By signing this form, you acknowledge and understand that you have been referred for evaluation and treatment for pelvic floor dysfunction. During the physical therapy evaluation for the problems you have reported, an assessment of your pelvic girdle, back, and hips will be performed by a physical therapist in order to identify any musculoskeletal problems.
Conditions that could include pelvic floor physical therapy as part of assessment and treatment include but are not limited to:
Urinary or fecal incontinence
Difficulty with bowel, bladder, or sexual functions
Pelvic organ prolapse
Chronic pelvic pain
Vulvodynia/Vestibulodynia
Vaginissmus or Dyspareunia
Interstitial Cystitis
Post-op prostatectomy rehabilitation
Pregnancy related pelvic girdle pain
Painful scars after childbirth or surgery
Persistent sacroiliac, low back, and/or hip pain
To evaluate your condition it may be necessary, initially and periodically, to have your physical therapist perform an internal pelvic floor muscle examination. This examination is performed by observing and/or palpation the perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength and endurance, scar mobility, and function of the pelvic floor region. Such evaluation may also include vaginal or rectal sensors for muscle biofeedback. You have the right to refuse internal assessment and treatment and your physical therapist can assess and treat the pelvic floor muscles externally, if needed.
Treatment for your reported condition may include, but not be limited to, the following: observation, palpation, use of vaginal or rectal sensors for biofeedback and/or electrical stimulation, or vaginal weights, ultrasound, heat, cold, stretching and strengthening exercises, soft tissue and/or joint mobilization, and
educational instruction.
Benefits of performing an internal pelvic floor evaluation may include but are not limited to the following:
Determining resting tone of the pelvic floor muscles (normal, over-, or under-active)
Assessment of all layers of the pelvic floor muscles for strength, timing, coordination, and endurance
Risks of performing an internal pelvic floor evaluation may include but are not limited to the following:
Pain or discomfort during or after the assessment
Spotting/bleeding during or after the assessment
Anxiety/emotional response
Skin reaction/irritation
Vaso-vagal response (nausea or light-headedness)
CONSENT
By signing below I acknowledge that I have read and understand the Informed Consent for Pelvic Health Evaluation and Treatment, and I consent to having an internal pelvic floor muscle evaluation and treatment.
By signing below I also acknowledge the following:
1. I understand an internal pelvic floor muscle exam, as well as internal muscle release techniques and/or strengthening exercises will be part of my subsequent treatment and I consent to these treatments
2. I understand that I can withdraw my consent at any time and will inform my physical therapist of any changes in preference
3. The purpose, risks, and benefit of this evaluation have been explained to me
4. I understand that I am responsible for immediately telling the examiner if I am having any discomfort or unusual symptoms during the evaluation
5. I have the option of having a second person present in the room (family member, friend, or clinic staff member) during the procedure and: