Chronic Pelvic Pain

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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 10 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.

Structure and scope

The panel wishes to take advantage of modern methods of delivering guideline information to clinicians dealing with these patients. We therefore plan to make a stepped information structure, in alignment with stepped care protocols. It is the vision of the panel to use new digital information sources like websites and apps to aid this process. Furthermore, the panel wishes to change the guideline according to the template used in all other non-oncology guidelines of the EAU. It has been 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.

Summary of Changes

For the 2016 version the panel has made updates focusing on two important changes to the guideline. The first one was to rewrite the guideline in such a way that it is centred around pain instead of being organ centred. Chapters in previous editions were named after the organ or after the specialist that is consulted by the patient. For the 2016 edition of this guideline, pain is the centre and all other information is built around this central theme. The guideline is partly theoretical to show the importance of using this pain centred approach. The biggest part, however, deals with the practical approach in diagnostics, treatment and management of patients with abdominal and pelvic pain. In this version the panel can only provide data on incidence, costs and quality of life issues in selected sub-chapters.

The second change the panel worked on is the way of presenting the practical aspects of pain. The guideline, based on pain in the centre, leads the healthcare professional through the different steps in the process of dealing with abdominal and pelvic pain patients. One could say that it is patient centred instead of complaint centred. Theoretical information will serve as background and can be read when needed.

This second focus of updating is of great importance for developing modern ways to make information available for the general clinicians who see the patient in their office. It contains red flags, associated conditions and available first line treatments. It is available for the medical specialist who sees a patient with chronic pain. The guideline highlights necessary investigations and phenotyping, treatment options, decision making on whether a treatment is rational or not, and how and when to refer to a specialised pelvic pain centre. Caregivers who treat patients for pain related problems like myofascial and sexological dysfunctions will find help in making treatment plans and in the timing of referring back to specialised pain care. The guideline will also aid those involved in coaching self-management and shared care.

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 the Chapters 5 ‘Gastrointestinal aspects of chronic pelvic pain’ and 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 guidelines [5].

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. These reference documents follow the updating cycle of the underlying large texts. All available material can be viewed and downloaded for personal use at the EAU website. The EAU website also includes a selection of EAU Guidelines 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 three urologists, a neuro-urologist, two consultants in pain medicine, a gynaecologist, a psychologist, a gastroenterologist and one sexologist.

The Panel is most grateful for the expertise and support given by Dr. A. Cottrell (Guidelines Associate) in the process of transforming the document into the 2016 guideline structure, according to the template used in all other non-oncology guidelines of the EAU.

The Panel is also grateful to Dr. N. Wood for his 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 subdivided into that with primarily diarrhoea or that with constipation. Phenotyping is based upon mechanisms when they are known (e.g., infection, ischaemic, autoimmune, 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 (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 subdivides 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 classification, 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 in 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

Subdividing pain syndromes

There is much debate on the subdivisions 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 thus be aimed at obtaining a differential diagnosis; repeated, unnecessary investigations are detrimental in the management of chronic pain syndromes.

2.A subdivision 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 autoimmune disorders.

3.In 2004 this expert 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 the light of these and other publications, the symptom classification table has been updated (Table 1).

The debate in relation to subdividing 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. Whether this is appropriate, only time and good research will tell. 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.

In Table 1 the classification has been set up according to the axis system used by IASP.

Table 1: EAU classification of chronic pelvic pain syndromes

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 10 years work developing the initial ideas, an updated version was accepted by 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 perceived in the 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 6 months. That is, it can be cyclical over a 6-month period, such as the cyclical pain of dysmenorrhoea. Six months is arbitrary, however, it was chosen because 3 months was not considered long enough if we include cyclical pain conditions. 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 subdivided 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 (CPPS)

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. CPPS is a subdivision 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 BPS. 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 authors of this text, never subdivide by anatomy and prefer to refer

to patients with pain perceived within the pelvis and no specific disease process as suffering from CPPS, subdivided 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 biopsychosocial 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 hence the 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 subdivision

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 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 authors 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 subdivided 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: Urological pain syndromes

Urological Pain Syndromes

Abdominal and Pelvic Pain Syndromes

Prostate pain syndrome

Prostate pain syndrome (PPS) is the occurrence of persistent or recurrent episodic 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 syndrome

Bladder pain syndrome (BPS) is the occurrence of persistent or recurrent pain 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 subclassifications [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 syndrome

Scrotal pain syndrome is the occurrence of persistent or recurrent episodic pain localised within the organs of the scrotum, and may be associated with symptoms suggestive of 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, as well as with symptoms suggestive of lower urinary tract and sexual dysfunction. 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 syndrome

Testicular pain syndrome is the occurrence of persistent or recurrent episodic pain perceived in the testes, and may be associated with symptoms suggestive of 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, as well as with symptoms suggestive of lower urinary tract and sexual dysfunction. Previous terms have included orchitis, orchialgia and orchiodynia. These terms are no longer recommended.

Epididymal pain syndrome

Epididymal pain syndrome is the occurrence of persistent or recurrent episodic pain perceived in the epididymis, and may be associated with symptoms suggestive of 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, as well as with symptoms suggestive of lower urinary tract and sexual dysfunction.

Penile pain syndrome

Penile pain syndrome is the occurrence of pain within the penis that is not primarily in 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 syndrome

Urethral pain syndrome is the occurrence of chronic or recurrent episodic pain 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 scrotal pain syndrome

Post-vasectomy scrotal pain syndrome is a scrotal pain syndrome that follows vasectomy. Post-vasectomy scrotal 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. Post-vasectomy pain may be as frequent as 1% following vasectomy, possibly more frequent. The mechanisms are poorly understood and it is for that reason considered a special form of scrotal pain syndrome.

Gynaecological Pain Syndromes: external genitalia

Vulvar pain syndrome

Vulvar pain syndrome is the occurrence of persistent or recurrent episodic vulvar pain. 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 subdivided 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 pain syndrome

Generalised vulvar pain syndrome refers to a vulvar pain syndrome in which the pain/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 pain syndrome

Localised vulvar pain syndrome refers to pain that can be consistently and precisely 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 subdivided into vestibular pain syndrome and clitoral pain syndrome.

Vestibular pain syndrome

Vestibular pain syndrome refers to pain that can be localised by point-pressure mapping to the vestibule or is well perceived in the area of the vestibule.

Clitoral pain syndrome

Clitoral pain syndrome refers to pain that can be localised by point-pressure mapping to the clitoris or is well perceived in the area of the clitoris.

Gynaecological system: internal pelvic pain syndromes

Endometriosis-associated pain syndrome

Endometriosis-associated pain syndrome is chronic or recurrent pelvic pain in patients with laparoscopically confirmed endometriosis, and the term is used when the symptoms persist despite adequate endometriosis treatment. 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. 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 pain syndrome with cyclical exacerbations

Chronic pelvic pain syndrome with cyclical exacerbations covers the non-gynaecological organ pain that frequently shows cyclical exacerbations (e.g., IBS or BPS) as well as pain similar to that associated with endometriosis/adenomyosis but 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 Syndrome (IBS)

IBS is the occurrence of chronic or recurrent episodic pain perceived in the bowel, in the absence of proven infection or other obvious local pathology. Bowel dysfunction is frequent. IBS is often associated with worry and preoccupation 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]: 3 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 (> 3 bowel movements per day or < 3 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 syndrome

Chronic anal pain syndrome is the occurrence of chronic or recurrent episodic pain 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 chronic anal pain syndrome

Intermittent chronic anal pain syndrome refers to severe, brief, episodic pain that seems to arise in the rectum or anal canal and occurs at irregular intervals. This is unrelated to the need to or the process of defecation. It may be considered a subgroup 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 pain syndrome

Pelvic floor muscle pain syndrome is the occurrence of persistent or recurrent episodic pelvic floor pain. There is no proven well-defined local 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. This syndrome may be associated with overactivity 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 syndrome

Coccyx pain syndrome is the occurrence of chronic or recurrent episodic pain 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.

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