Practice Guidelines

Chronic Pelvic Pain in Women: ACOG Updates Recommendations


Am Fam Physician. 2021 Feb 1;103(3):186-188.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Chronic pelvic pain is most often associated with endometriosis, bladder pain syndrome, or both but also shares the multifactorial aspects of other chronic pain syndromes.

• Neuromuscular pain conditions are common in chronic pelvic pain and can be diagnosed with palpation for pelvic floor muscle tenderness and with the FABER and Carnett tests for sources outside the pelvic floor.

• Pelvic floor physical therapy and trigger point injections can both improve vaginal pain and dyspareunia from neuromuscular chronic pelvic pain.

• Surgical interventions appear to offer no benefit in chronic pelvic pain.

From the AFP Editors

Chronic pelvic pain is associated with cognitive, behavioral, sexual, and emotional consequences. It is most often defined as noncyclic pain that lasts more than six months, and up to 26% of women meet these criteria. The American College of Obstetricians and Gynecologists (ACOG) has new recommendations for managing this condition.

Common Associated Conditions

The most common associated conditions are endometriosis and bladder pain syndrome, which affect between 60% and 70% of patients with chronic pelvic pain. Nearly one-half of patients with chronic pelvic pain have both conditions. Other common conditions that affect at least one in five patients with chronic pelvic pain are irritable bowel syndrome, interstitial cystitis, pelvic floor muscle tenderness, and depression.


Because chronic pelvic pain is often multifactorial, most patients will have multiple pain generators and comorbid conditions. Although many conditions are associated with chronic pelvic pain, determining how pain changes with sexual activity, menstruation, urination, and defecation is a good starting point. Patients often focus on visceral etiologies, yet neuromuscular issues such as myofascial trigger points may be more common and are often overlooked. Single-digit or swab palpation for tenderness of pelvic floor muscles, or palpation of the abdomen and the lower back, including the sacroiliac joints, that reproduces pain can identify possible neuromuscular conditions. In one small study, pelvic floor muscle tenderness or a positive flexion, abduction, and external rotation (FABER; Figure 1) test identified 85% of patients with chronic neuromuscular pelvic pain. A positive Carnett test, where abdominal tenderness increases with abdominal wall muscle contraction, also demonstrates neuromuscular pain. The Carnett test is described in a previous issue of American Family Physician (


Flexion, abduction and external rotation (FABER) test for hip or sacroiliac pain. This test, with single-digit pelvic floor muscle testing and the Carnett test, can identify most patients with neuromuscular pelvic pain. The examiner moves the leg into 45 degrees of flexion, then (A) externally rotates and (B) abducts the leg so that the ankle rests proximal

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at



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