What is the workup for Chronic Pelvic Pain Syndrome (CPPS)?

Workup of Chronic Pelvic Pain Syndrome (CPPS)

The workup for Chronic Pelvic Pain Syndrome should include a thorough history focusing on pain characteristics, urinary symptoms, sexual function, and psychosocial factors, followed by physical examination, basic laboratory testing with urinalysis and urine culture, and appropriate imaging based on clinical suspicion. 1, 2

Initial Assessment

History

• Pain characteristics:

  • Location (perineum, suprapubic region, testicles, penis tip, lower abdomen, back, rectum)
  • Relationship to bladder filling and emptying
  • Exacerbating factors (urination, ejaculation, specific foods/drinks)
  • Duration (must be at least 6 months for chronic classification)
  • Quality (pressure, discomfort, sharp, dull)

• Urinary symptoms:

  • Frequency, urgency, nocturia
  • Dysuria
  • Sense of incomplete emptying
  • Pattern of symptoms (constant vs. intermittent)

• Sexual function:

  • Dyspareunia/pain with ejaculation
  • Sexual dysfunction
  • Impact on sexual relationships

• Psychosocial assessment:

  • Depression and anxiety screening
  • History of trauma or abuse
  • Impact on quality of life and daily functioning

Physical Examination

• Abdominal examination
• Digital rectal examination (assess prostate tenderness, size, consistency)
• External genitalia examination
• Pelvic floor muscle assessment (tenderness, trigger points)
• Musculoskeletal examination of back and hips

Laboratory Testing

• Basic laboratory testing:

  • Urinalysis (to rule out infection, hematuria)
  • Urine culture (to detect clinically significant bacteria even with negative urinalysis)
  • Urine cytology (if history of smoking or unexplained microhematuria) 1

• Additional testing based on clinical suspicion:

  • Meares and Stamey 2- or 4-glass test (for men with suspected chronic bacterial prostatitis) 2
  • Microbiological evaluation for atypical pathogens when indicated

Imaging Studies

• Pelvic ultrasound:

  • First-line imaging for internal pelvic pain
  • Can identify hydrosalpinx, pelvic inflammatory disease, ovarian pathology
  • Transvaginal approach preferred for women 1

• MRI pelvis:

  • When ultrasound findings are nondiagnostic or inconclusive
  • Superior for evaluating pelvic venous disorders, chronic inflammatory disease, and adhesive disease
  • Use of gadolinium-based IV contrast agent is preferred 1

• CT abdomen and pelvis:

  • May be useful for suspected pelvic venous disorders or chronic inflammatory disease
  • Less sensitive than MRI for many pelvic conditions 1

• Cystoscopy:

  • Consider when diagnosis is in doubt or bladder pathology is suspected
  • Not necessary for uncomplicated presentations 1

Specialized Testing

• Urodynamics:

  • Should be used selectively when symptoms persist despite initial management
  • Particularly useful when invasive treatments are being considered 2

• Laparoscopy:

  • Reserved for severe cases or when endometriosis is strongly suspected in women 3

Differential Diagnosis Considerations

In Men:

• Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
• Interstitial cystitis/bladder pain syndrome (IC/BPS)
• Pelvic floor dysfunction
• Irritable bowel syndrome
• Musculoskeletal disorders

In Women:

• Endometriosis
• Interstitial cystitis/bladder pain syndrome
• Pelvic inflammatory disease
• Pelvic venous disorders (pelvic congestion syndrome)
• Adhesive disease
• Irritable bowel syndrome
• Pelvic floor dysfunction

Common Pitfalls and Caveats

1. Misdiagnosis: CPPS is often misdiagnosed or underdiagnosed due to symptom overlap with other conditions. Consider multiple organ systems as potential sources of pain 4, 5.

2. Overreliance on imaging: Physical examination findings and patient history are more important than imaging for diagnosis. Imaging should be guided by clinical suspicion 1.

3. Neglecting psychosocial factors: Psychological factors significantly impact CPPS and should be assessed as part of the initial workup 1, 3.

4. Overlooking overlap between conditions: Men may have symptoms that meet criteria for both IC/BPS and CP/CPPS, requiring consideration of both conditions in treatment planning 1.

5. Potassium sensitivity test: This test lacks specificity and sensitivity and is not recommended for routine clinical decision-making 1.

6. Delayed diagnosis: The complexity of CPPS often leads to delayed diagnosis. A systematic approach to evaluation can help avoid this pitfall 1.

By following this comprehensive workup approach, clinicians can more effectively identify the underlying causes of CPPS and develop appropriate treatment strategies that address both physical and psychological aspects of this complex condition.