Why do we have an internal exam?

People who suffer from pelvic pain often have pelvic floor dysfunction, but specifically hypertonic muscles, or muscles that are too tight. The pelvic floor muscles are a group of muscles attached to the front, back and sides of the pelvic bone and sacrum. Shaped like a hammock, they support the bladder, uterus (in women), prostate (in men) and rectum. They also wrap around your urethra, rectum, and vagina (in women). To maintain continence, relax and allow for urination, bowel movement and in women sexual intercourse, these muscles must be able to contract and relax.

When these muscles have too much tension (hypertonic) they will often cause pelvic pain or urgency and frequency of the bladder and bowels. When they are low-tone (hypotonic) they will contribute to stress incontinence and organ prolapse. You can also have a combination of muscles that are too tense and too relaxed.

· HYPOTONICITY (Weak pelvic floor muscles): contributing to stress incontinence, urge incontinence and pelvic organ prolapse. Incontinence is NOT a normal part of ageing.

· HYPERTONICITY (Tight pelvic floor muscles): contributing to urinary and fecal frequency, urgency and hesitancy, stopping and starting of the urine stream, painful urination, incomplete emptying, constipation, straining, pain with bowel movement, unexplained pain in your low back, pelvic region, hips, genital area or rectum, dyspareunia, vaginismus, vulvodynia, pudendal neuralgia, interstitial cystitis and chronic prostatitis, pain during intercourse, orgasm or sexual stimulation.

Pelvic floor dysfunction is diagnosed by specially trained doctors and physiotherapists by using internal and external “hands-on” or manual techniques to evaluate the function of the pelvic floor muscles. They will also assess your ability to contract and relax these muscles. Your bones and muscles of your lower back, hips and sacro-iliac joints will need to be assessed as well since these joints can stress your pelvic floor muscles.

If an internal examination is too painful, the connective tissue of your abdomen, thighs, groins and low back are often very tight. The connective tissue forms the container of the muscles, and this tissue often needs to be relaxed before any internal work can be done.

When your pelvic floor muscles are tight and weak, the tension is treated before the weakness. Once the muscles have reached a normal resting tone, and are able to relax fully, their strength is reassessed and strengthening exercises are prescribed, if appropriate.

Our pelvic floor muscles are quiet warriors within our bodies. They allow us to function without interruption, assisting in bowel, bladder and sexual function. They also contribute significantly to our core strength which allows our lower back to function with ease. But pelvic floor health is still neglected by many people, mostly because they’re a group of muscles we’re not even aware we have, let alone how to keep them in tip-top shape and use them appropriately in our daily activities.

Photo by Jared Rice on Unsplash

Gynaecologist, Dr. Arnold Kegel (recognize that name?) was the first person in the 1940s to teach women how to strengthen these important muscles. By inserting a finger into the vagina, he taught all his patients to do these exercises, assessing their muscle strength and giving feedback on how to perform the exercise.

These muscles are internal—we cannot see them, so in order to understand more about them we need to go by feel. Through the decades Kegels continue to be recommended as a crucial way of keeping these muscles in working order; however, over time healthcare practitioners who teach women how to do Kegels no longer do an internal exam to assess these muscles and ensure proper function and contraction. This neglect has led to an increasingly poor success rate and continuing frustration for women who diligently and obediently do these exercises preventatively or therapeutically.

Assessing the pelvic floor without doing an internal exam is like an orthopaedic surgeon or a physiotherapist doing a knee exam through a pair of jeans.

Treating any other part of the body without touching the affected body part to see which muscles are tight, or weak, and how the joints move and glide would be completely unacceptable.

Photo by Toa Heftiba on Unsplash

In Europe, an internal examination of the pelvic floor has been the gold standard by which treatment of the pelvic floor has been carried out for more than 30 years. In Canada, we are a more puritanical society, and it seems “weird” or “strange” to assess the pelvic floor by completing an internal exam of the vagina or rectum. However, when the pelvic floor muscles are assessed this way, the research has shown that the treatments carried out by a physiotherapist for pelvic floor problems are highly successful, and should be the first line of defense (before surgery or any other medical intervention) for both pelvic pain and incontinence.

The physiotherapist who carries out this work is a highly trained, sensitive professional who will discuss these issues with you thoroughly before carrying out the treatment. Internal palpation is an integral part of treating the pelvic floor and is the gold standard. Accept nothing less.



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