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Who can the Pelvic Health Physiotherapy team help?
This service is available for women and people assigned female at birth, who are over the age of 16 and have any of the symptoms listed below.
Physiotherapy can help a range of pelvic health conditions which include:

Problems with your pelvic floor muscles at any stage in life:
•    Leaking urine
•    Leaking poo/wind
•    Bladder or bowel urgency
•    Pelvic organ prolapse
•    Pelvic pain

Problems occurring in pregnancy or after birth:

•    Pelvic girdle pain
•    Lower back pain 
•    Rib pain 
•    Hip pain 
•    Coccyx pain

These are common problems that can affect women and people assigned female at birth but they are not something you have to put up with, seeing a pelvic health physiotherapist can help to reduce or resolve these problems.

What is self-referral and what do I need to do?
Self-referral is another way of getting to see a pelvic health Physiotherapist. It means that you don’t need to see the GP and wait for them to refer you. 

Please complete all questions on the form, this is to help the Physio team decide on the correct treatment for you.  Any incomplete forms will not be accepted and you risk not being seen by the physio team.

If you are unable to complete the form, please ask your GP, Midwife or healthcare professional for help.

Who is the self-referral NOT for?
The referral is not for men, children or for separation of the stomach muscles (diastasis recti of the abdominus muscle).  These will need to be referred to the Pelvic Health team by your GP.
What will happen next?
A specialist Pelvic Health Physiotherapist will look at the information you have written on the form and then once you are near the top of the waiting list you will be contacted with an appointment.  The treatment you receive will be the same as if your GP had referred you.
How do I know if I should see my GP?
If you have any concerns, you can always make an appointment to see your GP in the usual way and ask for a Physiotherapy referral or self-refer once you have seen them.

Screening questions

1. General screening questions

Please answer yes or no to the following questions. 
 

Do you feel a burning or stinging sensation when you wee?
Do you have blood in your urine?
Have you had any unusual or unexpected bleeding or staining from the vagina?
Do you have blood in your poo? (without other symptoms of piles)
Do you have a persistent change in your bowel habit? (needing to go more often, having runny poo and sometimes tummy pain)
Do you have persistent lower tummy pain, bloating or discomfort? (always caused by eating and maybe associated with loss of appetite or significant weight loss)
As you have answered YES to one or more of the questions above, have you seen a GP?

If you haven’t, please see a GP before referring yourself to physiotherapy and do not continue completing this form.

2.a Cauda equina syndrome 

Cauda equina syndrome is a rare but severe condition where the nerves at the bottom of the spine become compressed. Symptoms of cauda equina are acute low back pain and/or leg pain accompanied by any of the other symptoms below. 

Do you have acute low back pain?
Do you have pain going down both legs?

If you have answered no to both questions above you do not need to complete the questions in 2.b so please move on to section 3.
 

Status message

×Only complete this section if you answered yes to either of the questions above in section 2 about acute back pain or pain down both legs. 

2.b Cauda equina syndrome 

Only complete this section if you answered yes to either of the questions above in section 2 about acute back pain or pain down both legs. 

Do you have loss of feeling or pins and needles between your inner thighs or genitals?
Do you have numbness in or around your anus or buttocks?
Do you have altered feeling when using toilet paper to wipe yourself?
Do you have increasing difficulty when you try to stop or control your flow of pee?
Do you have loss of sensation when you pee?
Do you leak pee or have a recent need to use pads?
Do you have difficulty knowing whether your bladder is full or empty?
Are you unable to hold on when you need to poo or do you leak poo?
Do you have a loss of sensation in the vulva/vagina during sexual intercourse?

You have indicated that you have acute low back pain and/or pain going down both legs and have answered 'Yes' to one or more of the other questions in 2.b.

Please now do one of the following things depending on your symptoms:

  • If your symptoms started less than 2 weeks ago or your symptoms are getting worse- please seek urgent medical attention at your A&E department immediately.
  • If your symptoms started more than 2 weeks ago and your symptoms are not worsening- please see your GP for an appointment before referring yourself to Physiotherapy.

Do not continue to complete this form

Referring yourself to Pelvic Health Physiotherapy

Please complete all the details below and press submit.

Can we leave a voice message?
Are you currently serving in the armed forces and require treatment that is unable to be provided within forces medical services?
Does your condition prevent you from providing care to a dependent you live with?
Have you ever been diagnosed with a Learning Disability?
Do you need an interpreter?

Your pelvic health problem

Your symptoms

Please select all that apply. 

Pelvic floor dysfunction symptoms:
Pregnancy or postnatal musculoskeleteal related symptoms (under six months from delivery):

Duration

How long have you had this problem?

Getting worse?

Are your symptoms getting worse?

Pregnancy

Are you, or have you in the last year been, pregnant?