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The Female Pelvic Floor

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The Female Pelvic Floor Peter Petros The Female Pelvic Floor Function, Dysfunction and Management According to the Integral Theory Second Edition Peter Petros The Female Pelvic Floor Function, Dysfunction and Management According to the Integral Theory With 237 Figures and 3 Tables 123 PE Papa Petros MB BS (Syd) Dr. Med Sc (Uppsala) DS (UWA) MD (Syd) FRCOG FRANZCOG CU Dept of Gynaecology Royal Perth Hospital Western Australia ISBN 978-3-540-33663-1 Springer Medizin Verlag Heidelberg Cataloging-in-Publication Data applied for A catalog record for this book is available from the Library of Congress. Bibliographic information published by Die Deutsche Nationalbibliothek Die Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografi e; detailed bibliographic data is available in the Internet at http://dnb.d-nb.de. This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broad- casting, reproduction on microfi lm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer Medizin Verlag. Violations are liable for prosecution under the German Copyright Law. Springer Medizin Verlag springer.com © Springer Medizin Verlag Heidelberg 2007 Printed in Germany The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publisher cannot guarantee the accuracy of any information about dosage and application thereof contained in this book. In every individual case the user must check such information by consulting the relevant literature. SPIN 11740940 Cover Design: deblik Berlin, Germany Typesetting: TypoStudio Tobias Schaedla, Heidelberg, Germany Printer: Stürtz GmbH, Würzburg, Germany Printed on acid free paper 18/3160/yb – 5 4 3 2 1 0 Cover Idea by Sam Blight, Rangs Graphics The three arrows represent the three major force vectors featured in the Integral Theory which control the tensioning of ligaments and membranes in the pelvic fl oor. The enclosing circular brush stroke is inspired by the traditional ‘enso’ character in Zen calligraphy which represents non-duality or wholeness. This is to evoke the integrated approach covered in this book. The butterfl y represents the ‘butterfl y eff ect’ concept from Chaos Theory, also known as ‘sensitive dependence on initial conditions’, which describes how small variations in a dynamic non-linear system (such as the pelvic fl oor) can produce a ‘cascade’ of events leading to a major change in the state of the system. It also represents the freedom which this technology will give to women suff ering from the many pelvic fl oor dysfunctions which can be cured by applying the Integral Theory System. V Life is short, But the craft is long Hippocrates 460-377 BC Science is the father of knowledge, but opinion breeds ignorance. Hippocrates 460-377 BC Preface to 2nd Edition I would like to express my gratitude to my colleagues around the globe for the overwhelming support given to the fi rst edition of ‘Th e Female Pelvic Floor’. Th e publishers inform me that Spanish, Japanese, and Chinese translations are underway, an indication, perhaps, of the increasing acceptance of at least some of the concepts within the book. Since the release of the fi rst edition in September 2004, many new surgical techniques have been developed. Th ese have extended the concepts of suspensory slings to replace and to reinforce damaged vaginal fascia. New insights have been gained from further application of the Tissue Fixation System. Its use in anterior and posterior wall prolapse repair has unlocked new anatomical concepts concerning the relationship between the cervical ring and cardinal ligaments; also, uterosacral ligaments and rectovaginal fascia. Th ese advances have necessitated some further additions in Chapter 2, and extensive additions in Chapter 4, so as to better explain the anatomical basis for these recent surgical advances, and hopefully, for the newer techniques which will inevitably emerge in the coming years. Notwithstanding the immense progress achieved since the 1990 publication of the Integral Th eory, three important challenges remain: fi nding methods to more accurately assess the degree of damage in the various connective tissue structures; continuing to develop understanding of the interactions which lead to abnormal symptoms in the individual patient; and further minimizing the need for surgical operations. A central focus for these challenges is to apply them to those most in need of assistance, that is, the frail and the elderly, for example, Nursing Home patients. In this context, the 2nd edition of this book is presented as an invitation to colleagues to participate in the further development of this methodology, surgical technique and technology. Peter Petros, Royal Perth Hospital, Perth Western Australia, June 2006 VII Preface I fi rst encountered the Integral Th eory system in the early 1990’s at the Royal Perth Hospital laboratory in Western Australia where I was working on laparoscopic colposuspension. Even in prototype form, the IVS operation was so simple and eff ective that I adopted it immediately. Subsequently, based on my experiences, I wrote the following in the Medical Journal of Australia in October 1994: (the operations) promise a new era for women, virtually pain-free cure of prolapse and incontinence without catheters, and return to normal activities within days. Now, ten years later, more than 500,000 ‘tension-free’ anterior or posterior sling operations have been performed. One case in particular stands out from those early years. A woman patient in her mid-50’s came to see me with a fi ve year history of urinary retention which required an indwelling catheter. Th is woman had consulted more than a dozen medical specialists who had told her the same story: no cure was possible. Using the Structured Assessment of the Integral Th eory it was deduced that she had a posterior zone defect. I performed a Posterior IVS. Th e next day the patient was voiding spontaneously with low residuals, and she has remained well since. At fi rst I was sceptical about some of the other predictions of the Integral Th eory, in particular, surgical cure of nocturia, frequency, ‘detrusor instability’, chronic pelvic pain, intrinsic sphincter defect and ‘idiopathic faecal incontinence. However, the high cure rate obtained by following the diagnostic system described in this book soon convinced me that the Integral Th eory framework had much wider applications than those predicted in the original publications. It is self-evident that the Integral Th eory has now matured into an important medical Paradigm, every aspect of which is outlined in this book. Th e original work on the Integral Th eory was done at Royal Perth Hospital, Western Australia and the University of Uppsala, Sweden. However, the defi ning concepts concerning management and surgery were done at Royal Perth Hospital. It was here that the biomechanical and fl uid dynamic principles developed at the University of Western Australia’s Department of Mechanical and Materials Engineering and Fluid Dynamics were applied in practical form. For these works, Professor Petros received his Doctor of Surgery degree in 1999. It should be emphasized that this book is mainly clinically based. Using the Diagnostic Algorithm and ‘simulated operations’, techniques which are thoroughly described herein, it is possible for the generalist to achieve a high degree of diagnostic accuracy and high cure rates. Furthermore most conditions can be treated at the clinical level without the use of expensive diagnostic equipment or surgical facilities. Th is means that the methods described in this book can be accessed by medical professionals in less developed countries where resources and equipment may not be readily available. Peter Richardson FRCOG, FRANZCOG Immediate Past Chairman, National Association of Specialist Obstetricians and Gynaecologists of Australia (NASOG). Acknowledgments It is now almost twenty years since the fi rst threads of the Integral Th eory arrived in my consciousness. Th is book brings together these and all the other threads which have materialized over these years. Th roughout this time, I have had the unfl inching support of my family, my wife Margaret, and children Eleni, Angela and Emanuel, my brother, Dr Sid Papapetros, my co-director of the Kvinno Centre, Dr Patricia M. Skilling, and the staff at the Kvinno Centre, Carole Yelas, Linda Casey, Maria O’Keefe, Margeurite Madigan and Joan McCredie. No enterprise can be achieved without passion, the interest of other colleagues, and above all, teamwork. My hospital, Royal Perth Hospital, has been immensely supportive. Much of the experimental work was done with internal hospital support. I am especially indebted to Dr Bill Beresford, Director of Medical Services, Drs Jim Anderson and Richard Mendelson, Department of Radiology, Mr Ed Scull and Dr Richard Fox Department of Medical Physics, Professor Mark Bush, Department of Mechanical and Materials Engineering, University of Western Australia (UWA), Professor Yianni Attikiouzel, Centre for Intelligence Processing, UWA, Professor Byron Kakulas from the Department of Neuropathology, Professor John Papadimitriou and Dr Len Matz from the Department of Pathology, Dr Ivor Surveyor from the Department of Nuclear Medicine, Mr Terry York Director of the animal laboratory, personnel from the Departments of Pathology, Morbid Anatomy, Bacteriology and Biochemistry, Dr John Chambers, Emeritus Gynaecologist, and Dr Graham Smith, Head of Department Gynaecology, colleagues from the Department of Surgery, UWA, in particular Professor Bruce Gray, and Dr G Hool. Several colleagues played a seminal role in the late 1980s and early 1990s.
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