Diagnostic Considerations

Chronic pelvic pain syndrome is a common and debilitating condition of multifactorial etiology, including social, psychological, and biologic factors. This is a diagnosis of exclusion, after other etiologies of pelvic pain have been eliminated from the differential.^[28]

Differential Diagnoses

Workup

Forrest JB, Schmidt S. Interstitial cystitis, chronic nonbacterial prostatitis and chronic pelvic pain syndrome in men: a common and frequently identical clinical entity. J Urol. 2004 Dec. 172 (6 Pt 2):2561-2. [Medline].
Aaron LA, Herrell R, Ashton S, Belcourt M, Schmaling K, Goldberg J, et al. Comorbid clinical conditions in chronic fatigue: a co-twin control study. J Gen Intern Med. 2001 Jan. 16 (1):24-31. [Medline].
Pezzone MA, Liang R, Fraser MO. A model of neural cross-talk and irritation in the pelvis: implications for the overlap of chronic pelvic pain disorders. Gastroenterology. 2005 Jun. 128(7):1953-64. [Medline].
Perez CA, Lee HK, Georgiou A, Lockett MA. Technical factors affecting morbidity in definitive irradiation for localized carcinoma of the prostate. Int J Radiat Oncol Biol Phys. 1994 Mar 1. 28(4):811-9. [Medline].
Teegavarapu PS, Sahai A, Chandra A, Dasgupta P, Khan MS. Eosinophilic cystitis and its management. Int J Clin Pract. 2005 Mar. 59(3):356-60. [Medline].
Ambalathingal GR, Francis RS, Smyth MJ, Smith C, Khanna R. BK Polyomavirus: Clinical Aspects, Immune Regulation, and Emerging Therapies. Clin Microbiol Rev. 2017 Apr. 30 (2):503-528. [Medline]. [Full Text].
Imlay H, Xie H, Leisenring WM, Duke ER, Kimball LE, Huang ML, et al. Presentation of BK polyomavirus-associated hemorrhagic cystitis after allogeneic hematopoietic cell transplantation. Blood Adv. 2020 Feb 25. 4 (4):617-628. [Medline]. [Full Text].
Boeckh M, Erard V, Zerr D, Englund J. Emerging viral infections after hematopoietic cell transplantation. Pediatr Transplant. 2005 Dec. 9 Suppl 7:48-54. [Medline].
Fioriti D, Degener AM, Mischitelli M, Videtta M, Arancio A, Sica S, et al. BKV infection and hemorrhagic cystitis after allogeneic bone marrow transplant. Int J Immunopathol Pharmacol. 2005 Apr-Jun. 18(2):309-16. [Medline].
Carrigan DR. Adenovirus infections in immunocompromised patients. Am J Med. 1997 Mar 17. 102(3A):71-4. [Medline].
Bavastrelli M, Midulla M, Rossi D, Salzano M, Calzolari E, Midulla C, et al. Sexually active adolescents and young adults: a high-risk group for Chlamydia trachomatis infection. J Travel Med. 1998 Jun. 5(2):57-60. [Medline].
Wald A, Zeh J, Selke S, Warren T, Ryncarz AJ, Ashley R, et al. Reactivation of genital herpes simplex virus type 2 infection in asymptomatic seropositive persons. N Engl J Med. 2000 Mar 23. 342(12):844-50. [Medline].
Pierciaccante A, Pompeo ME, Fabi F, Venditti M. Successful treatment of Corynebacterium urealyticum encrusted cystitis: a case report and literature review. Infez Med. 2007 Mar. 15(1):56-8. [Medline].
Martin-Suarez I, D'Cruz D, Mansoor M, Fernandes AP, Khamashta MA, Hughes GR. Immunosuppressive treatment in severe connective tissue diseases: effects of low dose intravenous cyclophosphamide. Ann Rheum Dis. 1997 Aug. 56(8):481-7. [Medline]. [Full Text].
Kawabe Y, Eguchi K, Tsuboi M, Kita M, Tsukada T, Takashima H, et al. [Untoward effects of low dose methotrexate therapy in rheumatoid arthritis]. Ryumachi. 1996 Jun. 36(3):514-21. [Medline].
Ocampo-Piraquive V, Mondragón-Lenis I, De Los Rios JG, Cañas CA. Very Severe and Refractory Noninfectious Cystitis in Patients with Systemic Lupus Erythematosus: Potential Role of Rituximab Therapy. Case Rep Rheumatol. 2021. 2021:6610111. [Medline]. [Full Text].
Shahani R, Streutker C, Dickson B, Stewart RJ. Ketamine-associated ulcerative cystitis: a new clinical entity. Urology. 2007 May. 69 (5):810-2. [Medline].
Chu PS, Ma WK, Wong SC, Chu RW, Cheng CH, Wong S, et al. The destruction of the lower urinary tract by ketamine abuse: a new syndrome?. BJU Int. 2008 Dec. 102(11):1616-22. [Medline].
Li CC, Wu ST, Cha TL, Sun GH, Yu DS, Meng E. A survey for ketamine abuse and its relation to the lower urinary tract symptoms in Taiwan. Sci Rep. 2019 May 10. 9 (1):7240. [Medline]. [Full Text].
Kauffman CA. Diagnosis and management of fungal urinary tract infection. Infect Dis Clin North Am. 2014 Mar. 28(1):61-74. [Medline].
Aubron C, Suzuki S, Glassford NJ, Garcia-Alvarez M, Howden BP, Bellomo R. The epidemiology of bacteriuria and candiduria in critically ill patients. Epidemiol Infect. 2015 Feb. 143 (3):653-62. [Medline].
Barsoum RS. Schistosomiasis and the kidney. Semin Nephrol. 2003 Jan. 23(1):34-41. [Medline].
Haarala M, Alanen A, Hietarinta M, Kiilholma P. Lower urinary tract symptoms in patients with Sjögren's syndrome and systemic lupus erythematosus. Int Urogynecol J Pelvic Floor Dysfunct. 2000. 11(2):84-6. [Medline].
Lee YK, Jhang JF, Kuo HC. Clinical Outcome of Augmentation Enterocystoplasty for Patients with Ketamine-induced Cystitis. Pain Physician. 2017 Mar. 20 (3):E431-E436. [Medline]. [Full Text].
Mnif A, Loussaief H, Ben Hassine L, Chebil M, Ayed M. [Aspects of evolving urogenital tuberculosis. 60 cases]. Ann Urol (Paris). 1998. 32(5):283-9. [Medline].
Beard CJ, Lamb C, Buswell L, Schneider L, Propert KJ, Gladstone D, et al. Radiation-associated morbidity in patients undergoing small-field external beam irradiation for prostate cancer. Int J Radiat Oncol Biol Phys. 1998 May 1. 41(2):257-62. [Medline].
Levenback C, Eifel PJ, Burke TW, Morris M, Gershenson DM. Hemorrhagic cystitis following radiotherapy for stage Ib cancer of the cervix. Gynecol Oncol. 1994 Nov. 55(2):206-10. [Medline].
Wagenlehner FM, van Till JW, Magri V, Perletti G, Houbiers JG, Weidner W, et al. National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) symptom evaluation in multinational cohorts of patients with chronic prostatitis/chronic pelvic pain syndrome. Eur Urol. 2013 May. 63(5):953-9. [Medline].
Shurbaji MS, Dumler JS, Gage WR, Pettis GL, Gupta PK, Kuhadja FP. Immunohistochemical detection of chlamydial antigens in association with cystitis. Am J Clin Pathol. 1990 Mar. 93(3):363-6. [Medline].
Moussa OM, Eraky I, El-Far MA, Osman HG, Ghoneim MA. Rapid diagnosis of genitourinary tuberculosis by polymerase chain reaction and non-radioactive DNA hybridization. J Urol. 2000 Aug. 164(2):584-8. [Medline].
Etienne M, Caron F. [Management of fungal urinary tract infections]. Presse Med. 2007 Dec. 36(12 Pt 3):1899-906. [Medline].
Sandhu GS, Kline BC, Stockman L, Roberts GD. Molecular probes for diagnosis of fungal infections. J Clin Microbiol. 1995 Nov. 33(11):2913-9. [Medline]. [Full Text].
Min JK, Byun JY, Lee SH, Hong YS, Park SH, Cho CS, et al. Urinary bladder involvement in patients with systemic lupus erythematosus: with review of the literature. Korean J Intern Med. 2000 Jan. 15(1):42-50. [Medline].
De Vinci C, Pizza G, Cuzzocrea D, Menniti D, Aiello E, Maver P, et al. Use of transfer factor for the treatment of recurrent non-bacterial female cystitis (NBRC): a preliminary report. Biotherapy. 1996. 9(1-3):133-8. [Medline].
Egli A, Binggeli S, Bodaghi S, Dumoulin A, Funk GA, Khanna N, et al. Cytomegalovirus and polyomavirus BK posttransplant. Nephrol Dial Transplant. 2007 Sep. 22 Suppl 8:viii72-viii82. [Medline].
Xu HG, Fang JP, Huang SL, Zhou DH, Chen C, Huang K, et al. [Risk factors and treatment of hemorrhagic cystitis in children after hematopoietic stem cell transplantation]. Zhonghua Er Ke Za Zhi. 2006 Feb. 44(2):126-30. [Medline].
Philippe M, Ranchon F, Gilis L, Schwiertz V, Vantard N, Ader F, et al. Cidofovir in the Treatment of BK Virus-Associated Hemorrhagic Cystitis after Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant. 2016 Apr. 22 (4):723-30. [Medline].
Tzannou I, Papadopoulou A, Naik S, Leung K, Martinez CA, Ramos CA, et al. Off-the-Shelf Virus-Specific T Cells to Treat BK Virus, Human Herpesvirus 6, Cytomegalovirus, Epstein-Barr Virus, and Adenovirus Infections After Allogeneic Hematopoietic Stem-Cell Transplantation. J Clin Oncol. 2017 Nov 1. 35 (31):3547-3557. [Medline]. [Full Text].
Mott KE, Dixon H, Osei-Tutu E, England EC, Davis A. Effect of praziquantel on hematuria and proteinuria in urinary schistosomiasis. Am J Trop Med Hyg. 1985 Nov. 34(6):1119-26. [Medline].
Sommariva ML, Sandri SD, Ceriani V. Efficacy of sodium hyaluronate in the management of chemical and radiation cystitis. Minerva Urol Nefrol. 2010 Jun. 62(2):145-50. [Medline].
Damiano R, Cicione A. The role of sodium hyaluronate and sodium chondroitin sulphate in the management of bladder disease. Ther Adv Urol. 2011 Oct. 3(5):223-32. [Medline]. [Full Text].
Allen S, Kilian C, Phelps J, et al. The use of hyperbaric oxygen for treating delayed radiation injuries in gynecologic malignancies: a review of literature and report of radiation injury incidence. Support Care Cancer. 2012 Jan 14. [Medline].
Del Pizzo JJ, Chew BH, Jacobs SC, Sklar GN. Treatment of radiation induced hemorrhagic cystitis with hyperbaric oxygen: long-term followup. J Urol. 1998 Sep. 160(3 Pt 1):731-3. [Medline].
Chong KT, Hampson NB, Corman JM. Early hyperbaric oxygen therapy improves outcome for radiation-induced hemorrhagic cystitis. Urology. 2005 Apr. 65(4):649-53. [Medline].
Srisupundit S, Kraiphibul P, Sangruchi S, Linasmita V, Chingskol K, Veerasarn V. The efficacy of chemically-stabilized chlorite-matrix (TCDO) in the management of late postradiation cystitis. J Med Assoc Thai. 1999 Aug. 82(8):798-802. [Medline].
Ballen KK, Becker P, Levebvre K, Emmons R, Lee K, Levy W, et al. Safety and cost of hyperhydration for the prevention of hemorrhagic cystitis in bone marrow transplant recipients. Oncology. 1999 Nov. 57(4):287-92. [Medline].
Wu P, Wang Q, Huang Z, Wang J, Wu Q, Lin T. Clinical staging of ketamine-associated urinary dysfunction: a strategy for assessment and treatment. World J Urol. 2016 Sep. 34 (9):1329-36. [Medline].
Zeng J, Lai H, Zheng D, Zhong L, Huang Z, Wang S, et al. Effective treatment of ketamine-associated cystitis with botulinum toxin type a injection combined with bladder hydrodistention. J Int Med Res. 2017 Apr. 45 (2):792-797. [Medline]. [Full Text].
Jhang JF, Birder LA, Chancellor MB, Kuo HC. Patient characteristics for different therapeutic strategies in the management ketamine cystitis. Neurourol Urodyn. 2017 Mar. 36 (3):687-691. [Medline].
Sharma BN, Li R, Bernhoff E, et al. Fluoroquinolones inhibit human polyomavirus BK (BKV) replication in primary human kidney cells. Antiviral Res. 2011 Oct. 92(1):115-23. [Medline].

Media Gallery

Gross pathology of the bladder with candidal infection and hemorrhage.
Gross anatomy of the female pelvis.
Gross anatomy of the bladder.
Female perineal anatomy. The urogenital diaphragm and levator ani muscles have been removed, revealing the internal pudendal nerves and vessels, the rectum, and the posterior vaginal wall.
Schistosomiasis of the ureter.
Infiltration of yeast in the bladder wall.

of 6

Author

Lynda A Frassetto, MD Clinical Professor, Department of Internal Medicine, University of California, San Francisco, School of Medicine

Lynda A Frassetto, MD is a member of the following medical societies: American College of Physicians, American Society of Nephrology

Disclosure: Nothing to disclose.

Coauthor(s)

Benjamin Newell Breyer, MD, MS Assistant Professor, Trauma and Reconstruction, Department of Urology, University of California, San Francisco, School of Medicine

Benjamin Newell Breyer, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Urology, Department of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American Society for Reproductive Medicine, American Urological Association, Sexual Medicine Society of North America, Society for Male Reproduction and Urology, Society for the Study of Male Reproduction, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Antares.

Acknowledgements

Erik T Goluboff, MD Professor, Department of Urology, College of Physicians and Surgeons, Columbia University College of Physicians and Surgeons; Director of Urology, Allen Pavilion, New York Presbyterian Hospital

Erik T Goluboff, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Urological Association, Medical Society of the State of New York, New York Academy of Medicine, Phi Beta Kappa, and Society for Basic Urologic Research

Disclosure: Nothing to disclose.

Stephen W Leslie, MD, FACS Founder and Medical Director, Lorain Kidney Stone Research Center; Associate Professor of Surgery at Creighton University School of Medicine, Chief of Urology at Creighton University Medical Center

Stephen W Leslie, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, National Kidney Foundation, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Grannum R Sant, MD Residency Program Director, Charles M Whitney Professor and Chairman, Department of Urology, Tufts University School of Medicine

Grannum R Sant, MD is a member of the following medical societies: American Urological Association, International Association for the Study of Pain, Massachusetts Medical Society, Society for Basic Urologic Research, and Society of University Urologists

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment