Pelvic floor muscle exercises and mindfulness for women with endometriosis-associated pelvic pain: a randomised controlled pilot and feasibility study

To evaluate the feasibility of two different PFM exercise protocols (PFMC+R vs PFMR) and mindfulness in women with EAPP and explore changes in pelvic pain and PFM morphometry between the two groups.

This was a randomised controlled feasibility trial. Participants underwent an 8-week hybrid intervention (mixture of face-to-face and telehealth consultations) that included either PFMC+R or PFMR exercises, combined with mindfulness. 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 at baseline and after completion of the intervention by an assessor who was blinded to group allocation. 

Ninety-five women were assessed for eligibility, of which 45 participants with EAPP (recruitment rate 47%) were randomly assigned to either the PFMC+R exercise group (n=23) or the PFMR exercise group (n=22). No significant differences were observed between the two groups at baseline, except for a more severe stage of endometriosis and a higher prevalence of levator ani muscle tenderness in the PFMC+R exercise group than PFMR group. The PFMC+R exercise group had higher retention (89%) and attendance (86%) rates compared to the PFMR group (63%, 63%).  Mean adherence rate to the PFM exercise protocol were similar between the two groups (PFMC+R group 70% vs PFMR group 71%). The PFMC+R exercise group demonstrated a significantly lower intensity of general pelvic pain (MD=- 2.80, 95%CI -4.22, -1.45) and dyspareunia (MD=-2.43, 95%CI-3.90, -1.03), as well as larger anorectal angle (MD=3.61, 95%CI 2.52, 9.48) and anterior-posterior diameter of levator hiatus measurements (MD=0.34, 95%CI 0.14, 0.63) at rest compared with the PFMR group following the 8-week intervention program.

The PFMC+R exercise protocol was more feasible than the PFMR exercise protocol, and demonstrated greater improvements in EAPP symptoms and PFM morphometry. Additional research with a larger sample size and comparisons between mild-to-moderate and severe endometriosis disease is required to verify these findings.

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