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Starzec-Proserpio M, Frawley H, Bø K, Morin M. Effectiveness of nonpharmacological conservative therapies for chronic pelvic pain in women: a systematic review and meta-analysis. Am J Obstet Gynecol 2024:S0002-9378(24)00827-5. [PMID: 39142363 DOI: 10.1016/j.ajog.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 07/10/2024] [Accepted: 08/03/2024] [Indexed: 08/16/2024]
Abstract
OBJECTIVE To evaluate the effectiveness of nonpharmacological conservative therapies for women with CPP. DATA SOURCES A systematic search of electronic databases (Amed, CINAHL, PsycINFO, SportDiscuss, Medline, PubMed, Embase, and Cochrane Central Register of Controlled Trials) was performed in January 2023, and updated in December 2023. STUDY ELIGIBILITY CRITERIA Randomized controlled trials comparing a nonpharmacological conservative therapy to inert (eg, placebo, usual care) or nonconservative (eg, surgical, pharmacological) treatment were included. Conservative therapies of interest to this review were: multimodal physical therapy, predominantly psychological approaches, acupuncture, and other tissue-based monotherapies (eg, electrophysical agents, manual stretching). STUDY APPRAISAL AND SYNTHESIS METHODS All study data were aggregated, and analyses of the included studies were performed. Effects on pain; sexual measures; psychological and physical function; health-related quality of life; symptom severity/bother; pelvic floor muscle function and morphometry; perceived improvement; and adverse events were analyzed. Meta-analyses (random effects model) were conducted using postintervention scores for data that included similar interventions and outcomes. Standardized mean differences were calculated. A narrative summary of findings that could not be included in the meta-analysis is provided. The quality of the evidence was assessed with the Physiotherapy Evidence Database scale and the certainty of evidence with Grading of Recommendations, Assessment, Development, and Evaluations criteria. RESULTS Of 5776 retrieved studies, 38 randomized controlled trials including 2168 women (mean age 35.1±8.6) were included. Meta-analyses revealed that multimodal physical therapy resulted in lower pain intensity compared to inert or nonconservative treatments in both the short (standardized mean difference -1.69, 95% confidence interval -2.54, -0.85; high certainty) and intermediate-terms (standardized mean difference -1.82, 95% confidence interval -3.13, -0.52; moderate certainty), while predominantly psychological approaches resulted in no difference in pain intensity (standardized mean difference -0.18, 95% confidence interval -0.56, 0.20; moderate certainty) and a slight difference in sexual function (standardized mean difference -0.28, 95% confidence interval -0.52, -0.04; moderate certainty). The level of evidence regarding the meta-analysis of the effects of acupuncture on pain intensity (standardized mean difference 1.08, 95% confidence interval -1.38, 3.54, nonstatistically significant results in favor of control treatment) precluded any statement of certainty. A limited number of trials investigated individual tissue-based monotherapies, providing a restricted body of evidence. CONCLUSION This systematic review with meta-analysis revealed that multimodal physical therapy is effective in women with chronic pelvic pain with a high certainty of evidence.
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Affiliation(s)
- Małgorzata Starzec-Proserpio
- Department of Midwifery, Centre of Postgraduate Medical Education, Warsaw, Poland; Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Faculty of Medicine and Health Sciences, School of Rehabilitation, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Helena Frawley
- Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Australia; Allied Health Research, Royal Women's Hospital and Mercy Hospital for Women, Melbourne, Australia
| | - Kari Bø
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway; Department of Obstetrics and Gynecology, Akershus University Hospital, Lorenskog, Norway
| | - Mélanie Morin
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Faculty of Medicine and Health Sciences, School of Rehabilitation, Université de Sherbrooke, Sherbrooke, QC, Canada.
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Kadah S, Soh SE, Morin M, Schneider M, Ang WC, McPhate L, Frawley H. Are pelvic pain and increased pelvic floor muscle tone associated in women with persistent noncancer pelvic pain? A systematic review and meta-analysis. J Sex Med 2023; 20:1206-1221. [PMID: 37507352 DOI: 10.1093/jsxmed/qdad089] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/23/2023] [Accepted: 06/14/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND The association between pelvic pain and pelvic floor muscle (PFM) tone in women with persistent noncancer pelvic pain (PNCPP) is unclear. AIM To synthesize the evidence of the association between pelvic pain and PFM tone in women with PNCPP. METHODS A systematic review was conducted via MEDLINE, Emcare, Embase, CINAHL, PsycINFO, and Scopus to identify relevant studies. Studies were eligible if pelvic pain and PFM tone outcome measures were reported among women aged >18 years. The National Heart, Lung, and Blood Institute's Quality Assessment Tool for Observational Cohort and Cross-sectional Studies was used to assess study quality. Studies were pooled by assessment of PFM tone via a random effects model. Associations between the presence of pelvic pain and PFM tone were assessed with odds ratio (OR), while linear associations were assessed with Pearson or Spearman correlation. OUTCOMES Pelvic pain measures (intensity, threshold, and frequency) and resting PFM tone in women with PNCPP, as evaluated by any clinical assessment method or tool. RESULTS Twenty-four studies were included in this review. The presence of pelvic pain was significantly associated with increased PFM tone as assessed by digital palpation (OR, 2.85; 95% CI, 1.66-4.89). Pelvic pain intensity was inversely but weakly associated with PFM flexibility when evaluated through dynamometry (r = -0.29; 95% CI, -0.42 to -0.17). However, no significant associations were found between pelvic pain and PFM tone when measured with other objective assessment methods. CLINICAL IMPLICATIONS Pelvic pain and increased PFM tone may not be directly associated; alternatively, a nonlinear association may exist. A range of biopsychosocial factors may mediate or moderate the association, and clinicians may need to consider these factors when assessing women with PNCPP. STRENGTHS AND LIMITATIONS This review was reported according to the PRISMA guidelines. All possible findings from relevant theses and conference abstracts were considered in our search. However, nonlinear associations between pelvic pain and increased PFM tone were not assessed as part of this review. CONCLUSION Pelvic pain may be linearly associated with increased PFM tone and decreased PFM flexibility when measured with digital palpation or dynamometry; however, this association was not observed when other aspects of PFM tone were assessed through objective methods. Future studies are required using robust assessment methods to measure PFM tone and analyses that account for other biopsychosocial factors that may influence the association.
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Affiliation(s)
- Shaza Kadah
- Department of Physiotherapy, Monash University, Melbourne, Victoria 3199, Australia
- Department of Physical Therapy, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Sze-Ee Soh
- Department of Physiotherapy, Monash University, Melbourne, Victoria 3199, Australia
| | - Melanie Morin
- School of Rehabilitation Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Québec J1K2R1, Canada
| | - Michal Schneider
- Department of Medical Imaging and Radiation Sciences, Monash University, Melbourne, Victoria 3800, Australia
| | - W Catarina Ang
- Women's Health Services, Royal Women's Hospital, Melbourne, Victoria 3052 Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria 3010, Australia
| | - Lucy McPhate
- Department of General Medicine, The Royal Melbourne Hospital, Melbourne, Australia
| | - Helena Frawley
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria 3010, Australia
- Allied Health Research, The Royal Women's Hospital, Melbourne, Victoria 3052 Australia
- Allied Health Research, Mercy Hospital for Women, Melbourne, Victoria 3084, Australia
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McNamara HC, Frawley HC, Donoghue JF, Readman E, Healey M, Ellett L, Reddington C, Hicks LJ, Harlow K, Rogers PAW, Cheng C. Peripheral, Central, and Cross Sensitization in Endometriosis-Associated Pain and Comorbid Pain Syndromes. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:729642. [PMID: 36303969 PMCID: PMC9580702 DOI: 10.3389/frph.2021.729642] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022] Open
Abstract
Endometriosis-associated pain and the mechanisms responsible for its initiation and persistence are complex and difficult to treat. Endometriosis-associated pain is experienced as dysmenorrhea, cyclical pain related to organ function including dysuria, dyschezia and dyspareunia, and persistent pelvic pain. Pain symptomatology correlates poorly with the extent of macroscopic disease. In addition to the local effects of disease, endometriosis-associated pain develops as a product of peripheral sensitization, central sensitization and cross sensitization. Endometriosis-associated pain is further contributed to by comorbid pain conditions, such as bladder pain syndrome, irritable bowel syndrome, abdomino-pelvic myalgia and vulvodynia. This article will review endometriosis-associated pain, its mechanisms, and its comorbid pain syndromes with a view to aiding the clinician in navigating the literature and terminology of pain and pain syndromes. Limitations of our current understanding of endometriosis-associated pain will be acknowledged. Where possible, commonalities in pain mechanisms between endometriosis-associated pain and comorbid pain syndromes will be highlighted.
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Affiliation(s)
- Helen C. McNamara
- Royal Women's Hospital, Melbourne, VIC, Australia
- *Correspondence: Helen C. McNamara
| | - Helena C. Frawley
- Royal Women's Hospital, Melbourne, VIC, Australia
- School of Health Sciences, University of Melbourne, Parkville, VIC, Australia
- Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Jacqueline F. Donoghue
- Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Emma Readman
- Mercy Hospital for Women, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Martin Healey
- Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Lenore Ellett
- Mercy Hospital for Women, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Charlotte Reddington
- Royal Women's Hospital, Melbourne, VIC, Australia
- Mercy Hospital for Women, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | | | - Keryn Harlow
- Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Peter A. W. Rogers
- Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Claudia Cheng
- Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
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Conroy I, Mooney SS, Kavanagh S, Duff M, Jakab I, Robertson K, Fitzgerald AL, Mccutchan A, Madden S, Maxwell S, Nair S, Origanti N, Quinless A, Mirowski-Allen K, Sewell M, Grover SR. Pelvic pain: What are the symptoms and predictors for surgery, endometriosis and endometriosis severity. Aust N Z J Obstet Gynaecol 2021; 61:765-772. [PMID: 34028794 DOI: 10.1111/ajo.13379] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/04/2021] [Accepted: 04/30/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chronic pelvic pain (CPP) is a common condition which significantly impacts the quality of life and wellbeing of many women. Laparoscopy with histopathology is recommended for investigation of pelvic pain and identification of endometriosis with concurrent removal. Never-the-less, the association between endometriosis and pelvic pain is challenging, with endometriosis identified in only 30-50% of women with pain. AIMS To explore the predictors for undergoing surgery, for identifying endometriosis and endometriosis severity in a cohort of women with CPP. MATERIALS AND METHODS This study forms part of the Persistent Pelvic Pain project, a prospective observational cohort study (ANZCTR:ACTRN12616000150448). Women referred to a public gynaecology clinic with pain were randomised to one of two gynaecology units for routine care and followed for 36 months with 6-monthly surveys assessing demographics, medical history, quality of life, and pain symptoms measured on a Likert scale. Operative notes were reviewed and endometriosis staged. RESULTS Of 471 women recruited, 102 women underwent laparoscopy or laparotomy, of whom 52 had endometriosis (n = 37 stage I-II; n = 15 Stage III-IV). Gynaecology unit, pelvic pain intensity and lower parity were all predictors of surgery (odds ratio (OR) 0.342; 95% CI 0.209-0.561; OR 1.303; 95% CI: 1.079-1.573; OR 0.767; 95% CI: 0.620-0.949, respectively). There were no predictors identified for endometriosis diagnosis and the only predictor of severity was increasing age (OR 1.155; 95% CI: 1.047-1.310). CONCLUSIONS Gynaecology unit and pain intensity were key predictors of undergoing laparoscopy; however, pain severity did not predict endometriosis diagnosis or staging. These findings indicate the need to review current frameworks guiding practice toward surgery for pelvic pain.
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Affiliation(s)
- Isabelle Conroy
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Austin Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Samantha S Mooney
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Shane Kavanagh
- School of Health and Social Development, Deakin University, Melbourne, Victoria, Australia
| | - Michael Duff
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Ballarat Hospital, Ballarat, Victoria, Australia
| | - Ilona Jakab
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Katharine Robertson
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Peninsula Hospital, Langwarrin, Victoria, Australia
| | - Amy L Fitzgerald
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Monash Health, Clayton, Victoria, Australia
| | - Alexandra Mccutchan
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Western Health, Footscray, Victoria, Australia
| | - Siana Madden
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Sarah Maxwell
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Shweta Nair
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Western Health, Footscray, Victoria, Australia
| | - Nimita Origanti
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Alfred Health, Melbourne, Victoria, Australia
| | - Alish Quinless
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia.,South West Healthcare, Warrnambool, Victoria, Australia
| | - Kelly Mirowski-Allen
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Megan Sewell
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Sonia R Grover
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women (MHW), University of Melbourne, Melbourne, Victoria, Australia.,Austin Hospital, Melbourne, Victoria, Australia
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