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Does evidence support physiotherapy management of adult female chronic pelvic pain? A systematic review

S. Loving, J. Nordling, P. Jaszczak and T. Thomsen


Background and purpose

Chronic pelvic pain (CPP) is a debilitating condition among women with a major impact on health-related quality of life, work productivity and health care utilisation. The exact prevalence of chronic pelvic pain is not known, but 3.8% is commonly suggested. Musculoskeletal dysfunction is frequently cited as a possible aetiology. Physiotherapy is therefore recommended as one treatment modality. The aim of this systematic review was to source and critically evaluate the evidence for an effect of physiotherapy on pain, physical activity and quality of life in the treatment of female CPP.


Electronic databases, conference proceedings, text books and clinical guidelines were searched for quantitative, observational, and prospective clinical intervention studies of female chronic pelvic pain where physiotherapy was a sole or significant component of the intervention. Trial inclusion, data extraction according to predefined criteria and risk of bias assessment were performed by two independent authors. Methodological quality of the included clinical intervention studies was assessed using The Cochrane Collaboration’s tool for assessing risk of bias. Review Manager (RevMan) version 5.0 was used for data analysis. Effect estimates (relative risk, mean difference and mean change) with 95% confidence intervals were calculated for the above outcomes. For significant outcomes the numbers needed to treat were calculated.


The search strategy identified 3469 potential articles. Of these, 11 articles, representing 10 studies, met the inclusion criteria. There were 6 randomised clinical trials, 1 cohort study and 3 case series. Methodological quality was dependent on study type. Accordingly, level of evidence was judged higher in randomised clinical trials than in the other study types. Physiotherapy treatments varied between studies and were provided in combination with psychotherapeutic modalities and medical management. This did not allow for the ‘stand-alone’ value of physiotherapy to be determined. Heterogeneity across the studies, with respect to participants, interventions, outcome measures and times of follow-up, prevented meta-analysis. Narrative synthesis of the results, based on effect estimates and clinically relevant pain improvement, disclosed some evidence to support an effect of multidisciplinary intervention and Mensendieck somatocognitive therapy on female chronic pelvic pain.


Chronic pelvic pain in women is a major health care problem with no specific therapies and poor prognosis. There seems to be some evidence to support the use of a multidisciplinary intervention in the management of female chronic pelvic pain. Somatocognitive therapy is a new approach that appears to be promising and randomised clinical trials are underway in order to establish its evidence base.


Based on the findings of this review, recommendations for physiotherapy in chronic pelvic pain clinical guidelines, textbooks and narrative reviews should be interpreted with caution due to the lack of a sufficient evidence base. Only small and largely non-randomised studies have been undertaken of physiotherapeutic interventions and this greatly limits the available evidence on which to base clinical practice. High quality randomised clinical trials are therefore urgently needed.

DOI of refers to article: 10.1016/j.sjpain.2012.02.003.

Multidisciplinary Pain Centre, Department of Anaesthesiology, Herlev Hospital, University of Copenhagen, DK-2730 Herlev, Denmark. Tel.: +45 38681065; fax: +45 44535345.

  1. Conflict of interest: The authors declare no conflict of interest.

  2. Role of funding source: This study was supported by the Research Council at Herlev Hospital, University of Copenhagen; Dansk Smerteforum; Aase and Einar Danielsen’s Foundation and the Association of Danish Physiotherapists.

  3. Further reading: Review Manager (RevMan), Review Manager (RevMan) version 5.0. [accessed September 2011].O The Cochrane Collaboration. The Cochrane Library. [accessed September 2011].O The Cochrane specialised register group. The Cochrane Collaboration. [accessed September 2011].O The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Denmark. [accessed September 2011].O The Cochrane Pain, Palliative and supportive care group: [accessed September 2011].O The CONSORT statement: [accessed September 2011].


[1] Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol 1996;87:321–7.10.1016/0029-7844(95)00458-0Search in Google Scholar PubMed

[2] Latthe P, Latthe M, Say L, Gulmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health 2006;6:177, 10.1186/1471-2458/6/177 [p. 1–7].10.1186/1471-2458-6-177Search in Google Scholar PubMed PubMed Central

[3] 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. Br J Obstet Gynaecol 1999;106:1149–55.10.1111/j.1471-0528.1999.tb08140.xSearch in Google Scholar PubMed

[4] Merskey H, Bogduk N. Classification of chronic pain. 2nd ed. Seattle: IASP Press; 1994.Search in Google Scholar

[5] Wesselmann U. Chronic pelvic pain and urogenital pain syndromes. Pain, Clinical Updates 2008;16:1–4.Search in Google Scholar

[6] Fall M, Baranowski AP, Elneil S, Engeler D, Hughes J, Messelink EJ, Oberpenning F, de C, Williams AC. EAU guidelines on chronic pelvic pain. Eur Urol 2010;57:35–48.10.1016/j.eururo.2009.08.020Search in Google Scholar PubMed

[7] Stones W, Cheong YC, Howard FM, Singh S. Interventions for treating chronic pelvic pain in women. Cochrane Database Syst Rev 2005;2, 10.1002/14651858. in Google Scholar

[8] Cheong Y.C., Smotra G., Farquhar C. Non surgical interventions for the management of chronic pelvic pain (protocol). Cochrane Database Syst Rev 2010;11, 10.1002/14651858. Art. no.:CD008797.10.1002/14651858Search in Google Scholar

[9] Cheong Y, William SR. Chronic pelvic pain: aetiology and therapy. Best Pract Res Clin Obstet Gynaecol 2006;20:695–711.10.1016/j.bpobgyn.2006.04.004Search in Google Scholar PubMed

[10] Haugstad GK, Haugstad TS, Kirste UM, Leganger S, Klemmetsen I, Malt UF. Mensendieck somatocognitive therapy as treatment approach to chronic pelvic pain: results of a randomized controlled intervention study. Am J Obstet Gynecol 2006;194:1303–10.10.1016/j.ajog.2005.10.793Search in Google Scholar PubMed

[11] Montenegro ML, Vasconcelos EC, Candido Dos Reis FJ, Nogueira AA, Poli-Neto OB. Physical therapy in the management of women with chronic pelvic pain. Int J Clin Pract 2008;62:263–9.10.1111/j.1742-1241.2007.01530.xSearch in Google Scholar PubMed

[12] Flower A, Liu JP, Chen S, Lewith G, Little P. Chinese herbal medicine for endometriosis. Cochrane Database Syst Rev 2009;3, doi:10.1002/14651868. Art. no.: CD006568.10.1002/14651868Search in Google Scholar

[13] Jarrell JF, Vilos GA, Allaire C, Burgess S, Fortin C, Gerwin R, Lapensee L, Lea RH, Leyland NA, Marty P, Shenassa H, Taenzer P, Abu-Rafea B. Consensus guidelines for the management of chronic pelvic pain. J Obstet Gynaecol Can 2005;27:869–910.10.1016/S1701-2163(16)30993-8Search in Google Scholar PubMed

[14] Kennedy SH, More SJ. The initial management of chronic pelvic pain. R Coll Obstetr Gynecol 2005:41.Search in Google Scholar

[15] Howard FM, Perry CP, Carter JE, Minawi AM. Pelvic pain diagnosis and management. Philidelphia: Lippincott Wiiliams and Wilkens; 2000. p. 293, 363–80.Search in Google Scholar

[16] Wise D, Andersson R. A headache in the pelvic. A new understanding for chronic pelvic pain syndrome. Occidential: National Center for Pelvic Pain Research; 2008. p. 97–164.Search in Google Scholar

[17] Frawley H, Bower B. Pelvic pain. In: Bø K, Berghmans B, Mørkved S, Van Kampen M, editors. Evidence-based physical therapy for the pelvic floor. Bridging science and clinical practice. Philadelphia: Butterworth Heinemann, Elsevier; 2007. p. 249–65.Search in Google Scholar

[18] Sluka KA. Mechanisms and management of pain for the physical therapist. Seattle: IASP Press; 2009.Search in Google Scholar

[19] Baker PK. Musculoskeletal origins of chronic pelvic pain. Diagnosis and treatment. Obstet Gynecol Clin North Am 1993;20:719–42.10.1016/S0889-8545(21)00389-2Search in Google Scholar

[20] Kirste U, Haugstad GK, Leganger S, Blomhoff S, Malt UF. Kroniske bekkensmerter hos kvinner [Chronic pelvic pain in women]. Tidsskr Nor Laegeforen 2002;122:1223–7.Search in Google Scholar

[21] Srinivasan AK, Kaye JD, Moldwin R. Myofascial dysfunction associated with chronic pelvic floor pain: management strategies. Curr Pain Headache Rep 2007;11:359–64.10.1007/s11916-007-0218-0Search in Google Scholar PubMed

[22] Vincent K. Chronic pelvic pain in women. Postgrad Med J 2009;85:24–9.10.1136/pgmj.2008.073494Search in Google Scholar PubMed

[23] Wehbe SA, Fariello JY, Whitmore K. Minimally invasive therapies for chronic pelvic pain syndrome. Curr Urol Rep 2010;11:276–85.10.1007/s11934-010-0120-xSearch in Google Scholar PubMed

[24] Prendergast SA, Weiss JM. Screening for musculoskeletal causes of pelvic pain. Clin Obstet Gynecol 2003;46:773–82.10.1097/00003081-200312000-00006Search in Google Scholar PubMed

[25] Keus F, Wetterslev J, Gluud C, van Laarhoven CJ. Evidence at a glance: error matrix approach for overviewing available evidence. BMC Med Res Methodol 2010;10:90, 10.1186/1471-2288-(1-14).10.1186/1471-2288-10-90Search in Google Scholar PubMed PubMed Central

[26] Higgins J, Green S. Cochrane handbook for systematic reviews of interventions version 5.0.0. Chichester: Wiley Blackwell; 2008.10.1002/9780470712184Search in Google Scholar

[27] Copay AG, Glassman SD, Subach BR, Berven S, Schuler TC, Carreon LY. Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales. Spine J 2008;8:968–74.10.1016/j.spinee.2007.11.006Search in Google Scholar PubMed

[28] Farrar JT. What is clinically meaningful: outcome measures in pain clinical trials. Clin J Pain 2000;16:S106–12.10.1097/00002508-200006001-00018Search in Google Scholar PubMed

[29] Farrar JT, Young Jr JP, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001;94:149–58.10.1016/S0304-3959(01)00349-9Search in Google Scholar PubMed

[30] Dworkin RH, Turk DC, Wyrwich KW, Beaton D, Cleeland CS, Farrar JT, Haythorn-thwaite JA, Jensen MP, Kerns RD, Ader DN, Brandenburg N, Burke LB, Cella D, Chandler J, Cowan P, Dimitrova R, Dionne R, Hertz S, Jadad AR, Katz NP, Kehlet H, Kramer LD, Manning DC, McCormick C, McDermott MP, McQuay HJ, Patel S, Porter L, Quessy S, Rappaport BA, Rauschkolb C, Revicki DA, Rothman M, Schmader KE, Stacey BR, Stauffer JW, von Stein T, White RE, Witter J, Zavisic S. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain 2008;9:105–21.10.1016/j.jpain.2007.09.005Search in Google Scholar PubMed

[31] Moore RA, Eccleston C, Derry S, Wiffen P, Bell RF, Straube S, McQuay H. Evidence in chronic pain—establishing best practice in the reporting of systematic reviews. Pain 2010;150:386–9.10.1016/j.pain.2010.05.011Search in Google Scholar PubMed

[32] Moore RA, Smugar SS, Wang H, Peloso PM, Gammaitoni A. Numbers-needed-to-treat analyses—Do timing, dropouts, and outcome matter? Pooled analysis of two randomized, placebo-controlled chronic low back pain trials. Pain 2010;151:592–7.10.1016/j.pain.2010.07.013Search in Google Scholar PubMed

[33] Straube S, Derry S, Moore RA, Paine J, McQuay HJ. Pregabalin in fibromyalgia-responder analysis from individual patient data. BMC Musculoskelet Disord 2010;11:150, 10.1186/1471-2474-(1-8).10.1186/1471-2474-11-150Search in Google Scholar PubMed

[34] Haugstad GK, Haugstad TS, Kirste UM, Leganger S, Wojniusz S, Klemmetsen I, Malt UF. Continuing improvement of chronic pelvic pain in women after short-term Mensendieck somatocognitive therapy: results of a 1-year follow-up study. Am J Obstet Gynecol 2008;199:615–8.10.1016/j.ajog.2008.06.019Search in Google Scholar PubMed

[35] Daley AJ, Grimmett C, Roberts L, Wilson S, Fatek M, Roalfe A, Singh S. The effects of exercise upon symptoms and quality of life in patients diagnosed with irritable bowel syndrome: a randomised controlled trial. Int J Sports Med 2008;29:778–82.10.1055/s-2008-1038600Search in Google Scholar PubMed

[36] Everaert K, Devulder J, De Muynck M, Stockman S, Depaepe H, De Looze D, Van Buyten J, Ooesterlinck W. The pain cycle: implications for the diagnosis and treatment of pelvic pain syndromes. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:9–14.10.1007/s001920170087Search in Google Scholar PubMed

[37] Fitzgerald MP, Anderson RU, Potts J, Payne CK, Peters KM, Clemens JQ, Kotarinos R, Fraser L, Cosby A, Fortman C, Neville C, Badillo S, Odabachian L, Sanfield A, O’Dougherty B, Halle-Podell R, Cen L, Chuai S, Landis JR, Mickelberg K, Barrell T, Kusek JW, Nyberg LM. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol 2009;182:570–80.10.1016/j.juro.2009.04.022Search in Google Scholar PubMed

[38] Lukban J, Whitmore K, Bologna R, Kellogg-Spadt S, Lesher A, Fletcher E. The effect of manual physical therapy in patients diagnosed with interstitial cystitis, high-tone pelvic floor dysfunction, and sacroiliac dysfunction. Urology 2001;57:121–2.10.1016/S0090-4295(01)01074-3Search in Google Scholar PubMed

[39] Neville C, Mallinson T, Badillo SA, Fitzgerald CM, Hynes C. Comparison of PT and MD findings of physical examination of patients with and without chronic pelvic pain. J Women’s Health Phys Ther 2009;33:20.10.1097/01274882-200933010-00020Search in Google Scholar

[40] Shaw G, Srivastava ED, Sadlier M, Swann P, James JY, Rhodes J. Stress management for irritable bowel syndrome: a controlled trial. Digestion 1991;50: 36–42.10.1159/000200738Search in Google Scholar PubMed

[41] Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency–frequency syndrome. J Urol 2001;166: 2226–31.10.1016/S0022-5347(05)65539-5Search in Google Scholar PubMed

[42] de Bernardes NO, Marques A, Ganunny C, Bahamondes L. Use of intravaginal electrical stimulation for the treatment of chronic pelvic pain: a randomized, double-blind, crossover clinical trial. J Reprod Med 2010;55:19–24.Search in Google Scholar PubMed

[43] Hawk C, Long CR, Reiter R, Davis CS, Cambron JA, Evans R. Issues in planning a placebo-controlled trial of manual methods: results of a pilot study. J Altern Complement Med 2002;8:21–32.10.1089/107555302753507159Search in Google Scholar PubMed

[44] Heyman J, Ohrvik J, Leppert J. Distension of painful structures in the treatment for chronic pelvic pain in women. Acta Obstet Gynecol Scand 2006;85:599–603.10.1080/00016340500495017Search in Google Scholar PubMed

[45] Peters AA, van DE, Jellis B, van ZE, Hermans J, Trimbos JB. A randomized clinical trial to compare two different approaches in women with chronic pelvic pain. Obstet Gynecol 1991;77:740–4.10.1016/0020-7292(92)90764-ASearch in Google Scholar PubMed

[46] Lamvu 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. Am J Obstet Gynecol 2006;195:591–8.10.1016/j.ajog.2006.03.081Search in Google Scholar PubMed

[47] de Bernardes NO, Bahamodes L. Intravaginal electrical stimulation for the treatment of chronic pelvic pain. J Reprod Med 2005;50:267–72.Search in Google Scholar PubMed

[48] Oyama IA, Rejba A, Lukban JC, Fletcher E, Kellogg-Spadt S, Holzberg AS, Whit-more KE. Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone pelvic floor dysfunction. Urology 2004;64:862–5.10.1016/j.urology.2004.06.065Search in Google Scholar PubMed

[49] Albert H. Psychosomatic group treatment helps women with chronic pelvic pain. J Psychosom Obstet Gynaecol 1999;20:216–25.10.3109/01674829909075598Search in Google Scholar PubMed

[50] Barthel HR, Peniston JH, Clark MB, Gold MS, Altman RD. Correlation of pain relief with physical function in hand osteoarthritis: randomized controlled trial post hoc analysis. Arthritis Res Ther 2010;12:R7, 10.1186/ar2906(1-8).10.1186/ar2906Search in Google Scholar PubMed PubMed Central

[51] Hoffman DL, Sadosky A, Dukes EM, Alvir J. How do changes in pain severity levels correspond to changes in health status and function in patients with painful diabetic peripheral neuropathy. Pain 2010;149:194–201.10.1016/j.pain.2009.09.017Search in Google Scholar PubMed

[52] Moore RA, Straube S, Paine J, Phillips CJ, Derry S, Fibromyalgia McQuay HJ. Moderate and substantial pain intensity reduction predicts improvement in other outcomes and substantial quality of life gain. Pain 2010;149:360–4.10.1016/j.pain.2010.02.039Search in Google Scholar PubMed

[53] Zelman DC, Dukes E, Brandenburg N, Bostrom A, Gore M. Identification of cut-points for mild, moderate and severe pain due to diabetic peripheral neuropathy. Pain 2005;115:29–36.10.1016/j.pain.2005.01.028Search in Google Scholar PubMed

[54] Rothwell PM. External validity of randomised controlled trials: to whom do the results of this trial apply. The Lancet 2005;365:82–93.10.1016/S0140-6736(04)17670-8Search in Google Scholar

[55] Altman DG, Schulz KF, Moher D, Egger M, Davidoff F, Elbourne D, Gotzsche PC, Lang T. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med 2001;134:663–94.10.7326/0003-4819-134-8-200104170-00012Search in Google Scholar PubMed

[56] Turk DC, Dworkin RH, Revicki D, Harding G, Burke LB, Cella D, Cleeland CS, Cowan P, Farrar JT, Hertz S, Max MB, Rappaport BA. Identifying important out-come domains for chronic pain clinical trials: an IMMPACT survey of people with pain. Pain 2008;137:276–85.10.1016/j.pain.2007.09.002Search in Google Scholar PubMed

Received: 2011-08-18
Revised: 2011-12-20
Accepted: 2011-12-21
Published Online: 2012-04-01
Published in Print: 2012-04-01

© 2012 Scandinavian Association for the Study of Pain

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