H. Henry Lai, MD; Michel A. Pontari, MD; Charles E. Argoff, MD; Larissa Bresler, MD, DABMA; Benjamin N. Breyer, MD; J. Quentin Clemens, MD, FACS, MSCI; Elise JB De, MD; R. Christopher Doiron, MD, MPH; Dane Johnson, MD; Susan M. MacDonald, MD; Jill H. Osborne, MA; Sijo J. Parekattil, MD; Beth Shelly, PT, DPT, WCS, BCB PMD

Roger Chou, MD; Erin Kirkby, MS

Illustrator

Divya Lagisetti

Purpose

This Guideline covers the evaluation and treatment of men who present to a clinician with a complaint of chronic pelvic pain. The presentation of these men is widely variable. This variability in clinical presentations and multidisciplinary diagnostic and treatment considerations makes management challenging. This Guideline is intended for clinicians evaluating and managing male chronic pelvic pain. The following conditions are covered in this Guideline: (i) chronic prostatitis/ chronic pelvic pain syndrome (CP/CPPS), and (ii) chronic scrotal content pain (CSCP).

Methodology

The systematic review that informs the Guideline statements was based on searches in Ovid MEDLINE (1946 to June 6, 2023), the Cochrane Central Register of Controlled Trials (through May 2023), and the Cochrane Database of Systematic Reviews (through May 2023). Searches were supplemented by reviewing electronic databases reference lists of relevant articles. Criteria for inclusion and exclusion of studies were based on the Key Questions and the PICOTS of interest. An updated search was conducted in June 2024 using the same criteria to bring in relevant literature published since the initial search.

GUIDELINE STATEMENTS

Initial Evaluation

1. In the initial evaluation of patients with chronic pelvic pain, clinicians should include a comprehensive history, complete review of symptoms, physical examination, and laboratory studies to document symptoms and signs of chronic pelvic pain. Clinicians should screen for concurrent pelvic pathology and exclude other confusable disorders that could be the cause of patient symptoms as part of the initial assessment for pelvic pain. (Clinical Principle)
2. Clinicians may use validated questionnaires to assess pain levels, urinary symptoms, and quality of life. (Clinical Principle)
3. Clinicians should discuss patient psychosocial health, such as the presence of anxiety, depression, major life stress, and impact on quality of life and daily functioning. (Clinical Principle)
4. Clinicians should screen for neurological, musculoskeletal, and orthopedic abnormalities of the pelvis, hip, and lower spine in patients presenting with chronic pelvic pain. Identification of such abnormalities should prompt referral to an appropriate specialist. (Expert Opinion)
5. Clinicians should perform digital palpation of the pelvic floor muscle transrectally in men to identify tenderness suggesting a diagnosis of pelvic floor myalgia. (Expert Opinion)
6. Clinicians should perform a thorough scrotal examination in patients with chronic pelvic pain; a scrotal ultrasound may be performed. (Clinical Principle)
7. A prostate massage, two-glass or four-glass localization test may be performed if there is diagnostic uncertainty in distinguishing chronic bacterial prostatitis from CP/CPPS. (Expert Opinion)
8. Clinicians may utilize cystoscopy, urodynamics, and/or imaging when the diagnosis is unclear. (Clinical Principle)

Differential Diagnosis of Male Chronic Pelvic Pain

9. Clinicians should consider the diagnosis of IC/BPS in male chronic pelvic pain patients who experience an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes. (Expert Opinion)
10. Clinicians should consider the diagnosis of CP/CPPS in patients who experience chronic perineal pain, bilateral scrotal content pain, penile pain, suprapubic pain, dysuria, or pain with ejaculation. (Expert Opinion)
11. Clinicians should consider the diagnosis of CSCP in patients who experienced unilateral chronic scrotal pain in the absence of other pelvic sites of pain or urinary symptoms. (Expert Opinion)
12. In patients with isolated unilateral CSCP, clinicians may perform diagnostic spermatic cord block and/or ilioinguinal block. (Expert Opinion)

Management Approach

13. Treatment decisions should be made based on shared decision-making between the patient and clinician, with the patient informed of the risks, potential benefits, and treatment alternatives. Initial treatment should typically be nonsurgical. (Clinical Principle)
14. Clinicians should periodically reassess efficacy of treatment and discontinue ineffective treatments. The clinical diagnosis should be reconsidered if no improvement occurs after multiple treatment approaches. (Clinical Principle)
15. Clinicians may utilize a multimodal and multidisciplinary approach to pain management. If pain control is inadequate, referral to pain management should be discussed. (Clinical Principle)
16. Clinicians should encourage patients expressing significant distress secondary to chronic pelvic pain to seek treatment for mental health needs and discuss family, spousal, and/or local support systems. (Clinical Principle)

Treatment Options for Chronic Prostatitis/ Chronic Pelvic Pain Syndrome (CP/CPPS)

Behavioral/Non-Pharmacologic Treatments

17. In patients with CP/CPPS, clinicians may discuss lifestyle modification, including dietary changes and aerobic exercise. (Conditional Recommendation; Evidence Level: Grade C)

Alpha-Blockers

18. In patients with CP/CPPS and voiding symptoms, clinicians should offer treatment with an alpha-blocker. (Moderate Recommendation; Evidence Level: Grade B)

5-Alpha Reductase

19. Clinicians may prescribe 5-alpha reductase inhibitors to patients with CP/CPPS who also have voiding symptoms from BPH or enlarged prostate as determined by imaging or PSA level. (Expert Opinion)

Anti-inflammatory agents (including nonsteroidal anti-inflammatory drugs) 

20. Clinicians may prescribe anti-inflammatory agents as part of a multi-modal pain management strategy for treatment of pain in patients with CP/CPPS. (Conditional Recommendation; Evidence Level: Grade B)

PDE5-Inhibitors 

21. Clinicians may prescribe daily tadalafil for treatment of prostatitis symptoms in patients with CP/CPPS with or without concomitant erectile dysfunction. (Conditional Recommendation; Evidence Level: Grade B)

Analgesics

22. Clinicians may prescribe pharmacologic pain management agents (e.g., urinary analgesics, acetaminophen, non-opioid medications) after counseling patients on the risks and benefits. (Clinical Principle)

Neuropathic Medications

23. Clinicians may prescribe medications for neuropathic pain including the classes of tricyclic antidepressants, selective serotonin reuptake inhibitors, and gabapentinoids. (Conditional Recommendation; Evidence Level: Grade C)

Phytotherapeutics

24. In patients with CP/CPPS, clinicians may prescribe phytotherapeutics including saw palmetto, quercetin, and pollen extract to improve pain, voiding symptoms, and quality of life. (Conditional Recommendation; Evidence Level: Grade B)

Psychological Intervention

25. In patients with CP/CPPS, clinicians may offer cognitive behavioral therapy as an adjunct to other therapeutic interventions. (Conditional Recommendation; Evidence Level: Grade C)

Extracorporeal Shockwave Therapy (ESWT)

26. In patients with CP/CPPS, clinicians should discuss low-intensity extracorporeal shockwave therapy. (Moderate Recommendations; Evidence Level: Grade A)

Transcutaneous Electrical Nerve Stimulation (TENS)

27. Clinicians may offer transcutaneous electrical nerve stimulation for pain control in patients with CP/CPPS. (Conditional Recommendation; Evidence Level: Grade B)

Acupuncture

28. Clinicians may offer acupuncture to patients with CP/CPPS. (Conditional Recommendation; Evidence Level: Grade B)

Treatment Options for Pelvic Floor Myalgia

29. In men with pelvic floor myalgia or abdominopelvic muscle myalgia, clinicians may offer individualized manual physical therapy techniques (e.g., myofascial release of affected tissues both internally and externally). (Conditional Recommendation; Evidence Level: Grade C)
30. Clinicians may utilize electromyography biofeedback training to improve active pelvic floor muscle resting tone and relaxation time to improve pain, urination, and quality of life in patients with increased pelvic floor muscle tone. (Expert Opinion)

Treatment Options for Chronic Scrotal Content Pain (CSCP)

Behavioral/Non-pharmacologic Treatments

31. Clinicians should discuss lifestyle modification that may improve symptoms and implement as feasible. (Clinical Principle)

Medications

32. In patients with CSCP, clinicians may prescribe pharmacologic pain management agents such as acetaminophen, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, gabapentinoids, and non-opioid options after counseling patients on the risks and benefits. Multimodal therapy to pain management is recommended. (Clinical Principle)
33. In antibiotic-naïve patients with CSCP, clinicians may prescribe a single 10-day trial of antimicrobials. (Clinical Principle)

Procedures

34. Clinicians may recommend microsurgical denervation of the spermatic cord to CSCP patients, especially if they previously responded to a spermatic cord block. (Conditional Recommendation; Evidence Level: Grade C)
35. Clinicians may offer vasectomy reversal (vasovasostomy) as a suitable treatment option for patients who have post-vasectomy pain syndrome. (Expert Opinion)
36. Clinicians may offer patients with CSCP acupuncture and pelvic floor physical therapy. (Expert Opinion)
37. Clinicians may recommend transcutaneous electrical nerve stimulation for patients with CSCP. (Conditional Recommendation; Evidence Level: Grade C)
38. If all treatment options fail and the CSCP patient is still suffering from pain, clinicians may discuss consultation with a pain management specialist for further options (e.g., neuromodulation, neurostimulators, spinal blocks). (Expert Opinion)
39. Clinicians may offer epididymectomy to patients with pain and tenderness focal to the epididymis after failure of conservative therapies. (Expert Opinion)
40. Clinicians may offer inguinal (not scrotal) orchiectomy with removal of the entire spermatic cord for patients with CSCP. (Expert Opinion)

Treatments that Should Not be Offered to Patients with Chronic Pelvic Pain

41. Clinicians should not send patients for psychological interventions or dismiss for somatization prior to appropriate medical evaluation. (Clinical Principle)
42. Clinicians should refrain from repeated courses of antimicrobial therapy for treatment of patients with CP/CPPS or CSCP in the setting of negative urine cultures, negative tests for sexually transmitted disease, or following a vasectomy. (Clinical Principle)
43. Clinicians should not perform surgical procedures on the prostate (radical prostatectomy and outlet procedures for benign prostatic hyperplasia) to relieve pelvic pain but may discuss such procedures as part of multimodal therapy in patients with coexisting pain and prostate cancer or bladder outlet obstruction. (Expert Opinion) 
44. Clinicians should not utilize systemic (oral) long-term glucocorticoid administration to treat pelvic pain. (Expert Opinion)

Background

This Guideline covers the evaluation and treatment of men who present to a clinician with a complaint of chronic pelvic pain. The presentation of these men is widely variable. Some will present with pain isolated to a single side of the scrotum, while others will have pain throughout the pelvis, with or without urinary symptoms. In addition to pelvic pain, they may also have pain in many body areas outside of the pelvis. The wide variety of clinical presentations and multidisciplinary diagnostic and treatment considerations makes management challenging.

This Guideline is intended for clinicians evaluating and managing male chronic pelvic pain. The following conditions are covered in this Guideline: (i) chronic prostatitis/ chronic pelvic pain syndrome (CP/CPPS), and (ii) chronic scrotal content pain (CSCP). Although the diagnosis and management of interstitial cystitis/ bladder pain syndrome (IC/BPS) is covered in detail by a separate AUA Guideline,^1,2 male IC/BPS is common among men presenting with chronic pelvic pain, thus the diagnosis of male IC/BPS will be briefly discussed. These conditions may overlap in the individual patient as depicted in Figure 1.

Figure 1: Male Chronic Pelvic Pain Syndromes Covered in this Guideline

^{CP/CPPS = chronic prostatitis/ chronic pelvic pain syndrome, IC/BPS = interstitial cystitis/ bladder pain syndrome, CSCP = chronic scrotal content pain. Conditions may overlap in some men. For example, some men may have both features of CP/CPPS and IC/BPS.}

Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)

One of the confusing aspects of male pelvic pain is the terminology for prostatitis. The NIH definition of chronic pelvic pain was adopted by a 1995 NIH Consensus Conference.³ CP/CPPS belongs to category IIIA or IIIB in the NIH classification of prostatitis, which is distinct from categories I, II and IV (see Table 1).³

To date, there have been no clinically significant differences demonstrated between the two subclasses of CP/CPPS (IIIA versus IIIB).

Men with CP/CPPS have pain or discomfort in the pelvic region for at least three months within the past six months in the absence of identifiable causes of pain.³ The pain can occur in the perineum, lower abdomen/suprapubic area, testes, or penis. The pain may occur with ejaculation or during urination. It is often associated with sexual dysfunction and ED. CP/CPPS may be associated with other chronic pain conditions such as irritable bowel syndrome (IBS), fibromyalgia, migraine, and chronic fatigue syndrome.⁴ The clinical presentation can be quite variable.⁵ Variability is also seen in the presentation time frame as many men present with symptom duration of less than three months. Although these men would not be entered into a clinical trial, they should still be evaluated based on the presence of pain. Strict definitions used in research or clinical trials should be avoided in clinical practice as many patients may be misdiagnosed or experience delays in diagnosis and treatment when such research criteria are employed.

CP/CPPS is a diagnosis of exclusion. Confusable disorders include UTI (demonstration of uropathogenic bacteria detected by standard microbiological methods), urogenital cancer, prior radiation or chemotherapy, urethral stricture, neurologic disease affecting the bladder, or bladder outlet obstruction (BOO).⁶ Pelvic pain or discomfort is the cardinal symptom that distinguishes CP/CPPS from benign prostatic hyperplasia (BPH), which is characterized by lower urinary tract symptoms (LUTS). Men who have urinary urgency, and/or daytime/nighttime urinary frequency with or without urgency incontinence but do not have pelvic/bladder pain may have overactive bladder (OAB) or BOO. It is important to ensure the pain is not due to a reversible condition such as urinary retention, or a confusable disorder.

A review performed for the International Consultation on Urologic Disease (ICUD) sponsored by the Société International d’Urologie (SIU) indicated that the prevalence of prostatitis-like symptoms ranged from 2.2% to 16%, with a median prevalence approximating 7.1% for CP/CPPS.⁷ The mean prevalence in studies according to continent of origin ranged from 7.5 % in Asia to 12.2% in Africa, with North America, Europe and Australia in between. The relatively consistent rate across continents suggests that it may develop independent of environmental factors specific to a given society.  The RICE (RAND Interstitial Cystitis Epidemiology) study estimated that 1.8% of men (2 million) in the United States may have prostatitis-like symptoms.⁸

The etiology of CP/CPPS is unknown; however, clinicians have a much better understanding of the pathophysiology from the last 25 years of research. CP/CPPS is not due to an ongoing infection.⁹ Many studies have been conducted to investigate the presence of a specific causative organism, similar to gastric ulcers with H. pylori; however, no clear organism has been identified, though microbiological data from male subjects enrolled in the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Network identified overrepresentation of B. cenocepacia.¹⁰ Of interest is the finding from the NIH sponsored CPCRN that asymptomatic men have as many bacteria found on culture of EPS, semen, and the four components of the traditional Meares Stamey 4 glass test as men symptomatic for CP/CPPS.¹¹

An investigation of associated conditions in patients with CP/CPPS revealed other problems that provide insight into the possible etiology/pathophysiology. In the NIH CPCRN study, men with CP/CPPS were found to be six times more likely to have cardiovascular disease, the most common of which was hypertension.¹² To put this in context, the average age of men in this cohort was 42, and generally young for hypertension.⁶ They were also found to be five times more likely to have neurologic disease, the most common of which was vertebral disc disease. As the cardinal symptom is pain, it is not surprising that peripheral and central nervous system (CNS) abnormalities have been found in these patients.^{13, 14} Patients were also found to have increased rates of depression/anxiety and sinusitis. What has emerged is a picture of a complex interplay of multiple factors, including cardiovascular, psychological, immunological, neurologic, musculoskeletal and endocrine.¹⁵

Further insight into men with CP/CPPS was found in the NIH-sponsored MAPP study, a cohort study involving researchers of different backgrounds, including urologists. MAPP introduced the terminology UCPPS (urologic chronic pelvic pain syndrome) to include both IC/BPS and CP/CPPS, recognizing the potential overlaps between the two urologic chronic pain conditions.¹⁶ Even though this may be useful for research purpose, from a clinical management perspective, evidence is lacking to combine CP/CPPS and male IC/BPS into a single clinical entity. Thus, the Panel chose to present CP/CPPS and male IC/BPS in separate sections in this Guideline instead of using the umbrella term UCPPS. Men enrolled with an a priori diagnosis of CP/CPPS were found to have significant bladder symptoms, including pain with bladder filling and painful urge to urinate in up to 75% of cases.¹⁷ The majority of men (70%) with chronic pelvic pain also reported pain outside the pelvis. Men with pain outside the pelvis or with widespread pain distribution pattern were found to have more severe non-pelvic pain intensity, sleep disturbance, depression, anxiety, psychological stress, and worse quality of life (QOL) than those with localized pelvic pain.¹⁸ Chronic overlapping pain conditions were common; IBS (34%), migraine headache (24%), fibromyalgia (13%), and chronic fatigue syndrome (5%) were present in men with widespread pain. These patients also had higher rates of depression and anxiety as well as greater symptom severity.⁴ Men with CP/CPPS were found to have more difficulty relaxing their pelvic floor muscles (PFM) than asymptomatic controls, documenting the PFM dysfunction that is commonly seen in the clinic.¹⁹

A challenge for clinicians evaluating these patients is the necessity to assess for symptoms and etiologies outside of the usual urologic evaluation (e.g., neurological symptoms, gastrointestinal symptoms, musculoskeletal pain/tenderness). A multimodal and multidisciplinary approach has emerged as the recommended treatment approach for CP/CPPS patients. This concept is highlighted throughout the Guideline and includes discussion of specific evaluations and referral to other specialists and allied health professionals while continuing to manage urologic symptoms. Practice has evolved far from the days when the usual course of treatment of CP/CPPS included repeated courses of antibiotics for a deep-seated prostate infection that was not present.

Chronic Scrotal Content Pain (CSCP)

CSCP or chronic testicular pain or chronic orchialgia is defined as unilateral scrotal pain interfering with activities of daily living that has persisted for greater than three months of time.²⁰ CSCP is usually diagnosed after excluding other potential causes (e.g., testicular torsion, epididymitis, orchitis, abscess, testicular mass, varicocele).²¹ CSCP constitutes approximately 2.5% to 4.8% of all urology visits²² and is believed to affect over 100,000 men annually.²³

CSCP patients typically present with distinctive pain distributions and features. The pain is commonly described in the testes with tenderness in the epididymis and/or spermatic cord appreciated on physical examination. Neuropathic changes such as hypersensitivity or hyperalgesia in the region of the groin may accompany these findings.²⁴ The pain typically waxes and wanes. Validated, standard assessment tools are available to define pain in CSCP patients and assess the symptom severity as well as the response to treatment.^{24, 25}

The condition can be challenging both for the patient and clinician and requires a multi-disciplinary approach to management. Managing patient expectations through supportive counseling during this path is important to overall success. Some cases of CSCP are idiopathic, thus potential underlying causes should be ruled out with a thorough physical exam and detailed history (e.g., history of athletic injuries, biking or motorcycle trauma to the genitals). Some categories of CSCP include post-vasectomy pain syndrome (PVPS), post-inguinal hernia repair, pain caused by trauma, after abdominal surgery, radiation, and radicular pain from spinal or sacral issues.^26-30

Pelvic Floor Myalgia

Pelvic floor myalgia (normal PFM tone with pain on palpation) is common among men with chronic pelvic pain and may co-exist in many male chronic pelvic pain conditions, including CP/CPPS,  IC/BPS, and CSCP.^{31, 32} The incidence of pelvic floor tenderness on digital palpation in men with chronic pelvic pain varies in studies from 18.8% to 90% and is significantly higher in CP/CPPS patients compared to controls.^{31, 33-35} In the MAPP study, 47% of patients with CP/CPPS and/or IC/BPS had PFM tenderness on pelvic examination.³¹ The incidence in CSCP is reported to be 17.6%. The symptoms of PFM symptoms such as urinary hesitancy (p<0.01), constipation (p<0.01), and painful ejaculation (p<0.01) may distinguish these patients from those with chronic orchialgia from a different etiology.³²

Proper assessment of male chronic pelvic pain requires identification of potential musculoskeletal source of pain through a standardized abdominal and pelvic examination and can be appropriately addressed with pelvic floor physical therapy (PFPT). A complete review of all PFM diagnoses is beyond the scope of this Guideline; however, the International Continence Society (ICS) has published a terminology report on complete PFM assessment.³⁶ Besides pain on PFM palpation, other symptoms associated with pelvic floor myalgia include voiding difficulties (straining to void, urinary hesitancy, slow urine stream); pain with ejaculation; and/or pelvic pain radiating to the lower abdominal, groin, or coccyx areas.³⁶ Pelvic floor myalgia is clinically diagnosed by manual palpation of the PFM via standardized digital rectal examination (DRE) assessing for the presence of muscle tenderness with normal tone. Multiple sites of tenderness may be present in the PFM.³⁷ Pelvic floor tension myalgia (the pain on palpation discussed above, with, in addition, increased PFM tone) is another common diagnosis. While the term “pelvic floor myofascial pain – trigger point” is commonly used in the literature, there is no agreement as to what a trigger point is, and inter-tester reliability in identifying these trigger points is low; therefore, the terms pelvic floor myalgia and pelvic floor tension myalgia are the current accepted terminology.³⁸

Investigations such as algometry may contribute to the diagnosis.³⁶ The origin of pelvic floor myalgia and tone dysfunction is complex and poorly understood.^{39, 40}

METHODOLOGY

Determination of the Guideline scope and assessment of the final systematic review to inform Guideline statements was conducted in conjunction with the Male Chronic Pelvic Pain Guideline Panel. The systematic review utilized to inform this Guideline and methodological support was provided by an independent methodological consultant team at the Pacific Northwest Evidence-based Practice Center of Oregon Health & Science University (OHSU).

Panel Formation

The Panel was created in 2023 by the American Urological Association Education and Research, Inc. (AUAER). The Practice Guidelines Committee (PGC) of the American Urological Association (AUA) selected the Panel Chairs who in turn appointed the additional panel members following an open nomination process to identify members with specific expertise in this area. This is a multidisciplinary panel that includes representation from urology, physical therapy, neurology, and pain management, in addition to patient representation. Funding for the Panel was provided by the AUA; panel members received no remuneration for their work.

Searches and Article Selection

The systematic review that informs the Guideline statements was based on searches in Ovid MEDLINE (1946 to June 6, 2023), the Cochrane Central Register of Controlled Trials (through May 2023), and the Cochrane Database of Systematic Reviews (through May 2023). Searches were supplemented by reviewing electronic databases reference lists of relevant articles. Criteria for inclusion and exclusion of studies were based on the Key Questions and the PICOTS of interest. An updated search was conducted in June 2024 using the same criteria to bring in relevant literature published since the initial search.

Studies were selected that describe the diagnostic utility of physical examination, laboratory tests, imaging studies, and questionnaires or other instruments for evaluating patients presenting with chronic pelvic pain. As opposed to some other conditions with an objective reference standard, the conditions described in this Guideline are diagnosed primarily based on symptoms.

For treatment, the review focused on high priority interventions for each chronic pelvic pain condition, as determined by the Panel. Intervention outcomes were the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) and its subscores (pain, urinary symptoms, and QOL), other measures of pain and urinary symptoms, erectile function, likelihood of treatment response, and harms. The review included randomized trials, non-randomized trials, and comparative cohort studies that evaluated an included intervention against placebo, sham, usual care, no treatment, or another included intervention. Random effects meta-analysis was conducted on trials of low-intensity extracorporeal shock wave therapy (ESWT) versus sham or no ESWT. Evidence for other interventions was unsuitable for meta-analysis due to few studies, heterogeneity in interventions, and methodological limitations, and was summarized qualitatively. The systematic review was further supplemented by a review of published Cochrane reviews of interventions for CP/CPPS categorized as lower priority by the Panel. This supplemental work summarized the findings of published Cochrane review.

Data Abstraction

For studies that met inclusion criteria, a single investigator abstracted information on study design, year, setting, country, sample size, eligibility criteria, dose and duration of the intervention, population characteristics, results, and source of funding. Data abstractions were reviewed by a second investigator for accuracy, and discrepancies were resolved through discussion and consensus.

Risk of Bias Assessment

Two investigators independently assessed risk of bias using predefined criteria. Disagreements were resolved by consensus. For randomized trials and cohort studies, the OHSU review team adapted criteria for assessing risk of bias from the U.S. Preventive Services Task Force (USPSTF).⁴¹ Criteria for randomized trials included the use of appropriate randomization and allocation concealment methods, baseline comparability of groups, blinding, attrition, and use of intention-to-treat analysis. For cohort studies on prognostic factors, criteria included methods for assembling cohorts, attrition, blinding assessment of outcomes, and adjustment for potential confounding factors. For cohort studies, criteria included methods for assembling cohorts, attrition, blinding assessment of outcomes, and adjustment for potential confounding. For studies of diagnostic accuracy, the OHSU review team adapted criteria for assessing risk of bias from the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 instrument.⁴² Criteria for diagnostic accuracy studies included use of unbiased methods to select patients for inclusion, avoidance of case-control design, adequate description of the diagnostic test, use of pre-defined cutoffs for the diagnostic tests, use of a credible reference standard in all patients, independent interpretation of the diagnostic test and reference standard, and low rates of missing or uninterpretable data.

Studies were rated as “low risk of bias,” “medium risk of bias,” or “high risk of bias” based on the presence and seriousness of methodological shortcomings. Studies rated “low risk of bias” are generally considered valid. “Low risk of bias” randomized trials include clear descriptions of the population, setting, interventions, and comparison groups; utilize a valid method for allocation of patients to treatment; describe treatment groups that are similar on key demographic and clinical characteristics at baseline; report low dropout rates and clear reporting of dropouts; utilize blinding of patients, care providers, and outcome assessors; and perform appropriate analysis of outcomes. “Low risk of bias” diagnostic accuracy studies use unbiased methods to select patients; avoid spectrum bias (e.g., do not use case-control design); describe the diagnostic test clearly; apply the same reference standard to all patients; have low rates of missing or uninterpretable data; and ensure that interpretation of the reference standard is blinded to results of the diagnostic test, and vice versa.

Studies rated “medium risk of bias” are susceptible to some bias, though not necessarily enough to invalidate the results. These studies do not meet all the criteria for a rating of “low risk of bias” but have no flaw likely to cause major bias. Studies may be missing information, making it difficult to assess limitations and potential problems. The “medium risk of bias” category is broad, and studies with this rating vary in their strengths and weaknesses. Therefore, the results of some medium risk of bias studies are likely to be valid, while others may be only possibly valid.

Studies rated “high risk of bias” have significant flaws that may invalidate the results. They have a serious or “fatal” flaw in design, analysis, or reporting; large amounts of missing information; discrepancies in reporting; or serious problems in the delivery of the intervention. The results of “high risk of bias” studies could be as likely to reflect flaws in study design and conduct as true difference between compared interventions. Due to the paucity of data in some topic areas, the OHSU review team did not exclude studies rated “high risk of bias” a priori, but “high risk of bias” studies were considered to be less reliable than “low” or “medium risk of bias” studies.

Data Synthesis

Evidence was not suitable for meta-analysis due to small numbers of studies for specific interventions and comparisons, except for ESWT. For ESWT versus sham or no treatment, the OHSU review team performed meta-analysis using a profile likelihood random effects model in Stata/SE 16.1 (StataCorp LLC, College Station, TX) to estimate differences at follow-up in the NIH-CPSI total score (scale 0 to 43), pain scores (measured using the NIH-CPSI pain score [scale 0 to 21] or a pain VAS [scale 0 to 10]), urinary symptom scores (measuring using the NIH-CPSI urinary score [scale 0 to 10] or IPSS [scale 0 to 35]), NIH-CPSI QOL score (scale 0 to 12), and erectile function measured using the International Index of Erectile Function (IIEF, scale 0 to 75), variations of the IIEF (e.g., IIEF-5 [scale 5 to 25]), or an IIEF subscale (e.g., IIEF-EF [scale 0 to 30]). Outcomes were evaluated at the end of treatment (including outcomes evaluated up to 1 week following end of treatment) and at 4, 8 to 9, 12 to 13, 20 to 26, and 52 weeks following completion of treatment (“post-treatment”). Results were reported as MD for NIH-CPSI total score and QOL score, and as standardized MD for pain, urinary symptom and erectile function, due to the use of different measures by the trials to assess these outcomes. Statistical heterogeneity was evaluated using the test based on Q-statistic and I² statistic, and stratified analysis were performed on study risk of bias (low or moderate versus high), NIH CP/CPPS category (IIIB only or mixed category of IIIA and IIIB), type of ESWT (focused versus radial), use of sham control (yes or no), and whether ESWT was evaluated as an addition to a standardized therapeutic regimen (yes or no).

The primary analysis for ESWT excluded data reported from one trial at 4, 12-13, and 20-26 weeks since the trial reported mean values and standard deviations at these time points in the control group that were identical to the baseline values, which is extremely implausible.⁴³ However, we conducted a sensitivity analysis in which data from this trial at those time points was utilized, to evaluate how its inclusion impacted findings. One-year post-treatment results from this trial did not have the same data integrity concerns and were utilized in the analyses. We also conducted a sensitivity analysis excluding outlying trials to evaluate their impact on combined estimates and between-study heterogeneity.

Graphical and statistical tests were conducted to assess small sample effects (a marker of potential publication bias) using funnel plots and the Egger test when there were at least 8 trials in a meta-analysis. Although methods for assessing for small sample effects are usually recommended for analyses with at least 10 trials, a lower threshold was applied because no analysis had 10 or more trials.⁴⁴ Therefore, findings regarding potential small sample effects should be interpreted with caution.

Determination of Evidence Strength

The Grading of Recommendations Assessment, Development, and Evaluation (GRADE)⁴⁵ system was used to determine the aggregate evidence quality for each outcome or group of related outcomes informing Key Questions. GRADE defines a body of evidence in relation to how confident guideline developers can be that the estimate of effects as reported by that body of evidence, is correct. Evidence is categorized as high, moderate, low, and very low, and assessment is based on the aggregate risk of bias for the evidence base, plus limitations introduced as a consequence of inconsistency, indirectness, imprecision, and publication bias across the studies.⁴⁶ Additionally, certainty of evidence can be downgraded if confounding across the studies has resulted in the potential for the evidence base to overestimate the effect. Upgrading of evidence is possible if the body of evidence indicates a large effect or if confounding would suggest either spurious effects or would reduce the demonstrated effect.

The AUA employs a 3-tiered strength of evidence system to underpin evidence-based guideline statements. Table 2 summarizes the GRADE categories, definitions, and how these categories translate to the AUA strength of evidence categories. In short, high certainty by GRADE translates to AUA A-category strength of evidence, moderate to B, and both low and very low to C.

The AUA categorizes body of evidence strength as Grade A (e.g., well-conducted and highly-generalizable randomized controlled trials [RCTs] or exceptionally strong observational studies with consistent findings), Grade B (e.g., RCTs with some weaknesses of procedure or generalizability or moderately strong observational studies with consistent findings), or Grade C (e.g., RCTs with serious deficiencies of procedure or generalizability or extremely small sample sizes or observational studies that are inconsistent, have small sample sizes, or have other problems that potentially confound interpretation of data). By definition, Grade A evidence is evidence about which the Panel has a high level of certainty, Grade B evidence is evidence about which the Panel has a moderate level of certainty, and Grade C evidence is evidence about which the Panel has a low level of certainty.⁴⁷

AUA Nomenclature: Linking Statement Type to Evidence Strength

The AUA nomenclature system explicitly links statement type to body of evidence strength, level of certainty, magnitude of benefit or risk/burdens, and the Panel’s judgment regarding the balance between benefits and risks/burdens (Table 3). Strong Recommendations are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken because net benefit or net harm is substantial. Moderate Recommendations are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken because net benefit or net harm is moderate. Conditional Recommendations are non-directive statements used when the evidence indicates that there is no apparent net benefit or harm, or when the balance between benefits and risks/burden is unclear. All three statement types may be supported by any body of evidence strength grade. Body of evidence strength Grade A in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances and future research is unlikely to change confidence. Body of evidence strength Grade B in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances, but better evidence could change confidence. Body of evidence strength Grade C in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances, but better evidence is likely to change confidence. Conditional Recommendations also can be supported by any evidence strength. When body of evidence strength is Grade A with a conditional recommendation, the statement indicates that benefits and risks/burdens appear balanced, the best action depends on patient circumstances, and future research is unlikely to change confidence. When body of evidence strength is Grade B with a conditional recommendation, benefits and risks/burdens appear balanced, the best action also depends on individual patient circumstances and better evidence could change confidence. When body of evidence strength is Grade C with a conditional recommendation, there is uncertainty regarding the balance between benefits and risks/burdens, alternative strategies may be equally reasonable, and better evidence is likely to change confidence.

Where gaps in the evidence existed, the Panel provides guidance in the form of Clinical Principles or Expert Opinions with consensus achieved using a modified Delphi technique if differences in opinion emerged.⁴⁸ A Clinical Principle is a statement about a component of clinical care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature. Expert Opinion refers to a statement, achieved by consensus of the Panel, that is based on members’ clinical training, experience, knowledge, and judgment.

It should be noted that the systematic review included a question on diagnostic accuracy of history/tests/exam/etc. for pelvic pain. However, the studies had methodological limitations, including absence of a well-standardized reference standard, many studies compared one test against another, and studies had methodological limitations. As such, many of the statements on screening and evaluation are consensus-based.

Peer Review and Document Approval

An integral part of the guideline development process at the AUA is external peer review. The AUA conducted a thorough peer review process to ensure that the document was reviewed by experts who were knowledgeable in the area of male chronic pelvic pain. In addition to reviewers from the AUA PGC, Science and Quality Council (SQC), and Board of Directors (BOD), the document was reviewed by external content experts. Additionally, a call for reviewers was placed on the AUA website from April 18 to June 1, 2024 to allow any additional interested parties to request a copy of the document for review. Additional notifications were sent through various AUA membership and patient advocacy channels to further promote the availability of the document for review. The draft Guideline was distributed to 88 peer reviewers. All peer review comments were blinded and sent to the Panel for review. In total, 35 reviewers provided comments. At the end of the peer review process, a total of 634 comments were received. Following comment discussion, the Panel revised the draft as needed. Once finalized, the Guideline was submitted to the AUA PGC, SQC, and BOD for final approval.

See Figure 2 for an overview of diagnosis of male chronic pelvic pain conditions covered by the Guideline.

In the initial evaluation of patients with chronic pelvic pain, clinicians should include a comprehensive history, complete review of symptoms, physical examination, and laboratory studies to document symptoms and signs of chronic pelvic pain. Clinicians should screen for concurrent pelvic pathology and exclude other confusable disorders that could be the cause of patient symptoms as part of the initial assessment for pelvic pain. (Clinical Principle)

Clinicians may use validated questionnaires to assess pain levels, urinary symptoms, and quality of life. (Clinical Principle)

Clinicians should discuss patient psychosocial health, such as the presence of anxiety, depression, major life stress, and impact on quality of life and daily functioning. (Clinical Principle)

Clinicians should screen for neurological, musculoskeletal, and orthopedic abnormalities of the pelvis, hip, and lower spine in patients presenting with chronic pelvic pain. Identification of such abnormalities should prompt referral to an appropriate specialist. (Expert Opinion)

Clinicians should perform digital palpation of the pelvic floor muscle transrectally in men to identify tenderness suggesting a diagnosis of pelvic floor myalgia. (Expert Opinion)

Clinicians should perform a thorough scrotal examination in patients with chronic pelvic pain; a scrotal ultrasound may be performed. (Clinical Principle)

A prostate massage, two-glass or four-glass localization test may be performed if there is diagnostic uncertainty in distinguishing chronic bacterial prostatitis from CP/CPPS. (Expert Opinion)

Clinicians may utilize cystoscopy, urodynamics, and/or imaging when the diagnosis is unclear. (Clinical Principle)

After basic evaluation (including a detailed history, physical examination including pelvic examination, questionnaires, UA, mid-stream urine culture, PVR) and other optional testing outlined in statements 1 to 8, the male chronic pelvic pain patient may be categorized as having CP/CPPS, IC/BPS, or CSCP, with or without pelvic floor myalgia (see Figure 2). Some patients may have more than one feature; these clinical diagnoses are not mutually exclusive. For example, some men may have clinical presentation consistent with both CP/CPPS and male IC/BPS. 

Clinicians should consider the diagnosis of IC/BPS in male chronic pelvic pain patients who experience an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes. (Expert Opinion)

Clinicians should consider the diagnosis of CP/CPPS in patients who experience chronic perineal pain, bilateral scrotal content pain, penile pain, suprapubic pain, dysuria, or pain with ejaculation. (Expert Opinion)

Clinicians should consider the diagnosis of CSCP in patients who experienced unilateral chronic scrotal pain in the absence of other pelvic sites of pain or urinary symptoms. (Expert Opinion)

In patients with isolated unilateral CSCP, clinicians may perform diagnostic spermatic cord block and/or ilioinguinal block. (Expert Opinion)

Treatment decisions should be made based on shared decision-making between the patient and clinician, with the patient informed of the risks, potential benefits, and treatment alternatives. Initial treatment should typically be nonsurgical. (Clinical Principle)

Clinicians should periodically reassess efficacy of treatment and discontinue ineffective treatments. The clinical diagnosis should be reconsidered if no improvement occurs after multiple treatment approaches. (Clinical Principle)

Clinicians may utilize a multimodal and multidisciplinary approach to pain management. If pain control is inadequate, referral to pain management should be discussed. (Clinical Principle)

Clinicians should encourage patients expressing significant distress secondary to chronic pelvic pain to seek treatment for mental health needs and discuss family, spousal, and/or local support systems. (Clinical Principle)

Please refer to the AUA IC/BPS Guideline for the treatment of male IC/BPS.^{1, 2} As discussed earlier, male IC/BPS may co-exist with CP/CPPS in some patients with the differentiator being bladder-focused pain. Patients who do not respond to conventional CP/CPPS treatments should be reassessed to determine if they may have male IC/BPS with bladder pain and urinary symptoms in addition to other etiologies (Table 4).

See Figure 4 for treatment options of CP/CPPS. See Table 6 for evidence summary for CP/CPPS treatments. The treatment options described below for CP/CPPS are all off-label use.

Figure 4: Treatment of Chronic Prostatitis/ Chronic Pelvic Pain Syndrome (CP/CPPS)

In patients with CP/CPPS, clinicians may discuss lifestyle modification, including dietary changes and aerobic exercise. (Conditional Recommendation; Evidence Level: Grade C)

In patients with CP/CPPS and voiding symptoms, clinicians should offer treatment with an alpha-blocker. (Moderate Recommendation; Evidence Level: Grade B)

Clinicians may prescribe 5-alpha reductase inhibitors to patients with CP/CPPS who also have voiding symptoms from BPH or enlarged prostate as determined by imaging or PSA level. (Expert Opinion)

Clinicians may prescribe anti-inflammatory agents as part of a multi-modal pain management strategy for treatment of pain in patients with CP/CPPS. (Conditional Recommendation; Evidence Level: Grade B)

Clinicians may prescribe daily tadalafil for treatment of prostatitis symptoms in patients with CP/CPPS with or without concomitant erectile dysfunction. (Conditional Recommendation; Evidence Level: Grade B)

Clinicians may prescribe pharmacologic pain management agents (e.g., urinary analgesics, acetaminophen, non-opioid medications) after counseling patients on the risks and benefits. (Clinical Principle)

Clinicians may prescribe medications for neuropathic pain including the classes of tricyclic antidepressants, selective serotonin reuptake inhibitors, and gabapentinoids. (Conditional Recommendation; Evidence Level: Grade C)

In patients with CP/CPPS, clinicians may prescribe phytotherapeutics including saw palmetto, quercetin, and pollen extract to improve pain, voiding symptoms, and quality of life. (Conditional Recommendation; Evidence Level: Grade B)

In patients with CP/CPPS, clinicians may offer cognitive behavioral therapy as an adjunct to other therapeutic interventions. (Conditional Recommendation; Evidence Level: Grade C)

In patients with CP/CPPS, clinicians should discuss low-intensity extracorporeal shockwave therapy. (Moderate Recommendations; Evidence Level: Grade A)

Clinicians may offer transcutaneous electrical nerve stimulation for pain control in patients with CP/CPPS. (Conditional Recommendation; Evidence Level: Grade B)

Clinicians may offer acupuncture to patients with CP/CPPS. (Conditional Recommendation; Evidence Level: Grade B)

In men with pelvic floor myalgia or abdominopelvic muscle myalgia, clinicians may offer individualized manual physical therapy techniques (e.g., myofascial release of affected tissues both internally and externally). (Conditional Recommendation; Evidence Level: Grade C)

Clinicians may utilize electromyography biofeedback training to improve active pelvic floor muscle resting tone and relaxation time to improve pain, urination, and quality of life in patients with increased pelvic floor muscle tone. (Expert Opinion)

See Figure 5 for treatment options for CSCP. See Table 6 for evidence summary for CSCP treatments. The treatment options described below for CSCP are all off-label use.

Clinicians should discuss lifestyle modification that may improve symptoms and implement as feasible. (Clinical Principle)

In patients with CSCP, clinicians may prescribe pharmacologic pain management agents such as acetaminophen, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, gabapentinoids, and non-opioid options after counseling patients on the risks and benefits. Multimodal therapy to pain management is recommended. (Clinical Principle)

In antibiotic-naïve patients with CSCP, clinicians may prescribe a single 10-day trial of antimicrobials. (Clinical Principle)

Clinicians may recommend microsurgical denervation of the spermatic cord to CSCP patients, especially if they previously responded to a spermatic cord block. (Conditional Recommendation; Evidence Level: Grade C)

Clinicians may offer vasectomy reversal (vasovasostomy) as a suitable treatment option for patients who have post-vasectomy pain syndrome. (Expert Opinion)

Clinicians may offer patients with CSCP acupuncture and pelvic floor physical therapy. (Expert Opinion)

Clinicians may recommend transcutaneous electrical nerve stimulation for patients with CSCP. (Conditional Recommendation; Evidence Level: Grade C)

If all treatment options fail and the CSCP patient is still suffering from pain, clinicians may discuss consultation with a pain management specialist for further options (e.g., neuromodulation, neurostimulators, spinal blocks). (Expert Opinion)

Clinicians may offer epididymectomy to patients with pain and tenderness focal to the epididymis after failure of conservative therapies. (Expert Opinion)

Clinicians may offer inguinal (not scrotal) orchiectomy with removal of the entire spermatic cord for patients with CSCP. (Expert Opinion)

Clinicians should not send patients for psychological interventions or dismiss for somatization prior to appropriate medical evaluation. (Clinical Principle)

Clinicians should refrain from repeated courses of antimicrobial therapy for treatment of patients with CP/CPPS or CSCP in the setting of negative urine cultures, negative tests for sexually transmitted disease, or following a vasectomy. (Clinical Principle)

Clinicians should not perform surgical procedures on the prostate (radical prostatectomy and outlet procedures for benign prostatic hyperplasia) to relieve pelvic pain but may discuss such procedures as part of multimodal therapy in patients with coexisting pain and prostate cancer or bladder outlet obstruction. (Expert Opinion) 

Clinicians should not utilize systemic (oral) long-term glucocorticoid administration to treat pelvic pain. (Expert Opinion)

Progress in taking care of men with CP/CPPS and CSCP will require better understanding of what is causing persistence of the pain. We usually think of pain in response to some tissue injury (nociceptive) pain that then resolves with healing. We now know that the pain can also derive from a neurologic origin from either peripheral nerve roots (neuropathic pain) or even a lack of central pain inhibition (nociplastic), with the classic disease example being fibromyalgia.²⁴⁹ The molecular signatures of these neural changes are needed to identify more and better targets for treatment. Better patient phenotyping to permit more targeted treatment is also needed.

Some currently available treatments still require further testing to establish their role in the treatment of men with chronic pelvic pain:

Onabotulinumtoxin A (BTX-A)

BTX-A functions as a muscle relaxant, analgesic, and anti-inflammatory agent.²⁵⁰ It has been most commonly used as an intravesical injection and into skeletal muscle. It has also been used as a direct injection into the prostate. This has also been tried as a chemical denervation of the cord in men with CSCP, but no difference has been demonstrated to date over standard cord block.²⁵¹ A recent review of current literature concluded that beneficial effects of BTX-A on pain, QOL, and functional symptoms were seen in patients with certain chronic pelvic pain subtypes, but the current evidence level is too weak to allow recommendations for its use for treating CP/CPPS.²⁵² There is evidence of benefit for BTX-A to the PFM in women with chronic pelvic pain.²⁵³  BTX-A to the PFM is performed off label in men, and studies are needed.

Percutaneous Peripheral Tibial Nerve Stimulation (PTNS)

Given the large amount of data documenting neurologic alterations in patients with CP/CPPS both peripherally and centrally, it is possible that neuromodulation may be effective in some patients.^{16, 254} One study has compared PTNS versus sham PTNS for 12 weeks of outpatient sessions each in patients with category IIIB CP/CPPS.²⁵⁵ Another has compared percutaneous versus transcutaneous PTNS, again for 12 weeks each in patients with category IIIB CP/CPPS.²⁵⁶ Evidence from the two trials showed efficacy but suffered from methodological issues that prevent the Panel from currently recommending PTNS in men with CP/CPPS. For example, the RCT comparing PTNS to sham PTNS was rated as having high risk of bias, due to unclear randomization and allocation concealment methods, unclear blinding of outcome assessment, and failure to report attrition. Additional studies are needed to study the role of PTNS and sacral neuromodulation in managing CP/CPPS, especially given availability of implantable tibial stimulation devices.

Transcranial Magnetic Stimulation (TMS)

TMS can target areas in the brain involved in pain and pelvic floor control. It has been used most extensively to date in patients with depression but may hold promise for patients with pelvic pain requiring further studies. Repetitive TMS applied to supplemental motor areas involved in the control of PFM have produced increased or decreased pelvic floor tone depending on the frequency used.²⁵⁷ These effects are currently being investigated in clinical trials of patients with chronic pelvic pain and pelvic floor dysfunction.

Other Treatments for Chronic Scrotal Content Pain (CSCP)

There are multiple other evolving treatments for CSCP that have had some promising results to date but not substantial enough currently to recommend as a treatment:

Ultrasound Guided Targeted Peri-Spermatic Cord Cryoablation (UTC)

Ultrasound guided targeted peri-spermatic cord cryoablation (UTC) has been used as an option for patients who only had a partial reduction in pain after MDSC and who develop peri-incisional pain after MDSC. It is also an option for patients who want to pursue a less aggressive modality.²⁵⁸ This technology has also been used to target pudendal nerves and genitofemoral nerves with some success.^{259, 260}

Peri-Spermatic Cord and Peri-Epididymal BTX-A Injection

Published evidence on the use of BTX-A for CSCP is contradictory. A small pilot open-label study by Khambati et al. (n=18) showed that BTX-A may provide pain relief for a period of 3-6 months in CSCP patients.²⁶¹ However, a larger RCT (n=64) showed no benefit to this treatment option compared to sham cord block in patients who had a favorable response to lidocaine/bupivacaine cord blocks.²⁵¹

Targeted Robotic-Assisted Intra-Abdominal Denervation (TRAAD)

When initial surgical interventions fail, targeted robotic-assisted intra-abdominal denervation (TRAAD) is an option that has been described. This technique targets the inferior hypogastric nerve and genitofemoral nerve above the internal inguinal ring. The procedure is similar to the tri-neurectomy procedure where the ilioinguinal, ilio-hypogastric, and genitofemoral nerves are ligated.²⁶² Reported success rates range from approximately 70% to 80%.^{262, 263} TRAAD offers less cutaneous sensory deficits post-operatively compared to the tri-neurectomy technique. However, there are two reported cases of leg pain and spasms postoperatively: one that subsided over time, and the other had persistent pain requiring management with chronic opioids. TRAAD may be a modality for challenging cases with persistent groin pain refractory to standard management and orchiectomy.

Treatment of Pudendal Neuralgia

Pudendal nerve entrapment (PNE) can play a role in the onset and persistence of chronic pelvic pain in a small number of patients. True PNE is thought to be caused by the compression of the pudendal nerve at different levels along its course, often resulting from direct trauma to the nerve from biking on hard saddles, sitting on hard chairs, contact injuries (e.g., football) and pelvic trauma.²⁶⁴ Distribution of nerve entrapments locations have been found to be 35% in proximal S2/S3/S4 nerve roots, 25% in sciatic/lumbosacral, 18% in proximal pudendal/medial sciatic, 12% in S1/S2 nerve roots, 8% in Alcock’s canal level and 2% in obturator nerve entrapment.²⁶⁵

Nerve stretch injuries can develop from chronic straining with bowel movements or work that requires repetitive or vigorous squatting. The classic presentation is positional pain, such as pain with sitting in the perineal, rectal or penile area on one (occasionally on both) sides that improves when standing or laying down. Pain is generally not experienced when sitting on a toilet seat, as compared to a typical chair. Areas of numbness around the anus and perineum, as well as muscle fasciculation (involuntary muscle twitches) may also occur.  

As stated by Giulioni et al., “given the absence of pathognomonic radiological or electrophysiological findings, the diagnosis of PNE is mainly clinical and exclusionary.”²⁶⁶ Clinical criteria for diagnosis were established by the group from Nantes, but these lack clinical validation and do not apply to all potential sites of entrapment as described above.²⁶⁷ A more recent diagnostic concept called Neuropelviology has been proposed by Possover.²⁶⁸ This is largely driven by the patient’s history, including location, radiation, aggravating factors and associated symptoms. This is then followed by a clinical examination including neurological exam, and then imaging. This yields a presumptive diagnosis on which to base therapy.  

Among approaches that warrant further research are nerve blocks and neuromodulation for pudendal neuralgia type pain. Nerve blocks are used as a diagnostic test in patients who may be candidates for nerve release, and also as a rule-out measure.²⁶⁹ However, there is some evidence that patients with nerve pain typical of pudendal neuralgia who undergo dual site CT-guided pudendal nerve block may experience benefit at 3 months in half of patients, and 25% of patients at 6 months.²⁷⁰ If pudendal nerve block does not provide benefit for the duration of the anesthetic (e.g., 1 hour for lidocaine), the diagnosis should be reconsidered, including consideration of local sacral pathology, musculoskeletal factors (PFM, tendon injury, hip), organ-based pain, or centralized pain drivers, based on repeat history and evaluation. Neuromodulation modalities include sacral neuromodulation and direct neuromodulation of the pudendal nerve.^271-273 Also reported is pulsed high-frequency radiofrequency (PRF) treatment applied to the pudendal nerve under ultrasound guidance.²⁷⁴

The technique of pudendal nerve release was first done via an open approach by the Nantes group. Certainly, open surgery carries the risk of scar tissue and re-entrapment, and is not recommended. More recent reports include a laparoscopic approach facilitated by Laparoscopic Neuro-Navigation (LANN) described by Possover.²⁷⁵  A series by Lemos et al. describes the technique and outcomes after one year in 63 patients, male and female.²⁶⁵ One year after surgery, 78.3% of patients reported clinically relevant pain reduction, defined as > 50% reduction in numeric rating scale (NRS) score. Also described is a robotic-assisted approach to pudendal nerve release.²⁶⁶ The pain response in the robotic series was modest with the numerical pain rating scale improving at 3-month and 6-month postoperative follow-up visits, the numerical rating scale progressively reduced (8 versus 6, p < 0.001; and 6 versus 4, p < 0.001, respectively).  

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