Reframing Chronic Pelvic Pain in Women: Central Sensitization, Psychosocial Burden, and Mechanism-Based Multidisciplinary Care

Introduction and Hypothesis Chronic pelvic pain (CPP) often persists despite repeated organ-directed evaluation and treat- ment. We proposed that integrating disease-specific diagnosis with pain-mechanism phenotyping would provide a more clinically useful framework for explaining symptom persistence and selecting care.

A structured narrative review was conducted using PubMed/MEDLINE, PubMed Central, the Cochrane Library, professional guidelines, journal websites, and reference lists. English-language literature published from January 2020 to May 2026 was prioritized, with earlier seminal sources included for foundational concepts.

Evidence indicates that CPP commonly reflects interacting nociceptive, neuropathic, nociplastic, musculoskeletal, psychological, sexual, and social contributors. Central sensitization and nociplastic pain may help explain disproportionate, widespread, or persistent pain, while pelvic floor dysfunction, distress, catastrophizing, fear-avoidance, sleep disturbance, and sexual pain can intensify disability. Current guidelines and reviews support comprehensive assessment, pelvic floor physical therapy when indicated, pain neuroscience education, psychological pain interventions, sexual counseling, disease-specific treatment, and coordinated multidisciplinary follow-up. Treatment matching should be based on dominant mechanisms and patient-prioritized outcomes rather than diagnosis or pain intensity alone.

A mechanism-based biopsychosocial approach validates CPP as real while broadening therapeutic targets. Combining rigorous disease evaluation with pain phenotyping may reduce fragmented care and improve function, intimacy, quality of life, and patient–clinician communication.

Biopsychosocial model · Central sensitization · Chronic pelvic pain · Multidisciplinary care · Nociplastic pain · Pelvic floor dysfunction

Chronic pelvic pain (CPP) in women is not a single diag- nosis, but a complex and often disabling health condi- tion that crosses the boundaries of gynecology, urology, gastroenterology, musculoskeletal medicine, pain medicine, and mental health. It is commonly defined as persistent or recurrent pain perceived in the pelvic region, usually last- ing for 6 months or longer, and is associated with functional impairment, reduced quality of life, and substantial health care use. CPP has been described as a major clinical chal- lenge in women’s health shaped by the interaction of bio - logical, psychological, and social factors [1 ]. The Ameri- can College of Obstetricians and Gynecologists similarly emphasizes that CPP may persist even when it is not fully explained by identifiable gynecologic, urologic, or gastro- intestinal pathology [2]. Women with CPP are often evaluated through organ- based pathways and may receive separate diagnoses such as endometriosis, bladder pain syndrome/interstitial cystitis, vulvodynia, provoked vestibulodynia, dyspareunia, irritable bowel syndrome, or pelvic floor myalgia. These diagnoses Handling Editor: Jaromir Masata Editor in Chief: Maria A. Bortolini * Yael Sela [email protected] 1 Department of Nursing Sciences, Faculty of Social and Community Sciences, Ruppin Academic Center, 4025000 Emek Hefer, Israel 2 Department of Health Systems Management, Faculty of Health Sciences, Ariel University, 40700 Ariel, Israel 3 Myers-JDC-Brookdale Institute, Jerusalem, Israel International Urogynecology Journal are clinically meaningful and may guide specific treatment. However, they do not always explain the severity, persis- tence, distribution, or recurrence of pain. Earlier interdisci- plinary work conceptualized chronic pelvic pain syndrome as a multifactorial condition in which urogynecological, gastrointestinal, musculoskeletal, neurological, endocrine, immune, and psychological processes may interact [3]. This perspective remains relevant because many women continue to move between specialists and repeated investigations without receiving an integrated explanation for their pain experience. A central limitation of a purely organ-based model is that visible pathology does not consistently correspond to pain severity or treatment response. Contemporary pain science increasingly recognizes central sensitization and nociplastic pain as mechanisms that may contribute to persistent pel- vic pain. Nociplastic pain refers to pain arising from altered nociception despite no clear evidence of tissue damage or somatosensory disease sufficient to explain the pain [4 ]. In women with CPP, higher nociplastic pain features have been associated with greater pain severity, pain frequency, pain interference, pelvic myofascial pain, and high-impact pain [5]. In endometriosis-associated CPP, sensitization may con- tribute to pain within and beyond the pelvis, supporting the need to look beyond lesion-directed explanations alone [ 6, 7]. Similarly, in bladder pain syndrome/interstitial cystitis, response to treatment may depend on inflammatory, sensory, bladder-specific, and pain-processing phenotypes rather than on diagnosis alone [8]. This reframing is especially important because CPP affects much more than pain intensity. It may disrupt sexual function, intimacy, fertility-related decision-making, mood, sleep, work participation, physical activity, and trust in health care. Psychosocial factors are often misunderstood in CPP. Their relevance does not mean that pain is psy - chological or less real. Rather, pain catastrophizing, fear- avoidance, anxiety, depression, illness perceptions, trauma exposure, and distress may interact with neurophysiological pain mechanisms and contribute to symptom amplification, disability, repeated health care use, and reduced response to treatment. Recent guidelines increasingly support this broader approach. The 2024 Society of Obstetricians and Gynae- cologists of Canada guideline provides evidence-based recommendations for chronic pelvic pain management in adolescent and adult female individuals and emphasizes multifactorial assessment and care [9 ]. The 2026 European Association of Urology guideline similarly frames chronic pelvic pain as a multidimensional condition requiring atten- tion to pain mechanisms, emotional well-being, behavior, sexual function, and daily functioning [10]. Recent system- atic reviews also support the clinical relevance of biopsy - chosocial and conservative nonpharmacological approaches, particularly pelvic floor and multimodal physical therapy, while emphasizing the need for better-defined care models and patient-centered outcomes [11, 12]. The aim of this narrative review is to reframe CPP in women as a biopsychosocial and mechanism-based pain condition, with particular attention to mechanisms of pain persistence, psychosocial burden, sexual health, and multi- disciplinary care.

Design and Scope This article was designed as a structured narrative review of current evidence regarding central sensitization, nociplastic pain, psychosocial burden, sexual health, and mechanism- based multidisciplinary care in women with CPP. The pur - pose was to provide an integrative clinical synthesis rather than a systematic review, meta-analysis, or comprehensive evidence map. Accordingly, the review used a structured search strategy and predefined eligibility domains, but did not include duplicate independent screening, formal risk-of- bias appraisal, or quantitative synthesis. Information Sources and Search Strategy A structured literature search was conducted using PubMed/ MEDLINE, PubMed Central, the Cochrane Library, and publicly available professional guideline sources. Additional searches were performed through relevant journal websites and the reference lists of key reviews, guidelines, and empir- ical studies. The main search period covered publications from January 2020 to May 2026. Earlier seminal articles were included when they provided foundational concepts related to CPP, central sensitization, nociplastic pain, pelvic floor dysfunction, pain catastrophizing, or biopsychosocial models of chronic pain. Search terms were combined using Boolean operators and included chronic pelvic pain, chronic pelvic pain syndrome, women, female, central sensitization, nociplastic pain, pain modulation, overlapping pain conditions, pelvic floor dysfunction, pain catastrophizing, fear avoidance, anxiety, depression, psychological distress, sexual function, qual- ity of life, biopsychosocial model, multidisciplinary care, pelvic floor physical therapy, cognitive behavioral therapy, and acceptance and commitment therapy. Additional con - dition-specific searches included endometriosis-associated CPP, bladder pain syndrome, interstitial cystitis, vulvodynia, provoked vestibulodynia, dyspareunia, irritable bowel syn- drome, and pelvic floor tenderness. International Urogynecology Journal Eligibility Criteria and Synthesis Articles were considered for inclusion if they were avail- able in English and addressed CPP or related chronic pelvic pain conditions in women. Studies were included when they contributed evidence on central sensitization, nociplastic pain, altered pain modulation, overlapping pain conditions, psychosocial distress, sexual function, quality of life, pelvic floor dysfunction, biomarkers, treatment response, or mul- tidisciplinary management. Eligible publications included clinical guidelines, consensus statements, systematic and scoping reviews, narrative reviews, randomized controlled trials, observational studies, qualitative studies, mixed-

studies, and clinically relevant case reports. Case reports were included only when they illustrated diagnostic complexity, comorbidity, or mechanisms directly relevant to the review aim. Articles were excluded if they focused exclusively on male pelvic pain, acute pelvic pain, pregnancy-related pel- vic pain, postoperative pain, malignancy-related pain, or purely surgical management without relevance to chronic pain mechanisms, psychosocial burden, sexual health, or women’s health implications. Conference abstracts without full text and non-English publications were also excluded. Potentially relevant publications identified through the struc- tured searches were assessed for relevance to the predefined review domains. Titles and abstracts were initially reviewed, followed by full-text assessment when appropriate. Publica- tions were included when they met the eligibility criteria and contributed relevant evidence to one or more of the prede- fined mechanistic, psychosocial, functional, or management domains. The final narrative synthesis included 25 publications, comprising four clinical guidelines or professional guidance sources, ten systematic or scoping reviews and meta-analy- ses, four narrative or clinical reviews, six observational or prospective studies, and one other clinically relevant publi- cation. Because of the heterogeneity of diagnostic catego- ries, populations, mechanisms, interventions, and outcomes, findings were synthesized narratively. Greater interpretive weight was given to clinical guidelines, systematic and scoping reviews, randomized trials, prospective studies, and studies using validated assessment tools. A summary of the search strategy, eligibility criteria, and narrative synthesis framework is presented in Table  1. Synthesis and Discussion CPP as a Biopsychosocial and Mechanism‑Based Condition CPP in women is best understood not as a single disease entity, but as a clinical syndrome in which multiple mecha- nisms may converge over time. Traditional diagnostic path- ways commonly begin by asking which organ system is responsible for the pain. This approach is necessary because conditions such as endometriosis, bladder pain syndrome/ interstitial cystitis, vulvodynia, irritable bowel syndrome, pelvic floor myalgia, and musculoskeletal disorders may require specific evaluation and treatment. However, an organ-based model alone may be insufficient when pain persists despite disease-directed therapy, symptoms extend beyond a single anatomical site, or pain severity is not pro- portional to visible pathology. A biopsychosocial framework broadens clinical atten- tion from the location of pain to the mechanisms by which pain is generated, amplified, maintained, and experienced. Table 1 Structured narrative review framework Review element Specification Design and purpose Structured narrative review providing an integrative clinical synthesis rather than a systematic review, meta-analysis, or comprehensive evidence map Information sources PubMed/MEDLINE, PubMed Central, the Cochrane Library, professional guideline sources, relevant journal websites, and

lists of key publications Search period January 2020 to May 2026, with earlier seminal publications included when required for foundational concepts Core domains Chronic pelvic pain, central sensitization, nociplastic pain, pain modulation, overlapping pain conditions, pelvic floor dysfunction, psychosocial burden, sexual function, quality of life, and multidisciplinary care Eligibility English-language guidelines, reviews, randomized trials, observational studies, qualitative or mixed-methods studies, and clinically relevant case reports involving women with chronic pelvic pain or related conditions Selection process Potentially relevant publications were assessed against the predefined review domains and eligibility criteria, with full-text evaluation performed when appropriate Exclusions Male pelvic pain, acute pelvic pain, pregnancy-related pain, postoperative or malignancy-related pain, purely surgical reports without mechanism relevance, conference abstracts without full text, and non-English publications Synthesis approach Narrative synthesis with greater interpretive weight given to guidelines, systematic and scoping reviews, randomized or prospective studies, and studies using validated assessment tools International Urogynecology Journal Peripheral nociceptive input from pelvic organs, inflam - mation, hormonal factors, pelvic floor dysfunction, and musculoskeletal contributors may interact with altered pain processing, emotional distress, sleep disturbance, fear-avoid- ance, sexual pain, and prior health care experiences. This does not minimize the biological reality of pain. Rather, it recognizes that chronic pain is sustained through recipro- cal interactions among tissues, nerves, the central nervous system, behavior, and social context [1, 3]. Mechanism-informed phenotyping can make diagnosis more clinically useful. Two women with endometriosis may have very different pain profiles, and two women with bladder pain syndrome may differ in inflammatory mark - ers, urinary symptoms, pelvic floor tenderness, psychologi- cal distress, and central pain amplification. In women with CPP, higher nociplastic pain features have been associated with greater pelvic pain severity, pain frequency, pain inter- ference, pelvic myofascial pain, and high-impact pain [ 5]. Clinical profiling studies also indicate that diagnostic sub- groups of women with CPP differ in symptom patterns and quality-of-life impact, reinforcing the idea that diagnostic category alone is not sufficient to guide care [13]. Evidence from bladder pain syndrome/interstitial cystitis similarly suggests that treatment response may depend on inflamma- tory, sensory, bladder-specific, and pain-processing pheno- types rather than on diagnosis alone [8 ]. The purpose of a mechanism-based framework is there- fore not to replace medical diagnosis, but to integrate diagnosis with pain mechanisms, psychosocial burden, sexual health, and functional impact. Such an approach may reduce fragmented care, improve communication with patients, and support more individualized treatment plan- ning. The proposed integrated clinical logic is summarized in Fig.  1. Central Sensitization and Nociplastic pain Central sensitization and nociplastic pain may help explain why CPP may persist, spread, or become disproportion- ate to visible pelvic pathology [4 –7, 14]. In many women, pain begins with identifiable peripheral contributors such as endometriosis, bladder pain syndrome, pelvic floor dys- function, vulvodynia, inflammation, or musculoskeletal strain. Over time, persistent nociceptive input may alter pain processing within the peripheral and central nervous systems, producing heightened sensitivity to painful and non-painful stimuli [5 –7]. This process may help explain pain that extends beyond the pelvis, persists after disease- directed treatment, or coexists with other chronic pain con- ditions [6, 7]. The IASP definition of nociplastic pain is clinically useful because it validates pain as real and biologically grounded even when structural findings are limited or symptoms are not proportional to observed pathology [ 4]. Importantly, nociplastic pain does not exclude nociceptive or neuro - pathic mechanisms. Many women with CPP may have mixed Fig. 1 Mechanism-based biopsychosocial model of chronic pelvic pain in women. Chronic pelvic pain may begin with disease-specific or peripheral contributors, but pain persistence and disability are often shaped by central sensitization, nociplastic pain, pelvic floor dysfunction, psychosocial burden, sexual health consequences, and quality-of-life impairment. A mechanism-based approach integrates medical diagnosis with pain phenotyping, multidisciplinary care, and patient-prioritized outcomes International Urogynecology Journal mechanisms, including ongoing peripheral nociception, neu- ropathic-like symptoms, pelvic floor myofascial pain, and central pain amplification. Endometriosis-associated CPP illustrates the importance of this approach. Endometriosis is a well-recognized cause of pelvic pain, yet lesion location, extent, and severity do not always correspond to pain intensity or functional impair- ment. Some women continue to experience pain after hor - monal, surgical, or other disease-directed treatments. Karp and Stratton emphasized that endometriosis-associated CPP may involve neurogenic sensitization and pain beyond the pelvis, requiring attention to central mechanisms and comor- bid pain conditions [6 ]. A recent scoping review similarly concluded that central sensitization is increasingly recog- nized in endometriosis, but standardized methods for iden- tifying nociplastic pain remain limited [7 ]. Central sensitization is also relevant to vulvodynia and provoked vestibulodynia. Women with vulvodynia often report persistent vulvar pain, dyspareunia, pain with touch, and avoidance of sexual or gynecological contact. Rubal et al. highlighted the importance of considering central sensitization in diagnosis and individualized management [15], while Nimbi et al. showed that central sensitization symptoms in women with vulvodynia are linked with psy - chosocial factors and quality of life [16]. Clinically, central sensitization may be suspected when pain is widespread, persistent, disproportionate to findings, or accompanied by fatigue, sleep disturbance, heightened sensitivity, overlapping pain conditions, mood symptoms, or high pain interference. These features should not be used to label pain as unexplained or psychological. They should prompt assessment of additional therapeutic targets. At the same time, central sensitization should not become a diag- nostic shortcut; women with CPP still require careful evalu- ation for treatable gynecological, urological, gastrointestinal, neurological, and musculoskeletal contributors. Psychosocial Burden, Pain Catastrophizing, and Disability The psychosocial burden of CPP is part of how chronic pain is experienced, maintained, and translated into daily disabil- ity. Women living with CPP often face uncertainty, repeated investigations, delayed diagnosis, fragmented care, and dif- ficulty explaining symptoms that may not be visible or eas- ily localized. Over time, this uncertainty may contribute to distress, hypervigilance, reduced trust in health care, and avoidance of activities associated with pain. Psychosocial assessment should therefore be integrated into CPP care, not added only after biomedical explanations have been exhausted [1, 2]. Pain catastrophizing is an important cognitive-emotional process in chronic pain. It refers to an exaggerated negative orientation toward pain, including rumination, magnification of threat, and perceived helplessness. In CPP, catastrophiz- ing may intensify attention to pain, increase fear of symp - tom worsening, and reinforce avoidance behaviors. A sys- tematic review and meta-analysis of chronic cyclical pelvic pain demonstrated a significant positive association between pain catastrophizing and pain ratings [17]. It should not be interpreted as evidence that pain is imagined or exaggerated; rather, it reflects a modifiable response to persistent pain and uncertainty. Anxiety and depression are also clinically meaningful in CPP. A recent systematic review and meta-analysis confirmed a substantial burden of anxiety and depressive symptoms among women with CPP, with women with CPP approxi- mately twice as likely to have an anxiety disorder as women without CPP [18]. Their role is bidirectional: persistent pain can increase anxiety and depressive symptoms, while emo- tional distress may amplify pain perception, disrupt sleep, reduce coping resources, and impair engagement in treat- ment. Fear-avoidance links pain to disability when women avoid movement, sexual activity, exercise, urination, bowel function, gynecological examination, or daily tasks because they anticipate symptom worsening. Meta-analytic evidence across clinical pain populations further supports associations between pain catastrophizing, fear of pain, anxiety, depres- sion, pain intensity, and pain-related disability [19]. Avoid- ance can be protective in the short term, but over time may contribute to physical deconditioning, pelvic floor guarding, social withdrawal, sexual avoidance, and reduced confidence in the body. Somatic symptoms require careful and non-stigmatizing interpretation. Women with CPP may report fatigue, gastro- intestinal symptoms, urinary symptoms, diffuse pain, sleep disturbance, and heightened bodily sensitivity. These symp- toms may reflect overlapping pain conditions, central sensi- tization, autonomic dysregulation, psychological distress, or combined mechanisms. A case report of persistent CPP with comorbid somatic symptom disorder illustrates how central sensitization, distress, repeated investigations, and delayed integration of psychiatric and pain-focused care may coexist in complex presentations [20]. Because case reports are not generalizable, such evidence should be used only to illustrate clinical complexity. Psychological care should be presented as pain care. A systematic review of biopsychosocial approaches for female CPP found that cognitive behavioral therapy and acceptance and commitment therapy-based interventions may reduce pain and improve psychological outcomes [11]. Clinicians should avoid language that implies pain is only stress or all in the mind. A more constructive explanation is that chronic pain is influenced by nervous system sensitivity, pelvic tis- sues, sleep, mood, threat perception, muscle guarding, and International Urogynecology Journal lived experience. Such framing can reduce stigma, support the therapeutic alliance, and improve engagement with mul- tidisciplinary treatment. Sexual Function, Intimacy, and Quality of Life CPP affects far more than pain intensity. Because pelvic pain often involves body regions linked to sexuality, reproduc- tion, urination, bowel function, body image, and intimate relationships, its burden may be deeply personal and difficult to disclose. Women with CPP may experience pain during sexual activity, reduced sexual desire, avoidance of intimacy, fear of symptom worsening, distress during gynecological examination, and changes in body perception. These conse- quences are not secondary to the main pain problem; they are central to the clinical and lived burden of CPP. Sexual pain can function both as a symptom and as a driver of broader disability. Dyspareunia, vulvar pain, pro- voked vestibulodynia, endometriosis-associated pain, blad- der pain syndrome, and pelvic floor myalgia may all interfere with sexual function and intimacy. Pain-related fear may lead to avoidance of sexual activity or gynecological care, reinforcing anxiety, pelvic floor guarding, and relationship distress. Over time, pain, fear, avoidance, and emotional dis- tress may amplify one another [1, 3]. Vulvodynia and provoked vestibulodynia illustrate the need to assess sexual health as part of chronic pain care. Women with these conditions may report pain with touch, penetration-related pain, and avoidance of intimate or clini- cal contact. Central sensitization may intensify pain sen- sitivity and contribute to symptom persistence even when local findings are limited [15, 16]. Endometriosis-associated CPP similarly demonstrates the need to move beyond pain intensity alone. A systematic review and meta-analysis fur- ther demonstrated impaired sexual function across multiple domains in women with endometriosis, together with greater dyspareunia and chronic pelvic pain [21]. Treatment success should not be evaluated solely by lesion-directed outcomes or pain scores but also by changes in sexual function, emo- tional well-being, daily activity, and quality of life [6]. The importance of broader outcomes is reflected in clini- cal research. In a prospective study, Caruso et al. evaluated women with endometriosis-associated CPP using pain meas- ures as well as the Short Form-36, Female Sexual Function Index, and Female Sexual Distress Scale [22]. Although that study focused on a specific hormonal treatment, its outcome framework is relevant because it recognizes that improve- ment in CPP should include functioning, sexual well-being, and distress, not merely numerical pain reduction. Clinicians should normalize discussion of sexual function and intimacy as part of CPP care. Asking about sexual pain, avoidance, relationship impact, and emotional distress in a respectful and nonjudgmental way can identify needs that otherwise remain hidden. Depending on dominant mecha- nisms, treatment may include pelvic floor physical therapy, pain education, psychological pain therapy, sexual coun- seling, treatment of comorbid mood or anxiety symptoms, and coordinated communication among clinicians. Such approaches do not imply that sexual pain is psychological; rather, they recognize that sexual function is shaped by pain mechanisms, pelvic floor responses, emotional safety, rela- tionship context, and prior clinical experiences. Toward Mechanism‑Based Multidisciplinary Care Because CPP may be shaped by interacting mechanisms across multiple domains, treatment directed at a single organ system is unlikely to meet the needs of many women. Disease-specific diagnosis and treatment remain essential, but they should be integrated within a broader framework that also addresses pain amplification, pelvic floor function, emotional burden, sexual health, and daily functioning. The first step is comprehensive assessment. This includes evalua- tion of gynecological, urological, gastrointestinal, musculo- skeletal, neurological, and psychosocial contributors, while also asking how pain affects sleep, mood, sexual function, work, physical activity, and quality of life. Recent guidelines emphasize that CPP in adolescent and adult female individu- als should be approached through multifactorial assessment and management rather than a narrow search for a single pathology [9, 10]. Pelvic floor physical therapy is a central component of care for many women with CPP, particularly when pelvic floor tenderness, myofascial pain, guarding, dyspareunia, or pain with examination are present. Pelvic floor dysfunction may act both as a contributor to pain and as a consequence of pain-related guarding. Evidence from a systematic review and meta-analysis indicates that pelvic pain is associated with increased pelvic floor muscle tone when assessed by digital palpation, supporting the relevance of pelvic floor assessment in women with persistent pelvic pain [23]. A systematic review and meta-analysis found that multimodal physical therapy is effective in reducing pain in women with CPP, with high certainty of evidence for this intervention [12]. Clinically, this supports early referral to pelvic floor physical therapy when musculoskeletal contributors are suspected, rather than reserving it only for refractory cases. Pain neuroscience education is another important ele- ment of mechanism-based care. Many women with CPP have received incomplete or conflicting explanations for their symp- toms. Explaining central sensitization, nociplastic pain, pelvic floor guarding, and the interaction among pain, sleep, stress, and movement can help reduce fear and improve treatment engagement. The message should not be that pain is psycho- logical, but that the nervous system can become sensitized International Urogynecology Journal and that multiple treatment targets may help reduce pain and restore function. Psychological interventions have a role when pain is per- sistent, distressing, or associated with fear-avoidance, catastro- phizing, anxiety, depression, trauma-related vulnerability, or impaired coping. Cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based approaches, and other pain-focused interventions should be presented as part of pain care, not as evidence that symptoms are emotionally generated [11]. Medical and procedural treatments should likewise be matched to the dominant mechanisms and clinical phenotype. In endometriosis-associated CPP, hormonal or surgical treatment may be appropriate when disease activity or cyclical exacerba- tion is prominent, but persistent pain after lesion-directed treat- ment should prompt assessment of central sensitization, pelvic floor dysfunction, and comorbid pain conditions [6, 7]. The challenge for clinical systems is to avoid fragmented care. Women with CPP often move between gynecology, urology, gastroenterology, pain medicine, physiotherapy, and mental health services without a coordinated explanation or shared treatment plan. Interdisciplinary care programs may help address this gap by integrating multiple disciplines and treatment components, but program structure remains vari- able [24]. Mechanism-based multidisciplinary care does not require that every woman see every specialist; it requires that care be individualized according to active mechanisms and patient priorities [25]. Clinical Implications for Urogynecology For urogynecology practice, the main clinical implication is that CPP should be approached as a multidimensional condition. Diagnostic evaluation should remain rigorous, but clinicians should avoid presenting normal or inconclusive investigations as evidence that pain is not real. Instead, the clinical message should validate the patient’s pain while explaining how pain mechanisms, pelvic floor responses, mood, sleep, sexual func- tion, and prior health care experiences may interact [9–12]. This approach also supports a broader set of outcomes. Pain intensity remains important, but women may define meaning- ful improvement in terms of improved intimacy, reduced fear, greater mobility, better sleep, return to work or study, improved confidence in the body, and reduced need for repeated urgent consultations. These outcomes should be incorporated into clinical assessment, shared decision-making, and future inter- vention studies [9, 10, 22].

This review was designed as a structured narrative review rather than a systematic review or meta-analysis. Although the search strategy, eligibility criteria, and synthesis domains were defined in advance, the review did not include exhaustive database searching, duplicate independent screening, formal risk-of-bias assessment, or quantitative synthesis. The findings should therefore be interpreted as an integrative clinical synthesis rather than as a comprehensive summary of all available evidence. CPP is also heterogeneous, and the literature includes varied diagnostic definitions, clinical populations, out- come measures, and treatment approaches. Evidence from one subgroup, such as endometriosis-associated pain, vulvodynia, or bladder pain syndrome/interstitial cystitis, may not be directly generalizable to all women with CPP. Much of the evidence on central sensitization, psychosocial burden, and multidisciplinary care is cross- sectional or derived from specialized clinical settings, lim- iting generalizability to primary care or community-based populations. Despite these limitations, the review provides a clinically relevant framework for integrating emerging pain science, women’s health outcomes, and multidisci- plinary care in CPP. Research Gaps and Future Directions Important gaps remain in research, assessment, and clinical implementation. First, standardized methods are needed for identifying central sensitization and nociplastic pain in women with CPP. Although these concepts are increasingly discussed in endometriosis, vulvodynia, blad- der pain syndrome, and overlapping pain conditions, clini- cal tools and diagnostic thresholds remain inconsistent [ 7]. Second, future studies should develop clinically useful phenotypes that combine pelvic diagnosis, pain distribu- tion, central sensitization features, pelvic floor findings, psychosocial burden, sexual function, biomarkers, and quality-of-life impact. Diagnostic labels alone do not relia- bly predict pain severity, disability, or response to therapy. Evidence from bladder pain syndrome/interstitial cystitis suggests that urinary biomarkers and bladder characteris- tics may help explain treatment response in some popula- tions, but such findings require validation across larger and more diverse cohorts [8 ]. Third, longitudinal and pragmatic intervention research is needed. Many existing studies are cross-sectional, lim- iting understanding of how CPP develops, persists, and changes over time. Future trials should evaluate mech- anism-based treatment packages and stepped-care mod- els that reflect real-world complexity. Outcomes should extend beyond pain intensity to include pain interference, sexual function, sexual distress, quality of life, sleep, fatigue, emotional distress, work participation, health care use, and patient-perceived improvement. International Urogynecology Journal Finally, research should address communication, stigma, access, and care coordination. Many women with CPP report feeling dismissed, particularly when investigations do not reveal a clear structural cause. Specialized pelvic pain clinics and pelvic floor physical therapy are not equally available to all women. Scalable models, including primary-care-based path- ways, nurse-led education, telehealth-supported pelvic pain care, and collaborative care models, deserve further evaluation. Nurses, physiotherapists, psychologists, and other allied pro- fessionals may play important roles in education, validation, symptom tracking, care coordination, and continuity of care.

Chronic pelvic pain in women is a complex and heterogene- ous condition that cannot be fully understood through an organ-based model alone. Although gynecological, uro- logical, gastrointestinal, musculoskeletal, and neurological diagnoses remain clinically important, persistent pain often reflects interacting peripheral and central pain mechanisms together with functional and psychosocial contributors. A biopsychosocial and mechanism-based framework validates pain as real and biologically grounded while rec- ognizing that chronic pain is shaped by the nervous system, pelvic tissues, emotional processing, behavior, relationships, and social context. Women with CPP should therefore be assessed not only for pelvic pathology but also for pelvic floor dysfunction, pain amplification, psychological distress, sexual function, quality of life, and daily disability. Reframing CPP in this way may reduce fragmented care, improve patient–clinician communication, and support more meaningful outcomes. The aim is not only to reduce pain intensity, but also to restore function, intimacy, confidence, and quality of life. Ultimately, women with CPP need care that is diagnostically accurate, integrated, validating, and responsive to the full impact of pain on their lives. Author Participation Y Sela: Protocol/project development, data col- lection or management, data analysis, manuscript writing/editing. R Nissanholtz-Gannot: Protocol/project development, data analysis, manuscript writing/editing, other: critical intellectual review. K Grinberg: Protocol/project development, data collection or man- agement, data analysis, manuscript writing/editing. Funding Open access funding provided by Ruppin Academic Center. Data Availability Data sharing is not applicable because no new data- sets were generated or analyzed. Declarations Ethical Approval Ethical approval was not required because this article is a narrative review based exclusively on previously published litera- ture and did not involve human participants, identifiable human data, human tissue, or new data collection. Conflicts of Interest None. Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

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