Name

Date :
 Urogynecology assessment
Name: Date:
Clinical History
Previous perineal rehabilitation:
 No
 Yes date: practician:
o Manual
o Stimulation
o Biofeedback
o Therapeutic education
o Life style
Results:  very good,  good,  medium,  bad
Medics:  anticholinergics, Others: ……………………..
Local treatment:
 pessary,
 vaginal tampon,
 trophicity treatment,
 Ureteral obstructor
Surgery:
 TVT TOT,
 prolapsus,
 artificial sphincter,
 neuromodulation

Medical assessment
Chief complains
 Stress incontinence  Digestive pathology
 Urge incontinence  Urodynamic assessment:
 Prolapsus o inefficient sphincter,
 Pre surgery o urethral instability,
 Post-surgery o bladder instability
 Post-partum  Child
 Sexology

Age:
Life Habits:
 Occupation:  Alcohol
 Sport:  Lumbar belt
 Tabacco  Independent/dependent
Factors
 Weight/height:  Neurological disease:
 Diabetes o multiple sclerosis,
 Constipation o head/spinal injury,
 Hemorrhoids o stroke,
 Spasmophilia o hemiplegia,
 Hyperthyroid o Parkinson disease
 Chronic bronchitis/asthma  Rheumatological disease:
 Hypertension o low back pain,
 Psychological disease or treatment o discopathy,
 Nephrological disease o lumbar spinal stenosis,
 Urological disease:  Surgery:
o urinary infection, o TVT or TOT,
o malformation, o post chemotherapy,
o enuresis o prolapsus

Gynecological assessment
 Post-partum assessment:  Regular menstruations
 Breastfeeding  Urinary infection
o Yes:  complete  Mixt  Vagina infection
o No  Stress incontinence during pregnancy:
 Contraception o Yes:  1st Trimester,  2nd
o Yes: trimester,  3rd trimester, Not
  pill  ICU  condoms  Stress incontinence after delivery
 spermicide  Pain
o No  Intercourses:
 Menstruation return o Dyspareunia:  deep 
o Yes date: superficial,
o No o gap sensation
 Enuresis

Pregnancy

Date Delivery Baby Forceps/ Episioto Tear Baby Cranian Weight Issues Delivery
position vacuum my weight size added duration
Menopause assessment:
 Date: Age:
 Substitution treatment
 Stomach surgery:
o hysterectomy,
o prolapsus surgery,
o other
 Pessary
 Intercourse issues

Urinary assessment
Incontinence assessment
 Date of troubles o water
 Evolution:  better,  worst,  equal  Urge  Leak
 During the day  Incontinence characteristics
 During the night o like a gush of urine,
 Factors o drops,
o grade 1: cough, laugh, sneeze, o full bladder,
o grade 2: sport, running, load o sensitive/unsensitive,
transport o when the bladder is full during
o grade 3: fast walking, position intercourse
changing
 Urge incontinence:
o cold,

Urination assessment: urinary calendar

 Necessary to push to pee
 Incomplete draining
 Urinary without need
 Urinary protection:
o occasional,
o every day: how much: ….
 Pain after urinary
 Self-catheterization

Ano rectal assessment

 Hemorrhoids  Fissures
  Fistula o Perineal maneuver
 Anal incontinence  Barrier sensation
o Passive  Anal sensitivity
o Active  Urge
o Gas  Incomplete exoneration
o Stools  Laxatives
 Soiling  Anormal soiling:
 Constipation o mucus,
 How much stools by week o blood
 Stools texture:  Associated pain:
o normal, o lumbar,
o liquid, o abdominal,
o hard, o coccyx
o fragmented  Intestinal disease:
 Pushing during exoneration o hemorrhagic colic,
 Straining o Crohn disease,
o Vaginal maneuver o Other:
o Anal maneuver

Sexology:
 Vaginism
 Anorgasmia
 Anaphrodisia
 Frigidity
 Vulvodynia

Clinic assessment
 Pelvis:
o anteversion, o ptosis,
o retroversion ante-pulsion, o tonic,
o retropulsion, o scars with adherences,
o lateral deviation o diastasis,
 Rachis: o eventration/hernia,
o scoliotic deformation, o bloat
o curve increased  Breathing:
 Diaphragm: o abdo+costo+diafragm,
o flexible, o paradoxical,
o tense o pushed
 Abdomen:

Pelvic static disorders

 Vaginal gap
  Vaginal noise
 prolapsus
 discomfort
 pain

Vulvar-perineal inspection
 Trophicity:  good,  bad  Descending perineum
 Ano-vulvar length:  <2.5,  >2.5 cm  Descended perineum
 Nucleus fibrosis:  convex,  concave.  Prolapsus:
 Episiotomy scar: o cystocele grade…,
o normal, o Rectocele grade…,
o tensed, o Hysterocele grade…,
o inflammed, o colpocele ant grade…,
o infected, o colpocele post grade…
o fibrosis  Cough Automatism
 Vulva:  Vaginal tonicity normal, hypertonic,
o closed, hypotonic
o open:  grade 1 (22-25mm),   Levator muscle diastasis
grade 2 (25-30mm),  grade 3  Pain
(>33mm)  Synkinesis
 Infibulation  Perineal asynchronism

TESTING

Contraction quality maintain How much C R L

without
tiredness

0 Nothing 0 0

1 few 1s 1

2 Ok without resistance <5s 2

3 Ok without resistance >5s 3

4 Ok with light resistance >5s 5

5 Ok with strong >5s >5

resistance