculate more frequently, and take hot baths.


Most conventional advice about treating prostatitis, including diet modification and increasing sexual activity, is confusing and sometimes makes symptoms worse.

Most of our patients report to us that the dietary advice they have been given about caffeine, alcohol, spicy foods is confusing as they did not understand its basis. Furthermore, following this kind of dietary advice has little effect on their symptoms. In fact, many men who have come to see us for the Wise-Anderson Protocol for prostatitis have reported that alcohol often improves their symptoms and does not hurt them.

To add to the confusion, increasing sexual activity makes symptoms worse in a large majority of men. We have described the post-ejaculatory discomfort as a ‘pleasure spasm’ in our book, A Headache in the Pelvis. When a man’s pelvis is chronically constricted, instead of orgasm relaxing the pelvis, it actually increases its tension level and causes significant discomfort or pain in the pelvis that can last from a few hours to weeks.

Hot baths can temporarily relieve the symptoms of prostatitis.

One piece of conventional wisdom given to men diagnosed with prostatitis is to take hot baths. Most men report that hot baths temporarily relieve their symptoms. Hedelin and Jonsson in the Scandinavian Journal of Urology and Nephrology report that cold tends to aggravate symptoms of prostatitis and heat tends to ameliorate it (Scand J Urol Nephrol. 2007;41(6):516-20). This is common knowledge among urologists and is quickly learned by patients.

Regular baths tend to be more effective than sitz baths for prostatitis.

Patients are often told to take a sitz bath, a bath in which only the buttocks and hips are immersed in water. Patients have reported to us that taking a regular hot bath is more effective than simply immersing the pelvic area in a small tub of hot water. The sitz bath is often uncomfortable and does not allow for the kind of relaxation of the muscles of the pelvis and the reduction of the arousal of the nervous system that a regular hot bath affords. It is the central reduction of nervous arousal as well as the local relaxation of the pelvic muscles that is therapeutic for those suffering from what is diagnosed as prostatitis.

The heat of the hot water (and not what is put into the bath’s hot water) is what relaxes pelvic muscles.

We often hear of men putting Epsom salts or other bath salts into the bath water in an attempt to help calm down their symptoms. In our view, it is the heat of the bath that is therapeutic and not what is put into the bath. Saunas, steam baths, and hot showers help calm symptoms as well. Most cases of prostatitis, as we have discussed extensively in our research and in our book, are caused by chronically tightened pelvic muscles and not a prostate infection, inflammation, or prostate pathology. Getting into a hot bath is a remarkably fast reducer of muscle tension in the pelvis as well as a strong reducer of anxiety and autonomic nervous system arousal. We have often said that if there were a medication that offered the side-effect free benefit of hot water, it would be a major drug used in medicine.

Hot baths help symptoms of prostatitis but offer no permanent solution.

Heat and hot baths are palliative and can make the very distressing symptoms of what is diagnosed as prostatitis momentarily more tolerable. However, the hot water does not offer a permanent solution to these symptoms. Men will typically report that their symptoms feel better when they are in the hot bath but the effects of the hot water fade soon after they get out. Nevertheless, hot baths are a gift to those suffering from pain in the pelvis as the reduction of symptoms for any length of time is very welcomed by patients.

Hot baths help because most cases of prostatitis are caused by muscle contraction in the pelvis, and not by prostate pathology.

In our experience, most men diagnosed with prostatitis do not suffer from a pathology of the prostate gland but from chronically contracted muscles of the pelvic floor that form a cycle of tension, anxiety, pain in the pelvis, and protective guarding. This is the focus of our book, A Headache in the Pelvis. Once initiated, this cycle has a life of its own.

The Wise-Anderson Protocol (popularly known as the Stanford Protocol) has been developed to teach patients to effectively rehabilitate chronic pelvic floor contraction and lower the nervous arousal that feeds it. The success of our protocol in doing this has been documented to significantly reduce the symptoms of those whom we have treated who were diagnosed with prostatitis. Hot baths can help take the edge off of the pain in the process of this rehabilitation.

Paradoxical Relaxation and the Treatment of Chronic Pelvic Pain Syndrome

Paradoxical Relaxation and the Treatment of Chronic Pelvic Pain Syndrome

In a recent New York Times article (see excerpt below), the usefulness of concentration as an integral part of a discussion of mindfulness is discussed. The ability to concentrate is not a subject that is often discussed in the psychological literature on pain reduction; thus, this article is a welcome addition to the narrative of what we consider a critical issue in dealing successfully with chronic pelvic pain.


It has become clear over the last decade that nervous system arousal is a central issue to treat in those suffering from chronic pelvic pain syndromes. Gevirtz and Hubbard have convincingly shown emotional arousal raises the level of electrical activity in pain referring trigger points in those with myofascial-related pain. There have been recent studies evaluating the usefulness of hypnosis and cognitive therapy to deal with nervous system arousal, but it has been our observation that psychotherapy by itself has little effect on modulating or reducing chronic pelvic pain. Traditional methods of cognitive therapy help patients recognize their dysfunctional thinking and analyze distorted thoughts in order to discard them. In our work using the Wise-Anderson Protocol over the last 18 years, we have observed that these methods are not greatly helpful when patients’ pain goes on unabated and they remain helpless to do anything about it.

The method of Paradoxical Relaxation used in the Wise-Anderson Protocol is one of the main ingredients we use to help those with pelvic pain lower their autonomic nervous system arousal. Many of our patients who become competent in this methodology commonly report that they can significantly reduce their pain using this relaxation method.

Paradoxical Relaxation is the practice of focusing attention on sensation rather than mental thought. The aim is to take attention away from all thought—not analyze any of it. While it is sometimes useful to analyze dysfunctional thinking, that is not the aim of Paradoxical Relaxation. If someone is helpless to stop their chronic pain, it doesn’t matter how much analysis of dysfunctional thinking is done because the inability to affect the pain is the main driver of the sense of helplessness and disempowerment.

In the Paradoxical Relaxation session, the nervous system is deliberately deprived of the symbolic stimuli that cause it to become aroused. This break in arousal can help break a flare up of symptoms and moves in the direction of downwardly resetting the nervous system ‘idle speed.’

The most profound relaxation occurs when attention is controlled and kept focused in sensation. Just as the deepest sleep is dreamless (non-REM) sleep, relaxation that is void of thinking produces the deepest level of relaxation. This type of deep relaxation allows for an up-regulated nervous system to quiet down. The idea of relaxation depending on the control of attention rather than the releasing of such control is counter-intuitive, yet over the years patients using Paradoxical Relaxation in the Wise-Anderson Protocol have experienced the ability to control attention, to reduce pain, and ‘down regulate’ the nervous system.

Training attention to stay focused is a discipline that, as the New York Times article we quote below understands, has many benefits. In our work with pelvic pain, calming down nervous arousal to reduce pain is the most important of these benefits.

Excerpt from “The Power of Concentration” by Maria Konnikova in the New York Times on December 16, 2012.

The Power of Concentration


December 16, 2012

“MEDITATION and mindfulness: the words conjure images of yoga retreats and Buddhist monks. But perhaps they should evoke a very different picture: a man in a deerstalker, puffing away at a curved pipe, Mr. Sherlock Holmes himself. The world’s greatest fictional detective is someone who knows the value of concentration, of “throwing his brain out of action,” as Dr. Watson puts it. He is the quintessential unitasker in a multitasking world…

In 2011, researchers from the University of Wisconsin demonstrated that daily meditation-like thought could shift frontal brain activity toward a pattern that is associated with what cognitive scientists call positive, approach-oriented emotional states — states that make us more likely to engage the world rather than to withdraw from it.

Participants were instructed to relax with their eyes closed, focus on their breathing, and acknowledge and release any random thoughts that might arise. Then they had the option of receiving nine 30-minute meditation training sessions over the next five weeks. When they were tested a second time, their neural activation patterns had undergone a striking leftward shift in frontal asymmetry — even when their practice and training averaged only 5 to 16 minutes a day.

…But mindfulness goes beyond improving emotion regulation.”

Read the rest of the article here.

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.

Essays on Pelvic Pain

Essays on Pelvic Pain


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.

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


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.

Why Stress Triggers and Perpetuates Pelvic Pain Symptoms


Even slight amounts of stress can trigger pelvic pain symptoms.

Studies have shown that myofascial trigger points that are found in sore and painful muscles inside the pelvic floor are strongly affected by stress. Gevirtz and Hubbard did electromyographic monitored studies of the electrical activity of trigger points and their relationship to stress. Even the slightest increase in anxiety and nervous arousal caused a significant increase in the electrical activity of the trigger points. Individuals suffering from pelvic pain often report an increase in pelvic pain symptoms with stress and a decrease of pelvic pain symptoms with the reduction of stress and anxiety. For this reason, the Wise-Anderson Protocol trains patients with a relaxation method. This regularly reduces anxiety and nervous system arousal.

While individuals with pelvic pain often notice the relationship between stress and their symptoms, some people with pelvic pain are only rarely aware of the impact. The reason is that if you live, for instance, in a marriage where there is ongoing resentment, a work situation in which you deal with frustration regularly, or live with a sense of dread because of a general tendency to jump to catastrophic conclusions, you get used to these emotional currents and think they are just a part of life. You may not connect the dots in seeing their relationship to your symptoms. When you live in water, you don’t notice that you’re wet.

Many of our patients tend to live in a world of constant worry.

We know that when you have pelvic pain symptoms, you usually live with some level of anxiety and/or depression. Our recent study at Stanford shows a greater early morning rise in salivary cortisol in pelvic pain patients as opposed to normal, non-symptomatic control subjects. These findings which suggest heightened anxiety in individuals who suffer from pelvic pain syndromes. We have discussed in our book A Headache in the A Pelvis that an increased level of psychological distress in patients dealing with pelvic pain symptoms is equivalent to dealing with the same kind of stress people deal with who have heart disease or Crohn’s disease. Absent are studies of levels of dread, resentment, and anger in those who deal with pelvic pain, though it is our anecdotal experience that such emotions often punctuate the lives of many of our patients.

Many patients do not recognize the relationship between their emotional states and their pelvic pain symptoms.

Most people dealing with pelvic pain symptoms are not aware of the significance of their condition. When you are able to relax and let go of a level of anxiety you normally live with, and you witness a dramatic improvement in your symptoms, you usually find the wherewithal to earnestly do something about anxiety. It’s all about seeing the relationship between cause and effect.

To stop catastrophic thinking, you first have to recognize it. Pelvic pain can provide the impetus to decide to see things differently. This is because seeing things differently can reduce your symptoms. It is part of our language to distinguish between optimistic and pessimistic viewpoints by using the analogy of ‘seeing the glass half full or half empty.’ It is not a lie to say the glass is half full or half empty; they are both equally true. But for someone who knows the glass as half empty, and suffers from such a viewpoint, it takes an effort to choose the ‘half full’ perspective, because the perspective is so strongly ingrained.

Chronic states of anxiety, fear, dread, sorrow, resentment or anger must be addressed for any real resolution. Unfortunately, at this time, contemporary medicine has not been interested in the profound relationship between pelvic pain symptoms and ongoing dysfunctional emotional states. This is the reason why, in our view, conventional treatments have failed. The rehabilitation of attitudes that promote chronic states of anxiety, fear, dread, sorrow, resentment or anger is essential for anyone who is serious about stopping their pelvic pain.

The paradigm implied in the treatment protocol for pelvic pain developed at Stanford University.

It is a new paradigm to think you can voluntarily relax your habitually tight core which includes the anorectal area. When you call someone a “tight ass,” the implication is that such a person is characteristically in a chronic state—someone who is “tight-assed” or “anal” is considered a kind of person whose tendency is to be perfectionistic and cannot be reformed. Our protocol is based on the understanding that voluntary efforts to behaviorally change the default tone of the pelvic floor can change to one that is relaxed and at ease. This new understanding asserts that “tight asses” can become “relaxed asses.”

Like the insights of the new paradigm of neuroscience regarding the plasticity of the brain, we propose that the chronically tensed core, including the intestines and pelvic floor muscles, can be trained to be relaxed. We propose that the tendency to brace the viscera under stress can be changed without surgery or drugs. This is done through training in calming a chronically vigilant nervous system. In other words, the chronic tension associated with nervous system arousal can be brought under our voluntary control.

Changing this habitual inner posture is not brought about by drugs or surgery. It can be brought under the control of the patients’ disciplined consciousness. For patients who come to our clinic, the suffering with pelvic pain is what we believe provides the motivation for someone to learn to control catastrophic thinking, an upset nervous system, and the pelvic pain related to them. We are proposing that resolving chronically tight insides can’t be done by anyone else except by the person who is suffering. Over a lifetime, we believe that teaching people to calm down their insides under their own volition is the most cost effective method of dealing with pelvic pain, despite the fact that initially training people to do this has its costs. In our view, the psychophysical treatment of the Wise-Anderson Protocol represents the best framework within which someone can modify a contracted core.

A gentle approach to breaking the cycle.

The Wise-Anderson Protocol intervenes in all aspects of the tension-anxiety-pain cycle. Paradoxical Relaxation lowers pelvic tension and anxiety by lowering autonomic nervous system arousal and habitual pelvic tension. Trigger Point Release and certain myofascial release methods, including what we describe as skin rolling and pelvic floor yoga, deactivates trigger point pain, lengthens chronically contracted muscles, and makes the pelvic muscles more capable of relaxation.

Our understanding is a significant departure from the conventional view of prostatitis and chronic pelvic pain syndromes. We see pelvic pain as a physical expression of the way a person copes with life. We propose that pelvic pain is the result of a neuromuscular state perpetuated by anxiety and chronic bracing in both men and women. It is not the result of a foreign organism in the prostate gland in the case of prostatitis, an autoimmune disorder, or other contemporary explanations.

When certain predisposed individuals focus tension in the pelvic muscles, this chronic tension, over time, creates an inhospitable environment in the pelvic floor that gives rise to a cycle of tension, anxiety, and pain. Once this cycle is set into motion, it takes on a life of its own. Our treatment aims to restore the capacity of the pelvic tissue to relax, to perform its normal functions, and to return to a pain-free and dysfunction-free state.