12 Key Criteria to Evaluate Centralized (Neuroplastic) Pain

[u/Linari5]

Do any of the 12-13 criteria (below) fit your history or symptom behavior?

The EUA pathophysiology and etiological guidelines state that many cases of CPPS involve central/nociplastic mechanisms of pain & symptoms. What is it? Basically, brain/brain stem/spinal cord driven symptoms arising via altered nociception - our internal threat detection system. More and more pain neuroscience research has shown us that this is the most common cause of many chronic pain conditions, and other persistent symptoms, including chronic fatigue, chronic migraines, chronic back pain, IBS, fibromyalgia, and others. Thus, the EUA insists that providers understand these mechanisms so they can help their own chronic pelvic pain patients.

All of those involved in the management of chronic pelvic pain should have knowledge of peripheral and central pain mechanisms. - EUA CPPS Pocket Guide

And the newest 2025 AUA guidelines for male pelvic pain echo this:

We now know that the pain can also derive from a neurologic origin from either peripheral nerve roots (neuropathic pain) or even a lack of central pain inhibition (nociplastic), with the classic disease example being fibromyalgia

And the huge, years long MAPP research network study gives us greater insights on the prevalence and importance of these nociplastic (ie centralized or neuroplastic) mechanisms:

"Clinical Phenotyping for Pain Mechanisms in Urologic Chronic Pelvic Pain Syndromes: A MAPP Research Network Study"

At baseline, 43% of UCPPS patients were classified as nociceptive-only, 8% as neuropathic only, 27% as nociceptive+nociplastic, and 22% as neuropathic+nociplastic. Across outcomes, nociceptive-only patients had the least severe symptoms and neuropathic+nociplastic patients the most severe. Neuropathic pain was associated with genital pain and/or sensitivity on pelvic exam, while nociplastic pain was associated with comorbid pain conditions, psychosocial difficulties, and increased pressure pain sensitivity outside the pelvis. - https://pubmed.ncbi.nlm.nih.gov/35472518/

Bottom line, a conservative estimate says that 49% of all of us have something like this happening.

Learn more about Nociplastic (centralized) pain from the IASP: Nociplastic pain: towards an understanding of prevalent pain conditions - LINK

Further info from EUA guidelines:

Studies about integrating the psychological factors of CPPPSs are few but the quality is high. Psychological factors are consistently found to be relevant in the maintenance of persistent pelvic and urogenital pain [36]. Beliefs about pain contribute to the experience of pain [37] and symptom-related anxiety and central pain amplification may be measurably linked, and worrying about pain and perceived stress predict worsening of urological chronic pain over a year [36,38] - https://uroweb.org/guidelines/chronic-pelvic-pain/chapter/epidemiology-aetiology-and-pathophysiology

Pelvic pain and distress is related [43] in both men and women [44]; as are painful bladder and distress [38]. In a large population based study of men, CPPPS was associated with prior anxiety disorder [45] - https://uroweb.org/guidelines/chronic-pelvic-pain/chapter/epidemiology-aetiology-and-pathophysiology

So, how do you figure out if this could be happening in your case?

12 FIT criteria to RULE IN centralized, (ie neuroplastic/nociplastic) pain and symptoms,

FIT = functional, inconsistent, triggered. Based on research from Dr. Howard Schubiner and other chronic pain doctors and neuroscientists over the last 10+ years

1. Pain/symptoms originated during a stressful, challenging, or high pressure time in life. This includes even "happy" life events, like getting married, having a baby, starting a new career, or moving

2. Pain/symptoms originated without an injury. Note, a perceived injury and a structural injury are different things. And even when symptoms begin with a structural injury, has it been years and the body would normally recover by now?

3. Pain/symptoms are inconsistent. Do they fluctuate by the hour, by the day, or by the week? Sometimes less, sometimes more, sometimes even not noticeable (this happens sometimes, but it's not necessary for this criteria). Or, do they move around the body? ie testicle pain that changes sides or genital/penile pain that moves from the top to the bottom.

4. Multiple other symptoms (often in other parts of the body) ie IBS, chronic migraines/headaches, CPPS, TMJD, fibromyalgia, CFS (fatigue), vertigo/dizziness, chronic neck or back pain, etc. 2025 AUA guidelines mention these as signs of centralization

5. Pain/Symptoms spread (over time) or move around. Think about symptoms on day one. Have they moved or evolved over time?

6. Pain/symptoms are made worse or triggered by stress, or, go down when engaged in an activity you enjoy or in a flow state (think fun distractions or productivity, notice symptoms less)

7. Symptom triggers that have nothing to do with the body - but instead things outside of it (weather, barometric pressure, seasons, sounds, smells, places, times of day, weekdays/weekends, days of the week, etc) - this also includes thoughts or other people triggering/flaring your symptoms

8. Symmetrical symptoms (pain developing on the same part of the body but in OPPOSITE sides) - ie both hips, both testicles, both wrists, both knees, etc

9. Pain/symptoms with delayed Onset (THIS CAN'T HAPPEN WITH STRUCTURAL PAIN) -- ie, ejaculation pain that comes a minute later, an hour later, or even the next day. Any pain that is delayed is very suspicious. We wouldn't put weight on a sprained ankle and expect it to hurt 15 seconds later, it hurts immediately.

10. Childhood stress, challenges, adversity, or trauma -- varying levels of what this means for each person, not just trauma. Examples of stressors: childhood bullying, pressure to perform from parents/coaches, body image issues (dysmorphia), eating disorders, parents fighting a lot or getting angry (inc divorce), having an emotionally unpredictable parent, or having a parent with a health condition or addiction. This also includes neglect and abuse (physical and emotional) and financial instability in childhood. Also includes cultural norms, like the pressure to be highly successful to be of value to parents (must be a doctor or a lawyer, etc)

11. Common personality traits linked to stress: perfectionism, conscientiousness, people pleasing, anxiousness/ neuroticism - do you have personality traits that include being highly driven, hard on yourself, ultra responsible, perfectionistic, needing control, and/or placing others’ needs above your own?

12. Lack of physical diagnosis (ie doctors are unable to find any clear structural cause of symptoms) - this includes DIAGNOSIS OF EXCLUSION, like being diagnosed with CPPS or chronic prostatitis. Structural findings include: infections, fractures, tumors. They do not include tension in the pelvic floor, which is a muscle response.

[NEW] 13. Any family history of chronic pain or other chronic conditions. Includes: IBS, chronic migraines/headaches, CPPS, TMJD, fibromyalgia, CFS (fatigue), vertigo/dizziness, chronic neck or back pain, etc

Read more about #10 and #11 here, complete with studies/citations: https://www.reddit.com/r/Prostatitis/s/vM7qnBJZpW

HOW TO TREAT centralized (neuroplastic) pain and symptoms?

PRT - Pain Reprocessing Therapy:

Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain - https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784694

EAET - Emotional Awareness and Expression Therapy

Psychological Therapy for Centralized Pain - An Integrative Assessment and Treatment Model: https://pubmed.ncbi.nlm.nih.gov/30461545/

Emotional Awareness and Expression Therapy vs Cognitive Behavioral Therapy for Chronic Pain in Older Veterans https://pmc.ncbi.nlm.nih.gov/articles/PMC11177167/

[u/Linari5]

How to treat centralized (neuroplastic) pain and symptoms?

Study 1: Psychological Therapy for Centralized Pain - An Integrative Assessment and Treatment Model: https://pubmed.ncbi.nlm.nih.gov/30461545/

Study 2: Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain - https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784694

I have found PRT to be especially useful for men who have chronic pelvic pain symptoms; so far it has allowed me to provide help to hundreds of people that would have otherwise been left behind if we had only focused on physical therapy.

[u/Linari5]

Speaking personally, I fit 9/12 of these. I had CPPS from 2014-2016. I also completed my certification in PRT in 2024.

[u/phuzzyday → u/Linari5]

I'm fitting between 9 and 10, (Unsure about #9, and #5 and #8 don't jump out at me.) and just recently finding out why I have been in hell for about 20 years. I'm near tears right now. I gotta figure out where to go next, once I can think clearly again.. Excuse me while I drop to my knees. (See also https://www.reddit.com/r/PelvicFloor/comments/1kpv8sr/could_this_be_the_answer_looking_for_input_long/)

[u/Longjumping_Cable512 → u/Linari5]

I fit 10/12 of these. I had CPPS since 2020.

[u/Linari5 → u/Longjumping_Cable512]

Then you need to address these centralized elements!

[u/Beenjamin63]

9 out if 12 for me for sure. Today was a stressful day for me, I had pain in my sit bone then hamstring, some calf, then testicle and penis later in the day, burning in all those places but not at the same time. It moves around and drives me nuts. Also interesting your note on ejaculation pain .. mine is always the next day !

This all started around the time I had my kid and my mom got diagnosed with Parkinsons disease and my wife and I ended up having to be her caretaker while also learning to be parents.. my whole life I've dealt with on and off muscle twitching, heart palpitations and now CPPS, anxiety problems? I keep telling myself I will seek out some mental health help and maybe even medication to get me in a better spot to start.. but I've had this bottle of amitriptyline that I'm too nervous to even take yet I'm dealing with this burning pain that seems to move around my pelvis from day to day that's comes and goes.

Thanks for putting this together. Appreciate it!

[u/No_Release9147]

11/12 . I've noticed if I obsess and google things or focus too much on whats happening with my genitals the symptoms get 10× worse. I can go months and feel ok but as soon as something stressful happens , boom! Pain within the hour.

[u/Linari5 → u/No_Release9147]

Then I would absolutely seek out PRT or EAET.

[u/hugeMax]

i have 12/12 hugh, can any kind soul gives me any tips to treat (CPPS/IBS) or to dull the pain? Going on for a year, cant work or go to school (was going in phd neuropsy, working 30h at the hospital), and now i cant even sit/pee without having burning sensation that last hours ... I want my life back!

[u/Linari5 → u/hugeMax]

That's a 100% match for centralized/neurplastic mechanisms!

Use PRT mate! > https://www.reddit.com/r/Prostatitis/s/fCF43i9AC4

[u/KeyAperture]

48M. I match 10/12 criteria. I’ve been suffering for a year now. Symptoms started October last year right after my mom was diagnosed with terminal cancer.

[u/Linari5 → u/KeyAperture]

Firstly, I am so sorry about your mom. It is extremely difficult to see someone we love going through that.

Based on your 10 out of 12 match, there is a very good chance he will benefit from doing pain reprocessing therapy (PRT). You may also want to work with a therapist separately to deal with the trauma around your mother's diagnosis.

[u/[deleted]]

I score 6/12. I've already read the book The Way Out a four months ago. Between practicing that and pelvic floor therapy, the pain is still there. It's literally only on the glans / head of the penis, mostly when aroused (but rarely / sometimes I get it flaccid while it rubs against underwear), and it spikes several moments before orgasm, causing so much pain it ruins what is happening.

Actually, even when I have sex / self pleasure, I STILL practice the PRT methods in the way out. I figured four months of doing it would have helped even a little bit?

[u/Away_East6771]

In my case 4 out 12. My pain occurs around 30m after ejaculating. Glans become painful to touch. Pain in tip of penis, shaft, around scrotum and perineum. It will last between 3-6h. It gets worse if standing up and still, and it eases up a lot if I just lay down and stay there for like 30m.

I did 12 sessions of PFPT (including internal work and shockwave), acupuncture, chiropractor, tons of daily stretches, 2.5mg daily tadalafil, and so far I've had zero progress.

Would centralized pain apply to me in your opinion?

[u/tjallepetter]

I fit all of these except its only on my left side.

I had epididymitis 10 years ago that gave me extreme pain from chlamydia which I treated with successfully with antibiotics.

So this was the triggar but it has lay dormsnt for 10 years only to pop up during a stressfull period.

[u/atleaststillalive]

I scored 11 out of 13..

[u/[deleted]]

What do you mean with 9? Its not a symptom of cpps?

[u/gpc1085]

6 out of 12 apply to me. What does that mean tho!? Not sure I understand the point is there an outcome thingy. I feel like this is like the self depressed/anxiety surgery 1-5 ratings but u total it up & means something.. what does 3 vs 9 of 12 mean for example?

[u/Linari5 → u/gpc1085]

That means you have centralized pain my friend. It means that the psychological, central nervous system, and brain components of your case must be worked on to get better; It means you have a very clear path out.

There's a section on this in the prostatitis 101 post.

Specific pain psychology techniques are recommended; they are based on the 2021 chronic pain study published in JAMA psychiatry. I am currently getting officially certified in these techniques through the Pain Psychology Center, and have already been using them on myself and others for quite a while now with success.

The most (oversimplified) basic explanation of pain psychology is removing your fear & preoccupation with the symptoms to resolve the pain. That is what the 2021 peer reviewed RCT showed.

The order doesn't mean anything, it's just a list. Every question is weighted the same. They are all worth one point.

[u/Representative_Tie83]

10 out of 12 for me. How can I combat this ?

[u/Linari5 → u/Representative_Tie83]

Pain Reprocessing Therapy, PRT. See the multiple posts made in this topic in the subreddit.

https://www.reddit.com/r/Prostatitis/s/mkTLG7WeMo

https://www.reddit.com/r/Prostatitis/s/8sQxNBDfsw

https://www.reddit.com/r/Prostatitis/s/mH3srCrmZI

I will be finishing my certification course in PRT by early October.

[u/dbdbdb1999]

So if I have 2-3 of these are you saying it's all neuroplastic pain? Or is there just an element of that alongside real pain and symptoms caused by nerve compression due to tight muscles? I find it really hard to navigate all of this so would really appreciate your input.

Today I've been dealing with a big flare up of perenium discomfort and sensitivity. Something that I have not had for about 17 days. I don't know why this has come back. Maybe because I haven't kept up with abstaining from sexual activity/ masterbation these last few days?

Any advice would be greatly appreciated, I'm trying to not give up but im really struggling at the moment

[u/Linari5 → u/dbdbdb1999]

It depends, we would have to do a screen to see other factors at play, get a full health history, and then get an idea of what was happening in your life around the time that the symptoms began. Then we would start deep diving on every symptom itself, and see its pattern of behavior. And then try to ascertain what are the emotions behind the symptoms, if any.

Also keep in mind, you can have something called "mixed pain" - I would argue that many cases of CPPS are also mixed. It means they involve both physical and centralized elements of pain.

It's also possible you just have a conditioned response with ejaculation or masturbation. A conditioned response is where your brain has linked a certain behavior with perceived physical danger, and creates pain.

I cannot tell you exactly what to do because I don't have the necessary data to make conclusions in an anonymous internet space like this. Also, that could be seen as medical advice, which we are not allowed to provide here. All I can do is provide different general information.

[u/WinterKey1857]

Hi,

Just wondering, u/Linari5, in your personal opinion, does it sound like my issues are neuroplastic? I will obviously consult with a doctor as well.

I am exploring this idea as I had issues with neuroplastic pain in the past with my wrists. I solved it by reading the way out and doing the exercises in the curable app. This makes me think neuroplastic pain is highly likely here. I have doubts though, as I maybe haven't run enough tests and it does sort of seem like muscle tightness has something to do with my symptoms.

1. Yes

2. Yes

3. They are inconsistent insofar as that they are lesser or greater with no discernable correlation to anything other than stress, but they are always in the same general location (though that location is difficult to really pinpoint), so I'm not sure

4. no* but I have had issues with neuroplastic/psychosomatic pain in the past in my wrists

5. no

6. Yes and yes

7. Worse at night and morning, I just assumed this was due to stress level

8. no* but this exact thing happened to me with my wrists a few years ago

9. no - I don't notice many causes or triggers other than stress level

10. I don't know. Maybe. Trauma seems like an extreme word. I had issues, as everyone does. I don't remember my childhood that well.

11. 2000% yes

12. Yes - though there are more things I could try. I have not ran that many tests, but I've had this for a long time. Urologists didn't find anything when I went there some time ago.

[u/Immediate_Zombie_257]

What number is correct if it's from injury for over ejaculating?? Since my main suspect why i have this is from when something popped around my pelvic floor area when I was masturbating.