Chronic pelvic pain is often managed by multi-disciplinary teams, however little is known of individual beliefs and practice behaviours of health care professionals (HCP) from different disciplines.  According to ICS terminology, chronic pelvic pain (CPP) is characterised by persistent pain lasting longer than 6 months or recurrent episodes of abdominal/pelvic pain, hypersensitivity or discomfort often associated with elimination changes, and sexual dysfunction often in the absence of organic etiology”. CPP may affect as many as one in four women of reproductive age worldwide[1] and patients are often complex, present with a high degree of associated co-morbidities and may wait years for appropriate management. CPP also imposes considerable burden both to an individual and at a global economic level and so it is important to understand if variations of care exist among HCP.

Clinical practice guidelines are designed to assist decision making for HCPs. A recent systematic review has suggested the quality of clinical practice guidelines for the management of CPP is varied and may not match the understanding of current management principles for pain disorders[2]. Pharmaceutical and surgical interventions were most commonly recommended, with more variable advice related to psychological, physiotherapy and other conservative management strategies[2]. 

The aim of this study was to compare the current beliefs and practice behaviours of HCP (physiotherapists, gynaecologists and general practitioners) in the management of CPP in Australian women.

The prospective web-based study was observational and cross-sectional documenting HCPs’ beliefs and practice behaviours related to CPP.  The study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement for cross-sectional studies.

The participants in the study were Australian gynaecologists, GPs and physiotherapists from both public and private health settings in Australia.  The sample size was derived from the total combined population of Australian gynaecologists, urogynaecologists, GPs and physiotherapists. From an estimated population of 45,700 HCPs our estimated sample size was calculated to be 381 to be an accurate representation of these three professions in Australia. We calculated the sample size using a confidence level of 95% and margin of error of 5%.

Eligible participants were invited to complete an online 19-item questionnaire focused on beliefs and practice behaviours in the management of CPP.  An iterative process was used to develop the questionnaire:
Step 1.  A literature search was undertaken to find any existing questionnaire assessing HCP beliefs about and/or management of CPP. No validated or non-validated questionnaire was found for this purpose.
Step 2. Previous work by researchers[3]  that assessed physiotherapists’ beliefs and management practices of pelvic girdle pain between 2 cohorts (Australian and Norwegian physiotherapists) was used as a template for conducting the present study. 
Step 3. Information from clinical practice guidelines for the diagnosis and management of CPP disorders were adopted to develop questions that would assess HCPs’ beliefs and practice behaviours. These included the European Association of Urology (EAU) guidelines on CPP and National Institute for Health and Care Excellence (NICE) guidelines for diagnosis and management of endometriosis. 
Step 4. To improve face validity and ensure relevance of our novel questionnaire we sought early and sustained community engagement, gaining input and feedback from HCPs across disciplines and from different states of Australia.

The questionnaire covered three main areas:
Participant demographics, including age, gender, profession, workplace, training/education in chronic pain or pelvic pain, confidence in treating CPP and awareness/use of clinical guidelines.
Beliefs about pelvic pain. Participants were presented with statements regarding beliefs about pelvic pain that were derived from the Practitioner Attitudes and Beliefs (PABS-Q) and Back Beliefs Questionnaire (BBQ) and adapted for CPP. The PABS-Q and BBQ were deemed suitable as they assess HCPs’ and patients’ beliefs about low back pain (LBP). 
Participants were asked to rate factors that might influence a patient’s experience with CPP to determine awareness of potential mechanisms of CPP. 
Practice behaviours. Participants were asked to rate their common assessment strategies for CPP. This section attempted to determine if HCPs are examining the impact of CPP on functional, emotional and psychosocial measures, as per the EAU Guidelines.
Participants were then presented with two vignettes, each representing common CPP presentations that a HCP may see in clinical practice. One vignette referred to a specific diagnosis of endometriosis, while the other referred to a non-specific presentation of CPP. Following both vignettes, participants were asked to choose from a list of management options and the most frequent responses were ranked. 

Data were cleaned and checked for outliers and keystroke errors. Descriptive statistics were reported using means and standard deviations for normal continuous variables and frequency distributions for categorical variables. Heat maps were used for visual representation of specific questions for the entire cohort and for the three individual professions. Group comparisons (gynaecologists, GPs, physiotherapists) were explored with unpaired t-tests for age and Chi square for categorical variables using STATA/BE 17.0 (StataCorp, College Station, TX, USA).

In total, 446 of 538 responses were included for statistical analysis, including 75 gynaecologists, 184 GPs and 187 physiotherapists. Most of the respondents were female (88.1%) with male (11.7%) and other (0.2%) making up a smaller representation.

All three professions rated a patient’s beliefs (89.8%), nervous system sensitisation (85.7%), stress/anxiety/depression (91.9%), fear avoidance (83.3%), history of sexual/emotional/physical abuse (94.1%) and increased tone of pelvic floor muscles (85.0%) as very/extremely important factors in the development of CPP. Most gynaecologists (71.0%) and GPs (70.2%) always referred for pelvic ultrasound when assessing CPP. Physiotherapists assessed goal setting (88.8%) and screened for patients’ beliefs (80.9%) more often than gynaecologists (30.4%, 39.1%) and GPs (46.5%, 29.0%). All three groups reported that they screened for a history of sexual/emotional/physical abuse, however 76.5% of physiotherapists reported to do this “always”, as compared to 36.2% of gynaecologists and 44.8% of GPs.

The results suggest that the majority of HCPs followed guideline recommended care for the management of CPP, despite 64.1% and 47.8% of the cohort not being aware of the EAU guidelines for CPP or NICE guidelines for endometriosis respectively. Participants demonstrated good understanding of central and peripheral pain mechanisms, and recommended investigations for disease-associated pelvic pain, the majority assessed biopsychosocial factors and recommended referral to other HCPs for a multi-disciplinary team approach. This was despite almost half of gynaecologists (49.3%) and 43.5% of GPs reporting they had never completed a pain education course.

Encouragingly, the majority of Australian HCPs in this study demonstrated a good understanding of pain mechanisms and incorporated a biopsychosocial approach to assessment and treatment of women with CPP.  The responses indicated the majority of HCPs’ practice behaviours aligned with EAU guidelines for CPP and NICE guidelines for endometriosis.

This study also provides a platform for a broader discussion of the importance of formal care pathways for patients with CPP.  With Australia’s recent announcement of a commitment to increase funding for the establishment of endometriosis and pelvic pain clinics in each state and territory, it is imperative that we understand the barriers and enablers to guideline recommended and multidisciplinary care. Future research might include clinical audits or observation of HCP-patient interactions to provide further insight into practice behaviours and the implementation of multidisciplinary care in primary and secondary care settings in this area.

Ahangari, A., Prevalence of chronic pelvic pain among women: an updated review. Pain Physician, 2014. 17(2): p. E141-7.
Mardon, A.K., et al., Treatment recommendations for the management of persistent pelvic pain: a systematic review of international clinical practice guidelines. BJOG, 2021.
Beales, D., et al., Current practice in management of pelvic girdle pain amongst physiotherapists in Norway and Australia. Man Ther, 2015. 20(1): p. 109-16.