Assessment Methods Used in Pelvic Floor Physiotherapy in the Rehabilitation Process of a Patient with Pelvic Organ Prolapse: Qualitative Research

*Lähderinne Reetta¹,*Törnävä Minna², Kankkunen Päivi³

* Shared 1. authorship

¹School of Health Care, Savonia University of Applied Sciences, Kuopio, Finland.

²Social Services and Health Care, Tampere University of Applied Sciences, Tampere, Finland.

³Department of Nursing Science, University of Eastern Finland, Kuopio, Finland.

Abstract

Background: Pelvic organ prolapse (POP) is the descent of one or more structures of the vagina and uterus from their normal anatomical position. POP can be treated surgically or conservatively, such as with pelvic floor physiotherapy, which has been found to have a positive impact on urogenital symptoms and quality of life.

Objective: To describe the methods used to evaluate POP, its symptoms, and its treatment results in physiotherapy from the perspective of Finnish physiotherapists.

Methods: The study had a qualitative approach. The data was collected using thematic interviews and analyzed using inductive content analysis. Nineteen physiotherapists recruited via the Finnish Association of Physiotherapists in Pelvic Floor participated.

Results: The evaluation methods used in physiotherapy for the treatment of POP were interviews, observations, manual examinations, and biofeedback measurements. The most important assessment methods describing patient progress were the POP symptoms experienced and the changes in pelvic floor muscle function.

Conclusion: Finnish physiotherapists examine patients with POP using a variety of evaluation methods and validated outcome measures. The assessment of prolapse stage (POP-Q) involved some uncertainties.

Keywords: Female, Pelvic Floor Disorders, Physical Therapy Modalities, Symptom Evaluation, Qualitative Research

Introduction

Pelvic organ prolapse (POP) is a falling, slipping, or downward displacement of one or more structures of the vagina—the anterior vaginal wall, posterior vaginal wall, uterus, or apex of the vagina—from the normal anatomical position (Haylen et al., 2016). The cause of POP is multifactorial; parity, vaginal delivery, BMI (Vergeldt et al., 2015), and age (Brito et al., 2022; Vergeldt et al., 2015) have all been identified as risk factors. Other factors, like lifting heavy loads, constipation (Vergeldt et al., 2015), and genetics (Ashikari et al., 2021; L. Li et al., 2020), can also contribute to the weakening of the muscle and connective tissue structure of the pelvic floor, allowing the structures to descend (Saunders, 2017).

POP has multiple symptoms, like lower urinary tract disorders, lower abdominal pain, bowel symptoms, and sexual dysfunction, which are common in females with symptomatic POP (Harvey et al., 2021), causing a decrease in the quality of life. (Jokhio et al., 2020; Svihrova et al., 2014) Additionally, the symptom profile is often accompanied by other dysfunctions of the pelvic floor, such as urinary and defecation disorders and problems with sexual activity (Cameron, 2019; Fatton et al., 2020; Frigerio et al., 2018; Harvey et al., 2021; Karjalainen et al., 2022). According to Harvey et al’s (2021) literature review, urinary symptoms and sexual function disorders occur, on average, in over 50%, intercourse difficulties in 37–100%, and intestinal symptoms in about 40% of POP sufferers. POP is less often associated with pain symptoms, but pain due to pelvic floor pressure and lower back pain have been somewhat reported in studies related to the subject area. (Harvey et al., 2021)

There are different levels of POP (level 0–IV). Age, menopause and the number of births are connected to a higher POP level. The feeling of bulging and problems with sexual activity increase as the POP level increases, but otherwise, the exact threshold level in relation to the prevalence of different symptoms and the deposition level has not been verified.(Espuña-Pons et al., 2014; Wiegersma et al., 2017)

POP can be treated conservatively or surgically (Umachanger et al., 2020); conservative treatment includes 1) treatment devices, 2) lifestyle interventions, and 3) physical therapies (Dumoulin et al., 2016; Haylen et al., 2016). Physiotherapy, especially pelvic floor muscle (PFM) training, has been shown to have a positive impact on urogenital symptoms and quality of life (Brækken et al., 2010; Hagen et al., 2014; C. Li et al., 2016) and is recommended as a first-line treatment for the general female population (Bø et al., 2022), yet only a few relevant studies have been published internationally. According to these studies, PFM exercises, biofeedback training, and lifestyle guidance form the cornerstones of physiotherapy (Hagen et al., 2004, 2016).

To summarize the introduction, it can be stated that urinary and defecation disorders as well as problems with sexual activity are typical for POP. In addition, pain is a possible symptom. Physiotherapy is recommended as one form of conservative treatment, although there is still little evidence of its effectiveness. There is also a need for more evidence-based information about POP assessment methods used in physiotherapy.

The objective of this research was to describe the assessment methods used to evaluate POP, its symptoms, and treatment results in physiotherapy for females with POP to produce information that can be used in clinical work, education, and further research. The current article is part of a larger study regarding pelvic floor physiotherapy as part of the treatment of POP.

Methods

Design and Participants

This qualitative study was conducted in 2021–2022 in Finland. The participants were recruited via the Finnish Association of Physiotherapists in Pelvic Floor (Finnish Association of Physiotherapists in Pelvic Floor, 2022). A research bulletin was published in the association’s membership letter, on their website, and on their private Facebook page in January 2021. Those wishing to participate contacted the first author by e-mail between January and March 2021.

A study information letter, preliminary information form, consent form, and framework of the themed interview were sent to the participants. All participants were provided with written information about the study and informed that they could withdraw at any point. The participants gave written informed consent and completed the preliminary information form, which were returned to the first author by mail. The number of participants was 19, which was considered sufficient to achieve saturation (Moser & Korstjens, 2018).

This study was conducted in accordance with the Helsinki Declaration and the General Data Protection Regulation (GDPR; EU 2016/679, n.d.). The ethical challenges of qualitative research were noted (Sanjari et al., 2014), and attention was paid to ethical perspectives at all stages of the study. The research permit was approved by the board of the Finnish Association of Physiotherapists in Pelvic Floor (1/2021) based on the research group’s application.

The participants had each obtained their expertise in pelvic floor physiotherapy through professional education and courses in Finland or/and abroad. Only a few reported that they had acquired basic skills in pelvic floor physiotherapy during their original physiotherapy studies. Table 1 presents detailed participant characteristics.

Abbreviations: POP=pelvic organ prolapse

Data Collection

The data were collected through semi-structured thematic interviews, guided by a framework informed by prior research on the topic (Hagen et al., 2004, 2016), methodological literature (Kallio et al., 2016), and the physiotherapy process model as defined by the Finnish Association of Physiotherapists (2022). To confirm the dependability of the data collection (Elo et al., 2014; Lincoln & Guba, 1985), the interviews were piloted with three pelvic floor physiotherapists in March 2021. The interview process provided valuable experience in conducting thematic interviews and revealed that the first original theme was overly specific and partially overlapped with the second. Consequently, the theme ‘What assessment methods do you use in physiotherapy for a patient with POP?’ was revised to ‘What different things do you consider in physiotherapy for a patient with POP?

Individual interviews were conducted via Teams or telephone interviews in April–June 2021. Conducting the interviews via Teams or telephone enabled participation from all over Finland, and it was also considered an ethical solution during the COVID-19 pandemic. To improve the dependability of the data collection (Elo et al., 2014; Lincoln & Guba, 1985), the first author conducted all interviews.

The interviews began with securing permission to record the interview, encouraging the participant to share their views freely and at their own pace, to take breaks when needed, and they were informed about the definition POP given above. The interviews around the topic proceeded based on the interview guide (Table 2) and the participant’s responses to the initial questions. Clarification and follow-up questions helped to refine the responses (Polit & Beck, 2017). From time to time, the interviewer summarized what had been said to avoid misunderstandings. Saturation was reached at the 15th interview, but all 19 scheduled interviews were conducted. The interviews lasted from 25 to 80 minutes. The audio and video were recorded separately, and all files were stored appropriately and securely. The data were transcribed and analyzed by one of the first authors, with guidance and collaboration from the research team. Inductive content analysis was applied, as it was appropriate given the lack of prior descriptive data on the topic (Elo & Kyngäs, 2008). Transcription was carried out manually using Word documents, omitting any identifying information. The transcripts were double-checked to ensure verbatim accuracy and analytical richness. In total, 274 pages were produced (Times New Roman, 12-pt font, 1.5 line spacing). No AI tools were used at any stage of the study.

Data analysis

The data were manually analyzed using Word documents and their built-in tools—such as underlining, color coding, numbering, and tabulation—across three main phases: preparation, organization, and reporting. (Elo & Kyngäs, 2008; Polit & Beck, 2017). Inductive content analysis with data reduction, data grouping, and concept formation was conducted in order to allow the participants’ responses to be presented in a condensed and conceptual form (Kyngäs et al., 2020).

The transcripts were read line-by-line several times to create familiarity with the data, and a sentence or idea was first chosen for each context unit. At the same time, open coding was done by underlining the context units with different colors and making relevant notes. The data was organized first in its original form and later as reduced expressions, and the process continued with the formation of categories and sub-categories from the original themes, which were modified and reformulated until sub-categories, categories, and main themes corresponding to the descriptions given by the participants were developed (Table 3). The data analysis yielded 21 sub-categories, eight categories, and four main themes (Kyngäs et al., 2020). The Standards for Reporting Qualitative Research were followed (O’Brien et al., 2014).

Results

The main themes for the assessment methods used in pelvic floor physiotherapy for females with POP were interviews, observations, manual examinations, and biofeedback measurements.

Theme: Interview

The participants described interviews as an important and widely used part of physiotherapy. They are used to gather detailed information on a patient’s background and life situation, with the essential goal of clarifying the patient’s individual symptoms and their impact on everyday life, which then serve as the basis for setting the goals of physiotherapy.

“I do a very broad interview, and of course the patient’s experience is the biggest factor in finding out the scale of the problem and, in a way, what the symptoms are like and how they affect the patient’s life. It’s the first priority, and we also set goals based on symptoms.” (P1)

The participants used different pelvic floor questionnaires to get a comprehensive understanding of each patient’s situation and pelvic floor problems. These included urinary incontinence scoring, severity of urinary incontinence scoring, the Wexner Score for Obstructed Defecation Syndrome, the Pelvic Floor Distress Inventory (PFDI) and its short form (PFDI-20), the Pelvic Floor Impact Questionnaire (PFIQ-7), and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). In addition to these, the Visual Analogue Scale and pain drawings were used to evaluate discomfort and possible pain, and Patient-Specific Functional Scoring (PSFS) was used to describe functional disabilities. Some of the forms were administered in English because there was uncertainty about their availability in Finnish.

“I use the Wexner scale. And patients with prolapse may have pain and a feeling of pressure in the lower abdomen or pelvic floor, so sometimes I use a pain drawing.” (P4)

Interviews were also an essential part of monitoring patient progress. The responses showed that the most important thing was the patient’s experience of functional ability and changes in symptoms. The physiotherapists also used the questionnaires to determine progress, but their use was not always systematic.

“If urinary incontinence scoring and severity of urinary incontinence scoring forms have been filled out by the gynecologist, then I use them again [after physiotherapy].” (P9)

Theme: Observation

The participants used observations to assess the muscle function of the pelvic floor, during which they checked whether muscle contractions are performed correctly, whether inward movement of the perineum is visible, and the condition of the mucous membranes of the intimate area.

“Of course, I observe first. I look at the [pelvic floor] contraction and the condition of the mucous membranes.” (P7)

The physiotherapists estimated the degree of POP using the Valsalva Maneuver and observations, which was described numerically using the ordinal scale for stages of prolapse (0–4) and/or descriptively. This was typically done at the beginning of physiotherapy and was not seen as a primary indicator of progress; it was also seen as challenging and associated with uncertainty. The physiotherapists did not always tell the patient about the results of their assessment. They emphasized that diagnosis is not part of the physiotherapist’s responsibility.

“I also use Valsalva if I test the degree of prolapse. Of course, I’m not making a diagnosis. I don’t report it to the client; I evaluate it in my mind. I don’t feel that I have the know-how to do so… I trust the gynecologist’s assessment. I evaluate it with a numerical scale in my own mind.” (P8)

The participants emphasized the importance of properly assessing the functioning of the pelvic floor. They also paid attention to posture, body use, and movement, and their responses show that unbalanced posture and weakened body support is interpreted as causing unnecessary load and pressure on the pelvic floor.

“I look at the patient’s abdominal pressure regulation activity, either while they’re standing or lying down or both. It gives some idea of ​​how the pressure regulation works, whether it’s directed into the abdominal cavity or whether it’s bringing pressure down [towards the pelvic floor]…”(P12)

The physiotherapists observed the each patient’s breathing technique—whether it is shallow or whether the movement of the chest and diaphragm work well, enabling deep breathing and good cooperation with the pelvic floor. The responses emphasized the importance of observing how the core works in situations in which intra-abdominal pressure rises, such as lifting, standing up, or laughing. Incorrect muscle action patterns were viewed as causing even more pressure on the pelvic floor.

“I observe breathing and the breathing technique because it is known that the diaphragm and the pelvic floor cooperate or move at the same time and affect each other. And I explain this to the client… I check the posture and the pressure regulation of the middle body and the proper functioning of the pelvic floor. For example, in lifting situations, how does the patient’s core work, does the stomach bulge, does the stomach pull inward badly?” (P17)

Theme: Manual examination

The participants used manual examination to assess the muscle function and range of motion of the joints. The examination of muscle function focused on the pelvic floor and was performed by digital vaginal or rectal palpation in the supine and/or standing position. It included evaluation of muscle relaxation, flexibility, strength, and possible pain. The assessment in the standing position was seen as important because in this position the pressure on the pelvic floor is considered higher. Assessing the PFMs was done from the outside if the patient was tense.

“I do vaginal palpation; I examine the flexibility of the muscles, whether there is tension or pain, and whether the muscles activate.” (P4)

The physiotherapists categorized the PFM function numerically according to the Oxford Grading Scale and/or descriptively. They used digital palpation to assess the muscle function at the first visit, but it was also considered an essential method for assessing change and progress in muscle function.

“With Oxford, with that manual Oxford, I try to assess it [the muscle function] every time I palpate so there will also be a concrete number that shows whether there has been a change.” (P3)

The participants also used manual assessment to determine the muscle function of the middle body and pelvic girdle as well as joint mobility. These were considered to have some effect on the functioning of the pelvic floor.

“I palpate the abdominal muscles. I assess how the transverse abdominis muscle or the oblique abdominal muscles activate. The pelvic floor and core muscles should be activated together… I do the diastasis rectus test movement while supine and estimate it [inter-recti distance] at the navel and 4 cm above and below the navel.” (P18)

Theme: Biofeedback measurements

The participants used ultrasound and electromyography measurement (EMG) to assess the functioning of PFMs. Ultrasound was used transperineally and/or abdominally, with transperineal ultrasound considered well-suited to patients with POP. Ultrasound was also used to evaluate the diastasis rectus abdominis and the functioning of the transverse abdominis muscle, which may potentially affect POP.

“I use ultrasound abdominally but also, especially if the patient says that she possibly has a pelvic organ prolapse, transperineally in a standing position.” (P10)

The physiotherapists also used ultrasound to measure the amount of residual urine in cases of anterior vaginal wall prolapse or if the woman had difficulty emptying her bladder.

“I use the urine residual meter quite a lot, especially if the prolapse is on the anterior vaginal wall and the bladder doesn’t empty very well.” (P13)

The physiotherapists used electromyography measurement (EMG) with vaginal or anal electrodes—vaginal electrodes were more typical—at the beginning of physiotherapy and to track progress. Measurement was carried out in the supine, seated, and/or standing positions and during activities such as coughing. EMG was used to determine the different characteristics of muscle function, such as maximum speed and endurance strength, as well as the reactive functioning of the PFMs. The physiotherapists also observed how well the clients were able to relax their PFMs. During the measurement, they made sure that they performed the PFM contractions correctly, tested that the electrodes were sliding inwards, and observed whether the surrounding muscles remained relaxed. In cases of defecation problems, EMG with anal electrodes was used to measure electromyographic activity during straining.

“If a patient comes [to physiotherapy] with indications of a defecation problem, then measurement during straining will be done with the EMG.” (P15)

The participants considered EMG to be a suitable method for most females with POP, but there was some hesitation and challenges during its use. According to the respondents’ experience, larger prolapses can push the electrodes outwards, complicating the use of EMG and decreasing the reliability of the results.

“I think that it [EMG] is inaccurate for women with POP and a little difficult to use. If there is, for example, a slightly larger uterine prolapse, it may push the vaginal electrode outwards. That’s why I don’t use it a lot.” (P6)

Abbreviations: EMG=electromyography; PFM=pelvic floor muscle; POP=pelvic organ prolapse; US=ultrasound.

Discussion

The evaluation methods that the participants reported using in physiotherapy for the treatment of POP were interviews, observations, manual examinations, and biofeedback measurements. The most important factors describing patient progress were the symptoms experienced and changes in PFM functioning.

Most of the physiotherapists participating in this study worked in the private sector (63%), with considerably fewer in specialized medical care (26%), and in basic health care, (11%). This may be a coincidence, but it more likely reflects how physiotherapy for this patient group is organized within Finnish healthcare.

Physiotherapy (Bø et al., 2022) and lifestyle counseling are recommended as preventive and early interventions for POP. Obesity is a known risk factor, and constipation may also be associated with increased risk. Accordingly, weight management and constipation treatment are advised. However, current evidence is insufficient to support specific lifestyle modifications or exercise regimens for POP prevention. (Jeppson et al., 2025). To improve the accessibility and effectiveness of prevention and early intervention, contributions from primary health care should be strengthened, ensuring equal access regardless of financial status. Enhancing pelvic floor physiotherapy education could also support this goal, as competence in the field is typically acquired only through further training, according to both participants and existing knowledge.

The physiotherapists described a variety of typical symptoms associated with POP, including feelings of pressure and bulging in the vagina, various urinary and defecation disorders, and sexual dysfunction, which is consistent with previous studies on POP symptoms (Harvey et al., 2021). In addition to symptoms, the participants sought to understand the effect of POP on each woman’s daily life and functional ability, and their responses showed consideration of each of the areas of the International Classification of Functioning, Disability, and Health (ICF) (World Health Organization, 2013).

The participants used interviews and outcome measures in Finnish (Mattsson et al., 2017) to assess their patients’ unique situations, but it must be noted that not all have been validated in Finnish (Mattsson et al., 2017) or in this specific context (Chimeno‐Hernández et al., 2022; Hefford et al., 2012; Mathis et al., 2019). There was also some uncertainty about the existence of Finnish-language forms, and their use on a larger scale is therefore questionable; this is partly because of the lack of national guidelines for POP in Finland, such that physiotherapists must seek information from multiple sources. We believe that Finnish guidelines would increase the use of uniform and valid assessment methods and evidence-based physiotherapy practice for POP in Finland.

Weakened PFM function has also been associated with POP; females with POP have reduced PFM strength (Handa et al., 2019), and they have been found to generate less vaginal closure force during pelvic muscle contraction than control subjects (DeLancey et al., 2007). The participants emphasized the importance of assessing the function of the pelvic floor, which is necessary for choosing suitable exercises to strengthen it. They reported examining the functioning of the pelvic floor using different methods, checking the correct technique, and assessing PFM variables before and after treatment, which are consistent with clinical recommendations for effective PFMT for POP (Bø et al., 2022). There may be some concern about the reliability of electromyography in females with PFM dysfunction (Koenig et al., 2017); nevertheless, a moderate to strong correlation has been found between palpation, perineometry, and ultrasound measurements for assessing PFM contractions, which supports the use of different assessment methods based on the patient’s individual situation and the available instruments (Volløyhaug et al., 2016).

Pelvic floor function was seen as an important indicator of progress, which is reasonable because physiotherapy has been found to have a positive effect, especially on the intensity of symptoms (Brækken et al., 2010; Hagen et al., 2014; Resende et al., 2019). However, the assessment of prolapse stage (POP-Q) involved some uncertainties, and its use in monitoring progress was rare and generally seen as unimportant. This is understandable because assessment of the POP stage is not included in pelvic floor physiotherapy education in Finland, although POP-Q assessment by physiotherapists has been established as a reliable outcome measure (Stark et al., 2010), which highlights the need for open discussion on its use.

A qualitative approach was chosen to incorporate the opinions of every participant and to achieve a detailed understanding of the topic (Moser & Korstjens, 2017; Polit & Beck, 2017). To our knowledge, there are no other qualitative studies on this topic with which to compare our results. Two surveys of prolapse practice by UK women’s health physiotherapists have been published (Hagen et al., 2004, 2016), but comparisons would be difficult due to differences in research methods. Nevertheless, some similarities can be noted: in those studies, physiotherapists used several questionnaires to measure patient symptoms, and the strength or functioning of the pelvic floor formed an essential factor in monitoring progress.

Strengths and limitations

The trustworthiness of this research was assessed from the perspectives of credibility, dependability, confirmability, and transferability (Elo et al., 2014; Lincoln & Guba, 1985), and there are both strengths and limitations. The participants had expertise in pelvic floor physiotherapy, and they comprehensively represented the different regions and healthcare sectors of Finland, strengthening the credibility of the study, which was further reinforced by the richness of the interview material. The original excerpts in this article were translated from Finnish into English, which may impact their credibility, but the translation was done with a particular focus on identifying the most meaningfully accurate English version.

Dependability was ensured by an accurate description of the study process, underlining the consistency of the findings and enabling reproducibility. Confirmability was established by describing the qualitative data analysis thoroughly and by presenting the voices of the participants. However, two members of the research team have expertise with pelvic floor physiotherapy, which may have influenced confirmability. The use of an external interviewer and transcriber would have increased neutrality.

The results of this study also present the perspectives of Finnish physiotherapists. The transferability of the results to other contexts should be considered critically due to national differences in the education and healthcare systems.

Conclusions

Finnish physiotherapists use diverse assessment methods and validated outcome measures when treating patients with POP. Evaluating pelvic floor muscle function and activation technique is considered essential and aligns with clinical guidelines for effective PFMT. While surrounding structures and muscle coordination are also assessed, uncertainty remains regarding prolapse staging. POP may cause urinary, bowel, and sexual health issues. Pelvic floor physiotherapy plays a key role in prevention and early intervention, with symptom assessment being central to timely and appropriate care. Preventive education during pregnancy and postpartum is a shared responsibility among healthcare professionals. However, the current body of research remains limited, and further studies—especially those exploring patient perspectives—are needed to evaluate the effectiveness of physiotherapy methods for POP.

Acknowledgements

The authors would like to thank all the participants for their contributions to this study and for their important work in pelvic floor physiotherapy.

Conflicts of Interest and Source of Funding

The authors declare no conflict of interest.

Contact Person

Minna Törnävä, Social Services and Health Care, Tampere University of Applied Sciences, Tampere, Finland.

firstname.lastname@tuni.fi

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URN: http://urn.fi/urn:nbn:fi:jamk-issn-2954-1069-16