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Our practice is part of Robert Wood Johnson Medical Group, the faculty practice of Robert Wood Johnson Medical School, part of Rutgers, The State University of New Jersey. As many as one in three women are One of the largest multispecialty physician affected by gynecologic and bladder practices in the state, Robert Wood Johnson Medical Group consists of over 500 physicians conditions that impair their comfort with expertise in more than 200 subspecialty and quality of life. clinical programs. We provide a full range of highly specialized services for children and adults. Conditions may range from the mild to the more severe, and include urinary or fecal incontinence Information about the Medical Group’s clinical and pelvic organ prolapse. Prolapse occurs when services can be found online at: the uterus, bladder, rectum, or bowels drop down www.RWJMedicalGroup.org and create a bulge into the vaginal opening. For additional details about the Division of Many women view these problems as part of the Female Pelvic Medicine and Reconstructive normal aging process that simply can’t be cured. Surgery , click on the division’s link located on Fortunately, this is not the case. the Department of Obstetrics, Gynecology and Reproductive Sciences page (under Clinical The specialized physicians of Rutgers Robert Services--View Medical Services). Wood Johnson Medical Group’s Division of Female Pelvic Medicine and Reconstructive Urogynecology Surgery are dedicated to these important health Division of Female Pelvic Medicine and care problems. We provide a thorough evaluation, Two convenient locations! Reconstructive Surgery including state-of-the-art onsite testing and mini - mally invasive treatment options to improve quality Main Office: Somerset Office: of life and get women back to normal daily activities. Clinical Academic Building 1 World’s Fair Drive 125 Paterson Street Somerset, NJ 08873 Suite 4200 We also treat benign gynecologic conditions, including New Brunswick, NJ 08901 abnormal bleeding, fibroids, endometriosis, and pelvic pain using minimally invasive gynecologic treatments for quick recovery and minimal post- Phone: 732-235-6600 operative pain. Fax: 732-235-6630 Our specialists provide a comprehensive pelvic floor program that addresses the MEET OUR PHYSICIANS full range of pelvic floor disorders. P elvic The Division of Female Pelvic Medicine and Reconstructive conditions we treat include: Surgery is led by Division Chief Juana Hutchinson-Colas, MD, MBA. Drs. Hutchinson-Colas, Adrian Balica, and Saya • Urgency urinary incontinence Segal specialize in the care of women with pelvic floor and • Stress incontinence benign gynecologic disorders. Drs. Hutchinson-Colas and Division Chief: Juana Adrian Balica, MD • Fecal incontinence Segal are fellowship-trained urogynecologists who treat Hutchinson-Colas, MD, MBA • Cystocele/Rectocele/Enterocele urinary and fecal incontinence and pelvic organ prolapse using robotic and vaginal surgery, in addition to non- • Uterine prolapse/Vaginal prolapse surgical treatment. Dr. Balica is an active member of • Painful bladder conditions the American Association of Gynecologic Laparoscopists • Interstitial cystitis (AAGL) and is an expert in minimally invasive benign • Sexual dysfunction gynecologic surgery. Dr. Balica and Dr. Eckhard Kemmann • Genitourinary and rectovaginal fistula perform gynecologic ultrasound and are American • Urethral diverticulum Institute of Ultrasound in Medicine (AIUM)-certified in • Vaginal cysts gynecologic ultrasound. Eckhard Kemman, MD Saya Segal, MD, MSCE • Constipation • Postpartum pelvic floor dysfunction • Pelvic pain Diagnostic Gynecologic Services Treatment Options • Endometriosis Urodynamic Testing Non-Surgical • Fibroids and endometrial polyps Urodynamic testing is designed to evaluate the function of • Pelvic floor muscle training and strengthening the bladder during filling and emptying. This outpatient test • Pessary devices We perform diagnostic services at our Robert is used for women with urinary symptoms and pelvic organ • Medical therapy for incontinence Wood Johnson Medical Group clinical sites for prolapse. Testing is done in a private, comfortable setting and • Behavioral therapy optimal treatment. As a large number of women is invaluable in diagnosing complex incontinence problems. • Percutaneous posterior tibial nerve stimulation are affected by more than one pelvic floor disorder, Cystoscopy our team of physicians also works jointly with a Surgical Cystoscopy is performed to inspect the bladder, urethra, and • Robotic-assisted pelvic reconstructive surgery colorectal surgeon from our Medical Group to uteral function. It is performed under local anesthesia in perform thorough evaluations for women with • Laparoscopic hysterectomy the office setting for conditions including blood in the urine, • Vaginal reconstructive surgery bowel disorders. refractory incontinence, and chronic urinary tract infections. • Slings for urinary incontinence • Urethral bulking Endoanal Ultrasound and Anorectal Manometry We provide these diagnostic tests for women with • Vaginal cyst excision bowel com plaints, including fecal incontinence, to provide • Sacral neuromodulation comprehensive assessments prior to recommending • Fistula repair optimal treatment. • Anal sphincteroplasty • Operative hysteroscopy Hysteroscopy We perform diagnostic hysteroscopy in the office to Benefits of Minimally Invasive Surgery decrease hospital admission for OR procedures. • Shorter hospital stay • Smaller incisions Gynecologic Ultrasound • Faster recovery Women who have abnormal bleeding, pelvic pain, fibroids, • Less post-operative pain ovarian cysts, polyps, or postmenopausal bleeding are candidates for this noninvasive imaging of the pelvic organs. Call 732-235-6600.
Recommended publications
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    Prevalence of Malignant Uterine Pathology in Utero-Vaginal Prolapse After Vaginal Hysterectomy

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  • Female Pelvic Relaxation

    Female Pelvic Relaxation

    FEMALE PELVIC RELAXATION A Primer for Women with Pelvic Organ Prolapse Written by: ANDREW SIEGEL, M.D. An educational service provided by: BERGEN UROLOGICAL ASSOCIATES N.J. CENTER FOR PROSTATE CANCER & UROLOGY Andrew Siegel, M.D. • Martin Goldstein, M.D. Vincent Lanteri, M.D. • Michael Esposito, M.D. • Mutahar Ahmed, M.D. Gregory Lovallo, M.D. • Thomas Christiano, M.D. 255 Spring Valley Avenue Maywood, N.J. 07607 www.bergenurological.com www.roboticurology.com Table of Contents INTRODUCTION .................................................................1 WHY A UROLOGIST? ..........................................................2 PELVIC ANATOMY ..............................................................4 PROLAPSE URETHRA ....................................................................7 BLADDER .....................................................................7 RECTUM ......................................................................8 PERINEUM ..................................................................9 SMALL INTESTINE .....................................................9 VAGINAL VAULT .......................................................10 UTERUS .....................................................................11 EVALUATION OF PROLAPSE ............................................11 SURGICAL REPAIR OF PELVIC PROLAPSE .....................15 STRESS INCONTINENCE .........................................16 CYSTOCELE ..............................................................18 RECTOCELE/PERINEAL LAXITY .............................19
  • Pessary Information

    Pessary Information

    est Ridge obstetrics & gynecology, LLP 3101 West Ridge Road, Rochester, NY 14626 1682 Empire Boulevard, Webster, NY 14580 www.wrog.org Tel. (585) 225‐1580 Fax (585) 225‐2040 Tel. (585) 671‐6790 Fax (585) 671‐1931 USE OF THE PESSARY The pessary is one of the oldest medical devices available. Pessaries remain a useful device for the nonsurgical treatment of a number of gynecologic conditions including pelvic prolapse and stress urinary incontinence. Pelvic Support Defects The pelvic organs including the bladder, uterus, and rectum are held in place by several layers of muscles and strong tissues. Weaknesses in this tissue can lead to pelvic support defects, or prolapse. Multiple vaginal deliveries can weaken the tissues of the pelvic floor. Weakness of the pelvic floor is also more likely in women who have had a hysterectomy or other pelvic surgery, or in women who have conditions that involve repetitive bearing down, such as chronic constipation, chronic coughing or repetitive heavy lifting. Although surgical repair of certain pelvic support defects offers a more permanent solution, some patients may elect to use a pessary as a very reasonable treatment option. Classification of Uterine Prolapse: Uterine prolapse is classified by degree. In first‐degree uterine prolapse, the cervix drops to just above the opening of the vagina. In third‐degree prolapse, or procidentia, the entire uterus is outside of the vaginal opening. Uterine prolapse can be associated with incontinence. Types of Vaginal Prolapse: . Cystocele ‐ refers to the bladder falling down . Rectocele ‐ refers to the rectum falling down . Enterocele ‐ refers to the small intestines falling down .
  • Evidence Review No: 1

    Evidence Review No: 1

    Local Policy Statement No 12 POLICY STATEMENT TITLE/TOPIC: Specific Obstetric and Gynaecology procedures ISSUE DATE: November 2011 1) INSERTION AND REMOVAL OF INTRA UTERINE CONTRACEPTIVE DEVICES (IUCD) DEFINITION An IUCD is a birth control device that is placed in the uterus by a doctor. Although they can come in different shapes and sizes, IUCDs are generally about 1 1/2 inches long, in the shape of a T, and have a copper coating. IUCDs have strings that extend from the device in the uterus, through the cervix and into the vagina. They can be felt to ensure that the IUCD is still in place, but they cannot be seen outside of the body There are two types of IUCDs: those that release progestin and those that do not. COMMISSIONING RECOMMENDATION: The insertion and removal of any IUCD should only be undertaken in a primary care setting, it is not commissioned as a secondary care service RISKS IUCDs do not protect against sexually transmitted diseases (STDs). Women who get an STD while using an IUCD are also more likely to develop pelvic inflammatory disease (PID). In 2 percent to 10 percent of cases, the uterus will push the IUCD out of the body. Fever and chills are other side effects. IUCDs cause cramps and backaches in some women. Heavier bleeding than normal and spotting are also common side effects, though this usually only lasts for the first few months. There is a greater risk of having an ectopic pregnancy with an IUCD than without one. 2) VAGINAL PESSARIES DEFINITION A vaginal pessary is a plastic device that fits into the vagina to help support the uterus (womb), vagina, bladder or rectum.
  • Obstetrics and Gyneclogy

    Obstetrics and Gyneclogy

    3/28/2016 Obstetrics and Gynecology Presented by: Peggy Stilley, CPC, CPC-I, CPMA, CPB, COBGC Objectives • Procedures • Pregnancy • Payments • Patient Relationships 1 3/28/2016 Female Genital Anatomy Terminology and Abbreviations • Endometriosis • Neoplasm • BUS • TAH/BSO • G3P2 2 3/28/2016 Procedures • Hysterectomy • Prolapse repairs • IUDs • Colposcopy Hysterectomy • Approach • Open • Vaginal • Total Laparoscopic • Laparoscopic assisted • Extent • Total • Subtotal • Supracervical • Diagnosis 3 3/28/2016 CPT Codes • Abdominal 58150 – • With or without removal tubes/ovaries 58240 • Some additional services • Vaginal 58260-58270 • Size of uterus < 250 grams, > 250 grams 58275-58294 • Additional services CPT Codes • LAVH 58541-58544 • Detach uterus , cervix, and structures through the scope 58548-58554 • Uterus removed thru the vagina • TLH • Detach structures laparoscopically entire 58570- 58573 uterus, cervix, bodies • Removed thru the vagina or abdomen • LSH • Detaching structures through the scope, 58541 – 58544 leaving the cervix • Morcellating – removing abdominally 4 3/28/2016 Hysterectomy Additional procedures performed • Tubes & Ovaries removed • Enterocele repair • Repairs for incontinence • Marshall-Marchetti-Krantz • Colporrhaphy • Colpo-urethropexy • Urethral Sling • TVT, TOT 5 3/28/2016 Procedures • 57288 Sling • 57240 Anterior Repair • 57250 Posterior Repair • +57267 Add on code for mesh/graft • 57260 Combo of A&P • 57425 Laparoscopic Colpopexy • 57280 Colpopexy, Abdominal approach • 57282 Colpopexy, vaginal approach Example 1 PREOPERATIVE DIAGNOSES: 1. Menorrhagia unresponsive to medical treatment with resulting chronic blood loss anemia POSTOPERATIVE DIAGNOSES: 1. Menorrhagia 2. Blood loss anemia TITLE OF SURGERY: Total abdominal hysterectomy ANESTHESIA: GENERAL ENDOTRACHEAL ANESTHESIA. INDICATIONS: The patient is a lovely 52-year-old female who presented with menorrhagia that is non- responsive to medical treatment.
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    Gynecological-DBQ

    INTERNAL VETERANS AFFAIRS USE GYNECOLOGICAL CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION ON REVERSE BEFORE COMPLETING FORM. NAME OF PATIENT/VETERAN PATIENT/VETERAN'S SOCIAL SECURITY NUMBER NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire as part of their evaluation in processing the claim. VA reserves the right to confirm the authenticity of ALL DBQs completed by private health care providers. IS THIS DBQ BEING COMPLETED IN CONJUNCTION WITH A VA21-2507, C&P EXAMINATION REQUEST? YES NO If no, how was the examination completed (check all that apply)? In-person examination Records reviewed Other, please specify: Comments: ACCEPTABLE CLINICAL EVIDENCE (ACE) INDICATE METHOD USED TO OBTAIN MEDICAL INFORMATION TO COMPLETE THIS DOCUMENT: Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence.
  • Legacy Health

    Legacy Health

    Legacy Health Co-Management and Referral Guidelines Management of Pelvic Floor Dysfunction Phone: 503-413-3707 Legacy Physical Therapy Fax: 503-413-1504 Introduction After appropriate evaluation by your care providers, patients may be referred to pelvic floor physical therapy for management of pelvic floor muscle dysfunctions/pain, incontinence of urine or fecal matter, pelvic floor/girdle physical therapy. • Hypertonic pelvic floor dysfunction — vaginismus, dyspareunia, levator ani syndrome • Hypotonic pelvic floor muscles — organ prolapse, rectus diastasis • Continence issues after abdominal surgeries in male and female (prostate or hysterectomies), overactive bladder • Endometriosis, pelvic pain • Chronic constipation Evaluation Evaluation and A careful history and evaluation/physical exam will be performed to assess the origin and functional Management limitations of the patient. Muscle tone assessment, organ mobility, scar tissue mobility, bladder and/or bowel diary Treatment Strengthening or down-training PF muscles, with or without biofeedback, manual therapy, scar tissue release, electrical stimulation, trigger point release, visceral and myofascial mobilization, body mechanics and core stabilization. Duration One to six 60-minute visits with the physical therapist When to refer Refer when pain is limiting normal activities of daily living, if patient is not able to get to the bathroom dry, if sexual activity is painful (although dyspareunia alone is often not covered by insurance) Commonly referred ICD10 codes and descriptors for PT diagnoses R10.9 Abdominal pain K59.4 Anal spasm/proctalgia fugax R39.89 Bladder pain M53.3 Coccygodynia K59.00 Constipation, unspecified N81.10 Cystocele, unspecified (prolapse of anterior vaginal wall NOS) M62.0 Diastasis rectus post-partum N94.1 Dyspareunia — excludes psychogenic dyspareunia (F52.6).
  • Pelvic Floor Ultrasound in Prolapse: What's in It for the Surgeon?

    Pelvic Floor Ultrasound in Prolapse: What's in It for the Surgeon?

    Int Urogynecol J (2011) 22:1221–1232 DOI 10.1007/s00192-011-1459-3 REVIEW ARTICLE Pelvic floor ultrasound in prolapse: what’s in it for the surgeon? Hans Peter Dietz Received: 1 March 2011 /Accepted: 10 May 2011 /Published online: 9 June 2011 # The International Urogynecological Association 2011 Abstract Pelvic reconstructive surgeons have suspected technique became an obvious alternative, whether via the for over a century that childbirth-related trauma plays a transperineal [4, 5] (see Fig. 1) or the vaginal route [6]. major role in the aetiology of female pelvic organ prolapse. More recently, magnetic resonance imaging has also Modern imaging has recently allowed us to define and developed as an option [7], although the difficulty of reliably diagnose some of this trauma. As a result, imaging obtaining functional information, and cost and access is becoming increasingly important, since it allows us to problems, have hampered its general acceptance. identify patients at high risk of recurrence, and to define Clinical examination techniques, in particular if the underlying problems rather than just surface anatomy. examiner is insufficiently aware of their inherent short- Ultrasound is the most appropriate form of imaging in comings, are rather inadequate tools with which to assess urogynecology for reasons of cost, access and performance, pelvic floor function and anatomy. This is true even if one and due to the fact that it provides information in real time. uses the most sophisticated system currently available, the I will outline the main uses of this technology in pelvic prolapse quantification system of the International Conti- reconstructive surgery and focus on areas in which the nence Society (ICS Pelvic Organ Prolapse Quantification benefit to patients and clinicians is most evident.
  • Uro 2018-159 Issue Date: 02/2015 Review Date: 03/2021 © Liverpool Women’S NHS Foundation Trust

    Uro 2018-159 Issue Date: 02/2015 Review Date: 03/2021 © Liverpool Women’S NHS Foundation Trust

    Vaginal Pessary Information Leaflet What Is A Pessary? A pessary is a plastic or silicone device that fits into your vagina to support a prolapsed bladder, rectum or uterus (womb). There are different types but the most commonly used are either a ring or a shelf pessary. 71%- 90% of women are successfully fitted with a pessary. What Is A Prolapse? A prolapse means that your uterus, bladder or rectum is bulging or leaning into the vagina, because the muscular walls of the vagina have become weakened. This can sometimes be felt as a lump in the vagina. If the prolapse is large it may also cause difficulty when emptying the bladder or bowel. It is possible for women to have more than one type of prolapse. 50% of women can get a prolapse. Patients can have varying symptoms such as vaginal heaviness, pelvic pressure bulging into the vagina and backache. What Are The Different Types Of Prolapse? Cystocele A cystocele occurs when the vaginal wall that is next to the bladder becomes weakened. This causes the bladder to lean (or prolapse) into the vagina, where it may then be felt as a lump (See Figure 1) Cystocele Figure 1 Rectocele A rectocele occurs when the vaginal wall next to the rectum becomes weakened. This causes the rectum to lean (or prolapse) into the vagina, where it may then be felt as a lump. This type of prolapse may cause difficulty when opening your bowels. (See Figure 2) Figure 2 Uterine prolapse A Uterine prolapse occurs when the structures that support the womb weaken.
  • About Your Enterocele Or Rectocele Repair

    About Your Enterocele Or Rectocele Repair

    PATIENT & CAREGIVER EDUCATION About Your Enterocele or Rectocele Repair This information describes enteroceles and rectoceles and how they are repaired. About Enteroceles An enterocele (en-tuh-roh-seal), also called small bowel prolapse, occurs when the small intestine moves down and pushes at the top part of the vagina. This creates a bulge (see Figure 1). Figure 1. Female anatomy with and without a enterocele About Your Enterocele or Rectocele Repair 1/5 An enterocele happens when the roof of your vagina weakens. This can be caused by: Aging Vaginal deliveries of heavy babies Menopause A hysterectomy (surgery to remove your uterus) or other gynecologic surgery About Rectoceles A rectocele (rek-tuh-seal), also called a posterior prolapse, is when your rectum bulges into the back wall of your vagina (see Figure 2). Figure 2. Female anatomy with and without a rectocele A rectocele happens when the muscles in your vaginal wall weaken. This can be caused by: Aging Vaginal deliveries of heavy babies About Your Enterocele or Rectocele Repair 2/5 Menopause Treatment for Enteroceles or Rectoceles You will have a repair surgery. A repair surgery will strengthen the wall of your vagina with sutures (stitches). An enterocele repair stops the small intestine from bulging into your vagina. A rectocele repair stops the rectum from bulging into the vagina. Risks of having repair surgery Most people who have enterocele or rectocele repair surgery don’t have problems after their surgery. After your surgery, you may experience: Pain Vaginal bleeding Infection Injury to the bladder or ureters (tubes that take urine from the kidneys to the bladder) Incontinence (urinary leakage) Long-term or permanent problems urinating You may have to insert a catheter (thin, flexible tube) into your bladder to drain your urine.
  • OBGYN Outpatient Surgery Coding

    OBGYN Outpatient Surgery Coding

    OBGYN Outpatient Surgery Coding Anatomy Anatomy • Hyster/o – uterus, womb • Uter/o – uterus, womb • Metr/o – uterus, womb • Salping/o – tube, usually fallopian tube • Oophor/o – ovary • Ovari/o - ovary Terminology • Colpo – vagina • Cervic/o – cervix, lower part of the uterus, the “neck” • Episi/o – vulva • Vulv/o – vulva • Perine/o – the space between the anus and vulva Hysterectomy • A hysterectomy is an operation to remove a woman's uterus. • A woman may have a hysterectomy for different reasons, including: • Uterine fibroids that cause pain • bleeding, or other problems. • Uterine prolapse, which is a sliding of the uterus from its normal position into the vaginal canal. Hysterectomy • There are around 30 hysterectomy CPT codes. • To find the correct code you have to first check: • the surgical approach and • extent of the procedure. Surgical Approaches • Abdominal – the uterus is removed via an incision in the lower abdomen • Vaginal – the uterus is removed via an incision in the vagina • Laparoscopic – the procedure is performed using a laparoscope , inserted via several small incisions in the body. • Their are also CPT codes for laparoscopic-assisted vaginal approach. In this procedure ,the scope is inserted via a small incisions in the vagina. Extent of Procedure • Total hysterectomy: It includes laparoscopically detaching the entire uterine cervix and body from the surrounding supporting structures and suturing the vaginal cuff. It includes bivalving, coring, or morcellating the excised tissues, as required. The uterus is then removed through the vagina or abdomen. • Subtotal, partial or supracervical hysterectomy: It is the removal of the fundus or op portion of the uterus only, leaving the cervix in place.
  • Chronic Pelvic Pain D

    Chronic Pelvic Pain D

    Guidelines on Chronic Pelvic Pain D. Engeler (Chair), A.P. Baranowski, J. Borovicka, A. Cottrell (Guidelines Associate), P. Dinis-Oliveira, S. Elneil, J. Hughes, E.J. Messelink (Vice-chair), A. van Ophoven, Y. Reisman, A.C. de C Williams © European Association of Urology 2015 TABLE OF CONTENTS PAGE 1. INTRODUCTION 6 1.1 Aim 6 1.1.1 Structure and scope 6 1.2 Publication history 6 1.3 Panel composition 7 1.4 Methods 7 2. CHRONIC PELVIC PAIN 8 2.1 Introduction to chronic urogenital pain syndromes 8 2.2 Pain mechanisms - pain as a disease process 8 2.2.1 Ongoing peripheral visceral pain mechanisms as a cause of CPP 9 2.2.2 Central sensitisation - spinal and higher mechanisms of visceral pain 9 2.2.3 Spinal mechanisms and visceral hyperalgesia 9 2.2.4 Supraspinal modulation of pain perception 10 2.2.5 Higher centre modulation of spinal nociceptive pathways 10 2.2.6 Neuromodulation and psychology 10 2.2.7 Autonomic nervous system 10 2.2.8 Endocrine system 10 2.2.9 Genetics and chronic pain 10 2.3 Clinical paradigms and CPP 11 2.3.1 Referred pain 11 2.3.2 Referred pain to somatic tissues with hyperalgesia in the somatic tissues 11 2.3.3 Muscles and pelvic pain 11 2.3.4 Visceral hyperalgesia 11 2.3.5 Viscero-visceral hyperalgesia 11 2.4 Classification of CPP syndromes 12 2.4.1 Importance of classification 12 2.4.2 Pain syndromes 14 2.4.2.1 Definition of chronic pelvic pain (CPP) 14 2.4.2.2 Definition of chronic pelvic pain syndrome 14 2.4.2.2.1 Further subdivision of CPPS 14 2.4.2.2.2 Psychological considerations for classification 14 2.4.2.2.3 Functional considerations for classification 15 2.5.2.2.4 Multisystem subdivision 15 2.4.2.2.5 Dyspareunia 15 2.4.2.2.6 Perineal pain syndrome 15 2.5 Conclusions and recommendations: CPP and mechanisms 15 2.6 An algorithm for CPP diagnosis and treatment 16 3.