For more information on the Wise-Anderson Protocol

Reflections on Prostatitis and Chronic Pelvic Pain Treatment

Reflections on The  Prostatitis and Chronic Pelvic Pain Treatment and the path to Recovery

By David Wise, PhD

This paper is about sharing my observations about healing my own pelvic pain and my road to recovery.

Millions of men suffer from urinary frequency, urgency, pain with sitting, pain after sex, genital pain and pelvic pain and other symptoms called prostatitis/chronic pelvic pain syndrome. I suffered for over 20 years from what was is now diagnosed as prostatitis/chronic pelvic pain syndrome. This diagnosis is confusing to patients and doctors alike, and the story about this confusion surrounding the treatment of the condition remains to be told to a large audience.

Today, gratefully, my pain is gone and I have become an expert in a field I never wanted to be an expert in. As I think about it now, I can’t imagine the devastation of my life had I continued to be in pain. I always feel grateful. I hope this article can help clarify the confusion, misdiagnosis, and ineffective treatment of what is diagnosed as prostatitis in men and help many silently suffering men find a way back to having a life again.

I observed my own slow and awkward healing.

I am someone who has been interested in my internal life and its process, whether it is related to pelvic pain or to my interpersonal relationships. Naturally, over the years, I observed with great interest the mental and physical happenings in my body through the process of the resolution of my pelvic symptoms. In this essay, I want to share my experience of coming out of pain and what I have observed and learned about this experience in the hope that it can offer a roadmap to others.

When I was a young man experiencing the symptoms our patients come to see us with, I dutifully and sincerely went to the urologist trusting he would help me. I saw him for many years and was never helped by his methods. I was told that I had ‘prostatosis’. The doctor explained, as best he could, that what I had was like prostatitis, except there was no inflammation or infection. He said my prostate was ‘boggy’.

I never quite understood what he was saying. In retrospect, I can’t imagine he understood his explanation either even though he was a kind and intelligent man. It was clear he was telling me that my prostate gland was my problem except for the peculiar explanation that there was no problem with it except it was ‘boggy’. To me ‘boggy’ means soft or spongy. I didn’t understand how something spongy could cause me the pain and symptoms I had, but he was the doctor and I trusted him. Gratefully he told me that my symptoms would get better as I got older (he was wrong) but I appreciated that he gave me the hope that somehow, at some time, my symptoms would get better. As the doctor couldn’t help me, I lost faith seeing doctors. I had nowhere to go and no one to help me. People have asked me how I dealt with my symptoms for over two decades. My answer is that there was nothing heroic about it. I muddled through my life dealing with the symptoms day by day, as all of our patients do.

I took the insights of my recovery to Stanford.

After doing a version of the protocol we now offer, my pain went away in the 1990’s. Excitedly, I called Dr. Rodney Anderson, one of the world experts in prostatitis and pelvic pain and the head of the Pelvic Pain Clinic at Stanford University Medical Center in the Department of Urology, and shared my experience with him. For many years at Stanford Dr. Anderson worked closely with Dr. Thomas Stamey, who co-invented the test for bacterial prostatitis. Dr. Anderson finally came to the conclusion that what was typically diagnosed as prostatitis was not a prostate condition but a condition of the contracted muscles of the pelvic floor and as such was not helped by the conventional standard of treatment using antibiotics and anti-inflammatories.

My call to him that day in 1995, sharing my recovery, found him open to listening about my experience. Gratefully, he recognized the importance of what I told him about how I got out of pain after 22 years of suffering.

From that time Dr. Anderson and I immediately began working together at Stanford. At Stanford was where we saw pelvic pain patients and developed the Wise-Anderson Protocol (popularly called the “Stanford Protocol” in internet discussions) detailed in the first edition of our book, A Headache in the Pelvis. In our protocol, we saw and treated the muscles of the pelvis as the sources of what are commonly diagnosed as prostatitis symptoms and anxiety that inflamed them. We began treating the pelvic muscles and emotions of men’s anxiety related to them, as the key treatment for prostatitis with typical symptoms of prostatitis—not their prostates. I worked with Dr. Anderson as a Research Scholar at Stanford for 8 years.

Later, after I left Stanford, Dr. Anderson and I, along with Tim Sawyer, our senior physical therapist, continued our close collaboration and research into our protocol. The form of treatment changed from a conventional weekly visit format, to what has evolved into a 6 day monthly immersion clinic. In total, I have spent 18 years treating patients with the Wise-Anderson Protocol. We have published a number of papers and have presented our work in major scientific meetings in the US and internationally.

Getting to the top of the mountain to see below: how the discovery of San Francisco Bay is similar to finding the route out of pelvic pain.

When someone’s prostatitis symptoms go away, what happens? How does this healing occur? Here is an analogy that is helpful to me in explaining why conventional medical treatment has been unsuccessful in finding a prostatitis cure: Many years ago, European explorers sailed up and down the coast of California, yet from the ocean they could not see San Francisco Bay. Then, in 1769 Spanish explorer Gaspar de Portola set out for the port at Monterey. Believing he had missed the port, he continued sailing north up the coast. After a time at sea, short on food and water, Portola sent an expedition ashore. They landed in what is today known as Pacifica, and it was looking out from a ridge that they finally saw the San Francisco Bay.

The pathway out of symptoms diagnosed as prostatitis has not been visible from the ‘ocean’ of the conventional medical perspective, or even any common sense perspective. The symptoms are, frankly, weird, and only if you have experienced them can you really understand them. Just like de Portola, after many years of experimentation, blind alleys, hit and miss attempts and trying different ways to stop my pain, I too found the ‘ridge’ of understanding; that my pelvic pain was not an infection or problem with my prostate gland, as my urologists had told me, but was in fact a problem of chronically tightened muscles inside my pelvic floor. This chronic tightening in my pelvis was where I held my anxiety. Some people would call it me being “anal,” and that’s probably true.

I found relief when placing a finger inside, I pressed on these tightened muscles and stretched them or relaxed them. I noticed stress made my symptoms worse and alternatively I felt some temporary relief from a hot bath, a good night’s sleep or the resolution of some worry. I came to see that what made my symptoms better or worse was the tightening or relaxation of my pelvic muscles. While that might seem easy to fix, I found that the fix was neither easy nor obvious.

Why pelvic pain symptoms do not act like other symptoms.

Symptoms commonly diagnosed as prostatitis rarely respond to the normal treatments for pain. One of the reasons that these symptoms have fooled conventional medicine is that they are referred from places in the pelvic floor that are remote from the pain. For example, the cause of pain in the penis is typically found inside the pelvic floor, 10 inches away from where the pain is felt, on the anterior portion of the levator muscles. The cause of muscle based testicular pain can be muscle restriction and trigger points in the quadratus lumborum, an external muscle a good foot away from the testicles. Abdominal pain, urinary frequency and urgency, sexual pain, post-bowel movement pain, and other associated pain are typically caused by tenderness in the muscles inside and outside the pelvic floor.

Most doctors treating pelvic pain do not examine the muscles of the pelvic floor and related areas. In not examining these muscles, they fail to see that the symptoms of what is called nonbacterial prostatitis in the vast majority of cases can be recreated by pressing on specific muscles inside and outside the pelvic floor. Most importantly, when these sore and tender areas of muscle are loosened and what are called trigger points released, done in conjunction with reducing the anxiety that typically flares them up, symptoms diagnosed as prostatitis can reduce or go away.

Doctors typically treat men with prostatitis with medications. The National Institutes of Health have has done an exhaustive, careful study of antibiotics, alpha blockers and anti-inflammatories—the most commonly used drugs for pelvic pain in men diagnosed as prostatitis—and the conclusion of this and other studies was that these medications do not help. While surgery was never suggested to me when I was in pain, in hearing the reports of many patients I have treated who had surgery, I have concluded that surgery, another common ‘solution,’ is a bad idea. It almost always complicates the symptoms or makes them worse. I have never heard patients report that a nerve block or any surgery, including pudendal nerve or prostate resection surgery, resolved prostatitis symptoms. Exploratory procedures, CAT scans and other high tech imaging tests typically cannot find anything wrong. Blood and urine tests are typically normal. The conventional ways of diagnosing and treating what is diagnosed as nonbacterial prostatitis do not help. All of the men (and women) who have come to see us for treatment have been refractorily unhelped by all of their prior drug and surgical treatments.

A heart transplant won’t stop heartburn: treating the prostate will not help the chronic contraction of the pelvic muscles.

I’ve come to understand the importance of the insight that, how you look at a problem determines the method you use to fix it. My view that I had a muscle problem and not a prostate problem changed everything for me. When I witness the suffering of our patients, I see myself before I changed my viewpoint about my problem. Most men we see continue to think in some way that they have a prostate-related problem. Below are my thoughts about the confusion in the diagnosis and treatment of prostatitis.

A heart transplant is a wrong the treatment for heartburn. Cutting down pine trees doesn’t get rid of poison oak rashes. You have to be able to make a differential diagnosis to distinguish reflux pain in the esophagus from pain coming from the heart muscle. You have to distinguish poison oak from pine trees. My experience with men diagnosed with prostatitis over the years is that conventional medicine has erred in its differential diagnosis of their symptoms as pelvic pain. Most of our patients have reported that their doctor never did a culture for infection before prescribing antibiotics. Just as you have to know the difference between pain from a heart attack and pain from acid in the esophagus, so must you differentiate between pain coming from an infected or inflamed prostate gland and pain coming from the muscles inside and outside the pelvic floor. The distinction must be made between symptoms of prostatitis caused by prostate infection, which occurs in a tiny proportion of men diagnosed with prostatitis, and symptoms that are caused by a chronically tightened pelvis, which occur in the large majority of men. This is one of our original contributions to prostatitis treatment.

The misdiagnosis of chronic prostatitis.

All too often we see patients whose doctors ignorantly recommended they undergo invasive surgeries and treatments. All of them which failed to end the symptoms. A doctor who saw one of our patients for testicle pain recommended that he have the offending testicle removed. The patient gladly agreed to surgery with the hope it would end his pain. When surgery didn’t end the pain, the doctor told him they must’ve removed the wrong testicle. Tragically, the surgery to remove the second testicle also failed to stop the pain.

To my great dismay, we’ve seen men who’ve had their prostate glands removed, re-sectioned, and “roto-rootered.” We’ve seen men and women who’ve had their anal sphincters cut. One man elected to have a colostomy with the hope that not having bowel movements would cause his pain to stop. It never did. We have seen many patients addicted to narcotics and other medications that did little good for them and whose efficacy wore off.

In our practice, we’ve seen three women who had their bladders removed and many who’ve undergone hysterectomies, laparoscopies, and urethral dilations. None of it helped. Of course, we’ve seen a number of people who’ve had the pudendal nerve surgery, in which the ligaments that stabilize the pelvis are cut—and we have never seen any resolution of symptoms from this surgery or any surgery. From Botox and electrical stimulation to acupuncture and faith healing, nothing has been effective if the spasticity of the muscles and arousal of the nervous system is not addressed.

The patients who have done best in our program took ownership of their own healing

As the doctors couldn’t help me, I lost faith in them. I had nowhere to go and no one to help me, but I believed the doctor who told me my problem was related to my prostate gland. For years I went along in pain not knowing what to do and inadvertently experimenting with different methods of treatment.

One of the many difficulties of someone diagnosed with prostatitis or chronic pelvic pain syndrome is moving into the position of being your own researcher and doctor. It is not easy or comfortable for many people to abandon trust in the conventional viewpoints in favor of their own research and intuitive judgment. The most common form of muscle based pelvic pain in men is incorrectly named ‘prostatitis’ and both urologists and family practitioners continue to treat it as if it is a prostate problem rather than a problem of the pelvic muscles. I see now that healing muscle based pelvic pain in most of our patients required a journey away from this idea and the authority of the doctors who treat it with this conventional wisdom. This is not easy for many people.

I never wanted to know anything about the pelvis. When I first started having my problem, I wanted to go into the doctor and have him fix it and send me on my merry way. No patient wants to have to learn about this area of the body or its treatment. If you were to ask any pelvic pain patient whether they want to learn to be their own doctor, they would all say, “Don’t call me, I’ll call you.” But, the pelvic pain patient who is able to find a solution to their own pain is the patient who becomes their own researcher and ultimately relies on their own intuitions on what to do and who to believe.

This is a difficult situation for most of us. The patients I have seen who insist on listening to their doctors about this problem, remain in pain or in some cases get into trouble with surgery, narcotic medications and other drugs.

The maddening refusal of conventional doctors to understand most pelvic pain is a muscle-based problem and not an infection or inflammation based problem.

Despite the decision of the National Institutes of Health to change the name of nonbacterial prostatitis—by far the largest category of pain in men—to chronic pelvic pain syndrome, men who seek chronic pelvic pain treatment are routinely treated as if their problem comes from their prostate gland. When I was at the National Institutes of Health (NIH) meeting on prostatitis in 1999, it became very clear that there was only a handful of us who understood the majority of prostatitis cases to be the misdiagnosis of conditions unconnected to the prostate.

When Leroy Nyberg, then head of the section of the NIH covering prostatitis, was asked about the urology community’s refusal to shift paradigms about prostatitis from a prostate infection model to a pelvic floor muscle pain model, he said, “It doesn’t go over well when a big organization loses a disorder.” What was left unsaid was the ideological and economic disincentive of shifting perspectives. Unfortunately, the person who suffers from this is the patient.

Why healing muscle-based pain follows a circuitous route.

As I see it now, several major systems of the body converge in the precipitation and perpetuation of symptoms diagnosed as prostatitis. There is tender pelvic tissue that one cannot see, is hard to reach and is usually in motion. You also typically have to deal with what turns out to be a typical chronic prostatitis patient’s long-standing habit of catastrophic thinking and anxiety. (Elsewhere I’ve discussed literature that documents the relationship between anxiety, emotional distress, family dysfunction and pelvic pain). And then, of course, there is the unfortunate, dysfunctional tendency of the pelvic muscles to reflexively tighten against the pain, which instead of protecting the individual exacerbates the problem. I discuss this cycle in detail below.

One of the problems of conventional medical treatment for pelvic pain is that healing requires the expertise of a number of sub-specialties that do not talk to each other.

Pelvic pain tends to be treated by a variety of different medical sub-specialties—urology, gynecology, colo-rectal surgery, chiropractic, physical therapy, and psychology/psychiatry. The lack of communication between these subspecialties around pelvic pain leads to a piecemeal treatment of the problem. This is especially true in the treatment of the physical and mental aspects of the disorder, which are intimately intertwined. Finally, as is the theme of our program, the concept of teaching patients how to treat themselves is not the major focus of any of these subspecialties. As far as I’m concerned, the aspect of self-treatment as a therapeutic regimen is critical for most pelvic pain patients to get better.

The huge stress-related dimension of muscle-based pelvic pain is only recently being recognized and treated.

The stress/psychological dimension of pelvic pain wasn’t recognized for many years. Even today, many urologists not only have little understanding of the psychological dimension of pelvic pain, but they continue to look for its origin in men in the prostate gland. This completely ignores the central focus of the problem, which is in the muscles of the pelvis. Physical therapists who have somehow established themselves as those who can enter inside the pelvis to do physical treatment have little training in urology or psychology, and physical therapy treatment tends to focus on the treatment of myofascial tissue. Each medical subspecialty has its own strengths and limitations. I am clear that the skills that are required to treat pelvic pain are cross-disciplinary, and all of them cannot be found in any one specialty.

When someone is scared, frightened, or stressed the core of the body tightens in a guarded posture.

As I became aware of the continual muscle tension in my pelvis and began to work with it, I saw how difficult it was to relax. I didn’t understand then, as I do now, that muscles that have become shortened and developed the taut bands called trigger points cannot relax until the trigger points are physically released. This was a huge insight and explained a lot to me. It convinced me that treatment for prostatitis has to be cross-disciplinary and must go beyond the limited skill and understanding of conventional treatment. I understand now that chronically tightened pelvic muscles get stuck in that state and at a certain point begin to cause pain, which triggers a self-perpetuating cycle that has a life of its own even after the precipitating stress goes away.

Someone with pelvic pain typically walks around guarded and tight in the pelvis. ‘Girding your loins,’ a biblical euphemism, describes the tightening, guarding or protecting of the genitals. When we are not stressed, it’s difficult to appreciate the strength this physical contraction has, but muscle tightening in periods of ongoing stress can be profound.

The painful pelvic muscles have shortened, predisposing them to pain and dysfunction.

For years I meditated on and observed my symptoms, but never understood why I could do nothing about them. As I visualize it in my mind now, once pelvic muscle tightening occurs for a certain period of time, I imagine that the microscopic distance between the muscle tissues reduce, creating less air and less space in between these muscle fibers. After a while, taut bands of muscle called trigger points form. These trigger points can refer pain to other places in the pelvis. We illustrate and describe these trigger points and the areas to which they refer pain in our book A Headache in the Pelvis. These trigger points are pivotal in creating, “an inhospitable environment for the muscles, nerves, and structures within the pelvic basin.”

It’s clear to me that the tension-anxiety-pain-protective guarding cycle is the major obstacle to healing muscle based prostatitis.

The Tension-Anxiety-Pain-Protective Guarding Cycle

Chronic Pelvic Pain Treatment

For many years I experienced the tension-anxiety-pain-protective guarding cycle, but it wasn’t until we wrote A Headache in the Pelvis that I put it into words. This cycle is what I believe is at the heart of muscle based prostatitis symptoms. This cycle is the meeting of body and mind within the pelvic floor. I lived within the grip of this cycle for many years.

Men with chronic muscle based prostatitis are caught in the tension-anxiety-pain-protective guarding cycle, in which the pelvic muscles causing the pain can no long relax. They remain tense and sore making them subject to a reflexive protective guarding that makes the pain worse.

Protective guarding occurs as a reflex when we pull our hand away from a hot stove, when our eye flinches after something gets in it, or when we tighten up and withdraw from something that causes us pain. This reflex to tighten and pull away is very important for our survival and indeed it usually protects us.

The instinct to tighten up against pelvic pain diagnosed as prostatitis is dysfunctional because instead of helping, it makes the pain worse. Protective guarding against sore pelvic muscles further tightens them up. This dysfunctional protective guarding is intimately connected to the chronicity and perpetuation of chronic pelvic pain. This is why studies have shown that the muscle tone in the pelvic floor tends to be abnormally high in sufferers of chronic pelvic pain syndromes.

When I gave a talk at the National Institutes of Health, I asked participants to tighten up their pelvic muscles for a minute. I speculated that few would be willing to tighten up like this for the entire minute. I told them that if I asked everyone in the audience to tighten up the pelvic muscles for an hour no one would be surprised if there wasn’t anyone willing to do this. I then took them on an imaginary journey of tightening up their pelvic muscles for a whole day, and then a week, and then a month, and then a year. To someone without pelvic pain, such chronic contraction would be unimaginable.

Those who have symptoms diagnosed as prostatitis and chronic pelvic pain syndrome, experience this dysfunctional protective guarding for months and years. This is why many patients report that when they follow the instructions in our book to do “moment to moment relaxation of the pelvis,” their pelvic muscles invariably tighten up immediately after they stop. It was only after my pain went away that I stopped protectively guarding in the way that I had when I was symptomatic.

Pain prompts protective guarding which increases the pain, which then triggers catastrophic thinking and anxiety. Anxiety feeds into the pain and increases it as Gevirtz and Hubbard have demonstrated in many experiments showing trigger point activity increasing with anxiety. The tension-anxiety-pain-protective guarding cycle has resisted all conventional attempts at resolution.

The challenge of repetitively rehabilitating painful pelvic tissue. The necessity of repetitive loosening of the pelvic floor and of the anxiety related to it. Teaching our patients to do their own internal and external trigger point release.

We begin our treatment by teaching patients how to soften and release the trigger points of contracted pelvic tissue. This means identifying the sore trigger points and palpating them in specific ways for a certain period of time. (see article on physical therapy for pelvic pain)

Using our internal trigger point wand.internal trigger point wand.

To treat the hard-to-reach internal muscles, we developed an internal trigger point wand, which we have been using as part of a treatment study for the past four years. Our clinical study found that patients who did our protocol using the wand for six months saw their median level of pain/sensitivity in the trigger points in the pelvic floor muscles decrease from 7.5 to a 4 (on a scale of 1-10).

It’s clear to me now that repetitively loosening and softening the pelvic floor muscles is central to healing muscle based pelvic pain.

Restoring the pelvic muscles to a normal length and pain-free state requires repetitive, ongoing physical therapy self-treatment. Just as you would change any bad habit, repetition is key. You must repeatedly restore the tissue to a normal state until you over-ride its conditioned tendency to remain contracted. In the book Blink, author Malcom Gladwell restated an observation that a number of researchers have made, which is that mastery requires 10,000 hours of repetition. While 10,000 hours of repetition is not required to loosen a painful pelvis, repetitive physical loosening and relaxation are necessary for my experience of pelvic pain healing.

Along with releasing the tissue physically, I experienced daily the necessity of calming my nervous system down. If I didn’t, my symptoms seemed to stick around. I will discuss the focus on the nervous system below.

Not too much or too little pressure.

When I treated myself physically, I learned that I had to be careful about the level of pressure I used to working with my painful muscles.

I found that when one does myofascial/trigger point release on muscles inside and outside the pelvic floor, chronically tight pelvic muscles have to be rehabilitated within certain specific parameters of pressure and within certain time frames. Too much pressure created a flare-up and caused my pelvic tissue to guard; too little pressure did little good; stretching the tissue for too little time did not seem to give the tissue a chance to lengthen; stretching the tissue too long tended to create guarding and continuing soreness

I have noticed over the years that extremely sore and sensitive tissue in patients can be, as our senior physical therapist Tim Sawyer calls it, “hyperirritable.” Tim says that hyperirritable trigger points and pelvic tissue must be treated like you would hold a wounded dove in your hands. If you physically treat hyperirritable tissue with inappropriate pressure, you can cause long flare-ups of pain and increase anxiety. We have developed a guideline that pelvic floor trigger points and areas of sore muscle restriction should at first not be pressed beyond a 3 on a 0 to 10 pain scale. We then suggest increasing the pressure up to 7 on the 0 to 10 scale as long as the area doesn’t flare-up unduly. If there is a flare-up that continues for more than 24 hours, we believe too much pressure has been applied and it has to be reduced. When patients are treating themselves we ask them to stop their own physical therapy self-treatment for several days to allow the flare-up to calm down. Eventually, as trigger point sensitivity reduces, pressure can be increased to 7 on the 0-10 scale as long as there is a little flare-up of symptoms. If a sore tissue is properly palpated, the trigger point sensitivity and pain can significantly reduce or go away.

Unless we train our patients otherwise, some treat their sore pelvis roughly like a piece of meat; distancing themselves from it and using undue pressure. We train them to feel their pelvic muscles as they treat these muscles so that they do not flare themselves up from self-treatment.

Showing the pelvis unconditional kindness.

In my journey of healing my pelvic pain, I made a choice to listen to my pelvis. I adopted an attitude of kindness and unconditionality in which I came to understand that my pelvis did not want to hurt. I saw that my pelvis reacted to my impatience or negativity like I would react to someone else’s impatience or negativity. Absent words, the only way my pelvis spoke to me when it was not happy was with pain. In my own journey, I had to say, “I’ll do whatever it takes to help myself out of pain.” I’ve noticed that people who assume this attitude tend to do better because they’re forced to give up their own agenda and become interested in what it takes for their pelvis to calm down.

God heals and the physician collects the fee: learning to be kind to your own physician?

The body has a miraculous capacity to heal, and it is possible to recover from pelvic pain. During our body’s noble journey, however, we must consistently act in a way that helps the pelvis to heal and resist doing what interferes with its healing. In short, we have to be mindful of creating an environment that is hospitable for the sore contracted pelvic tissue to become normal.

Changing your attitude toward your pelvic pain.

At the end of our clinics, I do a process with our patients called, “talking to your pelvis.” I have patients feel their painful pelvis while I ask it questions. It is not uncommon for my patients to say, “I can’t believe how I’ve hated my pelvis” or “How unkind I’ve been to my pelvis.” Some have said, “Every time my pelvis hurts, I become frightened or angry or feel dread.” Others have said, “I felt that my pelvic pain was a way in which God was punishing me.” Patients attribute all kinds of motives and attributes to a sore, painful pelvis. They can assume different attitudes toward it that are often hateful, frightened, angry or frustrated. These kinds of attitudes toward the pelvis only tighten the pelvis, increase anxiety and nervous system arousal, and make things worse. When I speak to my pelvis now and ask it if it has anything to say to me, it says ‘Thank you.’

Calming down emotionally.

My journey with relaxation has been long. If I could have found a teacher like the one I am today when I was symptomatic, my journey would have been immeasurably easier. Relaxation did not come easily to me then, despite the fact that I had studied with Edmond Jacobson, who is considered the father of relaxation therapy. I tried to relax for many years, but I failed. Finally, I applied to my relaxation practice the principles I learned from Jacobson as well as those from my own spiritual exploration; to accept what is, to stop resisting the experience within that I couldn’t change, to let go of effort and of trying to achieve something with my relaxation, and to accept my pain and anxiety instead of fighting them. In my book Paradoxical Relaxation, I describe this method.

I have observed that it takes dozens of hours of Paradoxical Relaxation practice for people to begin to learn how to calm down the nervous system, especially when they’re in pain and anxious. Reducing emotional arousal and managing anxiety are the key issues addressed by our Paradoxical Relaxation method.

Becoming emotionally intelligent: managing the tendency to get lost in catastrophic thinking.

When I was beginning to do relaxation for my pain, I came to see that there was always the issue of my pain, and then there was the issue of my attitude toward my pain. They were two different things. As I was able to work with my pain physically and reduce my symptoms, I slowly stopped catastrophizing each flare-up because I came to see that I could reliably calm them down myself.

I’ve observed that for most of our patients, despair, anxiety, and pain tend to be waiting in the wings and ready to pounce when one begins treatment. It is important for patients using our protocol to be able to witness their catastrophic thinking so that they can release it instead of allowing it to sabotage their treatment. I often say to patients that they don’t have to believe everything they think, and that when they catastrophize they will typically confuse their thinking for reality.

Not being scared by a flare-up of symptoms.

In my journey, I had many symptom flare-ups. I would have periods of time during which I was pain-free for days or weeks. Then, something would happen and my symptoms would flare up as badly as they ever were. When my symptoms disappeared I thought my recovery was a done deal, and when they flared up, I sank down into despondency. When I went through this cycle of symptom improvement and then flare-up many times, I became less and less afraid of the symptoms flaring up because I knew I could resolve them with my own self-treatment.

Ending flare-ups through skilled self-treatment.

The majority of our patients who do our protocol consistently do get better. We have patients who were in chronic pain for many years who are now pain-free for the most part. Most have learned not to be afraid of symptom flare-ups, as they are more able to effectively resolve them. For this reason, we ask our patients to do a 52 week recorded course in Paradoxical Relaxation to begin to take the edge off emotional agitation that’s gone on for many years.

An emotional release often accompanies the physical.

The phenomenon of somato-emotional release is common when a certain group of pelvic pain patients who do myofascial trigger point release, especially inside the pelvis. For example, a woman we treated with pelvic pain who was repeatedly sexually abused, wept regularly both when we instructed her on internal trigger point release and when she began doing it herself. Constricted tissue and pain is often connected to the emotional environment in which it began. Understanding and allowing emotional expression of grief, fear, or anger during treatment and giving it space to emerge and be released is essential in pelvic healing.

Controlling the tendency to be ‘anal’.

Those who get pelvic pain tend to be what, in the vernacular, would be called ‘anal.’ The colloquial use of ‘anal’ means to be obsessive, devoted to detail and perfectionistic and also to have obsessive thinking. It’s associated with a tightening of the anus, and in fact, there is some truth in this pejorative colloquialism.

Managing the pelvic pain patient’s tendency toward perfectionism, obsessive-compulsive behavior, and compulsive working is a lifestyle and psychological change that needs to be modified.

Paradoxical Relaxation helps to stop compulsive doing.

Paradoxical Relaxation is the behavioral method we use to help our patients learn to, “stop compulsively doing.” The pelvic pain patient tends to rarely, if ever, relax. In the moment of relaxation, it’s necessary that you stop all doing; this means you stop trying to achieve, get somewhere, or accomplish something. In the state of not doing, the pelvic muscles can relax.

In my book Paradoxical Relaxation, I’ve discussed extensively the importance of training attention to rest in sensation outside of thinking because resting attention is what can help someone who is a compulsive doer to relax.

After patients do a full session of internal and external physical therapy, we encourage them to do half an hour to an hour of Paradoxical Relaxation. The reason I ask people to do this is that I see the importance in disengaging the muscles of the pelvis from activity after they’ve been lengthened in order to allow the sore, tightened, painful tissue to get used to being at a normal length.

Moving from doing to being.

I learned in my own recovery that I had to regularly stop and call a timeout in my life. I had to be able to profoundly relax to calm down my over active nervous system. In a large sense, I have learned that one of the essential components in healing pelvic pain is learning to, at some time during the day, move out of the doing mode and into the being mode.

The mantra that self-treatment is the way.

When I was symptomatic, the most important element of my suffering was the fact that I felt helpless about doing anything about my pain. As I recovered from my own symptoms and felt confidence in helping myself, everything got better. I have come to believe that the most important part of treating pelvic pain is giving patients the ability to reduce or stop their own pain and symptoms both physically and mentally. Doing this dispels anxiety and helplessness which in my view are the most debilitating symptoms among all the symptoms of chronic prostatitis. Chronic prostatitis or chronic pelvic pain syndrome tends to recur under stress, and the most important thing I believe we can do for a patient with symptoms diagnosed as prostatitis is to help him reduce or stop his symptoms by his own efforts.


In summary, here is what I have learned:

  • When men come to see us with symptoms diagnosed as chronic prostatitis, drug and surgical treatment has failed to help them
  • Men we see who have symptoms diagnosed as chronic prostatitis almost always have painful pelvic muscles and trigger points can be found related to symptoms. Anxiety and stress generally tends to makes them hurt more
  • Symptoms of what is diagnosed as chronic prostatitis occur as the result of chronic tightening of the pelvic muscles over many years, even though symptoms may appear to begin suddenly. The phrase “the fruit falls suddenly but the ripening takes time” reflects this phenomenon
  • When you are suffering from pain with no foreseeable end in sight, it is easy to get lost and caught up in negativity, catastrophic thinking and the anxiety and depression related to it. Anxiety and worry about symptoms makes them worse
  • These emotions can be exacerbated by feelings of helplessness when doctors are unable to successfully treat symptoms
  • We have been dismayed that most doctors who provide chronic pelvic pain treatment do not appear interested in looking beyond the assumed causes of chronic prostatitis because these symptoms are not responsive to drugs or surgery, the main tools of conventional medicine
  • It is possible for most men with symptoms diagnosed as nonbacterial chronic prostatitis to significantly reduce their pain or stop it through their own efforts when they are properly instructed
  • Resolving symptoms diagnosed as nonbacterial chronic prostatitis means relaxing the core physical part of us. While there are methods for strengthening the core, relaxing and loosening our core is harder and more complicated to do—but it is doable
  • Patients who take ownership of their own problem and ultimately use their own intuition to determine what to do seem to do best
  • I am convinced that patients who learn to treat all of their symptoms themselves do best; self-treatment is the way

At this time in history, someone who has pelvic pain is best served by taking responsibility for his or her own welfare and seeking out treatment that makes most intuitive sense to them.