Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates

FEMaLe: The use of machine learning for early diagnosis of endometriosis based on patient self-reported data-Study protocol of a multicenter trial

INTRODUCTION

Endometriosis is a chronic disease that affects up to 190 million women and those assigned female at birth and remains unresolved mainly in terms of etiology and optimal therapy. It is defined by the presence of endometrium-like tissue outside the uterine cavity and is commonly associated with chronic pelvic pain, infertility, and decreased quality of life. Despite the availability of various screening methods (e.g., biomarkers, genomic analysis, imaging techniques) intended to replace the need for invasive surgery, the time to diagnosis remains in the range of 4 to 11 years.

AIMS

This study aims to create a large prospective data bank using the Lucy mobile health application (Lucy app) and analyze patient profiles and structured clinical data. In addition, we will investigate the association of removed or restricted dietary components with quality of life, pain, and central pain sensitization.

METHODS

A baseline and a longitudinal questionnaire in the Lucy app collects real-world, self-reported information on symptoms of endometriosis, socio-demographics, mental and physical health, economic factors, nutritional, and other lifestyle factors. 5,000 women with confirmed endometriosis and 5,000 women without diagnosed endometriosis in a control group will be enrolled and followed up for one year. With this information, any connections between recorded symptoms and endometriosis will be analyzed using machine learning.

CONCLUSIONS

We aim to develop a phenotypic description of women with endometriosis by linking the collected data with existing registry-based information on endometriosis diagnosis, healthcare utilization, and big data approach. This may help to achieve earlier detection of endometriosis with pelvic pain and significantly reduce the current diagnostic delay. Additionally, we may identify dietary components that worsen the quality of life and pain in women with endometriosis, upon which we can create real-world data-based nutritional recommendations.

Heavy menstrual bleeding and dysmenorrhea in adolescents: A systematic review of self-management strategies, quality of life, and unmet needs

BACKGROUND

Heavy menstrual bleeding (HMB) and dysmenorrhea (DM) are common gynecological problems.

OBJECTIVE

To systematically review the needs, quality of life (QOL), and effectiveness of self-management strategies among young women (12-25 years) with DM or HMB.

SEARCH STRATEGY

Relevant terms were searched through PubMed, EBSCO, Google Scholar, ProQuest, and Ovid between 2010 and 2022.

SELECTION CRITERIA

Qualitative and quantitative studies published in peer-reviewed journals, females aged 12-25, exploring DM or HMB, reporting supportive care needs, quality of life, self-treatment strategies, and/or treatment-seeking behavior.

DATA COLLECTION AND ANALYSIS

Abstracts were reviewed for eligibility by two researchers. Included studies were extracted and assessed for quality independently by two authors, with discrepancies resolved through consensus or the involvement of a third researcher. Data extracted included study details, menstrual history, symptoms, self-care strategies, and quality of life. The Joanna Briggs Institute checklists were used for quality assessment.

MAIN RESULTS

The search returned 285 190 studies, of which 55 were eligible for inclusion. Prevalence rates of HMB and DM were in the ranges 4%-63% and 42%-94%, respectively. Over 80% of young women with DM and HMB experienced physical and psychological problems, including pelvic pain, sleep issues, mood disturbance, diarrhea, and nausea. Academic performance and daily activities were severely affected. Most (>62%) named their mothers as their primary source of information, and friends as the secondary source (10%-65%). Few studies explored needs, but they could be inferred and fell under school-related and social needs. QOL was poorer in those who had DM than those who did not. Pain was the most common issue that drove young women to find treatment. More than 70% used medication to reduce pain. More than half chose home remedies (e.g., heat therapy, massages, herbal tea, hot drinks). No studies provided information about the efficacy and dosage of medication and herbal remedies.

CONCLUSIONS

HMB and DM have a large impact on daily living, with large areas of unmet need. Limited access to information impairs the management of symptoms and consequent QOL.

When you see nothing at all: Outcomes following a negative laparoscopy. A systematic review

BACKGROUND

Persistent pelvic pain (PPP) is a complex and often debilitating condition. While widely accepted to be multifactorial in nature, the precise aetiology of PPP remains elusive. In many cases, women who undergo laparoscopy for PPP will have no visible pathology identified (a 'negative' laparoscopy). Currently, there are no consensus guidelines which outline the recommended management following a negative laparoscopy, and the woman's experiences and outcomes are not widely known.

AIMS

This review aims to identify and summarise the literature surrounding the experiences of women with PPP who have a negative laparoscopy; specifically, their outcomes of pain, quality of life (QoL), satisfaction with care, and their overall management.

MATERIALS AND METHODS

A systematic search of the electronic databases Ovid Medline, PubMed and Embase was performed. Studies in English exploring the outcomes of women with PPP following a negative laparoscopy were included.

RESULTS

Four studies consisting of a total of 200 women were included. Results were inconsistent. Three studies concluded that the majority of women with PPP had persistent pain following a negative laparoscopy. A single study found that pain significantly improved after negative laparoscopy. QoL outcomes varied, with two studies reporting a positive impact and two studies reporting a deleterious impact on QoL following a negative laparoscopy.

CONCLUSIONS

The impact on pain outcomes and QoL following a laparoscopy that does not diagnose pathology remains unknown, and the available evidence is insufficient to guide evidence-based practice. This review highlights a significant gap in our understanding of surgical management for PPP.

A Treatment Algorithm for High-Tone Pelvic Floor Dysfunction

OBJECTIVE

To develop evidence- and consensus-based clinical practice guidelines for management of high-tone pelvic floor dysfunction (HTPFD). High-tone pelvic floor dysfunction is a neuromuscular disorder of the pelvic floor characterized by non-relaxing pelvic floor muscles, resulting in lower urinary tract and defecatory symptoms, sexual dysfunction, and pelvic pain. Despite affecting 80% of women with chronic pelvic pain, there are no uniformly accepted guidelines to direct the management of these patients.

METHODS

A Delphi method of consensus development was used, comprising three survey rounds administered anonymously via web-based platform (Qualtrics XM) to national experts in the field of HTPFD recruited through targeted invitation between September and December 2021. Eleven experts participated with backgrounds in urology, urogynecology, minimally invasive gynecology, and pelvic floor physical therapy (PFPT) participated. Panelists were asked to rate their agreement with rated evidence-based statements regarding HTPFD treatment. Statements reaching consensus were used to generate a consensus treatment algorithm.

RESULTS

A total of 31 statements were reviewed by group members at the first Delphi round with 10 statements reaching consensus. 28 statements were reposed in the second round with 17 reaching consensus. The putative algorithm met clinical consensus in the third round. There was universal agreement for PFPT as first-line treatment for HTPFD. If satisfactory symptom improvement is reached with PFPT, the patient can be discharged with a home exercise program. If no improvement after PFPT, second-line options include trigger or tender point injections, vaginal muscle relaxants, and cognitive behavioral therapy, all of which can also be used in conjunction with PFPT. Onabotulinumtoxin A injections should be used as third line with symptom assessment after 2-4 weeks. There was universal agreement that sacral neuromodulation is fourth-line intervention. The largest identified barrier to care for these patients is access to PFPT. For patients who cannot access PFPT, experts recommend at-home, guided pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits.

CONCLUSION

A stepwise approach to the treatment of HTPFD is recommended, with patients often necessitating multiple lines of treatment either sequentially or in conjunction. However, PFPT should be offered first line.

Identifying Gaps in Pelvic Pain Education: A Scoping Review and Structured Analysis of Obstetrics and Gynecology Training Milestones

OBJECTIVE

Several clinical practice guidelines on the evaluation and management (EM) of chronic pelvic pain (CPP) have been published; however, it is not known whether obstetrics and gynecology (OBGYN) educational milestones are aligned with current practice recommendations. Therefore, this scoping review and structured analysis aims to identify gaps between clinical guidelines for the EM of CPP and OBGYN training milestones published by educational authorities like the Accreditation Council for Graduate Medical Education (ACGME) and the AAGL.

DATA SOURCES

The literature search was performed in MEDLINE, PubMed Central, and Bookshelf on the PubMed interface from January 2018 to September 2022. Peer-reviewed publications were included if they were a systematic review of recent practice guidelines and focused on female CPP. Publications that focused on a single pelvic pain condition or focused on a specific treatment were excluded.

METHODS OF STUDY SELECTION

Two reviewers extracted the data and appraised the study quality following the Critical Appraisal Skills Programme Checklist for systematic reviews. Four articles met inclusion criteria for thematic analysis. A reflexive thematic analysis via the inductive approach was performed to develop clinical themes common to all review articles and presumed important in the EM of CPP. Pelvic pain experts and Delphi methodology was used to assess validity and relevance of each theme in OBGYN training. Validated themes were used in a strengths weaknesses opportunities threats (SWOT) analysis of the ACGME and the AAGL Milestones used for training OBGYN residents and fellows. A SWOT analysis is an organizational tool used to analyze processes in terms of strengths, weaknesses, opportunities for improvement, and threats to implementing a potential change.

TABULATION, INTEGRATION, AND RESULTS

Twelve clinical themes were conceptualized and achieved ≥ 90% consensus as being important in the EM of CPP. Clinical themes pertained to pathophysiology, biopsychosocial approach, trauma-informed care, history and physical examination, diagnostic testing, multimodal/multidisciplinary management, pain education, and medical and surgical management. SWOT analysis showed that the ACGME Milestones lacked milestones specific to CPP, while the AAGL Milestones had 6 CPP-focused competencies with multiple milestones. Milestones on trauma-informed care and application of biopsychosocial assessment were notably absent.

CONCLUSION

OBGYN educational milestones published by the ACGME and the AAGL are not yet aligned with current clinical guidelines for the EM of CPP.

Pelvic Health Content in Canadian Entry-To-Practice Physiotherapy Programs: An Online Survey

Purpose

Pelvic health physiotherapy is an emerging and sensitive area of practice that offers effective conservative treatment for pelvic health conditions. Canadian entry-to-practice curriculum guidelines accord programs considerable flexibility regarding incorporating pelvic health content, which may lead to differences between programs and diverse levels of competence among new graduates. The purpose of this study was to determine the nature and extent to which pelvic health content is incorporated in entry-to-practice physiotherapy programs in Canada.

Method

We conducted a descriptive cross-sectional e-survey of representatives from Canadian entry-to-practice physiotherapy programs.

Results

Ten out of 15 Canadian programs participated. Programs incorporated pelvic health content throughout the required curriculum (n = 9) and in optional courses (n = 6). All participating programs covered musculoskeletal-related conditions, urinary incontinence, and pelvic pain conditions, and included anatomy and physiology, clinical reasoning, subjective assessment and pelvic floor muscle training topics. Three programs trained students in internal pelvic floor techniques in elective courses. All programs covered cisgender women populations, however, transgender populations were seldom covered.

Conclusions

This study provides an understanding of pelvic health curricular content that can serve as a first step towards standardizing and improving entry-level pelvic health training in Canada.

Neuromodulation for the management of chronic pelvic pain syndromes: A systematic review

BACKGROUND

Chronic pelvic pain is a burdensome condition that involves multiple medical sub-specialties and is often difficult to treat. Sacral stimulation for functional bladder disease has been well established, but little large-scale evidence exists regarding utilization of other neuromodulation techniques to treat chronic pelvic pain. Emerging evidence does suggest that neuromodulation is a promising treatment, and we aim to characterize the use and efficacy of such techniques for treating chronic pelvic pain syndromes.

MATERIALS AND METHODS

A systematic review of the literature demonstrating the treatment of chronic pelvic pain syndromes with neuromodulation. Abstracts were reviewed and selected for inclusion, including case series, prospective studies, and randomized controlled trials (RCTs). Case studies and publications in abstract only were not included. The reporting for this systematic review follows Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The literature search was performed using MEDLINE, Embase, Cochrane Library, PubMed, CINAHL, and Scopus.

RESULTS

A total of 50 studies were included in this review, three of which were randomized controlled trials, and the remaining were prospective and retrospective case series. The range of pelvic pain conditions treated included interstitial cystitis, peripheral neuralgia, pudendal neuralgia, gastrointestinal pain, urogenital pain, sacroiliac joint pain, and visceral chronic pelvic pain. We reported on outcomes involving pain, functionality, psychosocial improvement, and medication reduction.

CONCLUSIONS

Neuromodulation is a growing treatment for various chronic pain syndromes. Peripheral nerve stimulation was the least studied form of stimulation. Posterior tibial nerve stimulation appears to offer short-term benefit, but long-term results are challenging. Sacral nerve stimulation is established for use in functional bladder syndromes and appears to offer pain improvement in these patients as well. Dorsal root ganglion stimulation and spinal cord stimulation have been used for a variety of conditions with promising results. Further studies of homogeneous patient populations are necessary before strong recommendations can be made at this time, although pooled analysis may also be impactful.

Endometriosis, chronic pain, anxiety, and depression: A retrospective study among 12 million women

BACKGROUND

There is a lack of information regarding the impact of the physical symptoms associated with endometriosis and chronic pain on the mental health and well-being of affected women. Thus, our study aimed to evaluate the relationship between endometriosis, chronic pain, anxiety, and depression.

OBJECTIVE

Our study aimed to evaluate the relationship between endometriosis, chronic pain, and mental health disorders among women registered in a large database until 2014.

STUDY DESIGN

This was a retrospective population-based study involving 12,904,324 hospitalized women from the Healthcare Cost and Utilization Project (HCUP) database between 2007 and 2014. We calculated the prevalence of chronic pain, endometriosis, anxiety, and depression during the study period. We used multivariate logistic regression to examine the relationship between these variables.

RESULTS

An upward pattern was noted in the prevalence of chronic pain, while an opposite trend was seen for endometriosis during the study period. After adjusting for sociodemographic characteristics and comorbidities, including depression, the highest odds ratio of experiencing anxiety appeared in the group with both chronic pain and endometriosis (OR = 2.719, 95 % CI 2.481-2.979).

LIMITATIONS

HCUP is a cross-sectional administrative database that does not link patients' records over the years. Thus, we could not establish any temporal association between endometriosis, chronic pain, anxiety, and depression.

CONCLUSION

Potential associations were identified between endometriosis, with and without chronic pain, anxiety, and depression. We recommended that clinicians provide proper medical management of endometriosis-related pain through symptom management and adequate counseling for those suffering from anxiety and depression.

Botulinum Toxin for the Management of Pelvic Floor Tension Myalgia and Persistent Pelvic Pain: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review the literature on use of botulinum toxin to treat pelvic floor tension myalgia and persistent pelvic pain.

DATA SOURCES

The ClinicalTrials.gov , PubMed, EMBASE, and Scopus databases were searched from inception to November 2022 by two independent assessors (B.L.K. and F.G.L.). Identified studies were screened by title and abstract and included after full-text review. Data extraction was subsequently performed and recorded in Microsoft Excel.

METHODS

This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines after registration in PROSPERO (CRD42022289132). All randomized studies, prospective studies with more than five participants, and retrospective studies with more than 10 participants published in English or French and assessing the use of botulinum toxin for the treatment of pelvic floor tension myalgia and persistent pelvic pain in women were included. Meta-analyses were performed on randomized data.

TABULATION, INTEGRATION, AND RESULTS

Of 4,722 articles identified, 24 satisfied inclusion criteria. A meta-analysis of five randomized controlled trials totaling 329 participants demonstrated no differences in patient- and clinician-reported outcome measures, including pain, dyspareunia, sexual function, and vaginal manometry. Mean duration of follow-up was 6 months. A qualitative analysis of 14 prospective and four retrospective studies including 804 participants is supportive of botulinum toxin; however, the quality of data is low, and there is marked heterogeneity between studies.

CONCLUSION

Meta-analyses of randomized data do not support the use of botulinum toxin to treat pelvic floor tension myalgia and persistent pelvic pain. Failure of these data to confirm the findings of nonrandomized prospective studies that suggest a treatment benefit may be attributable to the absence of placebo control and confounding outcomes obtained from an active comparator group. Further randomized controlled trials with true placebo are strongly recommended.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022289132.

Presence of endometriosis and chronic overlapping pain conditions negatively impacts the pain experience in women with chronic pelvic-abdominal pain: A cross-sectional survey

BACKGROUND

Evidence of overlap between endometriosis and chronic pain conditions is emerging; however, little is known about how the pain experience differs based on the presence or absence of endometriosis.

OBJECTIVES

In a sample of women reporting chronic pelvic-abdominal pain (CPP), the aim of this study was to characterize differences in pain symptomatology between women with and without endometriosis and to examine the influence of chronic overlapping pain conditions (COPCs) on pain among these two groups.

DESIGN

This was a cross-sectional study, based on an online survey.

METHODS

Participants (aged 18+ years) completed a survey collecting pain diagnoses and symptoms assessing pelvic pain severity, pain interference, and pain impact. Independent sample t-tests, chi-square, and multiple linear regression models were employed to analyze group differences in pain symptomatology and COPCs.

RESULTS

Of the 525 respondents with CPP, 25% (n = 133) reported having endometriosis. Women with endometriosis were younger at the onset of pelvic pain, relative to women without endometriosis (p = 0.04). There were no differences in age, race, ethnicity, or duration of pelvic pain between women with and without endometriosis. Women with endometriosis reported higher pelvic pain severity (+0.8, 95% CI = 0.4-1.1), pain interference (+5.9, 95% CI = 2.4-9.3), and pain impact (+1.9, 95% CI = 0.8-2.9). Endometriosis was associated with a higher number of COPCs (p = 0.003), with 25% (n = 33) of women reporting ⩾3 overlapping pain conditions compared with 12% (n = 45) of those without endometriosis. Women with endometriosis had a higher frequency of fibromyalgia (p < 0.001), chronic fatigue syndrome (p < 0.001), and temporomandibular disorder (p = 0.001). The number of COPCs was associated with higher pain severity, interference, and impact, independently of endometriosis.

CONCLUSION

Women with endometriosis experienced higher levels of pain-related burden and COPCs compared with those without endometriosis. Pain intensity, interference, and impact increased with a higher number of pain conditions regardless of endometriosis presence.

The Impact of Preoperative Pain on Outcomes After Vaginal Reconstructive Surgery and Perioperative Pelvic Floor Muscle Training

IMPORTANCE

The impact of preoperative pain on outcomes can guide counseling.

OBJECTIVE

The objective of this study was to compare outcomes after vaginal reconstructive surgery and pelvic muscle training between women with and without preoperative pain.

STUDY DESIGN

This is a secondary analysis of the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial, which randomized patients to a surgical intervention (sacrospinous ligament fixation versus uterosacral vaginal vault suspension) and a perioperative behavioral intervention (pelvic floor muscle training vs usual care). Preoperative pain was defined as a response of "5" or greater on the pain scale or answering "moderately" or "quite a bit" on the Pelvic Floor Distress Inventory question "Do you usually experience pain in the lower abdomen or genital area?"

RESULTS

The OPTIMAL trial included 109 women with preoperative pain and 259 without pain. Although women with pain had worse pain scores and pelvic floor symptoms at baseline and postoperatively, they had greater improvement on pain scores (-2.3 ± 2.4 vs -0.2 ± 1.4, P < 0.001), as well as Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire scores. Among women with pain who underwent a sacrospinous ligament fixation, those who received pelvic floor muscle training had a greater reduction in pain compared with those in the usual care group (-3.0 ± 2.3 vs -1.3 ± 2.1, P = 0.008). Persistent or worsening pain was present at 24 months in 5 (16%) women with preoperative pain.

CONCLUSIONS

Women with preoperative pain experience significant improvements in pain and pelvic floor symptoms with vaginal reconstructive surgery. Pelvic floor muscle training perioperatively may be beneficial for select patients.

Chronic Pelvic Pain: Role of Imaging in the Diagnosis and Management

Chronic pelvic pain (CPP) in women is not uncommon, and it may be difficult to identify the exact cause difficult to manage. It is major health problem for women that affects the quality of their daily lives. The etiology of chronic pelvic pain may be of gynecological or non-gynecological origin and associated with several predisposing and precipitating factors. Psychological and social factors also contribute to the syndrome of CPP and must be evaluated before managing these patients. Due to multifactorial etiology, CPP needs a multidisciplinary approach for diagnosis and management. A detailed history and physical examination supported by appropriate laboratory tests and imaging are the keys to diagnosis. In this paper, the role of imaging in diagnosis and management of CPP is reviewed. Imaging findings should be correlated with detailed clinical examination findings as there are imaging findings that may be unrelated and not the cause of CPP in a particular patient, imaging findings should be correlated with the clinical circumstances.

Triangulation of a Needs Assessment on High-Tone Pelvic Floor Dysfunction

IMPORTANCE

High-tone pelvic floor dysfunction is a complex condition that is challenging to manage effectively. Pelvic floor physical therapy (PFPT) is often used in the treatment and relies on a coordinated effort between the physician, patient, and physical therapist. Collaboration is crucial for therapy success, but there is limited research that includes personal perspectives from these individuals.

OBJECTIVE

The objective of this qualitative study was to gain further insight from these groups to identify areas for improvement in patient counseling and understanding of the diagnosis of high-tone pelvic floor dysfunction and the role of physical therapy.

STUDY DESIGN

The following participants were recruited: urogynecologists, pelvic floor physical therapists, and patients. Semistructured interviews were conducted exploring participant experiences with therapy and management of the condition and surrounding phenomena.

RESULTS

Participants interviewed included 5 urogynecologists, 5 pelvic floor physical therapists, and 15 patients. Similarities in key themes were identified: (1) the usefulness of pelvic models and illustrations in counseling, (2) appropriate descriptions of therapy, (3) motivating factors for patients, and (4) patient barriers to completing therapy. Several emergent themes revealed a misalignment in perspectives, including (1) patients reporting an unclear understanding of PFPT, (2) patient unawareness of the intimacy of therapy, and (3) reports of unsupportive and unempathetic physician providers.

CONCLUSIONS

There are both similarities and discrepancies in the perspectives among physicians, pelvic floor physical therapists, and patients regarding high-tone pelvic floor dysfunction and PFPT. Acknowledging these comparisons and adapting practices could facilitate patient-centered care and improve patient understanding of their diagnosis.

Prevalence of pelvic pain in transgender individuals on testosterone

BACKGROUND

Pelvic pain has been reported in transmasculine individuals taking testosterone. There is a need for further investigation to increase understanding of the prevalence and risk factors of this pain.

AIM

We sought to determine the prevalence of pelvic pain reported by transmasculine individuals who had both a uterus and ovaries and were taking testosterone.

METHODS

We conducted an institutional review board-approved retrospective study of all transmasculine individuals who had been taking testosterone for at least 1 year and had a uterus and ovaries at the time of testosterone initiation. Charts of participating patients were reviewed to determine patient characteristics, testosterone use, and pelvic pain symptoms both before and after initiation of testosterone.

OUTCOMES

Patients reported experiences of pelvic pain while on testosterone.

RESULTS

Of 280 individuals who had been on testosterone for at least 1 year, 100 (36%) experienced pelvic pain while on testosterone. Of those patients, 71% (n = 71) had not experienced pelvic pain prior to starting testosterone. There were 42 patients (15%) who had pelvic pain prior to starting testosterone, 13 (31%) of whom no longer experienced pain once starting testosterone. The median (IQR) age at initiation of testosterone was 22 (19-41) years and duration of testosterone treatment was 48 (27-251) months.Those patients who experienced pelvic pain while on testosterone were significantly more likely to have also reported pelvic pain prior to starting testosterone (29% vs 7%, P < .001). These patients were also more likely to have a pre-existing diagnosis of dysmenorrhea (27% vs 7%, P < .001), endometriosis (6% vs 2%, P = .049), or ovarian cysts and/or masses (12% vs 2% P < .001). Patients with pelvic pain were also more likely to have been on a menstrual suppression agent prior to and overlapping testosterone initiation (22% vs 12%, P = .03) and to have used menstrual suppression for longer durations (median [IQR] 18 [6-44] vs 8 [4-15] months, P = .04).

CLINICAL IMPLICATIONS

Pelvic pain is common in transmasculine individuals who are initiating testosterone treatment, although testosterone has both positive and negative effects on pelvic pain in different individuals.

STRENGTHS AND LIMITATIONS

The major strengths of this study included large numbers of patients, ability to assess for documentation of pelvic pain prior to testosterone, and ability to determine an actual prevalence of pelvic pain. Major limitations included the study being a retrospective analysis in a single tertiary care center, the limitations of clinical documentation, and the lack of a standard pelvic pain evaluation process.

CONCLUSION

More than one-third of transmasculine patients with a uterus and ovaries had pelvic pain while on testosterone, with the majority reporting onset of pain after initiating testosterone.

The Effect of Affective Temperament, Pain Catastrophizing, and Anxiety Sensitivity on Pain Severity in Patients With Chronic Pelvic Pain: A Pilot Study

OBJECTIVE

The goals of this study were to investigate whether there was a dominant temperament type, and to assess the effect of temperament, pain catastrophizing, and anxiety sensitivity on pain severity, in female patients diagnosed with chronic pelvic pain (CPP) compared with healthy controls.

METHODS

This cross-sectional study involved 51 patients 18 to 65 years of age who were diagnosed with CPP without a history of psychiatric treatment and 97 healthy volunteer women with sociodemographic characteristics similar to those of the study group. A sociodemographic form prepared by the researchers, the Anxiety Sensitivity Index, the Pain Catastrophizing Scale, a temperament scale (Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire), and a visual analog pain scale (VAS) were completed. The results were compared between the patient and control groups. Multiple regression analyses were performed to examine the predictive effects of temperament characteristics, pain catastrophizing, and anxiety sensitivity on pain severity.

RESULTS

Scores on the Pain Catastrophizing Scale and the VAS were statistically significantly higher in the CPP group ( P <0.001). The frequency of depressive, cyclothymic, and irritable temperaments was found to be significantly higher in the CPP group (CPP: 7.78±3.32 vs. controls: 6.54±3.19; P =0.027; CPP:10.61±4.41 vs. controls: 8.82±4.21; P =0.017; CPP: 5.22±4.29 vs. controls: 3.75±3.41; P =0.025). According to the model established by temperament traits, anxiety sensitivity, and pain catastrophizing level, pain catastrophizing level explained 11.6% of the variance in pain severity. A 1-unit change in the score for pain catastrophizing level caused a 0.278-point change in the VAS total score ( P <0.01).

CONCLUSIONS

Cyclothymic, depressive, and irritable temperament types that increase the risk of affective disease are more common in patients with CPP. The level of pain catastrophizing in patients with CPP affects their perception of the severity of the pain.

Symptoms of complex pelvic pain: A survey in three cohorts of women

INTRODUCTION

There has been increased interest in addressing chronic pelvic pain and its complexity in women. The often multifactorial etiology of chronic pelvic pain and its heterogeneous presentation, however, make the condition challenging to manage. Overlap with other pain-related conditions is frequently reported, and chronic pelvic pain may impact sexual function. Nevertheless, little is known about the symptom burden of chronic pelvic pain and more complex pelvic pain in different groups of women. Thus, the aim of our study was to use a newly validated Norwegian version of the Amsterdam Complex Pelvic Pain Symptom Scale (ACPPS) to describe and compare the symptom severity of complex pelvic pain in three cohorts of women and to assess associations between demographic and gynecological characteristics and the severity of the condition.

MATERIAL AND METHODS

In our cross-sectional study, we collected self-reported data from patients referred to gynecological outpatient clinics, members of vulvodynia or endometriosis patient associations, and healthy volunteers. The 397 participants (47% response rate) completed an online survey about their demographic and gynecological characteristics and symptoms related to complex pelvic pain, including the Norwegian ACPPS. Score means on questionnaires, with standard deviations and 95% confidence intervals, were recorded. We used Pearson's chi-square test, Analysis of variance and multivariable linear regression were used to assess associations of demographic and gynecological characteristics with ACPPS scores.

RESULTS

Members of the patient associations had significantly higher self-reported symptom burden than patients and volunteers. Symptom burden was lower among older and postmenopausal women, and unemployed women scored higher than employed ones. Especially high scores on the ACPPS were found among women with complaints of chronic pelvic pain, at least moderate pelvic pain intensity, and/or chronic vulvar pain. Women who had experienced sexual assault and/or reported low sexual function also reported high scores. In multivariable regression, fibromyalgia, low mental health and past sexual assault were found to be associated with high scores on the ACPPS.

CONCLUSION

Many women in our study reported complex pelvic pain, and overlap with other pain-related conditions, low mental health and past sexual assault was associated with high symptom burden. Those findings support taking a biopsychosocial approach to treating women who present with such complaints.

Approach of Chronic Pelvic Pain with Top Flat Magnetic Stimulation

Materials and Methods

Vulvar Functional Status Questionnaire (VQ) was used for the evaluation of patient's chronic pelvic pain and muscle hypertone improvements. The interstitial cystitis was assessed by the Leary-Sant symptom and problem indexes (ICSI and ICPI). In this study, the scores resulting from the sum of the two indexes were evaluated as OSS (ICSI + ICPI).

Results

Women with chronic pelvic pain and muscle hypertone showed VQ mean values significantly lower than the controls (p  <  0.005) from the second treatment up to the sixth one. In 6 patients affected by interstitial cystitis, the mean score of OSS was significantly lower than the controls (p  <  0.005) from the second treatment up to 2 months follow-up after the last treatment session. No side effects were observed.

Conclusion

Based on these results, this technology may successfully manage muscle hypertonicity condition, the chronic pelvic pain, and interstitial cystitis.

Psychosocial predictors of change in sexual activity and sexual function after hysterectomy in women with pelvic pain

BACKGROUND

Potential impact on sexual function is an often-cited concern for many patients considering hysterectomy. The existing literature indicates that sexual function remains stable to slightly improved for most patients who undergo hysterectomy, but most studies demonstrate a small subset of patients in whom sexual function declines after surgery. Unfortunately, there is a lack of clarity as to surgical, clinical, and psychosocial factors that may influence the likelihood of sexual activity after surgery or the magnitude and direction of change in sexual function. Although psychosocial factors are strongly associated with overall female sexual function, there is minimal data exploring the potential impact of these factors on the change in sexual function after hysterectomy.

OBJECTIVE

This study aimed to evaluate the relationship between baseline psychosocial factors and both sexual activity and sexual function at 6 months after hysterectomy.

STUDY DESIGN

Patients undergoing hysterectomy for benign, non-obstetric indications were prospectively recruited as part of an observational cohort study evaluating presurgical predictors of posthysterectomy outcomes on pain, quality of life, and sexual function. The Female Sexual Function Index was administered before hysterectomy and 6 months after surgery. Presurgical psychosocial assessments included validated self-reported measures of depression, resilience, relationship satisfaction, emotional support, and social participation.

RESULTS

Complete data was available for 193 patients, of whom 149 (77.2%) reported sexual activity at 6 months after hysterectomy. In the binary logistic regression model examining sexual activity at 6 months, older age was associated with a lower likelihood of sexual activity (odds ratio, 0.91; 95% confidence interval, 0.85-0.96; P=.002). Higher relationship satisfaction before surgery was associated with a greater likelihood of sexual activity at 6 months (odds ratio, 1.09; 95% confidence interval, 1.02-1.16; P=.008). As expected, preoperative sexual activity was associated with a greater likelihood of postoperative sexual activity (odds ratio, 9.78; 95% confidence interval, 3.95-24.19, P<.001). Analyses using Female Sexual Function Index scores were limited to patients who were sexually active at both time points (n=132 [68.4%]). The total Female Sexual Function Index score did not change significantly from baseline to 6 months, but there were statistically significant changes in several individual domains of sexual function. Patients reported significant improvement in desire (P=.012), arousal (P=.023), and pain (P<.001) domains. However, significant decreases were reported in orgasm (P<.001) and satisfaction (P<.001) domains. The proportion of patients who met the criteria for sexual dysfunction was quite high (>60%) at both time points, but there was not a statistically significant change in the proportion from baseline to 6 months. In the multivariate linear regression model, there was no relationship between change in sexual function score and any of the variables examined, including age, endometriosis history, pelvic pain severity, or psychosocial measures.

CONCLUSION

In this cohort of patients with pelvic pain undergoing hysterectomy for benign indications, both sexual activity and sexual function remained fairly stable after hysterectomy. Higher relationship satisfaction, younger age, and preoperative sexual activity were associated with a greater probability of sexual activity at 6 months after surgery. Psychosocial factors, such as depression, relationship satisfaction, and emotional support, and history of endometriosis were not related to change in sexual function among patients who were sexually active both before hysterectomy and at 6 months after surgery.

Health literacy in women with chronic pelvic pain

INTRODUCTION AND HYPOTHESIS

Limited health literacy (HL) is a risk factor for poor patient outcomes, including pain. Chronic pelvic pain (CPP) is a prevalent disorder affecting up to 25% of women and coexists with multiple overlapping conditions. This study aimed to describe health literacy in women with CPP, primarily correlate HL to pain intensity and pain duration, and secondarily correlate HL to mood symptoms and pain catastrophizing. We hypothesized that women with CPP with higher HL would report lower levels of pain intensity and duration.

METHODS

This was a prospective, cross-sectional study. Forty-five women with CPP were recruited from outpatient Physical Medicine & Rehabilitation and Female Pelvic Medicine & Reconstructive Surgery clinics. Validated questionnaires were administered to evaluate pain intensity and duration, pain disability, psychological symptoms, pain catastrophizing, and health literacy. Statistical analyses included descriptive statistics of patient characteristics and summary scores, as well as Spearman's rank correlation coefficients (rho) to assess the strength of associations between summary scores and health literacy.

RESULTS

Forty-five women with CPP were enrolled with mean age of 49 years, majority non-Hispanic White, and median chronic pelvic pain duration of 7 years. Possible or high likelihood of limited health literacy was identified in 20% women with CPP (11.1% and 8.9%, respectively). Limited health literacy was moderately correlated with pain intensity, depressive symptoms, and pain catastrophizing. Pain duration was not significantly correlated with health literacy. The remaining 80% of women with CPP were likely to have adequate health literacy.

CONCLUSIONS

A majority of women with CPP in this single center study were likely to have adequate health literacy. Limited health literacy was seen in a minority of women with CPP but was moderately correlated with greater pain intensity, more depressive symptoms, and higher pain catastrophizing. This study identified that women with CPP were likely to have adequate HL, but underscores the importance of considering HL screening and interventions in those with higher pain intensity, depression, and pain catastrophizing.

Evaluation and Medical Management of Chronic Pelvic Pain

Chronic pelvic pain (CPP) is a challenging condition affecting an estimated 15% of females in the United States. Multiorgan system dysfunction results in the complex clinical pain presentation. Similar to other chronic pain syndromes, CPP is influenced by biopsychosocial factors and requires a multimodal approach for optimal pain management. This review summarizes the clinical evaluation and medical management of CPP with a comprehensive approach.

Pelvic Venous Disorders: An Update in Terminology, Diagnosis, and Treatment

Pelvic venous disorder (PeVD) is a term that encompasses all the interrelated causes of chronic pelvic pain (CPP) and perineal/lower extremity varicose veins of pelvic venous origin historically known as nutcracker syndrome, pelvic congestion syndrome, and May-Thurner syndrome, resulting in a more precise diagnosis that accounts for the underlying pathophysiology and anatomy. PeVD manifests as CPP with associated vulvar and lower-extremity varicosities, left flank pain and hematuria, and lower extremity pain and swelling secondary to obstruction or reflux in the left renal, ovarian, or iliac veins. This article will focus specifically on the most current nomenclature, evaluation, and management of CPP of venous origin.

Association Between Nociplastic Pain and Pain Severity and Impact in Women With Chronic Pelvic Pain

Exploring the relationship between nociplastic pain and the severity and impact of pelvic pain symptoms could lend insight into the heterogeneous symptom presentation and treatment response that complicates management of chronic pelvic pain. In this prospective cross-sectional study, we sought to evaluate relationships between degree of nociplastic pain, measured by the Fibromyalgia (FM) Survey Score, and multiple aspects of the chronic pelvic pain (CPP) experience, including severity, frequency, tenderness during pelvic myofascial exam, interference with daily life, and high-impact pain. The study included 303 women who presented to a tertiary referral clinic for chronic pelvic pain and endometriosis. Multiple measures of pelvic pain, including pain severity, frequency, interference, pelvic myofascial pain, and high-impact pain were examined in General Linear Models with FM Survey Score as the primary predictor of interest in models controlling for endometriosis, surgical history, use of opioids, body mass index, and patient age. Higher level of nociplastic pain was associated with greater pelvic pain severity, frequency, interference, and pelvic myofascial pain (all P < .05). For all models, degree of nociplastic pain was more strongly associated with pain outcomes than the presence of endometriosis, and use of opioids was the only stronger predictor of worse pain outcomes. The likelihood of high impact pain increased 7% for each additional point on the FM Survey Score. Degree of nociplastic pain was robustly associated with severity, frequency, and impact of pelvic pain, and was independent of the presence of endometriosis, history of surgical procedures for pelvic pain, age, and BMI. Trial registration: not applicable PERSPECTIVE: This article evaluates the impact of nociplastic pain on symptoms and functional status in chronic pelvic pain. These findings raise the possibility that a simple screening tool for nociplastic pain might provide clinically actionable information without the need for deep neurobiological phenotyping and may inform development of personalized management strategies.

Gonadotropin-releasing hormone analogues for endometriosis

BACKGROUND

Endometriosis is a common gynaecological condition affecting 6 to 11% of reproductive-age women and may cause dyspareunia, dysmenorrhoea, and infertility. One treatment strategy is medical therapy with gonadotrophin-releasing hormone analogues (GnRHas) to reduce pain due to endometriosis. One of the adverse effects of GnRHas is a decreased bone mineral density. In addition to assessing the effect on pain, quality of life, most troublesome symptom and patients' satisfaction, the current review also evaluated the effect on bone mineral density and risk of adverse effects in women with endometriosis who use GnRHas versus other treatment options.

OBJECTIVES

To assess the effectiveness and safety of GnRH analogues (GnRHas) in the treatment of painful symptoms associated with endometriosis and to determine the effects of GnRHas on bone mineral density of women with endometriosis.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO and the trial registries in May 2022 together with reference checking and contact with study authors and experts in the field to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) which compared GnRHas with other hormonal treatment options, including analgesics, danazol, intra-uterine progestogens, oral or injectable progestogens, gestrinone and also GnRHas compared with no treatment or placebo. Trials comparing GnRHas versus GnRHas in conjunction with add-back therapy (hormonal or non-hormonal) or calcium-regulation agents were also included in this review.  DATA COLLECTION AND ANALYSIS: We used standard methodology as recommended by Cochrane. Primary outcomes are relief of overall pain and the objective measurement of bone mineral density. Secondary outcomes include adverse effects, quality of life, improvement in the most troublesome symptoms and patient satisfaction.  Due to high risk of bias associated with some of the studies, primary analyses of all review outcomes were restricted to studies at low risk of selection bias. Sensitivity analysis including all studies was then performed.

MAIN RESULTS

Seventy-two studies involving 7355 patients were included. The evidence was very low to low quality: the main limitations of all studies were serious risk of bias due to poor reporting of study methods, and serious imprecision.  Trials comparing GnRHas versus no treatment  We did not identify any studies. Trials comparing GnRHas versus placebo There may be a decrease in overall pain, reported as pelvic pain scores (RR 2.14; 95% CI 1.41 to 3.24, 1 RCT, n = 87, low-certainty evidence), dysmenorrhoea scores (RR 2.25; 95% CI 1.59 to 3.16, 1 RCT, n = 85, low-certainty evidence), dyspareunia scores (RR 2.21; 95% CI 1.39 to 3.54, 1 RCT, n = 59, low-certainty evidence), and pelvic tenderness scores (RR 2.28; 95% CI 1.48 to 3.50, 1 RCT, n = 85, low-certainty evidence) after three months of treatment. We are uncertain of the effect for pelvic induration, based on the results found after three months of treatment (RR 1.07; 95% CI 0.64 to 1.79, 1 RCT, n = 81, low-certainty evidence). Besides, treatment with GnRHas may be associated with a greater incidence of hot flushes at three months of treatment (RR 3.08; 95% CI 1.89 to 5.01, 1 RCT, n = 100, low-certainty evidence). Trials comparing GnRHas versus danazol For overall pain, for women treated with either GnRHas or danazol, a subdivision was made between pelvic tenderness, partly resolved and completely resolved. We are uncertain about the effect on relief of overall pain, when a subdivision was made for overall pain (MD -0.30; 95% CI -1.66 to 1.06, 1 RCT, n = 41, very low-certainty evidence), pelvic pain (MD 0.20; 95% CI -0.26 to 0.66, 1 RCT, n = 41, very low-certainty evidence), dysmenorrhoea (MD 0.10; 95% CI -0.49 to 0.69, 1 RCT, n = 41, very low-certainty evidence), dyspareunia (MD -0.20; 95% CI -0.77 to 0.37, 1 RCT, n = 41, very low-certainty evidence), pelvic induration (MD -0.10; 95% CI -0.59 to 0.39, 1 RCT, n = 41, very low-certainty evidence), and pelvic tenderness (MD -0.20; 95% CI -0.78 to 0.38, 1 RCT, n = 41, very low-certainty evidence) after three months of treatment. For pelvic pain (MD 0.50; 95% CI 0.10 to 0.90, 1 RCT, n = 41, very low-certainty evidence) and pelvic induration (MD 0.70; 95% CI 0.21 to 1.19, 1 RCT, n = 41, very low-certainty evidence), the complaints may decrease slightly after treatment with GnRHas, compared to danazol, for six months of treatment. Trials comparing GnRHas versus analgesics  We did not identify any studies. Trials comparing GnRHas versus intra-uterine progestogens We did not identify any low risk of bias studies. Trials comparing GnRHas versus GnRHas in conjunction with calcium-regulating agents There may be a slight decrease in bone mineral density (BMD) after 12 months treatment with GnRHas, compared to GnRHas in conjunction with calcium-regulating agents for anterior-posterior spine (MD -7.00; 95% CI -7.53 to -6.47, 1 RCT, n = 41, very low-certainty evidence) and lateral spine (MD -12.40; 95% CI -13.31 to -11.49, 1 RCT, n = 41, very low-certainty evidence).  AUTHORS' CONCLUSIONS: For relief of overall pain, there may be a slight decrease in favour of treatment with GnRHas compared to placebo or oral or injectable progestogens. We are uncertain about the effect when comparing GnRHas with danazol, intra-uterine progestogens or gestrinone. For BMD, there may be a slight decrease when women are treated with GnRHas, compared to gestrinone. There was a bigger decrease of BMD in favour of GnRHas, compared to GnRHas in conjunction with calcium-regulating agents. However, there may be a slight increase in adverse effects when women are treated with GnRHas, compared to placebo or gestrinone. Due to a very low to low certainty of the evidence, a wide range of outcome measures and a wide range of outcome measurement instruments, the results should be interpreted with caution.

Applications of botulinum toxin to the female pelvic floor: Botulinum toxin for genito-pelvic pain penetration disorder and chronic pelvic pain in women

Chronic pain conditions like genito-pelvic pain penetration disorder and chronic pelvic pain cause significant morbidity in women worldwide and yet are underdiagnosed and undertreated. While the use of botulinum toxin for pain conditions has expanded, there are few randomized controlled studies of botulinum toxin for pelvic pain conditions in women. This paper provides an update on the current status and context for considering botulinum toxin treatment for these conditions to complement and expand currently available approaches. High quality clinical trials to evaluate safety and efficacy and to determine optimal doses and approaches to injection are urgently needed.

[Somatoform disorders-chronic pelvic pain in women]

Pelvic pain in women is a clinically common symptom and a frequent finding in general practitioner, urological, gynecological, and pediatric practice. The list of possible differential diagnoses is long and the clarification ranges from a visual diagnosis to technical and surgical examinations to complex interdisciplinary consultations. But when do we talk about chronic lower abdominal pain? What can be the cause of this and how can we approach it diagnostically and therapeutically? What should we pay attention to? The difficulty begins with the definition. If we look at the national and international guidelines and publications, we find different definitions for chronic pelvic pain. There are various causes of chronic pelvic pain. There is often a combination of physical and psychological factors, which is why it is often not possible to identify a single diagnosis behind chronic pelvic pain syndrome. The clarification of these complaints requires a biopsychosocial approach. Multimodal approaches should be considered in assessment and treatment, and experts from other disciplines should be consulted.

Cannabis smoking, tobacco cigarette smoking, and adenomyosis risk

OBJECTIVE

To investigate cannabis smoking and tobacco cigarette smoking in relation to adenomyosis risk.

DESIGN

We used data from a case-control study of adenomyosis conducted among enrollees ages 18-59 years of an integrated health care system in Washington State. The case-control study used 2 control groups given the challenge of selecting noncases when cases are diagnosed by hysterectomy.

SUBJECTS

Cases (n = 386) were enrollees with incident, pathology-confirmed adenomyosis diagnosed between April 1, 2001, and March 31, 2006. The 2 control groups comprised hysterectomy controls (n = 233) with pathology-confirmed absence of adenomyosis and population controls (n = 323) with an intact uterus selected randomly from the health care system population and frequency matched to cases on age.

EXPOSURE

Detailed data on cannabis and tobacco cigarette smoking history were ascertained through in-person structured interviews, allowing estimation of joint-years of cannabis smoking and pack-years of tobacco cigarette smoking.

MAIN OUTCOME MEASURES

Odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between cannabis smoking, tobacco cigarette smoking, and adenomyosis were estimated using multivariable unconditional logistic regression. Analyses were adjusted for age, reference year, menarche age, education, and pack-years of cigarette smoking (or joint-years of cannabis smoking).

RESULTS

No association was observed between cannabis smoking history and adenomyosis risk. However, we did observe the suggestion of an association between ever tobacco cigarette smoking and adenomyosis risk, comparing cases to hysterectomy controls (OR, 1.3; 95% CI, 0.9-1.9) and population controls (OR, 1.2; 95% CI, 0.8-1.8). Our data suggested a 50% increased odds of adenomyosis with >15 pack-years of smoking (vs. never smoking), comparing cases to hysterectomy controls (OR, 1.5; 95% CI, 0.9-2.6; Ptrend=.135). The suggestion of a 40% increased adenomyosis odds was observed with smoking >5-15 pack-years (vs. never smoking), comparing cases to population controls (OR, 1.4; 95% CI, 0.8-2.4; Ptrend=0.136).

CONCLUSION

In the first study of cannabis smoking and adenomyosis risk, no association was observed. However, our data suggested an increased odds of adenomyosis with history of tobacco cigarette smoking. Further research is warranted to replicate our results given the substantial morbidity with adenomyosis and frequency of cigarette smoking and recreational and medical cannabis use.

Analgesic Efficacy of Acupuncture on Chronic Pelvic Pain: A Systemic Review and Meta-Analysis Study

Chronic pelvic pain (CPP) is the pain occurred in the pelvic region longer than six months. The monotherapy of medicine may not adequate for the pain management of CPP and multidisciplinary approaches have been more recommended. The aim of this study is to evaluate the pain management efficacy of acupuncture compared with a control group on CPP. The articles of randomized controlled trial on CPP in PubMed and Embase databases were screened between January 2011 and September 2022 without language restriction to evaluate the treatment efficacy of acupuncture. The visual analogue scale/numerical rating scale (VAS/NRS) and total pain scores of National Institutes of Health—chronic prostatitis symptom index (NIH-CPSI) were served as outcome variables. Post-intervention mean scores were extracted and pooled for meta-analysis. Seventeen studies including 1455 patients were selected for meta-analysis. Both total pain scores of NIH-CPSI and VAS/NAS data revealed significant lower pain level in the acupuncture group than in the control group. Moreover, monotherapy with acupuncture revealed a significantly lower pain level than in the control group in both total pain scores of NIH-CPSI and VAS/NRS. These results indicated that acupuncture may have beneficial effects on pain management for CPP, even when administrated as a monotherapy.

Cannabis use preferences in women with myofascial pelvic pain: A cross-sectional study

Objective

Myofascial tenderness is present in most chronic pelvic pain conditions and causes significant distress to patients. Treatment is challenging and often not curative. Cannabis is often used for self-management of chronic pelvic pain. However, we do not know which concentrations and routes of administration are most acceptable to users. We aimed to investigate patterns and willingness of cannabis product use among both habitual users and non-users with myofascial pelvic pain (MPP), to inform therapeutic development.

Study design

We conducted a cross-sectional study of questionnaire responses from female patients with MPP from two tertiary pelvic pain centers. We aimed for a convenience sample of 100 responses with representation from both centers. Inclusion criteria were age over 18 with pelvic floor muscle tenderness on standard gynecologic examination. We collected information on demographics, pelvic pain history, cannabis use status, cannabis use preferences, validated opioid misuse risk assessment, and interest in using gynecologic cannabis products and used descriptive analyses.

Results

77/135 (57 %) questionnaire respondents were cannabis users and 58 (43 %) were non-users. Most users consume cannabis daily, (48.1 %) orally (66.2 %) or by smoking (60.7 %), and rated cannabis as effective at relieving pelvic pain. 37/58 (63.8 %) non-cannabis users responded that they would be willing to use cannabis for pelvic pain. Lack of information and potential adverse effects were the most common reasons for unwillingness to use. Approximately 3 of 4 respondents were willing to try vaginal or vulvar application of cannabis products for pelvic pain.

Conclusions

This cross-sectional study describes cannabis use patterns in MPP patients. Topical vulvar and vaginal cannabis products are of strong interest to both cannabis users and non-users and warrant further research.

Are fascial strains involved in chronic pelvic pain syndrome? An exploratory matched case-control study

BACKGROUND

Chronic pelvic pain (CPP) and chronic pelvic pain syndrome (CPPS) do not have a definite cause, even if their impact on quality of life was demonstrated. Furthermore, there is evidence of myofascial dysfunctions in a large number of CPP/CPPS, so that the role of fascia can be hypothesized.

METHODS

The aim of this exploratory matched case-control study was to assess whether fascial strains (FS) represent a factor associated with CPP/CPPS. The study followed the "Strengthening the Reporting of Observational Studies in Epidemiology" (STROBE) statement. We collected data from 189 subjects (cases: 58; controls: 131) who attended the clinic. The participants were managed through a 2:1 enrollment ratio. A standardized booklet requested for clinical information, previous FS and the following questionnaires: "National Institutes of Health Chronic Prostatitis Symptom Index" (NIH-CPSI), "Hospital Anxiety and Depression Scale" (HADS), "Fear Avoidance Belief Questionnaire" (FABQ). Each subject underwent a palpatory assessment to detect abnormal palpatory findings in the pelvic area.

RESULTS

The analyses showed that episiotomy, genito-urinary infections and surgery had a significantly increased odds ratio (OR) of 4.13, 3.1 and 3.08, respectively. FS as a whole had a significantly raised OR: 2.22 (1.14 to 4.33). The analysis was adjusted for physical activity and for type of job and OR decreased to 1.94 (0.82 to 4.61), losing its significance (p = 0.129). A strong correlation between symptoms' impact and CPP/CPPS was detected (rpbs = 0.710; p < 0.001) and a moderate one (0.3 < rpbs < 0.7; p < 0.001) was found considering anxiety, depression and abnormal palpatory findings.

CONCLUSION

This exploratory study suggests that FS could represent an etiological factor for developing CPP/CPPS. However, further research on fascial dysfunctions and relative implications in CPP/CPPS is needed for confirmation.

Incidence of Chronic Pelvic Pain in Females Attending a Gynaecology Outpatient Department

Background and Aims: Chronic pelvic pain (CPP) is a persistent pelvic pain that leads to reduced work performance and impaired quality of life in females. Nearly 15% of females report time off from paid work and around 45% report reduced work productivity. There is a paucity of studies to address the issue, especially with a multidisciplinary and multifactorial view. Various gynaecological disorders are associated with CPP such as endometriosis, adenomyosis, adhesions, chronic pelvic inflammatory disease, and pelvic congestion syndrome. The objective is to determine the frequency of CPP in females attending gynaecologic outpatient departments. Materials and Methods: A total of 201 patients aged 14–48 years attending the gynaecologic outpatient department for gynaecological disorders with complaints of lower abdominal pain were included in this study. Patients enrolled in the study were assessed by a detailed history and pelvic examination, and a structured questionnaire was filled out. Data were analysed using the statistical package for social sciences version 23.0 (International Business Machines Corporation, Armonk, New York, USA). Results: The mean age of the patients was 32.39±6.98 years. The frequency of CPP in females was observed as 95.52% (95% confidence interval: 91.67–97.93%) The rate of CPP was significantly high in females with parity ≤5 and those who had a duration of pain lower than 36 months. In multivariate analysis, adjusted odds ratio by stepwise logistic regression model showed that parity (parity 0–1) and duration of pain (≤36 months) were significantly associated with CPP in females. Conclusion: The study indicates that the most common gynaecological causes of CPP in females attending the outpatient department were those with endometriosis followed by adenomyosis. The management of CPP needs patient-centred care with a multidisciplinary approach. This will lead to early and effective management.

Micronized Palmitoylethanolamide, Hempseed Oil, and Maritime Pine Bark Dry Extract (Pelvipea®) for Pelvic Pain: An In Vitro Study for Urothelial Inflammation Treatment

Urothelial inflammation plays a key role in the pathogenesis of chronic pelvic pain due to its origin in the bladder. The aim of this study was to evaluate the efficacy of a patent-pending formulation (Pelvipea^®) composed of micronized palmitoylethanolamide (PEA), hempseed oil, and maritime pine bark dry extract in reducing urothelial inflammation, as well as the effect of each ingredient individually, in order to define the synergistic effect of the three ingredients. An in vitro bladder urothelium model composed of the T24 cell line was exposed to a conditioned media obtained by treating macrophage-differentiated THP-1 cells with different concentrations of the functional ingredients and a mixture of them in the presence of the pro-inflammatory stimulus of Escherichia coli. Cells exposed only to the inflammatory stimulus in the absence of pre-treatment were considered as a positive control for inflammation. The impact of each functional ingredient and their mixture on inflammation was evaluated by the determination of transcription factor NF-kB and of pro-inflammatory cytokine expression. Statistical analysis was performed using the t-test, comparing the mixture and the single ingredients for every condition tested. All results were reported as fold change (mean ± standard deviation), the ratio between the values obtained from the respective treatments for inflammation control. The three functional ingredients did not induce negative effects on THP-1 cell vitality. The levels of NF-kB were reduced following treatment with hempseed oil, maritime pine bark dry extract, and the mixture at all tested concentrations, and with micronized PEA from 25 to 200 μg/mL. Treatment with the mixture resulted in the lowest expression levels of interleukins (IL)-1β, IL-6, and IL-8 compared to the single functional ingredients at a concentration of 230 μg/mL, with values of 0.08 (±0.00), 0.01 (±0.00), and 0.32 (±0.01), respectively. The mixture of micronized PEA, hempseed oil, and maritime pine bark dry extract (Pelvipea^®) at 230 μg/mL showed the best efficacy in urothelial IL-1β, IL-6, and IL-8 reduction compared with the singular components. This formulation may represent a promising therapeutic option to relieve painful symptoms originating in the bladder. However, in vivo studies are needed to confirm these results.

The association between adverse childhood experiences and peripartal pain experience

ABSTRACT

Adverse childhood experiences (ACEs) are associated with altered ongoing and evoked pain experiences, which have scarcely been studied for the peripartum period. We aimed to investigate how ACEs affect pain experience in pregnancy and labor. For this noninterventional trial with a short-term follow-up, pregnant women were divided into a trauma group (TG) with ACEs (n = 84) and a control group (CG) without ACEs (n = 107) according to the Childhood Trauma Questionnaire. Pain experience in pregnancy and labor was recorded by self-report and the German Pain Perception Scale. Pain sensitivity prepartum and postpartum was assessed by Quantitative Sensory Testing and a paradigm of conditioned pain modulation (CPM), using pressure pain thresholds (PPTs) and a cold pressor test. The TG showed higher affective and sensory scores for back pain and a more than doubled prevalence of preexisting back pain. Pelvic pain differences were nonsignificant. The TG also exhibited increased affective scores (1.71 ± 0.15 vs 1.33 ± 0.11), but not sensory scores for labor pain during spontaneous delivery. There were no group differences in prepartum pain sensitivity. While PPTs increased through delivery in the CG (clinical CPM), and this PPT change was positively correlated with the experimental CPM (r = 0.55), this was not the case in the TG. The association of ACEs with increased peripartal pain affect and heightened risk for preexisting back pain suggest that such women deserve special care. The dissociation of impaired clinical CPM in women with ACEs and normal prepartum experimental CPM implies at least partly different mechanisms of these 2 manifestations of endogenous pain controls.

The burden of Chronic Pelvic Pain (CPP): Costs and quality of life of women and men with CPP treated in outpatient referral centers

INTRODUCTION

Chronic Pelvic Pain (CPP) is a complex, multifaceted condition that affects both women and men. There is limited literature on the cost utilization the healthcare system and CPP patients incur. The purpose of this analysis is to characterize the overall healthcare utilization, cost burden, and quality-of-life restrictions experienced by CPP patients using data from an outpatient pelvic rehabilitation practice.

METHODS

Healthcare utilization data was gathered by systematically reviewing and analyzing data from new patient visit progress notes stored in the clinic's electronic health records (EHR). We obtained in-network costs by using the FAIR Health Consumer online database. Overall costs were then calculated as the utilization times the per-unit costs from the FAIR database. Additionally, data on patients' visual analogue scale (VAS), absenteeism, presenteeism emergency room visits, usage of common pain medications, use of diagnostics, and participation in common treatment modalities was gathered.

RESULTS

Data from 607 patients was used. The overall cost burden per patient for all surgeries combined was $15,750 for in-network services. The cost burden for diagnostics was $5,264.22 and treatments was $8,937 per patient for in-network treatments.

CONCLUSION

Chronic Pelvic Pain was found to have a large cost burden of $29,951 for in-network services which includes treatments, diagnostics, and surgeries. This analysis sets the stage for future investigations involving data on costs of medications that patients have tried prior to presenting to us and costs associated with work hours lost.

Women with Chronic Pelvic Pain Demonstrate Increased Lumbopelvic Muscle Stiffness Compared to Asymptomatic Controls

Background: Although lumbopelvic muscle stiffness is commonly clinically assessed in women with chronic pelvic pain (CPP), it has not been objectively quantified in this population, and its association with other pain-related impairments has not yet been established. Objective: To compare superficial lumbopelvic muscle stiffness in women with and without CPP. In addition, pressure pain threshold (PPT) was compared between groups and the associations between muscle stiffness and PPT were assessed in women with CPP. Study Design: Case-control. Methods: Muscle stiffness and PPT of 11 lumbopelvic muscles were assessed in 149 women with CPP and 48 asymptomatic women. Subjective outcome measures, including pelvic floor function, health history, and psychosocial outcomes, were collected before muscle stiffness and PPT measurements. Analysis of covariance was used to compare muscle stiffness differences between groups, and independent t-tests were used to compare PPT between groups. Associations between measurements of PPT and muscle stiffness were calculated using correlation analysis. Results: Five of the 11 muscles measured were significantly stiffer in women with CPP than those without CPP (p < 0.05). PPT was significantly decreased in all muscles measured in women with CPP; however, there was not a significant association between muscle stiffness and PPT in women with CPP. Conclusion: The study identified the abdominal lumbopelvic muscles that have increased stiffness in women with CPP compared to asymptomatic women. In addition, muscle stiffness and PPT are two distinct impairments within this population. The results suggest that women with CPP have peripheral muscle impairments, which may be addressed without intravaginal or intrarectal intervention. Clinical Trial Registration: NCT04851730.

Dysmenorrhea catastrophizing and functional impairment in female pelvic pain

Background

Dysmenorrhea is suggested to increase the risk of chronic pain by enhancing central sensitization. However, little is known about whether emotional and cognitive responses induced by dysmenorrhea contribute to chronic pain interference. This study examined the association between catastrophizing specific to dysmenorrhea and both dysmenorrhea and chronic pelvic pain (CPP)-associated pain interference.

Methods

Women (N = 104) receiving care for CPP through a tertiary gynecological pain clinic between 2017 and 2020 were recruited. They completed the Pain Catastrophizing Scale, the Brief Pain Inventory-pain interference, and a separate questionnaire regarding dysmenorrhea symptoms and treatment preceding the development of CPP. Dysmenorrhea catastrophizing and interference measures were developed and tested for internal consistency and construct validity. Multiple linear regression models examined dysmenorrhea catastrophizing in association with dysmenorrhea interference and CPP-associated pain interference.

Results

Dysmenorrhea catastrophizing and interference measures demonstrated excellent internal consistency (Cronbach's Alpha = 0.93 and 0.92 respectively) and evidence of construct validity (correlated with dysmenorrhea severity and treatment, Ps < 0.01). Dysmenorrhea catastrophizing was moderately correlated with pain catastrophizing (ρ = 0.30, P = 0.003), and was associated with greater dysmenorrhea interference (P < 0.001) and CPP-associated pain interference (P = 0.032) accounting for general pain catastrophizing and other outcome-specific confounders. Dysmenorrhea intensity was most predictive of dysmenorrhea catastrophizing.

Conclusion

Among our clinical sample of women with CPP, dysmenorrhea catastrophizing was associated with greater dysmenorrhea interference and subsequent CPP-associated pain interference. More research is needed to determine whether reduction in dysmenorrhea catastrophizing leads to reduced pain interference associated with female pelvic pain.

Pelvic Pain in Transgender People Using Testosterone Therapy

Purpose: This descriptive study aimed to assess the characteristics of pelvic pain and explore predictive factors for pelvic pain in transgender (trans) individuals using testosterone therapy. Methods: An online cross-sectional survey was open between August 28, 2020, and December 31, 2020, to trans people presumed female at birth, using testosterone for gender affirmation, living in Australia, and >16 years of age. The survey explored characteristics of pelvic pain following initiation of testosterone therapy, type and length of testosterone therapy, menstruation history, and relevant sexual, gynecological, and mental health experiences. Logistic regression was applied to estimate the effect size of possible factors contributing to pain after starting testosterone. Results: Among 486 participants (median age = 27 years), 351 (72.42%) reported experiencing pelvic pain following initiation of testosterone therapy, described most commonly as in the suprapubic region and as "cramping." Median duration of testosterone therapy was 32 months. Persistent menstruation, current or previous history of post-traumatic stress disorder, and experiences of pain with orgasm were associated with higher odds of pelvic pain after testosterone therapy. No association was observed with genital dryness, intrauterine device use, previous pregnancy, penetrative sexual activities, touching external genitalia, or known diagnoses of endometriosis, vulvodynia, vaginismus, depression, anxiety, or obesity. Conclusions: Pelvic pain is frequently reported in trans people following initiation of testosterone therapy. Given the association with persistent menstruation and orgasm, as well as the known androgen sensitivity of the pelvic floor musculature, further research into pelvic floor muscle dysfunction as a contributor is warranted.

Complementary Approaches for Military Women with Chronic Pelvic Pain: A Randomized Trial

Introduction: Active duty (AD) women suffer with chronic pelvic pain (CPP) while providers tackle diagnoses and treatments to keep them functional without contributing to the opioid epidemic. The purpose of this randomized trial was to determine the effectiveness of noninvasive, self-explanatory mindfulness-based stress reduction (MBSR) or self-paced healthy lifestyle (HL) interventions on CPP in AD women. Methods: A 6-week, interventional prospective study with AD women aged 21-55 years at Mountain Home (MTHM), Idaho, was conducted. Women were randomly assigned to MBSR (N = 21) or HL (N = 20) interventions. The primary outcome was pain perception. The secondary outcomes were depression and circulating cytokine levels. Results: Women in the MBSR group exhibited reduced pain interference (p < 0.01) and depression (p < 0.05) alongside decreased interleukin (IL)-4 (p < 0.05), IL-6 (p < 0.05), eotaxin (p < 0.05), monocyte chemoattractant protein-1 (p = 0.06), and interleukin-1 receptor antagonist (IL-1ra) (p < 0.01) and increased vascular endothelial growth factor (p < 0.05). Women in the HL group did not have changes in pain; however, they did exhibit reduced depression (p < 0.05) alongside decreased granulocyte-macrophage colony-stimulating factor (p < 0.05) and increased tumor necrosis factor alpha (p < 0.05), stromal cell-derived factor-1 (p < 0.01), and IL-1ra (p < 0.01). Conclusions: AD women receiving MBSR or HL had reduced depression scores and altered circulating cytokine levels; however, only those receiving MBSR had reduced pain perception. Findings support MBSR as an effective and viable behavioral treatment for AD women suffering from CPP and provide premise for larger randomized controlled studies. Clinical Trial Registration: MOCHI-An RCT of mindfulness as a treatment for CPP in AD Women NCT04104542 (September 26, 2019).

Non-pharmacological therapies for treating chronic pelvic pain in women: A review

Chronic pelvic pain (CPP) is an intricate condition with multiple etiologies that lead to indefinite pain mechanisms. Physicians and researchers are challenged in its treatment, and the combined therapy of pharmacologic and non-pharmacologic treatment has been recognized as a multidisciplinary approach cited by guidelines and adopted in clinical practice. As an alternative therapy for CPP, non-pharmacologic therapies benefit patients and deserve further study. This study reviews the literature published from January 1991 to April 2022 on non-pharmacologic therapies for CPP in adult women. Based on a survey, this review found that the most commonly used non-pharmacological therapies for CPP include pelvic floor physical therapy, psychotherapy, acupuncture, neuromodulation, and dietary therapy. By evaluating the efficacy and safety of each therapy, this study concluded that non-pharmacological therapies should be included in the initial treatment plan because of their high degree of safety and low rate of side effects. To fill the lack of data on non-pharmacologic therapies for CPP, this study provides evidence that may guide treatment and pain management.

A Multidisciplinary Pelvic Pain Clinic: Integrated Health Psychology in a Specialty Care Setting

Purpose: Chronic pelvic pain (CPP) is a relatively common health problem, impacting around 25 million women globally. This study details the development of a multidisciplinary women's CPP clinic at a major U.S. academic medical center, and examines associations between mood, pain symptoms, and trauma history. Materials and Methods: Data were collected from 96 subjects, including self-report measures (Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Brief Trauma Questionnaire), pain intensity ratings, psychiatric diagnoses, and relevant medical history. Results: Most subjects reported at least one traumatic experience. Nearly half of subjects met criteria for an anxiety disorder and/or a depressive disorder. Most subjects were diagnosed with pelvic floor dysfunction, and more than half were referred to physical therapy. Women with abdominal/pelvic surgery history reported more traumatic experiences than women without surgical history. Women with a history of sexual abuse reported trying more medications and seeking care from a greater number of providers. Many reported pain duration of >2 years. Conclusions: Study findings related to mental health and trauma support a multidisciplinary CPP approach that includes a clinical health psychology component. Future research may investigate the therapeutic processes that apply to this population to identify targeted efficacious interventions.

Pelvic Venous Disorders (PeVD)

Pelvic venous disorders (PeVDs) have replaced the concept of pelvic congestion syndrome encompassing venous origin chronic pelvic pain (VO-CPP) in women. The evaluation of women with VO-CPP includes the assessment for other causes of pelvic pain as well as imaging evaluation for pelvic varicosities measuring greater than 5 mm diameter, ovarian vein diameter, and flow direction, as well as iliac vein diameter and signs of compression. Proper identification of these patients can lead to high degrees of success eliminating chronic pelvic pain following ovarian vein embolization and/or iliac vein stenting. Strong encouragement is provided to use the symptoms, varices, pathophysiology classification for these patients and upcoming research studies on the specific symptoms of patients with VO-CPP will help elucidate patient selection for intervention. Additional future randomized controlled trials are also upcoming to evaluate for outcomes of ovarian vein embolization and iliac vein.

Prevalence of chronic pelvic pain and primary dysmenorrhea in women of reproductive age in Ecuador

Background

Chronic pelvic pain (CPP) and primary dysmenorrhoea are debilitating conditions that can impair the quality of life of affected women. These conditions are frequently neglected, delaying proper diagnosis and healthcare provision. This study aimed to estimate the prevalence of CPP and primary dysmenorrhoea in Ecuador and identify potential variables associated with their occurrence.

Methods

We conducted a cross-sectional survey in an urban neighbourhood of Quito, the capital of Ecuador. A total of 2397 participants of 14–49 years of age were included. The data were collected through questionnaires administered by trained interviewers.The crude and adjusted prevalence ratios were calculated using a log-binomial regression model. The correlation between pain intensity catastrophising of symptoms were statistically analysed.

Results

The prevalence of CPP and primary dysmenorrhoea was 9.8% and 8.9%, respectively. Irritative urinary symptoms, primary dysmenorrhoea, and underlying mental disorders were associated with CPP, while smoking, irritable bowel syndrome, sleep disturbance, dyspareunia, and mental disorders were associated with primary dysmenorrhoea.

Conclusions

The prevalence of CPP and primary dysmenorrhoea in Ecuador was similar to that in other Latin American countries. Primary dysmenorrhoea is a risk factor of CPP, and less than a quarter of women are undergoing treatment for the condition. Our findings reinforce the importance of healthcare interventions in anticipating the diagnosis of these conditions in women of reproductive age.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01948-y.

Childhood betrayal trauma, dissociation, and shame impact health-related quality of life among individuals with chronic pelvic pain

BACKGROUND

High betrayal trauma (HBT), or interpersonal trauma perpetrated by someone close, is linked to dissociation and shame, while trauma perpetrated by someone less close, low betrayal trauma (LBT) is associated with post-traumatic stress disorder (PTSD).

OBJECTIVE

Child interpersonal trauma is common among women with chronic pelvic pain (CPP) and can negatively impact physical and mental health-related quality of life (HRQOL). Our study investigates unexplored connections between these variables.

PARTICIPANTS & SETTING

Survey data were analyzed from 96 English-speaking female patients with CPP at a women's health clinic (mean age = 33, 59 % White non-Hispanic, 62 % married or cohabitating, 61.5 % completed post-high school degree); prevalence of HBT and LBT were 65.2 % and 45.6 %, respectively.

METHODS

Multiple regression analyzed relationships between mental and physical HRQOL and dissociation, shame, and PTSD. Parallel mediation analyses examined indirect relationships between mental and physical HRQOL and exposure to childhood HBT and LBT.

RESULTS

Dissociation was related to worse physical HRQOL, while shame was related to worse physical and mental HRQOL. Dissociation and shame mediated relationships between childhood HBT and current mental (R² = 0.08, p = .01) and physical (R² = 0.11, p = .002) HRQOL. Shame, but not PTSD, mediated relationships between childhood LBT and current mental (R² = 0.14, p < .001) and physical (R² = 0.16, p < .001) HRQOL.

CONCLUSIONS

Our study provides preliminary evidence that dissociation and shame negatively impact HRQOL among individuals with CPP in the context of exposure to different types of childhood betrayal trauma. Replication studies to validate our results with larger samples and longitudinal designs are encouraged.

Chronic scrotal pain: Pathogenesis, clinical phenotypes and modern treatment concept (clinical lecture)

Chronic scrotal pain (CSP) is a general term, which defines variety of problems causing discomfort or pain in the scrotum, which can be caused by the problems with testicles and other structures of the scrotum: epididymis, vas deferens, paratesticular structures. For a practicing urologist, the diagnosis and treatment of chronic scrotal pain is always a difficult task due to the many reasons for its appearance and the variety of clinical symptoms. CSP is a widespread but poorly understood condition, the etiology of which often can not be identified. Pain localized in the scrotum makes up 38.8 % of all cases of chronic men’s pelvic pain. From 2.5 to 4.8 % of all visits to the urologist relate to CSP syndrome. Primary scrotal pain syndrome is not associated with infection or other local pathological processes that could cause pain. The treatment of chronic scrotal pain is challenging because the pain often does not react to the traditional treatments.

The purpose of this lecture is to draw the attention of urologists, general practitioners, and everyone who is interested in the problem of treating chronic scrotal pain to the possibilities of modern medicine in solving this multidisciplinary problem.

Clinical Review of Neuromusculoskeletal Complementary and Alternative Approaches for the Treatment of Chronic Pelvic Pain Syndrome

Chronic pelvic pain syndrome (CPPS) is a functional pain disorder characterized by ongoing pain in the apparent absence of clinically identifiable causes. The prevalence of functional pain disorders demonstrates the importance of adequate management of ongoing symptomatology, but due to the uncertain etiology and myriad patient presentation phenotypes, reliable treatment options are difficult to implement. New interventions involving non-pharmacological approaches to pain management have been investigated across a spectrum of clinical and pre-clinical studies. Given that conservative care such as exercise, counseling, and musculoskeletal therapy is widely recommended as first-line treatment for CPPS, an updated review of these and related methodologies are needed. Familiarizing physicians and the public with the newest evidence for complementary and alternative medicine (CAM) and other conservative care treatments will assist with the promotion of evidence-based practices in a safe and reliable manner. This review aimed to summarize the current evidence and proposed mechanisms for non-pharmacological treatment specific to CAM and management of chronic pelvic pain centered on neuromusculoskeletal focused intervention such as acupuncture, auriculotherapy, manipulation, manual therapy, myofascial release, and phototherapy. The discussion suggests that reported improvements in pelvic pain or related symptomatology may be attributed to changes in the peripheral inflammasome and somatic origins of peripheral sensitization. Robustness of the included clinical studies is discussed throughout the review, and attention is paid to delineating inclusion criteria of formally diagnosed CPPS compared to general pelvic or abdominal pain. Overall, this review consolidates the current state of evidence regarding the utilization of non-traditional interventions using CAM techniques for the management of chronic pelvic pain and recommends a future direction for the field.

A systematic review highlighting poor-quality of evidence for Content Validity of Quality of Life (QoL) Instruments in Female Chronic Pelvic Pain (CPP)

OBJECTIVES

To evaluate the content validity of 19 Patient Reported Outcome Measures (PROMs) used to measure QoL in women with CPP DESIGN AND SETTING: We searched EMBASE, MEDLINE, PsycINFO databases and Google Scholar from inception to August 2020. We included records describing the development or studies assessing content validity of PROMs. Two reviewers independently assessed the methodological quality of PROMs using the COSMIN checklist. Evidence was synthesised for relevance, comprehensiveness and comprehensibility. Quality of evidence was rated using a modified GRADE approach.

MAIN RESULTS

PROM development was inadequate for all instruments included in this review. No high-quality evidence ratings were found for relevance, comprehensiveness and comprehensibility. QoL was measured using generic instruments (68.42%, 13/19) rather than those specific to chronic pain (21.04%, 4/19) or pelvic pain (10.53%, 2/19). Quality of concept elicitation was inadequate for 90% of PROMs. Half of PROMs did not include patients in their development and only 40% were devised using a sample representative of the target population for which the PROM was developed. Cognitive interviews were conducted in one-fifth of PROMs and were mostly of inadequate/doubtful quality.

CONCLUSION

There is poor-quality of evidence for content validity of PROMs used to measure QoL in women with CPP.