Many ladies dread going to the Gynae and having a speculum inserted for a pap smear. Thankfully pelvic floor internal exams don’t require a speculum and most ladies are surprised by how easily they tolerate the assessment and treatment of their pelvic floor!
I thought it may be helpful to share here the explanation we send to ladies before their initial appointment so that they know what to expect in the session . I know I always like to have an idea of what to anticipate when I am going to see someone for the first time, especially if it is to do with my vagina or rectum.
Many of the ladies we see are already feeling quite disconnected from their pelvic region as a result of struggling with pain or incontinence, and remark on how helpful they found knowing what was going to happen at the session beforehand.
In order to get the most out of the appointment in the time we have, we ask that you fill out a detailed pre appointment questionnaire before coming to see us. One of the most important questions on this form asks what you are hoping to get out of the session. The form also asks about your births if you have had children and your bladder and bowel habits. We also ask where and when you experience pain, how much sleep you get, if you have any food allergies and how stressed you currently are. It’s important we get a good general overview of how you are doing, before we focus in on why you have come to see us.
When you arrive, we discuss anything that we have highlighted of interest in your pre appointment form, and spend time educating you about your pelvic floor muscles, how they form the base of your core and how and why you may be leaking, having pain or struggling with a vaginal wall prolapse. We also explain how stress and anxiety can impact on physical well being, and what the latest research is saying about how and why we experience chronic pain.
For the assessment, we start in standing. Looking at your posture, movement and breathing pattern in standing and feel your pelvic floor movement externally (through your clothes).
We then ask you to move over to the treatment bed and begin with assessing your tummy muscles for any separation (diastasis) and have a feel of wether you are holding any tension in your abdominal wall. We also want to assess if you have any sticky scar tissue around your caeser scar or any other abdominal scars.
Ideally we then do an internal examination to assess your pelvic floor. The internal exam is to check for any evidence of a prolapse, to palpate the muscle bulk, to grade your pelvic floor muscle strength and check for any trigger points or muscle spasm in the muscles.
Your examination at your initial appointment is likely to be an internal vaginal examination. If you are struggling with any bowel symptoms, a rectal examination may be helpful too.
The internal examination is not compulsory. A vaginal examination is performed with you lying on your back with your knees bent, your left leg rests against the wall, and your right leg is supported by your Physio. (The tension in your inner thighs is linked to your pelvic floor tension, so the more relaxed your legs are, the more relaxed your pelvic floor will be when we do the internal check).
We start with looking at your pelvis from the outside. We check your skin sensation and ask if each side feels the same when gentle pressure is applies. Looking at your perineum and vulva, we then ask you to lift your pelvic floor up as if holding a fart in, and then bear down as if doing a poo and then to cough. We will then check if you are still happy for us to check internally and explain as we place one lubricated gloved finger gently in to your vagina. Here we are feeling for any muscle tension (or trigger points) within the layers of the pelvic floor and establish if any pressure on any of the pelvic floor muscles reproduces any pain symptoms you may be experiencing.
With one finger still inside to feel what is happening, we ask you to lift your pelvic floor up as if you are holding a fart in or doing a ‘kegel’ so we can establish what your range of available movement is, and how much strength your muscles have. We want to know if you can activate the muscles and if you can fully let them go too.
We then ask you again to push down as if you are doing a poo so we can ensure that you are in fact lengthening your muscles (and not tightening them up) to empty effectively when you poop. This bearing down also indicates if you have any weakening (prolapse) of your vaginal walls. Getting you to cough also gives us a good indication of your pelvic floor muscle activation ability, strength and again can highlight any prolapse symptoms.
If you are struggling with feelings of heaviness and dragging associated with a vaginal prolapse, we may ask that you then stand up so we can assess what your vaginal walls and pelvic floor muscles are doing when you are standing up.
If you are struggling with bowel symptoms and would also benefit from a rectal examination, this is done with you lying on your side with your hips and knees flexed up to your chest. We start with having a quick check externally, again asking you to squeeze and bear down and then explain exactly what we are doing as we slowly place 1 lubricated gloved finger into your rectum. Again we are assessing the general muscle tone, and how well you can contract and relax the muscles around your back passage.
If at any stage you say, or we become aware that the internal examination is uncomfortable or you are feeling at all overwhelmed, we will take our finger out and continue the assesment with the ultrasound or at a later stage. I say to ladies before I ever do an internal exam that they must not be polite, if they are in any discomfort, to please let me know!
Please don’t worry if you would rather not have an internal at your first session. There is lots that that we can do without an internal and are very fortunate to have real time ultrasound machines at both of our La Lucia and Ballito branches we can use to scan your lower tummy and see what your muscles are doing around your bladder. While this doesn’t give us as much information as an internal exam does, it is still very helpful and a great starting point if you are unsure about an internal exam. The ultrasound machine is also extremely helpful for us to assess wether your deeper core is activating as it should be, especially if you are struggling with a diastasis post birth. Seeing what your muscles are doing on the screen helps you identify how to correctlly isolate and engage your transversus abdominal muscles which can struggle to activate effectively after being stretched in pregnancy.
I hope that this has been helpful in knowing what to expect at your initial appointment. Especially if you have been debating booking in for a ‘Hello Mom’ check or help with incontinence or pelvic pain!
Please do contact me (Lulu) or Chanty if you have any further questions. You can also see more about what we do on Instagram. Lulu: @luluphysio is based in La Lucia and Chanty @beautifulpelvis is based in Ballito.
To book an appointment with either of us, you can do so online here!