EAU Guidelines on Chronic Pelvic Pain
Authors:
M. Fall 1; A. P. Baranowski 2; S. Elneil 3; D. Engeler 4; J. Hughes 5; E. J. Messelink 6; F. Oberpenning 7; A. C. De C. Williams 8
Authors‘ workplace:
Department of Urology, Sahlgrenska Academy, Göteborg University, Göteborg, Sweden
1; Pain Management Centre, The National Hospital for Neurology and Neurosurgery, University College London Hospitals Foundation Trust, London, United Kingdom
2; Centre for Urogynaecology, The National Hospital for Neurology and Neurosurgery, University College London Hospitals Foundation Trust, London, United Kingdom
3; Department of Urology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
4; Pain Management Unit, The James Cook University Hospital, Middlesborough, United Kingdom
5; Department of Urology, University Hospital Groningen, Groningen, The Netherlands
6; Department of Urology, St-Agnes Hospital, Bocholt, Germany
7; University College London Hospitals Foundation Trust, London, United Kingdom
8
Published in:
Urol List 2010; 8(3): 93-106
Overview
Context:
These guidelines were prepared on behalf of the European Association of Urology (EAU) to help urologists assess the evidence-based management of chronic pelvic pain (CPP) and to incorporate the recommendations into their clinical practice.
Objective:
To revise guidelines for the diagnosis, therapy, and follow-up of CPP patients.
Evidence acquisition:
Guidelines were compiled by a working group and based on a systematic review of current literature using the PubMed database, with important papers reviewed for the 2003 EAU guidelines as a background. A panel of experts weighted the references.
Evidence synthesis:
The full text of the guidelines is available through the EAU Central Office and the EAU Web site (www.uroweb.org). This article is a short version of the full guidelines text and summarises the main conclusions from the guidelines on the management of CPP.
Conclusions:
A guidelines text is presented including chapters on chronic prostate pain and bladder pain syndromes, urethral pain, scrotal pain, pelvic pain in gynaecologic practice, neurogenic dysfunctions, the role of the pelvic floor and pudendal nerve, psychological factors, general treatment of CPP, nerve blocks, and neuromodulation. These guidelines have been drawn up to provide support in the management of the large and difficult group of patients suffering from CPP.
Key words:
bladder pain syndrome, chronic pelvic pain, EAU guidelines, interstitial cystitis, prostate pain syndrome, prostatitis
Sources
1. Fall M, Baranowski AP, Elneil S et al. EAU guidelines on chronic pelvic pain. European Association of Urology Web site.
http://www.uroweb.org/fileadmin/tx_eauguidelines/2009/Full/CPP.pdf. Updated March 2008.
2. Fall M, Baranowski AP, Fowler CJ et al. EAU guidelines on chronic pelvic pain. Arnhem, Netherlands: European Association of Urology; 2003.
3. Agency for Health Care Policy and Research. Washington, DC: US Department of Health and Human Services, Public Health Service 1992: 115–127.
4. Abrams P, Baranowski A, Berger R et al. A new classification is needed for pelvic pain syndromes—are existing terminologies of spurious diagnostic authority bad for patients? J Urol 2006; 175: 1989–1990.
5. Krieger JN, Nyberg Jr L, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA 1999; 282: 236–237.
6. Abrams P, Cardozo L, Fall M et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Subcommittee of the International Continence Society. Am J Obstet Gynecol 2002; 187: 116–126.
7. Baranowski AP, Abrams P, Berger RE et al. Urogenital pain – time to accept a new approach to phenotyping and, as a consequence, management. Eur Urol 2008; 53: 33–36.
8. van de Merwe JP, Nordling J, Bouchelouche P et al. Diagnostic criteria, classification, and nomenclature for painful bladder syndrome/interstitial cystitis: an ESSIC proposal. Eur Urol 2008; 53: 60–67.
9. Nickel JC, Weidner W. Chronic prostatitis: current concepts and antimicrobial therapy. Infect Urol 2000; 13: S22–28.
10. Barry MJ, Fowler Jr FJ, O’Leary MP et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol 1992; 148: 1549–1557, discussion 1564.
11. Nickel JC. Effective office management of chronic prostatitis. Urol Clin North Am 1998; 25: 677–684.
12. Litwin MS, McNaughton-Collins M, Fowler Jr FJ et al. The National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. Chronic Prostatitis Collaborative Research Network. J Urol 1999; 162: 369–375.
13. Meares EM, Stamey TA. Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest Urol 1968; 5: 492–518.
14. Nickel JC. The pre and post massage test (PPMT): a simple screen for prostatitis. Tech Urol 1997; 3: 38–43.
15. Nickel JC, Shoskes D, Wang Y et al. How does the pre-massage and postmassage 2-glass test compare to the Meares-Stamey 4-glass test in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol 2006; 176: 119–124.
16. Nickel JC, Krieger JN, McNaughton-Collins M et al. Alfuzosin and symptoms of chronic prostatitis-chronic pelvic pain syndrome. N Engl J Med 2008; 359: 2663–2673.
17. Gillenwater JY, Wein AJ. Summary of the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases Workshop on Interstitial Cystitis, National Institutes of Health, Bethesda, Maryland, August 28–29, 1987. J Urol 1988; 140: 203–206.
18. Nordling J, Anjum FH, Bade JJ et al. Primary evaluation of patients suspected of having interstitial cystitis (IC). Eur Urol 2004; 45: 662–669.
19. Twiss CO, Kilpatrick L, Triaca V et al. Evidence for central hyperexitability in patients with interstitial cystitis. J Urol 2007; 177: 49.
20. Burkman RT. Chronic pelvic pain of bladder origin: epidemiology, pathogenesis and quality of life. J Reprod Med 2004; 49(Suppl): 225–229.
21. Roberts RO, Bergstralh EJ, Bass SE et al. Incidence of physician diagnosed interstitial cystitis in Olmsted County: a community-based study. BJU Int 2003; 91: 181–185.
22. Parsons CL, Zupkas P, Parsons JK. Intravesical potassium sensitivity in patients with interstitial cystitis and urethral syndrome. Urology 2001; 57: 428–432.
23. Alagiri M, Chottiner S, Ratner V et al. Interstitial cystitis: unexplained associations with other chronic disease and pain syndromes. Urology 1997; 49(Suppl): 52–57.
24. Clauw DJ, Schmidt M, Radulovic D et al. The relationship between fibromyalgia and interstitial cystitis. J Psychiatr Res 1997; 31: 125–131.
25. Erickson DR, Morgan KC, Ordille S et al. Nonbladder related symptoms in patients with interstitial cystitis. J Urol 2001; 166: 557–561, discussion 561–562.
26. Weissman MM, Gross R, Fyer A et al. Interstitial cystitis and panic disorder— a potential genetic syndrome. Arch Gen Psych 2004; 61: 273–279.
27. Buffington CA. Comorbidity of interstitial cystitis with other unexplained clinical conditions. J Urol 2004; 172: 1242–1248.
28. Fall M, Johansson SL, Aldenborg F. Chronic interstitial cystitis: a heterogeneous syndrome. J Urol 1987; 137: 35–38.
29. Bullock AD, Becich MJ, Klutke CG et al. Experimental autoimmune cystitis: a potential murine model for ulcerative interstitial cystitis. J Urol 1992; 148: 1951–1956.
30. Dodd LG, Tello J. Cytologic examination of urine from patients with interstitial cystitis. Acta Cytol 1998; 42: 923–927.
31. Erickson DR, Davies MF. Interstitial cystitis. Int Urogynecol J Pelvic Floor Dysfunct 1998; 9: 174–183.
32. Peeker R, Fall M. Toward a precise definition of interstitial cystitis: further evidence of differences in classic and nonulcer disease. J Urol 2002; 167: 2470–2472.
33. Koziol JA, Adams HP, Frutos A. Discrimination between the ulcerous and the nonulcerous forms of interstitial cystitis by noninvasive findings. J Urol 1996; 155: 87–90.
34. Hanno PM. Amitriptyline in the treatment of interstitial cystitis. Urol Clin North Am 1994; 21: 89–91.
35. Fall M, Lindstrom S. Transcutaneous electrical nerve stimulation in classic and nonulcer interstitial cystitis. Urol Clin North Am 1994; 21: 131–139.
36. Peeker R, Haghsheno MA, Holmang S et al. Intravesical bacillus Calmette-Guerin and dimethyl sulfoxide for treatment of classic and nonulcer interstitial cystitis: a prospective, randomized doubleblind study. J Urol 2000; 164: 1912–1915, discussion 1915–1916.
37. Fritjofsson A, Fall M, Juhlin R et al. Treatment of ulcer and nonulcer interstitial cystitis with sodium pentosanpolysulfate: a multicenter trial. J Urol 1987; 138: 508–512.
38. Dundore PA, Schwartz AM, Semerjian H. Mast cell counts are not useful in the diagnosis of nonulcerative interstitial cystitis. J Urol 1996; 155: 885–887.
39. Johansson SL, Fall M. Clinical features and spectrum of light microscopic changes in interstitial cystitis. J Urol 1990; 143: 1118–1124.
40. Harrington DS, Fall M, Johansson SL. Interstitial cystitis: bladder mucosa lymphocyte immunophenotyping and peripheral blood flow cytometry analysis. J Urol 1990; 144: 868–871.
41. Peeker R, Aldenborg F, Haglid K et al. Decreased levels of S-10 protein in non-ulcer interstitial cystitis. Scand J Urol Nephrol 1998; 32: 395–398.
42. Koziol JA, Clark DC, Gittes RF et al. The natural history of interstitial cystitis: a survey of 374 patients. J Urol 1993; 149: 465–469.
43. Enerback L, Fall M, Aldenborg F. Histamine and mucosal mast cells in interstitial cystitis. Agents & Actions 1989; 27: 113–116.
44. van Haarst EP, van Andel G, Rijcken TH et al. Value of diagnostic ultrasound in patients with chronic scrotal pain and normal findings on clinical examination. Urology 1999; 54: 1068–1072.
45. Kaur H, Arunkalaivanan AS. Urethral pain syndrome and its management. Obstet Gynecol Surv 2007; 62: 348–351.
46. Newham AP, van der Spuy ZM, Nugent F. Laparoscopic findings in women with pelvic pain. S Afr Med J 1996; 86 (Suppl): 1200–1203.
47. Howard FM. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Ballieres Best Pract Res Clin Obstet Gynaecol 2000; 14: 467–494.
48. Porpora MG, Gomel V. The role of laparoscopy in the management of pelvic pain in women of reproductive age. Fertil Steril 1997; 68: 765–779.
49. Messelink EJ, Benson T, Berghmans B et al. Standardisation of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society. Neurourol Urodynam 2005; 24: 374–380.
50. Carter JE. Abdominal wall and pelvic myofascial trigger points. In: Howard FM, ed. Pelvic pain. Diagnosis and management. Philadelphia, PA: Lippincott Williams & Wilkins; 2000: 314–358.
51. Slocumb JC. Neurological factors in chronic pelvic pain: trigger points and the abdominal pelvic pain syndrome. Am J Obstet Gynaecol 1984; 149: 536–543.
52. Glazer HI, Rodke G, Swencionis C et al. Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature. J Reprod Med 1995; 40: 283–290.
53. Marthol H, Hilz MJ. Female sexual dysfunction: a systematic overview of classification, pathophysiology, diagnosis and treatment [in German]. Fortschr Neurol Psychiatr 2004; 72: 121–135.
54. Feldman HA, Goldstein I, Hatzichristou DG et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Ageing Study. J Urol 1994; 151: 54–61.
55. Kwan KS, Roberts LJ, Swalm DM. Sexual dysfunction and chronic pain: the role of psychological variables and impact on quality of life. Eur J Pain 2005; 9: 643–652.
56. Anderson RU, Wise D, Sawyer T et al. Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after trigger point release and paradoxical relaxation training. J Urol 2006; 176: 1534–1538, discussion 1538–1539.
57. Shabsigh R, Anastasiades A, Cooper KL et al. Female sexual dysfunction, voiding symptoms and depression: common findings in partners of men with erectile dysfunction. World J Urol 2006; 24: 653–656.
58. Salonia A, Zanni G, Briganti A et al. The ole of the urologist in the management of female sexual dysfunctions. Curr Opin Urol 2004; 14: 389–393.
59. Dalpiaz O, Kerschbaumer A, Mitterberger M et al. Female sexual dysfunction: a new urogynaecological research field. BJU Int 2008; 101: 717–721.
60. Levin RJ. The physiology of sexual arousal in the human female: a recreational and procreational synthesis. Arch Sex Behav 2002; 31: 405–411.
61. Baessler K, Bircher MD, Stanton SL. Pelvic floor dysfunction in women after pelvic trauma. BJOG 2004; 111: 499–502.
62. Srivastava R, Thakar R, Sultan A. Female sexual dysfunction in obstetrics and gynecology. Obstet Gynecol Surv 2008;63: 527–537.
63. Addis IB, Van Den Eeden SK, Wassel-Fyr CL et al. Sexual activity and function in middle-aged and older women. Obstet Gynecol 2006; 107: 755–764.
64. Borello-France D, Leng W, O’Leary M et al. Bladder and sexual function among women with multiple sclerosis. Mult Scler 2004; 10: 455–461.
65. Burina A, Sinanovic O. Bladder, bowel and sexual dysfunction in patient with multiple sclerosis [in Bosnian]. Med Arh 2006; 60: 182–184.
66. Achtari C, Dwyer PL. Sexual function and pelvic floor disorders. Best Pract Res Clin Obstet Gynaecol 2005; 19: 993–1008, quiz A1–8.
67. Heinberg LJ, Fisher BJ, Wesselmann U et al. Psychological factors in pelvic/urogenital pain: the influence of site of pain versus sex. Pain 2004; 108: 88–94.
68. Aslan E, Fynes M. Female sexual dysfunction. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19: 293–305.
69. AzamU. Late-stage clinical development in lower urogenital targets: sexual dysfunction. Br J Pharmacol 2006; 147(Suppl 2): S153–159.
70. Dorey G. Restoring pelvic floor function in men: review of RCTs. Br J Nurs 2005; 14: 1014–1018, 1020–1021.
71. Rosenbaum TY, Owens A. The role of pelvic floor physical therapy in the treatment of pelvic and genital pain-related sexual dysfunction (CME). J Sex Med 2008; 5: 513–523, quiz 524–525.
72. Wespes WE, Amar E, Eardley I et al. EAU guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. European Association of Urology Web site.
http://www.uroweb.org/fileadmin/tx_eauguidelines/2009/Full/Male_Sexual_Dysf.pdf. Updated March 2009.
73. Keefe FJ, Rumble ME, Scipio CD et al. Psychological aspects of persistent pain: current state of the science. J Pain 2004; 5: 195–211.
74. Eccleston C, Crombez G. Pain demands attention: a cognitiveaffective model of the interruptive function of pain. Psychol Bull 1999; 125: 356–366.
75. Sharpe M, Carson A. ‘Unexplained’ somatic symptoms, functional syndromes, and somatization: do we need a paradigm shift? Ann Intern Med 2001; 134: 926–930.
76. Savidge CJ, Slade P. Psychological aspects of chronic pelvic pain. J Psychosom Res 1997; 42: 433–444.
77. Latthe P, Mignini L, Gray R et al. Factors predisposing women to chronic pelvic pain: systematic review. BMJ 2006; 332: 749–755.
78. Raphael KG,Widom CS, Lange G. Childhood victimization and pain in adulthood: a prospective investigation. Pain 2001; 92: 283–293.
79. Poleshuck EL, Dworkin RH, Howard FM et al. Contributions of physical and sexual abuse to women’s experiences with chronic pelvic pain. J Reprod Med 2005; 50: 91–100.
80. Fitzgerald MP, Link CL, Litman HJ et al. Beyond the lower urinary tract: the association of urologic and sexual symptoms with common illnesses. Eur Urol 2007; 52: 407–415.
81. Tripp DA, Curtis Nickel J, Landis JR et al. Predictors of quality of life and pain in chronic prostatitis/ chronic pelvic pain syndrome: findings from the National Institutes of Health Chronic Prostatis Cohort Study. BJU Int 2004; 94: 1279–1282.
82. Smith KB, Tripp D, Pukall C et al. Predictors of sexual and relationship functioning in couples with chronic prostatitis/chronic pelvic pain syndrome. J Sex Med 2007; 4: 734–744.
83. Howard FM. Chronic pelvic pain. Obstet Gynecol 2003; 101: 594–611.
84. Weijenborg PTM, Greeven A, Dekker FW et al. Clinical course of chronic pelvic pain in women. Pain 2007; 132 (Suppl 1): S117–123.
85. Morley SJ, Eccleston C, Williams A. Systematic review and metaanalysis of randomised controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 1999; 80: 1–13.
86. Marjoribanks J, Proctor ML, Farquhar C. Nonsteroidal anti-inflammatory drugs for primary dysmenorrhoea. Cochrane Database Syst Rev 2003: CD001751.
87. Chew DJ, Buffington CA, Kendall MS et al. Amitriptyline treatment for severe recurrent idiopathic cystitis in cats. J Am Vet Med Assoc 1998; 213: 1282–1286.
88. Saarto T, Wiffen PJ. Antidepressants for neuropathic pain. Cochrane Database Syst Rev 2007: CD005454.
89. Wiffen P, Collins S, McQuay H et al. Anticonvulsant drugs for acute and chronic pain. Cochrane Database Syst Rev 2005: CD001133.
90. Wiffen PJ, McQuay HJ, Edwards JE et al. Gabapentin for acute and chronic pain. Cochrane Database Syst Rev 2005: CD005452.
91. McQuay H. Opioids in pain management. Lancet 1999; 353: 2229–2232.
92. Eisenberg E, McNicol E, Carr DB. Opioids for neuropathic pain. Cochrane Database Syst Rev 2006: CD006146.
93. Kemler MA, Barendse GA, van Kleef M et al. Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. N Engl J Med 2000; 343: 618–624.
94. Giannantoni A, Costantini E, Di Stasi SM et al. Botulinum A toxin intravesical injections in the treatment of painful bladder syndrome: a pilot study. Eur Urol 2006; 49: 704–709.
95. Liu HT, Kuo HC. Intravesical botulinum toxin A injections plus hydrodistension can reduce nerve growth factor production and control bladder pain in interstitial cystitis. Urology 2007; 70: 463–468.
Labels
Paediatric urologist UrologyArticle was published in
Urological Journal
2010 Issue 3
Most read in this issue
- CHRONIC PELVIC PAIN SYNDROME AND CURRENT TREATMENT OPTIONS
- CHANGING MANAGEMENT OF CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME
- OVERACTIVE BLADDER IN CHILDREN AND ADULT PATIENTS
- THE ROLE OF SACRAL NEUROMODULATION IN UROLOGIC PRACTICE