Evaluation of clinical practice guidelines (CPG) on the management of female chronic pelvic pain (CPP) using the AGREE II instrument

Abstract

Introduction and hypothesis Variations in guidelines may result in differences in treatments and potentially poorer health-related outcomes. We aimed to systematically review and evaluate the quality of national and international guidelines and create an inventory of CPG recommendations on CPP. Methods We searched EMBASE and MEDLINE databases from inception till August 2020 as well as websites of professional organizations and societies. We selected national and international CPGs reporting on the diagnosis and management of female CPP. We included six CPGs. Five researchers independently assessed the quality of included guidelines using the AGREE II tool and extracted recommendations. Results Two hundred thirty-two recommendations were recorded and grouped into six categories: diagnosis, medical treatment, surgical management, behavioural interventions, complementary/alternative therapies and education/research. Thirty-nine (17.11%) recommendations were comparable including: a comprehensive pain history, a multi-disciplinary approach, attributing muscular dysfunction as a cause of CPP and an assessment of quality of life. Two guidelines acknowledged sexual dysfunction associated with CPP and recommended treatment with pelvic floor exercises and behavioural interventions. All guidelines recommended surgical management; however, there was no consensus regarding adhesiolysis, bilateral salpingo-oophorectomy during hysterectomy, neurectomy and laparoscopic uterosacral nerve ablation. Half of recommendations (106, 46.49%) were unreferenced or made in absence of good-quality evidence or supported by expert opinion. Based on the AGREE II assessment, two guidelines were graded as high quality and recommended without modifications (EAU and RCOG). Guidelines performed poorly in the “Applicability”, “Editorial Independence” and “Stakeholder Involvement” domains. Conclusion Majority of guidelines were of moderate quality with significant variation in recommendations and quality of guideline development.

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“…To avoid this condition, clinical practice guidelines (CPGs) and clinical protocols are developed to provide physicians with references for medical care. These guidelines can be referenced in the clinical decision-making process to avoid subjectivity in decision making and provide consistent and appropriate medical care to patients (Correa et al, 2020;De Clercq, Kaiser, & Hasman, 2008;Ghai, Subramanian, Jan, Loganathan, & Doumouchtsis, 2021).…”

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“…Second, although some CPP guidelines imply the value of biopsychosocial care, the guidelines do not routinely recommend treatments following this approach (eg, patient education, physical therapy, and psychology) . When these treatments are recommended in the CPP guidelines, they are often vague and provide little direction for clinicians …”

“…Third, this Review failed to mention that surgery and pharmaceuticals are most frequently recommended as first-line care in the CPP guidelines . We believe this is a critical inaccuracy of the Review and should have been an important theme discussed throughout the article because it does not correlate with contemporary management of pain …”

“…Fourth, the authors did not discuss that nearly all of the CPP guidelines are of low quality . Nor did the Review accurately reflect the lack of comparable recommendations across the CPP guidelines, instead suggesting that guidelines have good consensus.…”

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