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CHRONIC PELVIC PAIN


Semir A. S. Al Samarrai

 

Chronic pelvic pain (CPP)is a multifactorial condition and therefore, quite often, poorly managed. Management requires knowledge of all pelvic organ systems and their association with systems and conditions, including musculoskeletal, neurologic, urologic, gynaecologic and psychological aspects, promoting a multidisciplinary approach. (1) 

Introduction to chronic urogenital pain syndromes:

Over the years much of the focus for chronic pelvic pain has been on peripheral-end-organ mechanism, such as inflammatory of infective conditions. However, both animal and clinical research have indicated that many of the mechanisms for the CPP syndromes are based within the central nervous system (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, independent of the original cause.

Pain mechanism of urogenital systems may involve:

1) Ongoing acute pain (2) (such as those associated with inflammation or infection)-which may involve somatic or visceral tissue.
2) Chronic pain, which especially involve the CNS (3).
3) Emotional congnitive, behavioural and sexual responses and mechanisms (4, 5, 6, 7).

The ongoing peripheral visceral pain as a cause of CPP is in the most cases not present by ongoing tissue trauma, inflammation or infection. (8, 9, 10, 11). However, condition that produce recurrent trauma, infection or ongoing inflammation may result in CPP in small proportion of cases.

Taxonomy places the phenotypes describing the correlations into a relationship hierarchy.

The EAU approach subdivides CPP into conditions that are pain syndromes and those that are non-pain syndromes. The latterone 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 (1).

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 (International Association for the study of Pain) for publication in January 2012 (1,12).

Pain Syndrome of the EAU was inspired by the IASP Classification (12, 13), and much work around what has become known as “pain as a disease” and it’s associated psychological, behavioural, sexual and functional correlates.

Definition:

Chronic pelvic pain (CPP) 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 (1).

Chronic pelvic pain may be subdivided into conditions with well-defined classical pathology(such as infection or cancer) and those with no obvious pathology.But the definition of the chronic pelvic pain syndrome CPPS is the occurrence of CPP when there is no proven infection or other obvious local pathology that may account for the pain, but this Syndrome is often associated with negative congnitive, behavioural, sexual or emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecologicaldysfunction (1).

The EAU classification of the chronic urogenital pain syndrome has been set up according to an axis system used by IASP (1+12):

This is divided into seven axises:

The first axis contains

a) The Specific disease associated pelvic pain
b) The Pelvic pain syndrome

The second axis contains the involved systems and are:

1) Urological
2) Gynaecological
3) Gastrointestinal
4) Peripheral nerves
5) Sexological
6) Psychological
7) Musculoskeletal

But our article will comprehend only the urological, sexological and psychological systems.

The third axis contains End organ as pain syndrome:

The urological are:

a) Prostate-Pain
b) Bladder-Pain
c) Scrotal, Testicular, and Epididymal-Pain
d) Penile and Urethral-Pain
e) Post Vasectomy-Pain

And the sexological are

a) Pelvic pain with sexual dysfunction
b) Dyspareunia
And the psychological are pelvic organ from the patient.

The fourth axis contains referral characteristics of pain and area.

a) Suprapubic
b) Inguinal
c) Urethral
d) Penile/clitoral
e) Perineal
f) Rectal
g) Back
h) Buttocks
i) Thighs

The fifth axis contains temporal characteristics of the pain as: (onset, acute, chronic, ongoing, sporadic, cyclical, and continuous) 

The sixth axis contains the really character of pain as: (Aching, Burning, Stabbing, Electric) 

The Seventh axis contains the associated symptoms to the chronic urogenital pain syndrome as: (Frequency, Nocturia, Hesitance, Dysfunction flow, Urge-incontinence)

But by the sexological pain syndrome are the sexological satisfaction, erectile dysfunction and by female the sexual avoidance by dyspareunia. 

The eight axis contains the Psychological Symptoms of the Chronic Urologenital pain syndromes as:
a) Anxiety about pain or putative cause of pain
b) Catastrofic thinking about pain
c) Depression attributed to pain or impact of pain (1, 12)

Psychological consideration 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, fear about pain or its implications, unhelpful coping strategies, and distress in relationships. Both anxiety and depression can be significant important concominant symptoms that are relevant to pain, disability and poor QoL (1) 

Catastrophic interpretation of pain has been shown to be 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 refractory nature of the patients’ symptoms. 

It is important to note that many of these biopsychsocial consequences are common to other persistent pain problems but may show varying degrees of salience for anyone 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 symptoms). (1) 

Functional consideration for classification

Functional disorders are pathologies that have arisen secondary to changes in the control mechanisms of an organ or system. That is they are disorders characterized by disturbance of function. Many CPPS, are associated with functional-abnormalities at a local and even systemic level. They also need to be defined as a part of the phenotype. 

Functional pain disorder may not express significant pathology in the organs that appear responsible to the primary symptoms, but they are associated with substantial neurobiological, physiological and sometimes anatomical changes in the Central Nervous System (CNS). (1) 

The 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. (1) 

The Perineal Pain Syndrome is 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 dysfunctions.(1) 

Perineal Pain Syndrome should be distinguish from pudendal neuralgia, which is a specific disease associated with pelvic pain that is caused by nerve damages. (1) 

References:

1. Engeler D, Baranowski AP, Elneil S, et al: Guidelines on Chronic Pelvic Pain 2012
http:/www.urowe.org/guidelines/online-guidelines/.
2. Linley JE, Rose K, Ooi L, et al. understanding inflammatory pain: ion channels contributing to acute and chronic nociception. Pflugers Arch. 2010 Apr;459(5):657-69
3. McMahon SB, Dmitrieva N, Koltzenburg M, et al. Visceral pain. Br J Anaesth 75(2): 132-144.
4. Bergeron S, Khalife S, Glazer Hl, et al. Surgical and behavioral treatments for vestibulodynia: two-and-one-half year follow up and predictors of outcome. Obstet Gynecol.2008 Jan; 111(1): 159-66.
5. Tripp DA, Nickel JC, Wang Y, et al. Catastrophizing and pain contingent rest predict patient adjustment in men with chronic prostatitis/chronic pain syndrome. J Pain. 2006 Oct;7(10):697-708.
6. Tripp DA, Nickel JC, Fitzgerarld MP, et al. Sexual functioning, catastrophizing, depression, and pain, as predictors of quality of life in women with interstitial cystitis/painful bladder syndrome. Urology.2009 May 73(5):987-92.
7. Nickel JC, Tripp DA, Pontari M, et al. Psychosocial phenotyping in women with interstitial cystitis/painful bladder syndrome: a case control study. J Urol. 2010 Jan; 183 (1):167-72.
8. Abrams PA, Baranowski AP, Berger RE, et al. A new classification is needed for pelvic pain syndromes—are existing terminologies of spurious diagnostic authority bad for patients? J Urol.2006 Jun;175(6):1989-90
9. Baranowski AP, AbramsP, Berger RE, et al. Urogenital pain—time to accept a new approach to phenotyping and, as a consequences, management. Eur Urol.2008 jan;53(1):33-6
10. Baranowski AP, Abrams P, et al. (2008). Urogenital Pain in Clinical Practice. New York, Informa Healthcare.
11. Hanno P, Lin A, Nording J, et al. Bladder Pain Syndrome Committee of the International Consultation on Incontinence. NeurourolUrodyn 29(1):191-198.
12. Merskey H, Bogduk N. Classification of Chronic Pain. Seattle, IASP press.
13. Fall M, Baranowski AP, Fowler CJ, et al. EAU guidelines on chronic pelvic pain. Eur Urol.2004 Dec;46(6):681-9.

Correspondence:
Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576
Email: fmcalsam@emirates.net.ae