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Chronic Pelvic Pain Syndrome (CPPS)

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

The chronic pelvic pain syndrome (CPPS) is characterized by

• chronic or recurrent pain for at least six months, which is perceived in structures of the pelvis
• the CPPS affects women and men
• without evidence of pelvic organ disease (diagnosis of exclusion)
• CPPS is associated with symptoms of the lower urinary tract and rectum and often has negative consequences regarding sexuality and psychological well-being.
• If pain is felt in a single organ or area (e.g., 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" leads the patient and the therapist astray. For the definition of chronic prostatitis, see bacterial prostatitis. Furthermore, terms like prostatodynia or vulvodynia are discouraged. EAU guidelines: (Engeler u.a., 2020).

Epidemiology of Chronic prostatitis

Recurrent pain in the prostate, testis, or penis is common: 5% of men aged 20–50 years, age peak between 20–49 years and above 70 years.

Etiology (Causes) of the Chronic Pelvic Pain Syndrome

The etiology of CPPS is heterogeneous, as implied by the definitions. A multifactorial genesis of pain with triggering and disease-sustaining factors is likely.

Pain type:

Visceral pain is typical for CPPS: sudden and severe onset, diffuse and difficult to localize, accompanying vegetative reactions, radiation of pain to skin and muscle regions, and hyperalgesia.

Disease-triggering factors:

Triggering factors are often (recurrent) infections, injuries, or dysfunctions, which repeatedly cause pain stimuli. The perceived pain may become independent of the trigger due to neuromodulatory processes.

Neuroplasticity of the CNS:

As the disease progresses, recurrent stimuli lead to central sensitization: increased sensitivity of pain receptors, pain pathways, and CNS areas. The lower threshold for pain perception (allodynia) causes pain perception in other areas, making diagnosis and therapy more difficult.

Muscular hyperalgesia

The low threshold for pain perception leads to pain and dysfunction of the pelvic floor (tendinopathy, myogeloses, or myofascial trigger points). Activation of the pelvic floor leads to pain during micturition or ejaculation, and avoidance behavior due to negative experiences develops.

Visceral hyperalgesia:

Visceral hyperalgesia is the increased perception of visceral afferents (storage, emptying, organ pain) by central sensitization. Visceral hyperalgesia is not only present in chronic pain due to the neuroplastic CNS processes. Even after acute cystitis, an overactive bladder can develop via this mechanism lasting several weeks.

Psychosomatic disorders:

Anxiety disorders, depression, and personality disorders are more frequent in patients with CPPS. There are several explanations for this: on the one hand, mental illness may negatively influence pain perception, and on the other hand, chronic pain leads to mental illness: exhaustibility and restrictions in daily life increase the risk of social and professional retreat, leading to, e.g., reactive depression.

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