Overview

Chronic pelvic pain in women is a commonly occurring and poorly understood condition. Little consensus on the definition of the condition exists-the duration of pelvic pain considered chronic in published studies varies from 3 months to more than 6 months, and the location and pathology of the pain are largely unspecified. The American College of Obstetricians and Gynecologists defines chronic pelvic pain as noncyclical pain of at least 6 months' duration that appears in locations such as the pelvis, anterior abdominal wall, lower back, or buttocks, and that is serious enough to cause disability or lead to medical care. Noncyclic chronic pelvic pain (CPP) is the focus of this review. Noncyclic CPP excludes chronic pelvic pain that is limited to dysmenorrhea (pain with menstruation), dyspareunia (pain with intercourse), dyschezia (pain with bowel movement), or dysuria (pain with urination). Noncyclic CPP is sometimes described simply as chronic pelvic pain in the literature because many subdivide chronic pelvic pain into dysmenorrhea, dyspareunia, and nonmenstrual CPP. For this review, we defined noncyclic CPP as pain that has persisted for more than 3 months, is localized to the anatomic pelvis (lower abdomen below the umbilicus), and is of sufficient severity that it causes the patient to become functionally disabled or to seek medical care. The chronic pelvic pain must always have a noncyclic component; however, there could also be cyclic pain in some individuals. CPP as described throughout this review refers to noncyclic or mixed cyclic/noncyclic pelvic pain unless otherwise noted. The causes of CPP are not well understood and may be associated with gynecologic (e.g., endometriosis) and nongynecologic (e.g., irritable bowel syndrome [IBS]) conditions. Diagnosis of an underlying cause is complicated because the pain is rarely associated with a single underlying disorder or contributing factor; Howard outlined more than 60 diseases and conditions associated with CPP. Frequently diagnosed etiologies include endometriosis, adhesions, IBS, and interstitial cystitis (IC)/painful bladder syndrome (PBS); however, a definitive diagnosis is often not made. Evidence reviews of therapeutics seek to identify and systematically summarize objective information about the evidence related to factors including the: Effectiveness of specific, well-defined treatments, Relative benefit of one treatment over another, Common side effects and serious risks of a treatment. We focused this review on therapies for women over the age of 18 with noncyclic or mixed cyclic/noncyclic chronic pelvic pain. The Key Questions (KQs) were: KQ1. Among women who have been diagnosed with noncyclic/mixed cyclic and noncyclic CPP, what is the prevalence of the following comorbidities: dysmenorrhea, major depressive disorder, anxiety disorder, temporomandibular joint pain disorder, fibromyalgia, IBS, interstitial cystitis (IC)/painful bladder syndrome (PBS), complex regional pain syndrome, vulvodynia, functional abdominal pain syndrome, low back pain, headache, and sexual dysfunction? KQ2. Among women with noncyclic/mixed cyclic and noncyclic CPP, what is the effect of surgical interventions on pain status, functional status, satisfaction with care, and quality of life? KQ3. What is the evidence that surgical outcomes differ if the etiology of noncyclic/mixed cyclic and noncyclic CPP is identified after surgery? KQ4. Among women with noncyclic/mixed cyclic and noncyclic CPP, what is the effect of nonsurgical interventions on pain status, functional status, satisfaction with care, quality of life, and harms? KQ5. What is the evidence for choosing one intervention over another to treat persistent or recurrent noncyclic/mixed cyclic and noncyclic CPP after an initial intervention fails to achieve target outcome(s)?

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