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Chronic Pelvic Pain Syndrome (CPPS)

• CPPS: definition and etiology
• CPPS: signs and symptoms, diagnostic workup
• CPPS: treatment

Definition

The chronic pelvic pain syndrome (CPPS) is characterized by:

• chronic or recurrent pain for at least six months that is perceived in pelvic structures;
• CPPS affects women and men;
• no evidence of pelvic organ disease (diagnosis of exclusion);
• CPPS is associated with symptoms of the lower urinary tract and rectum and often adversely affects sexuality and psychological well-being;
• If pain is perceived in a single organ or area (e.g., the urinary bladder, prostate, testis, perineum, vulva, or after vasectomy), more specific terms should be used: bladder pain syndrome, prostate pain syndrome, testicular pain syndrome, pelvic floor pain syndrome, vulvar pain syndrome, or postvasectomy testicular pain syndrome.

Obsolete terms:

In the absence of symptoms and signs of bacterial infection of the prostate, the term chronic prostatitis should not be used for CPPS. The suffix “-itis” in the disease term misleads patients and clinicians. For the definition of chronic prostatitis, see bacterial prostatitis. The terms prostatodynia and vulvodynia are also discouraged EAU guidelines: Chronic pelvic pain.

Epidemiology

Recurrent pain involving the prostate, testes, or penis is common and is among the most frequent urologic diagnoses in men younger than 50 years. Up to 5 % of men aged 20–50 years are affected; incidence peaks between 20 and 49 years and after age 70 years.

Etiology

The etiology of CPPS is heterogeneous. A multifactorial pathogenesis involving triggering and disease-sustaining factors is likely.

Pain type:

Visceral pain is typical of CPPS: it has a sudden and severe onset, is diffuse and difficult to localize, may be accompanied by autonomic reactions, may radiate to the skin and muscles, and is associated with hyperalgesia.

Disease-triggering factors:

These commonly include recurrent infections, injuries, or dysfunctions that repeatedly induce painful stimuli. In some patients, neuromodulatory processes allow pain to become independent of its initiating cause.

Neuroplasticity of the CNS:

Over time, recurrent stimuli lead to central sensitization, with increased sensitivity of pain receptors, pain pathways, and CNS areas. This lowers the threshold for pain perception (allodynia) and can cause pain in other regions, complicating diagnosis and treatment.

Muscular hyperalgesia:

The lowered threshold for pain perception may lead to pelvic floor insertional tendinopathies, myogeloses, or myofascial trigger points. Pelvic floor activation causes pain during voiding or sexual activity, resulting in avoidance behavior and negative experiences.

Visceral hyperalgesia:

Central sensitization increases the perception of visceral afferent signals related to storage, emptying, and organ pain. Visceral hyperalgesia due to neuroplastic CNS processes is not limited to chronic pain. Even after acute cystitis, this mechanism can cause an overactive bladder lasting several weeks.

Psychosomatic disorders:

Anxiety disorders, depression, and personality disorders are more common in patients with CPPS than in controls. Several explanations are possible: psychiatric disorders can intensify pain perception, whereas chronic pain can itself trigger or perpetuate psychiatric disorders.

References

EAU guidelines: Chronic pelvic pain

Krieger u.a. 1999 KRIEGER, J. N. ; NYBERG, Jr. ; NICKEL, J. C.: NIH consensus definition and classification of prostatitis.
In: Jama
282 (1999), Nr. 3, S. 236–7

Nickel 2003 NICKEL, J. C.: Recommendations for the evaluation of patients with prostatitis.
In: World J Urol
21 (2003), Nr. 2, S. 75–81

Schaeffer u.a. 2002 SCHAEFFER, A. J. ; DATTA, N. S. ; FOWLER, Jr. ; KRIEGER, J. N. ; LITWIN, M. S. ; NADLER, R. B. ; NICKEL, J. C. ; PONTARI, M. A. ; SHOSKES, D. A. ; ZEITLIN, S. I. ; HART, C.: Overview summary statement. Diagnosis and management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).
In: Urology
60 (2002), Nr. 6 Suppl, S. 1–4

  Deutsche Version: Chronische Prostatitis und chronisches Beckenschmerzsyndrom

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