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CURRENT ICS DEFINITION

Chronic Pelvic Pain (Syndromes)
Christian Cobreros
Nov 2017

CURRENT ICS DEFINITIONS:
The ICS Standard for Chronic Pelvic Pain (1) has been written by a multidisciplinary group of healthcare providers (WG), under the supervision of a Chairperson and according the published methodology of the Standard Steering Committee (SSC). (2)
ICS 2017 (1):
PainA subjective phenomenon described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.(3)”
Chronic pelvic painis characterized by persistent pain lasting longer than 6 months or recurrent episodes of abdominal/pelvic pain, hypersensitivity or discomfort often associated with elimination changes, and sexual dysfunction often in the absence of organic etiology. (4)”
A syndromeis a complex of concurrent symptoms and signs that is collectively indicative of a disease, dysfunction or disorder in the absence of obvious pathology. (NEW) Example: Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is one of the Chronic Pelvic Pain Syndromes. Footnote - This is an update of the ICS Standardisation Sub-committee report on the Standardisation of Lower Urinary Tract Function" (5)
DOMAINS OF CPPS
The WG identified the nine domains, each of which are considered in terms of symptoms, signs, and further evaluation. 
 The sub classification of CPPS into nine domains refers to the organ that is compromised. Domains facilitate phenotyping the patients, as well as development a pertinent animal models and new preclinical development of therapeutic strategies. This domain (and subdomains) are:
1. Lower Urinary Tract Domain (A. Bladder. B. Urethra)
2. Female Genital Domain (A. Vulva, vestibule, and clitoris. B. Intra-abdominal female genital pain. C. Pelvic floor muscle pain)
3. Male Genital Domain (A. Prostate. B. Scrotum. C. Epididymis. D. Testicle. E. Penis. F. Urethra. G. Sexual Pain)
4. Gastro-Intestinal Domain (A. Anorectum. B. Colorectum.)
5. Musculoskeletal Domain (A. Pelvic muscle pain. B. Coccyx pain syndrome. C. Pelvic Joint, ligament, or bony pain)
6. Neurological Domain (A.Complex Regional Pain Syndrome (CRPS). B. Somatic neuropathic pain. C. Pain following mesh surgery)
7. Psychological Domain (A. Worry, anxiety, and fear. B. Depression and depressed mood. C. Catastrophizing.)
8. Sexual Domain (A. Sexual desire disorder. B. Sexual arousal disorder. C.Orgasmic disorder. D. Sexual pain disorder.)
9. Comorbidities (A. Allergies. B. Chronic pain and fatigue syndromes. C. Systemic autoimmune syndromes/disease. D. Extraintestinal manifestations of inflammatory bowel disease.)
OTHER DEFINITIONS
EUROPEAN ASSOCIATION OF UROLOGY (EAU) (6)
"Pain syndromes
The original EAU classification was inspired by the IASP classification and much work around what has become known as “pain as a disease” and its associated psychological, behavioural, sexual and functional correlates. After 10 years work developing the initial ideas, an updated version was accepted by IASP Council for publication in January 2012."
"Definition of chronic pelvic pain (CPP)
Chronic pelvic pain is chronic or persistent pain perceived in structures related to the pelvis of either men or women. It is often associated with negative cognitive, behavioural, sexual and emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor or gynaecological dysfunction.”
Definition of chronic pelvic pain syndrome (CPPS)
Chronic pelvic pain syndrome is the occurrence of CPP when there is no proven infection or other obvious local pathology that may account for the pain. It is often associated with negative cognitive, behavioural, sexual or emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction. CPPS is a subdivision of CPP”.
INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN (IASP) (7,8)
"Chronic Pelvic Pain
Chronic pelvic pain is chronic or persistent pain perceived in structures related to the pelvis of either men or women. It is often associated with negative cognitive, behavioral, sexual and emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor or gynecological dysfunction.”
"Chronic Pelvic Pain Syndrome
Chronic pelvic pain syndrome (CPPS) is the occurrence of chronic pelvic pain where there is no proven infection or other obvious local pathology that may account for the pain. It is often associated with negative cognitive, behavioral, sexual or emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynecological dysfunction. CPPS is a subdivision of chronic pelvic pain (see above).”
Further Subdivision of the Chronic Pelvic Pain Syndromes
Pain perceived in the pelvis in the chronic pelvic pain syndromes may be focused within a single organ, more than one pelvic organ and even associated with systemic symptoms such as chronic fatigue syndrome, fibromyalgia or Sjögren’s syndrome.”
UNDERSTANDIG THE DEFINITION OF CPPS, WHY IT IS SO DIFFICULT
Definitions in chronic pelvic pain are always controversial, but we all know definitions are needed. The signs and symptoms that constitutes a syndrome could be referring to more than one specific disease, but in CPPS the main symptom that needs to be treated is pain, in the absence of inflammatory or infections signs the disease is the pain itself.
For the medical system, the need of a definition its well understood. Definitions help define phenotyping. For example, bladder pelvic pain can be associated with Hunner lesions found in cystoscopy in one patient , while another patient with the same symptoms and the same pain does not have bladder lesions. In this case, we have two phenotypes of bladder pelvic pain which can have different treatment, prognosis, psychological and social impacts.
For the patient, the definition brings him a sense of relief and of being understood and helps in acceptance of the illness as a chronic condition. This can move the patient forward towards rehabilitation programs, therapeutic algorithms, and in some cases is necessary for access to therapeutic programs.
HOW CAN WE INDIVIDUALIZE EACH PATIENT FOR EACH DOMAIN?
Treatment for every patient must be individualized, taking into consideration the patient’s personal perception of pain, and the biopsychosocial aspects of CPPS and taking into account any comorbities .
For every domain, several clinical aspects must be identified: symptoms, signs and clinical evaluation. The patient's personal interpretation and results of questionnaires are the symptoms. Signs are measurements, physical exams, and specific studies taken by the physician This process leads us to the subdomains and then to a specific syndrome, which in turn leads us to a specific algorithm of treatment. Having an algorithm for a specific subdomain that will have a universal use allows us to compare our results in treatment and better diagnosis worldwide.
WHICH IS THE MOST IMPORTANT STEP FOR THE PATIENTS CLASSIFICATION INTO DOMAINS?
The most difficult step in this classification is to correctly identify the patients “perception of pain”. We know that pain is a subjective phenomenon. There are different kinds of pain: nociceptive, somatic, visceral, centrally generated, hypersensitivity, or central sensitization pain. The classic pain affecting the CPPS is the hypersensitivity where an increased nerve activity from a standard stimulus has an unexpected clinical or tissue response.
But every pain is modulated by cognitive factors and present and past emotional experience so it’s difficult to say whether CPPS are an abnormal perception of a normal stimulus or a normal perception of an abnormal physiologic sensory stimulus (pain experience). Also, we have to consider that its widely accepted that CPPS are pain that remains for at least six weeks in some definitions, and six months in the ICS definition so we do have to take into account the impact of this pain in daily life, mood, sleep, relationships, and activities (psychology of pain).
REFERENCES
1-Doggweiler, R., Whitmore, K. E., Meijlink, J. M., Drake, M. J., Frawley, H., Nordling, J., Hanno, P., Fraser, M. O., Homma, Y., Garrido, G., Gomes, M. J., Elneil, S., van de Merwe, J. P., Lin, A. T.L. and Tomoe, H. (2017), A standard for terminology in chronic pelvic pain syndromes: A report from the chronic pelvic pain working group of the international continence society. Neurourol. Urodynam., 36: 984–1008. doi:10.1002/nau.23072
2-Rosier PF, de Ridder D, Meijlink J, et al. Developing evidence-based standards for diagnosis and management of lower urinary tract or pelvic floor dysfunction. 
Neurourol Urodyn 2012;31:621–4. https://www.ncbi.nlm.nih.gov/pubmed/22396134
3-Merskey H. Classification of chronic pain. 2nd ed. In: Merskey H, editor. Seattle: IASP Press; 1994.https://www.iasp-pain.org/files/Content/.../Classification-of-Chronic-Pain.pdf
4-Nickel JC, Shoskes DA, Wagenlehner FH. Management of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): The studies, the evidence, and the impact. World J
Urol 2013;31:747–53.https://www.ncbi.nlm.nih.gov/pubmed/23588814
5-Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: Report from the Standardisation Sub-Committee of the International Continence Society. Neurourol Urodyn 2002; 21:167–78.https://www.ncbi.nlm.nih.gov/pubmed/11857671
6-Engeler D, Baranowski AP, Borovicka J, Dinis-Oliveira P, Elneil S, Hughes J, Messelink EJ, de C Williams AC. EAU Guidelines on Chronic Pelvic Pain 2016. Available at: https://uroweb.org/wp-content/uploads/EAU-Guidelines-Chronic-Pelvic-Pain-2016-1.pdf)
7-Baranowski A, Abrams P, Berger R, Buffington T, Collett B, Emanuel F, Hanno P, Howard F, Hughes J, Nickel C, Nordling J, Tripp D, Vincent K, Wesselmann U, de C Williams AC. IASP Classification of Chronic Pain, Second Edition (Revised). Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 2011 Available at: https://www.iasp-pain.org/PublicationsNews/Content.aspx?ItemNumber=1673&navItemNumber=677
8-Merskey H, Bogduk N, International Association for the Study of Pain. Task force on taxonomy. Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. Seattle: IASP Press; 1994. https://www.iasp-pain.org/files/Content/.../Classification-of-Chronic-Pain.pdf

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