1/23/20

Vaginal Assessment of the

pelvic floor complex.
Kate Walsh Specialist Physiotherapist -Pelvic Health
Chelsea and Westminster Hospital
Saturday 25th January 2020

Scope of practice

Consent to treatment
Professional Use of chaperone
Issues
Confidentiality

Infection prevention/control

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Scope of practice
Standard 3: Work within the limits of your knowledge and skills
Keep within your scope of practice

3.1 You must keep within your scope of practice by only practising in the
areas you have appropriate knowledge, skills and experience for.

3.2 You must refer a service user to another practitioner if the care,
treatment or other services they need are beyond your scope of practice.
Standards of conduct, performance and ethics

HCPC (2016)

Consent to treatment

“You must make sure that you have consent from service users or other
appropriate authority before you provide care, treatment or other
services”.

• Standard 1.4 of the Standards of conduct, performance and ethics,

HCPC (2016)

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Consent: key points

“valid”
• The patient must be competent to take that particular decision
• Informed
• Not acting under duress
Consent maybe withdrawn at any time
Signature – this does not prove consent valid
• Assessment of capacity
• Our conclusions
• Our thought processes
• Relevant risk

Consent: key points contd.

The patient understands why the assessment/treatment has to be
done
• Relevant risks
• Benefits
• Alternatives

Photography/ video of patients

• Written consent

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Use of Chaperone
Risk assessment
• Lone-working
• Male therapists treating female patients
• Close technique in a state of undress
• Failure to communicate techniques with adequate explanation to
patients

• Chartered Society of Physiotherapy (2013)

Confidentiality

“Chartered Physiotherapists shall ensure the confidentiality and

security of information acquired in a professional capacity”

• Rule 3, Rules of Professional Conduct, CSP (2002)

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Infection prevention/control
• Establish and maintain a safe practice environment
• Equipment
• Therapist
• Patient
• Communication

Anatomy and mapping of the

female pelvis and pelvic floor
complex
EXTERNAL

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Aims
• Review and consolidate anatomy of the external pelvis, joints,
ligaments and muscles

• Understanding association between pelvic floor complex and lumbo-

pelvic region

• Enhance palpation skills of external pelvis and female pelvic floor

complex

• Consolidate knowledge in relation to the post-natal client

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The lumbo-
pelvic hip
complex

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Stability/ function
• Optimum function requires stability and mobility

• Static stability

• Dynamic stability

• Control (Diane Lee)

• Using optimum strategies to achieve function

• Brain/ CNS “controller”

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Form/Force closure

• Form Closure
Architecture of joints maintain integrity of system (shape, orientation
etc.)

• Force Closure
Extra forces needed to maintain integrity of system under load
(compressive forces generated by muscles, fascia, ligaments)

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Integrated Model of
Function (Lee 2004)
Framework for organizing the knowledge gained
through assessment and guiding treatment
planning

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Form Closure Force closure

Integrated
FUNCTION
Model of
Function
Motor Control
Emotions/awa (neural
reness patterning)

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Pelvic Mobility
3 planes of movement
• Ant/post (sagittal)
• Lateral tilt (coronal)
• Axial rotation (transverse)

Intra-pelvic mobility
• Sacroiliac joint
• Pubic symphysis

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SACRUM
Sacroiliac Joint
• Synovial joint with L-shaped articular surface
• Articular surfaces have complimentary ridges and depressions
• Joint capsule outer fibrous/inner synovial layer
NUTATION
• Forward flexion sacrum on ilium
• With posterior rotation ileum -> sacrum close packed position (stable)
COUNTERNUTATION
• Extension of sacrum on ilium
• With anterior rotation ileum on sacrum -> loose packed (unstable)

• Reciprocal movement at lumbo-sacral and sacrococcygeal junctions

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Common postures
• Slumped sitting

Posterior pelvic tilt

Counternutation

Compression top of pubic symphysis

Gap/widening inferiorly pubic symphysis and ischial tuberosities

(pain in “sitting bones”/long dorsal ligt.)

Lumbar flexion

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Common postures contd.

• Supine
Counternutation

• Sitting to standing
Slight nutation

• Forward flexion/extension
Complete nutation

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Common postures contd.

• Standing
Neutral pelvis
Slight nutation

• Standing - kyphotic/lordotic
• Pelvis - anterior tilt
• Complete nutation

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Pelvic
Ligaments
Key ligaments
• Anterior sacroiliac ligament
• Iliolumbar ligament
• Sacrococcygeal ligament (flex/extn
in response to pelvic floor
contraction/ relaxation )
• Sacrospinous ligament (resists
nutation)

• www.anatomy.tv

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Pelvic
Ligaments
Key ligaments
• Posterior sacro-iliac ligament
• Posterior sacrococcygeal ligament
• Long dorsal ligament (resists
counternutation)
• Sacrotuberous ligament (resists
nutation)
• Surperficial posterior sacrococcygeal
ligament

www.anatomy.tv

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Symphysis
Pubis
• Non synovial joint
• Reinforced by ligaments
Superior (fibres from abdominals and
adductors)
INFERIOR ARCUATE (stability)
Anterior
Posterior
• Inguinal ligament
• Nerve supply – pudendal and
genitofemoral (L1,2)
• Vulnerable to shear
• Gray’s anatomy for students

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Abdomino-Pelvic Cannister
• 85 joints
• specific tasks -> optimum strategies (specific co-contraction)
• Paul Hodges (2007) association of pelvic floor / diaphragm and
transversus abdominis
• Core stability
• Anticipatory feedforward activity of pelvic floor in response to Upper
limb activity (knack)
• Synergy

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Abdomino-Pelvic Cannister contd.

• Pelvic floor key role in dynamic stability (3d)
• Co-activation of trans abs with pelvic floor during lifting ->
Increased intra-abdominal pressure
Increased tension thoraco-lumbar fascia
Increased tension anterior abdominal fascia and linea alba
• Deep muscles LPHC prepare the body for loads via mechanisms that
increase intra-abdominal pressure.
• CNS - controller

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Summary key factors in successful load

transfer via the LPHC.

• Mobility maintained keeping intended path of movement

• Respiration supported
• Continence maintained
• Ability to control expected/unexpected perturbations
(internal/external)

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Studies :-
Pool Goudzwaard et al (2004)
• Increase SIJ stiffness when pelvic floor contract as group
• NOT with individual stimulation of muscles (ileococcygeus)

Pel et al (2008)
• Stimulation of trans ab. And pelvic floor -> significant decrease in
shear forces through SIJ
• Gluteus medius , minimus and piriformis increase compression
between innominate and sacrum but do not influence shear.

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Global Muscle Slings

• Posterior Sling – latissimus dorsi, gluteus maximus, thoracolumbar fascia

• Anterior Sling- external oblique, contra-lateral internal oblique,

contralateral adductors, anterior abdominal fascia

• Longitudinal Sling – erector spinae, thoraco-lumbar fascia, sacrotuberous

ligament, biceps femoris, peroneii

• Lateral Sling – gluteus medius, gluteus minimus, thoracolumbar fascia,

contralateral adductors

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PRACTICAL: External Palpation

Bony landmarks
•Anterior superior iliac spines (ASIS)
•Symphysis pubis
•Posterior superior iliac spines (PSIS)
•Inferior lateral angles of sacrum (ILA)
•Sacral sulci
•Femoral head
•Ischial tuberosities

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Practical : external palpation Contd.

Ligaments
• Arcuate
• Long dorsal
• Sacrotuberous
• Sacrospinous
• Ilio-lumbar

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Practical: external palpation contd.

Muscles
• Transversus abdominis
• Rectus abdominis
• Diaphragm
• Adductors
• Gluteals
• External Oblique

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Mapping: the Pelvic Floor and

Perineum
INTERNAL

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Orientation of
the Pelvis
• 3 dimensional

• Depth/width/height

• ASIS and symphysis pubis

perpendicular to floor

• Genital hiatus parallel

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Endopelvic
Fascia
• Support (and constriction of
urethro-vesical neck)
• Dense fibrous connective tissue
• Role in supporting pelvic organs,
continence and postural control
• Ashton-Miller and Delancey
(2009)
Pubovisceral muscle stretches x3
resting length during 2nd stage

• Delancey 2005

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Endopelvic Fascia

Endopelvic fascia surrounds vagina attaches to

Arcus Tendineous Fascia pelvis (ATFP) laterally
ATFP attaches to pubis bone ventrally and ischial
spine dorsally
Provides attachment points for support to
anchor urethra, bladder and vagina

Levator Ani
ATLA
Vesical neck
ATFP

Delancey, 2002

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Arcus
tendinous
Levator Ani
(ATLA)

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Arcus Tendineous Levator Ani (ATLA)

• Runs from ischial spine to posterior surface ipsilateral superior pubic

ramus
• Linear thickening of obturator internus fascia
• Attaches lateral to ATFP
• Palpable posterior aspect of symphysis pubis lateral to urethra

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Levator
Avulsion
• Traumatic dislodgement of muscle
from its bony insertion

• http://Sydney.edu.au/nepean/res
earch/obstretrics/pelvic-floor-
assessment/Pelvic Floor
assessment/Clinical levator
assessment.html

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Superficial
pelvic floor
muscles
www.anatomytv.com

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Superficial
Pelvic Floor

• Ischiocavernosus
• Bulbocavernosus
• Superficial transverse perineal
muscle
• Deep transverse perineal muscle

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Superficial pelvic floor

muscles (layer 1)

Ischiocavernosus
Perineum
Bulbocavernosus
Superficial transverse perineal

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Urethral sphincter
complex

Striated Urethral sphincter

Urethro-vaginal sphincter

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Urethral sphincter
complex contd.

Compressor urethra

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Deep pelvic Floor Muscles : Levator Ani

• Pubovisceral
puboperinealis
Pubovaginalis
Puboanalis
Puborectalis
• Pubococcygeus
• Ileococcygeus
• Coccygeus

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Deep pelvic floor

muscles

Coccygeus

Ileococcygeus

Pubococcygeus

Puboanalis

Obturator fascia

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Urogenital Hiatus

Rectum

Cervix
Vagina
urethra

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Levator Ani fascia

Superior fascia of the pelvic

diaphragm

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Quadratus Lumborum
Iliacus
Piriformis

Gluteus minimus

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Vertical Clock
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8 4

6
12 o’clock = symphysis pubis
4 and 8 o’clock = pubococcygeus
6 o’clock – perineal body/puborectalis

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Horizontal Clock
12

10 2

12 o’clock = coccyx
10 o’clock and 2 o’clock = Ileococcygeus
Base of finger over pubococcygeus

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HORIZONTAL CLOCK

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Associated pelvic
muscles
PIRIFORMIS
OBTURATOR INTERNUS

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Superficial pelvic floor and levator

attachments

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Deep Pelvic Floor Muscles

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Practical : Internal Mapping

Structures
• Bladder neck
• Urethra
• Arcus Tendineous Levator Ani (ATLA)
• Ischial spine

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Practical : Internal Mapping

Superficial pelvic floor muscles
• Bulbocavernosus
• Ischiocavernosus
• Superficial and deep perineii
• Observe the length of the perineal body
Deep pelvic floor muscles
• Pubovisceral muscle
-puboperinealis
-pubovaginalis
-puboanalis
-puborectalis

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Practical : Internal Mapping

Deep Pelvic Floor muscles (contd.)

• Pubococcygeus
• Ileococcygeus
• Coccygeus (Ischiococcygeus)

• Obturator Internus
• Piriformis
• Ischial spine

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Anal Sphincters

• Internal Anal Sphincter (IAS)

Circular smooth muscle

• External Anal Sphincter (EAS)

Deep and superficial components
Striated longitudinal muscle

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• Images courtesy of St Marks Hospital

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Puborectalis
Puboanalis and the
Anorectal Angle
www.anatomy.tv

Pubococcygeus

Puborectalis

Puboanalis

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Somatic Nerve Supply to the Pelvis

Somatic Motor Nerves

• Nerve to Levator Ani (S3- S5)
• Pudendal nerve (S2-4)

Somatosensory Nerves
• Pudendal (mixed)
• Ilioinguinal (L1)
• Genitofemoral (L1,2)
• Posterior femoral cutaneous nerve (L2,3,4)
• Obturator nerve (L2,3,4)

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Nerve supply Contd.

Nerve to Levator Ani
• Main somatic nerve supply for Levator Ani
• S3-5
• Sacral Plexus (L4,5 S1,2,3,4) lies on posterior pelvic wall anterior to
piriformis
Pudendal nerve
• Branches
-inferior rectal nerve
- perineal nerve
- dorsal nerve of clitoris
• Mixed nerve (motor, sensory and autonomic)

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Nerve supply contd.

Autonomic nerve supply

• Hypogastric nerve (L1-L2)
General visceral afferents
Sympathetic motor efferents

• Pelvic Splanchnic nerve (S2-S3)

General visceral afferents
Parasympathetic motor efferents

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Dermatomes

• Pelvic pain : diagnosis and management , Howard

2000

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Nerve Supply to the

perineum
a – pudendal nerve
b – posterior femoral
cutaneous nerve
c – obturator nerve
d – genitofemoral nerve

www.glowm.com

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Vulva and Perineum

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Practical: Mapping

• Vulva
• Labia Majora
• Labia Minora
• Vestibule
• Harts Line
• Bartholins Glands
• Perineum

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ASSESSMENT OF THE PELVIC

FLOOR COMPLEX

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www.integration.samhsa.
gov/clinical-
practice/handbook-
sensitive-practices4
healthcare.pdf

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Order of objective assessment

• Internal/external

• Rectal/vaginal/abdominal

• Order and specifics of assessment guided initially by subjective

findings then by what you find as you assess….

• Use observational and manual assessment skills

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External assessment
• Skin/superficial fascia
• Abdomen
• Breathing pattern
• Lumbar spine movements
• Hip and pelvic girdle ROM
• Intra-pelvic joint movements/symmetry (SIJ, Pubic symphysis)
• Pelvic girdle ligaments

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Before you start………

• Engage with the person
• take your time…no hurry
• Specific questions:-
• Anxiety?...history?
• Difficulty with previous examinations/procedures like this?
• How can you make it easier for the patient…
• Control…

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Pelvic floor/perineum
• Observe crook lying/side lying
• Scars
• Prolapse visible at rest
• Perineal descent at rest
• Haemorrhoids
• Quality of soft tissues vulva…dryness…
• Obvious areas of tightness e.g adductors, gluteals, piriformis,
abdominals, ribs ( flared?)
• Sensory testing

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Neuro testing

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Internal assessment.
Muscles (active system)
(Superficial layer/ vertical clock)
• Bulbocavernosus
• Ischiocavernosus
• Superficial transverse perineal muscle
• Deep transverse perineal muscle
• Perineal body (length/mobility?)

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Internal assessment contd.

(Deep layer /horizontal clock)
• Puborectalis
• Pubococcygeus
• Ileococcygeus
• Coccygeus

• Obturator Internus
• Piriformis

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Internal assessment contd.

• (passive system)
• Urethro-vesical junction
• Bladder neck
• Cervix
• Anterior and posterior wall support
-With/without cough
-Valsalva
• Fascial support

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Internal examination of the pelvic floor

• Position of patient/bed height/light
• Relaxed examination finger
• Palpate superficial muscles , bulbo .…pincer grip (gently!)…trigger points?
• Turn pad of finger upwards palpate urethra superior to pubic
symphysis…tenderness/mobility/urethral sphincter activity…?
• ATLA..avulsion?
• Slowly sweep vaginal wall from 2 o’clock to 10 o’clock (vertical clock)
- muscle bulk/symmetry?
-atrophy/scars ?
-soreness/pain ?
-faeces in rectum?

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Internal examination pelvic floor contd.

• Move deeper into the horizontal clock towards posterior pelvic floor
• Score the “lift” on Modified Oxford Scale Maximum Voluntary
Contraction
• More anterior compartment on vertical clock ->compression action
• Compare sides

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Muscle properties

• Strength
• Endurance
• Length
• Speed of contraction and release
• Stiffness- active/passive
• Symmetry/synergy/co-ordination

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What to assess?
• Muscle stiffness/resistance to passive stretch
• Quality of contraction … brisk/sluggish
• Controlled/fluctuating
• Direction/specific action
• Synergy – PF with diaphragm/breathing
• Co-contraction of transversus abdominis
• Compensatory muscle activity
• Release – easy/full
• Hypertonicity/shortening/asymmetry/trigger points
• Imbalance – anterior>posterior

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PERFECT scoring system

• Power – performance
• Endurance
• Repetition
• Fast (phasic)
• Elevation (posterior wall lifts MVC)
• Contraction (lower abs MVC)
• Timing (synchronicity)
Jo Laycock

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Modified Oxford Scale

0- Nil
1- flicker
2-weak (increase tensions and some lift/squeeze fingers)
3- moderate (posterior wall lifts)
4 – good (elevation of posterior wall against resistance and in-drawing
perineum)
5- strong (overcomes strong resistance against elevation of posterior
vaginal wall)

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Documentation
• Keep it simple
• Standardise your own system
• Objective
• Diagrams
• Focus of assessment – symptoms / signs

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Common post-natal pelvic floor

dysfunction
What are you going to find?

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• Urinary incontinence (urge/stress/mixed)

• Urinary Frequency/urgency
• Pelvic organ prolapse
• Pelvic pain
• Sexual dysfunction/dyspareunia
• Vaginal laxity
• Faecal urgency/incontinence
• Rectal pain
• Pelvic girdle pain

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