Pelvic Floor Muscle Evaluation: Physical Therapists Can Do What?!
By Courtney ClarkSeptember 9, 2013
Guest Post by Katie Band
Hello again! In my last blog I gave the low-down on me and what I do. I hope you found it to be educational or at least used it as something to get you to sleep! I also promised last time that I would give the quick and dirty as to what you can expect if you came in with a pelvic floor complaint. (Scroll down to see “conditions treated”)
My last blog went into detail about what an orthopedic manual physical therapist was. The purpose: enhance the readers knowledge, outline the skill set of this type of PT, and bring awareness to patients with pelvic floor complaints suggesting that just because pain, signs, or symptoms were most pronounced there, the dysfunction may not reside there, but is a rather a victim of something else, say the low back or ribcage. The ability to assess the quality of movement throughout the body is vital to treating pelvic floor dysfunction. I often see patients with pelvic floor complaints who have also had a history of low back, hip, ankle pain, the list literally goes on and on. That being said, a pelvic floor muscle assessment (PFMA) may not be where we begin as something else may be “driving the bus” a la Diane Lee. There are also times I have fantastically blessed patients that have never suffered much more than a paper cut but leak urine when they run >1.5 hours (stress urinary incontinence, SUI) after delivery. Depending on what I find, this latter individual with SUI may have a specifically pelvic floor driven issue.
Many individuals have seen a physical therapist or minimally have some type of idea of what a session might look like, but it certainly never involved anyone asking you to undress from the waste down. Hence why I decided I would write about what a pelvic floor muscle assessment would look like. I promise you, its not all that scary and you ALWAYS get to decide how much or how little we do.
An initial evaluation involves a historical review first and foremost. This will give me an idea of your chief complaint and important medical history. I feel very strongly about empowering patients to have a better understanding of their condition and take the time to provide a lot of education both during the initial evaluation as well as follow up visits. If a PFMA is deemed appropriate and if you are ready, I will ask you to sign a pelvic floor muscle assessment consent form (see page 23). I will then step out of the room and have you undress. The table will be set up with a flat sheet that you will place over yourself.
The pelvic floor has three distinct layers, all of which will be assessed intravaginally and/or intrarectally with a gloved, lubricated finger. In the event that penetration is too painful, we may not initially get past the first layer. That’s ok!
Layer 1: Primarily palpation to the tissue as seen in the picture. A pelvic floor contraction (PFC/kegel) and relaxation (bearing down as if passing gas) as well as a cough will be requested to assess the tissues movement.
Layer 2: The urogenital diaphragm. Insertion of the index finger to the first knuckle. A PFC will be completed again. Tissue will be assessed with pad of finger in clock manner (12-6 and 6-12 on either side).
Layer 3: The levator ani, the part of the pelvic floor that gets all the press. Top view is side view with the tailbone on R side of picture. Second view looks down into the pelvic basin with pubic bone in front (think of looking down into a bowl). All structures are palpated as seen in the picture and a PERFECT exam (see pages 633-634) will be completed here, giving information of the pelvic floor (PF) endurance (how long does it hold, 70% of the PF fibers do this) as well as its ability to quickly contract (30% of the PF fibers, aka quick flicks) and PF ability to relax and lengthen.
This is a bare bones, basic pelvic floor assessment. “There’s more??” Yes! So much more! However, my hope is that its something you feel less scared about. No speculum, no stirrups, and I promise to never hurt you. Stick around for my next blog on “kegels”.
*This site was utilized to provide an example of conditions often seen and treated. It is by no means an exhaustive list. Note: intravaginal examinations are not performed on pregnant women or those with current infections in the pelvic floor region, however, layer 1 can be safely assessed during pregnancy. Intrarectal examinations can be performed on pregnant women with the consent of the referring provider overseeing your care.
Please feel free to leave comments, questions, concerns! Until next time…