Internal Pelvic Floor Examination: What to Expect
If you've made it to this blog post, you're probably in one of two groups.
Either you're already scheduled for pelvic floor physical therapy and feeling nervous about the internal pelvic floor examination, or you're thinking about scheduling an appointment but are hesitant because you're unsure what the examination involves.
Either way, you're in the right place.
My hope is that this blog gives you a better understanding of what an internal pelvic floor examination is, why it may be recommended, and what to expect if you decide to have one performed.
I know the thought of an internal examination can feel intimidating. The good news is that you are always in control of the process, and by the end of this blog, my hope is that you feel more comfortable either scheduling that pelvic floor physical therapy appointment or keeping the one you already have on the calendar.
What Is an Internal Pelvic Floor Examination?
An internal pelvic floor examination is an assessment of the pelvic floor muscles and nerves. It is often compared to a gynecologic examination, but the purpose is very different.
During a gynecologic examination, your provider is typically evaluating structures such as the cervix, uterus, and ovaries. A speculum is often used, and the focus is on your reproductive organs.
During an internal pelvic floor examination, we're evaluating your muscles and nerves. We're looking at how your pelvic floor functions as part of your core system and how it works together with the rest of your body.
An internal examination allows us to assess things such as:
Pelvic floor muscle strength
Pelvic floor muscle coordination
Pain and tension within the pelvic floor muscles
Pelvic organ prolapse
Areas of irritation or sensitivity
How the pelvic floor is functioning as part of the core system
The examination is a valuable tool because it helps us understand not only what may be happening within the pelvis, but also how structures around the pelvis may be contributing to your symptoms.
Why an Internal Exam May Be Recommended
An internal pelvic floor examination is recommended for many pelvic floor conditions and symptoms because it allows us to directly assess the muscles and nerves that may be contributing to what you're experiencing.
Your pelvic floor muscles can play a role in a wide variety of symptoms, including:
Painful sex
Pelvic organ prolapse
Urinary leakage
Urinary urgency
Constipation
Chronic pelvic pain
Tailbone pain
Low back pain
Hip pain
Because the pelvic floor is connected to so many different functions within the body, an internal examination can provide valuable information about whether the pelvic floor muscles are contributing to your symptoms and help guide the most appropriate treatment plan.
What Happens During the Examination?
Before the examination begins, your provider should educate you on the anatomy and function of the pelvic floor and explain why they believe an internal pelvic floor examination would be beneficial for you. They should also discuss what they are hoping to learn from the examination based on your symptoms.
I've been doing this long enough now that I can usually tell patients what I expect to find before we even begin the examination. Based on your symptoms, I can often predict what you are likely to experience during the assessment.
For most examinations at my office, patients are positioned lying on their back for a vaginal examination or lying on their side facing away from me for a rectal examination.
The examination typically starts with an assessment of the vulva. I'm looking for things such as:
Skin irritation
Redness
Dryness
Other visible changes to the tissue
Next, I assess the first layer, or more superficial pelvic floor muscles, to evaluate for pain, tension, and muscle function.
From there, I assess the deeper third layer pelvic floor muscles. I typically begin toward the back of the pelvis near the sacrum and work my way toward the front while following the course of an important pelvic nerve called the pudendal nerve.
After assessing the muscles and nerves, I evaluate how the pelvic floor functions. This includes assessing:
Squeeze
Relaxation
A cough response, which is a quick pelvic floor contraction
I will also assess for pelvic organ prolapse. This involves bearing down to challenge the tissues and determine whether there is movement of the pelvic organs.
Most examinations are performed while lying on your back. However, if your symptoms are related to pelvic organ prolapse or stress urinary incontinence and are more noticeable while standing, I may recommend a standing pelvic floor examination. This allows us to assess how gravity impacts your symptoms and pelvic floor function.
There are a few logistical details that patients commonly ask about. The examination is performed using one gloved and lubricated finger inserted vaginally or rectally. The goal is to assess the muscles, nerves, and how they function.
The examination can be painful if you are already experiencing pain. However, I often find that symptoms improve as treatment is provided during the examination. I frequently tell my patients that we have to poke the bear to know that we're treating the correct bear.
Many patients have spent months or years trying to find answers for their symptoms. Surprisingly, one of the most relieving moments for some patients is when we are able to reproduce the symptoms that no one else has been able to identify. It helps confirm that we are looking in the right place and addressing the correct issue.
Most importantly, you are always in control of the examination. If at any point you are uncomfortable and want to stop, we stop. No questions asked.
Conditions an Internal Exam Can Help Assess
An internal pelvic floor examination can provide valuable information for a wide variety of pelvic health conditions and symptoms.
Some of the most common reasons I perform an internal pelvic floor examination include:
Pelvic organ prolapse
Pain with sex
Tailbone pain
Hip pain
Low back pain
Urinary urgency
Urinary frequency
Urinary leakage
Fecal urgency
Fecal frequency
Fecal leakage
Constipation
Unexplained abdominal pain
Endometriosis
Painful periods
The examination helps determine whether the pelvic floor muscles, nerves, or surrounding tissues may be contributing to your symptoms. It also helps guide treatment by identifying areas of pain, tension, weakness, poor coordination, or changes in support within the pelvis.
How to Prepare for the Appointment
Here are some of the most common questions we get asked before an internal pelvic floor examination.
Do I need to shave?
No. We absolutely do not care whether you shave or not.
Should I avoid sex before the appointment?
No. It does not matter whether you have sex before your appointment or avoid it beforehand.
Can I come on my period?
Yes. In fact, many of our patients do. About 25% of the patients we see are on their period during their appointment simply because of the nature of what we treat.
Many of our patients seek care for painful periods, and sometimes it is actually beneficial to assess these structures while symptoms are present.
What should I wear?
I recommend athleisure or comfortable clothing.
There will likely be a movement portion of your appointment following the examination. The examination should help guide your treatment plan and home exercise program, so comfortable clothing is usually your best bet.
Should I use the restroom before the appointment?
You can if you'd like, but it is not necessary.
This is not like getting an ultrasound at your doctor's office where a full bladder may be required. Whether your bladder is full or empty does not matter for the examination.
Should I bring questions?
Absolutely.
Most pelvic floor physical therapy appointments are at least an hour long. That sounds like plenty of time, but there is often a lot of information to cover. I recommend writing down your questions beforehand so you don't forget them once you get to your appointment.
What if I don't want an internal examination?
That is completely okay.
You are always entitled to decline an internal pelvic floor examination. No matter who you see, you should feel comfortable saying no if you do not want an internal assessment.
I've been doing this long enough that I can often make a pretty accurate hypothesis about which muscles are contributing to a patient's symptoms before ever performing an internal examination. I can still treat patients very effectively without performing the internal assessment.
The biggest difference is that the internal examination often provides confirmation of what we suspect is happening.
What the Findings Can Reveal
An internal pelvic floor examination can reveal a number of different findings that help explain why you may be experiencing certain symptoms.
Some of the most common findings include:
Tight pelvic floor muscles
Weak pelvic floor muscles
Impaired muscle coordination
Nerve irritation
Pelvic organ prolapse
Scar tissue restrictions
Referred pain patterns
One of the most valuable parts of the examination is identifying where symptoms are actually coming from. For example, I may have a patient who comes in with lower abdominal pain, but during the examination, we discover that the pain is actually being referred from the pelvic floor muscles.
At my clinic, I believe the examination should be used to guide treatment.
The examination helps determine which muscles need to be strengthened, which muscles need to learn to relax, and which movement patterns need to be retrained. That information allows us to build an individualized treatment plan and home exercise program based on your specific findings.
Ultimately, the examination is just one piece of the puzzle. The rehabilitation happens through the exercises and movement strategies that follow. Those exercises are what help create long-term symptom relief and lasting changes in how your body functions.
Common Questions and Concerns
Does it hurt?
Sometimes.
If you are currently experiencing pelvic pain symptoms, the examination can be uncomfortable because the goal is often to reproduce the symptoms you are already experiencing. By identifying which muscles, nerves, or tissues are contributing to your pain, we can better determine how to treat it.
I often tell my patients that we have to poke the bear to know that we're treating the correct bear.
Is it awkward or embarrassing?
It should not be embarrassing.
Most pelvic floor physical therapy clinics have a lengthy waitlist, which should tell you just how common these symptoms are. Pelvic floor physical therapists treat conditions like urinary leakage, painful sex, constipation, prolapse, and pelvic pain every single day.
Most of my patients tell me afterward that the examination was much easier and more comfortable than they expected. Many even tell me it was better than a gynecologic examination.
What if I have a history of trauma?
You are always in control of the examination.
If you have a history of trauma, you can absolutely decline the examination if that feels like the right decision for you. A good pelvic floor physical therapist should respect your boundaries and help you feel safe throughout the entire appointment.
Can I stop the examination?
Absolutely.
At any point during the examination, you can ask to stop and the examination will stop. No questions asked.
Is it normal to feel emotional?
Yes.
The pelvic floor muscles are an area where many people carry stress, tension, and emotions. Because of that, it is not uncommon to feel emotional during or after an examination.
By now, most people have heard of The Body Keeps the Score. Sometimes assessing and treating these tissues can bring emotions to the surface. If that happens, know that it is a normal response and something pelvic floor physical therapists see regularly.
Ready to Get Started?
If you're local to Northeast Texas, good news. We are currently accepting new patients in Canton, Rockwall, and Sulphur Springs, and we would love to help you.
My hope is that this blog has helped ease some of your nerves and given you a better understanding of what to expect during an internal pelvic floor examination.
Whether you're considering scheduling pelvic floor physical therapy for the first time, trying to decide whether to keep an upcoming appointment, or simply looking for more information, I hope you feel more confident moving forward.
Pelvic floor symptoms are incredibly common, and you do not have to navigate them alone. If you're ready to get answers and create a plan for lasting symptom relief, we'd love to help.
To schedule an appointment, fill out our contact form or call our office at 903-962-2600. We look forward to meeting you.
