History taking is tough. There’s always something else you could ask, something you entirely forgot to ask, something you should ask but don’t feel like asking. As students and new graduates, we begin our history taking on shaky legs, trying to remember all the most vital questions. As time goes on, we hone that skill, taking into consideration not just what’s required to satisfy insurance companies, but also the finer tuned specifics that allow us to better understand our patients.
I want to use this opportunity to offer additional questions that a PT in any setting can include to screen for pelvic floor conditions. Regardless of your specialty — geriatric, pediatric, orthopedic, neurological, or oncological — your patients have pelvic floors. Pelvic floor conditions don’t discriminate; they affect people of all ages, genders, and races. These conditions are isolating, embarrassing, under diagnosed and under treated. They may affect your patients ability to stay in school or stay at work. They may affect their ability to attend their child’s wedding or maintain intimacy with their partner. These conditions may affect the way they look at themselves and their bodies. A few simple questions can allow you to point them in the direction of help.
Today, I’m going to detail out 6 questions you should ask, and why. The biggest barrier to integrating this into your practice is gathering the gusto to use words like urine, stool, sex, penis and vagina while making eye contact with your patient. Once you have that down, the rest is easy.
1. Do you have pain in your pelvic region during any activity?
This is a question you should ask all patients with symptoms below the ribs. My pelvic pain patients rarely present with an absence of all other pains. They usually have hip pain, or pubic bone pain, low back pain or tailbone pain . . . sometimes all of that and more. The hip and low back do not exist or function in absence of the pelvic floor, and our care of those regions shouldn’t either. Not to mention the fact that pains in any and all of those regions can masquerade as one another. A labral tear can present as pelvic pain, pelvic pain can present as low back pain, and so on: this region is a tangled mesh of closely physically and functionally related structures.
Research has drawn links between many of these structures and symptoms. For instance, let’s look at the relationship between urinary incontinence, which affects nearly 33 million Americans per year, and low back pain, which affects nearly 31 million (7, 8). In a cross-sectional analysis by Smith et. al. in 2006, a total of 38,050 women were screened to find that urinary incontinence was more strongly related to frequency of low back pain than obesity and decreased levels of physical activity (2). Another study by Eliasson et. al. in 2008 screened 200 women with low back pain entering their physiotherapy clinic, and found that 78% of these women also experienced urinary incontinence (3). I’m not sure if this is a chicken or the egg situation, but those numbers are convincing enough for me to at least screen for one if treating the other.
The link between pelvic floor and orthopedic conditions doesn’t stop there. The hip is another region commonly affected by pelvic floor conditions, and vice versa. A paper by Coleman et. al. discussed the relationship between femoroacetabular impingement and chronic pelvic pain, including vulvodynia and clitorodynia. Over five years, patients who failed to experience symptom relief with conservative management underwent hip arthroscopy for pincer resection, cam resection, labral repairs and iliopsoas tendon release. 75% of those sent for hip arthroscopy experienced relief of both hip and pelvic pain. Seventy five percent! Isn’t that incredible? (5)
The Coleman study concluded by suggesting that gynecologists and orthopedists “should consider the possibility that hip disorders may cause or contribute to chronic pelvic pain and vulvar pain” and that clinicians should be cognizant of this relationships during evaluations. Now I’m going to extrapolate, but barely. I think physical therapists should consider the relationship between these structures during evaluations as well.
Asking this simple question could clue you in to another facet of what is happening in your patient’s body. All you have to do is open that door and see if they step through.
2. Do you ever lose control of your bladder or bowels?
This question is entirely appropriate for any patient with symptoms below the ribs. Considering how common incontinence is (1), we should be comfortable screening for it in our patients. While asking someone if they have a prior history of PT, a prior history of surgical procedures, a history of low back pain, we should also be asking them if they have any concerns regarding control of their urine and bowels.
Asking is not nearly as uncomfortable as you fear, and if they happen to say some variation of “yes,” you may be the first person that has ever found themselves in a position to help. You do not have to be able to treat them in order to point them in the right direction for care.
They may say “Why the heck are you asking me that?” That’s also reasonable. Just laugh those answers off and remind yourself how common these symptoms are.
Urinary and fecal incontinence goes greatly under reported, under diagnosed and under treated. Many people experiencing urinary and fecal incontinence symptoms do not know that they have a treatable condition. Many of them have never been asked by anyone in their health care team if they struggle with this. Physicians don’t always ask these questions because, just like you, they think it would be uncomfortable and don’t know how to manage it anyways. Patients don’t bring it up because they’re embarrassed. They’re just as nervous to be met with a blank stare from a health care provider that’s ill equipped to handle this information as you are of being met with a blank stare from a patient that thinks you’re crazy for asking.
Pelvic floor PT is dedicated to helping this patient population. You can be the one to shed that light on a struggle that has affected their quality of life for years.
3. Do you have difficulty emptying your bowel or bladder?
The muscles of the pelvic floor are responsible for what goes in and comes out of the pelvis. They control penetration, urination and defecation.
If you ask your patient the question above, you may get a variety of answers. If they give you some variation of the answer “yes”, ask them how seriously affected they are. To me, “yes” indicates possible tension of pelvic floor muscles. Some specifics you could be on the lookout for include urinary hesitancy, which means when they sit down to urinate, it takes some time, seconds or minutes, to initiate their urinary stream. Another possibility would be frequent emptying, meaning they make frequent trips to the bathroom getting out a bit at a time.
There are simple tips and tricks these patients can decrease these types of symptomes, some as simple as leaning forward and exhaling while they try to relax their pelvic floor muscles, using a squatty potty, dietary modifications, but sometimes that isn’t enough. If they find their symptoms troublesome, consult your local pelvic floor PT.
4. Do you ever have to wake up at night to urinate?
I’m sure all of us have experienced this before. While comfortably tucked away in your warm bed, you’re woken by this sensation in your bladder that you try to ignore. Sometimes, we successfully fall back asleep, never having to break out of our cozy cocoon, but other times that feeling nags until there’s no use trying to avoid it.
A 2010 study by Bosch et. al. revealed that young men, ages 20 to 40, wake up one time per night to urinate with a prevalence of 11% to 35.2%. Prevalence in women of a comparable age group was slightly higher at 20.4% to 43.9%. When looking at men and women over the age of 70, prevalence was as high as 93% for one void per night and even ranging up to 77.1% for twice per night (6).
As you see, nighttime urination is not necessarily abnormal. What you are screening for with this question is nocturia, or excessive nighttime urination. While one time per night may be annoying, or uncomfortable, what if you were waking every two hours, or even every 30 minutes to urinate? Imagine the effect that would have on your sleep quality, and imagine how badly you would want a solution if you knew one existed.
5. How frequently do you have to urinate during the day?
With this question, you are screening for polyuria or urinary frequency, which means having to urinate excessively during the day.
Normally, I won’t be concerned if my patient tells me they urinate every 2-5 hours, as long as this is typical for them. So what if your patient says they go every hour? Maybe that doesn’t bother them and that’s their normal. We all know “norms” only get us so far. But what if they say they go every hour and that started a couple years ago since they had a hysterectomy. What if they say they go every 30 minutes and they try to wait longer but if they do they’ll leak. Or what if they have to go every 15 minutes and will excuse themselves to the restroom four times during your one hour session, only to do the same thing during their meetings at work.
A normal bladder will have a capacity of about 500ml, or 16.9 ounces. The desire to urinate will typically kick in around 300ml, or 10.1 ounces. At that point, we get that initial feeling that reminds us our bladder exists, and then slowly builds until it becomes fairly urgent and we realize the moment is now. In an ideal world, we then take ourselves to the bathroom, fully empty our bladder, and don’t have to repeat for some hours.
So if your patient is urinating every 15, 20, 45 minutes, why? This can be a sign of something acute, like a UTI. Or it can be a sign of something more chronic, like overactive bladder syndrome, or interstitial cystitis. Frequent urination can be associated with pain and discomfort, but at the very least, it’s a massive inconvenience.
These people will appreciate you asking, and they’ll be ecstatic if you can offer them a treatment option they haven’t yet come across.
6. Do you have any pain with sexual activity?
Dyspareunia, or pain with sexual activity, is common, debilitating, and treatable. I won’t go too far into depth on this one, but this is a question health care providers should be asking both their female and male patients.
Some people struggle with painful sex for their entire lives. Some people only begin to experience this after surgery, child birth, trauma to the pelvic floor. People’s intimate relationships and personal lives are affected by the inability to perform this ADL, and it is an ADL.
Pain with sex can present as pain with penetration either at the vaginal opening or deeper, feeling like cramping in the abdomen. Pain can feel like dryness, or discomfort following orgasm. This diagnosis presents in a number of ways, and many are within the scope of pelvic floor physical therapy. For many of these folks, PT is a game changer.
Screen for pelvic floor conditions!
I don't think that vestibular specialists should be equipped to treat complex orthopedic conditions. I don't think acute care specialists should be equipped to treat complex pediatric conditions. I do, however, think that we should all have spidey senses that make our ears perk and body tingle when a patient reports something that we know they shouldn’t have to live with. Even if we can’t be the ones to help, we can be the ones to point them in the direction of those who can.
- Urinary Incontinence in Women Statistics. Phoenix Physical Therapy, PLC.
- Smith MD, Russell A, Hodges PW. Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Aust J Physiother. 2006;52:11-16.
- Eliasson K, Elfving B, Nordgren B, Mattsson E. Urinary incontinence in women with low back pain. Man Ther. 2007 Mar 14.
- Whitacker JL, Thompson JA, Teyhen DS, Hodges P. Rehabilitative Ultrasound Imaging of Pelvic Floor Muscle Function. JOSPT. 2007; 37(8):487-498.
- Coleman SH. Donegan S. Futterman S. Shah M. Coady D. The Relationship Between Femoracetabular Impingement and Chronic Pelvic Pain. ISHA Annual Scientific Meeting 2014.
- Bosch JLH. Weiss JP. The Prevalence and Causes of Nocturia. J Clin Urol. 2010; 184(2): 440-446
- What is Urinary Incontinence?
- Back Pain Facts and Statistics.