{"paper_id":"97571713-c7ba-411e-81cd-d0aa506c8505","body_text":"Chronic pelvic pain (CPP) is persistent pain perceived in structures linked to the pelvis lasting three or more months [ 1 ]. Its multifactorial nature and combination of pathological and psychological contributors often complicates the identification of specific aetiologies [ 1 ]. CPP in females is associated with a range of biopsychosocial symptoms, including pain, sexual, bladder and bowel dysfunction and emotional distress, necessitating a holistic management approach focused on reductions in pain and psychological distress and improvement in quality of life (QoL) rather than on treating a specific pathoanatomical cause [ 2 ].\nThe global prevalence of CPP in reproductive‐aged females is estimated to be ≥ 25% [ 3 ,  4 ,  5 ]. In the USA, CPP accounts for 40% of laparoscopies and 12% of hysterectomies performed annually, with 80% of cases having a non‐gynaecological origin [ 6 ]. In Australia, the economic burden of CPP is significant, estimated at 6.5 billion Australian dollars (AUD) yearly, with individual costs reaching up to AUD 20000, primarily due to productivity losses [ 5 ]. Among females with CPP, 68% report sexual dysfunction [ 7 ], 35% report irritable bowel syndrome [ 8 ] and 57% experience adverse effects on mental health and well‐being [ 9 ].\nSuch a complex array of physical and psychological symptoms may be best served via a multi‐, or interdisciplinary approach, where care from different disciplines is potentially more holistic in approach and may align with a biopsychosocial approach to care [ 10 ,  11 ]. This is supported by a recent Canadian clinical practice guideline on management of CPP, which proposes that ‘interdisciplinary management that includes psychological, physiotherapy, and medical treatment and is based on a biopsychosocial model offers more comprehensive and effective care than stand‐alone treatments for individuals with chronic pelvic pain’, with an evidence rating of moderate [ 10 ]. However this rating is based on one randomised controlled trial from 1991 [ 12 ].\nWhile potentially comprehensive and integrated, multidisciplinary models of care may only be available in tertiary care and metropolitan regions and be inaccessible for many women with CPP. Hence single discipline treatment continues to play an essential role. A skilled clinician representing a single discipline may be able to achieve equivalent outcomes for patients. Despite the emergence of multidisciplinary models of care in health services, it is currently unknown whether multidisciplinary models result in superior health outcomes for women with CPP.\nThis review aims to synthesise the available evidence from studies comparing multidisciplinary with single discipline treatment for females with CPP. Understanding the evidence supporting alternative models of care will help guide the allocation of resources for managing females with CPP.\n\nThis systematic review was designed and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta‐Analyses (PRISMA) guidelines [ 13 ]. The protocol was registered with PROSPERO (CRD42023420920).\nA comprehensive literature search was conducted from inception until March 2023, with an update in February 2025. The following databases were searched: CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, EMCARE, Ovid Medline, and Web of Science. An English‐language filter was applied. Population and intervention terms were derived from the EAU Chronic Pain guideline [ 1 ]. Medical Subject Headings terms were utilised, with relevant terms exploded as appropriate. Randomised controlled trial (RCT) filters from the Cochrane Handbook were applied specific to each database [ 14 ]. The search strategy was peer reviewed by a clinical librarian using the Peer Review of Electronic Search Strategies (PRESS) checklist prior to execution [ 15 ]. The full search strategy is provided in Appendix  S1 .\nEligibility assessment was independently conducted by two of three reviewers (DM, MT, RS). Studies were exported into Endnote (Version 20.3) [ 16 ] and uploaded into Covidence [ 17 ] for duplicate removal. Title and abstract screening were performed based on the inclusion and exclusion criteria. Full texts of potentially eligible studies were retrieved for further review. In cases of disagreement, a third reviewer was consulted. Hand‐searching of reference lists of included studies and relevant systematic reviews was also performed.\nInclusion criteria comprised females aged ≥ 13 years, the average age of menarche [ 18 ], with CPP lasting ≥ 3 months. Studies required at least two treatment arms: one multidisciplinary [ 19 ] or interdisciplinary [ 20 ,  21 ], and one single discipline. Included disciplines were those typically providing care in a public health service: medical, psychology, physiotherapy, nursing and dietetics/nutrition. Included studies reported pain, QoL, sexual function, anxiety, depression, pelvic floor dysfunction, analgesia use, and/or adverse events. Table  S1  presents full inclusion and exclusion criteria.\nThe risk of bias (RoB) in included studies was assessed using the Cochrane Risk of Bias tool version 2 [ 14 ,  22 ]. Two of three reviewers (DM, MT, RS) conducted this assessment independently, with discrepancies resolved by the third reviewer. The RoB Visualisation tool was used to generate a visual representation of bias [ 23 ].\nData extraction from each included article was conducted independently by two of three reviewers (DM, MT, RS). Extracted study characteristics included study design, sample size, participant demographics, multidisciplinary and single discipline descriptions including treatment provided, outcome measures, study time points and funding. All available relevant results were extracted including pre‐treatment, post‐treatment, and long‐term follow‐up data, within‐group changes and changes in between‐group differences. For outcomes presented in plot format without accessible numerical data, WebPlotDigitiser [ 24 ] was used for extraction.\nOutcomes of interest included pain, QoL, sexual function, anxiety and depression, pelvic floor dysfunction (specifically bowel and bladder dysfunction), analgesia use and adverse events.\nMeta‐analysis was performed when at least two studies reported data for the outcome [ 25 ]. Meta‐analyses were guided by the Cochrane Handbook for Systematic Review of Interventions [ 14 ], and performed in Revman v9.1.0 [ 26 ]. Random‐effects models were employed to account for anticipated heterogeneity among outcome measures and study designs [ 27 ]. A subgroup analysis was planned to explore the relative effect of a medical‐only comparator group to studies with other—non‐medical—disciplines as the comparator. This was to reflect current typical clinical practice where females with CPP consult only a medical doctor or consult a medical doctor first. We hypothesised that the addition of a second discipline would have greater effect when added to medical treatment due to the higher likelihood of biopsychosocial care provided by non‐medical disciplines.\nAs not all articles provided within‐group change data, post‐treatment results were used to calculate mean difference, or standardised mean difference, between‐groups for pain and QoL outcomes respectively, in accordance with the Cochrane systematic review handbook [ 14 ]. Sexual function mean difference meta‐analysis compared within‐group change scores. Studies reporting results as medians and interquartile ranges were assessed for skewness using an online skew calculator [ 28 ]. Studies without significant skew were converted to mean and standard deviation using an online calculator [ 29 ,  30 ,  31 ] and included in meta‐analyses.\nMinimal clinically important between group differences for pain using the Visual Analogue Scale (VAS) and Numerical Rating Scale (NRS) pain have been reported as 1.0cms [ 32 ,  33 ] and 1.39 units [ 34 ] respectively. A between‐group difference of > 1.39 for the pooled mean difference point estimate could therefore be considered as clinically meaningful, and > 1.0 considered possibly meaningful.\nThe GRADE system (Grades of Recommendation, Assessment, Development, and Evaluation) was utilised to assess the quality of findings from this review [ 14 ]. This assessment was conducted using GRADEpro software [ 35 ], and decisions to downgrade the certainty of evidence were in accordance with GRADE guidelines [ 36 ,  37 ,  38 ,  39 ].\n\nFigure  1  illustrates the flow of articles as per the PRISMA guidelines. Reasons for exclusion at full text screening are provided in Table  S2 . No additional articles were found through hand‐searching reference lists. Ultimately, 10 articles met the eligibility criteria, with the main characteristics of included articles presented in Table  1 . One article [ 40 ] was excluded from the results due to being a pilot study of a subsequent full study [ 41 ], which included all the pilot participants. Haugstad et al. [ 44 ] reported longer‐term follow‐up of the participants in their previous study [ 45 ] therefore these two articles are considered together as one study in this review. The total number of studies synthesised in this review was therefore eight. Results are presented in Table  2 .\nPreferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA) flow diagram [ 13 ].\nStudy characteristics.\nBardin et al. [ 40 ]\n(Data not included in results as all participants included in Bardin, 2023) [ 41 ];\nBrazil\nRCT\nn  = 73\nMDI: 37\nSDI: 36\nMean: MDI: 5.2\nSDI: 4.8\nMean (SD): MDI: 27.9 (9)\nSDI: 30.3 (10)\nMDI: Medical + Physiotherapist\nSDI: Medical\nMDI: Medical: oral amitriptyline 25 mg 1×/day\nPhysiotherapy:\nIn clinic: PFM contraction, stretching applied by researcher 1× per week\nHome programme: completed independently at home daily\nPain:\nIntensity of Sexual Pain\n(NRS 0–10); CST (NRS 0–10)\nSF: Friedrich Score; Frequency of intercourse\nBardin et al. [ 41 ];\nBrazil\nRCT\nn  = 111\nMDI‐1: 36\nMDI‐2: 38\nSDI: 37\nAge range y  ( n ):\nMDI‐1: < 20 (1), 20–45 (29)\nMDI‐2: < 20 (3), 20–45 (26)\nSDI: < 20 (1), 20–45 (26)\nMDI: Medical + Physiotherapist\nSDI: Medical\nMDI‐1: Medical: oral amitriptyline 25 mg 1×/day\nPhysiotherapy:\nIn clinic: PFM contraction, stretching applied by researcher 1× per week. Home programme: completed independently at home daily\nMDI‐2: Medical: oral Amitriptyline 25 mg 1×/day\nPhysiotherapy: electrical stimulation (interferential therapy)\\(applied to vulval area 30 min per week in clinic)\nPain: Intensity of Sexual Pain (NRS 0–10); CST (NRS 0–10); FSFI Pain\nSF: Friedrich Score; FSFI Total; Frequency of intercourse\nBorrego‐Jimenez et al. [ 42 ];\nSpain\nRCT\nn  = 123\nMDI: 48\nSDI: 75\nMean (SD):\nMDI: 46.1 (2.0)\nSDI: 56.8 (1.3)\nMDI: Medical + Physiotherapist\nSDI: Medical\nMedical: perphenazine and oral amitriptyline (2 and 25 mg) 1×/day, sodium hyaluronate 40 mg intravesical instillation 1 every 4 weeks\nPhysiotherapy: PFM exercise with biofeedback for 20 min 1×/week in clinic\nQoL:\nSF‐36\nRCT\nn  = 50\nMDI: 25\nSDI: 25\nMean (SD):\nMDI: 21.2\nSDI: 20.4\nMDI: Physiotherapist + Nutritionist\nSDI: Nutritionist\nPhysiotherapy: shockwave therapy to lower abdomen 1× session preceding the expected day for menstrual cycle and 3× sessions for initial 3 days of menstrual cycle in clinic\nNutritionist: dietary modifications for 3 months (3 successive menstrual cycles)\nRCT\nn  = 40\nMDI: 20\nSDI: 20\nMean (SD): MDI: 6.7 (0.8)\nSDI: 6.0 (0.8)\nMean (SD): MDI: 32.3 (1.43)\nSDI: 34.3 (2.0)\nMDI: Medical (gynaecologist) + Physiotherapist\nSDI: Medical\nMedical: dietary advice, sexology advice, ind 1 ividualised medication management ×2 sessions\nPhysiotherapy: MST and muscle MT (60 min ×10 sessions) in clinic\nPain: VAS (0‐10cms)\nAnxiety and Depression: GHQ‐30\nRCT\nn  = 20\nMDI: 10\nSDI: 10\nMDI: Medical (gynaecologist) + Physiotherapist\nSDI: Physiotherapist\nMedical: 5 mg intravaginal diazepam 1×/day\nPhysiotherapy: individualised PFM activation, respiratory and PFM coordination, PFM and external muscle stretching, biofeedback, electrical stimulation external electrodes and vaginal probe, heat, muscle‐relaxing postures 2× per week in clinic\nRCT\nn  = 101\nMDI: 53\nSDI: 48\nMean (SD): MDI: 35.1 (6.2)\nSDI: 37.2 (6.5)\nMDI: Medical + Physiotherapist\nSDI: Medical\nMedical: hormone therapy (progestin or combined oral contraceptive)\nPhysiotherapy: instructed self‐applied electrotherapy to the parasacral region S3‐S4 position 20 min 2×/day\nPain: VAS (0–10 cms); DDS 0–3; Pain diary\nQoL: EHP‐30\nSF: FSFI total analgesia use\nRCT—Pilot\nn  = 63\nMDI: 31\nSDI: 32\nMean (SD): MDI: 37.7 (7.3)\nSDI: 34.7 (8.1)\nMDI: Medical + Physiotherapist\nSDI: Medical\nMedical: hormone therapy, NSAIDs, dipyrone, paracetamol, or hyoscine butylbromide\nPhysiotherapy: brief mindfulness‐based therapy (4 onsite classes 1×/week + 3 weeks online)\nPain: NRS (0–10); McGill (data not reported); PCS (data not reported); Dyspareunia (NRS 0–10)\nQoL: SF‐36\nRCT\nn  = 62\nMDI: 32\nSDI: 30\nMean (SD): MDI: 39.7 (10.9)\nSDI: 36.2 (13.8)\nMDI: Medical (Gynaecologist), Physiotherapist + Nutritionist\nSDI: Physiotherapist\nPhysiotherapy: group body awareness, education + cognitive approach. Initial 10‐day session followed by 2‐day sessions after 3, 6 and 12 months.\nMedical: pain lecture.\nNutrition: nutrition lecture\nPain: NRS (0–10)\nQoL: EQ‐5D‐5L\nAnxiety/depression:\nHSCL‐25\nBladder function: ICIQ‐UI\nBowel function: St. Marks 0–24; ODS 0–25\nAbbreviations: CI, confidence interval; cms, centimetres; CPP, chronic pelvic pain; CRADI‐8, Colorectal‐Anal Distress Inventory‐8; CST, Cotton Swab Test; DDS, Deep Dyspareunia Scale; EHP‐30, The Endometriosis Health Profile‐30; EQ5D‐5L, European Quality of Life 5 Dimensions 5 Level Version; FSFI, Female Sexual Function Index; GHQ‐30, General Health Questionnaire‐30; HADS, Hospital Anxiety and Depression Scale; HSCL‐25, Hopkins Symptom Checklist‐25; ICIQ‐UI SF, International Consultation on Incontinence Questionnaire‐Urinary Incontinence Short Form; McGill, McGill Pain Questionnaire; MDI, Multidisciplinary Intervention; MDI‐1, Multidisciplinary Intervention Group 1; MDI‐2, Multidisciplinary Intervention Group 2; MRI, Magnetic Resonance Imaging; MST, Mesendieck Somatocognitive Therapy; MT, Manual Therapy;  n , number of participants; NI, No Information; NRS, Numerical Rating Scale; NSAIDs, Non‐steroidal Anti‐inflammatory Drugs; ODS, Obstructed Defaecation Syndrome; PCS, Pain Catastrophising Scale; PFDI‐20, Pelvic Floor Dysfunction Index‐20; PFM, Pelvic Floor Muscle; PSS‐10, Perceived Stress Scale‐10; QoL, Quality of Life; RCT, Randomised Controlled Trial; SD, Standard Deviation; SDI, Single Discipline Intervention; SF, Sexual Function; SF‐36, 36‐Item Short Form Survey; UDI‐6, Urinary Distress Inventory‐6; VAS, Visual Analogue Scale; y, years.\nResults of included studies.\nn  = 1\nSkin rash\nMDI: 6/37 (16%)\nSDI: 7/36 (19%)\nBardin et\nal. [ 41 ]\nMDI + SDI:  n  = 18 Sedation/dry mouth/\nheadache, dizziness/\nconstipation/rash.\nMDI‐2:  n  = 3 from ES (vulval numbness)\nSDI: 9/36 (25%)\nMDI‐1: 7/37 (19%)\nMDI‐2: 9/38 (24%)\nMDI: 2/48 (4%)\nSDI: 0/75 (0%)\n90 days: MDI: < 0.000\nSDI: 0.070\n12 months:\nMDI: < 0.000\nSDI: 0.077\nMDI: 1/20 (5%)\nSDI: 2/20 (10%)\nMDI:  n  = 6\nSpotting with mild pain; SDI:  n  = 0\nMDI: 14/53 (26%)\nSDI: 4/48 (8%)\nMDI: 6/32 (19%)\nSDI: 7/30 (23%)\nQoL :  EQ5D‐5L \n \n \n e\n(units, index value range −0.624 to 1.000)\nMDI: 9/31 (29%)\nSDI: 8/32 (25%)\nPain: Analgesia usage\nQoL: SF‐36 mental summary (units, range 0–100 per domain)\nMDI\nSDI\nMDI\nDecreased in  n  = 64%\nDecreased in  n  = 50%\n180.0 [116.5, 269.9]\nn  = 14% more participants reduced analgesia\n38.1 (−10.4, 86.6)\nNote:  \n p ‐Values rounded to 0.001, all other values rounded to 0.1.\nAbbreviations: CI, confidence interval; cms, centimetres; CST, cotton swab test; DDS, Deep Dyspareunia Score; EHP‐30, Endometriosis Health Profile‐30; EQ5D‐5L, European Quality of Life 5 Dimensions 5 Level Version; ES, Electrical Stimulation; FSFI, Female Sexual Function Index; GHQ‐30, General Health Questionnaire‐30; HSCL‐25, Hopkins Symptom Checklist‐25; ICIQ‐UI, International Consultation on Incontinence Questionnaire–Urinary Incontinence Short Form; MDI, Multidisciplinary Intervention; MDI‐1, Multidisciplinary Intervention Group 1; MDI‐2, Multidisciplinary Intervention Group 2;  n , number of Participants; NRS, Numerical Rating Scale; ODS, Obstructed Defecation Syndrome; Q1, Quartile 1; Q3, Quartile 3; QoL, Quality of Life; SD, Standard Deviation; SDI, Single Discipline Intervention; SEM, Standard Error of the Mean; SF, Sexual Function; SF‐36, 36‐Item Short‐Form Survey; VAS, Visual Analogue Scale.\nBardin 2023—between group analysis of Comparison group and both interventions.\nBardin 2023—between group analysis of comparison group versus MDI‐1.\nBardin 2023—between group analysis of comparison group versus MDI‐2.\nMerlino 2024—VAS and Marinoff scale measured at baseline and 6 months post intervention.\nNygaard 2020—EQ5D‐5L only reported pre intervention and at 12 months post intervention commencement.\nThe studies included a total of 570 female participants with sample sizes ranging from 20 [ 44 ] to 123 [ 42 ]. The mean age of participants varied from 20.4 years [ 43 ] to 56.8 years [ 42 ] across different studies. Conditions included endometriosis [ 47 ,  48 ], primary dysmenorrhea [ 43 ], vulvodynia [ 41 ,  46 ], bladder pain syndrome or interstitial cystitis [ 42 ], and non‐specific CPP [ 45 ,  49 ]. Pain duration averaged from one year [ 49 ] to over 10 years [ 49 ].\nOf the eight studies, five compared multidisciplinary interventions (medical and physiotherapy) versus a medical only intervention [ 41 ,  42 ,  45 ,  47 ,  48 ]. Three studies compared multidisciplinary interventions (medical and physiotherapy [ 46 ]; physiotherapy and nutrition [ 43 ]; or medical, physiotherapy and nutritional advice [ 49 ]) versus a physiotherapy only intervention. All multidisciplinary studies provided at least one treatment that was the same as the comparator arm, except one study which provided physiotherapy‐supervised group‐based movement therapy combined with gynaecological and nutritional education for the multidisciplinary group and individualised physiotherapy in the single discipline group [ 49 ].\nThe medical interventions included pharmacological treatments [ 41 ,  42 ,  45 ,  46 ,  47 ,  48 ] or pain education delivered by a gynaecologist [ 49 ]. Physiotherapy interventions included a range of exercise, physical and psychological therapies [ 41 ,  42 ,  43 ,  45 ,  46 ,  47 ,  48 ,  49 ]. Nutritionists provided dietary modifications [ 43 ] or educational sessions [ 49 ].\nIntervention duration varied from 7 weeks [ 48 ] to 12 months [ 49 ], with outcome measures consistently collected pre and post‐treatment. Only four studies [ 41 ,  42 ,  44 ,  48 ] measured additional follow‐up, and the timing of the follow‐ups were so varied that pooling in quantitative synthesis was inappropriate.\nThe RoB ratings for the included studies are shown in Figure  S1 , and interpreted according to the Cochrane Collaboration [ 50 ]. Four studies implemented random allocation and concealment, indicating a low RoB due to the randomisation process [ 41 ,  43 ,  45 ,  47 ]. Three studies reported groups with non‐comparable characteristics [ 42 ,  48 ,  49 ], with one having longer pelvic pain durations in the multidisciplinary groups [ 48 ], potentially favouring the single discipline group. Missing data raised serious concerns of bias for two studies [ 48 ,  49 ]. All studies were deemed to have high RoB in Domain 4 due to participants and therapists being aware of the treatment assignments, compounded by patient‐reported outcome measures as the primary outcome. However, participant awareness of the treatments being received and anticipated benefits of those treatments is reflective of usual clinical practice. Domain 4 was consequently discounted when allocating the overall RoB, so that studies with low(er) RoB could be more easily identified, thus aiding interpretation of the findings. Following this, four studies were still rated overall as having high RoB [ 42 ,  46 ,  48 ,  49 ], and four as having ‘some concerns’ [ 41 ,  43 ,  45 ,  47 ].\nMeta‐analyses were conducted for pain, QoL and sexual function. Other outcomes were synthesised narratively only, due to insufficient data for quantitative synthesis.\nPain was measured by the Visual Analogue Scale (VAS) [ 45 ,  46 ,  47 ], Numerical Rating Scale (NRS) [ 41 ,  43 ,  48 ,  49 ], and the pain subscale of the Female Sexual Function Index (FSFI) [ 41 ]. Three studies specifically measured experience of dyspareunia [ 46 ,  47 ,  48 ]. Seven of the eight studies measured pain using VAS or NRS and could be pooled using mean difference meta‐analysis (Figure  2A ) [ 41 ,  43 ,  45 ,  46 ,  47 ,  48 ,  49 ]. The analysis included 219 participants in the multidisciplinary group and 183 in the single discipline group. The comparisons included medical and physiotherapy versus medical [ 41 ,  45 ,  47 ,  48 ], nutrition and physiotherapy versus nutrition [ 43 ], medical and physiotherapy versus physiotherapy [ 46 ], and medical, physiotherapy and nutrition versus physiotherapy [ 49 ]. The results indicated a statistically significant mean between‐group difference in post‐treatment pain of −2.19 units (95% CI −3.17, −1.22;  p  = 0.002, heterogeneity 75%) in favour of multidisciplinary treatment. The difference exceeded our a priori specified minimal clinically important difference.\n(A) Mean difference meta‐analysis (post‐intervention scores) for pain intensity, assessed using NRS units or VAS 0–10 cm. (B) Mean difference meta‐analysis (post‐intervention scores) for pain intensity exploring subgroups. Studies grouped according to the discipline in the comparator group: Medical only treatment as the comparator group versus any other discipline as the comparator group.\nOther pain measures not included in the pain meta‐analysis showed mixed results. One study measuring pain with FSFI pain subscale found a between‐group difference favouring multidisciplinary versus single discipline treatment, consistent with the meta‐analysis finding [ 41 ]. One study using the cotton swab test found no difference between multidisciplinary versus single discipline treatment ( p  = 0.291) [ 41 ]. Dyspareunia pain was measured in three studies with inconsistent results [ 46 ,  47 ,  48 ]. Two studies found a statistically significant difference favouring multidisciplinary treatment [ 46 ,  48 ], while one study found no difference [ 47 ].\nSubgroup analysis was conducted for pain with four studies in the medical‐only comparator subgroup [ 41 ,  45 ,  47 ,  48 ] and three in the non‐medical single discipline (physiotherapy [ 46 ,  49 ] or nutrition [ 43 ]) comparator subgroup (Figure  2B ). For the medical‐only comparator studies, there was a statistically and clinically significant mean between‐group difference in pain of −2.17 units (95% CI −3.82, −0.52,  p  = 0.020,  I \n 2  = 52%) in favour of multidisciplinary treatments. For studies with non‐medical treatment as the single discipline comparator, the difference between multidisciplinary and single discipline was not significant (−2.21 units, 95% CI −5.44, 1.01,  p  = 0.100,  I \n 2  = 89%). However, the point estimates were very similar and there was no statistically significant difference between the subgroups ( p  = 0.960).\nQoL was measured using the 36‐Item Short Form Survey (SF‐36) [ 42 ,  48 ], the 30‐Item Endometriosis Health Profile (EHP‐30) [ 47 ], and the European Quality of Life 5 Dimensions 5 Level Version (EQ5D‐5L) [ 49 ]. Standardised mean difference meta‐analysis for QoL was conducted with three studies [ 42 ,  47 ,  49 ]. One study was excluded from the meta‐analysis because the SF‐36 summary total was not provided [ 48 ]. There was no statistically significant difference in post‐treatment QoL between multidisciplinary versus single discipline treatments: [ 42 ,  47 ,  49 ]–0.16 (95% CI −0.52, 0.20;  p  = 0.200,  I \n 2  = 0%) (Figure  3 ). Other QoL measures not included in the meta‐analysis (physical and mental health SF‐36 summaries) also found no difference between groups [ 48 ].\nStandardised mean difference meta‐analysis (post‐intervention scores) for quality of life, assessed using SF‐36, EHP‐30 and EQ‐5D‐5L.\nMeta‐analysis for sexual function was conducted with two studies that used the FSFI [ 41 ,  47 ]. There was a statistically significant between‐group difference in change from pre to post‐treatment favouring multidisciplinary treatment versus single discipline treatment: 2.47 FSFI units (95% CI 1.06, 3.88;  p  = 0.030,  I \n 2  = 0%) (Figure  4 ). In contrast, one study measured sexual function using both Friedrich score and frequency of intercourse and found no difference in change between groups using either measure [ 41 ].\nMean difference meta‐analysis (within‐group change scores) for sexual function, assessed using FSFI.\nTwo studies reported anxiety and depression [ 44 ,  49 ]. The General Health Questionnaire (GHQ‐30) anxiety and depression subscales were significantly different ( p  = 0.010 and p = 0 0.040, respectively) in favour of the multidisciplinary group versus single discipline at long term (12 months) follow‐up [ 44 ]. In contrast, there was no difference between physiotherapy alone and multidisciplinary treatment for anxiety and depression between groups using the Hopkins Symptom Checklist (HSCL‐25) ( p  = 0.241) [ 49 ].\nOne study investigated bladder and bowel dysfunction, with no between‐group difference found [ 49 ].\nOne study reported a significant reduction in a significant reduction in the average amount of days of analgesia use, with an average of 7 days in the multidisciplinary group, compared to 18 in the single discipline group ( p  = 0.005) [ 47 ]. Another study reported analgesic consumption decreased in 64% of participants in the multidisciplinary group compared to 50% in the single discipline group (statistical test not reported) [ 48 ].\nAdverse events were reported in two out of the eight studies, and were considered to be mild and transient [ 41 ,  47 ]. One study described a transient sensation of vulvar numbness following electrical stimulation in three participants [ 41 ]. The other study reported a higher incidence of adverse events (vaginal spotting) in the multidisciplinary group, compared to single discipline group [ 47 ].\nThe certainty of evidence using the GRADE approach resulted in an overall rating of moderate certainty for pain, low certainty for sexual function and very low certainty for all other findings (Table  S3 ).\n\nThis systematic review found moderate certainty evidence that multidisciplinary treatment of CPP may result in lower pain intensity scores than single discipline treatment, and low certainty that it is more effective for improving sexual function. Findings suggest QoL is not improved with multidisciplinary treatments but with very low certainty, and findings are inconclusive for other outcomes of interest in this review due to very limited and low‐quality data. Adverse events were infrequently reported and not likely to be clinically relevant as events were mild and transient. While available evidence supports a conclusion that multidisciplinary treatment is better for managing pain in females with CPP, further research may improve the confidence in this finding [ 51 ]. The comparators may be important to explain this apparent benefit, as when the studies with multidisciplinary interventions that included physiotherapy in addition to medical treatment were compared to medical treatments alone, the effect remained. This suggests there might be a summed effect of combining these two disciplines, or that the physiotherapy intervention added the biopsychosocial components and was important for this effect.\nThe high heterogeneity within our pain meta‐analysis may be explained by the different durations of treatments and the different amounts and quality of contact with health professionals between each study. More contact time with a healthcare practitioner may be an important contextual factor that influences the perceived effectiveness of the treatment [ 52 ,  53 ,  54 ] and from our review, more intensive treatments may provide a stronger additive effect [ 41 ,  45 ,  46 ,  47 ]. The two studies finding the smallest differences in post‐treatment pain were underpowered and had high drop‐out rates [ 48 ,  49 ]. Findings on the outcomes of anxiety/depression and bladder/bowel dysfunction were drawn from studies that were not powered for determining the effect of the intervention on these outcomes and were therefore at risk of type II error, or missing a true effect. From one trial, the effect on analgesia use appeared to favour inclusion of physiotherapy care in multidisciplinary care [ 48 ].\nNo directly comparable systematic reviews exist. The recent Canadian clinical practice guideline [ 10 ] recommended multidisciplinary care however this was based on an early RCT [ 12 ] that was ineligible for this systematic review due to the comparator arms (surgery versus no surgery). A systematic review of clinical practice guidelines for CPP highlighted that while some guidelines recommend a biopsychosocial approach, most recommended medical intervention; and that these guidelines are mostly of poor quality with insufficient supporting evidence [ 55 ]. A more recent systematic review in CPP found a biopsychosocial approach effective in reducing pain and improving QoL [ 56 ] however they did not compare multidisciplinary to single discipline care. While a multidisciplinary model of care may be more likely to provide biopsychosocial care, the two terms are not interchangeable, as single discipline care can also be biopsychosocial, especially if it is multimodal [ 57 ]. A systematic review with a similar question to our review found multidisciplinary biopsychosocial rehabilitation for patients was more effective than single discipline care with chronic low back pain [ 58 ], therefore the biopsychosocial aspect may be an important component of multidisciplinary care.\nThe strengths of our review lie in the methodological rigour, including our sensitive search strategy and the dual independent screening and data extraction processes, enhancing the internal validity of our findings. The novelty of this review is another strength, being the first to quantitatively compare multidisciplinary to single discipline treatment, in a population with a highly prevalent but under‐researched condition. Our review included a wide range of CPP conditions, increasing its external validity and relevance to current clinical practice where a wide range of pelvic pain conditions present to clinicians. Studies in our review largely reflect current [ 59 ] or recommended [ 10 ] multidisciplinary models of care for CPP, however the optimal combination of healthcare practitioners may be even more complex, and need to be guided by presenting phenotype and person‐centred care.\nOur review is in part limited by a lack of existing RCTs assessing the comparative effectiveness of multidisciplinary versus single discipline treatment for CPP. Further, some studies were excluded because they provided treatment not typically delivered by a practitioner in a public health service, e.g., yoga or acupuncture, and were therefore out of scope for this review question. Data in our review came from only five countries, perhaps reflecting health systems which are able to provide multidisciplinary models of care, and therefore may not be generalisable to all settings. Research in multidisciplinary care for CPP has emerged more recently than multidisciplinary care for other chronic pain conditions, e.g., low back pain [ 58 ], consequently the body of evidence is much smaller to date. Our search strategy was limited to English‐language publications, potentially omitting relevant studies published in other languages that may provide additional information in answer to the review question. Further, the studies included in our review exhibited significant heterogeneity in their study designs and model components, with differences in interventions, treatment dosages and durations, as well as disciplines included. Combining studies on models of managing CPP that have varied effectiveness risks diluting the observable benefits of the more effective combinations of treatments. However, this review provides a starting point from which new hypotheses can be generated for investigation in future studies and reviews.\nAll included studies had at least some concerns of RoB, which reduced their internal validity and the certainty of our findings. Finally, and importantly, the included studies themselves did not aim to compare multidisciplinary to single discipline care, but rather to test the effectiveness of a certain treatment that was added to an existing model of care. Our findings may reflect the contextual effects of the additional treatment, contact time/dosage, and healthcare staff involved, rather than the treatments themselves [ 52 ,  53 ,  54 ]. However, these contextual effects can be considered valuable in a biopsychosocial model of healthcare and therefore are important to include regardless of the discipline providing the treatment.\nThere is an urgent need for higher‐quality trials, which provide clearer description of the clinical presentation/phenotype in the CPP cohort, with appropriate power, and well‐designed interventions of sufficient dosage. Future studies should consider designing multidisciplinary treatments that comprehensively incorporate components shown to be effective in other chronic pain conditions [ 60 ,  61 ,  62 ]. Future RCTs could also specifically test the impact of seeing more than one discipline by providing the same dosage, treatments and contact time across both intervention groups, with the only difference being multidisciplinary in one group and single discipline in the other. Additionally, a future systematic review may consider grouping studies based on the treatments provided within a discipline, rather than the different disciplines providing treatment.\n\nOur findings provide a cautious recommendation that suggest seeing two or more disciplines may lead to better outcomes than seeing one discipline for treatment of pain and sexual function in females with CPP. A limitation to our findings is that few studies explicitly and directly tested multidisciplinary compared to single discipline care, while controlling for other influences on outcomes. More research is required to identify the essential components of effective multidisciplinary models of care for females with CPP, and indeed whether a single discipline can provide all these essential components.\n\nD.M. contributed to the study design, development of the search strategy, screening and acquisition of data, and analysis and interpretation, contributed to writing the initial and final versions of the manuscript, approves the final manuscript as submitted, agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. R.S. contributed to the study design, development of the search strategy, screening and acquisition of data, data analysis, interpretation and initial and final manuscript writing and approves the final manuscript as submitted. M.‐A.T. contributed to the study design, acquisition of data, analysis, interpretation and manuscript writing and approves the final manuscript as submitted. T.E. contributed to the study design, development of the search strategy and data analysis plan, data analysis, interpretation of the results, and revision of the manuscript for important intellectual content and also supervised the review process, and approves the final manuscript as submitted. H.F. conceived the project and contributed to the methods design, analysis, interpretation and manuscript writing and approves the final manuscript as submitted.\n\nThe authors have nothing to report.\n\nThe authors declare no conflicts of interest.\n\nFigure S1:  bjo18322‐sup‐0001‐FigureS1.docx.\nTable S1:  bjo18322‐sup‐0002‐TableS1.docx.\nTable S2:  bjo18322‐sup‐0003‐TableS2.docx.\nTable S3:  bjo18322‐sup‐0004‐TableS3.docx.\nAppendix S1:  bjo18322‐sup‐0005‐AppendixS1.docx.","source_license":"CC0","license_restricted":false}