Chronic Prostatitis Symptoms
In this essay I want to address the issue of the validity of many speculative theories on the internet about chronic prostatitis symptoms and CPPS symptoms and our view of the issue of the healing of the pelvic floor and the resolution of symptoms of prostatitis and chronic pelvic pain syndromes.
What causes the symptoms of prostatitis and chronic pelvic pain syndromes?
There are numerous ideas on the internet about what causes symptoms of prostatitis and chronic pelvic pain syndromes. For example, a few people propose that prostatitis and CPPS may be related to reflex sympathetic dystrophy. Attempts to make a case for pelvic pain as reflex sympathetic dystrophy are not new. While I am not an expert in RSD this is what I do know. It is generally agreed among clinicians and researchers that RSD is a condition that is complex and has features that are perplexing and poorly understood. It is characterized by regional pain, often in the hands or feet, autonomic, tissue and vasomotor changes, disorders of movement, muscle atrophy, and almost always psychological and social disturbance. Part of the controversy about RSD is whether the psychosocial disturbances and suffering are causative or at the effect of other factors – an issue of the chicken or the egg. The controversy about RSD reached a point where the name was changed to regional pain syndrome to eliminate the implication of agreement about the mechanism of the disorder. In a discussion I had with our senior physical therapist, in his experience RSD is an entirely different problem from one involving myofascial/trigger point pain. Your reader is correct that Trigger Point Release is not indicated with RSD although in some cases a patient originally diagnosed with RSD may simply have a hyper irritable myofascial pain syndrome and the diagnosis of RSD may have been incorrect.
Diagnostic criteria have been proposed for RSD by an international organization but these criteria are not universally accepted. Bottom line here is that this is a poorly understood and controversial condition that has no effective treatment.
RSD, as a general rule, does not respond to Trigger Point Release therapy. Furthermore, muscle atrophy, edema or swelling or disorders of movement are not prominent features in the pelvic pain we treat. What is telling for me is the fact that many patients with pelvic pain have responded favorably to our protocol whose physiotherapy component involves myofascial Trigger Point Release where RSD does not respond to this methodology. All of this makes the RSD/CPPS hypothesis dubious.
So pelvic pain as RSD is a speculation with little supporting evidence … a speculation that is no different from the speculation that pelvic pain is the result of an occult bacteria or is an autoimmune disease. At this point this idea offers no course of treatment or action that helps or protects someone, it offers no definitive evidence and importantly it tends to promote fear and helplessness in many who suffer from pelvic pain. I take the view that pelvic pain as RSD is an idea with little foundation that I choose to ignore until there is some compelling reason to entertain it.
In our book, A Headache in the Pelvis, we address a very important issue related to the question I am discussing here. This is the question of what to do with speculative theories about pelvic pain like the one that it may be related to RSD – theories that offer no treatment and serve to scare the reader. I quote our book below:
“We are often asked about other theories regarding the nature of chronic pelvic pain from people suffering with pelvic pain, a subject we touched upon earlier. Many of these individuals are already in an anxiety state and are looking for some kind of reassurance or guidance as to the nature of their condition and the best course of treatment. When they go on the internet, they read about various theories contending that chronic pelvic pain may be an auto-immune disorder, a condition in which occult bacteria are yet to be discovered, or a deteriorating neurological pelvic condition.
These theories do what we have described earlier. They tend to promote fear and helplessness in the sufferer.
When you have pelvic pain, it is deeply disturbing to read theories which promote fear, helplessness, and confusion or hear stories of people who are not doing well with their pain or dysfunction. When you have pain and dysfunction, you usually feel some degree of anxiety and helplessness which is often exacerbated by these kinds of theories. Some of our patients have asked us whether they should ignore the ideas that they read on the web or simply avoid the internet websites devoted to pelvic pain. Others have asked us if there is some way to find out if in fact they have the problem that these theories purport.
If a theory or an idea about your condition carries some course of action or treatment to help you without unacceptable risks, then it may be an idea that merits your careful consideration. You may wish to investigate the efficacy of such a course of treatment along with the risks and costs.
If the theory, on the other hands, carries with it (a) no course of treatment or action to be done to help or protect you, or if its treatment carries dangers you are not willing to risk, or (b) it offers some non-definitive evidence, and (c) it only helps to create fear, doubt, and disempowerment in your life, we suggest you tell yourself the following: “This is someone’s theory. There is no definitive proof for it. It offers nothing to help me or protect me. What it offers carries unacceptable risks. It creates fear and doubt in me. It is okay for me to disregard it as somebody’s unproven idea which I will consider if there emerges substantial evidence and/or something to do about it. Therefore I can ignore it as simply someone’s unproven idea. This kind of self-talk … is particularly important because anxiety tends to increase symptoms.”
A person who wrote about RSD and whether it is related to pelvic pain was obviously distressed that his symptoms of prostatitis did not improve with Trigger Point Release that was aggressive, and he was looking for some other answer to his difficulties. In my response to the description of his treatment, let me say that we at Stanford do not advocate aggressive physiotherapy in our protocol but a very specific method aimed at locating and deactivating trigger points inside and outside of the pelvic floor that tend to recreate symptoms of prostatitis as well as methods that systematically stretch the shortened and contracted pelvic tissue. It is common that the in beginning stages of treatment, temporary flare-ups occur. It is the normal course that the discomfort diminishes over time during and after physiotherapy. If it doesn’t, in my experience, the problem is often that the physical therapist is missing something.
In my view the whole issue we are dealing with about treatment for pelvic pain is simply this–how to allow the body to heal itself? I think contemporary medicine tends to forget that it is almost always the case that ‘the body heals itself and the doctor collects the fee.’ In the National Library of Medicine today, I found there were 3743 research articles listed on prostatitis and the symptoms of prostatitis. An infinitesimal 7 articles even contained the word healing. My view about treatment for pelvic pain is that we want to optimize the circumstances for the body to heal itself, we want to get out of the way of the healing of prostatitis, the tissues, muscles, and structures inside the pelvic floor. Healing is what we want as well as prostatitis relief. In my own case, when I began thinking this way, my condition began to resolve.
The Wise-Anderson Protocol is about healing. It is about creating a hospitable environment for the restoration of normal happy tissue inside the pelvic floor. The relaxation protocol allows the nervous system to quiet down so that the irritated tissues can heal and can stop being squeezed into an irritated state… a squeezing that in most people who have pelvic pain has become habitual and chronic. The relaxation protocol aims to change the habit of tightening the pelvic muscles under stress. The physiotherapy we do stretches and lengthens the pelvic tissue and deactivates trigger points to make room for a healthy life in the pelvic floor.
The idea of RSD as it is understood today, at least as I read it, implies a condition where healing is remote. I balk at theories that imply healing isn’t possible because of my personal experience and others who have gotten better with this problem. Healing is possible. The patients I have seen who have done the worst – especially those who have suffered from unwise medical interventions, have given the entire responsibility for curing their condition to someone or something outside them. They come to the doctor and say “fix me doc”. Any treatment for the kind of pelvic pain we treat needs to be the servant of the body’s healing mechanisms. This requires the intimate and whole hearted participation of the patient.
Physiotherapy alone, while an essential component, is usually inadequate to resolve symptoms because it alone cannot make this healing occur. I understand this experientially. It is tempting for someone to think that physiotherapy, this outside procedure, will fix them. In my experience, this person will be disappointed as I was. I had over 50 physiotherapy treatments and at the end of them all, I was still symptomatic and in pain. It was only after I saw that my problem came from my chronic tension, anxiety and habitually squeezing my pelvis – and particularly when I began the relaxation protocol in earnest, often up to 2 hours a day for over two years and doing moment-to-moment pelvic relaxation throughout the day, that my symptoms began to resolve. The pelvic pain of those we help is not simply a mechanistic problem that can be fixed from the outside with a physical therapist’s finger. The habit of tightening the pelvic floor is usually decades old and has been practiced thousands of times. It is part of a coping repertoire. Tightening their pelvic floor under stress is the default mode and keeps the tissue of the pelvic floor irritated and shortened.
Consider that there are 168 hours in a week. Let us say that a person goes to see the physical therapist 2 times a week. That quite a bit of physiotherapy. In the physiotherapy session, after a person takes off their clothes, gives the PT a report on their week and begins the physiotherapy itself, at the most there is probably 30-45 minutes of hands-on treatment. After the treatment, the tissue is lengthened (although sometimes temporarily irritated in the process). That is between 1 hour and 1.5 hours of therapeutic treatment per week. In a good pelvic floor physiotherapy session, the pelvic floor tissue has been lengthened and life has been made more livable for it. But after physiotherapy, there are 167-166 hours per week to live. The old habit of going 100 miles an hour in one’s life and tightening up the pelvis regularly and squeezing and shortening the irritated tissue can easily and quickly undo the therapeutic impact of the physiotherapy session. It makes no sense to think that a physical treatment that lasts less that .023% of your life can work if the old, symptom provoking habits go on unabated. In my view, the resolution of the kind of pelvic pain we treat is an inside job of cooperating with the healing mechanism of the body in the short run and the long run.
We have received hundreds of emails from people telling us that our theory described in A Headache in the Pelvis is the first one that makes sense to them. While I appreciate these comments, I am unmoved by them. I am moved when someone’s symptoms improve or go away. I am moved when the body responds to treatment with a big ‘yes’. Theories are cheap and yet to the lay person, they can sound convincing and formidable. In my view, a theory about pelvic pain is only as good as the efficacy of the treatment that it informs and serves the healing of the body. In other words, the most important issue is results — i.e., does the method that derives from the theory help the body’s healing thereby reducing or resolving symptoms? We do not help everyone who comes to see us. But if they do fit into a certain profile, they must do the entire protocol properly before making a judgment about its efficacy. They must participate and support their own healing. Results are what counts. Results mean that the patient has helped rally his or her body in healing itself.
David Wise, PhD