Persistent pelvic pain (PPP) is an umbrella term encompassing a variety of conditions that occur in men and women involving the lower urinary tract, the bowel and sexual function. While some conditions have an identifiable cause, such as endometriosis, irritable bowel syndrome or cancer, others, including vulvodynia, genito-pelvic pain/penetration disorder and non-specific prostatitis, do not. Its prevalence ranges from six to 27 per cent in women and from two to 10 per cent in men and it has substantial individual and socio-economic impacts, resulting in lower quality of life, increased anxiety and depression, reduced work capacity and high medical costs.

Treatment of PPP is challenging because of its heterogeneous and multidimensional nature. There is also limited evidence for many interventions. Specific treatments may be directed towards identified comorbid conditions or underlying pathologies. Historically, treatments have focused on pharmacological and invasive interventions including laparoscopy, hysterectomy, prostatectomy and cystoscopy but these do not reliably resolve pain and may contribute to it. Contemporary management adopts a biopsychosocial approach and individualised treatment according to the contributing factors. Treatment may include medical, psychological and physiotherapy interventions as appropriate as well as pain science education to support engagement and self-management.

In her Journal of Physiotherapy Invited Topical Review, Associate Professor Irmina Nahon evaluates physiotherapy interventions and approaches used to treat female and male PPP. In women, these include biopsychosocial management, multimodal physiotherapy, psychological approaches, manual therapy, graded exposure, electrotherapy, extracorporeal shock wave therapy, acupuncture and other individual interventions. The strongest evidence supports biopsychosocial management with multimodal physiotherapy combining interventions such as pelvic floor rehabilitation, manual therapy, exercise, education, biofeedback and behavioural and self-management strategies.

In men, the evidence is weaker overall but again, a multimodal physiotherapy approach incorporating manual therapy, relaxation training, biofeedback and self-management strategies was highlighted, with a focus on myofascial trigger point release and relaxation training. Other interventions with short- or long-term benefits include extracorporeal shock wave therapy and acupuncture.

The author notes that the evidence to date largely focuses on cisgender populations and that future research should prioritise greater inclusivity of transgender, non-binary and gender-diverse individuals. The heterogeneity and generally low quality of evidence is of concern and researchers should focus on improving methodological rigour through standardised diagnostic criteria, consistent intervention reporting and adequately powered, sham-controlled trials. Irmina suggests that a better understanding of both treatment-responsive phenotypes and underlying mechanisms may facilitate more personalised, mechanism-based models of care for people living with PPP.

For more information and to read the entire Invited Topical Review, click here.  

Dr Irmina Nahon APAM is an associate professor of physiotherapy at the University of Canberra and a pelvic health physiotherapist in private practice. Irmina is passionate about evidence-based, person-centred care that improves lives.