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Chronic pelvic pain in women

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Updated 2024 EAU guidelines for the diagnosis and management of chronic pelvic pain in women.

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 Society of Interventional Pain Physicians (ASIPP/NASS/AAPM/ASRA/IPSIS 2024), the European Association of Urology (EAU 2024), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2024,2023), the European Society for Vascular Surgery (ESVS 2022), the ...
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Diagnostic investigations

Initial evaluation: as per EAU 2024 guidelines, elicit a full history and evaluate to rule out treatable causes in all patients with chronic pelvic pain.
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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.
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Medical management

General principles: as per EAU 2024 guidelines, manage patients with chronic primary pelvic pain syndrome comprehensively within a multispecialty and multidisciplinary environment, taking all presenting symptoms into consideration.
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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.
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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.
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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.
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Specific circumstances

Patients with pelvic floor dysfunction
As per EAU 2024 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.
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