The Difference between a Gynecology Exam and Pelvic Floor Physical Therapy Exam
When a woman seeks out my help, we generally start our relationship with a consult call. This allows questions to be asked by both parties to make sure we are a good fit and I can provide the services necessary to help meet her goals.
During this call I describe what she may expect during the initial visit, including the possibility of a pelvic exam. I lightly joke that it doesn’t involve a speculum or stirrups, but I’m not really joking around.
To begin lets first look at how our professions are different.
OB-Gynecologist
A OB-Gynecologist is a medical doctor, trained in human pathology, with specialty training in treating diseases/disorders of the female reproductive organs. Obstetricians care for women who are pregnant, are involved with childbirth, for vaginal and cesarean delivery and through early postpartum. Part of the care OB-Gyn provide is prescription of medication and surgery.
Pelvic Floor Physical Therapist
A Physical Therapist (PT), such as myself is a movement expert. PTs are trained as a doctor of the physical therapy to treat people of all ages who have “medical problems or other health-related conditions that limit their ability to move and perform functional activities in their daily lives” (apta.org definition). This is most usually related to the musculoskeletal system, but can also include the nervous system integumentary (skin) system, organ systems, and the fascial system that may effect function. A pelvic floor PT (PFPT) is specially trained in the treating conditions of the muscles, joints, skin, connective tissue and organs that effect the function of the pelvis, including movement of the pelvis and joints connected to the pelvis. And since the uterus is a pelvic organ, a PFPT may have additional training in obstetrics, including fertility, pregnancy, birth and postpartum.
Both OB-gyns and PFPT perform pelvic exams to assess the pelvis and determine proper course of treatment. However, how the exams are performed is and what is assessed is very different.
OB-Gyn Exam
An OB-gyn is looking for problems in the external and internal reproductive organs, tissue mass/growths, pain, discharge, irritation/redness, that may be signs of infection or illness. During this exam, there is an external and internal screen. The typical position is on your back with your feet in stirrups and your bum slid down on the table. This gives the OB-gyn easier access to the pelvis.
The exam begins with an external visual assessment of the vulva and around the labia to rule out any masses, discharge or other skin conditions. Internally, is divided into two parts, the speculum exam and the bimanual exam. During the speculum exam, your doctor will slide a lubricated metal or plastic speculum to separate the walls of your vagina as the speculum opens. This allows your doctor an easier view of your cervix to scrape for a Pap test. Inserting a speculum may feel uncomfortable with pressure, but it should not be painful. If it is, mention it to your doctor.
After the speculum exam is the bimanual exam when your doctor inserts 1 or 2 gloved and lubricated fingers into your vagina. Then gently presses on your lower abdomen with the opposite hand to check for:
the size, shape and position of your uterus
tenderness or pain
enlarged ovaries, fallopian tubes, ovarian cysts or tumors
A bimanual exam should also not be painful and if it is may be the sign of an infection, muscle or tissue tension, scar adhesions or other condition. It is very important for your doctor to know if this portion is painful, even fleeting.
PFPT Exam
A PFPT is looking for problems in the external and internal muscles, bones and tissues of the pelvis, more specifically the pelvic floor, that may be the cause of pelvic floor dysfunction, such as pain, bladder disorders, sexual dysfunction and pain, prenatal and postpartum problems (back pain, etc), bowel dysfunction, bloating, etc. Just like the OB exam there is an external and internal screen. The position you are in depends on the PT performing the exam. The most common position is on your back with your legs supported on a small bolster in a butterfly position. You may also be asked to stand up to assess for a prolapse while in a gravity position.
The exam begins with an external screen of the perineal area to look for any scarring, tissue abnormalities, asymmetries or other skin conditions. The PFPT will then ask you to contract and relax your pelvic floor muscles to see what happens, then cough, then cough while holding a a pelvic floor muscle contraction. Then using a gloved finger the PFPT will palpate (gently press and feel) along the rim of the pelvic bones, along the perineum and inside of the labia for any pain or alternated sensation. You may be asked to contract several mores times in quick ways and holding to feel the pelvic floor muscle contraction, especially if an internal screen will be deferred.
After the external screen the PFPT will talk you through the internal screen, then once you are ready will slide one gloved and lubricated figure into your vagina. Through palpation of the vaginal wall, your muscles are assessed for atrophy, tightness, pain or other altered sensation and scarring or other restrictions and muscle strength. Pelvic floor muscle strength is assessed through palpation of each layer of the pelvic floor and with the patient performing multiple contraction and relaxation of varying lengths and intensity. During an internal screen the PFPT may also test your pelvic organ position, tailbone mobility and tenderness (which can also be performed rectally when indicated), internal hip muscle tightness and tenderness.
Just like an OB-gyn pelvic exam if at any time there is pain during a PFPT exam, speak up. This is necessary information for the PT to plan an appropriate plan of care and help you achieve your desired outcomes. Neither exam should be the cause of pain, but may elicit pain if there is a problem.
A pelvic exam is safe to perform during pregnancy, however most PFPT defer until the second trimester and then stop a few weeks prior to the due date for healthy uncomplicated pregnancies.
To recap the biggest difference between an OB-gyn and PFPT pelvic exam is the use of a speculum and what is assessed. In many states PT is a direct access state, which means you do not need to see a OB-gyn prior to seeing a PT, and this is because PFPTs are trained to look for red flags that may indicate a referral back to your OB-gyn for further testing.
So if you are concerned about a pelvic floor problem, especially if you are trying to conceive, are pregnant or just had a baby, now you know what to expect during an exam. Both exams are important in their own way, but a pelvic exam by a PFPT provides in depth information to keep your body functioning that is often over looked.