Treatment recommendations for the management of persistent pelvic pain: A systematic review of international clinical practice guidelines

Thank you to APS members Amelia Mardon, Hayley Leake, Thomas Astil, Lorimer Moseley, and Jane Chalmers, and their colleagues Kimberly Szeto, and Sandra Hilton for sharing the following recent publication.

Article first published online: 17 December 2021

Journal: Mardon, A. K., Leake, H. B., Szeto, K., Astill, T., Hilton, S., Moseley, G. L., & Chalmers, K. J. (2021). Treatment recommendations for the management of persistent pelvic pain: A systematic review of international clinical practice guidelines. BJOG: An International Journal of Obstetrics & Gynaecology.

DOI: https://doi.org/10.1016/j.nbd.2021.105528

Link: https://obgyn.onlinelibrary.wiley.com/ doi/abs/10.1111/1471-0528.17064?casa_ token=s4wSYr_5ZLgAAAAA:el76owYiMuebv_ fUr-k_hsCmX4BltPzcwh5HiJis_ a9VP22OcTzGxEscc194FJX7GEFGNTA1Kl_4H-k

Introduction

Females with persistent pelvic pain (PPP) report variability in recommended treatments despite the availability of clinical practice guidelines (CPGs) that aim to standardise care. There is a lack of a clear consensus for the best practice care for PPP. The objective of this study was to identify and summarise treatment recommendations across CPGs for the management of PPP, and appraise their quality.

Methods

Electronic databases, including MEDLINE, CENTRAL, EMBASE, EmCare, SCOPUS, the Cochrane Database of Systematic Reviews, Web of Science Core Collection, and relevant guideline databases were searched from their inception to June 2021. Included CPGs were those for the management of urogynaecological conditions in adult females associated with PPP, published in English, of any publication date, and endorsed by a professional organisation or society. We screened 1379 records and included 20 CPGs for seven conditions. CPG quality was assessed using The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Descriptive synthesis compiled treatment recommendations across CPGs.

Results

The CPGs provided 270 individual recommendations for 90 interventions. For quality appraisal, guidelines on average scored ‘excellent’ for the domains ‘scope and purpose’ (80.6%, SD = 13.3) and ‘clarity and presentation’ (74.4%, SD = 12.0); for other domains, average scores were satisfactory or poor. Four guidelines (endometriosis: NICE,

RANZCOG and ESHRE; polycystic ovary syndrome: Teede et al. 2018, International Evidence Based Guideline for the Assessment and Management of Polycystic Ovary Syndrome, Monash University, Melbourne, Australia) were deemed recommended for use. Treatment recommendations were most frequent for pharmaceutical and surgical interventions. Most recommendations for psychological were vague and ambiguous. Recommendations were variable Physiotherapy and other conservative interventions.

Conclusions

The quality of CPGs for PPP is generally poor. Several CPGs endorse the consideration of biopsychosocial elements of PPP. Yet most recommend pharmaceutical, surgical, and other biomedical interventions.

Implications/Discussion

We propose several gaps in the translational pipeline from research to clinical practice for the optimal management of PPP: 1) a lack of high-quality empirical evidence, in particular for psychosocial interventions; 2) poor quality CPGs and minimal involvement of consumer voices in their development; 3) minimal recommendations a multidisciplinary management approach; 4) poor applicability of PPP CPGs in clinical practice.

Declaration

AKM, KS, and HBL are supported by the Research Training Programme domestic (RTPd) Stipend as postgraduate students at the University of South Australia. TA is supported by the Research Training Programme domestic (RTPd) Stipend as a postgraduate student at the Western Sydney University. GLM, KJC, and KS are supported by a Leadership Investigator grant to GLM from the National Health & Medical Research Council of Australia (ID 1178444). GLM has received support from: Australian Medical Research Future Fund, Australian NHMRC, AIA Australia, SwissRe, Return to Work SA, International Association for the Study of Pain, ConnectHealth UK, Port Adelaide Football Club, Melbourne Football Club, Arsenal Football Club, and various sporting leagues throughout Europe and USA. Professional and scientific bodies have reimbursed him for travel costs related to presentation of research on pain at scientific conferences/ symposia. He has received speaker fees for lectures on pain and rehabilitation. He receives book royalties from NOIgroup publications, and Dancing Giraffe Press for books on pain and rehabilitation. He is the current Director of Painaustralia. KJC has received support from The Hospital Research Foundation and the Australian Health Research Alliance. She has received payment for presentations given on pelvic health. SH has received book royalties from OPTP. She has received payment for presentations given on pelvic pain. All other authors report no conflicts to disclose.