Australian healthcare professionals’ beliefs and practice behaviours in management of chronic pelvic pain: a cross-sectional survey
Jennifer Vardy
A * , Edwina Chan A , Marika Hart A , Rebecca Dallin A , Emma Wise A , Emmanuel Karantanis B C and Darren Beales A
A
B
C
Abstract
Chronic pelvic pain (CPP) is a common and debilitating condition, and sufferers present to healthcare professionals with variable complex symptoms and co-morbidities. This study aimed to investigate the current beliefs and practice behaviours of healthcare professionals towards the management of CPP in Australian females.
We distributed an online survey to Australian healthcare professionals. Participants were questioned regarding their beliefs, the importance of various contributing factors and assessment variables, and their management preferences for two CPP vignettes. Demographic information and responses were analysed with descriptive statistics.
Complete data were obtained and analysed from 446 respondents including gynaecologists (n = 75), general practitioners (GPs) (n = 184) and physiotherapists (n = 187). Most of the respondents were female (88.1%), with male (11.7%) and other (0.2%) making up a smaller representation. Physiotherapists rated themselves higher in understanding mechanisms of CPP (64.7% very good to excellent) compared to gynaecologists (41.3%) and GPs (22.8%). Physiotherapists also reported higher levels of confidence in managing patients with CPP (57.8% quite or extremely confident) compared to 41.3% of gynaecologists and 22.3% of GPs who reported being quite or extremely confident. All three professions rated 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 pelvic floor muscle function (85.0%) as very/extremely important factors in the development of chronic pelvic pain. Most gynaecologists (71.0%) and GPs (70.2%) always referred for pelvic ultrasound during assessment. Physiotherapists assessed goal setting (88.8%) and screened for patients’ beliefs (80.9%) more often than gynaecologists (30.4% and 39.1% respectively) and GPs (46.5% and 29.0% respectively).
All three groups of healthcare professionals demonstrated a good understanding of pain mechanisms and incorporated a biopsychosocial and multidisciplinary approach to management of females with chronic pelvic pain. However, both gynaecologists and GPs were less confident in their understanding of and management of CPP, and less likely to consider patient beliefs and goals. The findings of this online survey may assist in the provision of more targeted education to further improve management of this condition.
Keywords: biopsychosocial approach, chronic pelvic pain, endometriosis, e-survey, general practitioners, gynaecologists, persistent pelvic pain, physiotherapists.
Introduction
Chronic pelvic pain (CPP) encompasses pain perceived in the pelvis for 6 months or more (Engeler et al. 2020) and affects one in four females of reproductive age (Latthe et al. 2006; Ahangari 2014). Pain often accompanies complex co-morbidities including bladder, bowel, pelvic floor muscle, and sexual dysfunction, and these have a significant impact upon physical and mental health (Engeler et al. 2020), work, study and personal relationships (Armour et al. 2020). In Australia, healthcare costs and lost productivity related to CPP exceed A$6.5 billion annually (Armour et al. 2019). Current evidence suggests management should move away from an organ-centred and biomedical approach to multidisciplinary and biopsychosocial care (Engeler et al. 2013; Mardon et al. 2021).
Current clinical practice guidelines for CPP are of variable quality and recommend predominantly pharmacological and surgical interventions over conservative therapies such as psychology and physiotherapy (Mardon et al. 2021). The current European Association of Urology (EAU) guideline on CPP recommends that healthcare professionals (HCPs) focus on the biopsychosocial factors involved in pelvic pain (Engeler et al. 2020), which aligns to a contemporary approach to the management of pain disorders (Mitchell et al. 2017). It is therefore imperative that we review the current healthcare options for patients as high rates of Australian females with CPP, at significant personal cost, seek support from allied health and complementary therapies (Malik et al. 2022).
There is limited information available on current beliefs and practice behaviours of HCPs for the management of CPP. Previous qualitative studies suggest this complex and heterogenous population needs an individualised approach (Meriwether et al. 2023) because gynaecologists, while maintaining a biopsychosocial approach, may focus primarily on excluding organic disease (Schwind et al. 2015) and physiotherapists do not always prioritise addressing psychosocial factors (Beales et al. 2015).
The aim of this study was to document the current beliefs and practice behaviours of HCPs including gynaecologists/urogynaecologists (referred to hereafter collectively as gynaecologists), general practitioners (GPs) and physiotherapists with special interest in pelvic health, in the management of CPP in Australian females.
Methods
Study design
A cross-sectional online survey was designed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist to profile HCPs’ beliefs and practice behaviours related to CPP. The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was also adhered to (see Supplementary Table S5).
Participants
Eligible participants were registered HCPs (gynaecologists, GPs, physiotherapists) in Australia, who may manage CPP. Regarding physiotherapists, general and musculoskeletal physiotherapists do not tend to manage patients with chronic pelvic pain. We hypothesised that physiotherapists participating will have a special interest in pelvic health and pelvic floor muscle dysfunction with relevant training. We refer hereafter to these as pelvic health physiotherapists when describing physiotherapists. Participants were aged at least 18 years and could identify as any gender. Participants had sufficient English proficiency to complete the online survey.
Setting/recruitment strategies
Health care in Australia consists of both publicly funded and privately funded systems, and patients with CPP may interact with HCPs in either or both sectors. Once ethical approval had been obtained (Curtin University Human Research Ethics Committee approval HRE2021-0299), recruitment occurred in three phases over a 6-week period during June–July 2021. Eligible participants were invited to voluntarily complete the open online survey if they were ‘healthcare professionals working with women who suffer chronic pelvic pain’. A notice of invitation, containing a weblink to the questionnaire, was advertised directly through social media platforms such as Facebook, X (formally Twitter) and Instagram. Flyers with a quick response (QR) code with links to the online survey were also distributed at gynaecology and urogynaecology practices, GP clinics and physiotherapy practices. Emails and e-newsletters containing details of the study and the online survey link were forwarded to relevant HCPs via professional groups including Australian gynaecologist networks, GP networks, Rural Doctors Association of Australia, Continence Foundation Australia (Victorian branch), University Pelvic Health Physiotherapy Alumni, New South Wales, Western Australian and Victorian public hospital pelvic health physiotherapy groups. All participants volunteered; they were advised the survey would take ~10 min to complete. They were not offered incentives and they confirmed informed consent prior to participating.
Procedures
For participant anonymity and convenience, Qualtrics software (Qualtrics XM, Provo, UT, USA) was used to conduct the online survey. There was a total of 19 questions over 16 pages. The survey was completed in a single time-point and participants could not go back and adjust their answers to previous questions. Responses were ‘forced’ to eliminate missing data. Data were stored on a secure drive to protect unauthorised access.
An iterative process was used to develop the online survey to investigate the attitudes, beliefs and current practice behaviours in the management of CPP in Australian HCPs.
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 (Beales et al. 2015) that assessed physiotherapists’ beliefs and management practices of pelvic girdle pain between two cohorts (Australian and Norwegian physiotherapists) was used as a template.
Step 3. Information from clinical practice guidelines for the diagnosis and management of CPP disorders were utilised to develop questions that would assess HCPs’ beliefs and practice behaviours. These included the European Association of Urology (EAU) guidelines on CPP (Engeler et al. 2020) and National Institute for Health and Care Excellence (NICE) guidelines for diagnosis and management of endometriosis (National Institute of Health and Care Excellence 2017). These two guidelines were chosen because they were most referred to in Australian institutions. The EAU guidelines on CPP were also chosen because they included a multidisciplinary and biopsychosocial approach, which aligns with contemporary management of pain disorders (Mitchell et al. 2017). The NICE guidelines have also subsequently been recommended for use by a recent systematic review on CPP guidelines (Mardon et al. 2021). The Australian clinical practice guidelines for endometriosis (RANZCOG 2021) had not yet been published at the time of our survey development. Sections of the survey were developed to determine adherence to four strong recommendations for the management of CPP in the EAU guidelines (Engeler et al. 2020). These recommendations include: (1) HCPs should have knowledge of central and peripheral pain mechanisms; (2) early assessment should include investigations aimed at specific disease-associated pelvic pain; (3) assessment should include functional, emotional, behavioural and quality-of-life factors; and (4) CPP patients should be managed within a multidisciplinary environment (Engeler et al. 2020).
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. This included two urogynaecologists, one gynaecologist, one gynaecology registrar, one medical intern, one specialist pelvic health physiotherapist, five pelvic health physiotherapists, two GPs, two physiotherapy lecturers and three patients with CPP. This community consultation from a range of backgrounds helped modify the initial draft survey to ensure relevance across the disciplines and to improve likelihood of survey completion.
Step 5. Amendments were made following biostatistician input.
Step 6. After further review by some of the experts consulted within Step 4, suggestions and feedback were incorporated into the final online survey.
Demographics of the participants (age, gender, profession, workplace, training/education in chronic pain or pelvic pain, experience with treating CPP) were collected. Participants were asked to self-rate how often they manage patients with CPP, their confidence in treating CPP, and their confidence in understanding of mechanisms in CPP. Participants were asked about their knowledge and usage of current guidelines.
Participants were presented 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); however, they are not validated for pelvic pain. Responses are rated on a six-point scale (‘totally disagree’, ‘largely disagree’, ‘disagree to some extent’, ‘agree to some extent’, ‘largely agree’, ‘totally agree’). This section helped to establish participants’ knowledge of central and peripheral pain mechanisms, which is strongly recommended in the EAU Guidelines on CPP (Engeler et al. 2020).
Participants were asked to rate factors that might influence a person’s experience with CPP to determine awareness of potential mechanisms of CPP. Participants were also asked to rate their common assessment strategies for CPP and where they get their primary information regarding management and understanding of CPP from. This section attempted to determine if HCPs are examining the impact of CPP on functional, emotional and psychosocial measures, as per the EAU Guidelines (Engeler et al. 2020).
Participants were presented with two vignettes, each representing common CPP presentations in clinical practice. One vignette was devised around a specific diagnosis of endometriosis, whereas the other was devised around a non-specific presentation of CPP. Following both vignettes, participants were asked to choose four from a list of 28 initial management options to gain insight into their practice behaviours. Four choices were considered a reasonable number for an initial management plan. A ranking of the most frequent responses was made.
The sample size was derived from the total combined population of Australian gynaecologists, GPs and physiotherapists with a special interest in pelvic health (estimated as one-quarter of the total physiotherapist population). From an estimated population of 45,700 HCPs, our ideal sample size was calculated to be 381. We calculated the sample size using a confidence level of 95% and margin of error of 5%.
Statistical analysis
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. Group comparisons (physiotherapists, gynaecologists and GPs) were explored with unpaired t-tests for age and Chi-squared tests for categorical data. STATA/BE 17.0 (StataCorp, College Station, TX, USA) was used for statistical analysis.
Results
Participant characteristics
Surveys less than 80% completed (n = 70) and ‘other’ HCPs (n = 22) were excluded from final analysis. This left 446 responses available (gynaecologists = 75, GPs = 184, physiotherapists = 187). Those that failed to complete 80% of the survey were slightly younger than those who did not (~42.2 years compared to 45.8 years) (Table S1). GPs dropped out more than other professions. Those who dropped out tended to be less confident in the management of these disorders and reported less awareness of guidelines (Table S1).
Demographic characteristics of the final cohort are reported in Table 1. Most respondents were female (88.1%), with male (11.7%) and other (0.2%) making up a much smaller proportion. Half of the gynaecologists (50.7%) surveyed and 56.5% of GPs reported they had completed a pain education course compared to 92.5% of physiotherapists. Physiotherapists rated themselves higher in understanding mechanisms of CPP (64.7% very good to excellent) compared to gynaecologists (41.3%) and GPs (22.8%). Physiotherapists also reported higher levels of confidence in managing patients with CPP (57.8% quite or extremely confident) compared to 41.3% of gynaecologists and 22.3% of GPs who reported being quite or extremely confident. Awareness of the specific CPP guidelines was lower for GPs (87.5% reported not being aware of EAU guidelines for CPP, 62.5% of GPs reported not being aware of NICE guidelines for endometriosis).
| Whole cohort (n = 446) | Gynaecologist (n = 75, 16%) | GP (n = 184, 39%) | Physiotherapist (n = 187, 40%) | Comparison χ2 | ||
|---|---|---|---|---|---|---|
| Age years, mean (s.d., range) | 45.4 (12.95, 18–81) | 45.2 (11.59, 28–73) | 50.5 (14.0, 18–81) | 40.5 (10.25, 18–71) | 95% CI 50.26–57.96, P < 0.001 | |
| Gender | ||||||
| Female | 393 (88.1) | 55 (73.3) | 153 (83.2) | 185 (98.9) | 44.8267 P < 0.001 | |
| Male | 52 (11.7) | 20 (26.7) | 31 (16.8) | 1 (0.5) | ||
| Other | 1 (0.2) | 0 | 0 | 1 (0.5) | ||
| Years of experience | ||||||
| <5 | 40 (9.0) | 7 (9.3) | 21 (11.4) | 12 (6.4) | 12.97 P = 0.043 | |
| 5–10 | 99 (22.2) | 22 (29.3) | 32 (17.4) | 45 (24.1) | ||
| 10–20 | 148 (33.2) | 24 (32.0) | 53 (28.8) | 71 (38.0) | ||
| 21+ | 159 (35.6) | 22 (29.3) | 78 (42.4) | 59 (31.5) | ||
| Workplace | ||||||
| Public hospital | 68 (15.2) | 31 (43.3) | 0 | 37 (19.8) | 171.57 P < 0.001 | |
| Private hospital | 1 (0.2) | 0 | 0 | 1 (0.5) | ||
| Private practice | 276 (61.9) | 7 (9.3) | 157 (85.9) | 112 (59.9) | ||
| Other | 16 (3.6) | 1 (1.3) | 13 (7.1) | 2 (1.1) | ||
| Multi-site | 85 (19.1) | 36 (48.0) | 14 (7.6) | 35 (18.7) | ||
| Pain education/course | ||||||
| No education/course | 131 (29.4) | 37 (49.3) | 80 (43.5) | 14 (7.5) | 97.37 P < 0.001 | |
| <5 years ago | 268 (60.1) | 35 (46.7) | 74 (40.2) | 159 (85.1) | ||
| 5–10 years ago | 34 (7.6) | 2 (2.7) | 22 (12.0) | 10 (5.4) | ||
| More than 10 years ago | 13 (2.9) | 1 (1.3) | 8 (4.3) | 4 (2.1) | ||
| Understanding mechanisms of CPP | ||||||
| Very limited | 7 (1.6) | 0 | 4 (2.2) | 3 (1.60) | 75.95 P < 0.001 | |
| Limited | 62 (13.9) | 16 (21.3) | 36 (19.6) | 10 (5.35) | ||
| Average | 183 (41.0) | 28 (37.3) | 102 (55.4) | 53 (28.34) | ||
| Very good | 176 (37.2) | 25 (33.3) | 40 (21.7) | 101 (54.01) | ||
| Excellent | 28 (6.3) | 6 (8.0) | 2 (1.1) | 20 (10.70) | ||
| Confidence management of patients with CPP | ||||||
| Not confident | 28 (6.3) | 5 (6.7) | 15 (8.1) | 8 (4.3) | 57.67 P < 0.001 | |
| Slightly confident | 70 (15.7) | 18 (24.0) | 35 (19.0) | 17 (9.1) | ||
| Averagely confident | 168 (37.7) | 21 (28.0) | 93 (50.5) | 54 (28.9) | ||
| Very confident | 148 (33.2) | 24 (32.0) | 38 (20.6) | 86 (46.0) | ||
| Extremely confident | 32 (7.2) | 7 (9.3) | 3 (1.6) | 22 (11.8) | ||
| Awareness of EAU guidelines | ||||||
| No | 286 (64.1) | 50 (66.7) | 161 (87.5) | 75 (40.1) | 90.81 P < 0.001 | |
| Yes | 160 (35.9) | 25 (33.3) | 23 (12.5) | 112 (59.9) | ||
| Awareness of NICE guidelines | ||||||
| No | 213 (47.8) | 20 (26.7) | 115 (62.5) | 78 (41.7) | 32.14 P < 0.001 | |
| Yes | 233 (52.2) | 55 (73.3) | 69 (37.5) | 109 (58.3) |
Data reported as n (%) except for age.
CPP, chronic pelvic pain; EAU, European Association of Urology; GP, general practitioner; HCP, healthcare professional; NICE, National Institute for Health and Care Excellence; s.d., standard deviation.
Beliefs about CPP
All three groups of HCPs demonstrated mostly similar beliefs around CPP (Table 2). Most respondents (83.5%) largely disagreed or totally disagreed that ‘medication is the only way to treat CPP’ and 0% of the whole cohort largely agreed or totally agreed that ‘surgery is the most effective way to manage CPP’. Most respondents (72.4%) totally agreed or largely agreed that ‘mental stress could cause CPP in the absence of tissue damage’ and 79.4% totally agreed or largely agreed that ‘CPP patients will benefit from physical exercise’. One-fifth of GPs (20.6%) and 12.0% of gynaecologists agreed to some extent/largely agreed that CPP indicates the presence of an organic injury, compared to 7.5% of physiotherapists (Chi-squared 60.53, P < 0.001). One-quarter of GPs (25.5%) and 16.0% of gynaecologists agreed to some extent/largely agreed that an increase in CPP equals new or spread of tissue damage compared to 2.1% of physiotherapists (Chi-squared 107.84, P < 0.001).
| Whole cohort (n = 446) | Gynaecologist (n = 75, 16%) | GP (n = 184, 39%) | Physiotherapist (n = 187, 40%) | Comparison χ2 | ||
|---|---|---|---|---|---|---|
| Medication is the only way to relieve CPP (%) | 34.47 P < 0.001 | |||||
| Totally disagree | 56.5 | 69.3 | 42.9 | 64.7 | ||
| Largely disagree | 26.7 | 20.0 | 32.1 | 24.1 | ||
| Disagree some extent | 10.8 | 8.0 | 16.8 | 5.9 | ||
| Agree some extent | 5.8 | 1.3 | 8.2 | 5.4 | ||
| Largely agree | 0.2 | 1.3 | 0 | 0 | ||
| Totally agree | 0 | 0 | 0 | 0 | ||
| Surgery is the most effective way to treat CPP (%) | 41.26 P < 0.001 | |||||
| Totally disagree | 44.4 | 46.7 | 32.1 | 55.6 | ||
| Largely disagree | 33.4 | 34.7 | 34.8 | 31.6 | ||
| Disagree some extent | 16.4 | 14.7 | 20.6 | 12.8 | ||
| Agree some extent | 5.4 | 4.0 | 11.4 | 0 | ||
| Largely agree | 0.4 | 0 | 1.1 | 0 | ||
| Totally agree | 0 | 0 | 0 | 0 | ||
| Increase pain equals new or spread of tissue damage (%) | 107.84 P < 0.001 | |||||
| Totally disagree | 42.8 | 33.3 | 22.8 | 66.3 | ||
| Largely disagree | 29.8 | 38.7 | 29.4 | 26.7 | ||
| Disagree some extent | 13.2 | 12.0 | 22.3 | 4.8 | ||
| Agree some extent | 11.4 | 14.7 | 20.6 | 1.1 | ||
| Largely agree | 2.8 | 1.3 | 4.9 | 0.5 | ||
| Totally agree | 0 | 0 | 0 | 0.5 | ||
| Mental stress can cause CPP even in the absence of tissue damage (%) | 59.60 P < 0.001 | |||||
| Totally disagree | 1.4 | 2.7 | 1.1 | 1.1 | ||
| Largely disagree | 2.5 | 4.0 | 2.7 | 1.6 | ||
| Disagree some extent | 2.9 | 1.3 | 6.0 | 0.5 | ||
| Agree some extent | 20.8 | 21.3 | 30.4 | 11.2 | ||
| Largely agree | 36.1 | 44.0 | 37.5 | 31.6 | ||
| Totally agree | 36.3 | 26.7 | 22.3 | 54.0 | ||
| CPP indicates the presence of organic injury (%) | 60.53 P < 0.001 | |||||
| Totally disagree | 25.8 | 32.0 | 13.0 | 35.8 | ||
| Largely disagree | 36.3 | 36.0 | 30.0 | 42.8 | ||
| Disagree some extent | 24.2 | 20.0 | 36.4 | 13.9 | ||
| Agree some extent | 11.4 | 12.0 | 15.8 | 6.9 | ||
| Largely agree | 2.2 | 0 | 4.9 | 0.5 | ||
| Totally agree | 0 | 0 | 0 | 0 | ||
| CPP patients will benefit from physical exercise (%) | 56.26 P < 0.001 | |||||
| Totally disagree | 0.9 | 0 | 0.5 | 1.6 | ||
| Largely disagree | 1.1 | 0 | 2.2 | 0.5 | ||
| Disagree some extent | 2.7 | 2.7 | 4.9 | 0.5 | ||
| Agree some extent | 15.9 | 13.3 | 25.5 | 7.5 | ||
| Largely agree | 39.0 | 41.3 | 42.9 | 34.2 | ||
| Totally agree | 40.4 | 42.7 | 23.9 | 55.6 |
CPP, chronic pelvic pain; GP, general practitioner.
Factors that might influence a person’s experience with CPP
Statements regarding contributing factors to CPP revealed some similar beliefs between the professions (Table S2). All three professions rated 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 pelvic floor muscle dysfunction (85.0%) as very/extremely important factors in the development of CPP. LBP was also rated as being relevant, with 88.8% of the cohort ranking LBP as moderately to extremely important.
Regarding tissue damage, 31.9% of gynaecologists and 38.4% of GPs believed it was a very/extremely important contributing factor to CPP compared to 11.2% of physiotherapists (Chisquared 40.79, P < 0.001). More physiotherapists (30.2%) reported social factors as extremely important compared to 11.6% and 11.0% of gynaecologists and GPs respectively (Chi-squared 38.15, P < 0.001). More than half of physiotherapists (54.8%) rated hormonal changes as very and extremely important compared to 26.1% of gynaecologists and 39.5% of GPs (Chi-squared 34.15, P < 0.001). Most physiotherapists (81.6%) rated sleep as very or extremely important, compared to 63.8% of gynaecologists and 56.4% of GPs (Chi-squared 55.84, P < 0.001).
Assessment of CPP
There were similarities and differences in the types of assessment recommended by HCPs (Table S3), which align to their different training and healthcare roles. All professions recommended mid-stream urine sample (MSU) frequently and 70.2% of GPs and 71.0% of gynaecologists always refer for pelvic ultrasound. In contrast, computed tomography (CT)/magnetic resonance imaging (MRI) were rarely recommended by any of the HCPs. Swabs for thrush and sexually transmitted infections (STIs) were frequently recommended, with 97.6% of GPs and 88.4% of gynaecologists reporting that they always/sometimes perform swabs.
Of HCPs surveyed, 79.7% gynaecologists and 70.4% physiotherapists always performed vaginal examinations compared to 51.2% of GPs. Gynaecologists (69.6%) and GPs (41.5%) were more likely than physiotherapists (10.1%) to always perform bimanual examinations. Gynaecologists (43.5%) and physiotherapists (47.5%) were more likely than GPs (11.9%) to always assess trigger points in the pelvic floor, with 39.3% of GPs stating that they would ‘never’ assess trigger points. Over half of physiotherapists (51.4%) surveyed reported that they ‘always’ assess the lumbar spine in patients with CPP, compared to 7.2% of gynaecologists and 12.9% of GPs.
Out of all respondents, 60.8% reported that they ‘always’ assess psychosocial factors; however, only 22.0% of respondents ‘always’ use validated screening questionnaires. Physiotherapists were more likely to be involved with goal setting with their patients, with 88.8% of them responding that they ‘always’ assess this, compared to 30.4% of specialists and 29.0% of GPs. Physiotherapists were also more likely to screen their patients on beliefs about their disorder, with 80.9% responding that they ‘always’ do this, compared to 39.1% of specialists and 46.5% of GPs. All professionals 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.
Healthcare professionals’ priorities for the management of CPP related to endometriosis are presented in Table 3. The number one priority for all three HCP groups was referral to a pelvic health physiotherapist. GPs and gynaecologists recommended further screening in the form of diagnostic ultrasound and swabs for infection. The HCP groups selected ‘stress management’ as one of the most common treatment choices. In contrast to the medical practitioners, physiotherapists more commonly chose mindfulness/breathing and pelvic floor relaxation as their treatment preferences, which is likely a reflection of their training and role. All HCP groups selected referral to other HCPs as treatment choices, as well as pelvic health physiotherapists. Gynaecologists and physiotherapists selected referral to pain specialists and psychologists in their top choices whereas GPs chose referral to gynaecologists as their second most common treatment choice.
| Whole cohort (n = 446) | RANK | Gynaecologist (n = 75) | RANK | GP (n = 184) | RANK | Physiotherapist (n = 187) | RANK | ||
|---|---|---|---|---|---|---|---|---|---|
| Swabs for thrush/STI | 127 (28.5) | 6 | 10 (13.3) | 98 (53.3) | 2 | 19 (10.2) | |||
| Midstream urine | 109 (24.4) | 21 (28.0) | 63 (34.2) | 6 | 25 (13.4) | ||||
| Pelvic ultrasound | 119 (26.7) | 29 (38.7) | 4 | 77 (41.8) | 3 | 13 (7.0) | |||
| Laparoscopy/cystoscopy | 14 (3.1) | 1 (1.3) | 13 (7.1) | 0 (0) | |||||
| Pain medication review | 100 (22.4) | 25 (33.3) | 5 | 55 (29.9) | 20 (10.7) | ||||
| Hormonal medication review | 75 (16.8) | 22 (29.3) | 6A | 36 (19.6) | 17 (9.1) | ||||
| Vaginal oestrogen | 4 (0.9) | 1 (1.3) | 2 (1.1) | 1 (0.5) | |||||
| Amitriptyline/compound cream | 34 (7.6) | 7 (9.3) | 19 (10.3) | 8 (4.3) | |||||
| Botox to PFM | 5 (1.1) | 2 (2.7) | 2 (10.9) | 1 (0.5) | |||||
| Referral to gynaecologist/urogynaecologist | 108 (24.2) | 14 (18.7) | 72 (39.1) | 5 | 22 (11.8) | ||||
| Referral to pain specialist | 100 (22.4) | 34 (45.3) | 2 | 26 (14.1) | 40 (21.4) | ||||
| Referral to psychologist | 149 (33.4) | 4 | 22 (29.3) | 6A | 55 (29.9) | 72 (38.5) | 5 | ||
| Referral to sexual health counsellor/sex therapist | 26 (5.8) | 2 (2.7) | 3 (1.6) | 21 (11.2) | |||||
| Referral to PH physiotherapist | 317 (71.1) | 1 | 57 (76.0) | 1 | 102 (55.4) | 1 | 158 (84.5) | 1 | |
| Stress management | 208 (46.6) | 2 | 32 (42.7) | 3 | 73 (39.7) | 4 | 103 (55.1) | 2 | |
| Mindfulness exercises/breathing exercises | 138 (30.9) | 5 | 19 (25.3) | 16 (8.7) | 103 (55.1) | 3 | |||
| Trigger point/myofascial release PFM | 42 (9.4) | 15 (20.0) | 10 (5.4) | 17 (9.1) | |||||
| General exercise | 35 (7.8) | 2 (3.7) | 10 (5.4) | 23 (12.3) | |||||
| Acupuncture/dry needling | 9 (2.0) | 0 (0) | 7 (3.8) | 2 (1.1) | |||||
| PFM relaxation exercises | 155 (34.8) | 3 | 21 (28.0) | 36 (19.6) | 98 (52.4) | 4 | |||
| Dilator therapy | 11 (2.5) | 1 (1.3) | 1 (0.5) | 9 (4.8) | |||||
| Sleep hygiene review | 87 (19.5) | 8 (10.7) | 22 (12.) | 57 (30.5) | 6 |
Vignette 1. A femaled aged 21 years with a 5-year history of severe pelvic pain, initially cyclical but has now progressed to daily with cyclical exacerbations. Six months ago, she had a laparoscopy where she was diagnosed with endometriosis stage 3 and it was excised. She now presents post endometriosis excision surgery with worsening persistent pelvic pain, voiding dysfunction, deep and superficial dyspareunia. She is on hormonal suppressant therapy (oral contraceptive pill). She has a highly stressful job, is anxious about diagnosis and fertility and has poor sleep. Exercise includes running and high-intensity interval training classes (most days). Medications: oral contraceptive pill, panadol/ibuprofen as needed.
STI, sexually transmitted infection; GP, general practitioner; PFM, pelvic floor muscles; PH, pelvic health.
Data are presented as n (%).
The RANK column provides the top 6 management priorities for each group.
Healthcare professionals’ priorities for the management of non-specific CPP are listed in Table 4. All three groups selected the same treatment choices within their top three options: referral to a pelvic health physiotherapist, pelvic floor relaxation exercises and referral to a sexual health therapist. Both GPs and gynaecologists also selected ‘refer to a psychologist’ in their top treatment choices.
| Whole cohort (n = 420) | RANK | Gynaecologist (n = 69) | RANK | GP (n = 172) | RANK | Physiotherapist (n = 179) | RANK | ||
|---|---|---|---|---|---|---|---|---|---|
| Swabs for thrush/STI | 26 (6.2) | 6 (8.7) | 18 (10.5) | 1 (0.6) | |||||
| Midstream urine | 27 (6.4) | 2 (2.9) | 16 (9.3) | 4 (2.2) | |||||
| Blood tests | 11 (2.6) | 0 (0) | 7 (4.1) | 2 (1.1) | |||||
| Pelvic ultrasound | 43 (10.2) | 4 (5.8) | 30 (17.4) | 2 (1.1) | |||||
| Laparoscopy/cystoscopy | 6 (1.4) | 0 (0) | 6 (3.5) | 0 (0) | |||||
| Pain medication review | 31 (7.4) | 6 (8.7) | 15 (8.7) | 9 (5.0) | |||||
| Hormonal medication review | 10 (2.4) | 0 (0) | 7 (4.1) | 3 (1.7) | |||||
| Vaginal oestrogen | 19 (4.5) | 2 (2.9) | 10 (5.8) | 5 (2.8) | |||||
| Amitriptyline/compound cream | 83 (19.8) | 24 (34.8) | 4 | 29 (16.9) | 30 (16.8) | ||||
| Botox to PFM | 16 (3.8) | 7 (10.1) | 6 (3.5) | 2 (1.1) | |||||
| Referral to gynaecologist/urogynaecologist | 68 (16.2) | 8 (12) | 45 (26.2) | 5 | 7 (3.9) | ||||
| Referral to pain specialist | 17 (4.0) | 7 (10) | 3 (17.4) | 6 (3.4) | |||||
| Referral to psychologist | 97 (23.1) | 16 (23.2) | 6 | 47 (27.3) | 4 | 31 (17.3) | |||
| Referral to sexual health counsellor/sex therapist | 219(52.1) | 3 | 31 (44.9) | 3 | 76 (44.2) | 3 | 103 (57.5) | 3 | |
| Referral to PH physiotherapist | 323(76.9) | 1 | 51 (73.9) | 1 | 121 (70.3) | 1 | 141 (78.8) | 2 | |
| Stress management | 57 (13.6) | 9 (13.0) | 31 (18.0) | 17 (9.5) | |||||
| Mindfulness exercises/breathing exercises | 111 (26.4) | 5 | 10 (14.5) | 26 (15.1) | 75 (41.9) | 5 | |||
| Trigger point therapy/myofascial release to PFM | 103 (24.5) | 6 | 23 (33.3) | 5 | 36 (20.9) | 6 | 44 (24.6) | ||
| General exercise | 128 (30.5) | 4 | 13 (18.8) | 34 (19.8) | 81 (45.3) | 4 | |||
| Acupuncture/dry needling | 3 (0.7) | 0 (0) | 3 (1.7) | 0 (0) | |||||
| PFM relaxation exercises | 275 (65.5) | 2 | 42 (60.9) | 2 | 91 (52.9) | 2 | 142 (79.3) | 1 | |
| Dilator therapy | 74 (17.6) | 10 (14.5) | 14 (8.1) | 50 (27.9) | 6 | ||||
| Sleep hygiene review | 8 (1.9) | 2 (2.9) | 5 (2.9) | 1 (0.6) |
Vignette 2. A female aged 33 years presents with vulvodynia and dyspareunia which commenced 9 months ago. She has a history of thrush in the last year, recent swabs in last 1 week are negative for both thrush and STIs. She had a previous cystoscopy and laparoscopy 6 months ago, which were both normal. She reports relationship issues with her husband due to the inability to manage intercourse, and they are thinking of trying for a baby. She does nil regular exercise. Medications – nil regular. Vaginal examination shows pain at the introitus and on deeper palpation. On palpation of the vestibule, she is tender at ‘5 and 6 o’clock’. She has PFM tension on palpation, and she is unable to relax her muscles fully.
STI, sexually transmitted infection; GP, general practitioner; PFM, pelvic floor muscles; PH, pelvic health.
Data are presented as n (%).
The RANK column provides the top 6 management priorities for each group.
Discussion
This online survey provides insight into Australian HCP beliefs, knowledge and practice behaviours in managing CPP. Broadly speaking, gynaecologists, GPs and physiotherapists demonstrated a good understanding of pain mechanisms and incorporated a biopsychosocial approach to assessment and management of females with CPP. Their practice aligned with EAU guidelines for CPP (Engeler et al. 2020) and NICE guidelines for endometriosis (National Institute of Health and Care Excellence 2017). Collaboration between HCPs was high, with referral between the groups as well as to other professionals such as psychologists and sexual health therapists commonly recommended. Differences between the professions were likely indicative of their education and their distinct roles in the care pathways for the management of CPP. In terms of potentially important differences though, gynaecologists and GPs were less sure of their knowledge, less confident in managing CPP, and less likely to assess patient beliefs and goals, which are important considerations for patients who often do not feel listened to or legitimised when seeking care (Toye et al. 2014). Patients’ first interactions with primary healthcare providers are important as they may frame their future engagement with the healthcare system. It is important we better support our HCPs with training and education for holistic care.
Strengths of this study include the large sample size and the multidisciplinary nature of the participants and researchers. There were representatives from the public and private sectors, with many working in both systems. Nevertheless, respondents to the survey were self-selected and selection bias may have occurred by these participants being more interested and experienced in managing patients with CPP. We included only those respondents who completed 80% of the online survey, but did note some differences in those that were excluded. Notably, those excluded were less confident in managing CPP and had less awareness of guidelines. Further research might try to understand practice behaviours of these individuals. One way to achieve this might be through chart audits to look at real work practice behaviours, or through qualitative research methodology. Our results provide a baseline for future comparisons. Our findings may not directly reflect the management of CPP in other countries. Respondents were primarily female, though studies suggest more female HCPs are involved in the care of females with CPP (Mcgowan et al. 1999).
Our participants demonstrated good understanding of central and peripheral pain mechanisms, recommended investigations for disease-associated pelvic pain and largely assessed biopsychosocial factors (Engeler et al. 2020). Despite many gynaecologists and GPs never completing a pain education course, it appears knowledge of CPP and self-reported practice behaviours of respondents align well to contemporary understanding of pain disorders (Mitchell et al. 2017). Interdisciplinary referral for collaborative care was common to all HCPs; however, limited community referral and delayed access to pelvic health physiotherapists in the Australian setting has been noted for the management of incontinence and/or pelvic organ prolapse (Beaumont and Goode 2017; Brennen et al. 2019). Further barriers exist for a younger demographic with CPP including low health literacy and poor understanding of their condition and the treatment options available (Green et al. 2022). There is also societal stigma and cultural embarrassment associated with pelvic health concerns that may prevent access and engagement with treatments recommended.
There were several differences between the medical professionals’ and physiotherapists’ responses regarding assessment of CPP. This may reflect the different training and scope of practice of each profession; for example, gynaecologists and GPs more frequently recommended pelvic ultrasounds in the assessment of CPP (Table S3). This aligns with the recommendation to rule out significant pathology early in the triage of women with CPP (National Institute of Health and Care Excellence 2017; Wang et al. 2019). Physiotherapists more commonly screened psychosocial factors, used formal screening tools, assessed co-morbidities such as LBP and investigated patient goals. This may reflect the training of physiotherapists (Grossnickle et al. 2019) and additional time spent with complex patients to build trust and therapeutic alliance (Søndenå et al. 2020). Validated screening tools may assist in identifying psychosocial contributing factors such as pain catastrophisation and anxiety, which are associated with greater pain intensity and impact on health-related quality of life (Kalfas et al. 2022). In our study, 95.1% of participants rated a history of social/emotional/physical abuse as being ‘very’ or ‘extremely’ important. However, insufficient time to evaluate and counsel victims has been reported as a barrier to screening by obstetricians/gynaecologists (Farrow et al. 2018) despite it being an important component of trauma-informed care.
Refinement of formal care pathways for CPP may be a mechanism for improving HCP confidence in providing care in this area. Only 40.4% of total respondents ranked themselves as quite or extremely confident in managing patients with CPP. This may be due to the complexity and heterogeneity of patients presenting with CPP (Grossnickle et al. 2019; Nygaard et al. 2019), which can result in more challenges for management. This is consistent with the report that HCPs often struggled to feel competent in managing chronic non-malignant pelvic pain (Grossnickle et al. 2019). Education can also increase HCP confidence in managing complex pain disorders, though more work is needed in this area (Holopainen et al. 2020).
Conclusion
Most HCPs surveyed reported beliefs and practice behaviours that largely corresponded to guideline recommended care for the management of CPP. Interdisciplinary referrals were strongly supported, but barriers exist to providing timely and cost-efficient management. Further education and training of HCPs on the benefit of shared decision-making will help to improve patient experience within the healthcare system. Time to listen, legitimise and understand individual patient’s beliefs, expectations and experiences is imperative in providing a biopsychosocial and patient-centred approach to management. The combination of HCP and patient beliefs, behaviours and experiences might partially inform the development of much needed formal care pathways in the management of CPP. A collaborative community approach is needed to help guide more targeted research and education to further improve understanding and confidence in the management of CPP.
Authors’ note
This paper was originally presented as a poster presentation: Chan E, Hart M, Vardy J, et al. (2022) Beliefs and attitudes of Australian health care professionals towards chronic pelvic pain: a cross-sectional survey. In ‘International Continence Society’, Vienna. ePoster Presentation, Abstract 387. Available at https://www.ics.org/2022/abstract/387.
Author contributions
All authors conceived and designed the study. JV, EC, MH and RD collected the data and together with DB analysed the data and drafted the manuscript. JV, RD and DB conducted the statistical analysis. All authors reviewed and approved the final manuscript.
Acknowledgements
The authors thank the study participants and the stakeholders that provided feedback in the initial development of the questionnaire.
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