Pelvic Health Guide

Many physiotherapists provide pelvic health (internal examinations) services, and there is good evidence to support many of the interventions applied by physiotherapists in the treatment of pelvic health conditions. However, physiotherapy entry-to-practice education currently provides limited instruction in this area. Due to the nature of pelvic health services delivered by physiotherapists and the frequent need to incorporate internal examinations in the assessment and treatment of pelvic health conditions, it is important that both physiotherapists and members of the public understand how physiotherapists develop their competence and skills and the other considerations that need to be addressed in this area of practice.

Similarly, there is a need for clarity among patients and physiotherapists alike regarding the conditions that fit within the category of pelvic health (internal examinations) services and a need for common terminology to differentiate services related to conditions of the pelvic floor from services related to orthopedic conditions of the spine and pelvis.

Urinary incontinence, fecal incontinence, pelvic pain and disorders, and pre- and post-natal care are some of the conditions related to the pelvic floor treated by physiotherapists. The variety of terms used to describe this area of practice does not facilitate patient understanding of the services provided or the breadth of conditions treated.

The term Pelvic Health (Internal Examinations) is used in the regulatory context to indicate the performance of an internal examination by a physiotherapist for the purpose of assessment or treatment of conditions related to the pelvic floor.

The purpose of this guide is to clarify and elaborate on the regulatory expectations regarding competence development, communication, consent, and sensitive practice when working with individuals requiring pelvic health services.

Physiotherapists engaged in the provision of pelvic health services must be aware of the relevant Alberta legislation governing this area of practice. The Health Professions Act (HPA) identifies those activities that are restricted when carried out in relation to a health service.¹ These activities may only be performed by a member of a regulated health profession authorized to perform the activity by the Health Professions Restricted Activity Regulation (HPRAR).²

The HPA identifies activities as restricted in order to address public health and safety concerns and the inherent risks associated with the activities. According to the HPA, it is a restricted activity to “insert or remove instruments, devices, fingers or hands beyond the opening of the urethra, beyond the labia majora, or beyond the anal verge.”1 According to the HPRAR, pelvic health internal examinations are a restricted activity authorized to regulated members of the College of Physiotherapists of Alberta and may be performed “in the practice of physiotherapy and in accordance with the Standards of Practice.”2

This means that a physiotherapist who has the necessary authorization and competencies may perform an internal examination provided the pelvic health internal examination is appropriate for the patient’s condition, is performed in the context of providing a physiotherapy service, and is conducted in a manner consistent with the Standards of Practice for Physiotherapists in Alberta.

The Performance of Restricted Activities Standard of Practice identifies the authorization and supervision requirements related to the performance of pelvic health internal examinations. The Standard establishes the requirement that physiotherapists who wish to perform pelvic health internal examinations or provide pelvic health services must apply for and receive individual authorization from the College of Physiotherapists of Alberta.³

To receive authorization, the College of Physiotherapists of Alberta requires regulated members who perform pelvic health internal examinations and treat individuals with pelvic health conditions to:

• Complete a program of study including in its curriculum theory, practical and safety components as detailed in this document to develop their competence in this area of practice.
• Successfully complete a summative evaluation of the theory, practical and safety components of the course curriculum, administered by the course instructor and resulting in a passing grade.
• Read, understand, and agree to comply with the Standards of Practice, with particular attention to
  • Performance of Restricted Activities
  • Sexual Abuse and Sexual Misconduct
  • Consent

Physiotherapist interns are eligible to become authorized to perform pelvic health internal examinations and must apply for authorization if they have met the requirements for authorization. However, the Standard requires that regulated members on the Provisional Register (physiotherapist interns) only perform pelvic health internal examinations with the consent and under the direct supervision of a regulated member on the General Register.⁴

Many Canadian physiotherapy entry-to-practice programs include pelvic health content in the curriculum, preparing physiotherapists to screen for and provide basic patient education about conditions related to the pelvic floor. This education is designed to provide physiotherapists with the ability to identify patients with pelvic health conditions and provide appropriate referrals to physiotherapists who work in this area of practice. However, the entry-to-practice education is not extensive and typically does not include instruction in the comprehensive assessment and physical examination of pelvic health conditions, including the performance of internal examinations which are required to enable physiotherapists to deliver quality, safe, effective, client-centered assessment and treatment.

Post-graduate education programs related to this area of practice routinely begin with instruction in pelvic health internal examination skills. An internal examination may not be indicated in every patient case, and in some cases, patients may be reluctant to undergo an internal examination. However, clinicians who treat pelvic health conditions must have:

• The ability to determine when an internal examination is indicated and to determine when ongoing care is not appropriate in the absence of an internal examination.
• The ability to explain the rationale for the pelvic health internal examination to the patient.
• The knowledge, skills and attitudes required to appropriately perform a comprehensive pelvic health assessment, including an internal examination.

As with all physiotherapy services, a physiotherapist must:

• Provide those services that are clinically indicated and that the physiotherapist is competently able to provide.
• Provide services within the context of physiotherapy practice and in accordance with the Standards of Practice.
• Apply professional judgment to select and apply appropriate assessment procedures to evaluate clients’ health status.

Appropriate assessment includes taking a history and completing a physical examination relevant to presenting symptoms.

Specific to the assessment and treatment of pelvic health conditions, the Standards of Practice specify that physiotherapists:

• Perform restricted activities that they are competent, authorized or supervised to perform, within the context of physiotherapy practice, and when client assessment findings support their use.
• Practice within their level of competence and actively pursue continuous lifelong learning to maintain competence in existing and emerging areas of their practice.
• Refer to an appropriate health-care provider when the client’s interests and aspects of the client’s goals are best addressed by another provider.³

With the increasing use of virtual service provision by physiotherapists, there have been innovations in the delivery of pelvic health services. However, clinical practice guidelines clearly reinforce the importance of performing a physical examination for the purpose of diagnosing various types of urinary incontinence and providing interventions which are tailored for the client:

• “A careful history and comprehensive physical examination should constitute the foundation of evaluation related to uncomplicated urinary incontinence.
• Patient history alone should not be used as the sole determinate for diagnosing or treating UI [urinary incontinence].
• Pelvic floor muscle training should not be implemented without an appropriate evaluation and adequate patient training. Providing the patient with verbal instructions and written handouts alone does not constitute evidence-based pelvic floor muscle training.”⁵

If a physiotherapist is not authorized to perform restricted activities, the physiotherapist may still provide general information to patients and the public about pelvic health concerns, incontinence, or pelvic pain and inform patients of the treatment options available to address these concerns.

The College acknowledges that some spinal manipulation techniques may require the insertion of fingers beyond the anal verge. These are advanced techniques, taught as part of post-graduate training in the performance of spinal manipulation. Individuals trained in these techniques must be authorized in the performance of spinal manipulation by the College of Physiotherapists of Alberta. They must limit their activities to those consistent with their authorization to perform spinal manipulation, their individual competence and training, and must not represent that they provide treatment of pelvic health conditions. These techniques are considered separately from the considerations discussed in this Guide.

Individuals who perform internal examinations for the assessment or treatment of pelvic health conditions are required to complete a post-graduate program of study that includes as part of the curriculum the following components:

Theory

Anatomy, physiology, and pathophysiology of pelvic health conditions, within the scope of practice of physiotherapy including:

• Common conditions relevant to the pelvic floor*
• Prevalence of common conditions
• Common comorbidities
• Health system and societal impacts of pelvic health conditions

Assessment and treatment of common pelvic health conditions, including:

• Subjective and objective examination techniques
• Indications, contraindications, and cautions of assessment and treatment procedures
• Performance of a comprehensive assessment appropriate to the patient’s condition
• Differential diagnosis
• Different treatment approaches relevant for the pelvic health patient population
• Reliability and validity of outcome measures
• Research evidence regarding treatment methods and modalities

Practical

• Client communication and management skills such as client education and consent practices
• Performance of an internal examination involving the insertion or removal of instruments, devices, fingers or hands beyond the labia majora, or beyond the anal verge - including supervised performance and feedback from course instructors and model patients
• Performance of treatment techniques that involve the insertion or removal of instruments, devices, fingers or hands beyond the labia majora, or beyond the anal verge, including supervised performance and feedback from course instructors and model patients

Safety

• Adverse event management, including an overview of common risks in pelvic health physiotherapy
• Trauma-informed or sensitive practice
• Infection prevention and control measures

Evaluation

• Summative evaluation of theory, practical, and safety components of the curriculum

* These curriculum requirements constitute the minimum requirements that a physiotherapist must meet to apply for authorization to perform pelvic health internal examinations.

The College of Physiotherapists of Alberta does not approve, endorse, or accredit continuing education courses. It is the physiotherapist’s sole responsibility to reflect on their individual learning needs, the needs of the patient population they serve, and the curriculum content of available courses when selecting continuing education courses.

A physiotherapist’s individual competence will be determined in part by the nature and extent of the continuing education undertaken. Therefore, physiotherapists are instructed to carefully review the syllabus of potential course offerings to determine if a course will provide the necessary knowledge and skills to enable authorization and the provision of pelvic health (internal examinations) services to the patient population they serve.

Depending on the context in which the physiotherapist works, a limited program of study may be all the physiotherapist requires to enable them to address the needs of the patient population served. However, it is essential that the physiotherapist understand that their individual competence may be limited, either by the nature of the education completed or due to limited clinical experience. In such cases, the physiotherapist has a professional obligation to limit their practice to the areas in which they are competent and to refer patients to other providers with greater skill or experience when a patient’s needs are best served by another clinician.

The nature of pelvic health physiotherapy necessitates that it is practiced in a private treatment environment. A consequence of the private treatment environment is that opportunities for incidental observation, discussion, and learning with colleagues are unlikely to arise.⁶ This is in contrast to other areas of physiotherapy practice where it is typical for a new skill to be acquired and used in practice with opportunities for colleagues to observe the physiotherapist’s technique and facilitate skill development through informal, ongoing, feedback and discussion.

Considering the limited opportunity for incidental observation and peer feedback, or for clinical skill development through observation, a period of mentorship is strongly recommended for novice pelvic health physiotherapy practitioners, after gaining authorization to perform pelvic health internal examinations from the College of Physiotherapists of Alberta.

All aspects of physiotherapy practice include some risk. Pelvic health physiotherapy is no exception. Risks related to physiotherapy practice with this patient population include, but are not limited to:

• Skin irritation or allergic reactions
• Bleeding
• Infection
• Psychological trauma

Risks may vary depending on the patient population served and the specific treatment techniques employed by the physiotherapist. Consent conversations must include a discussion of material and special risks related to the assessment and treatment techniques proposed.

Physiotherapists must identify potential risks to client safety relevant to their practice, method of service delivery, and client population and develop policies, procedures, and mitigation strategies to address each of the identified risks.³ Physiotherapists are advised to develop Patient Safety Incident Management Plans relevant to their practice setting and resources available within the practice environment.

A Patient Safety Incident Management Plan documents:

• The patient safety risk considered.
• The appropriate response to a critical event or near miss occurring at the physiotherapy site.
• The respective roles and responsibilities of all individuals (physiotherapists, non-physiotherapist staff, patients, and families) in responding to a critical event.
• The type and location of resources to be used in response to a critical event.⁷
• Education provided to patients and families about treatment risks and how to respond to a critical event occurring after the patient leaves the physiotherapy site.

More information about Patient Safety Incident Management can be found here.⁷

Assessment and treatment techniques used when performing pelvic health internal examinations or treatments involve contact with mucous membranes and, therefore, necessitate the use of clean technique. Clean technique reduces the risk of infection and includes the use of hand hygiene, non-sterile, clean gloves, and clean work surfaces.⁸ Hand hygiene may be performed using either soap and water or alcohol-based hand sanitizer (60% alcohol content) and should be performed within the treatment room, immediately prior to donning gloves.⁹

Equipment and devices such as vaginal probes, cones, and pessary fitting rings are classified as semi-critical items according to the Spaulding Classification, due to their contact with mucous membranes.⁹ Physiotherapists employing these devices must be aware of and compliant with manufacturer directions regarding device use (e.g., single use, single patient use, or reusable). Reprocessing of reusable pelvic health physiotherapy devices must be consistent with the Spaulding Classification for the item, the manufacturer’s directions, and employer policies and procedures (when such procedures exist). In cases where there is a discrepancy between the Spaulding Classification of the device and manufacturer’s directions for reprocessing, physiotherapists are directed to use the higher level of disinfection/sterilization.⁹

Physiotherapists are directed to familiarize themselves with the Infection Control Standard of Practice,³ and with the Infection Prevention and Control Guide for Alberta Physiotherapists.⁹

Psychological trauma bears special attention when working with this patient population. It is estimated that 33% of females and 16% of males will experience sexual assault within their lifetime. Other estimates indicate that 50% of girls and 33% of boys will experience sexual abuse by the time they are 16 years old.¹⁰ With these statistics in mind, there is a high probability that all physiotherapists will encounter adult survivors of interpersonal or sexual violence within their practice settings.¹⁰ Physiotherapists working in pelvic health may be even more likely to encounter survivors of sexual abuse as pelvic pain and acute gynecological injury are common consequences of sexual abuse.

A significant proportion of individuals who have been sexually abused exhibit symptoms of PTSD, even years after the abuse occurred.^11,12,13 This may affect the individual’s response to seemingly innocuous procedures or interventions. Physiotherapists working in the area of pelvic health must also keep in mind that “examinations and procedures that health-care providers might consider innocuous or routine can be distressing for survivors of sexual abuse, because they may be reminiscent of the original trauma.”¹⁴ Physiotherapists working in the area of pelvic health need to be thoughtful and intentional in their interactions with patients, giving consideration to how their actions or comments could be misinterpreted or misunderstood.

Applying the principles of sensitive practice as a routine practice means assuming every patient you encounter may have a history of sexual abuse and then acting accordingly. Some ways that physiotherapists can exhibit sensitive practice include:¹⁴

• Slowing down, and taking the time to listen to the patient, to engage with them and develop a therapeutic relationship by being present and attentive to their concerns.
• Explaining what you are planning to do and why it is important.
• Obtaining informed consent before you begin and with each step of the assessment or treatment process.
• Remembering that patients with a history of sexual abuse demonstrate non-linear healing, meaning that what they can tolerate one day may be different the next. Physiotherapists can demonstrate an awareness of this by reaffirming consent for different treatment procedures at each appointment. This is not only consistent with sensitive practice; it is also an expectation outlined in the Standards of Practice³ and Consent Guide.¹⁵
• Including a clear and easily understood statement of your intent to provide a safe environment for survivors of sexual abuse such as the one below:

XYZ Clinic strives to foster an environment where patients feel safe and supported. Survivors of past trauma should be aware that experiencing an internal exam may be difficult and triggering for some people. To help you feel safe and avoid possible triggers, we ask that you tell your physiotherapist about any history that may make the assessment or treatment hard for you. This information helps your physiotherapist to work with you to find approaches to treatment that feel safer and less challenging for you. Your private information will be kept confidential.

• Discussing the option of having a third party/chaperone/support person present for the assessment/treatment or any portion thereof.
• Sharing control with the patient, by being alert and sensitive to non-verbal signs that the patient may no longer be comfortable with the assessment or treatment procedures, such as:
  • Physically withdrawing
  • Tensing hands or body
  • Shallow breathing
  • Decreased responses to questions
• Checking in with the patient to confirm ongoing consent to assessment and treatment.
• Making it clear to the patient with both words and actions that they can withdraw their consent at any time. Patients with a history of sexual abuse may need to be encouraged to advocate for themselves.

Consent considerations, including the requirements to obtain informed consent before commencing an assessment or treatment and to ensure ongoing consent to assessment and treatment are articulated in the Standards of Practice and are well-established principles within physiotherapy practice.³

Foundational to the consent process is the requirement that the physiotherapist clearly and effectively communicate the nature of the assessment techniques proposed, the assessment findings, and the treatment recommendations and what they will entail for the patient. The physiotherapist needs to tailor the content, format, and manner of patient education to ensure that the patient understands what to expect and what the physiotherapist is planning to do.

Physiotherapists providing pelvic health (internal examinations) services must consider that some aspects of their practice may differ from general physiotherapy practice, including:

• Patient awareness and expectations regarding what pelvic health services include.
• How an internal examination by a physiotherapist may differ from those conducted by a member of another health profession, for a different clinical purpose.
• How a history of sexual assault or interpersonal violence may affect the patient’s ability to tolerate an internal examination, particularly if that examination is of a longer duration than anticipated or is uncomfortable.

The Standards and the Consent Guide for Alberta Physiotherapists provide an overview of key expectations and principles related to consent. The overarching principle being that consent is not valid unless it is informed.^3,15

Physiotherapists working in pelvic health are encouraged to consider:

• How they will educate patients about what to expect and what is entailed by a physiotherapy pelvic health (internal examinations) assessment or treatment.
• How they will ensure that communication materials are presented in clear, patient-friendly language, and are written at an appropriate level.
• What processes they will implement to ensure that consent is obtained after patient education is provided and that informed consent has been provided by the patient.

The expectations regarding communication and consent specified in the Standards of Practice represent the minimum expectations that physiotherapists must meet. However, due to their nature, pelvic health services and internal examinations in particular demand that physiotherapists implement best practices and strive for excellence in their communication and consent practices.

Physiotherapists are encouraged to review the Standards of Practice in detail and consider how to implement best practices to support quality practice.

This appendix summarizes the College’s perspective on the physiotherapist’s role in pessary fitting.

In accordance with the Standards of Practice, when performing restricted activities, physiotherapists are required to:

• Perform restricted activities that they are authorized to perform
• Perform restricted activities that they are competent to perform
• Perform restricted activities within the context of physiotherapy practice and in accordance with the Standards of Practice

Legislation and Authorization

In Alberta, the act of inserting fingers or devices beyond the labia majora or anal verge, is a restricted activity. Physiotherapists can apply for authorization from the College of Physiotherapists of Alberta to perform pelvic health internal examinations and interventions. Once a physiotherapist has been granted authorization, there are no legislative barriers that limit a physiotherapist’s practice. As such, the legislation positively enables the Alberta physiotherapist to engage in pessary fittings.

Competence

Physiotherapists can apply for authorization following completion of a basic course in pelvic health internal examinations.

Discussion of prolapse and its relation to incontinence in preliminary pelvic health courses typically includes didactic instruction in grading the severity of a prolapse, symptoms, prevalence, and treatment techniques, and practical instruction in internal assessment including grading of prolapse.

Pessary fitting is not commonly a component of basic pelvic health continuing education.

As such, a basic course sufficient for the purpose of gaining authorization to perform pelvic health internal examination would not address the competence requirements for pessary fitting. The College expects that a physiotherapist considering engaging in pessary fitting will complete continuing education specific to this aspect of pelvic health practice to develop their competence prior to engaging in the activity.

Clinical Practice Considerations

Physiotherapists are direct access, primary care providers. As such, they are accountable for their practice and for the interventions they engage in, including appropriate assessment and treatment selection. The College of Physiotherapists of Alberta’s perspective is that physiotherapists only treat that which they assess. As with any patient care activity they engage in, the physiotherapist is required to be competent in the:

• Condition, including pathophysiology and appropriate assessment/reassessment techniques
• Treatment options and related evidence
• Indications, contraindications, and precautions of the treatments proposed

Regardless of whether a patient is referred to the physiotherapist or seeks the physiotherapist’s services without referral, the physiotherapist is required to conduct a comprehensive assessment, identify underlying pathophysiology, develop a treatment plan, identify indications, and rule out any cautions or contraindications to the treatment proposed, all within physiotherapy scope of practice.

If a physiotherapist engages in pessary fitting, it is expected that:

• The physiotherapist would engage in a comprehensive assessment of the patient’s presenting complaint and consider all the treatment options available.
• The physiotherapist has the knowledge and skills required to communicate assessment findings to patients and other health professionals using the appropriate assessment tools and terminology to facilitate collaborative practice and client-centered care.
• The physiotherapists critically appraise evidence related to short and long-term clinical outcomes related to pessary use before implementing the treatment into clinical practice.
• Pessary fitting would be one treatment option available, not the sole intervention a physiotherapist offers within the practice setting.

The physiotherapist must recognize their own limits and the limits of scope for the profession. They must reflect on whether they were the best person within a practice setting or geographic location to provide the patient with the necessary care.

Consistent with the ethical requirements to provide client-centered care and work collaboratively with other health professionals, the physiotherapist must communicate effectively with other health professionals involved in the management of the patient’s condition. It would be inappropriate, for example, for a family physician or gynecologist to discover that a patient had been fitted with a pessary by a physiotherapist during a medical examination and not through communication from the physiotherapist.

Under ideal circumstances, in addition to training in pessary fitting the physiotherapist would:

• Have accumulated practical experience working with pelvic health patients.
• Be working in a multidisciplinary practice or at minimum working collaboratively with physicians and other health professionals in their local community.

Practice scenarios

If a physiotherapist were to provide pessaries as the sole intervention they perform, the College would question whether the services constitute physiotherapy.

If a physiotherapist is providing pessaries at the direction of a physician, the physiotherapist is required to have authorization from the College of Physiotherapists of Alberta to perform pelvic health internal examinations and the services must meet the requirements established in the Standards of Practice. A physician’s referral does not alter these requirements.

If a physiotherapist were to employ another regulated health professional (who is duly authorized by the other professional’s regulatory body to insert fingers or devices beyond the labia majora), to provide pessaries, those services delivered by the other health professional would constitute the services of the other health profession and would not be considered physiotherapy services.

Historically, the provision of pelvic health physiotherapy services has been dominated by one-on-one, direct, in-person service provision by a physiotherapist to a patient and has focused on patient education, exercise prescription, and direct monitoring by the physiotherapist.

The College has received questions regarding the use of passive modalities to treat patients, at times using support personnel to deliver the services in question.

The College reminds all physiotherapists providing pelvic health physiotherapy services of the following:

• No modality, used in isolation constitutes physiotherapy services. For a service to be considered physiotherapy it must include:
  • A comprehensive assessment of the client’s underlying condition, their signs and symptoms
  • Identification of a physiotherapy diagnosis and prognosis and client goals
  • Development of an individualized, comprehensive treatment plan to address the client’s concern that is within the scope of practice of the profession
  • Client informed consent to the treatment methods proposed
• Physiotherapists must critically appraise evidence related to available treatment options before implementing them into clinical practice.
• Physiotherapists must maintain their familiarity with clinical practice guidelines, such as those of the Society of Obstetricians and Gynaecologists of Canada (SOGC) (2020) which state that “…currently there does not appear to be any clear added benefit of using adjunctive therapies (biofeedback, electrical stimulation, or vaginal cones)” [in the management urinary incontinence].⁵
• Use of supervisees in the provision of physiotherapy services must occur with the client’s consent.
• The physiotherapist must only assign those services which are appropriate for the supervisee’s skills and competence.
• The physiotherapist must not assign any services which involve any aspect of a restricted activity or any treatment which would require the supervisee to employ clinical reasoning, analysis and decision making to change the established plan of care without the input of the supervising physiotherapist.
• The physiotherapist must re-evaluate and monitor the client response to treatment provided and adjust or discontinue services no longer required or effective.
• The physiotherapist is responsible for all services billed using their registration number.
• The physiotherapist must avoid activities or situations where their professional judgment could be compromised or is for personal gain.

While the use of passive modalities in the provision of pelvic health services may be appropriate for some clients, registrants are advised to be aware of the requirements articulated in the Standards or Practice and to be alert to models of service provision which may otherwise impair the physiotherapist’s ability to meet the expectations articulated in the Standards.

The College is aware that some parties have suggested that physiotherapists have a role in the treatment of erectile dysfunction. At this time, it is a matter of discussion as to whether the treatment of this condition falls within the scope of practice for the physiotherapy profession.

In determining whether an emerging practice constitutes physiotherapy, the College employs the Is It Physiotherapy? Decision Tool. The tool highlights the considerations when the College is asked to determine if a service falls within scope of practice for the profession including:

• Legislative and regulatory requirements
• Evolution of the profession
• The professions knowledge, skills and judgment (competence)
• Evidence

Legislation and Regulatory Considerations

The College categorizes erectile dysfunction as a pelvic health condition. Physiotherapists do not provide treatment of any condition without performing an assessment appropriate to the patient complaint. Individuals wishing to provide services to this patient population must have received authorization from the College to perform pelvic health internal examinations and must possess the individual competence to assess and treat the condition.

All physiotherapists are subject to the Sexual Abuse and Sexual Misconduct Standard of Practice which defines sexual abuse as “touching of a sexual nature of a client’s genitals.” The Standard specifically identifies that the definition of a sexual nature “does not include conduct, behaviour, or remarks that are appropriate to the service provided.”

Given the provisions of legislation, it is essential that a physiotherapist’s training and actions be in accordance with authorization requirements, appropriate to address the patient’s condition and presenting concern, and grounded in evidence if the physiotherapist is treating patients with erectile dysfunction.

Evolution of the Profession

Given the current role of physiotherapy in the provision of pelvic health services, it may be reasonable to consider the treatment of erectile dysfunction as an evolution of the profession. This is also reasonable considering that some physiotherapy interventions intended to address conditions such as urinary incontinence may have secondary effects on sexual function.

Evidence

Individuals experiencing erectile dysfunction can be anticipated to be eager to seek treatment to address the problem. This creates the risk of service provision being driven by consumer demand rather than evidence of effective treatment methods. The vulnerability of the patient population is of particular concern if the proposed treatment involves a high-cost treatment method.

Where evidence regarding proposed treatment methods arises from industry, and is of questionable quality, rigor, reproducibility, and independence there is cause for concern and caution.

Competence

As autonomous health professionals, physiotherapist must have the knowledge, skills and competence required to conduct an assessment appropriate to the patient’s presenting complaint, determine the underlying impairment related to that complaint, and develop a treatment plan appropriate to address the underlying condition. The physiotherapy profession's knowledge, skills, and judgment (the competence) to assess erectile dysfunction are uncertain.

This is an area of practice that is not currently addressed in entry to practice physiotherapy education; therefore, a physiotherapist must be able to explain how they developed their skills and competence to assess erectile dysfunction, form a differential diagnosis, and develop a treatment plan through post-graduate continuing professional development.

Advice to the Profession

As this area of practice is viewed as non-traditional or emerging, physiotherapists who are considering providing pelvic health services to address erectile dysfunction must:

• Practice in accordance with all Standards of Practice.
• Be authorized to provide pelvic health physiotherapy services.
• Be attentive to the risks inherent in providing these services.
• Take steps to effectively mitigate risks.
• Critically appraise evidence relevant to the patient population, condition and treatments available, incorporating critically appraised evidence into practice.
• Clearly communicate the nature and limits of available evidence related to proposed treatments to patients.
• Be prepared to explain how they developed their knowledge and skills to provide services to this patient population.

1. Government of Alberta. Health Professions Act. https://kings-printer.alberta.ca/1266.cfm?page=H07.cfm&leg_type=Acts&isbncln=9780779838653&display=html
2. Government of Alberta. Health Professions Restricted Activity Regulation. https://kings-printer.alberta.ca/1266.cfm?page=2023_022.cfm&leg_type=Regs&isbncln=9780779840748&display=html
3. College of Physiotherapists of Alberta. Standards of Practice for Alberta Physiotherapists. https://www.cpta.ab.ca/for-physiotherapists/regulatory-expectations/standards-of-practice/
4. College of Physiotherapists of Alberta. Restricted Activities – Pelvic Health (Internal Examinations). https://www.cpta.ab.ca/for-physiotherapists/regulatory-expectations/restricted-activities/
5. Dufour S, Wu M. SOGC Clinical Practice Guideline No. 397: Conservative Care of Urinary Incontinence in Women. Journal of Obstetricians and Gynaecologists of Canada. 2020; 42(4):510-522.
6. Frawley HC, Neumann P, Delany C. An Argument for Competency-Based Training in Pelvic Floor Physiotherapy Practice. Physiotherapy Theory and Practice. DOI:10.1080/09593985.2018.1470706
7. College of Physiotherapists of Alberta. Patient Safety and Risk Management Guideline. https://www.cpta.ab.ca/for-physiotherapists/resources/guides-and-guidelines/patient-safety-and-risk-management-guidline/
8. Clean vs Sterile Dressing Techniques for Management of Chronic Wounds: A Fact Sheet. Journal of Wound, Ostomy and Continence Nursing. 2012; 39(2S):30-34.
9. College of Physiotherapists of Alberta. Infection Prevention and Control Guide for Alberta Physiotherapists. https://www.cpta.ab.ca/for-physiotherapists/resources/guides-and-guidelines/infection-prevention-and-control-guide/
10. University of Alberta. Understanding Sexual Assault. Available at: https://www.ualberta.ca/current-students/sexual-assault-centre/understanding-sexual-assault Accessed February 18, 2019.
11. Government of Quebec. Consequences of Adult Sexual Assault. Available at: https://www.inspq.qc.ca/en/sexualassault/understanding-sexual-assault/consequences Accessed February 15, 2019.
12. RAINN. Effects of Sexual Violence. Available at: https://www.rainn.org/effects-sexual-violence Accessed February 15, 2019.
13. Centers for Disease Control and Prevention. Sexual Violence: Fast Facts. Available at: https://www.cdc.gov/violenceprevention/sexualviolence/fastfact.html Accessed February 15, 2019.
14. Schachter CL, Stalker CA, Teram E, Lasiuk GC, Danilkewich A. Handbook on Sensitive Practice for Health Care Practitioners: Lessons from adult survivors of childhood sexual abuse. 2008. Ottawa: Public Health Agency of Canada.
15. College of Physiotherapists of Alberta. Consent Guide for Alberta Physiotherapists. https://www.cpta.ab.ca/for-physiotherapists/resources/guides-and-guidelines/consent-guide/