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Guidelines on Chronic Pelvic Pain M. Fall (chair), A.P. Baranowski, S. Elneil, D. Engeler, J. Hughes, E.J. Messelink, F. Oberpenning, A.C. de C. Williams © European Association of Urology 2008 TABLE OF CONTENTS PAGE 1. INTRODUCTION 5 1.1 The guideline 5 1.1.1 Publication history 5 1.2 Level of evidence and grade recommendations 5 1.3 References 6 1.4 Definition of pain (World Health Organization [WHO]) 6 1.4.1 Innervation of the urogenital system 7 1.4.2 References 8 1.5 Pain evaluation and measurement 8 1.5.1 Pain evaluation 8 1.5.2 Pain measurement 8 1.5.3 References 9 2. CHRONIC PELVIC PAIN 9 2.1 Background 9 2.1.1 Introduction to urogenital pain syndromes 9 2.2 Definitions of chronic pelvic pain and terminology (Table 4) 11 2.3 Classification of chronic pelvic pain syndromes 12 Table 3: EAU classification of chronic urogenital pain syndromes (page 10) Table 4: Definitions of chronic pain terminology (page 11) Table 5: ESSIC classification of types of bladder pain syndrome according to the results of cystoscopy with hydrodistension and of biopsies (page 13) 2.4 References 13 2.5 An algorithm for chronic pelvic pain diagnosis and treatment 13 2.5.1 How to use the algorithm 13 2.6 Prostate pain syndrome (PPS) 15 2.6.1 Introduction 16 2.6.2 Definition 16 2.6.3 Pathogenesis 16 2.6.4 Diagnosis 17 2.6.5 Treatment 17 2.6.5.1 Alpha-blockers 17 2.6.5.2 Antibiotic therapy 17 2.6.5.3 Non-steroidal anti-inflammatory drugs (NSAIDs) 17 2.6.5.4 Corticosteroids 17 2.6.5.5 Opioids 17 2.6.5.6 5-alpha-reductase inhibitors 18 2.6.5.7 Allopurinol 18 2.6.5.8 Phytotherapy 18 2.6.5.9 Muscle relaxants 18 2.6.5.10 Supportive therapies 18 2.6.5.11 Surgical management 18 2.6.6 References 19 2.7 Bladder pain syndrome/interstitial cystitis (BPS/IC) 23 2.7.1 Introduction 23 2.7.2 Definition 23 2.7.3 Pathogenesis 25 2.7.4 Epidemiology 26 2.7.5 Association with other diseases 27 2.7.6 Diagnosis 27 2.7.7 Biological markers 27 2.7.8 Interstitial cystitis (IC) in children and males 28 2.7.9 Medical treatment 28 2.7.10 Intravesical treatment 30 2.7.11 Interventional treatments 32 2.7.12 Treatments of limited efficacy and absence of recent publications 33 2.7.13 Non-pharmacological treatments 34 2 UPDATE MARCH 2008 2.7.14 Surgical treatment 35 2.7.15 References 39 2.8 Scrotal pain 54 2.8.1 Management of different conditions 54 2.8.2 References 55 2.9 Urethral pain syndrome 56 2.9.1 Treatment 57 2.9.2 References 57 3. PELVIC PAIN IN GYNAECOLOGICAL PRACTICE 57 3.1 Introduction 57 3.2 Clinical history 57 3.3 Clinical examination 57 3.3.1 Investigations 57 3.4 Dysmenorrhoea 57 3.5 Infection 58 3.5.1 Treatment 58 3.6 Endometriosis 58 3.6.1 Treatment 58 3.7 Gynaecological malignancy 58 3.8 Injuries related to childbirth 58 3.9 Conclusion 59 3.10 References 59 4. NEUROLOGICAL ASPECTS 60 4.1 Physiology of the urogenital system 60 4.2 Physiology of the bladder 60 4.2.1 Bladder filling 60 4.2.2 Afferent innervation of the bladder 60 4.2.3 Efferent innervation of the bladder 61 4.2.4 Central control of micturition 61 4.2.5 Physiology of the genital organs 61 4.3 Sexual dysfunction in men and women 63 4.4 References 64 5. NEUROGENIC CONDITIONS 66 5.1 Introduction 66 5.2 Pudendal nerve entrapment 66 5.3 Other neurogenic conditions 67 5.4 References 67 6. PELVIC FLOOR FUNCTION AND DYSFUNCTION 67 6.1 Introduction 67 6.2 Function 67 6.3 Dysfunction 68 6.4 Myofascial trigger points 68 6.5 Therapy 69 6.6 References 69 7. PSYCHOLOGICAL FACTORS IN CHRONIC PELVIC PAIN 70 7.1 Introduction 70 7.2 Psychological models of pain 70 7.3 Methodology 71 7.4 Psychological factors in assessment of pelvic pain 71 7.4.1 Psychological risk factors in the development of pelvic pain and adaptation to it 71 7.4.2 Anxiety 71 7.4.3 Depression and catastrophising 72 7.4.4 Impact of pain 72 7.5 Summary: assessment recommendations 72 7.5.1 Anxiety 73 UPDATE MARCH 2008 3 7.5.2 Depression 73 7.5.3 Sexual and physical abuse in childhood 73 7.6 Psychological factors in treatment of pelvic pain 73 7.7 References 74 8. GENERAL TREATMENT OF CHRONIC PELVIC PAIN 77 8.1 Simple analgesics 77 8.1.1 Paracetamol 77 8.1.2 Acidic antipyretic analgesics 77 8.1.3 Guidelines for use of NSAIDs and COX-2 selective agents 78 8.2 Neuropathic analgesics 78 8.2.1 Tricyclic antidepressants 78 8.2.2 Anticonvulsants 78 8.2.3 N-methyl-D-aspartate (NMDA) antagonists 78 8.2.4 Sodium channel blockers 79 8.3 Opioids 79 8.3.1 Guidelines for the use of opioid-like agents in chronic/non-acute urogenital pain 79 8.3.2 Morphine 80 8.3.3 Transdermal fentanyl 80 8.3.4 Methadone 80 8.3.5 Oxycodone 80 8.3.6 Other opioids and opioid-like agents 80 8.4 References 82 8.5 Nerve blocks 84 8.5.1 References 85 8.6 Transcutaneous electrical nerve stimulation (TENS) 85 8.6.1 Results of suprapubic TENS in BPS/IC 86 8.7 Sacral neuromodulation in pelvic pain syndromes 86 8.7.1 References 87 9. ABBREVIATIONS USED IN THE TEXT 89 4 UPDATE MARCH 2008 1. INTRODUCTION 1.1 The guideline The European Association of Urology (EAU) Guidelines Group for Chronic Pelvic Pain have prepared this guidelines document to help medical professionals assess the evidence-based management of chronic pelvic pain. The multidisciplinary panel of experts includes urologists, a neuro-urologist, anaesthesiologists, a gynaecologist and a psychologist. 1.1.1 Publication history The Chronic Pelvic Pain Guidelines were first published in 2003, with partial updates in 2007 and 2008. This 2011 publication presents an unrevised version of the full text. A full text update is foreseen in 2012. A quick reference document presenting the main findings of the Chronic Pelvic Pain guidelines is also available alongside scientific publications in the society journal European Urology (1,2). All texts can be viewed and downloaded for personal use at the EAU website: http://www.uroweb.org/guidelines/online-guidelines/. 1.2 Level of evidence and grade of guideline recommendations* References used in the text have been assessed according to their level of scientific evidence (Table 1), and guideline recommendations have been graded (Table 2) according to the Oxford Centre for Evidence-based Medicine Levels of Evidence (3). The aim of grading recommendations is to provide transparency between the underlying evidence and the recommendation given. Table 1: Level of evidence (LE)* Level Type of evidence 1a Evidence obtained from meta-analysis of randomised trials 1b Evidence obtained from at least one randomised trial 2a Evidence obtained from one well-designed controlled study without randomisation 2b Evidence obtained from at least one other type of well-designed quasi-experimental study 3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports 4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities Modified from Sackett et al. (3). It should be noted that when recommendations are graded, the link between the level of evidence and grade of recommendation is not directly linear. Availability of randomised controlled trials (RCTs) may not necessarily translate into a grade A recommendation where there are methodological limitations or disparity in published results. Alternatively, absence of high level evidence does not necessarily preclude a grade A recommendation, if there is overwhelming clinical experience and consensus. In addition, there may be exceptional situations where corroborating studies cannot be performed, perhaps for ethical or other reasons and in this case unequivocal recommendations are considered helpful for the reader. The quality of the underlying scientific evidence – although a very important factor – has to be balanced against benefits and burdens, values and preferences and cost when a grade is assigned (4-6). The EAU Guidelines Office, do not perform cost assessments, nor can they address local/national preferences in a systematic fashion. But whenever this data is available, the expert panels will include the information. Table 2: Grade of recommendation (GR)* Grade Nature of recommendations A Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial B Based on well-conducted clinical studies, but without randomised clinical trials C Made despite the absence of directly applicable clinical studies of good quality *Modified from Sackett et al. (3). UPDATE MARCH 2008 5 1.3 References 1. Fall M, Baranowski A, Elneil S, et al. EAU guidelines on chronic pelvic pain. Eur Urol 2010 Jan;57(1):35-48. http://www.ncbi.nlm.nih.gov/pubmed/19733958 2. Fall M, Baranowski AP, Fowler CJ, et al. EAU guidelines on chronic pelvic pain. Eur Urol 2004;46: 681-689. http://www.ncbi.nlm.nih.gov/pubmed/19733958 3. Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001). Produced by Bob Phillips, Chris Ball, Dave Sackett, Doug Badenoch, Sharon Straus, Brian Haynes, Martin Dawes since November 1998.
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