The College of Physiotherapists of Alberta, the College of Physiotherapists of Manitoba and the College of Physical Therapists of British Columbia have collaborated to generate this guide. The purpose of this guide is to provide direction to physiotherapists regarding how the Standards of Practice apply to pelvic health physiotherapy services. It will also detail regulatory expectations regarding:
- Post-graduate education
- Clinical practices to support excellence in the provision of pelvic health physiotherapy services.
Despite the shared approach to regulation of this area of physiotherapy practice, legislative differences exist between the three provinces and this may result in some variation in the regulatory requirements for practice. For further information, physiotherapists are advised to contact their provincial physiotherapy regulator.Pelvic Health (Internal Examinations) Guide
The physiotherapy treatment of pelvic health conditions has considerable high-quality supporting evidence. Many physiotherapists are interested in providing pelvic health (internal examinations) services; 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 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 just some of the many conditions related to the pelvic floor at are treated by physiotherapists. There is strong evidence to support the value of physiotherapy in the treatment of these conditions. However, 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.
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 client-centered assessment and treatment.
Fundamentally, physiotherapists do not provide treatment of any condition without performing an assessment appropriate to the patient complaint.
Post-graduate education programs related to this area of practice routinely begin with instruction in pelvic 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. Clinicians who treat pelvic health conditions must have:
- The ability to determine when an internal examination is indicated
- The ability to explain the rationale for the assessment to the patient
- The knowledge, skills and attitudes required to perform a comprehensive assessment appropriately
Individuals who do not possess the competence to perform internal examinations may not claim that they provide treatment of pelvic health conditions.
This does not preclude the ability of a physiotherapist to provide general information to patients and the public about pelvic health concerns, incontinence or pelvic pain and to inform patients of the treatment options available to address these concerns.
It is essential that physiotherapists be aware of relevant Alberta legislation regarding this area of practice. The Government Organization Act (GOA) 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 a regulation of the Health Professions Act (HPA), such as the Physical Therapists Profession Regulation (PTPR). The GOA identifies activities as restricted in order to address public health and safety concerns and the inherent risks associated with the activities. According to the GOA, 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 PTPR, pelvic health internal examinations are a basic restricted activity authorized to regulated physiotherapists on the General Register.2 This means that a physiotherapist on the General Register who has the necessary competencies may perform an internal examination, provided it is appropriate for the patient’s condition. The PTPR requires that members on the Provisional Register (PT Interns) only perform basic restricted activities with the consent and under the direct supervision of a regulated member on the General Register.2 The purpose of this guide is to clarify regulatory expectations regarding competence development, communication, consent, and sensitive practice when working with individuals requiring pelvic health services.
It is noted 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 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 and are authorized to registrants through their authority to perform spinal manipulation.
The Standards of Practice apply to all aspects of physiotherapy practice, including the performance of internal examinations and the treatment of pelvic health conditions, and require that physiotherapists:
- Practice within their level of competence, incorporating the required knowledge and skills to deliver quality client-centered care.
- Take appropriate actions (e.g., referral to another physiotherapist or health-care provider, courses, mentorship) in situations where they do not have the required competence to deliver quality client-centered care.
- Perform restricted activities that they are competent, authorized or supervised to perform, and comply with all relevant provincial legislation and regulatory requirements.3
Individuals who perform internal examinations for the assessment or treatment of pelvic health conditions are expected to complete a post-graduate program of study that includes as part of the curriculum the following components:
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
- Comorbidities, health system and societal impacts
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
- 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
- Infection prevention and control
- Adverse event management, including an overview of common risks in pelvic health physiotherapy
- Trauma-informed or sensitive practice
- Summative evaluation of theory, practical and safety components of the curriculum
*NOTE: Depending on the patient population considered and conditions treated, physiotherapists may require additional post-graduate education. These requirements constitute the minimum requirements to work in this area of practice.
Physiotherapy regulatory organizations do 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 courses offered when selecting continuing education courses.
Depending on the context in which the physiotherapists work, a limited program of study may be all that is required to enable them to address the needs of the patient population served. However, it is essential that the physiotherapist understand that his/her 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.
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.
Finally, diverse clinical experience and robust foundational skills in patient management, communication, treatment planning, and patient education are essential when working with this patient population. Recent graduates are strongly encouraged to develop their general clinical skills before pursuing training or establishing a practice in the area of pelvic health physiotherapy.
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.4 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 feedback and discussion.
Considering the limited opportunity for incidental observation and peer feedback, or for clinical skill development through observation, a period of mentorship or supervised practice is strongly recommended for novice pelvic health physiotherapy practitioners.
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.5 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.6
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.6 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.6
Physiotherapists are directed to familiarize themselves with the Infection Control Standard of Practice,3 and with the Infection Prevention and Control Resource Guide for Alberta Physiotherapists.6 Additional information regarding device reprocessing can be found in the Guide.
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
- 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 are also required to identify real and potential risks to patient safety relevant to their practice and to develop critical event management plans to address each of the identified risks.3 A critical event management plan documents:
- The patient safety risk considered.
- 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.
- 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
More information about Patient Safety Incident Management can be found here.7
The risk of psychological trauma bears special consideration 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.8 With these statistics in mind, the assertion that “all health care practitioners – whether they know it or not – encounter adult survivors of interpersonal violence in their practices”9 and sexual violence in particular, is well founded.
Survivors of sexual abuse generally demonstrate increased health-care utilization and are more likely to experience headaches, migraines, and chronic pain - conditions physiotherapists commonly treat.10,11,12 Physiotherapists working in the area of 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,10,11,12 and this may affect their response to seemingly innocuous procedures or interventions.
With such a high proportion of people having a history (whether recent or remote) of sexual abuse, all physiotherapists are advised to adopt sensitive practice as a routine practice in their patient interactions. 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.”9 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 this include:6
- 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, 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 fact by reaffirming patient consent for different treatment procedures at each appointment, rather than assuming past consent remains valid. This is not only consistent with sensitive practice; it is also an expectation outlined in the Standards of Practice3 and Consent Guide.13
- Including an explicit 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. In order 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
- Ensuring the patient has provided informed consent.
- 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 and may need to be “given permission” to say no.
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 Consent Standard 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, 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 with which patient education is provided 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 they may have previously experienced (when conducted by a member of another health profession and for different clinical purposes).
- 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 Consent Standard of Practice 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.3,13 For physiotherapists working in pelvic health, the key questions are:
- How will you educate patients about what to expect and what is entailed by a physiotherapy pelvic health (internal examinations) assessment or treatment?
- How can you ensure that communication materials are presented in clear, patient-friendly language, and are written at an appropriate level?
- What processes will you implement to ensure that consent is obtained after patient education is provided and that you have obtained informed consent?
While the expectations described in the Communication and Consent Standards of Practice are universally applicable to physiotherapy practice, they represent the minimum expectations that physiotherapists must meet. Due to their nature, pelvic health services and internal examinations in particular demand that physiotherapists not only meet these expectations but also implement best practices, consistently striving for excellence in their communication and consent practices. For example:
- While the Communication Standard of Practice indicates that printed education materials and diagrams may be reasonable methods to address communication barriers and facilitate patient education, physiotherapists who provide pelvic health services are strongly encouraged to implement these methods of education and communication with all patients.
- Although either written or verbal informed consent are acceptable in general practice, physiotherapists who provide pelvic health (internal examinations) services are encouraged to obtain consent in writing, after discussing what assessment and treatment will include.
Members are encouraged to review these Standards of Practice in detail and consider how to implement best practices to support quality practice. A sample consent form for pelvic health services can be found in Appendix 1. Members are encouraged to modify this form as appropriate for their practice setting and services provided. Additional recommendations regarding patient education can be found in Appendix 2. Additional guidance regarding communication considerations can be found in Appendix 3.
The Performace of Restricted Activities Standard of Practice (revised 2020) requires physiotherapists who wish to perform pelvic health internal examinations or provide pelvic health services to apply for and receive individual authorization from the College of Physiotherapists of Alberta to do so.
The College requires regulated members who perform 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
I authorize the physiotherapist, __________________________, to perform or assist in performing the following special procedures:
Manual techniques for the evaluation and treatment of incontinence or pelvic pain involving the insertion of a gloved finger(s) or specialized instrument beyond the labia majora or anal verge.
The physiotherapist has given me an explanation of the treatment, I have had the opportunity to ask and have my questions answered, and I understand the nature, risks, probable effects and alternative treatment options of the proposed treatment.
I have been advised that I can have another person accompany me to the assessment and/or treatment sessions.
I understand that I can withdraw my consent at any time.
The pelvic floor consists of a group of muscles and connective tissues that support the bladder, urethra and pelvic organs. Like other muscles in the body, the pelvic floor can become stretched and weak or may become over-active and tight in response to illness or injury. Physiotherapists treat pelvic health conditions by addressing muscle weakness or dysfunction to correct or improve problems such as incontinence, organ prolapse and pelvic pain.
What does a physiotherapy pelvic health internal examination look like?
Before treating any condition, a physiotherapist must first determine what the patient’s health concern is and its cause. This requires a thorough assessment of the patient’s health that will vary depending on the patient’s health concern.
An assessment will begin by gathering information from the patient about their general medical history, symptoms, and concerns. After this discussion, the physiotherapist will evaluate the patient’s condition. This typically begins by ruling out any underlying problems that the physiotherapist is not able to treat and becomes more specific to the patient’s concern as the assessment continues.
For health conditions such as urinary incontinence, the physiotherapy assessment generally includes an internal examination of the pelvic floor muscles and the presence of other concerns.
Patients can expect that physiotherapists will explain the assessment procedures they are using and their rationale. Patients can also expect that the physiotherapist will obtain the patient’s consent to proceed before completing any part of the examination.
Why/when is an internal exam needed?
An internal examination is often required when a physiotherapist is assessing or treating a condition of the pelvic floor. The internal examination is needed to assess pelvic floor muscle tone and strength, and among women, the presence or absence of pelvic organ prolapse.
This assessment helps the physiotherapist determine a plan of care to address the patient’s concern. However, patients may not always be comfortable with the idea of having an internal examination. Patients can expect that their physiotherapist will work with them to build rapport and find approaches to assessment and treatment that the patient is comfortable with over the course of the physiotherapy treatment program.
Patients always have the right to decline a physiotherapy assessment or treatment procedure. This may affect the treatment options available to them.
What education and training should a physiotherapist have?
Physiotherapists are required to have post-graduate training to work in pelvic health. Some physiotherapists may have also had the opportunity to work under mentorship of physiotherapists experienced in this area of practice. It is also important that a physiotherapist regularly use their skills to maintain them.
There is a wide range of courses available to physiotherapists who wish to develop their skills in this area. Physiotherapists are required to evaluate courses to determine those which will provide them with the skills required to provide pelvic health (internal examinations) services. The physiotherapy regulator in Alberta does not endorse any education program but does provide guidance regarding minimum curriculum expectations for courses.
Developing rapport with patients is just as important as experience and education. The patient should feel safe, respected, and listened to when in the physiotherapist’s care. The development of an effective therapeutic relationship is essential to the success of all physiotherapy services.
Physiotherapists should readily provide information about the course work or training they took to develop their skills and abilities and their authorization to provide these services. Physiotherapists should also provide information about how they maintain their skills. The patient must be able to make an informed choice of providers (balancing considerations of education, experience and rapport) to find a physiotherapist who can address the patient’s needs and provide quality physiotherapy care.
Condensing years of experience, expertise and knowledge into patient-friendly information can be a challenge. The following strategies may help to present essential information in an accessible manner.
Written materials should be presented at a grade 6-8 reading level. Some strategies include:
- Using bullet points, or short phrases.
- Using simple words to define complex terms early on in documents.
- Replacing multi-syllabic words with shorter, simple words.
- Breaking long sentences into 2 or 3 separate sentences.
- Field testing documents with individuals of different backgrounds, interests and reading levels (if possible), checking for understanding of the document and any sections in need of revision.
- Hiring a professional writer with no knowledge of the technical aspects of the topic to help simplify and clarify the content.
Diagrams and models
Consider including scale models or diagrams in teaching materials, presentations and one on one education sessions to facilitate patient understanding.
The physiotherapist asks the patient to tell them what they will say to their spouse/friend/other family member when they are asked about their physiotherapy appointment. By listening to what the patient says, the physiotherapist can assess comprehension of the information they have provided, identify any misunderstandings, and clarify or reinforce important information that the patient may not have retained.
Physiotherapists should also reflect on measures they can take to support physiotherapy access for diverse populations. This may include such measures as:
- Partnering with individuals from different communities to ensure that education materials are sensitive to cultural differences, either by soliciting members of the community to review and provide feedback on education materials or engaging with stakeholders to better understand cultural differences and how to address these differences in practice.
- Considering translation of education materials (by a qualified interpreter) into other languages common within the community served. Adopting the use of plain language and diagrams or models in patient education materials also promotes understanding among individuals with English as a second language and English language learners.
- Developing policies, practices and resources to support safety and inclusion of individuals belonging to gender and sexual minorities, including use of signage to denote inclusive spaces and gender-neutral washrooms.
The College of Physiotherapists of Alberta Resources
- Infection Prevention and Control Resource Guide for Alberta Physiotherapists.
- Practice Guideline – Critical Event Management Plans.
- Consent Guide for Alberta Physiotherapists.
College of Physiotherapists of Manitoba Resources
- Practice Direction 4.3 Informed Consent to Treatment
- Practice Direction 4.22 Physiotherapy Treatment of Pelvic Floor Dysfunction
- Practice Direction 4.5 Routine Practice
College of Physical Therapists of British Columbia Resources
- Infection Prevention and Control Resource.
- Consent to Treatment Booklet.