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
to the webmaster of chronicprostatitis.com"
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
vs. sitting during defecation as way of helping the relaxation
of the pelvic floor
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:
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.
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.
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.
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.)
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.
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."
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
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.
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
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
THE ISSUE OF HEALING AND THE RESOLUTION
OF SYMPTOMS OF PROSTATITIS AND CPPS
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.
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.
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.
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.
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.
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:
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.
theories do what we have described earlier. They tend to promote
fear and helplessness in the sufferer.
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.
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.
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.”
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.
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.
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.
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.
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
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.
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.