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MAJOR SYMPTOMS WE TREAT
Most of our patients have at least two or more symptoms. See a more detailed list with descriptions of the symptoms at the bottom of this page.
- Urinary Frequency / Urgency / Hesitancy
- Pain with Sitting
- Rectal / Perineum Pain
- Genital Pain
- Pain During or After Sex
- Pain or Relief After Bowel Movement
- Lower Abdominal Pain
- Tailbone / Low Back Pain
- Stress Can Increase Pain
- Hot Baths or Heat Help
- Depression / Anxiety About Symptoms
- Symptoms Reduce Quality of Life
- Conventional Treatments Don’t Help
- Medical Tests Find No Disease
PUDENDAL NEURALGIA
DIFFERENT MEDICAL SPECIALISTS CALL SYMPTOMS OF PUDENDAL NEURALGIA PAIN BY DIFFERENT NAMES
As we will discuss below, it has been our experience that symptoms of most patients we have seen who have been given the diagnosis of pudendal neuralgia are more accurately described as symptoms of pelvic floor dysfunction.
PUDENDAL NEURALGIA IS A RARE CONDITION
The theory of pudendal neuralgia purports that the reason why someone has the symptoms of pelvic floor dysfunction described above is because there is a pathology or entrapment of the pudendal nerve. As much of the scientific literature observes, pudendal neuralgia is a rare condition. In the popular press, WebMD as well discusses pudendal neuralgia as a rare problem with the pudendal nerve. In a 2009 Obstetrical and Gynecological survey (Volume 64 – Issue 3 – pp 190-199, Pudendal Neuralgia, Fact or Fiction?), authors conclude that the occurrence of pudendal neuralgia is a rare event…. Clinical neurophysiology tests have quite low diagnostic efficacy…. PN is said to be a diagnosis of exclusion and requires a high index of suspicion. Authors of this article also state: “ It is possible to have all the symptoms of pudendal nerve entrapment (otherwise known as pudendal neuralgia) based on the criteria specified at Nantes in 2006, without having an entrapped pudendal nerve.[7]”. According to the European Association of Urology: “pain relief following decompression of the nerve in Alcock’s canal (pudendal nerve entrapment surgery) is rarely achieved.”
We have found that pathology of the pudendal nerve is a rare occurrence in our practice as well. This diagnosis of pudendal neuralgia however, in the past several years, has been used more widely to label symptoms of what we believe, in most cases, is most commonly pelvic floor dysfunction. Below we discuss the symptoms of pelvic floor dysfunction.
DIAGNOSIS OF PELVIC FLOOR DYSFUNCTION (PFD)
In most cases, in our view, PFD is the result of routinely tightening the muscles of one’s pelvis as
an unconscious expression of anxiety over a period of years. This is like someone with TMJ grinding their teeth except the clenching is in the pelvis instead of the jaw. After some time, the chronically tightened pelvic muscles don’t relax back to their normal state and symptoms of pain and dysfunction occur as a result of this chronic pelvic muscle contraction. This chronic contraction can be confirmed by the manual palpation of these muscles by an experienced physician or practitioner. With PFD, painful trigger points form in the muscles.
We have described the location of these trigger points in the pelvis in our 2009 study published in the Journal of Urology that you can view in our research section. These trigger points and where they cause pain and symptoms are further explained and illustrated in the 6th edition of our book, A Headache in the Pelvis. The trigger points form a self-feeding cycle of tension, anxiety, pain, and protective guarding. This cycle tends to develop a life of its own when left untreated.
Our protocol is devoted to training patients to release relevant trigger points externally and internally, and related areas of sore tissue, as well as meaningfully reducing the high arousal of their nervous system associated with PFD. Our observations of many patients over the years inform us that reliable symptom reduction and resolution comes from addressing both the physical and nervous system aspects of the condition. To this end, over the past decade, we have offered the Wise-Anderson Protocol to qualifying patients in monthly 6-day intensive immersion clinics in Santa Rosa, California.
THE LIMITATIONS OF CONVENTIONAL TREATMENT
Conventional medical treatment (drugs, procedures, nerve blocks, surgery) tend to be of little help in the long term and often complicate symptoms. Physical therapy is often prescribed, and while it can offer some relief, treating PFD physically without addressing and remedying the underlying heightened level of anxiety and nervous arousal, and without training patients to do their own physical therapy themselves, yields short term relief in our experience.
PUDENDAL NEURALGIA IS BOTH A LOCAL AND SYSTEMIC DISORDER
Relief from pudendal neuralgia, with its often bewildering and troubling symptoms, is what those seeking help from any treatment are looking for when they go to a doctor. Conventional medical treatment, however, almost universally misunderstands pudendal neuralgia. The remedies it offers at best are partial and short-termed and at worst, remedies like surgical intervention or certain injections, can exacerbate the problem.
The fundamental error of conventional treatment is that it does not grasp the fact that pudendal neuralgia is both a systemic and local problem — systemic in that the nervous system, typically frequently aroused, chronically tightens up the pelvic muscles. It is a local problem in that chronic worry, anxiety and nervous arousal in certain individuals results in the local pain and dysfunction of the pelvic muscles. Without effectively treating both aspects, pudendal neuralgia remains.
Our 6-day clinic, offered throughout the year, is devoted to resolving both the local and systemic dimensions of pudendal neuralgia by training our patients in the most advanced internal and external physical therapy self-treatment (local treatment), and practicing our relaxation protocol, Extended Paradoxical Relaxation, which is aimed at reducing nervous system arousal daily.
THE WISE-ANDERSON PROTOCOL
6-Day Immersion Clinic
We began treating varieties of pelvic floor dysfunctions in patients at Stanford University in 1995 in conventional office visits. In 2003, we reorganized our treatment in a private practice in the form of a 6-day immersion clinic held in Santa Rosa, California. The clinic, limited to 14 patients and offered throughout the year, has evolved to implement the Wise-Anderson Protocol, a treatment to teach patients to rehabilitate the chronically contracted muscles of the pelvic floor and to reduce anxiety daily. The Wise-Anderson Protocol, done daily at home by patients we have trained in self-treatment, has helped to give many their lives back. The purpose of our self-treatment is to help patients become free from having to seek additional professional help. For over a decade, research has documented our results of training patients with self-treatment.
For more information, please visit our clinics page by clicking here.
For questions about cost and eligibility please fill out the form below, email us at ahip@sonic.net or contact our office at +1 (707) 332-1492.
SYMPTOMS OF PUDENDAL NEURALGIA
(Most of our patients have at least two or more symptoms)
- Dysuria can be very painful and thus, urination becomes a large ordeal and sets off further pain
- Burning or pain with urination is often disconcerting and associated with pelvic floor dysfunction
- Sometimes people feel no pain during urination but only after
- When the chronic spasm and myofascial contraction of the pelvic muscles is resolved, in many of our patients, dysuria is also resolved
- Often nocturia is a major problem because a patient’s sleep is so disturbed he or she is exhausted all the time
- Exhaustion from sleep deprivation tends to feed into the cycle of tension, pain, protective guarding and anxiety
- In men this is an important symptom to medically evaluate as to whether the source of the reduced stream is from prostate enlargement or other issues
- Some people with muscle based pelvic pain have to wait to initiate a stream of urine
- Reduced urinary stream can be a contributing symptom to low self-esteem and hypochondriasis, especially in younger men
- When urinary symptoms are part of muscle based chronic pelvic pain syndrome, after rehabilitating the pelvic floor, the flow of urine can improve
- Perineum is one of the most common sites of pelvic pain, is intimate, can hurt 24/7 and can be very distressing
- The perineum is the place where most muscles of the pelvic floor attach and therefore has many sources of referred pain (pain felt at a site other than where the cause is situated)
- Perineum is often the site of bicycle riding pain
- Perineum pain can be made worse by sitting or standing
- The perineum and the anal sphincter are parts of the body where the patients feel the feeling of “sitting on a golf ball”
- In a 2009 Stanford study of our work published in the Journal of Urology, it was documented that 79% of subjects complained of pain in the perineum
- We documented key abdominal and pelvic muscles that all refer pain to the perineum (rectus abdominus, adductor magnus, and coccygeus)
- Sitting is one of the great sufferings and scares in pelvic pain and makes all aspects of normal life difficult
- Patients often look for the padded seats in a restaurant because sitting is so uncomfortable
- Sitting pain can make it miserable to sit with friends or family and socialize
- Difficult to fly or drive for any distance without pain
- Sometimes patients have to go on disability because they can’t work because their job is a sitting job
- Sitting can trigger or exacerbate discomfort/pain/symptoms and can hurt in the front, back of the pelvis, or both
- Sitting pain usually starts out milder in the morning but increases after sitting through the day, and can last into the night
- Genital pain is usually referred from the anterior levator ani and one of the easier symptoms to resolve
- In men, pain at the tip and shaft of the penis is a common symptom
- In men, sometimes there is a redness at the tip, which can be accompanied by an irritation so that rubbing against underwear is uncomfortable
- In women, pain inside the vagina, on one side or another is common
- In women, sometimes vulvar pain accompanies pelvic pain
- Suprapubic (above the public bone) pain is a common symptom
- Suprapubic pain is common with patients who have urinary frequency, urgency, hesitancy and other anterior symptoms
- Sometimes pressing on this area can refer into the anorectal (anus and rectal) area and sometimes bladder pain is experienced here as well
- Pain can be on one side or another or in the middle
- In men this is an important symptom to medically evaluate as to whether the source of the reduced stream is from prostate enlargement or other issues
- Some people with muscle based pelvic pain have to wait to initiate a stream of urine
- Reduced urinary stream can be a contributing symptom to low self-esteem and hypochondriasis, especially in younger men
- When urinary symptoms are part of muscle based chronic pelvic pain syndrome, after rehabilitating the pelvic floor, the flow of urine can improve
- Low back pain is common and often confuses patients and practitioners because the symptoms are referred from the muscles of the pelvic floor, not the low back
- Discomfort can be on one side or another or migrate from one side to another
- Groin pain often is confused with a hernia
- We have seen patients who have had hernia repair for their pain that did not resolve their groin pain
- Relief after a bowel movement occurs when the tight pelvic muscles relax
- Discomfort after a bowel movement can be particularly disconcerting if it triggers symptoms more strongly for the rest of the day
- Little is written about this symptom when it occurs in the absence of hemorrhoids or anal fissures, but in our experience it is common
- The mechanism of defecation typically involves the filling up of the rectum with stool, which then sends a signal for the internal anal sphincter and puborectalis muscle to relax and triggers the experience of urgency to have a bowel movement
- Once the stool passes through the relaxed anal sphincter and out of the body, the internal anal sphincter reflexively closes
- When someone has pelvic pain and exacerbation of symptoms after a bowel movement, we propose that the internal anal sphincter tends to ‘over close’
- That is, it tightens up more than it was tight before the bowel movement and sometimes appears to go into a kind of painful spasm
- Post bowel movement pain appears to occur less frequently when someone is relaxed and not hurried, and whatever contributes to a more relaxed state during a visit to the bathroom may reduce this symptom
- Resolving post bowel movement pain in our patients tends to occur as their entire chronic pelvic muscle tension releases
- It is not uncommon for pain or sensation to appear in one part of the pelvis or abdomen and then the next day it is elsewhere
- Reduced interest in sex is common with pelvic pain
- In muscle related pelvic pain, there is typically no pathology of the physical structures involved in sexually activity
- Our view is that reduced libido is a mix of anxiety, reduced self-esteem and pelvic pain which all mitigate against sexual arousal and sexual interest, and resolution of pain and dysfunction of the pelvic muscles usually resolves reduced libido
- The scariest part of pelvic pain is the catastrophic thought that it will never go away
- It is a focus that distract your attention away from your life and with many patients, paints an unacceptable future
- Pelvic pain robs patients of the ability to be fully present in relationship with family and friends
- Social withdrawal often stems from chronic pain and it can detrimentally affect any enjoyment of the moment
- There is a major toll that chronic pelvic pain takes on relationships, including the partners of those in pain, such as the patient’s withdrawal from sex, withdrawal from going out and doing things with others, planning trips, parenting, socializing, and doing the normal activities of partnership or marriage
- Self-esteem almost always goes down when one has pelvic pain because patient’s almost always worry that no one will want to be with them
- Sleep disturbance is common
- Many patients wake up anxious, wondering if the pain has gone, disappointed every day that it isn’t
- Patients either wake up to urinate or because of pain and anxiety
- We wrote a paper about precipitous rise in cortisol in the morning amongst pelvic pain patients. Cortisol and Men with Chronic Prostatitis– American Urological Association Poster 2007
- Ordinary stresses, as well as extraordinary stress, tend to increase symptoms
- When stress has triggered pelvic pain, the stress also tends to trigger the tension-anxiety-pain-protective guarding cycle that continues after the stress has gone
- Helplessness and hopelessness is the real suffering with chronic pelvic pain
- Helplessness comes from a patient’s inability to stop pain/discomfort that is draining and scary
- What is disconcerting to many patients with chronic pelvic pain syndromes is that the conventional medical testing including imaging, blood and urine tests, and other testing fails to document any abnormalities or point in any therapeutic direction
- Conventional medical treatment including antibiotics, alpha blocks, anti-inflammatories, analgesic and all surgeries and procedures tend to fail in helping symptoms as well
- Can experience pain during sexual activity or afterward
- Pain is felt on the outside or inside of the vagina, or both
- Pelvic examination in which trigger points are palpated can often recreate symptoms of pain during sex
WHAT TEMPORARILY CAN HELP:
- Hot water or heat often helps temporarily
- Heat sometimes flares up symptoms; patients feel relief using cold packs or ice
- The family of drugs called benzodiazepines can often relieve symptoms for a few hours and are helpful when used skillfully
- Benzodiazepines are addictive and when used regularly for pelvic pain, they can lose their effectiveness
- Benzodiazepines typically make the user tired and should not be used when driving or having to be alert
- Naps, or vacations can sometimes help reduce pain