An Overview of Physiotherapy Assessment and Treatment of the Pelvic Floor

Original Editor - Jess Bell based on the course by Ibukun Afolabi
Top Contributors - Jess Bell, Kim Jackson, Tarina van der Stockt, Carin Hunter and Nupur Smit Shah

Introduction

This page aims to provide an introductory discussion of the physiotherapy assessment and treatment of the pelvic floor. Please note that further training is required through a reputable pelvic health education company before attempting the techniques discussed in this page. See the Resources section at the bottom of this page for links to pelvic and women's health special interest groups.

Clinic Environment

Before discussing the actual assessment and treatment of female pelvic health patients, it is useful to consider the environment in which you will be conducting your sessions. Where possible, it is important to be mindful of the clinic environment as the treatment setting has been shown to have an impact on a client’s health outcomes. The physical environment can help a client feel relaxed, safe and empowered or, conversely, feel stressed, threatened and tense. For instance:

• Daylight and windows have been shown to reduce fatigue and depression. Where this is not possible, indoor plants, aquariums, or nature-themed artworks can help to reduce stress
• The colour scheme can also have an impact:
  • Blue and green can promote relaxation and balance
  • Yellow and orange can energise or activate a space

For more information on evidence-based design in healthcare settings, please have a look at the following articles:

• Environmental needs, barriers, and facilitators for optimal healing in the postoperative process: a qualitative study of patients' lived experiences and perceptions
• A review of the impact of physical environmental factors on users
• Creating optimal healing environments in a health care setting

Creating a healing environment can be particularly important for women’s health clients as they may present with trauma, shame, embarrassment or other emotions associated with their condition.

The Initial Assessment

Prior to the initial assessment, it can be helpful to collect some initial information about your client by sending them:

• Forms and questionnaires
• Validated outcome measures
• Psychosocial inventories

There are many different Patient Report Outcome measures (PROs) for pelvic floor dysfunction. They can be used to:

• Screen for conditions
• Determine the impact of these conditions on an individual's quality of life
• Evaluate the effectiveness of a treatment
• Determine if an individual is satisfied with a treatment

The Pelvic Floor Disorders Consortium have found that the following outcome measures can be useful:

• To assess the severity of faecal incontinence the Cleveland Clinic Florida Incontinence Score and the St. Mark’s Incontinence Score can be used together
• To assess the severity of constipation, the Patient Assessment of Constipation and the Constipation Severity Instrument can be used together
• To assess stress and overflow incontinence, the Short Form of the Urogenital Distress Inventory can be used (this is in the final combined IMPACT tool discussed by Bordeianou et al.)
• The Short Form of the Pelvic Floor Distress Inventory, which is also in the final combined IMPACT tool, can be used to determine the impact of bowel and bladder dysfunction, and pelvic organ prolapse symptoms

For more information on these outcomes, please see the full article here.

Subjective Evaluation

Like any physiotherapy session, you must first complete a subjective assessment. During this assessment, it is necessary to actively listen to your client and gain an understanding of why she is coming to see you.

It has been suggested that motivational interviewing techniques may be beneficial for pelvic physiotherapy patients. Motivational interviewing is defined as:

"A collaborative conversation style for strengthening a person's own motivation and commitment to change."

It is an evidence-based intervention that helps to encourage health behaviour change. It has been used in areas such as weight loss, smoking cessation, alcohol consumption, and blood sugar control. It is also becoming more popular in physiotherapy practice. To learn more about motivational interview, please click here.

Other techniques that can be helpful during the subjective interview include:

• Asking open-ended questions
• Being curious / enquiring questioning
• Reflecting back to the client and summarising what has been said
• Listening without judgement
• Aiming to understand goals and what success would mean for the client
• Finding out about the impact of the client's condition on her life, work, relationships, emotions etc
• Asking about the client’s theories in order to gain insight into her beliefs about her condition

Establishing rapport, cultivating trust and safety and allowing the patient to feel heard are key goals of the initial assessment.

Objective Evaluation of the External Body

The external evaluation helps you to understand how the wider systems or structures may relate to pelvic floor dysfunction. It can also help to increase your client’s trust in your physical handling of her body.

While you may not be able to do everything in one session, you may choose to evaluate:

• Alignment
• Posture
• Movement patterns
• Breathing strategies
• Neural screen
• Abdominal wall function
• Abdominal viscera
• Spinal, hip, pelvic movements and range of motion
• Muscle strength and endurance
• Thorax
• Myofascial quality
• External scars
• The pressure system
• Motor control strategies
• Pelvic floor muscle function (externally)

Objective Evaluation of the Pelvic Floor

Please note that each country / state will have different rules and regulations about who can perform an internal examination. Many areas require specific post-graduate training. Please make sure you are familiar with the regulations / requirements in your own area before performing an internal examination and make sure you complete the necessary training.  

According to Abe-Takahashi et al., the most common method of evaluating the pelvic floor muscles is digital vaginal penetration, which will be discussed below.

Other methods include:

• Real-time ultrasound: a safe, simple, cheap, and readily accessible technique that can be used to assess pelvic floor contractions
• Perineometer: a simple, minimally invasive, low-cost tool that is used to measure pressure changes in the vagina after a voluntary contraction of the pelvic floor muscles

Before evaluating the pelvic floor, you must discuss with your client the purpose of the examination and explain what is involved, including the risks, benefits and alternatives in order to obtain informed consent. Your client may choose to decline an internal assessment.

If your client does proceed with an internal assessment, you should invite her feedback about what she is feeling.

Ask about:

• Symptom reproduction
• Pain
• Pressure
• Sensitivity
• Referral patterns

Before the assessment, set up the treatment table with sheets for draping, gloves and lubricant. It is important to provide an opportunity for your client to remove her undergarments in private.

Remember to wash your hands prior to beginning the assessment.

Figure 1. Muscles of the female perineum.

During the assessment:

• Observe the perineum, superficial pelvic floor muscles, vulva and then look at how the client reacts to palpation of these superficial pelvic floor elements
• Active tests
  • Provide cues to encourage pelvic floor engagement (e.g. “try to stop an imaginary stream of pee”)
• Assess for pelvic organ prolapse if appropriate (see below)
  • A detailed discussion of the examination and assessment of pelvic organ prolapse is available here
  • If a prolapse is suspected, a pelvic examination is required to determine the location / extent of the prolapse. The medical assessment is described as follows by Inglesia et al:
    • The vaginal opening and perineal body are observed while the client does a Valsalva manoeuvre
    • A speculum is used to assess the vaginal apex (cervix or vaginal cuff) and vaginal length is recorded
    • The client is asked to perform another Valsalva manoeuvre and the speculum is slowly removed in order to assess apical descent
    • The anterior and posterior vaginal walls are then examined
    • Measurements may be taken and the prolapse can be classified (i.e. using the POP-Q)
• Then gently introduce one or two fingers into the introitus and assess tissues internally, from superficial to deep checking for:
  • Muscle tone
  • Spasm
  • Structure
  • Position
  • Compliance
  • Tissue quality
  • Tissue texture
  • Scarring
  • Tender areas
  • Partial / complete levator ani muscle avulsion
• Assess muscle function
  • Assess responsiveness, lift, range of motion, strength, endurance and coordination
  • Compare sides
  • Observe accessory muscle recruitment
  • Assess for strain or Valsalva with the cue to lift the pelvic floor
• It may be useful to check, either vaginally or rectally, the impact of different actions, such as breathing, transversus abdominis engagement or coughing, on the pelvic floor
• Pelvic floor muscle strength is graded using a Modified Oxford Grading Scale:
  • 0 = no contraction
  • 1 = a flicker
  • 2 = weak
  • 3  = moderate contraction with a lift
  • 4 = good contraction with a lift
  • 5 = strong contraction with a lift

The following video demonstrates a pelvic floor examination. Please click through to watch this video on YouTube if you want to find out more.

During an internal examination, you will typically have your client hook-lying or side-lying. You can, however, also assess specific elements of pelvic floor muscle function in standing. Because standing is a more functional position, it can provide a more accurate understanding of how the pelvic floor functions in relation to gravity or under load.

Treatment

The treatment strategy must relate to the client’s goals and focus on what is important to her. This can help to encourage overall engagement. It is also important to encourage a client to feel connected to her body and feel that she has the power to change her system.

The initial treatment begins with awareness and increasing somatic awareness. This mind-body reconnection strategy is significant because women with pelvic floor conditions may have some “disconnect” to their pelvic floor. Awakening / reconnecting the pelvic floor is, therefore, a necessary starting point.

After reconnecting, it is possible to start to create a supple, dynamic, flexible, healthy, pain-free, strong, and resilient pelvic floor.

Treatment may focus on the following:

• Education
• Increasing somatic awareness
• Neuromuscular facilitation
• Improving pelvic biomechanics and synergies
• Improving flexibility and mobility of the pelvic floor muscles
• Increasing endurance and functional strength
• Integrated inner core retraining
• Teaching pressure management strategies
• Bladder and bowel retraining
• Manual therapy techniques
• Myofascial work
• Breath work
• Motor control training
• Down-regulating the nervous system
• Re-mapping the brain
• Pain management strategies
• Acupuncture or dry needling

It is important to adopt a bio-psycho-social-spiritual lens when working with women. Exploring how emotional health, mental health, relational health and spiritual health influence physical health is vital in these patients. Alongside this, it is important to consider how factors such as sleep, nutrition, hydration and movement, interact when working to restore pelvic health.

Specific Bladder and Bowel Retraining Techniques

Urinary Incontinence

Conservative approaches to managing urinary incontinence include behavioural and lifestyle modifications, pelvic floor retraining and using specific mechanical devices.

Specific techniques include:

• Kegel exercises
• Functional electrical stimulation (FES) may be a useful adjunct to pelvic floor retraining
• Vaginal cones (specifically for stress incontinence)

Overactive Bladder

Initial treatment for overactive bladder will include pharmacological therapy, bladder retraining, pelvic floor exercises and lifestyle modification. In particular, the focus may be on fluid modification, avoiding potential triggers and bladder retraining.

Constipation

It has been found that using a foot stool is an effective method to encourage defecation in constipated patients. Patients should also be encouraged to adopt a position where the upper body is bent forward.

Resources - Pelvic Physiotherapy Special Interest Groups

• Australia
  • Australian Physiotherapy Association - Women's, Men's and Pelvic Health
• Canada
  • Canadian Physiotherapy Association - Women's Health
• New Zealand
  • Physiotherapy New Zealand - Pelvic Womens and Mens Health
• South Africa
  • South African Society of Physiotherapists - Pelvic and Women's Health Physiotherapy Group
• United Kingdom
  • Pelvic Obstetric and Gynaecological Physiotherapy
• United States
  • American Physical Therapy Assocation - Pelvic health
• World Physiotherapy
  • International Organization of Physical Therapists in Pelvic and Women's Health (IOPTPWH)