ABPTS WMS cheat sheet

Pelvic floor muscle (PFM) manual exam uses Modified Oxford Scale 0-5; grade 3 = moderate contraction with lift, grade 5 = strong squeeze with lift and positive hold.

PFM strength testing per PERFECT scheme records Power, Endurance (seconds), Repetitions, Fast contractions, Every Contraction Timed, and Total time.

Levator ani avulsion is graded by the levator ani muscle avulsion (LAM) system: 0 = no avulsion, 1 = partial (<50% detachment), 2 = complete (>50% detachment).

Levator hiatus ballooning on Valsalva >25 mm on 2D/3D ultrasound is associated with prolapse; hiatal area >=40 cm2 indicates marked enlargement.

Pelvic organ prolapse quantification (POP-Q) stages: stage 0 = no prolapse; stage 1 = leading edge >1 cm above hymen; stage 2 = within 1 cm of hymen; stage 3 = >1 cm beyond hymen but not complete; stage 4 = complete vaginal eversion.

Diagnostic imaging and real-time ultrasound can confirm bladder neck funneling, detrusor wall thickness, and post-void residual; PVR >100-150 mL suggests incomplete emptying.

Prognosis for stress urinary incontinence is better with higher baseline PFM strength, shorter symptom duration, and absence of levator avulsion.

Vaginal palpation of the puborectalis and pubococcygeus assesses tone, symmetry, and tenderness; trigger points refer to urethra, vagina, and suprapubic region.

Screening for red flags (unexplained bleeding, pelvic mass, weight loss, night pain) precedes musculoskeletal diagnosis and warrants medical referral.

PFM training (PFMT) for stress incontinence: at least 8 contractions, 3 sets per day, for at least 8-12 weeks to achieve therapeutic effect.

Kegel exercise prescription should specify contraction duration, rest between contractions, number per set, sets per day, and position progression (supine to standing).

Hypopressive exercise reduces intra-abdominal pressure via diaphragmatic apnea and abdominal vacuum; use caution when pelvic organ prolapse is symptomatic.

Biofeedback improves PFM training adherence and is indicated when a patient cannot isolate the PFM or demonstrates Valsalva instead of contraction.

Bladder training for urge incontinence uses timed voiding with gradual interval lengthening (e.g., 30-60 min increments) and urge suppression techniques.

Postpartum PFMT reduces risk of persistent urinary incontinence; supervised training is superior to unsupervised home programs.

Manual therapy for pelvic pain includes trigger point release, myofascial release, and Thiele massage of the levator ani; avoid aggressive techniques in acute inflammation.

Electrical stimulation parameters for PFM strengthening: 35-50 Hz for strengthening, 10-20 Hz for urge suppression, with pulse width 200-300 microseconds.

Pessary fitting for prolapse or incontinence requires assessment of ring, cube, or Gellhorn type based on prolapse stage and vaginal support.

Pelvic girdle pain (PGP) is diagnosed by pain in the posterior pelvic girdle between the iliac crests and gluteal fold, often with positive provocation tests (posterior pelvic pain provocation, FABER, Gaenslen, ASLR).

Pregnancy-related diastasis recti abdominis is measured at the linea alba; inter-recti distance >2 cm at the umbilicus or >2.7 cm at 4.5 cm above is considered abnormal.

Osteitis pubis presents with localized symphysis pubis tenderness and pain on single-leg stance; differentiate from symphysis pubis dysfunction in pregnancy.

Piriformis syndrome produces buttock pain with reproduction on FAIR test (flexion, adduction, internal rotation) and tenderness at the sciatic notch.

Pudendal neuralgia is diagnosed by Nantes criteria, including pain in the pudendal nerve territory, worse with sitting, and relief with standing or lying.

Coccydynia is often associated with a laterally deviated or hypermobile coccyx; treatment includes manual mobilization, cushioning, and pelvic floor relaxation.

Endometriosis-related pelvic pain often presents with dysmenorrhea, dyspareunia, and cyclical pain; PT addresses pelvic floor hypertonicity and visceral mobility.

Menopause reduces estrogen, causing vaginal atrophy, decreased tissue elasticity, and increased risk of stress incontinence and prolapse.

Vulvodynia is classified as provoked, unprovoked, or mixed; PT includes desensitization, pelvic floor downtraining, and graded exposure.

Antepartum PT addresses pelvic girdle pain, low back pain, and safe exercise prescription; avoid supine exercise after 20 weeks due to vena cava compression.

Perineal massage from 34 weeks gestation reduces risk of perineal trauma requiring sutures in nulliparous women.

Perineal tears are classified: first degree = skin/vaginal mucosa; second = perineal muscles; third = anal sphincter (3a <50% EAS, 3b >50% EAS, 3c IAS involved); fourth = anal epithelium.

Postpartum pelvic floor assessment is typically deferred until 6 weeks after vaginal delivery and 8-12 weeks after cesarean or complicated delivery.

Cesarean delivery does not eliminate pelvic floor dysfunction; pregnancy itself increases risk of incontinence and prolapse.

Return to running postpartum is guided by load tolerance; general guidance suggests waiting until at least 12 weeks postpartum with progressive loading and pelvic floor clearance.

Diastasis recti abdominis in the immediate postpartum period is common; conservative management includes postural education and progressive loading rather than bracing alone.

Postpartum hemorrhage, infection, and thromboembolism are medical red flags requiring immediate referral rather than PT intervention.

Lactation and relaxin influence ligamentous laxity; progressive return to high-impact activity should be individualized.

Stress urinary incontinence is involuntary loss on effort, sneezing, or coughing; urge incontinence is involuntary loss with a sudden desire to void.

Overactive bladder syndrome includes urgency, frequency (>8 voids/day), and nocturia (>=1/night) with or without incontinence.

Pelvic floor muscle contraction should produce a visible inward lift of the perineum and cessation of urine flow; Valsalva indicates a technique error.

The Knack maneuver is a voluntary PFM contraction before and during a cough to reduce stress leakage.

Pelvic organ prolapse symptoms include a vaginal bulge, heaviness, and splinting; severity correlates poorly with POP-Q stage.

Fecal incontinence evaluation includes anal sphincter strength, rectal sensation, and the presence of a rectocele or sphincter defect.

Constipation management includes adequate fiber (25-30 g/day), fluid intake, and defecation posture with feet supported and avoidance of straining.

Pelvic floor hypertonicity (overactive PFM) presents with dyspareunia, dysuria, and difficulty relaxing; treatment includes downtraining and relaxation, not strengthening.

Post-void residual, urinalysis, and voiding diary are first-line assessments before initiating continence interventions.

Informed consent requires disclosure of risks, benefits, alternatives, and the right to refuse; document consent before internal pelvic examination.

Chaperone policy: offer a chaperone for internal examinations regardless of clinician or patient gender and document acceptance or refusal.

APTA Code of Ethics core principles include accountability, altruism, compassion, integrity, and professional duty; conflicts of interest must be disclosed.

Evidence hierarchy: systematic reviews/meta-analyses of RCTs rank highest; expert opinion and case reports rank lowest.

Number needed to treat (NNT) = 1 / absolute risk reduction; lower NNT indicates greater clinical benefit.

Sensitivity = true positives / (true positives + false negatives); specificity = true negatives / (true negatives + false positives).

Levels of evidence per Oxford CEBM: Level 1 = systematic reviews of RCTs; Level 5 = expert opinion or bench research.

Scope of practice: pelvic floor internal examination requires post-professional training and is within the PT scope in most US jurisdictions with appropriate education.

Documentation of pelvic floor findings should include muscle grade, tone, tenderness, and functional observations using objective, reproducible measures.

Pelvic floor muscle (PFM) manual exam uses Modified Oxford Scale 0-5; grade 3 = moderate contraction with lift, grade 5 = strong squeeze with lift and positive hold.

PFM strength testing per PERFECT scheme records Power, Endurance (seconds), Repetitions, Fast contractions, Every Contraction Timed, and Total time.

Levator ani avulsion is graded by the levator ani muscle avulsion (LAM) system: 0 = no avulsion, 1 = partial (<50% detachment), 2 = complete (>50% detachment).

Levator hiatus ballooning on Valsalva >25 mm on 2D/3D ultrasound is associated with prolapse; hiatal area >=40 cm2 indicates marked enlargement.

Pelvic organ prolapse quantification (POP-Q) stages: stage 0 = no prolapse; stage 1 = leading edge >1 cm above hymen; stage 2 = within 1 cm of hymen; stage 3 = >1 cm beyond hymen but not complete; stage 4 = complete vaginal eversion.

Diagnostic imaging and real-time ultrasound can confirm bladder neck funneling, detrusor wall thickness, and post-void residual; PVR >100-150 mL suggests incomplete emptying.

Prognosis for stress urinary incontinence is better with higher baseline PFM strength, shorter symptom duration, and absence of levator avulsion.

Vaginal palpation of the puborectalis and pubococcygeus assesses tone, symmetry, and tenderness; trigger points refer to urethra, vagina, and suprapubic region.

Screening for red flags (unexplained bleeding, pelvic mass, weight loss, night pain) precedes musculoskeletal diagnosis and warrants medical referral.

PFM training (PFMT) for stress incontinence: at least 8 contractions, 3 sets per day, for at least 8-12 weeks to achieve therapeutic effect.

Kegel exercise prescription should specify contraction duration, rest between contractions, number per set, sets per day, and position progression (supine to standing).

Hypopressive exercise reduces intra-abdominal pressure via diaphragmatic apnea and abdominal vacuum; use caution when pelvic organ prolapse is symptomatic.

Biofeedback improves PFM training adherence and is indicated when a patient cannot isolate the PFM or demonstrates Valsalva instead of contraction.

Bladder training for urge incontinence uses timed voiding with gradual interval lengthening (e.g., 30-60 min increments) and urge suppression techniques.

Postpartum PFMT reduces risk of persistent urinary incontinence; supervised training is superior to unsupervised home programs.

Manual therapy for pelvic pain includes trigger point release, myofascial release, and Thiele massage of the levator ani; avoid aggressive techniques in acute inflammation.

Electrical stimulation parameters for PFM strengthening: 35-50 Hz for strengthening, 10-20 Hz for urge suppression, with pulse width 200-300 microseconds.

Pessary fitting for prolapse or incontinence requires assessment of ring, cube, or Gellhorn type based on prolapse stage and vaginal support.

Pelvic girdle pain (PGP) is diagnosed by pain in the posterior pelvic girdle between the iliac crests and gluteal fold, often with positive provocation tests (posterior pelvic pain provocation, FABER, Gaenslen, ASLR).

Pregnancy-related diastasis recti abdominis is measured at the linea alba; inter-recti distance >2 cm at the umbilicus or >2.7 cm at 4.5 cm above is considered abnormal.

Osteitis pubis presents with localized symphysis pubis tenderness and pain on single-leg stance; differentiate from symphysis pubis dysfunction in pregnancy.

Piriformis syndrome produces buttock pain with reproduction on FAIR test (flexion, adduction, internal rotation) and tenderness at the sciatic notch.

Pudendal neuralgia is diagnosed by Nantes criteria, including pain in the pudendal nerve territory, worse with sitting, and relief with standing or lying.

Coccydynia is often associated with a laterally deviated or hypermobile coccyx; treatment includes manual mobilization, cushioning, and pelvic floor relaxation.

Endometriosis-related pelvic pain often presents with dysmenorrhea, dyspareunia, and cyclical pain; PT addresses pelvic floor hypertonicity and visceral mobility.

Menopause reduces estrogen, causing vaginal atrophy, decreased tissue elasticity, and increased risk of stress incontinence and prolapse.

Vulvodynia is classified as provoked, unprovoked, or mixed; PT includes desensitization, pelvic floor downtraining, and graded exposure.

Antepartum PT addresses pelvic girdle pain, low back pain, and safe exercise prescription; avoid supine exercise after 20 weeks due to vena cava compression.

Perineal massage from 34 weeks gestation reduces risk of perineal trauma requiring sutures in nulliparous women.

Perineal tears are classified: first degree = skin/vaginal mucosa; second = perineal muscles; third = anal sphincter (3a <50% EAS, 3b >50% EAS, 3c IAS involved); fourth = anal epithelium.

Postpartum pelvic floor assessment is typically deferred until 6 weeks after vaginal delivery and 8-12 weeks after cesarean or complicated delivery.

Cesarean delivery does not eliminate pelvic floor dysfunction; pregnancy itself increases risk of incontinence and prolapse.

Return to running postpartum is guided by load tolerance; general guidance suggests waiting until at least 12 weeks postpartum with progressive loading and pelvic floor clearance.

Diastasis recti abdominis in the immediate postpartum period is common; conservative management includes postural education and progressive loading rather than bracing alone.

Postpartum hemorrhage, infection, and thromboembolism are medical red flags requiring immediate referral rather than PT intervention.

Lactation and relaxin influence ligamentous laxity; progressive return to high-impact activity should be individualized.

Stress urinary incontinence is involuntary loss on effort, sneezing, or coughing; urge incontinence is involuntary loss with a sudden desire to void.

Overactive bladder syndrome includes urgency, frequency (>8 voids/day), and nocturia (>=1/night) with or without incontinence.

Pelvic floor muscle contraction should produce a visible inward lift of the perineum and cessation of urine flow; Valsalva indicates a technique error.

The Knack maneuver is a voluntary PFM contraction before and during a cough to reduce stress leakage.

Pelvic organ prolapse symptoms include a vaginal bulge, heaviness, and splinting; severity correlates poorly with POP-Q stage.

Fecal incontinence evaluation includes anal sphincter strength, rectal sensation, and the presence of a rectocele or sphincter defect.

Constipation management includes adequate fiber (25-30 g/day), fluid intake, and defecation posture with feet supported and avoidance of straining.

Pelvic floor hypertonicity (overactive PFM) presents with dyspareunia, dysuria, and difficulty relaxing; treatment includes downtraining and relaxation, not strengthening.

Post-void residual, urinalysis, and voiding diary are first-line assessments before initiating continence interventions.

Informed consent requires disclosure of risks, benefits, alternatives, and the right to refuse; document consent before internal pelvic examination.

Chaperone policy: offer a chaperone for internal examinations regardless of clinician or patient gender and document acceptance or refusal.

APTA Code of Ethics core principles include accountability, altruism, compassion, integrity, and professional duty; conflicts of interest must be disclosed.

Evidence hierarchy: systematic reviews/meta-analyses of RCTs rank highest; expert opinion and case reports rank lowest.

Number needed to treat (NNT) = 1 / absolute risk reduction; lower NNT indicates greater clinical benefit.

Sensitivity = true positives / (true positives + false negatives); specificity = true negatives / (true negatives + false positives).

Levels of evidence per Oxford CEBM: Level 1 = systematic reviews of RCTs; Level 5 = expert opinion or bench research.

Scope of practice: pelvic floor internal examination requires post-professional training and is within the PT scope in most US jurisdictions with appropriate education.

Documentation of pelvic floor findings should include muscle grade, tone, tenderness, and functional observations using objective, reproducible measures.