Initial Pelvic Floor Physiotherapy Assessment

"Notes transcribed with an AI scribe - patient consented verbally prior to commencing session."

Patient Information

• Sarah Jenkins, Age: 34 years 6 months, Female
• Currently on maternity leave from administrative role (sedentary, desk-based).
• Walking 30 mins daily with pram; keen to return to high-impact gym classes and running.
• Lives in a single-storey house with husband and two children (3 years old and 4 months old). Good support from partner.

Context

• Attended with 4-month-old infant.
• Referred by Dr Emily Chen (GP).

Subjective

• Presenting with stress urinary incontinence (SUI) and vaginal heaviness postpartum.
• Symptoms commenced following vaginal delivery 4 months ago. Heaviness is worse in the evenings (VAS 4/10).
• Exacerbated by coughing, sneezing, lifting toddler, and prolonged standing. Relieved by lying down. Attempted self-directed Kegels with nil improvement.
• SUI has slightly improved since the immediate postpartum period, but vaginal heaviness remains static.
• Mild SUI after first delivery 3 years ago, which resolved within 6 weeks without formal intervention.
• Avoids running, jumping, and heavy lifting; feels anxious about leaking in public.

Pelvic Health Symptoms

• Bladder symptoms:
  • Daytime frequency: 6–7x/day.
  • Nocturia: 1x/night (waking with infant).
  • Urgency: Nil.
  • Incontinence: SUI with coughing, sneezing, and lifting. Nil urge incontinence.
  • Pad usage: 1 panty liner daily for security.
  • Voiding difficulties: Nil hesitancy, straining, or incomplete emptying.
• Fluid intake: 2.5 L water daily (currently breastfeeding), 1x cup of coffee in the morning.
• Bowel symptoms:
  • Frequency: 1x/day.
  • Stool type: Bristol Stool Chart Type 2–3.
  • Urgency/Incontinence: Nil faecal or flatal incontinence.
  • Difficulties: Occasional straining required; uses footstool intermittently.
• Dietary intake: Balanced diet, adequate fibre intake, trying to increase fruit and vegetables.
• Prolapse-related symptoms:
  • Sensation of vaginal lump/heaviness at the introitus, worse at the end of the day or after carrying the toddler.
  • Nil manual digitation required to void or defecate.
• Sexual function symptoms:
  • Has not yet resumed intercourse postpartum due to fear of pain and heaviness.
• Associated symptoms: Mild low back ache after prolonged babywearing.

Past Medical History

• G2P2. Recent SVD 4 months ago: 3.8 kg infant, 2nd-degree perineal tear (sutured), prolonged second stage (2 hours). First delivery 3 years ago: SVD, 3.4 kg infant, intact perineum.
• Nil history of smoking or chronic respiratory conditions.
• Mother had surgical repair for pelvic organ prolapse at age 55.
• Currently breastfeeding exclusively (lactational amenorrhoea).

Patient Goals

• Short-term (6 weeks): Cease leaking with coughing/sneezing and resolve evening vaginal heaviness.
• Long-term (4 months): Return to 5 km continuous running and gym classes symptom-free.

Objective

• Informed verbal consent obtained for external observation and internal digital vaginal examination, with the option to stop at any time.
• Pelvic floor muscle assessment:
  • Method: Visual inspection and digital vaginal palpation in crook lying.
  • External observation: Well-healed perineal scar, nil erythema. Visible perineal descent on cough.
  • GH + PB: 4 cm + 3 cm at rest; 4.5 cm + 3 cm on Valsalva.
  • Prolapse: Grade 1 cystocele (anterior wall descent to -1 cm above hymen on Valsalva). Posterior wall and apical compartment intact.
  • Tone: Normal resting tone bilaterally; mild tenderness over superficial perineal scar.
  • Strength (Modified Oxford Scale): 3/5 bilaterally, weak ventral lift.
  • Endurance: 5-second hold at submaximal effort, 4 repetitions before fatigue and recruitment of gluteals/adductors.
  • Relaxation: Complete and rapid return to resting baseline.
  • Fast contractions: 5 repetitions before loss of coordination.
  • "The Knack": Delayed activation on cough; mild downward movement observed.
• Musculoskeletal assessment:
  • Posture: Mild thoracic kyphosis and anterior pelvic tilt in standing.
  • Lumbar spine ROM: Full and pain-free in all planes.
  • Diastasis Recti Abdominis (DRA): 2-finger width separation at umbilicus, 1.5-finger width at 4 cm above, good linea alba tension generated on curl-up with PFM co-activation.
  • Breathing pattern: Apical breathing noted at rest; able to transition to diaphragmatic breathing with tactile cueing.
• Midstream urine (MSU) completed by GP last week: NAD, negative for infection.

Issues

• Postpartum Stress Urinary Incontinence and Grade 1 Cystocele
  • Impression: PFM weakness and impaired coordination secondary to recent vaginal delivery, contributing to SUI and symptomatic Stage 1 anterior compartment prolapse.
  • Differential: Overactive bladder (ruled out subjectively).
  • Cueing provided for isolated PFM contraction in crook lying (visualisation of "lifting a blueberry") to eliminate gluteal/adductor overflow. Practised "The Knack" prior to coughing.
  • Patient successfully achieved isolated grade 3/5 contraction with diaphragmatic breathing and demonstrated improved pre-contraction timing on cough.
  • Educated on pelvic floor anatomy, the supportive role of PFM in managing prolapse, and the impact of intra-abdominal pressure (IAP) during lifting. Discussed bowel management and avoiding straining.

Evaluation

• Baseline established. Patient demonstrates good motor learning and body awareness once cued. High motivation to adhere to rehabilitation program.

Home Program

• PFM Endurance: 5-second holds x 6 reps, 3 sets/day in crook lying (progress to sitting as able).
• PFM Fast Twitches: 8 quick contractions, 3 sets/day.
• Functional bracing ("The Knack"): Engage PFM prior to coughing, sneezing, and lifting toddler/pram.
• Bowel habits: Consistently use a footstool (Squatty Potty) and exhale/bulge abdomen gently during defecation to avoid straining.
• Perineal massage: Gentle scar mobilisation with vitamin E oil for 2 mins daily.

Handouts

• "Pelvic Floor Muscle Exercises for Women" (Continence Foundation of Australia) emailed.
• "Good Bladder and Bowel Habits" leaflet provided physically.

Plan

• Review in 2 weeks to reassess PFM technique, check adherence to HEP, and progress exercises to upright functional positions.
• Send initial assessment summary letter to referring GP, Dr Emily Chen.
• Discuss pessary sizing options at the next visit if heaviness symptoms do not improve with conservative PFM training.
• Nil additional referrals required at this stage.