GENITO-URINARY PHYSIOTHERAPY

ASSESSMENT

Submitted by-
MUSKAN RASTOGI
SECOND SEMESTER
MPT(OBG)-GYNAECOLOGICAL PHYSIOTHERAPY
ROLL NO. 222139001
KASTURBA MEDICAL COLLEGE
MANGALORE

Moderated by
Ms. Namrata Singh Chauhan
M.P.T, Associate Professor
Department of Physiotherapy
Kasturba Medical College
Mangalore

1
 CONTENTS
[Link]. Name of the content Page no.
1. The Genitourinary system 3-8
2. Disorders of Pelvic Floor 9-14
3. Risk Factors for Pelvic floor disorders 15
4. Subjective Assessment 16-17
5. Objective Assessment 18-19
6. Visual Observation 19-20
7. Digital Palpation 21-25
8. Outcome measures 26-29
9. Investigations 30
10. Problem list 30
11. Goals 30
12. Treatment 30
13. References 31

2
 THE GENITOURINARY SYSTEM
The urogenital system, also called the genitourinary system, is concerned with the organs
of reproduction and urinary excretion. Although their functions are unrelated, the structures
involved in excretion and reproduction are morphologically associated and often use
common ducts.
The major structures of the urinary system are the kidneys, ureters, bladder, and urethra. The
major structures of the reproductive system in females are the ovaries, fallopian
tubes, uterus, and vagina.

Urinary System
1. Kidneys- The kidney's primary function is the elimination of waste from the bloodstream
by production of urine. They perform several homeostatic functions such as: -

1. Maintain volume of extracellular fluid

2. Maintain ionic balance in extracellular fluid.
3. Maintain pH and osmotic concentration of the extracellular fluid.
4. Excrete toxic metabolic by-products such as urea, ammonia, and uric acid.
The way the kidneys do this is with nephrons. There are over 1 million nephrons in each
kidney; these nephrons act as filters inside the kidneys. The kidneys filter needed materials
and waste. Needed materials go back into the bloodstream; unneeded materials become urine
and are expelled through the urethra.
In some cases, excess wastes crystallize as kidney stones. They grow and can become
painful irritants that may require surgery or ultrasound treatments. Some stones are small
enough to be forced into the urethra.
2. Ureters- The pelvic ureter extends from its crossing over the pelvic brim up to its
opening into the bladder. It measures about 13 cm in length and has a diameter of 5 mm.

3. Bladder- The bladder is a hollow muscular organ with considerable power of distension.
Its capacity is about 450 mL (15 oz), but it can retain as much as 3–4 liters of urine. When
distended, it is ovoid in shape. It has got: (1) an apex, (2) a superior surface, (3) a base, (4)
two inferolateral surfaces, and (5) a neck, which is continuous with the urethra. The base and
the neck remain fixed even when the bladder is distended.
4. Urethra- The female urethra extends from the neck of the bladder to the external urethral
meatus. It measures about 4 cm and has a diameter of about 6 mm. The bladder base forms
an angle with the posterior wall of the urethra called the posterior urethrovesical angle
(PUV), which normally measures 100°. The urethra runs downwards and forward in close
proximity to the anterior vaginal wall. About 1 cm from the lower end, it pierces the
triangular ligament. It ultimately opens into the vestibule about 2.5 cm below the clitoris.

3
4
Reproductive System
1. Ovaries- The ovaries are paired sex glands or gonads in female which are concerned
with:
 Germ cell maturation, storage, and its release.
 Steroidogenesis.
Each gland is oval in shape, and pinkish-grey in color and the surface is scarred during the
reproductive period. It measures about 3 cm in length, 2 cm in breadth and 1 cm in thickness.
Each ovary presents two ends—tubal and uterine, two borders—
mesovarium and free posterior and two surfaces— medial and lateral.
The ovaries are intraperitoneal structures. In nulliparae, the ovary lies in the ovarian fossa on
the lateral pelvic wall. The ovary is attached to the posterior layer of the broad ligament by
the mesovarium, to the lateral pelvic wall by the infundibulopelvic ligament and to the uterus
by the ovarian ligament.

2. Fallopian tubes- The uterine tubes are paired structures, measuring about 10 cm (4"),
and are situated in the medial three-fourth of the upper free margin of the broad ligaments.
Each tube has two openings, one communicating with the lateral angle of the uterine cavity,
called uterine opening, and measures 1 mm in diameter; the other is on the lateral end of the
tube, called pelvic opening or abdominal ostium, and measures about 2 mm in diameter.
The important functions of the tubes are— (1) transport of gametes, (2) to facilitate
fertilization, and (3) survival of the zygote through its secretion.

3. Uterus - The uterus is pyriform in shape and measures approximately 9 cm in length,

6.5 cm in width and 3.5 cm in thickness. It is divided anatomically and functionally into
body and cervix. It weighs 1 ounce (60 g). The line of division corresponds to the level of
the internal os, and here the mucous membrane lining the cavity of the uterus becomes
continuous with that of the cervical canal . At this level the peritoneum of the front of the
uterus is reflected on to the bladder, and the uterine artery, after passing almost transversely
across the pelvis, reaches the uterus, turns at right angle and passes vertically upwards along
the lateral wall of the uterus. The cervix is divided into vaginal and supravaginal portions.
The fundus of the uterus is that part of the corpus uteri which lies above the insertion of the
fallopian tubes. The cavity of the uterus communicates above with the openings of the
fallopian tubes, and by way of their abdominal ostia is in direct continuity with the peritoneal
cavity. The uterine cavity is triangular in shape with a capacity of 3 mL. The lower angle is
formed by the internal os. The lateral angle connecting to the fallopian tube is called the
cornual end. The wall of the uterus consists of three layers, the peritoneal covering called
perimetrium, the muscle layer or myometrium and the mucous membrane or endometrium.
The uterus is capable of distension during pregnancy, as well as with distended media
during hysteroscopic examination. Otherwise the two walls are in opposition.
Its endocervical cell lining are as follows:
 The cilia are directed downwards and prevent ascending infection.
 The cells sieve out abnormal sperms and allow healthy sperms to enter the uterus.
 It provides nutrition to the sperm.
 It allows the capacitation of sperms.
5
[Link]- The vagina is an elastic, muscular tube connected to the cervix proximally and
extends to the external surface through the vulva vestibule. The distal opening of the vagina
is usually partially covered by a membrane called the hymen. The vaginal opening is located
posterior to the urethra opening. The function of the vagina is for sexual intercourse and
childbirth. During sexual intercourse, the vagina acts as a reservoir for semen to collect
before the sperm ascending into the cervix to travel toward the uterus and fallopian tubes.
Also, the vagina also acts as an outflow tract for menses.

6
 MUSCLES OF THE PELVIC FLOOR
They are the Levator Ani, Coccygeus muscle , the piriformis and Obturator internus muscle.

7
DISORDERS OF PELVIC FLOOR

Classification

8
PELVIC ORGAN PROLAPSE
Pelvic Organ Prolapse is when 1 or more of the organs in the pelvis slip down from their
normal position and bulge into the vagina.

It can be the womb (uterus), bowel, bladder, or top of the vagina.

A prolapse is not life-threatening, but it can cause pain and discomfort.

Symptoms can usually be improved with pelvic floor exercises and lifestyle changes, but
sometimes medical treatment is needed.

Pelvic organ prolapse symptoms include:

 a feeling of heaviness around your lower tummy and genitals

 a dragging discomfort inside your vagina
 feeling like there's something coming down into your vagina – it may feel like sitting
on a small ball.
 feeling or seeing a bulge or lump in or coming out of your vagina.
 discomfort or numbness during sex
 problems peeing – such as feeling like your bladder is not emptying fully, needing to
go to the toilet more often, or leaking a small amount of pee when you cough, sneeze
or exercise (stress incontinence)

The investigations include:

 Bladder function tests, which measure how well bladder and the structures around it
work.
 A urinary tract X-ray (intravenous pyelography), which allows to view kidneys, bladder,
and ureters and see how well they’re working.
 A voiding cystourethrogram, which involves X-rays of your bladder before and after pee
and shows if there’s something wrong with the bladder or urethra.
 A CT scan of the pelvis, which can help to rule out other conditions.
 An ultrasound of the pelvis, which creates an image of your pelvic organs so that we can
see if more than one organ has slipped out of place.
 An MRI scan of the pelvis, which creates a 3D image of pelvic organs and muscles and
can help your doctor confirm pelvic organ prolapse.

URINARY INCONTINENCE
Urinary incontinence — the loss of bladder control — is a common and often embarrassing
problem. The severity ranges from occasionally leaking urine when you cough or sneeze to

9
having the urge to urinate that's so sudden and strong that the sufferer doesn’t get to a toilet
in time.
Urinary incontinence symptoms

Many people experience occasional, minor leaks of urine. Others may lose small to moderate
amounts of urine more frequently.

Types of urinary incontinence include:

 Stress incontinence. Urine leaks when you exert pressure on your bladder by
coughing, sneezing, laughing, exercising or lifting something heavy.
 Urge incontinence. You have a sudden, intense urge to urinate followed by an
involuntary loss of urine. You may need to urinate often, including throughout
the night. Urge incontinence may be caused by a minor condition, such as
infection, or a more severe condition such as a neurological disorder or diabetes.
 Overflow incontinence. You experience frequent or constant dribbling of urine
due to a bladder that doesn't empty completely.
 Functional incontinence. A physical or mental impairment keeps you from
making it to the toilet in time. For example, if you have severe arthritis, you may
not be able to unbutton your pants quickly enough.
 Mixed incontinence. You experience more than one type of urinary incontinence
— most often this refers to a combination of stress incontinence and urge
incontinence.

Ways to diagnose urinary incontinence include:

 A bladder diary: The person records how much they drink, when urination occurs,
how much urine is produced, and the number of episodes of incontinence.
 Physical exam: The doctor may examine the vagina and check the strength of the
pelvic floor muscles. They may examine the rectum of a male patient, to determine
whether the prostate gland is enlarged.
 Urinalysis: Tests are carried out for signs of infection and abnormalities.
 Blood test: This can assess kidney function.
 Postvoid residual (PVR) measurement: This assesses how much urine is left in the
bladder after urinating.
 Pelvic ultrasound: Provides an image and may help detect any abnormalities.

10
  Stress test: The patient will be asked to apply sudden pressure while the doctor looks
out for loss of urine.
 Urodynamic testing: This determines how much pressure the bladder and urinary
sphincter muscle can withstand.
 Cystogram: An X-ray procedure provide an image of the bladder.
 Cystoscopy: A thin tube with a lens at the end is inserted into the urethra. The doctor
can view any abnormalities in the urinary tract.

PELVIC FLOOR TENSION MYALGIA

Symptoms
• May relate to the sensation of pain: pain, tender, ache, discomfort
• May relate to the sensation of increased tone: tight, tense, narrow or constricted

Signs
Tenderness or tender point on palpation of PFMs per perineum, per Vaginam, or per rectum
as well one or more of the following signs:
• Lack of perineal and/or PFM descent with sustained increased intra‐abdominal pressure
• Absent, partial or delayed relaxation of perineum and/or PFM after contraction
• Nonrelaxing PFM
• Hypertonicity, or increased PFM tone, on a continuum from transient increase in tone to
spasm
• Fasciculation
• Reduced flexibility of the vaginal opening

Investigations
Muscle tenderness as assessed by digital algometry (palpometry)
The finding of increased tone from any tool which measures tone (dynamometry,
myotonometry, manometry, EMG, ultrasound or MRI)
• if EMG reveals an inconsistent or elevated resting baseline or slow de‐recruitment, this
suggests increased
myoelectrical activity, which may be termed overactivity in the PFM.

11
PELVIC FLOOR MYOFASCIAL PAIN SYNDROME

Symptoms
Presence of pain

Signs
Tender point in a taut band (localized increased tone) of skeletal muscle
Patient pain recognition on tender point palpation
Referral pattern
Local twitch response
The paired criteria of tender points in taut bands and predicted or recognized pain referral
form the most frequently cited combination of diagnostic criteria

Investigations
There is no consensus regarding objective laboratory tests for myofascial trigger point
diagnosis however MR elastography and ultrasound elastography has been reported to
investigate myofascial taut bands and trigger points in the trapezius muscle.
PELVIC FLOOR MYALGIA
Symptoms Pain, tender, ache, discomfort

Signs
Muscle tenderness or tender point on palpation of PFMs and normal tone in PFM per
perineum, per Vaginam, or per rectum

Investigations
Muscle tenderness as assessed by digital algometry (palpometry)
Finding of normal tone (measured by dynamometry, myotonometry, manometry, EMG,
ultrasound, or MRI)

DECREASED PFM TONE

Symptoms
a) Loose
12
 b) Lax
c) Gaping
d) Sagging
e) Open
f) Weak
g) Bulging
h) Full
i) Loss of control
Signs
Hypotonicity, decreased PFM tone, anal or introital gaping, excessive flexibility of the
vaginal opening, palpation of an anal sphincter gap or levator avulsion.
Deficit in PFM contractile function: absence of voluntary PFM contraction, decreased
strength (weakness), decreased sustained and repeated endurance, lack of perineal or PFM
elevation, no urethral lift, partial or uncertain levator closure, small to no change in levator
hiatus on contraction
Investigations
Any tool which measures tone (measured by dynamometry, myotonometry, manometry,
EMG, ultrasound, or MRI)
– If EMG reveals a reduced signal amplitude or peak microvolts, or shorter duration of
sustained contraction this suggests decreased myoelectrical activity, which may be termed
“underactivity” in the PFM

VAGINISMUS
Vaginismus is a sexual pain disorder that is characterized by difficulties and pain with
vaginal insertion (e.g., during sexual intercourse, or when using a tampon) as well as
significant fear and anxiety associated with penetration.

Symptoms
Pain, tight, tense, narrow, or constricted.
Signs
Transient increased tone—inability to maintain relaxation with attempted vaginal penetration
(f)
Increased PFM tone
Investigations
Assessment of resting tone (measured by dynamometry, myotonometry, manometry, EMG,
ultrasound or MRI)
Increased activation of PFM shown by perineal or peri‐anal EMG during attempted vaginal
penetration.

DYSPAREUNIA- genital pain experienced before, during, and after coitus.

VULVODYNIA- chronic and anonymous pain that is felt around the introitus of the vagina.
13
VESTIBULODYNIA- unexplained pain around the opening of the vagina and inner lips of the
vulva, aka the vestibule

PUDENDAL NEURALGIA
Symptoms -Pain in the distribution of the pudendal nerve and its referral areas,
Primarily the genitalia including the vulvovaginal, anorectal, and distal
urethral areas.
Worse in the sitting position
Pain does not wake the patient at night, no numbness of the perineum.
The patient may also have associated pelvic floor symptoms.
Signs
Nantes criteria sign: No loss of sensation in the pudendal distribution on objective testing.

Other signs include:

• Tenderness to palpation anywhere along the length of the pudendal nerve
• Increased tone and tenderness of the obturator internus or piriformis muscles (depending on
the location of the nerve irritation)
• Positive pudendal nerve neurodynamic test
• Positive pudendal nerve provocation test
Investigations
As per Nantes criteria: may be confirmed by relief of patient's pain after a pudendal nerve
block with or without guided imaging

PUDENDAL NERVE PROVOCATION TEST

14
RISK FACTORS OF PELVIC FLOOR DISORDERS.
Age
increasing age increases the risk of urinary incontinence/overactive bladder (UI/OAB),
pelvic organ prolapse.
Family history
Family history of pelvic floor dysfunction increases the risk of UI/OAB and AI.
Body weight
Greater BMI increased the risk of OAB/UI but only when women were divided into high
versus low BMI groups.
Active second phase of labour
Having a second phase of labour greater than 20 minutes to 1 hour increases the risk of UI.
Mode of birth
Vaginal delivery is generally associated with an increased risk of symptoms of PFD when
compared to Caesarean delivery.
Multiple pregnancy
Women with multiple pregnancy are at increased risk of PFD compared to those with
singleton pregnancy.

PFD symptoms pre-pregnancy

symptoms of pelvic floor dysfunction (PFD) pre-pregnancy increases the risk of PFD
symptoms post-pregnancy.

The genitourinary assessment is concerned with the detailed examination of the reproductive
and urinary organs.
1. Subjective Assessment
15
A focused genitourinary subjective assessment collects data about the signs and symptoms of
GU diseases, including any nutritional issues, relevant medical or family history of GU
disease, and any current treatment for related issues. interview questions used to explore the
medical and surgical history, symptoms related to the gastrointestinal and genitourinary
systems, and associated medications. The information gained from the interview process is
used to tailor the subsequent physical assessment and create a plan for patient care and
education.

 Ask about urinary symptoms, including dysuria, urinary frequency, or urinary

urgency. Dysuria is any discomfort associated with urination and often signifies a
urinary tract infection.
 Patients with dysuria commonly experience burning, stinging, or itching sensations. In
elderly patients, changes in mental status may be the presenting symptom of a urinary
tract infection.
 In women with dysuria, asking whether the discomfort is internal or external is
important because vaginal inflammation can also cause dysuria as the urine passes by
the inflamed labia.
 Abnormally frequent urination (e.g., every hour or two) is termed urinary frequency.
In older adults, urinary frequency often occurs at night and is termed nocturia. The
frequency of normal urination varies considerably from individual to individual
depending on personality traits, bladder capacity, or drinking habits. It can also be a
symptom of a urinary tract infection, pregnancy in females, or prostate enlargement in
males.
 Urinary urgency is an abrupt, intense, and often overwhelming need to urinate.
Urgency often causes urinary incontinence, a leakage of urine. When patients
experience urinary urgency, the desire to urinate may be constant, with only a few
milliliters of urine eliminated with each voiding.
 Some commonly asked interview questions
1. Have you ever been diagnosed with a bladder condition?
2. Have you ever had any surgery?
3. Are you currently taking any medications, herbs, or supplements?
4. Do you experience any pain or discomfort with urination?
5. Do you experience frequent urination?
6. Do you ever experience a strong urge to urinate that makes it difficult to reach the
bathroom in time (urinary urgency)?
7. Do you have any leakage of urine when you cough, sneeze, or jump? (Urinary
incontinence)
8. Do you have difficulty starting the flow of urine?

DEMOGRAPHIC DETAILS
NAME
AGE
DATE OF ASSESSMENT
16
 ADDRESS
PHONE NUMBER

CHIEF COMPLAINT- write the chief complaint in the patient’s language. It is the chief
concern of the patient.

HISTORY TAKING
 History of Present illness- is taken with an emphasis on the timeline of when the
problem started and how it developed over time, and the degree of
symptomatology- how much the problem is affecting the patients.
 Past History- Any history relevant to the HOPI is asked here.
 Pain History- history of pain in the lower abdomen, cyclic pain associated with
the periods, continuous pain- adhesions, take accurate bowel and bladder history
also to rule out any bowel pathology.
 Medical History- to know that they are taking any medication which may affect
their gynaecological health.
 Surgical History- history of any previous gynaecological surgeries.
 Antenatal History- If the patient is pregnant, take antenatal history trimester-
wise.
 Obstetric History- Taken to know no. of pregnancies, their outcomes,
gestational ages and weights, mode of delivery, age of the children, whether
there was infertility at any time, and if so, any investigations or treatment was
taken.
 Family History- Few conditions have a familial basis. The most common
example is infertility.
 Occupational History- Indicate no. of job hours, any symptoms felt at work, etc.
 Social History- Indicates how much the patient is well adjusted to her lifestyle,
relationships, and external influences, as they may affect the prospect of
recovery from any illness.

2. Objective Assessment
The genitourinary physiotherapy assessment is more focused on examining pelvic floor
muscles.

17
Genital Examination
Checklist for prior examination
a) The patient should understand and consent to the examination.

b) If there is a male therapist, there should be a female subordinate while assessing the
patient.

c) PATIENT POSITION
• Lying or upright
• If lying, hip/knee flexion, supine, side‐lying, or lithotomy
• Number of pillows, +/− support from assessor's body

d) Ask the patient to empty the bladder first for proper examination.

e) While checking the symmetry of PFM, remember that if examining in side‐lying, there
will be a gravity effect, and the dependent side may have a different feel to the upper
side and appear asymmetrical. This may affect the therapist’s perception of PFM
resting tone.

f) Therapists should take precautions while performing PFM assessment applied during
digital palpation tests in the presence of pelvic floor pain.

g) Number of digits used during digital palpation-

 For single-digit examination (Per Vaginam), usually the index finger is used.
 For two‐digit examination (PV), usually the index and middle digits are used.

h) Orientation (e.g., lateral placement or posterior midline) and depth of examining

finger(s) during internal digital palpation examination. The examining finger must be
as close to the PFM tissue to assess PFM response.
• When performing a PV examination, the assessor’s decision as to which side or
midline to examine will be determined by lumen capacity, the presence of
tenderness or defect, and the presence of firm stool within the rectum.
• Record depth of insertion of examining finger for differential assessment of
perineal versus levator ani muscle layers. Further identification of individual
muscles is not possible in all individuals.

i) To perform maximum voluntary contraction, the patient should be provided proper

instructions in terms of wording, number of reps, and how much rest should be given
between these repetitions to reproduce the best possible MVC.

j) A try to minimize the use of accessory muscles (abdominal, hip adductor) while
contracting the pelvic floor is a must as it can influence PFM Assessment.

18
 VISUAL OBSERVATION

 PER PERINEUM AT REST

 SKIN ASSESSMENT
Skin is observed for-
A. Integrity
B. Lesions
C. Scars
D. Redness
E. Swelling
F. Colour
G. Trophic changes/Atrophy

The therapist should look for any skin changes, colour, epidermal markings,
fissures, ulcers, masses, tender areas, the presence of any discharge and its
characteristics, e.g., frothy, purulent, clear, etc., and any other abnormalities seen
which could hinder the treatment protocol.

 PERINEAL BODY LENGTH- Distance from posterior margin of vestibule to

anterior anal verge. State if more than or less than 3 cm.

 PERINEAL BODY POSITION AT REST- Relationship of the position of the

perineal body to ischial tuberosities. Palpate ischial tuberosity and visually estimate
 the relationship.

19
 INTROITAL GAPING: Opening, or no coaptation of the vagina at rest. If the
introitus is not visible at rest the labia may need to be parted.

 PER PERINEUM WITH A PFM CONTRACTION

A. Voluntary contraction of the PFM: Self‐initiated activation of the PFM. Contraction of

the bulbospongiosus, bulbocavernosus, ischiocavernosus, and transverse perinei
muscles may be observed. The assessor may need to gently move the external
genitalia (parting of the labia, lifting the scrotum to one side) to visualize the perineal
response effectively.
B. Relaxation of the PFM: Return of the perineum to its original resting position
following the voluntary contraction.

 PER PERINEUM WITH AN INCREASE IN INTRA‐ABDOMINAL

PRESSURE (IAP)

A. Perineal movement with a sustained increase in IAP: Direction of perineal movement

during a sustained effort. As there may be a difference in PFM response to bearing
down versus Valsalva, it is important to state exact test instructions depending on the
test, as the observed response may vary.
B. Valsalva: Forceful exhalation against a closed mouth, glottis, and nose. Valsalva has
been shown to result in an increase in IAP and usually an increase in PFM activation.
C. Bearing down (as if defecating): A strain or push, which results in an increase in IAP
which exerts a downward pressure, usually accompanied by PFM relaxation.
D. Perineal movement with rapid increase in IAP: direction of perineal movement during
a rapid increase in IAP such as coughing, lifting, throwing. Clarify if the patient is
instructed to contract PFM before coughing to differentiate a voluntary (learned)
response from an involuntary response (unlearned).

20
DIGITAL PALPATION
 Sensation: Test for presence, absence, or altered quality of sensation in dermatomal
distributions, especially S2‐4. May include light touch, blunt, sharp, pain, cold, and
vibration modalities.
 Perineal scarring: Presence of scar tissue on the perineum. Using a fingertip, attempt
to slide the scar in all directions. Assess for adhesion or lack of skin mobility over
underlying tissue.
 Tone: state of the muscle, usually defined by its resting tension, clinically determined
by resistance to passive movement. The recommended position of the examining digit
(s) is to place the palmar surface of the examining finger on the ischiocavernosus,
bulbospongiosus or transverse perineal muscle belly at the thickest portion of the
muscle belly, per perineum. Pressure or stretch is applied perpendicular to the muscle
fibres to assess tone.
 Tenderness: Sensation of discomfort with or without pain; discomfort elicited through
palpation of any tissue indicates unusual sensitivity to pressure or touch. May be
generalized within a muscle.
 Tender point: Area of localized tenderness occurring in muscle, muscle‐tendon
junction, bursa, or fat pad
 Pudendal nerve neurodynamics: Neurodynamic assessment evaluates the length and
mobility of the nerve to assess neurogenic origin of pain. Tension is applied to the
nerve or specific component of the nerve by lengthening the nerve or by distracting
imposing tissues. Specific components of the pudendal nerve can be put under tension
such as the inferior rectal branch, the dorsal branch, and the perineal branch.
 Cotton swab test (f): A test for vestibular tissue sensitivity. The test is performed with
a cotton swab moistened with water or lubricating gel. Gentle pressure is applied to
the following areas of the vaginal vestibule in random order: 12:00, and quadrants 12–
3:00, 3:00–6:00, 6:00–9:00, 9:00–12:00

DIGITAL PALPATION PER PERINEUM FOR SACRAL REFLEX FUNCTION

 Bulbocavernosus reflex (f): A reflex contraction of the anal sphincter and

bulbocavernosus in response to squeezing the clitoris

DIGITAL PALPATION PER PERINEUM WITH PFM CONTRACTION

 Self‐initiated activation of the PFM. The bulbospongiosus/ bulbocavernosus,

ischiocavernosus, and transverse perinei muscles may be palpated separately. The
assessor may need to gently move the external genitalia (parting of the labia) to
palpate the perineal response effectively.

DIGITAL PALPATION PER VAGINAM RESTING STATE

 Sensation: test for presence, absence, or altered quality of light touch sensation

21
  Presence of scarring: Scar tissue along vaginal walls or apex. Using a fingertip,
attempt to slide the scar in all directions. Assess for adhesion or lack of
mucosal/vaginal wall mobility over the underlying tissue.
 Tone: The recommended position of the examining digit(s) is to place the palmar
surface of the examining finger on the levator ani, PV, or PR. Pressure or stretch is
applied perpendicular to the muscle fibers to assess the tone
 Fasciculation: individual brief twitches in a muscle. They may occur at rest or after
muscle contraction and may last several minutes.
 Tenderness: Sensation of discomfort with or without pain; discomfort elicited through
palpation of any tissue indicates unusual sensitivity to pressure or touch. It may be
generalized within a muscle.
 Pudendal nerve provocation test: Palpation of the pudendal nerve to reproduce the
patient's pain if entrapment is suspected. The nerve may be palpated at the ischial
spine, sacrospinous and Sacro tuberous ligaments, or pudendal canal.
 Flexibility of the vaginal opening: The capacity of the vaginal opening to expand in
response to stretching. Assessed by separating index and middle finger in the
mediolateral direction. Digital assessment of the vaginal opening likely represents the
width of the levator hiatus.
 Test for levator injury/avulsion: palpation of levator tissue, by placing finger(s)
between the side of the urethra and the edge of the muscle measured on each side. The
test is performed at rest and confirmed by asking the patient to contract and feeling for
the edge of the contractile tissue of the levator muscle.

DIGITAL PALPATION PER VAGINAM ON PFM CONTRACTION

Voluntary contraction of the PFM: Self‐initiated activation of the PFM. A contraction is

felt as a tightening, lifting, and squeezing action under the examining finger.
Technique:
• The recommended position of the examining digit(s) to assess levator ani contraction (PV)
unilaterally is to place the palmar surface of the examining finger on the lateral levator ani
muscle belly surface or “edge,” which may be identified by asking the patient to contract and
then relax.
The presence of contraction may be rated as:
A. No contraction
B. correct contraction (cephalad and ventral movement)
C. Contraction only with help from other muscles
D. Uncertain
E. Straining
F. Absent: Noncontracting PFM: During palpation, there is no palpable voluntary or
involuntary contraction of the PFM.

Digital muscle test (DMT): A test to evaluate PFM Strength.

Strength: Force‐generating capacity of a muscle.
Usually expressed as a maximum voluntary contraction measurement (MVC). A manual
muscle test (MMT) evaluates the strength of a muscle by moving the muscle through its full
22
range of motion against gravity and then against gravity with resistance. However, because
joint range of motion is not being assessed in the pelvic floor and PFM examination is
performed with a digit, not a hand, the term DMT is preferred. There are more than 25
published DMT scales which provide grade of strength ranging from absence to weakness to
increasing strength
A. Commonly used scales include: the ICS scale: absent, weak, normal (we propose the
word “moderate” instead of normal), or strong.
B. modified Oxford grading scale 0–5
C. Brink scale grades 3 components (pressure, displacement, and time) on a scale of 1–4
D. many others

Direction of pelvic floor movement: Direction of pelvic floor movement during voluntary
PFM contraction
palpated PV (on the posterior vaginal wall)
A. Pelvic floor elevation: normal finding
B. Pelvic floor descent: palpation of downward movement of the
C. PFM during attempted PFM contraction
D. No change

Endurance: Muscular endurance refers to the ability of a muscle or muscle group to perform
repeated contractions or to maintain a contraction for a predetermined period of time.
Fatigue: A decreased capacity to perform a maximum voluntary muscle action or a series of
repetitive contractions. Fatigue may occur due to central or peripheral mechanisms. A
fatigued muscle is unable to continue working even when the type of activity is changed.
Record the time at which fatigue starts to occur, or the number of contractions in a row
before onset of fatigue.

Sustained contraction endurance test: the number of seconds the patient can hold near
maximal or maximal PFM contraction. Record number of seconds contraction is sustained at
near maximal or maximal intensity.

Repeatability of contraction: The ability to repeatedly develop near maximal or maximal

force determined by assessing the maximum number of repetitions the patient can perform.
Record number of contractions in a row.

Number of rapid contractions performed: The number of repeated, quick MVCs

performed. This can be measured in two ways, according to the instruction:
Use the rating appropriate to the instruction:
1. Number of contractions repeated within a specific duration (i.e., a 10‐s period)
2. The elapsed time to perform a pre‐specified number of contractions (e.g., 10s) A
contraction should comprise an ascending and a descending phase with the PFM force
returning to the resting state in between. If the maximal force declines, the assessment ceases
A. Record the number of contractions repeated and the duration allowed to perform them.
B. Specify the exact number of contractions to be repeated and record the number of
seconds to completion.

23
 C. Qualitative descriptions can include quality and extent of contraction and relaxation
phases.

Relaxation post contraction: Return of the PFM to its original resting tone following the
voluntary contraction. The patient is able to relax the PFMs on demand, after a contraction
has been performed. Relaxation is felt as a termination of the contraction.
A. Yes: Relaxation felt directly after instruction: normal finding
B. Partial or delayed relaxation
C. No: Absent = nonrelaxing PFM

Coordination: The ability to use different parts of the body together smoothly and
efficiently. In the pelvic floor, co‐ordination may be an action between PFMs and organ
function (e.g., PFM relaxation during voiding), PFMs and an external environmental event
(e.g., movement of a limb) and PFMs and a rise in IAP (e.g., PFM contraction before a
cough). Co‐ordination is an aspect of motor control.
A. Present
B. Absent. If absent, describe pattern of incoordination. e.g., paradoxical contraction: the
inability to maintain PFM relaxation when it is expected; or lack of PFM contraction
when it is expected.

Co‐contraction: Contraction of two or more muscles at the same time. Co‐contraction of

muscles can be synergistic (e.g., resulting in an augmentation of motor activity) or it could
be counterproductive to normal function (e.g., contraction of antagonistic muscles resulting
in abnormal movement or training other muscles instead of the targeted ones, e.g., training of
gluteal muscles instead of the PFM).Activation or inhibition of PFM contraction may be task
dependent.

DIGITAL PALPATION PER VAGINAM ONLY (F) ON PFM CONTRACTION

Urethral lift: Elevation of the urethra in a cephalad direction. Index finger is placed along
the line of the
urethra (on the anterior vaginal wall)
A. Yes: Urethral lift palpable
B. No: No urethral lift palpable

Levator closure: Movement of right and left muscle bellies closer together during a PFM
contraction (palpated on the lateral vaginal wall). May be tested unilaterally if bi‐digital
assessment is uncomfortable for the patient.
A. Yes: Levator closure movement palpable
B. Partial/uncertain: Some closure movement palpable, but could be un‐certain, or
asymmetrical
C. No: No levator closure movement palpable

Levator hiatus size: The size of the levator hiatus measured during maximal contraction by
a digital examination

24
 A. With 2 fingers in the vagina, distance measured in centimetres (converted
approximately from finger widths) during PFM contraction.
B. LH transverse: The distance between the left and right muscle bellies just inferior to
the pubic bone
C. LH sagittal: The distance between the back of the pubic symphysis and the midline
raphe of the puborectalis

OUTCOME MEASURES
1. Incontinence quality of life instrument
25
OBJECTIVE-The Incontinence Quality of Life Instrument (I-QOL) is a self-report quality of
life measure specific to urinary incontinence.

INTENDED POPULATION-Women with urinary incontinence.

METHODS OF USE-The I-QOL has 22 questions with the following 3 subscales: avoid and
limiting behaviours (items), psychosocial impacts (9 items), and social embarrassment (5
items). It is easily self-administered and takes about 5 minutes to complete.

EVIDENCE

RELIABILITY The I-QOL had high internal consistency (alpha = 0.95) for the overall
summary score. The subscales were also internally consistent at alpha 0.87 for behaviors, 0.93
for psychosocial impacts, and 0.91 for social embarrassment. The intraclass coefficient
assessment of reproducibility at 2 weeks was 0.91 for the total score and 0.87, 0.91, and 0.88
for the behaviors, psychosocial impacts, and social embarrassment subscales, respectively.

VALIDITY- Construct validity was examined by comparing the I-QOL and its subscales to
related measures. All correlations were signficant at the 0.01 level except "bodily pain." I-
QOL scores were found to be more closely related to well-being (0.42) than to either mental
health (0.35) or bodily pain (0.15).

RESPONSIVENESS- Statistics summarizing responsiveness varied from 0.4 to 0.8 and were
associated with a 2% to 13% change in the I-QOL. Minimally important changes were defined
as the percent change in I-QOL score for the improved group using the measures of pad weight
and number of incontinent episodes and lowest category of improvement for patient global
impression rating

2. PFDI 20
OBJECTIVE
The Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20) is the short-form version of
the Pelvic Floor Distress Inventory (PFDI). Similar to the PFIQ-7, it is a health-related quality
of life questionnaire for women with pelvic floor conditions to fill out. The PFDI-20 is
comprised of 3 scales, which include the Urinary Distress Inventory-6 (UDI-6), Pelvic Organ
Prolapse Distress Inventory-6 (POPDI-6), and the Colorectal-Anal Distress Inventory-8
(CRADI-8).

INTENDED POPULATION- Women over the age of 18 with disorders of the pelvic floor
including urinary incontinence, pelvic organ prolapse, and faecal incontinence.

METHODS OF USE- Since it is comprised of the UDI-6, POPDI-6, and the CRADI-8, the
PFDI-20 includes 20 questions. Each question begins with a "yes" or "no" response. If "yes,"
the patient must indicate how much bowl, bladder, or pelvic symptoms have been bothering
them in the past 3 months on a 4-point scale that ranges from "not at all" (0) to "quite a bit" (4).
The scale scores are found individually by calculating the mean value of their corresponding
26
questions and then multiplying by 25 to obtain a value that ranges from 0 to 100. The sum of
the 3 scales are added together to get the PFDI-20 summary score, which ranges from 0 to 300.

EVIDENCE-

CORRELATION- Correlation, represented by r, ranges from -1.0 to +1.0. If the r value is 0

that means there is no correlation. If the r value is close to -1.0 that means that both values will
decrease linearly. If the r value is close to +1.0, both values will increase linearly.

Correlation of the short-form versions with the long-form versions:

 UDI-6 r=0.86
 POPDI-6 r=0.92
 CRADI-8 r=0.93
RELIABILITY The test-retest reliability, represented by intraclass correlation coefficients
(ICC):

 PFDI-20 ICC=0.93
 UDI-6 ICC=0.82
 POPDI-6 ICC=0.91
 CRADI-8 ICC=0.84
VALIDITY-The PFDI-20 demonstrates construct validity as it demonstrates a significant
association with appropriate measures of symptom severity and pelvic floor diagnoses. [1]

RESPONSIVENESS- Each of the 3 scales of the PFDI-20 demonstrated moderate to excellent

responsiveness with effect size and standardized response mean values ranging from 0.70 to
[Link] sensitivity of the PFDI-20 as a whole was excellent with an effect size of 1.48 P
< .0001 and standardized response mean of 1.09 P < .[Link] ability of the PFDI-20 to
discriminate between subjects who indicated that they were "worse" after surgery from those
who indicated they were "better" was excellent with a c-statistic of .95

3. PFIQ 7

OBJECTIVE
The Pelvic Floor Impact Questionnaire-7 (PFIQ-7) is a shortened, less comprehensive version
of the Pelvic Floor Impact Questionnaire (PFIQ). It was created by Barber and colleagues
(2004) to save time, yet remain effective, in clinical and research encounters. It is a health-
related quality of life questionnaire for women with pelvic floor conditions to fill out. It
includes scales from the Urinary Impact Questionnaire (UIQ-7), Pelvic Organ Prolapse Impact
Questionnaire (POPIQ-7), and the Colorectal-Anal Impact Questionnaire-7 (CRAIQ-7), which
are short-forms of their the longer versions. It is useful to determine changes in symptom-
severity over time and before and after treatments.

INTENDED POPULATION-Women over the age of 18 with pelvic floor conditions

including urinary incontinence, pelvic organ prolapse, and faecal incontinence.
27
METHODS OF USE- The PFIQ-7 consists of 7 questions that need to be answered 3 times
each (corresponds to the scales previously mentioned) considering symptoms related to the
bladder or urine, vagina or pelvis, and bowel or rectum and their effect on function, social
health, and mental health in the past 3 months. The responses for each question range from "not
at all" (0) to "quite a bit" (3). To get scale scores, the mean of each of the 3 scales is
individually calculated, which ranges from 0-3, this number is then multiplied by 100 and then
divided by 3. The scale scores are then added together to get the total PFIQ-7 score, which
ranges from 0-300. A lower score means there is a lesser effect on quality of life.

EVIDENCE

CORRELATION-Correlation of the short-form versions with the long-form versions:

 UIQ-7 r=0.96
 POPIQ-7 r=0.94
 CRAIQ-7 r=0.96

RELIABILITY- The test-retest reliability, represented by intraclass correlation coefficients

(ICC):

 PFIQ-7 ICC=0.77
 UIQ-7 ICC=0.81
 POPIQ-7 ICC=0.70
 CRAIQ-7 ICC=0.81
VALIDITY-The PFIQ-7 demonstrates construct validity as it demonstrates a significant
association with appropriate measures of symptom severity and pelvic floor diagnoses.

RESPONSIVENESS- The PFIQ-7 has shown moderate responsiveness between the pre-
and post-operative periods for pelvic and continence surgeries. The standardized
response mean (SRM) for all the sub scales fell within the range of 0.5 to 0.7. It showed
an effect size of 0.67 and a SRM of 0.63. However, the responsiveness has been shown
to be vary amongst different patients. The highest SRMs have been found in the UIQ-7
and the CRAIQ-7 and the lowest SRMs have been found in the POPIQ-7. However, the
SRM for the POPIQ-7 increased at 3 and 12 months in patients who underwent surgery
for pelvic organ prolapse.

4. BLADDER DIARY

28
BLADDER DIARIES record the patient’s voiding patterns in their environment and during
normal daily activity. The diary provides objective information on the number of micturition,
each voided volume, and the distribution of voiding between daytime and night-time. It also
records fluid intake, urine output, and urinary incontinence episodes.
Reliability: there were not differences in the proportion of patients classified as positive for
each symptom (urgency: P = 0.3173; incontinence: P = 1; nocturia: P = 0.0522; frequency: P
= 0.4386).
The Intraclass Correlation Coefficient (ICC) ranged from 0.67 to 0.92, except for night time
VVmax which was lower (0.54). Inter-observer reliability: ICC ranged from 0.64 to 0.99,
except for day time VVmax (0.29) and the number of urgency episodes (0.45).

Validity: Spearman correlation coefficients for ICIQ-UI SF and BSAQ ranged from 0.4 to
0.6 (P < 0.0001) and for UDS were lower (P < 0.05).

INVESTIGATIONS- mention the relevant investigations done.

29
PROBLEM LIST- mention the immediate problems the patient faces based on
which goals are decided.

GOALS
there are two types of goals-
LONG TERM GOALS- To prevent any complications that may arise.
To maintain the health of the patient
SHORT TERM GOALS- Are made so that symptoms can be solved in a short
span of time.

TREATMENT GIVEN- Documentation of the treatment given to the patients.

REFERENCES
30
1. Frawley H, Shelly B, Morin M, Bernard S, Bø K, Digesu GA, Dickinson T,
Goonewardene S, McClurg D, Rahnama'i MS, Schizas A. An International Continence
Society (ICS) report on the terminology for pelvic floor muscle assessment. Neurourology
and Urodynamics. 2021 Jun;40(5):1217-60.

2.Chapter1 and chapter 9, Konar H. DC Dutta's textbook of gynecology. JP Medical Ltd;

2016 Jun 30.

3. Patrick DL, Martin ML, Bushnell DM, Yalcin I, Wagner TH, Bueshing DP. Quality of
life of women with urinary incontinence. Urology 1999;53:71-6.

4. Barber MD, Walters MD, Bump RC. Short forms of two condition-specific quality-of-
life questionnaires for women with pelvic floor disorders (PFDI-20 adn PFIQ-7). Am J
Obstet Gynecol 2005;193:103-113.

5. Barber MD, Walters MD, Bump RC. Short forms of two condition-specific quality-of-
life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7).
American journal of obstetrics and gynecology. 2005 Jul 1;193(1):103-13.

6. Barber MD, Chen Z, Lukacz E, Markland A, Wai C, Brubaker L, Nygaard I, Weidner

A, Janz NK, Spino C. Further validation of the short form versions of the Pelvic Floor
Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ). Neurourology
and urodynamics. 2011 Apr;30(4):541-6.

7. Bright E, Cotterill N, Drake M, Abrams P. Developing and validating the International

Consultation on Incontinence Questionnaire bladder diary. European urology. 2014 Aug
1;66(2):294-300.

8. Locher JL, Goode PS, Roth DL, Worrell RL, Burgio KL. Reliability assessment of the
bladder diary for urinary incontinence in older women. The Journals of Gerontology Series
A: Biological Sciences and Medical Sciences. 2001 Jan 1;56(1):M32-5.

31