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Chronic Pelvic Pain
Introduction
Chronic pelvic pain is a persistent, disabling, or cyclic intermittent pain within the pelvis, most commonly affecting women. Although chronic pelvic pain in men is less prevalent, it exists with a distinct set of overlapping comorbidities. Chronic pelvic pain is often associated with conditions such as irritable bowel syndrome (IBS), major depressive disorder, anxiety, fibromyalgia, chronic central pain syndrome, interstitial cystitis, dyspareunia, and pelvic inflammatory disease. In the United States, 1 in 7 women are affected by this condition. Chronic pelvic pain in men may involve similar comorbidities, in addition to urogenital and erectile pain, retrograde ejaculation, urinary symptoms, sexual dysfunction, and emotional disturbances, although it typically presents from a masculine perspective.[1]
The clinical heterogeneity of chronic pelvic pain and its incompletely understood pathogenesis make treatment challenging. The prevalence of chronic pelvic pain is similar to that of migraine headaches, asthma, and chronic back pain. This condition shares pathophysiological mechanisms, such as central sensitization, with other chronic pain syndromes, including complex regional pain syndrome (CRPS). Diagnosis is typically made after 3 to 6 months of persistent pelvic pain and is largely based on patient history and physical examination. Numerous symptoms or precipitating factors may support the diagnosis. Although imaging and laboratory tests are often inconclusive, they can help identify comorbid conditions that contribute to chronic pelvic pain. Despite evaluation, an estimated 50% of cases remain undiagnosed.
Chronic pelvic pain is a form of centralized pain, where the body develops a lower threshold for discomfort or uncomfortable sensations, often as a result of chronic pain. For example, in women with endometriosis, the acute pain associated with the condition can become centralized over a 3- to 6-month period, evolving into chronic pain. In centralized pain, sensations that were previously mild to moderate may be perceived as severe (hyperalgesia), and even normal touch can be experienced as painful (allodynia). Chronic pelvic pain is strongly associated with prior physical or emotional trauma, supporting the view that its etiology may involve a functional somatic pain syndrome.
The treatment of chronic pelvic pain is often challenging, with limited evidence-based options available. Management typically targets the underlying or suspected etiology, such as comorbid mood disorders, neuropathic pain, or uterine dysfunction. Chronic pelvic pain affects approximately 4% to 16% of women.[2][3][4] Given the condition's prevalence, clinicians should maintain a high index of suspicion in patients presenting with chronic pelvic discomfort. Effective treatment requires a coordinated, interprofessional team approach, as collaboration across multiple specialties is crucial for achieving adequate pain relief. Some patients with chronic pelvic pain may benefit from cognitive behavioral therapy (CBT) or hormone replacement, whereas others may require more invasive interventions such as spinal cord stimulation or total hysterectomy.
Etiology
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Etiology
The European Association of Urology (EAU) classifies chronic pelvic pain syndrome using a multidimensional axis system, which includes factors such as pain location, temporal characteristics, and psychological elements. This system distinguishes between chronic primary pelvic pain (without identifiable pathology) and secondary pelvic pain (associated with an underlying disease).[EAU Guidelines on Chronic Pelvic Pain, 2025]
Chronic pelvic pain is commonly associated with conditions such as IBS, interstitial cystitis, and chronic fatigue syndrome, all of which are classified as overlapping chronic pain conditions. Chronic pelvic pain is strongly associated with mental health disorders, including posttraumatic stress disorder (PTSD) and major depressive disorder—conditions addressed in the EAU’s Axis VIII classification, which focuses on psychological symptoms. These comorbidities underscore the importance of an integrated psychological evaluation in diagnosis and management.
In more than half of chronic pelvic pain cases, comorbid conditions such as endometriosis, pelvic adhesions, IBS, or interstitial cystitis are present.[5] Multiple comorbidities may also coexist alongside chronic pelvic pain, further complicating diagnosis and management.[6] Although chronic pelvic pain was historically considered a form of reflex dystrophy, this condition is now understood as a chronic pain syndrome involving central sensitization and significant psychological components.[7]
The pathophysiology of chronic pelvic pain is thought to involve centralized pain mechanisms. Patients with chronic pelvic pain often develop hyperesthesia and allodynia, which are frequently exacerbated by pelvic floor dysfunction.[8] Various comorbidities, including chronic cystitis, endometriosis, adhesions, and musculoskeletal injuries, are commonly associated with chronic pelvic pain.[9]
Many individuals endure pain for over 2 years before seeking medical care.[10] The prolonged nature of this pain increases the risk of central sensitization, contributing to the development of chronic pelvic pain. As chronic pain progresses, the central nervous system undergoes systemic changes, entering a persistent state of heightened activity. Consequently, the central nervous system interprets various stimuli as painful.
Chronic pelvic pain is often secondary to comorbid conditions that cause chronic pain.[11] A synergistic effect can occur when dysfunction in an organ system leads to issues in another. For example, in interstitial cystitis, urologic dysfunction may trigger or worsen gastrointestinal symptoms such as IBS. As comorbidities accumulate, the persistence of symptoms promotes central sensitization, further intensifying pain perception. Over time, this heightened and sustained sensitivity leads to the development and maintenance of chronic pelvic pain.[12][13]
Pain may present as either widespread, as seen in chronic pain syndrome, or more localized, as in chronic pelvic pain. The distribution of pain often provides valuable clues for diagnosis and treatment planning. Patients with widespread pain involving the pelvis, multiple limbs, the axial skeleton, and areas above the diaphragm are more likely to have significant psychological comorbidities, such as generalized anxiety disorder, major depressive disorder, and PTSD, compared to those with focal pain. Emotional state and stress levels play a critical role in modulating visceral pain, including chronic pelvic pain.[14][15] Individuals with widespread pain typically require longer and more complex treatment than those with localized pelvic pain.[16][17]
Chronic pelvic pain has a significant psychiatric component. Both environmental and genetic factors are believed to have a role in the development of the condition. Women with chronic pelvic pain tend to experience higher rates of depression, anxiety, and sleep disorders. Repetitive trauma, such as childhood sexual abuse, may help explain both the somatic symptoms of chronic pelvic pain and the associated posttraumatic stress.[18][19][20][21]
Anatomical changes resulting from various pathologies may serve as primary contributors to the development of chronic pelvic pain. Conditions such as leiomyomas, nerve root entrapment, sacral cysts, and cauda equina syndrome have all been associated with chronic pelvic pain.[22][23] The risk of developing chronic pelvic pain is further elevated in patients who smoke, have underlying mental health conditions, or have experienced two or more episodes of pelvic inflammatory disease.[24] In many cases, IBS—a common comorbidity—remains undiagnosed or untreated before the onset of chronic pelvic pain.[25] Endometriosis is another frequently associated comorbidity, with strong links to both chronic pelvic pain and IBS.[26][27]
Epidemiology
Around 35% of patients with chronic pelvic pain have comorbid IBS. An estimated 61% of women with bladder pain syndrome have comorbid chronic pelvic pain, and nearly 50% of women with endometriosis report chronic pelvic pain. The overall prevalence of chronic pelvic pain among women ranges from about 4% to 16%. Despite this, only 33% of affected women seek medical care.[28] Gynecological comorbidities are present in approximately 20% of patients with chronic pain. Although urological and gastrointestinal comorbidities are more prevalent overall, endometriosis is by far the most commonly associated condition among patients who seek medical care for chronic pelvic pain.
Among patients with chronic pelvic pain who undergo elective surgery, 20% to 80% are found to have endometriosis. Conversely, approximately 70% of individuals with a prior diagnosis of endometriosis go on to develop chronic pelvic pain.[29][30]
Chronic pelvic pain primarily affects women, but it accounts for 2% to 16% of cases in men. Patients with a history of pelvic trauma or surgery are at a significantly higher risk of developing chronic pelvic pain compared to the general population. Approximately 28% of women experience persistent pelvic pain 3 months after an elective cesarean delivery, with 20% continuing to have persistent pain 6 months postoperatively.[31] Nearly 50% of women with chronic pelvic pain report a previous history of sexual or physical abuse.
Furthermore, among patients with both a history of abuse and chronic pelvic pain, one-third also have comorbid PTSD.[32][33] Up to 30% of women with a prior history of pelvic inflammatory disease go on to develop chronic pelvic pain. Additionally, 25% of patients who undergo elective hysterectomy for chronic pelvic pain secondary to adenomyosis continue to experience postoperative pain.[34][35]
Pathophysiology
The pathophysiology of chronic pelvic pain varies depending on the underlying condition. In endometriosis, cyclical pain arises from recurrent bleeding of ectopic endometrial implants, leading to inflammation and neurogenic sensitization. In pelvic congestion syndrome, dilated and engorged pelvic veins produce mechanical and ischemic pain. However, the majority of chronic pelvic pain cases are driven by central sensitization, a process in which persistent pain alters the nervous system, heightening sensitivity and amplifying discomfort, even after the original pathology has resolved.[36]
History and Physical
The history of a patient with chronic pelvic pain often reveals comorbid chronic pain conditions. Signs and symptoms of allodynia or hyperalgesia are indicative of central sensitization. The etiology of chronic pelvic pain is usually determined through a thorough review of the patient’s past medical and surgical history, as well as their urologic, sexual, psychological, gynecological, and obstetric history.
Chronic pelvic pain in women is typically defined as persistent, noncyclic pain, although it can also be cyclical. The pain is located within the pelvis and has lasted for more than 6 months. This symptom must not be related to pregnancy. The pain can be either constant or episodic. Some definitions exclude cyclical pain, as it may be classified as dysmenorrhea.[37][38]
The patient should be queried about factors that precipitate or alleviate the pain, including any relationship between menstruation and pain, urination, sexual activity, and bowel movements, as well as their responses to previous treatments. In cases of chronic pelvic pain in men, the history should include prior treatments for urethritis and prostate conditions. A detailed pain history may reveal additional areas of discomfort or a dermatomal distribution, which could suggest a non-visceral origin. A mental health evaluation is also crucial. Patients with chronic pelvic pain often report associated gastrointestinal, urinary, sexual, psychological, or menstrual symptoms. Quality of life should be assessed, as chronic pelvic pain can significantly impact daily functioning. Additionally, some patients may experience motor or autonomic dysfunction.[39]
Cramping, burning, hot, or electrical-type pain should be distinguished from sharp or dull pain. Fluctuations in pain related to the menstrual cycle should be differentiated from constant pain. Additionally, pain associated with urination or defecation, postcoital bleeding, postmenopausal bleeding, the onset of pain after menopause, a history of prior abdominal surgery or infection, or unexplained weight loss should also be documented if present.
Red flag findings that may indicate systemic disease include postcoital bleeding, postmenopausal bleeding or onset of pain, unexplained weight loss, pelvic mass, hematuria, and elevated acute-phase reactants. A comprehensive physical examination should be conducted, including a speculum examination, a bimanual examination, and a full abdominal assessment. The external genitalia should be inspected, and the pelvic floor musculature evaluated for tenderness or hypertonicity. During the bimanual examination, clinicians should assess for adnexal masses, uterine enlargement or tenderness, and restricted uterine mobility. Pain elicited by palpation of the lumbar spine, sacroiliac joints, and pelvis should also be documented.
The Carnett test can help assess abdominal wall pain in patients with chronic pelvic pain. The test is performed with the patient lying supine and raising both legs off the exam table. The examiner then applies pressure to the painful abdominal area to determine if pain intensifies with leg flexion and abdominal muscle contraction. In cases of myofascial pain, the patient typically experiences increased pain with leg flexion, while visceral pain tends to improve. Studies have shown that women with chronic pelvic pain can have up to five times more asymmetry in iliac crest height and symphyseal levels.[40]
Evaluation
Diagnosis is based on the findings from the history and physical examination. If the underlying cause of chronic pelvic pain is identified, it should be confirmed and managed appropriately. A cotton swab can be used to assess the abdomen for a cutaneous source of pain. Performing the cotton tip applicator test helps identify cutaneous allodynia and is highly sensitive for detecting this condition.[41] The impact on quality of life and daily functioning should also be evaluated, often through the use of a standardized questionnaire.[42] A digital rectal examination is a standard part of the evaluation for all patients, regardless of sex.
The first step in evaluating suspected chronic pelvic pain is to assess for alarm symptoms, signs of an acute abdomen, or potential malignancy. If none are present and no definitive diagnosis is established, laboratory testing and imaging are necessary. Initial lab work should include a complete blood count, erythrocyte sedimentation rate, urinalysis, urine pregnancy test, and testing for gonorrhea and chlamydia. A pelvic ultrasound should also be performed.
Transvaginal ultrasonography is a crucial component of the initial workup for chronic pelvic pain. This diagnostic tool helps identify cysts, masses, and adenomyosis, as well as detect hydrosalpinx, which can indicate pelvic inflammatory disease—a common comorbidity associated with chronic pelvic pain. Ultrasound is also valuable for detecting masses smaller than 4 cm that may be missed on physical examination.[43][44] If abnormalities are identified, magnetic resonance imaging (MRI) may be necessary for further evaluation.[45]
If the patient presents with severe, uncontrolled pain or signs of an acute abdomen, a standard emergency department evaluation is warranted.[46][47] When laparoscopy yields inconclusive results, chronic pelvic pain may indicate central sensitization or myofascial pain rather than CRPS, unless the diagnostic criteria for CRPS are definitively met.
Diagnostic nerve blocks can aid in identifying neuropathic components of chronic pelvic pain. Relief of symptoms following sacral nerve root anesthesia suggests peripheral nerve dysfunction as the underlying cause.[48] Pain mapping, conducted during laparoscopy under local sedation, involves probing pelvic structures while the patient rates the intensity of the pain. This technique helps localize the source of pain and informs targeted treatment strategies.[49]
In men, chronic pelvic pain should undergo an individualized diagnostic workup, which should include the following key components:
- Digital rectal examination
- International Index of Erectile Function (IIEF)
- Assessment of lower urinary tract symptoms
- National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI)
- Patient Health Questionnaire-9 (PHQ-9) to screen for depression
- UPOINT(S) classification, which evaluates urinary symptoms, psychosocial factors, organ-specific findings, infectious causes, neurological or systemic conditions, tenderness of pelvic floor muscles, and sexual dysfunction
A thorough diagnostic approach is essential to identify the underlying causes of chronic pelvic pain in men and guide individualized treatment strategies effectively.
Treatment / Management
Evidence-based literature on treating chronic pelvic pain is limited. For nonspecific chronic pelvic pain, treatment typically focuses on symptomatic pain relief.[50] Management of chronic pelvic discomfort should address both the underlying pathology and the psychological aspects of pain, including any comorbid mood disorders. When the origin of chronic pelvic pain is identified, treatment should target the specific disease process. If the source of pain remains unclear, further evaluation is recommended to determine the underlying condition.(A1)
The initial treatment for chronic pelvic pain with an unknown source typically involves over-the-counter analgesics, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), which are generally well tolerated. If these agents provide adequate pain relief, further management may be unnecessary. However, if pain persists and follows a cyclical pattern, hormonal therapies such as oral contraceptives, depot medroxyprogesterone, or an intrauterine device (IUD) are recommended.
If hormonal therapy is ineffective, or if the pain is noncyclical or suspected to be neuropathic, an evaluation for underlying mood disorders should be considered. If a mood disorder is identified, selective serotonin reuptake inhibitors are recommended. For suspected neuropathic pain without a mood disorder, treatment options include tricyclic antidepressants, pregabalin, gabapentin, or serotonin-norepinephrine reuptake inhibitors such as venlafaxine or duloxetine. If these treatments fail to control the pain, referral to a pain medicine specialist may be necessary, and consideration of opioid analgesics could be appropriate.[51][52] For neuropathic pain, studies have shown that gabapentin, either alone or in combination with amitriptyline, offers greater efficacy than amitriptyline alone.[53](A1)
Adjunct nonpharmacological treatments should be incorporated into the management of chronic pelvic pain. Pelvic floor physical therapy is particularly effective in identifying and addressing musculoskeletal contributors to chronic pelvic pain.[54] CBT is an essential component of treatment and is shown to reduce pain and stress while improving overall function. Mindfulness practices, which can be integrated into both physical therapy and CBT, also support pain and stress management.[55](B2)
In severe cases, peripheral nerve blocks and sacral nerve neuromodulation may be necessary. Hysterectomy can be considered for chronic pelvic pain of uterine origin, but it is typically reserved as a last resort. Oral contraceptives are generally ineffective in patients without cyclical pain.[56] Cyclobenzaprine can be effective in managing pain and improving sleep in patients with chronic pelvic pain.[57][58] If sacral nerve injury is suspected, a local corticosteroid injection may be used both diagnostically—to assess peripheral nerve involvement—and therapeutically for pain relief. Some providers may combine pharmacological therapy with interventional procedures to optimize treatment outcomes.(A1)
If a local corticosteroid injection provides effective pain relief, additional treatment options may include radiofrequency ablation, peripheral nerve blocks (targeting the sacral, hypogastric, or Ganglion of Impar), or neuromodulation with spinal cord stimulation.[59][60] The stimulus can be placed in the thoracic region (typically at T8) or retrogradely into the sacral segments, although the latter is technically challenging and typically performed by specialized clinicians. Subarachnoid pain pumps are effective for managing most pain syndromes but require more maintenance and carry a higher risk of severe complications compared to spinal cord stimulation. Botulinum toxin injections have been shown to reduce pain during sexual activity, alleviate pelvic pressure, and decrease persistent noncyclical pelvic pain.[61](A1)
Trigger point injections with a local anesthetic, such as lidocaine, offer another option for short-term pain relief. The pain relief from these injections often extends beyond the immediate effects. Typically used to alleviate hypertonicity and pain in the pelvic floor or abdominal wall muscles, trigger point injections can serve both therapeutic and diagnostic purposes in myofascial pain syndrome. Myofascial pain has been linked to centralized pain.[62][63] Additionally, patient education regarding the psychological aspects of chronic pelvic pain can significantly enhance outcomes when combined with CBT.[64][65](A1)
Differential Diagnosis
Chronic pelvic pain has a broad differential and often results from overlapping conditions. If chronic pelvic pain persists, central sensitization may develop, amplifying symptoms and complicating both diagnosis and treatment. Below is a systems-based overview of potential etiologies for chronic pelvic discomfort.
- Gynecological: Endometriosis, pelvic inflammatory disease, pelvic adhesion disease, recurrent ovarian cysts, uterine fibroids, leiomyoma, adenomyosis, hydrosalpinx, post-tubal ligation pain syndrome, and ovarian remnant syndrome.
- Urological: Interstitial cystitis (painful bladder syndrome), recurrent cystitis, urethral diverticulum, chronic urethritis, radiation cystitis, chronic urolithiasis, bladder cancer, and urethral syndrome.
- Gastroenterological: IBS, celiac disease, inflammatory bowel disease, colorectal carcinoma, and hernias.
- Musculoskeletal: Abdominal wall myofascial pain, fibromyalgia, coccygodynia, pelvic floor tension myalgia, and piriformis syndrome.
- Neurological or vascular: Ilioinguinal nerve entrapment, iliohypogastric nerve entrapment, pudendal neuralgia, spinal cord injury, pelvic congestion syndrome, peripheral neuropathy, and vulvar varicosities.
- Male-specific: Chronic prostatitis and prostate cancer.
- Psychiatric or functional: Somatization disorder and malingering.
Effective evaluation and management of chronic pelvic pain require a broad differential diagnosis and an interprofessional approach. Understanding the potential underlying etiologies, both somatic and psychosocial, guides tailored treatment strategies and improves patient outcomes.
Surgical Oncology
When the diagnostic workup indicates a potential malignancy, prompt referral to oncology is crucial for initiating disease-specific management. Early intervention can significantly improve outcomes, as delays in cancer treatment may lead to disease progression and a worsened prognosis.
Treatment Planning
As with any chronic pain syndrome, managing chronic pelvic pain requires a comprehensive approach that includes both pain management and psychological support. Addressing the emotional and mental health aspects is essential, as they often exacerbate symptoms and impede recovery.
Toxicity and Adverse Effect Management
Injection carries risks of vascular or nerve injury, steroid reactions, and procedural pain. Fluoroscopy often involves the use of a contrast agent, which carries a potential risk of renal toxicity, although the volume typically remains below 1 to 2 mL. Ultrasound guidance may not detect inadvertent vascular uptake, and blood aspiration is not a reliable alternative for this purpose. Bupivacaine (Marcaine) carries a higher risk of cardiotoxicity than lidocaine if accidentally injected intravascularly. This risk can be minimized by avoiding the use of bupivacaine.
These procedures should only be performed in facilities equipped with a code cart and staffed by personnel trained in Basic Cardiac Life Support (BCLS) and Advanced Cardiac Life Support (ACLS) to manage potential periprocedural complications. In rare cases where the use of bupivacaine is unavoidable, the facility must have lipid emulsion therapy (lipid rescue) readily available.[66] For this reason, bupivacaine is increasingly avoided in outpatient procedural settings.
All medications carry some degree of toxicity. In the management of chronic pelvic pain in men, particular caution should be exercised with medications that may cause urinary retention, especially given the likelihood of chronic prostatitis. When opioid therapy is initiated, a responsible adult should be educated on the administration of intranasal naloxone.
Prognosis
Following gynecologic surgical procedures for chronic pelvic pain, 46% of patients report improvement in pain, and 31% experience improvement in comorbid depressive symptoms. Prognosis tends to be poor in individuals with chronic pelvic pain, aligning with outcomes in other chronic pain syndromes. The most significant improvements in quality of life occur when the underlying cause of pain is addressed, alongside treatment of any coexisting mood disorders.
Physical therapy, particularly pelvic floor therapy, is an effective treatment for chronic pelvic pain. Patients who completed therapy used 22% fewer pharmacologic pain relievers compared to those who did not participate in treatment.[67] Additionally, therapy has been associated with reduced pain, urinary urgency, and frequency in individuals with chronic pelvic pain related to painful bladder syndrome.[68]
Hysterectomy resulted in 50% pain relief in 40% of patients with chronic pelvic pain of gynecologic origin.[69] However, up to 40% of patients may continue to experience chronic pelvic pain, and 5% may report worsening pain following surgery.[70] The prognosis for patients with chronic pelvic pain is generally more favorable in those with fewer comorbidities.[71]
The optimal timing for surgery in patients with chronic pelvic pain remains unclear, and long-term research on chronic pelvic pain treatment is limited. Many studies measure outcomes over months rather than years.[72][73] Pain mapping is effective in reducing pain in approximately 50% of patients.
Complications
A history of emotional trauma, forced intercourse, psychological abuse, and premorbid psychiatric issues should be considered when discussing chronic pelvic pain with patients. Many women with chronic pelvic pain have a history of abuse and experience comorbid PTSD. The incidence of male rape is vastly underreported, with an estimated 2.8 million American men affected each year.[74]
Patients with gynecological etiologies of chronic pelvic pain who undergo hysterectomy may continue to experience pelvic pain postoperatively. Tolerance to opioid analgesics can develop over time, requiring increased dosages to maintain adequate pain relief for chronic pelvic pain. Insomnia, common in patients with central pain disorders, should be addressed and treated appropriately.[75]
Laparoscopic surgery is inconclusive in identifying the source of pain in 40% of chronic pelvic pain cases.[76] Complications associated with laparoscopic surgery or hysterectomy include infection and bleeding.
Consultations
An interprofessional approach to diagnosing and managing chronic pelvic pain is essential, as it addresses both the physical and psychological aspects of the condition.[77] Collaborating across specialties ensures a comprehensive treatment plan that considers the multifactorial nature of this condition, ultimately improving patient outcomes and quality of life.
Deterrence and Patient Education
Patients with chronic pelvic pain should receive comprehensive education about the multifactorial nature of their condition. They should be encouraged to prioritize overall health through regular exercise, adequate sleep, and a balanced diet. Additionally, patients should understand the importance of open communication with their healthcare providers and adhering to prescribed medications and treatment plans.
Enhancing Healthcare Team Outcomes
Managing chronic pelvic pain requires a coordinated interprofessional healthcare team, including physical therapists, psychologists, pharmacists, and clinicians from multiple specialties. Without appropriate management, the morbidity associated with chronic pelvic pain can be significant. Clinicians should maintain a strong clinical suspicion for chronic pelvic pain in patients with a history of chronic pain or multiple chronic conditions.
The primary clinician typically coordinates the diagnosis and management of the underlying cause of chronic pelvic pain. Effectively addressing comorbid conditions, such as IBS or major depressive disorder, is essential for comprehensive pain management. Referral to a gynecologic surgeon may be warranted for diagnostic exploratory laparotomy or elective laparoscopic hysterectomy. If bladder involvement is suspected, consultation with a urologist is recommended for further evaluation.
In cases of chronic pelvic pain, a pain medicine specialist may offer interventions such as trigger point injections, nerve blocks, radiofrequency ablation, spinal cord stimulation, biofeedback, and relaxation techniques. Depending on the severity of the pain, prescription analgesics may be necessary for adequate pain relief. Pharmacists play a crucial role in coordinating care by educating patients on the proper use of medications and potential adverse effects. Physical therapists assist with pelvic floor strengthening, stretching, and relaxation strategies, whereas CBT specialists support patients in managing the psychological impact of chronic pain. Pain management nurses further contribute by assessing symptoms and providing patient education.
Managing chronic pelvic pain is often a lifelong process that requires continuous treatment. The impact of this condition can be significantly reduced through an interprofessional approach. A comprehensive combination of diagnostic and therapeutic strategies is crucial for effective management.
References
Franz J, Kieselbach K, Lahmann C, Gratzke C, Miernik A. Chronic Primary Pelvic Pain Syndrome in Men. Deutsches Arzteblatt international. 2023 Jul 24:120(29-30):508-518. doi: 10.3238/arztebl.m2023.0036. Epub [PubMed PMID: 36922749]
Zondervan KT, Yudkin PL, Vessey MP, Dawes MG, Barlow DH, Kennedy SH. Prevalence and incidence of chronic pelvic pain in primary care: evidence from a national general practice database. British journal of obstetrics and gynaecology. 1999 Nov:106(11):1149-55 [PubMed PMID: 10549959]
Level 2 (mid-level) evidenceGrace VM, Zondervan KT. Chronic pelvic pain in New Zealand: prevalence, pain severity, diagnoses and use of the health services. Australian and New Zealand journal of public health. 2004 Aug:28(4):369-75 [PubMed PMID: 15704703]
Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstetrics and gynecology. 1996 Mar:87(3):321-7 [PubMed PMID: 8598948]
Level 2 (mid-level) evidenceWilliams RE, Hartmann KE, Sandler RS, Miller WC, Steege JF. Prevalence and characteristics of irritable bowel syndrome among women with chronic pelvic pain. Obstetrics and gynecology. 2004 Sep:104(3):452-8 [PubMed PMID: 15339753]
Level 2 (mid-level) evidenceTirlapur SA, Kuhrt K, Chaliha C, Ball E, Meads C, Khan KS. The 'evil twin syndrome' in chronic pelvic pain: a systematic review of prevalence studies of bladder pain syndrome and endometriosis. International journal of surgery (London, England). 2013:11(3):233-7. doi: 10.1016/j.ijsu.2013.02.003. Epub 2013 Feb 15 [PubMed PMID: 23419614]
Level 1 (high-level) evidenceEngeler DS, Baranowski AP, Dinis-Oliveira P, Elneil S, Hughes J, Messelink EJ, van Ophoven A, Williams AC, European Association of Urology. The 2013 EAU guidelines on chronic pelvic pain: is management of chronic pelvic pain a habit, a philosophy, or a science? 10 years of development. European urology. 2013 Sep:64(3):431-9. doi: 10.1016/j.eururo.2013.04.035. Epub 2013 Apr 28 [PubMed PMID: 23684447]
Level 1 (high-level) evidencePotts JM, Payne CK. Urologic chronic pelvic pain. Pain. 2012 Apr:153(4):755-758. doi: 10.1016/j.pain.2011.10.005. Epub 2011 Dec 5 [PubMed PMID: 22153018]
Level 3 (low-level) evidenceLamvu G, Williams R, Zolnoun D, Wechter ME, Shortliffe A, Fulton G, Steege JF. Long-term outcomes after surgical and nonsurgical management of chronic pelvic pain: one year after evaluation in a pelvic pain specialty clinic. American journal of obstetrics and gynecology. 2006 Aug:195(2):591-8; discussion 598-600 [PubMed PMID: 16729951]
Zondervan KT, Yudkin PL, Vessey MP, Dawes MG, Barlow DH, Kennedy SH. Patterns of diagnosis and referral in women consulting for chronic pelvic pain in UK primary care. British journal of obstetrics and gynaecology. 1999 Nov:106(11):1156-61 [PubMed PMID: 10549960]
Level 2 (mid-level) evidenceFall M, Baranowski AP, Elneil S, Engeler D, Hughes J, Messelink EJ, Oberpenning F, de C Williams AC, European Association of Urology. EAU guidelines on chronic pelvic pain. European urology. 2010 Jan:57(1):35-48. doi: 10.1016/j.eururo.2009.08.020. Epub 2009 Aug 31 [PubMed PMID: 19733958]
Level 1 (high-level) evidenceHellman KM, Patanwala IY, Pozolo KE, Tu FF. Multimodal nociceptive mechanisms underlying chronic pelvic pain. American journal of obstetrics and gynecology. 2015 Dec:213(6):827.e1-9. doi: 10.1016/j.ajog.2015.08.038. Epub 2015 Aug 20 [PubMed PMID: 26299416]
Giamberardino MA, Costantini R, Affaitati G, Fabrizio A, Lapenna D, Tafuri E, Mezzetti A. Viscero-visceral hyperalgesia: characterization in different clinical models. Pain. 2010 Nov:151(2):307-322. doi: 10.1016/j.pain.2010.06.023. Epub 2010 Jul 16 [PubMed PMID: 20638177]
Level 2 (mid-level) evidencePhillips ML, Gregory LJ, Cullen S, Coen S, Ng V, Andrew C, Giampietro V, Bullmore E, Zelaya F, Amaro E, Thompson DG, Hobson AR, Williams SC, Brammer M, Aziz Q. The effect of negative emotional context on neural and behavioural responses to oesophageal stimulation. Brain : a journal of neurology. 2003 Mar:126(Pt 3):669-84 [PubMed PMID: 12566287]
Nickel JC, Tripp DA, International Interstitial Cystitis Study Group. Clinical and psychological parameters associated with pain pattern phenotypes in women with interstitial cystitis/bladder pain syndrome. The Journal of urology. 2015 Jan:193(1):138-44. doi: 10.1016/j.juro.2014.07.108. Epub 2014 Aug 1 [PubMed PMID: 25092637]
Level 2 (mid-level) evidenceGriffith JW, Stephens-Shields AJ, Hou X, Naliboff BD, Pontari M, Edwards TC, Williams DA, Clemens JQ, Afari N, Tu F, Lloyd RB, Patrick DL, Mullins C, Kusek JW, Sutcliffe S, Hong BA, Lai HH, Krieger JN, Bradley CS, Kim J, Landis JR. Pain and Urinary Symptoms Should Not be Combined into a Single Score: Psychometric Findings from the MAPP Research Network. The Journal of urology. 2016 Apr:195(4 Pt 1):949-54. doi: 10.1016/j.juro.2015.11.012. Epub 2015 Nov 14 [PubMed PMID: 26585679]
Fenton BW, Grey SF, Tossone K, McCarroll M, Von Gruenigen VE. Classifying Patients with Chronic Pelvic Pain into Levels of Biopsychosocial Dysfunction Using Latent Class Modeling of Patient Reported Outcome Measures. Pain research and treatment. 2015:2015():940675. doi: 10.1155/2015/940675. Epub 2015 Aug 18 [PubMed PMID: 26355825]
Walker E, Katon W, Harrop-Griffiths J, Holm L, Russo J, Hickok LR. Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. The American journal of psychiatry. 1988 Jan:145(1):75-80 [PubMed PMID: 3337296]
Nolan TE, Metheny WP, Smith RP. Unrecognized association of sleep disorders and depression with chronic pelvic pain. Southern medical journal. 1992 Dec:85(12):1181-3 [PubMed PMID: 1470959]
Level 2 (mid-level) evidenceLorençatto C, Petta CA, Navarro MJ, Bahamondes L, Matos A. Depression in women with endometriosis with and without chronic pelvic pain. Acta obstetricia et gynecologica Scandinavica. 2006:85(1):88-92 [PubMed PMID: 16521687]
Level 2 (mid-level) evidenceNickel JC, Tripp DA, Pontari M, Moldwin R, Mayer R, Carr LK, Doggweiler R, Yang CC, Mishra N, Nordling J. Childhood sexual trauma in women with interstitial cystitis/bladder pain syndrome: a case control study. Canadian Urological Association journal = Journal de l'Association des urologues du Canada. 2011 Dec:5(6):410-5. doi: 10.5489/cuaj.11110. Epub [PubMed PMID: 22154637]
Level 2 (mid-level) evidenceLippman SA, Warner M, Samuels S, Olive D, Vercellini P, Eskenazi B. Uterine fibroids and gynecologic pain symptoms in a population-based study. Fertility and sterility. 2003 Dec:80(6):1488-94 [PubMed PMID: 14667888]
Level 2 (mid-level) evidencePossover M, Schneider T, Henle KP. Laparoscopic therapy for endometriosis and vascular entrapment of sacral plexus. Fertility and sterility. 2011 Feb:95(2):756-8. doi: 10.1016/j.fertnstert.2010.08.048. Epub 2010 Sep 25 [PubMed PMID: 20869701]
Haggerty CL, Peipert JF, Weitzen S, Hendrix SL, Holley RL, Nelson DB, Randall H, Soper DE, Wiesenfeld HC, Ness RB, PID Evaluation and Clinical Health (PEACH) Study Investigators. Predictors of chronic pelvic pain in an urban population of women with symptoms and signs of pelvic inflammatory disease. Sexually transmitted diseases. 2005 May:32(5):293-9 [PubMed PMID: 15849530]
Williams RE, Hartmann KE, Sandler RS, Miller WC, Savitz LA, Steege JF. Recognition and treatment of irritable bowel syndrome among women with chronic pelvic pain. American journal of obstetrics and gynecology. 2005 Mar:192(3):761-7 [PubMed PMID: 15746669]
Level 2 (mid-level) evidenceSeaman HE, Ballard KD, Wright JT, de Vries CS. Endometriosis and its coexistence with irritable bowel syndrome and pelvic inflammatory disease: findings from a national case-control study--Part 2. BJOG : an international journal of obstetrics and gynaecology. 2008 Oct:115(11):1392-6. doi: 10.1111/j.1471-0528.2008.01879.x. Epub 2008 Aug 19 [PubMed PMID: 18715239]
Level 2 (mid-level) evidenceChoung RS, Herrick LM, Locke GR 3rd, Zinsmeister AR, Talley NJ. Irritable bowel syndrome and chronic pelvic pain: a population-based study. Journal of clinical gastroenterology. 2010 Nov-Dec:44(10):696-701. doi: 10.1097/MCG.0b013e3181d7a368. Epub [PubMed PMID: 20375730]
Level 2 (mid-level) evidenceZondervan KT, Yudkin PL, Vessey MP, Jenkinson CP, Dawes MG, Barlow DH, Kennedy SH. Chronic pelvic pain in the community--symptoms, investigations, and diagnoses. American journal of obstetrics and gynecology. 2001 May:184(6):1149-55 [PubMed PMID: 11349181]
Laufer MR, Goitein L, Bush M, Cramer DW, Emans SJ. Prevalence of endometriosis in adolescent girls with chronic pelvic pain not responding to conventional therapy. Journal of pediatric and adolescent gynecology. 1997 Nov:10(4):199-202 [PubMed PMID: 9391902]
Level 2 (mid-level) evidenceMowers EL, Lim CS, Skinner B, Mahnert N, Kamdar N, Morgan DM, As-Sanie S. Prevalence of Endometriosis During Abdominal or Laparoscopic Hysterectomy for Chronic Pelvic Pain. Obstetrics and gynecology. 2016 Jun:127(6):1045-1053. doi: 10.1097/AOG.0000000000001422. Epub [PubMed PMID: 27159755]
Richez B, Ouchchane L, Guttmann A, Mirault F, Bonnin M, Noudem Y, Cognet V, Dalmas AF, Brisebrat L, Andant N, Soule-Sonneville S, Dubray C, Dualé C, Schoeffler P. The Role of Psychological Factors in Persistent Pain After Cesarean Delivery. The journal of pain. 2015 Nov:16(11):1136-46. doi: 10.1016/j.jpain.2015.08.001. Epub 2015 Aug 20 [PubMed PMID: 26299436]
Rapkin AJ, Kames LD, Darke LL, Stampler FM, Naliboff BD. History of physical and sexual abuse in women with chronic pelvic pain. Obstetrics and gynecology. 1990 Jul:76(1):92-6 [PubMed PMID: 2359571]
Meltzer-Brody S, Leserman J, Zolnoun D, Steege J, Green E, Teich A. Trauma and posttraumatic stress disorder in women with chronic pelvic pain. Obstetrics and gynecology. 2007 Apr:109(4):902-8 [PubMed PMID: 17400852]
Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, Sondheimer SJ, Hendrix SL, Amortegui A, Trucco G, Songer T, Lave JR, Hillier SL, Bass DC, Kelsey SF. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. American journal of obstetrics and gynecology. 2002 May:186(5):929-37 [PubMed PMID: 12015517]
Level 1 (high-level) evidenceStovall TG, Ling FW, Crawford DA. Hysterectomy for chronic pelvic pain of presumed uterine etiology. Obstetrics and gynecology. 1990 Apr:75(4):676-9 [PubMed PMID: 2248635]
Champaneria R, Shah L, Moss J, Gupta JK, Birch J, Middleton LJ, Daniels JP. The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness. Health technology assessment (Winchester, England). 2016 Jan:20(5):1-108. doi: 10.3310/hta20050. Epub [PubMed PMID: 26789334]
Level 1 (high-level) evidenceSpeer LM, Mushkbar S, Erbele T. Chronic Pelvic Pain in Women. American family physician. 2016 Mar 1:93(5):380-7 [PubMed PMID: 26926975]
Howard FM. Chronic pelvic pain. Obstetrics and gynecology. 2003 Mar:101(3):594-611 [PubMed PMID: 12636968]
Giamberardino MA, Affaitati G, Fabrizio A, Costantini R. Myofascial pain syndromes and their evaluation. Best practice & research. Clinical rheumatology. 2011 Apr:25(2):185-98. doi: 10.1016/j.berh.2011.01.002. Epub [PubMed PMID: 22094195]
Tu FF, Holt J, Gonzales J, Fitzgerald CM. Physical therapy evaluation of patients with chronic pelvic pain: a controlled study. American journal of obstetrics and gynecology. 2008 Mar:198(3):272.e1-7. doi: 10.1016/j.ajog.2007.09.002. Epub [PubMed PMID: 18313447]
Level 2 (mid-level) evidenceNasr-Esfahani M, Jarrell J. Cotton-tipped applicator test: validity and reliability in chronic pelvic pain. American journal of obstetrics and gynecology. 2013 Jan:208(1):52.e1-5. doi: 10.1016/j.ajog.2012.11.005. Epub 2012 Nov 15 [PubMed PMID: 23159690]
Burckhardt CS, Anderson KL. The Quality of Life Scale (QOLS): reliability, validity, and utilization. Health and quality of life outcomes. 2003 Oct 23:1():60 [PubMed PMID: 14613562]
Level 2 (mid-level) evidenceHolland TK, Cutner A, Saridogan E, Mavrelos D, Pateman K, Jurkovic D. Ultrasound mapping of pelvic endometriosis: does the location and number of lesions affect the diagnostic accuracy? A multicentre diagnostic accuracy study. BMC women's health. 2013 Oct 29:13():43. doi: 10.1186/1472-6874-13-43. Epub 2013 Oct 29 [PubMed PMID: 24165087]
Level 2 (mid-level) evidenceMeredith SM, Sanchez-Ramos L, Kaunitz AM. Diagnostic accuracy of transvaginal sonography for the diagnosis of adenomyosis: systematic review and metaanalysis. American journal of obstetrics and gynecology. 2009 Jul:201(1):107.e1-6. doi: 10.1016/j.ajog.2009.03.021. Epub 2009 Apr 26 [PubMed PMID: 19398089]
Level 1 (high-level) evidenceCody RF Jr, Ascher SM. Diagnostic value of radiological tests in chronic pelvic pain. Bailliere's best practice & research. Clinical obstetrics & gynaecology. 2000 Jun:14(3):433-66 [PubMed PMID: 10962636]
Jacobson TZ, Duffy JM, Barlow D, Koninckx PR, Garry R. Laparoscopic surgery for pelvic pain associated with endometriosis. The Cochrane database of systematic reviews. 2009 Oct 7:(4):CD001300. doi: 10.1002/14651858.CD001300.pub2. Epub 2009 Oct 7 [PubMed PMID: 19821276]
Level 1 (high-level) evidenceCottrell AM, Schneider MP, Goonewardene S, Yuan Y, Baranowski AP, Engeler DS, Borovicka J, Dinis-Oliveira P, Elneil S, Hughes J, Messelink BJ, de C Williams AC. Benefits and Harms of Electrical Neuromodulation for Chronic Pelvic Pain: A Systematic Review. European urology focus. 2020 May 15:6(3):559-571. doi: 10.1016/j.euf.2019.09.011. Epub 2019 Oct 19 [PubMed PMID: 31636030]
Level 1 (high-level) evidenceRandy Jinkins J. The anatomic and physiologic basis of local, referred and radiating lumbosacral pain syndromes related to disease of the spine. Journal of neuroradiology = Journal de neuroradiologie. 2004 Jun:31(3):163-80 [PubMed PMID: 15356442]
Swanton A, Iyer L, Reginald PW. Diagnosis, treatment and follow up of women undergoing conscious pain mapping for chronic pelvic pain: a prospective cohort study. BJOG : an international journal of obstetrics and gynaecology. 2006 Jul:113(7):792-6 [PubMed PMID: 16827762]
Level 2 (mid-level) evidenceCheong YC, Smotra G, Williams AC. Non-surgical interventions for the management of chronic pelvic pain. The Cochrane database of systematic reviews. 2014 Mar 5:2014(3):CD008797. doi: 10.1002/14651858.CD008797.pub2. Epub 2014 Mar 5 [PubMed PMID: 24595586]
Level 1 (high-level) evidenceSator-Katzenschlager SM, Scharbert G, Kress HG, Frickey N, Ellend A, Gleiss A, Kozek-Langenecker SA. Chronic pelvic pain treated with gabapentin and amitriptyline: a randomized controlled pilot study. Wiener klinische Wochenschrift. 2005 Nov:117(21-22):761-8 [PubMed PMID: 16416358]
Level 3 (low-level) evidenceAllen C, Hopewell S, Prentice A, Gregory D. Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis. The Cochrane database of systematic reviews. 2009 Apr 15:(2):CD004753. doi: 10.1002/14651858.CD004753.pub3. Epub 2009 Apr 15 [PubMed PMID: 19370608]
Level 1 (high-level) evidenceLewis SC, Bhattacharya S, Wu O, Vincent K, Jack SA, Critchley HO, Porter MA, Cranley D, Wilson JA, Horne AW. Gabapentin for the Management of Chronic Pelvic Pain in Women (GaPP1): A Pilot Randomised Controlled Trial. PloS one. 2016:11(4):e0153037. doi: 10.1371/journal.pone.0153037. Epub 2016 Apr 12 [PubMed PMID: 27070434]
Level 3 (low-level) evidenceHaugstad GK, Kirste U, Leganger S, Haakonsen E, Haugstad TS. Somatocognitive therapy in the management of chronic gynaecological pain. A review of the historical background and results of a current approach. Scandinavian journal of pain. 2018 Jul 1:2(3):124-129. doi: 10.1016/j.sjpain.2011.02.005. Epub 2018 Jul 1 [PubMed PMID: 29913743]
Level 2 (mid-level) evidenceLouw A, Zimney K, O'Hotto C, Hilton S. The clinical application of teaching people about pain. Physiotherapy theory and practice. 2016 Jul:32(5):385-95. doi: 10.1080/09593985.2016.1194652. Epub 2016 Jun 28 [PubMed PMID: 27351903]
Harada T, Momoeda M, Taketani Y, Hoshiai H, Terakawa N. Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis: a placebo-controlled, double-blind, randomized trial. Fertility and sterility. 2008 Nov:90(5):1583-8. doi: 10.1016/j.fertnstert.2007.08.051. Epub 2007 Dec 27 [PubMed PMID: 18164001]
Level 1 (high-level) evidenceTofferi JK, Jackson JL, O'Malley PG. Treatment of fibromyalgia with cyclobenzaprine: A meta-analysis. Arthritis and rheumatism. 2004 Feb 15:51(1):9-13 [PubMed PMID: 14872449]
Level 1 (high-level) evidenceMoldofsky H, Harris HW, Archambault WT, Kwong T, Lederman S. Effects of bedtime very low dose cyclobenzaprine on symptoms and sleep physiology in patients with fibromyalgia syndrome: a double-blind randomized placebo-controlled study. The Journal of rheumatology. 2011 Dec:38(12):2653-63. doi: 10.3899/jrheum.110194. Epub 2011 Sep 1 [PubMed PMID: 21885490]
Level 1 (high-level) evidenceFritz J, Chhabra A, Wang KC, Carrino JA. Magnetic resonance neurography-guided nerve blocks for the diagnosis and treatment of chronic pelvic pain syndrome. Neuroimaging clinics of North America. 2014 Feb:24(1):211-34. doi: 10.1016/j.nic.2013.03.028. Epub 2013 Aug 1 [PubMed PMID: 24210321]
Martellucci J, Naldini G, Carriero A. Sacral nerve modulation in the treatment of chronic pelvic pain. International journal of colorectal disease. 2012 Jul:27(7):921-6. doi: 10.1007/s00384-011-1394-2. Epub 2011 Dec 29 [PubMed PMID: 22203519]
Abbott JA, Jarvis SK, Lyons SD, Thomson A, Vancaille TG. Botulinum toxin type A for chronic pain and pelvic floor spasm in women: a randomized controlled trial. Obstetrics and gynecology. 2006 Oct:108(4):915-23 [PubMed PMID: 17012454]
Level 1 (high-level) evidenceMontenegro ML, Braz CA, Rosa-e-Silva JC, Candido-dos-Reis FJ, Nogueira AA, Poli-Neto OB. Anaesthetic injection versus ischemic compression for the pain relief of abdominal wall trigger points in women with chronic pelvic pain. BMC anesthesiology. 2015 Dec 1:15():175. doi: 10.1186/s12871-015-0155-0. Epub 2015 Dec 1 [PubMed PMID: 26628263]
Kim DS, Jeong TY, Kim YK, Chang WH, Yoon JG, Lee SC. Usefulness of a myofascial trigger point injection for groin pain in patients with chronic prostatitis/chronic pelvic pain syndrome: a pilot study. Archives of physical medicine and rehabilitation. 2013 May:94(5):930-6. doi: 10.1016/j.apmr.2012.12.011. Epub 2012 Dec 21 [PubMed PMID: 23262156]
Level 3 (low-level) evidencePeters AA, van Dorst E, Jellis B, van Zuuren E, Hermans J, Trimbos JB. A randomized clinical trial to compare two different approaches in women with chronic pelvic pain. Obstetrics and gynecology. 1991 May:77(5):740-4 [PubMed PMID: 1826544]
Level 1 (high-level) evidenceAllegrante JP. The role of adjunctive therapy in the management of chronic nonmalignant pain. The American journal of medicine. 1996 Jul 31:101(1A):33S-39S [PubMed PMID: 8764758]
American College of Medical Toxicology. ACMT Position Statement: Guidance for the Use of Intravenous Lipid Emulsion. Journal of medical toxicology : official journal of the American College of Medical Toxicology. 2017 Mar:13(1):124-125. doi: 10.1007/s13181-016-0550-z. Epub 2016 Apr 27 [PubMed PMID: 27121236]
Anderson RU, Harvey RH, Wise D, Nevin Smith J, Nathanson BH, Sawyer T. Chronic pelvic pain syndrome: reduction of medication use after pelvic floor physical therapy with an internal myofascial trigger point wand. Applied psychophysiology and biofeedback. 2015 Mar:40(1):45-52. doi: 10.1007/s10484-015-9273-1. Epub [PubMed PMID: 25708131]
FitzGerald MP, Payne CK, Lukacz ES, Yang CC, Peters KM, Chai TC, Nickel JC, Hanno PM, Kreder KJ, Burks DA, Mayer R, Kotarinos R, Fortman C, Allen TM, Fraser L, Mason-Cover M, Furey C, Odabachian L, Sanfield A, Chu J, Huestis K, Tata GE, Dugan N, Sheth H, Bewyer K, Anaeme A, Newton K, Featherstone W, Halle-Podell R, Cen L, Landis JR, Propert KJ, Foster HE Jr, Kusek JW, Nyberg LM, Interstitial Cystitis Collaborative Research Network. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. The Journal of urology. 2012 Jun:187(6):2113-8. doi: 10.1016/j.juro.2012.01.123. Epub 2012 Apr 12 [PubMed PMID: 22503015]
Level 1 (high-level) evidenceHartmann KE, Ma C, Lamvu GM, Langenberg PW, Steege JF, Kjerulff KH. Quality of life and sexual function after hysterectomy in women with preoperative pain and depression. Obstetrics and gynecology. 2004 Oct:104(4):701-9 [PubMed PMID: 15458889]
Level 2 (mid-level) evidenceLamvu G. Role of hysterectomy in the treatment of chronic pelvic pain. Obstetrics and gynecology. 2011 May:117(5):1175-1178. doi: 10.1097/AOG.0b013e31821646e1. Epub [PubMed PMID: 21508759]
Martinez A, Howard FM. The efficacy of laparoscopic surgical treatment of ovarian remnant and ovarian retention syndromes. Journal of minimally invasive gynecology. 2015 Feb:22(2):245-9. doi: 10.1016/j.jmig.2014.10.007. Epub 2014 Oct 16 [PubMed PMID: 25460318]
Level 2 (mid-level) evidenceShakiba K, Bena JF, McGill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery. Obstetrics and gynecology. 2008 Jun:111(6):1285-92. doi: 10.1097/AOG.0b013e3181758ec6. Epub [PubMed PMID: 18515510]
Level 2 (mid-level) evidenceMolegraaf MJ, Torensma B, Lange CP, Lange JF, Jeekel J, Swank DJ. Twelve-year outcomes of laparoscopic adhesiolysis in patients with chronic abdominal pain: A randomized clinical trial. Surgery. 2017 Feb:161(2):415-421. doi: 10.1016/j.surg.2016.08.014. Epub 2016 Nov 17 [PubMed PMID: 27866713]
Level 1 (high-level) evidenceMgolozeli SE, Duma SE. "Whenever I think about this, I feel like killing myself, because life has no meaning to me anymore": an exploration of the consequences of rape victimization for men. International journal of qualitative studies on health and well-being. 2025 Dec:20(1):2437905. doi: 10.1080/17482631.2024.2437905. Epub 2024 Dec 11 [PubMed PMID: 39660427]
Level 2 (mid-level) evidenceCosar E, Çakır Güngör A, Gencer M, Uysal A, Hacivelioğlu SO, Özkan A, Şen HM. Sleep disturbance among women with chronic pelvic pain. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2014 Sep:126(3):232-4. doi: 10.1016/j.ijgo.2014.03.034. Epub 2014 May 21 [PubMed PMID: 24913201]
Level 2 (mid-level) evidenceKang SB, Chung HH, Lee HP, Lee JY, Chang YS. Impact of diagnostic laparoscopy on the management of chronic pelvic pain. Surgical endoscopy. 2007 Jun:21(6):916-9 [PubMed PMID: 17103271]
Level 2 (mid-level) evidencePaspulati RM. Chronic Pelvic Pain: Role of Imaging in the Diagnosis and Management. Seminars in ultrasound, CT, and MR. 2023 Dec:44(6):501-510. doi: 10.1053/j.sult.2023.10.006. Epub 2023 Oct 23 [PubMed PMID: 37879545]