Chronic Pelvic Pain

Full Text Guidelines Summary of Changes Scientific Publications & Appendices Pocket Guidelines Archive Panel

To access the pdfs & translations of individual guidelines, please log in as EAU member.
Non-EAU members can view the web versions.
To become an EAU member, click here.

EAU GUIDELINES ON
CHRONIC PELVIC PAIN

(Limited text update March 2017)

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: S. Goonewardene, M.P. Schneider

Introduction

The EAU Guideline for Chronic Pelvic Pain 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. The EAU 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.

This pocket version aims to synthesise the important clinical messages described in the full text and is presented as a series of ‘graded action based recommendations’, which follow the standard for levels of evidence used by the EAU (see Introduction chapter of the EAU Guidelines book ISBN 978-90-79754-91-5).

Chronic pelvic pain syndromes

Classification

Much debate over the classification of chronic pelvic pain (CPP) has occurred, is ongoing and will continue in the future. Classification involves three aspects of defining a condition: phenotyping, terminology and taxonomy.

Definition of 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.)

Definition of 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.

Table 1: Classification of chronic pelvic pain syndromes

Axis I

Region

Axis II

System

Axis III

End-organ as pain syndrome as identified from Hx, Ex and Ix

Axis IV

Referral

characteristics

Axis V

Temporal

characteristics

Axis VI

Character

Axis VII

Associated

symptoms

Axis VIII

Psychological

symptoms

Chronic

pelvic

pain

Specific

disease

associated

pelvic pain

OR

Pelvic pain syndrome

Urological

Prostate

Suprapubic

Inguinal

Urethral

Penile/clitoral

Perineal

Rectal

Back

Buttocks

Thighs

ONSET

Acute

Chronic

ONGOING

Sporadic

Cyclical

Continuous

TIME

Filling

Emptying

Immediate post

Late post

TRIGGER

Provoked

Spontaneous

Aching

Burning

Stabbing

Electric

UROLOGICAL

Frequency

Nocturia

Hesitance

Dysfunctional flow

Urgency

Incontinence

GYNAECOLOGICAL

Menstrual

Menopause

GASTROINTESTINAL

Constipation

Diarrhoea

Bloatedness

Urgency

Incontinence

NEUROLOGICAL

Dysaesthesia

Hyperaesthesia

Allodynia

Hyperalegesie

SEXOLOGICAL

Satisfaction

Female dyspareunia

Sexual avoidance

Erectile dysfunction

Medication

MUSCLE

Function impairment

Fasciculation

CUTANEOUS

Trophic changes

Sensory changes

ANXIETY

About pain

or putative

cause of pain

Catastrophic

thinking about

pain

DEPRESSION

Attributed to

pain or impact

of pain

Attributed to

other causes

Unattributed

PTSD

SYMPTOMS

Re-experiencing

Avoidance

Bladder

Scrotal

Testicular

Epididymal

Penile

Urethral

Post-vasectomy

Gynaecological

Vulvar

Vestibular

Clitoral

Endometriosis associated

CPPS with cyclical exacerbations

Dysmenorrhoea

Gastrointestinal

Irritable bowel

Chronic anal

Intermittent chronic anal

Peripheral nerves

Pudendal pain syndrome

Sexological

Dyspareunia

Pelvic pain with sexual dysfunction

Psychological

Any pelvic organ

Musculo-skeletal

Pelvic floor muscle

Abdominal muscle

Spinal

Coccyx

Table 2: Chronic Pelvic Pain Syndromes

Urological Pain Syndromes

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 includes infection (types I and II), which the authors feel should not be considered under PPS, but as specific disease-associated pelvic pain.

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 emotionalconsequences, 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.

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 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 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 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.

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 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 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 subsumed 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-pressuremapping 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.

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 sub-divided 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 Pain Syndromes: 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.

CPPS with cyclical exacerbations

CPPS 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 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 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: 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.

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.

Epidemiology, Aetiology and Pathophysiology

Chronic visceral pain, pelvic pain and abdominal aspects of pelvic pain

Recommendations

GR

All of those involved in the management of Chronic Pelvic Pain (CPP) should have knowledge of peripheral and central pain mechanisms.

A

The early assessment of patients with CPP should involve:

investigations aimed at specific disease-associated pelvic pain

assessment of functional, emotional, behavioural, sexual and other quality of life issues, such as effect on work and socialisation.

A

CPPS patients should be managed in a multi-specialty and multi-disciplinary environment with consideration of all their symptoms.

A

Diagnostic Evaluation

History and physical examination

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, primary anatomical or functional disease of the pelvic organs, and neurogenic disease must be ruled out. 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. As well as a local examination, a general musculoskeletal and neurological examination should be considered an integral part of the assessment and be undertaken, if appropriate.

Figure 1: Diagnosing chronic pelvic pain

Figure 2: Phenotyping of pelvic pain

Recommendations for diagnostic evaluation

Recommendations for the management of Prostate Pain Syndrome (PPS)

GR

Adapt diagnostic procedures to the patient. Specific diseases with similar symptoms must be excluded.

A

Use a validated symptom and quality of life scoring instrument, such as the NIH-CPSI (Chronic Prostatitis Symptom Index), for initial assessment and follow-up.

B

Assess prostate pain syndrome associated negative cognitive, behavioural, sexual, or emotional consequences, as well as symptoms of lower urinary tract and sexual dysfunctions.

B

Recommendations for the management of Bladder Pain Syndrome (BPS)

GR

Patients with bladder pain should undergo general anaesthetic rigid cystoscopy in accordance with the International Society for the Study of BPS (ESSIC) guidelines.

A

After primary exclusion of specific diseases, patients with symptoms according to the above definition should be diagnosed with BPS by subtype and phenotype.

A

Assess BPS associated non-bladder diseases systematically.

A

Assess BPS associated negative cognitive, behavioural, sexual, or emotional consequences.

A

Use a validated symptom and quality of life scoring instrument for initial assessment and follow-up.

B

Recommendations for the management of gynaecological aspects of CPP

GR

All women with pelvic pain should have a full gynaecological history and evaluation, including laparoscopy to rule out a treatable cause (e.g. endometriosis).

A

Recommendations for the management of anorectal pain syndrome

GR

Functional testing is recommended in patients with anorectal pain.

A

Recommendations for the management of pudendal neuralgia

GR

Rule out confusable diseases.

A

If a peripheral nerve pain syndrome is suspected, early referral should occur to an expert in the field, working within a multi-disciplinary team environment.

B

Imaging and neurophysiology helps diagnosis but image and nerve locator guided local anaesthetic injection is preferable.

B

Recommendations for the management of sexological aspects in CPP

GR

Patients presenting with symptoms suggestive for chronic pelvic pain syndrome, should be screened for abuse, without suggesting a causal relation with the pain.

B

The bio-psychosocial model should be applied in the evaluation of the effect of chronic pelvic pain syndrome on the sexual function of the patient.

B

The bio-psychosocial model should be incorporated in research in the role of chronic pelvic pain in sexual dysfunction.

B

Recommendations for the management of psychological aspects of CPP

GR

Psychological distress is common in pelvic pain in women, but should be interpreted in the context of pain.

A

Ask patients what they think is the cause of their pain to allow the opportunity to inform and reassure as appropriate.

B

Recommendations for the management of pelvic floor function

GR

Use the International Continence Society (ICS) classification on pelvic floor muscle function and dysfunction.

A

In patients with chronic pelvic pain syndrome it is recommended to actively look for the presence of myofascial trigger points.

B

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. Providing information that is personalised and responsive to the patient’s problems, conveying belief and concern, is a powerful way to allay anxiety. Additional written information or direction to reliable sources 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.

Recommendations for the management of Prostate Pain Syndrome (PPS)

GR

Offer multimodal and phenotypically directed treatment options for PPS.

A

Single use of antimicrobial therapy (quinolones or tetracyclines) is recommended in treatment-naïve patients over a minimum of six weeks with a duration of PPS less than one year.

A

α-blockers are recommended for patients with a duration of PPS less than one year.

A

High-dose pentosane polysulphate is recommended in PPS.

A

Acupuncture is recommended for use in PPS.

B

Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for use in PPS, but long-term side-effects have to be considered.

B

For PPS with significant psychological distress, psychological treatment focused on PPS is

recommended.

B

Recommendations for the management of Bladder Pain Syndrome (BPS)

GR

Offer subtype and phenotype-oriented therapy for the treatment of BPS.

A

Multimodal behavioural, physical and psychological techniques should always be considered alongside oral or invasive treatments of BPS.

A

Administer amitriptyline for use in BPS.

A

Offer oral pentosane polysulphate for the treatment of BPS.

A

Treatment with oral pentosane polysulphate plus subcutaneous heparin is recommended especially in low responders to pentosane polysulphate alone.

A

Administer intravesical lidocaine plus sodium bicarbonate prior to more invasive methods.

A

Administer intravesical pentosane polysulphate before more invasive treatment alone or combined with oral pentosane polysulphate.

A

Administer submucosal injection of Botulinum toxin type A (BTX-A) plus hydrodistension if intravesical instillation therapies have failed.

A

All ablative organ surgery should be the last resort for experienced and BPS knowledgeable surgeons only.

A

Offer intravesical hyaluronic acid before more invasive measures.

B

Offer intravesical chondroitin sulphate before more invasive measures.

B

Offer transurethral resection (or coagulation or laser) of bladder lesions, but in BPS type 3 C only.

B

Offer neuromodulation before more invasive interventions.

B

Offer dietary advice.

C

Offer intravesical heparin before more invasive measures alone or in combination treatment.

C

Offer intravesical bladder wall and trigonal injection of BTX-A if intravesical instillation therapies have failed.

C

Corticosteroids are not recommended for long-term treatment.

C

Bladder distension is not recommended as a treatment of BPS.

C

Recommendations for the management of scrotal pain syndrome

GR

Start with general treatment options for chronic pelvic pain.

A

Inform about the risk of post-vasectomy pain when counselling patients planned for vasectomy.

A

To reduce the risk of scrotal pain, open instead of laparoscopic inguinal hernia repair is recommended.

A

It is recommended that during inguinal hernia repair all the nerves in the spermatic cord are identified.

A

For patients who are treated surgically, microsurgical denervation of the spermatic cord is recommended.

A

We recommend that orchiectomy should not be done, unless all other therapies, including pain management assessment, have failed.

C

Recommendations for the management of urethral pain syndrome

GR

Start with general treatment options for chronic pelvic pain.

A

It is recommended that patients with urethral pain syndrome are treated in a multi-disciplinary and multimodal programme.

B

When patients are distressed, it is recommended to refer them for pain-relevant psychological treatment to improve function and quality of life.

B

Recommendations for the management of gynaecological aspects of CPP

GR

Provide therapeutic options such as hormonal therapy or surgery in well-defined disease states.

B

Provide a multi-disciplinary approach to pain management in persistent disease states.

B

Recommendations for functional anorectal pain

GR

Bio-feedback treatment is recommended in patients with pelvic pain and dyssynergic defecation.

A

Offer botulinum toxin type A and electrogalvanic stimulation in chronic anal pain syndrome.

B

Offer percutaneous tibial nerve stimulation in chronic anal pain syndrome.

B

Offer sacral neuromodulation in chronic anal pain syndrome.

C

Offer inhaled salbutamol in intermittent chronic anal pain syndrome.

C

Recommendations for the management of pudendal neuralgia

GR

Neuropathic pain guidelines are well-established. Standard approaches to management of neuropathic pain should be utilised.

A

Recommendations for the management of sexological aspects in CPP

GR

Offer behavioural strategies to the patient and his/her partner to cope with sexual dysfunctions.

B

Training of the pelvic floor muscles is recommended to improve quality of life and sexual function.

B

Recommendations for the management of pelvic floor functions

GR

Apply myofascial treatment as first line treatment.

A

In patients with an overactive pelvic floor, biofeedback is recommended as therapy adjuvant to muscle exercises.

A

When myofascial trigger points are found, treatment by pressure or needling is recommended.

A

Recommendations for the management of chronic/non-acute urogenital pain by opioids

GR

All other reasonable treatments must have been tried and failed, before considering opioid treatment.

A

The decision to instigate long-term opioid therapy should be made by an appropriately trained specialist in consultation with another physician (including the patient and their family doctor).

A

Where there is a history or suspicion of drug abuse, a psychiatrist or psychologist with an interest in pain management and drug addiction should be involved.

A

This short booklet is based on the more comprehensive EAU Guidelines (ISBN 978-90-79754-91-5), available to all members of the European Association of Urology at their website, http://www.uroweb.org/guidelines/.

Top
×