Chronic pelvic pain: bladder pain, endometriosis, pudendal neuralgia

Chronic pelvic pain is mostly a clinical diagnosis. Diagnose bladder pain syndrome after excluding mimics, treat endometriosis pain with hormones first, and apply the Nantes criteria before calling pain pudendal neuralgia.

1. Bladder pain syndrome is a clinical diagnosis. AUA calls for history, examination and laboratory testing to document typical symptoms and exclude other disorders; cystoscopy and urodynamics are for diagnostic doubt, and cystoscopy for suspected Hunner lesions ¹.
2. Treat bladder pain multimodally and nonsurgically first. Except for Hunner lesions, initial treatment should be nonsurgical, with multimodal pain management, stress management and manual physical therapy when available; Hunner lesions are fulgurated or injected with triamcinolone ¹.
3. Some bladder treatments should not be offered. AUA advises against long-term oral antibiotics, intravesical BCG outside trials, high-pressure long-duration hydrodistension and long-term oral glucocorticoids ¹.
4. Endometriosis pain: hormones first. ESHRE 2022 recommends combined hormonal contraceptives or progestogens for dysmenorrhea, dyspareunia and non-menstrual pain; GnRH agonists or antagonists are second-line, and aromatase inhibitors are for pain refractory to other medical or surgical treatment. Hormone choice is a shared decision weighing side effects and cost ².
5. Laparoscopy is no longer the gatekeeper. ESHRE now reserves laparoscopy for patients with negative imaging or when empirical treatment fails or is inappropriate ².
6. Pudendal neuralgia uses the Nantes criteria. Pain in the pudendal territory, worse sitting, not waking the patient at night, with no objective sensory loss and relief from an anesthetic pudendal block ³.

Objective perineal sensory loss or pain that wakes the patient at night argues against pudendal entrapment and should prompt a search for another lesion ³.

• The potassium sensitivity test does not identify other disorders and is positive in bacterial and radiation cystitis ¹.
• AUA: counsel patients considering pentosan polysulfate about macular damage and vision-related injury ¹.
• Patients with Hunner lesions are treated differently from those without them ¹.
• GnRH agonists need add-back therapy to prevent bone loss and hypoestrogenic symptoms ².
• Nantes exclusions include purely coccygeal, gluteal or hypogastric pain and exclusively paroxysmal pain ³.
• Visceral pelvic pain is diffuse and referred because visceral and somatic afferents converge on shared spinal neurons ⁴.
• AUA lists DMSO, heparin and lidocaine as intravesical options and intradetrusor onabotulinumtoxinA when other treatments fail ¹.
• After surgery for endometrioma, ESHRE recommends long-term hormone treatment to prevent recurrence in women not seeking conception ².

• Requiring cystoscopy with hydrodistension in every patient before diagnosing bladder pain syndrome ¹.
• Insisting on laparoscopy before any hormonal treatment for suspected endometriosis ².
• Diagnosing pudendal neuralgia when the pain is purely coccygeal ³.
• Prescribing long-term oral antibiotics or steroids for bladder pain with repeatedly negative cultures ¹.