{"paper_id":"038ff28b-d600-41d0-8761-75bfa855a739","body_text":"The presence of abnormal palpatory findings in the sacrococcygeal area is correlated with chronic pelvic pain: a cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The presence of abnormal palpatory findings in the sacrococcygeal area is correlated with chronic pelvic pain: a cross-sectional study Daniele Origo, Fulvio Dal Farra, Marco Tramontano This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6289612/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Apr, 2025 Read the published version in International Urology and Nephrology → Version 1 posted You are reading this latest preprint version Abstract Objective This study examines the prevalence of abnormal palpatory findings (APFs) in the different pelvic areas among individuals with chronic pelvic pain syndrome (CPP-CPPS) and assesses correlations between APFs with clinical and psychosocial symptoms. Methods In this cross-sectional study, 326 participants (162 CPP-CPPS patients, 164 controls) underwent a standardized palpatory assessment of the sacroiliac, sacrococcygeal, and pelvic floor regions. The manual procedure was performed by two expert physiotherapists with a certification in osteopathic manipulation, following a consensus training. Symptom severity and psychosocial variables were assessed using the NIH Chronic Prostatitis Symptom Index (NIH-CPSI), the Hospital Anxiety and Depression Scale (HADS), and the Fear Avoidance Belief Questionnaire (FABQ). Correlation analyses explored relationships between APFs, the presence of pain, and psychosocial variables. Results In the sample we examined, CPP/CPPS symptoms were located in different abdominal and pelvic areas (41%), and both sexual and urinary functions were involved (60%). APFs were strongly associated with CPP-CPPS, particularly in the sacrococcygeal (r = 0.609, p < 0.01) and pelvic floor (r = 0.62, p < 0.01) areas. Multivariate analysis confirmed that sacrococcygeal dysfunction (OR: 3.02, CI: 1.96–4.65) and pelvic floor dysfunction (OR: 2.99, CI: 1.87–4.78) were independently associated with CPP-CPPS, whereas sacroiliac findings showed a weak correlation. Significant but weak correlations were also observed between APFs and psychosocial measures, including HADS and FABQ, indicating limited associations between anxiety, depression and fear-avoidance beliefs with APFs. Conclusions The results of this study highlight the relevance of sacrococcygeal and pelvic floor APFs as potential clinical markers in CPPS, supporting the rationale of targeted manual therapy interventions. This study suggests a role for multimodal management in CPP-CPPS, with future research needed to evaluate the predictive value of these dysfunctions. Chronic Pelvic Pain Chronic Pelvic Pain Syndrome Coccydynia Pelvic Floor Sacrococcygeal Manual Therapy Palpatory Findings Figures Figure 1 Figure 2 Figure 3 Introduction Chronic pelvic pain (CPP) is a non-malignant pain localized in the pelvis and anatomically related structures, lasting for at least six months and leading to negative emotional, behavioral, and sexual consequences ( 1 ). Chronic pelvic pain syndrome (CPPS) is characterized by persistent or recurrent pelvic pain associated with symptoms leading to urogenital dysfunction, but also intestinal and lower urinary tract domains ( 2 ). Non-specific diffuse pain, in absence of a documentable pathology, may involve one or more pelvic organs, the abdominal wall, the genital area, and might be associated with systemic symptoms ( 3 ). Furthermore, conditions such as irritable bowel syndrome, interstitial cystitis, painful bladder and fibromyalgia resulted highly prevalent in people with CPP/CPPS, thus requiring a reconsideration of the patient’s physical, psychological, and social needs ( 4 , 5 ). The epidemiological data on CPP/CPPS are disparate, due to the varying quality of the studies. Prevalence is definitely higher in women, with a lifetime prevalence ranging from 5.7–26.6% ( 6 ), while 10% of men experience CPP/CPPS ( 7 ). Patients typically present dysfunctions in the pelvic floor muscles, which resulted in hyperactivity. Tissue palpation may reveal the presence of trigger points (TPs) in adjacent muscles, such as the piriformis, gluteus maximus, and iliopsoas ( 8 ), as well as tenderness in the suprapubic, abdominal, and intrapelvic regions ( 9 ). Multimodal physical treatments (patient education, biofeedback, manual therapy, and injections to address abdominal and pelvic TPs) appeared to be an effective therapeutic choice ( 10 , 11 ). In a recent position statement, the Italian Society of Colo-Rectal Surgery emphasized the need for a multimodal clinical approach in CPPS, highlighting the importance of a careful assessment of the musculoskeletal system, but also posture, joints, and tissues in general, which are often underrated ( 12 ). In this context, the physical assessment of postures, joints mobility and tissues characteristics are frequently performed by different healthcare professionals such as physiotherapists, osteopaths and chiropractors, according to their competences and educational backgrounds ( 13 ). The presence of abnormal palpatory findings (APFs) in terms of joint mobility restriction, alterations of tissue texture and tenderness areas are detectable by palpation procedures and guides the physical assessment of such approaches ( 14 ). Although the contribution of the myofascial dysfunctions has been largely demonstrated in CPP/CPPS, so far no study investigated which parts of the pelvic region appear to be the most involved in this condition. From this perspective, it becomes relevant to take into account the anatomical and functional relationships of the pelvic floor (e.g., muscles, ligaments, and fascia, forming a sort of sling supporting the internal organs). These soft tissues attach to the pelvic girdle and posteriorly to the sacrum and coccyx, which are crucial for anchoring the muscles forming the pelvic floor ( 15 ). Our hypothesis is that specific pelvic dysfunctional areas, detectable in a form of APFs, might be more involved than others in the contribution to chronic pain. Therefore, the primary aim of this study is to assess and quantify the presence of abnormal palpatory findings (APFs) of the pelvic area in patients with CPPS. Secondarily, to correlate the presence of APFs to symptoms, signs, physical and psychosocial variables of people presenting CPP/CPPS. Methods Study design and setting This cross-sectional investigation was carried on in the period ranging from September 2023 and June 2024. All the procedures have been conducted in a rehabilitative outpatient clinic located in Milan. The study protocol was approved by the Institutional Review Board of the SOMA Clinical Institute (registration number: SIOM-AA0025), and all the participants gave informed consent before being tested. This study was conceived and reported following the “Strengthening the reporting of observational studies in epidemiology (STROBE) statement” checklist for cross-sectional studies ( 16 ). Participants Individuals with CPP/CPPS were recruited on a voluntary basis from the population of patients referring to the clinic. Each patient who had already received a medical diagnosis of CPP/CPPS was offered the possibility to participate. People without CPP/CPPS were recruited by flyers among students and personnel attending the clinic, or the annex college campus. Inclusion criteria were people aged 18–65, with or without CPP/CPPS. Conversely, we excluded people affected by serious medical conditions affecting the musculoskeletal system (e.g., multiple fractures, rheumatism), unresolved cancer, current pregnancy or any impossibility to undergo a palpatory assessment in the pelvic area, both due to physical or cognitive issues. In addition, we also excluded people receiving physical or manipulative treatments elsewhere. Each participant with CPP/CPPS was matched to a subject without pain, based on their age and gender. Outcome measures All the participants recruited for the study received a booklet requesting socio-demographics, clinical information, and containing three different questionnaires. This booklet included questions related to symptoms localization and duration, physical activity (frequency, duration, intensity) and previous trauma. In addition, the following questionnaires were incorporated. The “NIH-Chronic Prostatitis Symptom Index” (NIH-CPSI) was implemented to investigate the symptom severity; it contains three main domains: pain, urinary symptoms and quality of life impact. The NIH-CPSI is considered a reliable and cross-culturally validated instrument, frequently considered in the functional assessment of people with CPP/CPPS ( 17 ). The “Hospital Anxiety and Depression Scale” (HADS) is a 14-items questionnaire based on a 4-points Likert score (0–3), and it is considered a reliable instrument to detect anxiety and depression states, measured by two distinct scores ( 18 ). The “Fear Avoidance Belief Questionnaire” (FABQ) measures fear of pain and consequent activity avoidance, and it has been successfully translated into Italian language. It is composed of 16 items, based on a 7-points Likert scale (0–6) expressing the agreement the subject has with regards to the different statements ( 19 ). Physical assessment Subsequently, each subject underwent a standardized palpatory assessment performed by two expert physiotherapists (more than 15 years of experience), with a certification in osteopathic manipulation. Before testing, the assessors went through a procedure of consensus training, consisting of 9 hours of practice, divided into three main sessions (3 hours each), and a 2-hours final meeting when consensus has been definitely reached. With regard to this, the use of a Digital Hand-Held Dynamometer (PainTest™ FPX 25 Algometer, Wagner Instruments, Greenwich, USA) was used, since it proved to be a valid and reliable tool ( 20 ). The assessors agreed upon a palpatory force ranging between 0.80 and 1.00 kg, and after adequate training, in 95% of the trials, they were able to consistently maintain this force range. The manual assessment was exclusively aimed to detect APFs in the ileo-sacral joints, sacrococcygeal region and in the pelvic floor area. Based on the principles of the TART model, alterations in the tissue texture, joint movement reduction and tenderness or pain evocation are considerable APFs, attributable to the presence of somatic dysfunction ( 21 , 22 ). From this point on, the expressions “APFs” and “dysfunction” are considerable synonymous. The procedure consisted of three different standardized maneuvers, aimed to assess the presence and the grade of dysfunction of two joint complexes and a soft-tissue region. The first technique was oriented to the sacroiliac joint: with the patient in a prone position, the operators placed two fingers on the inferior groove of the posterior inferior iliac spine, to verify the position in the frontal plane. The fingers are then flexed approximately 30° medially and caudally to contact the sacral base, which is assessed in the coronal plane. The fingers are subsequently moved to the inferior lateral angle of the sacrum to perform a similar assessment in the coronal plane. Next, the operators placed the fingers on the sacral base and the inferior lateral angle of the sacrum ipsilaterally, applying pressure to evaluate the ability of the sacrum to perform nutation and counternutation, as well as to assess for palpatory tenderness. The assessors then placed the fingers on the left base and the right inferior lateral angle of the sacrum, then vice versa, applying pressure to induce movement, assessing for both the range of motion and tenderness ( 23 ). The second technique was oriented to the sacrococcygeal joint assessment: the assessors placed a finger on the coccyx with the patient in a prone position, palpating the entire contour of the bone, while asking the patient the presence of pain. The patient was then instructed to take a deep breath, and operators observed the movement of the coccyx facilitated by the pelvic diaphragm muscles, which follow the downward movement of the thoracic diaphragm during in-breathing( 24 ). Regarding the third technique: the assessors applied pressure to the pelvic diaphragm muscles between the ischium, pubic bone, and coccyx, evaluating for any palpatory tenderness and the ability of the muscles to move caudally in conjunction with a deep inspiration ( 25 ). The above-described techniques are represented in Figs. 1, 2 and 3. Finally, the assessors had the possibility to grade the dysfunction as follows: absence of APFs was scored as 0; movement reduction, or altered tissue texture, or pain evocation was scored as 1; the co-presence of APFs corresponded to a score of 2. Sample size calculation In this study no study sample calculation was performed, since the presence of physical dysfunctions (joint restrictions, tissue texture alterations, tenderness) were not measured in any previous study dealing with CPP/CPPS, and no expected mean for the outcome of interest was retrievable in literature. For these reasons, the consecutive enrolling of the subjects stopped when a considerable number of participants was definitely reached for each group. Statistical Analysis The main characteristics of the sample were reported in a descriptive way. The distribution for continuous variables was tested via Kolmogorov-Smirnov test. Since no normal distribution was found, the U-Mann-Whitney test for independent samples was applied to test any possible differences between the two groups in terms of age, thus verifying the success of the matching procedure. Spearman correlation test was implemented to verify any possible correlation between the condition of CPP/CPPS and all the other variables of interest, such as the presence and severity of pelvic dysfunctions, the questionnaire scores, levels of physical activity and a history of a previous trauma. As a secondary analysis, a multivariate analysis (logistic regression) was considered to highlight any possible association between the presence of specific APFs (independent variables or covariates) and the condition of CPP/CPPS (dependent variable). Results Characteristics of the sample A total of 326 individuals were recruited, specifically 162 people with a CPP/CPPS condition and 164 healthy people. The mean age of the participants was 35.62 +/- 12.2, and all the main characteristics of the sample are detailed in Table 1. Please, consider table 1 approximately here. The majority of people with CPP/CPPS presented symptoms for more than 3 years (38.9%) and only the 8% of the cases complained of symptoms for 3-6 months. In addition, 15.4% of the cases reported sexual dysfunctions, the 6.8% complained of urinary disturbances and 59.9% reported both of the functions as impaired. As for the localization, 38.9% of CPP/CPPS people reported symptoms in different abdominal and pelvic areas, 13% in the pubic region, 9.9% in the coccygeal area and the 6.2% in the perineal region. Further details are reported in Table 2. Please consider table 2 approximately here The sacrococcygeal dysfunction was present in the 78% of the people suffering from CPP/CPPS, the sacro-iliac dysfunction in the 72%, though in the 56% of these cases it was assessed as of “low severity”. The dysfunction of the pelvic floor was detected in 80% of the people with CPP/CPPS. Correlations Analysis A significant moderate-to-strong correlation resulted between the condition of CPP/CPPS and the presence of sacrococcygeal and pelvic floor dysfunctions (r= 0.609 and r= 0.62, p<0.01, respectively), but not with the sacroiliac dysfunction where the correlation was present, yet weak (0.269, p<0.01). The correlation between the presence of CPP/CPPS with the severity of the dysfunctions overlaps the above reported data (r= 0.655, r= 0.642, r= 0.315, p< 0.01, respectively). A significant weak correlation was found between having CPP/CPPS and the HADS total score (r= 0.264, p<0.01), also considering both the anxiety (r= 0.258, p<0.01) and the depression sub-scores (r= 0.210, p<0.01). In the same way, a significant weak correlation was detected with the FABQ score (r= 0.273, p<0.01). Finally, a minimal significant correlation was found between presenting a CPP/CPPS condition and the frequency or the amount of physical activity (r= 0.126 and r= 0.140, p<0.05 respectively). All the correlations are reported in Table 3. Please consider table 3 approximately here Secondary Analysis A multivariate analysis was implemented to provide a prediction model considering the presence of CPP/CPPS as a dependent variable and the abnormal palpatory findings as covariates. The sacro-coccygeal and the pelvic floor dysfunctions’ severity resulted as factors significantly associated with CPP/CPPS [exp B: 3.02 (1.96-4.65) and 2.99 (1.87-4.78), p<0.001, respectively). No significant association was found with the sacroiliac dysfunction [exp B: 1.57 (0.97-2.53). Further details are reported in Table 4. Please consider table 4 approximately here Discussion Summary of results To the best of our knowledge, this study represents the first attempt to understand whether APFs are prevalent in the sacrococcygeal, sacroiliac, or pelvic floor areas in patients with CPP/CPPS. Our results indicate a significant presence of these clinical signs at the level of the coccyx and the pelvic muscles, which are closely related from an anatomical and functional point of view (15). Furthermore, the distribution and the impact of the symptoms in our sample resulted in line with previous epidemiological studies (5,6). Indeed, pain appears to be located in various pelvic areas, both urological and sexual disturbances are highly prevalent in this population and the impact of this condition largely affects people in terms of perceived pain, urinary function and quality of life, as reported by NIH-CPSI questionnaire. Weak correlations were detected between the presence of pelvic APFs and levels of anxiety, depression and fear-avoidance beliefs, whereas no significant correlations were obtained between the presence of APFs and previous trauma or the frequency, duration and volume of physical activity. Clinical interpretation The findings of this study are consistent with existing literature regarding the contribution of pelvic myofascial and articular structures in subgroups of patients suffering from CPP/CPPS (26). It is noteworthy to highlight the hypothesis that myofascial release, through a multimodal approach, could restore the physiological blood flow necessary for patient comfort, as a reduction in blood flow to the tissues may sustain this debilitating syndrome (27). Consequently, pelvic muscle dysfunction and their anatomical relationships, combined with psychosocial factors and pain misperception, are involved variables and a timely understanding of these factors is crucial for an optimal therapeutic approach (28). Although in CPP/CPPS the scientific literature rightly considered traumatic experiences, distress, pain and non-pelvic comorbidities (29), the results of our study reveal only a weak correlation with the anxiety and depression scale, and with the fear-avoidance beliefs questionnaire. This fact raises the question on whether the emotional state is the cause or the effect of a condition that so significantly impacts quality of life. It seems easy to imagine how such a condition could induce neurobiological mechanisms related to anxiety, depression and distress (30). Our results did not show neither a relevant correlation, nor a statistically significant association between sacro-iliac joint APFs and the presence of CPP/CPPS. The sacroiliac joint plays a key role in distributing forces from the upper body, and its movement and load-bearing capacity are influenced by the lumbosacral spine (31). It is involved in pelvic girdle pain in cases of pelvic bone asymmetry, movement asymmetry, leg length discrepancy, joint instability, pregnancies, inflammation, fractures, or the presence of tender or trigger points in ligaments and muscles, as well as altered muscular recruitment (32,33). In summary, the SIJ seems to be linked to anatomical, biomechanical, and functional lumbopelvic kinematic conditions, which are not correlated with the specific clinical condition and symptomatology of CPP/CPPS. The high prevalence of sacrococcygeal APFs in CPP/CPPS warrants further clinical consideration. This joint is included in the taxonomy of CPP/CPPS, both from the perspective of symptomatic manifestation and in terms of assessment opportunities (34). The literature reports the effectiveness of Walther's ganglion block in managing pelvic-perineal pain (35). Walther's ganglion is a small but significant ganglion of the sympathetic chain, located in the coccygeal region. It represents the final ganglion of the paravertebral chain and plays a role in the autonomic regulation of visceral functions in the pelvic region. Although less known than other ganglia, it is an essential part of the sympathetic nervous system, with potential clinical implications, particularly in the context of chronic pelvic pain and autonomic dysfunction of the pelvic organs. It is located between the sacrococcygeal joint and the tip of the coccyx, within the pelvic fascia (36). In addition, the coccyx is anatomically supported by a series of important muscles and ligaments, including the sacrococcygeal ligament and the filum terminale, which insert into its upper part. The lateral edges of the coccyx serve as insertion sites for the coccygeal muscles, the gluteus maximus, and the sacro-tuberous ligament, among others. Inferiorly, the ilio-coccygeus muscle inserts onto the tip of the coccyx. These muscles and ligaments are essential for pelvic floor support and contribute to voluntary bowel control (37). Women with coccydynia report an increase in pain during the premenstrual period, and sometimes dyspareunia. The character of the pain appears to be more related to spasm of the levator ani muscle, as patients complain of pain during defecation or sexual intercourse (38). The levator ani muscle, which inserts onto the coccyx, can be hypertonic, with palpable trigger points, and manifests with proctalgia, pelvic muscle tension, and ano-vaginal pain (39). In this context, clinical and radiological evaluation of the coccyx is useful to assess its shape, joint physiology, palpatory sensitivity, and tissue quality (40). Prolonged sedentary positions can be a dysfunctional cause of the coccyx, with Shapiro attributing it to prolonged incorrect sitting positions (slouched position), akin to a “television disease” (41). Indeed, the importance of altered sitting postures, associated with fascial insults in the abdominal and pelvic areas (e.g., repeated inflammations, surgical scars), has recently been emphasized as an exposure factor in the development of CPP/CPPS (42,43). Both coccydynia and pelvic pain syndrome are associated with pelvic floor dysfunctions, with signs and symptoms that may overlap in some cases, even if they are not classified as diseases (44). This may lead to diagnostic delays, the development of chronic pain with the associated psychosocial consequences, which can dramatically evolve (45). Nonetheless, contractures may have a functional origin related to daily activities, or they may have a systemic, metabolic, or endocrinological origin (such as thyroid and parathyroid dysfunctions), or result from venous insufficiency (46). Furthermore, myofibroblasts can interact with the extracellular matrix following trauma and inflammation, triggering a loop in which a rigid matrix stimulates the contraction of myofibroblasts, resulting in further secretion of rigid extracellular matrix (47). It is well known that the reparative activity of myofibroblasts is also sensitive to mechanical stress (48). Therefore, it is important to educate the patient about correct postural behaviors and the contribution of minor trauma and inflammation to symptom expression, in order to engage the patient in the treatment process. In summary, pain is the defining feature of CPP/CPPS condition, rather than the consequence of underlying pathological processes. In other words, pain itself constitutes the pathological process (5). Coccygodynia is considered a symptom rather than a distinct clinical disease, thus not requiring a separate clinical recognition (49). Muscular hypertonicity can be clinically identified, even if the manual assessment lacks high reliability (22). These factors highlight the need for a high clinical expertise in the assessment and management of CPP/CPPS (2). It is worth emphasizing that APFs may be present in patients with CPP/CPPS, regardless of pain topography. For this reason, they could be useful in sub-grouping patients who may potentially respond to manual therapy, as well as in identifying the likelihood for developing CPP/CPPS. Future research, through longitudinal studies, could verify whether coccyx and pelvic muscle dysfunctions can be considered clinical predictors for the development of CPP/CPPS. Generalisability of the results Considering the sample size and the selection criteria we adopted for this study, we have reason to assume that our sample could be representative of the real population. However, the totality of the recruited subjects attended the same clinical setting, and the vast majority of healthy people were students or employers of the Institute, so that a selection bias might be present. The findings we obtained were related to the presence of APFs, which can be detected through a palpatory assessment. As largely known, manual procedures are prone to reliability issues, which can affect both internal and external validity of a study (22,50). However, studies demonstrated that procedures of consensus training and standardization of the manual techniques may improve intra- and inter-operator agreements. With regard to this, our experience is consistent with the results of these studies, since our operators agreed in 95% of the observations during the consensus stage. In addition, we reported a detailed description of the manual techniques we implemented for this study, in order to improve the generalization of this study. Concerning the palpatory assessments, it is important to remark how these types of procedures are safe, easy-practicable and cost-effective, so that they are reproducible in different conditions and in various clinical settings (51). Limitations The limitations of this study include the intrinsic constraints of a cross-sectional design, which prevents the establishment of a causal relationship between the presence of sacrococcygeal and pelvic floor APFs, and the development of CPP/CPPS. Additionally, the absence of sample size calculation may limit the generalizability of the findings, and potential selection bias cannot be excluded as participants were drawn from a specific clinical setting. Furthermore, the implementation of a palpatory assessment introduces a reliability issue, which could affect the generalization of the results. Finally, the lack of longitudinal follow-up restricts the ability to evaluate the long-term progression (or resolution) of these dysfunctions. Conclusions This study highlights a statistically significant correlation between sacrococcygeal and pelvic muscle APFs, and the presence of CPP/CPPS. While the cross-sectional design precludes the evidence of causality, our findings suggest that APFs in these anatomical areas could represent relevant clinical markers for identifying patients who may benefit from targeted therapeutic interventions, such as manual therapy. Further longitudinal studies are warranted to explore the long-term impact of these dysfunctions, and to better understand their role in the development and management of CPP/CPPS. Declarations Competing interests: The authors have no conflicts of interest to disclose. Funding: The authors declare no funds were received for this study Aknowledgements: The authors would like to aknowledge Alessio Boni, Giada Carnevale, Gaia Fenu, Alessandro Franchini, Silvia Magni, Chiara Montanari and Salvatore Santorini for their contribution to the organization of the research procedures. Data availability statement: The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethics Approval statement: This study was conducted in accordance with the Declaration of Helsinki and approved by the SOMA Institutional Review Board (registration number: SIOMAA0025]. 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PMID: 12914662; PMCID: PMC183845. Monticone M, Baiardi P, Bonetti F, Ferrari S, Foti C, Pillastrini P, Rocca B, Vanti C, Zanoli G. The Italian version of the Fear-Avoidance Beliefs Questionnaire (FABQ-I): cross-cultural adaptation, factor analysis, reliability, validity, and sensitivity to change. Spine (Phila Pa 1976). 2012 Mar 15;37(6):E374-80. doi: 10.1097/BRS.0b013e31822ff5a7. PMID: 22422439. Lee SC, Wu LC, Chiang SL, Lu LH, Chen CY, Lin CH, Ni CH, Lin CH. Validating the Capability for Measuring Age-Related Changes in Grip-Force Strength Using a Digital Hand-Held Dynamometer in Healthy Young and Elderly Adults. Biomed Res Int. 2020 Apr 20;2020:6936879. doi: 10.1155/2020/6936879. PMID: 32382565; PMCID: PMC7191369. Licciardone JC, Kearns CM. Somatic dysfunction and its association with chronic low back pain, back-specific functioning, and general health: results from the OSTEOPATHIC Trial. J Am Osteopath Assoc. 2012 Jul;112(7):420-8. PMID: 22802542. Vismara L, Bergna A, Tarantino AG, Dal Farra F, Buffone F, Vendramin D, Cimolin V, Cerfoglio S, Pradotto LG, Mauro A. Reliability and Validity of the Variability Model Testing Procedure for Somatic Dysfunction Assessment: A Comparison with Gait Analysis Parameters in Healthy Subjects. Healthcare (Basel). 2024 Jan 11;12(2):175. doi: 10.3390/healthcare12020175. PMID: 38255064; PMCID: PMC10815658. Gartenberg A, Nessim A, Cho W. Sacroiliac joint dysfunction: pathophysiology, diagnosis, and treatment. Eur Spine J. 2021 Oct;30(10):2936-2943. doi: 10.1007/s00586-021-06927-9. Epub 2021 Jul 16. PMID: 34272605. Talasz H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A. Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing-a dynamic MRI investigation in healthy females. Int Urogynecol J. 2011 Jan;22(1):61-8. doi: 10.1007/s00192-010-1240-z. Epub 2010 Aug 31. PMID: 20809211. Montenegro ML, Mateus-Vasconcelos EC, Rosa e Silva JC, Nogueira AA, Dos Reis FJ, Poli Neto OB. Importance of pelvic muscle tenderness evaluation in women with chronic pelvic pain. Pain Med. 2010 Feb;11(2):224-8. doi: 10.1111/j.1526-4637.2009.00758.x. Epub 2009 Dec 9. PMID: 20002593. Aredo JV, Heyrana KJ, Karp BI, Shah JP, Stratton P. Relating Chronic Pelvic Pain and Endometriosis to Signs of Sensitization and Myofascial Pain and Dysfunction. Semin Reprod Med. 2017 Jan;35(1):88-97. doi: 10.1055/s-0036-1597123. Epub 2017 Jan 3. PMID: 28049214; PMCID: PMC5585080. Dal Farra F, Aquino A, Tarantino AG, Origo D. Effectiveness of Myofascial Manual Therapies in Chronic Pelvic Pain Syndrome: A Systematic Review and Meta-Analysis. Int Urogynecol J . 2022;33(11):2963-2976. doi:10.1007/s00192-022-05173-x Grinberg K, Sela Y, Nissanholtz-Gannot R. New Insights about Chronic Pelvic Pain Syndrome (CPPS). Int J Environ Res Public Health. 2020 Apr 26;17(9):3005. doi: 10.3390/ijerph17093005. PMID: 32357440; PMCID: PMC7246747. Lamvu G, Carrillo J, Ouyang C, Rapkin A. Chronic Pelvic Pain in Women: A Review. JAMA. 2021 Jun 15;325(23):2381-2391. doi: 10.1001/jama.2021.2631. PMID: 34128995. Piontek K, Ketels G, Klotz SGR, Dybowski C, Brünahl C, Löwe B. The longitudinal association of symptom-related and psychological factors with health-related quality of life in patients with chronic pelvic pain syndrome. J Psychosom Res. 2022 Feb;153:110707. doi: 10.1016/j.jpsychores.2021.110707. Epub 2021 Dec 21. PMID: 34954604. Ha KY, Lee JS, Kim KW. Degeneration of sacroiliac joint after instrumented lumbar or lumbosacral fusion: a prospective cohort study over five-year follow-up. Spine (Phila Pa 1976). 2008 May 15;33(11):1192-8. doi: 10.1097/BRS.0b013e318170fd35. PMID: 18469692. Sakamoto A, Gamada K. Altered musculoskeletal mechanics as risk factors for postpartum pelvic girdle pain: a literature review. J Phys Ther Sci. 2019 Oct;31(10):831-838. doi: 10.1589/jpts.31.831. Epub 2019 Oct 19. PMID: 31645815; PMCID: PMC6801337. Hungerford B, Gilleard W, Hodges P. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine (Phila Pa 1976). 2003 Jul 15;28(14):1593-600. PMID: 12865851. Kiapour A, Joukar A, Elgafy H, Erbulut DU, Agarwal AK, Goel VK. Biomechanics of the Sacroiliac Joint: Anatomy, Function, Biomechanics, Sexual Dimorphism, and Causes of Pain. Int J Spine Surg. 2020 Feb 10;14(Suppl 1):3-13. doi: 10.14444/6077. PMID: 32123652; PMCID: PMC7041664. Malhotra N, Goyal S, Kumar A, Kanika, Singla V, Kundu ZS. Comparative evaluation of transsacrococcygeal and transcoccygeal approach of ganglion impar block for management of coccygodynia. J Anaesthesiol Clin Pharmacol. 2021 Jan-Mar;37(1):90-96. doi: 10.4103/joacp.JOACP_588_20. Epub 2021 Apr 10. PMID: 34103830; PMCID: PMC8174441. Oh CS, Chung IH, Ji HJ, Yoon DM. Clinical implications of topographic anatomy on the ganglion impar. Anesthesiology. 2004 Jul;101(1):249-50. doi: 10.1097/00000542-200407000-00039. PMID: 15220800. Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner J. 2014 Spring;14(1):84-7. PMID: 24688338; PMCID: PMC3963058. Nathan ST, Fisher BE, Roberts CS. Coccydynia: a review of pathoanatomy, aetiology, treatment and outcome. J Bone Joint Surg Br. 2010 Dec;92(12):1622-7. doi: 10.1302/0301-620X.92B12.25486. PMID: 21119164. Dunphy L, Wood F, Mubarak ES, Coughlin L. Levator Ani Syndrome Presenting with Vaginal Pain. BMJ Case Rep. 2023 May 4;16(5):e255190. doi: 10.1136/bcr-2023-255190. PMID: 37142285; PMCID: PMC10163556. Fogel GR, Cunningham PY 3rd, Esses SI. Coccygodynia: evaluation and management. J Am Acad Orthop Surg. 2004 Jan-Feb;12(1):49-54. doi: 10.5435/00124635-200401000-00007. PMID: 14753797. Shapiro S. Low back and rectal pain from an orthopedic and proctologic viewpoint; with a review of 180 cases. Am J Surg. 1950 Jan;79(1):117-28, illust. doi: 10.1016/0002-9610(50)90202-9. PMID: 15399361. Origo D, Piloni S, Tarantino AG. Secondary dysmenorrhea and dyspareunia associated with pelvic girdle dysfunction: A case report and review of literature. J Bodyw Mov Ther. 2021 Jul;27:165-168. doi: 10.1016/j.jbmt.2021.03.013. Epub 2021 Mar 19. PMID: 34391229. Origo D, Dal Farra F, Bruni MF, Catalano A, Marzagalli L, Bruini I. Are fascial strains involved in chronic pelvic pain syndrome? An exploratory matched case-control study. Int Urol Nephrol. 2023 Mar;55(3):511-518. doi: 10.1007/s11255-022-03448-2. Epub 2022 Dec 15. PMID: 36522568. Neville CE, Carrubba AR, Li Z, Ma Y, Chen AH. Association of coccygodynia with pelvic floor symptoms in women with pelvic pain. PM R . 2022;14(11):1351-1359. doi:10.1002/pmrj.12706 Calati R, Laglaoui Bakhiyi C, Artero S, Ilgen M, Courtet P. The impact of physical pain on suicidal thoughts and behaviors: Meta-analyses. J Psychiatr Res. 2015 Dec;71:16-32. doi: 10.1016/j.jpsychires.2015.09.004. Epub 2015 Sep 11. PMID: 26522868. Dijkstra JN, Boon E, Kruijt N, Brusse E, Ramdas S, Jungbluth H, van Engelen BGM, Walters J, Voermans NC. Muscle cramps and contractures: causes and treatment. Pract Neurol. 2023 Feb;23(1):23-34. doi: 10.1136/pn-2022-003574. Epub 2022 Dec 15. PMID: 36522175. Hildebrand KA, Zhang M, van Snellenberg W, King GJ, Hart DA. Myofibroblast numbers are elevated in human elbow capsules after trauma. Clin Orthop Relat Res. 2004 Feb;(419):189-97. doi: 10.1097/00003086-200402000-00031. PMID: 15021153; PMCID: PMC2950171. Hinz B. The myofibroblast: paradigm for a mechanically active cell. J Biomech. 2010 Jan 5;43(1):146-55. doi: 10.1016/j.jbiomech.2009.09.020. Epub 2009 Oct 3. PMID: 19800625. Wray CC, Easom S, Hoskinson J. Coccydynia. Aetiology and treatment. J Bone Joint Surg Br. 1991 Mar;73(2):335-8. doi: 10.1302/0301-620X.73B2.2005168. PMID: 2005168. Zambonin Mazzoleni G, Bergna A, Buffone F, et al. A Critical Appraisal of Reporting in Randomized Controlled Trials Investigating Osteopathic Manipulative Treatment: A Meta-Research Study. J Clin Med . 2024;13(17):5181. Published 2024 Aug 31. doi:10.3390/jcm13175181. Buffone F, Monacis D, Tarantino AG, et al. Osteopathic Treatment for Gastrointestinal Disorders in Term and Preterm Infants: A Systematic Review and Meta-Analysis. Healthcare (Basel) . 2022;10(8):1525. Published 2022 Aug 12. doi:10.3390/healthcare10081525 Tables Table 1 . Characteristics of the sample. CPP/CPPS Healthy people Number per group Gender (M/F) Age Physical activity (n. of time/week) Physical activity (hours/week) Sacro-coccygeal dysfunction (severity 0-2) Sacro-iliac dysfunction (severity 0-2) Pelvic floor dysfunction (severity 0-2) NIH-CPSI a (pain) NIH-CPSI b (urinary) NIH-CPSI c (quality of life) NIH-CPSI total score HADS anxiety HADS depression HADS total score FABQ score 162 59/103 32.5 (26-43) 1 (0-3) 2 (0-4) 2 (1-2) 1 (0-1) 2 (1-2) 8 (5-11) 2 (0-5) 7 (4-9) 17 (10-22) 8 (5-12) 7 (4-10) 15 (9-21) 19 (6-31) 164 59/105 31.5 (26-45) 2 (0-3) 3 (0-6) 0 (0-0) 0 (0-1) 0 (0-0) 0 (0-1) 1 (0-2) 0 (0-2) 2 (0-7) 6 (4-9) 5 (2-8) 11 (6-16) 6 (0-17) Abbreviations. CPP/CPPS: chronic pelvic pain/chronic pelvic pain syndrome; NIH-CPSI: National Institute of Health-Chronic Prostatitis Symptoms Index; HADS: Hospital Anxiety and Depression Scale; FABQ: Fear Avoidance Belief Questionnaire. Table 2 . Symptoms’ characteristics in the CPP/CPPS group. Symptoms functional impact N (%) None Sexual Urinary Both (29) 18% (25) 15% (11) 7% (97) 60% Symptoms duration N (%) 3-6 months 6-12 months 1-3 years >3 years 13 (8%) 34 (21%) 52 (32%) 63 (39%) Symptoms localization N (%) No specific localization Lumbo-Sacral Sacro-coccygeal Lower abdomen Sacro-iliac Pubis Perineum More than one area 25 (16%) 4 (3%) 16 (10%) 8 (5%) 7 (4%) 21 (14%) 10 (7%) 63 (41%) Table 3 is available in the Supplementary Files section. Table 4. Logistic regression analysis (multivariate analysis). Dysfunction B Exp(B) 95% CI Sacro-coccygeal dysfunction Sacro-iliac dysfunction Pelvic floor dysfunction 1.1 * 0.45 1.09 * 3.02 1.57 2.99 (1.96 - 4.65) (0.97 - 2.53) (1.87 - 4.78) Dependent variable: presence of a CPP/CPPS condition. Covariates: sacrococcygeal dysfunction severity; sacroiliac dysfunction severity; pelvic floor dysfunction. CI: confidence interval. *= p<0.001. Additional Declarations No competing interests reported. Supplementary Files Table3.docx Cite Share Download PDF Status: Published Journal Publication published 25 Apr, 2025 Read the published version in International Urology and Nephrology → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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23:21:59\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":30791,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Table3.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6289612/v1/ff24af76a136dbdc0df9e0cd.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"The presence of abnormal palpatory findings in the sacrococcygeal area is correlated with chronic pelvic pain: a cross-sectional study\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eChronic pelvic pain (CPP) is a non-malignant pain localized in the pelvis and anatomically related structures, lasting for at least six months and leading to negative emotional, behavioral, and sexual consequences (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). Chronic pelvic pain syndrome (CPPS) is characterized by persistent or recurrent pelvic pain associated with symptoms leading to urogenital dysfunction, but also intestinal and lower urinary tract domains (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eNon-specific diffuse pain, in absence of a documentable pathology, may involve one or more pelvic organs, the abdominal wall, the genital area, and might be associated with systemic symptoms (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). Furthermore, conditions such as irritable bowel syndrome, interstitial cystitis, painful bladder and fibromyalgia resulted highly prevalent in people with CPP/CPPS, thus requiring a reconsideration of the patient’s physical, psychological, and social needs (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eThe epidemiological data on CPP/CPPS are disparate, due to the varying quality of the studies. Prevalence is definitely higher in women, with a lifetime prevalence ranging from 5.7–26.6% (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e), while 10% of men experience CPP/CPPS (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003ePatients typically present dysfunctions in the pelvic floor muscles, which resulted in hyperactivity. Tissue palpation may reveal the presence of trigger points (TPs) in adjacent muscles, such as the piriformis, gluteus maximus, and iliopsoas (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e), as well as tenderness in the suprapubic, abdominal, and intrapelvic regions (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eMultimodal physical treatments (patient education, biofeedback, manual therapy, and injections to address abdominal and pelvic TPs) appeared to be an effective therapeutic choice (\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e). In a recent position statement, the Italian Society of Colo-Rectal Surgery emphasized the need for a multimodal clinical approach in CPPS, highlighting the importance of a careful assessment of the musculoskeletal system, but also posture, joints, and tissues in general, which are often underrated (\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). In this context, the physical assessment of postures, joints mobility and tissues characteristics are frequently performed by different healthcare professionals such as physiotherapists, osteopaths and chiropractors, according to their competences and educational backgrounds (\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). The presence of abnormal palpatory findings (APFs) in terms of joint mobility restriction, alterations of tissue texture and tenderness areas are detectable by palpation procedures and guides the physical assessment of such approaches (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eAlthough the contribution of the myofascial dysfunctions has been largely demonstrated in CPP/CPPS, so far no study investigated which parts of the pelvic region appear to be the most involved in this condition. From this perspective, it becomes relevant to take into account the anatomical and functional relationships of the pelvic floor (e.g., muscles, ligaments, and fascia, forming a sort of sling supporting the internal organs). These soft tissues attach to the pelvic girdle and posteriorly to the sacrum and coccyx, which are crucial for anchoring the muscles forming the pelvic floor (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eOur hypothesis is that specific pelvic dysfunctional areas, detectable in a form of APFs, might be more involved than others in the contribution to chronic pain.\\u003c/p\\u003e\\u003cp\\u003eTherefore, the primary aim of this study is to assess and quantify the presence of abnormal palpatory findings (APFs) of the pelvic area in patients with CPPS. Secondarily, to correlate the presence of APFs to symptoms, signs, physical and psychosocial variables of people presenting CPP/CPPS.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003e \\u003cem\\u003eStudy design and setting\\u003c/em\\u003e \\u003c/p\\u003e\\u003cp\\u003eThis cross-sectional investigation was carried on in the period ranging from September 2023 and June 2024. All the procedures have been conducted in a rehabilitative outpatient clinic located in Milan. The study protocol was approved by the Institutional Review Board of the SOMA Clinical Institute (registration number: SIOM-AA0025), and all the participants gave informed consent before being tested. This study was conceived and reported following the “Strengthening the reporting of observational studies in epidemiology (STROBE) statement” checklist for cross-sectional studies (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e \\u003cem\\u003eParticipants\\u003c/em\\u003e \\u003c/p\\u003e\\u003cp\\u003eIndividuals with CPP/CPPS were recruited on a voluntary basis from the population of patients referring to the clinic. Each patient who had already received a medical diagnosis of CPP/CPPS was offered the possibility to participate. People without CPP/CPPS were recruited by flyers among students and personnel attending the clinic, or the annex college campus.\\u003c/p\\u003e\\u003cp\\u003eInclusion criteria were people aged 18–65, with or without CPP/CPPS. Conversely, we excluded people affected by serious medical conditions affecting the musculoskeletal system (e.g., multiple fractures, rheumatism), unresolved cancer, current pregnancy or any impossibility to undergo a palpatory assessment in the pelvic area, both due to physical or cognitive issues. In addition, we also excluded people receiving physical or manipulative treatments elsewhere. Each participant with CPP/CPPS was matched to a subject without pain, based on their age and gender.\\u003c/p\\u003e\\u003cp\\u003e \\u003cem\\u003eOutcome measures\\u003c/em\\u003e \\u003c/p\\u003e\\u003cp\\u003eAll the participants recruited for the study received a booklet requesting socio-demographics, clinical information, and containing three different questionnaires.\\u003c/p\\u003e\\u003cp\\u003eThis booklet included questions related to symptoms localization and duration, physical activity (frequency, duration, intensity) and previous trauma. In addition, the following questionnaires were incorporated.\\u003c/p\\u003e\\u003cp\\u003eThe “NIH-Chronic Prostatitis Symptom Index” (NIH-CPSI) was implemented to investigate the symptom severity; it contains three main domains: pain, urinary symptoms and quality of life impact. The NIH-CPSI is considered a reliable and cross-culturally validated instrument, frequently considered in the functional assessment of people with CPP/CPPS (\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eThe “Hospital Anxiety and Depression Scale” (HADS) is a 14-items questionnaire based on a 4-points Likert score (0–3), and it is considered a reliable instrument to detect anxiety and depression states, measured by two distinct scores (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eThe “Fear Avoidance Belief Questionnaire” (FABQ) measures fear of pain and consequent activity avoidance, and it has been successfully translated into Italian language. It is composed of 16 items, based on a 7-points Likert scale (0–6) expressing the agreement the subject has with regards to the different statements (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e \\u003cem\\u003ePhysical assessment\\u003c/em\\u003e \\u003c/p\\u003e\\u003cp\\u003eSubsequently, each subject underwent a standardized palpatory assessment performed by two expert physiotherapists (more than 15 years of experience), with a certification in osteopathic manipulation. Before testing, the assessors went through a procedure of consensus training, consisting of 9 hours of practice, divided into three main sessions (3 hours each), and a 2-hours final meeting when consensus has been definitely reached. With regard to this, the use of a Digital Hand-Held Dynamometer (PainTest™ FPX 25 Algometer, Wagner Instruments, Greenwich, USA) was used, since it proved to be a valid and reliable tool (\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). The assessors agreed upon a palpatory force ranging between 0.80 and 1.00 kg, and after adequate training, in 95% of the trials, they were able to consistently maintain this force range.\\u003c/p\\u003e\\u003cp\\u003eThe manual assessment was exclusively aimed to detect APFs in the ileo-sacral joints, sacrococcygeal region and in the pelvic floor area. Based on the principles of the TART model, alterations in the tissue texture, joint movement reduction and tenderness or pain evocation are considerable APFs, attributable to the presence of somatic dysfunction (\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e). From this point on, the expressions “APFs” and “dysfunction” are considerable synonymous.\\u003c/p\\u003e\\u003cp\\u003eThe procedure consisted of three different standardized maneuvers, aimed to assess the presence and the grade of dysfunction of two joint complexes and a soft-tissue region.\\u003c/p\\u003e\\u003cp\\u003eThe first technique was oriented to the sacroiliac joint: with the patient in a prone position, the operators placed two fingers on the inferior groove of the posterior inferior iliac spine, to verify the position in the frontal plane. The fingers are then flexed approximately 30° medially and caudally to contact the sacral base, which is assessed in the coronal plane. The fingers are subsequently moved to the inferior lateral angle of the sacrum to perform a similar assessment in the coronal plane. Next, the operators placed the fingers on the sacral base and the inferior lateral angle of the sacrum ipsilaterally, applying pressure to evaluate the ability of the sacrum to perform nutation and counternutation, as well as to assess for palpatory tenderness. The assessors then placed the fingers on the left base and the right inferior lateral angle of the sacrum, then vice versa, applying pressure to induce movement, assessing for both the range of motion and tenderness (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eThe second technique was oriented to the sacrococcygeal joint assessment: the assessors placed a finger on the coccyx with the patient in a prone position, palpating the entire contour of the bone, while asking the patient the presence of pain. The patient was then instructed to take a deep breath, and operators observed the movement of the coccyx facilitated by the pelvic diaphragm muscles, which follow the downward movement of the thoracic diaphragm during in-breathing(\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eRegarding the third technique: the assessors applied pressure to the pelvic diaphragm muscles between the ischium, pubic bone, and coccyx, evaluating for any palpatory tenderness and the ability of the muscles to move caudally in conjunction with a deep inspiration (\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eThe above-described techniques are represented in Figs.\\u0026nbsp;1, 2 and 3.\\u003c/p\\u003e\\u003cp\\u003eFinally, the assessors had the possibility to grade the dysfunction as follows: absence of APFs was scored as 0; movement reduction, or altered tissue texture, or pain evocation was scored as 1; the co-presence of APFs corresponded to a score of 2.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003cem\\u003eSample size calculation\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn this study no study sample calculation was performed, since the presence of physical dysfunctions (joint restrictions, tissue texture alterations, tenderness) were not measured in any previous study dealing with CPP/CPPS, and no expected mean for the outcome of interest was retrievable in literature.\\u003c/p\\u003e\\n\\u003cp\\u003eFor these reasons, the consecutive enrolling of the subjects stopped when a considerable number of participants was definitely reached for each group.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003cem\\u003eStatistical Analysis\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe main characteristics of the sample were reported in a descriptive way.\\u003c/p\\u003e\\n\\u003cp\\u003eThe distribution for continuous variables was tested via Kolmogorov-Smirnov test. Since no normal distribution was found, the U-Mann-Whitney test for independent samples was applied to test any possible differences between the two groups in terms of age, thus verifying the success of the matching procedure.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eSpearman correlation test was implemented to verify any possible correlation between the condition of CPP/CPPS and all the other variables of interest, such as the presence and severity of pelvic dysfunctions, the questionnaire scores, levels of physical activity and a history of a previous trauma. As a secondary analysis, a multivariate analysis (logistic regression) was considered to highlight any possible association between the presence of specific APFs (independent variables or covariates) and the condition of CPP/CPPS (dependent variable).\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003cem\\u003eCharacteristics of the sample\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA total of 326 individuals were recruited, specifically 162 people with a CPP/CPPS condition and 164 healthy people. The mean age of the participants was 35.62 +/- 12.2, and all the main characteristics of the sample are detailed in Table 1.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003cem\\u003ePlease, consider table 1 approximately here.\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;The majority of people with CPP/CPPS presented symptoms for more than 3 years (38.9%) and only the 8% of the cases complained of symptoms for 3-6 months. In addition, 15.4% of the cases reported sexual dysfunctions, the 6.8% complained of urinary disturbances and 59.9% reported both of the functions as impaired.\\u003c/p\\u003e\\n\\u003cp\\u003eAs for the localization, 38.9% of CPP/CPPS people reported symptoms in different abdominal and pelvic areas, 13% in the pubic region, 9.9% in the coccygeal area and the 6.2% in the perineal region. Further details are reported in Table 2.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003cem\\u003ePlease consider table 2 approximately here\\u003c/em\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe sacrococcygeal dysfunction was present in the 78% of the people suffering from CPP/CPPS, the sacro-iliac dysfunction in the 72%, though in the 56% of these cases it was assessed as of \\u0026ldquo;low severity\\u0026rdquo;. The dysfunction of the pelvic floor was detected in 80% of the people with CPP/CPPS.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eCorrelations Analysis\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA significant moderate-to-strong correlation resulted between the condition of CPP/CPPS and the presence of sacrococcygeal and pelvic floor dysfunctions (r= 0.609 and r= 0.62, p\\u0026lt;0.01, respectively), but not with the sacroiliac dysfunction where the correlation was present, yet weak (0.269, p\\u0026lt;0.01). The correlation between the presence of CPP/CPPS with the severity of the dysfunctions overlaps the above reported data (r= 0.655, r= 0.642, r= 0.315, p\\u0026lt; 0.01, respectively).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eA significant weak correlation was found between having CPP/CPPS and the HADS total score (r= 0.264, p\\u0026lt;0.01), also considering both the anxiety (r= 0.258, p\\u0026lt;0.01) and the depression sub-scores (r= 0.210, p\\u0026lt;0.01). In the same way, a significant weak correlation was detected with the FABQ score (r= 0.273, p\\u0026lt;0.01). Finally, a minimal significant correlation was found between presenting a CPP/CPPS condition and the frequency or the amount of physical activity (r= 0.126 and r= 0.140, p\\u0026lt;0.05 respectively).\\u003c/p\\u003e\\n\\u003cp\\u003eAll the correlations are reported in Table 3.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003ePlease consider table 3 approximately here\\u003c/em\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eSecondary Analysis\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA multivariate analysis was implemented to provide a prediction model considering the presence of CPP/CPPS as a dependent variable and the abnormal palpatory findings as covariates. The sacro-coccygeal and the pelvic floor dysfunctions\\u0026rsquo; severity resulted as factors significantly associated with CPP/CPPS [exp B: 3.02 (1.96-4.65) and 2.99 (1.87-4.78), p\\u0026lt;0.001, respectively). No significant association was found with the sacroiliac dysfunction [exp B: 1.57 (0.97-2.53). Further details are reported in Table 4.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003ePlease consider table 4 approximately here\\u003c/em\\u003e\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003e\\u003cem\\u003eSummary of results\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTo the best of our knowledge, this study represents the first attempt to understand whether APFs are prevalent in the sacrococcygeal, sacroiliac, or pelvic floor areas in patients with CPP/CPPS. Our results indicate a significant presence of these clinical signs at the level of the coccyx and the pelvic muscles, which are closely related from an anatomical and functional point of view (15). Furthermore, the distribution and the impact of the symptoms in our sample resulted in line with previous epidemiological studies (5,6). Indeed, pain appears to be located in various pelvic areas, both urological and sexual disturbances are highly prevalent in this population and the impact of this condition largely affects people in terms of perceived pain, urinary function and quality of life, as reported by NIH-CPSI questionnaire. Weak correlations were detected between the presence of pelvic APFs and levels of anxiety, depression and fear-avoidance beliefs, whereas no significant correlations were obtained between the presence of APFs and previous trauma or the frequency, duration and volume of physical activity.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eClinical interpretation\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe findings of this study are consistent with existing literature regarding the contribution of pelvic myofascial and articular structures in subgroups of patients suffering from CPP/CPPS (26). It is noteworthy to highlight the hypothesis that myofascial release, through a multimodal approach, could restore the physiological blood flow necessary for patient comfort, as a reduction in blood flow to the tissues may sustain this debilitating syndrome (27). Consequently, pelvic muscle dysfunction and their anatomical relationships, combined with psychosocial factors and pain misperception, are involved variables and a timely understanding of these factors is crucial for an optimal therapeutic approach (28).\\u003c/p\\u003e\\n\\u003cp\\u003eAlthough in CPP/CPPS the scientific literature rightly considered traumatic experiences, distress, pain and non-pelvic comorbidities (29), the results of our study reveal only a weak correlation with the anxiety and depression scale, and with the fear-avoidance beliefs questionnaire. This fact raises the question on whether the emotional state is the cause or the effect of a condition that so significantly impacts quality of life. It seems easy to imagine how such a condition could induce neurobiological mechanisms related to anxiety, depression and distress (30).\\u003c/p\\u003e\\n\\u003cp\\u003eOur results did not show neither a relevant correlation, nor a statistically significant association between sacro-iliac joint APFs and the presence of CPP/CPPS. The sacroiliac joint plays a key role in distributing forces from the upper body, and its movement and load-bearing capacity are influenced by the lumbosacral spine (31). It is involved in pelvic girdle pain in cases of pelvic bone asymmetry, movement asymmetry, leg length discrepancy, joint instability, pregnancies, inflammation, fractures, or the presence of tender or trigger points in ligaments and muscles, as well as altered muscular recruitment (32,33). In summary, the SIJ seems to be linked to anatomical, biomechanical, and functional lumbopelvic kinematic conditions, which are not correlated with the specific clinical condition and symptomatology of CPP/CPPS.\\u003c/p\\u003e\\n\\u003cp\\u003eThe high prevalence of sacrococcygeal APFs in CPP/CPPS warrants further clinical consideration. This joint is included in the taxonomy of CPP/CPPS, both from the perspective of symptomatic manifestation and in terms of assessment opportunities (34). The literature reports the effectiveness of Walther\\u0026apos;s ganglion block in managing pelvic-perineal pain (35). Walther\\u0026apos;s ganglion is a small but significant ganglion of the sympathetic chain, located in the coccygeal region. It represents the final ganglion of the paravertebral chain and plays a role in the autonomic regulation of visceral functions in the pelvic region. Although less known than other ganglia, it is an essential part of the sympathetic nervous system, with potential clinical implications, particularly in the context of chronic pelvic pain and autonomic dysfunction of the pelvic organs. It is located between the sacrococcygeal joint and the tip of the coccyx, within the pelvic fascia (36).\\u003c/p\\u003e\\n\\u003cp\\u003eIn addition, the coccyx is anatomically supported by a series of important muscles and ligaments, including the sacrococcygeal ligament and the filum terminale, which insert into its upper part. The lateral edges of the coccyx serve as insertion sites for the coccygeal muscles, the gluteus maximus, and the sacro-tuberous ligament, among others. Inferiorly, the ilio-coccygeus muscle inserts onto the tip of the coccyx. These muscles and ligaments are essential for pelvic floor support and contribute to voluntary bowel control (37).\\u003c/p\\u003e\\n\\u003cp\\u003eWomen with coccydynia report an increase in pain during the premenstrual period, and sometimes dyspareunia. The character of the pain appears to be more related to spasm of the levator ani muscle, as patients complain of pain during defecation or sexual intercourse (38). The levator ani muscle, which inserts onto the coccyx, can be hypertonic, with palpable trigger points, and manifests with proctalgia, pelvic muscle tension, and ano-vaginal pain (39).\\u003c/p\\u003e\\n\\u003cp\\u003eIn this context, clinical and radiological evaluation of the coccyx is useful to assess its shape, joint physiology, palpatory sensitivity, and tissue quality (40). Prolonged sedentary positions can be a dysfunctional cause of the coccyx, with Shapiro attributing it to prolonged incorrect sitting positions (slouched position), akin to a \\u0026ldquo;television disease\\u0026rdquo; (41). Indeed, the importance of altered sitting postures, associated with fascial insults in the abdominal and pelvic areas (e.g., repeated inflammations, surgical scars), has recently been emphasized as an exposure factor in the development of CPP/CPPS (42,43).\\u003c/p\\u003e\\n\\u003cp\\u003eBoth coccydynia and pelvic pain syndrome are associated with pelvic floor dysfunctions, with signs and symptoms that may overlap in some cases, even if they are not classified as diseases (44). This may lead to diagnostic delays, the development of chronic pain with the associated psychosocial consequences, which can dramatically evolve (45).\\u003c/p\\u003e\\n\\u003cp\\u003eNonetheless, contractures may have a functional origin related to daily activities, or they may have a systemic, metabolic, or endocrinological origin (such as thyroid and parathyroid dysfunctions), or result from venous insufficiency (46). Furthermore, myofibroblasts can interact with the extracellular matrix following trauma and inflammation, triggering a loop in which a rigid matrix stimulates the contraction of myofibroblasts, resulting in further secretion of rigid extracellular matrix (47). It is well known that the reparative activity of myofibroblasts is also sensitive to mechanical stress (48). Therefore, it is important to educate the patient about correct postural behaviors and the contribution of minor trauma and inflammation to symptom expression, in order to engage the patient in the treatment process.\\u003c/p\\u003e\\n\\u003cp\\u003eIn summary, pain is the defining feature of CPP/CPPS condition, rather than the consequence of underlying pathological processes. In other words, pain itself constitutes the pathological process (5). Coccygodynia is considered a symptom rather than a distinct clinical disease, thus not requiring a separate clinical recognition (49). Muscular hypertonicity can be clinically identified, even if the manual assessment lacks high reliability (22). These factors highlight the need for a high clinical expertise in the assessment and management of CPP/CPPS (2).\\u003c/p\\u003e\\n\\u003cp\\u003eIt is worth emphasizing that APFs may be present in patients with CPP/CPPS, regardless of pain topography. For this reason, they could be useful in sub-grouping patients who may potentially respond to manual therapy, as well as in identifying the likelihood for developing CPP/CPPS.\\u003c/p\\u003e\\n\\u003cp\\u003eFuture research, through longitudinal studies, could verify whether coccyx and pelvic muscle dysfunctions can be considered clinical predictors for the development of CPP/CPPS.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eGeneralisability of the results\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eConsidering the sample size and the selection criteria we adopted for this study, we have reason to assume that our sample could be representative of the real population. However, the totality of the recruited subjects attended the same clinical setting, and the vast majority of healthy people were students or employers of the Institute, so that a selection bias might be present.\\u003c/p\\u003e\\n\\u003cp\\u003eThe findings we obtained were related to the presence of APFs, which can be detected through a palpatory assessment. As largely known, manual procedures are prone to reliability issues, which can affect both internal and external validity of a study (22,50). However, studies demonstrated that procedures of consensus training and standardization of the manual techniques may improve intra- and inter-operator agreements. With regard to this, our experience is consistent with the results of these studies, since our operators agreed in 95% of the observations during the consensus stage. In addition, we reported a detailed description of the manual techniques we implemented for this study, in order to improve the generalization of this study.\\u003c/p\\u003e\\n\\u003cp\\u003eConcerning the palpatory assessments, it is important to remark how these types of procedures are safe, easy-practicable and cost-effective, so that they are reproducible in different conditions and in various clinical settings (51).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eLimitations\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe limitations of this study include the intrinsic constraints of a cross-sectional design, which prevents the establishment of a causal relationship between the presence of sacrococcygeal and pelvic floor APFs, and the development of CPP/CPPS. Additionally, the absence of sample size calculation may limit the generalizability of the findings, and potential selection bias cannot be excluded as participants were drawn from a specific clinical setting. Furthermore, the implementation of a palpatory assessment introduces a reliability issue, which could affect the generalization of the results. Finally, the lack of longitudinal follow-up restricts the ability to evaluate the long-term progression (or resolution) of these dysfunctions.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eThis study highlights a statistically significant correlation between sacrococcygeal and pelvic muscle APFs, and the presence of CPP/CPPS. While the cross-sectional design precludes the evidence of causality, our findings suggest that APFs in these anatomical areas could represent relevant clinical markers for identifying patients who may benefit from targeted therapeutic interventions, such as manual therapy. Further longitudinal studies are warranted to explore the long-term impact of these dysfunctions, and to better understand their role in the development and management of CPP/CPPS.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests:\\u0026nbsp;\\u003c/strong\\u003eThe authors have no conflicts of interest to disclose.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding:\\u0026nbsp;\\u003c/strong\\u003eThe authors declare no funds were received for this study\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAknowledgements:\\u0026nbsp;\\u003c/strong\\u003eThe authors would like to aknowledge Alessio Boni, Giada Carnevale, Gaia Fenu, Alessandro Franchini, Silvia Magni, Chiara Montanari and Salvatore Santorini for their contribution to the organization of the research procedures.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData availability statement:\\u0026nbsp;\\u003c/strong\\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics Approval statement:\\u0026nbsp;\\u003c/strong\\u003eThis study was conducted in accordance with the Declaration of Helsinki and approved by the SOMA Institutional Review Board (registration number: SIOMAA0025].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eParticipants consent statement:\\u003c/strong\\u003e Written informed consent was obtained from all participants prior to their inclusion in the study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contributions (CRediT taxonomy):\\u003c/strong\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eDO\\u003c/strong\\u003e: Conceptualization; Investigation; Data curation; Formal analysis; Writing \\u0026ndash; original draft. Project administration\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eFDF\\u003c/strong\\u003e: Conceptualization; Methodology; Formal analysis; Data curation; Writing \\u0026ndash; review \\u0026amp; editing; Supervision.\\u003cbr\\u003e\\u0026nbsp;\\u003cstrong\\u003eMT\\u003c/strong\\u003e: Methodology; Writing \\u0026ndash; review \\u0026amp; editing; Supervision.\\u003c/p\\u003e\\n\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eFall M, Baranowski AP, Elneil S, Engeler D, Hughes J, Messelink EJ, Oberpenning F, de C Williams AC; European Association of Urology. EAU guidelines on chronic pelvic pain. Eur Urol. 2010 Jan;57(1):35-48. doi: 10.1016/j.eururo.2009.08.020. Epub 2009 Aug 31. PMID: 19733958.\\u003c/li\\u003e\\n\\u003cli\\u003eParsons BA, Baranowski AP, Berghmans B, Borovicka J, Cottrell AM, Dinis-Oliveira P, Elneil S, Hughes J, Messelink BEJ, de C Williams AC, Abreu-Mendes P, Zumstein V, Engeler DS. Management of chronic primary pelvic pain syndromes. BJU Int. 2022 May;129(5):572-581. doi: 10.1111/bju.15609. Epub 2021 Oct 27. PMID: 34617386.\\u003c/li\\u003e\\n\\u003cli\\u003eAbrams P, Baranowski A, Berger RE, Fall M, Hanno P, Wesselmann U. A new classification is needed for pelvic pain syndromes--are existing terminologies of spurious diagnostic authority bad for patients? J Urol. 2006 Jun;175(6):1989-90. doi: 10.1016/S0022-5347(06)00629-X. PMID: 16697782.\\u003c/li\\u003e\\n\\u003cli\\u003eLee J, Ellis B, Price C, Baranowski AP. Chronic widespread pain, including fibromyalgia: a pathway for care developed by the British Pain Society. Br J Anaesth. 2014 Jan;112(1):16-24. doi: 10.1093/bja/aet351. Epub 2013 Nov 5. PMID: 24196696.\\u003c/li\\u003e\\n\\u003cli\\u003eLatthe P, Latthe M, Say L, G\\u0026uuml;lmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health. 2006 Jul 6; 6:177. doi: 10.1186/1471-2458-6-177. PMID: 16824213; PMCID: PMC1550236.\\u003c/li\\u003e\\n\\u003cli\\u003eAhangari A. Prevalence of chronic pelvic pain among women: an updated review. Pain Physician. 2014 Mar-Apr;17(2): E141-7. PMID: 24658485\\u003c/li\\u003e\\n\\u003cli\\u003eShoskes DA, Berger R, Elmi A, Landis JR, Propert KJ, Zeitlin S; Chronic Prostatitis Collaborative Research Network Study Group. Muscle tenderness in men with chronic prostatitis/chronic pelvic pain syndrome: the chronic prostatitis cohort study. J Urol. 2008 Feb;179(2):556-60. doi: 10.1016/j.juro.2007.09.088. Epub 2007 Dec 21. PMID: 18082223; PMCID: PMC2664648.\\u003c/li\\u003e\\n\\u003cli\\u003eNamazi G, Chauhan N, Handler S. Myofascial pelvic pain: the forgotten player in chronic pelvic pain. Curr Opin Obstet Gynecol. 2024 Aug 1;36(4):273-281. doi: 10.1097/GCO.0000000000000966. Epub 2024 May 21. PMID: 38837702.\\u003c/li\\u003e\\n\\u003cli\\u003ePastore EA, Katzman WB. Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain. J Obstet Gynecol Neonatal Nurs. 2012 Sep-Oct;41(5):680-91. doi: 10.1111/j.1552-6909.2012.01404.x. Epub 2012 Aug 3. PMID: 22862153; PMCID: PMC3492521.\\u003c/li\\u003e\\n\\u003cli\\u003eRoss V, Detterman C, Hallisey A. Myofascial Pelvic Pain: An Overlooked and Treatable Cause of Chronic Pelvic Pain. J Midwifery Womens Health. 2021 Mar;66(2):148-160. doi: 10.1111/jmwh.13224. Epub 2021 Mar 31. PMID: 33788379.\\u003c/li\\u003e\\n\\u003cli\\u003eBonder JH, Chi M, Rispoli L. Myofascial Pelvic Pain and Related Disorders. Phys Med Rehabil Clin N Am. 2017 Aug;28(3):501-515. doi: 10.1016/j.pmr.2017.03.005. PMID: 28676361.\\u003c/li\\u003e\\n\\u003cli\\u003eMenconi C, Marino F, Bottini C, La Greca G, Gozzo C, Losacco L, Carlucci D, Navarra L, Martellucci J. Evaluation and management of chronic anorectal and pelvic pain syndromes: Italian Society of Colorectal Surgery (SICCR) position statement. 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PMID: 22802542.\\u003c/li\\u003e\\n\\u003cli\\u003eVismara L, Bergna A, Tarantino AG, Dal Farra F, Buffone F, Vendramin D, Cimolin V, Cerfoglio S, Pradotto LG, Mauro A. Reliability and Validity of the Variability Model Testing Procedure for Somatic Dysfunction Assessment: A Comparison with Gait Analysis Parameters in Healthy Subjects. Healthcare (Basel). 2024 Jan 11;12(2):175. doi: 10.3390/healthcare12020175. PMID: 38255064; PMCID: PMC10815658.\\u003c/li\\u003e\\n\\u003cli\\u003eGartenberg A, Nessim A, Cho W. Sacroiliac joint dysfunction: pathophysiology, diagnosis, and treatment. Eur Spine J. 2021 Oct;30(10):2936-2943. doi: 10.1007/s00586-021-06927-9. Epub 2021 Jul 16. PMID: 34272605.\\u003c/li\\u003e\\n\\u003cli\\u003eTalasz H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A. Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing-a dynamic MRI investigation in healthy females. Int Urogynecol J. 2011 Jan;22(1):61-8. doi: 10.1007/s00192-010-1240-z. Epub 2010 Aug 31. PMID: 20809211.\\u003c/li\\u003e\\n\\u003cli\\u003eMontenegro ML, Mateus-Vasconcelos EC, Rosa e Silva JC, Nogueira AA, Dos Reis FJ, Poli Neto OB. Importance of pelvic muscle tenderness evaluation in women with chronic pelvic pain. Pain Med. 2010 Feb;11(2):224-8. doi: 10.1111/j.1526-4637.2009.00758.x. Epub 2009 Dec 9. PMID: 20002593.\\u003c/li\\u003e\\n\\u003cli\\u003eAredo JV, Heyrana KJ, Karp BI, Shah JP, Stratton P. Relating Chronic Pelvic Pain and Endometriosis to Signs of Sensitization and Myofascial Pain and Dysfunction. Semin Reprod Med. 2017 Jan;35(1):88-97. doi: 10.1055/s-0036-1597123. Epub 2017 Jan 3. PMID: 28049214; PMCID: PMC5585080.\\u003c/li\\u003e\\n\\u003cli\\u003eDal Farra F, Aquino A, Tarantino AG, Origo D. Effectiveness of Myofascial Manual Therapies in Chronic Pelvic Pain Syndrome: A Systematic Review and Meta-Analysis. \\u003cem\\u003eInt Urogynecol J\\u003c/em\\u003e. 2022;33(11):2963-2976. doi:10.1007/s00192-022-05173-x\\u003c/li\\u003e\\n\\u003cli\\u003eGrinberg K, Sela Y, Nissanholtz-Gannot R. New Insights about Chronic Pelvic Pain Syndrome (CPPS). Int J Environ Res Public Health. 2020 Apr 26;17(9):3005. doi: 10.3390/ijerph17093005. PMID: 32357440; PMCID: PMC7246747.\\u003c/li\\u003e\\n\\u003cli\\u003eLamvu G, Carrillo J, Ouyang C, Rapkin A. Chronic Pelvic Pain in Women: A Review. JAMA. 2021 Jun 15;325(23):2381-2391. doi: 10.1001/jama.2021.2631. PMID: 34128995.\\u003c/li\\u003e\\n\\u003cli\\u003ePiontek K, Ketels G, Klotz SGR, Dybowski C, Br\\u0026uuml;nahl C, L\\u0026ouml;we B. The longitudinal association of symptom-related and psychological factors with health-related quality of life in patients with chronic pelvic pain syndrome. J Psychosom Res. 2022 Feb;153:110707. doi: 10.1016/j.jpsychores.2021.110707. Epub 2021 Dec 21. PMID: 34954604.\\u003c/li\\u003e\\n\\u003cli\\u003eHa KY, Lee JS, Kim KW. Degeneration of sacroiliac joint after instrumented lumbar or lumbosacral fusion: a prospective cohort study over five-year follow-up. Spine (Phila Pa 1976). 2008 May 15;33(11):1192-8. doi: 10.1097/BRS.0b013e318170fd35. PMID: 18469692.\\u003c/li\\u003e\\n\\u003cli\\u003eSakamoto A, Gamada K. Altered musculoskeletal mechanics as risk factors for postpartum pelvic girdle pain: a literature review. J Phys Ther Sci. 2019 Oct;31(10):831-838. doi: 10.1589/jpts.31.831. Epub 2019 Oct 19. PMID: 31645815; PMCID: PMC6801337.\\u003c/li\\u003e\\n\\u003cli\\u003eHungerford B, Gilleard W, Hodges P. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine (Phila Pa 1976). 2003 Jul 15;28(14):1593-600. PMID: 12865851.\\u003c/li\\u003e\\n\\u003cli\\u003eKiapour A, Joukar A, Elgafy H, Erbulut DU, Agarwal AK, Goel VK. Biomechanics of the Sacroiliac Joint: Anatomy, Function, Biomechanics, Sexual Dimorphism, and Causes of Pain. Int J Spine Surg. 2020 Feb 10;14(Suppl 1):3-13. doi: 10.14444/6077. PMID: 32123652; PMCID: PMC7041664.\\u003c/li\\u003e\\n\\u003cli\\u003eMalhotra N, Goyal S, Kumar A, Kanika, Singla V, Kundu ZS. Comparative evaluation of transsacrococcygeal and transcoccygeal approach of ganglion impar block for management of coccygodynia. J Anaesthesiol Clin Pharmacol. 2021 Jan-Mar;37(1):90-96. doi: 10.4103/joacp.JOACP_588_20. Epub 2021 Apr 10. PMID: 34103830; PMCID: PMC8174441.\\u003c/li\\u003e\\n\\u003cli\\u003eOh CS, Chung IH, Ji HJ, Yoon DM. Clinical implications of topographic anatomy on the ganglion impar. Anesthesiology. 2004 Jul;101(1):249-50. doi: 10.1097/00000542-200407000-00039. PMID: 15220800.\\u003c/li\\u003e\\n\\u003cli\\u003eLirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner J. 2014 Spring;14(1):84-7. PMID: 24688338; PMCID: PMC3963058.\\u003c/li\\u003e\\n\\u003cli\\u003eNathan ST, Fisher BE, Roberts CS. Coccydynia: a review of pathoanatomy, aetiology, treatment and outcome. J Bone Joint Surg Br. 2010 Dec;92(12):1622-7. doi: 10.1302/0301-620X.92B12.25486. PMID: 21119164.\\u003c/li\\u003e\\n\\u003cli\\u003eDunphy L, Wood F, Mubarak ES, Coughlin L. Levator Ani Syndrome Presenting with Vaginal Pain. BMJ Case Rep. 2023 May 4;16(5):e255190. doi: 10.1136/bcr-2023-255190. PMID: 37142285; PMCID: PMC10163556.\\u003c/li\\u003e\\n\\u003cli\\u003eFogel GR, Cunningham PY 3rd, Esses SI. Coccygodynia: evaluation and management. J Am Acad Orthop Surg. 2004 Jan-Feb;12(1):49-54. doi: 10.5435/00124635-200401000-00007. PMID: 14753797.\\u003c/li\\u003e\\n\\u003cli\\u003eShapiro S. Low back and rectal pain from an orthopedic and proctologic viewpoint; with a review of 180 cases. Am J Surg. 1950 Jan;79(1):117-28, illust. doi: 10.1016/0002-9610(50)90202-9. PMID: 15399361. \\u003c/li\\u003e\\n\\u003cli\\u003eOrigo D, Piloni S, Tarantino AG. Secondary dysmenorrhea and dyspareunia associated with pelvic girdle dysfunction: A case report and review of literature. J Bodyw Mov Ther. 2021 Jul;27:165-168. doi: 10.1016/j.jbmt.2021.03.013. Epub 2021 Mar 19. PMID: 34391229. \\u003c/li\\u003e\\n\\u003cli\\u003eOrigo D, Dal Farra F, Bruni MF, Catalano A, Marzagalli L, Bruini I. Are fascial strains involved in chronic pelvic pain syndrome? An exploratory matched case-control study. Int Urol Nephrol. 2023 Mar;55(3):511-518. doi: 10.1007/s11255-022-03448-2. Epub 2022 Dec 15. PMID: 36522568. \\u003c/li\\u003e\\n\\u003cli\\u003eNeville CE, Carrubba AR, Li Z, Ma Y, Chen AH. Association of coccygodynia with pelvic floor symptoms in women with pelvic pain. \\u003cem\\u003ePM R\\u003c/em\\u003e. 2022;14(11):1351-1359. doi:10.1002/pmrj.12706\\u003c/li\\u003e\\n\\u003cli\\u003eCalati R, Laglaoui Bakhiyi C, Artero S, Ilgen M, Courtet P. The impact of physical pain on suicidal thoughts and behaviors: Meta-analyses. J Psychiatr Res. 2015 Dec;71:16-32. doi: 10.1016/j.jpsychires.2015.09.004. Epub 2015 Sep 11. PMID: 26522868.\\u003c/li\\u003e\\n\\u003cli\\u003eDijkstra JN, Boon E, Kruijt N, Brusse E, Ramdas S, Jungbluth H, van Engelen BGM, Walters J, Voermans NC. Muscle cramps and contractures: causes and treatment. Pract Neurol. 2023 Feb;23(1):23-34. doi: 10.1136/pn-2022-003574. Epub 2022 Dec 15. PMID: 36522175.\\u003c/li\\u003e\\n\\u003cli\\u003eHildebrand KA, Zhang M, van Snellenberg W, King GJ, Hart DA. Myofibroblast numbers are elevated in human elbow capsules after trauma. Clin Orthop Relat Res. 2004 Feb;(419):189-97. doi: 10.1097/00003086-200402000-00031. PMID: 15021153; PMCID: PMC2950171.\\u003c/li\\u003e\\n\\u003cli\\u003eHinz B. The myofibroblast: paradigm for a mechanically active cell. J Biomech. 2010 Jan 5;43(1):146-55. doi: 10.1016/j.jbiomech.2009.09.020. Epub 2009 Oct 3. PMID: 19800625.\\u003c/li\\u003e\\n\\u003cli\\u003eWray CC, Easom S, Hoskinson J. Coccydynia. Aetiology and treatment. J Bone Joint Surg Br. 1991 Mar;73(2):335-8. doi: 10.1302/0301-620X.73B2.2005168. PMID: 2005168.\\u003c/li\\u003e\\n\\u003cli\\u003eZambonin Mazzoleni G, Bergna A, Buffone F, et al. A Critical Appraisal of Reporting in Randomized Controlled Trials Investigating Osteopathic Manipulative Treatment: A Meta-Research Study. \\u003cem\\u003eJ Clin Med\\u003c/em\\u003e. 2024;13(17):5181. Published 2024 Aug 31. doi:10.3390/jcm13175181.\\u003c/li\\u003e\\n\\u003cli\\u003eBuffone F, Monacis D, Tarantino AG, et al. Osteopathic Treatment for Gastrointestinal Disorders in Term and Preterm Infants: A Systematic Review and Meta-Analysis. \\u003cem\\u003eHealthcare (Basel)\\u003c/em\\u003e. 2022;10(8):1525. Published 2022 Aug 12. doi:10.3390/healthcare10081525\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003e\\u0026nbsp;\\u003cstrong\\u003eTable 1\\u003c/strong\\u003e. Characteristics of the sample.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"643\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 33.3333%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 33.3333%;\\\"\\u003e\\n \\u003cp\\u003eCPP/CPPS\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 33.3333%;\\\"\\u003e\\n \\u003cp\\u003eHealthy people\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 33.3333%;\\\"\\u003e\\n \\u003cp\\u003eNumber per group\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eGender (M/F)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eAge\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003ePhysical activity (n. of time/week)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003ePhysical activity (hours/week)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eSacro-coccygeal dysfunction (severity 0-2)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eSacro-iliac dysfunction (severity 0-2)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003ePelvic floor dysfunction (severity 0-2)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eNIH-CPSI a (pain)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eNIH-CPSI b (urinary)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eNIH-CPSI c (quality of life)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eNIH-CPSI total score\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eHADS anxiety\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eHADS depression\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eHADS total score\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eFABQ score\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 33.3333%;\\\"\\u003e\\n \\u003cp\\u003e162\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e59/103\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e32.5 (26-43)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e1 (0-3)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e2 (0-4)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e2 (1-2)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e1 (0-1)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e2 (1-2)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e8 (5-11)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e2 (0-5)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e7 (4-9)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e17 (10-22)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e8 (5-12)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e7 (4-10)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e15 (9-21)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e19 (6-31)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 33.3333%;\\\"\\u003e\\n \\u003cp\\u003e164\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e59/105\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e31.5 (26-45)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e2 (0-3)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e3 (0-6)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0 (0-0)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0 (0-1)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0 (0-0)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0 (0-1)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e1 (0-2)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0 (0-2)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e2 (0-7)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e6 (4-9)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e5 (2-8)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e11 (6-16)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e6 (0-17)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAbbreviations.\\u003c/strong\\u003e CPP/CPPS: chronic pelvic pain/chronic pelvic pain syndrome; NIH-CPSI: National Institute of Health-Chronic Prostatitis Symptoms Index; HADS: Hospital Anxiety and Depression Scale; FABQ: Fear Avoidance Belief Questionnaire.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 2\\u003c/strong\\u003e. Symptoms\\u0026rsquo; characteristics in the CPP/CPPS group.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"643\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"top\\\" style=\\\"width: 643px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSymptoms functional impact\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eN (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 321px;\\\"\\u003e\\n \\u003cp\\u003eNone\\u003c/p\\u003e\\n \\u003cp\\u003eSexual\\u003c/p\\u003e\\n \\u003cp\\u003eUrinary\\u003c/p\\u003e\\n \\u003cp\\u003eBoth\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 321px;\\\"\\u003e\\n \\u003cp\\u003e(29) 18%\\u003c/p\\u003e\\n \\u003cp\\u003e(25) 15%\\u003c/p\\u003e\\n \\u003cp\\u003e(11) 7%\\u003c/p\\u003e\\n \\u003cp\\u003e(97) 60%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"top\\\" style=\\\"width: 643px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSymptoms duration\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eN (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 321px;\\\"\\u003e\\n \\u003cp\\u003e3-6 months\\u003c/p\\u003e\\n \\u003cp\\u003e6-12 months\\u003c/p\\u003e\\n \\u003cp\\u003e1-3 years\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026gt;3 years\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 321px;\\\"\\u003e\\n \\u003cp\\u003e13 (8%)\\u003c/p\\u003e\\n \\u003cp\\u003e34 (21%)\\u003c/p\\u003e\\n \\u003cp\\u003e52 (32%)\\u003c/p\\u003e\\n \\u003cp\\u003e63 (39%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"top\\\" style=\\\"width: 643px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSymptoms localization\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eN (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 321px;\\\"\\u003e\\n \\u003cp\\u003eNo specific localization\\u003c/p\\u003e\\n \\u003cp\\u003eLumbo-Sacral\\u003c/p\\u003e\\n \\u003cp\\u003eSacro-coccygeal\\u003c/p\\u003e\\n \\u003cp\\u003eLower abdomen\\u003c/p\\u003e\\n \\u003cp\\u003eSacro-iliac\\u003c/p\\u003e\\n \\u003cp\\u003ePubis\\u003c/p\\u003e\\n \\u003cp\\u003ePerineum\\u003c/p\\u003e\\n \\u003cp\\u003eMore than one area\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 321px;\\\"\\u003e\\n \\u003cp\\u003e25 (16%)\\u003c/p\\u003e\\n \\u003cp\\u003e4 (3%)\\u003c/p\\u003e\\n \\u003cp\\u003e16 (10%)\\u003c/p\\u003e\\n \\u003cp\\u003e8 (5%)\\u003c/p\\u003e\\n \\u003cp\\u003e7 (4%)\\u003c/p\\u003e\\n \\u003cp\\u003e21 (14%)\\u003c/p\\u003e\\n \\u003cp\\u003e10 (7%)\\u003c/p\\u003e\\n \\u003cp\\u003e63 (41%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\u003cp\\u003eTable 3 is available in the Supplementary Files section.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 4.\\u0026nbsp;\\u003c/strong\\u003eLogistic regression analysis (multivariate analysis).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"643\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eDysfunction\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eB\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eExp(B)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e95% CI\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003eSacro-coccygeal dysfunction\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003eSacro-iliac dysfunction\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003ePelvic floor dysfunction\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e1.1\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e0.45\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e1.09\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e3.02\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e1.57\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e2.99\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e(1.96 - 4.65)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e(0.97 - 2.53)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e(1.87 - 4.78)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eDependent variable: presence of a CPP/CPPS condition. Covariates: sacrococcygeal dysfunction severity; sacroiliac dysfunction severity; pelvic floor dysfunction. CI: confidence interval.\\u003c/p\\u003e\\n\\u003cp\\u003e*= p\\u0026lt;0.001.\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Chronic Pelvic Pain, Chronic Pelvic Pain Syndrome, Coccydynia, Pelvic Floor, Sacrococcygeal, Manual Therapy, Palpatory Findings\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6289612/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6289612/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eObjective\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study examines the prevalence of abnormal palpatory findings (APFs) in the different pelvic areas among individuals with chronic pelvic pain syndrome (CPP-CPPS) and assesses correlations between APFs with clinical and psychosocial symptoms.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn this cross-sectional study, 326 participants (162 CPP-CPPS patients, 164 controls) underwent a standardized palpatory assessment of the sacroiliac, sacrococcygeal, and pelvic floor regions. The manual procedure was performed by two expert physiotherapists with a certification in osteopathic manipulation, following a consensus training. Symptom severity and psychosocial variables were assessed using the NIH Chronic Prostatitis Symptom Index (NIH-CPSI), the Hospital Anxiety and Depression Scale (HADS), and the Fear Avoidance Belief Questionnaire (FABQ). Correlation analyses explored relationships between APFs, the presence of pain, and psychosocial variables.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn the sample we examined, CPP/CPPS symptoms were located in different abdominal and pelvic areas (41%), and both sexual and urinary functions were involved (60%). APFs were strongly associated with CPP-CPPS, particularly in the sacrococcygeal (r = 0.609, p \\u0026lt; 0.01) and pelvic floor (r = 0.62, p \\u0026lt; 0.01) areas. Multivariate analysis confirmed that sacrococcygeal dysfunction (OR: 3.02, CI: 1.96–4.65) and pelvic floor dysfunction (OR: 2.99, CI: 1.87–4.78) were independently associated with CPP-CPPS, whereas sacroiliac findings showed a weak correlation. Significant but weak correlations were also observed between APFs and psychosocial measures, including HADS and FABQ, indicating limited associations between anxiety, depression and fear-avoidance beliefs with APFs.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe results of this study highlight the relevance of sacrococcygeal and pelvic floor APFs as potential clinical markers in CPPS, supporting the rationale of targeted manual therapy interventions. This study suggests a role for multimodal management in CPP-CPPS, with future research needed to evaluate the predictive value of these dysfunctions.\\u003c/p\\u003e\",\"manuscriptTitle\":\"The presence of abnormal palpatory findings in the sacrococcygeal area is correlated with chronic pelvic pain: a cross-sectional study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-04-14 23:21:54\",\"doi\":\"10.21203/rs.3.rs-6289612/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"4f44f5e3-5c3e-426f-9154-f4e7bf81fb60\",\"owner\":[],\"postedDate\":\"April 14th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-04-28T16:00:55+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-6289612\",\"link\":\"https://doi.org/10.1007/s11255-025-04521-2\",\"journal\":{\"identity\":\"international-urology-and-nephrology\",\"isVorOnly\":false,\"title\":\"International Urology and Nephrology\"},\"publishedOn\":\"2025-04-25 15:57:20\",\"publishedOnDateReadable\":\"April 25th, 2025\"},\"versionCreatedAt\":\"2025-04-14 23:21:54\",\"video\":\"\",\"vorDoi\":\"10.1007/s11255-025-04521-2\",\"vorDoiUrl\":\"https://doi.org/10.1007/s11255-025-04521-2\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6289612\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6289612\",\"identity\":\"rs-6289612\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}