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 vagina 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 pelvis; 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, nerves, ligaments disorder”. 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