WHY INTRAPELVIC BIOFEEDBACK MEASUREMENT IS NOT A RELIABLE INDICATOR OF THE USEFULNESS OF THE WISE-ANDERSON PROTOCOL AND THE ISSUE OF THE THERAPEUTIC USEFULLNESS OF PELVIC FLOOR BIOFEEDBACK

David Wise, Ph.D.

"written to the webmaster of chronicprostatitis.com"

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, like the person whose comment you sent to me, 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 to find that the biofeedback measurement seemed to indicate (erroneously) that tension was not a central problem in my pelvic pain.

I didn't understand then what I understand now which is that the electrical activity in the anal sphincter is, for the most part, the only area that the anal biofeedback sensor measures, and often says very little about what is going on with the other 20 some odd 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 includes a chronically tight anal sphincter as well in some) and 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 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 small website, www.pelvicpainhelp.com, we have video clips of an important study, replicated many times, demonstrating that at rest, the electrical activity inside a trigger point in the trapezius, monitored by an a needle electromyographic electrode is quite high while the electrical activity of the tissue less than an inch away from the 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 and 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.

Bottom line here is that in my experience, electrical measurement of the anal sphincter, (or the opening of the vagina) used alone, is often 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 our protocol that treats 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 in working with pelvic pain 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 to and inside the pelvis. This is one reason why we have offered trainings 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 our 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.

Anal fissures, hemorrhoids, constipation and other manifestations of headaches in the pelvis

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 people 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 American suffer from hemorrhoids. 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 which then 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 cows 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 to treat hemorrhoids and anal fissures. We have seen patients who are anxious about their rectal discomfort 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. Both surgery, the procedure of stretching or dilating the anal sphincter under anesthesia and the application of topical agents to the internal anal sphincter 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 risk of short term and sometimes long term fecal incontinence.

This conventional medical treatment of 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 of the anal sphincter, hemorrhoid or slow transit times involved in constipation. Procedures, surgery, laxatives and other medications are the usual options for patients suffering from these 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 the anal fissure or hemorrhoid is an expression of a viewpoint that sees no value and sees no intelligence in the symptoms someone with such a condition is experiencing. 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 one is under, 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 for the big picture of a person’s life and how one’s symptom 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 and time urgency around bowel habits that leads to anal fissures, hemorrhoids and constipation. The chronic pelvic tension, inappropriate diet, and bowel habits associated with most anal fissures, hemorrhoids and constipation do not come out of the blue. 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 they have evacuated 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 (www.naturesplatform.com) 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 to initiate defecation. A long study examining the effect of squatting during defecation and hemorrhoids 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 know 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. On www.naturesplatform.com a device is sold that allows one to easily squat during defecation. When pelvic pain also involves 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 treatments 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 as described on www.naturesplatform.com 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 anal fissures and hemorrhoids and certain kinds of constipation.

THE ISSUE OF HEALING AND THE RESOLUTION OF SYMPTOMS OF PROSTATITIS AND CPPS

David Wise, Ph.D.

In this essay I want to address the issue of the validity of many speculative theories on the internet about prostatitis and CPPS and our view of the issue of the healing of the pelvic floor and the resolution of symptoms of prostatitis and chronic pelvic pain syndromes.

There are numerous ideas on the internet about what causes prostatitis and chronic pelvic pain syndromes. For example a few people propose that prostatitis and CPPS may be related to reflex sympathetic dystrophy. Attempts to make a case for pelvic pain as reflex sympathetic dystrophy are not new. While I am not an expert in RSD this is what I do know. It is generally agreed among clinicians and researchers that RSD is a condition that is complex and has features that are perplexing and poorly understood. It is characterized by regional pain, often in the hands or feet, autonomic, tissue and vasomotor changes, disorders of movement, muscle atrophy and almost always psychological and social disturbance. Part of the controversy about RSD is whether the psychosocial disturbances and suffering is causative or at the effect of other factors – an issue of the chicken or the egg. The controversy about RSD reached a point where the name was changed to regional pain syndrome to eliminate the implication of agreement about the mechanism of the disorder. In a discussion I had with our senior physical therapist, in his experience RSD is an entirely different problem from one involving myofascial/trigger point pain. Your reader is correct that Trigger Point Release is not indicated with RSD although in some cases a patient originally diagnosed with RSD may simply have a hyper irritable myofascial pain syndrome and the diagnosis of RSD may have been incorrect.

Diagnostic criteria have been proposed for RSD by an international organization but these criteria are not universally accepted. Bottom line here is that this is a poorly understood and controversial condition that has no effective treatment.

RSD, as a general rule does not respond to Trigger Point Release therapy. Furthermore muscle atrophy, edema or swelling or disorders of movement are not prominent features in the pelvic pain we treat. What is telling for me is the fact that many patients with pelvic pain have responded favorably to our protocol whose physical therapy component involves myofascial Trigger Point Release where RSD does not respond to this methodology. All of this makes the RSD/CPPS hypothesis dubious.

So pelvic pain as RSD is a speculation with little supporting evidence ... a speculation that is no different from the speculation that pelvic pain is the result of an occult bacteria or is an autoimmune disease. At this point this idea offers no course of treatment or action that helps or protects someone, it offers no definitive evidence and importantly it tends to promote fear and helplessness in many who suffer from pelvic pain. I take the view that pelvic pain as RSD is an idea with little foundation that I choose to ignore until there is some compelling reason to entertain it.

In our book, A Headache in the Pelvis, we address a very important issue related to the question I am discussing here. This is the question of what to do with speculative theories about pelvic pain like the one that it may be related to RSD – theories that offer no treatment and serve to scare the reader. I quote our book below:

“We are often asked about other theories regarding the nature of chronic pelvic pain from people suffering with pelvic pain, a subject we touched upon earlier. Many of these individuals are already in an anxiety state and are looking for some kind of reassurance or guidance as to the nature of their condition and the best course of treatment. When they go on the internet, they read about various theories contending that chronic pelvic pain may be an auto-immune disorder, a condition in which occult bacteria are yet to be discovered, or a deteriorating neurological pelvic condition.

These theories do what we have described earlier. They tend to promote fear and helplessness in the sufferer.

When you have pelvic pain, it is deeply disturbing to read theories which promote fear, helplessness, and confusion or hear stories of people who are not doing well with their pain or dysfunction. When you have pain and dysfunction, you usually feel some degree of anxiety and helplessness which is often exacerbated by these kinds of theories. Some of our patients have asked us whether they should ignore the ideas that they read on the web or simply avoid the internet websites devoted to pelvic pain. Others have asked us if there is some way to find out if in fact they have the problem that these theories purport.

If a theory or an idea about your condition carries some course of action or treatment to help you without unacceptable risks, then it may be an idea that merits your careful consideration. You may wish to investigate the efficacy of such a course of treatment along with the risks and costs.

If the theory, on the other hands, carries with it (a) no course of treatment or action to be done to help or protect you, or if its treatment carries dangers you are not willing to risk, or (b) it offers some non-definitive evidence, and (c) it only helps to create fear, doubt, and disempowerment in your life, we suggest you tell yourself the following: “This is someone’s theory. There is no definitive proof for it. It offers nothing to help me or protect me. What it offers carries unacceptable risks. It creates fear and doubt in me. It is okay for me to disregard it as somebody’s unproven idea which I will consider if there emerges substantial evidence and/or something to do about it. Therefore I can ignore it as simply someone’s unproven idea. This kind of self-talk … is particularly important because anxiety tends to increase symptoms.”

A person who wrote about RSD and whether it is related to pelvic pain was obviously distressed that his symptoms did not improve with Trigger Point Release that was aggressive, and he was looking for some other answer to his difficulties. In my response to the description of his treatment, let me say that we at Stanford do not advocate aggressive physical therapy in our protocol but a very specific method aimed at locating and deactivating trigger points inside and outside of the pelvic floor that tend to recreate symptoms as well as methods that systematically stretch the shortened and contracted pelvic tissue. It is common that the in beginning stages of treatment, temporary flare-ups occur. It is the normal course that the discomfort diminishes over time during and after physical therapy. If it doesn’t, in my experience, the problem is often that the physical therapist is missing something.

In my view the whole issue we are dealing with about treatment for pelvic pain is simply this--how to allow the body to heal itself? I think contemporary medicine tends to forget that it is almost always the case that ‘the body heals itself and the doctor collects the fee.’ In the National Library of Medicine today, I found there were 3743 research articles listed on prostatitis. An infinitesimal 7 articles even contained the word healing. My view about treatment for pelvic pain is that we want to optimize the circumstances for the body to heal itself, we want to get out of the way of the healing of the tissues, muscles and structures inside the pelvic floor. Healing is what we want. In my own case, when I began thinking this way, my condition began to resolve.

The Wise-Anderson Protocol is about healing. It is about creating a hospitable environment for the restoration of normal happy tissue inside the pelvic floor. The relaxation protocol allows the nervous system to quiet down so that the irritated tissues can heal and can stop being squeezed into an irritated state… a squeezing that in most people who have pelvic pain has become habitual and chronic. The relaxation protocol aims to change the habit of tightening the pelvic muscles under stress. The physical therapy we do stretches and lengthens the pelvic tissue and deactivates trigger points to make room for a healthy life in the pelvic floor.

The idea of RSD as it is understood today, at least as I read it, implies a condition where healing is remote. I balk at theories that imply healing isn’t possible because of my personal experience and others who have gotten better with this problem. Healing is possible. The patients I have seen who have done the worst – especially those who have suffered from unwise medical interventions, have given the entire responsibility for curing their condition to someone or something outside them. They come to the doctor and say “fix me doc”. Any treatment for the kind of pelvic pain we treat needs to be the servant of the body’s healing mechanisms. This requires the intimate and whole hearted participation of the patient.

Physical therapy alone, while an essential component, is usually inadequate to resolve symptoms because it alone cannot make this healing occur. I understand this experientially. It is tempting for someone to think that physical therapy, this outside procedure, will fix them. In my experience this person will be disappointed as I was. I had over 50 physical therapy treatments and at the end of them all, I was still symptomatic and in pain. It was only after I saw that my problem came from my chronic tension, anxiety and habitually squeezing my pelvis – and particularly when I began the relaxation protocol in earnest, often up to 2 hours a day for over two years and doing moment-to-moment pelvic relaxation throughout the day, that my symptoms began to resolve. The pelvic pain of those we help is not simply a mechanistic problem that can be fixed from the outside with a physical therapist’s finger. The habit of tightening the pelvic floor is usually decades old and has been practiced thousands of times. It is part of a coping repertoire. Tightening their pelvic floor under stress is the default mode and keeps the tissue of the pelvic floor irritated and shortened.

Consider that there are 168 hours in a week. Let us say that a person goes to see the physical therapist 2 times a week. That quite a bit of physical therapy. In the physical therapy session, after a person takes off their clothes, gives the PT a report on their week and begins the physical therapy itself, at the most there is probably 30-45 minutes of hands-on treatment. After the treatment, the tissue is lengthened (although sometimes temporarily irritated in the process). That is between 1 hour and 1.5 hours of therapeutic treatment per week. In a good pelvic floor physical therapy session, the pelvic floor tissue has been lengthened and life has been made more livable for it. But after physical therapy, there are 167-166 hours per week to live. The old habit of going 100 miles an hour in one’s life and tightening up the pelvis regularly and squeezing and shortening the irritated tissue can easily and quickly undo the therapeutic impact of the physical therapy session. It makes no sense to think that a physical treatment that lasts less that .023% of your life can work if the old, symptom provoking habits go on unabated. In my view the resolution of the kind of pelvic pain we treat is an inside job of cooperating with the healing mechanism of the body in the short run and the long run.

We have received hundreds of emails from people telling us that our theory described in A Headache in the Pelvis is the first one that makes sense to them. While I appreciate these comments, I am unmoved by them. I am moved when someone’s symptoms improve or go away. I am moved when the body responds to treatment with a big ‘yes’. Theories are cheap and yet to the lay person, they can sound convincing and formidable. In my view a theory about pelvic pain is only as good as the efficacy of the treatment that it informs and serves the healing of the body. In other words, the most important issue is results -- ie. does the method that derives from the theory help the body’s healing thereby reducing or resolving symptoms? We do not help everyone who comes to see us. But if they do fit into a certain profile, they must do the entire protocol properly before making a judgment about its efficacy. They must participate and support their own healing. Results are what counts. Results mean that the patient has helped rally his or her body in healing itself.

Sincerely,

David Wise, Ph.D.

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

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

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