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INTRODUCTION

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Chronic, nonmalignant pain syndromes of the perineal area have been well described in the medical literature dating back more than 100 years. However, the etiology of these focal pain syndromes is poorly understood. The patient who is experiencing pain in the perineal area is often embarrassed because these areas of the body are considered taboo in our society. These pain syndromes are frequently underreported and underrecognized.

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Patients with these pain syndromes often have seen a variety of specialists in different subspecialties—including urologists, gynecologists, gastroenterologists, proctologists, and internists—and, despite an extensive evaluation, no specific etiology has been found in the majority of cases. Not surprisingly, many of these patients are frustrated because they have suffered from chronic pain for many years, but the disease has not been “given a name” and the pain is not controlled. It is important to recognize that these focal chronic pain syndromes of the perineal area do exist. The etiology of these pain syndromes is not known, and a specific secondary cause can be identified in a minority of patients only. Although these patients often are depressed, rarely are these pain syndromes the only manifestation of a psychiatric disease. Currently available treatment strategies are empirical only. Although complete cures are uncommon, effective treatment modalities exist to lessen the impact of pain and offer reasonable expectations of an improved functional status.

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The intent of this chapter is to first give a brief overview of the current taxonomy of perineal pain in the context of pelvic pain and of the neurobiology of the perineal area and then to review the clinical characteristics and treatment strategies of the different perineal pain syndromes.

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DEFINITION OF PERINEAL PAIN

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Similar to other areas in the health sciences, where multiple disciplines are involved, developing a uniform and comprehensive terminology that improves clinical communication and enhances research efforts into the etiology of perineal pain remains a challenge. The International Association for the Study of Pain (IASP) appointed a Task Force in Taxonomy early on to develop descriptions of pain syndromes and detailed pain definitions.1 This pain terminology has been recently updated2 by PUGO's Classification Committee (PUGO is IASPs Special Interest Group for Urogenital and Pelvic Pain; PUGO has recently been renamed as the IASP Special Interest Group on Abdominal and Pelvic Pain) to reflect the emerging and multidisciplinary field of pelvic and urogenital pain. This taxonomy has been used in this chapter and reflects the multifactorial nature of perineal pain, requiring a multidisciplinary approach, as well as the multisystem aspects of the perineal pain complaint. To briefly review the concept of this 2012 taxonomy, perineal pain is presented under the umbrella term chronic pelvic pain. Chronic pelvic pain is chronic or persistent pain perceived in structures related to the pelvis of either men or women. Here, perceived indicates that the patient and clinician, to the best of their ability from ...

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