Exploring a Potential Link Between Slipping Rib Syndrome, Sexual Activity, and Sexual Pain Disorders: A Cross-Sectional Study

Exploring a Potential Link Between Slipping Rib Syndrome, Sexual Activity, and Sexual Pain Disorders: 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 Exploring a Potential Link Between Slipping Rib Syndrome, Sexual Activity, and Sexual Pain Disorders: A Cross-Sectional Study Jenny Niedenfuehr, David Stevens This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7395838/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Slipping Rib Syndrome (SRS) is an underrecognized condition involving hypermobility of the false ribs (ribs 8–10), leading to pain across the entire abdominal and pelvic region. This study explored a potential link between SRS, sexual activity, and sexual and pelvic pain disorders. Methods A cross-sectional survey was distributed through convenience sampling (July 2024-November 2024). Sociodemographic questions, diagnostic timelines, and Patient Global Impression of Change (PGIC) were used to assess the self-reported efficacy of pelvic floor physical therapy (PFPT) for sexual and pelvic pain among those with SRS. Results Seventy-nine SRS patients participated, primarily female (91.2%), white (96.9%), with an average age of 33.4 years. Delay in SRS diagnosis averaged 5.4 years, with common misdiagnoses of costochondritis, anxiety, or gastrointestinal issues. Over half (54.4%) had EDS, mainly the hypermobile subtype (81.1%). More than 50% reported having a moderate to severe impact on sexual activity because of their SRS symptoms, and 26.9% attributed their pain to SRS. Common comorbidities included hypertonic pelvic floor (45.2%), endometriosis (21.6%), vaginismus (19.4%), interstitial cystitis (16.1%), and pudendal neuralgia (12.9%). Only 50% with both endometriosis and SRS could consistently differentiate between symptoms. For those participating in PFPT for treating sexual/pelvic pain symptoms, the average PGIC score was 4.5, indicating no change to minimal improvement, and 18.2% experienced worsening symptoms. Similarly, when attempting diaphragmatic breathing, 31.3% reported worsened symptoms and 41.7% reported no change in sexual/pelvic pain symptoms. Conclusion This is the first study to show that SRS impacts sexual activity and may even contribute to sexual and pelvic pain disorders. SRS symptoms overlap with conditions like endometriosis, which may complicate diagnosis. More research is needed to contribute to underscoring the link between the rib cage, pelvic floor, and nerve issues to improve quality of life, diagnostic strategies, and management among patients with SRS. Sexual pain slipping rib syndrome pelvic pain sexual activity Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Slipping rib syndrome (SRS) is a debilitating condition that occurs when the false ribs (ribs 8–10) become abnormally mobile (Madeka et al., 2023 ). This results in the loss of intercostal cartilaginous attachments, leading to a defect in the costal margin (Madeka et al., 2023 ). With the disorientation of the false ribs, they can curl, slip, and override the superior rib, leading to the impingement of the intercostal nerves (McMahon, 2018 ). There is no epidemiological data on SRS, including its prevalence and incidence (Van Tassel et al., 2019 ). Symptoms of SRS include clicking and popping of the ribs and intense to mild pain radiating throughout the abdomen and rib region (Hansen et al., 2024 ). These symptoms are often exacerbated by daily activities such as bending, exercising, reaching, and lifting items (Madeka et al., 2023 ; Hansen et al., 2024 ). Differential rib diagnoses for this condition may include Tietze syndrome, 12th rib syndrome, and costochondritis, and SRS is typically diagnosed by exclusion (Rosenberg et al., 2024; Jung et al., 2020 ). Despite the intensity of SRS symptoms on a patient’s quality of life, the condition remains dismissed, overlooked, and even mistaken for more common conditions such as gallbladder disease, spinal radiculopathy, shoulder abnormalities, and abdominal disorders, highlighting the dire need for more research for this disease (Hansen et al., 2024 ). Connective-tissue disorders such as hypermobility spectrum disorders, Marfan syndrome, and Ehlers-Danlos syndrome (EDS) are at increased risk for SRS due to the weaknesses and disruptions in the fibrous and cartilage surrounding the ribs and instability of the spine (Madeka et al., 2023 ). Patients who have also had surgical procedures, including thoracic surgery and laparoscopic procedures, are also shown to be at risk for developing SRS (Patel et al., 2021 ; van Delft et al., 2016 ). Hormonal changes also lead to further rib instability among individuals with hypermobility (Davelaar et al., 2008). Among these individuals with hypermobility and EDS, emerging evidence has also identified associations with sexual and pelvic pain disorders (Glayzer et al., 2021 ; Gillam et al., 2020), which can have multiple causes (e.g., orthopedic, musculoskeletal, hormonal, inflammatory, neurologic, vascular, spinal, and mast-cell mediated). Furthermore, these findings underscore the need for more understanding of the interplay between connective-tissue disorders, rib disorders, and sexual and pelvic pain disorders to improve patient care in this population. Gaps in the current literature point to the need for more research that evaluates the characteristics, symptomology, and treatment strategies among those with pelvic and sexual pain disorders in patients with SRS. While previous studies surround surgical interventions, treatments, medications, and diagnostics (Madeka et al., 2023 ), there is little insight into patient quality of life and co-occurring comorbidities among SRS patients. SRS can also impact the spine, contributing to muscle imbalance, and both the thoracic and lumbar spine have also been shown to affect the pelvic region, suprapubic region, sexual organs, and bladder functioning (Hansen et al., 2024 ; Jung et al., 2020 ; Kim et al., 2023 ). Indeed, these gaps in provider knowledge and current research further compound delays in diagnoses and a lack of provider understanding. To our knowledge, no studies have been conducted on the intersection of sexual and pelvic pain and SRS. This study seeks to bridge the gap between rib symptomology and pelvic and sexual functioning and activity. The main objective of this study was to understand potential associations between SRS and sexual and pelvic pain disorders, allowing for greater awareness among the medical community of unique and overlapping symptoms that may compound sexual intimacy and sexual and pelvic pain symptoms. Findings should help inform providers about potential connections between SRS and sexual and pelvic pain disorders. Methods An anonymous cross-sectional online study was conducted from June 2024 to October 2024 on patients diagnosed with SRS. Convenience sampling methods were employed for recruitment via social media platforms as they are inexpensive, readily available, and well-suited for rare diseases. In addition, these sampling methods allow for the simultaneous examination of multiple variables and factors. Since the true prevalence of SRS is unknown, sample size could not be calculated. This study follows the Strengthening the Reporting of Observational Studies (STROBE) guidelines, providing a transparent framework for future research reproducibility (von Elm et al.,2007). Aligned with STROBE guidelines, the study offers a transparent background, rationale, and presentation of the study design, methodology, results, analyses, and discussion. The [name of university] Institutional Review Board (IRB) was granted exempt status with protocol ID number ET00042278. Recruitment Participants were recruited through Facebook, Reddit, Instagram, and X (formerly known as Twitter) communities with an orthopedic focus. Previous studies have validated social media platforms as effective recruitments due to their ability to access and reach a diverse sample of patients and difficult-to-reach populations with ‘rare’ chronic conditions such as Ehlers-Danlos syndrome, hypermobile spectrum disorders, dysautonomia, and sexual pain disorders such as vulvodynia and vestibulodynia (Fuster et al., 2025 ; Glayzer et al., 2021 ). These platforms have also been portrayed as having practical and unique audience bases existing for each one, as patients with chronic conditions and underrecognized conditions are known to rely on social media platforms to find social support and health-related information outside of their health providers (Halverson et al., 2021 ). X (formerly known as Twitter) has faster, direct interactions in real-time, while Reddit has similar interactions but anonymous conversations where identities are not revealed (Zapcic et al., 2023 ). Prior literature has suggested that Reddit can also access hard-to-reach populations (Zapcic et al., 2023 ). Additionally, interactive and slower-paced discussions are present on Facebook and Instagram, and Facebook has specific groups and pages for each health condition (Ellington et al., 2022 ; Fitzgerald et al., 2003; Frandsen et al., 2006). The survey was titled “Slipping Rib Syndrome Survey” and was included in our recruitment flyer. This title was intentionally vague to reduce selection bias (Glayzer et al., 2021 ). The study was advertised with a link describing the study purpose and aims, informed consent, a QR code, inclusion criteria, and contact information of the principal investigator. Upon clicking the link to the survey, participants were required to read through the guidelines on Qualtrics and provide their informed consent before moving to the next page. Participants were told they could stop the survey anytime and were not required to answer all the questions. To prevent participants from re-entering the survey, Qualtrics automatically blocked participants' IP addresses once the survey was completed to secure the study. Eligibility criteria Interested individuals were screened for eligibility with the initial screening questions. Inclusion criteria were as follows: 1) A diagnosis of slipping rib syndrome (confirmed or suspected) from a healthcare provider, 2) age of 18 years or older, and 3) able to read, write, and speak English fluently. Participants who did not meet these criteria were excluded from the study. Statistical Analysis Frequencies and percentages were calculated using IBM SPSS software version 28 for Windows. Categorical data (gender, race, and comorbid conditions) were expressed as frequencies and percentages. In contrast, continuous data (age, number of misdiagnoses before receiving a diagnosis of SRS, number of years before receiving a diagnosis of SRS after onset of symptoms, number of providers sought, patient impression global change scores) were presented as continuous data (means and averages). Missing data was excluded from the analysis. Table 1 Sociodemographics and health-related characteristics of SRS participants (n = 64) Variable n % Gender Female 59 91.2% Male 3 4.7% Non-Binary / Third Gender 1 1.6% Prefer not to say 1 1.6% Race and Ethnicity White 62 96.9% Asian or Pacific Islander 1 1.6% Hispanic or Latino 1 1.6% Black or African American 0 0% Native American 0 0% Other 0 0% Mean SD Age (Years) 33.4 11.6 Health-Related Characteristics Mean SD Number of Misdiagnoses Before Receiving a Diagnosis of SRS 3.1 2.2 Number of Providers Seen Before Receiving a Diagnosis of SRS 5.2 4.3 Years Between Symptom Onset and SRS Diagnosis 5.4 4.7 Results Table 1 presents the sociodemographics of this sample population. A total of 132 participants accessed the survey; however, 50 people did not meet eligibility requirements, which included being over 18 years of age, able to speak, read, or write in English, and having a confirmed or suspected diagnosis of SRS. Overall, 82 individuals consented and met eligibility criteria, but three chose not to continue the study, resulting in 79 participants who completed the survey. In total, 64 participants completed the survey in its entirety, and 15 skipped occasional questions related to intimacy, surgery, comorbidities, symptoms, treatments, or sociodemographics. Due to the limited sample size, we included all 79 participants in the final sample. Figure 1 portrays the flow analysis of the full participation in the survey. The majority of participants identified as female (91.2%), with a few identifying as male (4.7%), non-binary or third gender (1.6%), or preferring not to disclose their gender (1.6%). The sample was predominantly white (96.9%), with the rest identifying as Asian or Pacific Islander (1.6%) and Hispanic or Latino (1.6%). No participants identified as Black, African American, Native American, or other racial/ethnic groups. The mean age of the participants was 33.4 years (SD = 11.6), with ages ranging from 19 to 64 years. On average, participants reported that it took 5.4 ± 4.7 years (range: 0.3–20 years) from the onset of symptoms to receive a diagnosis of SRS, during which they consulted an average of five providers and received an average of three misdiagnoses. In total, 78.4% reported being diagnosed with other conditions before receiving a diagnosis of SRS (reported in the Appendix) , with costochondritis (17.6%), anxiety (15.2%), and irritable bowel syndrome (8.5%) as being the most common. Other misdiagnosed conditions reported included gallbladder issues (4.9%), gastritis (3.0%), endometriosis (3.0%), overactive nervous system (3.0%), complex regional pain syndrome (2.4%), gastroesophageal reflux disease (1.8%), acid reflux (1.2%), muscular pain or strain (1.2%), depression (1.2%), asthma (1.2%), gallstones (1.2%), fibromyalgia (1.2%), chest pain (1.2%), and hiatal hernia (1.2%). Sexual Activity and Sexual Pain Rib symptoms were reported to impact sexual activity among the SRS sample (n = 79). Specifically, 7.6% reported no impact, 30.4% reported a mild effect, 31.7% reported a moderate effect, 19.0% encountered severe implications, and 11.4% stated their condition completely prevented intimacy. Additionally, 26.9% of respondents also suggested that their rib symptoms contributed directly to their sexual pain symptoms, while 48.1% were not sure. Comorbid Conditions Comorbidities (as reported in Table 2 ) among people with a vulva (n = 62) included hypertonic pelvic floor (45.2%), endometriosis (21.6%), vaginismus (19.4%), interstitial cystitis (16.1%), pudendal neuralgia (12.9%), persistent genital arousal disorder (9.7%), vestibulodynia with no identifiable cause (9.7%), Bartholin's cysts (6.5%), congenital neuroproliferative vestibulodynia (4.8%), clitorodynia (4.8%), pelvic inflammatory disease (4.8%), clitoral adhesions (4.8%), and pudendal nerve entrapment (4.8%), inflammatory vestibulodynia (4.8%), and hormonally-mediated vestibulodynia (4.8%) acquired neuroproliferative vestibulodynia was reported by one participant (1.6%), and lichen sclerosis (3.2%). Among the three participants with a penis who responded to questions about male-specific urological or pelvic conditions, pudendal neuralgia and chronic pelvic pain syndrome were each reported by one participant (33.3%). Additionally, 21% total participants reported having “other conditions”, including pelvic instability, normal vulvar pain associated with menopause, herniated discs, pelvic floor dysfunction with pain during arousal, chronic bacterial vaginosis (BV)/yeast infections, congenital clitoral phimosis, ovarian cysts (on the same side as SRS) with heavy menstruation that exacerbates chest pain, hypermobility spectrum disorder, neurogenic bladder, polycystic ovary syndrome, and pelvic floor dysfunction with rectocele, cystocele, and enterocele. All comorbidities are listed in Table 2 . Ehlers-Danlos Syndrome comorbidity Out of the 68 participants who answered Ehlers-Danlos Syndrome (EDS) related questions, 37 participants (54.4%) reported being diagnosed with Ehlers-Danlos Syndrome (EDS), a connective tissue disorder. Among participants diagnosed with Ehlers-Danlos Syndrome (EDS), the majority (81.1%) had hypermobile EDS, followed by 8.1% with classical EDS. Other subtypes, including classical-like EDS, vascular EDS, brittle cornea syndrome (BCS), and musculocontractural EDS, accounted for 2.7%. Alternative subtypes, such as kyphoscoliotic EDS, arthrochalasia EDS, cardiovascular EDS, myopathic EDS, spondylodysplastic EDS, dermatospraxis EDS, or periodontal EDS,were not reported. Of those without a confirmed EDS diagnosis, 32.4% suspected they might have the condition, 54.8% did not believe they had it, and 12.9% indicated they were uncertain. Endometriosis symptom overlap Out of the 61 participants who answered endometriosis-related questions, 14 participants (23.0%) indicated they had endometriosis. Only 50% indicated they could always differentiate between their SRS and endometriosis symptoms. The rest of the participants could often (21.4%), sometimes (21.4%), or rarely (7.1%) differentiate between the SRS and endometriosis symptoms. Physical therapy and diaphragmatic breathing for treating sexual and pelvic pain symptoms Pelvic Floor Physical Therapy Of the respondents who participated in pelvic floor physical therapy (PFPT) (n = 33) for their sexual and pelvic pain symptoms, the average PGIC score was 4.5 ± 1.4, indicating no change to minimal improvement (Fig. 2 ). Approximately 24.2% reported no change in symptoms, while 6.1% reported being much worse, 6.1% much worse, and 6.1% minimally worse. Additionally, 39.4% reported minimal improvement, 12.1% much improvement, and 6.1% very much improvement in symptoms. Diaphragmatic Breathing For respondents who participated in diaphragmatic breathing (n = 48), the average PGIC score was 3.7 ± 1.5, indicating no change to minimally worsening SRS symptoms (Fig. 3 ). Approximately 41.7% reported no change in symptoms, 18.8% noted minimal improvement, and 8.3% experienced significant improvement. On the other hand, 31.3% felt worse, with 12.5% reporting they were very much worse, 14.6% much worse, and 4.2% minimally worse. No respondents reported being very much improved. Table 2 Comorbidities among SRS participants who identified as having a vulva (n = 62) Condition Yes (%) No (%) Unsure (%) Hypertonic Pelvic Floor Dysfunction 45.2 41.9 12.9 Vaginismus 19.3 53.2 27.4 Chronic Pelvic Pain Syndrome (CPPS) 19.4 62.9 17.7 Recurrent Candidiasis 17.4 74.2 8.1 Interstitial Cystitis 16.1 69.4 14.5 Pudendal Neuralgia (PN) 12.9 61.3 25.8 Vaginitis 11.3 77.4 11.3 Vulvodynia (No identifiable cause) 11.3 62.9 25.8 Persistent Genital Arousal Disorder (PGAD) 9.7 74.2 16.1 Vestibulodynia (No identifiable cause) 9.7 67.7 22.6 Bartholins Cysts 6.5 82.3 11.3 Congenital Neuroproliferative Vestibulodynia 4.8 74.2 21.0 Clitorodynia 4.8 77.4 17.7 Pelvic Inflammatory Disease 4.8 75.8 19.4 Clitoral Adhesions 4.8 82.3 12.9 Pudendal Nerve Entrapment (PNE) 4.8 62.9 32.3 Inflammatory Vestibulodynia 3.2 74.2 22.6 Hormonally-Mediated Vestibulodynia 3.2 72.6 24.2 Lichen Sclerosis 3.2 80.7 16.1 Acquired Neuroproliferative Vestibulodynia 1.6z 77.4 21.0 Other 21.0 69.4 9.7 Discussion This is the first cross-sectional study to highlight the potential relationship between SRS and sexual activity, pelvic pain disorders, and sexual pain disorders. In our study sample, SRS symptom onset began for most during adolescence or early adulthood, with the youngest individual in our sample receiving a diagnosis at 19 years old. Given that the average time to diagnosis from symptom onset is greater than five years, healthcare providers should remain vigilant of symptoms at least as early as approximately 14 years old. Due to the difficulty in diagnosing SRS, misdiagnoses are common among this patient population (Hansen et al., 2024 ). In our study, participants received, on average, three misdiagnoses and waited at least 5 years to receive a diagnosis from SRS symptom onset. The delays can compound patient trauma and lead to more extensive and unnecessary investigations and health care costs that may or may not be necessary. The most common misdiagnoses were costochondritis, anxiety, irritable bowel syndrome, gallbladder issues, Gastroesophageal Reflux Disease (GERD), Complex Regional Pain Syndrome (CRPS), overactive nervous system, and depression. These results indicate that medical providers default to diagnosing commonly recognized conditions and psychosomatic disorders when patients complain of rib, abdomen, and nerve pain rather than considering differential diagnoses. Diagnostic overshadowing is also common, particularly if patients have pre-existing conditions, further delaying appropriate care. This tendency is consistent with literature indicating that gallbladder disease, abdominal organ disorders, spinal radiculopathy, and shoulder injuries are often considered before SRS (Hansen et al., 2024 ). Due to these delays, patients resort to self-diagnosis before seeking confirmation from specialists, but some abandon the diagnostic process entirely, opting instead for chronic pain management (Hansen et al., 2024 ). SRS diagnosis requires specialist expertise, as traditional imaging methods may be inadequate (Madeka et al., 2023 ). Current best practices include ultrasound visualization and a gentle physical assessment, with Hansen et al. (2020) recommending three diagnostic criteria: (1) at least 1 cm of separation at the 10th rib's anterior insertion, (2) abnormal rib mobility upon palpation, and (3) reproduction of pain at the separation site. A comprehensive evaluation and detailed patient history are essential for accurate diagnosis, effective treatment, and improved quality of life. The results of our study suggested that SRS have other comorbidities such as hypertonic pelvic floor (45.2%) and chronic pelvic pain syndrome (19.4%). Although there is no existing literature confirming SRS as a direct contributor to chronic pelvic pain, research has indicated that pain from subcostal nerves can affect the lateral abdominal wall muscles, potentially radiating or causing discomfort in the loin, groin, and suprapubic regions (Jung et al., 2020 ). SRS has also been known to mimic symptoms of abdominal conditions, intercostal muscle strains, thoracic pain, and gallbladder disease (Madeka et al., 2023 ). However, due to the limited research on SRS and the supporting evidence of associated imbalances, further studies are needed to explore the relationship between the pelvis and the ribs. The overlapping symptomatology of SRS, endometriosis, and hypermobility disorders such as Ehlers-Danlos Syndrome (EDS) is a diagnostic challenge often overlooked in clinical settings. SRS symptoms may directly overlap with endometriosis symptoms as they can be isolated in the same area, which has not been reported in the literature previously. Thoracic endometriosis symptoms, which may contribute to pain in the diaphragm and abdomen (Larrain et al., 2018), also overlap with SRS symptoms. However, some patients may struggle to distinguish between the two, particularly if they only consult and are evaluated by endometriosis specialists. Participants who also reported comorbid hypermobility disorders, such as Ehlers-Danlos syndrome, underscore a potential link between connective tissue laxity and the exacerbation of both rib and pelvic symptoms (Davelaar et al., 2008). Based on the findings, 31 out of 68 participants did not have a confirmed EDS diagnosis. Of these 31 participants, 10 believed they could have it, and 4 were unsure. As delays in diagnosis are common among EDS patients (Anderson et al., 2021), this result warrants more attention and awareness in clinical settings. Among the SRS patients in our sample, sexual and pelvic pain symptoms are highly prevalent. Participants reported that rib dysfunction and pain can directly impact sexual activity, with 31.7% describing a moderate impact, 19.0% a severe impact, and 11.4% stating it completely prevented intimacy. Notably, 27.9% of respondents specifically attributed their SRS as a contributor to their sexual pain disorders, marking the first documented evidence of this association. These results may indicate a biomechanical link between the rib cage, diaphragm, and pelvic floor. Previous findings have shown that pelvic floor length was shown to change during the respiratory cycle along with changes in the intra-abdominal pressure and abdominal wall displacement, suggesting the existence of a biomechanical connection (Crowley et al., 2023). Evidence has also suggested that mechanical instability in the lower back (including the lower ribs) and the hips exacerbates or limits sexual activity (Niedenfuehr et al., 2023; Vanti et al., 2023 ). While pelvic pain and sexual pain disorders have received more attention within gynecology, urology, and PFPT, the role of the rib cage in these conditions is largely overlooked, and more research is needed to evaluate this link. PFPT is a recommended treatment for patients with sexual and pelvic pain disorders and intimacy related issues (Jorge et al., 2024 ), which often includes the prescription of myofascial release of the abdomen, back, and surrounding muscles near the rib cage, diaphragmatic breathing, and stretches (Pendergast 2017). The average PGIC score was 4.5, indicating no change to minimal improvement in sexual/pelvic pain symptoms. Notably, 18.3% of participants reported worsening symptoms, suggesting that PFPT can be potentially harmful for those with SRS. Stretching exercises and other treatments such as myofascial release and lengthening exercises can be a contraindication for individuals with Ehlers-Danlos syndrome and SRS (Buryk Iggers, 2022; Muldowney & Muldowney, 2015 ). Diaphragmatic breathing is a deep breathing exercise commonly suggested by many PFPT practitioners. Among our sample, 75% of participants reported having no change or worsened SRS symptoms when asked to perform diaphragmatic breathing. This may be because diaphragmatic breathing involves the expansion of the diaphragm, causing the abdomen to rise and the lower ribs to expand outward (Crawford et al., 2023; Russo et al., 2017 ), which may further destabilize the rib joints in patients with SRS, potentially exacerbating SRS instability. Altered breathing patterns are reported among hEDS patients (Hakimi et al., 2022 ; Hakimi et al., 2024 ) but are not underscored in the literature among SRS patients. Consequently, these patients may not be appropriate candidates for PFPT, performing diaphragmatic breathing, or any other modalities for treating their pelvic floor and sexual pain disorders until their SRS symptoms are better managed and evaluated correctly. Providers must treat these patients with much more caution and precision when approaching these modalities, given the results of our survey study and the fragility of EDS and SRS patients. Additionally, since SRS is challenging to diagnose, some patients with sexual or pelvic pain conditions may have SRS without being aware of it. Therefore, both patients and providers should be attentive to reports of worsening pain symptoms following PFPT and/or diaphragmatic breathing. Furthermore, reinforcing the idea that pain symptoms are the result of an overactive nervous system or psychological symptoms can further compound suffering, trauma, delays in diagnoses, and increased pain. Limitations Limitations of this cross-sectional study include recall bias, small sample size, selection bias, the lack of validated scales, and the inability to infer causality, all of which are common among cross-sectional studies for rare conditions. First, biases related to self-reporting may consist of recall bias. Patients may not be able to recall or report their symptoms accurately. Second, the small sample size may have impacted the generalizability. Due to the nature of this disease and patients' inaccessibility, we could not recruit many patients with this condition from online forums. However, given the rarity of SRS, recruiting a large cohort of SRS patients may be quite difficult at this time. Third, some patients who participated in this study may have had a misdiagnosis, given how long it takes to receive a proper diagnosis. Some patients diagnosed with SRS may also have an alternative condition, given that this condition, among many connective-tissue comorbidities, lacks standard diagnostic criteria and consists of a broad spectrum of symptoms that could lead to misdiagnosis. Fourth, selection bias is also possible, as survey respondents may not represent the broader SRS population. This may impact generalizability. Fifth, this priority population's lack of validated scales is a limitation. Although more psychometric research and testing are needed with EDS and SRS patients, the results do not diminish the current findings. Finally, cross-sectional designs limit the ability to infer causality as the information collected occurs at a single point. A total of participants reported having some type of SRS, which suggests that the surgery may have impacted their ability to engage in sexual activity or their sexual pain disorders. Overall, while these limitations may affect the generalizability of the results, the results do not take away the importance of these issues among a subset of the SRS and sexual pain and pelvic pain population. Future longitudinal and prospective studies with larger sample sizes are needed to determine the prevalence and infer causality. More research is required for providers to understand the overlap and distinctions between SRS symptoms and other gynecological, urological, and gastroenterological conditions to improve diagnostic accuracy, treatment strategies, and overall quality of life. Conclusion SRS is a debilitating condition that significantly impacts the lives of those who live with it daily. SRS can impact sexual activity and sexual/pelvic pain disorders, and common treatments for such disorders such as PFPT and diaphragmatic breathing provide little to no benefits to SRS patients and instead have the potential to cause harm. More attention is needed for SRS in various medical disciplines, including gynecology, urology, PFPT, and others. Given these conditions' complexity and overlapping comorbidities, a comprehensive diagnosis, provider awareness, interdisciplinary collaboration, effective treatments, and surgical management can significantly improve health outcomes. Declarations Author Contribution JN led the study design, methodology, data curation, and analysis. DS supported the study design and conceptualization. JN and DS wrote the manuscript, read the manuscript, edited it, and approved the final version. All authors declare no financial or nonfinancial interests or commercial associations that may be relevant to the submitted work. References Anderson LK, Lane KR. The diagnostic journey in adults with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders. J Am Association Nurse Practitioners. 2021;34(4):639–48. https://doi.org/10.1097/JXX.0000000000000672 . 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Halverson CME, Clayton EW, Garcia Sierra A, Francomano C. Patients with Ehlers-Danlos syndrome on the diagnostic odyssey: Rethinking complexity and difficulty as a hero's journey. Am J Med Genet C. 2021;187(4):416–24. https://doi.org/10.1002/ajmg.c.31935 . Hakimi A, Bergoin C, Mucci P. Evidence of ventilatory constraints during exercise in hypermobile Ehlers-Danlos syndrome. Eur J Appl Physiol. 2022;122(11):2367–74. https://doi.org/10.1007/s00421-022-05017-y . Hakimi A, Bergoin C, De Jesus A, Hermand E, Fabre C, Mucci P. Impairment of lung volume perception and breathing control in hypermobile Ehlers-Danlos syndrome. Sci Rep. 2024;14(1):8119. https://doi.org/10.1038/s41598-024-58890-2 . Hansen AJ, Hayanga J, Toker A, Badhwar V. Costal margin reconstruction for slipping rib syndrome: Outcomes of more than 500 cases and advancements beyond earlier sutured repair technique. JTCVS Open. 2024;19:347–54. https://doi.org/10.1016/j.xjon.2024.03.007 . Hansen AJ, Hayanga JWA, Toker A, Badhwar V. (2024). Healthcare economic burden of unresolved slipping rib syndrome. Thoracic: Chest Wall . Presented at the 104th Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada, April 27–30, 2024. https://doi.org/10.1016/j.xjon.2024.09.022 Jorge CH, Bø K, Catai C, Oliveira Brito C, Driusso LG, P., Tennfjord K, M. Pelvic floor muscle training as treatment for female sexual dysfunction: a systematic review and meta-analysis. Am J Obstet Gynecol. 2024;231(1):51–e661. https://doi.org/10.1016/j.ajog.2024.01.001 . Jung J, Lee M, Choi D. Twelfth rib syndrome: a case report. J Int Med Res. 2020;48(9). https://doi.org/10.1177/0300060520952651 . Kim CW, Goldstein I, Komisaruk BR, Goldstein SW, Kim NN, Hartzell-Cushanick R, Uloko M, Yee A. Lumbar endoscopic spine surgery for persistent genital arousal disorder/genitopelvic dysesthesia resulting from lumbosacral annular tear–induced sacral radiculopathy. J Sex Med. 2023;20(2):210–23. https://doi.org/10.1093/jsxmed/qdac017 . Larraín D, Suárez F, Braun H, Chapochnick J, Diaz L, Rojas I. Thoracic and diaphragmatic endometriosis: Single-institution experience using novel, broadened diagnostic criteria. J Turkish German Gynecol Association. 2018;19(3):116–21. https://doi.org/10.4274/jtgga.2018.0035 . Madeka I, Alaparthi S, Moreta M, Peterson S, Mojica JJ, Roedl J, Okusanya O. A Review of Slipping Rib Syndrome: Diagnostic and Treatment Updates to a Rare and Challenging Problem. J Clin Med. 2023;12(24):7671. https://doi.org/10.3390/jcm12247671 . McBeath AA, Keene JS. The rib-tip syndrome. J Bone Joint Surg. 1975;57:795–7. https://doi.org/10.2106/00004623-197557060-00012 . McMahon LE. Slipping Rib Syndrome: A review of evaluation, diagnosis and treatment. Semin Pediatr Surg. 2018;27:183–8. https://doi.org/10.1053/j.sempedsurg.2018.05.009 . Muldowney K, Muldowney K. Living life to the fullest with Ehlers-Danlos Syndrome: Guide to living a better quality of life while having EDS. Outskirts; 2015. Niedenfuehr J, Stevens DM. A scoping review: sexual activity and functioning before and after surgery for femoroacetabular impingement (FAI), labral tears, and hip dysplasia. Sex Med Reviews. 2023;11(4):349–58. https://doi.org/10.1093/sxmrev/qead036 . Patel NG, Patel DM, Patel MV, Patel MM, Patel TR, Patel SY. Diagnostic value of dynamic high-frequency ultrasound for the slipping rib and twelfth rib syndrome: A case series with review. Curr Med Imaging. 2021;17(4):459–63. https://doi.org/10.2174/1573405616666201005114406 . Prendergast SA. Pelvic Floor Physical Therapy for Vulvodynia: A Clinician's Guide. Obstet Gynecol Clin N Am. 2017;44(3):509–22. https://doi.org/10.1016/j.ogc.2017.05.006 . Rosenberg M, Sina RE, Conermann T. (2024, January 26). Tietze syndrome. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK564363/ Russo MA, Santarelli DM, O’Rourke D. The physiological effects of slow breathing in the healthy human. Breathe. 2017;13(4):298–309. 10.1183/20734735.009817 . van Delft EA, van Pul KM, Bloemers FW. The slipping rib syndrome: A case report. Int J Surg case Rep. 2016;23:23–4. https://doi.org/10.1016/j.ijscr.2016.04.009 . Van Tassel D, McMahon LE, Riemann M, Wong K, Barnes CE. Dynamic ultrasound in the evaluation of patients with suspected slipping rib syndrome. Skeletal Radiol. 2019;48:741–51. https://doi.org/10.1007/s00256-018-3133-z . Vanti C, Ferrari S, Chiodini M, Olivoni C, Bortolami A, Pillastrini P. Sexual Disability in Low Back Pain: Diagnostic and Therapeutic Framework for Physical Therapists. Healthc (Basel Switzerland). 2023;12(1):80. https://doi.org/10.3390/healthcare12010080 . von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. PLoS Med. 2007;4(10):e296. https://doi.org/10.1371/journal.pmed.0040296 . Zapcic I, Fabbri M, Karandikar S. Using Reddit as a source for recruiting participants for in-depth and phenomenological research. Int J Qualitative Methods. 2023;22:1–8. https://doi.org/10.1177/1609406923111627 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7395838","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":530653827,"identity":"a6e4da92-c33d-46fc-8ad3-f875fd79f15e","order_by":0,"name":"Jenny 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1","display":"","copyAsset":false,"role":"figure","size":33341,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFlow analysis of participation in SRS survey\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7395838/v1/04bd4e14fdccd720bbf77834.png"},{"id":93882003,"identity":"c3035c82-b093-4138-aa28-7b7241f75230","added_by":"auto","created_at":"2025-10-19 16:52:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":36534,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePGIC scores of sexual or pelvic pain symptoms among patients who participated in PFPT as a treatment for their sexual or pelvic pain symptoms\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7395838/v1/64ea69fd1d397354059595cf.png"},{"id":93883275,"identity":"3af7a9a8-b193-4d95-bdd1-641011395fb6","added_by":"auto","created_at":"2025-10-19 17:00:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":35510,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePGIC scores of SRS symptoms among patients who participated in diaphragmatic breathing\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7395838/v1/e4ed3cfa4544b368b19426df.png"},{"id":93882009,"identity":"5e065dee-f3e5-47cf-ac8c-0dc18afeb2b9","added_by":"auto","created_at":"2025-10-19 16:52:02","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":32533,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMisdiagnoses Among SRS Patients\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: Potential explanations that have come up once have included a wide range of conditions such as obesity, Nutcracker Syndrome, sacroiliitis, small intestinal bacterial overgrowth (SIBO), pancreatitis, an inflamed spleen, central sensitization, respiratory infections, growing pains, post-traumatic stress disorder (PTSD), psychosomatic pain, diaphragm tension, gas, eating disorders, gastroparesis, superior mesenteric artery syndrome (SMAS), abdominal muscle separation, kidney stones, scar tissue from C-sections, gastrointestinal upset, piriformis syndrome, facet joint issues, herniated discs, adenomyosis, gastrointestinal pain, mirib displacement, hypochondria, slow gut transit, side stitches, concerns about breast size, xiphoidynia, pulled muscles, bruising, enlarged kidneys, volvulus, gastroenteritis, seizures (teizes), intercostal neuralgia, rib flare, thoracic myofascial strain, labral tears of the shoulder, symptoms related to hereditary neuropathy with liability to pressure palsies (HNPP), trapped gas, pleurisy, abdominal migraines, fibromyalgia, muscle spasms, hormonal imbalances, and a hypertonic pelvic floor.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7395838/v1/4beb0caf68e4cea320dbf64b.png"},{"id":96805486,"identity":"869fcdea-f0b0-4211-ab97-88607c5622c5","added_by":"auto","created_at":"2025-11-26 09:10:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1035365,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7395838/v1/42c7b968-005f-46a0-a4b4-458587eedb91.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring a Potential Link Between Slipping Rib Syndrome, Sexual Activity, and Sexual Pain Disorders: A Cross-Sectional Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSlipping rib syndrome (SRS) is a debilitating condition that occurs when the false ribs (ribs 8\u0026ndash;10) become abnormally mobile (Madeka et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This results in the loss of intercostal cartilaginous attachments, leading to a defect in the costal margin (Madeka et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). With the disorientation of the false ribs, they can curl, slip, and override the superior rib, leading to the impingement of the intercostal nerves (McMahon, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). There is no epidemiological data on SRS, including its prevalence and incidence (Van Tassel et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Symptoms of SRS include clicking and popping of the ribs and intense to mild pain radiating throughout the abdomen and rib region (Hansen et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). These symptoms are often exacerbated by daily activities such as bending, exercising, reaching, and lifting items (Madeka et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Hansen et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Differential rib diagnoses for this condition may include Tietze syndrome, 12th rib syndrome, and costochondritis, and SRS is typically diagnosed by exclusion (Rosenberg et al., 2024; Jung et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Despite the intensity of SRS symptoms on a patient\u0026rsquo;s quality of life, the condition remains dismissed, overlooked, and even mistaken for more common conditions such as gallbladder disease, spinal radiculopathy, shoulder abnormalities, and abdominal disorders, highlighting the dire need for more research for this disease (Hansen et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eConnective-tissue disorders such as hypermobility spectrum disorders, Marfan syndrome, and Ehlers-Danlos syndrome (EDS) are at increased risk for SRS due to the weaknesses and disruptions in the fibrous and cartilage surrounding the ribs and instability of the spine (Madeka et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Patients who have also had surgical procedures, including thoracic surgery and laparoscopic procedures, are also shown to be at risk for developing SRS (Patel et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; van Delft et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Hormonal changes also lead to further rib instability among individuals with hypermobility (Davelaar et al., 2008). Among these individuals with hypermobility and EDS, emerging evidence has also identified associations with sexual and pelvic pain disorders (Glayzer et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Gillam et al., 2020), which can have multiple causes (e.g., orthopedic, musculoskeletal, hormonal, inflammatory, neurologic, vascular, spinal, and mast-cell mediated). Furthermore, these findings underscore the need for more understanding of the interplay between connective-tissue disorders, rib disorders, and sexual and pelvic pain disorders to improve patient care in this population.\u003c/p\u003e\u003cp\u003eGaps in the current literature point to the need for more research that evaluates the characteristics, symptomology, and treatment strategies among those with pelvic and sexual pain disorders in patients with SRS. While previous studies surround surgical interventions, treatments, medications, and diagnostics (Madeka et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), there is little insight into patient quality of life and co-occurring comorbidities among SRS patients. SRS can also impact the spine, contributing to muscle imbalance, and both the thoracic and lumbar spine have also been shown to affect the pelvic region, suprapubic region, sexual organs, and bladder functioning (Hansen et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Jung et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Kim et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Indeed, these gaps in provider knowledge and current research further compound delays in diagnoses and a lack of provider understanding. To our knowledge, no studies have been conducted on the intersection of sexual and pelvic pain and SRS. This study seeks to bridge the gap between rib symptomology and pelvic and sexual functioning and activity.\u003c/p\u003e\u003cp\u003eThe main objective of this study was to understand potential associations between SRS and sexual and pelvic pain disorders, allowing for greater awareness among the medical community of unique and overlapping symptoms that may compound sexual intimacy and sexual and pelvic pain symptoms. Findings should help inform providers about potential connections between SRS and sexual and pelvic pain disorders.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eAn anonymous cross-sectional online study was conducted from June 2024 to October 2024 on patients diagnosed with SRS. Convenience sampling methods were employed for recruitment via social media platforms as they are inexpensive, readily available, and well-suited for rare diseases. In addition, these sampling methods allow for the simultaneous examination of multiple variables and factors. Since the true prevalence of SRS is unknown, sample size could not be calculated.\u003c/p\u003e\u003cp\u003e This study follows the Strengthening the Reporting of Observational Studies (STROBE) guidelines, providing a transparent framework for future research reproducibility (von Elm et al.,2007). Aligned with STROBE guidelines, the study offers a transparent background, rationale, and presentation of the study design, methodology, results, analyses, and discussion. The [name of university] Institutional Review Board (IRB) was granted exempt status with protocol ID number ET00042278.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eRecruitment\u003c/h2\u003e\u003cp\u003eParticipants were recruited through Facebook, Reddit, Instagram, and X (formerly known as Twitter) communities with an orthopedic focus. Previous studies have validated social media platforms as effective recruitments due to their ability to access and reach a diverse sample of patients and difficult-to-reach populations with \u0026lsquo;rare\u0026rsquo; chronic conditions such as Ehlers-Danlos syndrome, hypermobile spectrum disorders, dysautonomia, and sexual pain disorders such as vulvodynia and vestibulodynia (Fuster et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Glayzer et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). These platforms have also been portrayed as having practical and unique audience bases existing for each one, as patients with chronic conditions and underrecognized conditions are known to rely on social media platforms to find social support and health-related information outside of their health providers (Halverson et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eX (formerly known as Twitter) has faster, direct interactions in real-time, while Reddit has similar interactions but anonymous conversations where identities are not revealed (Zapcic et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Prior literature has suggested that Reddit can also access hard-to-reach populations (Zapcic et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Additionally, interactive and slower-paced discussions are present on Facebook and Instagram, and Facebook has specific groups and pages for each health condition (Ellington et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Fitzgerald et al., 2003; Frandsen et al., 2006).\u003c/p\u003e\u003cp\u003eThe survey was titled \u0026ldquo;Slipping Rib Syndrome Survey\u0026rdquo; and was included in our recruitment flyer. This title was intentionally vague to reduce selection bias (Glayzer et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The study was advertised with a link describing the study purpose and aims, informed consent, a QR code, inclusion criteria, and contact information of the principal investigator. Upon clicking the link to the survey, participants were required to read through the guidelines on Qualtrics and provide their informed consent before moving to the next page. Participants were told they could stop the survey anytime and were not required to answer all the questions. To prevent participants from re-entering the survey, Qualtrics automatically blocked participants' IP addresses once the survey was completed to secure the study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cp\u003eInterested individuals were screened for eligibility with the initial screening questions. Inclusion criteria were as follows: 1) A diagnosis of slipping rib syndrome (confirmed or suspected) from a healthcare provider, 2) age of 18 years or older, and 3) able to read, write, and speak English fluently. Participants who did not meet these criteria were excluded from the study.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eFrequencies and percentages were calculated using IBM SPSS software version 28 for Windows. Categorical data (gender, race, and comorbid conditions) were expressed as frequencies and percentages. In contrast, continuous data (age, number of misdiagnoses before receiving a diagnosis of SRS, number of years before receiving a diagnosis of SRS after onset of symptoms, number of providers sought, patient impression global change scores) were presented as continuous data (means and averages). Missing data was excluded from the analysis.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSociodemographics and health-related characteristics of SRS participants (n\u0026thinsp;=\u0026thinsp;64)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-Binary / Third Gender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrefer not to say\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRace and Ethnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian or Pacific Islander\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHispanic or Latino\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack or African American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNative American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (Years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHealth-Related Characteristics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of Misdiagnoses Before Receiving a Diagnosis of SRS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of Providers Seen Before Receiving a Diagnosis of SRS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYears Between Symptom Onset and SRS Diagnosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the sociodemographics of this sample population. A total of 132 participants accessed the survey; however, 50 people did not meet eligibility requirements, which included being over 18 years of age, able to speak, read, or write in English, and having a confirmed or suspected diagnosis of SRS. Overall, 82 individuals consented and met eligibility criteria, but three chose not to continue the study, resulting in 79 participants who completed the survey. In total, 64 participants completed the survey in its entirety, and 15 skipped occasional questions related to intimacy, surgery, comorbidities, symptoms, treatments, or sociodemographics. Due to the limited sample size, we included all 79 participants in the final sample. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e portrays the flow analysis of the full participation in the survey.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe majority of participants identified as female (91.2%), with a few identifying as male (4.7%), non-binary or third gender (1.6%), or preferring not to disclose their gender (1.6%). The sample was predominantly white (96.9%), with the rest identifying as Asian or Pacific Islander (1.6%) and Hispanic or Latino (1.6%). No participants identified as Black, African American, Native American, or other racial/ethnic groups. The mean age of the participants was 33.4 years (SD\u0026thinsp;=\u0026thinsp;11.6), with ages ranging from 19 to 64 years.\u003c/p\u003e\u003cp\u003eOn average, participants reported that it took 5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 years (range: 0.3\u0026ndash;20 years) from the onset of symptoms to receive a diagnosis of SRS, during which they consulted an average of five providers and received an average of three misdiagnoses. In total, 78.4% reported being diagnosed with other conditions before receiving a diagnosis of SRS (reported in the \u003cem\u003eAppendix)\u003c/em\u003e, with costochondritis (17.6%), anxiety (15.2%), and irritable bowel syndrome (8.5%) as being the most common. Other misdiagnosed conditions reported included gallbladder issues (4.9%), gastritis (3.0%), endometriosis (3.0%), overactive nervous system (3.0%), complex regional pain syndrome (2.4%), gastroesophageal reflux disease (1.8%), acid reflux (1.2%), muscular pain or strain (1.2%), depression (1.2%), asthma (1.2%), gallstones (1.2%), fibromyalgia (1.2%), chest pain (1.2%), and hiatal hernia (1.2%).\u003c/p\u003e\n\u003ch3\u003eSexual Activity and Sexual Pain\u003c/h3\u003e\n\u003cp\u003eRib symptoms were reported to impact sexual activity among the SRS sample (n\u0026thinsp;=\u0026thinsp;79). Specifically, 7.6% reported no impact, 30.4% reported a mild effect, 31.7% reported a moderate effect, 19.0% encountered severe implications, and 11.4% stated their condition completely prevented intimacy. Additionally, 26.9% of respondents also suggested that their rib symptoms contributed directly to their sexual pain symptoms, while 48.1% were not sure.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eComorbid Conditions\u003c/h2\u003e\u003cp\u003eComorbidities (as reported in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) among people with a vulva (n\u0026thinsp;=\u0026thinsp;62) included hypertonic pelvic floor (45.2%), endometriosis (21.6%), vaginismus (19.4%), interstitial cystitis (16.1%), pudendal neuralgia (12.9%), persistent genital arousal disorder (9.7%), vestibulodynia with no identifiable cause (9.7%), Bartholin's cysts (6.5%), congenital neuroproliferative vestibulodynia (4.8%), clitorodynia (4.8%), pelvic inflammatory disease (4.8%), clitoral adhesions (4.8%), and pudendal nerve entrapment (4.8%), inflammatory vestibulodynia (4.8%), and hormonally-mediated vestibulodynia (4.8%) acquired neuroproliferative vestibulodynia was reported by one participant (1.6%), and lichen sclerosis (3.2%).\u003c/p\u003e\u003cp\u003e Among the three participants with a penis who responded to questions about male-specific urological or pelvic conditions, pudendal neuralgia and chronic pelvic pain syndrome were each reported by one participant (33.3%).\u003c/p\u003e\u003cp\u003eAdditionally, 21% total participants reported having \u0026ldquo;other conditions\u0026rdquo;, including pelvic instability, normal vulvar pain associated with menopause, herniated discs, pelvic floor dysfunction with pain during arousal, chronic bacterial vaginosis (BV)/yeast infections, congenital clitoral phimosis, ovarian cysts (on the same side as SRS) with heavy menstruation that exacerbates chest pain, hypermobility spectrum disorder, neurogenic bladder, polycystic ovary syndrome, and pelvic floor dysfunction with rectocele, cystocele, and enterocele. All comorbidities are listed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEhlers-Danlos Syndrome comorbidity\u003c/h3\u003e\n\u003cp\u003eOut of the 68 participants who answered Ehlers-Danlos Syndrome (EDS) related questions, 37 participants (54.4%) reported being diagnosed with Ehlers-Danlos Syndrome (EDS), a connective tissue disorder. Among participants diagnosed with Ehlers-Danlos Syndrome (EDS), the majority (81.1%) had hypermobile EDS, followed by 8.1% with classical EDS. Other subtypes, including classical-like EDS, vascular EDS, brittle cornea syndrome (BCS), and musculocontractural EDS, accounted for 2.7%. Alternative subtypes, such as kyphoscoliotic EDS, arthrochalasia EDS, cardiovascular EDS, myopathic EDS, spondylodysplastic EDS, dermatospraxis EDS, or periodontal EDS,were not reported. Of those without a confirmed EDS diagnosis, 32.4% suspected they might have the condition, 54.8% did not believe they had it, and 12.9% indicated they were uncertain.\u003c/p\u003e\n\u003ch3\u003eEndometriosis symptom overlap\u003c/h3\u003e\n\u003cp\u003eOut of the 61 participants who answered endometriosis-related questions, 14 participants (23.0%) indicated they had endometriosis. Only 50% indicated they could always differentiate between their SRS and endometriosis symptoms. The rest of the participants could often (21.4%), sometimes (21.4%), or rarely (7.1%) differentiate between the SRS and endometriosis symptoms.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePhysical therapy and diaphragmatic breathing for treating sexual and pelvic pain symptoms\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003ePelvic Floor Physical Therapy\u003c/h2\u003e\u003cp\u003eOf the respondents who participated in pelvic floor physical therapy (PFPT) (n\u0026thinsp;=\u0026thinsp;33) for their sexual and pelvic pain symptoms, the average PGIC score was 4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4, indicating no change to minimal improvement (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Approximately 24.2% reported no change in symptoms, while 6.1% reported being much worse, 6.1% much worse, and 6.1% minimally worse. Additionally, 39.4% reported minimal improvement, 12.1% much improvement, and 6.1% very much improvement in symptoms.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eDiaphragmatic Breathing\u003c/h2\u003e\u003cp\u003eFor respondents who participated in diaphragmatic breathing (n\u0026thinsp;=\u0026thinsp;48), the average PGIC score was 3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5, indicating no change to minimally worsening SRS symptoms (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Approximately 41.7% reported no change in symptoms, 18.8% noted minimal improvement, and 8.3% experienced significant improvement. On the other hand, 31.3% felt worse, with 12.5% reporting they were very much worse, 14.6% much worse, and 4.2% minimally worse. No respondents reported being very much improved.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComorbidities among SRS participants who identified as having a vulva (n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCondition\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUnsure (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypertonic Pelvic Floor Dysfunction\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45.2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.9\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.9\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVaginismus\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27.4\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChronic Pelvic Pain Syndrome (CPPS)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e19.4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e62.9\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e17.7\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRecurrent Candidiasis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e17.4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e74.2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e8.1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInterstitial Cystitis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e16.1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e69.4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e14.5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePudendal Neuralgia (PN)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e12.9\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e61.3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e25.8\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVaginitis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e11.3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e77.4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e11.3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVulvodynia (No identifiable cause)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e11.3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e62.9\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e25.8\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePersistent Genital Arousal Disorder (PGAD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e9.7\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e74.2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e16.1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVestibulodynia (No identifiable cause)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e9.7\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e67.7\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e22.6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBartholins Cysts\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e6.5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e82.3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e11.3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCongenital Neuroproliferative Vestibulodynia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e4.8\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e74.2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e21.0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClitorodynia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e4.8\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e77.4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e17.7\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePelvic Inflammatory Disease\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e4.8\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e75.8\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e19.4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClitoral Adhesions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e4.8\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e82.3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e12.9\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePudendal Nerve Entrapment (PNE)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e4.8\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e62.9\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e32.3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInflammatory Vestibulodynia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e3.2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e74.2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e22.6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHormonally-Mediated Vestibulodynia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e3.2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e72.6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e24.2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLichen Sclerosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e3.2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e80.7\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e16.1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAcquired Neuroproliferative Vestibulodynia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e1.6z\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e77.4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e21.0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOther\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e21.0\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e69.4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e9.7\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first cross-sectional study to highlight the potential relationship between SRS and sexual activity, pelvic pain disorders, and sexual pain disorders. In our study sample, SRS symptom onset began for most during adolescence or early adulthood, with the youngest individual in our sample receiving a diagnosis at 19 years old. Given that the average time to diagnosis from symptom onset is greater than five years, healthcare providers should remain vigilant of symptoms at least as early as approximately 14 years old.\u003c/p\u003e\u003cp\u003eDue to the difficulty in diagnosing SRS, misdiagnoses are common among this patient population (Hansen et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In our study, participants received, on average, three misdiagnoses and waited at least 5 years to receive a diagnosis from SRS symptom onset. The delays can compound patient trauma and lead to more extensive and unnecessary investigations and health care costs that may or may not be necessary. The most common misdiagnoses were costochondritis, anxiety, irritable bowel syndrome, gallbladder issues, Gastroesophageal Reflux Disease (GERD), Complex Regional Pain Syndrome (CRPS), overactive nervous system, and depression. These results indicate that medical providers default to diagnosing commonly recognized conditions and psychosomatic disorders when patients complain of rib, abdomen, and nerve pain rather than considering differential diagnoses. Diagnostic overshadowing is also common, particularly if patients have pre-existing conditions, further delaying appropriate care. This tendency is consistent with literature indicating that gallbladder disease, abdominal organ disorders, spinal radiculopathy, and shoulder injuries are often considered before SRS (Hansen et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Due to these delays, patients resort to self-diagnosis before seeking confirmation from specialists, but some abandon the diagnostic process entirely, opting instead for chronic pain management (Hansen et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). SRS diagnosis requires specialist expertise, as traditional imaging methods may be inadequate (Madeka et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Current best practices include ultrasound visualization and a gentle physical assessment, with Hansen et al. (2020) recommending three diagnostic criteria: (1) at least 1 cm of separation at the 10th rib's anterior insertion, (2) abnormal rib mobility upon palpation, and (3) reproduction of pain at the separation site. A comprehensive evaluation and detailed patient history are essential for accurate diagnosis, effective treatment, and improved quality of life.\u003c/p\u003e\u003cp\u003eThe results of our study suggested that SRS have other comorbidities such as hypertonic pelvic floor (45.2%) and chronic pelvic pain syndrome (19.4%). Although there is no existing literature confirming SRS as a direct contributor to chronic pelvic pain, research has indicated that pain from subcostal nerves can affect the lateral abdominal wall muscles, potentially radiating or causing discomfort in the loin, groin, and suprapubic regions (Jung et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). SRS has also been known to mimic symptoms of abdominal conditions, intercostal muscle strains, thoracic pain, and gallbladder disease (Madeka et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). However, due to the limited research on SRS and the supporting evidence of associated imbalances, further studies are needed to explore the relationship between the pelvis and the ribs.\u003c/p\u003e\u003cp\u003eThe overlapping symptomatology of SRS, endometriosis, and hypermobility disorders such as Ehlers-Danlos Syndrome (EDS) is a diagnostic challenge often overlooked in clinical settings. SRS symptoms may directly overlap with endometriosis symptoms as they can be isolated in the same area, which has not been reported in the literature previously. Thoracic endometriosis symptoms, which may contribute to pain in the diaphragm and abdomen (Larrain et al., 2018), also overlap with SRS symptoms. However, some patients may struggle to distinguish between the two, particularly if they only consult and are evaluated by endometriosis specialists. Participants who also reported comorbid hypermobility disorders, such as Ehlers-Danlos syndrome, underscore a potential link between connective tissue laxity and the exacerbation of both rib and pelvic symptoms (Davelaar et al., 2008). Based on the findings, 31 out of 68 participants did not have a confirmed EDS diagnosis. Of these 31 participants, 10 believed they could have it, and 4 were unsure. As delays in diagnosis are common among EDS patients (Anderson et al., 2021), this result warrants more attention and awareness in clinical settings.\u003c/p\u003e\u003cp\u003eAmong the SRS patients in our sample, sexual and pelvic pain symptoms are highly prevalent. Participants reported that rib dysfunction and pain can directly impact sexual activity, with 31.7% describing a moderate impact, 19.0% a severe impact, and 11.4% stating it completely prevented intimacy. Notably, 27.9% of respondents specifically attributed their SRS as a contributor to their sexual pain disorders, marking the first documented evidence of this association. These results may indicate a biomechanical link between the rib cage, diaphragm, and pelvic floor. Previous findings have shown that pelvic floor length was shown to change during the respiratory cycle along with changes in the intra-abdominal pressure and abdominal wall displacement, suggesting the existence of a biomechanical connection (Crowley et al., 2023). Evidence has also suggested that mechanical instability in the lower back (including the lower ribs) and the hips exacerbates or limits sexual activity (Niedenfuehr et al., 2023; Vanti et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). While pelvic pain and sexual pain disorders have received more attention within gynecology, urology, and PFPT, the role of the rib cage in these conditions is largely overlooked, and more research is needed to evaluate this link.\u003c/p\u003e\u003cp\u003ePFPT is a recommended treatment for patients with sexual and pelvic pain disorders and intimacy related issues (Jorge et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), which often includes the prescription of myofascial release of the abdomen, back, and surrounding muscles near the rib cage, diaphragmatic breathing, and stretches (Pendergast 2017). The average PGIC score was 4.5, indicating no change to minimal improvement in sexual/pelvic pain symptoms. Notably, 18.3% of participants reported worsening symptoms, suggesting that PFPT can be potentially harmful for those with SRS. Stretching exercises and other treatments such as myofascial release and lengthening exercises can be a contraindication for individuals with Ehlers-Danlos syndrome and SRS (Buryk Iggers, 2022; Muldowney \u0026amp; Muldowney, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDiaphragmatic breathing is a deep breathing exercise commonly suggested by many PFPT practitioners. Among our sample, 75% of participants reported having no change or worsened SRS symptoms when asked to perform diaphragmatic breathing. This may be because diaphragmatic breathing involves the expansion of the diaphragm, causing the abdomen to rise and the lower ribs to expand outward (Crawford et al., 2023; Russo et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), which may further destabilize the rib joints in patients with SRS, potentially exacerbating SRS instability. Altered breathing patterns are reported among hEDS patients (Hakimi et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Hakimi et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) but are not underscored in the literature among SRS patients.\u003c/p\u003e\u003cp\u003eConsequently, these patients may not be appropriate candidates for PFPT, performing diaphragmatic breathing, or any other modalities for treating their pelvic floor and sexual pain disorders until their SRS symptoms are better managed and evaluated correctly. Providers must treat these patients with much more caution and precision when approaching these modalities, given the results of our survey study and the fragility of EDS and SRS patients. Additionally, since SRS is challenging to diagnose, some patients with sexual or pelvic pain conditions may have SRS without being aware of it. Therefore, both patients and providers should be attentive to reports of worsening pain symptoms following PFPT and/or diaphragmatic breathing. Furthermore, reinforcing the idea that pain symptoms are the result of an overactive nervous system or psychological symptoms can further compound suffering, trauma, delays in diagnoses, and increased pain.\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eLimitations of this cross-sectional study include recall bias, small sample size, selection bias, the lack of validated scales, and the inability to infer causality, all of which are common among cross-sectional studies for rare conditions. First, biases related to self-reporting may consist of recall bias. Patients may not be able to recall or report their symptoms accurately. Second, the small sample size may have impacted the generalizability. Due to the nature of this disease and patients' inaccessibility, we could not recruit many patients with this condition from online forums. However, given the rarity of SRS, recruiting a large cohort of SRS patients may be quite difficult at this time. Third, some patients who participated in this study may have had a misdiagnosis, given how long it takes to receive a proper diagnosis. Some patients diagnosed with SRS may also have an alternative condition, given that this condition, among many connective-tissue comorbidities, lacks standard diagnostic criteria and consists of a broad spectrum of symptoms that could lead to misdiagnosis. Fourth, selection bias is also possible, as survey respondents may not represent the broader SRS population. This may impact generalizability. Fifth, this priority population's lack of validated scales is a limitation. Although more psychometric research and testing are needed with EDS and SRS patients, the results do not diminish the current findings. Finally, cross-sectional designs limit the ability to infer causality as the information collected occurs at a single point. A total of participants reported having some type of SRS, which suggests that the surgery may have impacted their ability to engage in sexual activity or their sexual pain disorders.\u003c/p\u003e\u003cp\u003eOverall, while these limitations may affect the generalizability of the results, the results do not take away the importance of these issues among a subset of the SRS and sexual pain and pelvic pain population. Future longitudinal and prospective studies with larger sample sizes are needed to determine the prevalence and infer causality. More research is required for providers to understand the overlap and distinctions between SRS symptoms and other gynecological, urological, and gastroenterological conditions to improve diagnostic accuracy, treatment strategies, and overall quality of life.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSRS is a debilitating condition that significantly impacts the lives of those who live with it daily. SRS can impact sexual activity and sexual/pelvic pain disorders, and common treatments for such disorders such as PFPT and diaphragmatic breathing provide little to no benefits to SRS patients and instead have the potential to cause harm. More attention is needed for SRS in various medical disciplines, including gynecology, urology, PFPT, and others. Given these conditions' complexity and overlapping comorbidities, a comprehensive diagnosis, provider awareness, interdisciplinary collaboration, effective treatments, and surgical management can significantly improve health outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJN led the study design, methodology, data curation, and analysis. DS supported the study design and conceptualization. JN and DS wrote the manuscript, read the manuscript, edited it, and approved the final version. All authors declare no financial or nonfinancial interests or commercial associations that may be relevant to the submitted work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAnderson LK, Lane KR. The diagnostic journey in adults with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders. 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This study explored a potential link between SRS, sexual activity, and sexual and pelvic pain disorders.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional survey was distributed through convenience sampling (July 2024-November 2024). Sociodemographic questions, diagnostic timelines, and Patient Global Impression of Change (PGIC) were used to assess the self-reported efficacy of pelvic floor physical therapy (PFPT) for sexual and pelvic pain among those with SRS.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eSeventy-nine SRS patients participated, primarily female (91.2%), white (96.9%), with an average age of 33.4 years. Delay in SRS diagnosis averaged 5.4 years, with common misdiagnoses of costochondritis, anxiety, or gastrointestinal issues. Over half (54.4%) had EDS, mainly the hypermobile subtype (81.1%). More than 50% reported having a moderate to severe impact on sexual activity because of their SRS symptoms, and 26.9% attributed their pain to SRS. Common comorbidities included hypertonic pelvic floor (45.2%), endometriosis (21.6%), vaginismus (19.4%), interstitial cystitis (16.1%), and pudendal neuralgia (12.9%). Only 50% with both endometriosis and SRS could consistently differentiate between symptoms. For those participating in PFPT for treating sexual/pelvic pain symptoms, the average PGIC score was 4.5, indicating no change to minimal improvement, and 18.2% experienced worsening symptoms. Similarly, when attempting diaphragmatic breathing, 31.3% reported worsened symptoms and 41.7% reported no change in sexual/pelvic pain symptoms.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis is the first study to show that SRS impacts sexual activity and may even contribute to sexual and pelvic pain disorders. SRS symptoms overlap with conditions like endometriosis, which may complicate diagnosis. More research is needed to contribute to underscoring the link between the rib cage, pelvic floor, and nerve issues to improve quality of life, diagnostic strategies, and management among patients with SRS.\u003c/p\u003e","manuscriptTitle":"Exploring a Potential Link Between Slipping Rib Syndrome, Sexual Activity, and Sexual Pain Disorders: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-19 16:51:57","doi":"10.21203/rs.3.rs-7395838/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","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":"09139c7a-a12b-4c99-b493-37220ddb307b","owner":[],"postedDate":"October 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-26T09:09:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-19 16:51:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7395838","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7395838","identity":"rs-7395838","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}