Physical therapy for chronic pelvic pain in women: what a 38-trial meta-analysis found

A 2025 systematic review and meta-analysis in the American Journal of Obstetrics and Gynecology evaluated whether nonpharmacological conservative therapies are effective for women with chronic pelvic pain (CPP) ^[2]. Its central finding was that multimodal physical therapy resulted in lower pain intensity than inert or nonconservative treatments, with high certainty of evidence in the short term ^[2].

What the review included

The authors searched eight databases in January 2023 and updated the search in December 2023: AMED, CINAHL, PsycINFO, SportDiscus, Medline, PubMed, Embase and the Cochrane Central Register of Controlled Trials ^[2]. Only randomized controlled trials were eligible. Each had to compare a nonpharmacological conservative therapy with either an inert comparator, such as placebo or usual care, or a nonconservative treatment, such as surgery or medication ^[2]. Of 5,776 retrieved studies, 38 trials were included, enrolling 2,168 women with a mean age of 35.1 ± 8.6 years ^[2].

The review grouped conservative therapies into four categories ^[2]:

• Multimodal physical therapy ^[2].
• Predominantly psychological approaches ^[2].
• Acupuncture ^[2].
• Other tissue-based monotherapies, such as electrophysical agents and manual stretching ^[2].

The abstract does not describe which components made up multimodal physical therapy in the included trials ^[2].

How outcomes were measured and graded

The outcomes analyzed were pain; sexual measures; psychological and physical function; health-related quality of life; symptom severity or bother; pelvic floor muscle function and morphometry; perceived improvement; and adverse events ^[2]. Where trials tested similar interventions and measured similar outcomes, results were pooled in random-effects meta-analyses of postintervention scores, and findings that could not be pooled were summarized narratively ^[2].

Trial quality was assessed with the Physiotherapy Evidence Database (PEDro) scale, and certainty of evidence with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria ^[2]. Effects were expressed as standardized mean differences (SMDs) ^[2]. In the reported results, negative pain SMDs accompanied lower pain with the conservative therapy, and the positive acupuncture SMD was described as favoring the control treatment ^[2].

Multimodal physical therapy

In the short term, multimodal physical therapy resulted in lower pain intensity than inert or nonconservative treatments, with an SMD of -1.69 (95% confidence interval -2.54 to -0.85) and high certainty ^[2]. The effect was also seen in the intermediate term, with an SMD of -1.82 (95% confidence interval -3.13 to -0.52), although certainty was rated moderate rather than high ^[2]. The intermediate-term interval is wider than the short-term interval, but it lies entirely on the side favoring physical therapy ^[2]. The abstract does not define the time windows for short-term and intermediate-term follow-up ^[2].

The authors concluded that multimodal physical therapy is effective in women with CPP, with a high certainty of evidence ^[2]. Among the four categories examined, it is the only one for which the abstract reports both a clear pain benefit and a high-certainty grade ^[2].

Predominantly psychological approaches

Predominantly psychological approaches resulted in no difference in pain intensity, with an SMD of -0.18 (95% confidence interval -0.56 to 0.20) and moderate certainty ^[2]. They produced a slight difference in sexual function, with an SMD of -0.28 (95% confidence interval -0.52 to -0.04), also at moderate certainty ^[2]. The abstract does not report pooled results for these approaches on psychological function or quality of life, so the pain finding is not a verdict on every outcome they target ^[2].

Acupuncture and tissue-based monotherapies

For acupuncture, the pooled SMD for pain intensity was 1.08 (95% confidence interval -1.38 to 3.54), a result that was not statistically significant and that favored the control treatment in direction ^[2]. The authors stated that the level of evidence precluded any statement of certainty for this comparison, so the result neither supports nor rules out an effect of acupuncture on pain in this population ^[2].

Only a limited number of trials investigated individual tissue-based monotherapies, such as electrophysical agents or manual stretching, and the authors described this body of evidence as restricted ^[2].

Where this fits in care

Of the conservative therapies this review examined, multimodal physical therapy has the strongest evidence for lowering pain intensity in women with CPP ^[2]. AthleticsMD, which describes itself as Maryland's first independent Comprehensive Outpatient Rehabilitation Facility, offers physical therapy and chronic pain management in Columbia and Laurel/Fort Meade, Maryland ^{[AthleticsMD]}. Readers considering these services should talk with a clinician about whether they are appropriate ^{[AthleticsMD]}.

Limitations

• The comparator group combined inert treatments, such as placebo or usual care, with nonconservative treatments, such as surgery or medication, so the pooled physical therapy effect does not show how it compares with any single alternative ^[2].
• Pooling relied on postintervention scores, and the abstract does not report statistical heterogeneity between trials ^[2].
• Adverse events were among the outcomes analyzed, but the abstract does not report their results, so the safety profile cannot be judged from this summary ^[2].
• The included women had a mean age of 35.1 years, so applicability to older women is not established by these data ^[2].
• The acupuncture estimate and the tissue-based monotherapy evidence were too uncertain or too sparse to support firm conclusions ^[2].
• This summary draws on the abstract only; intervention content, follow-up duration and the causes of CPP in the included trials are not described there ^[2].