A treatment algorithm for high-tone pelvic floor dysfunction (HTPFD) was developed using a Delphi method to reach consensus among experts in urology, urogynecology, minimally invasive gynecology, and pelvic floor physical therapy (PFPT). HTPFD is a neuromuscular disorder characterized by non-relaxing pelvic floor muscles, leading to lower urinary tract symptoms, defecatory issues, sexual dysfunction, and pelvic pain. Despite affecting 80% of women with chronic pelvic pain, there are no uniformly accepted guidelines for management. The Delphi process involved three rounds of anonymous surveys to identify consensus on treatment statements. A total of 31 statements were reviewed in the first round, with 10 reaching consensus. In the second round, 28 statements were reviewed, with 17 reaching consensus. The third round confirmed clinical consensus. PFPT was universally agreed as first-line treatment, with a recommended duration of 8–12 weeks. If no improvement is seen, second-line options include trigger point injections, vaginal muscle relaxants, and cognitive behavioral therapy (CBT). OnabotulinumtoxinA (BTXA) injections are recommended as third-line treatment, while sacral neuromodulation is considered fourth-line. The largest barrier to care is access to PFPT. For patients unable to access PFPT, alternatives include home-based pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits. The algorithm emphasizes a stepwise approach, with patients often requiring multiple treatment lines. PFPT should be offered first-line. Chronic pelvic pain affects one-quarter of women, costing over $5.8 billion annually. HTPFD is present in 60–90% of women with chronic pelvic pain. It is characterized by tight, weakened, or painful pelvic floor muscles, interfering with normal physiological function. Diagnosis relies on practitioner examination, and treatment pathways are limited by lack of level I evidence. The algorithm provides a structured approach to HTPFD treatment, with PFPT as first-line, followed by other interventions based on response to treatment. While PFPT has strong evidence, challenges in access and patient compliance remain. Alternative therapies, including BTXA and SNM, are considered for refractory cases. The algorithm highlights the need for further research to improve HTPFD care.A treatment algorithm for high-tone pelvic floor dysfunction (HTPFD) was developed using a Delphi method to reach consensus among experts in urology, urogynecology, minimally invasive gynecology, and pelvic floor physical therapy (PFPT). HTPFD is a neuromuscular disorder characterized by non-relaxing pelvic floor muscles, leading to lower urinary tract symptoms, defecatory issues, sexual dysfunction, and pelvic pain. Despite affecting 80% of women with chronic pelvic pain, there are no uniformly accepted guidelines for management. The Delphi process involved three rounds of anonymous surveys to identify consensus on treatment statements. A total of 31 statements were reviewed in the first round, with 10 reaching consensus. In the second round, 28 statements were reviewed, with 17 reaching consensus. The third round confirmed clinical consensus. PFPT was universally agreed as first-line treatment, with a recommended duration of 8–12 weeks. If no improvement is seen, second-line options include trigger point injections, vaginal muscle relaxants, and cognitive behavioral therapy (CBT). OnabotulinumtoxinA (BTXA) injections are recommended as third-line treatment, while sacral neuromodulation is considered fourth-line. The largest barrier to care is access to PFPT. For patients unable to access PFPT, alternatives include home-based pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits. The algorithm emphasizes a stepwise approach, with patients often requiring multiple treatment lines. PFPT should be offered first-line. Chronic pelvic pain affects one-quarter of women, costing over $5.8 billion annually. HTPFD is present in 60–90% of women with chronic pelvic pain. It is characterized by tight, weakened, or painful pelvic floor muscles, interfering with normal physiological function. Diagnosis relies on practitioner examination, and treatment pathways are limited by lack of level I evidence. The algorithm provides a structured approach to HTPFD treatment, with PFPT as first-line, followed by other interventions based on response to treatment. While PFPT has strong evidence, challenges in access and patient compliance remain. Alternative therapies, including BTXA and SNM, are considered for refractory cases. The algorithm highlights the need for further research to improve HTPFD care.