Excerpts from
A Headache in the Pelvis:

David Wise Ph.D. and Rodney Anderson, MD

SUMMARY OF OUR UNDERSTANDING

We have identified a group of chronic pelvic pain syndromes that we believe is caused by the overuse of the human instinct to protect the genitals, rectum, and contents of the pelvis from injury or pain by contracting the pelvic muscles. This tendency becomes exaggerated in predisposed individuals and over time results in chronic pelvic pain and dysfunction. The state of chronic constriction creates pain-referring trigger points, reduced blood flow, and an inhospitable environment for the nerves, blood vessels, and structures throughout the pelvic basin. This results in a cycle of tension, anxiety, and pain, which has previously been unrecognized and untreated.

Understanding this tension, anxiety, and pain cycle has allowed us to create an effective treatment. Our program breaks the cycle by rehabilitating the shortened pelvic muscles and connective tissue supporting the pelvic organs while simultaneously using a specific methodology to modify the tendency to tighten the muscles of the pelvic floor under stress.

It is our understanding that the chronic pelvic pain syndromes begin with a person’s habit of focusing tension in the muscles of the pelvis. This tendency sets the stage for the disorder. What triggers the symptoms can be a major stress or several minor stresses occurring simultaneously. The stressors can be psychological or physical.

The reason that chronic pain and dysfunction resist a simple mechanical fix is that they tend to come out of a background of a life-long habit of focusing tension in the pelvic muscles. It is necessary to rehabilitate the pelvic muscles in conjunction with changing the predisposition to pelvic tensing under conditions of stress.

In order to make our understanding clear, we offer the allegory below followed by a step-by-step analysis of the story. We advise our readers to take time to read the allegory as it will help clarify their understanding.

AN ALLEGORY

Once upon a time, there was a land called the pelvic floor upon which the whole world depended for its survival and pleasure. The pelvic floor provided vital services for the world including filtering and eliminating wastes, providing sexual pleasure, and helping structurally support the world in its various activities. The land of the pelvic floor performed these services best when its citizens lived a life of balance between work and rest.

It came to pass that the world went through a period of strife, and the citizens of the pelvic floor were required to work more and more. Night shifts became common place. In some parts of the land, citizens were required to work twenty four hours a day, seven days a week, with no rest.

Soon the pelvic floor citizens were completely exhausted and very unhappy. They had stopped doing their jobs well. Their normal processing of wastes was no longer done efficiently, and they became able to give little pleasure to the world. Their cries of distress were increasingly heard.

Painful protests from the pelvic floor were made with demands for a return to the balance between rest and work. The world, however, did not seem to understand what the pelvic floor was trying to say.

So the world hired a consultant who suspected the source of the problem to be foreign troublemakers and recommended sending in legions of anti-troublemakers. The troublemakers, however, could not be found and the problem continued.

The world became desperate and decided to hire a new consultant who saw the problem differently. The new consultant said, “If you want to solve this problem, you must go to the land of the pelvic floor and listen to its complaints.” The world replied: “We don’t know how to talk to or understand the pelvic floor. We have never had a conversation with it.” The consultant answered: “I know the language of the pelvic floor and will teach you how to understand what it is trying to tell you.”

After meetings with the pelvic floor and the consultant, the world finally understood that its contribution to the problem was the demand it made for the pelvic floor to work constantly. So the world decided to change this. However, while the world agreed in principle to stop demanding constant work, it often forgot this agreement and lapsed back into its old habit of making unreasonable work demands. The consultant had to remind the world over and over to stop forcing the pelvic floor to work constantly. This was not easy for the world to learn.

After a while, the world said to the consultant: “Your method seems to be working much of the time but why is everything not completely back to normal?” The consultant replied: “Both you and the land of the pelvic floor are used to the unhappy state of affairs that has existed for many years. If you are not reminded, you will continue to force the citizens of the pelvic floor to work without rest.”

The world, however, was not the only perpetuator of the problem. The pelvic floor had also gotten used to the misery of constant work and had forgotten how to rest even when the world allowed it.

Therefore, a curriculum was set up for the pelvic floor as well. The people of the pelvic floor went to special clinics where they learned to stretch the contracted posture that they developed due to their constant work. This stretching and their lessons in learning not to fall back into the old habits enabled them to relearn how to relax and rest.

As the world and the pelvic floor learned to coexist in a balance of work and rest, the land of the pelvic floor became a happy place again.

Pelvic pain and dysfunction result from overused and chronically tensed pelvic musculature

In our allegory, the world stands for you, the conscious person, who makes decisions and sends commands to your body. You send these commands, often out of habit. They feel normal and familiar to you.

The pelvic floor is your pelvis and the contents of your pelvis, including your genitals, rectum, and the muscles that hold up the contents of your abdomen. It also includes the structures that are involved in urination, defecation, sexual activity, and physical movement. These functions and their myriad of biochemical, nervous, and mechanical processes go on often without requiring your awareness, will, conscious effort, or attention.

We see in the allegory that the problem begins when the world demands that the pelvic floor work on a constant basis. Normally, the pelvic floor muscles are dynamic, working, and resting throughout the day. Even though they tighten, they have the ability to relax. The relaxed state allows for proper oxygenation, nutrition, management of wastes and rejuvenation of tissue.

The pelvic floor muscles are not meant to be chronically contracted. When muscles are chronically tensed, they tend to shorten and eventually accommodate so that the posture of a shortened state of the muscles feels normal. This chronic shortening impedes the ability of the tissues to have proper oxygenation, nutrition, management of wastes and rejuvenation of tissue.

People who have pelvic pain syndromes tend to habitually focus tension in the pelvic muscles as a response to stress, anxiety, trauma, or pain. In our allegory, we allude to this by saying that the continual strife of the world prompted it to make the pelvic floor work too much.

The tendency to focus tension in the pelvic muscles is not an accident. Some have suggested that a person’s inclination to focus tension in the pelvic muscles begins with toilet training. The child is able to stop his parent’s reaction to soiling by tightening his pelvic muscles. Over time, tightening the pelvis becomes a conditioned reaction to any situation in which anxiety arises. Let us be clear that this idea of focusing tension in the pelvic muscles as a result of early toilet training is simply an idea and we do not propose that it should be taken as fact. It is however, a compelling explanation of how pelvic tension may well begin early in life.

Research has shown, and it is our clinical experience as well, that people with chronic pelvic pain syndrome have elevated pelvic floor tension even when resting. The pain and dysfunction gets worse in the presence of stress. Most of our patients notice this relationship between stress and the severity in their symptoms. This observation leads to the heart of our understanding.

In our allegory, we see that the constant demand made upon the pelvic floor leads to a disruption in its ability to function. It is our view that, over time, a constant demand on the pelvic floor to tense results in an environment that is inhospitable to the nerves, blood vessels, and structures within it. The pelvic floor is not made of steel and in certain individuals is quite disturbed by chronic tension.

We believe that the person who has the kind of pelvic pain we discuss in this book has sore and irritated pelvic tissue. This tissue is not viewed by conventional medicine as pathological. We believe that this sore, shortened, contracted tissue is a very real physical condition. People who have chronic pelvic pain feel this soreness and irritation acutely. It sometimes feels like a burning, tearing or area of raw tissue. When the doctor or physical therapist trained in myofascial/Trigger Point Release feels the inside of the rectum or vagina in patients with CPPS, he or she often reports feeling areas of restriction and areas of tension and taut bands (trigger points) which, when touched, cause patients to jump with pain. Some professionals who work inside the pelvic floor of people with pelvic pain describe the tissue as gunky or rock-like. Areas within the pelvic floor which have been subjected to years of continual contraction need time to heal even when the muscles are no longer under tension. When physical therapy is properly done, the gunky, rock-like tissue often becomes soft, supple and pain free.

The painful pelvis is like a continually contracted fist

Imagine tightening your fist as hard as you can for an hour. You notice that there are places of lighter color in your hand, which result from squeezing the blood out of the blood vessels. Your hand will feel uncomfortable and you feel relieved to stop the squeezing.

Now imagine you maintain this clenched fist for a day. Now imagine you maintain this fist for a week. Now imagine a month of tightening your fist constantly twenty-four hours a day. Now imagine doing it for a year. Now imagine doing it for several years. This is one way to understand the state of the pelvic floor in people with pelvic pain.

Imagine, after several years, you stopped tightening your fist. Do you think the great discomfort and irritability of the tissues of your hand would immediately stop? Almost certainly not. It is not hard to imagine that you would want to rub your hand, massage it, take each finger, and stretch it out to relieve it from the contracted state it had been in. Nor would it be hard to imagine that, even after you stopped tightening your fist, your fist would still be sore. It would take some time, some pampering, and most importantly, no chronic retightening of the fist before your hand felt normal again.

Imagine continually tensing your pelvis

Chronically tightening your fist is one thing. Now imagine you were asked to tighten your pelvic muscles for 30 seconds as if you were stopping yourself from urinating. For most people this pelvic tightening would not be the most pleasant thing to do but it would be doable. Imagine you tightened up in the pelvis like this for a minute. It would still be doable. Now imagine you were asked to keep your pelvic muscles continually tensed for 30 minutes… now 1 hour… now 6 hours,.. now 12 hours … now 24 hours … now 1 week,.. now 1 month … now 1 year… now 2 years… now 5 years.

People who have never had pelvic pain are incredulous at being asked to contract their pelvic muscles for 30 minutes. The prospect of continual tightening of the pelvic muscles for a week, month, or year would be unthinkable and yet the research shows increased tone in the pelvic floor for people with pelvic pain. Dealing with such a condition is the focus of our protocol.

In our allegory the consultant the world first chose refers to the traditional physician who routinely assumes the presence of infection as the source of the difficulty (foreign troublemakers). But, treating these troublemakers, or the presumed bacteria, has failed to resolve the problem of chronic pelvic pain syndromes. The recent research has shown antibiotics to be no more effective that a sugar pill or placebo. The second consultant who is called in refers to a clinician trained in our viewpoint and protocol. The clinician sees the problem emanating from within the individual. In our allegory the new consultant offers the solution we suggest, which is aimed at rehabilitating the chronically contracted posture of the tissues in the pelvic floor as well as teaching the individual to cease the habitual and chronic pelvic tensing.

In our allegory, we make the point that ‘the world’ has lost communication with the pelvis. Most of our patients tend to be out of touch with what is going on in their pelvis. We offer a method to open communication with the pelvis to help bring about a healing of the sore and irritated pelvic tissues.

Healing pelvic muscles by changing bad habits

If chronic tension results in an irritation of selective contents of the pelvic floor, which gives rise to pain, then anything one does to reduce or eliminate the tension has the potential of eliminating the pain. The restoration of the contracted tissues to a normal state of flexibility and relaxation has to be done repetitively.

It is the repetitive application of our method that gives the pelvic muscles a chance to return to their normal state. The methods used to accomplish this are called Paradoxical Relaxation and Trigger Point Release. Paradoxical Relaxation, as we discuss in depth in Chapter 4, trains the patient to break the habit of chronically tensing the pelvic muscles. Trigger Point Release, described in Chapter 5, makes it possible for the pelvic muscles to adequately relax through the aid of a therapist who literally lengthens the constricted pelvic tissue.

We tell our patients to expect ups and down, and not to celebrate when symptoms reduce, or to despair when they flare-up. This is easy to say and not so easy to do when you are anxious and in pain.

There are important reasons why chronic pelvic pain syndromes are misunderstood and why progress is slow. One reason is that the pelvic muscles are almost always active in the service of the normal functions in life. The pelvic muscles need a rest from their chronic contraction. There are two factors that make this difficult. The first is that you can’t simply rest the pelvic muscles for any extended period. They are needed to allow you to stand up, to hold in urine, to walk, to lift — to do the things that allow you to be able to function normally. It is a delicate juggling act to deal with the need for rest and healing of this vital part of the body on the one hand and the demand on the pelvic muscles to do the work required to function in life.

The other factor that operates against the healing of the pelvic floor is the conditioned tendency to focus tension in it when under stress. This is usually a deeply ingrained tendency, especially when this focus of tension has been practiced many times without awareness. Modifying this habit so that contracting the pelvic muscles under stress is not the default mode is no small enterprise. Changing this habit is the focus of the method of Paradoxical Relaxation.

In our allegory, we show that while the intervention of the second consultant began helping the situation, the situation did not immediately go back to normal. The process of healing takes time, especially inside an active pelvic floor.

Reassurance and emotional support helps pelvic pain syndrome

In his study of prostatitis, Harry Miller, M.D., a urologist from the urology department of George Washington University, reported on his treatment of men who had prostatitis. Dr. Miller offered stress management therapy for these men. He gave men very simple and kindly advice not unlike that of a grandmother to her grandson. Miller’s approach reinforced the idea to his patients that there was a relationship between how they managed the stress in their life and their symptoms. In doing so he helped most of his patients reduce their symptoms.

Dr. Miller’s work focused on the person and not the prostate. He addressed the social and psychological context in which pelvic pain occurs. Similarly, the approach discussed in this book insists that chronic pelvic pain syndromes are a problem of the person which includes but is not limited to a sore part of the person’s body.

What seems obvious may not be the problem: the source of the disorder in interstitial cystitis may not simply be the bladder

The locus of the problem in interstitial cystitis may not be limited to the bladder, but found in the muscles of the pelvic floor. Treatment protocols in traditional medicine have focused exclusively on the bladder.

Some compelling evidence throws doubt on this view that the bladder is the essential problem in interstitial cystitis. One study showed that when the pelvic muscles of patients with IC were palpated, the pelvic muscles appeared to be the source of the pain. The bladder was rarely found to be painful when touched. In a Finnish study, 25 out of 31 women who were diagnosed with IC reported pain in the pelvic muscles and not in the bladder when the bladder and the pelvic floor were palpated.

Perhaps even more compelling is the experience we had with a patient whose level of pain with IC prompted a physician to remove the bladder. The bladder removal did not reduce the pain. Unfortunately this is not the only patient whose bladder was removed and whose pain persisted.

We are suggesting that the source of the problem with IC may not be the bladder. Instead, the source may be the nerves, muscles, and blood vessels in the pelvic floor connecting to the bladder.

Our multidisciplinary treatment protocol

Our treatment team is multidisciplinary and consists of a physician, a psychologist, and a physical therapist. The urologist or gynecologist does the initial diagnosis and makes sure that the condition is appropriate for our protocol. His or her work involves an examination of the patient, the administration of various medical tests, and interpretation of the results. It is the physician’s findings that rule out serious illness as a factor in the patient’s symptoms.

The psychologist’s primary role in the treatment team is to train the patient in Paradoxical Relaxation for the purpose of profoundly relaxing of the pelvic floor and modifying the habit of focusing tension in the pelvic floor under stress. The psychologist on our team teaches a method to help the patient stop the catastrophic and negative thinking associated with the condition of pelvic pain and dysfunction. This method requires regular practice as the negative thinking arises during the course of a day. The method is simple and easily learned and applied.

The physical therapist usually administers the Trigger Point Release and teaches participants to do their own Trigger Point Release. Self-administered internal Trigger Point Release is taught. The physical therapist also teaches the patient a home program of stretches, not unlike a home yoga program, except that these stretches are oriented toward the rehabilitation of the chronically tensed pelvic muscles.

The treatment is most likely to help when you reduce the
stress in your life

John B., a 38 year-old small business owner, came to see us with pelvic pain and urinary dysfunction. Upon examining him, we determined that, in fact, he had no problems of an organic nature. He had trigger points inside his pelvic floor that when palpated exactly recreated his symptoms.

Under normal circumstances, John was someone we would be optimistic we could help but it became clear he was not. He owned a car repair facility where he employed 45 people, and his business consumed his days from 6 in the morning until 9 at night. His wife was unhappy because of his absence from their relationship. His children had behavioral and academic problems at school. He was also involved in a lawsuit with his brother-in-law with whom he had owned a previous business. He was in the middle of a major renovation of his house that left both he and his wife, on a mattress on the floor.

John had no time for himself, let alone the time to do physical therapy and daily relaxation to relax his pelvic floor. Under the circumstances, the program we offered probably would have been wasted because he would not be able to do it properly in the face of the demands and stress calling for his attention. Only when John himself decided that his life would have to change would our treatment have a chance of helping him resolve his pelvic pain.

Effective treatment requires adherence to the complete program

Patients who seem to get the best results from our treatment are those who are clearly committed to earnestly practicing our approach. Usually these patients have suffered for a long time and have seen numerous doctors and explored many avenues. These patients often assume the attitude of “I will do whatever it takes to get better,” and have no problem following the protocol. We tend to discourage patients who are skittish or unsure about doing our treatment. These are usually patients whose level of pain and dysfunction is minimal and who have been suffering for a short period of time.

Chronic pelvic pain as a functional disorder

Prostatitis and other chronic pelvic pain syndromes are sometimes seen as ‘functional disorders’. This viewpoint is most clearly expressed by Dr. Jeanette Potts, who has maintained that nonbacterial prostatitis and chronic pelvic pain syndromes are functional disorders. Pelvic pain syndromes are defined by the fact that these conditions show no glaring physical abnormalities to account for the pain and suffering they cause. They are defined as a problem in function, not in structure. In other words, the structures within the pelvic floor of those with chronic pelvic pain syndromes tend to have healthy structures that display a disturbance in function. Hence they are a functional disorder.

Having a functional disorder does not mean it is all in your head

We do not dismiss functional disorders as any less real than a broken bone. More than a few patients have told us that they have seen doctors who have told them that there is nothing wrong and that they should either live with their condition or go to a psychiatrist. This is naturally disturbing to a patient who is faced with his doctor telling him that his pain and dysfunction are somehow not real or treatable.

People with functional disorders often have more than one

In our practice we have noticed that there is a high incidence of irritable bowel syndrome in the patients we see with pelvic pain. Given the proximity of the colon and the pelvis, it makes sense that both could be the result of a chronic abdominal/pelvic tension. While gastroenterology and urology make a distinction between the urogenital system and gastrointestinal tract, the body doesn’t necessarily make any such distinctions or recognize any such boundaries.

The concepts of threshold, pelvic pain, and functional disorders

When first facing pelvic pain, one faces what seems to be a monolithic, undifferentiated curtain of pain and distress that feels incomprehensible and overwhelming. Patients usually feel helpless in the face of pelvic pain because they know little or nothing about what they can do about their condition. Therefore, the concept of a threshold, and proximity to the threshold, is often a useful idea to patients because a perspective can be gained on one’s progress.

We assess the effectiveness of our treatment by looking at the presence, intensity, and frequency of symptoms. Consider the following graph upon which you can locate your proximity to the threshold above which you are symptomatic and below which you are not. When patients are able to see their symptoms from the viewpoint of their proximity to the symptom threshold, they can gauge their progress and relieve their sense of helplessness and confusion when their symptoms wax and wane.

One’s proximity to the symptom threshold

Figure I
#4 (chronically symptomatic)
#3 (symptoms wax and wane)
_____________________________________________________
SYMPTOM THRESHOLD
#2 (no symptoms when slightly below threshold
-- can become symptomatic at the slightest stress)
#1 (no symptoms)

In Figure I, the person who is located in position #1 is well below the threshold, displays no symptoms, and can tolerate a great amount of tension in the pelvic floor without becoming symptomatic. Even when this person’s pelvic tension goes over the threshold the pelvic tissue is not irritated, and the pelvic floor muscles are flexible and immediately drop below the threshold after the individual has stopped tensing.

The person situated in position #2 represents someone who likely will have pelvic pain but on an intermittent basis. It does not take great increases in pelvic tension to throw this person’s tension level above the threshold where he or she will become symptomatic. The person at position #2, generally speaking, has a reduced level of flexibility in the pelvic floor and often does not relax as easily as #1 once the muscles are tensed over the level of the threshold.

People with pelvic pain who fall under #2 in our diagram are often bewildered at what brings on their symptoms. They conclude that there was nothing much that seemed to be associated with the onset of symptoms, and that the pain is random. Our explanation is that, when someone is slightly below the threshold, what is a non-event for a normal person is often stressful enough to throw a #2 over threshold and into symptoms.

At position #3 is the individual who has mild but persistent symptoms that wax and wane. This is the person who is ‘surfing’ the threshold. Symptoms associated with #3, while seeming to be almost always present, occasionally drop below threshold only to come back inexplicably. The person at position #3 usually experiences chronic but more or less tolerable pain and dysfunction.

At position #4 is the individual who has chronic and intractable pelvic pain and/or dysfunction. He or she doesn’t drop below the symptom threshold. When asked to describe the frequency and severity of symptoms, this person will report that the symptoms are always present, 24 hours a day, seven days a week, and that the symptoms strongly impact his or her life. Our treatment aims to lower baseline pelvic tension and irritability of individuals in positions #2, #3, and #4 to the #1 position.

Anxiety increases your symptoms

Most of the patients we see with chronic pelvic pain syndromes have what we have referred to earlier in this chapter as trigger points in their pelvic muscles. The way we determine the existence of trigger points is discussed in the section on Trigger Point Release. To reiterate, a trigger point is a taut band within a muscle that is painful either spontaneously or when touched and which refers pain to a site remote from it when it is activated. Trigger points are exquisitely sensitive and it is not uncommon for the patient to jump when the trigger point is pressed. We determine the presence of a trigger point through a digital/rectal or digital/vaginal examination. The doctor inserts a finger inside the rectum or vagina and presses on the muscles to assess the tissue and to find trigger points.

A 1994 study sheds much light on the relationship between trigger points and stress. McNulty, Gevertz, Hubbard, and Berkoff inserted a needle electrode directly into a trigger point and monitored its electrical activity with a machine called an electromyograph. It appears that the higher the electrical activity in a trigger point, the higher the level of pain. Another needle was placed immediately adjacent to the first needle to monitor electrical activity of the tissue there.

Patients were given the stressful task of doing mental arithmetic. The scientists wanted to determine what the effects of stress were on the trigger points being monitored, and the differences, if any, between the responses of the trigger points to stress and the responses of the adjacent tissue. The results of the study indicated that the electrical activity of the trigger points increased during this stressful activity while the adjacent, non-trigger point tissue remained electrically unresponsive.

These findings are remarkable. They suggest that in some way the nervous system that is connected to emotional activity and arousal is selectively connected to trigger points and not to non-trigger point tissue. Understanding this, it is easy to understand why patients with pelvic pain and dysfunction routinely report that their symptoms are aggravated by stress.
Anxiety, anger, fear, and sorrow can cause increased pain in areas that have trigger points. Furthermore, your attitude toward your body and symptoms can serve to aggravate your symptoms. If you are aware of pain every day during urination or sexual activity, and you feel anxious each time you are aware of your pain, it is clearly very important to shift your thoughts and attitude about your symptoms.

Plato taught that we need to be kind to each other because each of us is engaged in a mighty struggle in our lives. Compassion for the most difficult of people comes from understanding their struggle. Letting go of anger and fear toward the rectum and genitals is simply an expression of your understanding and compassion for your own struggle. Discovering compassion toward oneself and one’s body is part of our protocol. As patients understand the language of the pelvic floor and their struggle with their habit of chronically tightening it, their attitude can change from fear to compassion and understanding.

Tension leads to anxiety which leads to pain

Chronic pelvic pain has been resistant to effective treatment because of what we call the tension, anxiety, pain cycle. This is a cycle in which chronic tension has shortened the muscles in the pelvic floor and, as discussed earlier, created an environment in which the pelvic floor can be said to be functioning like a clenched fist. This leads to pain and dysfunction. The pain is a signal of alarm to which the body responds with a heightened state of arousal or anxiety. Anxiety always produces increased tension, which then produces more pain, which then produces more anxiety.

The Tension-Anxiety-Pain Cycle

We often see patients in pain who are emotionally upset about their pain. Their hands are often cold and clammy; they are agitated and can’t seem to sit still. These patients are caught in the active grip of the tension-anxiety-pain cycle.

The difficulty of intervening effectively on behalf of these patients is illustrated in the children’s jump rope game called “double dutch.” In this game, two children, facing each other, turn two ropes, one clockwise, and the other counter-clockwise, as one child jumps both of the ropes.

The difficulty in double dutch is found in entering through both swinging ropes into the jumping space. Children who successfully “jump double dutch” are able to watch the two ropes as they follow closely one after another and to determine the split second when there is a space through which they can enter. Even for an athletic and bright child, double dutch is a challenge. Similarly, the events that occur in the tension-anxiety-pain cycle follow so closely one after the other, that we could call this “triple dutch.” Entering into these events to stop the cycle is not a small challenge.

A gentle approach to break the tension-anxiety-pain cycle

We intervene in this cycle in all three of its aspects.
Paradoxical Relaxation lowers pelvic tension and anxiety by lowering autonomic nervous system arousal in general and habitual pelvic tension in particular. Trigger Point Release deactivates trigger point pain, lengthens chronically contracted muscles, and makes the pelvic muscles more capable of relaxation. We have found that an effective way of beginning therapy when someone is caught in the grips of the tension-anxiety-pain cycle is to start treatment gradually. If the patient can not tolerate any pressure inside the rectum or vagina, we begin treatment by simply inserting a finger with no pressure anywhere. If they cannot tolerate the insertion of the finger, we hold the finger gently touching the opening of the rectum or vagina without moving at all. In backing up and reducing the intensity of the treatment to a tolerable level, we find a baseline from which to begin.

John J., a patient from Minneapolis, could not tolerate any pressure inside his pelvic floor. When we instructed his wife in the Trigger Point Release, we told her to simply insert her finger inside his rectum and not to press anywhere. She did this for a week on a daily basis and, with our instruction, she began slightly pressing on a trigger point. Gradually, as her husband could tolerate more of it, she increased the pressure. After a few months, he was able to tolerate the pressure that we normally exert at the beginning of treatment with most patients.

Similarly, John J. was not able to lie down and do the first lesson in the relaxation training for more than three minutes. We instructed him to do Paradoxical Relaxation for two minutes each day, which he did for a week or so. Following this, we increased the relaxation time gradually, until he reported actually relaxing for over a period of half an hour.

In summary: it is when you can find a method to rehabilitate the chronically tensed and shortened muscles, restore their original length and flexibility, and change the habit of continually squeezing them and the nerves, blood vessels and structures they contain, that a substantial number of patients with previously untreatable pelvic pain can experience a marked improvement or abatement of symptoms.

Our understanding is a radical departure from the conventional view of prostatitis and chronic pelvic pain syndromes. We see pelvic pain as often being a physical expression of the way a person copes with life. We propose that pelvic pain is the result of a neuromuscular state and not the result of a foreign organism in the prostate gland or an auto-immune disorder. 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 tension, anxiety, and pain. Once the cycle of tension, anxiety, and pain 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. This rehabilitative protocol consists of the simultaneous use of Paradoxical Relaxation and Trigger Point Release described in the next chapter.