Men's Health Physiotherapy Pelvic Assessment

Original Editor - Stacy Schiurring based on the course by Pierre Roscher
Top Contributors - Stacy Schiurring, Kim Jackson, Jess Bell and Lucinda hampton

Introduction

Disclaimer: This page aims to provide an introductory discussion of men's health physiotherapy assessment techniques. 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 men's health special interest groups.

Biopsychosocial Model

New information and research is being published frequently on men's pelvic health. Men's health physiotherapy is a quickly expanding and growing speciality area of practice. It is important to practise within a physiotherapy scope of practice and refer to other medical and therapeutic specialities as needed for proper treatment of this medically complex patient population.

Please read here for more in-depth information on the biopsychosocial model with regards to men's health. Please read here for more general information on the biopsychosocial model.

The use of assessment tools in men's health physiotherapy allows the therapist to track changes over time, but can also serve as a motivator for the patient to see their progress over multiple treatment sessions.

The Therapeutic Relationship

It can be uncomfortable for patients to talk about issues related to urinary incontinence and sexual dysfunction. Patients may be embarrassed about discussing these intimate details with their healthcare provider. The development of a strong therapeutic relationship is beneficial as it can help patients feel comfortable and at ease. Confidentiality and privacy are important for pelvic health patients. A private treatment room will allow the patient to feel more comfortable to share sensitive information. It is also advisable to ask whether the patient would like their partner to be present during the session. Patients who have the support of their partners tend to have better therapeutic outcomes.

Subjective Examination/ The Interview

Physiotherapy assessments start with a well-structured subjective assessment to gain insight into the patient's past and current medical and mental state. Subjective interviews should start with well-phrased open-ended question such as ”what can I help you with?" or "what has brought you in to see me today?” Allow the patient time to answer questions without interruption and listen carefully to their ideas, concerns and expectations. After carefully listening to their story, the therapist can then start asking more specific questions to gain further insight into their condition.

Questionnaires

The use of questionnaires may provide a non-threatening strategy for a patient to express their concerning symptoms and highlight areas of concern for the physiotherapist to focus on during the rest of the assessment. Questionnaires may be sent to patients before a scheduled appointment or they may complete them in the room with you.

Useful Questionnaires for Men's Pelvic Assessments:

• Expanded Prostate Cancer Index Composite (EPIC): a health-related quality of life instrument that measures a wide spectrum of urinary, bowel, sexual, and hormonal symptoms. The EPIC is a validated instrument recommended by the Fourth International Consultation for Sexual Medicine in 2015.
• International Index of Erectile Function (IIEF): a self-reported outcome measure to evaluate erectile dysfunction and other sexual problems in men. There is a 5- and 15-question version of this outcome measure. The IIEF is a validated instrument recommended by the Fourth International Consultation for Sexual Medicine in 2015.
• Erection Hardness Scale (EHS): a self-reported outcome measure to evaluate subjective erection hardness. Research has found that this scale has merit for use in clinical practice, and can complement and supplement other assessment questionnaires.
• International Consultation on Incontinence Questionnaire (ICIQ): a questionnaire for evaluating the effect of urinary incontinence frequency and severity on quality of life. This questionnaire has been found to have good validity and reliability.
• NIH Chronic Prostatitis Symptom Index: a questionnaire for the assessment of symptom severity in men with chronic prostatitis/chronic pelvic pain syndrome. Research has shown this questionnaire to be reliable, valid, and responsive to change.
• Depression Anxiety Stress Scales (DASS): an outcome measure designed to assess the fundamental symptoms of depression, anxiety, and stress/tension. Research has found this scale to have strong convergent, discriminant, and nomological validity.
• Pelvic Floor Distress Inventory (PFDI): a health-related quality of life questionnaire for pelvic floor conditions. The PFDI is recommended by the International Consultation on Incontinence for assessing pelvic floor dysfunction.
• Self Evaluation of Breathing Questionnaire (SEBQ): was developed to measure breathing-related symptoms and their severity.

Medical History

It is important to establish a timeline when asking about pelvic health symptoms.

Gather information about the specific interventions a client has had. It is important to find out all the details of each procedure. For example, if the patient has a history of prostate cancer, ask about specifics such as: the dosage of radiotherapy that was given; whether the nerves were spared during a radical prostatectomy; what was the time frame between the diagnosis and intervention for their prostate cancer?

Ask about the timeline for any pain, erectile dysfunction or incontinence. Is there a history of spinal pain, hip pain or pelvic pain? Are there any psychiatric conditions or other medical conditions for which they are being treated? Have they introduced any new activities or have there been changes in their activities?

Ask for a complete list of all medication a patient is taking, especially specific medicines for erectile dysfunction as well as any “herbal” products they may be taking. While the prescription of medication is not within a physiotherapist's scope of practice, it is important to know what the patient is taking to be aware of any interactions or side effects.

Symptoms

Bladder

For more information on incontinence, urgency, frequency or any other bladder problems related to men's health physiotherapy, please read this article.

Once the type of incontinence is recognised, the cause of the incontinence must be identified. Creating a full clinical picture of the patient's incontinence symptoms will help identify the root cause of the incontinence and aid in the creation of an adequate physiotherapy plan of care.

Examples of assessment questions:

• Do they leak with activity e.g. coughing, sneezing, running, jumping or simply just transferring from sitting to standing? (stress incontinence)
• When they leak, is it a lot or a small dribble?
• How frequently do they urinate? (frequency, urgency)
• Do they get a sudden urge and are they unable to delay passing urine? (frequency, urgency)
• How much is leaking, how many pads are they using per day?
• Do they use pads just in case? (behavioural)

Objective testing of incontinence may involve weighing incontinence pads and keeping strict fluid intake and output measurements over a specific time frame. Weighing of pads is helpful to determine the amount of leakage that is occurring.

Dietary habits play a role in both bladder and bowel health. The volume of fluid intake affects bladder health. Men may restrict fluids to help prevent leaking, but this can result in more concentrated urine that can irritate the bladder and subsequently cause frequency, urgency or urge incontinence. Certain fluids can also irritate the bladder lining such as caffeine, citric juices and alcohol.

A bladder diary is a useful tool to monitor volumes, as well as types of fluid intake.

Bladder Diary

A bladder diary is a helpful assessment tool to identify the patient’s pattern and frequency of urination over a 24-hour period.

Features of a bladder diary:

• Self-reported
• Tracks three-consecutive 24-hour periods
• Patient records all meals and drinks
• Patient records all eliminations (bowel and bladder):
  • They should record if they are using male incontinence pads
  • If possible, it is preferable that they get an accurate measurement of how much urine they are passing (e.g. use a measuring cup)
• Keeps track of daily activities / activity levels

Example of how a bladder diary can be useful clinically:

• A patient with stress incontinence may record low urine outputs and a high number of used incontinence pads because they are leaking urine throughout the day
• A patient with urge incontinence will record a high number of urinary voids with small output volumes.

The Bristol Stool Chart can be helpful in determining if a patient is constipated.

Bowel Habits

When questioning a patient about their bowel habits, it is important to ask about dietary factors, as well as toilet positioning. The ideal position for defecation involves sitting with a forward lean and legs supported in a squat-like position. This allows the anatomical sling of the puborectalis around the rectum to relax and enables a bowel movement.

Sexual Dysfunction

Men can be uncomfortable talking about specific issues related to sexual dysfunction. Using the EPIC and IIEF questionnaires is particularly helpful to open up a dialogue about what type of dysfunction a patient is experiencing. A clear clinical picture of the causes of sexual dysfunction is key for successful sexual rehabilitation.

For more information on sexual dysfunction, please read this article.

Sexual dysfunction symptoms to screen for:

• Erectile dysfunction (ED)
• Sexual interest dysfunctions
• Sexual arousal dysfunctions
• Premature/rapid/early or delayed ejaculation
• Anejaculation
• Orgasmic dysfunction
• Sexual aversion disorder
• Priapism (prolonged erection of the penis)
• Peyronie’s disease (a painful curvature of the penis)
• Orgasm-associated incontinence
• Urinary incontinence in relation to sexual stimulation
• Altered perception of orgasm
• Orgasm associated pain
• Penile shortening
• Penile deformity

Pain

Men can experience different types of pelvic and sexual related pain. Use of questionnaires can help open conversations about a patient's pain. It can be helpful to have the patient's partner present during these conversations for moral support and patient comfort.

Pain can occur after treatment for prostate cancer. Post-operative pain after a radical prostatectomy typically resolves. However, pain can become persistent for a few reasons. Continued spasm in the pelvic floor muscles can result in persistent nociceptive pain and injury to the surrounding nerves can result in neuropathic pain. Focused questioning around the type of pain, area of pain, aggravating and easing factors, as well as a 24-hour pattern can help to determine the source of the painful symptoms.

Pain can come from the pelvic floor due to chronic prostatitis e.g. chronic pelvic pain syndrome (CPPS). For more information on pelvic floor pain as related to men's health physiotherapy, please read this article.

A patient can experience penile or scrotal pain. Peter Dornan PT published a map of the pudendal nerve which outlines different dysfunctions of each of the three branches and how each branch can influence pelvic pain. This can be very useful in the differential diagnosis for pelvic pain. The Pelvic Pain Foundation of Australia shares information on pudendal neuralgia (PN), as well as a useful diagram adapted from Peter Dornan's work. See this article for more information on pudendal neuralgia.

Objective Assessment or Physical Examination

The physiotherapy physical examination is important to assess pelvic floor function. Assessment of the male pelvic floor will determine if it has adequate muscle strength, length, coordination and endurance to function optimally. The objective examination should be based on the findings from the subjective interview and used to determine the origins of reported symptoms.

There are a few ways to assess the male pelvic floor objectively.

External Observation

External observation of the scrotum, testicles and penis during a pelvic floor muscle contraction can be observed. In men, a correct pelvic floor contraction will result in a lifting action of the penis.

Male pelvic floor contraction, external observation of genitals:

• Incorrect technique: any bearing down during contraction
• Correct technique: a lifting action during contraction

Musculoskeletal and Neuromuscular Assessments

Musculoskeletal and / or neuromuscular assessments may not be necessary for all men's health patients. It is important to use your clinical judgment to determine when these assessments may be appropriate. For example, when examining a patient with pelvic pain, it is often helpful to assess the lumbar spine and hips, and do a neurological examination of the spine.

Breathing assessments are also helpful, especially in men's health patients who have pressure issues, such as urinary or faecal incontinence. For these patients, an assessment of the thoracic spine and rib mobility would be indicated.

Abdominal assessments may be indicated as well. Recall that the abdominal fascia is continuous with the groin, scrotum, and penile tissue. Any sort of injury or abdominal surgery could affect the mobility of the fascia.

Real-Time Ultrasound Testing (RTUS)

Transabdominal RTUS is a valid and reliable objective method of measuring the function of the male pelvic floor.

Supra-pubic method: An ultrasound (US) probe is placed on the lower abdomen supra-pubically in a mid-sagittal location. A clear transverse image of the bladder is seen if the bladder has enough urine in it. If the patient is asked to perform a pelvic floor contraction, a bladder base (floor) lift in the cephalad direction can be visualised.

Trans-perineal method: The US probe is placed on the perineum, mid-sagittal between the anus and the penis. Sagittal images of the bladder are obtained. From this view, it is possible to assess and focus on anterior structures of the male pelvic floor. This can be useful for visualising pelvic floor contractions, which is helpful for both the clinician (i.e. for the assessment) and as a tool for patient education.

Limitations of RTUS:

• The supra-pubic method cannot identify specific components of the pelvic floor
• For the supra-pubic method, the bladder must be relatively full of urine which can be a problem for men with more severe continence problems
• Regardless of which method is used, RTUS cannot differentiate if an absence of pelvic floor movement is due to a lack of mobility (e.g. tightness or spasm of the pelvic floor muscles) or weakness / absence of active muscle contraction

In light of these limitations, it is clear that clinicians must look at the full clinical picture of the patient, and not only at isolated findings.

The following short video demonstrates supra-pubic transabdominal RTUS. Please watch at time 5:30 to see the sustained endurance test discussed below.

Internal Assessment

Digital Rectal Exam

An internal assessment of the pelvic floor is a highly skilled procedure which requires specialisation and advanced training. An internal assessment should not be performed until the physiotherapist is clinically competent.

A digital rectal examination (DRE) can be performed to evaluate the effectiveness of a pelvic floor muscle contraction and to determine if there are any tight or painful internal structures. This is a relatively invasive assessment option and can be quite painful, especially in patients who are post-radical prostatectomy. DRE is not recommended for urinary incontinence assessment as it may not be reliable in assessing the muscles primarily responsible for urethral closure pressure. For patients after radiation that are experiencing tightness and spasm of the pelvic floor, a DRE can be helpful to feel the soft tissue limitations and muscle trigger points.

RTUS is an alternative to DRE. It can be used when DRE is contraindicated or when male patients are uncomfortable or reluctant to have a DRE.

DRE Contraindications:

If a prostate infection is suspected, the examination should be deferred until the infection has resolved.

Absolute:

• Absence of anus
• Immunosuppressed patient
• Imperforate anus
• Prolapsed thrombosed internal haemorrhoids
• Stricture
• Severe anal pain
• Unwilling patient

Relative:

• Acute abdomen
• Coagulopathy
• Major rectal trauma
• Post-operative anal surgery
• Recent acute myocardial infarction
• Valvular heart disease or prosthetic valves

Standardised Tests

The following standardised tests can be used to assess pelvic floor muscle ability:

• Rapid Response Test (RRT): patients are instructed to “perform 10 maximal pelvic floor muscle contractions and relaxations as fast as possible” with the elapsed time recorded as the outcome measure.
• Sustained Endurance Test (SET): patients are instructed to “hold a maximal contraction for as long as possible, whilst continuing to breathe” with the clasped time recorded as the outcome measure.

Verbal instructions to perform a correct pelvic floor muscle contraction are: “stop the flow of urine and shorten the penis while continuing to breathe.”

Patient Education

Pelvic floor disorders, incontinence and sexual dysfunction can be very overwhelming. Providing patient education on these conditions is helpful and empowering to the patient. Establishing the patient's base knowledge is important to ensure appropriate knowledge is being shared in the most beneficial manner.

When sharing information:

• Do not to use complex medical jargon
• Give information the patient is ready to understand
• Use visual aids and pictures to help with the explanations
• Provide take home resources
• Ask if the patient would like their partner present during education sessions

Resources

Links to questionnaires and assessment forms:

• Expanded Prostate Cancer Index Composite
• International Index of Erectile Function
• Erection Hardness Scale
• International Consultation on Incontinence Questionnaire
• NIH Chronic Prostatitis Symptom Index
• Depression Anxiety Stress Scales
• Pelvic Floor Distress Inventory
• Self Evaluation of Breathing Questionnaire

• Bladder Diary Form

Patient Education Handouts:

• Johns Hopkins Medicine list of dietary bladder irritants
• Kaiser Permanente Medicine list of dietary bladder irritants

Clinical Resources:

• Pudendal Nerve Map

Professional Associations and Formal Continuing Education Courses:

• American Physical Therapy Association: Academy of Pelvic Health
• American Physical Therapy Association: On-Demand: Male Pelvic Pain Course
• Australian Physiotherapy Association: Men's Health
• Australian Physiotherapy Association: Male Pelvic Health