Introduction

Urologic disorders and pelvic pain present an obvious relationship. A large proportion of the human population has endured pain or discomfort of a simple urinary tract infection. And one of the earliest adventures in human surgical intervention arose in the centuries BC as the Greeks ‘cut for stone’ to relieve the obstruction and pain of urinary bladder calculi. However, now that most of the urogynaecologic organ maladies of infection, neoplasia and obstruction are understood, we are still left with a noisome bag of discomforts lacking any clear pathogenesis. These are the urologic chronic pelvic pain syndromes (UCPPS). The majority of these conditions arise from either a possible urinary bladder source known as bladder pain syndrome/interstitial cystitis (BPS/IC) or prostate source known as prostate pain syndrome (PPS), named chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in the United States. The European Association of Urology attempted to update and provide a classification of pelvic pain disorders to suggest avenues for further management (Fall et al. 2010). Their pelvic pain descriptions fit into neat little boxes of urological, gynaecological, anorectal, neuromuscular and ‘other’ categories. These non-malignant pain conditions or syndromes perceived in structures related to the pelvis of both males and females do not deserve more specific diagnoses because the aetiology and pathogenesis remains a mystery – ‘a riddle wrapped in a mystery inside an enigma’ – and we depend on a complex symptomatic analysis to help guide us in evaluation and therapy. Regrettably the final common pathway often defaults as a referral to a pain management team. While awaiting elucidation of the cellular and molecular pathogenic mechanisms of UCPPS, we should rely on a diagnostic and therapeutic algorithm to direct logical evaluation and multimodal management. We must develop alternative ways of thinking about managing these urologic pain conditions. UCPPS needs to be viewed as much more than an organ-specific disease, but rather as a biopsychosocial disorder. The central problem is pain. Traditional biomedical treatment for UCPPS has failed (Anderson 2006). Antibiotics, α-blocking agents and anti-inflammatory agents as well as virtually all other pharmaceuticals have shown unimpressive outcomes in ameliorating the effects of these disorders. The biopsychosocial model of this condition rather than the biomedical model holds the key to understanding the pathogenesis and possible future treatments. Phenotyping is one current trend and we recommend it for approaching patients with these disorders allowing specific guideline development for multimodal therapy (Baranowski et al. 2008, Nickel et al. 2009, Shoskes et al. 2009). Some of the recent developments and approaches arose from clinical investigation and treatment protocols supported by the National Institutes of Health (NIH) in the United States over the past 10 years. A descriptive phenotyping classification allows understanding of epidemiology, aetiology and potential design of randomized clinical trials. Clinically identifiable domains suggested include: urinary, psychosocial, organ specific, infection, neurological/systemic and muscle tenderness (Nickel & Shoskes 2009, Shoskes et al. 2009) (Table 12.1).

Table 12.1 Percentage of patients with specific myofascial trigger point tenderness

The early chapters of this book present a diverse range of symptoms and describe multiple aetiological possibilities for chronic pelvic pain (CPP). The aim of this chapter is to review evidence regarding urologic conditions associated with pelvic pain, provide a description of good urologic evaluation, and focus on one specific management approach involving manipulation of the pelvic floor neuromuscular tissue using both physiotherapeutic and psychological maneuvers (the Wise-Anderson Stanford Protocol).

Urologic diagnostic evaluation