Reviewer ’s report  
 
Title:  Are pelvic adhesions associated the pain, physical, emotional and functional 
characteristics of women presenting with chronic pelvic pain? A cluster analysis  
 
Version: 0 Date: 30 Jan 2017 
 
Reviewer:  Andrea  Rapkin  
 
Reviewer’s report:  
 
The manuscript presents the results of hierarchal cluster analysis of demographic and clinical 
characteristics and adhesion scores for 62 women undergoing laparoscopy for chronic pelvic 
pain.  The authors found that the reported pain and other cha racteristics have little or no 
correlation with adhesion scores and that most women who had adhesions had low pain scores.  
 
1) In the Background, first paragraph, the author's state that there are currently no effective 
interventions for chronic pelvic pain a nd cite references 5 and 6; reference 6 was 
withdrawn and shouldn't be included in the bibliography. Reference 5 is a meta - analysis 
of single treatments which obscures the fact there are publications supporting 
multidisciplinary management.  One in partic ularly germane to the current study is Peters 
AA et al 1991 describing a RCT of an integrated compared to traditional medical and/or 
surgical management.   
 
2) In the second paragraph the author's state that they have shown that "adhesiolysis  may 
only benefit a subgroup of patients, and cite references 5 and 7.  Reference 5 is a review 
of non -surgical management. Reference 7 is of interest; however the study was stopped 
before recruitment reached the statistically powered sample size due to lo w enrollment, 
so results are questionable.  In addition, studies which do not show improvement in pain 
were omitted, e.g. Swank DJ Lancet 2003.  
 
3) In the second paragraph the authors  state there is some evidence to suggest dense 
vascular adhesions are more likely to result in pain, and that adhesions attached to ovaries 
are more likely to result in pain, two references are cited, 6 which was withdrawn and 
therefore should not be cited, and 8, Peters et al. However, a study by Rapkin in 1986, did 
not find an association between density or site of adhesions and pelvic pain.  A 
retrospective study by Steege and Stout (1991) found the presence of psychosocial 
compromise was associated with a lack of salutary response with adhesiolysis. The 
findings are relevant t o this attempt to develop a phenotype associated with adhesions  
 
4) Authors should describe the meaning of clinical phenotype in this setting, and cite 
publications whereby clinical phenotypes can be helpful for guiding management in 
patients with chronic pa in. Not all readers are familiar with the concept of phenotype 
unrelated to genotype.  
 
5) In the Methodology section: Patients were excluded if they had psychiatric disorders for 
which they were taking medication. Please justify why such patients were excluded.  
Were all patients receiving some form of medication for chronic pelvic pain excluded, or 
just those receiving hormonal medications i.e., anticonvulsants or tricyclic 
antidepressants?  Were subjects assessed for co -morbidities outcome such as pre sence of 
comorbid chronic pain or psychiatric diagnosis or history of physical, sexual or 
psychological trauma?  If not why were such factors excluded and how does this impact 
the outcome, given that co morbidities and trauma impact chronic pain?   
 
6) For th e patients in the study who came to the point of undergoing laparoscopy, were other 
common causes of other chronic pelvic pain queried or excluded, i.e., abdominal wall and 
pelvic floor myofascial pain, neuropathic pain, irritable bowel syndrome, and bladd er 
pain syndrome? These need not have been exclusionary, but other comorbid pelvic pain 
disorders would affect the outcome of the current study and therefore the methodology 
should be further detailed. If not ruled out, how does this affect the outcome of the 
current study?  
 
7) In the Results section on page 6, the authors may want to describe why after delineating 
three clusters, they further subdivided cluster 2, and only cluster 2, into three subgroups.  
 
Does Figure 1 contain an error?  Cluster 2 is divide d into 3 subgroups, subgroup 1 with better 
social function, longer duration and moderate severity and subgroup 2 with short duration of 
pain, however looking at the table, subgroup 3 the duration of pain appears to be 50, is this years 
or months, compared with subgroup 1, 9.6 years, subgroup 2, 1.8 years therefore subgroup 3, 
does not have a short duration of pain.  Perhaps there is an error in the Table?   ?  Again, in 
subgroup 3, it seems odd that the worst pain intensity was 1.6, whereas the average pain  intensity 
was a 10. Is there an error?  
 
Also, subgroup 3 supposedly had the worst current pain. Is this derived from the EHP pain? 
What about the McGill  
 
8) On page 7, the authors present in Table 2, the site and presence of adhesions, however the 
adhesion s coring system that was used includes a number of other features, including 
density and length of adhesion. Were these relevant to any of the cluster analysis and is 
there a reason why the distribution of density or length of adhesion was not included in 
the table? Why include Table 2?  
 
9) On page 7, second paragraph, the word" ironically" should be removed from this 
sentence.  More objective would be to state the evidence; pro and con from the literature.   
It also reflects a degree of naiveté about the etiolo gy of pain in patients with chronic 
pelvic pain in general and adhesions specifically. Again in the first paragraph of the Intro, 
the word "ironically" should be removed.  Other studies have demonstrated no correlation 
between locations or density of adhes ions and pain and no response to adhesiolysis.  
 
11) The statement "we did not find a correlation with the nature of pain and the site or type of 
adhesions" should be clarified.  What is meant by "the nature of pain"?  Are the authors 
referring to the severity of pain, the duration of pain, and other associated pain features?  
 
12) What are the authors referring to by the statement that they cannot exclude historical 
adhesions related episodic pain?  Using the words historical adhesion related episodic as 
adjectives  for the noun of pain obscures the meaning of the sentence.  Did the authors 
mean that patients would have had severe pain that was related to adhesions more than 6 
months prior to the administration of the questionnaire? This seems farfetched.  
 
13) A conclusi on that cognitive behavioral assessment has been advocated, yet is it not 
routinely used in the management of is true, however given the previous statement , "that 
traditional gynecological approach to history taking and management strategy will not be 
adequate for pain and expectation management", a more forceful conclusion is in order.  
In fact the literature is replete with examples of whereby history and evaluation of 
patients with chronic pelvic pain must include cognitive, emotional behavior and other  
physical assessments prior to embarking on surgical management.    
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in a n organisation that may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relat ion to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
None  
 
I agree to the open peer review policy of the journal. I understand tha t my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be included as confidential comments 
to the editors, which will not be published . 
 
I agree to the open peer review policy of the journal