{"paper_id":"fc32a40c-f94b-4e16-bcc2-4bb142ec196e","body_text":"REVIEW ARTICLE\nEvaluation of clinical practice guidelines (CPG) on the management\nof female chronic pelvic pain (CPP) using the AGREE II instrument\nVishalli Ghai1,2 & Venkatesh Subramanian1 & Haider Jan1 & Jemina Loganathan1 & Stergios K. Doumouchtsis1,2,3,4 &\nCHORUS: An International Collaboration for Harmonising Outcomes, Research and Standards in Urogynaecology and\nWomen’s Health (i-chorus.org)\nReceived: 26 January 2021 / Accepted: 8 May 2021\n# The Author(s) 2021\nAbstract\nIntroduction and hypothesis Variations in guidelines may result in differences in treatments and potentially poorer health-related\noutcomes. We aimed to systematically review and evaluate the quality of national and international guidelines and create an\ninventory of CPG recommendations on CPP.\nMethods We searched EMBASE and MEDLINE databases from inception till August 2020 as well as websites of professional\norganizations and societies. We selected national and international CPGs reporting on the diagnosis and management of female\nCPP. We included six CPGs. Five researchers independently assessed the quality of included guidelines using the AGREE II tool\nand extracted recommendations.\nResults Two hundred thirty-two recommendations were recorded and grouped into six categories: diagnosis, medical treatment,\nsurgical management, behavioural interventions, complementary/alternative therapies and education/research. Thirty-nine\n(17.11%) recommendations were comparable including: a comprehensive pain history, a multi-disciplinary approach, attributing\nmuscular dysfunction as a cause of CPP and an assessment of quality of life. Two guidelines acknowledged sexual dysfunction\nassociated with CPP and recommended treatment with pelvic floor exercises and behavioural interventions. All guidelines\nrecommended surgical management; however, there was no consensus regarding adhesiolysis, bilateral salpingo-\noophorectomy during hysterectomy, neurectomy and laparoscopic uterosacral nerve ablation. Half of recommendations (106,\n46.49%) were unreferenced or made in absence of good-quality evidence or supported by expert opinion. Based on the AGREE\nII assessment, two guidelines were graded as high quality and recommended without modifications (EAU and RCOG).\nGuidelines performed poorly in the “Applicability”, “Editorial Independence” and “Stakeholder Involvement” domains.\nConclusion Majority of guidelines were of moderate quality with significant variation in recommendations and quality of\nguideline development.\nKeywords AGREE II tool . Chronic pelvic pain . Guidelines . Sexual dysfunction . Systematic review\n* Vishalli Ghai\nvishalli.ghai25@gmail.com\nVenkatesh Subramanian\nvenkatesh.subramanian@nhs.net\nHaider Jan\nhaider.jan@nhs.net\nJemina Loganathan\njemina.loganathan@nhs.net\nStergios K. Doumouchtsis\nsdoum@yahoo.com\n1 Department of Obstetrics and Gynaecology, Epsom & St Helier\nUniversity Hospitals NHS Trust, Dorking Road, London KT18 7EG,\nUK\n2 St George’s University of London, Crammer Terrace, London SW17\n0RE, UK\n3 Laboratory of Experimental Surgery and Surgical Research N.S.\nChristeas, National and Kapodistrian University of Athens, Medical\nSchool, Athens, Greece\n4 School of Medicine, American University of the Caribbean,\nCupecoy, Sint Maarten\nhttps://doi.org/10.1007/s00192-021-04848-1\n/ Published online: 19 June 2021\nInternational Urogynecology Journal (2021) 32:2899–2912\n\nIntroduction\nChronic pelvic pain (CPP) is a debilitating condition, affecting\n15% of women worldwide [1]. It is associated with significant\nsocio-economic burden and long-term morbidity [ 2]. CPP is\ndefined as pain lasting > 6 months or recurrent episodes of\nabdominal/pelvic pain, hypersensitivity or discomfort often\naccompanied by elimination changes and sexual dysfunction\n[3]. CPP remains a challenging disorder to treat because of the\ncomplexities of pain sensation and unclear aetiology.\nStandard medical and surgical treatments seldom prove effec-\ntive at improving quality of life and pain intensity among\naffected women [ 4]. Furthermore, the variation in outcome\nreporting of trials evaluating interventions has prevented the\nsynthesis of data to identify effective treatments and draw\nclinically relevant conclusions in the context of guideline for-\nmation [5].\nClinical practice guidelines (CPG) are systematically de-\nveloped statements using best available research evidence [6].\nThey aim to improve the delivery and quality of patient care\nand health outcomes. Adoption of CPG attempts to eliminate\nvariation, standardize medical care and implement effective\ntreatments. Guidelines are developed using standardized\nmethods and processes including: engaging stakeholder\ngroups, identifying, quality assessment and synthesis of re-\nsearch evidence as well using consensus methods to derive\nrobust guideline recommendations. The methodological qual-\nity of guidelines has been inconsistent [ 7–10].\nGuidelines based on poor evidence or those that fail to\nreflect the needs of women may contribute to the delivery of\nsuboptimal, ineffective or even harmful interventions thereby\ncompromising the quality of care. To date, there has been no\nevaluation of the methodological quality of national or inter-\nnational guidelines on female CPP. In this systematic review,\nwe aimed to evaluate the methodological quality of CPP\nguidelines, produce a comprehensive inventory of recommen-\ndations and explore the relationships between recommenda-\ntions and evidence.\nMethods\nThis systematic review was designed and reported according\nto the Preferred Reporting Items for Systematic Reviews and\nMeta-Analyses (PRISMA) guideline [ 11]. It was performed\nby a working group of CHORUS, an International\nCollaboration for Harmonizing Outcomes in Research and\nStandards in Urogynaecology and Women ’sH e a l t h(https://\ni-chorus.org ). This study is part of a wider project for\nestablishing core outcome sets (COS) in CPP. We followed\na methodological approach implemented successfully by pre-\nvious studies by CHORUS working groups appraising the\nquality of clinical guidelines in various areas of gynaecology\n[7, 8, 10].\nSearch strategy\nA comprehensive literature search was undertaken using the\nMEDLINE and EMBASE databases. Searches were per-\nformed from database inception to August 2020 using the\nfollowing MESH terms: “chronic pelvic pain”,p e l v i cp a i n”,\n“idiopathic chronic pelvic pain”, “guidance”, “guideline” and\n“recommendation”. Reference lists of included guidelines\nwere hand-searched. We subsequently searched websites of\nspecialist societies and professional organizations including\ngastroenterology, gynaecology, pain medicine and urology\nto identify additional guidelines. (A list of these can be\nfound in Appendix 3.)\nSelection of guidelines\nWe included guidelines reporting on the diagnosis and man-\nagement of CPP in women. Two researchers (VG, VS)\nreviewed the full text of retrieved guidelines independently\nto assess eligibility. Guidelines in languages other than\nEnglish, specific to a particular condition (i.e. endometriosis,\nbladder pain syndrome), local/regional guidelines or if an up-\ndated guideline was available by the same organization were\nexcluded. We excluded editorials, reviews, position state-\nments, consensus statements, expert opinions, practice stan-\ndards, practice alerts/bulletins and primary studies as these\ndocuments do not meet the criteria of assessment or purpose\nof the AGREE II tool [12]. Discrepancies regarding suitability\nfor inclusion were resolved by discussion with a senior author\n(SKD) and a consensus reached. A PRISMA flow chart is\nincluded to demonstrate the search and guideline inclusion\nprocess (Appendix 2).\nData extraction\nTwo researchers (VG and VS) extracted guidelines character-\nistics independently including: country of origin, year of pub-\nlication, consensus methods, stakeholders involved, disease\narea examined, description of database search, search terms\nused, language restriction, da te of searches, inclusion/\nexclusion criteria and quality assessment instrument.\nTwo researchers (VG and VS) mapped recommendations\nindependently according to five pre-defined areas: (1) diagno-\nsis, (2) medical management of pain, (3) surgical management\nof pain, (4) behavioural interventions, (5) complementary and\nalternative therapies for pain and (6) education and research.\nWe defined behavioural interventions as exercise, dietary\nmodification, physiotherapy an d psychologic al treatment.\nComplementary/alternative therapies were defined as acu-\npuncture, dry needling, homoeopathy, massage, reflexology\nand transcutaneous electric nerve stimulation (TENS). We\nreported levels of evidence used to support recommendations\nin guidelines. Supporting evidence was categorized according\n2900 Int Urogynecol J (2021) 32:2899–2912\n\nto the evidence-based medicine criteria [Cochrane reviews,\nsystematic review, randomized control trials (RCT), non-\nrandomized control trials, expert opinion and no reference].\nDiscrepancies were resolved by discussion with a third author\n(SKD). In cases where a recommendation supported by mul-\ntiple sources of evidence of varying quality, we documented\nthe highest quality of evidence.\nQuality assessment of included guidelines\nFive researchers (VG, VS, HJ, JL, SKD) were trained and\nassessed the quality of guidelines independently using the\nAGREE II tool. This is a validated instrument consisting of\n23 items grouped into six quality domains and two further\nglobal rating items: (1) scope and purpose (items 1 –3), (2)\nstakeholder involvement (items 4 –6), (3) rigour of develop-\nment (items 7–14 items), (4) clarity of presentation (items 15–\n17), (5) applicability (items 18–21) and (6) editorial indepen-\ndence (items 22–23). Each item was rated using a seven-point\nLikert scale from 1 (strongly disagree) and 7 (strongly agree)\n[12]. The “Stakeholder Involvement” domain focuses on the\nextent to which the guideline was developed by the appropri-\nate stakeholders and represents the views of its intended users\n[12]. The “Editorial Independence” is concerned with the for-\nmulation of recommendations not being unduly biased with\ncompeting interests [12]. Refer to Appendix 1 for a detailed\ndescription of each domain assessed by the AGREE II tool.\nData analysis\nDomain quality scores were calculated by the summation of\nscores per item and standardized using a prescribed equation\n[12]. An overall guideline score was derived as a mean of all\nsix domain quality scores. This approach has been adopted by\nprevious studies using the AGREED II tool to evaluate clini-\ncal guidelines [7, 13].\nThere is no consensus regarding using AGREE II scores to\ndifferentiate between high- and low-quality guidelines or rec-\nommendation of guidelines. For the purpose of this study, we\nconsidered a domain score < 50% as low quality [ 7, 10]. The\noverall guideline score was used to categorize guidelines into\nthe following: low quality (0 –30%), moderate quality (31 –\n60%) and high quality (61–100%) [7]. Based on these ratings,\nhigh-quality guidelines were recommended, moderate quality\nguidelines were recommended with modifications and low\nquality guidelines were not recommended [9, 7].\nInter-rater reliability of assessments was tested for agree-\nment using the Fleiss ’ kappa co-efficient. Scores of ≤ 0 indi-\ncated no agreement, 0.01 –0.20 indicated poor agreement,\n0.21–0.40 indicated fair agreement, 0.41–0.60 indicated mod-\nerate agreement, 0.61 –0.80 indicated substantial agreement\nand 0.81–1.0 indicated almost perfect agreement [14].\nTabulation and data\nDescriptive statistics were calculated for all domains (median,\nrange and interquartile range). We used tables to map recom-\nmendations, the supporting evidence for recommendations\nand the hierarchy of evidence.\nPatient and public involvement\nThere has been no patient involvement as this study is a sys-\ntematic review of existing research.\nResults\nThe electronic literature search yielded 1294 titles and ab-\nstracts. We screened 639 titles and abstracts following the\nexclusion of 655 duplicate records (Appendix 2 for\nPRISMA flow chart). A further three guidelines were identi-\nfied from examination of references lists and websites of\nsocieties/associations (Appendix 3). In total, we included six\nguidelines comprising four national and two international\nguidelines: American College of Obstetricians and\nGynaecologists (ACOG), American Society of Reproductive\nMedicine (ASRM), European Association of Urology (EAU),\nInternational Society of Psychosomatic Obstetrics and\nGynaecology (ISPOG), Royal College of Obstetricians and\nGynaecologists (RCOG) and The Society of Obstetricians\nand Gynaecologists of Canada (SOGC) (Table 1).\nAlthough the ASRM guideline focused on women with\nendometriosis, it also considers the wider issue and common\npresenting complaint of female CPP. As our working group is\ndeveloping a COS on CPP, the consensus of the authors was\nto include this guideline to provide a more comprehensive\ninventory of CPP regardless of diagnosis.\nThe ACOG practice bulletin, although it is not titled a\nCPG, was developed using methodology that met the criteria\nof assessment by the AGREE II tool and was therefore\nincluded.\nThe EAU guideline is directed to both women and men\nwith CPP. For the purpose of this study we excluded recom-\nmendations that were relevant to men. However, this did not\nimpact the assessment of guideline development as the\nAGREE II tool is an evaluation of the methods involved in\nthe development of guidelines rather than the recommenda-\ntions themselves.\nGuideline characteristics\nGuidelines were published between 2002 and 2020. They\nspecifically reported on the management including treatment\nof CPP. The number or type of stakeholders involved in the\ndevelopment of guidelines was not reported by two guidelines\n(ISPOG and RCOG). In four guidelines (ACOG, ASRM,\n2901Int Urogynecol J (2021) 32:2899–2912\n\nTable 1 Guideline characteristics\nGuideline Organization Country/\nregion\nof origin\nStakeholders (n;\nlocation)\nScope Consensus\nmethod\nIdentification of\nevidence\nQuality\nassessment of\nevidence\nConsensus Guidelines\nfor the Management\nof Chronic Pelvic Pain\n(2018)\nThe Society of\nObstetricians\nand\nGynaecolog-\nists of\nCanada\n(SOGC)\nCanada Obstetricians and\nGynaecologists\n(12, various\nlocations in\nCanada)\nDiagnosis and\nmanagement\nNot\nreported\nDatabase: Cochrane,\nMEDLINE\nSearch terms: not\nreported\nLanguage restriction:\nnot reported\nDate of searches:\n1982–1994\nInclusion/exclusion\ncriteria: unclear\nCanadian Task\nForce om\nPreventative\nHealth\nInternational Society of\nPsychosomatic\nObstetrics and\nGynaecology\n(ISPOG) European\nConsensus\nStatement-Chronic\nPelvic Pain in Women\n(2015)\nInternational\nSociety of\nPsychosoma-\ntic Obstetrics\nand\nGynaecology\n(ISPOG)\nEurope Unclear Medical,\npsychologi-\ncal and\npsychoso-\nmatic\ndiagnostics\nand\ntreatment\nUnclear Database: MEDLINE,\nPsychLit/PsychINFO,\nAnnals of the German\nSociety for\nPsychosomatic\nGynaecology and\nObstetrics\nSearch terms: “chronic\npelvic”,\n“endometriosis”,\n“pelvic congestion\nsyndrome”, “bladder\ndysfunction”, “pelvic\nfloor hypertonic\ndisorder”\nLanguage restriction:\nnot reported\nDate of searches:\nMEDLINE:\n1966–December\n2010),\nPsychLit/PsychINF-\nO:\nNovember\n2001–December\n2007, Annals of the\nGerman Society for\nPsychosomatic\nGynaecology and\nObstetrics:\n1983–2010\nInclusion/exclusion\ncriteria: Unclear\nNot reported\nConsensus statement for\nthe management of\nchronic pelvic pain\nand endometriosis:\nproceedings of an\nexpert panel\nconsensus (2002)\nAmerican\nSociety of\nReproductive\nMedicine\n(ASRM)\nUSA Practicing\ngynaecologists\n(> 50, from\nvarious\nlocations)\nMethodological\nexperts\n(location or number\nnot reported)\nMedical and\nsurgical care\nDelphi Database: MEDLINE\nSearch terms: not\nreported\nLanguage restriction:\nnot reported\nDate of searches:\n1966–2001\nInclusion/exclusion\ncriteria: Unclear\nNot reported\nThe initial management\no fc h r o n i cp e l v i cp a i n\n(2012)\nRoyal College\nof\nObstetricians\nand\nGynaecolog-\nists (RCOG)\nUK Not reported Investigation\nand\nmanagement\nNot\nreported\nDatabase: Cochrane\nLibrary, Cochrane\nRegister of\nControlled Trials\n(CENTRAL),\nMEDLINE\nSearch terms: “chronic\ndisease”,\nScottish\nIntercollegia-\nte Guidelines\nNetwork\n(SIGN)\n2902 Int Urogynecol J (2021) 32:2899–2912\n\nEAU and SOGC), stakeholders included various health pro-\nfessionals (gynaecologists, urologists, neurologist, gastroen-\nterologist, pain medicine, psychologist and sexologist) and\nmethodological experts in clinical guideline development.\nThe number of stakeholders in these guidelines ranged from\n12 to 52. No guideline reported the involvement of women\nwith CPP during the development process or reported their\nexperiences of the recommended interventions. All guidelines\ndeveloped recommendations applicable to high-income set-\ntings. One guideline (ASRM) described consensus develop-\nment methods including the modified Delphi method. No\nguidelines provided a detailed search strategy used to identify\nsupporting evidence for recommendations. Four guidelines\n(ACOG EAU, RCOG and SOGC) described methods to qual-\nity assess research evidence (Table 1).\nMethods on quality assessment of research evidence\nTwo guidelines were graded as high (EAU and RCOG) and\nfour guidelines were graded as moderate quality (ACOG,\nASRM, ISPOG and JOGC). The EAU and RCOG guidelines\nscored highly with overall mean scores of 69.86% and\n62.50% respectively. The remaining four guidelines scored\nless than 50% overall mean scores including the ACOG\nTable 1 (continued)\nGuideline Organization Country/\nregion\nof origin\nStakeholders (n;\nlocation)\nScope Consensus\nmethod\nIdentification of\nevidence\nQuality\nassessment of\nevidence\n“dysmenorrhoea”,\n“pelvic pain”\nLanguage restriction:\nnot reported\nDate of searches:\nMEDLINE:\n1966–2001\nInclusion/exclusion\ncriteria: Unclear\nGuidelines on chronic\npelvic pain\n(2014)\nEuropean\nAssociation\nof Urology\n(EAU)\nEurope Gynaecologist\nNeuro-Urologist\nGastroenterologist,\nUrologists\nPain medicine\nconsultants\nPsychologist\nSexologist (number\nor location not\nreported)\nManagement Not\nreported\nDatabase: Cochrane\nLibrary, Cochrane\nRegister of\nControlled Trials\n(CENTRAL),\nBandolier, EMBASE,\nMEDLINE,\nPsychINFO\nSearch terms: Not\nreported\nLanguage restriction:\nEnglish\nDate of searches:\nJanuary\n1995–May 2011\nInclusion/exclusion\ncriteria: Unclear\nOxford Centre\nfor\nEvidence-ba-\nsed Medicine\nLevels of\nEvidence\nPractice Bulletin.\nChronic Pelvic Pain\n(2020)\nAmerican\nCollege of\nObstetricians\nand\nGynaecolog-\nists (ACOG)\nUSA Obstetricians and\nGynaecologists\n(number and\nlocation not\nreported)\nDiagnosis and\nmanagement\nNot\nreported\nDatabase: Cochrane,\nMEDLINE\nSearch terms:n o t\nreported\nLanguage restriction:\nEnglish\nDate of searches:\nJanuary\n2000–May 2019\nInclusion/exclusion\ncriteria: included\nprimary studies,\ncommentaries, review\narticles, excluded\nabstracts\nUS Preventative\nTask Force\n2903Int Urogynecol J (2021) 32:2899–2912\n\n(48.06%), ASRM (48.03%), SOGC (47.34%) and ISPOG\n(31.55%) guidelines (Table 2).\nMean domain scores varied greatly from 13.16% to\n81.11%. Guidelines performed best in the “Scope and\nPurpose” (mean 81.11%, range 54.44–93.30) and “Clarity of\nPresentation” (mean 76.85%, range 53.33 –97.78) domains.\nThe ASRM and EAU guidelines achieved the highest scores\nin the “Scope and Purpose ” domain. The ACOG and EAU\nguidelines achieved the highest scores in the “Clarity of\nPresentation” domain (Table 2). Guidelines were of low qual-\nity in the “Applicability” (mean 13.61%, range 0.83 –29.17),\n“Editorial Independence” (mean 40.28%, range 0 –91.67%)\nand “Stakeholder Involvement ” (mean 44.44%, range\n14.44– 60.00) domains. The ACOG, SOGC and ISPOG\nguidelines recorded the lowest scores in these domains\n(Table 2).\nThe Fleiss kappa index varied between 0.217 to 0.386 and\ndemonstrated fair agreement between reviewers (Table 2).\nRecommendations for clinical practice\nIn total, we extracted 228 recommendations across six guide-\nlines. We grouped recommendations into the following cate-\ngories: diagnosis (96 recommendations), medical treatment\n(72 recommendations), surgical treatment (29 recommenda-\ntions), behavioural/physical interventions (18 recommenda-\ntions), alternative treatments (7 recommendations) and\neducation/research (5 recommendations).\nOverall, 39 recommendations (17.11%) were comparable\nacross guidelines including a comprehensive pain history,\nmultifactorial nature of CPP including attributing muscular\ncauses of CPP, an assessment of quality of life and multi-\ndisciplinary approach. There was significant variation in rec-\nommendations regarding hormonal treatment, role of surgical\ninterventions (adhesiolysi s, hysterectomy, presacral\nneurectomy and uterosacral nerve ablation) as well the effec-\ntiveness of psychological and physical therapies.\nRisks of interventions and procedures were reported in five\nguidelines (ACOG, ASRM, EAU, SOGC and RCOG). The\nrationale of clinical decision making was discussed in all\nguidelines,\nDiagnosis\nNinety-seven recommendations regarding diagnosis and in-\nvestigation of CPP were made across guidelines. Of these,\n39 recommendations (40.21%) were comparable across all\nsix guidelines. Included guidelines described the multifactori-\nal nature of CPP including causes such as bladder pain syn-\ndrome (BPS), irritable bowel syndrome (IBS) and muscular/\nmyofascial dysfunction. All guidelines attributed CPP to\nmuscular/myofascial causes including trigger points.\nUrological conditions such as BPS and interstitial cystitis\nTable 2 AGREE II scores and recommendations\nGuideline Scope and\npurpose\nStakeholder\ninvolvement\nRigour of\ndevelopment\nClarity of\npresentation\nApplicability Editorial\nindependence\nGlobal\nrating\nFleiss kappa Appraisers\nrecommendation\nOverall\nscore\nACOG 77.78%\n(85)\n34.44%\n(46)\n49.17%\n(158)\n81.11%\n(88)\n0.83%\n(21)\n45.00%\n(37)\n66.67%\n(25)\n0283 (CI\n0.225–0.340)\nRecommend with\nmodifications\n48.06%\nARSM 93.3%\n(99)\n38.89%\n(50)\n49.58%\n(159)\n72.22%\n(80)\n14.17%\n(37)\n20.00%\n(22)\n73.33%\n(27)\n0.386 (CI\n0.323–0.449)\nRecommend with\nmodifications\n48.03%\nEAU 82.22%\n(89)\n60.00%\n(69)\n62.50%\n(190)\n97.78%\n(103)\n25.00%\n(50)\n91.67%\n(65)\n80.00%\n(29)\n0.243 (CI\n0.154–0.332)\nRecommend 69.86%\nISPOG 54.44%\n(64)\n14.44%\n(28)\n30.42%\n(113)\n53.33%\n(63)\n3.33%\n(24)\n33.33%\n(30)\n26.67%\n(13)\n0.241\n(0.180–0.301)\nNone 31.55%\nSOGC 88.89%\n(95)\n60.00%\n(69)\n47.08%\n(153)\n78.89%\n(86)\n9.17%\n(31)\n0.00\n(10)\n60.00%\n(23)\n0.279 (CI\n0.218–0.340)\nRecommend with\nmodifications\n47.34%\nRCOG 90.00%\n(\n96)\n58.89%\n(68)\n67.50%\n(202)\n77.78%\n(85)\n29.17%\n(55)\n51.67%\n(41)\n70.00%\n(26)\n0.217 (CI\n0.153–0.280)\nRecommend 62.50%\nMean\n(SD)\n81.11% (14.23) 44.44%\n(18.57)\n51.04%\n(13.03)\n76.85%\n(14.39)\n13.61%\n(11.50)\n40.28%\n(31.22)\nNA NA NA NA\nNotes\n() scores in brackets represent raw scores\n% are scaled scores calculated using the following formula: (obtained score – minimum possible score)/(maximum score– minimum score)\nOverall score calculated as mean of six domains\nCI: confidence interval\nSD: standard deviation\n2904 Int Urogynecol J (2021) 32:2899–2912\n\nwere featured in five guidelines (ACOG, ASRM, EAU,\nISPOG and RCOG). Three guidelines referred to endometri-\nosis (ASRM, ISPOG and RCOG) and four guidelines alluded\nto nerve damage (ACOG, EAU, ISPOG and RCOG). IBS was\ndescribed as a contributing factor by three guidelines (ACOG,\nASRM and RCOG).\nA detailed pain history was recommended by all guide-\nlines; however, only two guidelines suggested a visual ana-\nlogue scale (VAS) to measure pain intensity (ISPOG and\nSOGC). All guidelines recommended the evaluation of psy-\nchosocial factors including the recognition of concomitant\nmood disorders and assessment of quality of life. However,\nno guideline specified which patient-reported outcome mea-\nsurement instrument to utilize.\nInvestigation of CPP varied among guidelines. The role of\nimaging such as transvaginal ultrasound to exclude\nadenomyosis, adnexal masses and endometriosis was recom-\nmended by three guidelines (ASRM, ISPOG and RCOG).\nMRI was recommended by the RCOG guideline to diagnose\nadenomyosis; however, its ability to accurately detect\nendometriotic deposits was uncertain (ASRM and RCOG).\nDiagnostic laparoscopy was recommended by five guidelines\n(ASRM, EAU, ISPOG, RCOG, SOGC). However, the RCOG\nguideline suggested laparoscopy as a second-line investiga-\ntion if other therapeutic interventions fail. Cystoscopy was\nrecommended by the SOGC guideline only.\nA multi-disciplinary and multi-speciality approach to pain\nmanagement was explicitly stated by five guidelines (ACOG,\nEAU, ISPOG, RCOG and SOGC). Furthermore, the ACOG,\nISPOG and EAU guidelines also recommended that care of\npatients with CPP should be undertaken by pain medicine\nspecialists.\nMedical treatment\nSeventy-two recommendations were extracted regarding med-\nical treatment of CPP. No recommendations were comparable\nin this domain. Nineteen recommendations focused on anal-\ngesia. Treatments with the highest grade of recommendations\n(i.e. level of evidence 1a and grade A recommendation) were\nparacetamol, NSAIDs (non-steroidal anti-inflammatory\ndrugs), gabapentin, antidepressants, topical capsaicin and opi-\noids (Table S3).\nSimple analgesia including paracetamol and NSAIDs was\nspecifically recommended by two guidelines (EAU and\nASRM). The use of anticonvulsants such as pregabalin and\ngabapentin to treat CPP was described by four guidelines\n(ACOG, EAU, ISPOG and SOGC). Pain management with\nopioids was described by two guidelines (EAU and SOGC).\nHowever, only the EAU guideline stated which opioid to use,\nthe preferred route of administration, a detailed consenting\nprocess including risks of addiction and dependency as well\nas plans for monitoring. In comparison, the ACOG guideline\ndid not recommend treatment of CPP using opioids. Adjuvant\nmedications such as tricyclic anti-depressants were suggested\nby four guidelines (ACOG, EAU, ISPOG and SOGC).\nHormonal treatment was recommended for underlying\ngynaecological causes such as endometriosis by three guide-\nlines (ASRM, SOGC and RCOG). The use of oral contracep-\ntives as a first-line treatment was stated by two guidelines\n(ASRM and SOGC). Progestins, Danazol and GnRH ana-\nlogues were considered as first-line treatments in women with\nsuspected endometriosis by the SOGC guideline. The ASRM\nguideline considered these as second-line treatments and rec-\nommended that an alternative diagnosis should be sought if\nadequate pain relief was not achieved. The RCOG also rec-\nommended hormonal treatment however did not specify\nwhich agents. A diagnostic laparoscopy was recommended\nin instances where pain was refractory to hormonal treatment\nafter 3 to 6 months (Table S3).\nDisease-specific treatments were described for BPS, chron-\nic anal pain syndrome, irritable bowel syndrome (IBS) and\nmyofascial dysfunction by four guidelines (ACOG, ASRM,\nEAU and SOGC). For suspected IBS, antispasmodics were\nrecommended by one guideline (RCOG). A comprehensive\nlist of BPS treatments including lifestyle modifications, oral\nmedications, neuromodulation, intravesical therapies includ-\ning trigonal and submucosal injections as well as\nhydrodistension was detailed by one guideline (EAU).\nManagement of chronic anal pain syndrome using inhaled\nsalbutamol, botulinum toxin A, electrogalvanic stimulation\nand percutaneous tibial nerve stimulation was described by\nthe EAU guideline (Table S3).\nSurgical treatment\nThis domain consisted of 29 recommendations. However,\nno recommendations were comparable despite surgical\nmanagement described by all guidelines. Twenty-four rec-\nommendations specifically referred to surgical procedures.\nThe highest grade of recommendations supported hyster-\nectomy for refractory symptoms, hysterectomy with ovar-\nian conservation for endometriosis/adenomyosis and treat-\nment of peritoneal pockets frequently associated with en-\ndometriosis and did not support routine adhesiolysis\n(Table S4). It must be noted that recommendations were\ngraded A or B and the level of evidence varied between I to\nII-2. One guideline did not describe a level of evidence\nsupporting recommendations (ACOG). No recommenda-\ntion of the highest grade (i.e. level of evidence I and grade\nA) was noted in the surgical domain (Table S4).\nHysterectomy was recommended by three guidelines for\nrefractory and severe symptoms (ASRM, ISPOG and\nSOGC). One guideline advised bilateral salpingo-\noophorectomy during hysterectomy to relieve symptoms such\nas CPP secondary to endometriosis (ASRM). In contrast, the\n2905Int Urogynecol J (2021) 32:2899–2912\n\nSOGC guideline suggested ovarian conservation was an ac-\nceptable option during hysterectomy for adenomyosis/endo-\nmetriosis. The use of HRT after hysterectomy and bilateral\noophorectomy for CPP secondary to endometriosis was de-\nscribed by a single guideline (SOGC).\nPresacral neurectomy and laparoscopic uterosacral nerve\nablation were discussed by two guidelines (ASRM and\nSOGC). The ASRM guideline did not recommend these in\ninstances of endometriosis-related CPP. However, it did sug-\ngest that presacral neurectomy may be beneficial in reducing\nthe severity of dysmenorrhoea. The SOGC guideline stated\nthe role of presacral neurectomy for pain reduction in endo-\nmetriosis remained unclear (Table S4).\nThere was a difference in recommendations regarding\nadhesiolysis. Laparoscopic adhesiolysis was supported by\nthe ISPOG guideline; however, the SOGC and ACOG guide-\nlines did not recommend routine laparoscopic adhesiolysis in\nthe context of CPP. The RCOG guideline recognized the ben-\nefit of dividing dense vascular adhesions to reduce pelvic pain\nbut did not support adhesiolysis of fine adhesions (Table S4).\nThree guidelines (ASRM, ISPOG and SOGC) recom-\nmended surgical treatment of endometriosis using laparoscop-\nic ablation or excision. A single guideline (EAU) described\nsacral neurostimulation for chronic anal pain syndrome.\nTransurethral resection of bladder lesions in type 3 BPS was\nrecommended by the EAU guideline. Ablative surgery for\nBPS was advised by a single guideline as a last resort and\nby knowledgeable surgeons only (EAU) (Table S4).\nBehavioural/physical interventions\nEighteen recommendations described behavioural interven-\ntions. No recommendations were comparable across guide-\nlines. The highest grade (i.e. level of evidence I and grade\nA) of recommendations supported psychological interven-\ntions combined with medical/surgical, biofeedback treatment\nin pelvic pain and dyssynergic defecation and biofeedback as\nan adjunct to muscle exercises in overactive pelvic floor mus-\ncles (Table S5).\nPsychological treatments were recommended by three\nguidelines (ACOG, EAU and ISPOG). The EAU and\nISPOG guidelines recommended integrating psychological\ninterventions with standard medical/surgical treatments for\nCPP. The EAU guideline specifically referred to the role of\npsychological treatment in various conditions including PBS,\nurethral pain syndrome and chronic vulvar pain.\nThe ACOG guideline recommended cognitive behavioural\ntherapy, pelvic floor physiotherapy or sexual therapy alone or\nin combination to manage m yofascial dysfunction and\ndyspareunia secondary to CPP. Only one guideline (EAU)\nrecommended training pelvic floor muscles to improve quality\nof life and sexual function. The EAU guideline advocated\nusing behavioural strategies for patients and their partners\nwith sexual dysfunction secondary to CPP.\nPhysiotherapy was recommended by a single guideline\n(EAU) for BPS and pelvic floor overactivity. Pelvic floor\nmuscle treatment was considered a first-line treatment in\nCPP by the EAU guideline.\nOnly one guideline (SOGC) reported the use of exercise in\nthe treatment of CPP due to myofascial dysfunction. No fur-\nther details regarding the type of exercise (aerobic or resis-\ntance) were provided (Table S5).\nComplementary and alternative treatments\nSeven recommendations focused on alternative treatments.\nNo recommendations were comparable across guidelines.\nThe highest grade (i.e. level of evidence I and grade A) of\nrecommendations supported treatment of myofascial trigger\npoints by dry needling or pressure (Table S5). There were\nconflicting statements regarding dry needling of trigger points\n(EAU and ISPOG).\nOne guideline reported limited data supporting the use of\nalternative therapies to treat CPP including acupuncture, trig-\nger point treatment, reflexology, biofeedback, distension ther-\napy, homoeopathy and Thiele massage (ISPOG). A single\nguideline (EAU) supported the use of alternative therapies\nsuch as TENS to treat CPP. There were no consistent recom-\nmendations regarding acupuncture and use was limited to spe-\ncific clinical scenarios. The EAU guideline did not recom-\nmend acupuncture in the treatment of BPS. However, the\nACOG guideline supported use of acupuncture in CPP sec-\nondary to muscoskeletal aetiology (Table S5).\nRecommendations for education and research\nFive recommendations were relevant to education and re-\nsearch. No recommendations were comparable in this domain.\nOne guideline advised incorporating CPP into the curricula of\nhealth professionals (SOGC). Two guidelines outlined future\nresearch priorities including the role of gene therapy, effec-\ntiveness of surgical management and investigating myofascial\nand sexual dysfunction in CPP (EAU and SOGC).\nEvidence supporting recommendations\nThree guidelines (EAU, RCOG and SOGC) reported the grad-\ning of evidence used to support recommendations. Each\nguideline used a different grading scale including the Oxford\nCentre for Evidence-based Medicine Levels of Evidence\n(EAU), the Scottish Intercollegiate Guidelines Network\n(SIGN) grading system (RCOG) and the Canadian Task\nForce on Periodic Health Exam grading (SOGC). Of note,\nthe ACOG guideline evaluated evidence using the US\nPreventative Services Task Force grading system; however,\n2906 Int Urogynecol J (2021) 32:2899–2912\n\nthe level of evidence supporting each recommendation was\nnot reported.\nThe total number of references cited in guidelines ranged\nfrom 22 to 644. The number of Cochrane reviews cited by\neach guideline ranged from 1 to 20. One guideline did not use\nany Cochrane reviews to support recommendations. The total\nnumber of RCTs used per guideline ranged from 6 to 32.\nAlmost half of the recommendations (106, 46.49%) were\nunreferenced, made in the absence of good quality evidence\nor supported by expert opinion.\nDiscussion\nMain findings\nThere is significant variation in CPP guideline quality and\nrecommendations. We identified 189 unique recommenda-\ntions but only 39 recommendations were comparable across\n6 guidelines. A lack of consensus was observed in recommen-\ndations regarding medical and surgical treatments as well as\ncomplementary/alternative therapies. Nearly half of recom-\nmendations (108, 46.55%) were unreferenced, or made in ab-\nsence of good quality evidence or supported by expert opin-\nion. The quality of guidelines was variable; only two guide-\nlines were assessed as high quality using the AGREE II in-\nstrument. Guidelines performed poorly in the“Applicability”,\n“Editorial Independence ” and “Stakeholder Involvement ”\ndomains.\nStrength and limitations\nTo our knowledge, this is the first study to systematically\nappraise the methodological quality and map recommenda-\ntions of CPP guidelines. We used robust and reproducible\nmethods that have been successfully implemented in previous\nstudies. To improve the scientific rigour of this review, five\nreviewers trained in using the AGREE II tool assessed guide-\nlines, thereby minimizing possible bias arising from data col-\nlection or inherent limitations of the AGREE II tool related to\ninter-observer variations. Nevertheless, the inter-rater agree-\nment among reviewers was fair.\nThis study has limitations. The AGREE II instrument is\nused to assess the rigour of guideline development rather than\nthe quality of guideline content. Scoring achieved using the\nAGREED II tool is not a reflection of applicability or imple-\nmentation in clinical practice [ 15]. All reviewers were from\nthe same medical speciality and this may have influenced\nscores assigned to guidelines. However, as our focus was fe-\nmale CPP we feel that the clinical and research expertise of the\nassessors may counteract this limitation. Our research group\nincluded individuals with clinical expertise in minimal access\ngynaecological surgery (HJ and VG), reproductive medicine\nand surgery (VS) and urogynaecology (JL and SKD), thus\nproviding different clinical perspectives from sub-specialities\nwithin gynaecology. Our ability to synthesize and compare\nrecommendations was limited by the varied scope and small\nnumber of guidelines. However, by including guidelines that\nare diverse may provide a comprehensive and informative\noverview of available guidance. We included guidelines pub-\nlished between 2002 and 2018. However, only two guidelines\n(ACOG and SOGC) were published after the introduction of\nstandardized terminology in CPP syndromes [ 3]. The use of\nstandardized terminology can help improve identification, di-\nagnosis and treatment. Our understanding and approach to\nCPP is an evolving process; however, guidelines may not be\nan accurate reflection if they are not updated regularly.\nInterpretation\nThis systematic review reflects variations in guideline recom-\nmendations and the poor quality of guideline development.\nSimilar results were found in studies critically appraising the\nquality of guidelines including BPS, endometriosis, obstetric\nperineal lacerations and the use of transvaginal mesh implants\nin prolapse [ 7, 8, 10, 16]. Challenges of guideline develop-\nment are not unique to a specific area of medicine but repre-\nsent a generic issue arising from a lack of standardization. Our\nfindings contribute to the existing body of evidence\nsupporting the need to harmonize national and international\nguidelines. A coordinated and collaborative approach is re-\nquired among guideline developers. Guidelines should be de-\nveloped using transparent and robust methods such as those\noutlined by the AGREE II tool. This will facilitate the com-\nparability and harmonization of guidelines and their recom-\nmendations as differences in guideline development methods\ncan result in varying recommendations. Standardized guide-\nline development will minimize any unwarranted and unjusti-\nfied variations in clinical practice.\nVarious terminology has been used by authors and organi-\nzations to describe clinical practice recommendations. These\nhave included clinical practice guidelines, consensus state-\nments, position statements, practice alerts and hybrid terms\nsuch as consensus guidelines. Such terms can be indicative\nof the level of evidence and strength of recommendations.\nHowever, authors have used these terms interchangeably with\na lack of consistency and available evidence. This poses a\nparticular problem and possibly a challenge in harmonization\nof clinical guidance, as encountered in this study, of identify-\ning “true” clinical practice guidelines that are developed using\nrigorous methodology. The use of inconsistent terminology\nmay mislead clinicians about the level of confidence to place\nin recommendations and the process by which they were de-\nveloped. Further consensus initiatives are needed for transpar-\nency and clarity regarding the definitions of these terminolo-\ngies [17].\n2907Int Urogynecol J (2021) 32:2899–2912\n\nGuidelines support and provide an evidence base to the\nclinical decisions made in daily practice. However, we ob-\nserved that almost half of all recommendations were made\ndespite the absence of good quality evidence. The shortage\nof primary research supporting the management of women\nwith CPP may prohibit the development of useful guidelines\n[18]. Furthermore, the quality of existing RCTs evaluating\nCPP interventions is variable with significant variability in\noutcome selection and reporting [5]. A working group within\nCHORUS is currently in the progress of establishing core\noutcome sets (COS) in CPP. Implementation of a COS will\npromote greater reporting consistency and reduce outcome\nreporting bias by stipulating a minimum set of criteria to re-\nport. It will also facilitate the comparability and synthesis in\nmeta-analysis to produce high-quality results leading to in-\nformed healthcare decisions.\nDiagnostic and therapeutic guideline recommendations are\nhelpful in standardizing and improving the quality of care.\nHowever, they are limited and may not be relevant or apply\nin every clinical field of practice. CPP is a manifestation\nresulting from various underlying conditions that may evolve\nand develop into regional pain disorders. The complex\naetiology of CPP and scarcity of available evidence may cause\nclinicians to resort to their own experience or seek expert\nopinions. A holistic approach is needed as underlying causes,\ntreatment options and concerns of women with CPP can vary.\nAdditionally, groups/societies publish guidelines for their\nmembers rather than a broader audience. The focus and scope\nof guidelines may be influence d by the clinical/scientific\ntheme, interests or priorities of publishing societies/\nprofessional groups. For example, professional bodies for\ngynaecologists may focus on endometriosis only in women\npresenting with CPP. This may have contributed to the vari-\nability of recommendations for the management of female\nCPP observed in this study. The inclusion of a multidisciplin-\nary stakeholder committee will help produce concise and col-\nlaborative recommendations that prevent duplicate investiga-\ntions and the recommendation of ineffective treatments. This\nstudy indicated that guidelines performed poorly in the\nStakeholder Involvement domain reflecting unilateralism in\ntheir approach to CPP including a lack of engagement and\nparticipation with their target audience, i.e. women with CPP.\nIn this review, all guidelines recommended surgical inter-\nvention; however, there was no consensus among guidelines.\nThe lack of consistent recommendations presents difficulty\nwhen supporting or refuting the effectiveness of surgical pro-\ncedures, such as adhesiolysis, to manage female CPP. The\nbenefit of bilateral salpingo-oophorectomy during hysterecto-\nmy was also unclear with contradictory advice given in two\nguidelines. There is a place for hysterectomy in the manage-\nment of CPP particularly due to endometriosis; however, pa-\ntient selection is paramount [ 19]. Furthermore, recent studies\nhave shown that bilateral removal of normal ovaries during\nhysterectomy does not result in improved outcomes but in fact\nis associated with increased morbidity [ 19–21]. Guidelines\nshould not only focus on identifying effective interventions\nby utilizing the best available evidence but also provide guid-\nance on which patient factors may contribute to the success\nand failure of such interventions [22].\nIn an era of patient-centred care, it was concerning that no\nguideline reported including women with CPP in the devel-\nopment process. Views and perceptions of women with CPP\ncan be incorporated to frame the overarching theme of future\nguidelines as well as ensure the quality and relevance of rec-\nommendations. For example, all guidelines discussed the as-\nsociation of sexual abuse and CPP. However, no guideline\nspecifically outlined recommendations pertaining to sexual\nabuse. Furthermore, no guideline reported women ’s experi-\nences to support the use of recommended interventions.\nThese insights are invaluable for policymakers and guideline\ndevelopers. The identification of barriers and facilitators can\ninfluence the successful implementation of interventions. In\nthis review, included guidelines may not have incorporated\nqualitative research findings because of a lack of primary\nqualitative studies exploring the experiences of women with\nCPP [18, 23].\nThe detrimental impact of CPP on quality of life outcomes\nhas been described and identified as a priority for women with\nCPP [18]. Despite this, quality of life assessment is only re-\nported by half of RCTs evaluating treatments for CPP [5]. Our\nfindings demonstrated that all guidelines referred to the mea-\nsurement of quality of life; however, there was no recommen-\ndation regarding which measurement instrument to utilize.\nOur previous systematic review identified 17 quality of life\nmeasurement instruments; however, further research is re-\nquired to assess the validity of such instruments in a CPP\npopulation [5].\nThere is an increased prevalence of sexual dysfunction ob-\nserved in women with CPP compared with those without CPP\n(69.6% versus 30.4%) [24]. Underlying pelvic floor dysfunc-\ntion including pelvic floor muscle overactivity and myofascial\ntrigger points have been implicated in sexual disorders.\nDespite the impact of sexual dysfunction on the psychological\nand emotional well-being of women, we only identified two\nguidelines that recognized concurrent sexual dysfunction in\nwomen with CPP [ 25]. The ACOG and EAU guideline rec-\nom\nmended pelvic floor physiotherapy to improve quality of\nlife and sexual function. Although there is increasing evidence\nto support the use of physiotherapy in CPP and sexual dys-\nfunction, it remains underused in clinical practice [26].\nSimilarly, exercise has been successfully incorporated into\nmultidisciplinary treatment programmes to treat female CPP\n[4, 27]. Available evidence suggests that physical activity/\nexercise as an intervention is associated with few adverse\nevents and may improve pain intensity, physical function\nand consequently quality of life [ 28]. However, our study\n2908 Int Urogynecol J (2021) 32:2899–2912\n\ndemonstrated that only one guideline recommended the use of\nexercise in the management of CPP despite such benefits.\nGuideline developers need to incorporate multidisciplinary\ntreatment modalities such as physiotherapy and exercise to\nmaximize treatment benefits derived from conventional\nmedical/surgical interventions.\nOur findings are consistent with other studies that noted the\nApplicability, Editorial Independence and Stakeholder\nInvolvement domains as areas of improvement for future\nguideline development [7, 8, 10, 16].\nOur findings suggest that guidelines performed poorly in\nthe Stakeholder Involvement domain. Guidelines failed to en-\ngage and involve women with CPP in the development pro-\ncess. Most guidelines were unsuccessful at including individ-\nuals from relevant professional groups therefore narrowing\ntheir scope to managing CPP. For example, only a single\nguideline included health professionals from various disci-\nplines such as gastroenterology, neurology, pain medicine,\nurology and psychology. The inclusion of a multidisciplinary\nguideline development group will help produce concise and\ncollaborative recommendations. Furthermore, in complex\nconditions such as CPP which may be due to a single or\nmultiple concurrent causes or indeed idiopathic, input from\nmultiple specialities is required. It is vital that clinical path-\nways are efficient and coordinated. A diagnostic pathway can\noften be a frustrating and negative experience for women with\nCPP hindered by delay [18]. Guideline developers such as the\nNational Institute of Clinical Excellence (NICE) have initia-\ntives such as the Patient Public Involvement Programme\n(PPIP) to support opportunities for patients and the public to\nbe involved in developing guidance. Additionally, guideline\ndevelopers can contact patient organizations to assist with the\nrecruitment and inclusion of patients on their panels.\nThe Applicability domain refers to the implementation of\nguideline recommendations. Various factors can influence the\nsuccessful implementation of guidelines such as the aware-\nness of recommendations, associated costs and resource im-\nplications. Development of guidelines without effective and\nstructured implementation strategies may not lead to the ex-\npected changes in clinical practice. Identification of barriers\nand facilitators in advance and incorporating these into the\nguideline development process can lead to tailored implemen-\ntation strategies. These can improve adherence and avoid un-\nnecessary investigations and inadequate interventions [29].\nMaintaining editorial independence is vital to ensure the\nreliability and validity of recommendations. Influence or in-\nterference from funding bodies or conflicts of interest from\nmembers of the guideline development group can introduce\nbias and undermine the credibility of the guideline develop-\nment process. Conflicts of interest can be mitigated by guide-\nline developers obtaining and presenting full and transparent\ndisclosures.\nConclusion\nThe majority of guidelines were of moderate quality with sig-\nnificant variation in recommendations and the quality of\nguideline development. Adoption of standardized guideline\ndevelopment methods will ensure guideline recommendations\nare relevant, reliable and transferrable to clinical practice.\nAppendix 1\nTable 3 AGREE II domains and\ndefinitions Domain Definition\n1. Scope and Purpose Is concerned with the overall aim of the guideline, the specific health questions and the\ntarget population\n2. Stakeholder\nInvolvement\nFocuses on extent to which guideline was developed by appropriate stakeholders and\nrepresents the views of its intended users\n3. Rigour of\nDevelopment\nRelates to the process used to gather and synthesize the evidence, the methods to\nformulate the recommendations and to update them\n4. Clarity of\nPresentation\nDeals with the language, structure and format of the guideline\n5. Applicability Pertains to the likely barriers and facilitators to implementation, strategies to improve\nuptake and resource implications of applying the guideline\n6. Editorial\nIndependence\nIs the formulation of recommendations not being unduly biased with competing\ninterests\n2909Int Urogynecol J (2021) 32:2899–2912\n\nAppendix 2\nRecords iden/g415fied through \ndatabase searching\n(n =1294)\nScreeningIncluded Eligibility Iden/g415fica/g415on\nAddi/g415onal records iden/g415fied \nthrough other sources\n(n = 12)\nRecords a/g332er duplicates removed\n(n =651)\nRecords screened\n(n = 651)\nRecords excluded a/g332er \nreading /g415tle or abstract\n(n = 630)\nFull-text ar/g415cles assessed \nfor eligibility\n(n = 21)\nFull-text ar/g415cles excluded, \nwith reasons\n(n = 16)\nNot a guideline (bulle/g415n, \nreviews) (5)\nOutdated guideline (1)\nDuplicate guideline (1)\nEndometriosis related (4)\nProstate related –(1)\nNon-specific pain-(2) \nNot in English (1)\nUnable to obtain full text \n(1) \nStudies included in \nqualita/g415ve synthesis\n(n = 6)\nFig. 1 PRISMA flow diagram\n2910 Int Urogynecol J (2021) 32:2899–2912\n\nAppendix 3. List of specialist society websites\nsearched\nAmerican Association of Family Practice (AAFP).\nAmerican College of Obstetricians and Gynaecologists\n(ACOG).\nBritish Association of Urological Surgeons (BAUS).\nBritish Fertility Society (BFS).\nBritish Society of Gastroenterology (BSG).\nBritish Society of Gynaecological Imaging (BSGI).\nBritish Society of Gynaecological Endoscopy (BSGE).\nBritish Society of Pain (BPS).\nBritish Society Psychosomatic Obstetrics, Gynaecology\nand Andrology (BSPOGA).\nBritish Society of Urogynaecology (BSUG).\nBritish Society of Biopsychosocial Obstetrics and\nGynaecology.\nInstitute of Psychosexual Medicine.\neGuidelines.co.uk\nEuropean Association of Urology (EAU).\nEuropean Society of Gastroenterology (ESGE).\nEuropean Society of Gynaecology.\nEuropean Society Gynaecological Endoscopy (ESGE).\nFaculty of Pain Medicine.\nIndian College of Obstetricians and Gynaecologists\n(ICOG).\nInternational Association for the study of pain.\nInternational Federation of Gynaecology and Obstetrics\n(FIGO).\nInternational Urogynecology Association (IUGA).\nNational Institute of Clinical Excellence (NICE).\nRoyal Australian and New Zealand College of Obstetrics\nand Gynaecology (RANZOG).\nRoyal College of Obstetricians and Gynaecologists\n(RCOG).\nScottish Intercollegiate Guidelines Network (SIGN).\nTurning Research into Practice.\nSupplementary Information The online version contains supplementary\nmaterial available at https://doi.org/10.1007/s00192-021-04848-1.\nAuthors’ contribution V Ghai: Study conception, design, data collection,\nanalysis, drafted the manuscript.\nV Subramanian: Data collection, analysis, review of draft manuscript.\nH Jan: Data collection and review of draft manuscript.\nJ Loganathan: Data collection and review of draft manuscript.\nSK Doumouchtsis: Study conception, review of study design, data\ncollection and draft manuscript.\nDeclarations\nConflict of interest The authors report no conflicts of interest.\nDetails of ethical approval This review is based on data published in\nprevious trials. No approval was required from an institutional review\nboard.\nOpen Access This article is licensed under a Creative Commons\nAttribution 4.0 International License, which permits use, sharing, adap-\ntation, distribution and reproduction in any medium or format, as long as\nyou give appropriate credit to the original author(s) and the source, pro-\nvide a link to the Creative Commons licence, and indicate if changes were\nmade. The images or other third party material in this article are included\nin the article's Creative Commons licence, unless indicated otherwise in a\ncredit line to the material. If material is not included in the article's\nCreative Commons licence and your intended use is not permitted by\nstatutory regulation or exceeds the permitted use, you will need to obtain\npermission directly from the copyright holder. To view a copy of this\nlicence, visit http://creativecommons.org/licenses/by/4.0/.\nReferences\n1. 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