EAU Guidelines On Chronic Pelvic Pain 2018 Large Text

EAU Guidelines on
Chronic
Pelvic Pain
D. Engeler (Chair), A.P. Baranowski, J. Borovicka,
A.M. Cottrell, P. Dinis-Oliveira, S. Elneil, J. Hughes,
E.J. Messelink (Vice-chair), A.C. de C Williams
Guidelines Associates: B. Parsons, S. Goonewardene
© European Association of Urology 2018

TABLE OF CONTENTS PAGE
1. INTRODUCTION 4
1.1 Aim 4
1.2 Publication history 4
1.3 Available Publications 4
1.4 Panel composition 4
1.5 Terminology 5
2. METHODOLOGY 12
2.1 Methods 12
2.2 Review 13
2.3 Future goals 13
3. EPIDEMIOLOGY, AETIOLOGY AND PATHOPHYSIOLOGY 13

3.1 Chronic visceral pain 13
3.1.1 Incidence 14
3.1.2 Prevalence 14
3.1.3 Influence on Quality of Life 14
3.1.4 Costs 14
3.1.5 Risk Factors and underlying causes 14
3.1.5.1 Risk factors 14
3.1.5.2 Underlying causes 15
3.1.5.3 Clinical paradigms in visceral pain 18
3.2 Pelvic Pain 19
3.2.1 Incidence 19
3.2.2 Prevalence 19
3.2.2.1 Prostate Pain syndrome 19
3.2.2.2 Bladder Pain syndrome 19
3.2.2.3 Sexual pain syndrome 19
3.2.2.4 Myofascial pain syndromes 20
3.2.3 Influence on QoL 20
3.2.4 Costs 20
3.2.5 Risk factors and underlying causes 20
3.2.5.1 Prostate Pain Syndrome 20
3.2.5.2 Bladder Pain syndrome 20
3.2.5.3 Scrotal Pain Syndrome 20
3.2.5.4 Urethral Pain Syndrome 21
3.2.5.5 Vaginal and vulvar pain syndromes 21
3.2.5.6 Associated conditions in pelvic pain syndromes 21
3.3 Abdominal aspects of pelvic pain 24
3.3.1 Incidence 24
3.3.2 Prevalence 24
3.3.3 Influence on QOL 24
3.3.4 Costs 24
3.3.5 Risk factors & underlying causes 24
3.4 Summary of evidence and recommendations: CPP and mechanisms 24
4. DIAGNOSTIC EVALUATION 25
4.1 General Evaluation 25
4.1.1 History 25
4.1.1.1 Anxiety, depression, and overall function 25
4.1.1.2 Urological aspects 25
4.1.1.3 Gynaecological aspects 26
4.1.1.4 Gastrointestinal aspects 26
4.1.1.5 Peripheral nerve aspects 26
4.1.1.6 Myofascial aspects 27
4.1.2 Physical Evaluation 27
4.2 Supplemental evaluation 28
4.2.1 Assessing pain and related symptom 28
4.2.2 Focused myofascial evaluation 29
2 CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018

4.2.3 Neurological 29
4.2.4 Imaging 30
4.2.5 Laboratory Tests 30
4.2.6 Invasive tests 31
4.3 Diagnostic algorithm 32
4.4 Other painful conditions without a urological cause 33
4.5 Summary of evidence and recommendations: diagnostic evaluation 34
4.5.1 Diagnostic evaluation of PPS 34
4.5.2 Diagnostic evaluation of BPS 35
4.5.3 Diagnostic evaluation of scrotal pain syndrome 35
4.5.4 Diagnostic evaluation of urethral pain syndrome 35
4.5.5 Diagnostic evaluation of gynaecological aspects chronic pelvic pain 35
4.5.6 Diagnostic evaluation of anorectal pain syndrome 35
4.5.7 Diagnostic evaluation of pudendal neuralgia 36
4.5.8 Diagnostic evaluation of sexological aspects in CPP 36
4.5.9 Diagnostic evaluation of psychological aspects of CPP 36
4.5.10 Diagnostic evaluation of pelvic floor function 37
5. MANAGEMENT 37
5.1 Conservative management 37
5.1.1 Pain education 37
5.1.2 Physical therapy 37
5.1.3 Psychological therapy 39
5.1.4 Dietary treatment 39
5.2 Pharmacological management 40
5.2.1 Drugs for chronic pelvic pain syndrome 40
5.2.1.1 Mechanisms of action 40
5.2.1.2 Comparisons of agents used in pelvic pain syndromes 40
5.2.2 Analgesics 44
5.2.2.1 Mechanisms of action 45
5.2.2.2 Comparisons within and between groups in terms of efficacy and safety 45
5.3 Surgical management 47
5.3.1 Surgery 47
5.3.2 Neuromodulation 49
5.3.3 Nerve blocks 50
5.4 Summary of evidence and recommendations: management 50
5.4.1 Management of PPS 50
5.4.2 Management of BPS 51
5.4.3 Management of scrotal pain syndrome 52
5.4.4 Management of urethral pain syndrome 52
5.4.5 Management of gynaecological aspects of chronic pelvic pain 52
5.4.6 Management of anorectal pain syndrome 52
5.4.7 Management of pudendal neuralgia 53
5.4.8 Management of sexological aspects in CPP 53
5.4.9 Management of psychological aspects in CPP 53
5.4.10 Management of pelvic floor dysfunction 53
5.4.11 Management of chronic/non-acute urogenital pain by opioids 54
6. EVALUATION OF TREATMENT RESULTS 54

6.1 Evaluation of treatment 54
6.1.1 Treatment has not been effective 54
6.1.1.1 Alternative treatment 54
6.1.1.2 Referral to next envelope of care 54
6.1.1.3 Self-management and shared care 54
6.1.2 Treatment has been effective 54
7. REFERENCES 55
8. CONFLICT OF INTEREST 82
9. CITATION INFORMATION 82
CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018 3

1. INTRODUCTION
1.1 Aim
This guideline plays an important role in the process of consolidation and improvement of care for patients
with abdominal and pelvic pain. From both literature and daily practice it has become clear that abdominal
and pelvic pain are areas still under development. This guideline has been recognised as a cornerstone for
important developments that have taken place in the past ten years.
This guideline aims to expand the awareness of caregivers in the field of abdominal and pelvic pain and to
assist those who treat patients with abdominal and pelvic pain in their daily practice. The guideline is a useful
instrument not only for urologists, but also for gynaecologists, surgeons, physiotherapists, psychologists and
pain doctors.
It must be emphasised that clinical guidelines present the best evidence available to the experts. However
following guideline recommendations will not necessarily result in the best outcome. Guidelines can never
replace clinical expertise when making treatment decisions for individual patients, but rather help to focus
decisions - also taking personal values and preferences/individual circumstances of patients into account.
Guidelines are not mandates and do not purport to be a legal standard of care.
Structure and scope

The panel wishes to take advantage of modern methods of delivering guideline information to clinicians
dealing with these patients. In 2016, a stepped information structure was made, in alignment with stepped
care protocols, using new digital information sources like websites and apps to aid this process. Furthermore,
the guideline was changed according to the template used in all other non-oncology guidelines of the EAU. It
was recognised that structuring a guideline on chronic pain is quite different from structuring one on another
subject. A multi-disciplinary approach is of utmost importance and demands a broad view. In 2016, the
guideline was rewritten to be centred around pain instead of being organ-centred. It is partly theoretical to
show the importance of using this pain-centred approach. The biggest part, however, deals with the practical
approach to diagnostics, treatment and management of patients with abdominal and pelvic pain.
1.2 Publication history

The EAU Guidelines on Chronic Pelvic Pain were first published in 2003 [1] which formed the basis of a
scientific publication in European Urology in 2004 [2]. Also, in the 2003 edition the concept of Chronic Pelvic
Pain Syndromes (CPPS) was introduced, which is now referred to as “pain as a disease process”. Partial
updates of the CPP Guidelines were published in 2008 and formed the basis for another scientific publication
in European Urology in the year 2010 [3, 4].
Two chapters were added at that time: Chapter 5 ‘Gastrointestinal aspects of chronic pelvic pain’ and
Chapter 7 ‘Sexological aspects of chronic pelvic pain’. In the 2014 edition minor revisions were made in
Chapter 5 ‘Gastrointestinal aspects of chronic pelvic pain’ and Chapter 8 ‘Psychological aspects of chronic
pelvic pain’.
For the 2015 edition the Panel critically reviewed the sub-chapter on bladder pain syndrome which is now
a comprehensive part of the guideline [5]. In 2017 a scoping search was performed covering all areas of the
guideline and it was updated accordingly.
1.3 Available Publications

Alongside the full text version, a quick reference document (Pocket Guidelines) is available, presenting key
findings of the Chronic Pelvic Pain Guidelines. This reference document follows the updating cycle of the
underlying large texts. All available material can be viewed for personal use at the EAU website. The EAU
website also includes a selection of EAU Guideline articles as well as translations produced by national
urological associations: http://www.uroweb.org/guidelines/online-guidelines/.
1.4 Panel composition

The panel of experts responsible for this document include four urologists, (one of which has a sub-
specialisation in neuro-urology and one is a sexologist), two consultants in pain medicine, a gynaecologist, a
psychologist and a gastroenterologist.
The Panel is also grateful to Ms. S. Bennett, Ms. J. Birch and Dr. N. Wood for their expertise, time and diligence
in undertaking a review of these guidelines from a patient perspective.

1.5 Terminology
Definitions of CPP terminology

Classification
Much debate over the classification of CPP has occurred, is ongoing and will continue in the future.
Classification involves three aspects of defining a condition: phenotyping, terminology and taxonomy.
Phenotyping
Phenotyping is describing the condition. For example, chronic bladder pain may be associated with the
presence of Hunner’s ulcers and glomerulation on cystoscopy, whereas other bladder pain conditions may
have a normal appearance on cystoscopy. These are two different phenotypes. The same is true for irritable
bowel syndrome (IBS), which may be sub-divided into that associated primarily with diarrhoea or that with
constipation. Phenotyping is based upon mechanisms when they are known (e.g., infection, ischaemic,
auto-immune, or neuropathic). In the absence of well-defined mechanisms, describing the condition by its
symptoms, signs and, where possible, by investigations, has been demonstrated to have clinical and research
validity in many situations. When pain is the main symptom and pain as a disease process is considered the
cause, the condition is often referred to as a pain syndrome - a well-defined collection of symptoms, signs and
investigation results associated with pain mechanisms and pain perception as the primary complaint.
Terminology
Terminology is the words that are used within classification, both to name the phenotype and within the
definition of the phenotype. Examples of names for phenotypes associated with the bladder include interstitial
cystitis, painful bladder syndrome or bladder pain syndrome (BPS). The EAU, the International Society for the
study of BPS (known as ESSIC), the International Association for the Study of Pain (IASP) and several other
groups now prefer the term bladder pain syndrome. In the pain syndromes, the role of the nervous system in
generating the sensations is thought to be pivotal, but the term syndrome is also comprehensive and takes into
account the emotional, cognitive, behavioural, sexual and functional consequences of the chronic pain.
When defining the phenotype, the terminology used in that definition must also be clear and if necessary
defined. One of the most important guiding principles is that spurious terminology should be avoided. Terms
that end in “itis” in particular should be avoided unless infection and or inflammation is proven and considered
to be the cause of the pain [6]. It must be appreciated that end-organ inflammation may be secondary and
neurogenic in origin and not a primary cause of the pain.
Taxonomy
Taxonomy places the phenotypes into a relationship hierarchy. The EAU approach sub-divides CPP into
conditions that are pain syndromes and those that are non-pain syndromes. The latter are conditions that have
well-recognised pathology (e.g., infection, neuropathy or inflammation), whereas the former syndromes do not
and pain as a disease process is the mechanism. Other terms for the non-pain syndromes include “classical
conditions”, “well-defined conditions” and “confusable diseases”. Although the EAU approach deals primarily
with urological conditions, this approach to classification can be applied to all conditions associated with pain
perception within the pelvis; the classification has been developed to include non-urological pain and was
accepted by the IASP for publication in January 2012.
Classification of CPP syndromes
Importance of classification
It should be obvious to all that a condition cannot be treated unless it is defined. However, the reasons for
classifying CPP go far beyond that.
Clues to the mechanism

As a result of systematic phenotypic and taxonomic classifications, similarities and differences between
conditions become clear. Drawing comparisons between the phenotypes of different disorders allows one to
compare disorders such as bladder and bowel pain syndromes, thus facilitating research and treatment.
Guidelines for best treatment options

As conditions become better defined, more specific treatment approaches can be adopted. In particular, there
will be a move away from treatments based upon spurious terms (e.g., antibiotics and non-steroidal anti-
inflammatory drugs for the “-itis” conditions). Generic treatments aimed at groups of conditions will be more
commonplace and based upon research evidence.

Research platform
Only by clearly defining the phenotype being investigated can research be valued or applied to the clinical
situation.
Patient needs
A diagnosis, or name, for a set of symptoms can provide patients with a sense of being understood, as well
as hope for relief. It may therefore help in acceptance of the problem as chronic, resolution of unfounded
fears about its implications (if not life-threatening), and engagement in therapeutic endeavours, as well as in
self-management. However, it may also lead to accessing information of variable quality associated with the
diagnosis or name, and the possibility of generating new concerns about long-term consequences or about
appropriateness of treatment.
IASP definitions
Sub-dividing pain syndromes
There is much debate on the sub-divisions of the pain syndromes within the hierarchical taxonomy. The EAU
has led the way in this regard and the guiding principles are as follows [2]:
1. The pain syndromes are defined by a process of exclusion. In particular, there should be no evidence of
infection or inflammation. Investigations by end-organ specialists should therefore be aimed at obtaining
a differential diagnosis; repeated, unnecessary investigations are detrimental in the management of
chronic pain syndromes.
2. A sub-division phenotype should only be used if there is adequate evidence to support its use. For
instance, in non-specific, poorly localised pelvic pain without obvious pathology, only the term chronic
pelvic pain syndrome (CPPS) should be used. If the pain can be localised to an organ, then a more
specific term, such as rectal pain syndrome, may be used. If the pain is localised to multiple organs,
then the syndrome is a regional pain syndrome and the term CPPS should once again be considered.
As well as defining the patient by a specific end-organ phenotype, there are several other more general
descriptors that need to be considered. These are primarily psychological (e.g., cognitive or emotional),
sexual, behavioural and functional. Psychological and behavioural factors are well-established factors
which relate to quality of life (QoL) issues and prognosis. In North America a research programme, the
MAPP program (Multi-disciplinary Approach to the study of Chronic Pelvic Pain research) has been
devised to investigate the importance of these factors and looks at all types of pelvic pain irrespective of
the end-organ where the pain is perceived. It also looks at systemic disorder associations, such as the
co-occurrence of fibromyalgia, facial pain, or auto-immune disorders.
3. In 2004 the panel introduced the concept of managing the polysymptomatic nature of CPP, since then
others have developed their own schemes, such as Nickel’s UPOINT [7], modified by Magri et al. [8]. In
light of these and other publications, the symptom classification table has been updated (Table 1).
The debate in relation to sub-dividing the pain syndromes remains ongoing. As more information is collected
suggesting that the central nervous system (CNS) is involved, and indeed may be the main cause of many
CPP conditions (e.g., bladder, genitalia, colorectal or myofascial), there is a general tendency to move away
from end-organ nomenclature. Only time and good research will determine whether this is appropriate. To
enable such research, it is essential to have a framework of classification within which to work. Any hierarchical
taxonomy must be flexible to allow change.

Axis I Axis II Axis III Axis IV Axis V Axis VI Axis VII Axis VIII
Region System End-organ as pain syndrome Referral Temporal Character Associated Psychological
as identified from Hx, Ex characteristics characteristics symptoms symptoms
and Ix
Chronic Specific disease Urological Prostate Suprapubic ONSET Aching UROLOGICAL ANXIETY
pelvic associated Inguinal Acute Burning Frequency About pain
Bladder
pain pelvic pain Urethral Chronic Stabbing Nocturia or putative
Scrotal Penile/clitoral Electric Hesitance cause of pain
OR Testicular Perineal ONGOING Dysfunctional flow
Epididymal Rectal Sporadic Urgency Catastrophic thinking about
Pelvic pain Back Cyclical Incontinence pain
syndrome Penile Buttocks Continuous
Urethral Thighs GYNAECOLOGICAL DEPRESSION
Postvasectomy TIME Menstrual Attributed to
Filling Menopause pain or impact
Gynaecological Vulvar Emptying of pain
Vestibular Immediate post GASTROINTESTINAL
Clitoral Late post Constipation Attributed to
Diarrhoea other causes
CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018

Endometriosis associated
TRIGGER Bloatedness
CPPS with cyclical exacerbations Provoked Urgency Unattributed
Spontaneous Incontinence
Dysmenorrhoea
PTSD
Gastrointestinal Irritable bowel NEUROLOGICAL SYMPTOMS
Dysaesthesia Re-experiencing
Chronic anal
Table 1: EAU classification of chronic pelvic pain syndromes
Hyperaesthesia Avoidance
Intermittent chronic anal Allodynia
Hyperalegesie
Peripheral nerves Pudendal pain syndrome
Sexological Dyspareunia SEXUOLOGICAL

Satisfaction
The classification has been set up according to the axis system used by IASP.
Pelvic pain with sexual dysfunction Female dyspareunia

Sexual avoidance
Psychological Any pelvic organ
Erectile dysfunction
Medication
Musculo-skeletal Pelvic floor muscle
Hx = History; Ex = Examination; Ix = Investigation; PTSD = post-traumatic stress disorder.

Abdominal muscle
MUSCLE
Spinal
Function impairment
Coccyx Fasciculation
CUTANEOUS
Trophic changes
Sensory changes
7
Pain syndromes
The original EAU classification [2] was inspired by the IASP classification [9] and much work around what has
become known as “pain as a disease” and its associated psychological, behavioural, sexual and functional
correlates. After ten years of work developing the initial ideas, an updated version was accepted by the IASP
Council for publication in January 2012.
Definition of chronic pelvic pain (CPP)

Chronic pelvic pain is chronic or persistent pain perceived* in structures related to the pelvis of either men or
women. It is often associated with negative cognitive, behavioural, sexual and emotional consequences as well
as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor or gynaecological dysfunction.
[*Perceived indicates that the patient and clinician, to the best of their ability from the history, examination and
investigations (where appropriate) has localised the pain as being discerned in a specified anatomical pelvic
area.]
In the case of documented nociceptive pain that becomes chronic/persistent through time, pain must have
been continuous or recurrent for at least six months. That is, it can be cyclical over a six-month period, such
as the cyclical pain of dysmenorrhoea. Although arbitrary, six months was chosen because three months was
not considered long enough if cyclical pain conditions are included. If non-acute and central sensitisation pain
mechanisms are well documented, then the pain may be regarded as chronic, irrespective of the time period.
Cyclical pain is included in the classification and hence dysmenorrhoea needs to be considered as a chronic
pain syndrome if it is persistent and associated with negative cognitive, behavioural, sexual, or emotional
consequences.
Chronic pelvic pain may be sub-divided into conditions with well-defined classical pathology (such as infection
or cancer) and those with no obvious pathology. For the purpose of this classification, the term “specific
disease-associated pelvic pain” is proposed for the former, and “chronic pelvic pain syndrome” for the latter.
The following classification only deals with CPPS.
Definition of chronic pelvic pain syndrome

Chronic pelvic pain syndrome is the occurrence of CPP when there is no proven infection or other obvious
local pathology that may account for the pain. It is often associated with negative cognitive, behavioural, sexual
or emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel or
gynaecological dysfunction. Chronic Pelvic Pain Syndrome is a sub-division of CPP.
Further subdivision of CPPS

Pain perception in CPPS may be focused within a single organ, more than one pelvic organ and even
associated with systemic symptoms such as chronic fatigue syndrome (CFS), fibromyalgia (FM) or Sjögren’s
syndrome. When the pain is localised to a single organ, some specialists may wish to consider using an end
organ term such as Bladder Pain Syndrome (BPS) (Table 2). The use of such a phrase with the terminology
“syndrome” indicates that, although peripheral mechanisms may exist, CNS neuromodulation may be more
important and systemic associations may occur. When the pain is localised to more than one organ site, the
term CPPS should be used. Many, including some of the panel members never sub-divide by anatomy and
prefer to refer to patients with pain perceived within the pelvis, and no specific disease process, as suffering
from CPPS, sub-divided by psychological and functional symptoms.
Psychological considerations for classification

Many CPPSs are associated with a range of concurrent negative psychological, behavioural and sexual
consequences that must be described and assessed. Examples that need to be considered are depression,
anxiety, fears about pain or its implications, unhelpful coping strategies, and distress in relationships. Both
anxiety and depression can be significant important concomitant symptoms that are relevant to pain,
disability and poor QoL. Catastrophic interpretation of pain has been shown to be a particularly salient
variable, predicting patients’ report of pain, disability, and poor QoL, over and above psychosocial variables
such as depression or behavioural factors such as self-reported sexual dysfunction. It is suggested that
CPPS sometimes creates a sense of helplessness that can be reported as overwhelming, and may be
associated with the refractory nature of the patients’ symptoms. It is important to note that many of these bio-
psychosocial consequences are common to other persistent pain problems but may show varying degrees of
importance for any one individual suffering from CPPS. In all patients with CPPS, these consequences must
be clearly described as part of the phenotype (where the term phenotype is used to indicate the observable
characteristics of the syndrome).

Functional considerations for classification
Functional disorders, for the purpose of this document, are pathologies that have arisen secondary to changes
in the control mechanisms of an organ or system. That is, they are disorders characterised by disturbance of
function. As an example, slow colonic transit is a functional disorder of the bowel - the normal function of the
bowel is not occurring as a result of changes in the mechanisms that produce defecation, and therefore bowel
control is abnormal. The term is not used in the sense of a psychiatric functional disorder. Many CPPSs are
associated with functional abnormalities at a local and even systemic level. These also need to be defined as a
part of the phenotype.
Functional pain disorders may not express significant pathology in the organs that appear responsible for the
primary symptoms, but they are associated with substantial neurobiological, physiological and sometimes
anatomical changes in the CNS.
Multi-system sub-division
It is recognised that the end-organ where the pain is perceived may not be the centre of pain generation.
This classification is based upon the most effective and accepted method of classifying and identifying
different pain syndromes, that is, by site of presentation. It is argued that keeping the end-organ name in the
classification is inappropriate because, in most cases, there are multi-systemic causes and effects, with the
result that symptoms are perceived in several areas. This is an area in which discussions are ongoing, and
despite there being strong arguments for both keeping and dispensing with end-organ classification, the panel
have not taken the umbrella approach of referring to all pain perceived in the pelvis as CPPS.
Dyspareunia
Dyspareunia is defined as pain perceived within the pelvis associated with penetrative sex. It tells us nothing
about the mechanism and may be applied to women and men. It is usually applied to penile penetration, but is
often associated with pain during insertion of any object. It may apply to anal as well as vaginal intercourse. It
is classically sub-divided into superficial and deep.
Perineal pain syndrome

Perineal pain syndrome is a neuropathic-type pain that is perceived in the distribution area of the pudendal
nerve, and may be associated with symptoms and signs of rectal, urinary tract or sexual dysfunction. There is
no proven obvious pathology. It is often associated with negative cognitive, behavioural, sexual and emotional
consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological
dysfunction. Perineal pain syndrome should be distinguished from pudendal neuralgia which is a specific
disease associated with pelvic pain that is caused by nerve damage.
Table 2: Chronic Pelvic Pain Syndromes
Urological Pain Syndromes

Prostate pain Prostate pain syndrome (PPS) is the occurrence of persistent or recurrent episodic
syndrome pain (which is convincingly reproduced by prostate palpation). There is no proven
infection or other obvious local pathology. PPS is often associated with negative
cognitive, behavioural, sexual or emotional consequences, as well as with symptoms
suggestive of lower urinary tract and sexual dysfunction. The term “chronic prostatitis”
continues to be equated with that of PPS. In the authors’ and others’ opinion, this is
an inappropriate term, although it is recognised that it has a long history of use. The
National Institutes of Health (NIH) consensus [10] includes infection (types I and II),
which the authors feel should not be considered under PPS, but as specific disease-
associated pelvic pain. The term prostadynia has also been used in the past but is no
longer recommended by the expert panel. Please note that some of the authors of the
IASP document disagree with this term and suggest that CPPS of the male is used
instead of PPS, which has been agreed by the majority.

Bladder pain Bladder pain syndrome (BPS) is the occurrence of persistent or recurrent pain
syndrome perceived in the urinary bladder region, accompanied by at least one other symptom,
such as pain worsening with bladder filling and day-time and/or night-time urinary
frequency. There is no proven infection or other obvious local pathology. BPS is often
associated with negative cognitive, behavioural, sexual or emotional consequences, as
well as with symptoms suggestive of lower urinary tract and sexual dysfunction. BPS
is believed to represent a heterogeneous spectrum of disorders. There may be specific
types of inflammation as a feature in subsets of patients. Localisation of the pain can
be difficult by examination, and consequently, another localising symptom is required.
Cystoscopy with hydrodistension and biopsy may be indicated to define phenotypes.
Recently, ESSIC has suggested a standardised scheme of sub-classifications [11] to
acknowledge differences and make it easier to compare various studies. Other terms
that have been used include “interstitial cystitis”, “painful bladder syndrome”, and
“PBS/IC” or “BPS/IC”. These terms are no longer recommended.
Scrotal pain Scrotal pain syndrome is the occurrence of persistent or recurrent episodic pain
syndrome localised within the organs of the scrotum, and may be associated with symptoms
suggestive of lower urinary tract or sexual dysfunction. There is no proven infection or
other obvious local pathology. Scrotal pain syndrome is often associated with negative
cognitive, behavioural, sexual or emotional consequences. Scrotal pain syndrome is a
generic term and is used when the site of the pain is not clearly testicular or epididymal.
The pain is not in the skin of the scrotum as such, but perceived within its contents, in a
similar way to idiopathic chest pain.
Testicular pain Testicular pain syndrome is the occurrence of persistent or recurrent episodic pain
syndrome perceived in the testes, and may be associated with symptoms suggestive of lower
urinary tract or sexual dysfunction. There is no proven infection or other obvious
local pathology. Testicular pain syndrome is often associated with negative cognitive,
behavioural, sexual or emotional consequences. Previous terms have included orchitis,
orchialgia and orchiodynia. These terms are no longer recommended.
Epididymal pain Epididymal pain syndrome is the occurrence of persistent or recurrent episodic pain
syndrome perceived in the epididymis, and may be associated with symptoms suggestive of
lower urinary tract or sexual dysfunction. There is no proven infection or other obvious
local pathology. Epididymal pain syndrome is often associated with negative cognitive,
behavioural, sexual or emotional consequences.
Penile pain Penile pain syndrome is the occurrence of pain within the penis that is not primarily in
syndrome the urethra, in the absence of proven infection or other obvious local pathology. Penile
pain syndrome is often associated with negative cognitive, behavioural, sexual or
emotional consequences, as well as with symptoms suggestive of lower urinary tract
and sexual dysfunction.
Urethral pain Urethral pain syndrome is the occurrence of chronic or recurrent episodic pain
syndrome perceived in the urethra, in the absence of proven infection or other obvious local
pathology. Urethral pain syndrome is often associated with negative cognitive,
behavioural, sexual or emotional consequences, as well as with symptoms suggestive
of lower urinary tract, sexual, bowel or gynaecological dysfunction. Urethral pain
syndrome may occur in men and women.
Post-vasectomy Post-vasectomy scrotal pain syndrome is a scrotal pain syndrome that follows
scrotal pain vasectomy. Post-vasectomy scrotal pain syndrome is often associated with negative
syndrome cognitive, behavioural, sexual or emotional consequences, as well as with symptoms
suggestive of lower urinary tract and sexual dysfunction. Post-vasectomy pain may be
as frequent as 1% following vasectomy, possibly more frequent. The mechanisms are
poorly understood and for that reason it is considered a special form of scrotal pain
syndrome.

Gynaecological Pain Syndromes: external genitalia
Vulvar pain Vulvar pain syndrome is the occurrence of persistent or recurrent episodic vulvar pain.
syndrome There is no proven infection or other local obvious pathology. It is often associated
with negative cognitive, behavioural, sexual or emotional consequences, as well as
with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological
dysfunction. Although pain perceived in the vulva was included under sexual disorders
in the DSM-IV-R manual for classifying psychiatric disorders, there is no scientific
basis for this classification, and pain perceived in the vulva is best understood as a
pain problem that usually has psychological consequences. There is no evidence
for its classification as a psychiatric disorder. The International Society for the Study
of Vulvovaginal Disease (ISSVD) has used the term vulvodynia, where we use the
term vulvar pain syndrome. According to the ISSVD, vulvodynia is vulvar pain that
is not accounted for by any physical findings. The ISSVD has defined vulvodynia as
“vulvar discomfort, most often described as burning pain, occurring in the absence
of relevant visible findings or a specific, clinically identifiable, neurologic disorder”. If
physical findings are present, the patient is said to have vulvar pain due to a specified
cause. The ISSVD has sub-divided vulvodynia based on pain location and temporal
characteristics of the pain (e.g. provoked or unprovoked). The following definitions are
based on that approach.
Generalised vulvar Generalised vulvar pain syndrome refers to a vulvar pain syndrome in which the pain/
pain syndrome burning cannot be consistently and precisely localised by point-pressure mapping
via probing with a cotton-tipped applicator or similar instrument. Rather, the pain is
diffuse and affects all parts of the vulva. The vulvar vestibule (the part that lies between
the labia minora into which the urethral meatus and vaginal introitus open) may be
involved but the discomfort is not limited to the vestibule. This pain syndrome is often
associated with negative cognitive, behavioural, sexual or emotional consequences.
Previous terms have included “dysesthetic vulvodynia” and “essential vulvodynia”, but
are no longer recommended.
Localised vulvar Localised vulvar pain syndrome refers to pain that can be consistently and precisely
pain syndrome localised by point-pressure mapping to one or more portions of the vulva. Clinically, the
pain usually occurs as a result of provocation (touch, pressure or friction). Localised
vulvar pain syndrome can be sub-divided into vestibular pain syndrome and clitoral
pain syndrome.
Vestibular pain Vestibular pain syndrome refers to pain that can be localised by point-pressure
syndrome mapping to the vestibule or is well perceived in the area of the vestibule.
Clitoral pain Clitoral pain syndrome refers to pain that can be localised by point-pressure mapping
syndrome to the clitoris or is well-perceived in the area of the clitoris.
Gynaecological system: internal pelvic pain syndromes
Endometriosis- Endometriosis-associated pain syndrome is chronic or recurrent pelvic pain in patients
associated pain with laparoscopically confirmed endometriosis, and the term is used when the
syndrome symptoms persist despite adequate endometriosis treatment. It is often associated
dysfunction. Many patients have pain above and beyond the endometriotic lesions;
this term is used to cover that group of patients. Endometriosis may be an incidental
finding, is not always painful, and the degree of disease seen laparoscopically does not
correlate with severity of symptoms. As with other patients, they often have more than
one end-organ involved. It has been suggested that this phenotype should be removed
from the classification because the endometriosis may be irrelevant.
Chronic pelvic Chronic pelvic pain syndrome with cyclical exacerbations covers the non-
pain syndrome gynaecological organ pain that frequently shows cyclical exacerbations (e.g., IBS or
with cyclical BPS) as well as pain similar to that associated with endometriosis/adenomyosis but
exacerbations where no pathology is identified. This condition is different from dysmenorrhoea, in
which pain is only present with menstruation.
Dysmenorrhoea Dysmenorrhoea is pain with menstruation that is not associated with well-defined
pathology. Dysmenorrhoea needs to be considered as a chronic pain syndrome if it
is persistent and associated with negative cognitive, behavioural, sexual or emotional
consequences.

Gastrointestinal Pelvic Pain Syndromes
Irritable bowel IBS is the occurrence of chronic or recurrent episodic pain perceived in the bowel, in
syndrome (IBS) the absence of proven infection or other obvious local pathology. Bowel dysfunction is
frequent. IBS is often associated with worry and pre-occupation about bowel function,
and negative cognitive, behavioural, sexual or emotional consequences, as well as with
symptoms suggestive of lower urinary tract or gynaecological dysfunction. The above
classification is based upon the Rome III Criteria [12]: three months of continuous
or recurring symptoms of abdominal pain or irritation that may be relieved with a
bowel movement, may be coupled with a change in frequency, or may be related to a
change in stool consistency. Two or more of the following are present at least 25% of
the time: change in stool frequency (> three bowel movements per day or < three per
week); noticeable difference in stool form (hard, loose, watery or poorly formed stools);
passage of mucus in stools; bloating or feeling of abdominal distension; or altered
stool passage (e.g., sensation of incomplete evacuation, straining, or urgency). Extra-
intestinal symptoms include: nausea, fatigue, full sensation after even a small meal, and
vomiting.
Chronic anal pain Chronic anal pain syndrome is the occurrence of chronic or recurrent episodic pain
syndrome perceived in the anus, in the absence of proven infection or other obvious local
pathology. Chronic anal pain syndrome is often associated with negative cognitive,
behavioural, sexual or emotional consequences, as well as with symptoms suggestive
of lower urinary tract, sexual, bowel or gynaecological dysfunction.
Intermittent Intermittent chronic anal pain syndrome refers to severe, brief, episodic pain that seems
chronic anal pain to arise in the rectum or anal canal and occurs at irregular intervals. This is unrelated
syndrome to the need to or the process of defecation. It may be considered a sub-group of the
chronic anal pain syndromes. It was previously known as “proctalgia fugax” but this
term is no longer recommended.
Musculoskeletal System
Pelvic floor muscle Pelvic floor muscle pain syndrome is the occurrence of persistent or recurrent episodic
pain syndrome pelvic floor pain. There is no proven well-defined local pathology. It is often associated
dysfunction. This syndrome may be associated with over-activity of or trigger points
within the pelvic floor muscles. Trigger points may also be found in several muscles,
such as the abdominal, thigh and paraspinal muscles and even those not directly
related to the pelvis.
Coccyx pain Coccyx pain syndrome is the occurrence of chronic or recurrent episodic pain
syndrome perceived in the region of the coccyx, in the absence of proven infection or other
obvious local pathology. Coccyx pain syndrome is often associated with negative
cognitive, behavioural, sexual or emotional consequences, as well as with symptoms
suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction. The
term “coccydynia” was used but is no longer recommended.
2. METHODOLOGY
2.1 Methods
For the 2018 edition of the EAU Guidelines the Guidelines Office have transitioned to a modified GRADE
methodology across all 20 guidelines [13, 14]. For each recommendation within the guidelines, there is an
accompanying online strength rating form which addresses a number of key elements namely:
1. the overall quality of the evidence which exists for the recommendation, references used in this text
are graded according to a classification system modified from the Oxford Centre for Evidence-Based
Medicine Levels of Evidence [15];
2. the magnitude of the effect (individual or combined effects);
3. the certainty of the results (precision, consistency, heterogeneity and other statistical or study related
factors);
4. the balance between desirable and undesirable outcomes;
5. the impact of patient values and preferences on the intervention;
6. the certainty of those patient values and preferences.

These key elements are the basis which panels use to define the strength rating of each recommendation. The
strength of each recommendation is represented by the words ‘strong’ or ‘weak’ [16]. The strength of each
recommendation is determined by the balance between desirable and undesirable consequences of alternative
management strategies, the quality of the evidence (including certainty of estimates), and nature and variability
of patient values and preferences. The strength rating forms will be made available online.
Additional information can be found in the general Methodology section of this print, and online at the EAU
website: http://www.uroweb.org/guideline/. A list of associations endorsing the EAU Guidelines can also be
viewed online at the above address.
The 2012 full text update was based on a systematic review of literature using the Embase and Medline
databases, the Cochrane Central Register of controlled trials and the PsycINFO and Bandolier databases to
identify the best evidence from randomised controlled trials (RCTs) (Level of Evidence 1 (LE: 1)) according to
the rating schedule adapted from the Oxford Centre for Evidence-based Medicine Levels of Evidence. Where
no LE: 1 literature could be identified the search was moved down to the next lower level on the rating scale.
Extensive use of free text ensured the sensitivity of the searches, resulting in a substantial body of literature
to scan. Searches covered the period January 1995 to July 2011 and were restricted to English language
publications.
In 2017, a scoping search for the previous five years was performed, covering all areas of the guideline with the
exception of the gynaecological aspects, and the guideline was updated accordingly.
For the 2018 print, a scoping search was performed, covering all areas of the guideline starting from the last
cut-off date of May 2016 with a cut-off date of May 2017. Embase, Medline, the Cochrane Central Register
of Controlled Trials and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases were
searched and were restricted to English language publications. A total of 938 unique records were identified,
retrieved and screened for relevance of which 17 publications were selected for inclusion in the 2018
guidelines. A detailed search strategy is available online: https://uroweb.org/guideline/chronic-pelvic-pain/. The
gynaecological aspects of the guideline will be reviewed and fully updated in the 2019 edition.
2.2 Review
This document was subject to peer review prior to publication in 2015.
2.3 Future goals

The results of ongoing and new systematic reviews will be included in the 2018 update of the Chronic Pelvic
Pain Guidelines. Ongoing systematic reviews are:
• What are the benefits and harms of electrical neuromodulation vs. best clinical practice or no treatment in
CPP? [17].
• What are the benefits and harms of Botulinum Toxin A vs. best clinical practice or no treatment or sham
or placebo in CPP?
3. EPIDEMIOLOGY, AETIOLOGY AND

PATHOPHYSIOLOGY
3.1 Chronic visceral pain
Definition of pain
Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage (IASP Taxonomy).
Introduction to chronic pelvic pain syndromes

Over the years much of the focus for CPP has been on peripheral-end-organ mechanisms, such as
inflammatory or infective conditions. However, both animal and clinical research have indicated that many of
the mechanisms for the CPPSs are based within the CNS. Although a peripheral stimulus such as infection
may initiate the start of a CPP condition, the condition may become self-perpetuating as a result of CNS

modulation. As well as pain, these central mechanisms are associated with several other sensory, functional,
behavioural and psychological phenomena. It is this collection of phenomena that forms the basis of the pain
syndrome diagnosis and each individual phenomena needs to be addressed in its own right through multi-
specialty and multi-disciplinary care. Although ongoing peripheral organ pathology can produce persistent and
chronic pain, the main focus of these guidelines is on CPPSs in which no peripheral ongoing pathology (such
as infection or neoplastic disease) is detected. The main exception is when pain is due to peripheral nerve
damage.
3.1.1 Incidence
No adequate data on incidence were found.
3.1.2 Prevalence
In a large European study undertaken in 2004 [18] it was found that chronic pain of moderate to severe
intensity occurs in 19% of adult Europeans, seriously affecting the quality of their social and working lives.
There are some differences between countries but not much spread is seen. A more recent study in the UK
found a prevalence of CPP of 14.8% in women over 25 years [19].
3.1.3 Influence on Quality of Life

Assessing the QoL in pelvic pain patients is challenging due to the multi-faceted nature of the complaints and
the overlap between the different pelvic pain syndromes [20]. Assessment of QoL is further complicated due to
the complex pathology of pain itself [21].
Pelvic pain syndromes do have an impact on QoL [22, 23]. This may result in depression, anxiety, impaired
emotional functioning, insomnia and fatigue [22, 24]. If these aspects are identified and targeted early in the
diagnostic process, the associated pain symptoms may also improve [25]. Addressing comorbidities will help
in further improving QoL [26]. Quality of life assessment is therefore important in patients with pelvic pain and
should include physical, psychosocial and emotional tools, using standardised and validated instruments [23].
The impact of pain on QoL has been assessed in an extensive European study [18]. In-depth interviews with
4,839 respondents with chronic pain (about 300 per country) showed: 66% had moderate pain (Numeric Rating
Scale [NRS] = 5-7) and 34% had severe pain (NRS = 8-10), 46% had constant pain, 54% had intermittent pain.
Fifty-nine per cent had suffered with pain for two to fifteen years, 21% had been diagnosed with depression
because of their pain, 61% were less able or unable to work outside their home, 19% had lost their job and
13% had changed jobs because of their pain. Sixty per cent visited their doctor about their pain two to nine
times in the last six months. Only 2% were currently treated by a pain management specialist.
3.1.4 Costs
No adequate data on costs were found.
3.1.5 Risk Factors and underlying causes

3.1.5.1 Risk factors
Risk factors include many different factors from various areas, including genetic, psychological state, recurrent
physical trauma and endocrine factors.
The endocrine system is involved in visceral function. Significant life events, and in particular, early life events
may alter the development of the hypothalamic-pituitary-adrenal axis and the chemicals released. Increased
vulnerability to stress is thought to be partly due to increased corticotrophin-releasing hormone (CRH) gene
expression. Up-regulation of CRH has been implicated in several pain states such as rectal hypersensitivity to
rectal distension. This model suggests an action of CRH on mast cells. A range of stress-related illnesses have
been suggested, e.g. IBS and BPS. There is evidence accumulating to suggest that the sex hormones also
modulate both nociception and pain perception. Stress can also produce long-term biological changes which
may form the relation between chronic pain syndromes and significant early life and adverse life events [27].
Asking the patient about these events is important as they have an effect on a patient’s psychological wellbeing
[28-30].
Genetics also play a role in assessing the risk of developing chronic pain. An individual who has one chronic
pain syndrome is more likely to develop another. Family clusters of pain conditions are also observed and
animals can be bred to be more prone to apparent chronic pain state. A range of genetic variations have
been described that may explain the pain in certain cases; many of these are to do with subtle changes
in transmitters and their receptors. However, the picture is more complicated in that developmental,

environmental and social factors also influence the situation. Evidence that BPS may have a genetic
component has been presented in several identical twin studies, but genetics may contribute to less than one
third of total variation in susceptibility to BPS [31, 32].
Studies about integrating the psychological factors are few but the quality is high. Psychological factors
are consistently found to be relevant in the maintenance of persistent pelvic and urogenital pain within the
current neurobiological understanding of pain. Beliefs about pain contribute to the experience of pain [33]
and symptom-related anxiety and central pain amplification may be measurably linked, as in IBS [34], and
catastrophic thinking about pain and perceived stress predict worsening of urological chronic pain over a year
[35]. Central sensitisation has been demonstrated in symptomatic endometriosis [36] and central changes are
evident in association with dysmenorrhoea and increasingly recognised as a risk for female pelvic pain [37].
The various mechanisms of CNS facilitation, amplification and failure of inhibition, mean that there is no simple
relationship between physical findings, pain experienced and resulting distress and restriction of activities.
Diagnoses that assign women’s pain to psychological origins, as is common in primary care [38] due to
scepticism about the reality or severity of their pain [39], undermines any therapeutic relationship [40]. Division
of aetiology into organic vs. psychogenic is unscientific. Pelvic pain and distress may be related [41, 42] in men
as well as in women [43]; the same is true of painful bladder and distress [35, 44]. In a large population based
study of men, CPPS was associated with prior anxiety disorder [45]. The only systematic review [46] of risk
factors for chronic non-cyclical pelvic pain in women included, as well as medical variables: sexual or physical
abuse (Odds Ratio (OR) from 1.51 to 3.49); psychological problems such as anxiety (OR: 2.28, 95% Confidence
Interval (CI): 1.41- 3.70) and depression (OR: 2.69, 95% CI: 1.86-3.88); multiple somatic problems (OR: 4.83,
95% CI: 2.50-9.33); and psychosomatic symptoms (OR: 8.01, 95% CI: 5.16-12.44).
Many studies have reported high rates of childhood sexual abuse in adults with persistent pain, particularly
in women with pelvic pain [47, 48]. In these studies it is suggested that there is increased frequency of
sexual abuse or trauma history, anxiety and depression in women with CPP [49-53]. The only prospective
investigation into the relationship between childhood sexual abuse, physical abuse, or neglect, and “medically
unexplained pain”, including pelvic pain, used court records to compare women with a definite history with
matched classmates [30] and concluded that physically and sexually abused individuals were not at risk for
increased pain, although women with pain problems as adults were more likely to report earlier sexual or
physical abuse or neglect. The correlation between childhood victimisation and pain may concern retrospective
explanations for pain; controlling for depression significantly weakens the relationship between childhood
abuse and adult pain [54]. Disentangling the influences and inferences requires further prospective studies or
careful comparisons [27]. There is some evidence for a specific relationship between rape and CPP (and with
fibromyalgia and functional gastrointestinal disorders) [55]; and, recent sexual assault may prompt presentation
of pelvic pain [47, 56]. Few studies have been found of sexual or physical abuse in childhood and pelvic pain in
men, although it has known adverse effects on health [55, 57]. In the BACH study, it was found that men who
reported having experienced sexual, physical, or emotional abuse had increased odds (3.3 compared to 1.7)
for symptoms suggestive of CPP. The authors suggested that clinicians may wish to screen for abuse in men
presenting with symptoms suggestive of CPP. Conversely, clinicians may wish to inquire about pelvic pain in
patients who have experienced abuse [58].
3.1.5.2 Underlying causes

The mechanisms that serve as an underlying cause for chronic pelvic pain are:
1. Ongoing acute pain mechanisms [59] (such as those associated with inflammation or infection), which
may involve somatic or visceral tissue.
2. Chronic pain mechanisms, which especially involve the CNS [6].
3. Emotional, cognitive, behavioural and sexual responses and mechanisms [60-62].
Symptoms and signs of neuropathic pain appear to be common in CPP patients and assessment of
neuropathic pain should be considered in that group of patients. The presence or absence of endometriosis
does not seem to change this [63].
Chronic pain mechanisms may include altered resting state neuromotor connectivity, for instance in men with
chronic prostatitis/CPPS [64].
Table 3 illustrates some of the differences between the somatic and visceral pain mechanisms. These underlie
some of the mechanisms that may produce the classical features of visceral pain; in particular, referred pain
and hyperalgesia.

Table 3: Comparison between visceral and somatic pain
Visceral pain Somatic pain

Effective painful stimuli Stretching and distension, Mechanical, thermal, chemical and
producing poorly localised pain. electrical stimuli, producing well
localised pain.
Summation Widespread stimulation produces Widespread stimulation produces a
significantly magnified pain. modest increase in pain.
Autonomic involvement Autonomic features (e.g., nausea Autonomic features less frequent.
and sweating) frequently present.
Referred pain Pain perceived at a site distant to Pain is relatively well localised but
the cause of the pain is common. well recognised.
Referred hyperalgesia Referred cutaneous and muscle Hyperalgesia tends to be localised.
hyperalgesia is common, as is
involvement of other visceral
organs.
Innervation Low density, unmyelinated C fibres Dense innervation with a wide
and thinly myelinated A∂ fibres. range of nerve fibres.
Primary afferent physiology Intensity coding. As stimulation Two fibre coding. Separate fibres
increases, afferent firing increases for pain and normal sensation.
with an increase in sensation and
ultimately pain.
Silent afferents 50-90% of visceral afferents These fibres are very important in
are silent until the time they are the central sensitisation process.
switched on. Silent afferents present, but form a
lower percentage.
Central mechanisms Play an important part in the Sensations not normally perceived
hyperalgesia, viscerovisceral, become perceived and non-
visceromuscular and noxious sensations become
musculovisceral hyperalgesia. painful. Responsible for the
allodynia and hyperalgesia of
chronic somatic pain.
Abnormalities of function Central mechanisms associated Somatic pain associated with
with visceral pain may be somatic dysfunction, e.g., muscle
responsible for organ dysfunction. spasm.
Central pathways and As well as classical pathways, Classical pain pathways.
representation there is evidence for a separate
dorsal horn pathway and central
representation.
Ongoing peripheral pain mechanisms in visceral pain

In most cases of CPP, ongoing tissue trauma, inflammation or infection is absent [65-68]. However, conditions
that produce recurrent trauma, infection or ongoing inflammation may result in CPP in a small proportion of
cases. For example, out of a large cohort with acute bacterial prostatitis, 10.5% ended up with a state of CPPS
[69]. It is for this reason that the early stages of assessment include looking for these pathologies [11]. Once
excluded, ongoing investigations for these causes are rarely helpful and indeed may be detrimental.
When acute pain mechanisms are activated by a nociceptive event, as well as direct activation of the peripheral
nociceptor transducers, sensitisation of those transducers may also occur, therefore magnifying the afferent
signalling. Afferents that are not normally active may also become activated by the change, that is, there may
be activation of the so-called silent afferents. Although these are mechanisms of acute pain, the increased
afferent signalling is often a trigger for the chronic pain mechanisms that maintain the perception of pain in the
absence of ongoing peripheral pathology (see below) [70, 71].
There are a number of mechanisms by which the peripheral transducers may exhibit an increase in sensibility.
1. Modification of the peripheral tissue, which may result in the transducers being more exposed to
peripheral stimulation.
2. There may be an increase in the chemicals that stimulate the receptors of the transducers [72].
3. There are many modifications in the receptors that result in them being more sensitive.

In general, the effect of 1 and 2 is to lower the threshold and the effect of 3 is to increase responsiveness to
external stimuli. Some of the chemicals responsible for the above changes may be released from those cells
associated with inflammation, but the peripheral nervous system may also release chemicals in the positive
and inhibitory loops [73-75].
Central sensitisation as a mechanism in visceral pain

It is important to appreciate that nociception is the process of transmitting information to centres involved in
perception of a stimulus that has the potential to cause tissue damage. Pain is far more complex and involves
activation of the nociceptive pathways but also the emotional response. The brain may affect the modulation of
pain pathways at the spinal cord level.
Central sensitisation [76] is responsible for a decrease in threshold and an increase in response duration
and magnitude of dorsal horn neurons. It is associated with an expansion of the receptive field. As a result,
sensitisation increases signalling to the CNS and amplifies what we perceive from a peripheral stimulus.
As an example, for cutaneous stimuli, light touch would not normally produce pain, however, when central
sensitisation is present, light touch may be perceived as painful (allodynia). In visceral hyperalgesia (so called
because the afferents are primarily small fibres), visceral stimuli that are normally sub-threshold and not
usually perceived, may be perceived. For instance, with central sensitisation, stimuli that are normally sub-
threshold may result in a sensation of fullness and a need to void or to defecate. Non-noxious stimuli may
be interpreted as pain and stimuli that are normally noxious may be magnified (true hyperalgesia) with an
increased perception of pain. As a consequence, one can see that many of the symptoms of BPS and IBS may
be explained by central sensitisation. A similar explanation exists for the muscle pain in FM.
It is now well accepted that there are both descending pain-inhibitory and descending pain-facilitatory
pathways that originate from the brain [77]. Several neurotransmitters and neuromodulators are involved
in descending pain-inhibitory pathways. The main contenders are the opioids, 5-hydroxytryptamine and
noradrenaline.
The autonomic nervous system also plays a role in sensitisation. There is good evidence that damaged afferent
fibres may develop a sensitivity to sympathetic stimulation, both at the site of injury and more centrally,
particularly in the dorsal horns. In visceral pain, the efferent output of the CNS may be influenced by central
changes (again, those changes may be throughout the neuraxis), and such modification of the efferent
message may produce significant end-organ dysfunction. These functional abnormalities can have a significant
effect on QoL and must be managed as appropriate.
Psychological mechanisms in visceral pain

Psychological processes of emotions, thought and behaviour involve networks rather than distinct centres.
Some of these processes are sophisticated and others fundamental in evolutionary terms, and their interaction
with pain processing is complex.
Various psychological processes affect pain neuromodulation at a higher level. Inhibiting or facilitating both
the nociceptive signal reaching the consciousness and appraisal and interpretation of that signal, will also
modulate the response to the nociceptive message and hence the pain experience. Further, descending
pathways represent cognitive, emotional and behavioural states at spinal and peripheral levels. Functional
magnetic resonance imaging (fMRI) has indicated that the psychological modulation of visceral pain probably
involves multiple pathways. For instance, mood and attentional focus probably act through different areas of
the brain when involved in reducing pain [78].
This psychological modulation may act to reduce nociception within a rapid time frame but may also result
in long-term vulnerability to chronic visceral pain, through long-term potentiation. This involvement of
higher centre learning may be at both a conscious and subconscious level, and is clearly significant in the
supratentorial neuroprocessing of nociception and pain. Long-term potentiation [79] may occur at any level
within the nervous system, so that pathways for specific or combinations of stimuli may become established,
resulting in an individual being vulnerable to perceiving sensations that would not normally be experienced as
painful.
An important review [27] of CPP in women identifies the notion that women without physical findings to which
pain can be causally attributed differ in psychological characteristics from women with physical findings. It
argues for better methodology, and for greater use of idiographic methods. Women with pelvic pain often have
other non-pain somatic symptoms, and current or lifetime anxiety and depression disorder [19]; they may have
a history of physical or sexual abuse in childhood of unclear significance. Studies that describe these non-pain

somatic symptoms as ‘medically unexplained’ or ‘psychosomatic’ or ‘somatoform’ disorders are unhelpful,
misinterpreting absence of physical finding to indicate psychological origins of the complaint [80, 81]. Pain
studies describe multiple processes by which pain may spread from one site to another, or in time, including
central sensitisation (see previous section), viscerovisceral cross sensitisation in relation to multiple pain sites
[82], activation of the hypothalamic-pituitary axis and dysregulation of serotonergic pathways [83] that can
render pain levels sensitive to stress. Some pain problems which affect sexual activity are diagnosed as sexual
problems (e.g. ‘dyspareunia’) when pain is the central problem and not contingent on sexual activity alone [84].
Better integration of sexology and mainstream psychology for pelvic pain in both men and women is needed
[85], building on a biopsychosocial formulation [86, 87].
The term psychosomatic symptoms can best be understood as multiple somatic symptoms not associated
with or indicative of any serious disease process. Medical and surgical history may also be important [88].
There have been a few studies of maintenance of, or recovery from, pelvic pain in relation to psychological
factors of importance in pain. Those that described pelvic pain as medically unexplained or psychosomatic,
due to the lack of physical findings, have been discarded, because such a distinction is inconsistent with
known pain mechanisms [80].
Understanding the psychological components of pain

Psychological processes of emotions, thought and behaviour involve networks rather than distinct centres,
and their interaction with pain processing is complex, producing inhibition and facilitation of signal processing,
appraisal, and response. Models that integrate the psychological factors consistently found to be relevant in
the maintenance of persistent pelvic and urogenital pain with current neurobiological understanding of pain are
few but the quality is high (see 3.1.5.1).
There is no evidence that women with CPP without physical findings are primarily presenting a psychological
problem [27]. Anxiety and post-traumatic stress symptoms are common in some women with CPP [38, 89] and
with vulvar pain [90], and may account for substantial variance in health status, treatment use and treatment
outcome; for instance, women’s expectations about vulvar pain on penetration predicted pain, sexual function
and sexual satisfaction [91]. Negative investigative findings do not necessarily resolve women’s anxieties about
the cause of pain [92, 93] and anxiety often focuses on what might be ‘wrong’ [94]. Depression may be related
to pain in various ways, as described above. Until measures are available that are adequately standardised in
patients with pain, anxiety and distress may be best assessed by questions about concerns about the cause of
pain, the hope that diagnosis will validate pain, the struggle with unpredictability, and the implications of pain
for everyday life [95, 96]. Reference to the studies of the IMMPACT group [97] is recommended for guidance on
outcome measures suitable for pain trials.
Stress can modify the nervous system to produce long-term biological changes. These structural changes
may be responsible for significant early life and adverse life events which are associated with chronic pain
syndromes [30]. The patient should be asked about adverse life events that may produce these biological
responses and affect a patient’s general psychological well-being [29, 30, 98].
3.1.5.3 Clinical paradigms in visceral pain

Referred pain
Referred pain is frequently observed and its identification is important for diagnosis and treatment. Referral
is usually somatic to somatic, or visceral to somatic. However, there is no reason why pain cannot also be
perceived within the area of an organ with the nociceptive signal having arisen from a somatic area. Referred
pain may occur as a result of several mechanisms but the main theory is one of convergence-projection. In the
convergence-projection theory, as an example, afferent fibres from the viscera and the somatic site of referred
pain converge onto the same second order projection neurons. The higher centres receiving messages from
these projection neurons are unable to separate the two possible sites from the origin of the nociceptive signal
[66, 70, 99].
Hyperalgesia refers to an increased sensitivity to normally painful stimuli. In patients that have passed a renal
stone, somatic muscle hyperalgesia is frequently present, even a year after expulsion of the stone. Pain to
non-painful stimuli (allodynia) may also be present in certain individuals. Somatic tissue hyperaesthesia is
associated with urinary and biliary colic, IBS, endometriosis, dysmenorrhoea, and recurrent bladder infections.
Vulvar pain syndromes are examples of cutaneous allodynia that, in certain cases, may be associated with
visceral pain syndromes, such as BPS. Referred pain with hyperalgesia is thought to be due to central
sensitisation of the converging viscero-somatic neurons. Central sensitisation also stimulates efferent activity
that could explain the trophic changes that are often found in the somatic tissues.

Muscles and pelvic pain
In the urogenital pain syndromes, muscle tenderness and trigger points may be implicated as a source of pain.
Central mechanisms are of great importance in the pathogenesis of this muscle hyperalgesia. The muscles
involved may be a part of the spinal, abdominal or pelvic complex of muscles. It is not unknown for adjacent
muscles of the lower limbs and the thorax to become involved. Pain may be localised to the trigger points
but it is more often associated with classical referral patterns. As well as trigger points, inflammation of the
attachments to the bones (enthesitis) and of the bursa (bursitis) may be found [100]. Certain postures affect
the different muscles in different ways, and as a consequence, may exacerbate or reduce the pain. Stress has
been implicated as both an initiator of pelvic myalgia and as a maintenance factor. As a result, negative sexual
encounters may also have a precipitating effect [27].
Visceral hyperalgesia
The increased perception of stimuli in the viscera is known as visceral hyperalgesia, and the underlying
mechanisms are thought to be responsible for IBS, BPS and dysmenorrhoea. The mechanisms involved are
often acute afferent input (e.g., due to infection) followed by long-term central sensitisation. Viscero-visceral
hyperalgesia is thought to be due to two or more organs with converging sensory projections and central
sensitisation. For instance, overlap of bladder and uterine afferents or uterine and colon afferents.
3.2 Pelvic Pain

3.2.1 Incidence
No adequate data on incidence were found.
3.2.2 Prevalence
3.2.2.1 Prostate Pain syndrome
There is only limited information on the true prevalence of PPS in the population. As a result of significant
overlap of symptoms with other conditions (e.g. benign prostatic enlargement and BPS), purely symptom-
based case definitions may not reflect the true prevalence of PPS [101, 102]. In the literature, population-based
prevalence of prostatitis symptoms ranges from 1 to 14.2% [103, 104]. The risk of prostatitis increases with age
(men aged 50-59 years have a 3.1-fold greater risk than those aged 20-39 years).
3.2.2.2 Bladder Pain syndrome

Reports of BPS prevalence have varied greatly, along with the diagnostic criteria and populations studied.
Recent reports range from 0.06% to 30% [105-114]. There is a female predominance of about 10:1 [111,
115-117] but possibly no difference in race or ethnicity [101, 118, 119]. The relative proportions of classic and
non-lesion disease are unclear. Incidence in studies has ranged from 5 to 50% [120-124]. There is increasing
evidence that children under eighteen may also be affected, although prevalence figures are low; therefore,
BPS cannot be excluded on the basis of age [125].
3.2.2.3 Sexual pain syndrome

In the 1980s an association between CPP and sexual dysfunction was postulated. In two reviews the
relationship between PPS and health status, with influence on sexual activity, was addressed [126, 127]. In a
Chinese study of men with CPP 1,768 males completed the questionnaires. The overall prevalence of sexual
dysfunction was 49%. Erectile dysfunction (ED) is the most investigated sexual dysfunction in PPS patients.
The reported prevalence of ED ranges from 15.1% to 48%, varying with evaluation tools and populations
[128, 129]. Erectile dysfunction was prevalent in 27.4% of Italian men aged 25-50 [130], 15.2% among Turkish
men (significantly higher than in the control group) [131] and 43% among Finnish men with PPS [132]. The
prevalence of ED was found to be higher in young men with PPS than in the general population. According to
other studies men with pelvic pain had a higher chance of suffering from ED [133, 134]. Recently, a significant
correlation between “chronic prostatitis”, CPP symptoms (measured by NIH-CPSI) and ED (measured by
International Index of Erectile Function [IIEF]) was confirmed [135], while other studies using the same
questionnaires were not able to confirm such a correlation [87, 136]. Some studies also report ejaculatory
dysfunction, mainly premature ejaculation [128, 129, 137, 138].
In community-based studies in the UK [139], New Zealand [140] and Australia [141], a substantially larger
proportion of the women with CPP reported dyspareunia (varying between 29% and 42%) than women without
CPP (varying between 11% and 14%). Only a few studies have investigated sexual problems within clinical
populations [142]. Another study showed that all of the sexual function domains (desire, arousal, lubrication,
orgasm, satisfaction, and pain) were significantly lower in women with CPP than in women without CPP [142].
In line with the results of community based studies, patients with CPP reported more sexual problems such as
dyspareunia, problems with desire or arousal and lubrication than women without CPP [142-144]. One study of

patients enrolled in chronic pain treatment programs in England has reported that 73% had pain-related sexual
problems [145].
3.2.2.4 Myofascial pain syndromes

The relationship between muscular dysfunction (especially over-activity) and pelvic pain has been found in
several studies [146]. Rectal pain treated with pelvic floor muscle therapy is only relieved when patients learn to
relax their pelvic floor muscles [147, 148]. The vast majority (92.2%) of men visiting a tertiary centre for pelvic
pain had dysfunction of the pelvic floor muscles. This finding was true regardless of evidence of inflammation
(prostatitis or cystitis) [149]. This relationship has been found in chronic prostatitis [150], BPS [151] and vulvar
pain [152]. Dysfunction of the pelvic floor directly affects function of the pelvic viscera and vice versa. Both
systems can act as the primary signal to the spinal cord, with a cascade of reactions ascending to the CNS as
a result. The muscle itself ends up with a diminished length, leading to restrictions even when it is in a relaxed
state.
3.2.3 Influence on QoL

Data on the influence on QoL will be included in the next version of the guidelines.
3.2.4 Costs
No adequate data on costs were found.
3.2.5 Risk factors and underlying causes

The risk factors are unspecific for most of the pain syndromes in the pelvic area. They are described in 3.1.5.1.
The underlying causes, including the mechanisms are described here for the different clinical pain syndromes.
3.2.5.1 Prostate Pain Syndrome

Pain is the main symptom in PPS. As a common feature of chronic pain syndromes, no single aetiological
explanation has been found. One explanation [153] is that the condition probably occurs in susceptible men
exposed to one or more initiating factors, which may be single, repetitive or continuous. Several of these
potential initiating factors have been proposed, including infectious, genetic, anatomical, neuromuscular,
endocrine, immune (including autoimmune), or psychological mechanisms. These factors may then lead to
a peripheral self-perpetuating immunological, inflammatory state and/or neurogenic injury, creating acute
and then chronic pain. Based on the peripheral and the central nervous system, sensitisation involving
neuroplasticity may lead to a centralised neuropathic pain state [153]. This could also explain why tissue
damage is not usually found in PPS. There is growing evidence for a neuropathic origin and association with
CNS changes of pain in PPS and anxiety appears to be a risk factor for its development [45].
3.2.5.2 Bladder Pain syndrome

An initial unidentified insult to the bladder, leading to urothelial damage, neurogenic inflammation and pain
is thought to be the cause of BPS. However, BPS might be a local manifestation of a systemic disorder. No
infection has as yet been implicated. Nevertheless, urinary infection is significantly more frequent during
childhood and adolescence, in patients with BPS in adulthood [154]. Experimental induction of CPP by
O-antigen deficient bacterial strains reinstates the bacterial hypothesis [155]. Pancystitis, with associated
perineural inflammatory infiltrates, and mast cell count increase is an essential part of BPS type 3 C [156],
but is scant in non-lesion BPS [30, 78, 157, 158]. Cystoscopic and biopsy findings in both lesion and non-
lesion BPS are consistent with defects in the urothelial glycosaminoglycan (GAG) layer, which might expose
submucosal structures to noxious urine components [159-166] and a consequent cytotoxic effect [167,
168]. Basic and clinical studies indicate that autonomic dysfunction with sympathetic predominance may be
implicated in BPS [169, 170].
An association has been reported between BPS and non-bladder syndromes such as FM, CFS, IBS,
vulvodynia, depression, panic disorders, migraine, sicca syndrome, temporomandibular joint disorder, allergy,
asthma and systemic lupus erythematosus [171-177].
Risk of BPS correlates with a number of non-bladder syndromes in each patient [178]. Recent work showing
non-lesion BPS to have significantly more FM, migraine, temporomandibular joint disorder and depression than
BPS type 3 C patients, emphasises the need for subtyping [179].
3.2.5.3 Scrotal Pain Syndrome

Often scrotal pain is not associated with any specific pathology. Pain is perceived in the testes, epididymis,
or the vas deferens. The ilioinguinal, genitofemoral and the pudendal nerves innervate the scrotum [180]. Any

pathology or intervention at the origin or along the course of the nerves may result in pain perceived in the
scrotum [181].
Two special forms of scrotal pain syndrome can be described. The first one is the post-vasectomy scrotal pain
syndrome which occurs following vasectomy. The mechanisms are poorly understood and it is for that reason
considered a special form of scrotal pain syndrome. Incidence of post-vasectomy pain is 2-20% among all
men who have undergone a vasectomy [182]. In men with post-vasectomy pain, 2-6% have a Visual Analogue
Scale (VAS) score > 5 [183]. In a large cohort study of 625 men, the likelihood of scrotal pain after six months
was 14.7%. The mean pain severity on a VAS score was 3.4/10. In the pain group, 0.9% had quite severe pain,
noticeably affecting their daily life. In this cohort, different techniques were used to perform the vasectomy. The
risk of post-vasectomy pain was significantly lower in the no-scalpel vasectomy group (11.7% vs. the scalpel
group 18.8%) [184].
The second special form of scrotal pain is post-inguinal hernia repair pain. It is seen as a complication of hernia
repair, but in trials it is seldom reported or it is put under the term chronic pain (not specified). In studies that
have explicitly mentioned scrotal pain, there was a difference in incidence between laparoscopic and open
hernia repair. In almost all studies, the frequency of scrotal pain was significantly higher in the laparoscopic
than in the open group [181, 185]. In one particular study, there was no difference at one year but after five
years, the open group had far fewer patients with scrotal pain [186].
3.2.5.4 Urethral Pain Syndrome

Some mechanisms for the development of urethral pain syndrome have been proposed. The intimate relation
of the urethra with the bladder (both covered with urothelium) suggests that urethral pain syndrome may be
a form of BPS. Mechanisms thought to be basic for BPS may also apply to the urethra. This means that the
specific testing with potassium has been used to support the theory of epithelial leakage [187, 188]. Another
possible mechanism is neuropathic hypersensitivity following urinary tract infection [189]. The relationship with
gynaecological and obstetric aspects is unclear. In a small group of patients with urethral pain, it has been
found that grand multi-parity and delivery without episiotomy were more often seen in patients with urethral
syndrome, using univariate analysis [190].
3.2.5.5 Vaginal and vulvar pain syndromes

Pain in the vagina or the female external genital organs is often due to infection or trauma, as a consequence
of childbirth or surgery. Pain is usually a precedent to dyspareunia. When the pain persists for more than six
months, it can be diagnosed as vulvar pain syndrome previously known as “vulvodynia” or “chronic vaginal
pain” with no known cause. It is still a poorly understood condition, and thus difficult to treat.
There are two main sub-types of vulvar pain syndrome: generalised, where the pain occurs in different areas of
the vulva at different times; and focal, where the pain is at the entrance of the vagina. In generalised vulvar pain
syndrome, the pain may be constant or occur occasionally, but touch or pressure does not initiate it, although
it may make the pain worse. In focal vulvar pain syndrome, the pain is described as a burning sensation that
comes on only after touch or pressure, such as during intercourse.
The possible causes of vulvar pain syndrome are many and include:
• history of sexual abuse;
• history of chronic antibiotic use;
• hypersensitivity to yeast infections, allergies to chemicals or other substances;
• abnormal inflammatory response (genetic and non-genetic) to infection and trauma;
• nerve or muscle injury or irritation;
• hormonal changes.
3.2.5.6 Associated conditions in pelvic pain syndromes

Nerve damage
Spinal pathology and any pathology along the course of the nerve involved may result in neuropathic pain in
the distribution of these nerves. Neoplastic disease, infection and trauma, surgical incisions and post-operative
scarring may result in nerve injury [191].
Pudendal neuralgia is the most often mentioned form of nerve damage in the literature. Anatomical variations
may pre-dispose the patient to developing pudendal neuralgia over time or with repeated low-grade trauma
(such as sitting for prolonged periods of time or cycling) [192, 193].

The pudendal nerve may be damaged at the level of:
1. The piriformis muscle. For example, as part of a piriformis syndrome: in some cases, the nerve may pass
through the muscle and hence be trapped; or in other cases, muscle hypertrophy or spasm is implicated.
2. The sacrospinal/sacrotuberous ligaments, possibly accounting for 42% of cases.
3. Within Alcock’s canal (medial to the obturator internus muscle, within the fascia of the muscle), possibly
accounting for 26% of cases.
4. Multiple levels in 17% of cases.
The site of injury determines the site of perceived pain and the nature of associated symptoms (e.g., the more
distal the damage, the less likely the anal region will be involved).
The clinical presentation depends on different factors. There is a wide age range, as one would expect with
a condition that has so many potential causes. There is a suggestion that, the younger the patient, the better
the prognosis. Essentially, the sooner the diagnosis is made, as with any compression nerve injury, the better
the prognosis, and older patients may have a more protracted problem [194-196]. Six out of ten cases are
observed in women. Some special situations can be listed:
• In orthopaedic hip surgery, pressure from the positioning of the patient, where the perineum is placed
hard against the brace, can result in pudendal nerve damage [197, 198]. The surgery itself may also
directly damage the nerve. Pelvic surgery such as sacrospinous colpopexy is clearly associated with
pudendal nerve damage in some cases [199, 200]. In many types of surgery, including colorectal,
urological and gynaecological, pudendal nerve injury may be implicated.
• Fractures of the sacrum or pelvis may result in pudendal nerve/root damage and pain. Falls and trauma to
the gluteal region may also produce pudendal nerve damage if associated with significant tissue injury or
prolonged pressure.
• Tumours in the pre-sacral space must be considered. Tumours invading the pudendal nerve may occur
and there may also be damage from surgery for pelvic cancer [201].
• The pudendal neuralgia of birth trauma is thought to resolve in most cases over a period of months.
However, rarely, it appears to continue as painful neuropathy. Multiple pregnancies and births may pre-
dispose to stretch neuropathy in later life. This is more difficult to be certain about [202].
• Child birth and repeated abdominal straining associated with chronic constipation [203] are thought to
pre-dispose elderly women to post-menopausal pelvic floor descent and stretching of the pudendal
nerve with associated pain. Changes in the hormone status may also be a factor. In the Urogenital Pain
Management Centre, the commonest associations with pudendal neuralgia appear to be: history of
pelvic surgery; prolonged sitting (especially young men working with computer technology); and post-
menopausal older women.
Sexual dysfunction
Chronic pelvic pain is a clinical condition that results from the complex interactions of physiological and
psychological factors and has a direct impact on the social, marital and professional lives of men and women.
Men
Chronic pain and its treatment can impair our ability to express sexuality. In a study in England, 73% of
patients with chronic pain had some degree of sexual problems as result of the pain [145]. These problems
can occur because of several factors. Psychological factors like decrease in self-esteem, depression and
anxiety can contribute to loss of libido. Physiological factors like fatigue, nausea and pain itself can cause
sexual dysfunction. Pain medications (opioids, and the selective serotonin re-uptake inhibitors [SSRIs]) can also
decrease libido [204] and delay ejaculation. The number of studies on the effects of CPP on sexual function is
limited. Sexual dysfunction is often ignored because of a lack of standardised measurements. At present, the
most commonly used tool is the IIEF questionnaire [136].
The presence of pelvic pain may increase the risk for ED independent of age [205-207]. On the other hand,
cross-sectional data suggest no improvement of lower urinary tract symptoms (LUTS) by an increased
frequency of ejaculation [127]. Although mental distress and impaired QoL related to illness could contribute
to sexual dysfunction observed in patients with PPS, the presence of erectile and ejaculatory disorders is more
frequently related to symptoms suggestive of a more severe inflammatory condition [138]. These arguments are
important for the understanding of the close relationship between CPP symptoms, disturbed sexuality, impact
on QoL, and psychological implications including depression and more failure anticipation thoughts [126-129,
208, 209]. Sexual dysfunction heightens anger, frustration and depression, all of which place a strain on the
patients’ relationships. The female partners of men with sexual dysfunction and depression often present with
similar symptoms including pain upon intercourse and depressive symptoms. Men with CPP have reported a
high frequency of sexual relationship dissolution and psychological symptoms, such as depression and suicidal
thinking [126, 207]. Prostate Pain Syndrome patients reported greater sexual and relationship problems [126,

207, 210]. On the other hand, it was found that men with PPS did not report significantly decreased sexual
satisfaction compared to controls [211]. There is consensus that therapeutic strategies reducing symptoms of
pelvic pain are of relevance in relation to changes in sexual function. Also intimacy and having sex can yield
positive experiences that will reduce the pain. The CNS plays an important role in this mechanism.
Women
Chronic pelvic pain leads to substantial impairment in QoL and several sexual dysfunctions [140, 212-214]. It
seems reasonable to expect that pain, extreme fatigue, depressive mood and pain drugs will affect women’s
sexuality. Women with CPP reported significantly more pain, depression, and anxiety symptoms and were
physically more impaired than women in the control group. In comparison with controls, women with CPP
reported significantly more sexual avoidance behaviour, non-sensuality, and complaints of “vaginismus” [215].
In one study of CPP patients’ feelings and beliefs about their pain or illness, 40 out of 64 participants cited
sexual dysfunction as one of the main problems the illness had caused, making it the most frequent complaint
[216]. Patients with CPP reported more sexual problems than women with any other type of chronic pain
problem [217]. The quality of intimate relationships is closely connected with sexual function [218]. Satisfaction
with sexual relationships appears to be associated with higher marital functioning [219]. In addition sexual
dissatisfaction is related to sexual dysfunction. When one partner suffers from chronic pain, the ability of both
partners to cope with the pain and the extent to which partners are supportive of the chronic pain sufferer have
been found to be a predictor of sexual functioning [219].
Approximately two-thirds of patients in another study reported reduced frequency in their sexual relations as a
result of CPP [220]. One study demonstrated that CPP patients reported worse sexual function with regard to
desire, arousal, lubrication, orgasm, satisfaction, and more frequent and severe pain with vaginal penetration
than women without CPP [221]. In an interview with 50 chronic pain sufferers and their spouses, 78% of the
pain sufferers and 84% of partners described deterioration, including cessation of their sex life [206]. In a study
in patients with back pain, half reported decreased frequency of sex since the onset of chronic pain [145]. The
Female Sexual Function Index (FSFI) has been developed as a brief, multi-dimensional self-report instrument
for assessing the key dimensions of sexual function in women, which includes desire, subjective arousal,
lubrication, orgasm, satisfaction, and pain. Using the FSFI, women with CPP reported worse sexual function in
all subscales and total score than women without CPP. The largest differences between women with CPP and
without CPP were seen for the domains of pain and arousal. The total score and the subscales of the FSFI had
high levels of internal consistency and test-retest reliability when assessed in a sample of women with CPP.
The FSFI also showed good ability to discriminate between women with and without CPP [221].
Myofascial pain
Chronic pelvic pain can simply be a form of myalgia, due to the muscles being used in an abnormal way, in
this case, the pelvic floor muscles. Studies in the field of chronic prostatitis support the idea that patients with
CPP have more muscle spasm and increased muscle tone and report pain when the pelvic floor muscles are
palpated [222]. Muscle relaxation can diminish spasm and pain [223]. Repeated or chronic muscular overload
can activate trigger points in the muscle. A report from the Chronic Prostatitis Cohort Study showed that 51%
of patients with prostatitis and only 7% of controls had any muscle tenderness. Tenderness in the pelvic floor
muscles was only found in the CPP group [150].
In 1999, the first ideas about the neurological aspects of the pelvic floor muscles in relation to CPP were
published. The probability of CNS breakdown in the regulation of pelvic floor function was suggested as a
mechanism for development of CPP. Of the patients presenting with pelvic pain, 88% had poor to absent pelvic
floor function [149]. Basic studies on the role of neurogenic inflammation have also elucidated some important
phenomena. Irritation of the prostate, bladder and pelvic floor muscles results in expression of C-fos-positive
cells in the CNS. There appears to be convergence of afferent information onto central pathways. Once the
central changes have become established, they become independent of the peripheral input that initiated them
[224].
Repeated or chronic muscular overload can activate trigger points in the muscle. Trigger points are defined as
hyper-irritable spots within a taut band. Other criteria for trigger points are: recognition of the pain as ‘familiar’,
and pain on stretching the muscle. Apart from pain, trigger points prevent full lengthening of the muscle,
thereby restricting the range of movement. Pain as a result of these trigger points is aggravated by specific
movements and alleviated by certain positions. Positions and movements in which the shortened muscle is
stretched are painful. Patients know which activities and postures influence pain. Trigger points can be located
within the pelvic floor muscles and in adjacent muscles such as the abdominal, gluteal and iliopsoas muscles.
Pain is aggravated by pressure on the trigger point (e.g., pain related to sexual intercourse). Pain also worsens
after sustained or repeated contractions (e.g., pain related to voiding or defecation).

3.3 Abdominal aspects of pelvic pain
3.3.1 Incidence
Epidemiological data on IBS and CPP are scarce [225]. Chronic Pelvic Pain has been shown to be one of
the most common functional disorders in women of reproductive age. The monthly incidence rate of CPP
published by Zondervan was 1.58/1000 [226].
3.3.2 Prevalence
Using a vague definition of continuous or episodic pain situated below the umbilicus over six months, one
study reported that CPP was one of the most common diagnosis in primary care units in Great Britain [226].
The monthly prevalence rate of CPP in this study was 21.5/1,000, with an annual prevalence of 38.3/1,000.
The prevalence rates increase significantly with older age and vary significantly between regions in the UK.
The overall prevalence of anorectal pain in a sample of USA householders was 6.6% and was more common
in women [227]. Irritable Bowel Syndrome is associated with common gynaecologic problems (endometriosis,
dyspareunia, and dysmenorrhoea) [228]. Fifty per cent of women who presented with abdominal pain to
the gynaecologic clinic or were scheduled for laparoscopy due to CPP had symptoms of IBS [229]. In a
survey from Olmsted county 20% of women reported CPP and 40% of those met criteria for IBS [20]. This
overlap of CPP and IBS was associated with an increased incidence of somatisation. Not gynaecological
surgical procedures but only psychosocial variables predict pain development without a different incidence
of IBS in a prospective and controlled study [230]. Clinical features of pelvic floor dysfunction, gynaecological
and psychological features are related to disordered anorectal function in IBS patients but do not predict
physiological anorectal testing.
3.3.3 Influence on QOL

There is little known on health related quality of life (HRQoL) in patients with CPP. There is a need to develop
validated disease specific HRQoL instruments for CPP in addition to sound measurement properties. More
data are available in patients with IBS treated at referral centres who have comparable HRQoL scores as
patients with other common disorders such as diabetes, end-stage renal disease, and inflammatory bowel
disease [231]. Sub-groups of IBS with predominance of diarrhoea or constipation show no difference in
HRQoL. Multi-variate analysis shows that HRQoL in patients with IBS is affected by sex and psychological
conditions.
3.3.4 Costs
Costs combine direct health-care costs and societal costs (productivity loss) such as under-performance
and absenteeism from work. The annual costs to society can be calculated by using the average population
earnings. In Germany direct care costs are estimated at €791 and societal costs €995 per patient with IBS per
year which may be comparable to patients with CPP [232].
3.3.5 Risk factors & underlying causes

Risk factors are covered in Section 3.1.5.
3.4 Summary of evidence and recommendations: CPP and mechanisms
Summary of evidence LE
CPP mechanisms are well defined and involve mechanisms of neuroplasticity and neuropathic pain. 2
The mechanisms of neuroplasticity and neuropathic pain result in increased perception of afferent 1
stimuli which may produce abnormal sensations as well as pain.
End-organ function can also be altered by the mechanisms of neuroplasticity so that symptoms of 1
function can also occur.
The diagnosis of a CPPS as a pain syndrome is essential as it encourages a holistic approach to 2
management with multi-specialty and multi-disciplinary care.

Recommendations Strength rating
All of those involved in the management of Chronic Pelvic Pain (CPP) should have Strong
knowledge of peripheral and central pain mechanisms.
The early assessment of patients with CPP should involve investigations aimed at specific Strong
disease-associated pelvic pain.
The early assessment of patients with CPP should involve assessment of functional, Strong
emotional, behavioural, sexual and other quality of life issues, such as effect on work and
socialisation.
Manage CPPS patients in a multi-specialty and multi-disciplinary environment with Strong
consideration of all their symptoms.
4. DIAGNOSTIC EVALUATION
4.1 General Evaluation
4.1.1 History
History is very important for the evaluation of patients with CPP. Pain syndromes are symptomatic diagnoses,
which are derived from a history of pain perceived in the region of the pelvis, and absence of other pathology,
for a minimum of three out of the past six months. This implies that specific disease-associated pelvic pain
caused by bacterial infection, cancer, drug-induced pathology (e.g. ketamine use) [233], primary anatomical or
functional disease of the pelvic organs, and neurogenic disease must be ruled out.
4.1.1.1 Anxiety, depression, and overall function

Distress is best understood in the context of pain and of the meaning of pain to the individual and is
best assessed ideographically rather than normatively. Almost all diagnostic measures and standardised
instruments of anxiety and depression are designed for people without significant physical problems, so are
hard to interpret in CPP [234-236].
Anxiety about pain often refers to fears of missed pathology (particularly cancer) as the cause of pain [33], or to
uncertainties about treatment and prognosis. These can drive healthcare seeking behaviour [24]. The question:
“What do you believe or fear is the cause of your pain?” has been suggested [237]. Anxiety may also concern
urinary urgency and frequency as a possible problem in social settings.
Depression or depressed mood are common in chronic pain [238] e.g, often related to losses consequent
to chronic pain (work, leisure activities, social relationships, etc.). Due to the lack of suitable assessment
instruments, it is better to ask a simple question such as “How does the pain affect you emotionally?” If the
answer gives cause for concern about the patient’s emotional state, further assessment should be undertaken
by an appropriately qualified colleague.
Most measures of restricted function are designed primarily for musculoskeletal pain and may emphasise
mobility problems rather than the difficulties of the individual with pelvic or urogenital pain. A promising
specific measure, UPOINT, was introduced and in a later version the sexological aspects were added [239].
However, it may underassess relevant psychological variables [43]. Generic QoL measures are helpful. If such
an instrument is not already used in the clinic, the Brief Pain Inventory [240] provides a broad and economical
assessment of interference of pain with various aspects of life in multiple languages. (For further suggested
instruments see [241]). In a study, more pain, pain-contingent rest, and urinary symptoms were associated with
poorer function [62].
4.1.1.2 Urological aspects

Pain may be associated with urological symptoms. A detailed history of lower urinary tract functions should
be taken. Dysfunctions of the lower urinary tract may exacerbate symptoms, as pain may interfere with the
function of the lower urinary tract. Micturition in all its aspects should be addressed. Special attention should
be paid to the influence of micturition on the experience of pain.
Prostate pain syndrome

Prostate pain syndrome is diagnosed from a history of pain perceived in the region of the prostate (convincingly
reproduced by prostate palpation), and absence of other lower urinary tract pathology, for a minimum of three
out of the past six months. As mentioned above, specific disease-associated pelvic pain must be ruled out.

A thorough history is an important first step in the evaluation of PPS. It should include type of pain and
localisation. Pain is often reported in other pelvic areas outside the prostate such as perineum, rectum,
penis, testicles and abdomen [54]. In addition, associated lower urinary tract symptoms, sexual function,
psychological, social and economic factors should be addressed. Determination of the severity of disease,
its progression and treatment response can be assessed only by means of a validated symptom-scoring
instrument (see section 4.2.3). These subjective outcome measures are recommended for the basic evaluation
and therapeutic monitoring of patients in urological practice.
Bladder pain syndrome

Bladder pain syndrome should be diagnosed on the basis of pain, pressure or discomfort associated
with the urinary bladder, accompanied by at least one other symptom, such as daytime and/or night-time
increased urinary frequency, the exclusion of confusable diseases as the cause of symptoms, and if indicated,
cystoscopy with hydrodistension and biopsy (Table 4) [11].
The nature of pain is key to disease definition:

1. pain, pressure or discomfort perceived to be related to the bladder, increasing with increasing bladder
content;
2. located suprapubically, sometimes radiating to the groins, vagina, rectum or sacrum;
3. relieved by voiding but soon returns [242-246];
4. aggravated by food or drink [246].
Bladder pain syndrome type 3 can lead to a small capacity fibrotic bladder with or without upper urinary tract
outflow obstruction.
4.1.1.3 Gynaecological aspects

A detailed medical history outlining the nature, frequency and site of pain; its relationship to precipitating
factors and the menstrual cycle, may help define the aetiology. A menstrual and sexual history, including a
history of sexually transmitted diseases, vaginal discharge, as well as previous sexual trauma is mandatory as
well as up to date cervical cancer screening.
4.1.1.4 Gastrointestinal aspects

The predominant symptoms that patients are interviewed about are discomfort or pain in relation to their
bowel habits, daily activities, and eating. A precise history of dysfunctional voiding or defecation should be
asked, ideally applying symptom questionnaires for urinary and anorectal symptoms (e.g., Rome III criteria
for anorectal pain). Excessive straining at most defecations, anal digitations in dyssynergic defecation, and a
sensation of anal blockage may be found in patients with chronic anal pain. History of anxiety and depression
with impaired QoL is often encountered in anorectal functional disorders and should be evaluated.
Diagnostic criteria for chronic anal pain syndrome (chronic proctalgia) according to the Rome III criteria are as
follows and must include all of the following: chronic or recurrent rectal pain or aching, episodes last at least 20
minutes and exclusion of other causes of rectal pain such as ischaemia, inflammatory bowel disease, cryptitis,
intramuscular abscess and fissure, haemorrhoids, prostatitis, and coccygodynia. These criteria should be
fulfilled for the past three months with symptom onset at least six months before diagnosis [247].
The chronic anal pain syndrome includes the above diagnostic criteria and exhibits exquisite tenderness during
posterior traction on the puborectalis muscle (previously called “Levator Ani Syndrome”). Pathophysiology of
pain is thought to be due to over-activity of the pelvic floor muscles.
Intermittent chronic anal pain syndrome (proctalgia fugax) consists of all the following diagnostic criteria, which
should be fulfilled for three months: recurrent episodes of pain localised to the anus or lower rectum, episodes
last from several seconds to minutes and there is no anorectal pain between episodes. Stressful life events
or anxiety may precede the onset of the intermittent chronic anal pain syndrome. The attacks may last from
a few seconds to as long as 30 minutes. The pain may be cramping, aching or stabbing and may become
unbearable. However, most patients do not report it to their physicians and pain attacks occur less than five
times a year in 51% of patients.
4.1.1.5 Peripheral nerve aspects

A proportion of patients will be able to relate the onset of pain to an acute event such as surgery, sepsis or
trauma, and occasionally, cycling for a prolonged period. Chronic injury is more frequent, such as associated
with sitting for prolonged periods over time. Many will be idiopathic.

The pain is classically perceived in the perineum from anus to clitoris/penis. However, less-specific pain
distribution may occur, and this may be due to anatomical variation, involvement of branches of the nerve
rather that the main nerve, CNS central sensitisation, and consequently, the involvement of other organs
and systems in a regional pain syndrome. Other nerves in the vicinity may also be involved, for example,
inferior cluneal nerve and perineal branches of the posterior femoral cutaneous nerve. The musculoskeletal
system may become involved, confusing the pain picture as aches and pain developing in the muscles due to
immobility and disability, possibly magnified by the CNS changes.
Burning is the most predominant adjective used to describe the pain. Crushing and electric may also be used,
indicating the two components - a constant pain often associated with acute sharp episodes. Many patients
may have the feeling of a swelling or foreign body in the rectum or perineum, often described as a golf or
tennis ball. The term pain has different meanings to patients and some would rather use the term discomfort or
numbness.
Aggravating factors include any cause of pressure being applied, either directly to the nerve or indirectly to
other tissue, resulting in pudendal traction. Allodynia is pain on light touch due to involvement of the CNS, and
may make sexual contact and the wearing of clothes difficult. These patients often remain standing, and as a
consequence, develop a wide range of other aches and pains. Soft seats are often less well-tolerated, whereas
sitting on a toilet seat is said to be much better tolerated. If unilateral, sitting on one buttock is common. The
pain may be exacerbated by bowel or bladder evacuation.
Pudendal nerve damage may be associated with a range of sensory phenomena. In the distribution of the
nerve itself, as well as unprovoked pain; the patient may have paraesthesia (pins and needles); dysaesthesia
(unpleasant sensory perceptions usually but not necessarily secondary to provocation, such as the sensation
of running cold water); allodynia (pain on light touch); or hyperalgesia (increased pain perception following a
painful stimulus, including hot and cold stimuli). Similar sensory abnormalities may be found outside of the area
innervated by the damaged nerve, particularly for visceral and muscle hyperalgesia.
The cutaneous sensory dysfunction may be associated with superficial dyspareunia, but also irritation and
pain associated with clothes brushing the skin. There may also be a lack of sensation and pain may occur in
the presence of numbness. Visceral hypersensitivity may result in an urge to defecate or urinate. This is usually
associated with voiding frequency, with small amounts of urine being passed. Pain on visceral filling may occur.
Anal pain and loss of motor control may result in poor bowel activity, with constipation and/or incontinence.
Ejaculation and orgasm may also be painful or reduced.
Many of those suffering from pudendal neuralgia complain of fatigue and generalised muscle cramps,
weakness and pain. Being unable to sit is a major disability, and over time, patients struggle to stand and they
often become bedbound. The immobility produces generalised muscle wasting, and minimal activity hurts. As
a consequence of the widespread pain and disability, patients often have emotional problems, and in particular,
depression. Patients with CPP are also often anxious and have the tendency to catastrophise. Depression,
catastrophising and disability are all poor prognostic markers. Cutaneous colour may change due to changes in
innervation but also because of neurogenic oedema. The patient may describe the area as swollen due to this
oedema, but also due to the lack of afferent perception.
4.1.1.6 Myofascial aspects

When taking a history from a patient with pelvic pain, it is important to address the function of all the organs
in the pelvic area. The following items certainly should be addressed: lower urinary tract function, anorectal
function, sexual function, gynaecological items, presence of pain and psychosocial aspects. One cannot state
that there is a pelvic floor dysfunction based only on the history. But there is a suspicion of pelvic floor muscle
dysfunction when two or more pelvic organs show dysfunction, for instance a combination of micturition and
defecation problems.
4.1.2 Physical Evaluation

The clinical examination often serves to confirm or refute the initial impressions gained from a good history.
The examination should be aimed at specific questions where the outcome of the examination may change
management. Prior to an examination, best practice requires the medical practitioner to explain what will
happen and what the aims of the examination are to the patient. Consent to the examination should occur
during that discussion and should cover an explanation around the aim to maintain modesty as appropriate
and, if necessary, why there is a need for rectal and/or vaginal examination. Finally, the risk of exacerbating
the pain should form a part of that request. A record of the discussion should be noted. The possibility of

the presence of a chaperone should be discussed with the patient. As well as a local examination, a general
musculoskeletal and neurological examination should be considered an integral part of the assessment and
undertaken if appropriate. Following the examination, it is good practice to ask the patient if they had any
concerns relating to the conduct of the examination and that discussion should be noted.
There is no specific diagnostic test for CPPS, therefore, procedures are on the one hand directed towards
identification and exclusion of specific diseases associated with pelvic pain, and on the other hand may be
used for phenotypic description. Abdominal and pelvic examination to exclude gross pelvic pathology, as well
as to demonstrate the site of tenderness is essential. Abnormalities in muscle function should also be sought.
Examination of the external genitalia is a part of the evaluation. In patients with scrotal pain, gentle palpation
of each component of the scrotum is performed to search for masses and painful spots. The penis and urethra
may be palpated in a similar way. Many authors recommend that one should assess cutaneous allodynia
along the dermatomes of the abdomen (T11-L1) and the perineum (S3), and the degree of tenderness should
be recorded. The bulbocavernosus reflex in the male may also provide useful information concerning the
intactness of the pudendal nerves. Clinical pelvic examination should be a single digit examination if possible.
The usual bi-manual examination can generate severe pain so the examiner must proceed with caution. A
rectal examination is done to look for prostate abnormalities in male patients including pain on palpation and to
examine the rectum and the pelvic floor muscles regarding muscle tenderness and trigger points.
At clinical examination, perianal dermatitis may be found as a sign of faecal incontinence or diarrhoea. Fissures
may be easily overlooked and should be searched for thoroughly in patients with anal pain. Rectal digital
examination findings may show high or low anal sphincter resting pressure, a tender puborectalis muscle in
patients with the Levator Ani Syndrome, and occasionally increased perineal descent. The tenderness during
posterior traction on the puborectalis muscle differentiates between Levator Ani Syndrome and unspecified.
Functional Anorectal Pain is used in most studies as the main inclusion criterion. Dyssynergic (paradoxical)
contraction of the pelvic muscles when instructed to strain during defecation is a frequent finding in patients
with pelvic pain. Attention should be paid to anal or rectal prolapse at straining, and ideally during combined
rectal and vaginal examination to diagnose pelvic organ prolapse.
A full clinical examination of the spinal, muscular, nervous and urogenital systems is necessary to aid in
diagnosis of pudendal neuralgia, especially to detect signs indicating another pathology. Often, there is little
to find in pudendal neuralgia and frequently findings are non-specific. The main pathognomonic features are
the signs of nerve injury in the appropriate neurological distribution, for example, allodynia or numbness.
Tenderness in response to pressure over the pudendal nerve may aid the clinical diagnosis. This may be
elicited by per rectal or per vaginal examination and palpation in the region of the ischial spine and/or Alcock’s
canal. Muscle tenderness and the presence of trigger points in the muscles may confuse the picture. Trigger
points may be present in a range of muscles, both within the pelvis (levator ani and obturator internus muscles)
or externally (e.g., the piriformis, adductors, rectus abdominus or paraspinal muscles).
4.2 Supplemental evaluation

If history is suggestive of lower urinary tract, gynaecological, anorectal or other known aetiology disease,
diagnostic workup should follow respective guidelines.
4.2.1 Assessing pain and related symptoms

Determination of the severity of disease, its progression and treatment response can be assessed only by
means of a reliable symptom-scoring instrument. These subjective outcome measures are recommended for
the basic evaluation and therapeutic monitoring of patients. Pain should always be assessed (see below) to
identify progression and treatment response. As well as doing this in the clinic, the patient can keep a daily
record (pain diary). This may need to include other relevant variables such as voiding, sexual activity, activity
levels, or analgesic use.
Increased attention to patient reported outcomes gives prominence to patients’ views on their disease and pain
diaries, in patients’ own environments, improve data quality.
Quality of life should also be measured because it can be very poor compared to other chronic diseases [248,
249]. In a study [62] more pain, pain-contingent rest, and urinary symptoms were associated with greater
disability (also measured by self-report), and pain was predicted by depression and by catastrophising
(helplessness subscale).

Where the primary outcome of treatment is pain relief, it is useful before starting treatment to agree a clinically
useful level of relief [250]. The most reliable methods are:
• a five point verbal scale: none, mild, moderate, severe, very severe pain;
• a VAS score from one to ten;
• an eleven point numerical scale.
An 11 point numerical scale
Pain assessment ratings are not independent of cognitive and emotional variables [62]. Target outcomes of
pain severity, distress and disability co-vary only partly, and improvement in one does not necessarily imply
improvement in the others. When the primary outcome is pain its meaning should be anchored in discussion of
clinically important difference [250].

Reliable, valid indices of symptoms and QoL are the NIH-CPSI [251] and the International Prostate Symptom
Score (I-PSS) [252].

Symptom scores may help to assess the patient and act as outcome measures. The O’Leary-Sant Symptom
Index, also known as the Interstitial Cystitis Symptom Index (ICSI) was validated in a large study [253].
Gastrointestinal questionnaire
The functional anorectal pain disorders (anorectal pelvic pain) are defined and characterised by duration,
frequency, and quality of pain. More complex questionnaires are used in the setting of IBS. The validated
IBS-Symptom Severity Scale (IBS-SSS) includes the broadest measurement of pain-related aspects [254, 255].
However, as different instruments measure different endpoints of chronic abdominal pain in IBS, a comparison
of published studies is often impossible.
Sexual function assessment

In males the most frequent effects on sexual function are ED and premature ejaculation. These can
be evaluated by proper questionnaires namely IIEF and PEDT (premature ejaculation diagnostic tool). In
comparison with controls, women with CPP reported significantly more sexual avoidance behaviour, non-
sensuality, and complaints of “vaginismus” [215]. The FSFI has been developed as a brief, multi-dimensional
self-report instrument for assessing the key dimensions of sexual function in women, which includes desire,
subjective arousal, lubrication, orgasm, satisfaction, and pain. The corresponding evidence in men is lacking.
4.2.2 Focused myofascial evaluation

Pelvic floor muscle testing can be done by the medical doctor but a consultation of the pelvic floor by a
physiotherapist is a good alternative. A vaginal or rectal examination is performed to assess the function of the
pelvic floor muscles, according to the International Continence Society (ICS) report. This assessment has been
tested and shows satisfactory face validity and intra-observer reliability. It can therefore be considered suitable
for use in clinical practice [256]. Rectal examination is a good way to test the pelvic floor function in men [257].
There is a growing number of reports on the use of ultrasound (US) in establishing the function of the pelvic
floor muscles. The exact place in the diagnostic setting needs to be addressed in the future [258]. In a cohort
study of 72 men with CPP, the relationship between the locations of the trigger point and the referred pain
was examined. Ninety percent of the patients showed tenderness in the puborectalis muscle and 55% in the
abdominal wall muscles. Of the patients in whom trigger points were found in the puborectalis, 93% reported
pain in the penis and 57% in the suprapubic region. Patients with trigger points in the abdominal muscles
reported pain in the penis (74%), perineum (65%) and rectum (46%) [259]. In addition, a broad musculoskeletal
tender point evaluation, including muscles outside the pelvis, helps to diagnose the myofascial pain aspects of
the pelvic pain [260].
4.2.3 Neurological
Injections
An injection of local anaesthetic and steroid at the site of nerve injury may be diagnostic. Differential block
of the pudendal nerve helps to provide information in relation to the site where the nerve may be trapped
[261-271]. Infiltration at the ischial spine requires the use of a nerve stimulator/locator. Both motor (anal

contraction) and sensory endpoints may be noted. The anatomical endpoint may be localised by fluoroscopy,
computed tomography (CT) guidance, or the use of US. Ultrasound avoids any form of radiation, whereas CT
guidance involves a significant amount of radiation. Currently, fluoroscopy is probably the imaging technique
most frequently used because it is readily available to most anaesthetists that perform the block. Currently,
infiltration of the pudendal nerve within Alcock’s canal is primarily undertaken with the use of CT. As well as
injecting around the pudendal nerve, specific blocks of other nerves arising from the pelvis may be performed.
Electrophysiological studies
These may reveal signs of perineal denervation, increased pudendal nerve latency, or impaired
bulbocavernosus reflex [272-276]. However, for an abnormality to be detected, significant nerve damage is
probably necessary. Pain may be associated with limited nerve damage, therefore, these investigations are
often normal.
4.2.4 Imaging
Ancillary studies should be performed according to appropriate guidelines for exclusion of diseases with known
aetiology presenting with symptoms identical to those of CPP. Once the latter diagnosis is established studies
can be useful to assess functional abnormalities and phenotype conditions such as BPS, and chronic anal pain
syndrome.
Ultrasound
Has limited value but may reassure patients. However, over-investigating may be detrimental.
MRI
Magnetic resonance neurography has been increasingly used in specialised centres for the diagnosis of the
location (proximal vs. peripheral) and degree (total vs. partial) of nerve injury in the peripheral nervous system,
earlier and with higher specificity than conduction studies.
MR defecating proctogram
Magnetic resonance imaging in conjunction with MR defecography has become the most valuable imaging
technique to assess anorectal function dynamically. MRI studies simultaneously outline the anatomy of the
pelvic floor and visualise different structural and functional pathologies, by applying dynamic sequences after
filling of the rectum with a viscous contrast medium (e.g., US gel). The following pathologies can be visualised:
pelvic floor descent, an abnormal anorectal angle while squeezing and straining, rectal intussusception,
rectocele, enterocele and cystocele. However, limitations of MR defecography are the left lateral position and
the limited space for the patient, which may reduce the ability to strain and thereby reduce the sensitivity of the
method, underestimating the size of entero- and rectoceles as well as the amount of intussusception.
Functional neuroimaging
Functional neuroimaging, functional magnetic resonance imaging (fMRI) is currently being re-evaluated as a
research tool and some groups have raised issues around over interpretation [277]. With regards to pain, fMRI
findings may represent a pain matrix or may represent non-specific threat processing [278]. Currently this panel
cannot recommend fMRI as a clinical tool.
4.2.5 Laboratory Tests
Microbiology tests
Laboratory diagnosis has been classically based on the four-glass test for bacterial localisation [279]. Besides
sterile pre-massage urine (voided bladder urine-2), PPS shows < 10,000 cfu/mL of uropathogenic bacteria
in expressed prostatic secretions and insignificant numbers of leukocytes or bacterial growth in ejaculates.
However, this test is too complex for use by practising urologists. Diagnostic efficiency may be enhanced cost-
effectively by a simple screening procedure, that is, the two-glass test or pre-post-massage test (PPMT) [280,
281]. Overall, these tests help only a little in the diagnosis of PPS, because 8% of patients with suggested PPS
have been found to have positive prostatic localisation cultures, similar to the percentage of asymptomatic men
[282].

Urine dipstick and urine culture (including culture for TB if sterile pyuria) are recommended in all patients
suspected of having BPS. Urine cytology is also recommended in risk groups.

Gynaecological aspects of chronic pelvic pain
Vaginal and endocervical swabs to exclude infection are recommended.
4.2.6 Invasive tests
Anorectal pain
Anorectal manometry with sensory testing (pressure volume measurement: barostat) may be useful to diagnose
dyssynergic defecation and hypersensitivity of the rectum which are typical for patients with CPP and IBS.
Flexible rectosigmoidoscopy or colonoscopy should be considered in patients with anorectal pain to rule out
coincidental colorectal pathology.
Laparoscopy for females

Laparoscopy is perhaps the most useful invasive investigation to exclude gynaecological pathology [283, 284]
and to assist in the differential diagnosis of CPP in women [285]. Often, it is combined with cystoscopy [286,
287] and/or proctoscopy to help identify the site of multi-compartment pain.
Psychological considerations around laparoscopy

Three very different studies of laparoscopy suggest that it can improve pain through resolving concerns about
serious disease [288], although showing women the photograph of their pelvic contents did not improve on
explanation alone [289]; and integrating somatic and psychological assessment from the start rather than
dealing with psychological concerns only after excluding organic causes of pelvic pain [290].
Cystoscopy and bladder biopsy

Despite controversy on the diagnostic and follow-up value of cystoscopy in BPS [291-295], the panel believes
that objective findings are important for diagnosis, prognosis and ruling out other treatable conditions (a
standardised scheme of diagnostic criteria will also contribute to uniformity and comparability of different
studies) [296]. Endoscopically, BPS type 3 displays reddened mucosal areas often associated with small
vessels radiating towards a central scar, sometimes covered by a small clot or fibrin deposit - the Hunner
lesion [245]. The scar ruptures with increasing bladder distension, producing a characteristic waterfall type of
bleeding. There is a strong association between BPS type 3 and reduced bladder capacity under anaesthesia
[297]. Non-lesion disease displays a normal bladder mucosa at initial cystoscopy. The development of
glomerulations after hydrodistension is considered to be a positive diagnostic sign although they can be
observed without BPS [298]. Biopsies are helpful in establishing or supporting the clinical diagnosis of both
classic and non-lesion types of the disease [160, 187, 296, 299, 300]. Important differential diagnoses to
exclude, by histological examination, are carcinoma in situ and tuberculous cystitis.
Table 4: E
SSIC classification of BPS types according to results of cystoscopy with hydrodistension and
biopsies [11]
Cystoscopy with hydrodistension

Not done Normal Glomerulationsa Hunner’s lesionb
Biopsy
Not done XX 1X 2X 3X
Normal XA 1A 2A 3A
Inconclusive XB 1B 2B 3B
Positivec XC 1C 2C 3C
aCystoscopy: glomerulations grade 2-3.
bLesion per Fall’s definition with/without glomerulations.
cHistology showing inflammatory infiltrates and/or detrusor mastocytosis and/or granulation tissue and/or
intrafascicular fibrosis.

4.3 Diagnostic algorithm
Figure 1: Diagnosing chronic pelvic pain
Chronic Pelvic Pain
Physical
History
examinaon
Specific disease
associated
yes with pelvic pain
Symptom of a well
known disease
no
Pelvic pain
syndrome
Organ specific
symptoms present
yes
Urology Gynaecology Gastro- Neurology Sexology Pelvic

enterology floor
Phenotype and proceed according to Chronic Pelvic Pain Guideline.

Figure 2: Phenotyping of pelvic pain - UPOINT classification
Phenotyping Assessment
Urology Urinary flow, micturion diary, cystoscopy, ultrasound, uroflowmetry.
Psychology Anxiety about pain, depression and loss of funcon, history of negave sexual experiences.
Ask for gynaecological, gastro-intesnal, ano-rectal, sexological complaints.

Organ specific
Gynaecological examinaon, rectal examinaon.
Infecon Semen culture and urine culture, vaginal swab, stool culture.
Ask for neurological complaints (sensory loss, dysaesthesia).

Neurological
Neurological tesng during physical examinaon: sensory problems, sacral reflexes and muscular funcon.
Tender muscle Palpaon of the pelvic floor muscles, the abdominal muscles and the gluteal muscles.
Sexological Erecle funcon, ejaculatory funcon, post-orgasmic pain.
4.4 Other painful conditions without a urological cause
Dysmenorrhoea
Menstrual pain or ‘dysmenorrhoea’ may be primary or secondary. Primary dysmenorrhoea classically begins
at the onset of ovulatory menstrual cycles and tends to decrease following childbirth [285]. Secondary
dysmenorrhoea suggests the development of a pathological process, such as endometriosis [284],
adenomyosis [301] or pelvic infection, which need to be excluded.
Infection
In pre-menopausal women, a history of pelvic inflammatory disease (PID) must be excluded. A patient’s sexual
history should be taken along with swabs to exclude chlamydia and gonorrhoea infection. Bacterial and viral
genital tract pathogens should also be excluded [302], as they can cause severe pelvic/vaginal/vulvar pain
[303] and are associated with ulcerating lesions and inflammation, which may lead to urinary retention [304].
If there is any doubt about the diagnosis, laparoscopy may be helpful, as one of the differential diagnoses is
endometriosis.
Endometriosis and adenomyosis

The incidence of endometriosis is rising in the developed world. It has widespread impact on women’s lives
[305], with pain more important than physical findings in determining QoL [306]. The precise aetiology is
unknown, but an association with infertility is recognised [307]. A diagnosis is usually made when a history of
secondary dysmenorrhoea and/or dyspareunia exists. On examination, there is often tenderness in the lateral
vaginal fornices, reduced uterine mobility, tenderness in the recto-vaginal septum, and on occasion, adnexal
masses. Laparoscopy is the most useful diagnostic tool [308-310]. Endometriotic lesions affecting the urinary
bladder or causing ureteric obstructions can occur, as well as lesions affecting the bowel, which may lead
to rectal bleeding in association with menstruation. Adenomyosis is associated with augmented pain during
menses. It is diagnosed by an US scan of the uterus, which often shows cystic dilatation of the myometrium
[311].
Gynaecological malignancy
The spread of gynaecological malignancy of the cervix, uterine body or ovary will cause pelvic pain depending
on the site of spread.
Injuries related to childbirth

Trauma occurring at the time of childbirth may lead to CPP related to the site of injury. Female sexual
dysfunction is perhaps the commonest presenting problem [312]. There is often a transient problem with
oestrogen deficiency in the post-partum period and during breastfeeding, which can compound this situation.
Denervation of the pelvic floor with re-innervation may also lead to dysfunction and pain.

Pain associated with pelvic organ prolapse and prolapse surgery
Pelvic organ prolapse is often asymptomatic, unless it is so marked that it causes back strain, vaginal pain
and skin excoriation [313]. Prolapse is often a disease of older women, and it is often associated with post-
menopausal oestrogen deficiency, which may lead to pain associated with intercourse. Prolapse surgery may
entail the use of non-absorbable mesh (usually in the form of “mesh kits”) [314-316]. Although they may have
a role in supporting the vagina, they are also associated with several complications including bladder, bowel
and vaginal trauma [315]. In a subset of these patients, chronic pain may ensue, because mesh insertion may
cause nerve and muscle irritation [312]. Patients should be fully evaluated clinically and may need specialised
imaging, using contrast mediums if necessary, to make a diagnosis.
Haemorrhoids
Chronic pelvic pain is rare in haemorrhoidal disease because endoscopic and surgical treatment is mostly
effective in acute disease. The most frequent aetiology of pain without significant bleeding is thrombosed
external haemorrhoids or an anal fissure. Haemorrhoidal pain on defecation associated with bleeding is usually
due to prolapse or ulceration of internal haemorrhoids. Anaemia from haemorrhoidal bleeding is rare but may
arise in patients on anti-coagulation therapy, or those with clotting disorders.
Anal fissure
Anal fissures are tears in the distal anal canal and induce pain during and after defecation. The pain can last
for several minutes to hours. Persistence of symptoms beyond six weeks or visible transversal anal sphincter
fibres define chronicity. Fissures located off the midline are often associated with specific diseases such as
Crohn’s disease or anal cancer. Internal anal sphincter spasms and ischaemia are associated with chronic
fissures.
Proctitis
Abdominal and pelvic pain in patients with inflammatory bowel disease and proctitis are often difficult to
interpret. Faecal calprotectin may help to differentiate between inflammation and functional pain, to spare
steroids.
Irritable bowel syndrome

Although IBS can be associated with pelvic pain, the panel consider a full discussion of this topic beyond the
scope of these guidelines. A number of high quality clinical guidelines address this topic [317, 318].
4.5 Summary of evidence and recommendations: diagnostic evaluation
4.5.1 Diagnostic evaluation of PPS
Prostate pain syndrome is associated with negative cognitive, behavioural, sexual, or emotional 2b
consequences, as well as with symptoms suggestive of lower urinary tract and sexual dysfunction.
Prostate pain syndrome has no known single aetiology. 3
Pain in PPS involves mechanisms of neuroplasticity and neuropathic pain. 2a
Prostate pain syndrome has a high impact on QoL. 2b
Depression and catastrophic thinking are associated with more pain and poorer adjustment. 3
The prevalence of PPS-like symptoms is high in population-based studies (> 2%). 2b
Reliable instruments assessing symptom severity as well as phenotypic differences exist. 2b

Adapt diagnostic procedures to the patient. Exclude specific diseases with similar Strong
symptoms.
Use a validated symptom and quality of life scoring instrument, such as the National Strong
Institutes of Health Chronic Prostatitis Symptom Index, for initial assessment and
follow-up.
Assess prostate pain syndrome associated negative cognitive, behavioural, sexual, Strong
or emotional consequences, as well as symptoms of lower urinary tract and sexual
dysfunctions.
4.5.2

4.5.3 Diagnostic evaluation of BPS
BPS has no known single aetiology. 3
Pain in BPS does not correlate with bladder cystoscopic or histologic findings. 2a
BPS Type 3 C can only be confirmed by cystoscopy and histology. 2a
Lesion/non-lesion disease ratios of BPS are highly variable between studies. 2a
The prevalence of BPS-like symptoms is high in population-based studies. 2a
BPS occurs at a level higher than chance with other pain syndromes. 2a
BPS has an adverse impact on QoL. 2a
Reliable instruments assessing symptom severity as well as phenotypical differences exist. 2a

Perform general anaesthetic rigid cystoscopy in patients with bladder pain to subtype and Strong
rule out confusable disease.
Diagnose patients with symptoms according to the EAU definition, after primary exclusion Strong
of specific diseases, with bladder pain syndrome (BPS) by subtype and phenotype.
Assess BPS associated non-bladder diseases systematically. Strong
Assess BPS associated negative cognitive, behavioural, sexual, or emotional Strong
consequences.
Use a validated symptom and quality of life scoring instrument for initial assessment and Strong
follow-up.
4.5.4 Diagnostic evaluation of scrotal pain syndrome
The nerves in the spermatic cord play an important role in scrotal pain. 2b
Ultrasound of the scrotal contents does not aid in diagnosis or treatment of scrotal pain. 2b
Post-vasectomy pain is seen in a substantial number of men undergoing vasectomy. 2b
Scrotal pain is more often noticed after laparoscopic than after open inguinal hernia repair. 1b
4.5.5 Diagnostic evaluation of urethral pain syndrome
Urethral pain syndrome may be a part of BPS. 2a
Urethral pain involves mechanisms of neuroplasticity and neuropathic pain. 2b
4.5.6 Diagnostic evaluation of gynaecological aspects chronic pelvic pain
Clinical history and examination are mandatory when making a diagnosis. 2a
Laparoscopy is well-tolerated and does not appear to have negative psychological effects. 1b

Take a full gynaecological history and evaluate to rule out a treatable cause Strong
(e.g. endometriosis) in all women with chronic pelvic pain.
Refer to a gynaecologist if clinical suspicion of a gynaecological cause for pain following Strong
complete urological evaluation. Laparoscopy should be undertaken in accordance with
gynaecological guidelines.
4.5.7 Diagnostic evaluation of anorectal pain syndrome
Tenderness on traction is the main criterion of the chronic anal pain syndrome. 1a

Recommendation Strength rating
Anorectal function tests are recommended in patients with anorectal pain. Strong
4.5.8 Diagnostic evaluation of pudendal neuralgia
Multiple sensory and functional disorders within the region of the pelvis/urogenital system may occur 2
as a result of injury to one or more of many nerves. The anatomy is complex.
There is no single aetiology for the nerve damage and the symptoms and signs may be few or 1
multiple.
Investigations are often normal. 2
The peripheral nerve pain syndromes are frequently associated with negative cognitive, behavioural, 1
sexual, or emotional consequences.

Rule out confusable diseases, such as neoplastic disease, infection, trauma and spinal Strong
pathology.
If a peripheral nerve pain syndrome is suspected, refer early to an expert in the field, Weak
working within a multi-disciplinary team environment.
Imaging and neurophysiology help diagnosis but image and nerve locator guided local Weak
anaesthetic injection is preferable.
4.5.9 Diagnostic evaluation of sexological aspects in CPP
Chronic pain can lead to decline in sexual activity and satisfaction and may reduce relationship 2a
satisfaction.
Patients who reported having sexual, physical or emotional abuse show a higher rate of reporting 2b
symptoms of PPS.
Sexual dysfunctions are prevalent in patients with PPS. 2b
In men with PPS the most prevalent sexual complaints are ED and ejaculatory 3
dysfunction.
In females with CPPS all sexual function domains are lower. The most reported dysfunctions are 2a
sexual avoidance, dyspareunia and “vaginismus”.
Vulvar pain syndrome is associated with BPS. 3
Women with BPS suffer significantly more from fear of pain, dyspareunia and decreased desire. 2a
Pelvic floor muscle function is involved in the excitement and orgasm phases of sexual response. 3
Chronic pain can cause disturbances in each of the sexual response cycle phases. 2b

Screen patients presenting with symptoms suggestive for chronic pelvic pain syndrome Weak
for abuse, without suggesting a causal relation with the pain.
4.5.10 Diagnostic evaluation of psychological aspects of CPP
There is no evidence that distress generates complaints of pelvic pain, or that multiple symptoms 2b
suggest unreality of pain.
Current or recent sexual abuse are possible contributory factors in pelvic pain. 2a

Assess patient psychological distress in relation to their pain. Strong
Ask patients what they think is the cause of their pain to allow the opportunity to inform Strong
and reassure.

4.5.11 Diagnostic evaluation of pelvic floor function
The ICS classification is suitable for clinical practice. 2a
Over-activity of the pelvic floor muscles is related to chronic pelvic pain, prostate, bladder and vulvar 2a
pain.
Over-activity of the pelvic floor muscles is an input to the CNS causing central sensitisation. 2b
There is no accepted standard for diagnosing myofascial trigger points. 2a
There is a relation between the location of trigger point and the region where the pain is perceived. 3

Use ICS classification on pelvic floor muscle function and dysfunction. Strong
In patients with chronic pelvic pain syndrome it is recommended to actively look for the Weak
presence of myofascial trigger points.
5. MANAGEMENT
The philosophy for the management of chronic pelvic pain is based on a bio-psychosocial model. This is a
holistic approach with the patients’ active involvement. Single interventions rarely work in isolation and need to
be considered within a broader personalised management strategy.
The management strategy may well have elements of self-management. Pharmacological and non-
pharmacological interventions should be considered with a clear understanding of the potential outcomes and
end points. These may well include: psychology, physiotherapy, drugs and more invasive interventions.
Treatment philosophy
Providing information that is personalised and responsive to the patient’s problems, conveying belief and
concern, is a powerful way to allay anxiety [319]. Additional written information or direction to reliable sources
of information is useful; practitioners tend to rely on locally produced material or pharmaceutical products of
variable quality while endorsing the need for independent materials for patients [320].
5.1 Conservative management
5.1.1 Pain education

It is always valuable to include education about the causes of pain, including eliciting from patients their
anxieties about undiscovered pathology and addressing them. Information improves adherence to treatment
and underpins self-management, as shown in many other painful and non-painful disorders but not specifically
in pelvic and abdominal pain except by a small qualitative study [321].
5.1.2 Physical therapy

The physiotherapist is part of the pain management team, together with the pain doctor and the psychologist.
The therapeutic options for physiotherapists may not be the same in every country. Physiotherapists can either
specifically treat the pathology of the pelvic floor muscles, or more generally treat myofascial pain if it is part of
the pelvic pain syndrome. In most studies that have been done looking at the effect of physiotherapy in pelvic
pain, the treatment of the pelvic floor is only part of the pain management. In a review about physiotherapy
in women with pelvic pain, it was concluded that recommendations for physiotherapy should be given with
caution [322]. The review found six RCTs, of which three showed level 1b evidence with low-risk of bias. One
of these three found that Mensendieck somatocognitive therapy showed a pain reduction after one year follow-
up of 64%. This approach consists of myofascial relaxation and tension, improving posture and movement in
combination with cognitive behaviour therapy (CBT) [323].
Pelvic floor muscle pain

Treating pelvic floor over-activity and myofascial trigger points should be considered in the management of
CPP. Treatment should be done by specialised physiotherapists who are trained not only in the musculoskeletal
aspects of pain, but also in the psychological mechanisms and the role of the CNS in chronic pain.

For patients with CPP and dysfunction of the pelvic floor muscles, it is very helpful to learn how to relax the
muscles when the pain starts. By doing this, the circle of pain-spasm-pain can be interrupted. In the case of
shortened muscles, relaxation alone is not enough. Stretching of the muscle is mandatory to regain length and
function. Studies on physical therapy for pelvic floor pain syndrome have been sparse. A single blinded RCT
with myofascial physical therapy and general massage was carried out in patients with prostate or bladder
pain. The global response rate to treatment with massage was significantly better in the prostate than in
the bladder pain group (57% vs. 21%). In the prostate pain group, there was no difference between the two
treatment arms. In the bladder pain group, myofascial treatment did significantly better than the massage.
Massage only improved complaints in the prostate pain group. The fact that the prostate pain group consisted
of only men is mentioned as a possible confounding factor [324].
Myofacial trigger point release

Treatment of myofascial trigger points can be done by manual therapy, dry needling and wet needling. The
evidence for all the different treatments is weak, with most studies showing no significant difference between
these techniques, though most studies were small and heterogeneous with regards to the patients and
methods. There is no evidence that manual techniques are more effective than no treatment [325]. Most studies
of dry needling have compared with wet needling. Different systematic reviews have come to the conclusion
that, although there is an effect of needling on pain, it is neither supported nor refuted that this effect is better
than placebo [326]. Other reviews have concluded that the same is true for the difference between dry and wet
needling [327, 328].
Physiotherapy in BPS
General muscular exercise may be beneficial in some BPS patients [329]. Transvaginal manual therapy of
the pelvic floor musculature (Thiele massage) in BPS patients with high-tone dysfunction of the pelvic floor
significantly improved several assessment scales [330]. The role of specific levator ani trigger point injections
in women with CPP has been studied [331]. Each trigger point was identified by intravaginal palpation and
injected with bupivacaine, lidocaine and triamcinolone. Seventy-two percent of women improved with the
first trigger point injection, with 33% being completely pain-free. Efficacy and safety of pelvic floor myofascial
physical therapy has been compared with global therapeutic massage in women with BPS; global response
assessment (GRA) rate was 59% and 26%, respectively. Pain, urgency and frequency ratings, and O’Leary-
Sant IC Symptom and Problem Index decreased in both groups during follow-up, and did not differ significantly
between the groups. This suggests that myofascial physical therapy is beneficial in women with BPS [332].
Anal Pain Syndrome

In a recently published RCT, it is demonstrated that biofeedback treatment was superior to electrogalvanic
stimulation and massage for treating chronic anal pain syndrome [147]. One hundred and fifty-seven patients
who had at least weekly rectal pain were investigated, but only patients with tenderness on traction of the
pelvic floor showed a significant treatment benefit. In patients with tenderness of the puborectalis muscle
(Rome II: Highly likely Levator Ani Syndrome), 87% reported adequate relief after one month of biofeedback vs.
45% for electrogalvanic stimulation, and 22% for massage. These results were maintained at twelve months
with adequate relief after nine sessions of biofeedback in 58% of the whole group (Rome II: Highly likely
and Possible Levator Ani Syndrome), after galvanic stimulation in 27% and massage in 21% of patients. As
previously described in dyssynergic defecation, the ability to expel a 50 mL water filled balloon and to relax
pelvic floor muscles after biofeedback treatment were predictive of a favourable therapeutic outcome [147].
The pathophysiology of the chronic anal pain syndrome is therefore similar to that of dyssynergic defecation,
and this favours the role of the pelvic floor muscles in the pathophysiology of both conditions. Other treatment
modalities have been less successful.
Treatment of sexual dysfunctions and CPP

Couples often benefit from early referral for relationship and sexual counselling during their treatment
course [333]. Specific behavioural strategies for women who have urogenital complaints and female sexual
dysfunction often include exploring alternatives to sexual intercourse (manual or oral pleasuring), different coital
positions (female superior or side lying), and pacing, such as limiting thrusting to less than that causes pain.
Planning for the time of intercourse is important, and scheduling a clinic visit after intercourse might be useful
to identify specific sites and causes of post-coital flares. The corresponding evidence in men is lacking.
Other behavioural changes involve pre- and post-coital voiding, application of ice packs to the genital or
suprapubic area [333, 334], and use of vaginal dilators before penile penetration. An alternative is to use natural
dilators such as different fingers or sex toys. Hypoallergenic non-irritating lubricants can be used to reduce
vulvar, urethral, and vaginal friction, and women with signs of vulvovaginal atrophy may benefit from introital

application of minimally absorbed locally applied oestrogen cream [335]. In patients with an overactive pelvic
floor, referral for physical therapy, myofascial release, and internal pelvic floor muscle massage may offer relief
[336].
Other physical therapy interventions

Electromagnetic therapy. A small, sham-controlled, double-blind study of four weeks showed a significant,
sustained effect over a one-year period for CPPS [337].
Microwave thermotherapy. In uncontrolled studies significant symptomatic improvement has been reported
from heat therapy, for example, transrectal and transurethral thermotherapy [338, 339].
Extracorporeal shockwave therapy. A small sham-controlled double-blind study of four times weekly perineal
extracorporeal shockwave therapy (n=30) in men with chronic pelvic pain syndrome showed significant
improvement in pain, QoL, and voiding compared to the control group (n=30) over twelve weeks [340]. Two
other randomised sham-controlled studies, have been published more recently, one comparing ten treatment
sessions over two weeks (n=40 vs. n=40) [341], another with four times weekly treatments (n=20 vs. n=20)
[342]. Both concluded there was a significant effect in terms of total NIH-CPSI score and pain at twelve weeks.
Unfortunately, no long term effects at 24 weeks could be shown in a published follow-up study of the second
[343].
Acupuncture. In a small three-arm randomised trial of CPPS in men, electro-acupuncture was superior to
sham treatment and advice and exercise alone [344]. Another more recent randomised study comparing
acupuncture (n=50) vs. sham-controlled (n=50) once weekly treatment for six weeks showed significant long
lasting improvement at 24 weeks in terms of response rate and overall symptom scores [345]. Two systematic
reviews and meta-analyses have been published in 2016 analysing seven randomised-controlled studies on
a total of 471 participants comparing acupuncture to sham control or oral medical treatment [346, 347]. Both
came to the conclusion that acupuncture was effective and safe, significantly reducing total NIH-CPSI scores
compared to sham or medical treatment, and should be considered as a treatment option. However, the
durability of this effect is not known.
Posterior tibial nerve stimulation. One sham-controlled medium-sized study (n=89) demonstrated significant
improvement in total NIH-CPSI score and visual analogue scale for pain in men with category IIIB chronic
prostatitis/CPP [348].
Transcutaneous electrical nerve stimulation. Despite the popularity of transcutaneous electrical nerve
stimulation (TENS) and the number of trials undertaken, a systematic review has been unable to provide good
evidence for or against its use in the management of chronic pain [349]. Furthermore, rigorous trials should be
undertaken to provide some clarity for a commonly used intervention.
5.1.3 Psychological therapy

Psychological interventions may be directed at pain itself or at adjustment to pain as shown by improved
function and mood and reduced health-care use with or without pain reduction. Ideally, treatment follows
general principles and practice in the field of chronic pain [350, 351], but these have been neglected in pelvic
pain. Two systematic reviews and meta-analyses of the few heterogeneous trials of psychologically based
treatment for pelvic pain [352, 353] found some short-term benefits for pain, of around 50%, comparable
to that from pharmacotherapy, but this was not sustained at follow-up. Surprisingly, the single component
treatments for chronic pelvic pain, counselling about US results [274], and emotional disclosure [354], showed
improvements in pain, as did one that combined psychological therapy with acupuncture for endometriosis-
related pain [355], while three more standard multi-component (including psychological) treatments for pain
[290, 323, 356] did not provide pain or symptom relief. Another RCT of multi-component treatment also
showed no effect on pain but benefits for distress [357], as did an RCT of mindfulness meditation for women
with bladder pain [358]. The importance of multi-disciplinary treatment is emphasised by several reviews
[43, 359, 360], and the need for high quality psychological treatment evaluation is underlined [359]. For less
disabled and distressed patients, this can be delivered in part over the internet [361]. Several other reviews
make positive comments on psychological involvement [362], and recommend addressing psychological
concerns from the outset, directed at the pain itself, with the intended outcome of reducing its impact on life
[34], or at adjustment to pain, with improved mood and function and reduced health-care use, with or without
pain reduction [36]. A good model of such an intervention, albeit a pilot study, is by Tripp et al [363] for men
with chronic pelvic pain.
5.1.4 Dietary treatment

Scientific data are limited and dietary restriction alone does not produce significant symptomatic relief,
however, consider the involvement of a dietician.

5.2 Pharmacological management
5.2.1 Drugs for chronic pelvic pain syndrome

In this section the evidence available for specific CPPSs is presented. Where there is no evidence the reader
is directed to the section on analgesics below (5.2.3) where more generic use is discussed. There is a large
discrepancy in the treatment effects reported in case series and controlled trials that results from a large
placebo effect or publication bias. As a result of the multifactorial origin of for example PPS, one reason
for treatment failure in some large randomised placebo-controlled trials may be the heterogeneity of the
patient population. One strategy for improving treatment effects may be stratification of patient phenotypes.
A prospective series of phenotypically directed treatment for PPS has shown significant improvement of
symptoms and QoL [364]. Monotherapeutic strategies for the treatment of PPS may fail [275], therefore, most
patients require multimodal treatment aimed at the main symptoms, and taking comorbidity into account. In the
past ten years, results from RCTs have led to advances in standard and novel treatment options.
5.2.1.1 Mechanisms of action

Mechanisms of action are discussed as appropriate under the drugs headings below.
5.2.1.2 Comparisons of agents used in pelvic pain syndromes
Prostate Pain Syndrome (PPS)

Anti-inflammatory drugs
For non-steroidal anti-inflammatory agents (NSAIDs), a trial with celecoxib reported that the pain subscore,
QoL subscore, and total NIH-CPSI score were in favour of the treatment arm vs. placebo, but effects were
limited to the duration of therapy [276]. In a meta-analysis, two studies of NSAIDs [276, 282] and one with
prednisolone [272] were pooled. Anti-inflammatory drugs were 80% more likely to have a favourable response
than placebo. An updated network meta-analysis with more restrictive inclusion criteria regarding documented
outcome measures but a wider spectrum of drugs (including glycosaminoglycans, phytotherapy and
tanezumab) a significant effect on total NIH-CPSI scores and treatment response rates could be demonstrated.
Overall, a moderate treatment effect has been shown for anti-inflammatory drugs, but larger studies are needed
for confirmation, and long-term side-effects have to be taken into account.
α-blockers
Positive results from RCTs of α-blockers, i.e. terazosin [365, 366], alfuzosin [367], doxazosin [368, 369],
tamsulosin [370, 371], and silodosin [372] have led to widespread use of α-antagonists in the treatment of
PPS in recent years. Whereas one systematic review and meta-analysis has not reported a relevant effect of
α-blockers due to study heterogeneity [373], another network meta-analysis of α-blockers [374] has shown
significant improvement in total symptoms, pain, voiding, and QoL scores. In addition, they had a higher rate of
favourable response compared to placebo [relative risk (RR) 1.4, 95% CI 1.1-1.8, p=0.013]. However, treatment
responsiveness, i.e. clinically perceptive or significant improvement, may be lower than expected from the
change in mean symptom scores. Overall, α-blockers seem to have moderate but significant beneficial
effects. This probably is not the case for long-standing PPS patients [375]. Future studies should show if
longer duration of therapy or some sort of phenotypically directed (e.g. patients with PPS and relevant voiding
dysfunction) treatment strategies will improve treatment outcomes.
Antibiotic therapy
Empirical antibiotic therapy is widely used because some patients have improved with antimicrobial therapy.
Patients responding to antibiotics should be maintained on medication for four to six weeks or even longer.
Unfortunately, culture, leukocyte and antibody status of prostate-specific specimens do not predict antibiotic
response in patients with PPS [376], and prostate biopsy culture findings do not differ from those of healthy
controls [377]. The only randomised placebo-controlled trials of sufficient quality have been done for oral
antibiotic treatment with ciprofloxacin (six weeks) [153], levofloxacin (six weeks) [378], and tetracycline
hydrochloride (twelve weeks) [379]. The studies have been analysed in meta-analyses [374, 380]. Although
direct meta-analysis has not shown significant differences in outcome measures, network meta-analysis has
suggested significant effects in decreasing total symptom, pain, voiding, and QoL scores compared with
placebo. Combination therapy of antibiotics with α-blockers has shown even better outcomes in network
meta-analysis. Despite significant improvement in symptom scores, antibiotic therapy did not lead to
statistically significant higher response rates [380]. In addition, the sample sizes of the studies were relatively
small and treatment effects only modest and most of the time below clinical significance. It may be speculated
that patients profiting from treatment have had some unrecognised uropathogens. If antibiotics are used, other
therapeutic options should be offered after one unsuccessful course of a quinolone or tetracycline antibiotic
over six weeks.

5-α-reductase inhibitors
Although a few small pilot studies with 5-α-reductase inhibitors supported the view that finasteride may
improve voiding and pain, the first RCT published in a peer-reviewed journal did not support this, but the study
did lack power [381]. In another RCT, finasteride provided better amelioration of symptoms compared to saw
palmetto over a one-year period, but lacked a placebo-control arm [382]. A six-month placebo-controlled
study showed a non-significant tendency towards better outcome in favour of finasteride, possibly because of
a lack of statistical power [383]. The NIH-CPSI scores decreased significantly in a subgroup of men enrolled
in a prostate cancer risk reduction study treated with dutasteride compared to placebo [384]. Patients (n=427,
age 50 to 75, elevated prostate-specific antigen [PSA]) were included if they had significant “prostatitis-like”
symptoms at baseline. Based on the evidence, 5-α-reductase inhibitors cannot be recommended for use in
PPS in general, but symptom scores may be reduced in a restricted group of older men with an elevated PSA
[384].
Phytotherapy
Phytotherapy applies scientific research to the practice of herbal medicine. An adequately powered placebo-
controlled RCT of a pollen extract (Cernilton), showed clinically significant symptom improvement over a
twelve-week period in inflammatory PPS patients (NIH Cat. IIIA) [385]. The effect was mainly based on a
significant effect on pain. Another pollen extract (DEPROX 500) has been shown to significantly improve
total symptoms, pain and QoL compared to ibuprofen [386]. A recent systematic review and meta-analysis
of pollen extract for the treatment of PPS showed significant improvement in overall QoL [387]. Quercetin, a
polyphenolic bioflavonoid with documented antioxidant and anti-inflammatory properties, improved NIH-CPSI
scores significantly in a small RCT [388]. In contrast, treatment with saw palmetto, most commonly used for
benign prostatic hyperplasia, did not improve symptoms over a one-year period [382]. In a systematic review
and meta-analysis, patients treated with phytotherapy were found to have significantly lower pain scores than
those treated with placebo [374]. In addition, overall response rate in network meta-analysis was in favour of
phytotherapy (RR: 1.6; 95% CI: 1.1-1.6).
Pregabalin is an anti-epileptic drug that has been approved for use in neuropathic pain. In an adequately
powered randomised placebo-controlled study, which was the only report included in a recently published
Cochrane review [389], a six-week course of pregabalin (n=218) compared to placebo (n=106) did not result in
a significant reduction of NIH-CPSI total score [390].
Pentosane polysulphate is a semi-synthetic drug manufactured from beech-wood hemicellulose. One study
using oral high-dose (3 x 300 mg/day) demonstrated a significant improvement in clinical global assessment
and QoL over placebo in men with PPS, suggesting a possible common aetiology [391].
Muscle relaxants (diazepam, baclofen) are claimed to be helpful in sphincter dysfunction or pelvic floor/
perineal muscle spasm, but there have been few prospective clinical trials to support these claims. In one
RCT, a triple combination of a muscle relaxant (thiocolchicoside), an anti-inflammatory drug (ibuprofen) and an
α-blocker (doxazosin) was effective in treatment-naïve patients, but not superior to an α-blocker alone [369].
Botulinum toxin type A (BTX-A) showed some effect in the global response assessment and the NIH-
CPSI pain subdomain score in a small randomised placebo-controlled study of perineal skeletal muscle
injection (100 U). However, patient numbers were low (thirteen in the BTX-A group and sixteen in the placebo
group), and follow-up was too short to draw definitive conclusions. Side-effects are unclear [392]. In another
randomised-controlled study of intraprostatic injection of BTX-A (100 or 200 U depending on prostate volume)
vs. placebo (n=30 in both groups) a significant improvement of total NIH-CPSI and subdomain scores could
be shown at six months [393]. However, no real placebo effect could be demonstrated, which suggests
unblinding. No definitive conclusion can be drawn.
Zafirlukast, a leukotriene antagonist, and prednisone in two low-power placebo-controlled studies failed to
show a benefit [272, 394]. More recently, a placebo-controlled phase IIa study of tanezumab, a humanised
monoclonal antibody against the pain mediating neurotrophin, nerve growth factor, failed to demonstrate
significant effect [395].
Tanezumab is a humanised monoclonal antibody that specifically inhibits nerve growth factor (NGF), and
should only be used in clinical trials.
Allopurinol
There is insufficient evidence for the use of allopurinol in PPS [396, 397].

Bladder Pain Syndrome
Treatments of significant value for BPS
Anti-histamines
Mast cells may play a role in BPS. Histamine is one of the substances released by mast cells. Histamine
receptor antagonists have been used to block the H1 [398] and H2 [399] receptor subtypes, with variable
results. A prospective placebo-controlled RCT of hydroxyzine or oral pentosane polysulphate did not show a
significant effect [400].
Amitriptyline
Amitriptyline is a tricyclic antidepressant. Several reports have indicated improvement of BPS symptoms after
oral amitriptyline [116, 401, 402]. Amitriptyline has been shown to be beneficial when compared with placebo
plus behavioural modification [403]. Drowsiness is a limiting factor with amitriptyline, nortriptyline is sometimes
considered instead.
Pentosane polysulphate
Is a semi-synthetic drug manufactured from beech-wood hemicellulose. Subjective improvement of pain,
urgency, frequency, but not nocturia, has been reported [404, 405]. Pentosane polysulphate had a more
favourable effect in BPS type 3 C than in non-lesion disease [406]. Response was not dose dependent but
related more to treatment duration. At 32 weeks, about half the patients responded. Combination therapy
showed a response rate of 40% compared to 13% with placebo. For patients with an initial minor response to
pentosane polysulphate, additional subcutaneous heparin was helpful [407, 408].
Immunosuppressants
Azathioprine treatment has resulted in disappearance of pain and urinary frequency [409]. Initial evaluation of
cyclosporin A (CyA) [410] and methotrexate [411] showed good analgesic effect but limited efficacy for urgency
and frequency. Corticosteroids are not recommended in the management of patients with BPS because of a
lack of evidence.
Intravesical Treatments
Intravesical drugs are administered due to poor oral bio-availability establishing high drug concentrations within
the bladder, with few systemic side-effects. Disadvantages include the need for intermittent catheterisation
which can be painful in BPS patients, cost and risk of infection [412].
• Local anaesthetics
There are sporadic reports of successful treatment of BPS with intravesical lidocaine [413, 414].
Alkalisation of lidocaine improves its pharmacokinetics [415]. Combination of heparin, lidocaine and
sodium bicarbonate gave immediate symptom relief in 94% of patients and sustained relief after two
weeks in 80% [416]. Intravesical instillation of alkalised lidocaine or placebo for five consecutive days
resulted in significantly sustained symptom relief for up to one month [417].
• Hyaluronic acid and chondroitin sulphate are described to repair defects in the GAG layer. Despite
the fact that intravesical GAG replenishment has been in use for about twenty years for BPS/IC, most of
the studies are uncontrolled and with a small number of patients. Based on the studies available there
are differences by virtue of substance classes, whether they are natural GAG layer components, dosage
formulations, or concentrations. More important, there are differences in proven efficacy. Randomised
controlled trials are only published for chondroitin sulphate, a combination containing chondroitin
sulphate and hyaluronic acid and pentosane polysulphate. One large prospective non-randomised study
indicated hyaluronic acid significantly ameliorated sexual functions domains in IC/BPS patients [418]. It
is well documented that intravesical instillations are a valuable and beneficial therapy, but distinct patient
groups need to be confirmed by definite diagnostic findings [419].
• Intravesical heparin
Bladder pain syndrome patients were treated with heparin for three months, and over half had control
of symptoms, with continued improvement after one year of therapy [420]. Kuo reported another trial of
intravesical heparin for three months in women with frequency-urgency syndrome and a positive potassium
test. Symptomatic improvement was reported in 80% of BPS patients [421]. Intravesical heparin plus dorsal
tibial nerve stimulation in patients with refractory BPS was studied and it was shown that voiding frequency,
pain score and maximum cystometric capacity were significantly better after two and twelve months [422].

Hyperbaric oxygen (HBO) has a moderate effect on a small subgroup of BPS patients. Disadvantages include
high cost, limited availability of treatment sites, and time-consuming treatment [408].
Treatments of limited value for BPS
Cimetidine
There is limited data to suggest that cimetidine improves symptoms of BPS in the short-term [423]. Compared
with placebo for three months, cimetidine significantly improved symptom scores, pain and nocturia, although
the bladder mucosa showed no histological changes in either group [424].
Prostaglandins
Misoprostol is a prostaglandin that regulates various immunological cascades. After three months of treatment
with misoprostol, 14/25 patients had significantly improved, with twelve showing a sustained response after a
further six months [425]. The incidence of adverse drug effects was 64%.
L-Arginine
Oral treatment with the nitric oxide (NO) synthase substrate L-arginine decreases BPS-related symptoms [426-
428]. Nitric oxide is elevated in patients with BPS [429]. However, others have not demonstrated symptomatic
relief or changes in NO production after treatment [430, 431].
Oxybutynin is an anti-cholinergic drug used in overactive detrusor dysfunction. Intravesical oxybutynin

combined with bladder training improves functional bladder capacity, volume at first sensation, and
cystometric bladder capacity [432]. However, an effect on pain has not been reported.
Duloxetine (a serotonin-noradrenaline re-uptake inhibitor antidepressant with a licence for the management of
neuropathic pain) did not significantly improve symptoms of BPS [433]. Administration was safe, but tolerability
was poor due to nausea. Based on these preliminary data, duloxetine cannot be recommended for treatment of
BPS.
Clorpactin is a derivative of hypochloric acid previously used to treat BPS [434-438]. Due to high complication
rates, clorpactin instillations can no longer be recommended [434, 435, 437, 439, 440].
Dimethyl sulphoxide (DMSO) and Bacillus Calmette Guérin (BCG) have been used in the past. There is
insufficient evidence to recommend the use of either.
Scrotal Pain Syndrome

Treatment of chronic scrotal pain is based on the principles of treating chronic pain syndromes, as described
throughout these guidelines [441].
Chronic gynaecological pain

It is difficult to compare the wide variation of drugs from an efficacy and safety perspective as they have such
diverse uses/indications.
In those gynaecological patients where CPP is unrelated to any of the well-defined conditions, it is often
difficult to determine a therapeutic pathway other than a multi-disciplinary chronic abdomino-pelvic pain
management plan. A Cochrane review suggests there may be some evidence (moderate) supporting the
use of progestogens. Though efficacious, physicians need to be conversant with progestogenic side effects
(e.g. weight gain, bloatedness - the most common adverse effects) which can stop some patients from
accepting such medication. Gonadotrophins, such as goserelin, are also thought to help such pain. However,
when compared with progestogens, their efficacy remains limited, as is the case when comparing gabapentin
with amitriptyline. The quality of evidence is generally low and is drawn from single studies [353].
Current hormonal contraceptives (e.g. the combined oral contraceptive pill and the progesterone-only pill),
and intrauterine contraceptive devices (Mirena IUS™) have multiple biologic effects. Their mechanism
of action maybe via a primary or secondary contraceptive action. For combined oral contraceptives and
progestin-only methods, the main mechanisms are ovulation inhibition and changes in the cervical mucus
that inhibit sperm penetration. The hormonal methods, particularly the low-dose progestin-only products and
emergency contraceptive pills, have effects on the endometrium that, theoretically, could affect implantation.
Their effectiveness as contraceptives range from 92-99.9% [273]. The precise mechanism of intrauterine
contraceptive devices is unclear. Current evidence indicates they exert their primary effect before fertilisation,
reducing the opportunity of sperm to fertilise an ovum. Their efficacy approaches 99% [442].

Gonadotropin-releasing hormone (GnRH) binds to specific receptors on pituitary gonadotrophs. Prolonged
activation of GnRH receptors by GnRH leads to desensitisation and consequently to suppressed gonadotropin
secretion. By contrast, GnRH antagonists compete with GnRH for receptors on gonadotropin cell membranes,
inhibit GnRH-induced signal transduction and consequently gonadotrophin secretion. These compounds are
free of agonistic actions, which might be beneficial in certain clinical applications, such as reducing the size of
fibroids, endometrial bleeding and endometriosis [443].
Pelvic Floor, Abdominal and Chronic Anal Pain
Botulinum toxin type A (pelvic floor)

Botulinum toxin type A has been injected into trigger points. It is more expensive than lidocaine and has not
been proven to be more effective [444]. Reviews do not support the injection of BTX-A into trigger points [445].
Pelvic floor muscle over-activity plays a role in CPP. Botulinum toxin type A, as a muscle relaxant, can be used
to reduce the resting pressure in the pelvic floor muscles. In women with high resting pressure in the pelvic
floor muscles, it has been found that BTX-A lowers this pressure significantly. The magnitude of reduction
was significantly higher than that in the placebo group. On the pain score (VAS), no intergroup differences
were found in this relatively small randomised study [446]. Botulinum toxin type A can also be injected at
the sphincter level to improve urination or defecation. Relaxation of the urethral sphincter alleviates bladder
problems and secondarily the spasm. In a cohort study of thirteen patients with CPP, BTX-A was injected into
the external urethral sphincter. Subjectively, eleven patients reported a substantial change in pain symptoms,
from 7.2 to 1.6 on a VAS [447].
Botulinum toxin type A (chronic anal pain syndrome)

In CPP associated with spasm of the levator ani muscles, treatment of the puborectalis and pubococcygeus
muscle by BTX-A appears to be promising in some women, as shown in a pilot study (n=12). The inclusion
criteria were dependent only on vaginal manometry with over-activity of the pelvic floor muscles, defined as
a vaginal resting pressure > 40 cm H2O. Although dyspareunia and dysmenorrhoea improved, non-menstrual
pelvic pain scores were not significantly altered [448]. In the following double-blinded, randomised, placebo-
controlled trial, the same group defined pelvic floor myalgia according to the two criteria of tenderness on
contraction and hypertension (> 40 cm H2O) and included 60 women. In this larger study, non-menstrual pelvic
pain was significantly improved compared to those treated with placebo (VAS score 51 vs. 22; p=0.009). It was
concluded therefore that BTX-A is effective at reducing pelvic floor-muscle associated pain with acceptable
adverse effects such as occasional urinary and faecal stress incontinence [446]. However, recently, a small RCT
failed to show any benefit of BTX-A [449].
Intermittent chronic anal pain syndrome

Due to the short duration of the episodes, medical treatment and prevention is often not feasible. Inhaled β-2
adrenergic agonist salbutamol was effective in an RCT in patients with frequent symptoms and shortened
pain duration [450]. Other treatment options are topic diltiazem and BTX-A [451]. However, there is still some
controversy regarding the duration of pain of intermittent chronic and chronic anal pain syndrome. RCTs often
use different definitions, extending the pain duration (with a shift to chronic pain) in order to include more
patients and to better evaluate the study-drug action.
Abdominal pain associated with Irritable Bowel Syndrome

Linaclotide, a minimally absorbed peptide guanylate cyclase-C agonist at a dose of 290 μg once daily
significantly improved abdominal pain (48.9% vs. 34.5% placebo-treated) and bowel symptoms associated
with irritable bowel syndrome with constipation (IBS-C) over 26 weeks of treatment [452]. Diarrhoea was the
most common adverse event in patients treated with linaclotide (4.5%). However, although it is known to
overlap with IBS pelvic pain, effect on the latter was not assessed in this study.
Delta-9-tetrahydrocannabinol (THC) shows only equivocal evidence of analgesic effects in chronic abdominal
pain. In a recently published phase II trial no difference was found between THC tablet and a placebo tablet in
reducing pain outcome in patients with chronic abdominal pain [453].
5.2.2 Analgesics
If the use of simple analgesics fails to provide adequate benefit, then consider using the neuropathic agents,
and if there is no improvement, consider involving a specialist pain management centre with an interest in
pelvic pain. Chronic Pelvic Pain is well defined and involves multiple mechanisms as described in previous
sections of chapters. The management requires a holistic approach with biological, psychological and social
components. Few studies have specifically looked at medications used in CPP [454], therefore, a wider look at
the literature has been undertaken and further specific research is required. The agents concerned are divided

for ease of description. Combinations often provide a greater benefit than individual agents. They may also
allow lower individual dosages and thus minimise side-effects. The aim of using these drugs is to allow patients
to improve their QoL. This is best measured by assessing their function as well as pain severity. If the use of
these agents does not allow this, then they should be withdrawn. Unfortunately, the failure of one agent does
not exclude potential benefit of an alternative. If the benefit is limited by side-effects, then the lowest effective
dose should be found (by dose titration). Sometimes, patients will prefer a higher level of pain and have fewer
side-effects.
5.2.2.1 Mechanisms of action

Mechanisms of action are discussed as appropriate under the drug headings below.
5.2.2.2 Comparisons within and between groups in terms of efficacy and safety
Paracetamol (acetaminophen)
Paracetamol is a well-tolerated analgesic in a class of its own. This is an antipyretic analgesic with a central
mechanism of action [455]. It is often available over the counter without prescription. A review questions its
routine use as a first line analgesic based on inadequate evidence of efficacy in many pain conditions including
dysmenorrhoea [456]. It will not be effective for all patients and individual responses should be reviewed when
deciding on longer term use.
Non-steroidal anti-inflammatory agents (NSAIDs)

These agents are anti-inflammatory, antipyretic analgesics that act by inhibiting the enzyme cyclooxygenase
(COX). They have a peripheral effect, hence their use in conditions involving peripheral or inflammatory
mechanisms. They are commonly used for pelvic pain; many are available over the counter and are usually well
tolerated. There is no good evidence to suggest one NSAID over another for pelvic pain. Guidelines for use of
NSAIDs and COX-2 selective agents have been developed. They have more side-effects than paracetamol,
including indigestion, headaches and drowsiness.
The evidence for their benefit in CPP is weak or non-existent and are often limited by side-effects. For pelvic
pain in which inflammatory processes are considered important, such as dysmenorrhoea [457], NSAIDs are
more effective than placebo and paracetamol, but with a higher incidence of side-effects. For pelvic pain in
which central mechanisms may be incriminated, such as endometriosis [458], then the evidence is lacking for
NSAIDs despite their common use.
At a practical level, if NSAIDs are considered for use, they should be tried (having regard for the cautions and
contraindications) and the patient reviewed for improvement in function as well as analgesia. If this is not
achieved, or side-effects are limiting, then they should be withdrawn.
Neuromodulators
These are agents that are not simple analgesics but used to modulate neuropathic or centrally mediated pain.
There are several classes commonly used with recognised benefits in pain medicine. They are taken on a
regular basis and all have side-effects that may limit use in some patients. In the UK, the National Institute
for Health and Clinical Excellence (NICE) has reviewed the pharmacological management of neuropathic
pain [459]. Not all the agents are licensed for use in pain management but there is a history and evidence
to demonstrate their benefit. The evidence for treatment of CPP is lacking but is present for other painful
conditions. For this chapter, most of the evidence is from non-pelvic pain sources. The general method for
using these agents is by titrating the dose against benefit and side-effects. The aim is for patients to have an
improvement in their QoL, which is often best assessed by alterations in their function. It is common to use
these agents in combination but studies comparing different agents against each other, or in combination, are
lacking. Some of these agents are also used for specific conditions. Early identification of neuropathic pain with
a simple questionnaire could facilitate targeted therapy with neuromodulators [63].
Antidepressants
Tricyclic antidepressants
The tricyclic antidepressants (TCAs) have multiple mechanisms of action including, blockade of acetylcholine
receptors, inhibition of serotonin and noradrenaline re-uptake, and blockade of histamine H1 receptors. They
also have anxiolytic affects [460] and are frequently limited by their side-effects. Tricyclic antidepressants have
a long history of use in pain medicine and have been subjected to a Cochrane review [461], suggesting that
they are effective for neuropathic pain. Amitriptyline is the most commonly used member at doses from 10 to
75 mg/day (sometimes rising to 150 mg/day). This is titrated against benefit or side-effects and can be taken at
night [459]. Nortriptyline and imipramine are used as alternatives.

Other Antidepressants
Duloxetine is a serotonin-noradrenaline re-uptake inhibitor (SNRI) antidepressant licensed for use in
depression, urinary stress incontinence and neuropathic pain. There is moderately strong evidence of benefit in
diabetic neuropathy and fibromyalgia at a dose of 60 mg/day [462]. Side-effects are common and may result in
its discontinuation.
Selective serotonin re-uptake inhibitors are antidepressants with fewer side-effects. They are effective for
depression, but there have been insufficient studies to demonstrate their benefit in pelvic or neuropathic pain
[461-463].
Anticonvulsants
Anticonvulsants are commonly used in the management of neuropathic pain. There are general studies and
some looking more particularly at pelvic pain. Individual agents have been systematically reviewed. Their use is
suggested in the NICE Neuropathic Guidelines [459].
Carbamazepine has a long history of use in neuropathic pain. Evidence exists for its benefit [464]. Trials have
tended to be of short duration, showing only moderate benefit. There are side-effects; some of which may be
serious. It is no longer a first choice agent. Other anticonvulsant agents are available with fewer serious side-
effects.
Gabapentin is commonly used for neuropathic pain and has been systematically reviewed [465]. It provides
good quality relief with NNT of approximately six. Side-effects are common, notably drowsiness, dizziness and
peripheral oedema. For higher dose levels, reference should be made to local formularies, and many clinicians
do not routinely exceed 2.4 g/day in divided doses (most commonly three times daily). One study of women
with CPP has suggested that gabapentin alone or in combination with amitriptyline provides better analgesia
than amitriptyline alone [466]. A more recent pilot study suggests that gabapentin is beneficial and tolerable; a
larger study is required to provide a definitive result [467].
Pregabalin is a commonly used neuromodulator with good evidence of efficacy in some neuropathic conditions
but the NNT varies depending on the condition [468]. The dose for benefit is in the range of 300 to 600 mg/day.
The same systematic review found that doses less than 150 mg/day are unlikely to provide benefit. A review
for chronic pelvic pain syndrome (prostate) only found a single reviewable study that does not show overall
symptom improvement but suggests individual symptoms may improve (e.g. pain, QoL) and side-effects were
common demonstrating the need for further robust studies [389]. As with gabapentin, side-effects are common
and may not be tolerated by patients. A formal assessment of efficacy against side-effects is required with
the patient in order to determine longer-term treatment. Other anticonvulsants are available but not commonly
used for managing pain. Other agents can be used in the management of neuropathic pain but they are
best administered only by specialists in the management of pain and familiar with their use. They tend to be
considered after the standard options have been exhausted. As with all good pain management, they are used
as part of a comprehensive multi-dimensional management plan.
Opioids
Opioids are used for chronic non-malignant pain and may be beneficial for a small number of patients. Often
patients will stop taking oral opioids due to side-effects or insufficient analgesic effect [469]. They should only
be used in conjunction with a management plan with consultation between clinicians experienced in their use.
It is suggested that a pain management unit should be involved along with the patient and their primary care
physician.
There are well established guidelines for the use of opioids in pain management as well as considering the
potential risks [470]. There is also information available online for patients [470]. Opioids Aware is a web-
based resource for patients and healthcare professionals, jointly produced by the Faculty of Pain Medicine
of Royal College of Anaesthetists and Public Health England, to support prescribing of opioid medicines for
pain. http://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware/. There are several agents available in
the group. They can be divided into weak (e.g., codeine, dihydrocodeine and tramadol) or strong opioids (e.g.,
morphine, oxycodone, fentanyl and hydromorphone). Oral administration is preferable, but if poorly tolerated,
a percutaneous (patch) route may have advantages. More invasive approaches are less commonly used and
within the realms of specialist units. Side-effects are common, including constipation, nausea, reduced QoL,
opioid tolerance, hormonal and immunological effects along with psychological changes and require active
management.

There is a growing understanding of opioid-induced hyperalgesia; a situation in which patients taking opioids,
paradoxically, become more sensitive to painful stimuli [470]. This is another reason for these drugs to be used
in a controlled way for long-term management of non-malignant pain.
Morphine is the standard opioid with which many physicians are familiar. The aim is to use a slow or sustained
release preparation starting with a low-dose and titrating the dose every three days to one week against
improvement in both function and pain. Side-effects should also be monitored and managed accordingly.
Particular attention should be paid to the management of constipation.
There are a variety of other agents available and some are mentioned below:
Transdermal fentanyl may be considered when oral preparations are restricted (e.g., ileostomy). It may also be
beneficial when there are intolerable side-effects from other opioids.
Methadone has a long record of use as an opioid. There is a theoretical advantage of benefit with its N-methyl-
D-aspartate receptor (NMDA) antagonist activity. This may be relevant in neuropathic pain [471].
Oxycodone may have greater efficacy than morphine in some situations, such as hyperalgesic states including
visceral pain [472].
Tramadol is an established analgesic with dual effects on opioid receptors and serotonin release. More
recently, tapentadol, has been released with opioid action and noradrenaline re-uptake inhibition. It is too early
to assess its real value in the armamentarium for pain management.
5.3 Surgical management
5.3.1 Surgery
Bladder Pain Syndrome (BPS)
Bladder distension
Although bladder hydrodistension is a common treatment for BPS, the scientific justification is scarce. It can be
part of the diagnostic evaluation, but has limited therapeutic role.
Hydrodistension and Botulinum toxin type A

Botulinum toxin type A may have an antinociceptive effect on bladder afferent pathways, producing
symptomatic and urodynamic improvements [124]. Treatment with hydrodistension and hydrodistension plus
intravesical BTX-A has been compared [473]. There was symptomatic improvement in all patients. However,
in the hydrodistension-only group, 70% returned to their previous symptoms after one month, while in the
BTX-A-treated patients, VAS score and functional and cystometric bladder capacity improved at three months.
Botulinum toxin type A trigonal-only injection seems effective and long-lasting as 87% of patients reported
improvement after three months follow-up [474]. Over 50% reported continued benefit nine months after the
first treatment. When re-treatment was needed, similar results were obtained. The authors concluded that
this treatment is safe, effective and can be repeated. Adverse effects of BTX-A administration for IC/BPS
were significantly less than for overactive bladder syndrome, namely in increased post-void residual volumes
and decreased voiding efficiency [475]. Recent RCTs have confirmed benefits and long efficacy of BTX-A
administration [476-479]. The American Urological Association (AUA) guidelines panel has recently upgraded
BTX-A treatment from fifth to a fourth line treatment [480].
Transurethral resection (TUR), coagulation and laser

Endourological destruction of bladder tissue aims to eliminate urothelial, mostly Hunner lesions. Since the
1970s resection and fulguration have been reported to achieve symptom relief, often for more than three years
[481, 482]. Prolonged amelioration of pain and urgency has been described for transurethral laser ablation as
well [483].
Open Surgery for BPS

Bladder pain syndrome is benign and does not shorten life, thus operative procedures rank last in the
therapeutic algorithm. There is no evidence that it relieves pain. Surgery for refractory BPS is only appropriate
as a last resort for patients with refractory end-stage disease. Major surgery should be preceded by thorough
pre-operative evaluation, with an emphasis on determining the relevant disease location and subtype. If surgery
is considered, the panel’s advice is to refer the patient to a specialist centre experienced in managing CPP with
a multi-disciplinary team approach.

Four major techniques are common:
1. Urinary diversion without cystectomy. As early as 1967, it was reported that bladder augmentation
without removal of the diseased tissue was not appropriate [484]. Reports that unresected BPS bladders
cease to induce symptoms after loss of contact with urine are scarce [121, 485].
2. Supratrigonal cystectomy with subsequent bladder augmentation represents the most favoured
continence-preserving surgical technique. Various intestinal segments have been used for supratrigonal
augmentation [486-488].
3. Subtrigonal cystectomy. Subtrigonal resection has the potential of removing the trigone as a possible
disease site, but at the cost of requiring ureteral re-implantation. Trigonal disease is reported in 50% of
patients and surgical failure has been blamed on the trigone being left in place [489]. In contrast, another
study [490] reported six out of seventeen patients being completely cured by supratrigonal resection
[489]. A recent study on female sexuality after cystectomy and orthotopic ileal neobladder showed pain
relief in all patients, but only one regained normal sexual activity [491].
4. Cystectomy with formation of an ileal conduit still ranks first in current USA practice trends for
BPS surgery [492]. For cosmetic reasons, continent diversion is preferred, particularly in younger
patients. After orthotopic bladder augmentation, particularly when removing the trigone, voiding may
be incomplete and require intermittent self-catheterisation. Patients considering these procedures must
be capable of performing, accepting and tolerating self-catheterisation. For patients with BPS who
develop recurrent pain in the augmented bladder or continent pouch after enterocystoplasty or continent
urinary diversion, retubularisation of a previously used bowel segment to form a urinary conduit has been
recommended [493]. It is important to note that pregnancies with subsequent lower-segment Caesarean
section have been reported after ileocystoplasty [493, 494].
Prostate Pain Syndrome

There is no evidence for surgical management, including transurethral incision of the bladder neck, radical
transurethral resection of the prostate or, in particular, radical prostatectomy in the management of chronic
pain in patients with PPS. Recently, a large Chinese randomised-controlled trial of circumcision combined
with a triple oral therapy (ciprofloxacin, ibuprofen, tamsulosin) vs. oral therapy alone has been published
for patients with PPS (total n=774) [495]. It is hypothesised that there may be some immunological
interaction via pathogenic antigen presenting cells in the foreskin with CD4+ T cells causing autoimmunity
to the prostate gland. They reported an improvement in total NIH-CPSI score and subdomain scores at
twelve weeks. However, despite a large cohort, the study results are questionable because of the weak
theoretical background, and a potential large placebo effect lacking a sham control. In addition, no long-term
effectiveness has been reported. Before having an impact on recommendations, the results of this study have
to be independently confirmed and the treatment effect must persist.
Testicular Pain Syndrome

Microsurgical denervation of the spermatic can be offered to patients with testicular pain. In a long term follow-
up study, patients who had a positive result on blocking the spermatic cord were found to have a good result
following denervation [496].
Chronic Anal and Abdominal Pain Syndrome

Chronic anal pain syndrome after stapled procedures, such as hemorrhoidopexy (PPH) or stapled transanal
rectal resection (STARR) may respond to excision of the scarred staple line as shown in 21 consecutive
patients with an overall improvement of pain in 85.7% of patients undergoing scar excision surgery [497].
An early scar excision before three to six months after pain onset was associated with better pain relief.
Adhesiolysis is still in discussion in the pain management after laparotomy/laparascopy for different surgical
indications in the pelvis and entire abdomen. A recent study has shown, that adhesiolysis is associated with
an increased risk of operative complications, and additional operations and increased health care costs as
compared to laparoscopy alone [498].
Urethral Pain Syndrome

There is no specific treatment that can be advised. Management should be multi-disciplinary and multi-modal
[499]. Laser therapy of the trigonal region may be a specific treatment. One trial comparing two forms of
laser reported good results, but did not compare with sham treatment [500]. The majority of publications on
treatment of urethral pain syndrome have come from psychologists [189].

Presumed intra-abdominal adhesions
In gynaeocological patients with CPP and presumed adhesions, there is no consensus as to whether
adhesiolysis should be performed to improve pain [501, 502].
Extensive surgery for endometriosis is challenging and is still considered to be controversial, as there is at least
one RCT showing no benefit in pain relief after the removal of early extensive endometriosis compared to sham
surgery [503, 504]. In patients with adenomyosis, the only curative surgery is hysterectomy but patients can
benefit from hormonal therapy and analgesics (see 5.2.1).
Pudendal Neuralgia and surgery

Decompression of an entrapped or injured nerve is a routine approach and probably should apply to the
pudendal nerve as it applies to all other nerves. There are several approaches and the approach of choice
probably depends upon the nature of the pathology. The most traditional approach is transgluteal; however,
a transperineal approach may be an alternative, particularly if the nerve damage is thought to be related to
previous pelvic surgery [196, 263, 505-509]. Currently, there has been only one prospective randomised study
[507]. This study suggests that, if the patient has had the pain for less than six years, 66% of patients will
see some improvement with surgery (compared to 40% if the pain has been present for more than six years).
Surgery is not the answer for all patients. On talking to patients that have undergone surgery, providing the
diagnosis was clear-cut; most patients are grateful to have undergone surgery but many still have symptoms
that need management.
5.3.2 Neuromodulation
The role of neuromodulation in the management of pelvic pain should only be considered by specialists in
pelvic pain management. These techniques are only used as part of a broader management plan and require
regular follow-up. The research base is developing and the techniques broadening (e.g., spinal cord stimulation
(SCS), sacral root stimulation, dorsal root ganglion stimulation or peripheral nerve stimulation). These are
expensive interventional techniques for patients refractory to other therapies. Therefore, it is inappropriate to
provide a detailed review in this publication. In the UK, guidance has been published for SCS in neuropathic
pain [510]. This emphasises the comments above. This guidance suggests a trial period of stimulation before
full implementation. Neuromodulation is still finding its role in pelvic pain management. There has been growing
evidence in small case series or pilot studies, but more detailed research is required [511]. Its role in overactive
bladder and faecal incontinence is more robust but is limited for pain.
Bladder Pain Syndrome

A comparison of sacral neuromodulation (SNM) vs. pudendal nerve stimulation (PNS), showed an overall 59%
improvement in symptoms with PNS vs. 44% with SNM. Most patients who tested both a sacral and pudendal
electrode chose PNS as the better site. Follow-up showed marked improvements in voiding variables and
validated BPS symptom questionnaires. Over 90% of patients treated with neuromodulation stated that they
would undergo implantation again [512]. Long-term results were verified in a retrospective study of patients
from 1994 to 2008 [513]. Permanent SNM implantation was performed in patients who showed at least 50%
improvement in symptoms with a temporary peripheral nerve evaluation test [513]. Median follow-up was
61.5 months. Good long-term success of SNM was seen in 72%, with a 28% explantation rate. The most
frequent reason for explantation was poor outcome (54% of the failed patients). The revision rate was 50%. In
a study of women who underwent permanent device implantation from 2002 to 2004 [465], mean pre- /post-
operative pelvic pain and urgency/frequency scores were 21.61 ± 8.6/9.22 ± 6.6, and mean pre-/post-operative
VAS scores were 6.5 ± 2.9/2.4 ± 1.1. Mean follow-up was 86 ± 9.8 months. Sacral neuromodulation showed
adequate improvement for the symptoms of refractory BPS. The re-operation rate was 25%.
Pudendal Neuralgia
Pudendal neuralgia represents a peripheral nerve injury and as such should respond to neuromodulation by
implanted pulse generators. However, it is important that the stimulation is perceived in the same site as the
perceived pain. Spinal cord stimulation (SCS) may be effective for thoraco-lumbar afferents. However, it is
difficult to obtain appropriate stimulation from SCS for the sacral nerves including pudendal. There is limited
experience with sacral root stimulation and as a result stimulation for pudendal neuralgia should only be
undertaken in specialised centres and in centres that can provide multi-disciplinary care [514-517].
Chronic Anal Pain Syndrome

In a large cohort of 170 patients with functional anorectal pain from the St. Mark’s Hospital (Harrow, Middlesex,
United Kingdom) sacral nerve stimulation was used in three patients (two improved), while biofeedback was
the most used modality with the greatest treatment effect in patients with defecatory dysfunction (29 patients,

17 improved) [451]. Sacral neuromodulation has been reported to be somewhat beneficial in two uncontrolled
studies, showing improvement in about half the patients [518, 519]. Martellucci et al have evaluated sacral
neuromodulation in 27 patients, including 18 patients with previous pelvic surgery. Sixteen patients (59%)
responded to testing and had a definitive implantation with long-term follow-up of 37 months with sustained
response, while no patients after stapler surgery responded to neuromodulation [519]. Sacral neuromodulation
may be a choice in patients with CPP who failed to respond to biofeedback and drug therapy. The less invasive
PTNS was tested in twelve women with CPP lasting for at least six months and showed an improvement in
pain, QoL and sexual life [520]. No “sham” SNM or PTNS control group were used in either cited studies, which
limits their value as an important placebo effect cannot be ruled out.
5.3.3 Nerve blocks

Nerve blocks for pain management are usually carried out by specialists in pain medicine as part of a broader
management plan [66]. They may have a diagnostic or therapeutic role. Textbooks have been written on the
subject and practitioners using them should be trained in appropriate patient selection, indications, risks and
benefits. Many such interventions also require understanding and expertise in using imaging techniques to
perform the blocks accurately. Diagnostic blocks can be difficult to interpret due to the complex mechanisms
underlying the painful condition or syndrome. Sustained but limited benefit may lead to more permanent
procedures (e.g., radiofrequency procedures). There is a weak evidence base for these interventions for chronic
non-malignant pain [521].
Pudendal Neuralgia
The role of injections may be divided into two. First, an injection of local anaesthetic and steroid at the sight
of nerve injury may produce a therapeutic action. The possible reasons for this are related to the fact that
steroids may reduce any inflammation and swelling at the site of nerve irritation, but also because steroids may
block sodium channels and reduce irritable firing from the nerve [522]. However, a recent paper by Labat et al.
challenges this [523]. The second possible benefit is diagnostic. It has already been indicated that when the
pudendal nerve is injured there are several sites where this may occur. Differential block of the pudendal nerve
helps to provide information in relation to the site where the nerve may be trapped [261-271].
Infiltration at the ischial spine requires the use of a nerve stimulator/locator. Both motor (anal contraction) and
sensory endpoints may be noted. The anatomical endpoint may be localised by fluoroscopy, CT guidance,
or the use of US. US avoids any radiation, whereas CT guidance involves a significant amount of radiation.
Currently, fluoroscopy is probably the imaging technique most frequently used because it is readily available
to most anaesthetists that perform the block. Currently, infiltration of the pudendal nerve within Alcock’s canal
is primarily undertaken with the use of CT. As well as injecting around the pudendal nerve, specific blocks
of other nerves arising from the pelvis may be performed. Pulsed radio frequency stimulation has also been
suggested as a treatment [524].
5.4 Summary of evidence and recommendations: management
5.4.1 Management of PPS
Phenotypically directed treatment may improve treatment success. 3
α-blockers have moderate treatment effect regarding total pain, voiding, and QoL scores in PPS. 1a
Antimicrobial therapy has a moderate effect on total pain, voiding, and QoL scores in PPS. 1a
NSAIDs have moderate overall treatment effects on PPS. 1a
Phytotherapy has some beneficial effect on pain and overall favourable treatment response in PPS. 1a
Pentosane polysulphate improves global assessment and QoL score in PPS. 1b
There are insufficient data on the effectiveness of muscle relaxants in PPS. 2b
Pregabalin is not effective for the treatment of PPS. 1b
BTX-A injection into the pelvic floor (or prostate) may have a modest effect in PPS. 2b
Acupuncture is superior to sham acupuncture in improving symptoms and QoL. 1a
Posterior tibial nerve stimulation is probably effective for the treatment of PPS. 1b
Extracorporeal shock wave therapy is probably effective over the short term. 1b
There are insufficient data supporting the use of other surgical treatments, such as transurethral 3
incision of the bladder neck, transurethral resection of the prostate, or radical prostatectomy in
patients with PPS.
Cognitive behavioural therapy designed for PPS may improve pain and QoL. 3

Offer multimodal and phenotypically directed treatment options for Prostate Pain Weak
Syndrome (PPS).
Use antimicrobial therapy (quinolones or tetracyclines) over a minimum of six weeks in Strong
treatment-naïve patients with a duration of PPS less than one year.
Use α-blockers for patients with a duration of PPS less than one year. Strong
Offer high-dose oral pentosane polysulphate in PPS. Weak
Offer acupuncture in PPS. Strong
Offer non-steroidal anti-inflammatory drugs (NSAIDs) in PPS, but long-term side-effects Weak
have to be considered.
5.4.2 Management of BPS
There is insufficient data for the long-term use of corticosteroids. 3
Limited data exist on effectiveness of cimetidine in BPS. 2b
Amitriptyline is effective for pain and related symptoms of BPS. 1b
Oral pentosane polysulphate is effective for pain and related symptoms of BPS. 1a
Oral pentosane polysulphate plus subcutaneous heparin is effective for pain and related symptoms of 1b
BPS, especially in initially low responders to pentosane polysulphate alone.
Intravesical lidocaine plus sodium bicarbonate is effective in the short term. 1b
Intravesical pentosane polysulphate is effective, based on limited data, and may enhance oral 1b
treatment.
There are limited data on the effectiveness of intravesical heparin. 3
Intravesical chondroitin sulphate may be effective. 2b
There is insufficient data for the use of bladder distension as a therapeutic intervention. 3
Hydrodistension plus BTX-A is superior to hydrodistension alone. 1b
Intravesical BCG is not effective in BPS. 1b
Transurethral resection (coagulation and laser) may be effective in BPS type 3 C. 3
Sacral neuromodulation may be effective in BPS. 3
Pudendal nerve stimulation is superior to SNM for treatment of BPS. 1b
Avoidance of some food and drink may reduce symptoms. 3
Outcome of cystectomy for BPS is variable. 3

Offer subtype and phenotype-oriented therapy for the treatment of Bladder Pain Strong
Syndrome (BPS).
Always consider offering multimodal behavioural, physical and psychological techniques Strong
alongside oral or invasive treatments of BPS.
Administer amitriptyline for treatment of BPS. Strong
Offer oral pentosane polysulphate for the treatment of BPS. Strong
Offer oral pentosane polysulphate plus subcutaneous heparin in low responders to Weak
pentosane polysulphate alone.
Administer intravesical lidocaine plus sodium bicarbonate prior to more invasive methods. Weak
Administer intravesical pentosane polysulphate before more invasive treatment alone or Strong
combined with oral pentosane polysulphate.
Administer submucosal injection of botulinum toxin type A (BTX-A) plus hydrodistension if Strong
intravesical instillation therapies have failed.
Only undertake ablative organ surgery as the last resort and only by experienced and Strong
BPS-knowledgeable surgeons.
Offer intravesical hyaluronic acid before more invasive measures. Weak
Offer intravesical chondroitin sulphate before more invasive measures. Weak
Offer transurethral resection (or coagulation or laser) of bladder lesions, but in BPS type Strong
3 C only.
Offer neuromodulation before more invasive interventions. Weak
Offer dietary advice. Weak

Offer intravesical heparin before more invasive measures alone or in combination Weak
treatment.
Offer intravesical bladder wall and trigonal injection of BTX-A if intravesical instillation Strong
therapies have failed.
Do not recommend corticosteroids for long-term treatment. Strong
Do not use bladder distension as a treatment of BPS. Weak
5.4.3 Management of scrotal pain syndrome
Microsurgical denervation of the spermatic cord is an effective therapy for scrotal pain syndrome. 2b
Vasovasostomy is effective in post-vasectomy pain. 2b

Inform about the risk of post-vasectomy pain when counselling patients planned for Strong
vasectomy.
Do open instead of laparoscopic inguinal hernia repair, to reduce the risk of scrotal pain. Strong
In patients with testicular pain improving after spermatic block, offer microsurgical Weak
denervation of the spermatic cord.
5.4.4 Management of urethral pain syndrome
There is no specific treatment for urethral pain syndrome. 4
5.4.5 Management of gynaecological aspects of chronic pelvic pain
Therapeutic options, including pharmacotherapy and surgery, can treat endometriosis effectively. 1b
Psychological treatment (CBT or supportive psychotherapy) can improve pain and sexual and 1b
emotional function in vaginal and vulvar pain syndrome.
All other gynaecological conditions (including dysmenorrhea, obstetric injury, pelvic organ prolapse 3
and gynaecological malignancy) can be treated effectively using pharmacotherapy.

Involve a gynaecologist to provide therapeutic options such as hormonal therapy or Strong
surgery in well-defined disease states.
Provide a multi-disciplinary approach to pain management in persistent disease states. Strong
5.4.6 Management of anorectal pain syndrome
Summary of evidence on functional anorectal pain LE

Biofeedback is the preferred treatment for chronic anal pain syndrome. 1a
Electrogalvanic stimulation is less effective than biofeedback. 1b
Botulinum toxin type A is effective. 1b
Percutaneous tibial nerve stimulation is effective in anal pain. 3
Sacral neuromodulation is effective in anal pain. 3
Inhaled salbutamol is effective in intermittent chronic anal pain syndrome. 3

Undertake biofeedback treatment in patients with chronic anal pain. Strong
Offer botulinum toxin type A and electrogalvanic stimulation in chronic anal pain Strong
syndrome.
Offer percutaneous tibial nerve stimulation in chronic anal pain syndrome. Weak
Offer sacral neuromodulation in chronic anal pain syndrome. Weak
Offer inhaled salbutamol in intermittent chronic anal pain syndrome. Weak
5.4.7 Management of pudendal neuralgia
There are multiple treatment options with varying levels of evidence. 3

Neuropathic pain guidelines are well-established. Use standard approaches to Strong
management of neuropathic pain.
5.4.8 Management of sexological aspects in CPP
Pelvic floor muscle physical therapy may offer relief of pain and reduction in sexual complaints. 2b

Offer behavioural strategies to the patient and his/her partner to reduce sexual Weak
dysfunctions.
Offer pelvic floor muscle therapy as part of the treatment plan to improve quality of life Weak
and sexual function.
5.4.9 Management of psychological aspects in CPP

For CPP with significant psychological distress, refer patient for CPP-focused Strong
psychological treatment.
5.4.10 Management of pelvic floor dysfunction
Myofascial treatment is effective. 1b
Biofeedback improves the outcome of myofascial therapy. 1a

Apply myofascial treatment as first line treatment. Weak
Offer biofeedback as therapy adjuvant to muscle exercises, in patients with anal pain due Strong
to an overactive pelvic floor.

5.4.11 Management of chronic/non-acute urogenital pain by opioids

Prescribe opioid treatment, following multi-disciplinary assessment and only after other Strong
reasonable treatments have been tried and failed.
The decision to instigate long-term opioid therapy should be made by an appropriately Strong
trained specialist in consultation with the patient and their family doctor.
Where there is a history or suspicion of drug abuse, involve a psychiatrist or psychologist Strong
with an interest in pain management and drug addiction.
6. EVALUATION OF TREATMENT RESULTS

6.1 Evaluation of treatment
For patients with chronic visceral pain, a visit to the clinician is important because they can ask questions, talk
about how the process is going and have some time with the caregiver who understands the nature of their
pain. First evaluation should take place after about six weeks to see if the treatment has been successful or
not. When necessary adaptations are made and a next evaluation is planned.
6.1.1 Treatment has not been effective

6.1.1.1 Alternative treatment
In cases where the treatment initiated did not have enough effect, an alternative approach is advised. The first
thing to do is a thorough evaluation of the patients’ or care providers’ adherence to the treatment that was
initiated. Ask the patient if they have taken the medication according to the prescription, if there were any side-
effects and if there were any changes in pain and function. Adjustment of medication or dose schemes might
help. Another important thing to do is to read the reports of other caregivers like the physiotherapist and the
psychologist. Has the therapy been followed until the end, what was the opinion of the therapist about the
changes that were observed? In cases where the sessions had been ended by the patient, ask the patient why
they made that decision. Check if the patient has understood the idea behind the therapy that was prematurely
stopped.
6.1.1.2 Referral to next envelope of care

If patients and doctors come to the conclusion that none of the therapies given showed enough effect, then
referral to a next envelope of care is advised. Unfortunately, the terminology used to describe the nature and
specialisation level of centres providing specialised care for visceral pain patients is not standardised and
country-based. This does not facilitate easy referral schemes. It is advised that patients are referred to a centre
that is working with a multi-disciplinary team and nationally recognised as specialised in pelvic pain. Such a
centre will re-evaluate what has been done and when available, provide specialised care.
6.1.1.3 Self-management and shared care

Patients who find themselves confronted with CPP, for which there is no specific treatment option available,
will have to live with their pain. They will need to manage their pain, meaning that they will have to find a way to
deal with the impact of their pain on daily activities in all domains of life. Self-help programmes maybe advised
and can be of help. The patient may also benefit from shared care, which means that a caregiver is available for
supporting the self-management strategies. Together with this caregiver the patient can optimise and use the
management strategies.
6.1.2 Treatment has been effective

In cases where treatment has been effective the caregiver may pay attention to fallback prevention. If the
patient feels the same pain again, it helps to start at an early stage with the self-management strategies that
he/she has learned during the former treatment. By doing so they will have the best chance of preventing the
development of pelvic pain syndromes again.

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8. CONFLICT OF INTEREST
All members of the EAU Chronic Pelvic Pain Guidelines working panel have provided disclosure statements
on all relationships that they have that might be perceived to be a potential source of conflict of interest. This
information is publically accessible through the European Association of Urology website http://www.uroweb.
org/guidelines/. This document was developed with the financial support of the European Association of
Urology. No external sources of funding and support have been involved. The EAU is a non-profit organisation
and funding is limited to administrative assistance and travel and meeting expenses. No honoraria or other
reimbursements have been provided.
9. CITATION INFORMATION
The format in which to cite the EAU Guidelines will vary depending on the style guide of the journal in which the
citation appears. Accordingly, the number of authors or whether, for instance, to include the publisher, location,
or an ISBN number may vary.
The compilation of the complete Guidelines should be referenced as:

EAU Guidelines. Edn. presented at the EAU Annual Congress Copenhagen 2018. ISBN 978-94-92671-01-1.
If a publisher and/or location is required, include:

EAU Guidelines Office, Arnhem, The Netherlands. http://uroweb.org/guidelines/compilations-of-all-guidelines/
References to individual guidelines should be structured in the following way:

Contributors’ names. Title of resource. Publication type. ISBN. Publisher and publisher location, year.

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© European Association of Urology 2018

3. EPIDEMIOLOGY, AETIOLOGY AND PATHOPHYSIOLOGY 13

2 CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018

6. EVALUATION OF TREATMENT RESULTS 54

CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018 3

Structure and scope

1.2 Publication history

1.3 Available Publications

1.4 Panel composition

4 CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018

Definitions of CPP terminology

Classification of CPP syndromes

Clues to the mechanism

Guidelines for best treatment options

CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018 5

6 CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018

CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018

Sexological Dyspareunia SEXUOLOGICAL

Pelvic pain with sexual dysfunction Female dyspareunia

Hx = History; Ex = Examination; Ix = Investigation; PTSD = post-traumatic stress disorder.

Definition of chronic pelvic pain (CPP)

Definition of chronic pelvic pain syndrome

Further subdivision of CPPS

Psychological considerations for classification

8 CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018

Perineal pain syndrome

Table 2: Chronic Pelvic Pain Syndromes

Urological Pain Syndromes

CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018 9

10 CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018

CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018 11

12 CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018

2.3 Future goals

3. EPIDEMIOLOGY, AETIOLOGY AND

Introduction to chronic pelvic pain syndromes

CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018 13

3.1.3 Influence on Quality of Life

3.1.5 Risk Factors and underlying causes

14 CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018

3.1.5.2 Underlying causes

CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018 15

Visceral pain Somatic pain

Ongoing peripheral pain mechanisms in visceral pain

16 CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018

Central sensitisation as a mechanism in visceral pain

Psychological mechanisms in visceral pain

CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018 17

Understanding the psychological components of pain

3.1.5.3 Clinical paradigms in visceral pain

18 CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018

3.2 Pelvic Pain

3.2.2.2 Bladder Pain syndrome

3.2.2.3 Sexual pain syndrome

CHRONIC PELVIC PAIN - LIMITED UPDATE MARCH 2018 19

3.2.2.4 Myofascial pain syndromes

3.2.3 Influence on QoL

3.2.5 Risk factors and underlying causes

Urology Urinary flow, micturion diary, cystoscopy, ultrasound, uroflowmetry.

Ask for gynaecological, gastro-intesnal, ano-rectal, sexological complaints.

Sexological Erecle funcon, ejaculatory funcon, post-orgasmic pain.