Author: Betsey Stec, PT DPT
N2 Physical Therapy Louisville location
In order to understand what actually goes on during a pelvic floor physical therapy evaluation, we must first ask ourselves, “What is the pelvic floor?”
Pelvic Floor Anatomy
The pelvic floor is comprised of muscles, tendons, ligaments and connective tissue that forms a “floor” at the base of our pelvis. This pelvic floor has four main functions we like to call them the ‘four “S’s”.
- Supportive: The pelvic organs our bladder, bowels and in females the uterus and vaginal canal rely on the pelvic floor to stay supported and function properly.
- Sphincteric: The sphincters of the pelvic floor help keep us continent when the muscles are strong. We also rely on the muscles to relax when it is time to urinate or defecate.
- Sexual: The superficial muscles of the pelvic floor help with clitoral and penile erection and arousal.
- Stabilization: The pelvic floor muscles play a significant role in the stabilizing our hips, pelvic and lower back.
This next drawing is a wonderful visual of the pelvic floor muscles (colored pink) in relation to the organs. Now imagine if the pelvic floor is weak or injured; that could affect the position of the organs allowing gravity to pull them downwards. This can lead to a rectal, bladder or uterine prolapse, or urinary or fecal incontinence. Next, imagine that the pelvic floor muscles were too tight. This could change the expansibility of the rectum causing constipation, preventing normal flow of urine through the urethra and can even tighten up the vaginal canal, leading to dyspareunia (painful sex) or pelvic pain.
Now that we have a better understanding of the functions of the pelvic floor, what actually goes on during a pelvic floor evaluation?
Step 1: History Intake
A thorough physical therapy evaluation will begin with the therapist taking an extensive history. This does not mean just reading through your medical chart but actually sitting down with you and hearing what you as a patient have to say. Because pelvic floor dysfunction is multifactorial, the physical therapist will ask you questions about the characteristics of your pain, symptoms, bowel and bladder habits, diet, fluid intake, lifestyle choices, career, stress levels, pregnancy history, trauma, medications etc. This is a time for patients to be heard and for us as clinicians to begin formulating our physical therapy diagnosis. No diagnosis is the same and we need to hear from YOU in order to form our clinical reasoning.
Step 2: Postural Examination
What does your posture have to do with your pelvic problem? More than you can imagine! Changes in your skeletal alignment will change the length and tension of the pelvic floor musculature. Physical therapists will analyze your posture typically in standing and sitting. The PT will analyze the alignment of your entire body starting from your head all the way down to your feet. Misalignment can occur from bad habits, desk jobs, muscle weakness, muscle imbalances, scoliosis, leg length differences etc. Addressing bad postural habits, strengthening weak muscles or stretching tight muscles can directly improve your pelvic floor dysfunction.
Step 3: Movement Analysis
During the history intake, the physical therapist will discover what activities, exercises, postures or movements exacerbate your symptoms. If a mother complains of stress incontinence when picking up her children’s toys off the floor, you better believe the PT will be going to ask her to mimic picking up a toy. We want to see the quality of her movement and to assess if she exhibits a movement pattern impairment. By teaching proper squatting or lifting techniques, the mother will soon see a significant change in her incontinence.
Step 4: Orthopedic Assessment
Surprise! Pelvic Floor PT’s are actually just your everyday orthopedic physical therapists who have taken extensive continuing education courses in order to treat your pelvic floor. But to be fair to you, we are still going to use our orthopedic knowledge during the evaluation and follow-up treatments. We will evaluate your spine, sacroiliac joints, hip joints, rib cage and even analyze your breathing patterns before we ask you to take your undergarments off. If we find dysfunction such as a tight hip, stiff low back or faulty breathing pattern, chances are we will tackle those deficits first.
Step 5: Pelvic Floor Assessment
A pelvic floor assessment involves both an external and internal examination of the vagina and/or rectum. The internal assessment is the gold standard assessment for evaluating the strength, length, and quality of the pelvic floor. The PT will also check for trigger points and tension. It is a common misconception that all women should be performing kegels (pelvic floor contractions). However, if a woman has a tight or painful pelvic floor, doing kegel exercises will potentially make the muscles tighter and may even translate to more pain for the patient. When people ask “should I be doing kegels?” There is no way of answering them without performing a pelvic floor internal assessment or knowing the history of the patient. For patients who are too symptomatic or prefer not to have the internal examination performed, an external examination can be performed as well.
Step 6: Patient Education
This is a favorite step for all physical therapists. Often times, patients with pelvic pain have been through the ringer by the time they see us. Frustration, depression, and helplessness are common feelings when starting the process of pelvic floor physical therapy. Now is the time for you to understand the findings from the physical therapy evaluation, learn what the physical therapy plan consists of and finally, understand what YOU can do for yourself. Typically during this time we will also discuss the patient’s home exercise plan or at least introduce the idea to them before we get started with treatment.
Step 7: Treatment
“My goodness how many more steps are there?” Finally, we are at the point of treatment. Depending on what the physical therapist finds during the evaluation, here is a small (but not inclusive) list of what might happen during your initial visit:
- Muscle trigger point release to the pelvic floor musculature
- Mobilization of tight joints such as hips, coccyx, lumbar or thoracic spine
- Muscle energy techniques to free up restricted motion
- Pelvic floor muscle education with manual feedback or electrical stimulation if needed
- Biofeedback to assist in downregulation or relaxation of the pelvic floor musculature or upregulation to increase the pelvic floor contraction.
The physical therapist will set you up with a plan which involves some work on your part. Contrary to popular belief, your pain or dysfunction will not simply disappear with a pain pill, injection, chiropractic adjustment or massage. Again, pelvic floor dysfunction is multifactorial and as physical therapists, we are not trying to alleviate your pain temporarily, we are striving to help you rehabilitate and heal for long term results.
If you would like to set up an evaluation with any one of our other wonderful physical therapists at one of three clinics in the Boulder/Denver area, please contact us for more information!
-Dr. Betsey Stec PT, DPT
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