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Chronic pelvic pain in women

What's new

The American Academy of Family Physicians (AAFP) has published an updated guideline for the management of chronic pelvic pain in women. Nonpharmacological interventions include pelvic floor physical therapy and cognitive behavioral therapy, with or without sex therapy. Pharmacological options include nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentin, serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine, and tricyclic antidepressants (TCAs). .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of chronic pelvic pain in women are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2025,2016), the American Society of Interventional Pain Physicians (ASIPP/NASS/AAPM/ASRA/IPSIS 2025), the European Association of Urology (EAU 2025), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2024,2023), the ...
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Diagnostic investigations

Initial evaluation: as per AAFP 2025 guidelines, elicit a detailed history and perform a focused abdominal, musculoskeletal, and pelvic examination in all patients with chronic pelvic pain. Assess for common comorbidities, including behavioral health disorders and other chronic pain conditions.
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  • Diagnostic imaging

  • Anorectal function tests

  • Psychosocial assessment

  • Screening for infections

Diagnostic procedures

Diagnostic laparoscopy: as per AAFP 2016 guidelines, refer patients with severe chronic pelvic pain for laparoscopy if the diagnosis remains unclear after the initial evaluation.
B
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Medical management

General principles: as per AAFP 2025 guidelines, consider implementing a biopsychosocial approach with a multimodal, interdisciplinary treatment plan for chronic pelvic pain when a clear etiology is absent.
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  • NSAIDs

  • Opioids

  • Antidepressants

  • Anticonvulsants

  • Cannabinoids

  • Hormone therapy

Nonpharmacologic interventions

Lifestyle modifications: as per SOGC 2024 guidelines, consider advising lifestyle changes, including dietary modifications, exercise, and smoking cessation, as part of chronic pain management.
C
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  • Psychotherapy

  • Pelvic floor muscle training

  • Acupuncture

Therapeutic procedures

Trigger point injections, indications: as per SOGC 2024 guidelines, consider offering targeted therapies, such as trigger point injections and nerve blocks, in specific clinical circumstances where there is no response to modalities with higher evidence.
E
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  • Trigger point injections (technical considerations)

  • Botulinum toxin injections

Surgical interventions

Indications for surgery: as per SOGC 2024 guidelines, consider offering surgery for chronic pelvic pain after pain beliefs and treatment expectations are explored and with counseling about the rationale for surgery, the uncertainty of the evidence surrounding outcomes, and the possibility that pain could be unchanged or worse after surgery.
B
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Specific circumstances

Patients with pelvic floor dysfunction
As per EAU 2025 guidelines:
Offer myofascial release therapy as first-line therapy in patients with pelvic floor dysfunction.
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Offer biofeedback as adjuvant to muscle exercises in patients with anal pain due associated with overactive pelvic floor.
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  • Patients with anorectal pain syndrome

  • Patients with pudendal neuralgia (medical therapy)

  • Patients with pudendal neuralgia (pudendal nerve block)

  • Patients with IBS

  • Patients with pelvic congestion syndrome (diagnostic imaging)

  • Patients with pelvic congestion syndrome (local procedures)

  • Patients with pelvic congestion syndrome (pelvic vein embolization)

  • Patients with pelvic congestion syndrome (indications for surgery)

Patient education

General counseling
As per RCOG 2012 guidelines:
Recognize that many patients seek consultation to find an explanation for their pain, and often they already have a theory or a concern about the origin of the pain. Discuss these ideas during the initial consultation.
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Address the multifactorial aspects of chronic pelvic pain early. Aim to develop a partnership between the clinician and the patient to outline a management strategy.
B
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