ACOG PRACTICE BULLETIN

Clinical Management Guidelines for Obstetrician–Gynecologists

NUMBER 218
Committee on Practice Bulletins—Gynecology. This Practice Bulletin was developed by the American College of Obstetricians and
Gynecologists’ Committee on Practice Bulletins–Gynecology in collaboration with Lee A. Learman, MD, PhD, and Katherine
W. McHugh, MD.

Chronic Pelvic Pain

Chronic pelvic pain is a common, burdensome, and costly condition that disproportionately affects women. Diagnosis
and initial management of chronic pelvic pain in women are within the scope of practice of specialists in obstetrics and
gynecology. The challenging complexity of chronic pelvic pain care can be addressed by increased visit time using
appropriate coding modifiers, as well as identification of multidisciplinary team members within the practice or by
facilitated referral. This Practice Bulletin addresses the diagnosis and management of chronic pelvic pain that is not
completely explained by identifiable pathology of the gynecologic, urologic, or gastrointestinal organ systems. When
evidence on chronic pelvic pain treatment is limited, recommendations are extrapolated from treatment of other
chronic pain conditions to help guide management. The evaluation and management of potential gynecologic
etiologies of pelvic pain (ie, endometriosis, adenomyosis, leiomyomas, adnexal pathology, vulvar disorders) are
discussed in other publications of the American College of Obstetricians and Gynecologists (1–4).

from an inflammatory, infectious, or anoxic event or

Background traumatic injury that resolves over time with treatment
Definition and repair. When pain persists, a chronic stress pheno-
A lack of consensus on the definition of chronic pelvic type may emerge and is characterized by a vicious cycle
pain has impeded efforts to understand its prevalence and of physical and psychologic consequences. Prolonged
the success of treatment alternatives (5). The American activity restriction can lead to physical deconditioning.
College of Obstetricians and Gynecologists and the Continued fear, anxiety, and distress can lead to long-
ReVITALize data definitions initiative define chronic term deterioration in mood and social isolation. Although
pelvic pain as “pain symptoms perceived to originate mood symptoms are ubiquitous in chronic pain syn-
from pelvic organs/structures typically lasting more than dromes, criteria for major depression are met in approx-
6 months. It is often associated with negative cognitive, imately 12–33% of women across samples of women
behavioral, sexual and emotional consequences as well living with or seeking care for chronic pelvic pain (7–9).
as with symptoms suggestive of lower urinary tract, sex-
ual, bowel, pelvic floor, myofascial, or gynecological Epidemiology
dysfunction” (6). Cyclical pelvic pain is considered A systematic review of high-quality studies by the World
a form of chronic pelvic pain if it has significant cogni- Health Organization in 2006 found the prevalence to range
tive, behavioral, sexual, and emotional consequences (6). from approximately 2.1% to 24% for noncyclical pain, 8%
This Practice Bulletin does not address cyclic pain syn- to 21.1% for dyspareunia, and 16.8% to 81% for dysmen-
dromes (eg, dysmenorrhea, Mittelschmerz) but does dis- orrhea (10). An updated review published in 2014 used
cuss dyspareunia as a component of chronic pelvic pain. a more stringent definition (noncyclical pain lasting at least
Chronic pelvic pain differs from acute pelvic pain in 6 months) and found prevalence estimates that ranged from
several important ways. Acute pain typically arises 5.7% to 26.6% (11). Familiarity with contributors to

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chronic pelvic pain unrelated to the female reproductive
system is important, with the most common being irritable Box 1. Common Conditions Associated
bowel syndrome, interstitial cystitis or painful bladder syn- With Chronic Pelvic Pain
drome, pelvic floor muscle tenderness, and depression. The
estimated prevalence of these conditions ranges from 20% Visceral
to 60% in women with chronic pelvic pain (7, 12–14). In c Gynecologic

a systematic review that included nine studies of 1,016 Adenomyosis

B

Adnexal mass
B

women with chronic pelvic pain who were evaluated for Chronic pelvic inflammatory disease/chronic
B

other conditions, the mean prevalence of bladder pain syn- endometritis

drome was 61% (range 11–97%; CI, 58–64%); of endome- Endometriosis
B

triosis, 70% (range 28–93%; CI, 67–73%); and of co- Leiomyoma

B

existing bladder pain syndrome and endometriosis, 48% Ovarian remnant syndrome
B

Pelvic adhesions
B

(range 16–78%; CI, 44–51%) (15). Vestibulitis

B

Vulvodynia
B

Pathophysiology
c Gastrointestinal
Recent evidence supports the importance of central BCeliac disease
sensitization in perpetuating chronic pain syndromes. BColorectal cancer and cancer therapy
Central sensitization occurs when peripheral pain pro- BDiverticular colitis
vokes an exaggerated response by the interneurons, which BInflammatory bowel disease
amplifies the pain perception. The resulting pathologic BIrritable bowel syndrome
changes involve the central nervous system’s response to c Urologic
BBladder cancer and cancer therapy
noxious stimuli, the activation of specific brain regions, BChronic or complicated urinary tract infection
the hypothalamic–pituitary–adrenal axis, and the auto- BInterstitial cystitis
nomic nervous system, all of which increase psychologic BPainful bladder syndrome
distress (16). Central sensitization explains why patients BUrethral diverticulum
with chronic pelvic pain feel pain in response to innocuous Neuromusculoskeletal
stimuli (allodynia) and feel a heightened response to
c Fibromyalgia
painful stimuli (hyperalgesia). The abnormal central pro-
c Myofascial syndromes
cessing of sensory information can explain why endome- Coccydynia
B

triosis pain can persist despite effective treatment (17). Musculus levator ani syndrome
B

c Postural syndrome
Differential Diagnosis
c Abdominal wall syndromes
The differential diagnosis for chronic pelvic pain is Muscular injury
B

extensive. Organizing the possibilities into visceral Trigger point

B

and neuromusculoskeletal disorders and psychosocial c Neurologic

contributors can facilitate evaluation and treatment Abdominal epilepsy

B

while maintaining awareness of the likely multifactorial Abdominal migraine

B

etiology (Box 1). Neuralgia

B

Neuropathic pain
B

The multifactorial nature of chronic pelvic pain

lends itself to an interdisciplinary model of care that Psychosocial
c Abuse
seeks to identify and treat an individual’s physical pain
Physical, emotional, sexual
B
generators as well as comorbid conditions, such as
c Depressive disorders
depression and anxiety, which together create the symp-
Major depressive disorder
B
tomatology and contribute to the overall burden of dis- Persistent depressive disorder (dysthymia)
B

ease (9). For example, a chronic pelvic pain patient’s Substance-induced or medication-induced
B

pain may not improve until her endometriosis is treated, depressive disorder
reactive pelvic floor myalgia is addressed, central sensi- c Anxiety disorders

tization is controlled with neuromodulator treatment, and Generalized anxiety disorder

B

depression is in remission. Panic disorder

B

Social anxiety disorder

B
Visceral etiologies include disorders of the gyneco-
Substance-induced or medication-induced
B

logic, gastrointestinal, and urologic organ systems. anxiety disorder

Visceral pain results from stimulation of nociceptors of
(continued)
organs, which are particularly sensitive to distention,

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 definition of this condition, and diagnostic criteria are
Box 1. Common Conditions Associated variable (19). Further research is needed to establish
With Chronic Pelvic Pain (continued) greater consistency in diagnosis and homogeneity in
c Somatic symptom disorders treatment studies.
BSomatic symptom disorder with pain features
BSomatic symptom disorder with somatic
characteristics
Clinical Considerations
c Substance use disorder
BSubstance abuse
and Recommendations
Substance dependence
< What is the initial evaluation for a patient who
B

presents with chronic pelvic pain?

ischemia, and inflammation. The pain is typically diffuse
and poorly defined without spatial discernment because A detailed medical history and physical examination,
of differing densities of visceral sensory innervation and with particular attention to the abdominal and pelvic
scattering of input in the central nervous system. neuromusculoskeletal examination, are recommended for
Autonomic symptoms, including diaphoresis, vital sign the evaluation of chronic pelvic pain. Physical findings
abnormalities, and gastrointestinal symptoms, often that increase the likelihood of neuromusculoskeletal
accompany visceral pain and can confuse the diagnosis. contributors to chronic pelvic pain include pelvic floor
Patients are often focused on the viscera as the cause of muscle tenderness and abdominal wall tenderness that
pain, and so visceral etiologies should be addressed early reproduce the patient’s pain.
and often, with reassurance that these diagnoses are not Perhaps the most critical portions of the evaluation of
being overlooked. chronic pelvic pain are a detailed medical, surgical, and
Neuromusculoskeletal disorders are extremely com- gynecologic history and a thorough physical examination
mon and often overlooked, which prolongs patient (20, 21). Self-administered screening forms completed by
discomfort and delays appropriate treatment. No univer- patients in advance and increased visit times with appropriate
sal consensus exists on diagnostic criteria for neuro- coding modifiers can optimize the practice effect of chronic
musculoskeletal pain, but the symptoms often can be pelvic pain care. A systematic history begins with patient-
a result of myofascial trigger points or neurovascular reported information completed before the visit, a detailed
entrapment that is due to surgical injury or inflammation chronology of symptoms, and a review of previous treat-
of tendons or ligaments. Pain is reproducible on exam- ments. Eliciting pain aggravators and alleviators related to
ination with palpation of the affected muscle groups but sexual activity and menstruation is a good starting point, but
does not typically trigger an autonomic response. The this information needs to be supplemented with an under-
pathophysiology of neuromusculoskeletal pain is poorly standing of pain and other symptoms associated with phys-
understood but is likely related to repeated microtrauma, ical activity and urinary and gastrointestinal function. The
acute trauma, or postural misalignment, which results in Pelvic Pain Assessment Form published by the International
hypertonicity and a myofascial pain syndrome (18). Pelvic Pain Society includes many of these assessments and
Psychosocial factors play a role in all types of pain is freely available for clinical use in four languages (22).
and can affect symptom severity and prognosis. Pelvic The medical history should include specific chro-
pain and dyspareunia are more prevalent in women with nology, triggers, and treatments of pain as well as
a history of abuse, mental illness, lack of support, social a review of all medical diagnoses, surgical procedures
stressors, and relationship discord. These comorbidities do and findings, obstetric details, medications, and allergies.
not alter the visceral or neuromusculoskeletal pain gen- Psychosocial factors are also important and may influ-
erators but may worsen the associated symptom burden ence treatment choices. The success or failure of previous
and psychological effects. Treating psychosocial factors as treatment attempts also may be instructive.
separate but equally important pain contributors can Focusing the physical examination on the abdominal
increase the woman’s awareness of her conscious and and pelvic neuromusculoskeletal system, with inclusion
unconscious perception of pain and facilitate her recovery. of a visceral examination, addresses most chronic pelvic
Pelvic congestion syndrome is a proposed etiology pain etiologies. Attention to underlying myofascial
of chronic pelvic pain related to pelvic venous insuffi- structures in addition to the viscera is highly likely to
ciency. Although venous congestion appears to be yield an accurate diagnosis (20, 21). Evaluation should
associated with chronic pelvic pain, evidence is insuffi- include palpation of the lower back, sacroiliac joints,
cient to conclude that there is a cause-and-effect relation- pubic symphysis, as well as the abdomen and genitalia.
ship (19). In addition, there is no consensus on the Focal tenderness of the abdomen or the pelvic floor can

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be found with a single digit examination or examination Symptom questionnaires can be completed before or
with a cotton tipped swab (23). during the visit to assist in screening for depression (29),
Several physical examination findings are indicative interstitial cystitis (30), and irritable bowel syndrome
of neuromusculoskeletal chronic pelvic pain etiologies, (31). Patients with unexplained urinary symptoms (eg,
with two findings that indicate potential benefit from frequency, urgency) and bladder pain may benefit from
physical therapy. The presence of pelvic floor muscle referral for additional evaluation. Patients with irritable
tenderness or a positive result on the forced flexion, bowel syndrome symptoms and risk factors may warrant
abduction, and external rotation (FABER) test correctly additional evaluation to rule out inflammatory bowel dis-
classified neuromusculoskeletal pain in 85% of patients ease or colon cancer through appropriate referrals to pri-
in a small U.S. study (24). A study in Denmark also mary care or gastroenterology, or both. Patients with
showed a strong association between chronic pelvic pain complex mood symptoms, suicidal thoughts, or other risk
of myofascial origin and the presence of pelvic floor factors may benefit from evaluation by a mental health
muscle tenderness and hypertonicity (25). Both studies professional.
used trained examiners in research settings and likely
overestimate associations found in clinical practice. < What are the roles of pelvic floor physical
The abdominal examination finding most associated therapy, cognitive behavioral therapy, and
with chronic pelvic pain can be demonstrated by the Carnett sex therapy in the treatment of chronic pelvic
test (26). A positive Carnett test result is defined by tender- pain?
ness that worsens or does not improve during an abdominal
wall muscle contraction. A negative Carnett test result in- Chronic pelvic pain and associated dyspareunia often
stem from a combination of myofascial and psychosocial
dicates visceral pain that improves during the muscle con-
causes, both of which should be addressed in the
traction when the abdominal wall shields the viscera from
treatment plan. Referral for pelvic floor physical therapy,
the examiner’s finger. A positive Carnett test result is inde-
sex therapy, or cognitive behavioral therapy, alone or in
pendently associated with severity of chronic pelvic pain to
combination, is recommended to manage the myofascial
a similar degree as pelvic floor muscle tenderness (27).
and psychosocial causes and consequences of chronic
Laboratory and imaging tests for chronic pelvic
pelvic pain and associated dyspareunia.
pain are limited in their utility and should be tailored to
the individual patient’s symptoms and physical exami- A systematic review that included 202 randomized
trials of treatments for chronic tension headache, fibro-
nation findings. For example, patients with risk factors
myalgia, and chronic musculoskeletal pain (low back,
for chronic sexually transmitted infection should be
neck, knees, hips) found slight-to-moderate improvement
tested for gonorrheal, chlamydial, mycoplasmal, and
in pain and functioning after exercise, multidisciplinary
trichomonal infections. Patients with uterine or adnexal
rehabilitation, acupuncture, cognitive behavioral therapy,
tenderness or suspicion of a pelvic mass should have
and mind–body practices. Although these treatments
further evaluation for visceral gynecologic causes of
were not associated with serious harms, few studies
chronic pelvic pain using transvaginal ultrasonography
and possibly diagnostic laparoscopy (3, 28). Suspicion monitored patients for outcomes beyond the immediate
treatment period (32).
of chronic pelvic inflammatory disease can be evaluated
further with endometrial biopsy and transvaginal
ultrasonography. Pelvic Floor Physical Therapy
Pelvic floor muscle tenderness is commonly associated
< What additional evaluation should be per- with chronic pelvic pain. Physical therapists use a wide
formed when nongynecologic etiologies are range of modalities and tools tailored to each patient’s
suspected? specific symptoms and clinical findings. These include
external and internal tissue mobilization and myofascial
Evaluation for common nonreproductive conditions that release, manipulative therapies to mobilize visceral,
contribute to chronic pelvic pain should include screen- urogenital, and joint structures; electrical stimulation;
ing for interstitial cystitis or painful bladder syndrome, active pelvic floor retraining; biofeedback; bladder
irritable bowel syndrome, diverticulitis, and comorbid and bowel retraining; and pelvic floor muscle stretching
mood disorders (depression, anxiety). Additional testing (33–35). In one randomized trial, pelvic floor physical
or referral may be required for patients who screen therapy and levator-directed trigger-point injections
positive for any of these conditions to rule out other were equally effective in markedly decreasing vaginal
causes of urinary, gastrointestinal, or constitutional pain and sex-related pain (36). Patients who do not
symptoms in patients with risk factors. improve with pelvic floor physical therapy may be

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found to have treatable musculoskeletal disorders iden- chronic pelvic pain. These medications can be prescribed
tified by a physician specializing in physical medicine by obstetrician–gynecologists.
and rehabilitation (37). Antidepressant medications are most commonly
prescribed, alone or with psychotherapy, for management
Cognitive Behavioral Therapy of moderate to severe depression. Antidepressant medi-
Although pelvic pain may be due to an inciting event, the cations also have been evaluated in nondepressed
chronicity of pain predisposes patients to depression, patients with chronic pain syndromes. Although no
anxiety, and social isolation. And, depression worsens studies have established the benefit of antidepressant
the quality of life for women with chronic pelvic pain use for improvement in chronic pelvic pain specifically,
(38). Instead of attempting to determine which order is a systematic review of 37 double-blind randomized trials
primary, or blaming one condition for causing the other, found that SNRIs and tricyclic antidepressants were
both need to be treated with equal urgency. superior to placebo for improving depressive symptoms,
Cognitive behavioral therapy is a goal-oriented pain, and quality of life in patients with neuropathic pain
therapy and, when used in conjunction with medical syndromes such as fibromyalgia and diabetic neuropathy,
and physical therapies, has the advantage of addressing with a number-needed-to-treat of 24 patients for one to
the effects of depression and pain on relationships and experience a clinical improvement. The analgesic effec-
other aspects of well-being. The evidence that supports tiveness of SNRIs and tricyclic antidepressants was not
the benefit of cognitive behavioral therapy and other evaluated separately in subgroup analyses (45).
counseling approaches for the treatment of chronic pelvic Cochrane reviews of individual antidepressants show
pain comes primarily from studies in which counseling is that duloxetine (an SNRI) is superior to placebo for the
a component of multidisciplinary care (39, 40). Studies management of neuropathic pain from diabetic neuropathy
of patients with other chronic pain syndromes show and fibromyalgia (46), whereas trials of venlafaxine (a selec-
small-to-moderate benefits of cognitive behavioral ther- tive serotonin reuptake inhibitor with weak SNRI properties)
apy when compared with no therapy (41). Patients learn for neuropathic pain showed strong placebo effects and high
to modulate their thoughts and manipulate their environ- potential for selection bias (47). No published trials have
ment to lessen their pain perception and improve coping established the efficacy of duloxetine or venlafaxine in the
skills. treatment of chronic pelvic pain in women.
Emotional well-being should be assessed at every Tricyclic antidepressants (eg, amitriptyline, nortrip-
visit and professional counseling should be considered tyline, and desipramine) are commonly used to treat
and offered to every patient with chronic pelvic pain. It is neuropathic pain. However, there is only weak evidence
critical that the patient understands that referral does not of efficacy (48–50). A 2009 double blind randomized
mean that the pain is psychosomatic or any less real. controlled trial (RCT) found that gabapentin and nortrip-
Instead, counseling enables patients to obtain support in tyline worked better in combination than either drug
parallel with the other treatments being recommended to worked in isolation for chronic neuropathic pain (51).
address the chronic pelvic pain generators. Based upon their effectiveness for other neuropathic
pain syndromes, gabapentin and pregabalin are recom-
Sex Therapy mended for the treatment of neuropathic chronic pelvic
Although there may be a myofascial component to pain. These medications can be prescribed by obstetrician–
genito–pelvic pain, this condition may require the addi- gynecologists. Neuropathic medications have a role in the
tional expertise of individual counseling, couples ther- medical management of chronic pelvic pain once under-
apy, or sex therapy to overcome the specific psychosocial lying visceral etiologies have been addressed and a neu-
barriers to recovery (4, 42). Sex therapy can be a useful ropathic component of the pain syndrome has been
adjunctive treatment to physical therapy to assist couples diagnosed (52). However, many studies are not specific to
in the return to normal, pain-free intercourse; female chronic pelvic pain and are small or retrospective in nature
orgasmic disorder and genito–pelvic pain have been (53). Because neuropathic pain is often associated with
shown to improve with sex therapy (43, 44). tissue injury, it is critical to assess for and treat concurrent
myofascial dysfunction. Treatment with neuropathic
< What is the role of neuropathic medications in medications may improve the effectiveness of physical
the treatment of chronic pelvic pain? therapy and myofascial dysfunction by improving senso-
rineural tolerance of stimuli.
Based upon their effectiveness for other neuropathic pain Calcium channel alpha 2-delta ligand medications
syndromes, serotonin–norepinephrine reuptake inhibitors (gabapentin or pregabalin) are common treatments for
(SNRIs) are recommended for patients with neuropathic chronic pelvic pain. Although there is a lack of evidence

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specific to women with chronic pelvic pain, a 2016 pilot (eg, 10% per month) may be better tolerated than faster
RCT looked at the potential effectiveness of gabapentin tapering rates (57). When weaning is not possible because
in women with chronic pelvic pain and showed it to be of patient intolerance of withdrawal symptoms or analge-
a beneficial, well-tolerated, and cost-effective therapy sic alternatives, opioids should be prescribed according to
(54). A Cochrane review of gabapentin for general neu- the CDC prescribing guidelines (57). For more informa-
ropathic pain in adults showed overall improvement with tion, see the American College of Obstetricians and Gy-
the medication, particularly for those with postherpetic necologists’ Opioid Resources webpage, available at
neuralgia or peripheral diabetic neuropathy. The benefit https://www.acog.org/About-ACOG/ACOG-Departments/
was modest, with approximately three or four out of 10 Tobacco–Alcohol–and-Substance-Abuse/Opioids.
study participants experiencing at least a 50% reduction
in pain with gabapentin, as compared with one or two out < When is it appropriate to involve pain special-
of 10 who received placebo (53). ists or to refer patients for multidisciplinary
A Cochrane review did not find sufficient evidence care for the treatment of chronic pelvic pain?
to recommend muscle relaxants for myofascial pain (55);
Referral to pain medicine specialists may be part of the
however, only two studies were evaluated. Treatment
multidisciplinary care of women with chronic pelvic
should be individualized to the patient’s pain and comor-
pain. The timing of consultation or referral to multidis-
bidities as well as tolerance of adverse effects.
ciplinary care should be individualized based upon the
complexity of the patient’s condition, the primary clini-
< What is the role of opioid analgesics in the cian’s expertise, and the availability of resources. A vari-
treatment of chronic pelvic pain? ety of specialists may focus their practice on specific
elements of pain management, such as medication man-
Opioids are not recommended for the treatment of
agement or interventional procedures. However, a multi-
chronic pelvic pain. Patients already on opioids should
modal approach is needed for management of chronic
be slowly weaned. Although there is a role for opioids in
pelvic pain. Specialists certified by the American Board
the treatment of acute pain, nonpharmacologic and
of Pain Medicine are trained to develop comprehensive
nonopioid treatments are preferred for chronic pelvic
treatment plans for pain. Pain medicine specialists are also
pain. Opioids neglect the underlying etiology; increase
helpful in providing pharmacotherapy recommendations
the risk of adverse medication effects, tolerance, or
when multiple agents may be needed to address central
overdose; and may contribute to the opioid dependence
and peripheral sources of pain. Because they are not
epidemic (56).
trained to identify and treat primary sources of pelvic pain,
The Centers for Disease Control and Prevention
pain medicine specialists should be part of a multidisciplin-
(CDC) guidelines for the use of opioids in the treatment
ary care program that includes, at minimum, a gynecolo-
of chronic pain recommend that other than active cancer
gist, a psychologist, and a physical therapist (9, 39).
or end-of-life palliative care, opioids should not be
considered as first-line or routine therapy (57). The < What is the role of procedural treatments in
CDC guidelines emphasize use of concurrent nonopioid the management of chronic pelvic pain?
pain medications, measurement of pain and function, and
avoiding the use of opioids and benzodiazepines For myofascial etiologies of chronic pelvic pain, such as
together. Chronic opioid use is associated with serious trigger points and nerve entrapment, procedural treat-
adverse effects such as respiratory depression and life- ments can be useful in conjunction with other modalities.
long opioid use disorder and more common effects such
as constipation, dry mouth, nausea, vomiting, drowsi- Trigger Point Injections
ness, confusion, tolerance, physical dependence, and Trigger point injections of saline, anesthetic, steroids, or
withdrawal symptoms when stopping opioids (57). opioids, in isolation or in combination with other
Patients already taking opioid medications should be treatment modalities, are recommended to improve pain
slowly weaned and transitioned to a therapy to address and functional ability in patients with myofascial chronic
the etiology and symptoms of chronic pelvic pain (57), pelvic pain. Trigger point injections can be performed by
which may necessitate referral to a pain or addiction appropriately trained obstetrician–gynecologists. Trigger
specialist. During the process of weaning, review of treat- point injections are safe and can provide immediate relief
ment goals, review of state prescription drug monitoring of a hyperalgesic muscle cutaneous nerve entrapment or
program data, urine drug screens, and robust addiction fascial trigger point (58) but may require repeated doses
counseling are encouraged to optimize the chance for full benefit (18, 59). Evidence that trigger point in-
of successful cessation. Tapering the dose slowly jections are beneficial regardless of the injectant used

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raises the possibility that needle insertion itself may manipulation showed weaker evidence of benefit. None of
produce a strong placebo effect or be effective on its own the studies focused on women with chronic pelvic pain (66).
(60). Trigger point injections are beneficial for pelvic Preliminary evidence from a single-arm trial that evaluated
floor muscle spasm refractory to pelvic floor physical the success of a group-based therapeutic yoga program for
therapy and medications (61) and may be more beneficial women with chronic pelvic pain showed clinically important
than ischemic compression physical therapy alone for the and statistically significant improvements in baseline pain,
treatment of abdominal wall trigger points in patients emotional well-being, and sexual function after 6 weeks of
with chronic pelvic pain (59). Patients should be coun- yoga practice (67).
seled regarding expectations and anticipated concurrent Selective cannabinoids (ie, synthetic cannabinoids that
therapies before starting injections. contain only tetrahydrocannabinol [THC] and cannabis-
based extracts that contain a combination of THC and
Botulinum Toxin Injections cannabidiol [CBD]) for chronic neuropathic pain have been
The evidence is inconclusive regarding the value of the focus of several recent systematic reviews (68, 69). A
botulinum toxin injections for myofascial pain syn- systematic review of 11 randomized trials that included
dromes from all sources (62). Therefore, their use should 1,219 patients showed a statistically significant but clinically
be reserved for the treatment of myofascial pelvic pain small benefit averaging less than 1 point on a 0–10-point
refractory to physical therapy (63). pain scale (68). Another review included the findings from
24 randomized trials (1,334 patients) in a meta-analysis that
Other Procedures showed inconsistent improvements in pain across trials, with
There is limited evidence to support laparoscopic uterosac- most showing no effect (69). Participants in the trials had
ral nerve ablation and presacral neurectomy in the treatment heterogeneous diagnoses including multiple sclerosis, dia-
of chronic pelvic pain. A large RCT found no improvement betic neuropathy, brachial plexus injury, and
in pain scores or quality of life after laparoscopic uterosacral chemotherapy-induced pain. None of the studies in either
nerve ablation in chronic pelvic pain (64). Most studies that review focused on women with chronic pelvic pain (68, 69).
evaluated presacral neurectomy included patients that had
dysmenorrhea, and there is insufficient evidence to support < What is the role of laparoscopic adhesiolysis
nerve interruption in the treatment of chronic pain (65). in the management of chronic pelvic pain?

< What are the roles of complementary, alterna- The routine use of laparoscopic adhesiolysis is not
tive, and integrative medicine therapies in the recommended for the management of chronic pelvic
treatment of chronic pelvic pain? pain. Laparoscopic adhesiolysis is not helpful for the
treatment of chronic pelvic pain after visceral gyneco-
Data from randomized trials are needed to evaluate logic causes such as endometriosis, adenomyosis, and
whether complementary and integrative therapies studied adnexal disorders have been excluded. However, intra-
for other chronic pain disorders are effective for chronic operative findings may support the role of adhesiolysis in
pelvic pain. However, based on evidence of benefit for specific circumstances such as bowel stricture and dense
the treatment of nongynecologic chronic pain, acupunc- adhesions tethering the uterus.
ture and yoga can be considered for the management of Adhesions are common in patients who have
chronic pelvic pain of musculoskeletal etiology. undergone previous abdominal surgery and in patients
Complementary and integrative therapies have been with inflammatory conditions such as pelvic inflamma-
studied in patients with chronic musculoskeletal and neuro- tory disease and endometriosis. Pelvic adhesiolysis was
pathic pain syndromes of the head, neck, back, and once a common procedure in patients undergoing
extremities as well as fibromyalgia. These therapies can be laparoscopy for chronic pelvic pain (70). Early uncon-
biologically based (natural compounds), mind–body (such as trolled studies showed large magnitude, short-lived im-
relaxation, yoga, and tai chi), manipulative (such as massage provements after lysis of adhesions, whereas later
and osteopathic manipulation), and bioenergetic (acupunc- randomized trials show no benefit when compared with
ture) (32, 66). A systematic review of 32 studies of chronic diagnostic laparoscopy (71), which challenges the value
pain management included six randomized trials of acu- of laparoscopic adhesiolysis for chronic pelvic pain and
puncture that showed strong evidence of benefit for reducing the presumption that adhesions cause chronic pelvic pain.
pain and opioid use in patients with chronic musculoskeletal A systematic review of two RCTs and 11 cohort studies
pain. One of the trials showed short-term benefit of auricular on laparoscopic adhesiolysis found a lack of evidence of
acupuncture in pregnant women with low back and posterior benefit, an increased risk of bowel injury, and a high rate of
pelvic pain. Studies of yoga, relaxation, tai chi, massage, and negative laparoscopies (defined in the review as no

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diagnostic findings other than adhesions) (71). In a long- and comorbid mood disorders (depression, anxiety).
term follow-up study of one of the RCTs included in the Additional testing or referral may be required for
systematic review, pain outcomes were poorer 12 years after patients who screen positive for any of these con-
laparoscopic adhesiolysis than after diagnostic laparoscopy ditions to rule out other causes of urinary, gastroin-
alone (72). Among the study participants reporting outcomes testinal, or constitutional symptoms in patients with
at 12 years, 42% in the diagnostic laparoscopy group, and risk factors.
19% in the adhesiolysis group reported complete relief of < Referral to pain medicine specialists may be part of
abdominal pain (relative risk, 1.3; P5.033) (72). the multidisciplinary care of women with chronic
pelvic pain. The timing of consultation or referral to
Summary multidisciplinary care should be individualized based
upon the complexity of the patient’s condition, the
of Recommendations primary clinician’s expertise, and the availability of
resources.
The following recommendation is based on good and < Based on evidence of benefit for the treatment of
consistent scientific evidence (Level A): nongynecologic chronic pain, acupuncture and yoga
can be considered for the management of chronic
< The routine use of laparoscopic adhesiolysis is not rec-
ommended for the management of chronic pelvic pain. pelvic pain of musculoskeletal etiology.

The following recommendations are based on limited or

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Level B—Recommendations are based on limited or
inconsistent scientific evidence.
Level C—Recommendations are based primarily on
consensus and expert opinion.

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This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care and use
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