{"paper_id":"7e4f3968-6d98-450c-8197-9b2ffc5b0889","body_text":"Vol.:(0123456789)\nInternational Urogynecology Journal \nhttps://doi.org/10.1007/s00192-026-06899-8\nREVIEW ARTICLE\nReframing Chronic Pelvic Pain in Women: Central Sensitization, \nPsychosocial Burden, and Mechanism‑Based Multidisciplinary Care\nYael Sela1  · Keren Grinberg1  · Rachel Nissanholtz‑Gannot2,3 \nReceived: 20 July 2026 / Accepted: 26 August 2026 \n© The Author(s) 2026\nAbstract\nIntroduction and Hypothesis Chronic pelvic pain (CPP) often persists despite repeated organ-directed evaluation and treat-\nment. We proposed that integrating disease-specific diagnosis with pain-mechanism phenotyping would provide a more \nclinically useful framework for explaining symptom persistence and selecting care.\nMethods A structured narrative review was conducted using PubMed/MEDLINE, PubMed Central, the Cochrane Library, \nprofessional guidelines, journal websites, and reference lists. English-language literature published from January 2020 to \nMay 2026 was prioritized, with earlier seminal sources included for foundational concepts.\nResults Evidence indicates that CPP commonly reflects interacting nociceptive, neuropathic, nociplastic, musculoskeletal, \npsychological, sexual, and social contributors. Central sensitization and nociplastic pain may help explain disproportionate, \nwidespread, or persistent pain, while pelvic floor dysfunction, distress, catastrophizing, fear-avoidance, sleep disturbance, and \nsexual pain can intensify disability. Current guidelines and reviews support comprehensive assessment, pelvic floor physical \ntherapy when indicated, pain neuroscience education, psychological pain interventions, sexual counseling, disease-specific \ntreatment, and coordinated multidisciplinary follow-up. Treatment matching should be based on dominant mechanisms and \npatient-prioritized outcomes rather than diagnosis or pain intensity alone.\nConclusions A mechanism-based biopsychosocial approach validates CPP as real while broadening therapeutic targets. \nCombining rigorous disease evaluation with pain phenotyping may reduce fragmented care and improve function, intimacy, \nquality of life, and patient–clinician communication.\nKeywords Biopsychosocial model · Central sensitization · Chronic pelvic pain · Multidisciplinary care · Nociplastic pain · \nPelvic floor dysfunction\nIntroduction\nChronic pelvic pain (CPP) in women is not a single diag-\nnosis, but a complex and often disabling health condi-\ntion that crosses the boundaries of gynecology, urology, \ngastroenterology, musculoskeletal medicine, pain medicine, \nand mental health. It is commonly defined as persistent or \nrecurrent pain perceived in the pelvic region, usually last-\ning for 6 months or longer, and is associated with functional \nimpairment, reduced quality of life, and substantial health \ncare use. CPP has been described as a major clinical chal-\nlenge in women’s health shaped by the interaction of bio -\nlogical, psychological, and social factors [1 ]. The Ameri-\ncan College of Obstetricians and Gynecologists similarly \nemphasizes that CPP may persist even when it is not fully \nexplained by identifiable gynecologic, urologic, or gastro-\nintestinal pathology [2].\nWomen with CPP are often evaluated through organ-\nbased pathways and may receive separate diagnoses such \nas endometriosis, bladder pain syndrome/interstitial cystitis, \nvulvodynia, provoked vestibulodynia, dyspareunia, irritable \nbowel syndrome, or pelvic floor myalgia. These diagnoses \nHandling Editor: Jaromir Masata\nEditor in Chief: Maria A. Bortolini\n * Yael Sela \n yaels@ruppin.ac.il\n1 Department of Nursing Sciences, Faculty of Social \nand Community Sciences, Ruppin Academic Center, \n4025000 Emek Hefer, Israel\n2 Department of Health Systems Management, Faculty \nof Health Sciences, Ariel University, 40700 Ariel, Israel\n3 Myers-JDC-Brookdale Institute, Jerusalem, Israel\n\n International Urogynecology Journal\nare clinically meaningful and may guide specific treatment. \nHowever, they do not always explain the severity, persis-\ntence, distribution, or recurrence of pain. Earlier interdisci-\nplinary work conceptualized chronic pelvic pain syndrome \nas a multifactorial condition in which urogynecological, \ngastrointestinal, musculoskeletal, neurological, endocrine, \nimmune, and psychological processes may interact [3]. This \nperspective remains relevant because many women continue \nto move between specialists and repeated investigations \nwithout receiving an integrated explanation for their pain \nexperience.\nA central limitation of a purely organ-based model is that \nvisible pathology does not consistently correspond to pain \nseverity or treatment response. Contemporary pain science \nincreasingly recognizes central sensitization and nociplastic \npain as mechanisms that may contribute to persistent pel-\nvic pain. Nociplastic pain refers to pain arising from altered \nnociception despite no clear evidence of tissue damage or \nsomatosensory disease sufficient to explain the pain [4 ]. In \nwomen with CPP, higher nociplastic pain features have been \nassociated with greater pain severity, pain frequency, pain \ninterference, pelvic myofascial pain, and high-impact pain \n[5]. In endometriosis-associated CPP, sensitization may con-\ntribute to pain within and beyond the pelvis, supporting the \nneed to look beyond lesion-directed explanations alone [ 6, \n7]. Similarly, in bladder pain syndrome/interstitial cystitis, \nresponse to treatment may depend on inflammatory, sensory, \nbladder-specific, and pain-processing phenotypes rather than \non diagnosis alone [8].\nThis reframing is especially important because CPP \naffects much more than pain intensity. It may disrupt sexual \nfunction, intimacy, fertility-related decision-making, mood, \nsleep, work participation, physical activity, and trust in \nhealth care. Psychosocial factors are often misunderstood \nin CPP. Their relevance does not mean that pain is psy -\nchological or less real. Rather, pain catastrophizing, fear-\navoidance, anxiety, depression, illness perceptions, trauma \nexposure, and distress may interact with neurophysiological \npain mechanisms and contribute to symptom amplification, \ndisability, repeated health care use, and reduced response \nto treatment.\nRecent guidelines increasingly support this broader \napproach. The 2024 Society of Obstetricians and Gynae-\ncologists of Canada guideline provides evidence-based \nrecommendations for chronic pelvic pain management in \nadolescent and adult female individuals and emphasizes \nmultifactorial assessment and care [9 ]. The 2026 European \nAssociation of Urology guideline similarly frames chronic \npelvic pain as a multidimensional condition requiring atten-\ntion to pain mechanisms, emotional well-being, behavior, \nsexual function, and daily functioning [10]. Recent system-\natic reviews also support the clinical relevance of biopsy -\nchosocial and conservative nonpharmacological approaches, \nparticularly pelvic floor and multimodal physical therapy, \nwhile emphasizing the need for better-defined care models \nand patient-centered outcomes [11, 12].\nThe aim of this narrative review is to reframe CPP in \nwomen as a biopsychosocial and mechanism-based pain \ncondition, with particular attention to mechanisms of pain \npersistence, psychosocial burden, sexual health, and multi-\ndisciplinary care.\nMethods\nDesign and Scope\nThis article was designed as a structured narrative review of \ncurrent evidence regarding central sensitization, nociplastic \npain, psychosocial burden, sexual health, and mechanism-\nbased multidisciplinary care in women with CPP. The pur -\npose was to provide an integrative clinical synthesis rather \nthan a systematic review, meta-analysis, or comprehensive \nevidence map. Accordingly, the review used a structured \nsearch strategy and predefined eligibility domains, but did \nnot include duplicate independent screening, formal risk-of-\nbias appraisal, or quantitative synthesis.\nInformation Sources and Search Strategy\nA structured literature search was conducted using PubMed/\nMEDLINE, PubMed Central, the Cochrane Library, and \npublicly available professional guideline sources. Additional \nsearches were performed through relevant journal websites \nand the reference lists of key reviews, guidelines, and empir-\nical studies. The main search period covered publications \nfrom January 2020 to May 2026. Earlier seminal articles \nwere included when they provided foundational concepts \nrelated to CPP, central sensitization, nociplastic pain, pelvic \nfloor dysfunction, pain catastrophizing, or biopsychosocial \nmodels of chronic pain.\nSearch terms were combined using Boolean operators and \nincluded chronic pelvic pain, chronic pelvic pain syndrome, \nwomen, female, central sensitization, nociplastic pain, \npain modulation, overlapping pain conditions, pelvic floor \ndysfunction, pain catastrophizing, fear avoidance, anxiety, \ndepression, psychological distress, sexual function, qual-\nity of life, biopsychosocial model, multidisciplinary care, \npelvic floor physical therapy, cognitive behavioral therapy, \nand acceptance and commitment therapy. Additional con -\ndition-specific searches included endometriosis-associated \nCPP, bladder pain syndrome, interstitial cystitis, vulvodynia, \nprovoked vestibulodynia, dyspareunia, irritable bowel syn-\ndrome, and pelvic floor tenderness.\n\nInternational Urogynecology Journal \nEligibility Criteria and Synthesis\nArticles were considered for inclusion if they were avail-\nable in English and addressed CPP or related chronic pelvic \npain conditions in women. Studies were included when they \ncontributed evidence on central sensitization, nociplastic \npain, altered pain modulation, overlapping pain conditions, \npsychosocial distress, sexual function, quality of life, pelvic \nfloor dysfunction, biomarkers, treatment response, or mul-\ntidisciplinary management. Eligible publications included \nclinical guidelines, consensus statements, systematic and \nscoping reviews, narrative reviews, randomized controlled \ntrials, observational studies, qualitative studies, mixed-\nmethods studies, and clinically relevant case reports. Case \nreports were included only when they illustrated diagnostic \ncomplexity, comorbidity, or mechanisms directly relevant \nto the review aim.\nArticles were excluded if they focused exclusively on \nmale pelvic pain, acute pelvic pain, pregnancy-related pel-\nvic pain, postoperative pain, malignancy-related pain, or \npurely surgical management without relevance to chronic \npain mechanisms, psychosocial burden, sexual health, or \nwomen’s health implications. Conference abstracts without \nfull text and non-English publications were also excluded. \nPotentially relevant publications identified through the struc-\ntured searches were assessed for relevance to the predefined \nreview domains. Titles and abstracts were initially reviewed, \nfollowed by full-text assessment when appropriate. Publica-\ntions were included when they met the eligibility criteria and \ncontributed relevant evidence to one or more of the prede-\nfined mechanistic, psychosocial, functional, or management \ndomains.\nThe final narrative synthesis included 25 publications, \ncomprising four clinical guidelines or professional guidance \nsources, ten systematic or scoping reviews and meta-analy-\nses, four narrative or clinical reviews, six observational or \nprospective studies, and one other clinically relevant publi-\ncation. Because of the heterogeneity of diagnostic catego-\nries, populations, mechanisms, interventions, and outcomes, \nfindings were synthesized narratively. Greater interpretive \nweight was given to clinical guidelines, systematic and \nscoping reviews, randomized trials, prospective studies, and \nstudies using validated assessment tools. A summary of the \nsearch strategy, eligibility criteria, and narrative synthesis \nframework is presented in Table  1.\nSynthesis and Discussion\nCPP as a Biopsychosocial and Mechanism‑Based \nCondition\nCPP in women is best understood not as a single disease \nentity, but as a clinical syndrome in which multiple mecha-\nnisms may converge over time. Traditional diagnostic path-\nways commonly begin by asking which organ system is \nresponsible for the pain. This approach is necessary because \nconditions such as endometriosis, bladder pain syndrome/\ninterstitial cystitis, vulvodynia, irritable bowel syndrome, \npelvic floor myalgia, and musculoskeletal disorders may \nrequire specific evaluation and treatment. However, an \norgan-based model alone may be insufficient when pain \npersists despite disease-directed therapy, symptoms extend \nbeyond a single anatomical site, or pain severity is not pro-\nportional to visible pathology.\nA biopsychosocial framework broadens clinical atten-\ntion from the location of pain to the mechanisms by which \npain is generated, amplified, maintained, and experienced. \nTable 1  Structured narrative review framework\nReview element Specification\nDesign and purpose Structured narrative review providing an integrative clinical synthesis rather than a systematic review, meta-analysis, or \ncomprehensive evidence map\nInformation sources PubMed/MEDLINE, PubMed Central, the Cochrane Library, professional guideline sources, relevant journal websites, and \nreference lists of key publications\nSearch period January 2020 to May 2026, with earlier seminal publications included when required for foundational concepts\nCore domains Chronic pelvic pain, central sensitization, nociplastic pain, pain modulation, overlapping pain conditions, pelvic floor \ndysfunction, psychosocial burden, sexual function, quality of life, and multidisciplinary care\nEligibility English-language guidelines, reviews, randomized trials, observational studies, qualitative or mixed-methods studies, and \nclinically relevant case reports involving women with chronic pelvic pain or related conditions\nSelection process Potentially relevant publications were assessed against the predefined review domains and eligibility criteria, with full-text \nevaluation performed when appropriate\nExclusions Male pelvic pain, acute pelvic pain, pregnancy-related pain, postoperative or malignancy-related pain, purely surgical \nreports without mechanism relevance, conference abstracts without full text, and non-English publications\nSynthesis approach Narrative synthesis with greater interpretive weight given to guidelines, systematic and scoping reviews, randomized or \nprospective studies, and studies using validated assessment tools\n\n International Urogynecology Journal\nPeripheral nociceptive input from pelvic organs, inflam -\nmation, hormonal factors, pelvic floor dysfunction, and \nmusculoskeletal contributors may interact with altered pain \nprocessing, emotional distress, sleep disturbance, fear-avoid-\nance, sexual pain, and prior health care experiences. This \ndoes not minimize the biological reality of pain. Rather, it \nrecognizes that chronic pain is sustained through recipro-\ncal interactions among tissues, nerves, the central nervous \nsystem, behavior, and social context [1, 3].\nMechanism-informed phenotyping can make diagnosis \nmore clinically useful. Two women with endometriosis \nmay have very different pain profiles, and two women with \nbladder pain syndrome may differ in inflammatory mark -\ners, urinary symptoms, pelvic floor tenderness, psychologi-\ncal distress, and central pain amplification. In women with \nCPP, higher nociplastic pain features have been associated \nwith greater pelvic pain severity, pain frequency, pain inter-\nference, pelvic myofascial pain, and high-impact pain [ 5]. \nClinical profiling studies also indicate that diagnostic sub-\ngroups of women with CPP differ in symptom patterns and \nquality-of-life impact, reinforcing the idea that diagnostic \ncategory alone is not sufficient to guide care [13]. Evidence \nfrom bladder pain syndrome/interstitial cystitis similarly \nsuggests that treatment response may depend on inflamma-\ntory, sensory, bladder-specific, and pain-processing pheno-\ntypes rather than on diagnosis alone [8 ].\nThe purpose of a mechanism-based framework is there-\nfore not to replace medical diagnosis, but to integrate \ndiagnosis with pain mechanisms, psychosocial burden, \nsexual health, and functional impact. Such an approach \nmay reduce fragmented care, improve communication with \npatients, and support more individualized treatment plan-\nning. The proposed integrated clinical logic is summarized \nin Fig.  1.\nCentral Sensitization and Nociplastic pain\nCentral sensitization and nociplastic pain may help explain \nwhy CPP may persist, spread, or become disproportion-\nate to visible pelvic pathology [4 –7, 14]. In many women, \npain begins with identifiable peripheral contributors such \nas endometriosis, bladder pain syndrome, pelvic floor dys-\nfunction, vulvodynia, inflammation, or musculoskeletal \nstrain. Over time, persistent nociceptive input may alter \npain processing within the peripheral and central nervous \nsystems, producing heightened sensitivity to painful and \nnon-painful stimuli [5 –7]. This process may help explain \npain that extends beyond the pelvis, persists after disease-\ndirected treatment, or coexists with other chronic pain con-\nditions [6, 7].\nThe IASP definition of nociplastic pain is clinically useful \nbecause it validates pain as real and biologically grounded \neven when structural findings are limited or symptoms are \nnot proportional to observed pathology [ 4]. Importantly, \nnociplastic pain does not exclude nociceptive or neuro -\npathic mechanisms. Many women with CPP may have mixed \nFig. 1  Mechanism-based biopsychosocial model of chronic pelvic \npain in women. Chronic pelvic pain may begin with disease-specific \nor peripheral contributors, but pain persistence and disability are \noften shaped by central sensitization, nociplastic pain, pelvic floor \ndysfunction, psychosocial burden, sexual health consequences, and \nquality-of-life impairment. A mechanism-based approach integrates \nmedical diagnosis with pain phenotyping, multidisciplinary care, and \npatient-prioritized outcomes\n\nInternational Urogynecology Journal \nmechanisms, including ongoing peripheral nociception, neu-\nropathic-like symptoms, pelvic floor myofascial pain, and \ncentral pain amplification.\nEndometriosis-associated CPP illustrates the importance \nof this approach. Endometriosis is a well-recognized cause \nof pelvic pain, yet lesion location, extent, and severity do \nnot always correspond to pain intensity or functional impair-\nment. Some women continue to experience pain after hor -\nmonal, surgical, or other disease-directed treatments. Karp \nand Stratton emphasized that endometriosis-associated CPP \nmay involve neurogenic sensitization and pain beyond the \npelvis, requiring attention to central mechanisms and comor-\nbid pain conditions [6 ]. A recent scoping review similarly \nconcluded that central sensitization is increasingly recog-\nnized in endometriosis, but standardized methods for iden-\ntifying nociplastic pain remain limited [7 ].\nCentral sensitization is also relevant to vulvodynia and \nprovoked vestibulodynia. Women with vulvodynia often \nreport persistent vulvar pain, dyspareunia, pain with touch, \nand avoidance of sexual or gynecological contact. Rubal \net al. highlighted the importance of considering central \nsensitization in diagnosis and individualized management \n[15], while Nimbi et al. showed that central sensitization \nsymptoms in women with vulvodynia are linked with psy -\nchosocial factors and quality of life [16].\nClinically, central sensitization may be suspected when \npain is widespread, persistent, disproportionate to findings, \nor accompanied by fatigue, sleep disturbance, heightened \nsensitivity, overlapping pain conditions, mood symptoms, \nor high pain interference. These features should not be used \nto label pain as unexplained or psychological. They should \nprompt assessment of additional therapeutic targets. At the \nsame time, central sensitization should not become a diag-\nnostic shortcut; women with CPP still require careful evalu-\nation for treatable gynecological, urological, gastrointestinal, \nneurological, and musculoskeletal contributors.\nPsychosocial Burden, Pain Catastrophizing, \nand Disability\nThe psychosocial burden of CPP is part of how chronic pain \nis experienced, maintained, and translated into daily disabil-\nity. Women living with CPP often face uncertainty, repeated \ninvestigations, delayed diagnosis, fragmented care, and dif-\nficulty explaining symptoms that may not be visible or eas-\nily localized. Over time, this uncertainty may contribute to \ndistress, hypervigilance, reduced trust in health care, and \navoidance of activities associated with pain. Psychosocial \nassessment should therefore be integrated into CPP care, \nnot added only after biomedical explanations have been \nexhausted [1, 2].\nPain catastrophizing is an important cognitive-emotional \nprocess in chronic pain. It refers to an exaggerated negative \norientation toward pain, including rumination, magnification \nof threat, and perceived helplessness. In CPP, catastrophiz-\ning may intensify attention to pain, increase fear of symp -\ntom worsening, and reinforce avoidance behaviors. A sys-\ntematic review and meta-analysis of chronic cyclical pelvic \npain demonstrated a significant positive association between \npain catastrophizing and pain ratings [17]. It should not be \ninterpreted as evidence that pain is imagined or exaggerated; \nrather, it reflects a modifiable response to persistent pain and \nuncertainty.\nAnxiety and depression are also clinically meaningful in \nCPP.\nA recent systematic review and meta-analysis confirmed \na substantial burden of anxiety and depressive symptoms \namong women with CPP, with women with CPP approxi-\nmately twice as likely to have an anxiety disorder as women \nwithout CPP [18]. Their role is bidirectional: persistent pain \ncan increase anxiety and depressive symptoms, while emo-\ntional distress may amplify pain perception, disrupt sleep, \nreduce coping resources, and impair engagement in treat-\nment. Fear-avoidance links pain to disability when women \navoid movement, sexual activity, exercise, urination, bowel \nfunction, gynecological examination, or daily tasks because \nthey anticipate symptom worsening. Meta-analytic evidence \nacross clinical pain populations further supports associations \nbetween pain catastrophizing, fear of pain, anxiety, depres-\nsion, pain intensity, and pain-related disability [19]. Avoid-\nance can be protective in the short term, but over time may \ncontribute to physical deconditioning, pelvic floor guarding, \nsocial withdrawal, sexual avoidance, and reduced confidence \nin the body.\nSomatic symptoms require careful and non-stigmatizing \ninterpretation. Women with CPP may report fatigue, gastro-\nintestinal symptoms, urinary symptoms, diffuse pain, sleep \ndisturbance, and heightened bodily sensitivity. These symp-\ntoms may reflect overlapping pain conditions, central sensi-\ntization, autonomic dysregulation, psychological distress, or \ncombined mechanisms. A case report of persistent CPP with \ncomorbid somatic symptom disorder illustrates how central \nsensitization, distress, repeated investigations, and delayed \nintegration of psychiatric and pain-focused care may coexist \nin complex presentations [20]. Because case reports are not \ngeneralizable, such evidence should be used only to illustrate \nclinical complexity.\nPsychological care should be presented as pain care. A \nsystematic review of biopsychosocial approaches for female \nCPP found that cognitive behavioral therapy and acceptance \nand commitment therapy-based interventions may reduce \npain and improve psychological outcomes [11]. Clinicians \nshould avoid language that implies pain is only stress or all \nin the mind. A more constructive explanation is that chronic \npain is influenced by nervous system sensitivity, pelvic tis-\nsues, sleep, mood, threat perception, muscle guarding, and \n\n International Urogynecology Journal\nlived experience. Such framing can reduce stigma, support \nthe therapeutic alliance, and improve engagement with mul-\ntidisciplinary treatment.\nSexual Function, Intimacy, and Quality of Life\nCPP affects far more than pain intensity. Because pelvic pain \noften involves body regions linked to sexuality, reproduc-\ntion, urination, bowel function, body image, and intimate \nrelationships, its burden may be deeply personal and difficult \nto disclose. Women with CPP may experience pain during \nsexual activity, reduced sexual desire, avoidance of intimacy, \nfear of symptom worsening, distress during gynecological \nexamination, and changes in body perception. These conse-\nquences are not secondary to the main pain problem; they \nare central to the clinical and lived burden of CPP.\nSexual pain can function both as a symptom and as a \ndriver of broader disability. Dyspareunia, vulvar pain, pro-\nvoked vestibulodynia, endometriosis-associated pain, blad-\nder pain syndrome, and pelvic floor myalgia may all interfere \nwith sexual function and intimacy. Pain-related fear may \nlead to avoidance of sexual activity or gynecological care, \nreinforcing anxiety, pelvic floor guarding, and relationship \ndistress. Over time, pain, fear, avoidance, and emotional dis-\ntress may amplify one another [1, 3].\nVulvodynia and provoked vestibulodynia illustrate the \nneed to assess sexual health as part of chronic pain care. \nWomen with these conditions may report pain with touch, \npenetration-related pain, and avoidance of intimate or clini-\ncal contact. Central sensitization may intensify pain sen-\nsitivity and contribute to symptom persistence even when \nlocal findings are limited [15, 16]. Endometriosis-associated \nCPP similarly demonstrates the need to move beyond pain \nintensity alone. A systematic review and meta-analysis fur-\nther demonstrated impaired sexual function across multiple \ndomains in women with endometriosis, together with greater \ndyspareunia and chronic pelvic pain [21]. Treatment success \nshould not be evaluated solely by lesion-directed outcomes \nor pain scores but also by changes in sexual function, emo-\ntional well-being, daily activity, and quality of life [6].\nThe importance of broader outcomes is reflected in clini-\ncal research. In a prospective study, Caruso et al. evaluated \nwomen with endometriosis-associated CPP using pain meas-\nures as well as the Short Form-36, Female Sexual Function \nIndex, and Female Sexual Distress Scale [22]. Although that \nstudy focused on a specific hormonal treatment, its outcome \nframework is relevant because it recognizes that improve-\nment in CPP should include functioning, sexual well-being, \nand distress, not merely numerical pain reduction.\nClinicians should normalize discussion of sexual function \nand intimacy as part of CPP care. Asking about sexual pain, \navoidance, relationship impact, and emotional distress in a \nrespectful and nonjudgmental way can identify needs that \notherwise remain hidden. Depending on dominant mecha-\nnisms, treatment may include pelvic floor physical therapy, \npain education, psychological pain therapy, sexual coun-\nseling, treatment of comorbid mood or anxiety symptoms, \nand coordinated communication among clinicians. Such \napproaches do not imply that sexual pain is psychological; \nrather, they recognize that sexual function is shaped by pain \nmechanisms, pelvic floor responses, emotional safety, rela-\ntionship context, and prior clinical experiences.\nToward Mechanism‑Based Multidisciplinary Care\nBecause CPP may be shaped by interacting mechanisms \nacross multiple domains, treatment directed at a single \norgan system is unlikely to meet the needs of many women. \nDisease-specific diagnosis and treatment remain essential, \nbut they should be integrated within a broader framework \nthat also addresses pain amplification, pelvic floor function, \nemotional burden, sexual health, and daily functioning. The \nfirst step is comprehensive assessment. This includes evalua-\ntion of gynecological, urological, gastrointestinal, musculo-\nskeletal, neurological, and psychosocial contributors, while \nalso asking how pain affects sleep, mood, sexual function, \nwork, physical activity, and quality of life. Recent guidelines \nemphasize that CPP in adolescent and adult female individu-\nals should be approached through multifactorial assessment \nand management rather than a narrow search for a single \npathology [9, 10].\nPelvic floor physical therapy is a central component of \ncare for many women with CPP, particularly when pelvic \nfloor tenderness, myofascial pain, guarding, dyspareunia, or \npain with examination are present. Pelvic floor dysfunction \nmay act both as a contributor to pain and as a consequence \nof pain-related guarding. Evidence from a systematic review \nand meta-analysis indicates that pelvic pain is associated \nwith increased pelvic floor muscle tone when assessed by \ndigital palpation, supporting the relevance of pelvic floor \nassessment in women with persistent pelvic pain [23]. A \nsystematic review and meta-analysis found that multimodal \nphysical therapy is effective in reducing pain in women with \nCPP, with high certainty of evidence for this intervention \n[12]. Clinically, this supports early referral to pelvic floor \nphysical therapy when musculoskeletal contributors are \nsuspected, rather than reserving it only for refractory cases.\nPain neuroscience education is another important ele-\nment of mechanism-based care. Many women with CPP have \nreceived incomplete or conflicting explanations for their symp-\ntoms. Explaining central sensitization, nociplastic pain, pelvic \nfloor guarding, and the interaction among pain, sleep, stress, \nand movement can help reduce fear and improve treatment \nengagement. The message should not be that pain is psycho-\nlogical, but that the nervous system can become sensitized \n\nInternational Urogynecology Journal \nand that multiple treatment targets may help reduce pain and \nrestore function.\nPsychological interventions have a role when pain is per-\nsistent, distressing, or associated with fear-avoidance, catastro-\nphizing, anxiety, depression, trauma-related vulnerability, or \nimpaired coping. Cognitive behavioral therapy, acceptance and \ncommitment therapy, mindfulness-based approaches, and other \npain-focused interventions should be presented as part of pain \ncare, not as evidence that symptoms are emotionally generated \n[11]. Medical and procedural treatments should likewise be \nmatched to the dominant mechanisms and clinical phenotype. In \nendometriosis-associated CPP, hormonal or surgical treatment \nmay be appropriate when disease activity or cyclical exacerba-\ntion is prominent, but persistent pain after lesion-directed treat-\nment should prompt assessment of central sensitization, pelvic \nfloor dysfunction, and comorbid pain conditions [6, 7].\nThe challenge for clinical systems is to avoid fragmented \ncare. Women with CPP often move between gynecology, \nurology, gastroenterology, pain medicine, physiotherapy, and \nmental health services without a coordinated explanation or \nshared treatment plan. Interdisciplinary care programs may \nhelp address this gap by integrating multiple disciplines and \ntreatment components, but program structure remains vari-\nable [24]. Mechanism-based multidisciplinary care does not \nrequire that every woman see every specialist; it requires that \ncare be individualized according to active mechanisms and \npatient priorities [25].\nClinical Implications for Urogynecology\nFor urogynecology practice, the main clinical implication is that \nCPP should be approached as a multidimensional condition. \nDiagnostic evaluation should remain rigorous, but clinicians \nshould avoid presenting normal or inconclusive investigations \nas evidence that pain is not real. Instead, the clinical message \nshould validate the patient’s pain while explaining how pain \nmechanisms, pelvic floor responses, mood, sleep, sexual func-\ntion, and prior health care experiences may interact [9–12].\nThis approach also supports a broader set of outcomes. Pain \nintensity remains important, but women may define meaning-\nful improvement in terms of improved intimacy, reduced fear, \ngreater mobility, better sleep, return to work or study, improved \nconfidence in the body, and reduced need for repeated urgent \nconsultations. These outcomes should be incorporated into \nclinical assessment, shared decision-making, and future inter-\nvention studies [9, 10, 22].\nLimitations\nThis review was designed as a structured narrative \nreview rather than a systematic review or meta-analysis. \nAlthough the search strategy, eligibility criteria, and \nsynthesis domains were defined in advance, the review \ndid not include exhaustive database searching, duplicate \nindependent screening, formal risk-of-bias assessment, or \nquantitative synthesis. The findings should therefore be \ninterpreted as an integrative clinical synthesis rather than \nas a comprehensive summary of all available evidence.\nCPP is also heterogeneous, and the literature includes \nvaried diagnostic definitions, clinical populations, out-\ncome measures, and treatment approaches. Evidence \nfrom one subgroup, such as endometriosis-associated \npain, vulvodynia, or bladder pain syndrome/interstitial \ncystitis, may not be directly generalizable to all women \nwith CPP. Much of the evidence on central sensitization, \npsychosocial burden, and multidisciplinary care is cross-\nsectional or derived from specialized clinical settings, lim-\niting generalizability to primary care or community-based \npopulations. Despite these limitations, the review provides \na clinically relevant framework for integrating emerging \npain science, women’s health outcomes, and multidisci-\nplinary care in CPP.\nResearch Gaps and Future Directions\nImportant gaps remain in research, assessment, and \nclinical implementation. First, standardized methods are \nneeded for identifying central sensitization and nociplastic \npain in women with CPP. Although these concepts are \nincreasingly discussed in endometriosis, vulvodynia, blad-\nder pain syndrome, and overlapping pain conditions, clini-\ncal tools and diagnostic thresholds remain inconsistent [ 7].\nSecond, future studies should develop clinically useful \nphenotypes that combine pelvic diagnosis, pain distribu-\ntion, central sensitization features, pelvic floor findings, \npsychosocial burden, sexual function, biomarkers, and \nquality-of-life impact. Diagnostic labels alone do not relia-\nbly predict pain severity, disability, or response to therapy. \nEvidence from bladder pain syndrome/interstitial cystitis \nsuggests that urinary biomarkers and bladder characteris-\ntics may help explain treatment response in some popula-\ntions, but such findings require validation across larger and \nmore diverse cohorts [8 ].\nThird, longitudinal and pragmatic intervention research \nis needed. Many existing studies are cross-sectional, lim-\niting understanding of how CPP develops, persists, and \nchanges over time. Future trials should evaluate mech-\nanism-based treatment packages and stepped-care mod-\nels that reflect real-world complexity. Outcomes should \nextend beyond pain intensity to include pain interference, \nsexual function, sexual distress, quality of life, sleep, \nfatigue, emotional distress, work participation, health care \nuse, and patient-perceived improvement.\n\n International Urogynecology Journal\nFinally, research should address communication, stigma, \naccess, and care coordination. Many women with CPP report \nfeeling dismissed, particularly when investigations do not \nreveal a clear structural cause. Specialized pelvic pain clinics \nand pelvic floor physical therapy are not equally available to all \nwomen. Scalable models, including primary-care-based path-\nways, nurse-led education, telehealth-supported pelvic pain \ncare, and collaborative care models, deserve further evaluation. \nNurses, physiotherapists, psychologists, and other allied pro-\nfessionals may play important roles in education, validation, \nsymptom tracking, care coordination, and continuity of care.\nConclusions\nChronic pelvic pain in women is a complex and heterogene-\nous condition that cannot be fully understood through an \norgan-based model alone. Although gynecological, uro-\nlogical, gastrointestinal, musculoskeletal, and neurological \ndiagnoses remain clinically important, persistent pain often \nreflects interacting peripheral and central pain mechanisms \ntogether with functional and psychosocial contributors.\nA biopsychosocial and mechanism-based framework \nvalidates pain as real and biologically grounded while rec-\nognizing that chronic pain is shaped by the nervous system, \npelvic tissues, emotional processing, behavior, relationships, \nand social context. Women with CPP should therefore be \nassessed not only for pelvic pathology but also for pelvic \nfloor dysfunction, pain amplification, psychological distress, \nsexual function, quality of life, and daily disability.\nReframing CPP in this way may reduce fragmented care, \nimprove patient–clinician communication, and support more \nmeaningful outcomes. The aim is not only to reduce pain \nintensity, but also to restore function, intimacy, confidence, \nand quality of life. Ultimately, women with CPP need care \nthat is diagnostically accurate, integrated, validating, and \nresponsive to the full impact of pain on their lives.\nAuthor Participation Y Sela: Protocol/project development, data col-\nlection or management, data analysis, manuscript writing/editing.\nR Nissanholtz-Gannot: Protocol/project development, data analysis, \nmanuscript writing/editing, other: critical intellectual review.\nK Grinberg: Protocol/project development, data collection or man-\nagement, data analysis, manuscript writing/editing.\nFunding Open access funding provided by Ruppin Academic Center.\nData Availability Data sharing is not applicable because no new data-\nsets were generated or analyzed.\nDeclarations \nEthical Approval Ethical approval was not required because this article \nis a narrative review based exclusively on previously published litera-\nture and did not involve human participants, identifiable human data, \nhuman tissue, or new data collection. \nConflicts of Interest None.\nOpen Access This article is licensed under a Creative Commons Attri-\nbution 4.0 International License, which permits use, sharing, adapta-\ntion, distribution and reproduction in any medium or format, as long \nas you give appropriate credit to the original author(s) and the source, \nprovide a link to the Creative Commons licence, and indicate if changes \nwere made. 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