Chronic Pelvic Pain Syndrome (CPPS)

Chronic Pelvic Pain Syndrome is defined as urogenital pain without identifiable infection lasting longer than 3 months. It is sometimes known as Chronic Non Bacterial Prostatitis in men.

The terms Chronic Pelvic Pain and Chronic Non Bacterial Prostatitis do not completely describe the syndrome as we understand it today as

1. The pain is not always solely confined to the urogenital region. It might also involve the legs, lower back , flank or abdomen. In some cases there is concomitant headache , upper body discomfort or other general symptoms confusing both patients and doctors alike.

2. The term Chronic Non Bacterial Prostatitis implies it stems from the prostate. The prostate is only one of several pelvic structures from which pain signals can be perpetuated.

3. The “pain” might not be a pain as such but a discomfort , pressure , pull , burn , itch , tingle or even urge to urinate or move the bowels. In some cases there is an element of genital arousal but in an uncomfortable way.

It is often assumed that CPPS is solely a male problem. However we often see females with similar complaints. These patients often complain of persistent urinary frequency , difficulty in emptying the bladder , pain on urination , pain during intercourse , anal or vaginal itch, burning or sensitivity and bladder or clitoral discomfort. Oftentimes they would have been given antibiotics or pain killers without improvement.

Understanding CPPS and how to approach it

We now know that CPPS is a syndrome that has manifestations that can be urogenital, gastrointestinal , neurological , muscular skeletal , sexual and psychosocial in presentation. What this means is that people with CPPS can have different problems like bowel urge or difficulty in urination or penile or vaginal burning or leg or bladder pain while having the same disorder.

This is because the pelvis contains the organs, muscles and nerves responsible for sex and reproduction, bowel and urine evacuation and lumbosacral, hip and leg function and stability.

Any injury, inflammation or infection that starts a chronic pain loop in any of these structures can cause CPPS and its associated problems.

In order to log each person’s symptoms and individualise a treatment plan, the International Continence Society has categorised all symptoms to nine broad groups. This also helps greatly in clinical research and in planning a multidisciplinary approach.

The Role of Hypertonic Pelvic Floor Muscles in CPPS

The final common pathway of continued pain , inflammation, overstimulation or injury to any pelvic structures is continous c afferent signalling or “pain spamming” to the spinal cord and brain.

This results in hypersensitivity of the pelvic organs and nerves and hypertonic or overly tight pelvic floor muscles. If allowed to continue it can even up regulate the pain and mood centres in the brain causing psychosocial symptoms.

Overly tight muscles lead to difficulty in bladder and bowel emptying, pain during sex, pain in the hip, groin, lower back and tail bone. They also cause formation of trigger points leading to pain flares with certain movements or activities or time of the month.

The nerves within the hypertonic muscles behave like entrapped nerves causing their supply areas to be hypersensitive and to itch, burn and tingle.

Relaxation of the involved muscles and release of their trigger points are therefore a key to resolving the situation. We utilise different strategies including trigger point injections , Botox, TENS, shockwave therapy and myofascial release to achieve relaxation of the muscles and trigger points. Medications to treat neuropathic pain and muscle relaxants often work better than pain medication.

Managing CPPS takes patience and commitment as it is unlikely to be resolved in a week. In some cases joint management with a pain specialist is necessary.

Identifying and addressing all possible triggers in each patient is important to maintain remission.

This article refers to CPPS which is a diagnosis of exclusion. There are many organic causes of pelvic pain that require a physicians immediate attention.  See link below.