What does CPP (Chronic Pelvic Pain) refer to in the context of women's health?

What is CPP in Women's Health?

CPP stands for Chronic Pelvic Pain, defined as cyclical or noncyclical pain involving the pelvis, lower abdomen, vulva, vagina, or perineum lasting at least 6 months. 1, 2

Core Definition and Scope

• CPP is persistent pain perceived to be related to structures in the pelvic region, lasting more than 6 months, in the absence of infection or other identifiable acute causes. 1, 3
• The condition affects approximately one quarter of women worldwide and represents the single most common presenting complaint at gynecologic office visits. 1, 2
• CPP causes significant morbidity with substantial public health impact and downstream costs, though these are poorly quantified due to the variety of etiologies. 1, 2

Anatomical Distribution

CPP can manifest in distinct anatomical locations:

• Deep or internal pelvic pain - involving structures within the true pelvis 1, 2
• Perineal, vulvar, or vaginal pain - affecting external genital structures 1, 2
• Lower abdominal pain - perceived in the suprapubic or lower quadrant regions 2, 3

Key Clinical Characteristics

• Pain may be cyclical (related to menstrual cycle) or noncyclical (constant or intermittent without menstrual pattern). 1, 3
• Associated symptoms frequently include dysmenorrhea (painful periods), dyspareunia (painful intercourse), dysuria (painful urination), and dyschezia (painful defecation). 4
• The condition often coexists with other functional somatic pain syndromes including irritable bowel syndrome and chronic fatigue syndrome. 3
• Psychological comorbidities are common, with approximately 40% of CPP patients reporting anxiety and depression scores requiring treatment. 5

Major Etiological Categories

Gynecologic Causes

• Endometriosis - the most common identifiable gynecologic cause, typically presenting with cyclical pain 6, 4
• Adenomyosis - uterine tissue invasion causing chronic pain 2, 6
• Pelvic inflammatory disease - chronic inflammatory sequelae from untreated infections 2, 6
• Pelvic congestion syndrome (pelvic venous disorders) - characterized by engorged periuterine and periovarian veins 6
• Adhesions - intraperitoneal scarring, though causal linkage to pain remains unclear 1, 6

Urologic Causes

• Interstitial cystitis/bladder pain syndrome - unpleasant bladder-related sensation with lower urinary tract symptoms exceeding 6 weeks 1, 7
• Chronic urinary tract infections and urethral syndrome 4

Gastrointestinal Causes

• Irritable bowel syndrome - altered gut biome and dysregulated brain-gut associations 4, 7
• Inflammatory bowel diseases 2, 6

Musculoskeletal Causes

• Pelvic myofascial pain - muscular trigger points and dysfunction 1, 2, 6
• Pelvic girdle pain 2, 6
• Levator syndrome and coccygodynia 4

Important Clinical Context

• CPP is conceptualized as a symptom rather than a diagnosis, requiring investigation to identify underlying causes. 3, 7
• The condition represents a chronic regional pain syndrome with incompletely mapped cognitive and neurologic contributors. 1
• In postmenopausal women, vaginal bleeding and suspected adnexal masses should take precedence over general pain complaints due to elevated risk of endometrial and ovarian neoplasia. 1, 2, 6
• A history of physical, sexual, or emotional abuse is reported by approximately 50% of women with CPP and correlates with worse health outcomes including higher analgesic use, sick leave, and anxiety scores. 5, 8

Critical Pitfalls

• Do not assume CPP has a single-organ pathological origin - the condition is multifactorial and requires evaluation across multiple organ systems. 9
• Do not overlook psychological comorbidities - nearly half of CPP patients have history of trauma, and psychological factors are strongly associated with symptom severity. 5, 8
• Recognize that in many cases, no specific etiology can be identified despite thorough evaluation, and CPP functions as a chronic pain syndrome requiring multimodal management. 3