Taxonomies for Chronic Visceral Pain

Winfried Häuser; Andrew Baranowski; Bert Messelink; Ursula Wesselmann

Pain. 2020;161(6):1129-1135.

Background

In the past, pain associated with viscera has typically been considered as a symptom of visceral disease. It was only more recently that the medical specialties of gynecology, gastroenterology, and urology have recognized that visceral pain can be a pain syndrome in its own right. As visceral pain has been recognized as a chronic pain syndrome, which often occurs as a comorbid condition together with other chronic pain syndromes,^[5,22,26] several medical and scientific associations have developed taxonomies for specific visceral pain conditions.

Taxonomies in general are defined as hierarchical arrangements of terms that describe a particular branch of science or field of knowledge. Ideally, terms are selected and arranged to be mutually exclusive, thus creating an ordered universe with a place for everything and everything in its place. However, medicine does not lend itself well to such pure rationalism.^[19] The open conceptual question remains whether taxonomies should use a "lumping" or "splitting" approach. Specifically, the question has been raised if different diagnostic manifestations of a basic pathological process have been divided into multiple diagnostic silos by taxonomies, creating artifactual comorbidity in certain circumstances.^[14]

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Table 1. Comparison of key features of taxonomies of chronic visceral pain I.
Organisation (references)	Target audience	Scope of the taxonomy	Basement of taxonomy	Selection of developers	No. of working groups and experts	Methods used to develop criteria
European Association of Urology (EAU)^9–11	Primarily urologists, other clinicians	Guidance in clinical practice for clinicians treating patients with CPP	Pain mechanisms and anatomic regions. Partially based on medical specialties	Clinical expertise in the field from different disciplines and no conflict of interests	About 10	Based on 2012 IASP visceral pain Taxonomy report¹⁵
International Association for the Study of Pain (IASP) and World Health Organization (WHO) collaboration^3,20,23,24	Clinicians and researchers	To create a classification system for chronic pain that is applicable in clinical settings for specialized pain management and in primary care.	Pathophysiology and anatomic regions	Clinical expertise in the field, different disciplines, one patient advocate	A Task Force of 20 members.	Group consensus; guidelines for classification in overlapping fields were specified
International Continence Society (ICS)⁷	Clinicians and researchers	Facilitation of research, enhancement of therapy development, support of health care delivery.	Nine domains, mostly organ based, and psychological and sexual aspects.	The ICS Standardisation Steering Committee selected the members and 2 mentors and 5 consultants (including a patient advocate)	15 members	Other guidelines, consensus documents, and scientific publications
Special interest Group on abdominal and pelvic pain of IASP (PUGO)¹⁵	Clinicians and clinician scientists	Clinical-based taxonomy to be incorporated in to the IASP taxonomy	Clinical pain presentation and pain mechanisms	Multidisciplinary and multispecialty with clinical and research experience	16 members	Literature and consensus opinion from multiple specialties and disciplines with an emphasis on pain mechanisms; specific details are not reported; the recommendations were incorporated in 2012 into the IASP Classification of Chronic pain, revised Second Edition referred here as the 2012 IASP visceral pain Taxonomy¹⁵
Rome Foundation⁸	Clinical scientists to make recommendations for diagnosis and treatment that can be applied in research and clinical practice	Functional gastrointestinal disorders	Anatomical regions	Scientific and clinical expertise	18 committees (117 authors from 23 countries)	Systematic search of literature, nonstructured consensus, external review
Mental health care groups of the World Health Organization (WHO)^1,2,17,25	Clinicians and researchers	Mental disorders with predominant somatic symptoms	Not known	Scientific and clinical expertise	17 mental health care specialists	Not reported

CPP, chronic pelvic pain; IBS, irritable bowel syndrome; ICD, International Classification of Diseases; IPPS, International Pelvic Pain Society; ISSVD, International Society for the Study of Vulvovaginal Disease; ISSWHSH, International Society for the Study of Women's Sexual Health; PUGO, Pain of Urogenital Origin (Special Interest Group of IASP).

Table 2. Comparison of key features of taxonomies of chronic visceral pain II (alphabetical order).
Organisation (references)	Definition chronic visceral (abdominal) pain	Validation studies	Overlap of IASP with other taxonomies	Pain, "symptom" or "disease in its own right?"
European Association of Urology (EAU)^9–11	Chronic pelvic pain is chronic or persistent pain perceived in structures related to the pelvis of either men or women. 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	Not known	The terminology is based on the 2012 IASP visceral pain Taxonomy The Rome III criteria for IBS were adapted.	Disease
International Association for the Study of Pain (IASP) and World Health Organization (WHO) collaboration for ICD-11 Taxonomy^3,20,23,24	Pain originating from internal organs. Chronic primary and secondary visceral pains are often associated with significant emotional distress (such as anger, anxiety, and depression) and functional disability (interference in everyday life, reduced participation, and effect on cognition).	One study⁴	Rome foundation criteria for IBS and abdominal/epigastric pain syndrome were adapted. EAU criteria for interstitial cystitis and pain bladder syndrome were adapted	Disease
International Continence Society (ICS)⁶	Chronic visceral pain arises from visceral organs, with involvement of the organ capsule with aching, and is localized. Chronic pelvic pain is characterized by persistent pain lasting longer than 6 months or recurrent episodes of abdominal/pelvic pain, hypersensitivity or discomfort often associated with elimination changes, and sexual dysfunction often in the absence of organic etiology	None	This guideline is described as complementary to the 2012 IASP visceral pain Taxonomy and the EAU guideline. The Rome III criteria for IBS were adapted.	Disease
Special Interest Group on abdominal and pelvic pain of IASP (PUGO)¹⁵	Built on the concept of complex regional pain syndromes and the mechanisms of pain as a primary condition including the psychosocial, sexual, and behavioural aspects	None	Informed the IASP 2012 and the EAU classifications The Rome III criteria for IBS were adapted	Disease
Rome Foundation⁷	None	Multiple studies all over the world	IBS as listed in all other taxonomies. Abdominal and epigastric pain syndromes are listed in IASP/WHO ICD-11	Symptom (disorder of the brain-gut interaction)
Mental health care groups of the World Health Organization (WHO)^2,12,17,25	None	Some studies all over the world	None.	Symptom (mental disorder)

IASP, International Association for the Study of Pain; IBS, irritable bowel syndrome; ICD, International Classification of Diseases; PUGO, Pain of Urogenital Origin (Special Interest Group of IASP).

Table 3. Comparison of key features of classification systems of mental health care associations (modified from 1).
Term	Bodily distress syndrome¹²	Somatic symptom disorder²	Bodily distress disorder¹³	Bodily stress syndrome¹⁷
Developed for	Clinical research and practice	DSM-5	ICD-11	ICD-11 PHC
Developed by	Danish working group of mental health care specialists for functional disorders	Working group of American Psychiatric Association	Working group of WHO	Working group of WHO
Defined as a mental disorder	No: intends to challenge the mental–physical dichotomy (psychosocial and physiological)	Yes	Yes	Yes
Key features	Physical symptom patterns or clusters of cardiopulmonary, gastrointestinal, musculoskeletal, or general symptoms that result in significant distress or impairment	Excessive, disproportionate, or maladaptive responses to one or more physical symptoms or sensations of any aetiology that result in significant distress or impairment	Excessive, disproportionate, or maladaptive responses to one or more physical symptoms or sensations of any aetiology that result in significant distress or impairment	At least 3 persistent symptoms over time of cardiorespiratory, gastrointestinal, musculoskeletal, or general symptoms of tiredness and exhaustion that result in significant distress or impairment
Emotional or behavioural responses required	Not required for diagnosis, but considered common and may be important for treatment	Yes (see above)	Yes (see above)	Yes (see above)
Symptoms medically explained or not	Medically unexplained physical symptoms	Both medically unexplained and medically explained physical symptoms	Both medically unexplained and medically explained physical symptoms	Medically unexplained physical symptoms
Exclusion/differential diagnoses	Psychiatric and general medical diagnoses have to be excluded; IBS and FM are not excluded	Certain psychiatric disorders have to be excluded; general medical diagnoses are not excluded	Does not exclude presence of depression or anxiety; general medical diagnoses are not excluded. If a medical condition is causing or contributing to the symptoms, the degree of attention is clearly excessive in relation to its nature and progression.	Psychiatric and general medical diagnoses have to be excluded; IBS and FM are not excluded
Hypothesized aetiology	Hyperarousal of the autonomic nervous system; HPA axis hyperactivity	No assumptions about aetiology	No assumptions about aetiology	Hyperarousal of the autonomic nervous system

DSM, diagnostic and statistical manual; FM, fibromyalgia; HPA, Hypothalamic–pituitary–adrenal; IBS, irritable bowel syndrome; ICD, International Classification of Diseases; WHO, World Health Organsization.

Authors and Disclosures

Winfried Häuser^a,b,*, Andrew Baranowski^c, Bert Messelink^d and Ursula Wesselmann^e

^aDepartment Internal Medicine 1 (Gastroenterology, Hepatology, Oncology, Infectious Diseases), Klinikum Saarbrücken, Saarbrücken, Germany, ^bDepartment Psychosomatic Medicine and Psychotherapy, Technische Universität München, Munich, Germany, ^cThe National Hospital for Neurology and Neurosurgery, University College London Hospitals Foundation Trust, London, United Kingdom, ^dDepartment of Urology and Sexology, Medical Centre Leeuwarden, the Netherlands, ^eDepartments of Anesthesiology/Division of Pain Medicine, Neurology and Psychology, University of Alabama at Birmingham, Birmingham, AL, United States

*Corresponding author
Address: Internal Medicine 1, Klinikum Saarbrücken, Saarbrücken, Germany. Tel.: 149-681-9632020; fax: 149-681-9632020. E-mail address: whaeuser@klinikum-saarbruecken.de (W. Häuser).

Conflict of interest statement
B. Messelink is a member of the EAU taxonomy group. A. Baranowski was Chair of the PUGO taxonomy group from 2004 to 2012, which developed the 2012 IASP SIG visceral pain taxonomy. He was a member of the EAU, and he has contributed to the IASP-ICD-11 Taxonomy process and has authored on the subject. U. Wesselmann serves on the External Consultant Board for the "NIH Preclinical Screening Platform for Pain," a novel preclinical pain therapy screening platform that has been launched at the National Institute for Neurological Disorders and Stroke in the United States as part of the NIH Helping to End Addiction Long-term Initiative. In her capacity as a special government employee of the U.S. Food and Drug Administration (FDA), she has served as a voting member of the FDA Anesthetic and Analgesic Drug Products Advisory Committee. She has served as a consultant for Grünenthal GmbH and Ironwood Pharmaceuticals Inc. UW is a member of the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the U.S. Food and Drug Administration (FDA) https://www.acttion.org since 2012. As a member of ACTTION, she is an inaugural committee member of the working group Addressing Disparities in the Distribution and Assessment of Pain and its Treatments (ADDAPT) since 2017 and a committee member of the ACTTION-American Pain Society Pain Taxonomy (AAPT) collaboration, where she serves as the cochair for the taxonomy working group developing the AAPT Diagnostic Criteria for Chronic Abdominal, Pelvic, and Urogenital Pain since 2014. She was member of the PUGO taxonomy group of IASP from 2004 to 2012, which developed the 2012 IASP SIG visceral pain taxonomy, and served as the elected chair of PUGO during that time from 2005 to 2008. She served as a consulting member of the International Continence Society guideline panel for the Standardization of Terminology for Chronic Pelvic Pain from 2011 to 2016. She has contributed to the IASP-ICD-11 Taxonomy process and has authored on the subject. The remaining author has no conflicts interest to declare.

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Taxonomies for Chronic Visceral Pain

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