Chronic pelvic pain (CPP) causes substantial personal burden for the woman and socioeconomic burden for society. Current clinical recommendations for the management of this condition rely solely on expert opinion or do not account for recent high-quality published evidence [1]. Moreover, they predominantly focus on medical and surgical treatments, offering limited guidance on first-line, non-pharmacological conservative therapies [1], which are currently widely endorsed in other chronic pain conditions [2]. Adequate and up-to-date guidance for non-pharmacological, conservative therapies for women with CPP is constrained by a lack of robust review of the available evidence. Consequently, the selection of optimal treatment for CPP in women remains challenging for health professionals and patients alike, leading to a limited understanding of the effectiveness of conservative approaches. Therefore, we conducted the first review with a meta-analysis aiming to assess the effectiveness of different non-pharmacological, conservative therapies for women experiencing CPP. This will fill the critical gap in our current understanding of this problem, by offering a thorough overview of up-to-date available data to support evidence-based decision-making.

A systematic search of electronic databases (Amed, CINAHL, PsycINFO, SportDiscus, Medline, PubMed, Embase, and Cochrane Central Register of Controlled Trials) was performed in January 2023, and updated in December 2023. The protocol was prospectively registered. Randomized controlled trials (RCTs) comparing non-pharmacological, conservative therapies to inert (e.g., placebo, waitlist, usual care) or non-conservative treatment (e.g., surgical, pharmacological) in women with CPP without a defined pathology, disease, or event (e.g., cancer, infection) were included. Conservative therapies of interest to this review were: multimodal physiotherapy (i.e., trials investigating comprehensive approaches within the scope of physiotherapy, involving several different modalities for instance education, pelvic floor muscle exercises, massage, self-management strategies), predominantly psychological approaches (e.g., cognitive behavioural therapy, mindfulness), acupuncture (e.g., traditional acupuncture, electro-acupuncture), and other tissue-based monotherapies (i.e., predominantly biomedically focused, tissue-based unimodal treatments, such as electrophysical agents, manual stretching). All study data were aggregated, and an analysis of the included studies was performed for pain intensity outcomes. Meta-analyses (using a random effects model) were conducted considering post-treatment value scores. To enhance the interpretability of the results, the obtained standardized mean difference values were transformed to a mean difference (MD) on a typical 0-10 pain scale. The value of 1.1 points on a typical 0-10 pain scale was interpreted as a minimal, clinically meaningful threshold for between-group differences [3]. The quality of the evidence was assessed with the PEDro scale and the certainty of evidence with Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria.

Of 5776 retrieved studies, 38 RCTs including 2168 women (mean age 35.1±8.6) were included. Twenty-six RCTs (68%) were assessed to have moderate to high-quality evidence (PEDro score at least 6/10) and 12 RCTs (33%) to have low-quality (PEDro score 5/10 or less). Meta-analyses revealed that multimodal physiotherapy resulted in significantly lower pain intensity compared to inert or non-conservative treatment at both the post-treatment (MD -2.87 [95% CI -4.32, -1.45]; high certainty of evidence as assessed with the GRADE) and 12-36 weeks follow-up (MD -3.09 [95% CI -5.32, -0.88]; moderate certainty of evidence). Predominantly psychological approaches resulted in non-significant differences in pain intensity between the groups (MD -0.31 [95% CI -0.95, 0.34]; moderate certainty of evidence). The meta-analysis of the effects of acupuncture on pain intensity indicated no statistically significant results (MD 1.83 [95% CI -2.35, 6.02] favoring control treatment). The level of certainty for acupuncture was so low that it precluded any conclusion. A limited number of trials investigated individual tissue-based monotherapies, and a meta-analysis could not be performed.

This review and meta-analysis offer novel and much-needed findings, presenting robust data on the effectiveness of a wide array of non-pharmacological, conservative therapies for women experiencing CPP without a defined pathology or disease. The results revealed that multimodal physiotherapy is effective in the management of CPP, leading to significantly and clinically meaningful lower pain intensity at post-treatment (high certainty) and at 12-36 weeks follow-up (moderate certainty) when compared to inert or non-conservative treatment. Predominantly psychological approaches likely result in no difference in pain intensity (moderate certainty) and for acupuncture, the current level of evidence does not allow for any conclusion. There may be some beneficial effects related to tissue-based monotherapies (e.g., electrophysical agents), however, the available body of evidence is very limited.

This systematic review and meta-analysis revealed that multimodal physiotherapy is effective in women with CPP with a high certainty of evidence. Therefore, this approach should be offered as a first-line, non-pharmacological, conservative treatment option and endorsed by clinical practice guidelines.

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