Assessing use of eau recommendations in diagnostic and therapeutic strategies for chronic pelvic pain syndrome: a case vignette study on dutch pelvic floor physiotherapists practices

Background Chronic Pelvic Pain Syndrome (CPPS) presents as pain located in the pelvic area lasting for at least six months, often with a multifactorial aetiology. The International Continence Society divides CPPS in multiple domains; one is the musculoskeletal domain. Pelvic floor physiotherapy is a recommended treatment and is advised in the European Association of Urologist (EAU) guidelines. However, in the Netherlands, it is unclear which treatment strategies are used by pelvic floor physiotherapists (PFPs) for CPPS patients due to the lack of a Dutch evidenced- based guideline for physiotherapists. This study provides an overview of the adherence to the EAU guideline by PFPs in managing CPPS patients.

A case vignette study using two case vignettes and a general questionnaire defining contextual data. Participants were PFPs treating patients with CPPS in primary care. We contacted 550 qualified PFPs registered in the Dutch national quality registry for physiotherapy. Main outcome measure: first, adherence to EAU guidelines and second, the adherence compared to level of education and caseload.

Of the invited participants, 198 completed the survey. Of these, 29 (14.6%) scored higher than 80% for both case vignettes; fifty-four (27%) scored 80% for the male case vignette and 30 (15%) scored 80% for the female case.

Our findings show low adherence to the EAU guideline’s proposed diagnostic and treatment criteria. PFPs should become more familiar with implementation of this guideline.

Guideline adherence, Pelvic floor disorder, Pelvic pain, Physical therapy

Chronic pelvic pain syndrome (CPPS) is pain in the pel - vic region characterized by either continuous or intercur- rent episodes of pain for over six months without clear evidence for clinical pathology [1]. CPPS is a syndrome found in both men and women with a prevalence in men ranging from 1.9—9.6% compared to 5.7—26.6% in women [2–6]. CPPS often presents with symptoms of *Correspondence: Myrthe Wissing [email protected] 1 Department of Obstetrics and Gynaecology, Radboudumc Nijmegen, Geert Grooteplein Zuid 10, Nijmegen, GA 6525, The Netherlands 2 Department of Anesthesiology Chronic Pain and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands 3 Department of Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands Page 2 of 7Wissing et al. BMC Women’s Health (2025) 25:272 the lower urinary tract and lesser pelvis inducing sexual, bowel and gynaecological dysfunction. The exact aetiol - ogy of CPPS remains unknown, but a high interference with gynaecologic, urologic, gastrointestinal, musculo - skeletal and psychosocial comorbidities is observed [1]. In 22%—94% of CPPS cases, myofascial pelvic pain is involved [7]. Ideally, CPPS should be treated at a dedi - cated multidisciplinary centre specialized in chronic pain in the area of the lesser pelvis [8, 9]. The International Continence Society (ICS) has divided CPPS in nine different domains based on different organ systems. The fifth domain is the Musculoskeletal domain; this involves pain originated from the pelvic muscles, fas- cia, ligaments, joints, or bones. This subdivision of the domain chronic pelvic muscle pain (CPMP) is especially relevant for pelvic floor physiotherapists (PFPs) as they have expertise in diagnostic and treatment modalities for pelvic floor muscle dysfunctions [10]. Therefore, patients with CPMP are often referred to PFPs [1]. Currently, several CPMP treatment strategies are available, including myofascial manual techniques and biofeedback therapy as recommended in the annually updated, evidence based European Urology Association (EAU) guideline (see Table  1) [1, 11–14]. In the Neth - erlands, no national evidence-based physiotherapeutic guideline is available for Chronic Pelvic Pain, although using the general Chronic Pelvic Pain guidelines is taught and recommended in the master’s degree (MSc)-curricu- lum of PFPs. In recent years, the level of PFP training has evolved. Historically, PFPs were educated to the bache - lor’s degree level (BSc). Since 2014, they can be awarded a master’s degree (MSc), which applies a different level of the European Qualifications Framework (level 7 instead of level 6), resulting in a higher qualification standard for PFPs. [15–17]. We conducted a case vignette study to provide an over- view of the adherence to EAU guideline by Dutch PFPs in managing CPPS patients. Moreover, we compared PFPs’ level of education and workload with the adherence to European guidelines.

Participants The participating PFPs were accredited professionals with a sufficient case load and were all members of the Dutch Association of Pelvic Floor Physical Therapy. Eli - gible participants met the inclusion criteria if they had completed a licensed course in pelvic floor physiotherapy in the Netherlands and were registered in the National Quality Register for Physiotherapists (NQRP).[18]. Due to privacy constraints of the Dutch Association of Pelvic Floor Physiotherapists, we were unable to con - tact all PFPs directly via email. An online search pro - vided contact information of 87% of PFPs, who were sent an email requesting for their participation. This email included the study’s background and a request for informed consent. Once informed consent was received, PFPs were sent a link to the online survey, and further contact remained by email. The online survey was admin- istered using the database Castor EDC. PFPs completed the surveys in between February 2020 and May 2020. During this period, three reminders were sent. Design A case vignette study consisting of case vignettes and a general questionnaire containing baseline questions (contextual data, patient load and educational level) were developed based on the current EAU guidelines for Chronic Pelvic Pain [1]. Our study was approved by the Central Committee on Research Involving Human Subjects of Arnhem and Nijmegen (file number: 2023–16474). The case vignette and general questionnaire Two case vignette studies and a general questionnaire were developed by the research group (abbreviations of the researchers: MR-SW-KN-KV-MS),describing the case of a male and female CPPS patient (Figs.  1 and 2). A case vignette is a validated and generally accepted method for assessing the diagnostic steps and clinical reasoning of health care professionals [19–22]. Both cases consisted of six questions: two on the diagnostic strategy, two on the therapeutic options, and two on the number of treat - ment sessions needed. The multiple choice questions (questions 2–4 for each case) contained three or four answer options; the first question on diagnostic strategy Table 1 Recommended strategies for assessing and managing a CPPS patient by Pelvic Floor Physiotherapists by the EAU guidelines Diagnostic modalities - Vaginal and rectal examination - Broad musculoskeletal evaluation (including muscles outside the pelvis) Treatment modalities - Myofascial trigger point release - Myofascial stretching and relaxation - Transvaginal manual therapy of the pelvic floor musculature - Biofeedback treatment - Electromagnetic therapy - Microwave thermotherapy - Extracorporeal shockwave therapy - Acupuncture - Posterior tibial nerve stimulation - Transcutaneous electrical nerve stimulation Page 3 of 7 Wissing et al. BMC Women’s Health (2025) 25:272 had seven answer options. The respondents were asked to give the three most applicable options for each case. The general questionnaire included questions on con - textual data, educational level (BSc or MSc), years of work experience, case load of patients in their practice, and different CPPS diagnostic and interventional strate - gies available in their practice. Validation and pre‑test The case vignettes were developed by a group of experts including three accredited pain specialists (KV-MS- SW), a urogynaecologist (KN), and two PFPs (MR-LS). The case vignettes were developed based on real clinical cases and on the EAU guidelines for CPPS presented in the guideline [1]. The case vignettes were pilot tested by a panel of 5 PFPs (SS-CO-SH-SSp-MD). The results of the pilot were discussed in the research group and altera - tions were made if needed. The final versions of both case vignettes are presented in Additionl file 1: Appendix 1. The scoring system An expert group consisting of a PFP , urogynaecologist and pain specialist (MR-KN-SW) reviewed the results of both vignettes and compared the answer options with the EAU guidelines [1 ]. They divided 10 points for each answer option based on a consensus in the complete research group (MR-SW-KN-KV-MS-MW) and established the definite scoring system (see Additionl file 1: Appendix  1 and 2). The maximum score for both cases was 43 points (= equal to 100% agreement with the guideline). Based on expert consensus, we determined the cut-off value for success at 80% (i.e., 34 points). Secondly, we were inter - ested whether a high case load or educational level of the PFPs would improve guideline adherence. A sufficient case load was defined at > 1 new patient per week and a high case load was defined at > 5 new patients per week. Data analysis The statistical analysis was performed with IBM SPSS Statistics for Windows, version 25. The general question- naire and multiple choice questions were analysed using descriptive statistics and presented in frequencies, mean and standard deviation. A Chi-square test was used to determine if there was a statistical significant association between educational level and case vignettes scores, and between case load and case vignettes scores, with a significance level of 0,05. Fig. 1 Male vignette Fig. 2 Female Vignette Page 4 of 7Wissing et al. BMC Women’s Health (2025) 25:272

Contextual data Of the 635 registered PFPs in the Netherlands, 550 PFPs were approached based on availability of internet contact information and were invited to take part in this study. Of these 550 PFPs, 277 PFPs returned the survey (41%). Seventy-nine surveys were excluded as they were incom - plete, leaving a total of 198 completed surveys (36%) for analysis (Fig. 3). The contextual data of the PFPs are sum- marised in Table 2. Table  2 presents contextual data of the pelvic floor physiotherapists including information on work experi - ence and level of education. The case vignettes The complete case vignettes are presented in Additionl file 1: Appendix  1. A great variety of possible answers were given to the questions for both vignettes. The thera- pists were very divided which diagnostic or therapeutic modality should be used in the case vignettes. When comparing the responses to the advice in the EAU guideline, 29 (14.6%) of the 198 therapists scored 80% or higher for both case vignettes. Fifty-four (27%) therapists scored 80% for the male case vignette, and 30 (15%) scored 80% for the female case. Hundred and twenty six (64%) therapists scored for neither of the case vignettes 80%. The PFPs’ educational levels are listed in Table  2. A schism is seen in educational level compared to the Euro- pean Qualification Framework. The majority had an educational level of BSc (71%), the remainder qualified at MSc level (29%). Additionally, four PFPs were a PhD (candidate) (2%). Significantly more BSc therapists fol - lowed the EAU guidelines compared to MSc therapists; 27 of 141 compared to 2 of 57 respectively (p = 0,005) (Table 3). In addition to the comparisons of education and scor - ing, the number of patients treated was compared to the scoring. The PFP were asked how many new patients they admitted for diagnostic or therapeutic consultation in a Fig. 3 Flow Chart Inclusion Respondents Page 5 of 7 Wissing et al. BMC Women’s Health (2025) 25:272 week. A total of 136 PFPs had a high case load (defined as 5 new patients in a week) (Table 2). Eight of the 61 thera- pists, with less than 5 new cases a week, scored 80% or more for both case vignettes compared to 21/136 thera - pists with more than 5 new cases a week. No significant difference was found in adherence to the EUA guide - line between therapists with a high or low caseload (p = 0.680) (Table 3).

This is the first evaluation of the adherence to EAU mul - tidisciplinary guidelines by Dutch PFPs, using a case vignette study. We assessed the clinical diagnostic and treatment strategies of chronic pelvic muscular pain by Dutch PFPs on a scoring system based on the EAU guide- lines [1]. A poor adherence to the guideline recommen - dations was found, based on the answers given by the PFPs. There was a significant difference in adherence to the EAU guideline in favour of BSc-educated PFPs. The case load was not associated with adherence to EAU guidelines. Only 15% of the therapists answered according to the EAU guideline in both case vignettes. Of the respondents, 26% scored 80% for one of the cases, answering according to current guidelines. This shows that, although the cur - rent EAU guidelines for CPPS provide a recommenda - tion for how to treat a patient, this does not guarantee a good implementation of the guideline and/or a uniform physiotherapeutic approach and treatment. Compared to the literature on adherence to guidelines in general, the compliance wase found low [23]. For example, in a study amongst primary care physicians in the USA, 70% of the physicians understood that CPPS is a non-infectious dis - ease; however only 5% referred patients to PFPs while antibiotic therapy was the chosen therapy by 72% of the primary care physicians [24]. This indicates that primary care physicians have little awareness of the current guide- lines concerning CPPS. Other case vignette studies have also described poor adherence to current guidelines [25–31]. For example, in palliative care of cancer patients, the adherence to the national Dutch guideline on the diagnosis and treatment of pain in patients with cancer was inconclusive: in case of a pharmacological treatment (99%) or invasive treat - ment (95%) adherence was high, in contrast to the rec - ommendations on the use of a one-dimensional pain scale (23%) and performing a multidimensional pain assessment (15%) [25]. As noted above, a significant difference was found in guideline adherence in favour of BSc-educated PFPs. The EAU Chronic Pelvic Pain guideline is taught in its full extent in the MSc-curriculum, and the clinical rea - soning is practiced with a patient case in small study groups. Therefore, a higher adherence was expected to the guideline in MSc-educated PFPs. We also expected a higher caseload would improve guideline adherence, but this was not confirmed by our results. This may be due to the extended interests of MSc-educated PFPs; their focus may shift from clinical practice to research or additional tasks, as would be expected of level 7 EQF educated PFPs [15–17]. Additionally, MSc-educated PFPs might choose for individualized treatments, as recommendations in guidelines are not always suitable for every patient and subsequently match the treatment with the patients’ needs [32]. Altered management strategies may be due to previous positive experiences or the attitude and beliefs of a PFP [33, 34]. Table 2 Contextual data of the pelvic floor physiotherapists * One therapist did not mention the caseload Characteristic Number of participants Mean (SD) Total 198 Age in years 49.4 (10.8) Gender female 196 Years’ experience 12.7 (7.7) Hours per week working 24.4 (7.9) Working in primary health care 177 Self-confident with simple pain patients 188 Self-confident with complex pain patients 145 > 5 new patients a week 136* BSc pelvic floor physiotherapy 141 MSc pelvic floor physiotherapy 57 PhD or PhD candidate 4 Table 3 Overview adherence to the guideline based on education and caseload * P-value determined by using the chi-square test, α = 0.05; n = number of participants Scored 80% (n) Adherence guidelines (%) Total of participants (n) P-value* Education BSc level 114 27 19 141 0.005 MSc level 55 2 4 57 Caseload High case load 53 8 13 61 0.680 Low case load 115 21 15 136 Page 6 of 7Wissing et al. BMC Women’s Health (2025) 25:272 Strengths The majority of Dutch PFPs were invited to participate. Moreover, the study was supported by the board of the Dutch Association of Pelvic Floor Physiotherapists. Fur - thermore the case vignettes were developed and recon - structed by an expert group based on EAU guidelines for Chronic Pelvic Pain. The response rate of 41% was good, similar to other chronic pain studies with case vignettes (24–43%) [25–27]. Another strength is the involvement of an expert-based scoring system in which multiple experts participated. Despite the absence of formal validation, the expert-based approach offers sev - eral advantages. It leverages the specialized knowledge and experience of professionals who are deeply familiar with the subject matter, ensuring that the scoring reflects nuanced and contextually appropriate judgments. They reached consensus for the scoring system in comparing the case vignettes with the EAU guidelines. The expert group verified their consensus within the research team for validation and reached agreement for the practice based scoring system based.

Due to privacy constraints, we were unable to communi - cate with the Dutch Association of Pelvic Floor Physiother- apists about PFPs’ email-addresses and therefore we were unable to reach all PFPs, however the overall response rate was good (41%). A further limitation was the use of case vignettes as this may cause bias related to socially desir - able answers. However, case vignettes are the best option to represent clinical reality without case variety. We did not include a question in our questionnaire to determine knowledge about the (inter)national guidelines to avoid biased answers. Another limitation is the lack of an vali - dated scoring system for the case vignettes. An evidence based scoring is not available and only a practice based scoring based on expert opinion was possible to review the

of the case vignettes as seen in other literature[25, 29, 30, 35]. We recognize the inherent limitations of using an unvalidated scoring system however expert-based scor- ing remains a valuable method for obtaining informed and contextually relevant evaluations of case studies. The lack of adherence to the EAU guidelines for CPPS seen in our study marks the cruciality to enhance edu - cational efforts and clinical training focused on EAU guidelines for PFPs. Strategies should be developed to improve implementation of EAU guideline among all practicing PFPs. A Dutch CPPS guideline specifically for PFPs might help for an improved adherence to the guide- lines. However, more prospective randomized clinical trials are needed to provide evidence for the guidelines in recommendations in diagnostic and treatment modali- ties for CPPS by PFPs. Future research should explore the barriers and facilitators influencing guideline adher - ence among PFPs in different practice settings. This could inform tailored interventions aimed at optimizing guide - line implementation and improving patient outcomes in the management of chronic pelvic pain.

Adherence to EAU guidelines is low resulting in a vari - ety of CPPS diagnostic and treatment modalities used by PFPs; only 15% adhered to the guidelines in the case vignettes. To conclude, a minority of the Dutch PFPs fol - low the EAU CPPS guideline recommendations. Based on these results more attention should be paid to imple - menting the EAU guidelines in the Netherlands and developing a Dutch CPPS guideline. Abbreviations BSc Bachelor of Science CPMP Chronic Pelvic Muscular Pain CPPS Chronic Pelvic Pain Syndrome EAU European Association of Urology ICS International Continence Society MSc Master of Science NQRP The National Quality Register for Physiotherapists PFP Pelvic Floor Physiotherapist Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12905- 025- 03782-4. Additional file 1.

We are grateful to all the PFPs who participated. We would like to specifically thank the PFPs that helped develop the case vignettes (LS-SS-CO-SH-SSp-MD) Authors’ contributions MW and MR wrote the main manuscript. MR and MW collected the data. MW and MR analyzed the data. MW prepared all figures. All authors were contributors of the project development and manuscript editing. MW and MR are joint authors. Funding This work was supported by the Dutch Association of Pelvic Floor Physiothera- pists to stimulate scientific research in the field of pelvic floor physiotherapy in Chronic Pelvic Pain Syndrome. Data availability The datasets generated and/or analysed during the current study are not publicly available due to privacy restraints but are available on request. Declarations Ethics approval and consent to participate The Central Committee on Research Involving Human Subjects of Arnhem and Nijmegen approved this study (file number 2023–16474). All participants gave written informed consent before data collection was initiated. Consent for publication Consent for publication was included in the informed consent. Competing interests The authors declare no competing interests. Page 7 of 7 Wissing et al. BMC Women’s Health (2025) 25:272 Received: 28 November 2023 Accepted: 6 May 2025

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