The Multidisciplinary Approach to Defining the Urologic Chronic Pelvic Pain Syndromes

Meeting Review

RIU0394_06-17.qxd 6/17/08 4:40 PM Page 157 MEETING REVIEW The Multidisciplinary Approach to Defining the Urologic Chronic Pelvic Pain Syndromes Report from a National Institutes of Health Workshop, December 13-14, 2007, Baltimore, MD [Rev Urol. 2008;10(2):157-159] © 2008 MedReviews, LLC Key words: Chronic prostatitis • Chronic pelvic pain syndrome • Interstitial cystitis • Painful bladder syndrome • Irritable bowel syndrome • Fibromyalgia • Chronic fatigue syndrome nterstitial cystitis and chronic prostatitis remain clinical enigmas, partly because the conditions are so ill-defined, partly because they overlap so much with each other and other local and systemic pain syndromes, and partly because our management strategies are rather poor. Recently, the condition traditionally identified as interstitial cystitis has become known as interstitial cystitis/painful bladder syndrome (IC/PBS), painful bladder syndrome, and/or bladder pain syndrome, whereas chronic nonbacterial prostatitis syndromes have become known as chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) or simply I Reviewed by J. Curtis Nickel, MD, FRCSC, Queen’s University, Kingston, Ontario, Canada. chronic pelvic pain syndrome. The overall purpose of the National Institutes of Health (NIH) Urologic Chronic Pelvic Pain Workshop was to begin to redefine these 2 major urologic pelvic pain syndromes in the context of the other major syndromes with which they are commonly associated (eg, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome). The specific aims of the workshop were to discuss disease definitions and diagnostic protocols of these major chronic pelvic pain disorders, discuss the interrelationships among these disorders, and identify common symptomatology and diagnostic assessment to ensure complete evaluation of all relevant comorbidities. Finally, it was hoped that the workshop would lead to development of a diagnostic algorithm that could be tested in a “pilot” study. The participants included a planning committee, a designated advisory panel, and interested researchers, clinicians, patients, and other stakeholders. The following is a brief synopsis of the discussion. Chronic Prostatitis/Chronic Pelvic Pain Syndrome This male genitourinary pain syndrome is associated with variable pain/discomfort in the perineum, suprapubic area, testicles, and groin, as well as pain/discomfort with ejaculation and voiding. It is further associated with urinary storage and voiding symptoms and potential sexual dysfunction. The symptoms have a severe impact on activities and result in very poor quality of life. Psychosocial parameters that modulate symptoms and severity include depression, poor coping strategies, and some VOL. 10 NO. 2 2008 REVIEWS IN UROLOGY 157 RIU0394_06-17.qxd 6/17/08 4:40 PM Page 158 Defining Urologic Chronic Pelvic Pain Syndromes continued forms of maladaptive social interaction. There is considerable overlap between the symptoms of CP/CPPS and interstitial cystitis. Interstitial Cystitis/Painful Bladder Syndrome abuse, and similar health-care utilization. There are many similarities between IBS and general chronic pelvic pain (particularly IC/PBS); nevertheless, both are treated as completely different clinical entities. The hallmark of this syndrome seen in men and women (predominantly described in women) is pelvic pain, typically related to the bladder (filling or emptying). Other related symptoms include urinary frequency, urgency, nocturia, and dyspareunia. It too is associated with psychosocial correlates that impact on severity and quality of life. Definitions and nomenclature surrounding this syndrome have been the focus of considerable North American and European attention, and it is hoped that the efforts of this meeting will lay the groundwork for a conclusive definition that is acceptable to all stakeholders. Fibromyalgia Irritable Bowel Syndrome Chronic Fatigue Syndrome Irritable bowel syndrome (IBS) is characterized by abdominal pain associated with altered bowel habit. Epidemiologic studies have identified an association between IC/PBS and IBS. Both syndromes have relatively similar prevalence, coexistence of mental and somatoform disorders, common history of past sexual and physical The diagnosis of chronic fatigue syndrome, which like IC/PBS occurs primarily in women, is characterized by severe debilitating fatigue lasting at least 6 consecutive months. In addition to the fatigue, individuals report many other muscular, infectious, and neuropsychiatric symptoms, as well as sleep disturbances. Fibromyalgia is defined by widespread pain of more than 3 months’ duration and the presence of a defined number of sites of amplified tenderness. As in many patients with chronic pelvic pain syndromes, Discussion Many patients with chronic pelvic pain are found to carry multiple diagnoses. There is significant overlap with common core symptoms, including abdominal distension and pain, headache, fatigue, bowel and bladder dysfunction, sexual disorders, and multiple psychosocial problems. The initial objective of this December 2007 working meeting was to examine the interrelationships and common symptomatology required for development of an expanded diagnostic and man- There is significant overlap with common core symptoms, including abdominal distension and pain, headache, fatigue, bowel and bladder dysfunction, sexual disorders, and multiple psychosocial problems. fibromyalgia is associated with sleep dysfunction, depression, anxiety, cognitive disturbance, exercise intolerance, and pronounced fatigue. agement algorithm for urologic chronic pelvic pain. A further aim was to develop a “pilot testing” of a clinical phenotyping research program in chronic pelvic pain. From March through May 2008, a multicenter pilot study examined the interrelationships and common symptomatology and psychosocial parameters between IC/PBS and 3 related conditions: IBS, cystic fibrosis, and chronic fatigue syndrome. The NIH plans an important follow-up symposium on June 17, 2008 in Bethesda, MD. This symposium, titled “Defining the Chronic Main Points • Interstitial cystitis and chronic prostatitis remain clinical enigmas, partly because the conditions are so ill-defined, partly because they overlap so much with each other and other local and systemic pain syndromes, and partly because our management strategies are rather poor. • The overall purpose of the National Institutes of Health (NIH) Urologic Chronic Pelvic Pain Workshop was to begin to redefine these 2 major urologic pelvic pain syndromes in the context of the other major syndromes with which they are commonly associated (eg, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and others). • A major NIH funding initiative, the Multidisciplinary Approach to Pelvic Pain (MAPP), is set to begin in July 2008. The overall purpose of the MAPP Network will be to conduct multidisciplinary, collaborative, multisite, basic, translational, and clinical research addressing urologic chronic pelvic pain syndrome. 158 VOL. 10 NO. 2 2008 REVIEWS IN UROLOGY RIU0394_06-17.qxd 6/17/08 4:40 PM Page 159 Defining Urologic Chronic Pelvic Pain Syndromes Pelvic Pain Syndromes: A New Beginning,” will take this effort up 1 more notch. More importantly, a major NIH funding initiative, the Multidisciplinary Approach to Pelvic Pain (MAPP), is set to begin in July 2008. The overall purpose of the MAPP Network will be to conduct multidisciplinary, collaborative, multisite, basic, translational, and clinical research address- ing urologic chronic pelvic pain syndrome. It is anticipated that these studies will increase our understanding of the pathophysiology, biologic and behavioral risk factors, natural history, and genetics of this condition. An important focus of the MAPP Network will be investigation of the biologic and behavioral relationships between IC/PBS and CP/CPPS and other frequently related symptom-based conditions, such as fibromyalgia, IBS, and chronic fatigue syndrome. The ultimate aim of the December 2007 Baltimore workshop, the June 2008 Bethesda symposium, and the upcoming MAPP research program is to provide findings useful for the development of future prevention or treatment strategies. VOL. 10 NO. 2 2008 REVIEWS IN UROLOGY 159