Chronic pelvic pain syndrome (CPPS) is one of the unresolved problems in urology. There are multiple recommendations for the management of CPPS, and the BJUI guideline of guidelines on bladder pain syndrome by Malde et al.  summarizes differences in nomenclature, definitions and recommended diagnostic tests and treatments between major national and international guidelines. CPPS is defined according to the European Association of Urology as chronic or persistent pain perceived in structures related to the pelvis without proven infection or other obvious local pathology that may account for the pain, and it is often associated with negative cognitive, behavioural, sexual and emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor or gynaecological dysfunction . Despite exacerbations of CPPS symptoms, so‐called ‘flares’ (i.e. sudden appearance or worsening of symptoms) that highly affect the patients’ quality of life and strongly challenge their treating physicians, relevant characteristics of CPPS such as frequency, intensity, duration and risk factors are largely unknown.
In this month’s issue of the BJUI, Sutcliffe et al.  bring light into this darkness and present their findings from the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network. A total of 385 participants were eligible for participation in their one‐year, multi‐site longitudinal study. Symptom flares were very common, with approximately three‐quarters of the sample reporting at least one flare (23% reported one flare, 28% two to three flares and 25% four or more flares), flare duration ranged widely from 1 to 150 days, and variability in symptoms, frequency, and duration was very relevant both between and within participants. Risk factors for greater flare burden (greater flare frequency, symptom intensity and/or duration) were female gender, worse non‐flare symptoms and bladder hypersensitivity or chronic overlapping pain conditions. These new insights into the characteristics of CPPS close several gaps in our knowledge, but also raise many questions. What are the reasons that one‐quarter of patients with CPPS did not experience flares and what can we learn from this specific subgroup to optimize our treatment strategies? What are the pathomechanisms involved? Can we use biomarkers to identify patients at risk of CPPS flares? Would there be protective factors to obviate CPPS flares? How can we optimize the management of CPPS flares to improve the quality of life of affected patients? Despite these many questions, there is light at the end of the tunnel: the aforementioned MAPP Research Network (www.mappnetwork.org). This network, established by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health in 2008, is a whole‐body initiative which has enormously expanded our knowledge in the field of CPPS in recent years. Such research networks, unifying highly multidisciplinary approaches through the collaboration of scientists, epidemiologists and clinicians, are essential to push the borders of knowledge, paving the way for novel management strategies. Together we are strong, with basic and clinical research linked by translation and reverse translation enabling innovations and finally resulting in better patient care. However, although a customized, patient‐tailored bio‐psycho‐social approach engaging the patient in a collaborative journey towards self‐management is strongly recommended and generally accepted for CPPS , flares remain a major issue. We still have to solve this Gordian knot; however, per aspera ad astra! The next steps are to prevent flares and to find an optimal flare treatment.
by Thomas M. Kessler
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- A longitudinal analysis of urologic chronic pelvic pain syndrome flares in the MAPP Research Network. BJU Int 2019; 124: 522– 31 , , et al.
- Contemporary management of chronic prostatitis/chronic pelvic pain syndrome. Eur Urol 2016; 69: 286– 97 , , , , , .