Demystifying Pelvic Floor Therapy: What to Expect from Internal Exams
If you are nervous about proceeding with pelvic floor therapy after hearing about internal exams or internal treatment, you are not alone. Let’s demystify the internal pelvic floor exam to help you feel more confident and at ease during your pelvic floor therapy evaluation, or perhaps to calm any fears preventing you from scheduling it. Before we dive into what exactly an internal exam is and how it is different from a gynecological exam, let’s discuss what pelvic floor therapy even is in the first place.
What is pelvic floor therapy?
Pelvic floor therapy should be the first stop for people experiencing any of the following concerns:
Urinary leakage at rest, during sneezing, laughing, or coughing, while working out
Bowel leakage and constipation
Needing to use the bathroom frequently or urgently
Pelvic pain conditions
Pelvic organ prolapse
Orthopedic pain
Birth preparation support
Returning to an active life postpartum
Pelvic floor therapy is a speciality area of physical therapy and occupational therapy. At practices like ours at Bloom Pelvic Therapy, we address the root cause of pelvic floor dysfunction using a whole-body approach to achieve lasting results.
The unique thing about pelvic floor concerns is that two people could be experiencing the same concern, such as urinary leakage, with completely different origins or root causes. Pelvic floor therapists are skillfully trained to examine the pelvic floor muscles intra-vaginally or intra-rectally to determine what factors related to your pelvic floor are contributing to your issue. For example, is your pelvic floor holding too much tension? Not enough? Is it a weakness issue? A timing and coordination issue? Is there anything related to past surgical or birth history contributing, such as scar tissue? The answer… It depends!
This is why a pelvic floor assessment is beneficial, though never mandatory, to provide the most precise clinical interpretation of your current pelvic floor concerns to inform the best way to tackle them through an individualized treatment plan. We really mean it when we say our treatment plans are as unique as you!
The pelvic floor muscles sit like a hammock within the pelvis and are largely responsible for allowing things to exit or enter the body vaginally or rectally – think for urination, bowel movements, birth, or penetration. You could see why an issue in this system as it works together with your core and the rest of your body, may pave the way for issues with urination, bowel movements, prolapse, pain with sex, birth and recovery, and other pelvic health concerns.
What Is an Internal Pelvic Floor Exam?
We recognize that merely the thought of an internal pelvic floor assessment may be off putting to many people. Rest assured that a pelvic floor exam is very different from a gynecological exam or well woman exam. This is largely because our exams have an entirely different purpose. It involves no instruments or speculums and is performed gently with open communication to ensure you are comfortable the entire time. There are no speculums, pap smears, cell sampling, or anything of the like. Our goal is primarily to palpate or feel the muscles that are surrounding the vaginal or rectal walls to determine how they are contributing to your symptoms whereas a gynecologist may be assessing the tissue of the vagina or cervix.
Internal pelvic floor exams involve the therapist first explaining to you exactly what the assessment will entail and then proceeding with the exam, given your verbal and signed consent, using one gloved and lubricated finger. By palpating, or in layman’s terms, “feeling,” the pelvic floor muscles through the vaginal or rectal walls, your pelvic floor therapist is able to determine your pelvic floor’s state of tension, strength, endurance, range of motion, and presence of scar tissue or myofascial restriction. This is something that instruments or apparatuses are unable to properly measure at this day and age. There can be differences right versus left, front versus back, and so on that may be related to other parts of your body, such as an ankle injury years ago and resultant compensatory patterns.
It is important to know that there are other options besides internal exams that could also provide your therapist helpful information, such as a visual external assessment of the vulvar area without touch or even palpating the muscles around areas such as your sit bones over clothing.
Why Internal Exams Are Important
Identifying patterns between your pelvic floor and entire body is extremely helpful as your pelvic floor therapist is working with you to understand the root cause of your symptoms using a whole-body approach. While the internal pelvic floor muscle assessment is never mandatory or required to seek treatment, it can be an instrumental step in ensuring your treatment plan is catered to the state of your specific pelvic floor and how your entire body relates to it.
Pelvic floor therapy can still be provided without an internal exam, though it will be based on a strong hypothesis of your pelvic floor strength and tone. Most clients partake in the internal assessment during their initial evaluation.
The strategies hand selected for you for follow up treatment sessions are, put simply, based on the information from your internal assessment, orthopedic assessment, history, lifestyle factors, and other areas. By identifying your specific pelvic muscle strength, tone, coordination, tender points or trigger points, and scar tissue, we are able to choose the right treatments for you at the right time. This may include targeted exercises to relieve the issue long-term, specific stretches or breathing strategies, manual therapies, and other approaches.
You Are In Control
The goal for the internal exam is not to create or push through pain. Many clients are surprised that the internal pelvic floor assessment is much more gentle than any gynecological exam they have had in the past. This is because the purpose and areas assessed are completely different, there is more time to move slowly and verbalize each step along the way, and pelvic floor therapists are specifically trained to make internal assessments as comfortable as possible, especially for those experiencing pelvic pain.
During an internal exam, you are encouraged to ask questions, share any concerns, and share anything that you are feeling throughout the exam.
What to Expect During the Exam
Before the exam:
During the evaluation (and any follow ups), you will be one-on-one with the undivided attention of your pelvic floor therapist for the full hour. Before getting to the internal exam, your therapist will discuss your symptoms, history, and goals. They may lead you through a movement screening as well as assess myofascial restriction in other areas outside your pelvic floor such as your abdomen or inner thigh muscles.
When it is time for the internal assessment, the pelvic therapist may use a pelvic model to explain what exactly the assessment entails, which area or muscles they will be assessing, and will ensure you are completely comfortable before proceeding. There will always be time before, during, and after the exam for you to ask any questions.
Your therapist will step out of the room for you to undress your lower body, lie on the mat table, and cover with a top sheet – in our clinic at Bloom, we use soft sarongs for you to cover with. No paper gowns or paper tables here. And yes, you can keep your socks on!
During the exam:
Your therapist will knock on the door and make sure you are all set before they enter. While we have our clients read and sign a consent form during the intake process, consent is always ongoing. We remind each and every person before proceeding that at any time during internal exams or internal manual therapy if they would like to stop altogether or take a break, we are happy to do so. We make sure each client knows that they are in control during the exam and can verbalize if they would like to discontinue or alternatively use a hand gesture (stop sign or hand raise).
Good news - No stirrups! You will have a top sheet draped over you during the internal exam. Some clients laugh about why we as pelvic therapists step out of the room for them to change or what the purpose of the sheet is if we are going to “see everything” anyways. The truth is that we take every step possible to ensure our clients feel as comfortable as possible across the board. These little things can make a big difference in comfort.
Your pelvic therapist will approach from the side of you rather than the end of the table as you may be used to for gynecologic visits. Leg position may vary depending on what is most comfortable for you. While lying on your back, some people prefer to have legs bent with feet planted on the mat table. Others may prefer one leg down and one leg up to feel a bit more at ease or to lean their leg against the provider or a pillow. Some may prefer a butterfly posture while others may find this to feel more uncomfortable or vulnerable. The point is – there is no one-size-fits-all. We adjust positioning to meet your needs, keep you comfortable, and ensure your body and mind feels in a position of ease.
During the exam, your therapist may first visually assess your muscle tone and palpate some of the muscles externally, such as the muscles near your sit bones or the perineal area. Depending on your concerns, your pelvic therapist may do a more in-depth vulvar screen at this visit or later visits where they are screening areas of the skin for any signs that may warrant collaboration with a specialist. During each step of the exam, the therapist will verbalize where they will be placing their hand and when so that there are no surprises.
After the external assessment, the therapist will slowly place one gloved, lubricated finger at the entrance to the vagina to begin the internal assessment. They will progress their finger to assess the tone of the 3 layers of pelvic floor muscles – assessing the muscles adjacent to the vaginal canal to the left, right, back, and front. They may ask you to try to activate or engage those muscles, relax the muscles, or bear down, which is like pushing the finger out. This will give the therapist a sense of your ability to consciously control the muscles of your pelvic floor, their range of motion, any differences in tone between sides, and provides a clue into your pelvic floor strength and coordination. Keep in mind that this is only one part of the greater picture of your pelvic health as it does not account for how your pelvic floor operates under normal conditions, such as when you are up and active!
If someone is experiencing severe pelvic pain or muscle tension, the exam (and following manual therapies) may be completed layer by layer, or little by little, thus assessing and treating only the muscles around the vaginal opening first before proceeding in later sessions to deeper pelvic floor muscle layers as appropriate. The pace of progression and muscles assessed and treated will be dependent on your specific situation.
When they have finished the exam, the therapist will slowly remove their finger. They will step out for you to dress. There will be wipes or tissues for you to use if you wish before getting dressed.
After the exam:
Your therapist will knock on the door to ensure readiness before coming back into the room to discuss findings with you. They may use a 2D or 3D pelvic model to outline exactly where your areas of concern are and which muscles are involved. They will explain the results to you in a way that makes sense and start discussing actionable steps that will be a part of your overall plan towards healing. This may include additional manual therapies internally or externally, movement, exercise, mobility, postural support, habit and lifestyle changes, and other techniques through consistent treatment sessions.
After you leave your appointment, you may experience mild soreness or you may feel completely “normal.” Either way, it is helpful to note how you feel after the exam and for how long. This will provide your therapist with important information.
If you do notice soreness, deep diaphragmatic breathing, mobility, and walking may be helpful to decrease any discomfort. If you are usually sore during or after pelvic exams, this is important to talk to your therapist about as they can provide you some strategies to use during and after internal exams or manual therapies to keep the discomfort to a minimum if present at all.
What’s Next?
Now that you have a clear picture of what an internal exam entails and the purpose, we hope that any fears of the unknown have decreased. This part of the exam is one part of creating a larger clinical picture of contributors to your concerns and future treatment strategies to support you best.
For expert care, our pelvic floor therapists at Bloom Pelvic Therapy are here to help you every step of the way! Give our Client Care Coordinators a call at 813-515-9008 or submit an online inquiry to learn more about how we can help you get the relief and support you deserve
FAQ About Internal Exams
What if I haven’t shaved or waxed? Trust us, we are not concerned with your grooming. However you are comfortable, we are comfortable!
Can I do an internal exam while on my period? Of course. Pelvic floor therapists can still complete internal pelvic floor exams and manual therapies when their client is on their period. We will simply add a little extra pad beneath you on the table to make sure you feel at ease. Nothing else about the exam will be different. We will make sure you are comfortable throughout!
Are internal exams painful? While everyone’s pain experience is different, we take every measure possible to ensure a gentle internal exam that creates minimal discomfort. If your main concern that brought you to pelvic therapy is pelvic pain or painful well woman exams for instance, we understand that this would be a significant concern. By reading your cues and fostering open communication, we will ensure that you are as comfortable as possible by proceeding with the exam and different steps of the exam at times that are appropriate for you.
Do I need a referral from my gynecologist for a pelvic floor exam? No, you are able to directly access appointments with your pelvic floor therapist without the need for a referral from a doctor. Of course, if there is any question or concern that should be brought to your gynecologist’s attention or clearance required after surgery for instance, collaboration with your physician will be essential. At Bloom Pelvic Therapy, we help to facilitate this collaboration for optimal outcomes.
Can I have an internal exam if I am less than 6 weeks postpartum? Most often, internal exams are postponed until after the 6-week clearance by the gynecologist postpartum. However, there are times prior to this time that internal exams are warranted, which can be a collaborative decision with your therapist and gynecologist. Either way, there is valuable information that can be gleaned from an external exam as well as a movement screening and improvements that can be made in your symptoms through treatment strategies without needing the internal exam right away. In other words, you are able to start pelvic floor therapy and then proceed with the internal exam once the time is right.
Can I do an internal exam when pregnant? Yes! You can certainly undergo internal exams and manual therapies while pregnant. Out of an abundance of caution and due to the many changes going on during this timeframe, we typically do not complete an internal exam or manual therapies within the first trimester. We do perform internal exams and treatment during the second and third trimesters, which can provide valuable insight into any pelvic floor dysfunction or necessary birth preparation.