Category: Anatomy/Physiology

News flash: There’s more to caring for your pelvic health than physical therapy. Whether or not you are sexually active, you should have had your first pelvic exam by age 21. If you haven’t because you think they’re scary or not needed, that’s understandable! No judgment here! There is a lot of mystery when it comes to pelvic exams, so let me help clarify so you can know what to expect. 

Who performs a pelvic exam?  

A pelvic exam is usually performed by a gynecologist, but your primary care doctor or a nurse practitioner are also qualified to perform it. 

What happens before and during a pelvic exam?

According to the Cleveland Clinic, you should be getting ready for your pelvic exam a full day before by not placing anything into your vagina, like tampons. This also includes abstaining from sex. Inserting something into your vagina prior may cause the pelvic exam to be less comfortable or interfere with the exam. 

Before a pelvic exam starts, you may be asked for a urine sample, so drink up before just in case, and don’t empty your bladder before you leave the house! 

If you are menstruating let your doctor know so he or she can make the proper arrangements for the exam room, such as placing a disposable chuck on the table. No need to feel embarrassed though! Chances are, you are probably not the first patient your gynecologist has seen who is having her period, and, if she’s a woman, she has likely been there herself and gets it. 

When the appointment starts, your doctor will talk to you about past and/or current health issues and will then leave the room to provide you with privacy while changing into a gown for the examination.

During a pelvic exam, which should take all of 10 minutes, a gynecologist checks the health of your female anatomy, like the vulva, cervix and uterus. 

Your gynecologist will push on your lower stomach to examine the organs.

They may have you maneuver your hips to the table’s edge. You will place your feet in stirrups. 

The insertion of the speculum can be a particularly intimidating part of the pelvic exam, but remember—even if it is uncomfortable, you should never be in pain! A speculum will be inserted so the gynecologist can see your vagina and cervix. If the regular sized speculum feels too intense, don’t be shy—please ask that they use a junior sized speculum instead. 

You will typically get a Pap test, also known as a smear, which involves taking cells from your cervix, and it should feel like just a minor pinch. (A bit of trivia: The test was named after the Greek doctor Georgios Papanicolaou who developed it in 1941, allowing women to get treatment much earlier and survive.) Vaginal fluid may also be collected. The bimanual exam involves the doctor feeling your vagina from the inside and outside simultaneously. That’s to check for any important changes in your organs. You may also need a rectal exam, which involves the insertion of your doctor’s finger. This can be done as part of the doctor’s routine, if you present with particular symptoms, or if the doctor believes it will help him make a potential diagnosis. You might have a breast exam, and an HPV test. You may even get your heart and lungs checked. 

What happens after the pelvic exam? 

The doctor may speak to you and you can learn about how and when to access test results. 

What is the doctor looking for during a pelvic exam? Why is it so important that I go to my pelvic exam?

One of the things your doctor is testing for is cancer. If you’re a young person, you may think that’s not a concern, but cancer can strike anyone. 

A Pap test is a way to detect cervical cancer or suspicious cells that may lead to it. HPV is the most common STI and can lead to cervical cancer. When cervical cancer is found early, the survival rate is as high as 91%, but once it spreads, it is much more difficult to treat. 

One thing a digital rectal exam can detect is rectal tumors. As with cervical cancer, the survival rate is good in the early stages, but not as the disease progresses, so early diagnosis is essential.

Your gynecologist is also checking for ovarian cancer. If you are of Ashkenzazi Jewish descent, you have a 1 in 40 chance of having a BRCA gene mutation, which increases your chance of a number of cancers, including ovarian. However, ovarian cancer has a 94% survival rate when diagnosed early.

You may be tested for STIs like chlamydia or gonorrhea. Typically, a chlamydia or gonorrhea test is done via either a urine sample or swab sample in a procedure called a nucleic acid amplification test (NAAT). 

A pelvic exam is also a reliable test for pelvic floor dysfunction! If even the junior sized speculum hurts or if the internal digital examination is very painful, that may be your body’s way of telling you that it’s time to schedule an appointment with your local pelvic floor physical therapist. In fact, one of the screening questions that we pelvic floor PTs ask is “Do you have a history of pain during gynecological exams?”

How can I make my pelvic exam more comfortable?

There are steps you can take to make your pelvic exam more comfortable. Communicating with your provider and deep breathing is suggested. As I mentioned, you can request the speculum be a pediatric one and that it be warmed and lubricated. You can also employ one of my favorite techniques, diaphragmatic breathing, to help relax your pelvic floor muscles during the examination. 

You may want to ask friends and family for their gynecologist recommendations to find the best match. 

If you have sexual trauma, it’s very important to communicate that to your gynecologist. He or she can slow down the examination to ensure maximal comfort and can stop if you need to. This article provides excellent ways to start that conversation.

I hope I’ve made you feel more comfortable about pelvic exams. Also, don’t be afraid to involve your physical therapist as well! We can be great resources for names of trusted gynecologists, or to discuss the details of the process with you to help you prepare mentally. We’re also happy to be in contact with your gynecologist, if you need us to talk with them about your pelvic floor dysfunction. But I bet after your first pelvic exam, you’ll probably realize there wasn’t much to be afraid of after all! And you’ll have that amazing, priceless peace of mind that comes with knowing your pelvic health is being prioritized just as it should be. 

When you’re in pain, all you can think about is getting out of it, but if you have pelvic floor dysfunction, that’s going to take a lot of work. You have to get a diagnosis, research the right clinician and/or therapist, commit to months (or sometimes years) of therapy, and do all the “homework” your therapist assigns. Oh, and let’s not forget the emotional work as you learn to be patient while your body becomes a more functional and less painful place to exist. The good news? The process can be a lot easier when you have the right plan in place.

First, let’s talk about getting a proper diagnosis because without that, you can’t receive proper treatment. Even if an internist or gynecologist is familiar with pelvic floor dysfunction, that doesn’t mean you’ll be immediately (or ever) receiving that diagnosis. As I say in my book The Inside Story, misdiagnosis happens because pelvic floor dysfunction may not be at the top of your doctor’s mind. He or she might want to run diagnostics or perform further testing. If you do, in fact, have PFD, these tests will be negative, because they do not detect pelvic floor muscle overactivity. Your doctor may be wonderful and well-intentioned, however many of them simply do not know about PFD from their medical school training. (Shout out to Tight Lipped, a wonderful organization that is working on fixing that problem! Learn more about it here.) You will likely have better luck with a urogynecologist, whose specialty is the pelvic floor, or an internist or gynecologist who has a history of recognizing pelvic floor disorders. But even if you get the right diagnosis, you may find a clinician who doesn’t have a good understanding of how pelvic floor dysfunction needs to be treated.

If your doctor can’t relatively quickly determine your pain driver, or primary source of pain, then you might have to advocate for yourself. In America, we have direct access. This means you can go ahead and schedule an appointment with a pelvic floor physical therapist without a referral. (Keep in mind that not all states allow for the same level of direct access, so make sure you know the rules in your state before seeing a therapist.) 

In the same way you should ask for a recommendation for a good doctor, you should do the same for a pelvic floor physical therapist. You may feel like you are the only one experiencing your symptoms, but I promise you that is not the case. Don’t be surprised if you find out your aunt or friend had the same problem and knows of a skilled provider. The internet can also be a good starting point for research. In the USA, you should search the American Physical Therapy Association’s website for a trusted therapist in your area.

Make sure your therapist has at least six months of experience. Sometimes this information will be found on their website or LinkedIn, but don’t be afraid to ask. 

Also ask how many continuing education classes your therapist has taken and which ones. Personally speaking, I like the Herman & Wallace Pelvic Rehabilitation Institute. Their courses and teachers are amazing!

Finding a therapist who solely treats pelvic floor dysfunction may be tough, but at least half of his or her patients should be experiencing PFD. 

Inquire about your therapist’s credentialing. The letters you see may be confusing, so let me help you break the code! WCS is very good. This stands for the ​​Board Certified Women’s Health Clinical Specialist from the American Physical Therapy Association, the gold standard within the physical therapy community for being considered an expert in pelvic health. (To put it in perspective, I am pretty sure I studied longer and harder for my WCS than for my licensing examination!) There are other letters you may want to look for. BCB-PMD means that one is board certified in biofeedback for pelvic muscle dysfunction. PRPC means that the clinician has Pelvic Rehabilitation Practitioner Certification through Herman & Wallace. CLT is a Certified Lymphedema Therapist. 

Now, evaluate your choice. Interviewing your pelvic floor physical therapist might seem like a tough thing to do, but it is vital. Do a trial visit. Consider how you feel. Is your therapist caring or dismissive? Is the staff friendly, and helpful with insurance or payment plans? Are you given homework? Has your therapist outlined your goals? A therapist may be great at what he or she does, but it’s important that you feel comfortable. As you will notice on my website, I allow potential patients the opportunity to receive a free phone consultation before making an appointment with me. 

Having pelvic floor dysfunction can be a scary and frustrating experience, but it’s less so when you are well-informed about your options and when you are empowered to best take care of your body. Whether you choose to seek care with Revitalize Physical Therapy or another respected healthcare provider, I hope this guide allows you to be your own best advocate. To your health!