Adapting Pelvic Muscle Exam for Patients with Obesity

A few weeks ago, a pelvic course participant shared some sensitive and intimate thoughts about being at a course and being "the biggest girl in class." This week, we will address specific strategies for communicating with your patients and for adapting your exam techniques when appropriate. The following quote is from an educational book for Nurse Practitioners, and echoes a very healthy and realistic sentiment about our role when working with patients in pelvic rehabilitation.

"If the exam is limited by obesity, the patient should be told in a clear, non-judgmental manner. Patients have a right and responsibility to understand the findings of the health care visit."

Unfortunately, according to the authors, women who are obese are less likely to receive routine gynecologic care due to bias and fear of judgement, or even practical issues like exam tables, gowns, and equipment not being adequate. Another issue is that of mobility: is the exam table too narrow for safety and comfortable positioning? In my own clinical practice, I have had patients ask me: "Is that massage table going to hold me?" In order to answer that question, you need to know what the safe weight limits are for your chairs, walkers, exam tables, and any other equipment your patients may use. You might imagine that if a patient is concerned about falling off of a table, completing an appropriate exam could be difficult due to muscle guarding. Other techniques recommended include the following:

- ask an assistant to gently hold back skin folds if vagina or vulva is obscured
- ask the patient to flex her hips upward if able
- ask patient to help hold back excess skin in lower abdomen if helpful
- ultrasound may be used rather than palpation as needed (this is in reference to a medical gynecologic exam, but how might rehab US contribute to our toolkit?)
- document any difficulty with the examination - placing a small towel or pillow under the patient's hips may also help in viewing the cervix

This "Bias Tool Kit" offers further suggestions to avoid causing harm when evaluating a woman who is obese:

- if you would like to weigh the patient, ask for consent first, using sensitive language, i.e. "would you like to be weighed today?" and maintain privacy
- in addition to considering equipment like tables, think about having a stepstool with a handle, properly sized blood pressure cuffs, sturdy, armless chairs, and a long exam speculum
- use words that patients find more acceptable, such as excess weight or BMI

Advice to the nurse practitioners include the following to counter the fact that obese women are often discriminated against:

"If the exam is limited by obesity, the patient should be told in a clear, non-judgmental manner. Patients have a right and responsibility to understand the findings of the health care visit." For example, for a medical exam: "Due to the shape and size of your body, I wasn't able to feel your uterus and ovaries." Any similarly needed communications can be shared in a professional and warm tone.

While sensitive topics can require patience, practice, and an abundance of professionalism, everyone wins when difficult subjects are approached with honesty. Thanks again to Erin B. for shining her light on this sensitive and valuable topic.