126. Pelvic floor internal exam: Do I have to? What happens?

In this solo episode, I talk about:

• What may happen in a pelvic floor appointment (specific to internal assessment)
• The importance of finding a therapist that feels right to you (we don’t all practice the same)
• My clinical practice process and how each patient influences this
• What happens when you have your period 

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Thanks for joining me!
Here is where you can find out how to work with me:  www.pelvicfloorprojectspace.com/

mel@pelvicfloorprojectspace.com

Transcript

SPEAKER_00 0:00

So this is another solo episode and I reflect on these every single time I do them. It's crazy how like they're actually way easier. I don't have the time with anybody else. I don't have to um plan out a conversation and send it to anybody, and I can literally do it whenever I want, and they tend to be shorter because it's just myself talking. But I cannot bring myself to do them. I literally leave them till the last minute because I dread talking to myself. And every single time I have to kind of pop myself up, well, just talk and don't overthink it. But we all have our things. So today I'm covering what happens in a in a pelvic health physio appointment and specifically the dreaded internal exam. I find that whenever somebody comes in here, it's interesting to see how some people will literally skip in here. They are so excited to learn about their body. And if it means in any type of internal work, they're even more fascinated because this is a mysterious area that they just wish that they knew more about and they're excited to learn more about their body. Whereas you can see in the body language of other people, they're literally kind of shaking in their boots in the waiting room, and I can tell that they maybe haven't slept the night before because this seems so scary. And I find that the the thing, not the hardest part of my job, that the part that I take the most seriously is just trying to figure out the person as quick as I can to ease their mind so that they get the most that they can out of the appointment. And an internal exam does not need to happen. I find myself trying to kind of spit that out as soon as I can because there's a lot of information that, you know, maybe your friend has sent you to come or your doctor, your midwife, or or you've looked on social media about what is involved in a pelvic floor appointment. And a lot of times the internal exam will come up and people think, I have to have that, so I'm not gonna go. So I think one of the main things that I want to say is that doesn't need to happen. And another thing that I have to say is that obviously I'm talking today about the way I practice, and so I can't speak to how everybody else practices. I think there are probably some physios that prefer that that be part of their assessment because that's how they feel most comfortable. Whereas I've I would say that um less than 50% of the first appointments that I see with people involve that, and sometimes it never involves that. So overall, when someone comes in to see me, I don't have a preconceived notion of anything that's gonna happen. I ask them to fill out a form that that gives me some detail, but essentially I start every appointment the same. Hi, trying to make some small chat that makes them feel comfortable, and then I say, Can you tell me in your words what makes you come in here? And they give me some information, and I'm always assessing, for example, your body language or um, you know, how you tell your story, and and I really quickly am trying to figure out what are the main things that that bring you in here. And for some people it might be like, I leak, I have pain, and um I I came because I'm tired of that. And other people will come in a little bit more vague, kind of just like, I'm here because my friend sent me, they told me it's a good idea to come, or my midwife said what this would be a good thing to do in pregnancy, and then I have to tease out a little bit more, like, what about it? Like, we all have a certain amount of time and money, so what made you choose this? Like, what do you really want to get out of this? And and just like I said, after I figure out what their symptoms are or their reason for booking, I always ask, what do you want to get out of our time together? And um I, for example, on the day of recording this, I had a lady that came in today saying, I just want you to assess. I want you to assess my body because I feel so different in my body after having a baby and I want to know what's going on. Um, and other people will come in here and say, I want you to look at my pelvic floor because my Cairo, for example, told me to have my pelvic floor assessed. Other people say I just want some exercises. So again, I don't have a checklist of what we have to do in the appointment. I'm gonna ask you first and foremost, what do you want to get out of this? Listeners, whether you're a busy mom, a fitness enthusiast, or just navigating everyday life, millions of women experience challenges like bladder leaks, prolapse, or pain. It can feel overwhelming. But it doesn't have to be. 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One of the things that I've heard, an analogy I've heard before about the internal exam, is that, well, how could you, and I would say that this was even early on in my after I had my training, I kind of took out of the training that you will not be able to know what's going on in the pelvic floor until you do an internal exam. And to some extent, I kind of agree, I can't confirm anything unless I'm either, you know, palpating with my fingers or using some type of imaging. But again, it depends on what someone's coming in for, whether or not I absolutely have to have that information. I've heard before the analogy that, well, if if um you have knee pain and you come into the clinic, how could you possibly get the physio to see anything if you have leave your snow pants on, like your pants and your snowpants? How could they possibly know what's going on with your knee if they can't look at it or touch it? And I would say, um, yeah, if someone says I want to know exactly what's going on, um, and they're refusing to take off their ski pants, I might not be able to tell them. Whereas if they come in saying, I just need to start moving, or I'm I'm fearful of starting movement and I want some exercises, I can give them some exercises without knowing exactly what's going on. So I use the same analogy with the pelvic floor. It it kind of depends what you want to get out of it. But if your goal is to learn more about in general the pelvic floor or start with exercises, I don't need to touch your pelvic floor to start you with that. So once I um establish kind of what you know what they're coming in for, then I will spend some time explaining um the anatomy of the pelvic floor and perhaps the core. Depends on what their symptoms are. So I'll explain perhaps all of the factors that I'm thinking about, and then I'm and then I'll ask them to tell me where they want to start. I love analogies. That's how I explain everything. And I think about parenting. Like, if I went in, let's say, for example, I was having an issue with the behaviors of one of my children, and I went to some sort of, I'm making this up as I go, parenting expert, and they said, here, Melissa, these are five things that you and Patrick can think about as far as options to help your child. And everybody's gonna pick something different. Like there's always options, and maybe some of them are a bit more conservative than others, um, you know, and the same thing goes for helping people navigate the symptoms in their pelvic floor. I might give them a menu of options like do you want me to start you with exercise? Um, do you want to know more about pessaries? Do you want to know more about um different surgical options? Like I'll give them all the different options and then they'll tell me where they want to start. And again, I'm always reading someone's body language. Some people literally are taking their clothes off as they come in the door, they're so comfortable. And so that might be where I start because I can tell that's the most interesting to them. Whereas other people, their body language says no. And and and so that's kind of how I decide. Um if for some reason that, you know, in that first appointment, someone um says, Yes, I I would like to try the um like try the pelvic floor assessment. It depends, again, what their symptoms are, what I would do. I can't say that I do the exact same thing every single time I assess someone's pelvic floor um internally. It's kind of like saying that every single person with shoulder pain is going to be assessed the exact same way. There's just so many things that go into deciding what we look at first. Before I actually get to any type of internal kind of assessment, I like to give, find out kind of where they're at. Like what do they already know about their pelvic floor? Um, what does it feel like when they actively try to tighten their pelvic floor versus relax? I might get them to do this in different positions. I might get them to see how it relates to their abdominals or their breathing and just start to connect their essentially their control over the area. I find this always goes better than when I just say, Okay, come in, take off your clothes, I'm going in. Then it becomes a little bit more shocking to people versus something that they're learning from. I very commonly find myself saying, I like to think of this more as a pelvic floor learning experience versus an assessment. I mean, at the end of the day, I'm trying to assess what's going on, but many people are coming in more with just a lack of understanding of how the pelvic floor floor works in relationship to our bladder, our bowel. And it starts more as a learning experience than more than a treatment. Um, but there's many people that come in prepared for it. Other people feel very uncomfortable because they haven't had their toes done, they haven't waxed, they don't feel clean, they haven't shaved their legs. Um everybody has to come when they feel most comfortable. The period. A lot of people wonder, can I still have any type of internal work done or assessment if I have my period? The way I usually explain it is that I already am using when I do anything internal, I use a glove and a lubricant. So the fact that there's a different colored lubricant in there really doesn't affect me. But if you don't feel comfortable, I completely understand. I always have extra tampons here if people need to put a tampon in after. Um, but essentially once we've established that that that's gonna happen, I I start by showing them different images on my computer around like um what I'm what I'm gonna do or or showing them this will be kind of the entry that I go into. This is what it looks like on this model for it to tighten and relax. And um I, as I'm leaving the room, I leave sheets on the bed, I explain everything, and I say to them, I will explain everything as I go. I'm not just gonna go in, do something, and come out. I'm gonna help you understand your body as we go through this. I leave the room and I let them know I will knock before I come in. Um, when I come in, I tend to start on their right side. So I position myself on my stool over on the right side of the bed where I've got some different models sitting beside me that I can use. I always find that if I'm showing them on something else what I'm doing, it just makes it feel so much less uncomfortable to them if I can make it anatomical and educational rather than just uncomfortable. I always explain to them, this is for you. I don't have a checklist of things that I have to do. Please ask me anything. There's no stupid questions, because at the end of the day, the more that you can picture this area and understand it, the better off you'll be. And like, stop me if at any time you don't want me to do this. And um I I I often explain things to them before I even look. Before I even look, I s at this time I still have come in. I'm sitting beside them, I'm talking to them, and I haven't even looked at their genitalia yet. They're covered with a sheet. And um, before I even look, I quite often will explain, depending on um what they're coming in for. For example, prolapse. Let's say they're coming in and they want me to assess uh, you know, their level of prolapse. I will spend time explaining prolapse before I even go in. Because do you can you imagine that if I explain to them some of the things that I expect to find and what prolapse is like, it's it's different than me going in and saying, Oh, I found prolapse. Like if I explain to them before, I expect to find some level of prolapse because you've had a vaginal birth. That's very different than than me going in and be like, oh, here's prolapse. Um, estrogen is another example, like a lot of women that are post-menopausal, it's very different if before I even look, I explain. Now listen, I'm gonna take a look first at some of the tissue, tissues in the area just to make sure everything looks pink and lubricated. Because it would be very normal for women your age that are not using estrogen that I see different tissue changes. Like it's more pale in color or it looks more frail. And that's very different than going in and be like, whoa, it sounds looks like you have low estrogen. So I find I try to give some context before I go in as to what I'm I'm going to be looking for. And of course, I'm looking for body language. Like if somebody at this point is sitting there and really holding their legs together and it doesn't feel comfortable for them to open their legs, I'll sit there and say, Are you okay with this? Tell me what's going on. And maybe they share with me, oh man, like I've had so many things in this area that are traumatic, like I'm having a hard time. And so I spend a lot of time at that point just explaining, of course you do, and you know, you know, how can I help you? And there's never a point where I'm forcing myself in when someone's body language says no. I remember a lady who um was very kind of open that um she felt more comfortable bringing in her own gloves and her own lubricant, and so that I of course I was receptive to that. And and then from there, what I do depends on on what you're coming in for. A lot of people in pregnancy will come in with the goal to, I want to be proactive, I want to learn about my pelvic floor, I want to have the best birth I can, I want to help my recovery. So I definitely look at this as a as an opportunity to teach them about their body rather than just an assessment. And so I'll go in and I'll I'll show them with a combination of the models I have and images on my computer, things like what it looks like when the baby comes out and how that's related to the pelvic floor, how the pelvic floor is related to the anatomy of the uterus and the diaphragm and where we want to push from and what it get them to feel what it feels like to squeeze on my finger because that's not what we want when a baby comes out, versus relax. I I go in and I often push on the muscles to the point where I'm gonna create a bit of discomfort. And then I say to them, What do you notice? And they said, Oh, I create tension, which is normal. When we have pain, we create tension and they can see, oh, they can start to put the dots together that this is where my baby's gonna come out of. I don't want tension in that area, and so then I'll go through with them different things they can do in their body that help them feel relaxation, which is very different for each person. Some people, it's really kind of different breathing cues that help them feel that relaxation. For some people, it's visuals. For some reason, some people think and imagine different things, and that's what helped them relax. But that tactile feedback of me pushing on the muscles can often give them that. But from there we can talk about, yeah, where to push from, like what muscles in your body will create push above the level of the baby and how to feel that with the relaxation. A lot of people are very tactile learners and they get a lot out of that. Um, the postpartum woman, it's very common that people come in and are nervous, maybe about like, oh my gosh, I had some tearing, I'm expecting the worst down there, or I assume something's really wrong because I'm having pain with sex. Um, some people just say, like, I just thought somebody would look. I couldn't believe that my care provider never looked down there. And so postpartum, again, not mandatory, but some people find it very helpful when they can understand what their discomfort's from. I think too often the scar, the scar of the epesiotomy gets blamed when when sometimes it's different areas of the pelvic floor holding tension. Just because, so even after the incision or the scar heals, it doesn't mean the muscles just go back to kind of a normal tension. Quite often they're holding, and that can be giving you some of your discomfort, and you think it's a healing issue. So I find that's a time where people find it very helpful to learn, like, oh my gosh, I'm doing okay, and these are some things I can work on. Um, another reason that someone might come in and and and wish for some assessment of their pelvic floor, people that are experiencing pain with sex, because this can feel like, oh my gosh, is something wrong with my muscles? Is something wrong with my vagina? Um, I don't know how to relax. And so in this case, I always think of like I like the term, the the this is how I think of it, is like red light, green light. I am not gonna push my finger into your pelvic floor if I'm getting a red light because I'm trying to help you relax and learn how to soften your muscles for penetration. And so if I create more discomfort or fear, that's not good, we're not gonna get anywhere. So, where what I would do um lots of times, these people would start with more like not internal work, but more external explanation, going home, working on relaxation techniques and and feeling more control of their pelvic floor. And then I might use the visuals and the models to show them, you know, when I put my finger right at the entry of your vagina, these are the muscles. Now tighten on my finger, relax. Do you feel that difference between tighten and relax? When I go in farther, I'll show them where in the pelvis I am and get them maybe to tighten and relax, and then get them to notice that perhaps when they relax their whole body, how that influences their pelvic floor or the squeeze on my finger, um, how different breathing techniques, and and I find that it's it's really interesting when people start putting the dots together, they're like, oh my God, I don't relax when I'm having when I'm going to have sex because I'm anticipating pain. Whereas I can see that if I take my time or if I think about softening my body or breathing, then I can allow that finger to go in easier to a green light, if you will. So that would be something I might do. And then help them transition afterwards to what do they need to do to move forward from here? So if they're able to relax here in the clinic, what do they need to do at home? Would it be something that you need to practice with yourself? When do dilators come in? Um, you know, when is it helpful to practice with your partner? Because no two people are the same. And I'll come up with a plan um specific to them. Listeners, I know many of you are physios that are perhaps new to the area of pelvic health and feeling like you could benefit from some guidance as the complexity of your caseload goes up. I offer mentorship and I'm here to help. Let's figure out a structure that works best for you. My contact details are in the show notes, so please do reach out. Prolapse, I kind of already talked about. I find prolapse is something that as soon as people have any symptoms, they Google and they expect the worst. And um, this is a time, and it's really hard to practice or sorry, really hard to imagine. I think it's hard for us to imagine all the organs in our pelvis and how they're oriented. So I bring out all of my props. I often use toilet paper, rolls, balloons, my models to show what the anatomy looks like and and what happens in prolapse and be able to explain to them what's happening in their body. Um, I'm able to do pessary fitting. So sometimes they're here because they want to know about pessaries. Maybe we do pessary fitting. Um, and I think it's important to know kind of, you know, what's going on with your anatomy in order to make up a plan. And again, from from that assessment, we might talk about different options and when they should contact their doctor and when they should ask for a referral to gynecology and and all that. I've had some people that have come in before that have fear of medical exams or or PAPs. Um, one girl comes to mind that hated her routine PAP test because of some previous trauma. So her goal of coming in was to just feel more agency over those muscles. So it was very similar to the example I gave with pain with intercourse, is just helping her recognize in Her body, what she needed to be able to relax. Because generally, I kind of know different things, um, different ideas to help people relax. And when they think, Oh man, I can feel that that helped, then I would say to them, Okay, tell me why you were able to relax here, um, your pelvic floor, and allow my finger in. And you don't feel like you can do that at your doctor's office. And, you know, very common that people say, I feel like they just go so much faster, or they don't explain anything. And so this is where I would throw it back to them and say, Well, what if you ask them to take their time or explain things? Because it's well within your rights to be able to explain what you need in order to relax. Same goes for having intercourse. Anything through the anus. So, in a female, there's two different entry points. Um, obviously the vagina and the anus. And I often explain to people like the vagina generally feels like a little bit less nerve-wracking for people. Going in through the anus, it's just farther back geographically. So let's say there's some different tensions in the back part of the pelvic floor. Sometimes this will be closer to the hip or closer to the tailbone or the SI joints. Sometimes it's just a matter of being able to get farther back in the pelvis to work on the muscles that um are closer to that area. Um, sometimes I would go in there um in the anus to be able to talk to people about pooping mechanics or tailbone pain is a big one. It's the tailbone lives so far back in the pelvis that through the anus gives you closer access to those muscles. And um, I find, oh, I haven't actually really talked that in in so far. I'm picturing people are lying on their back for this assessment. I stay on their side the whole time. I'm not looking at the vagina the whole time. But I find when it comes to working through the anus or on the tailbone, I tend to prefer people on their tummy or on their side. I that's just my personal preference. Um, but again, it's not like I just say, oh, you're here, you have to have an anal rectal exam. It it would be something that I decide or that I decide with the patient. Um, through for a man, that's the only way into the pelvic floor. But um again, this would always come before after or after showing them all the musculature in the area and explaining, you know, how to feel control of those muscles before I actually go in there. Because if someone's not able to relax, then what's the point of the treatment, right? If if if I'm trying to help them relax tension or teach them about relaxing to be able to poop, if I don't have strategies to help them relax, what's my whole point of doing that assessment, right? Or that treatment. Um men, men obviously, like I said, that's the only way into their pelvic floor from um to be able to access the inside. Having said that, both men and women, I do a lot of external palpation. There are points along the tailbone and around the sit bones that you can access the pelvic floor from the outside. And sometimes it's a matter of feeling that and helping them connect the dots where they start to feel more comfortable. It's like, okay, I'll let you go in. But a lot of men will describe with pelvic, like when they have pelvic floor tension, groin pain, deep hip pain, again, tailbone pain. Um, I have a gentleman recently that has a lot of um like scrotal testicular penis pain from uh a previous surgery and and pelvic floor tension. Um so I think the big take home from that is just it depends why you come in, like what I would do. I would never make you do that. I would explain everything before I go and while I do it. And chances are good I would make that you would be going home first, or I'd be ensuring that you feel kind of comfortable with the pelvic floor. Like, what does it feel like to tense it? What does it feel like to relax it so that you can work with me in the treatment instead of feel like you're just fighting me? Now, it's crazy what um people take out of these appointments. I find that a lot of times it's you get just this kind of like, wow, I didn't even have a picture in my head about that. Like, this is fascinating. Like some people literally leave skipping out of here because they're just so um amazed by how cool their pelvic floor is, and and they're like, I didn't even realize those muscles were there. I didn't realize how much influence that I had over those muscles. A lot of people get a lot of realization, they connect a lot of dots around, like, oh I can feel in that area, which is why I came in here. Maybe it's pea issues, poop issues, sex sex issues, I can feel all the tension, but I can feel how this is related to my whole body because I can feel that when I relax tension in my whole body, my pelvic floor benefits. A lot of people start to kind of recognize that their pelvic floor is just part of the whole body. A lot of emotion can come out of working on the pelvic floor. And I can, as soon as I see the tears well up or people start feeling emotional, I always say, please, it's okay, like let it out. I am comfortable with tears. Um, we hold a lot in our pelvis, a lot of emotion can be held in the pelvis, so it is I am never surprised if that comes out. Um, I really recently did an episode about purity culture because I do see that a lot of times people that have either grown up sometimes in a very religious environment or or or culturally there's been certain messages about how much shame they have around that area, and or maybe how messages in their home they realize, wow, like I feel like this has always been a very protected, shameful area, and I can recognize that the way I feel about it is influencing tension. Um, some people, once you explain their anatomy and why they're having symptoms, they're like, wow, I'm not as broken as I thought I was. I thought my my mind went to worst case scenario and I thought everything was so bad, but thanks for explaining this. I don't feel so broken anymore. Um, another thing that they might recognize again is just that the habits they have with perhaps breathing or exercise or the way they engage their core, that tactile feedback in the pelvis can help them realize that tension that they hold in other areas. It's like, wow, I can see that that's sending tension down into my pelvic floor. No wonder I'm leaking. So people get different things out of this um pelvic floor assessment. I can't have to go back and say, like, I am talking about how I treat, and no two people are the same. It'd be like a teacher coming on here and saying, This is how I teach and this is how I think about the children. No two teachers are the same. And so when I can't suggest enough, when you're thinking about seeing a pelvic health physio, do your homework, um, whether it be to check out their website, email them, call the physio. I get a lot of uh phone calls from people saying, What do what should I expect in the appointment? And I'm always happy to return those calls because you should pick someone that feels good to you. One of the questions I frequently get is, Does it hurt? Well, I say, Well, the goal is definitely not that I hurt you. Sometimes it's kind of like if you go in to see a physio with a sore shoulder. I mean, in a in a way, we get information when we replicate that pain or we root reproduce the pain, it gives us information. But I'm not gonna sit there and try to hurt you the whole session. Um, my goal is to help you kind of get get over your symptoms or get past your symptoms. So if I just keep creating more pain, I don't think we're gonna get there. I think some take-home messages I would have are um think about the messages you hear, whether it be from friends or social media, that there's an if the social media is full of black and white information, like if you go to a pelvic floor physio, expect an internal exam. Um, no, do your homework, check out who feels right to you in your area. Absolutely, you should go into an appointment and be able to kind of say what your symptoms are and say what you want to get out of the appointment. I mean, you're the one paying for the appointment, so it's okay to say this is what I want to get out of this, and it's also okay to choose what you want to do. And if someone offers you or sells you you have to do an internal exam, you do not have to say yes. Um, and I would always be thinking of like what do you need to get out of that? Because when um I'm uh whenever I'm going to do that, I always have an idea of what we're trying to get out of it. I don't just do it because. So it's it's okay to go in and have an idea of what you like what purpose would it serve? Um and ask questions because the more you can picture the area and understand it, the more you'll be able to make sense of your symptoms. And I hope that you're able to get something out of my rambling conversation with myself, and that in some way, shape, or form, you feel more comfortable going to see a pelvic health physio for the first time. And that's a wrap. If you enjoyed the show, can I ask you a big favor? Would you do one of three things for me? Number one, leave a review because we could all use a little positive feedback sometimes. Number two, download the episodes because it helps me see what people are interested in. Or number three, share it with somebody else. Because sharing is caring. Catch you next time.