DIGITAL PALPATION of the PELVIC FLOOR MUSCLE
Editor: Jenniffer Voelkl Guevara, November 2016

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Current definition:


  • The process of using one’s fingers / hands as part of assessment, to gather information about the tissues (1)
  • Messelink and colleagues (2005) define digital palpation as an easy way to perform physical examination and to assess the pelvic floor muscles and surrounding areas at rest, and during contraction and relaxation and they should be palpated circumferentially. They state the importance of determining the patient´s position while the palpation was performed, time of the day and instructions given to the patient as well (2)

Perspectives:


It is a well-known technique used by physicians, and physical therapists to assess pelvic floor muscles ability to contract or relax and to assess surrounding pelvic areas as well.
The first description was made by Kegel, asking to perform a contraction perceived as an inward and squeezing movement around the finger placed in the distal one third of the vagina; however it was used only for teaching purposes in regards on how to perform a good contraction (3)

Digital palpation can be performed in different position such as supine, lithotomy, lateral and standing, using lubricated gloves and one or two finger may be used during the assessment.
Carrier (2006) states that it is possible to discern between muscles such as puborectalis (cranial/ventral movement), or pubococcygeus (cranial and medial movement narrowing the elevation of the urogenital hiatus) and elevation of the bladder neck (placing the examining finger behind the urethra and vesicourethral junction) (4)

Messelink and colleagues (2005) describes the digital palpation as follows:
The gloved and lubricated index finger of the examiner is introduced into the vagina (women) or the anus (women/men). Digital palpation should be performed with the patient in the supine and standing position. In the supine position, the hips and the knees should be flexed. If the knees are bent, the patient should not hold the legs herself, legs should be relaxed. Palpation is performed with one finger because two finger may stretch the pelvic floor muscles and thereby influence the ability to contract. It is important to be very clear as to what is expected from the patient. Asking for a pelvic floor contraction will not be enough in most cases. The instruction ‘‘lift’’ and ‘‘squeeze’’ are useful. Palpation with two fingers the supine position is used to measure the genital hiatus and to get information on the pelvic organs. For anal palpation, the patient is put in left lateral position (2)

Some functions of the pelvic floor muscles can be tested during physical examination. For instance a voluntary contraction of the pelvic floor muscles can be assessed by inspection and palpation (2)

Pelvic floor muscle strength can be assessed and graded according to the modified Oxford grading system; furthermore several measurement techniques based on pelvic floor palpation have been developed in the past years, this include The Brink score (5), which employs a 4-point scale to assess the contraction pressure, vertical displacement and endurance of squeeze, and the Laycock PERFECT assessment Scheme, which scheme uses a 6-point scale to score strength and endurance, timing and activation of fast fibers (6)

It is the best way to determine pelvic floor function in terms of strength, voluntary/involuntary contraction, muscle relaxation and pain.

Controversies:


Currently, there is no gold standard for the assessment of PFM function, though digital palpation is a subjective measurement; still it is a good way to determine muscle function, in terms of muscle´s ability to contract and relax and to establish goals of treatment.

  • Digital palpation is a helpful technique to use in daily clinical practice in case education and feedback over pelvic floor contraction is needed, however there are important factors in assessing pelvic floor muscle function such as involuntary reflex contractions in the presence of increased intra-abdominal pressure and muscle tone which are not included in ICS standardization of terminology on pelvic floor assessment.
  • Reproducibility and quantification of testing is questionable, there is no validated scale to quantify contractions of the pelvic floor muscles, no systematic research is provided to determine the quality of a contraction. Although in general Brik scale and Perfect Scheme scales have acceptable intra observer and inter-observer reliability, they have showed that they are not suitable for research purposes (7)

References:


  • 1. Kari Bo, Helena Frawley, Bernard Haylen, Yoram Abramov, Fernando Almeida, Bary Berghmans, Maria Bortolini, Chantale Dumoulin, Mario Gomes, Doreen McClurg, Jane Meijlink, Elizabeth Shelly, Emanuel Trabuco, Caroline Walker, Amanda Wells. An international urogynecological association (IUGA) / international continence society (ICS) joint report on the terminology for the conservative and non-pharmacological management of female pelvic floor dysfunction
  • 2. Messelink, B., Benson, T., Berghmans, B., Bo, K., Corcos, J., Fowler, C... & Nijeholt, G. A. (2005). Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society. Neurourology and urodynamics, 24 (4), 374.
  • 3. Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol. 1948;56:238 –249
  • 4. Carrier. The pelvic floor. 2006;384-386
  • 5. Wells, T. J., Brink, C. A., Diokno, A. C., & Gillis, G. L. (1991). Pelvic muscle exercise for stress urinary incontinence in elderly women. Journal of the American Geriatrics Society, 39 (8), 785-791.
  • 6. Laycock, J., Jerwood, D. (1994). Pelvic Floor Muscle Assessment: The PERFECT Scheme. Physiotherapy, 87, p. 631–642.
  • 7.Slieker‐ten Hove, M. C. P., Pool‐Goudzwaard, A. L., Eijkemans, M. J. C., Steegers‐Theunissen, R. P. M., Burger, C. W., & Vierhout, M. E. (2009). Face validity and reliability of the first digital assessment scheme of pelvic floor muscle function conform the new standardized terminology of the International Continence Society. Neurourology and urodynamics, 28(4), 295-300.