Chronic Pelvic Pain (CPP)

Author: Christian Cobreros
Last Updated: November 2018

Current definition:
Persistent pain lasting longer than 6 months or recurrent episodes of abdominal/pelvic pain, hypersensitivity or discomfort often associated with elimination changes, and sexual dysfunction often in the absence of organic etiology (1)

History:

There are different definitions from different society guidelines and classifications that have evolved over the last decades.

IASP (2011): Chronic pelvic pain syndrome (CPPS) is the occurrence of chronic pelvic pain where there is no proven infection or other obvious local pathology that may account for the pain. It is often associated with negative cognitive, behavioral, sexual or emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynecological dysfunction. CPPS is a subdivision of chronic pelvic pain. (7,8)

European Association of Urology Guidelines in Chronic Pain (2016): Chronic pelvic pain syndrome as a persistent pain in structures related to the pelvis, in either men or women, is often associated with negative cognitive, behavioral, sexual and emotional consequences, as well as with symptoms and signs related to lower urinary tract, sexual, bowel, pelvic floor or gynecological dysfunction (6).

Controversy:

Definitions in the field of chronic pelvic pain are always controversial, but we all know definitions are needed. Since pain is a subjective phenomenon, trying to get a definition of a syndrome that is present in males and females with a different anatomy, and taking into account that different organs may be involved, is quite a challenge. However, what ultimately needs to be treated is pain. Furthermore, pain treatment must be individualized for each patient, taking into consideration the patient’s personal "perception of this pain".

It is accepted that there are different type of pains: nociceptive, somatic, visceral, centrally generated, hypersensitivity, or central sensitization pain. The classic pain associated with CPP is hypersensitivity where increased nerve activity from a standard stimulus has an unexpected clinical or tissue response. However, since all pain is modulated by cognitive factors and past/present emotional experience, it is difficult to say whether CPP is an abnormal perception of a normal stimulus or a normal perception of an abnormal physiologic sensory stimulus (pain experience). Also, we have to consider that it is widely accepted that CPP is pain that persists for at least six weeks in some definitions, and six months in the ICS and other definitions. Therefore, it is essential to take into account the impact of this pain on the quality of life, mood, sleep, relationships, functioning and activities (psychology of pain).

References:

1-Doggweiler, R., Whitmore, K. E., Meijlink, J. M., Drake, M. J., Frawley, H., Nordling, J., Hanno, P., Fraser, M. O., Homma, Y., Garrido, G., Gomes, M. J., Elneil, S., van de Merwe, J. P., Lin, A. T.L. and Tomoe, H. (2017), A standard for terminology in chronic pelvic pain syndromes: A report from the chronic pelvic pain working group of the international continence society. Neurourol. Urodynam., 36: 984–1008.doi:10.1002/nau.23072
2-Rosier PF, de Ridder D, Meijlink J, et al. Developing evidence-based standards for diagnosis and management of lower urinary tract or pelvic floor dysfunction. Neurourol Urodyn 2012;31:621-4 https://www.ncbi.nlm.nih.gov/pubmed/22396134
3-Merskey H. Classification of chronic pain. 2nd ed. In: Merskey H, editor. Seattle: IASP Press; 1994
4-Nickel JC, Shoskes DA, Wagenlehner FH. Management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): The studies, the evidence, and the impact. World J Urol 2013;31:747–53 https://www.ncbi.nlm.nih.gov/pubmed/23588814
5-Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: Report from the Standardisation Sub-Committee of the International Continence Society. Neurourol Urodyn 2002; 21:167–78.https://www.ncbi.nlm.nih.gov/pubmed/11857671
6-Engeler D, Baranowski AP, Borovicka J, Dinis-Oliveira P, Elneil S, Hughes J, Messelink EJ, de C Williams AC. EAU Guidelines on Chronic Pelvic Pain 2016. Available at: https://uroweb.org/wp-content/uploads/EAU-Guidelines-Chronic-Pelvic-Pain-2016-1.pdf
7-Baranowski A, Abrams P, Berger R, Buffington T, Collett B, Emanuel F, Hanno P, Howard F, Hughes J, Nickel C, Nordling J, Tripp D, Vincent K, Wesselmann U, de C Williams AC. IASP Classification of Chronic Pain, Second Edition (Revised). Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 2011 Available at: https://www.iasp-pain.org/PublicationsNews/Content.aspx?ItemNumber=1673&navItemNumber=677
8-Merskey H, Bogduk N, International Association for the Study of Pain. Task force on taxonomy. Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. Seattle: IASP Press; 1994. https://www.iasp-pain.org/files/Content/.../Classification-of-Chronic-Pain.pdf

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