Guidelines emphasize the need for pelvic health physiotherapists to develop proficiency in clinical examination skills [1]. These skills are typically developed through peer-to-peer examinations, which present ethical, cultural, and emotional concerns, and provide limited opportunity for feedback on learner performance. Simulation is a growing area in health sciences education and can address these concerns. Through this study, we aimed to (1) develop a simulation model of the female perineum and pelvic floor for hands-on education, and (2) evaluate physiotherapists’ perceptions of its fidelity, educational value, and improvements required prior to implementation.

An innovative pelvic floor palpation model (PelviSim; Figure 1) was developed by the senior author and a biomedical engineering student based on current literature and in consultation with six academic and three clinical pelvic health physiotherapists. The model, made from three-dimensional  (3D) printed polymer and casted silicone, includes anatomical representations of the pelvic bones, ligaments, nerves, and muscles based on DeLancey [2]. PelviSim was designed to support training in palpation per vaginum and per anum and allows learners to manually locate the different pelvic floor muscles (PFMs) while the educator can simulate contraction, relaxation, and changes in muscle tone. The model facilitates palpation skills through providing 3D visualization for both the learner and the instructor. 

As part of an iterative development process, after the team received approval from the institutional research board, two focus groups of experienced pelvic health physiotherapists were recruited and consented. Participants were introduced to the model, asked to identify anatomical structures, performed selected pelvic examination components, and assessed the fidelity of simulated muscle contraction. The sessions were audio recorded and transcribed for inductive qualitative thematic analysis, which was performed independently by two members of the research team. Participants answered questions on the MiSSES (Michigan Standard Simulation Experience Scale) [3], adapted for this application, using a Likert scale.

Six pelvic health physiotherapists, each with >10 years of practice experience, participated. Participants consistently agreed that the model improves self-efficacy in anatomical knowledge, understanding PFM function, performing a clinical palpation assessment, and evaluating PFM contractile strength (Figure 2). While the participants assessed the model as having high fidelity, some important suggestions for improvement were provided. Four themes emerged from the qualitative analysis:   

- Anatomy and nomenclature: Discrepancies in terminology and anatomical knowledge impacted the participants’ impressions of model fidelity. The PFM nomenclature and attachment points were not always consistent with participants’ prior learning.  

- Inclusion of the superficial pelvic floor muscles: While the team had decided not to include representations of the bulbospongiosus and ischeocavernosus, the participants felt that these muscles were important to anatomical fidelity.   

- Broader application: Participants identified that the model would have great utility for other applications, including patient education, graded exposure, dilator use practice, student and peer evaluation, and manual therapy technique training.  

- Durability: Participants had concerns around the material attracting dirt and the durability of muscle attachment points.

The PelviSim model was found to have great potential utility in pelvic health physiotherapy education, as participants strongly agreed that it enhances learning in anatomy, pelvic floor muscle function, and clinical skills. Participants agreed that the simulator demonstrates adequate realism, particularly in terms of anatomical features, tissue texture, spatial relationship, and internal structures. The discrepancies observed between clinicians’ understanding of anatomy and current anatomical knowledge further support the need for this model. The proposed minor adjustments have already been addressed, and the model is ready for a new round of focus group consultations.

The PelviSim model represents a promising educational tool with strong potential to enhance training in pelvic anatomy and examination skills in pelvic health physiotherapy education.

Frawley, Helena C., Patricia Neumann, and Clare Delany. An argument for competency-based training in pelvic floor physiotherapy practice. Physiotherapy theory and practice. 2019; 35.12 : 1117-1130.
DeLancey, John OL. Lies, damned lies, and pelvic floor illustration: confused about pelvic floor anatomy? You are not alone. International Urogynecology Journal 2022; 33.3: 453-457.
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