Jenny Blizard BSc (Hons), Chartered Physiotherapist, PGDip and PGCert in Women’s Health Physiotherapy, MCSP, HCPC

UKA Accredited Athletics Coach (Endurance)

Clinic Director

Female Pelvic Health Physiotherapy Appointment - What To Expect

Prior to your appointment you will be asked to complete two comprehensive questionnaires which ask you detailed questions about the reason for seeking help and what your GOAL is. This will help Jenny (your physiotherapist) plan the assessment. It is important that you provide as much detail as possible and complete the questionnaires as soon as possible so that she can ensure that the appointment is suitable for you. The questionnaires are secure documents that can ONLY be viewed by the treating physiotherapist.

Depending on what your concerns/problems are it is likely we will assess your movements (for example how your perform certain activities), abdominal muscles, muscle strength. This assessment is individual to what each client needs, there is no one set “recipe”.

If your problems are related to your pelvic floor, an internal examination is often advised to assess your pelvic floor function, this can be completed at the first appointment or at a subsequent appointment. You will be taken through what it involves and why it is advisable. You can read more about a pelvic floor examination below. After the assessment your physiotherapist may continue with treatment (depending on time available), this may comprise of: -

- Manual “hands on” treatment
- Acupuncture
- Advice and education
- Home exercise program (via an app/email with videos) 

Often the treatment provided blends with the assessment process to see how your body/tissues respond so that an appropriate discussion of the findings and what the potential plan forward might be.

Finally your physiotherapist will discuss with you the findings and plan further assessment/treatment and rehabilitation with you. If you require help from another professional, this will also be discussed with you.

How many sessions will I need? 

The length of time and number of sessions you will require is very varied. Some females may only require 2 sessions, others may require two sessions per week for a short period, finally some females may be seen sporadically over a year to 18 months. Your Physiotherapist will discuss a treatment plan with you at your first appointment. 

The aim is to ensure that you have been assessed and treated completely or have an ongoing plan in place for an expected completion of your goal. This may take place over a few weeks or few months dependent on the nature of the issue you require help with. If you do just want an assessment and guidance on a path forward that you aim to work on independently with no further help from your physiotherapist please do let us know at the beginning of your assessment or on your initial questionnaire so that we can plan the session accordingly.

The initial 60 minute session includes an assessment, treatment (where required) a discussion of the findings and set up and provision of an individualised exercise program including videos and detailed instructions sent via email and can also be viewed in a secure app. For further information about the app go to https://www.physiapp.com/

Chaperone

A chaperone is a third party person who attends the appointment and aims to provide support and reassurance to you and witness the continuing consent to a procedure. All clients are entitled to bring a chaperone. If you would like to bring a chaperone, please inform us prior to your appointment. You may ask for a chaperone at any time however and have the right to decline/delay treatment if you change your mind and would like a chaperone present.

Privacy

We understand the highly sensitive nature of many of the conditions that women may have. All our clinic rooms are private and all information is kept as strictly confidential. Only the treating physiotherapist has access to your treatment notes. 

Questions?

If you do have any questions then please get in touch with the clinic on 01302511755 or send Jenny an email to her private account which is [email protected]

Pelvic Floor Assessment - What Does This Involve? 

Pelvic floor and continence problems may require an internal examination to fully assess the pelvic floor. This type of *assessment is different to a GP or gynaecologist assessment for the following reason. Female pelvic health physiotherapists will always take a detailed history by asking you a number of questions relating to your problem. If the physiotherapist suspects a medical reason for your symptoms they may suggest you visit your GP for medical examination or testing. If a medical examination is not indicated the physiotherapist may suggest and only with your consent that a vaginal  examination is performed to accurately assess the pelvic floor and surrounding structures.

You do not have to have this examination, and you have the right to change your mind at any point during the examination. Please be aware that we are unable to perform this examination at the time of your monthly cycle so please bear this is mind when booking your appointment.

Female pelvic health physiotherapists look at how the muscles, joints and nerves work and interact. For this reason we don’t use medical equipment and will often examine muscles both externally and internally (manually using a finger). The pelvic floor is extremely complicated and needs thorough assessment so that treatment can be tailored to the individual’s needs. 

Problems with the pelvic floor can occur when the muscles are too weak (hypotonic) too tight (hypertonic) or can be a combination of both! It is very important to determine with the pelvic floor muscles: - 

. Strength and endurance
. Balance between the left and right sides
. Whether the muscles can both contract and relax effectively
. The resting position and muscle tone of the pelvic floor
. Whether the anterior and posterior pelvic muscles are working
appropriately 

Once we have performed the necessary tests then we can establish a picture of how the findings relate to your problem and plan a treatment program based on short and longer term goals. This treatment may include a combination of exercise, manual therapy and condition related education.

*When Doctors are conducting a medical assessment they are wanting to check that there is nothing abnormal and sinister present and that the anatomy is correct. They will usually use a speculum and may take a swab
to rule out infections. Some people may find this uncomfortable, however these assessments may be necessary to rule out pathology.

Use Of Point Of Care Ultrasound Scanning (POCUS) in Female Pelvic Health Physiotherapy 

POCUS is the use of ultrasound scanning providing a “window” into your body to show you real time functioning or movement of your muscles along with the positioning of your pelvic organs (vagina, bladder, rectum). POCUS will also show you in real time how that function, movement and positioning changes with limb movements and activation of your pelvic floor. In addition, POCUS can identify whether you are emptying your bladder fully, assess the proper functioning of the external anal sphincter (sometimes damaged during childbirth), check for pelvic organ prolapse and also assess the muscle function of your abdominal wall including a diastasis recti.

This “window” allows you and your therapist to visualise the organs and movements with muscle contractions. This is extremely helpful in allowing you to see the movements at the same time as feeling for the movement, providing greater feedback than just feeling alone. Often, the biggest barrier to performing a regular and progressive pelvic floor rehabilitation program is lack of awareness of the correct technique - real time ultrasound scanning overcomes this barrier.

Ultrasound scanning has been shown to be one of the safest medical techniques. It has been used to provide valuable pictures and other diagnostic information for four decades, with no evidence of any harm. We use ultrasound scanning through a transducer placed either on the abdominal wall or on the outside of the vaginal entrance using a sterile technique.

Dynamic ultrasound scanning for assessment of a diastasis recti (tummy gap postnatal).

This type of scan allows the measurement of the width and depth of the linea alba and the functioning of the abdominal muscles following childbirth. The dynamic visual assessment allows a progressive and individualised exercise program to be undertaken.

Dynamic Ultrasound Scanning Of The Pelvic Floor And Pelvic Organs

Here the ultrasound probe is placed outside the vaginal entrance. In this position we can evaluate the functioning of the pelvic floor, assess for pelvic organ prolapse.

Dynamic Ultrasound Scanning Of External Anal Sphincter 

Here the ultrasound probe is placed outside the vaginal entrance. The ultrasound waves can isolate the shape and contraction of the external anal sphincter which can often get injured during childbirth.

Dynamic ultrasound scanning of the pelvic floor and bladder through the abdomen

Here you can see the bladder clearly (the black bit) and the movement of the pelvic floor downwards and upwards at the base of the bladder during a pelvic floor contraction. We can  assess pelvic floor function in lying and standing. We can also assess whether you are fully emptying your bladder with ultrasound. 

A Specialist Postnatal Assessment Is Recommended For All Females Following Delivery (From 6 Weeks Onwards): -

• In depth check of pelvic floor strength and tummy gap
• Assessment of any physical problems arising from pregnancy and birth
• A bespoke postnatal recovery programme devised especially for you, your lifestyle and fitness goals. This includes specific and safe post-natal exercises to improve stability, posture and strength. 
• Return to running program (if required) following evidenced based guidelines on a safe return to running postnatally

You are welcome to attend any time postnatal in particular if you have postnatal concerns but we are unable to perform an internal exam to check your pelvic floor strength before 6 weeks. If you have had a Caesarean section then it is recommended that you seek help as soon as possible.

Electroacupuncture For Overactive Bladder Syndrome (OAB)

An overactive bladder is when the bladder muscle contracts before the bladder is full. The symptoms of an overactive bladder include: the need to urinate often, urgently and generally without much warning causing bladder leakage (Urge incontinence) In addition, your bladder may wake you up more than once during the night (Nocturia). 

The National Institute Of Clinical Excellence (NICE) clinical guidance states that the initial treatment for OAB symptoms is the assessment and treatment of pelvic floor muscle (PFM) function, bladder training, and behavioural techniques with a specialist physiotherapist. Despite initial physiotherapy intervention however, unfortunately some women experience persistent symptoms. 

As a subsequent option, your doctor may prescribe medication which is designed to reduce unwanted overactivity or sensitivity of your bladder (antimuscarinic drugs) but the common side effects of these drugs can be dry eyes, dry mouth, constipation or blurred vision. 

More invasive options such as Botox injections, nerve stimulation implants or bladder surgery may be considered, but these also may have potential risks or side effects and are only offered if the initial non-invasive treatments have not been effective. 

Acupuncture for OAB

Recent evidence points towards acupuncture as a useful tool in the management of overactive bladder symptoms with very minimal, if any, side effects. Research suggests that percutaneous tibial nerve stimulation (PTNS) is an effective treatment option for OAB. Current research also indicates that electroacupuncture (EA) is a suitable and less costly alternative, behaving in a very similar way to PTNS and studies have found no significant difference between PTNS and EA. 

Percutaneous tibial nerve stimulation or PTNS has been found to be effective for treating OAB and is recommended by NICE guidance but only when other options have not been effective and it is certainly not routine. You can read about PTNS and the evidence for its effectiveness in the box below. 

How does it work? 

PTNS and EA are considered to work to reduce bladder muscle (called the detrusor muscle) overactivity by in simple terms: 

1) reducing the sensitivity of the nerves that make you want to pee and 2) increasing the activity of the nerves that allow you to store urine, thereby restoring balance back to the bladder. 

Clinical experience has shown that EA for OAB is more effective starting at the same time as the initial recommended interventions. This is because most women with OAB have a tendency to increase the activity of the pelvic floor in response to the urges and find it difficult to start pelvic floor re-training when they are attempting to control the urges by increasing the action of their pelvic floor. 

The procedure

Acupuncture needles are placed at Spleen 6 (SP6) and Kidney 2 (KI2) acupuncture points and electrodes are attached (see image below). Electrodes are then placed on the acupuncture needles to provide stimulation. The machine intensity can then be turned up to your individual preference and is continued for a duration of 20 minutes. The procedure is relatively painless once the initial needles have been placed in the points. Mild tingling is felt between the two needles. 

Electroacupuncture procedure for the treatment of OAB

Follow up appointments

NICE guidance has recommended that treatments are weekly for a period of 12 weeks. After this further “top up” sessions may be required at less regular intervals, monthly, 3 monthly or 6 monthly intervals depending on an individual's symptoms. Clinical experience shows that most women start to see an improvement within the first few sessions if the treatment is going to be effective. We do not recommend continuing with the treatment if we have not seen some improvement after the first few sessions. Having OAB is very stressful and this stress can maintain the cycle of OAB by increasing the sensitivity of your nerves that control the bladder. Having a period of time dampening down OAB through the use of EA allows you to start to use other treatment methods such as pelvic floor relaxation and breathing exercises that produce a more permanent change. Some women find that the OAB disappears altogether as they have broken the cycle. 

Booking an appointment 

If you feel that you would like to try EA for OAB then book an initial appointment for Here. Once booked you will be provided with two confidential and comprehensive forms to complete. The first form is to provide detailed information to the physiotherapist about your problem you require help with and the second form is an outcome measure which asks you questions about your current status of bladder function so we can use this to assess improvements made with the treatment. Your initial consultation will be 60 minutes and should include EA in the first session. The second appointment is usually 60 minutes, this is required to assess and provide treatment interventions to enhance the effect of EA such as a pelvic floor assessment, assessment for back pain which can be related to OAB, fluid intake and lifestyle advice. It is expected but not assumed that future follow up will be 30 minutes long. Complex cases may require further 60 minute appointments.