Chronic Pelvic Pain Syndrome (CPPS): A Disease or Symptom? Current Perspectives on Diagnosis, Treatment, and Prognosis

Chronic Pelvic Pain Syndrome

Introduction:

CPPS is a common pain condition with international general population prevalence rates ranging between 4 and 25% in women and between 2 and 18% in men. CPPS not only affects the body but also the mind due to its constantly disturbing nature leading to a compromised quality of life.

Definition:

Chronic pelvic pain syndrome (CPPS) can be described as an intermittent or constant pain condition in the pelvic area that has persisted for at least 6 months without an obvious pathology that accounts for the pain.

It is associated with physical symptoms suggestive of gastroenterological, urogenital, and/or sexual dysfunction as well as with psychopathological symptoms.

Epidemiology:

Epidemiologically chronic pelvic pain (CPPS) has a greater incidence in women than in men and primarily occurs in individuals between the ages of 36 and 50 years. The etiology of chronic pelvic pain is often not understood. It can be difficult and complex to determine the cause of pain, hence it is very difficult to detect the epidemiology and prevalence of CPPS in population facts.

Etiology of CPPS:

There is no specific cause for CPPS and many patients are not able to identify a specific set of problems that can cause symptoms and allow for the diagnosis to be made. CPPS may originate from one or more organ systems or pathologies and may have multiple contributing factors.

Causes and Diagnosis:

A number of mechanisms have been suggested as the pathophysiological basis of CPPS:

  1. An infectious process, but no conclusive evidence has been found and antibiotic treatment is ineffective;
  2. A neurogenic inflammation that includes local chemical changes.
  3. Hypoxia. A disrupted blood flow to the pelvic area, reduced micro-vascular density of the bladder’s submucosa layer, followed by decreased perfusion is supported by clinical improvement following hyperbaric treatment and,
  4. Weakness or cramps of the pelvic floor muscles. None of the above have been mentioned as the sole cause of the syndrome, and it is estimated that these mechanisms interact.

Chronic pelvic pain may be caused by interstitial cystitis, prostatitis or other conditions. The cause of the chronic pain depends on the condition.

Causes of interstitial cystitis may include:

  • Autoimmune disorders
  • Bacterial infection
  • Bladder trauma
  • Genetics
  • Pelvic floor muscle dysfunction
  • Trauma to the pelvic floor
  • Risk factors for prostatitis may include:
  • Increasing age
  • Infection caused by bacteria in urine that enter the prostate
  • Sexually transmitted infections
  • Nerve damage to the urinary tract
  • Genetics
  • Autoimmune disorders

Diagnosing Chronic Pelvic Pain Syndrome:

Diagnosis is largely based on detailed history and physical evaluation of the pelvic floor musculature along with examination of musculoskeletal structures around the pelvic floor.

Musculoskeletal examination to exclude different musculoskeletal disorders such as examination and assessment for pelvic girdle pain, posture assessment, and lumbar region assessment for example, to rule out neuropathic pain.

Pelvic Examination:

A pelvic floor examination may reveal signs of infection, abnormal growths, or tense pelvic floor muscles. This examination is specifically focused to identify the areas of tenderness and changes in sensation.

Examination of external genitalia for any signs of infection, inflammation, vulvar malignancy

For a confirmed diagnosis of CPPS, a questionnaire called the Chronic Pelvic Symptom Index (CPSI) is used to assess the symptoms and to guide treatment decisions.

Other tests may include:

Urinalysis: This test checks for blood cells, germs (like bacteria) or excess protein in the urine.

Urine culture: This test will rule out a urinary tract infection (UTI), as symptoms of chronic pelvic pain syndromes are similar to UTI symptoms.

Cystourethroscopy: Also known as a cystoscopy, this test examines the inside of your bladder and urethra.

CT scan: This test uses X-rays and a computer to make detailed images of the urinary tract.

Above tests are mainly used to rule out any other factors life infections or trauma to the pelvic floor. As such the pelvic floor muscle dysfunction is difficult to identify in above tests.

Symptoms:

Symptoms may include:

  • Persistent pain in the region between the pelvis and the umbilicus
  • Discomfort (pain or burning) when micturiting
  • Urinary frequency or urgency
  • Feeling of incomplete emptying of bladder
  • Discomfort when the bladder is full
  • Pain during intercourse
  • Erectile dysfunction or pain during ejaculation (men)

Treatment:

Chronic pelvic pain syndrome has been treated with several different interventions with limited success.

Although CPPS is common, the aetiology and maintenance of CPPS are still largely unknown and the successful management of this pain syndrome remains challenging. Several single-track medical and non-medical treatment strategies have failed to be sufficient. Therefore, a multidisciplinary approach combining medical, psychotherapeutic, and physiotherapeutic treatment strategies is recommended.

Physical Therapy Management:

The optimal treatment of chronic pelvic pain is based on a biopsychosocial model delivered by a multidisciplinary approach. This multidisciplinary treatment includes oral analgesics and other medications, pain management, pelvic floor rehabilitation, nerve stimulation therapies, teaching cognitive coping strategies, education about the importance of planning and pacing exercise and activities

Pelvic Floor Rehabilitation:

Pelvic floor rehabilitation is an essential component of the treatment.

Common treatment interventions include:

  • Manual therapy of the pelvic floor muscles
  • Biofeedback(EMG biofeedback and Kegel perineometer)
  • Electrical stimulation as appropriate
  • Myofascial release of painful trigger points ofthe pelvic floor divided into internal and external release.
  • Relaxation techniques.
  • Pelvic Floor Muscles exercises and core stabilization
  • Specific stretches (pelvic floor muscles, adductors, or iliopsoas for example)
  • Postural correction.

Physiotherapy and Pain Management:

Pain management and cognitive coping strategies should include education about how psychological factors, such as catastrophizing, pain-related fear, and anxiety, may affect sexual function and the perception of pain during intercourse and other activities for which patients may report pain.

Pain management should also include educating patients about the importance of planning and pacing exercise and activities. The goal is to enable patients to pace their activity to achieve a similar amount each day. Overactive patients may experience constant pain with exacerbations called flare-ups, while others may have constant pain with flare-ups associated with minimal activity.

In addition, therapy can include education about vulvodynia, dyspareunia (painful intercourse), muscle relaxation and vaginal dilation. The goals of the therapy are to reduce the fear of pain and other pain-related cognitions associated with intercourse, increase sexual activity level, and decrease pain.

Communication and Support: An Important Component for Treatment and Prognosis of CPPS

CPPS is a chronic disorder. Not only do individuals suffer from pain physiologically and psychologically but there is also a long-term impact on their family life. Treatment regime and rehabilitation require sometimes an extended period of time. Both the care providers involved and patients should be aware of the facts. Communication, education, and peer/family/community support are important for a successful intervention. There must be effective communication and exchange of patient information between physicians in general practice and rehab care providers involved in the multidisciplinary therapeutic team. Education is an essential component for individuals and their sexual partners to understand and accept the concept changes in current perspectives on CPPS. A clear explanation of the nature of the disorder, chronic pain cycle, treatment options/courses, and possible outcomes should be available to the patients and their sexual partners if applicable. Communication between patients and their sexual partners is highly suggested and involvement of the patient’s sexual partner is encouraged from the beginning of medical intervention.

Prognosis:

As such, limited treatment modalities exist to cure CPPS, but treatments based on the cooperation of patient and physician makes this condition more bearable. Over time, this condition may improve or stabilize on its own.

In the past, the CPPS was identified to have poor prognosis but in recent years, the prognosis for CPPS has improved with the advent of multimodal treatment, protocols aimed at quieting the pelvic nerves through myofascial trigger point release, anxiety control, stress management, yoga, psychotherapy and chronic pain therapy.

References:

  1. Grinberg K, et al, New insights about Chronic Pelvic Pain Syndrome (CPPS); Int J Environ Res Public health 2020.
  2. JiChao H, et al; Case report: New insights into persistent chronic pelvic pain syndrome with comorbid somatic symptom disorder, Frontiers in Psychiatry; vol 14; Jan 20, 2023.
  3. Rees J, et al; Diagnosis and treatment of chronic bacterial prostatitis and chronic pelvic pain syndrome: A consensus guideline. BJU International; 116(4); 509-525.
  4. Brunahl CA, et al; Combined Cognitive-Behavioural and Physiotherapeutic Therapy for Patients with Chronic    Pelvic Pain Syndrome (COMBI-CPPS): study protocol for a controlled feasibility trial;BMC triala, vol 19, No    20; 2018