Gynecological exams performed by a medical doctor are well known in the pelvic health world. Once a female is sexually active (or no later than the age of 21 for a female who is not sexually active), it is recommended that females undergo their first appointment with a gynecologist. A gynecologist is a physician who specializes in women's health with a focus on the female reproductive system and organs. An obstetrician is a physician who specializes in caring for women during their pregnancies and postpartum.
Fun fact: an obstetrician (OB/GYN) is a gynecologist, but a gynecologist (GYN) may not necessarily be an obstetrician. You can find out the difference by looking at the letters after the doctor's name.
A few reasons would see an OB/GYN:
- STD checks
- pregnancy/childbirth and postpartum care
- menstrual issues
- birth control treatments
- fertility care
- hormone disorders
- bowel or bladder dysfunctions
- menopause related changes (ie. changes in estrogen levels)
- cancers of the reproductive tract and breast
- Well Women Exams including pap smears, urine samples, possible blood work, vulvar check.
The American College of Obstetricians and Gynecologist (ACOG) says that a typical gynecological exam includes:
General physical exam: height, weight, blood pressure, general medical information
External genital exam: visually looking at the vulva
Pelvic exam: with the use of a speculum to observe the vagina and cervix, as well as a gloved/lubricated finger to assess internal organs
Now onto my bread and butter --- the PELVIC FLOOR MUSCLE ASSESSMENT.
A pelvic floor muscle assessment with a physical therapist varies significantly from a gynecological exam. The focus during the pelvic floor muscle assessment is not on the organs, but on the muscles. Physical therapists are the musculoskeletal and neuromuscular experts- we know all about bones, muscles + nerves, including how they function together.
A typical pelvic floor assessment with a pelvic health physical therapist includes:
1. An external assessment:
looking at the quality of the vulvar tissue - is there atrophy? dryness? redness? Any skin lesions? scars?
looking at the position of the perineum (area between the rectum and vaginal canal
looking and palpating the extra-pelvic tissues and bones (inner thighs, gluteals, pubic bone, lower belly, etc.)
2. An intra-vaginal assessment:
(Using one or two gloved fingers with lubrication)
pelvic floor muscle strength (the amount of tension with squeeze/lift aka Kegel), endurance (how long can you hold) and coordination (is it a smooth movement up/down).
pelvic floor muscle excursion : can you contract? (Kegel), can you relax? Can you lengthen?
pelvic floor muscle awareness: can you feel a squeeze and a lift? Can you feel a relaxation? Can you feel a bulge? Do you feel what the pelvic therapist feels or different
pelvic floor sensation: any difference in the ability to feel touch from the left to right sides?
pelvic floor muscle palpation: do touching these muscles cause any discomfort? Reproduce any of your symptoms of urgency/pain/pressure etc.
assessing for prolapse (descent of the pelvic organs)
pelvic floor muscle movement in coordination with the core muscles and breath.
The Pelvic Floor Clock
When assessing the pelvic floor muscles intra-vaginally, physical therapists often utilize whats called the "pelvic floor clock" in order to communicate where they are touching internally to the patient, as well as to know what muscles they are touch. We can see these muscles like we can the biceps muscle, so we must reliance on our palpation skills!
Check out this photo to the right demonstrating the pelvic floor clock.
A rectal muscle examination can also be performed by a pelvic health physical therapist. This may be utilized with symptoms such as constipation, fecal incontinence, or pain with sitting. This type of assessment is using performed while laying on your side, or on your belly.
Now to compare these two assessments, they are very different. When thinking about the postpartum check-in with the OB/GYN, remember: they are the experts on reproductive health/wellness with their focus is on the internal organs, NOT the muscles. Pelvic health physical therapists focus on how the pelvic floor muscles are coordinating and working in relation to the rest of the body.
In my opinion, all women should be getting an annual or bi-annual "well-women" pelvic floor muscle assessment, OR sooner if you are experiencing any pelvic floor muscle related symptoms (ie. incontinence, pain/pressure at the pelvis/hips or low back, or sexual dysfunction). After your 6-week postpartum check- in, ask your OB/GYN for a referral to a pelvic health physical therapist, even if you just aren't sure.
OBGYNs and pelvic floor physical therapists often refer to each other - OBGYNs send patients to physical therapists when they find musculoskeletal issues. Physical therapists refer to OBGYNs when they notice any non-musculoskeletal concerns.
Here is a great video by Julie Sarton from Sarton Physical Therapy on what you should expect during your first pelvic floor physical therapy visit.
Click here for the handout I put together on a pelvic floor muscle assessment self guide, If you are interested in performing your own pelvic floor muscle assessment.