A multimodal approach to the treatment of CPP is needed because of its complex nature. The pelvic floor muscles consist of the coccygeus muscle and the levator ani, a three muscle complex consisting of the iliococcygeus, pubococcygeus, and the puborectalis. These muscles provide a hammock support system for the pelvic organs while also playing a role in maintaining urinary and fecal continence. Strengthening of the pelvic floor muscles by providing increased muscle endurance can improve incontinence and improve pelvic pain through reduction of muscle spasm. Physical therapy for the pelvic floor muscles includes numerous elements including external and internal mobilization techniques, Kegel exercises, biofeedback, and electrical stimulation.

External techniques can utilize connective tissue manipulation, myofascial release, trigger point therapy or joint mobilization. With these techniques, stretching exercises are taught in order to maintain the proper resting tone of the pelvic, abdominal, hip, thighs, hamstrings, and lower back muscles. Additionally, core strengthening is performed to increase pelvic stability. Connective tissue manipulation, or “skin rolling,” aims to decrease tight skin and fascia of the abdomen and inner thighs which are thought to cause referred pain as well as have an association with trigger point activity. The therapist palpates the affected tissue between the thumb and fourth fingers to mobilize the thickened, restricted tissue to increase blood flow and restore mobility. While skin rolling anecdotally leads to improved pain, large randomized placebo-controlled trials are lacking. Myofascial release aims to restore symmetry to the pelvic anatomy by stretching fascial planes. In addition to its use for the back, hip, and hamstring muscles, the pelvic floor muscles can be directly targeted by using the ischial tuberosities as grips in order to obtain a full stretching of those muscles. Joint mobilization consists of passively moving a joint that is restricted and cannot be adequately stretched by the patient alone. After manipulation, the patient has greater mobility which can be maintained with stretching exercises. This is often done in sacroiliac joint dysfunction [18]. Therapists that specialize in pelvic therapy often undergo numerous courses and require certification particularly if they perform some of the more invasive maneuvers and manipulations.

Treatment of the pelvic floor internally involves the insertion of a finger or instrument into the vagina or rectum. The muscles and connective tissues are directly massaged to release trigger points. Applying pressure until the trigger point relaxes may be done along with trigger point injection therapy.

Kegel exercises involve contracting and relaxing the pelvic floor muscles in order to increase muscle tone and maintain an appropriate balance of the pelvic musculature. The key to Kegel exercises is to identify the proper muscles in which to contract and relax. An often cited approach is stopping the flow of urine which will identify that you have targeted the proper muscles. The correct approach is then to perform these exercises on a regular basis on an empty bladder; starting and stopping your urine flow may actually do harm. Patients are often told to hold the contraction for 2–3 s with 5 sets of 10 repetitions every day. While performing any of these exercises, it is important to keep your abdominal muscles, buttocks, and thighs relaxed.

Biofeedback therapy utilizes an immediate feedback system with physiologic neuromuscular activity assessment and amplification. The goal of biofeedback being the immediate reinforcement of a specific behavior or movement in order to establish a learned routine. Its use for bladder control and anal sphincter control can improve incontinence while the ability to emphasize muscle relaxation of the pelvic floor muscles can be utilized in pelvic pain patients [19]. When the activity of a physiologic process via cutaneous or intravaginal/intrarectal sensors is noted, an auditory or visual response is generated. The signals of muscle contractions, relaxation, and muscle activity are generated in real time and allow for the patient to immediately see when the appropriate muscles are contracted. The frequencies of sessions are individualized and may be once a week or even monthly. Improvement may be seen rapidly within the first few sessions but have shown significant improvement after 3–6 months [18].

Measuring the electrical activity of a muscle through electromyography (EMG) may be preferred over the manometric pressure readings in biofeedback as electromyography will show the electrical potentials of a depolarized muscle as well as monitoring of motor units bioelectrical activity. This in turn provides a good indicator of physiologic muscle activity with more lightweight and activity tolerating electrodes than compared to pressure probes [19].

Often the utilization of electrical stimulation is performed in conjunction with biofeedback in order to assist with the appropriate isolation and identification of the pelvic floor muscles. By applying a small electrical current to the pelvic floor muscles you can increase muscle strength, decrease muscle spasm and increase endurance via recruitment of fast twitch pelvic muscle fibers [20].

Topical agents have been trialed for the treatment of pelvic pain. Acyclovir ointment applied to painful areas has shown improvement in painful symptoms. Corticosteroids are often utilized, although when combined with lidocaine, amitriptyline, or ketoprofen, the topical compounded treatment showed increased efficacy. Topical amitriptyline–ketamine used for the treatment of pelvic and perineal pain has been shown to have pain relief in 85 % of patients with a low incidence of adverse effects [21]. The use of 5-fluorouracil has fallen out of favor because of a higher incidence of adverse effects [19].

Vaginal diazepam has anecdotally been used for the treatment of chronic pelvic pain. It was thought to have the effect of decreasing skeletal muscle spasm via decreased neuronal depolarization without the adverse effects commonly seen with oral diazepam. As women with vulvar pain syndromes were found to have hypertonicity of the pelvic floor musculature, vaginal diazepam seemed to offer an additional treatment option [44]. Currently, it is being used off-label for pelvic floor dysfunction and urogenital pain. While a few small studies have shown some improved outcomes, large randomized, placebo-controlled trials are lacking [45–47].