Self-referral for Pelvic Health Physiotherapy at North Bristol NHS Trust

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.

General screening 

The below information is about your general health, not just your pelvic health problem and it's important that you read it carefully. This will make sure that any potential serious problems or 'red flags' are dealt with correctly by your GP or healthcare professional. 

You will have opportunity to tell us about your pelvic health symptoms further down the page.

If you have any of the following symptoms, please speak to a GP before referring yourself to pelvic health physiotherapy:

• Burning or stinging sensation when you pee
• Blood in your pee.
• Unusual or unexpected bleeding or staining from the vagina.
• Blood in your poo (without other symptoms of piles).
• Persistent change in your bowel habit (needing to go more often, having runny poo and sometimes tummy pain).
• Persistent lower tummy pain, bloating or discomfort (always caused by eating and maybe associated with loss of appetite or significant weight loss).

I have read and understood the above, and I don’t have any of the above symptoms

Cauda equina 

Cauda Equina Syndrome is a rare but severe condition where the nerves at the bottom of the spine become compressed. 

If you have new sudden and severe low back pain and/or leg pain AND any of the following symptoms which started within the last two weeks, or your symptoms are getting worse then please do not complete this form and call NHS 111 or attend A&E as you may require immediate medical attention:

• Loss of feeling pins and needles between your inner thighs or genitals.
• Numbness in or around your anus or buttocks.
• Altered feeling when using toilet paper to wipe yourself.
• Increasing difficulty when you try to stop or control your flow of pee.
• Loss of sensation when you pee.
• Leaking urine or recent need to use pads.
• Not knowing when your bladder is either full or empty.
• Unable to hold on when you need to poo or leak poo.
• Inability to stop a bowel movement or leaking.
• Loss of sensation in the vulva/vagina during sexual intercourse.

If you have had low back pain and/or leg pain AND any of the symptoms above for more than two weeks and they are not getting worse then please make an appointment with your GP, before seeing a pelvic health physiotherapist.

I have read and understood the above, and I don’t have any of the above symptoms