Integral Theory

The Integral Theory System. A simplified clinical approach with illustrative case histories

PETER E. PAPA PETROS(1,2) (1) University of Western Australia

Abstract: The integral theory:VWDWHVWKDWSURODSVHDQGSHOYLFÁRRUV\PSWRPVVXFKDVXULQDU\VWUHVVXUJHDEQRUPDOERZHODQGEODGGHUHPSW\LQJ and some forms of pelvic pain, mainly arise, for different reasons, from laxity in the or its supporting ligaments, a result of altered connective tissue. Normal Function: 7KHRUJDQVDUHVXVSHQGHGE\OLJDPHQWVDJDLQVWZKLFKPXVFOHVFRQWUDFWWRRSHQRUFORVHWKHRXWOHWWXEHV XUHWKUDDQGDQXV7KHVHOLJDPHQWVIDOOQDWXUDOO\LQWRD]RQHFODVVLÀFDWLRQDQWHULRUPLGGOHDQGSRVWHULRU Dysfunction: 'DPDJHGOLJDPHQWVZHDNHQWKHIRUFHRIPXVFOHFRQWUDFWLRQFDXVLQJSURODSVHDQGDEQRUPDOEODGGHUDQGERZHOV\PSWRPV Diagnosis: $SLFWRULDOGLDJQRVWLFDOJRULWKPUHODWHVVSHFLÀFV\PSWRPVWRGDPDJHGOLJDPHQWVLQHDFK]RQH Treatment:,QPLOGFDVHVQHZSHOYLFÁRRUPXVFOHH[HUFLVHVEDVHGRQDVTXDWWLQJSULQFLSOHVWUHQJWKHQWKHQDWXUDOFORVXUHPXVFOHVDQGWKHLU OLJDPHQWRXVLQVHUWLRQVWKHUHE\LPSURYLQJWKHV\PSWRPVSUHGLFWHGE\WKH7KHRU\:LWKPRUHVHYHUHFDVHVSRO\SURS\OHQHWDSHVDSSOLHGWKURXJK “keyhole” incision using special instruments reinforce the damaged ligaments, restoring structure and function. Problems which can be potentially addressed by application of the Integral System: Urinary stress incontinence; Urinary urge incontinence; $EQRUPDOEODGGHUHPSW\LQJ)DHFDOLQFRQWLQHQFHDQG´REVWUXFWHGHYDFXDWLRQµ ´FRQVWLSDWLRQ· 3HOYLFSDLQDQGVRPHW\SHVRIYXOYRG\QLDDQG interstitial cystitis; Organ prolapse. Key words: Integral Theory; diagnosis; minisling; ligaments; connective tissue; pictorial algorithm.

INTRODUCTION The Integral Theory states that prolapse and most pelvic ÁRRUV\PSWRPVVXFKDVXULQDU\VWUHVVXUJHDEQRUPDOERZHO DQG EODGGHU HPSW\LQJ DQG VRPH IRUPV RI SHOYLF SDLQ mainly arise, for different reasons, from laxity in the vagina or its supporting ligaments, a result of altered connective tissue.1-5%LUWKUHODWHGOD[LW\ÀJFRPSRXQGHGE\DJHLQJ are the principal causes of ligament laxity. The Integral Theory has evolved into the Integral Theory System, which applies the damaged ligament theory to • Function – the role of competent suspensory ligaments in organ support and function. • Dysfunction-how damaged ligaments upset the musculoelastic control mechanism to cause prolapse and DEQRUPDOERZHODQGEODGGHUV\PSWRPV • Diagnosis- how to diagnose which damaged ligaments are causing which prolapse and which symptoms. )LJ   %LUWKUHODWHG OD[LW\7KH GLDJUDP VKRZV WKH EDE\·V KHDG severely stretching ligaments and other tissues in and outside the • TreatmentLQPLOGFDVHVQHZSHOYLFÁRRUPXVFOHH[HUFLVHV vagina. This may cause various degrees of looseness, prolapse of the EDVHG RQ D VTXDWWLQJ SULQFLSOH VWUHQJWKHQ WKH QDWXUDO EODGGHUDQGERZHODQGXULQHDQGERZHOLQFRQWLQHQFH)XQGDPHQWDO closure muscles and their ligamentous insertions. With to any surgical treatment is the approximation of laterally displaced more severe cases, polypropylene tapes applied through tissues, and the strengthening of damaged suspensory ligament(s). “keyhole” incision using special instruments, reinforce the damaged ligaments, restoring structure and function. 7KHEODGGHUVLWVRQWRSRIWKHYDJLQDDQGLVSDUWO\DWWDFKHG to it. Muscles pull against the ligaments to close or open the PART 1 urethra. Therefore loose ligaments may weaken the muscle THE DYNAMIC ANATOMY OF NORMAL FUNCTION FRQWUDFWLRQWRFDXVHSUREOHPVZLWKFORVXUH LQFRQWLQHQFH  Bladder, bowel and uterus )LJ  LV D VFKHPDWLF YLHZ RI WKH EODGGHU ERZHO DQG uterus with the woman in a sitting position. The organs DUHVWRUDJHFRQWDLQHUV7KHEODGGHUVWRUHVXULQHWKHXWHUXV the foetus, and the rectum faeces. Each organ is connected WR WKH RXWVLGH E\ D WXEH WKH XUHWKUD ZKLFK LV DERXW FP ORQJYDJLQDZKLFKLVFPORQJDQGWKHDQXVDERXW FPORQJ7KHPHQVWUXDOEORRGDQGIRHWXVSDVVWKURXJKWKH vagina. Urine and faeces pass through the urethra and anus. 0XVFOHV FRPSUHVV WKHVH WXEHV WR FORVH WKHP DQG VWUHWFK them open for emptying. The importance of suspensory ligaments “Problems of bladder, bowel, prolapse, and some types of pelvic pain, mainly originate from the vaginal ligaments, not from the organs themselves”- Integral Theory 1996. )LJ7KHRUJDQVDQGWKHLURXWOHWWXEHV

Pelviperineology 2010; 29: 37-51 http://www.pelviperineology.org 37 P.E.P. Petros

Fig. 3 - Unsuspended ligaments have no shape, strength or )LJ   )RXU OLJDPHQWV VXVSHQG WKH RUJDQV IURP DERYH OLNH D function. VXVSHQVLRQ EULGJH 7KH SHULQHDO ERG\ 3%  VXSSRUWV WKH RUJDQV IURPEHORZ&/ FDUGLQDOOLJDPHQW or opening (evacuation of urine). Figure 3 indicates what WKH YDJLQD EODGGHU DQG ERZHO ZRXOG ORRN OLNH ZLWK QR predispose to prolapse, and development of posterior zone OLJDPHQWVWRVXVSHQGWKHPDEORERIWLVVXHZLWKQRIRUP symptoms. no structure, no strength, and no function. The pelvic muscles GDUNUHG ÀJKDYHDGXDOIXQFWLRQ $OLJDPHQWLVOLNHDWKLFNFRUGLQDVXVSHQVLRQEULGJHÀJ organ support, and opening and opening and closure of ,QIDFWWKHYDJLQDLVVXVSHQGHGH[DFWO\OLNHDVXVSHQVLRQ urethra and anorectum. They extend from the coccyx to the EULGJHZLWKWKHOLJDPHQWVDERYHDQGWKHPXVFOHV DUURZV  SXELFERQHDQGFRQWUDFWWRVXSSRUWWKHYDJLQDEODGGHUDQG EHORZ 7KH PXVFOH IRUFHV DUURZV  FRQWUDFW DJDLQVW WKH ERZHOIURPEHORZ7KHUHGDUURZVLQGLFDWHWKHGLUHFWLRQV VXVSHQVRU\OLJDPHQWVWRJLYHWKHEULGJHIRUPDQGVWUHQJWK ZKHUHWKHPXVFOHVFRQWUDFWEDFNZDUGVWRRSHQWKHVHRUJDQV 7KH RUJDQV ÀJ  DUH VXVSHQGHG IURP DERYH E\ WKH forwards to close them. YDJLQDO OLJDPHQWV  H[DFWO\ OLNH D VXVSHQVLRQ EULGJH$OO An external striated muscle opening and closure the ligaments are attached to the vagina and/or uterus. The PHFKDQLVPÀJ.7&8, 9-17 YDJLQDVXSSRUWVWKHEODGGHUVLWXDWHGDERYHLWDQGWKHUHFWXP 3XW VLPSOLVWLFDOO\ ZKHQ WKH PXVFOHV SXOO EDFNZDUGV VLWXDWHGEHORZLWVRDQ\WKLQJZKLFKGDPDJHVWKHYDJLQDO EOXHDUURZV WKHXUHWKUDDQGDQXVDUHSXOOHGRSHQYDVWO\ VWUXFWXUHFDQDOVRDIIHFWWKHEODGGHUDQGUHFWXP GHFUHDVLQJLQWUDFDYLW\UHVLVWDQFHWRWKHth power, so that the Separating the lower end of the vagina from the rectum ZRPDQFDQTXLFNO\DQGHDVLO\HYDFXDWHKHUXULQHDQGIDHFHV LVDVROLGPDVVRIWLVVXHWKHSHULQHDOERG\ 3% FRPSOH[ ZKHQWKHPXVFOHVSXOOIRUZDUGV  EODFNDUURZV WKHXUHWKUD ZKLFKLVDERXWFPORQJ,IWKLVLVGDPDJHGWKHUHFWXPPD\ DQGDQXVDUHFORVHGE\DYDVWLQFUHDVHLQUHVLVWDQFHWRWKHth EXOJHIRUZDUGVLQWRWKHYDJLQDDVDUHFWRFRHOH power. Normally all the organs, even the vagina, are kept in The uterus is an anchoring point for the ligaments - WKHFORVHGSRVLWLRQE\VORZWZLWFKPXVFOHFRQWUDFWLRQ it needs to be preserved where possible * The closure mechanism is a little more complex than that depicted 7KHUROHRIWKHXWHUXVLQPDLQWDLQLQJWKHVWUXFWXUHÀJ LQÀJLQYROYLQJDGLVWDODQGSUR[LPDOPHFKDQLVPIRUFORVXUHRIWKH 7-10 DQGIXQFWLRQRIWKHSHOYLFÁRRULVJUHDWO\XQGHUHVWLPDWHG XUHWKUDODQGDQDOWXEHV Some doctors routinely recommend removal of the uterus How damaged ligaments may cause incontinence or GXULQJ VXUJHU\ IRU SURODSVH ,W LV SUHIHUDEOH WR UHWDLQ WKH emptying disorders. :H VDZ IURP WKH VXVSHQVLRQ EULGJH XWHUXV ZKHUHYHU SRVVLEOH DV PDQ\ LPSRUWDQW OLJDPHQWV diagram, that the muscles pull against the ligaments. are attached to it. During the menopause, the ovaries cease production of oestrogen. Since oestrogen is essential for maintaining the strength of the ligaments, the detrimental HIIHFWVRIK\VWHUHFWRP\RQSURODSVHDQGLQFRQWLQHQFHEHFRPH especially evident after the menopause. Hysterectomy UHGXFHV WKH EORRG VXSSO\ WR WKH FDUGLQDO DQG XWHURVDFUDO ligaments, weakening them further. All these factors

)LJ  7KH YDJLQD LV VXVSHQGHG IURP DERYH OLNH D VXVSHQVLRQ EULGJHZLWKWKHOLJDPHQWVDERYHDQGWKHPXVFOHV DUURZV EHORZ )LJ7KHXWHUXVIXQFWLRQVOLNHWKHNH\VWRQHRIDQDUFK5HPRYH 36 SXELF V\PSK\VLV6 VDFUXP 38/ SXERXUHWKUDO OLJDPHQW the arch, and the whole structure is put at risk of a downward ATFP=arcus tendineus fascia ; USL=uterosacral ligament. collapse.

38 The integral theory system

)LJ7KHPXVFOHVVXSSRUWWKHRUJDQVYDJLQDEODGGHUDQGERZHO IURPEHORZDQGDOVRRSHQDQGFORVHWKHPE\H[WHUQDOGLUHFWLRQDO muscle forces (arrows).

So if the suspensory ligaments are loose, the muscle VWUHQJWKZHDNHQVDQGPD\QRWEHDEOHWRNHHSWKHEODGGHU RU ERZHO HPSW\LQJ WXEHV FORVHG $V D FRQVHTXHQFH RI this, a patient may feel a leakage of urine, wind or faeces, “incontinence”. Another related condition is failure to close WKH YDJLQDO WXEH VR ZDWHU PD\ HQWHU WKH YDJLQD GXULQJ )LJ7KHFRUWH[RIWKHEUDLQJLYHVGLUHFWLRQVIRUFORVXUH & DQG VZLPPLQJ RU FRPSODLQ RI YDJLQDO ÁDWXV ,I WKH GDPDJHG RSHQLQJ 2 1HUYHV´1µDWWKHEDVHRIWKHEODGGHUVHQVHZKHQ WKHEODGGHULVIXOODQGVHQGLPSXOVHVWRWKHEUDLQ'HSHQGLQJRQ ligaments do not allow the muscles to open these same WKHVLWXDWLRQWKHEUDLQVHQGVGLUHFWLRQVHLWKHUIRUFORVXUH & RU HPSW\LQJWXEHVDSDWLHQWPD\KDYHWRVWUDLQWRHPSW\KHU opening (O). Like instructions from the orchestra conductor, these EODGGHU RU ERZHO ´HYDFXDWLRQ GLVRUGHUµ RU ´HPSW\LQJ directions, “C” and “O”, engage all the muscles, , ligaments disorder”. DQGWLVVXHVUHTXLUHGIRUHDFKIXQFWLRQ7KH3RQVDORZHUSDUWRIWKH EUDLQZRUNVDVDFRRUGLQDWLQJVWDWLRQ A Symphony Orchestra 7KH YDJLQD EODGGHU ERZHO PXVFOHV DQG OLJDPHQWV EODGGHU LV IXOO DQG VHQG LPSXOVHV WR WKH EUDLQ7KHVH DUH ÀJ  DUH OLNH LQVWUXPHQWV LQ DQ RUFKHVWUD  7KH EUDLQ LV perceived as urgency, a desire to go to the toilet. the conductor, and ensures that all the instruments work * I am grateful to Dr Alfons Gunnemann for the orchestra analogy harmoniously to produce the right music. Every instrument LQ WKH RUFKHVWUD KDV D VSHFLÀF WDVN 'DPDJH WR HYHQ RQH The brain and its nerves- a sophisticated feedback system instrument will affect the performance. 7KH EUDLQ GLUHFWV 7KH EUDLQ ZRUNV OLNH WKH FRPSXWHU DW D ELJ WHOHSKRQH WKH RUFKHVWUD WR RSHQ WKH EODGGHU DQG ERZHO  RU WR FORVH exchange. Think of the nerves as telephone wires going out LW 'HSHQGLQJ RQ ZKDW VWUXFWXUH LV GDPDJHG WKH EODGGHU WR WKH EODGGHU WKH YDJLQD DQG ERZHO 7KHVH RUJDQV KDYH PD\ QRW EH DEOH WR FORVH SURSHUO\ DQG WKH SDWLHQW OHDNV VHQVRUVZKLFKVHQGVLJQDOVSRVWHULRUWRWKHEUDLQYLDDQRWKHU ´LQFRQWLQHQFHµ RUVKHPD\QRWEHDEOHHPSW\KHUEODGGHU set of nerves, to inform it as to what is happening. The RUVKHPD\KDYHERWKSUREOHPV1HUYHVDWWKHEDVHRIWKH EUDLQUHFHLYHVDQGSURFHVVHVWKHVHVLJQDOVDQGGHSHQGLQJ EODGGHU ¶1·LQWKHGLDJUDPZKLFKIROORZV VHQVHZKHQWKH RQZKDWLVUHTXLUHGVHQGVRXWRUGHUVYLDDVHULHVRIQHUYHV Most of this co-ordination occurs in “automatic mode”. The patient is not aware of what is happening. Sometimes, a SDWLHQWPD\DFWXDOO\LQVWUXFWWKHEUDLQ)RUH[DPSOHLILWLV LQFRQYHQLHQWWRHPSW\WKHEODGGHURUERZHOWKHPXVFOHVFDQ EHSXOOHGXSZDUGVWRFORVHRIIWKHXUHWKUDODQGDQDOWXEHV Pushing down assist emptying the urine and faeces. During LQWHUFRXUVH WKH YDJLQD FDQ EH QDUURZHG E\ SXOOLQJ WKH muscles upwards. This action grips the penis, and increases WKHVHQVDWLRQIRUERWKSDUWQHUV

PART 2 DYSFUNCTION - THE ROLE OF LAX LIGAMENTS IN THE CAUSATION OF SYMPTOMS AND PROLAPSE

The structure of ligaments A ligament is a complicated contractile structure which QHHGVWREHERWKHODVWLFDQGVWURQJDQGKDYHWKHDELOLW\WR Fig. 8 - An external striated muscle opening and closure mechanism. contract or relax according to whether the urethra and anus 7KHUHGOLQHVUHSUHVHQWWKHSHOYLFPXVFOHV)LEURPXVFXODUH[WHQVLRQV DUHEHLQJFORVHGRURSHQHG,WUHOLHVRQLWVFROODJHQFRQWHQW IURPWKHVHPXVFOHÀEUHVORRSDURXQGWKHXUHWKUDDQGDQRUHFWXPWR IRU VWUHQJWK HODVWLQ IRU ÁH[LELOLW\ VPRRWK PXVFOH IRU activate closure and opening. contractility, and nerves to co-ordinate all these functions.

39 P.E.P. Petros

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)LJ7KHEDE\·VKHDG FLUFOHV PD\GDPDJHWKHOLJDPHQWVDQG vaginal tissues to varying degrees as it descends through the vagina WR FDXVH VWUHVV LQFRQWLQHQFH·· F\VWRFRHOH ¶· XWHULQHDSLFDO SURODSVH ¶· DQG UHFWRFRHOH ¶· 38/ SXERXUHWKUDO OLJDPHQW ATFP=arcus tendineus fascia pelvis; USL=uterosacral ligament. Not shown are cardinal ligament (Middle Zone) and Perineal Body (Posterior zone).

)LJ$XWHUXVFKURQLFDOO\EXOJLQJRXWRIWKHYDJLQD7KHZKLWH DUHDVDUHFDXVHGE\FKURQLFIULFWLRQ

Fig. 11 - This diagram illustrates the cystocoele “2”, rectocoele ´µDQG XWHUXVµµ DOO SXVKLQJ LQWR WKH YDJLQD DV ´OXPSVµ OLNH D JORYH WXUQLQJ LQVLGH RXW $OO DUH FDXVHG E\ ORRVHQHVV LQ WKH suspensory ligaments and their associated tissues.

)LJ3LFWRULDO'LDJQRVWLF$OJRULWKP7KHDQWHULRU SXERXUHWKUDO  and posterior (uterosacral) ligaments are in purple. The middle ligaments (ATFP& cardinal) are not shown in this diagram. There are 3 columns, one for each ligament group and the symptoms )LJ$F\VWRFRHOHEXOJLQJRXWRIWKHYDJLQDOHQWUDQFHGXULQJ and prolapses (lumps) associated with damage to these ligaments. straining. /DEHOOLQJLV¶IURQW·DQG¶EDFN·LQVWHDGRI¶DQWHULRU·DQG¶SRVWHULRU·

 The integral theory system

&ROODJHQÀEUHVZRUNOLNHWKHVWHHOURGVLQFHPHQW6LQJOH YDJLQDOFDQDOÀJLVXQOLNHO\WRGDPDJHMXVWRQHVLQJOH FROODJHQ ÀEUHV DUH ´JOXHGµ WRJHWKHU WR JLYH OLJDPHQWV VWUXFWXUH $OO VWUXFWXUHV ZLOO EH GDPDJHG WR D JUHDWHU RU strength. The elastin content gives them elasticity. It is the lesser extent. This explains appearance of a cystocoele, for change in collagen which is the ultimate cause of prolapse example, months or years after apparently successful surgery and incontinence. for prolapse of the uterus. Further prolapse can occur in How ligaments are stretched and damaged during perhaps 30-50% of cases after a successful vaginal repair. pregnancy and labour 7KHSUREOHPLVWKDWRQFHWKHYDJLQDOWLVVXHVDUHGDPDJHG $V ZH VDZ IURP WKH VXVSHQVLRQ EULGJH GLDJUDP WKH LWLVGLIÀFXOWWRIXOO\UHSDLUWKHP,WLVOLNHUHSDLULQJIUD\HG PXVFOHVSXOODJDLQVWWKHOLJDPHQWVZKLFKVXSSRUWWKHEULGJH cloth. The surgeon repairs one area, only to see it give way ,IWKHOLJDPHQWVDUHVWUHWFKHGDQGORRVHQHGGXULQJFKLOGELUWK LQ DQRWKHU DUHD 7KDW LV ZK\ ZH KDYH WR FUHDWH DUWLÀFLDO DVLQÀJDSDWLHQWPD\GHYHORSDSURODSVHD´GUDJJLQJµ OLJDPHQWVE\XVLQJWDSHV SDLQORZLQWKHDEGRPHQEODGGHUV\PSWRPVIRUH[DPSOH A cystocoele´EDOORRQVµRXWIURPDERYHÀJ7KHFDXVH XUJHQF\IUHTXHQF\QRFWXULDRUHYHQSUREOHPVZLWKERZHO is damage to the middle ligaments (ATFP and/or cardinal emptying or faecal incontinence. ligaments) and the anterior wall of the vagina. &RPPHQFLQJ  PRQWKV EHIRUH FKLOGELUWK WKH ´JOXHµ A rectocoele,ÀJEDOORRQVRXWIURPEHORZ6HSDUDWLQJ EHWZHHQ WKH FROODJHQ URGV EHJLQV WR VRIWHQ LQ UHVSRQVH WR the lower end of the vagina from the rectum is the perineal KRUPRQHV IURP WKH SODFHQWD ´DIWHUELUWKµ  7KLV H[SODLQV WKH RQVHW RI EODGGHU ERZHO DQG SDLQ V\PSWRPV DW WKLV ERG\DPDMRUVXSSRUWLQJVWUXFWXUHDVLWRFFXSLHVRI WLPH 6RPH  KRXUV EHIRUH GHOLYHU\ KRZHYHU WKLV WKH SRVWHULRU YDJLQDO ZDOO $ UHFWRFRHOH PD\ EH FDXVHG softening accelerates, and the collagen rods lose 95% of their E\ GDPDJH WR WKH XWHURVDFUDO OLJDPHQWV KLJK UHFWRFRHOH  strength.18'XULQJGHOLYHU\WKHEDE\·VKHDGJUHDWO\VWUHWFKHV DQGRU UHFWRYDJLQDO IDVFLD  SHULQHDO ERGLHV PLG  ORZ these collagen rods. Of course, the rods “re-glue” soon after rectocoele. GHOLYHU\ EXW RIWHQ WKH\ ´UHJOXHµ LQ D ORRVH DQG H[WHQGHG Uterine prolapse ÀJ  LV FDXVHG E\ GDPDJH WR WKH position. Neither the ligaments nor the muscles can now cardinal and uterosacral ligaments. work properly, and this may lead to prolapse of the uterus, F\VWRFRHOHUHFWRFRHOHDQGDZLGHUDQJHRIEODGGHUERZHO A perspective on organ prolapse DQGSHOYLFSDLQV\PSWRPV ÀJ :RPHQZKRKDYHKDG 7KH RUJDQV EXOJH WR YDU\LQJ GHJUHHV &OHDUO\ D VHYHUH &DHVDULDQ VHFWLRQV PD\ DOVR EHFRPH LQFRQWLQHQW EXW WKH\ SURODSVH VXFK DV WKH XWHULQH SURODSVH DERYH UHTXLUHV KDYH OHVV VWUHWFKLQJ DQG WKHUHIRUH IHZHU SUREOHPV WKDQ WUHDWPHQW,IWKHEXOJHLVPLQRUDQGWKHUHDUHQRDVVRFLDWHG vaginal delivery patients. Loose ligaments may occur in symptoms, there is no need for treatment. However, a patient ZRPHQZKRKDYHQHYHUKDGFKLOGUHQ6XFKZRPHQDUHERUQ with loose ligaments, or they may have a congenital defect in PD\KDYHVHYHUHV\PSWRPVZKLFKPD\UHTXLUHWUHDWPHQW WKHLUFROODJHQ$OOWKHVHFRQGLWLRQVDUHSRWHQWLDOO\FXUDEOHE\ even though the prolapse is minor. FUHDWLRQRIDUWLÀFLDOOLJDPHQWVDVZLOOEHH[SODLQHGODWHU When are these symptoms and prolapses problematical? The effect of age and menopause If a patient answers “yes” to one of the following, she has Both collagen and elastin deteriorate markedly after the DSUREOHP menopause, and this explains the vast increase in prolapse 1. You lose urine during exertion or coughing. and incontinence which occurs after this event. A partly 

 P.E.P. Petros

The Diagnostic Algorithm indicates which ligaments are Characteristics of faecal incontinence causing symptoms and prolapse Typical symptoms, in order of severity, are uncontrolled 7KH'LDJQRVWLF$OJRULWKPZKLFKIROORZVLVDVLPSOLÀHG ZLQGORVVOLTXLGVRLOLQJVROLGIDHFDOVRLOLQJ7KHUHDUHWZR YHUVLRQRIWKDWSXEOLVKHGLQWKHWH[WERRN´7KH)HPDOH3HOYLF PDLQFDWHJRULHVSDWLHQWVZLWKIDHFDOLQFRQWLQHQFHFDXVHGE\ nd Floor” 2 (GLWLRQ  6SULQJHU+HLGHOEHUJ7RXVHWKLV DQDQDOVSKLQFWHUWRUQDWFKLOGELUWKDQGDQRWKHUZKHUHQR GLDJUDPDWLFNLVSODFHGLQHYHU\FROXPQZKLFKGHVFULEHVD REYLRXVFDXVHFDQEHIRXQG7KHDQDOVSKLQFWHUFRQVWULFWV SDWLHQW·VV\PSWRPVDQGWKHGLDJUDPZLOOLQGLFDWHWKH]RQH the lower part of the anus. It is what a patient feels when of damage, anterior, middle, or posterior ligaments. VKHFRQWUDFWVKHUPXVFOHVWRGHOD\ERZHOHPSW\LQJ:KHUH How to use the Diagnostic Algorithm. Simply tick every FROXPQZKLFKGHVFULEHVDV\PSWRP2QHQHHGVWRWLFNDOO QR REYLRXV FDXVH FDQ EH IRXQG LW LV FDOOHG ´LGLRSDWKLF the relevant columns for symptoms such as urgency and incontinence”. It is “idiopathic incontinence” which is emptying, which may occur in more than one column. In SRWHQWLDOO\FXUDEOHE\UHFRQVWUXFWLQJWKHDQWHULRURUSRVWHULRU such cases, other associated symptoms which are more ligaments. VSHFLÀFZLOOKHOSWRJXLGHWKHGLDJQRVLV Characteristics of lumps (prolapse) in the vagina Definitions for Symptoms Initially, these only appear during straining. The three • Stress incontinence Urine loss on effort, such as coughing, PDLQFDXVHVRIVXFK¶OXPSV·DUHIURPWKHEODGGHU F\VWRFRHOH exercise. ´µ XWHUXV ´µ DQGERZHO UHFWRFRHOH´µ ÀJ7KHVH • Abnormal emptying ,QDELOLW\ WR HPSW\ WKH EODGGHU RU FDQRQO\EHDFFXUDWHO\GLDJQRVHGE\DYDJLQDOH[DPLQDWLRQ DEQRUPDOÁRZ DV QRW DOO OXPSV DUH DFFRPSDQLHG E\ V\PSWRPV :KHUH • Urgency$QXQFRQWUROODEOHGHVLUHWRSDVVXULQH symptoms accompany the prolapse, the symptoms may • Frequency Going more than 8 times a day to the toilet to JLYHDQLQGLFDWLRQRIZKHUHWKHSUREOHPLV)RUH[DPSOHLID pass urine. patient has a lump plus nocturia, pelvic pain and urgency, it • Nocturia Getting up twice or more per night to pass urine. is highly likely that she has weak posterior ligaments, as per • Faecal incontinence Uncontrolled soiling from the WKH'LDJQRVWLF'LDJUDPÀJ ERZHO • Obstructed defaecation or constipation 'LIÀFXOW\ LQ New time efficient pelvic floor exercises HPSW\LQJWKHERZHO strengthen muscles and ligaments • Pelvic pain.3DLQLQWKHORZHUDEGRPHQORZHUSRVWHULRU or during intercourse. Some types of vulvodynia and ,Q  ZH ÀUVW FRQFHLYHG DQRWKHU DSSURDFK WR SHOYLF interstitial cystitis are often associated with pelvic pain. ÁRRUH[HUFLVHV:HNQHZIURPRXUXOWUDVRXQGVWXGLHVWKDW the traditional Kegel methods were NOT addressing the Symptoms occur in groups – an aid to diagnosis posterior closure muscles, which stretch, rotate, and close For example, urgency symptoms are indicated in all 3 WKHSUR[LPDOXUHWKUDDJDLQVWWKHSXERXUHWKUDOOLJDPHQW columns. Symptom grouping is the only way we can deduce 2XU XOWUDVRXQG VWXGLHV KDG GHPRQVWUDWHG WKDW VTXDWWLQJ which column (ligament) is causing the urgency. Fortunately, exercises the very same muscles which close the urethra urgency almost always occurs in tandem with at least one during coughing. We also reasoned that strengthening a other symptom. pelvic muscle would also strengthen the ligament against Characteristics of pain* caused by posterior which it contracted, and we knew from the surgery, that it ligament looseness was ligament weakness which was causing the incontinence ‡ /RZDEGRPLQDO¶GUDJJLQJ·SDLQXVXDOO\XQLODWHUDORIWHQ SUREOHPV right-sided :HWKHUHIRUHDGGHGVTXDWWLQJH[HUFLVHVWRWKHWUDGLWLRQDO ‡ /RZVDFUDOSDLQ SDLQQHDUWKHWDLOERQH Kegel programme. Our target group of patients were those • Pain on deep penetration with intercourse ZLWKV\PSWRPVZKLFKZHUHERWKHUVRPHEXWQRWVXIÀFLHQWO\ ‡ /RZDEGRPLQDODFKHWKHQH[WGD\DIWHULQWHUFRXUVH WRUHTXLUHVXUJHU\7KHUHVXOWVZHUHGUDPDWLF7KLVSDWLHQW • Tiredness JURXS UHSRUWHG D PRUH WKDQ  LPSURYHPHQW LQ VXFK ‡ ,UULWDELOLW\ V\PSWRPVDVXUJHQF\QRFWXULDSHOYLFSDLQDQGDEQRUPDO ‡ 3DLQ ZRUVHQV GXULQJ WKH GD\ DQG LV UHOLHYHG E\ O\LQJ EODGGHU HPSW\LQJ 7KH PRVW LQWHUHVWLQJ REVHUYDWLRQ down however, was that those patients who were cured, did not • Pain is reproduced on pressing the cervix or the posterior QHHGWRUHPHPEHUWRFRQWUDFWWKHLUSHOYLFÁRRULQDGYDQFH wall of the vagina if a patient has had a hysterectomy. They coughed, and did not leak.19-21 * There is growing evidence that some types of introital $ PDMRU SUREOHP ZLWK SHOYLF ÁRRU H[HUFLVHV LV WKDW K\SHUVHQVLWLYLW\ ¶YXOYRG\QLD·  DQG SHUKDSV HYHQ VRPH W\SHV RI ZRPHQZLWK\RXQJIDPLOLHVDQGMREVVLPSO\GRQRWKDYH EODGGHU SDLQ ¶LQWHUVWLWLDO F\VWLWLV  PD\ EH SDUW RI WKH SRVWHULRU ]RQH V\PSWRPFRPSOH[LQÀJXUHQRFWXULDXUJHQF\DQGDEQRUPDOEODGGHU time to perform them regularly. Even with our highly emptying. motivated group, the dropout rate was 50%. Because of WKLVZHFRQFOXGHGWKDWWKHSURJUDPPHUHTXLUHGUHDQDO\VLV Characteristics of ‘vulvodynia’ :HNQHZWKDWWKHVORZWZLWFKPXVFOHÀEUHVZHUHWKHSULPH $ EXUQLQJ SDLQ RYHU WKH HQWUDQFH RI WKH YDJLQD DQG FRQWULEXWRUVWRFRQWLQHQFH6LWWLQJRQD´ÀWEDOOµLQVWHDGRI anus, with extreme sensitive to touch. This condition is DFKDLULVDYHU\VLPSOHDQGHIIHFWLYHH[HUFLVHWHFKQLTXH RIWHQ DVVRFLDWHG ZLWK GUDJJLQJ ORZHU DEGRPLQDO SDLQ DQG DVLWUHTXLUHVDEDODQFHGXSULJKWSRVLWLRQZLWKFRRUGLQDWHG VRPHWLPHVSDLQIXOEODGGHUFRQGLWLRQV FRQWUDFWLRQ RI DEGRPLQDO EDFN DQG SHOYLF ÁRRU PXVFOHV Characteristics of bladder emptying difficulty 8QOLNHDOOWUDGLWLRQDO.HJHOH[HUFLVHVZKLFKUHTXLUHDWWHQWLRQ Typical symptoms are a slow stream, starting and DQGWLPHVLWWLQJRQD´ÀWEDOOµUHTXLUHVQRH[WUDWLPHWREHVHW VWRSSLQJGULEEOLQJDIWHUPLFWXULWLRQKDVEHHQFRPSOHWHGD DVLGHGXULQJWKHGD\:HKDYHIRXQGWKDWWKH´ÀWEDOO·PHWKRG IHHOLQJWKDWWKHEODGGHUKDVQRWHPSWLHG2IWHQVXFKSDWLHQWV DSSOLHGDORQHZDVZHOODFFHSWHGDQGUHVXOWVVHHPHGHTXDOO\ have chronic urinary infections. effective in the short-term.

 The integral theory system

)LJ6LWWLQJRQDUXEEHU´ÀWEDOOµLQVWHDGRIDFKDLUVWUHQJWKHQ )LJ$QH[DPSOHRI¶QH[WJHQHUDWLRQ·QRQVWUHWFKPRQRÀODPHQW all the pelvic slow-twitch muscles, and their ligamentous WDSH6XFKWDSHVDUHSXUSRVHNQLWWHGQRWFXWIURPVKHHWVZLWKÀQHU attachments. ÀEULOVDQGOHVVZHLJKWSHUXQLWDUHD7KH\GRQRWIUDJPHQWDQGDUH less likely to surface in the wound. Surgery based on the Integral Theory System Minislings- a new horizon for stress incontinence, and “Tension-free” techniques Beginning in the late 1980s repair of cystocoele, rectocoele, and prolapse of the uterus. an entirely new surgical method for stress incontinence 7KH7)6ÀJZDVWKHÀUVWPLQLVOLQJ,WZDVDSSOLHGLQODWH was introduced. Polypropylene tapes were placed around 2003 to a patient with stress incontinence and uterovaginal WKH PLGGOH SDUW RI WKH XUHWKUD EHVW NQRZQ DV WKH´797· SURODSVH6LQFHWKHUHKDVEHHQDSURIXVLRQRIRWKHU RSHUDWLRQ  WR UHLQIRUFH WKH SXERXUHWKUDO OLJDPHQWV WKHQ D minislings introduced for cure of stress incontinence, for little later, the posterior ligaments (infracoccygeal sacropexy, example, TVT-Secur, Mini Arc, Ophira, and many others. “PIVS”).5 This method, now known as the “tension-free Because the TFS is a tensioned sling, it can also address WDSHµWHFKQLTXHKDVUHYROXWLRQL]HGWKHWUHDWPHQWRIVWUHVV QRW RQO\ SURODSVH EXW DOVR PDQ\ V\PSWRPV IURP WKH incontinence (SI) and prolapse surgery. The operations are 3LFWRULDO'LDJQRVWLF$OJRULWKP ÀJ LQFOXGLQJXUJHQF\ FRQGXFWHGYLDFPLQFLVLRQVLQWKHDEGRPLQDOVNLQMXVWDERYH QRFWXULDDEQRUPDOHPSW\LQJDQGSHOYLFSDLQ WKHSXELFERQHJURLQRUSHULQHXP7KHUHLVPLQLPDOSDLQ Like other minislings, the TFS uses only small sections of hospital stay is reduced to 1 or 2 days, and patients generally PRQRÀODPHQWWDSH ÀJ VRLWFDXVHVOHVVWLVVXHLUULWDWLRQ KDYH IHZ SUREOHPV SDVVLQJ XULQH DIWHU WKH RSHUDWLRQ7KH ,WXVHVDELRHQJLQHHULQJSULQFLSOHVLPLODUWRWKDWRIDEXWWUHVVHG cure rate is high in the longer term. Later variations of these FDWKHGUDOFHLOLQJ ÀJ IRUF\VWRFRHOHDQGUHFWRFRHOHUHSDLU RSHUDWLRQVLQFOXGHWKHWUDQVREWXUDWRU 727 DSSURDFKIRU ,W DYRLGV WKH VSDFHV EHWZHHQ UHFWXP EODGGHU DQG YDJLQD SI (very successful), and the addition of mesh sheets to the DQGVRLWLVQRWVXEMHFWWRWKHDGKHVLYHFRPSOLFDWLRQVVHHQ 727 DQG 3,96 WHFKQLTXHV QRW VR VXFFHVVIXO  7KH RQO\ with large mesh. As with all polypropylene implantations, VLJQLÀFDQWSUREOHPZLWKDOOWDSHPHVKLPSODQWRSHUDWLRQV WKHPDLQFRPSOLFDWLRQLVUHMHFWLRQRIWKHWDSHE\WKHERG\·V was partial or total rejection of the tape/mesh. More recently, immune mechanisms. However, this occurs only in a small DQ HYHQ OHVV LQYDVLYH PHWKRG WKH ´PLQLVOLQJµ KDV EHHQ percentage of patients, as only very small segments of tape 22 introduced to address incontinence and organ prolapse. are used, and the anchor prevents “slippage” into the wound, a major cause of erosion. Only a tensioned minisling can reliably improve symptoms Essential to cure of posterior zone symptoms with the posterior “tension-free” sling was restoration of tissue WHQVLRQ E\ DSSUR[LPDWLRQ RI ODWHUDOO\ GLVSODFHG WLVVXHV5 With the infracoccygeal sacropexy (“posterior IVS”), WKLV FRXOG RQO\ EH GRQH ZLWK D VXWXUH ZKLFK ZDV QHLWKHU VXIÀFLHQWO\VWURQJQRUUHOLDEOH The TFS minisling, was designed to precisely reconstruct and tension the 5 main structures which support WKH RUJDQV SXERXUHWKUDO $7)3 FDUGLQDO XWHURVDFUDO OLJDPHQWV DQG SHULQHDO ERG\ ÀJ  DQG WR DSSUR[LPDWH laterally displaced tissues.

PART 3 ILLUSTRATIVE CASE HISTORIES The following illustrative case histories are taken from the ÀOHVRIWKH.YLQQR&HQWUH3HUWK:HVWHUQ$XVWUDOLDWKHÀUVW clinic in the world to apply the Integral Theory System.

ANTERIOR ZONE DAMAGE )LJ7)6DSSOLFDWRU¶$Sµ¶$·LVWKHVRIWWLVVXHDQFKRUZKLFK In this section, we give a series of typical case reports from VLWVRQWKHVDGGOH¶6·7KHWDSH¶7·LVD¶QH[WJHQHUDWLRQµQRQVWUHWFK PDFURSRURXVPRQRÀODPHQWSRO\SURS\OHQHWDSH7KHSRO\SURS\OHQH SDWLHQWV ZKR FDPH WR WKH &OLQLF ZLWK SDUWLFXODU SUREOHPV WDSHSDVVHVWKURXJKWKHXQLGLUHFWLRQDO¶WUDSGRRU·DWWKHEDVHRIWKH ZKLFK PDLQO\ GHULYH IURP IURQW SXERXUHWKUDO  OLJDPHQW DQFKRU 7KLV RQHZD\ V\VWHP RI WLJKWHQLQJ EULQJV WKH ODWHUDOO\ looseness, in particular, stress incontinence. We also discuss displaced ligaments and fascia towards the midline. RWKHUOHVVW\SLFDOSUREOHPV

 P.E.P. Petros

)LJ   7KH 7)6 ZRUNV OLNH D EXWWUHVVHG FDWKHGUDO FHLOLQJ VWUXFWXUH7KH SLOODUV ERQH  SURYLGH WKH DQFKRULQJ SRLQW IRU WKH EHDPV WDSHV  ZKLFK LQ WXUQ SURYLGH VXIÀFLHQW VXSSRUW IRU WKH ZHDNHU SODVWHU ERDUG YDJLQD  /LNH D ZLUH VXVSHQVLRQ EULGJH tensioned TFS tapes provide a much stronger support than meshes which have a tendency to sag.

Stress incontinence (leaking during coughing) is the main symptom for front ligament looseness. Mrs CYL,was 55 years old, and she had had 3 normal GHOLYHULHV 7KH XOWUDVRXQG VKRZHG WKDW KHU EODGGHU DQG XUHWKUD EHFDPH RQH ODUJH IXQQHO ZKHQ VKH FRXJKHG DQG WKHXULQHMXVWUDQRXW7KH'LDJQRVWLF'LDJUDPFRQÀUPHG WKDWWKHGDPDJHZDVLQWKHIURQWOLJDPHQWFROXPQÀJ 0D[LPDO8UHWKUDO&ORVXUH3UHVVXUHZDVFP+2 “Mixed” stress and urge incontinence from front ligament looseness Mrs JC, was a 38 year para 2. She had stress incontinence, DQGVKHDOVRZHWZLWKXUJHQF\WLPHVDGD\EHIRUHVKH Fig. 21 - Anterior Zone defect The tick indicates only front ligament DUULYHGDWWKHWRLOHW6KHKDGEHHQUHIXVHGVXUJHU\IRUKHU damage. A TFS polypropylene tape was inserted through a very VWUHVV LQFRQWLQHQFH EHFDXVH D XURG\QDPLF WHVW KDG VKRZQ VPDOO LQFLVLRQ LQ WKH YDJLQD WR UHSDLU WKH IURQW OLJDPHQW ÀJ  DQ ´XQVWDEOH EODGGHUµ :LWK UHIHUHQFH WR WKH 'LDJQRVWLF  7KHSDWLHQWZHQWKRPHWKHQH[WGD\HQWLUHO\GU\ 'LDJUDPÀJLWZDVHYLGHQWWKDWVKHKDGVSHFLÀFPLGGOH RUSRVWHULRU]RQHV\PSWRPVLQGLFDWLQJWKDWKHUSXERXUHWKUDO OLJDPHQW 38/ ZDVSUREDEO\FDXVLQJERWKSUREOHPVVWUHVV Bedwetting from childhood caused by a lax front ligament DQGXUJH7KLVZDVFRQÀUPHGZLWKD´VLPXODWHGRSHUDWLRQµ 0LVV0ZDV\HDUVROGSDUD6KHKDGZHWKHUEHG gently pressing an instrument upwards on one side in the DVDFKLOG%HGZHWWLQJFOHDUHGDWSXEHUW\EXWVKHVWLOOZHW SRVLWLRQRI38/DWPLGXUHWKUDMXVWEHKLQGWKHSXELFERQH with coughing and exercise, and with urge. Ultrasound This controlled her urine loss on coughing, and greatly GHPRQVWUDWHG EODGGHU QHFN URWDWLRQ LQGLFDWLQJ WKDW WKH GLPLQLVKHGKHUXUJHV\PSWRPV6KHZDVFXUHGRIERWKVWUHVV IURQW OLJDPHQW SXERXUHWKUDO  ZDV ORRVH +HU EODGGHU and urge with a polypropylene sling placed around the symptoms were cured with a TFS sling which reinforced middle of her urethra to strengthen the front ligament. KHUSXERXUHWKUDOOLJDPHQWV

Fig. 20 - The TFS minisling (Tissue Fixation System) a new DSSURDFK WR VXUJHU\ IRU SURODSVH ,W ZRUNV E\ DSSUR[LPDWLQJ ODWHUDOO\ GLVSODFHG WLVVXHV DQG E\ UHLQIRUFLQJ WKH  VXVSHQVRU\ OLJDPHQWVRIWKHYDJLQD38/ SXERXUHWKUDO $7)3FDUGLQDO &/  Fig. 22 - The “mini” or “micro” sling is inserted exclusively from XWHURVDFUDO 86/ DQGDOVRWKHSHULQHDOERG\ 3%  the vagina. It avoids most complications of “tension-free” slings.

 The integral theory system

Bedwetting from childhood and faecal incontinence caused by a lax front ligament In contrast, Miss G, 18 years old, had continued wetting ZHW KHU EHG VLQFH FKLOGKRRG DQG DOVR KDG VWUHVV XULQDU\ and faecal incontinence. On examination, her urine loss ZDV FRQWUROOHG E\ JHQWOH SUHVVXUH XSZDUGV LQ WKH YDJLQD DSSOLHGMXVWEHKLQGWKHSXELFERQH7UDQVSHULQHDOXOWUDVRXQG GHPRQVWUDWHG URWDWLRQ RI EODGGHU QHFN LQGLFDWLYH RI D ORRVHDQWHULRU SXERXUHWKUDO OLJDPHQW$WWKHZHHNSRVW operative visit, all symptoms were cured, and there was a UHPDUNDEOH WUDQVIRUPDWLRQ LQ WKH SDWLHQW·V SV\FKRORJLFDO state. Stress faecal incontinence caused by a lax front ligament 0UV7\HDUVROGFDPHWRVHHXVEHFDXVHVKHORVWXULQH and solid faeces on coughing. Again, symptom grouping gave us the clue that her symptoms originated from SXERXUHWKUDO OLJDPHQW GDPDJH +HU DVVHVVPHQW LQGLFDWHG she had damaged front ligaments, which was successfully addressed with a polypropylene midurethral sling.27 Comment 7KH ERZHO ZRUNV LQ D VLPLODU ZD\ WR WKH EODGGHU If a ligament is loose, the muscles which close the ERZHO FDQQRW ZRUN SURSHUO\ DQG WKH SDWLHQW PD\ OHDNZLQGÁXLGRUVROLGIDHFHV

MIDDLE ZONE DAMAGE (CYSTOCOELE) In this section, a series of typical case reports is presented from patients who came to our Clinic with particular SUREOHPV ZKLFK PDLQO\ GHULYH IURP PLGGOH OLJDPHQW

)LJ   $QWHULRU =RQH 'HIHFW 6WUHVV DQG IDHFDO LQFRQWLQHQFH *URXSLQJRI6,V\PSWRPVZLWK),DQGDEVHQFHRIRWKHUSRVWHULRU zone sympotms indicates anterior ligament damage.

looseness. Mostly patients with a cystocoele, only complain of a “lump” in the vagina. However, they sometimes have V\PSWRPVRIXUJHQF\DQGGLIÀFXOW\LQHPSW\LQJWKHEODGGHU DQGFKURQLFEODGGHULQIHFWLRQV Urge incontinence caused by cystocoele occurring after prolapse repair Mrs DV was 53 years old. She had had a successful repair of the uterosacral ligaments for prolapse of the uterus 12 months earlier. She came to see us, stating that her symptoms had reappeared in the past few weeks. ,WZDVQRWHGIURP0UV'9·VTXHVWLRQQDLUHWKDWWKHQRFWXULD DQGSHOYLFSDLQVKHKDGPRQWKVDJRUHPDLQHGFXUHGÀJ 25. When she was examined, it was evident that her posterior ligaments (uterosacrals)were intact. There was no prolapse of the uterus. However, a cystocoele was seen just inside the vaginal entrance on straining. Her urgency symptoms were UHOLHYHGE\JHQWO\VXSSRUWLQJWKHF\VWRFRHOHLQGLFDWLQJWKDW this was the cause of her urge symptoms. The cystocoele ZDVFXUHGE\7)6$7)3DQGFDUGLQDOOLJDPHQWRSHUDWLRQÀJ 5HOLHIRIXUJHQF\DQGLPSURYHGEODGGHUHPSW\LQJZHUH reported immediately after the surgery.22 Comment Mrs DV is a good example of what happens in patients with damaged ligaments. In up to 30% of cases, repairing one part of the vagina can EHIROORZHGE\DQRWKHUOXPSRUV\PSWRPDSSHDULQJ weeks, months or even years later. )LJ$QWHULRU=RQH'HIHFW6WUHVVDQG8UJHQF\LQ0UV-&·VFDVH Recurrent or chronic cystitis – its relationship to DUHERWKPRVWOLNHO\FDXVHGE\GDPDJHWRWKHIURQWOLJDPHQW%HFDXVH abnormal emptying, cystocoele and prolapse of the uterus urge symptoms may derive from all 3 zones, all 3 spaces are ticked. 'LDJQRVLVRIDQWHULRU]RQHGHIHFWZDVPDGHE\GHGXFWLRQXVLQJWKH Whilst there are many causes of cystitis, this presentation SUHVHQFHRI6,DQGDEVHQFHRIRWKHU]RQHVSHFLÀFV\PSWRPV FRQFHUQVSDWLHQWVZKRKDYHUHFXUUHQWF\VWLWLVEHFDXVHWKH\

 P.E.P. Petros

)LJ7KHFHLOLQJMRLVWSULQFLSOHIRUF\VWRFRHOHUHSDLU6FKHPDWLF view into the anterior wall of the vagina. The horizontal tape provides structural support to the proximal half of the anterior vaginal wall and recreates the cervical ring. The vertical U-sling joins with existing ATFP structures to provide structural support to the distal half of the vagina.

KDG  SUHYLRXV RSHUDWLRQV IRU SURODSVH DQG LQFRQWLQHQFH some years earlier. She offered the cardinal symptom of this FRQGLWLRQ´P\EODGGHUHPSWLHVXQFRQWUROODEO\LPPHGLDWHO\ P\ IRRW WRXFKHV WKH ÁRRU RQ JHWWLQJ RXW RI EHG LQ WKH morning.” She also lost urine on standing up from a chair, RUEHQGLQJGRZQ Fig. 25 - Middle Zone Defect The ticks indicated a middle or On examination, she did NOT lose urine during coughing, SRVWHULRUGHIHFWIRU0UV'97KHSUHVHQFHRIDF\VWRFRHOHDEVHQFH RIDSURODSVHRIWKHXWHUXVDQGLWVVSHFLÀFV\PSWRPVQRFWXULDDQG a common feature of this condition. The large amount of urine SHOYLFSDLQLQGLFDWHGLWZDVDPLGGOHOLJDPHQWSUREOHP PHDVXUHGZLWKDKRXUSDGWHVWYDOLGDWHGWKHVHULRXVQHVV RIWKLVODG\·VSUREOHP7KHUHZDVYHU\OLWWOHPRYHPHQWRI KHU EODGGHU QHFN GXULQJ VWUDLQLQJ ZLWK XOWUDVRXQG WHVWLQJ FDQQRW HPSW\ WKHLU EODGGHU DGHTXDWHO\ GXH WR GDPDJHG FRQVLVWHQW ZLWK WKH WKLFN VFDUULQJ REVHUYHG LQ WKH EODGGHU ligaments in the middle or posterior parts of the vagina. QHFN DUHD RI KHU YDJLQD 7KLV VFDUULQJ LPPRELOL]HG WKH ,QWKHDXWKRU·VH[SHULHQFHF\VWRFRHOHDQGSURODSVHRIWKH muscles and ligaments needed to close the urethra, hence XWHUXVDUHPDMRUFRUUHFWDEOHFDXVHVRIDEQRUPDOHPSW\LQJ 5 the name, “tethered vagina”. A graft placed in this DQGFKURQLFEODGGHULQIHFWLRQV DUHD ÀJ  UHVWRUHG HODVWLFLW\ DQG YDVWO\ LPSURYHG KHU Other causes of recurrent cystitis incontinence. $Q\WKLQJZKLFKLUULWDWHVWKHLQVLGHRIWKHEODGGHUVXFK Comment The “tethered vagina” syndrome is still not DV D SRO\S D EODGGHU VWRQH RU SHQHWUDWLRQ RI D SODVWLF a well-recognized condition. It is entirely iatrogenic, mesh after a surgical procedure for incontinence can cause DQGLVFDXVHGE\H[FHVVLYHVFDUULQJIURPSUHYLRXV recurrent cystitis. The mesh can cause irritation per se, or EHFRPHFDOFLÀHGLQWRDVWRQH,QVHUWLQJDF\VWRVFRSHLQWRWKH EODGGHULVWKHEHVWPHWKRGIRUGLDJQRVLQJVXFKDSUREOHP Other causes of abnormal emptying? $Q\WKLQJ ZKLFK LQWHUUXSWV WKH PHVVDJHV IURP WKH EUDLQ PD\FDXVHWKLVSUREOHP2QHFDXVHZKLFKLVRIWHQVWDWHGLV GLDEHWHV+RZHYHULQWKHDXWKRU·VH[SHULHQFHPDQ\SDWLHQWV ODEHOOHG DV ´GLDEHWLF QHXURSDWK\µ LQ IDFW KDG GDPDJHG uterosacral ligaments which prevented the opening muscles from working properly. Such patients had accompanying symptoms such as nocturia, urgency and pelvic pain, as SHU WKH 3LFWRULDO 'LDJQRVWLF $OJRULWKP 'LDJUDP ÀJ  DQGZHUHDEOHWREHFXUHG$PXFKUDUHUFDXVHRIDEQRUPDO HPSW\LQJ PXOWLSOH VFOHURVLV FDQQRW EH FXUHG DQG RIWHQ UHTXLUHVLQWHUPLWWHQWVHOIFDWKHWHUL]DWLRQ Severe wetting on getting out of bed in the morning caused by excessive scarring from previous surgery “tethered vagina” – a hitherto unrecognised problem Fig. 27 - The diagram shows how a cystocoele “2”, droops 0UV (0  \HDUV ROG ZDV UHIHUUHG ZLWK D KLVWRU\ RI downwards in a sac, preventing it from emptying. The urine pool worsening incontinence over the previous 2 years. She had gets infected over time, leading to chronic cystitis.

 The integral theory system

ZRUN0\XULQHGULEEOHVDZD\DIWHU,VWDQGXSDQG,RIWHQ ZHWWKHWRLOHWVHDW,KDYHSUREOHPVZLWKEODGGHULQIHFWLRQVµ Mrs LM had symptoms typical of looseness in the SRVWHULRU OLJDPHQWV ÀJ  :KHQ ZH H[DPLQHG KHU ZH QRWHG WKDW VKH KDG VLJQLÀFDQW SURODSVH RI WKH XWHUXV EXW it was not protruding. A TFS “minisling” was inserted to reinforce the damaged uterosacral ligaments. The advantage of the TFS method is that it can precisely tighten the vaginal PHPEUDQHWRSUHYHQWVHQVLWLYHQHUYHHQGLQJVIURPÀULQJRII DWDORZEODGGHUYROXPH,WLVDYHU\PLQLPDOWHFKQLTXH DQGLVSHUIRUPHGHQWLUHO\IURPWKHYDJLQD0UV/0UHTXLUHG only an overnight stay in hospital, and she returned to work in 7 days. When reviewed at 9 months, she was getting up RQO\RQFHSHUQLJKWWRHPSW\KHUEODGGHU6KHVDLGWKDWKHU ORZDEGRPLQDOSDLQZDVVWLOOSUHVHQWEXWZDVEHWWHU +HUEODGGHUHPSW\LQJDOVRZDVQRWHQWLUHO\FXUHGEXWKDG LPSURYHG VLJQLÀFDQWO\ DQG VKH KDG QRW KDG DQ\ EODGGHU infections since the operation. The posterior TFS “minisling” operation is performed entirely from the vagina, which makes it minimally invasive and less painful than other sling procedures which pierce the skin. It has a one-way tightening system, so it can restore WKHWHQVLRQLQWKHOLJDPHQWV ZKLWHDUURZV $GHTXDWHWLVVXH WHQVLRQLVUHTXLUHGWRVXSSRUWWKHQHUYHVZKLFKFDXVHSDLQ and urgency symptoms. Without restoring the tension, it is )LJ0DUWLXVVNLQJUDIWDSSOLHGWRWKHEODGGHUQHFNDUHDRIWKH XQOLNHO\WKDWVXFKV\PSWRPVFDQEHFXUHG YDJLQDVXEVHTXHQWWRH[WHQVLYHIUHHLQJRIWKHXUHWKUDDQGYDJLQD Comment on the causation of urgency, nocturia and IURP DGKHVLRQV WR WKH SXELF ERQH DQG HDFK RWKHU LQ D FDVH RI pain by damaged ligaments “tethered vagina syndrome”. 6WURQJXWHURVDFUDOOLJDPHQWVDUHUHTXLUHGWRVXSSRUW WKHSDLQÀEUHVZKLFKUXQLQVLGHWKHPDQGWRDQFKRU surgeries. It is called the “tethered vagina syndrome” EHFDXVH GHQVH VFDU WLVVXH LQ WKH YDJLQD ´WHWKHUVµ the muscles, and prevents them from closing the XUHWKUDO WXEH 7KLV FRQGLWLRQ ZDV QRW SUHYLRXVO\ recognized as originating from a scarred vagina. It ZDVWKRXJKWWRRULJLQDWHIURPWKHEODGGHULWVHOIDQG ZDV VWLOOLVE\PDQ\ WUHDWHGZLWKGUXJVZKLFKRI course, cannot succeed, as the cause is mechanical. Treatment involves restoration of elasticity in the EODGGHUQHFNDUHDRIYDJLQDXVLQJVRPHVRUHRIVNLQ graft. Restoration of continence following skin graft surgery is the ultimate proof of the Integral Theory .

POSTERIOR ZONE DEFECTS In this section, some typical case reports from patients DUH SUHVHQWHG IURP SUREOHPV ZKLFK PDLQO\ GHULYH IURP posterior (uterosacral) ligament looseness. Structural and functional consequences of laxity in the uterosacral ligaments 7KH SUREOHPV DVVRFLDWHG ZLWK SRVWHULRU XWHURVDFUDO  ligament damage are usually far more complicated and serious, than those seen with damaged anterior or middle ligaments. Sometimes patients complain of just a “lump” in the vagina without accompanying symptoms. However, V\PSWRPV VXFK DV SHOYLF SDLQ QRFWXULD DQG DEQRUPDO emptying are found as accompaniments to the prolapse. +RZHYHU WKHVH V\PSWRPV PD\ RFFXU ZLWKRXW VLJQLÀFDQW prolapse. Laxity in the uterosacral ligaments associated with uterovaginal prolapse nocturia, urgency, abnormal emptying and pelvic pain 0UV/0\HDUVROGVWDWHG´,JHWXSWLPHVDQLJKW Fig. 29 - Posterior Zone Defect Ticks in the posterior column are ,ÀQGWKLVYHU\WLULQJDV,KDYHWRZRUNQH[WGD\,KDYHD typical for symptoms from damaged uterosacral ligaments. Ticks GUDJJLQJSDLQRQWKHULJKWVLGHZKLFKFDQEHTXLWHGLVWUDFWLQJ are inserted in all column for urge and emptying. Grouping of E\WKHHQGRIWKHGD\,DPDOZD\VJRLQJWRWKHWRLOHWDW V\PSWRPVLQGLFDWHVHLWKHUDPLGGOHRUSRVWHULRUGHIHFW$EVHQFHRI DF\VWRFRHOHRQYDJLQDOH[DPLQDWLRQFRQÀUPHGDSRVWHULRUGHIHFW

 P.E.P. Petros

the muscle forces which stretch the vagina to VXSSRUWWKHSDLQÀEUHV$VWKHSHQLVWKUXVWVLQWRWKH VXSSRUWWKHQHUYHVDQGYROXPHUHFHSWRUVDWEODGGHU posterior part of the vagina, it will cause pain if it EDVH/RRVHWLVVXHVZLOOQRWVXSSRUWWKHSDLQQHUYHV VWUHWFKHVWKHXQVXSSRUWHGQHUYHÀEUHV ZKLFK´GURRSµDQGÀUHRIIVHQGLQJVLJQDOVRISDLQWR WKHEUDLQ/LNHDWUDPSROLQHZLWKGDPDJHGVSULQJV Severe Pelvic pain caused by uterosacral loose ligaments will not allow the muscles to stretch ligament looseness. WKHYDJLQD7KHEODGGHUQHUYHVDUHXQVXSSRUWHGDQG 0UV'ZDVD\HDUROGSDUD6KHDWWHQGHGZLWKVHYHUH ÀUHRIISUHPDWXUHO\FDXVLQJXUJHDQGIUHTXHQF\ SDLQLQWKHULJKWVLGHRIKHUDEGRPHQ6RPH\HDUVSUHYLRXVO\ she had previously attended a London hospital which had Pain during intercourse and bowel problems developed an international reputation using psychological caused by posterior ligament looseness. tests to prove that such pain was psychological in origin. 0UV50ZDVD\HDUROGSDUD6KHVWDWHG´,DOZD\V 0UV'KDGUHDGZLGHO\RQWKHVXEMHFWRISDLQ+HUIDFLDO KDYHXUJHQF\WRHPSW\P\ERZHOEXW,DPDOVRIUHTXHQWO\ expression indicated a person who was guarded. Her lit FRQVWLSDWHG,JHWXSWLPHVDQLJKWWRSDVVXULQH,KDYH XSDIWHUVKHDQVZHUHGSRVLWLYHO\WRWKHIROORZLQJTXHVWLRQV SUREOHPV HPSW\LQJ P\ EODGGHU 0\ ZRUVW SUREOHP LV DVVKHNQHZWKDWZHNQHZZKDWKHUSUREOHPZDV WKDW,FDQ·WKDYHVH[DQ\PRUH$OPRVWHYHU\WLPH,KDYH “Do you have pain on deep penetration with intercourse? LQWHUFRXUVHP\ERZHOVRSHQ “Do you get up more than twice per night to pass urine? 5HIHUHQFHWRKHU'LDJQRVWLF'LDJUDPÀJLQGLFDWHG ´'R\RXKDYHSUREOHPVHPSW\LQJ\RXUEODGGHU" WKDW PRVW RI 0UV 50·V EODGGHU SUREOHPV SUREOHPV PD\ “Do you have urgency?” KDYH EHHQ FDXVHG E\ GDPDJHG SRVWHULRU OLJDPHQWV 2Q Positive answers to at least some symptoms other than pain examination, however, there was very minimal prolapse. DUHUHTXLUHGEHIRUHZHFDQSUHGLFWWKDWWKHSDLQLVFDXVHGE\ This was consistent with the Theory, which states that major damage to the posterior ligaments. There are, after all, many V\PSWRPVPD\EHFDXVHGE\PLQLPDOSURODSVHDQGDKLJKUDWH other causes of chronic pelvic pain in the 30 plus age group, RILPSURYHPHQW XSWR ZDVSRVVLEOHZLWKDSRVWHULRU IRUH[DPSOHHQGRPHWULRVLVLQIHFWLRQLQWKH)DOORSLDQWXEHV sling. No predictions were made for the urge to empty her SUREOHPVZLWKODUJHLQWHVWLQHWRQDPHMXVWDIHZ ERZHODQGKHUFRQVWLSDWLRQ6KHZDVDGYLVHGWKHVHFRXOGEH 7KLVLVZKDWVKHVDLGRQHZHHNDIWHUKHUSDLQZDVFXUHGE\ due to many other causes, so we were reluctant to predict a small operation which tightened her posterior ligaments.28 cure for these symptoms. A posterior TFS “minisling” was ´,ZDVDOPRVWVXLFLGDODIWHULQWHUPLQDEOHDWWDFNVRISDLQ inserted to repair the posterior ligaments. Mrs RM was RQP\ULJKWVLGH,WKDVQRZEHHQDZHHNVLQFHWKHRSHUDWLRQ discharged the next day with very little pain, and she went to DQG,IHHOOLNHDUDEELWWKDWKDVEHHQUHOHDVHGIURPDWUDS ZRUNWKHIROORZLQJZHHN6KHDWWHQGHGZLWKKHUKXVEDQGIRU 0\PLQGNHHSVVFDQQLQJXSDQGGRZQP\ERG\VHDUFKLQJ WKHSRVWRSHUDWLYHYLVLW6PLOLQJDQGFRQÀGHQWVKHUHSRUWHG IRU WKH SDLQ ZKLFK IRU VR ORQJ KDV EHHQ P\ FHQWUH DQG FXUHRIDOOKHUERZHOV\PSWRPVDQGDPDMRULPSURYHPHQW focus.” in her other symptoms. 7KHRSHUDWLRQÀJZDVVLPSOHDQGLWZDVSHUIRUPHG Comment on losing faeces during intercourse entirely under local anaesthesia. A 3 cm incision was made This patient was a challenge to us, as some of her LQWKHYDJLQDEHKLQGWKHFHUYL[7ZRVXWXUHV JUHHQOLQHV  symptoms were not the typical symptoms seen in the were inserted to tighten the ligaments (white arrows). Diagnostic Diagram. We had encountered women Comment RSHQLQJWKHLUEODGGHUGXULQJLQWHUFRXUVHEHIRUHEXW 7KLVFRQGLWLRQVHYHUHSHOYLFSDLQFDXVHGE\ORRVH QHYHUWKHLUERZHO,QVXFKFDVHVZHUHO\RQWKHRWKHU SRVWHULRUOLJDPHQWVLVVWLOOQRWZHOOUHFRJQL]HGE\ typical symptoms to guide us as to which ligaments WKH PDMRULW\ RI J\QDHFRORJLVWV7KH RSHUDWLRQ ÀJ KDYHEHHQGDPDJHGDQGRQWKHJXLGLQJSULQFLSOHRI XQIRUWXQDWHO\KDVDVLJQLÀFDQWUHFRYHU\UDWHDV this type of surgery, “repair the structure, and you it approximates damaged tissue to damaged tissue. will repair the function”. Insertion of a polypropylene sling gave a higher Comment on pain with intercourse V\PSWRPDWLFFXUHUDWHE\FUHDWLQJDFROODJHQRXVUH Earlier we discussed how a loose ligament will not LQIRUFHPHQWEHWWHUDEOHWRVXSSRUWWKHXQP\HOLQDWHG endings. Vulvodynia – pain and burning at the entrance to the vagina caused by posterior ligament looseness. 0UV3ZDV\HDUVROGSDUDZLWKFKURQLFSHOYLFSDLQ diagnosed as having a psychological cause. Her General Practitioner, an empathetic and caring man rang the doctor EHIRUH VKH DUULYHG DQG DVNHG WKDW ZH ´KDQGOH KHU YHU\ FDUHIXOO\µ DV VKH ZDV VHYHUHO\ GLVWXUEHG SV\FKRORJLFDOO\ that this was the reason for her pain, and “there was nothing DQ\RQH FRXOG GR IRU KHUµ 7KH ÀUVW LPSUHVVLRQ RI WKLV ODG\GLGLQGHHGÀWWKHGHVFULSWLRQRIKHU*3+HUIDFHZDV FRQWRUWHGVKHVSRNHUDSLGO\DQGZLWKREYLRXVDQ[LHW\6KH had visited many specialists over the years for her pain. She had undergone several diagnostic laparoscopies, even a hysterectomy, and had attended a pain clinic. None of these treatments had helped her pain. The consensus from RWKHUVSHFLDOLVWVDVUHSRUWHGWRWKH*3ZDVWKDWKHUSUREOHP ZDVSV\FKRORJLFDO+HUUHSOLHVWRWKHTXHVWLRQQDLUHJDYHWKH Fig 30 - The TFS posterior minisling repairs and tightens the ÀUVWKLQWWKDWWKLVZRPDQPD\KDYHDSK\VLFDOFDXVHIRUKHU posterior ligaments (arrows) without penetrating the skin of the SUREOHP GDPDJH WR KHU SRVWHULRU OLJDPHQWV 6KH ZRNH  EXWWRFNV WLPHVSHUQLJKWWRHPSW\KHUEODGGHU QRFWXULD ZRUHSDGV

 The integral theory system

DK\VWHUHFWRP\%\WKHWLPH0UV-0.ZDV\HDUVROGWKH FKURQLFSHOYLFSDLQDQGORZDEGRPLQDODFKHKDGUHWXUQHG 6KHKDGGHYHORSHGSURODSVHRIWKHYDJLQDDQGEODGGHUZLWK VLJQLÀFDQW EODGGHU V\PSWRPV XUJHQF\ DQG QRFWXULD 7KH UHWXUQRIV\PSWRPVFDQEHDWWULEXWHGWRDJHUHODWHGORVVRI collagen, and weakening of the posterior ligaments, a long- WHUPSUREOHPLQSDWLHQWVZKRKDYHKDGK\VWHUHFWRP\ Abnormal emptying and chronic bladder infection caused by looseness in the posterior ligaments 0UV .% D  \HDU SDUD  ÁLJKW DWWHQGDQW KDG D ORQJ KLVWRU\RILQDELOLW\WRHPSW\KHUEODGGHUDQGFKURQLFEODGGHU LQIHFWLRQVGDWLQJEDFNWRKHUWHHQDJH\HDUV6KHFDPHWRXV EHFDXVHWKHLQIHFWLRQVZHUHEHFRPLQJPRUHIUHTXHQWDQG ZHUHDIIHFWLQJKHUDELOLW\WRZRUNRQORQJÁLJKWV+HUVLWXDWLRQ had reached a stage where she felt forced to consider leaving Fig. 31 - Approximation of uterosacral ligaments A small 3cm her profession. She was diagnosed as having congenitally WUDQVYHUVHLQFLVLRQLQWRWKHYDJLQDMXVWEHORZWKHFHUYL[JDYHDFFHVV weak posterior ligaments. She did not respond to our pelvic for tightening her loose posterior ligaments (white arrows). ÁRRU UHJLPH DQG VKH UHTXHVWHG VXUJLFDO UHFRQVWUXFWLRQ of the ligaments. We agreed, having advised her that she may need a caesarian section if she fell pregnant, as any FRQWLQXDOO\DVVKHZHWWLPHVSHUGD\DQGKDGGLIÀFXOWLHV YDJLQDO GHOLYHU\ FRXOG GLVUXSW KHU RSHUDWLRQ +HU EODGGHU HPSW\LQJKHUEODGGHU6KHDOVRKDGIDHFDOLQFRQWLQHQFH:H returned to normal emptying immediately after the surgery, DVNHGKHULIVKHKDGWROGKHU*HQHUDO3UDFWLWLRQHUDERXWKHU DQGVKHUHSRUWHGQRIXUWKHUEODGGHULQIHFWLRQVHYHQ\HDUV EODGGHUDQGERZHOSUREOHPV6KHVDLGVKHKDGRQO\FRQVXOWHG afterwards KLPDERXWWKHEXUQLQJSDLQDURXQGKHUYDJLQDDQGDQXV6KH Comment on abnormal bladder emptying in the VDLGWKDWKHUYDJLQDZDVVRWHQGHUWKDWVKHFRXOGQ·WKDYH younger woman Congenitally weak posterior VH[XDO LQWHUFRXUVH DQG VRPHWLPHV KDG SUREOHPV VLWWLQJ OLJDPHQWVPXVWDOZD\VEHFRQVLGHUHGDVDFDXVHRI Examination revealed a prolapse of the posterior part of her DEQRUPDOEODGGHUHPSW\LQJLQWKH\RXQJHUZRPDQ vagina. The entrance to the vagina was hypersensitive- she as these women do not generally have a cystocoele. UHFRLOHGZKHQJHQWO\WHVWHGZLWKDFRWWRQEXGWKHFODVVLFDO ,QFUHDVHGGLIÀFXOW\LQHPSW\LQJWKHEODGGHUDWSHULRG test for “vulvodynia” (pain at the entrance of the vagina). time in such women is highly suggestive that the :HGLGQRWFODLPWKDWZHFRXOGFXUHWKLVODG\·VSDLQDV cause is looseness in the posterior ligaments. Other there are many other causes for pelvic pain. Nevertheless, symptoms such as pelvic pain, urgency and nocturia LW ZDV H[SODLQHG WKDW KHU YDJLQDO SURODSVH QHHGHG WR EH DUH IUHTXHQWO\ SUHVHQW DQG WKHVH PD\ EHFRPH À[HGDQGWKDWWKHUHZDVDVWURQJSRVVLELOLW\WKDWVRPHRI worse during period time. Though not helpful with her symptoms would also improve with a sling inserted 0UV.%JRRGUHVXOWVLQ\RXQJZRPHQKDYHEHHQ into the posterior part of her vagina, a fairly minor day-care DFKLHYHGDWRXU&OLQLFE\HQFRXUDJLQJVXFKSDWLHQWV procedure.29, 30 WR´VTXDWµLQVWHDGRIEHQGLQJDQGWRVLWRQDÀWEDOO 7KH ÀUVW WKLQJ ZH QRWLFHG DW WKH  ZHHN SRVWRSHUDWLYH DWZRUNLQVWHDGRIDFKDLU7KHVHH[HUFLVHVZRUNE\ YLVLWZDVWKHDEVHQFHRIWHQVLRQLQKHUIDFH6KHZDVVPLOLQJ strengthening the pelvic muscles and ligaments. and calm. Her pain was gone, as was her urgency and faecal $Q\HDUROGZRPDQQRWDEOHWRSDVVXULQHUHTXLULQJVHOI incontinence. Her nocturia had reduced to 2 per night, and -catheterisation caused by posterior ligament looseness. KHUEODGGHUHPSW\LQJZDV´LPSURYHGµ $GLDJQRVLVWKDWDSDWLHQW·VSDLQLVRISV\FKRORJLFDORULJLQ There is a prevalence of this condition in Nursing Homes. LV QRW HQWLUHO\ XQUHDVRQDEOH$Q\ W\SH RI FKURQLF SDLQ LV 0DQ\SDWLHQWVUHTXLUHLQGZHOOLQJFDWKHWHUV VXIÀFLHQWWRXQVHWWOHHYHQWKHPRVWUDWLRQDOSHUVRQDQGVXFK Mrs R was 87 years old, and weighed 90kg. She had had a SDWLHQWV GR EHFRPH ´SV\FKRORJLFDOO\ GLVWXUEHGµ %XW WKLV K\VWHUHFWRP\\HDUVHDUOLHU)RUVRPH\HDUVVKHQHHGHGWR GLVWXUEDQFHLVXVXDOO\VHFRQGDU\WRWKHSDLQ VHOIFDWKHWHUL]HWLPHVDGD\DVVKHFRXOGQRWSDVVXULQH DGHTXDWHO\ 6KH KDG ODUJH UHVLGXDO YROXPHV WKH DPRXQW Comment UHWDLQHGLQWKHEODGGHUDIWHUSDVVLQJXULQH 2QWHVWLQJZH We do not claim that all vulvodynia patients have this FRQÀUPHG VKH DOVR KDG VHYHUH LQFRQWLQHQFH ZLWK D ODUJH causation. However, if other symptoms of posterior PHDVXUHG XULQH ORVV RYHU D  KRXU SHULRG 6KH KDG rd OLJDPHQW ORRVHQHVV VXFK DV QRFWXULD DEQRUPDO degree prolapse of the vagina. We inserted a posterior sling, EODGGHUHPSW\LQJDQGXUJHQF\DUHJURXSHGZLWKWKH SHUIRUPHGDUHFWRFRHOHUHSDLUDQGSHULQHDOERG\UHSDLU6KH YXOYRG\QLDWKHUHLVDVWURQJSRVVLELOLW\WKDWWKLVSDLQ passed urine immediately after the surgery. Her nocturia, FDQEHLPSURYHGLQPDQ\SDWLHQWVZLWKDSRVWHULRU previously 5 times per night, reduced to twice per night. sling for repair of the posterior ligaments. Comment on how age causes ligament looseness and Hysterectomy for lower posterior ache and pelvic pain EODGGHUHPSW\LQJGLIÀFXOWLHV caused by posterior ligament looseness. The tissues of the vagina and its supporting ligaments Mrs JMK developed chronic lower posterior pain and PD\ ORRVHQ FRQVLGHUDEO\ ZLWK DJH 7KH HIIHFW RI SDLQ ZLWK LQWHUFRXUVH DIWHU D GLIÀFXOW IRUFHSV GHOLYHU\ RI this is that many older women, especially those in her second child 50 years ago, when she was 27 years old. 1XUVLQJ +RPHV FDQQRW HPSW\ WKHLU EODGGHU DQG 7KHSDLQZRUVHQHGDIWHUWKHELUWKRIKHUWKLUGFKLOG\HDUV WKH\UHTXLUHLQGZHOOLQJFDWKHWHUV7KHVHFDWKHWHUVDUH ODWHU7KHSDLQZDVFRQVWDQWDQGGHELOLWDWLQJDQGVKHDOVR a major cause of chronic cystitis, as they introduce KDG KHDY\ PHQVWUXDO EOHHGV %\ WKH DJH RI  WKH SDLQ EDFWHULD:HKDYHUHWXUQHGPDQ\ZRPHQWRQRUPDO KDG ZRUVHQHG VXIÀFLHQWO\ WR UHTXLUH FRQVXOWDWLRQ ZLWK D PLFWXULWLRQE\UHFRQVWUXFWLQJWKHSRVWHULRUOLJDPHQWV specialist gynaecologist. He told her that she needed to have DQGWLJKWHQLQJWKHQHLJKERXULQJWLVVXHV

 P.E.P. Petros

Faecal incontinence, “constipation” and bleeding caused by caused by posterior ligament looseness. 0UV'09\HDUROGSDUDFRPSODLQHGRIDOXPSLQ the vagina. She had a 2nd degree prolapse of the uterus, urgency, and nocturia. She also had faecal incontinence, FRQVWLSDWLRQ ÀJ DQG RFFDVLRQDO EOHHGLQJ IURP WKH ERZHO 6KH KDG EHHQ LQYHVWLJDWHG IRU WKH EOHHGLQJ E\ D VSHFLDOLVWZKRIRXQGQRHYLGHQFHRIERZHOFDQFHU,QWKH early days where the Diagnostic Algorithm was applied, we sometimes encountered patients with symptoms whose origin we did not fully understand. One example of this is WKH FRQVWLSDWLRQ IDHFDO LQFRQWLQHQFH DQG EOHHGLQJ ZKLFK KDGDIÁLFWHGWKLVODG\)DHFDOLQFRQWLQHQFHZDVQRWSDUWRI the Diagnostic Diagram at that time. In all such cases, we followed the principles of the Theory, “ repair the structure, and you will improve the symptoms”. We repaired the SURODSVHRIWKHXWHUXVE\UHLQIRUFLQJWKHSRVWHULRUOLJDPHQWV with a polypropylene sling. Mrs DMV had a good result. Her faecal incontinence was cured, her constipation improved, DQGKHUEOHHGLQJGLVDSSHDUHG31, 32 Explanation for Mrs DMV’s improvement in her “constipation” and bleeding. The reason for improvement LQ WKLV ODG\·V ´FRQVWLSDWLRQµ DQG EOHHGLQJ ZDV GLVFRYHUHG VRPH\HDUVODWHUE\DQ$XVWULDQFROOHDJXH'U$EHQGVWHLQ31 :LWKUHIHUHQFHWRWKHGLDJUDPÀJLWLVHYLGHQWWKDWWKH XWHUXV YDJLQD DQG UHFWXP ERZHO  DUH VXVSHQGHG E\ WKH uterosacral ligaments, like the apex of a tent. If the guy rope of the tent (posterior ligament) is loose, the wall of the tent will sag inwards, in this case, the wall of the vagina and UHFWXP,WLVGLIÀFXOWWRKDYHDQRUPDOERZHOPRWLRQZKHQ WKHERZHOZDOOVDUHORRVHDQGVDJJLQJLQWRWKHFDYLW\RIWKH ERZHO)XUWKHUPRUHWKHVDJJLQJZDOORIWKHUHFWXP ERZHO  caused congestion of the veins close to the cavity similar to what happens with a haemorrhoid. This congestion caused )LJ3RVWHULRU=RQH'HIHFW'LIÀFXOW\ZLWKERZHOHYDFXDWLRQ EOHHGLQJLQWRWKHERZHOFDYLW\IURPWLPHWRWLPH LQDSDWLHQWZLWKDODUJHUHFWRFRHOHLQGLFDWHVSHULQHDOERG\GDPDJH The tape lifted up and tightened the attachments of the DGGHGWRSRVWHULRUOLJDPHQWGDPDJH%RWKQHHGHGWREHUHSDLUHG XWHUXVYDJLQDDQGUHFWXPWRWKHWDLOERQHLQWKHVDPHZD\ a guy rope does to the apex of a tent. This tightened the tissues, restored the function and improved her symptoms. SXVKHGDVLGHE\FKLOGELUWKWKHUHFWXPSURWUXGHVLQWR the vagina. The traditional method relies on suturing Bowel emptying problems cured by repair of posterior GDPDJHGWLVVXHWRGDPDJHGWLVVXHXQGHUVLJQLÀFDQW ligaments and perineal body tension. This method is very painful, and is prone to 0UV9&'\HDUVSUHVHQWHGZLWKDUHFWRFRHOHIDHFDO UHFXU7KH7)6UHSDLUFUHDWHVDQDUWLÀFLDOOLJDPHQWWR LQFRQWLQHQFH DQG GLIÀFXOW\ ZLWK HPSW\LQJ KHU ERZHO ÀJ SHUPDQHQWO\MRLQWKHODWHUDOO\GLVSODFHGERGLHV 6KHVWDWHG´HYHU\WLPH,QHHGWRRSHQP\ERZHOV,KDYH WRSUHVVP\ÀQJHUVLQWRWKHSRVWHULRUZDOORIP\YDJLQDVR Urinary urgency, pelvic pain and nocturia cured by Pelvic ,FDQHPSW\,ÀQGWKHQHFHVVDU\K\JLHQHDIWHUFRPSOHWLRQ Floor Exercises TXLWH XQSOHDVDQWµ ,Q 0UV9&'·V FDVH ZH IRXQG WKDW KHU 0LVV%\HDUVJDYHWKLVVWRU\¶,EHJDQWRH[SHULHQFH SHULQHDOERG\KDGEHHQVWUHWFKHGYHU\WKLQO\DQGWKHPXVFOH symptoms of urgency, pelvic pain and nocturia at the age EHOOLHVRIWKLVVWUXFWXUHKDGEHHQSXVKHGWRWKHVLGHDOORZLQJ RIVXIÀFLHQWO\WRVHHNPHGLFDODGYLFH,VDZGLIIHUHQW the rectocoele to protrude into the vagina as a sac containing VSHFLDOLVWV,ZDVJLYHQGUXJVWRVWRSWKHEODGGHUFRQWUDFWLQJ faeces. That is why she had to press into the lower part of ,VSHQWDVPDOOIRUWXQHRQKHUEDOPHGLFLQHV1RWKLQJVHHPHG her vagina to facilitate evacuation. to work”. Finally she contacted our Clinic through an Her posterior ligaments were repaired with a sling, and her intermediary. She worked overseas, and could not attend the SHULQHDOERG\ZDVUHSDLUHGLQWKHWUDGLWLRQDOZD\ZLWKRXW Clinic for a formal assessment. We advised her how to use a D VOLQJ 7KH UHFWRFRHOH DQG ERZHO HYDFXDWLRQ GLIÀFXOW\ ODUJHUXEEHUÀWEDOODVDVXEVWLWXWHIRUDFKDLUDQGWRGHYHORS ZHUHLQLWLDOO\FXUHGEXWUHFXUUHGZLWKLQPRQWKVDVGLG JRRGSHOYLFÁRRUKDELWVVXFKDVVTXDWWLQJZKHUHYHUSRVVLEOH UHTXLUHPHQWWRDVVLVWHYDFXDWLRQE\SUHVVLQJKHUÀQJHUVLQWR LQVWHDGRIEHQGLQJ HUHFWSRVWXUHDQGH[HUFLVH7KHUHVXOW the posterior wall of her vagina. The faecal incontinence ZDVUHPDUNDEOHYLUWXDOO\DOOKHUV\PSWRPVGLVDSSHDUHGDQG UHPDLQHG FXUHG DQG ZH DWWULEXWHG WKLV WR WKH FRQWLQXLQJ VKHUHPDLQHGFXUHGDWODVWFRQWDFW\HDUVODWHU action of the posterior sling. The rectocoele and lax perineal Comment Non-surgical treatment of posterior ERG\ZHUHUHSDLUHGE\WKH7)6 7LVVXH)L[DWLRQ6\VWHP  ligament symptoms A vast improvement in symptoms DGMXVWDEOH WDSH WHFKQLTXH ÀJ  %RZHO HYDFXDWLRQ VXFK DV SHOYLF SDLQ XUJHQF\ DEQRUPDO HPSW\LQJ returned to normal, and the rectocoele remained cured at her DQG QRFWXULD KDV EHHQ DFKLHYHG LQ PDQ\ SDWLHQWV 2year review. DWWHQGLQJRXU&OLQLFE\WKHUHJLPHXWLOL]HGE\0LVV Comment Why a tape was necessary for repair of %LQSDUWLFXODUVXEVWLWXWLQJD´ÀWEDOOµIRUDFKDLU the perineal body7KHUHDUHUHDOO\SHULQHDOERGLHV DQG VTXDWWLQJ LQVWHDG RI EHQGLQJ  7KLV UHJLPH LV MRLQHGWRJHWKHUZLWKDÀEURXVEDQG:KHQWKHVHDUH especially effective in the younger woman.

50 The integral theory system

major cause of fecal incontinence. Pelviperineology 2008; 27: 102. 3HWURV 3( 6ZDVK 0 &RUUHFWLRQ RI DEQRUPDO JHRPHWU\ DQG G\VIXQFWLRQE\VXVSHQVRU\OLJDPHQWUHFRQVWUXFWLRQJLYHVLQVLJKWV into mechanisms for anorectal angle formation. Pelviperineology  3HWURV 3( 6ZDVK 0 5ROH RI SXERUHFWDOLV PXVFOH LQ DQDO FRQWLQHQFH FRPPHQWV RQ RULJLQDO ' SHOYLF XOWUDVRXQG GDWD from Chantarasorn & Dietz. Pelviperineology, 2008; 27;105. 17. Petros PE, Swash M, Kakulas B. Stress urinary incontinence results from muscle weakness and ligamentous laxity in the SHOYLFÁRRU3HOYLSHULQHRORJ\ 5HFKEHUJHU 7 8OGEMHUJ 1  2[OXQG + &RQQHFWLYH WLVVXH changes in the cervix during normal pregnancy and pregnancy FRPSOLFDWHG E\ D FHUYLFDO LQFRPSHWHQFH 2EVWHWV & Gynecol. 1988; 71:563-567. 19. 3HWURV3(DQG6NLOOLQJ303HOYLFÀRRUUHKDELOLWDWLRQDFFRUGLQJ to the Integral Theory of Female Urinary Incontinence- First UHSRUW (XURSHDQ - 2EVWHWULF  *\QHFRORJ\ DQG 5HSURGXFWLYH Fig. 33 - Large rectocoele repair. Approximation of the perineal Biology 2001; 94: 264-269. ERG\ 3% DQGXWHURVDFUDOOLJDPHQWV 86/ E\WLJKWHQLQJWKH7)6 20. Petros PE and Skilling 30 7KH SK\VLRORJLFDO EDVLV RI SHOYLF HIIHFWLYHO\EORFNVHQWU\RIWKHUHFWRFRHOHLQWRWKHYDJLQD$ DQXV ÁRRUH[HUFLVHVLQWKHWUHDWPHQWRIVWUHVVXULQDU\LQFRQWLQHQFH%U RVF=rectovaginal fascia; CL=cardinal ligament. -2EVWHW*\QDHFRO 21. Skilling PM, Petros PE. Synergistic non-surgical management of Permission to publish SHOYLFÁRRUG\VIXQFWLRQVHFRQGUHSRUW,QW-8URJ\QH The Editors grant permission for any individual, group or  company to reproduce any text or document in this series $EHQGVWHLQ % 3HWURV 3( 5LFKDUGVRQ 3$ /LJDPHQWRXV UHSDLU of articles, with the sole condition that this article is quoted XVLQJWKH7LVVXH)L[DWLRQ6\VWHPFRQÀUPVDFDXVDOOLQNEHWZHHQ as a literature reference, and any diagram is appropriately damaged suspensory ligaments and urinary and fecal incontinence. 3HOYLSHULQHRORJ\ acknowledged in the text. 6LYDVOLRJOX $$ 8QOXELOJLQ ( $\GRJPXV 6 &HOHQ ( 'ROHQ , $ 3URVSHFWLYH 5DQGRPL]HG &RPSDULVRQ RI 7UDQVREWXUDWRU REFERENCES Tape and Tissue Fixation System Minisling in the Treatment of 1. Petros P E, Ulmsten U. An Integral Theory of female urinary Female Stress Urinary Incontinence: 3 Year Results, 2010, J. LQFRQWLQHQFH $FWD 2EVWHWULFLD HW *\QHFRORJLFD 6FDQGLQDYLFD Pelviperineology (in press). 6XSSOHPHQW 6HNLJXFKL < .LQM\R 0 ,QRXH + 6DNDWD + DQG .XERWD 2. Petros P E, Ulmsten U. An Integral Theory and its Method, for < 2XWSDWLHQW PLG XUHWKUDO WLVVXH À[DWLRQ V\VWHP VOLQJ IRU the Diagnosis and Management of female urinary incontinence, urodynamic stress urinary incontinence, The Journal of Urology Scandinavian Journal of Urology and Nephrology 1993; 27 2009; 182:2810-3. Supplement No 153 – 1-93. 25. Petros PE Richardson PA. A 3 year follow-up review of uterine/ 3. Petros P E, The International Continence Society and Integral vault prolapse repair using the TFS minisling. ANZJOG 2009; Theory systems for management of the incontinent female -a  FRPSDUDWLYHDQDO\VLV3HOYLSHULQHRORJ\ ,QRXH + 6HNLJXFKL < .RKDWD < 6DWRQR< +LVKLNDZD.  3HWURV 3 ( 8OPVWHQ 8 3DSDGLPLWULRX - 7KH $XWRJHQLF 7RPLQDJD7 DQG 2RED\DVKL 0 7LVVXH )L[DWLRQ 6\VWHP 7)6  1HROLJDPHQW SURFHGXUH$ WHFKQLTXH IRU SODQQHG IRUPDWLRQ RI to repair uterovaginal prolapse with uterine preservation: A DQ DUWLÀFLDO QHROLJDPHQW $FWD 2EVWHWULFLD HW *\QHFRORJLFD preliminary report on perioperative complications and safety J. 6FDQGLQDYLFD6XSSOHPHQW 2EVWHW*\QDHFRO5HV²  3HWURV3(1HZDPEXODWRU\VXUJLFDOPHWKRGVXVLQJDQDQDWRPLFDO +RFNLQJ , ([SHULPHQWDO 6WXG\ 1R  'RXEOH LQFRQWLQHQFH FODVVLÀFDWLRQ RI XULQDU\ G\VIXQFWLRQ LPSURYH VWUHVV XUJH DQG XULQDU\ DQG IHFDO FXUHG E\ VXUJLFDO UHLQIRUFHPHQW RI WKH DEQRUPDOHPSW\LQJ,QW-8URJ\QHFRORJ\ SXERXUHWKUDOOLJDPHQWV3HOYLSHULQHRORJ\  3HWURV3(,QÁXHQFHRIK\VWHUHFWRP\RQSHOYLFÁRRUG\VIXQFWLRQ 3HWURV3(6HYHUHFKURQLFSHOYLFSDLQLQZRPHQPD\EHFDXVHG /DQFHW E\OLJDPHQWRXVOD[LW\LQWKHSRVWHULRUIRUQL[RIWKHYDJLQD$XVW  3HWURV3(8OPVWHQ85ROHRIWKHSHOYLFÁRRULQEODGGHUQHFN 1=-2EVWHW*\QDHFRO opening and closure: I muscle forces, Int. J. Urogynecol. and 3HWURV 3( DQG %RUQVWHLQ - 9XOYDU YHVWLEXOLWLV PD\ EH D 3HOYLF)ORRUO referred pain arising from laxity in the uterosacral ligaments-  3HWURV3(8OPVWHQ85ROHRIWKHSHOYLFÁRRULQEODGGHUQHFN DK\SRWKHVLVEDVHGRQSURVSHFWLYHFDVHUHSRUWV$1=-2 * opening and closure: II vagina. Int. J. Urogynecol. and Pelvic ² )ORRU %RUQVWHLQ-=DUIDWL'3HWURV3(3&DXVDWLRQRIYXOYDUYHVWLEXOLWLV 9. Petros PE, Swash M. The Musculoelastic Theory of anorectal $1=-2*² function and dysfunction. Pelviperineology, 2008; 27: 89-93. $EHQGVWHLQ % %UXJJHU %$ )XUWVFKHJJHU$ 5LHJHU 0 3HWURV 10. Petros PE, Swash M. Directional muscle forces activate anorectal PE, Role of the uterosacral ligaments in the causation of rectal continence and defecation in the female, Pelviperineology 2008; LQWXVVXVFHSWLRQDEQRUPDOERZHOHPSW\LQJDQGIHFDOLQFRQWLQHQFH  a prospective study. Pelviperineology 2008; 27;118-121. 3HWURV3(6ZDVK0$'LUHFWWHVWIRUWKHUROHRIWKHSXERXUHWKUDO 3HWURV3(5LFKDUGVRQ3$)HFDOLQFRQWLQHQFHFXUHE\VXUJLFDO ligament in anorectal closure. Pelviperineology 2008; 27: 98. reinforcement of the pelvic ligaments suggests a connective tissue aetiology. Pelviperineology 2008; 27: 111-113. 3HWURV 3( 6ZDVK 0 5HÁH[ FRQWUDFWLRQ RI WKH OHYDWRU SODWH increases intra-anal pressure, validating its role in continence. Pelviperineology 2008; 27: 99. Correspondence to: 3HWURV 3( 6ZDVK 0 $EGRPLQDO SUHVVXUH LQFUHDVH GXULQJ Professor Peter Petros anorectal closure is secondary to striated pelvic muscle $2VERUQH3GH&ODUHPRQW:$$XVWUDOLD contraction. Pelviperineology, 2008; 27:100-101. 7HO1R0 3HWURV3(6ZDVK0$SURVSHFWLYHHQGRDQDOXOWUDVRXQGVWXG\ )D[ VXJJHVWVWKDWLQWHUQDODQDOVSKLQFWHUGDPDJHLVXQOLNHO\WREHD Email: [email protected]

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