• American College of Obstetricians and Gynecologists (ACOG). Chronic pelvic pain. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2004 Mar. 17 p. (ACOG practice bulletin; no. 51). [150 references]

This is the current release of the guideline.

Chronic pelvic pain*, including pain thought to be related to:

• Physical and sexual abuse
• Pelvic inflammatory disease
• Endometriosis
• Interstitial cystitis
• Irritable bowel syndrome
• Obstetric history
• Past surgery
• Musculoskeletal disorders

*Chronic pelvic pain is defined as noncyclic pain of 6 or more months' duration that localizes to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks and is of sufficient severity to cause functional disability or lead to medical care.

Diagnosis
Management
Treatment

Internal Medicine
Obstetrics and Gynecology
Pediatrics

Physicians

• To aid practitioners in making decisions about appropriate obstetric and gynecologic care
• To provide information on the differential diagnosis of chronic pelvic pain and review the available evidence on treatment options for women with chronic pelvic pain

Women and adolescent girls who experience chronic pelvic pain

Diagnosis

1. Patient history and physical examination
2. Differential diagnosis
3. Imaging (transvaginal ultrasonography, magnetic resonance imaging, computed tomography)
4. Laparoscopy
5. Intravesical potassium sensitivity testing
6. Intrastitial cystitis symptom index
7. Cystoscopy

Management

1. Mental health referral
2. Multidisciplinary treatment

Treatment

1. Antidepressants - tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRI)
2. Local anesthetic injection
3. Analgesics – cyclooxygenase isoenzyme 2 (COX-2) agents, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids
4. Combination oral contraceptives
5. Gonadotropin-releasing hormone (GnRH) agonists
6. Progestins
7. Exercise
8. Physical therapy
9. Dietary modifications
10. Surgical approaches, including:
    • Excision or destruction of endometriotic tissue
    • Hysterectomy
    • Adhesiolysis
    • Sacral nerve stimulation
    • Presacral neurectomy
    • Uterine nerve ablation
11. Psychotherapy (cognitive therapy, operant conditioning, behavioral modification)
12. Complementary or alternative medicine, including:
    • Herbal and nutritional therapy
    • Magnetic field therapy
    • Acupuncture, acupressure, and transcutaneous nerve stimulation

• Rate of reported reduction in pelvic pain
• Duration of pain reduction
• Relapse rate

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and November 2003. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Systematic Review

Not stated

Expert Consensus

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

The following recommendations are based on good and consistent scientific evidence (Level A):

• Combined oral contraceptives should be considered as a treatment option to decrease pain from primary dysmenorrhea.
• Gonadotropin-releasing hormone (GnRH) agonists are effective in relieving pelvic pain associated with endometriosis and irritable bowel syndrome, as well as in women with symptoms consistent with endometriosis who do not have endometriosis. Thus, empiric treatment with GnRH agonists without laparoscopy should be considered as an acceptable approach to treatment.
• Nonsteroidal antiinflammatory drugs, including cyclooxygenase isoenzyme 2 (COX-2) inhibitors, should be considered for moderate pain and are particularly effective for dysmenorrhea.
• Progestins in daily, high doses should be considered as an effective treatment of chronic pelvic pain associated with endometriosis and pelvic congestion syndrome.
• Laparoscopic surgical destruction of endometriosis lesions should be considered to decrease pelvic pain associated with stages I to III endometriosis.
• Presacral neurectomy may be considered for treatment of centrally located dysmenorrhea but has limited efficacy for chronic pelvic pain or pain that is not central in its location. Uterine nerve ablation or transection of the uterosacral ligament also can be considered for centrally located dysmenorrhea, but it appears to be less effective than presacral neurectomy. Combining uterine nerve ablation or presacral neurectomy with surgical treatment of endometriosis does not further improve overall pain relief.
• Adding psychotherapy to medical treatment of chronic pelvic pain appears to improve response over that of medical treatment alone and should be considered.

The following recommendations are based on limited or inconsistent scientific evidence (Level B):

• GnRH agonists should be considered as a treatment option for chronic pelvic pain because they have been shown to relieve endometriosis-associated pelvic pain.
• Surgical adhesiolysis should be considered to decrease pain in women with dense adhesions involving the bowel, but it is unclear if lysis of other types of adhesions is effective.
• Hysterectomy is an effective treatment for chronic pelvic pain associated with reproductive tract symptoms that results in pain relief in 75 to 95% of women and should be considered.
• Sacral nerve stimulation may decrease pain in up to 60% of women with chronic pelvic pain and should be considered as a treatment option.
• Various physical therapy modalities appear to be helpful in the treatment of chronic pelvic pain and should be considered as a treatment option.
• Nutritional supplementation with vitamin B₁ or magnesium may be recommended to decrease pain of dysmenorrhea.
• Injection of trigger points of the abdominal wall, vagina, and sacrum with local anesthetic may provide temporary or prolonged relief of chronic pelvic pain and should be considered.
• Treatment of abdominal trigger points by the application of magnets to the trigger points may be recommended to improve disability and reduce pain.
• Acupuncture, acupressure, and transcutaneous nerve stimulation therapies should be considered to decrease pain of primary dysmenorrhea.

The following recommendations are based primarily on consensus and expert opinion (Level C):

• A detailed history and physical examination are the basis for differential diagnosis of chronic pelvic pain and should be used to determine appropriate diagnostic studies.
• Antidepressants may be helpful in the treatment of chronic pelvic pain.
• Opioid analgesics can be used to provide effective relief of severe pain with a low risk of addiction but do not necessarily improve functional or psychologic status and are not well studied in patients with chronic pelvic pain.

Definitions:

Grades of Evidence

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendations

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Appropriate diagnosis and management of chronic pelvic pain in women and adolescent girls

Drug treatment side effects

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

An implementation strategy was not provided.

Living with Illness

Effectiveness
Patient-centeredness

• American College of Obstetricians and Gynecologists (ACOG). Chronic pelvic pain. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2004 Mar. 17 p. (ACOG practice bulletin; no. 51). [150 references]

Not applicable: The guideline was not adapted from another source.

2004 Mar

American College of Obstetricians and Gynecologists - Medical Specialty Society

American College of Obstetricians and Gynecologists (ACOG)

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Gynecology

Not stated

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on October 11, 2007. The information was verified by the guideline developer on December 3, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.