Review
“One gloomy 5 a.m. in the winter of 2006, unable to sleep and trawling the Net yet again for some explanation of the chronic condition that had made my life a misery, I came across an extract from a book with the ugly title, A Headache in the Pelvis. Here, after two years of expensive consultations and invasive medical tests, I found at last an accurate description of my plight. What to do? I had given up on official medicine. Its drugs made me sick. Its operations threatened my manhood without promising relief. . . . Now A Headache in the Pelvis talked about years of stressful overachieving, sitting at a desk, and an embattled mental attitude that had led me to tense the muscles of my pelvic floor so that they had atrophied and were pinching the nerves that crossed them from bladder, penis, and prostate. . . . I was definitely suffering enough. And growing curious. On your back, allowing your breath to establish its own pattern, eliminating all words from your mind, you focus on tension in the body and just, well, nothing, let it be. You go to meet the pain itself, and again, let it be.
“It took many months. . . . I shall remember for the rest of my life the day when, from the dry, knitted tension of my forehead, a great warm wave rose up and crashed across my chest and limbs, sweeping everything before it: thought, tension, pain. For five minutes I was pain free, utterly relaxed. It was the beginning of the way back.”
—Tim Parks for the London Times
“This is a book that helps patients empower themselves in their own healing. With this book, patients learn how to gain control over their chronic pelvic pain. It is not a hocus-pocus solution; it is a long-term program that must be adapted into one’s daily routine. I have witnessed firsthand how patients willing to change their behavior have been able to find healing. . . . When I see patients after they’ve read the book I can often see a change in their faces. To understand that we have the ability to affect our own healing process can be life changing.”
—Ragi Doggweiler, MD, associate professor, director of Neuro-Urology and Integrative Medicine, Division of Urology, University of Tennessee, Knoxville
“After reading over the sixth edition of A Headache in the Pelvis, all I can say is ‘Wow.’ . . . Drs. Wise and Anderson have done it again! This has truly become the ‘Bible’ for patients, both men and women, who suffer from pelvic floor muscle dysfunction. The book demystifies a condition that is so frequently overlooked and often mistreated in clinical practice. It empowers patients to be their own caregiver, while it encourages partnerships with clinicians who can be tremendously helpful in the patient’s path to symptom improvement. A Headache in the Pelvis is on the top of my recommendation list.”
—Robert Moldwin, MD, author of The Interstitial Cystitis Survival Guide
“Many pelvic pain patients go from doctor to doctor, specialist to specialist, without improvement, often feeling abandoned. A majority of patients with chronic pelvic pain do not respond to conventional therapies (antibiotics and anti-inflammatory drugs), leaving a huge void. Drs. Wise and Anderson offer a therapeutic option that can bring relief to many.”
—Bart Gershbein, MD, clinical instructor, Department of Urology, University of California School of Medicine, San Francisco
“The sixth edition of A Headache in the Pelvis, by Drs. Rodney Anderson and David Wise, continues to be one of the most useful books for people who suffer from chronic pelvic floor pain. The book details a method for resolving pelvic pain by rehabilitating the pelvic floor muscles that have often been the brunt of anxiety or a reaction to a trauma or surgery. This new edition has filled in many of the answers raised since the publication of the first edition of this book in 2003. . . . This new treatment model is based upon Drs. Rodney Anderson and David Wise’s work at Stanford University Medical Center.”
—Erik Peper, PhD, professor, Institute of Holistic Health Studies, San Francisco State University
“Drs. Wise and Anderson have updated their important book on pelvic pain. This work has changed the way I think about pelvic pain. I now can find the clues in the physical exam (pelvic muscle spasm) that I had previously missed. This book is required reading for any clinician dealing with pelvic pain patients.”
—Stephen Bearg, MD, obstetrician-gynecologist, past chairman, Department of Obstetrics and Gynecology, Marin General Hospital, Kentfield, California
“A Headache in the Pelvis is an excellent book, brimming with warmth, compassion, and insight. It describes a pioneering method that empowers patients with pelvic pain to understand and help reduce their pain and symptoms. It is the very best kind of medicine, in that it teaches patients how to reduce their own symptoms themselves. This book is for people affected by pelvic pain and for family members who care about them; it’s also for the medical providers who work with these patients.”
—Marlene Cresci Cohen, PhD, director, Behavioral Sciences, Valley Family Medicine Residency, Modesto, California, and professor, Volunteer Faculty Department of Family Medicine University of California, Davis
“A Headache in the Pelvis is a lamp in the dark human suffering of chronic pelvic pain. This book is a precious document that will help many people.”
—Robert Blum, MD, former chief, Department of Neurosurgery, Marin General Hospital, Marin County, California
“I highly recommend this book to colleagues, clients, and friends all the time. It does a great job explaining the connections between muscle tension and pain symptoms. . . . I find that after the first reading, the book needs to be read and reread.”
—Marilyn Freedman, PT, DPT, BCB-PMD, CAPP
“This compelling understanding of chronic pelvic pain syndromes offers a new and pioneering approach to its alleviation.”
—Frank Werblin, PhD, professor of Neuroscience, University of California, Berkeley
“Since its first edition, A Headache in the Pelvis has been enthusiastically welcomed by patients suffering from urological pelvic pain syndromes (UCPPS), ... Although I recommend A Headache in the Pelvis to all of my patients, I have happily discovered that more and more physical therapists are recommending the book to their referring doctors and to their patients. In many ways, this book communicates effectively to a wide audience, as it is accessible and empowering to patients, interesting and insightful to health care providers.”
—Jeannette Potts, MD, director, Center for Pelvic Pain, Alternative and Medical Urology Services, Urological Institute University Hospitals of Cleveland, Case Western Reserve University
“A Headache in the Pelvis is a very important contribution to understanding and treating pelvic pain. It is also an illuminating discussion of the relationship of mental and physical interaction in the production of disease and an approach to a truly comprehensive treatment of illness that has relevance to a whole range of contemporary morbidities.”
—Donald L. Fink, MD, professor emeritus, University of California, San Francisco School of Medicine
“The work described here by Drs. Wise and Anderson is at the forefront of the understanding and treatment of chronic pelvic pain syndromes like prostatitis. Their approach sees the big picture of these disorders and breaks new ground in our understanding of the subtlety of the mind-body continuum.”
—A. S. Hadland, MD, former director, Integrative Medicine Pain Management Service, Kaiser Permanente
“It is important for the patient to learn all he can about his disease, especially if he has prostatitis/chronic pelvic pain syndrome. That is difficult because doctors seldom agree on the cause, cure, or treatment. The information contained in A Headache in the Pelvis will be essential for these patients.”
—Mike Hennenfent, president of the Prostatitis Foundation
“This book is something different, something not seen before in the field of prostatitis/chronic pelvic pain. This book will take you to a place you have never been before within prostatitis/chronic pelvic pain syndrome. The relaxation techniques, exercise, and trigger point release all are outlined and explained in great detail. Examples used to explain various points are truly excellent and enlightening. Pick up this book and you will be taken into a world of relaxation, calm, and above all a way to possibly ease your symptoms. The authors have created a new portal into the condition and offer you through the book just what they do to help sufferers get better. Lie back, relax, and you will not be able to put this book down. To suddenly be aware of your pelvic pain in the ways outlined in this book is a truly enlightening experience. This time last year we could not have dreamed it possible to see a book like this on the bookshelf. Every UK urologist should read this book. If you can afford it, you may wish to buy your doctor a copy.”
—The British Prostatitis Support Association
Review
“I have witnessed the therapeutic benefits of this book”
Since its first edition, A Headache in the Pelvis has been enthusiastically welcomed by patients suffering from urological pelvic pain syndromes (UCPPS), which may have been previously diagnosed as prostatitis or interstitial cystitis/painful bladder syndrome.
I have specialized in UCPPS for over 15 years, and have been impressed by the educational merits of this book, which provides factual medical information to the patient without exacerbating fears or anxieties. Indeed, I have witnessed the therapeutic benefits of this book, as it provides validation to patients along with empowering management strategies. A Headache in the Pelvis addresses both the physical and emotional aspects of UCPPS in a caring and methodical way, which patients find accessible and nurturing. It has become a wonderful adjuvant to physiotherapy and self care, as well as a support tool for loved ones living with a man or woman who has UCPPS.
Although I recommend A Headache in the Pelvis to all of my patients, I have happily discovered that more and more physical therapists are recommending the book to their referring doctors and to their patients. In many ways, this book communicates effectively to a wide audience, as it is accessible and empowering to patients, interesting and insightful to healthcare providers.
Jeannette Potts, MD
Director, Center for Pelvic Pain, Alternative and Medical Urology Services
Urological Institute
University Hospitals of Cleveland
Case Western Reserve University
Cleveland, Ohio
About the Author
David Wise, Ph.D., is a psychologist who spent eight years in the Department of Urology at Stanford University Medical Center as a research scholar in the development of a new treatment for prostatitis and chronic pelvic pain syndromes. His research interest is in behavioral medicine and autonomic self-regulation. Rodney Anderson, M.D. is a professor of Urology at Stanford University Medical School. His specialty is neurourology. His interest and expertise focuses on chronic pelvic pain syndromes, pelvic floor dysfunction, interstitial cystitis, benign prostatic hyperplasia, urinary incontinence, urinary retention, spinal cord injuries, spina bifida, multiple sclerosis, Parkinsonism, and stroke. He was the chief of the pelvic pain clinic at Stanford. He has also directed a clinic devoted to the problem of female sexual dysfunction. He is actively engaged in clinical research at Stanford for a variety of disorders.
Excerpt. © Reprinted by permission. All rights reserved.
Chapter 1
Chronic Pelvic Pain Is Easy to Understand
Millions of men and women suffer from pelvic pain, discomfort, or dysfunction that drugs, surgery, and conventional treatment do not help. If you are one of them, you may have experienced rectal, genital, or abdominal discomfort or pain, increased discomfort or pain sitting down, discomfort or pain during or after sexual activity, or urinary frequency, urgency, and hesitancy.
If you’re reading this book, you’ve probably gone to a doctor or many doctors who found little or no physical basis for your symptoms. Your tests came back normal. You may have been diagnosed with pelvic floor dysfunction, prostatitis, chronic pelvic pain syndrome, coccydynia (tailbone pain), chronic proctalgia, proctalgia fugax, pelvic floor myalgia, piriformis syndrome, interstitial cystitis, urethral syndrome, or other related diagnoses, but found no relief. We are proposing in this book that all of these different diagnoses are essentially different names for the same problem, a problem we are calling A Headache in the Pelvis.
The amelioration or resolution to the kind of pelvic pain we treat and discuss in depth in this book has eluded the best medical minds for recorded history. Most people reading this book would not be reading it if they were able to find help within the context of conventional treatment. It is not uncommon for individuals with pelvic pain to either have it on a continual basis or to have it wax and wane for many years and to go from doctor to doctor receiving little help. To date, there is no solution to this problem offered by the best conventional medicine. Conventional or not, for the most part, there is very little that has helped pelvic floor related pain and dysfunction. The Wise-Anderson Protocol offers real understanding and help.
Pelvic pain we describe is a condition of sore, irritated pelvic floor tissue that is never given a chance to heal. Our book offers an intimate understanding of this problem based on one of the author’s twenty-two-year history with it and his experience of its resolution as well as a subsequent twenty-four years of experience of treating several thousand patients in collaboration with skilled colleagues. We discuss this understanding in detail in the next chapter. Instead of pelvic pain with related symptoms discussed in this book being the result of an infection, a trapped nerve, an autoimmune disorder, or degenerative disease, we propose that it is a psychophysical problem. Both the physical and psychological aspects must be strongly addressed for any chance at a satisfactory resolution of symptoms.
An Intimate Look at Pelvic Pain
The major contributing factor involves a chronically knotted up, contracted pelvis—typically a physical response to years of worry—that leads to tight, irritated pelvic floor tissue, leading to a reflex response in the pelvic tissue of protective guarding that creates a self-feeding cycle that gives pelvic pain a life of its own. In what we can call pelvic pain related to pelvic floor dysfunction, sore pelvic floor tissue once established doesn’t have a chance to heal the way other sore human tissue heals. You can think about the ongoing reflex protective guarding of irritated, sore pelvic tissue as a kind of ongoing pelvic charley horse.This chronic charley horse keeps the pelvic tissue irritated and preventing its otherwise natural healing. Ongoing pain from this sore tissue leads to protective pelvic muscle guarding, anxiety, continued dysfunctional protective guarding, and chronic painful tissue irritation.
In scientific studies, it has been documented that the Wise-Anderson Protocol helps a majority of patients.
Dealing with these central aspects of pelvic pain is daunting in the most ideal of circumstances. With the best of treatment we can offer, resolving one’s pelvic pain is a challenge and with some individuals beyond our ability to help. But we do help the large majority of those we treat. Indeed, the large majority of qualifying patients are helped by the program explained in this book, called the Wise-Anderson Protocol.
How This Book Can Help You
You are holding in your hands the seventh, definitive edition of A Headache in the Pelvis. It is a streamlined edition of a book that we originally published in 2008. Since its publication, the book has been read by tens of thousands, and the feedback from readers has informed our refinements to the protocol, as has our clinical work. Some readers of our book have reported that they have significantly reduced their symptoms by reading about and then applying the methods we describe here. That being said, we cannot recommend using the methods that we describe here on oneself or others without proper supervision from someone competent in these methods. We don’t know how a reader relates to his or her body and do not want to be responsible for actions individuals take, in relationship to themselves, that we cannot supervise and correct when necessary. Pressing on a trigger point for one individual may mean using too little pressure, for another just enough pressure, and for another bruising pressure. The process described in Extended Paradoxical Relaxation may result in a significant relaxation of tension and symptoms in one individual, yet in another individual this instruction may be wholly misinterpreted and result in tension that increases and that sours him on using this method.
Nevertheless, some readers have designed their own programs using our model and have helped themselves. They have written to us with gratitude for our road map. Others have been less successful at doing this on their own.
The basic goal of the Wise-Anderson Protocol is to train patients to become expert in reducing or stopping their own symptoms. We have found that when treatment for pelvic pain by a professional is confined to weekly or biweekly visits without a committed self-treatment daily program of pelvic floor relaxation, stretching, and effective physical therapy self-treatment, it tends to be a tepid intervention. The Wise-Anderson Protocol sees the treatment of pelvic pain as an inside job.
Self-Treatment Is the Core of Our Method
For understandable reasons relating to constraints of time in conventional treatment, training patients in self-treatment tends to be an afterthought in most treatments of pelvic pain. Lip service is given to patient daily self-treatment but with little time for patient training or backup. The Wise-Anderson Protocol makes the training of the patients in doing their treatment its primary goal.
The Wise-Anderson Protocol Is Not Easy or Quick
Most of us are resistant to changing our routine. It is our experience that taking at least two hours or more a day to do one’s home program for at least many months is the bare minimum for our protocol to be effective. Carving out two hours or more from one’s life bumps up against real barriers for most people. These barriers include the huge inertia of a routine shaped by the demands of work and family and a desire for downtime that often makes one feel there is no room for any other activity. Our patients tend to stick to their home practice over the long term when they see that their symptoms are improving.
In our experience, only the yearning to get out of pain and the related suffering of pelvic pain syndromes is a strong enough motivation for patients to accommodate the self-treatment requirements we describe.
A Road Map of Pelvic Pain Healing
The biggest contribution we have to offer is a new view of the problem of pelvic pain and a road map for its amelioration. If we have done this in writing this book, we have accomplished something important. However this book is used, we hope that the Wise-Anderson Protocol can shine a light on the path of resolving pelvic pain.
The Different Names for Pelvic Pain: The Elephant and the Blind Men
Chronic pelvic pain goes by many names. You will find a comprehensive list in this chapter. It may be called prostatitis by a urologist or coccygodynia or pudendal nerve compression syndrome by a colorectal surgeon. Other names used to describe the same condition include chronic genital pain, prostatodynia, pudendal neuralgia essential anorectal pain, idiopathic pelvic pain, pelvic floor dysfunction, pelvic floor myalgia, levator ani syndrome, and spastic piriformis syndrome. Three specialists may give you three different diagnoses.
There’s an old parable about ten blind men who came upon an elephant. One touched the elephant’s leg and remarked, “Oh, this creature is like a tree trunk.” Another was under the stomach, pushed up, and said, “Oh, no. This creature is like a soft ceiling.” A third pulled the tail and said, “No, this creature is a rope connected to a tree.” All the blind men were right and all the blind men were wrong; their answers were incomplete because they each had access to limited information. Similarly, there’s a lack of communication among many medical specialists; if they all spoke to each other, they would see that they are often talking about the same condition. In this book, we aspire to see the whole elephant.
The Source of Pelvic Pain Symptoms
There is a simple physical basis for chronic pelvic pain symptoms. The seemingly wide array and variability of the symptoms are simply expressions of the same underlying problem, whether you’re a man or a woman. The Wise-Anderson Protocol does not treat the symptoms; instead, it treats what triggers those symptoms. Our approach substantially reduces or abates symptoms in a large majority of qualifying patients who undertake our full protocol.
In this book we will use the terms a headache in the pelvis, chronic pelvic pain syndrome(s), chronic pelvic pain, pelvic pain, and CPPS synonymously to refer to all the conditions discussed.
Diagnoses You May Have Received
Men
• Prostatitis (National Institutes of Health categories)
I. Acute bacterial prostatitis
II. Chronic bacterial prostatitis
IIIA. CPPS nonbacterial inflammatory prostatitis
III. CPPS nonbacterial noninflammatory prostatitis
IV. Asymptomatic inflammatory prostatitis
• Orchalgia and/or epididymitis
• Proctalgia fugax
Women
• Urethral syndrome
• Vulvodynia (vulvar vestibulitis)
• Proctalgia fugax
Both Men and Women
• Interstitial cystitis
• Levator ani syndrome
• Pudendal nerve entrapment syndrome (pudendal neuralgia)
Throughout History, Pelvic Pain Disorders Have Never Had a Solution
For many years, chronic pelvic pain syndromes have posed an enigma to the medical/healing community. In men, nonbacterial prostatitis, for example, has routinely been confused with acute or chronic bacterial prostatitis, even though an accurate and easy method for diagnosis has been available for years. At the same time, nonbacterial prostatitis, which makes up the overwhelming number of cases of prostatitis, tends to be regarded by doctors as a kind of wastebasket diagnosis for pelvic symptoms that the doctor does not understand or know how to treat. Gross pathology, as measured by the latest medical instruments, has not been able to explain the degree of suffering caused by these disorders.
Doctors often tell patients with chronic pelvic pain syndromes that they can find little or nothing wrong with them.
What we are proposing in this book is that these conditions are rather like a headache, except that the location of the headache is in the pelvis. Hence A Headache in the Pelvis is our title. And the basis for all these conditions is chronic pelvic floor muscle irritation, triggered and perpetuated by chronic muscle tension. If chronic pelvic pain syndromes are, in fact, a headache in the pelvis, then treatment needs to be radically different from what has traditionally been followed.
A Headache in the Pelvis is the name we are giving to chronic pelvic pain syndromes where no gross pathology has been found. These syndromes often include pain and dysfunction related to urination, defecation, and sexual activity. This discomfort or pain and dysfunction occurs in both men and women. One person may experience only one symptom while another may experience all symptoms. Sometimes symptoms inexplicably vary from day to day or week to week. Symptoms vary, as do their anatomical locations, yet we propose that the trigger for these symptoms is the same and that a common effective treatment exists for all of them.
Even though many people suffer from a headache in the pelvis, most of them feel alone in their difficulty. The pelvic area is considered private and is often very difficult to talk about, even with close friends or relatives. Basically, most people want the areas of the genitals and rectum to work but don’t want to know much about them or to have to pay any attention to them.
These areas of the body are not treated with much appreciation. This is a truth that is reflected in how we word profanities. What do we call people with whom we are angry? Usually terms related to defecation or procreation. Indeed, these are terms of denigration. In our culture, the genitals and rectum are shrouded in shame and guilt. When a pelvis becomes chronically sore and irritated, sufferers often feel alone and afraid and are reluctant to share their experience, especially as they find neither a doctor or friend who can really understrand their symptoms.
Quite simply, if you haven’t experienced chronic pelvic floor pain and dysfunction, you don’t understand it because you’ve never experienced the weird kinds of symptoms that occur with it. The healing of the abused pelvis, as Steven Levine has stated eloquently, in part involves bringing the genitals and rectum “back into the heart.” To begin with, this means changing one’s attitude from shame, and rejection to compassion and appreciation.
Common Symptoms in Men and Women with Pelvic Pain
Below is a list of the most common symptoms we see in the patients we have been able to help. Most experience several to many of the symptoms. Rarely do patients have all of them.
Urinary Symptoms: Frequency, Urgency, Hesitancy, Dribbling, Dysuria (Burning with Urination), Nocturia (Nighttime Urination)
Frequency and Urgency
• Urinary frequency in our patients ranges from annoying to debilitating.
• There is commonly a feeling of something always nagging in the bladder/urethra/genitals, and typically, after patients urinate, they report that they don’t feel “emptied” during or after urination and are left with the feeling of having to urinate again even though there is little to urinate.
• Frequency/urgency can result in the feeling of having to be near a bathroom; sometimes one can hardly hold in the urge to urinate when it arises. Some patients feel that their lives revolve around staying near a toilet.
Nocturia (Frequent Nighttime Urination) for Men and Women
• Urinary urgency and frequency at night can deprive patients of sleep.
• Exhaustion from sleep deprivation tends to feed into the cycle of tension, pain, protective guarding, and anxiety.
Dysuria (Discomfort, Pain, or Burning Before, During, or After Urination)
• Discomfort, pain, or burning during urination is associated with pelvic-floor dysfunction.
• When the trigger points, chronic spasm, and myofascial contraction of the pelvic muscles are resolved, dysuria is also resolved in many of our patients.
• Some patients experience discomfort only after urination, not during.
• In a subset of individuals, dysuria can be quite painful, and urination becomes an ordeal and sets off further pain.
