Pelvic Floor Physical Therapy in Deep Infiltrating Endometriosis and Chronic Pelvic Pain: A Scoping Review Within an Integrated Center-of-Excellence Framework

This research project is a scoping review focused on the role of pelvic floor physical therapy (PFPT) and broader physical-rehabilitation interventions in women with endometriosis, particularly deep infiltrating endometriosis (DIE) and chronic pelvic pain (CPP). The project aims to systematically map, classify, and critically appraise the current evidence regarding rehabilitative and non-pharmacological therapeutic approaches used in this patient population, while positioning these interventions within a modern multidisciplinary center-of-excellence framework. Endometriosis is increasingly recognized not only as a gynecological condition, but as a chronic systemic inflammatory and neuro-functional disease associated with complex pain mechanisms, including nociceptive, neuropathic, and nociplastic pain pathways. Many patients experience persistent pelvic pain, pelvic-floor dysfunction, myofascial trigger points, dyspareunia, bowel and bladder dysfunction, and central sensitization even after optimal medical or surgical management. Despite the growing use of pelvic floor physical therapy in specialized endometriosis centers, the available literature remains fragmented across heterogeneous study designs, and there is currently no comprehensive synthesis integrating PFPT into a structured perioperative and multidisciplinary treatment model. The primary purpose of this project is to provide a comprehensive overview of all contemporary PFPT and rehabilitation techniques used in endometriosis management, including manual therapy, myofascial release, trigger-point therapy, pelvic-floor muscle re-education, biofeedback, electrophysical modalities (such as TENS, NMES, HILT, PEMF, and CRMRF), therapeutic exercise, breathing retraining, mind-body interventions, hydrotherapy, and pain neuroscience education. The review also seeks to evaluate the clinical outcomes associated with these techniques, including pain reduction, quality of life, sexual function, urinary and bowel function, mental health, functional recovery, and fertility-related outcomes. Methodologically, the study follows the Joanna Briggs Institute (JBI) framework for scoping reviews and the PRISMA-ScR reporting guidelines. A structured PICo-based search strategy was conducted across major databases including MEDLINE/PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar, covering publications from 1995 through May 2025. The review includes systematic reviews, meta-analyses, randomized controlled trials, observational studies, qualitative research, narrative reviews, and institutional clinical protocols relevant to PFPT and rehabilitation in endometriosis. An important objective of this project is the development of a translational “center-of-excellence” treatment algorithm integrating pelvic floor rehabilitation with advanced excision surgery, neuropelveology, behavioral pain science, nutrition, and fertility-preservation strategies. The project specifically emphasizes phenotype-based treatment selection and perioperative integration of rehabilitation into deep endometriosis surgery pathways. Additionally, the review aims to identify major evidence gaps in the current literature, including the lack of ENZIAN/ASRM stratification, inconsistent assessment of central sensitization, absence of standardized outcome measures, and limited perioperative rehabilitation protocols. The expected outcomes of this project include: * A comprehensive classification of PFPT and rehabilitation interventions used in endometriosis care. * Identification of the most effective techniques and dose-response parameters currently supported by evidence. * Development of a clinically translatable multidisciplinary treatment framework for high-volume endometriosis centers. * Clarification of how PFPT can be integrated perioperatively alongside deep multi-organ excision surgery. * Establishment of a future research agenda focused on mechanism-informed, phenotype-stratified, and outcomes-based rehabilitation studies in endometriosis. Ultimately, this project seeks to advance the understanding of pelvic floor rehabilitation as a structural and indispensable component of modern endometriosis management, rather than merely an adjunctive therapy. By synthesizing current evidence and proposing an integrated model of care, the review aims to support the development of more personalized, multidisciplinary, and evidence-based treatment strategies for women living with endometriosis and chronic pelvic pain.