How to Talk About the Internal Exam With Your Client
OTs in Pelvic Health Podcast · 13 min listen
Clients used to arrive at my New York City practice having already decided. I've been to another therapist. The pain is still there, I'm still leaking, and the work we did didn't change it. So I'm here because I want an internal exam. I want to find the missing piece.
And I'd offer them the choice. We can do an internal exam today, or we don't have to — there are so many other ways to get this information.
They almost always chose the internal exam.
"I started to wonder whether the way I was setting it up was the problem."
Most of my clients were on the type A side. Driven, ambitious. And whether they'd been told by a previous practitioner or simply assumed it, they treated the internal exam as the gold standard. Of course they wanted the option that would give them the most information.
Which made me look harder at my own language. Was I actually offering a real choice — or was I presenting one good option and one acceptable one?
In this episode:
- The phrase that was quietly pressuring clients toward one option
- Two words I stopped using in the exam conversation, and why
- Four exam options, presented as genuine equals, with the words I use for each
- The follow-up question that personalizes it further
- Why offering a choice turned out to affect the pelvic floor before I ever put a hand on anyone
Experimenting on my own
I didn't have another OT to turn to. All my mentors were PTs at that point, and this was over a decade ago — there simply wasn't much conversation about consent or trauma-informed care yet.
So I experimented. Here's what I landed on.
I started asking far more often whether something was okay. And I told clients up front that I was going to.
What to say
By the way, this is going to be really redundant. You're going to hear me ask about a billion times today whether things are okay. That's because I want to make sure that they are.
Then, before anything else:
What to say
Is it okay if I give you the options now about what the exam could look like?
The two words I stopped using
"This is what I typically do."
"This is what I normally do."
I wondered whether presenting something as typical or normal was unconsciously pressuring the client. Well, I want to do what's typical. I want what's normal.
If I didn't present any one of these options as better than the others, I felt like I was giving a client a genuine chance to choose what their nervous system needed that day.
The four options
Here's how I lay them out. We've already talked about the role of the pelvic floor by this point, and about breathing — that the pelvic floor and the diaphragm look like parentheses of one another and move together.
An update since this episode
A quick note if you're listening to the episode as well as reading this. When I recorded it I offered three options. I now offer four.
The one I've added comes first, and it's the least invasive of the four. The longer I've practiced, the clearer it's become that this is where being trauma-informed actually lives — not in how gently we perform an exam, but in how many genuine ways we can offer to gather the same information.
Feedback-based assessment
You stay fully dressed. You might sit on a ball, or I might use my hands on the outside of your body, to give you feedback during the session.
We can learn a great deal this way about how you're moving, how you're breathing, and how your system is responding — without you undressing at all.
Clothes on, observing your breathing
I'm going to look at your breathing. We've already talked about how breathing is such an instrumental part of your core and pelvic floor — it's the top part of that canister.
By watching your breathing, I'll have a chance to see how your muscles are contracting and how they're relaxing. This can be done with your clothes entirely on.
External, disrobed from the waist down
You disrobe from the waist down, and I take a look at the muscles right around your vaginal opening.
We'll look at what happens when you breathe, what happens when you bear down, and what it looks like when you do a kegel. I'll check that you're coordinated — not only within the muscle movement itself, but within the larger system of your core, your abdominal muscles and your respiratory diaphragm. All the things we talked about when you first walked into my office.
Internal exam
I don't use a speculum. This isn't like a typical gynecology exam. I'm going to use a gloved finger, and you'll feel my finger at your vaginal opening.
I'll check what the strength of your muscles is. I'll check coordination. I'll check your ability to relax. And I'll check your endurance.
I teach all four of these in depth, including exactly how to introduce each one and what you can learn from it, in OT Pioneers and in the Level 1 Functional Pelvic Health Practitioner program.
And then the line that matters most:
What to say
In all of these, we're going to get information we can put together so you can meet the goals you came to see me for.
Do any of these sound like an exam you're open to today?
Then personalize it further
Usually they'd ask some questions. Then they'd say, you know what, I'm really thinking this one.
And I'd follow with:
What to say
Is there any part of this exam that's not going to work for you today?
Now we're personalizing the experience. I gave them the options, and then we customize even further. What will put them at ease? What are they most comfortable with?
Learn with me for free
Start where every pelvic health OT starts, with a free AOTA-approved CEU class. Take either one, or both.
New to pelvic health?
The OT Practitioner's Role in Pelvic Health
Where pelvic health sits in OT scope of practice, plus simple interventions you can use with clients tomorrow.
Free · 1 hour · 0.1 AOTA CEU
Sign up for freeWondering where it fits in your setting?
The OT's Guide to Pelvic Health Practice Settings
Nine settings where OTs are already doing this work, from hospitals and SNFs to living rooms and L&D units. No private practice required.
Free · 1 hour · 0.1 AOTA CEU
Sign up for freeWhy this matters more than the exam itself
People are generally not used to being asked what they prefer.
I think we're socialized to put up with whatever the authority figure presents — especially in medical situations.
My hope, in letting a client know they had agency over what felt right for their body, was that they'd start to expect more of it elsewhere. With their partner. With their children. With their friends. With other medical providers.
"Opening up the conversation and reminding the client that they had a choice was the single most powerful thing I could do in their pelvic floor exam."
They realized there wasn't one right way. And that set the stage for the continuity of care — that there was never one right answer or one right solution. Only their right solution, and their right approach.
What I came to believe
Over the years, practicing this way, I started to see something.
You can give the best evidence-based care. You can do everything exactly the way you were taught. But if we're missing the relationship side, or the trauma-informed side, we're missing an enormous opportunity to empower our clients — not just in that session, but in their lives.
The ripple effect of feeling that agency, of being able to speak up for what you really need, is incredibly powerful.
So many of the clients I saw were navigating a world of things being done to them, with no choice in it. When we start to enable clients to see that they can genuinely be an agent in their own life, the nervous system takes a pause and starts breathing, sometimes for the first time.
And I realized that by giving someone agency in their own life — starting with their healthcare and rippling outward — I was affecting their pelvic floor without ever putting a hand on them.
That set me down a path of discovering ways to treat pelvic floor clients that don't always involve a hands-on approach.
This is the start of a much deeper conversation. But it starts here, with how we talk about the exam.
