Pelvic Floor Assessment Sheet

Form Filling and Clinical Assessment Guidance for Physiotherapists

Purpose of the Form

The Pelvic Floor Assessment Sheet is a focused clinical documentation tool used to evaluate pelvic floor muscle structure, tone, strength, endurance, coordination, and tenderness, and to guide individualized pelvic floor rehabilitation planning. It is applicable in conditions such as urinary and fecal incontinence, pelvic organ prolapse, pelvic pain, dyspareunia, postnatal dysfunction, post-gynaecological surgery rehabilitation, and core–pelvic floor dysfunction.

The form supports:

  • Standardized internal pelvic floor examination
  • Objective grading of pelvic floor muscle performance
  • Identification of tone abnormalities and pain patterns
  • Safe and ethical pelvic health practice
  • Clear linkage between assessment findings and treatment planning
  • Medico-legal documentation

Patient Identification Section

How to Fill

Record:

  • Patient name
  • Age and sex
  • Date of assessment
  • UHID number
  • Reason for assessment (e.g., urinary incontinence, pelvic pain, postnatal weakness)

Clinical Guidance

The reason for assessment should clearly state the functional or clinical indication, as pelvic floor findings must always be interpreted in the context of presenting symptoms.

Observation

This section documents external and visual findings prior to or in addition to internal examination.

Pubic Crest

What to assess

  • Tissue integrity
  • Tenderness
  • Scar presence
  • Patient response to palpation

How to fill
Describe notable findings briefly.

Clinical interpretation
Tenderness or altered tissue quality may indicate musculoskeletal contribution or post-surgical changes.

Vaginal Canal

What to assess

  • Tissue tone
  • Moisture
  • Elasticity
  • Patient comfort

How to fill
Document qualitative findings.

Clinical interpretation
Reduced elasticity or discomfort may be associated with hormonal changes, postnatal status, or chronic pelvic pain.

Visible Bulging

What to assess
Observe for bulging at rest or with strain/cough.

How to fill
Tick Yes or No.

Clinical interpretation
Visible bulging suggests pelvic organ prolapse or poor pressure management and warrants careful exercise selection.

Superficial Contraction

What to assess
Ask the patient to perform a gentle pelvic floor contraction.

How to fill
Tick Present or Absent.

Clinical interpretation
Absence indicates poor neuromuscular awareness and may require motor re-education before strengthening.

Ultrasound Report (If Any)

How to fill
Record findings if pelvic floor ultrasound is available.

Clinical interpretation
Ultrasound complements manual assessment but does not replace functional palpation.

Internal Examination

(Must be performed only with informed consent, appropriate training, and institutional guidelines)

Palpation

What to assess
Assess overall muscle tone.

How to fill
Tick one:

  • Soft
  • Firm
  • Hypertonic
  • Hypotonic

Clinical interpretation

  • Hypertonic muscles require relaxation and down-training
  • Hypotonic muscles require graded strengthening

Tenderness

What to assess
Assess pain response during palpation.

How to fill
Tick Yes or No.
If Yes, document location using the clock-face method.

Clinical interpretation
Localized tenderness suggests myofascial trigger points or pain-dominant pelvic floor dysfunction.

Power – Modified Oxford Scale

What This Measures

Pelvic floor muscle strength and lift quality during voluntary contraction.

How to Fill

Tick the grade that best represents the contraction:

  • 0 – No contraction
  • 1 – Flicker
  • 2 – Weak lift
  • 3 – Moderate lift
  • 4 – Good lift
  • 5 – Strong lift with sustained hold

Clinical Interpretation

Grades 0–2 indicate significant weakness, while grades 4–5 indicate good functional strength but still require endurance and coordination training.

Endurance & Repetitions

Max Hold Time

What to assess
Ask the patient to hold a maximal voluntary contraction.

How to fill
Record duration in seconds.

Clinical interpretation
Low endurance is common even when strength is adequate and must be addressed in training.

Repetitions (10-sec Hold)

What to assess
Number of sustained contractions the patient can perform.

How to fill
Record total repetitions achieved.

Contraction Log

What to assess
Document consistency and fatigue across multiple contractions.

How to fill
Record hold times for each repetition and add comments if needed.

Clinical interpretation
Rapid fatigue suggests poor endurance or over-recruitment of accessory muscles.

Treatment Plan

This section directly translates assessment findings into intervention.

EMG Modes

How to fill
Tick applicable mode:

  • EMG Activation
  • EMG Relaxation
  • ETS (Electrical Triggered Stimulation)

Clinical interpretation

  • Activation modes are used for weakness
  • Relaxation modes are used for hypertonicity and pain

Exercise Plan

How to fill
Document:

  • Exercise type
  • Repetitions
  • Hold time
  • Sets
  • Position (e.g., crook lying, sitting, standing)
  • External load if any
  • Mode and parameters (if using devices)

Clinical interpretation
Exercise prescription must match the identified impairment—strength, endurance, coordination, or relaxation.

Notes / Recommendations

How to fill
Include:

  • Home exercise advice
  • Lifestyle or bladder habit recommendations
  • Precautions
  • Follow-up plan

Therapist Authentication

How to Fill

Record:

  • Physiotherapist name
  • Signature
  • Date

Clinical Significance

This confirms professional accountability and ethical completion of an intimate examination.

Clinical Summary

The Pelvic Floor Assessment Sheet provides a structured, objective framework for evaluating pelvic floor muscle function and guiding targeted rehabilitation. Accurate completion requires technical competence, ethical practice, patient-centered communication, and sound clinical reasoning. When used correctly, this form supports safe, effective, and individualized pelvic health physiotherapy care

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