Our study aims to investigate the associations between endometriosis-related pelvic pain and pelvic floor muscle strength, endurance, and relaxation ability, as well as quality of life, physical activity, and the presence of pelvic floor symptoms. Furthermore, it aims to assess the function of muscles synergistic with the pelvic floor in comparison with healthy controls.
Study design: Cross-sectional study. Target population: Women of reproductive age (18-50 years) with endometriosis, as well as healthy controls. Sampling method: Convenience sampling; participants will be recruited via online platforms and in medical outpatient clinics. Inclusion criteria: Women aged 18-50 years in reproductive age will be included. The study group will consist of women with self-reported endometriosis, while the control group will include women who are gynecologically healthy and report no history of endometriosis. Additional inclusion criteria are adequate knowledge of the Hungarian language, access to the internet, and provision of informed consent. Exclusion criteria: Lack of capacity to provide informed consent, severe physical or cognitive impairment, pregnancy, postpartum period, and diagnosed malignant disease. Expected sample size: 100-140 participants. Study methodology and procedures Participants will be recruited using convenience sampling. The study consists of two parts. The questionnaire package includes general questions (sociodemographic and anthropometric data, physical activity and exercise habits, assessment of the presence and intensity of pelvic pain, and obstetric-gynecological history), as well as several validated self-administered questionnaires. Body mass index (BMI) will be calculated based on self-reported height and weight. Pain intensity will be assessed using the Visual Analogue Scale (VAS). The following validated instruments are included: VAS (Visual Analogue Scale) (Freyd, 1923) A unidimensional, 11-point scale widely used to assess subjective pain intensity ranging from 0 (no pain) to 10 (worst imaginable pain). Participants will rate their average and worst pain over the past four weeks, as well as their current pain at the time of questionnaire completion. GPAQ (Global Physical Activity Questionnaire) (Armstrong \& Bull, 2006; Ács et al., 2020) A 16-item questionnaire developed by the WHO to assess physical activity across work, transportation, and recreational domains, including sedentary behavior. Activity levels are expressed in minutes per week. Participants will be classified as physically active if they engage in at least 150 minutes of recreational physical activity per week, based on WHO recommendations (WHO, 2023). SF-36 (Short Form Health Survey) (Ware \& Sherbourne, 1992) A self-administered questionnaire measuring health-related quality of life across eight domains, including physical functioning, bodily pain, role limitations (physical and emotional), social functioning, mental health, and general health. Scores range from 0 to 100, with higher scores indicating better quality of life. EHP-30 (Endometriosis Health Profile) (Jones et al., 2001) A disease-specific, validated questionnaire assessing the impact of endometriosis on quality of life across five domains: pain, control and powerlessness, emotional well-being, social support, and self-image. Scores range from 0 to 100, with higher scores indicating worse quality of life. PPIQ (Pelvic Pain Impact Questionnaire) (Chalmers et al., 2017; Kovács-Szabó et al., 2025) A culturally adapted and validated Hungarian instrument assessing the impact of pelvic pain on daily life over the past month. It includes 10 items rated on a 0-4 Likert scale, with higher scores indicating greater impact. APFQ (Australian Pelvic Floor Questionnaire) (Baessler et al., 2009; Hock et al., 2023) A 38-item questionnaire assessing bladder, bowel, prolapse, and sexual function, along with symptom-related distress. Domain scores range from 0 to 10, with a total maximum score of 40 indicating severe pelvic floor dysfunction. Instrumental measurements Objective assessment of pelvic floor muscle function will be performed using the Myomed 932 surface EMG device. The aim of the measurement is to determine pelvic floor muscle endurance, maximal voluntary contraction, and relaxation ability using surface electromyography and a vaginal manometric probe.
University of Pécs Faculty of Health Sciences
Pécs, Baranya, Hungary
RECRUITINGVaginal manometry (Myomed)
Pelvic floor muscle function will be assessed using intravaginal pressure manometry with the Myomed 932 device (Enraf-Nonius B.V., Rotterdam, The Netherlands) and a conical vaginal probe. All assessments will be performed by the same trained pelvic floor physiotherapist following a standardized protocol. Participants will be instructed to empty their bladder before the assessment and will be evaluated in the supine position. After correct probe placement and baseline calibration, participants will perform three maximal voluntary contractions (MVCs), and the highest pressure value (hPa) will be used to determine maximal pelvic floor muscle strength. Muscle endurance will be assessed by maintaining a contraction at approximately 80% of maximal effort, while dynamic muscle function will be evaluated by recording the number of rapid contractions performed within 30 seconds. Only correctly performed pelvic floor muscle contractions without compensatory activation of the abdominal, hip addu
Time frame: at baseline/enrollment
pain levels
With Numeric Rating Scale 0-10 pelvic pain levels are measured. It utilizes an 11-point scale ranging from 0 to 10, where 0 represents no pain and 10 indicates the worst pain. Participants were asked to rate their average and maximum pain levels over the previous four weeks and their current pain intensity at the time of assessment.
Time frame: at baseline/at enrollment
physical activity
Physical activity levels were assessed with the Global Physical Activity Questionnaire. Physical activity will be assessed using the Global Physical Activity Questionnaire (GPAQ), a validated instrument developed by the World Health Organization. The GPAQ consists of 16 items assessing physical activity in three domains (work, transport, and leisure-time) as well as sedentary behavior. Responses will be used to calculate total physical activity expressed in metabolic equivalent (MET)-minutes per week according to the WHO GPAQ analysis guidelines.
Time frame: at baseline/enrollment
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Study Type
OBSERVATIONAL
Enrollment
100
Pelvic floor function
Measuring pelvic floor function including sexual, bowel, urinary tract function via Australian Pelvic Floor Questionnaire. Hungarian version. The Australian Pelvic Floor Questionnaire (APFQ) is a validated instrument used to assess pelvic floor dysfunction in four domains: bladder function, bowel function, prolapse symptoms, and sexual function. The questionnaire consisted of 38 items, along with additional items evaluating the subjective burden of symptoms. Items are primarily rated on a 4-point scale, and domain scores are calculated as a proportion of the maximum possible score and multiplied by ten, resulting in values ranging from 0 to 10. The total score ranges from 0 to 40, with higher scores indicating more severe pelvic floor dysfunctions.
Time frame: at baseline/enrollment
Health-related quality of life
Health related quality of life is measured by the Endometriosis Health Profile. Endometriosis Health Profile-30 (EHP-30): The EHP-30 is a validated, disease-specific patient-reported outcome questionnaire designed to assess health-related quality of life in women with endometriosis. The core instrument consists of 30 items across five domains: pain, control and powerlessness, emotional well-being, social support, and self-image. Higher scores indicate greater impairment in quality of life. The EHP-30 is widely used in clinical research to evaluate disease burden and treatment outcomes in patients with endometriosis.
Time frame: at baseline/enrollment
Effect of pelvic pain on the participants' everyday life
The effect of pelvic pain on the women's everyday life was measured by the Pelvic Pain Impact Questionnaire. The Pelvic Pain Impact Questionnaire (PPIQ) is a self-administered instrument designed to assess the impact of pelvic pain on daily function. It consists of eight mandatory and two optional items, each rated on a 5-point Likert scale. The total score ranges from 0 to 32 (0-40 if including the two optional items), with higher scores indicating a greater negative impact of pelvic pain on daily activities.
Time frame: at baseline/enrollment