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

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.

The Therapeutic Relationship

Issues around urinary incontinence and sexual dysfunction can be uncomfortable to talk about. Patients may be embarrassed about discussing these intimate details with their healthcare provider. The development of a strong therapeutic relationship is beneficial towards helping 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 conformation 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. Good subjective interviews should start with a well-phrased open-ended question such as ”What can I help you with/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 more 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.
• 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 they have had, and all the details of each procedure. For example, if the patient has a history of prostate cancer, ask about the specifics such as the dosage of radiotherapy that was given, whether the nerves were spared during a radical prostatectomy, what were the time frames 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? Any Psychiatric conditions, or other medical conditions for which they are being treated?

Ask for a complete list of all medication a patient is taking. Make sure to ask about specific medicines for erectile dysfunction as well as any “herbal” products they may be taking. While the prescription of medication is not within a physiotherapists scope of practice, it is important to know what the patient is taking to be aware of any interaction 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 aide in the creation of an adequate physiotherapy treatment plan of care.

Examples of assessment questions:

• Do they leak with activity eg coughing, sneezing, running, jumping or simply just 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 unable to delay? (frequency, urgency)
• How much is leaking, how many pads a day are they using?
• Do they use pads just in case? (behavioural)

Objective testing of incontinence may involve incontinence pad weighing accompanied by 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 as a method to 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),
  • making notes if they are using male incontinence pads
  • preferable if they are able to get an accurate measurement of how much urine they are putting out (e.g. use a measuring cup)
• Keeps track of daily activities: activity levels

Example of how 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.

Bowel Habits

In addition to asking about dietary habits, when questioning a patient about their bowel habits it is important to ask about: 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 allow for a bowel movement.

Sexual Dysfunction

Men can be uncomfortable talking about specific issues surrounding sexual dysfunction. The use of the EPIC and IIEF is particularly helpful to open up the dialogue about what type of dysfunction they are experiencing. A clear clinical picture of the causes of sexual dysfunction is key to being able to successful sexual rehabilitation.

For more information on sexual dysfunction as related to men's health physiotherapy, 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 comfort of the patient.

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. Or 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 it influences pelvic pain. This can be very useful in 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.

Objective Assessment or Physical Examination

The physiotherapy physical examination is important to assess the pelvic floor function. As a physiotherapist, you want to determine if the pelvic floor has adequate muscle strength, length and endurance to function optimally. As mentioned above, it is imperative to determine the root cause of the symptoms. Your objective examination should be based on your findings from the interview and used to determine the origins of the 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 (PFM) contraction can be observed. This allows the Physiotherapist to visualise if there is any bearing down during contraction (incorrect technique) or whether there is a lifting action during contraction (correct technique). In men, a correct pelvic floor contraction will result in a lifting action of the penis.

Musculoskeletal Assessment

Breathing here?

Ultrasound Assessment

Real-Time Ultrasound Testing (RTUS)

Transabdominal RTUS is a valid and reliable method objective method of measuring the male pelvic floor functioning. 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, and a bladder base (floor) lift, in a cephalad direction, is seen as a correct action for the PFM. Specific components of PFM cannot be identified with this method. A limitation of RTUS is that the patient requires the bladder to be relatively full of urine to be able to assess the movement thereof, which can be a problem for men with more severe continence problems

Transperineal RTUS is another method used that is slightly more complicated. The US probe is placed on the perineum, mid-sagittal between the anus and the penis. Sagittal images of the bladder are obtained. It is possible with this method to assess and focus on anterior structures when it comes to teaching correct PFM contractions.

Another limitation of real-time ultrasound of the pelvic floor is that the absence of movement on ultrasound may be from a lack of mobility eg tightness or spasm of the pelvic floor muscles rather than just weakness or absence of contraction. This is another example in pelvic health physiotherapy where it is so important to put the full clinical picture of the patient together and not only look at isolated findings.

Internal Assessment

A per rectal assessment/digital rectal examination (DRE) can be performed to evaluate the effectiveness of pelvic floor muscle contraction as well as whether there are any tight or painful structures. This is a relatively invasive option and can be quite painful, especially in patients post radical prostatectomy. For urinary incontinence assessment, a DRE may also not be reliable in assessing the muscles that are primarily responsible for urethral closure pressure so may not be as helpful for urinary incontinence.

An alternative to DRE is real-time ultrasound, and this can be used as an alternative method when DRE is contraindicated. For patients after radiation that are experiencing tightness and spasm of the pelvic floor, a DRE can be helpful to feel the soft tissue and muscles. Men are often reluctant to have a DRE which can be associated with a sense of shame

Patient Education

Issues around the pelvic floor, incontinence and sexual dysfunction can be very overwhelming, and education around the condition is very helpful. When sharing information, it is important to remember not to use complex medical jargon, to only give the information the patient would like to know, to use visual aids and pictures to help with the explanations and to give resources to take with them. Certain patients arrive with a referral letter and are very informed about their current situation, and some patients are self-referred. Establishing their base knowledge is a helpful way to make sure you can correct any misinformation and fill in any blanks they may have.

Resources

Links to questionnaires and assessment forms:

• Expanded Prostate Cancer Index Composite
• International Index of Erectile Function
• 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