Pelvic physiotherapy is a conservative approach recognised as a first-line treatment for conditions such as stress urinary incontinence in females. Digital palpation is a key clinical assessment tool used by physiotherapists during pelvic examinations[1]. There are currently no standardised training requirements[2], and no empirical data exist on the scope and optimal training methods for acquiring competence in pelvic examinations using digital palpation. This study aimed to examine the training received by physiotherapists to perform internal digital examinations and explore physiotherapists’ experiences and recommendations to guide best educational practices.

This was a cross-sectional study in which physiotherapists were invited to anonymously complete an electronic survey on Qualtrics between May and August 2024. The survey was developed with input from a physiotherapy steering committee and feedback from two physiotherapists who tested the survey. The survey was distributed globally through social media and relevant organisations. After confirming eligibility, i.e., pelvic physiotherapists or physiotherapists performing internal digital examinations, and providing consent, participants were asked sociodemographic questions, followed by a series of questions regarding their training, experiences, and recommendations. Concerning their experiences, participants were asked to identify the methods used during their training and rate them, on 5-point Likert scales, across four criteria (Figure 1) which were identified as essential by the steering committee. Responses were used to rank the methods from the least ideal to most ideal for each criterion. The survey questions aimed to collect mainly quantitative data, which are presented descriptively.

A total of 249 physiotherapists completed the survey, with ages ranging from 25 to 74 years. Participants were from various continents, with Europe (44%), North America (25%), and Oceania (20%) being the most represented. Of all participants, 233 (94%) identified as female. Participants had diverse educational backgrounds and clinical experience.

Regarding training, 238 (96%) participants reported having received training to perform internal examinations. Of these, 212 (89%) received their initial training as postgraduate students and 26 (11%) received it as undergraduate students. Reported training settings varied, with higher education institutions being the most common. The time allocated to practice and theory varied greatly, ranging from 1 to 25+ hours. Training on male anatomy was less common than female anatomy and was more commonly completed at the postgraduate level. Training methods varied, with peer physical examination being the most reported. Figure 1 illustrates the least ideal to the most ideal training method.

The most recommended setting was higher education institutions and the least recommended (other than no training at all) was a course offered by a commercial individual or organisation. The peer physical examination method received the highest level of recommendation and the least recommended (other than no training methods) was individual practice on patients in a clinical setting with no real-time supervision.

Adequate, standardised training is essential for high-quality patient care in pelvic physiotherapy. Our study highlights global variations in training modalities and identifies gaps in training that may need to be addressed. Although peer training was the least ‘comfortable’, it was also one of the highest rated methods for acquiring competence in internal digital examinations. Despite the challenges of generalising the findings and implementing recommendations due to contextual differences, this study provides valuable global insights into training for internal digital examinations in physiotherapy. Further research is needed to refine educational practices based on the purpose of training, taking into account available resources, sociocultural factors, and unmet population needs, while upholding the highest ethical standards[3].

This study is the first to examine physiotherapists’ training to perform internal digital examinations. The findings provide a basis for improving training for pelvic physiotherapy practice, ultimately ensuring better care and more skilled practitioners.

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Frawley HC, Neumann P, Delany C. An argument for competency-based training in pelvic floor physiotherapy practice. Physiother Theory Pract. 2019;35(12):1117-1130. doi:10.1080/09593985.2018.1470706
Delany C, Frawley H. A process of informed consent for student learning through peer physical examination in pelvic floor physiotherapy practice. Physiotherapy. 2012;98(1):33-39. doi:10.1016/j.physio.2011.04.347