Elsevier

European Urology

Volume 64, Issue 3, September 2013, Pages 431-439
European Urology

Guidelines
The 2013 EAU Guidelines on Chronic Pelvic Pain: Is Management of Chronic Pelvic Pain a Habit, a Philosophy, or a Science? 10 Years of Development

https://doi.org/10.1016/j.eururo.2013.04.035Get rights and content

Abstract

Context

Progress in the science of pain has led pain specialists to move away from an organ-centred understanding of pain located in the pelvis to an understanding based on the mechanism of pain and integrating, as far as possible, psychological, social, and sexual dimensions of the problem. This change is reflected in all areas, from taxonomy through treatment. However, deciding what is adequate investigation to rule out treatable disease before moving to this way of engaging with the patient experiencing pain is a complex process, informed by pain expertise as much as by organ-based medical knowledge.

Objective

To summarise the evolving changes in the management of patients with chronic pelvic pain by referring to the 2012 version of the European Association of Urology (EAU) guidelines on chronic pelvic pain.

Evidence acquisition

The working panel highlights some of the most important aspects of the management of patients with chronic pelvic pain emerging in recent years in the context of the EAU guidelines on chronic pelvic pain. The guidelines were completely updated in 2012 based on a systematic review of the literature from online databases from 1995 to 2011. According to this review, levels of evidence and grades of recommendation were added to the text. A full version of the guidelines is available at the EAU office or Web site (www.uroweb.org).

Evidence synthesis

The previously mentioned issues are explored in this paper, which refers throughout to dilemmas for the physician and treatment team as well as to the need to inform and engage the patient in a collaborative empirical approach to pain relief and rehabilitation. These issues are exemplified in two case histories.

Conclusions

Chronic pelvic pain persisting after appropriate treatment requires a different approach focussing on pain. This approach integrates the medical, psychosocial, and sexual elements of care to engage the patient in a collaborative journey towards self-management.

Introduction

The study and treatment of visceral pain syndromes have many facets. As emphasised by this group of experts working on various aspects of chronic pelvic pain within the European Association of Urology (EAU) guidelines project, the problem is complex, multifactorial, and multidimensional.

Philosophically, there are conflicting standpoints. Chronic pain has to be regarded as a disease in its own right and requires attention accordingly. This includes multidisciplinary care, which differs from the organ-centred view; general awareness of the importance of this approach is relatively recent. In contrast, the ultimate goal of therapy is treatment of a cause and its cure, if possible, or at least exclusion of serious diseases. Reaching this goal requires adequate clinical investigation, including relevant phenotyping of conditions with symptoms related to the prostate, bladder, urethra, and genital organs. An everyday dilemma in consultation with the patient with chronic pelvic pain is the fact that too much or too little attention to the clinical workup may ruin the outcome.

This article demonstrates the complexity of this area and discusses the approach to be taken. In the clinical situation, apart from awareness of good evidence-based treatment, experience and diversified knowledge are needed. This area is evolving and extremely important, since chronic pain is one of the most common reasons for disability.

The name given to a condition can have major implications; however, arriving at a diagnosis is not an easy process in view of the many dimensions that need to be considered [1], [2]. The EAU Chronic Pelvic Pain Guidelines Group has led much of this work when considering pain perceived in the pelvis [3], [4], [5]. Many groups have tried to tackle the issue from different viewpoints [6], [7], [8], [9], [10], [11], [12]. When the diagnostic terminology is inappropriate, harm can result for a number of reasons [13].

Pain associated with a well-described disease process requires that the disease be treated as the priority [3]. Pain management is also important and may reduce chronicity [14], [15]. When there is pain in the absence of an obvious ongoing disease process, we are dealing with a pain syndrome [1], [3]. In that case, it is essential to address the following, as appropriate: predisposing factors and causes [16], [17], [18], the chronic pain mechanisms for ongoing pain [3], [19], the associated visceral dysfunctions [20], [21], the associated musculoskeletal dysfunctions [22], [23], [24], the emotional consequences [25], [26], [27], the behavioural consequences [25], the sexual consequences [26], [28], and the social consequences [29]. Identifying these characteristics as a part of the phenotype is an important element of the classification if we wish to ensure appropriate management [3], [11], [18], [21], [30], [31], [32], [33], [34].

Section snippets

Evidence for what we do and the risks of integrating or not integrating care

Management of chronic pelvic pain syndrome (CPPS) is challenging. Understanding the aetiopathogenesis of the condition remains inadequate, and current treatment strategies are frequently ineffective. Researchers and clinicians in the field generally agree that patients with CPPS are not a homogeneous group presenting with pain arising in pelvic organs but rather are individuals with widely different clinical phenotypes. It is likely that different mechanisms and dynamics are the basis for the

Specifying risk and harm

The clinician is faced with a dilemma. Comprehensive investigation, which satisfies physician and patient that nothing treatable has gone undetected, risks strengthening the patient's beliefs in biomedical solutions as the only route and may make it harder to create a transition to management strategies when nothing is found. However, engaging a chronic pain model at an early stage, without carrying out all investigations, runs the risk of failure to detect a treatable cause of pain and

Agreeing on a management plan with the patient and managing expectations

When a management plan is based on a shared model of pain, there is always reason to address recovery of activity and function no matter what other treatment is initiated, since pain relief does not reliably bring recovery of function. Although the patient and clinician often posit pain as the only barrier to recovering the patient's previous lifestyle, anxieties regarding the possibility of undetected disease (eg, cancer) or risk of damage (eg, when pain in the vulva or penis is contingent on

Exemplary cases

The following cases exemplify the salient points previously raised that need to be considered in a patient presenting with pelvic/urogenital pain: Assessment and treatment should be seen as multidimensional, and approved standard terminology should be used. Assessment should be appropriate, avoiding under-investigation and over-investigation. The management plan should be explained to, and agreed to by, the patient. The treatment should integrate different dimensions of care (eg, physiotherapy

Realism versus aspiration

Physicians have been trained to cure patients. Over the years, the number of investigational options has increased. Physicians can use these options to attempt to make an adequate diagnosis. Patients with chronic pelvic pain are desperate for a cure, and physicians in turn feel obliged to establish a diagnosis and rule out life-threatening conditions such as cancer. Diagnostic investigations often seem appropriate, and when the first attempt is unsuccessful, another, more highly technical set

Conclusions

The management of patients with chronic pelvic pain is challenging. Because of the multifactorial causes and multidimensional consequences of this pain, health care providers should be aware of well-described mechanisms outside the usual organ limits. The EAU guidelines on chronic pelvic pain propose that treatment strategies are most successful if they are undertaken in the broader scope of an integrated care model by a team with the necessary knowledge and skills to treat pain patients [3].

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