FROM PHENOTYPE TO PAIN MECHANISM: INTEGRATING UPOINTS AND CENTRAL SENSITIZATION IN CHRONIC PERINEAL PAIN REHABILITATION

S.C. Longo¹, F. Quarta², L. De Palma³, G. Frasca³, R. Lopes⁴, S. Lanza¹, M. Cavallo¹, M. Floridia¹, G. Sicuso¹, F. D'Urso⁵, G. Farì⁶ | ¹Rehabilitation Unit, M. Paternò Arezzo Hospital, Provincial Health Authority, Ragusa, Italy; ²Department of Biological and Environmental Science and Technologies (Di.S.Te.B.A.), University of Salento, Lecce, Italy; ³Unit of Physical, Rehabilitation Medicine and Spinal Cord, Polyclinic of Bari, Italy; ⁴Department of Biomedical and Biotechnological Sciences, University of Catania, Italy; ⁵Medicina Fisica e Riabilitativa -AOU Federico II di Napoli, Italy; ⁶Department of Experimental Medicine (Di.Me.S.), University of Salento, Lecce, Italy

Introduction. Chronic perineal pain is a heterogeneous condition in which pelvic floor myofascial dysfunction, organ-specific symptoms, neuropathic mechanisms, psychosocial factors and central sensitization may coexist. This may explain symptom overlap and incomplete response to standard rehabilitation. UPOINTS phenotyping classifies patients across urinary, psychosocial, organ-specific, infectious, neurological/systemic, tenderness and sexual domains, whereas the Central Sensitization Inventory (CSI) identifies a relevant nociplastic component. This controlled study assessed whether UPOINTS-informed rehabilitation integrated with CSI profiling improves outcomes versus standard pelvic floor rehabilitation (1,2).
Methods. Eight adults >=18 years old with perineal pain lasting >=3 months and eligible for pelvic floor rehabilitation were enrolled after consent. Exclusion criteria were active urogenital infection, active pelvic malignancy, recent pelvic surgery, major neurological disease, pregnancy, and recent pharmacological or infiltrative treatments confounding outcomes. Baseline assessment included physiatric history, pelvic floor examination, trigger-point mapping, urinary, sexual and functional symptoms, UPOINTS phenotyping and CSI administration; CSI >=40 indicated relevant central sensitization. Participants received standard pelvic floor rehabilitation or an individualized program tailored to positive UPOINTS domains and CSI profile. Primary outcomes were pain intensity and functional impact; secondary outcomes were quality of life, sexual function, and benefit maintenance at follow-up.
Results. Baseline pain intensity and symptom duration were comparable between groups. UPOINTS assessment showed heterogeneous profiles, with frequent myofascial tenderness and variable urinary, psychosocial, neurological/systemic and sexual involvement. Several patients had CSI >=40, supporting central sensitization in a meaningful subgroup. Compared with standard rehabilitation, the phenotype-guided program was associated with greater improvement in pain intensity and functional impact, especially in patients with multidomain involvement and higher CSI scores. In patients with a stronger nociplastic component, standard rehabilitation produced less consistent benefit, whereas individualized management allowed more targeted modulation of myofascial, behavioral, functional and neurophysiological contributors.
Conclusions. Integrating UPOINTS phenotyping with CSI assessment may orient pelvic floor rehabilitation toward the dominant pain mechanism and the most relevant symptomatic domains. These exploratory findings suggest that phenotype-guided rehabilitation may be preferable to standardized protocols in complex chronic perineal pain, particularly when pelvic floor hypertonicity, urinary symptoms, sexual dysfunction and central sensitization coexist. Because of the small n, results require confirmation in controlled studies with longer follow-up and validated measures of pain, sexual function, quality of life and pelvic pain-related disability.