Endometriosis-associated pelvic pain (EAPP) is defined as persistent or recurrent pelvic pain in individuals diagnosed with endometriosis through laparoscopy. Women with EAPP frequently report general pelvic pain, dysmenorrhea, dyspareunia, dyschezia, as well as dysuria. Alterations in pelvic floor muscle (PFM) function, specifically increased PFM tone, have been observed in women with EAPP.[1]  PFM exercise is commonly prescribed by physiotherapists for women with EAPP to reduce elevated resting PFM tone, improve PFM contraction and relaxation and reduce pelvic pain. However, the feasibility and effects of different types of PFM exercises (PFM contraction-plus-relaxation [PFMC+R] vs PFM relaxation-only [PFMR]) in women with EAPP are unknown. Mindfulness has been shown to be effective in reducing pelvic pain[2]; therefore, adding mindfulness to a PFM exercise protocol could improve the feasibility and clinical outcomes. This study aimed to evaluate the feasibility and acceptability of PFM protocols and mindfulness in women with EAPP, and changes in pelvic pain and PFM morphometry.

This was a pilot randomised controlled trial. Participants underwent an 8-week hybrid intervention (8 individual supervised face-to-face and telehealth consultations). Participants were randomised to either PFMC+R or PFMR interventions, with both groups receiving the same mindfulness programme. Randomisation occurred pre-intervention in a 1:1 ratio using random permuted blocks. During face-to-face intervention sessions, both groups used a surface electromyography biofeedback unit. At home, participants were instructed to use alternative biofeedback methods, such as a mirror or self-palpation. The PFM protocol for each group was gradually progressed by increasing repetitions and changing exercise positions (supine, sitting, and standing).  The primary outcome was feasibility, specifically retention rate. The secondary outcomes were EAPP symptoms assessed by validated pain questionnaires and PFM morphometry measured by transperineal ultrasound imaging at baseline and after completion of the intervention by an assessor who was blinded to group allocation. Sample size was calculated based on retention rate using data from a previous multimodal physiotherapy interventional study of 30 women with EAPP.[3] Assuming 86% of women completed pelvic floor physiotherapy and both baseline and post-intervention assessments, a 95% confidence interval (CI), and a margin of error of 0.1, the required sample size was 46 women in total. To account for potential dropouts (15%), a total of 56 (28 per group) participants were required.

Ninety-five women were assessed for eligibility, from which 45 participants with EAPP (recruitment rate 47%) were randomly assigned to either the PFMC+R group (n=23) or the PFMR group (n=22). The PFMC+R group had higher retention, acceptability, and attendance rates compared to the PFMR group (86% vs 63% retention, 82% vs 63% acceptability, and 85% vs 63% attendance respectively) (Table 1).  The PFMC+R group demonstrated a significantly lower intensity of general pelvic pain and dyspareunia compared to the PFMR group (Table 2). Additionally, the PFMC+R group had larger anorectal angle and anterior-posterior diameter of levator hiatus measurements at rest post-intervention, suggesting a lower PFM resting tone and greater PFM relaxation compared to the PFMR group (Table 2).

The PFMC+R exercise protocol was more feasible and acceptable than the PFMR exercise protocol, and demonstrated greater improvements in EAPP symptoms and PFM morphometry. As we fell just short of our a priori sample size estimate, further research with a larger sample size is required to verify these findings. Additionally, adequately powered studies are required to determine whether the severity of endometriosis disease alters the response to these interventions.

Physiotherapists may consider incorporating a hybrid intervention programme that combines PFMC+R exercises with mindfulness for women with EAPP, as this protocol may be more feasible and potentially beneficial in reducing general pelvic pain intensity, dyspareunia, and resting PFM tone compared to a PFMR exercise plus mindfulness protocol.

Mabrouk M, Raimondo D, Del Forno S, et al. Pelvic floor muscle assessment on three- and four-dimensional transperineal ultrasound in women with ovarian endometriosis with or without retroperitoneal infiltration: a step towards complete functional assessment. Ultrasound Obstet Gynecol. Aug 2018;52(2):265-268.
Moreira MdF, Gamboa OL, Pinho Oliveira MA. A single-blind, randomized, pilot study of a brief mindfulness-based intervention for the endometriosis-related pain management. Eur J Pain. 2022;26(5):1147-1162.
Armour M, Cave AE, Schabrun SM, et al. Manual Acupuncture Plus Usual Care Versus Usual Care Alone in the Treatment of Endometriosis-Related Chronic Pelvic Pain: A Randomized Controlled Feasibility Study. The Journal of Alternative and Complementary Medicine. 2021;27(10):841-849.