PFM Examination Flashcards
Exam includes:
- internal exam
- external exam
- rectal exam
Academy of Pelvic health statements:
- internal examination of the PFM is considered within the scope of PT practice –> with appropriate post-graduate training
- PFM examination requires performance of tests & measures to aid in evaluation & treatment of specific medical conditions
Professional responsibilities:
- ethical and professional behavior
- proper infection control protocol
- patient history shows indication
- usage of proper terminology
- privacy-draping
- explanation/communication of all procedures
- consent for evaluation and treatment (patient choice)
- documentation
- referral sources shoulder be familiar with exam procedures
Indications for PFM examination:
1) incontinence (urinary or fecal)
2) Pelvic pain (perineal, abdominal, low back, hip)
3) prolapse of pelvic organs (one or more)
4) pelvic floor muscle assessment for HEP
5) scar tissue or related symptoms
6) constipation
Contraindications for Internal PFM examination
1) lack of consent
2) immediate postpartum (= 6 weeks)
3) Post op- (needs physician OK, +6 weeks)
4) severe vaginitis or atrophy
5) infection
6) severe pelvic pain
7) pediatric clients
8) ** sexual abuse (** precaution)
9) pregnancy (precaution)
PFM exam overview:
- Vaginal examination:
- not a gynecological assessment, no speculum, not called a “pelvic exam”
- Vaginal or rectal tone and size
- muscle symmetry
- contraction/relaxation
- reflexes, sensation, and pain
- strength and endurance
PFM exam overview - Rectal:
- enables better assessment of puborectalis muscle function
- allows for mobilization of the coccyx
- performed for male patients with dysfunction
PFM exam overview - other:
- sEMG/biofeedback assessment
- perform a MSK assessment of pelvis and surrounding mm
- posture and breathing patterns
Exam preparations:
1) obtain and document informed consent per facility policy
2) give clear verbal description of examination with illustration or model use as appropriate
3) patient is given permission to terminate the exam at any time and/or to ask questions
4) patient is offered opportunity to have a 2nd person in the room
Set up:
- good lighting
- assemble all needed supplies before examination
- privacy
Patient:
- empties bladder
- disrobes below the waist
- position patient in side lying or supine using pillows
- provide appropriate draping materials for privacy, such as using sheet or gown
Therapist:
- observes universal precautions
- uses latex-free, powder free gloves
- has lubricant open and nearby
- has waste receptacle available
- maintains eye contact, watches for facial expressions, other non-verbal cues
- explains exam again and acknowledges patient “readiness”
- provides ongoing communication
- avoids light movements that may convey inappropriate behavior
- position yourself for good visual and inspection and comfort
External PFM exam - observation:
Observation:
- bony landmarks
- skin integrity
- external anatomy
- perineal body mobility
Patient position:
- supine in hooklying with draping lifted for adequate viewing of structures
- other positions may be utilized in the clinic
External PFM exam - observation:
Purpose: the appearance of external structures can tell you much about the health of the tissues
Review of Landmarks:
- L5 spinous process
- Iliac crest
- PSIS
- ILA
- Coccyx (should be gloved)
- ischial tuberosity
- greater trochanter
External PFM exam - observation - color:
- color, redness/discoloration
- irritation, excoriations, dermatitis
- swelling, inflammation
- skin lesions/scars
External PFM exam - observation - vaginal introitus:
- closed
- gaping
- visible prolapse
External PFM exam - observation - hemorrhoids:
- red, active (potentially painful)
- blue latent
- skin tags, empty
Sensation testing:
- S3-5
- L and R
Identification of vulvar structures:
- mons pubis
- vulva
- prepuce–> clitoris
- perineal body
anus - labia majora
- labia minora
External PFM exam - observation:
- pain/discomfort/trigger point/muscle tension
- vaginal discharge
- vaginal mucosa: red d/t inflammation, white appearance d/t atrophic vaginitis (* or lichens sclerosis)
External PFM exam:
Palpation of muscles:
- using exam gloves
- assessing for tenderness, scar tissue, muscle overactivity, tender points
- screening several points on the PFM for pain
Anal wink test:
- tests S3-4-5
- absence may indicate spinal injury or cauda aquina
- how to perform:
Perineal body mobility and descent testing:
- voluntary contraction: engagement of PFM
- voluntary relaxation: deep breathe
- involuntary contraction: cough reflex
- involuntary relaxation: bear down reflex
Perineal body assessment procedure - voluntary contraction:
command: please contract PFM
if present:
- anus retracts/”winks”
- perineal body draws in/ascends
- clitoral hood descent/”nods”
Perineal body assessment procedure - voluntary relaxation:
command: please relax the pelvic floor muscles; observe after a contraction of the pelvic floor
voluntary relaxation if present:
- relaxation after the contraction
- perineal body descends from elevated position to in line or above ischial tubes
Perineal body assessment procedure - involuntary contraction:
command: please cough
if present: contraction of PFM or no movement
if absent: bulging of the perineal body
- what does this mean if absent???????????
Perineal body assessment procedure - involuntary relaxation:
command: bear down gently as if passing gas
Involuntary PFM relaxation:
- if present: small bulge
- if absent: contraction of no movement
- watch patient effort - some patients do not bear down fully for fear of leaking
- this is NOT a full valsava maneuver but a normal lengthening of the PFM
Perineal descent testing:
- patient is asked to bear down STRONGLY
- if present = PB is caudal to the IT –> this is abnormal lengthening
Passive (at rest) perineal descent:
- if present = flattened perineal body –> * abnormal resting position –> normal is supported
Internal PFM examination - overview:
- performed with lubrication and 1-2 finger widths for palpation
- muscle assessment: palpation of muscle, perform strength test (MMT), PERFECT test
- Tissue support testing: pelvic organ prolapse
Therapist is positioned at
side or foot of the plinth
Compare R from L using light and firm pressure
- size of muscle: normal, loose, tight
- symmetry of structure and tone
- asymmetry = circumferential defects may be d/t episiotomy, tears, lacerations, trauma, surgical scars
- sensation = difference of sensation from right to left as needed
Deep PFM/pelvic diaphragm:
Locate the “LA test location”:
- move your index finger along the vaginal wall
- note the change in tone (the cliff): usually until the proximal IP joint is beyond the introitus, approx. ~4-6cm
Deep PFM/pelvic diaphragm:
- move back slightly until your index finger rests on the thickest part of the LA muscle = ~4 and 8 o’clock OR 3 and 9 o’clock
- use light and firm pressure and compare sides: muscle size and symmetry, sensation, pain/triggerpoints/tension
Obturator Internus Palpation:
- from the LA test position move further into the vaginal canal (caudal)
- orient finger laterally at 2:00 & 10:00
- Resist bent knee hip ER:
- OI shoulder contract under your finger
- -OI works best at 30 deg hip flexion
MMT - Voluntary PFM contraction:
LA test location = ~4 and 8 oclock OR 3 and 9 o’clock
observe for accessory muscle use:
- absent or present
- name the muscles (gluteals, adductors, overuse of abdominals)
- observe the patient’s whole body during PFM contraction for breath holding, pelvic tilt, etc
Internal Pelvic Floor muscle examination - MMT
MMT (0-5 scale, Laycock):
0 = no contraction present
1 = Flicker
2 = contract but no lift
3 = lift toward the pubis and head
4 = lift and compression of examining fingers (can hold against resistance)
5 = lift of examination fingers, deflection
PERFECT - Scale by Laycock
Test of voluntary PFM contraction at MVC:
P = Power = MMT E = Endurance = How long can they hold, up to 10 seconds R = Repetitions = How many can they do, up to 10 reps F = Fast Twitch Contractions = rapid contract/relax E = Elevation = Lift of exam finger up to pubic bone C = Co-contraction of TA and PFM T = Timing = cough should elicit contraction
Tissue Support Testing (POP)
- place one or two fingers into the vaginal iontroitus to the PIP (2nd knuckle)
- continue to hold the labia minor apart with the other hand
- observe or feel for movement during cough or bearing down
- cue for “strong” bearing down
Prolapse Grading system:
Grade 1 = Not visible at the introitus/*hymen
Grade 2 = bearing down results in tissue at the introitus
Grade 3 = bearing down results in tissue outside the introitus
Anterior POP:
- gently pull down on the posterior vaginal wall
- ask patient to cough or bear down
- observe/feel for anterior wall movement posterior (toward table) and inferiorly (towards feet)
