What This Guideline Covers
The EAU 2025 Chronic Pelvic Pain guideline provides evidence-based recommendations across 20 topic areas. The key (Strong-rated) recommendations are summarised below; the complete recommendation tables — including Weak recommendations with their strength ratings — plus classification and evidence tables are in the Full Guidelines tab.
Key Recommendations at a Glance
Every Strong-rated EAU recommendation. Where the guideline labels its sections, they are used as sub-headings.
- All of those involved in the management of chronic pelvic pain should have knowledge of peripheral and central pain mechanisms.
- The early assessment of patients with chronic pelvic pain should involve investigations aimed at excluding disease- associated pelvic pain.
- Assess functional, emotional, behavioural, sexual and other quality of life issues, such as effect on work and socialisation, early in patients with chronic pelvic pain and address these issues as well as the pain.
- Build up relations with colleagues to be able to manage Chronic Primary Pelvic Pain Syndrome comprehensively, in a multi- specialty and multi-disciplinary environment with consideration of all their symptoms.
Recommendation – general
- Take a full history and evaluate to rule out a treatable cause in all patients with chronic pelvic pain.
Diagnostic evaluation of Primary Prostate Pain Syndrome
- Adapt diagnostic procedures to the patient. Exclude specific diseases with similar symptoms.
- Use a validated symptom and quality of life scoring instrument, such as the National Institutes of Health Chronic Prostatitis Symptom Index, for initial assessment and follow-up.
- Assess primary prostate pain syndrome- associated negative cognitive, behavioural, sexual, or emotional consequences, as well as symptoms of lower urinary tract and sexual dysfunctions.
Diagnostic evaluation of Primary Bladder Pain Syndrome
- Perform general anaesthetic rigid cystoscopy in patients with bladder pain to subtype and rule out confusable disease.
- Diagnose patients with symptoms according to the EAU definition, after primary exclusion of specific diseases, with primary bladder pain syndrome (PBPS) by subtype and phenotype.
- Assess PBPS-associated non-bladder diseases systematically.
- Assess PBPS-associated negative cognitive, behavioural, sexual, or emotional consequences.
- Use a validated symptom and quality of life scoring instrument for initial assessment and follow-up.
Diagnostic evaluation of gynaecological aspects of chronic pelvic pain
- Take a full uro-gynaecological history in those who have had a continence or prolapse non-absorbable mesh inserted and consider specialised imaging of the mesh.
- Refer to a gynaecologist following complete urological evaluation if there is a clinical suspicion of a gynaecological cause for pain. Laparoscopy should be undertaken in accordance with gynaecological guidelines.
Diagnostic evaluation of Anorectal Pain Syndrome
- Anorectal function tests are recommended in patients with anorectal pain.
Diagnostic evaluation of nerves to the pelvis
- Rule out confusable diseases, such as neoplastic disease, infection, trauma and spinal pathology.
Diagnostic evaluation of psychological aspects of CPP
- Assess patient psychological factors related to the pain, e.g., pain-related fear, anxiety and depressive symptoms.
- Ask patients what they think is the cause of their pain and other symptoms to allow the opportunity to inform and reassure.
Diagnostic evaluation of pelvic floor function
- Use the International Continence Society classification for pelvic floor muscle function and dysfunction.
Management of Primary Prostate Pain Syndrome
- Use antimicrobial therapy (quinolones or tetracyclines) over a minimum of six weeks in treatment-naïve patients with a duration of PPPS less than one year.
- Use a-blockers for patients with a duration of PPPS less than one year.
- Offer acupuncture in PPPS.
Management of Primary Bladder Pain Syndrome
- Offer subtype and phenotype-oriented therapy for the treatment of Primary Bladder Pain Syndrome (PBPS).
- Always consider offering multimodal behavioural, physical and psychological techniques alongside oral or invasive treatments of PBPS.
- Administer amitriptyline for treatment of PBPS.
- Offer oral pentosane polysulphate for the treatment of PBPS.
- Do not recommend oral corticosteroids for longterm-term treatment.
- Consider submucosal bladder wall and trigonal injection of botulinum toxin type A plus hydrodistension if intravesical instillation therapies have failed.
- Only undertake ablative and/or reconstructive surgery as the last resort and only by experienced and PBPS- knowledgeable surgeons, following a multi- disciplinary assessment including pain management.
- Offer transurethral resection (or coagulation or laser) of bladder lesions, but in PBPS type 3 C only.
Management of Scrotal Pain Syndrome
- Inform about the risk of post-vasectomy pain when counselling patients planned for vasectomy.
- Do open instead of laparoscopic inguinal hernia repair, to reduce the risk of scrotal pain.
Management of gynaecological aspects of chronic pelvic pain
- Involve a gynaecologist to provide therapeutic options such as hormonal therapy or surgery in well-defined disease states.
- Provide a multi-disciplinary approach to pain management in persistent disease states.
- All patients who have developed complications after mesh insertion should be referred to a multi-disciplinary service (incorporating pain medicine and surgery).
Functional anorectal pain
- Undertake biofeedback treatment in patients with chronic anal pain.
Management of pudendal neuralgia
- Neuropathic pain guidelines are well- established. Use standard approaches to management of neuropathic pain.
Management of psychological aspects in chronic pelvic pain
- For chronic pelvic pain with significant psychological distress, refer patient for chronic pelvic pain-focused psychological treatment.
Management of pelvic floor dysfunction
- Offer biofeedback as therapy adjuvant to muscle exercises, in patients with anal pain due to an overactive pelvic floor.
Management of chronic/non-acute urogenital pain by opioids
- Opioids and other drugs of addiction/ dependency should only be prescribed following multi-disciplinary assessment and only after other reasonable treatments have been tried and failed.
- The decision to instigate long-term opioid therapy should be made by an appropriately trained specialist in consultation with the patient and their family doctor.
- Where there is a history or suspicion of drug abuse, involve a psychiatrist or psychologist with an interest in pain management and drug addiction.