The Female Pelvic Floor Function, Dysfunction and Management According to the Integral Theory

I f rst encountered the Integral T 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 ef 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 f ve year history of urinary retention which required an indwelling catheter. T 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 T eory it was deduced that she had a posterior zone defect. I performed a Posterior IVS. T e next day the patient was voiding spontaneously with low residuals, and she has remained well since.

Author Notes

PE Papa Petros Emeritus Consultant, Royal Perth Hospital, Western Australia Professor (Adjunct), University of Western Australia

Preface to 2nd Edition	p. VI
Preface	p. VII
Acknowledgments	p. VIII
Foreword	p. X
Frequently Used Abbreviations and Acronyms	p. XIX
Chapter 1 Overview	p. 1
1.1 Introduction	p. 1
1.1.1 The Problem	p. 1
Urinary Incontinence	p. 1
Frequency of Urination	p. 1
Nocturia	p. 2
Bowel Dysfunction	p. 2
Abnormal Bladder Emptying	p. 2
Chronic Pelvic Pain	p. 2
Other Problems	p. 2
1.1.2 The Integral Theory - A New Perspective	p. 2
1.1.3 A Guide to the Diagrams Used in this Book	p. 3
Series 1 Static Anatomy	p. 3
Series 2 Dynamic Anatomy	p. 5
Series 3 Functional Anatomy	p. 6
1.2 Overview of Pelvic Floor Function and Dysfunction According to the Integral Theory	p. 7
1.2.1 Basic Tenets of the Integral Theory	p. 7
Structure and Form	p. 9
Function and Dysfunction	p. 9
Causes of Dysfunction - Delineating the Zones of Damage	p. 9
Diagnosis of Damage	p. 10
Surgical Repair of Connective Tissue Structures	p. 11
1.3 Summary Chapter 1	p. 12
Chapter 2 The Anatomy and Dynamics of Pelvic Floor Function and Dysfunction	p. 14
2.1 The Anatomy of Pelvic Floor Function	p. 14
2.1.1 Introduction	p. 14
2.1.2 The Role of Ligaments, Muscles and Fascia in Creating Form, Strength and Function	p. 15
2.1.3 The Role of Connective Tissue Structures	p. 15
2.1.4 The Key Ligaments of the Pelvic Floor Structure	p. 16
The Pubourethral Ligament (PUL)	p. 16
The Arcus Tendineus Fascia Pelvis (ATFP)	p. 17
The Uterosacral Ligaments (USL)	p. 17
The Pubovesical Ligament (PVL)	p. 17
The Precervical Arc of Glivernet	p. 18
The Trigone	p. 18
Fascial attachment of the vagina to ATFP	p. 18
Organ Spaces	p. 19
The Pubocervical Fascia	p. 19
The Rectovaginal Fascia	p. 19
The Cervical Ring	p. 20
The Role of Proximal Cervical Ring Fascia in Preventing Everting Vaginal Prolapse	p. 20
The Role of Proximal Cervical Ring Fascia in Preventing Peripheral Neurologically Derived Symptoms	p. 20
2.1.5 The Muscles of the Pelvic Floor	p. 21
The Upper Layer of Muscles	p. 22
The Middle (Connecting) Layer of Muscles	p. 23
The Lower Layer of Muscles	p. 23
The Special Case of the Puborectalis Muscle	p. 24
2.2 The Dynamics of Pelvic Floor Function	p. 25
2.2.1 The Dynamics of the Striated Pelvic Floor Muscles	p. 25
The Dynamics of Urethral Opening and Closure - Urethral Perspective	p. 25
The Dynamics of Urethral Closure and Opening - Vaginal Perspective	p. 27
2.2.2 Pelvic Floor Dynamics - The 'Mechanical' Dimension	p. 28
Resting Closed	p. 28
Closure During Effort	p. 29
Urethral Opening by External Striated Muscle Forces During Micturition	p. 30
2.2.3 Pelvic floor dynamics - the neurological dimension	p. 31
Urethral Closure	p. 31
Urethral Opening (Micturition)	p. 31
The Role of Connective Tissue Tension in the Peripheral Neurological Control Mechanism for Micturition	p. 32
2.3 The Role of Connective Tissue in Pelvic Floor Function and Dysfunction	p. 34
2.3.1 The Biomechanics of the Vagina	p. 35
The Effect of Pregnancy Hormones on Connective Tissue	p. 36
The Effect of Age on Connective Tissue	p. 36
The Role of Connective Tissue in Transmitting Muscle Forces - The Sail Analogy	p. 36
The Positive Effect of Uterine Conservation in Preserving Ligament Integrity	p. 37
2.3.2 The Role of Connective Tissue in the Maintenance of Form (Structure) and Function	p. 37
The Causes of Damaged Connective Tissue	p. 38
Structural Effects of Damaged Connective Tissue	p. 38
Lax Connective Tissue and Diminution of the Force of Muscle Contraction	p. 39
2.3.3 The Role of Connective Tissue in Balance and Imbalance of Pelvic Muscle Forces - Effects on Micturition and Closure	p. 40
Closure at Rest and Effort	p. 40
Normal Micturition - A Controlled Temporary Unbalancing of the Closure System	p. 41
The Role of Damaged Connective Tissue in Incontinence Causation	p. 42
Symptomatic Manifestations of Imbalance Caused by Damaged Connective Tissue	p. 44
2.3.4 The Role of Connective Tissue in Anorectal Opening, Closure and 'Idiopathic' Faecal Incontinence	p. 45
Existing Concepts for Anorectal Closure, Opening, and Faecal Incontinence	p. 46
Anorectal Function According to the Integral Theory	p. 46
Connective Tissue Laxity and Anorectal Dysfunction	p. 48
The Role of Striated Muscle in Faecal Incontinence	p. 49
'Constipation'	p. 49
Dislocation of Anal Mucosa	p. 50
2.4 Summary Chapter 2	p. 50
Chapter 3 Diagnosis of Connective Tissue Damage	p. 51
3.1 The Integral Theory Diagnostic System: Overview	p. 51
3.2 The Integral Theory Diagnostic System	p. 54
3.2.1 The Clinical Assessment Pathway	p. 54
Introduction	p. 54
Using the Clinical Assessment Pathway in a Clinical Assessment	p. 54
3.2.2 The Structured Assessment Pathway	p. 55
Introduction	p. 55
Phase 1 Data Collection and Correlation	p. 58
Phase 2 Data Analysis	p. 62
Phase 3 Verification Using 'Simulated Operations'	p. 63
Deciding which Structural Defects to Repair Surgically in 'Difficult' Cases	p. 67
3.3 Working with Symptoms in the Integral Theory Diagnostic System	p. 67
3.3.1 The Reliability of symptoms	p. 67
3.3.2 The Variability of Symptoms in Patients with Similar Anatomical Defects	p. 69
3.3.3 Assessing Probability: The Impact of Different Structures on the Variability of Incontinence Symptoms	p. 69
3.3.4 The Anatomical Basis for the Diagnostic Summary Sheet	p. 71
Anterior Zone Defect Symptoms	p. 71
Middle zone defect symptoms	p. 72
Posterior zone defect symptoms	p. 72
Diagnosing Causes of Symptom Recurrence after Surgery	p. 75
3.3.5 An Anatomical Basis For ICS Definitions and Descriptions	p. 76
The Role of the Peripheral Neurological Control Mechanism in the 'Unstable Open' State	p. 77
Motor Urgency (Anterior, Middle & Posterior Zones)	p. 78
Nocturia - Posterior Defect	p. 78
Sensory Urgency (Posterior, Middle, Anterior Zone Defects)	p. 78
Unconscious Incontinence, Continuous Leakage (Anterior, Posterior Zone Defects)	p. 79
Detrusor Instability (Posterior, Anterior, Middle Zone Defects)	p. 79
Unstable Urethra (Posterior, Anterior, Middle Zone Damage)	p. 79
Inability to Micturate with Neurological Damage	p. 80
Change of Compliance (posterior, anterior, middle zone defects)	p. 80
Bladder Sensation (Posterior, Anterior, Middle Zone Defects)	p. 80
Bladder Capacity	p. 80
Urethral Function During Storage (Anterior, Posterior Zone Defects)	p. 80
Genuine Stress Incontinence (Anterior, Posterior Zone Defects)	p. 81
Cough Activated Detrusor Instability	p. 81
Reflex Incontinence	p. 81
Detrusor Acontractility, Underactivity, Overflow Incontinence, Post-Micturition Dribble (Posterior, Middle Zone Defects)	p. 82
Detrusor/Bladder Neck dyssynergia (Anterior, Posterior Zone Defects)	p. 82
3.4 Summary Chapter 3	p. 82
Chapter 4 Reconstructive Pelvic Floor Surgery According to the Integral Theory	p. 83
4.1 Introduction	p. 83
4.2 The Integral Theory Approach to Reconstructive Pelvic Floor Surgery	p. 83
4.2.1 The Conceptual Bases of Minimally Invasive Pelvic Floor Surgery	p. 83
The Indications: Major Prolapse, or Major Symptoms with Minor Prolapse	p. 84
The Tissues: Conservation and Reinforcement of Tissue	p. 85
The Structure: The Synergistic Interaction of Connective Tissue Components	p. 85
The Methods: Avoidance of Post-Operative Pain and Urinary Retention	p. 85
The Tools: Reinforcement of Damaged Collagenous Tissues	p. 86
A Tissue Fixation System	p. 88
A Clarification: 'Tension-free' Tapes are not 'without Tension'	p. 89
4.2.2 The Surgical Principles of the Integral Theory	p. 90
Introduction	p. 90
Conservation and Reinforcement of Tissue: Implications for Surgery	p. 91
Adapting Surgical Technique for Wound Healing, Tissue Weakness and Scarring	p. 91
Patient Care Issues Specific to Day-Care Pelvic Floor Surgery	p. 93
4.2.3 Surgical Practice According to the Integral Theory	p. 95
Correction of Connective Tissue Damage	p. 95
Repair of Damaged Ligaments through Creation of Artificial Neoligaments	p. 96
Repair of Damaged Fascia	p. 102
4.3 Application of the Integral Theory Surgical System according to Zone of Damage	p. 110
4.3.1 Surgery of the Anterior Zone	p. 110
The Structures of the Anterior Zone	p. 110
The Methods: Strengthening a Weakened Pubourethral Ligament with a Tape	p. 112
Potential Intra-Operative Complications of Mid-urethral 'Tension-Free' Tape Slings	p. 119
Testing for Continence at the End of Midurethral Tape Operations	p. 120
4.3.2 Surgery of the Middle Zone	p. 120
The Structures of the Middle Zone	p. 120
Sites of damaged fascia	p. 122
The Indications for Surgery in the Middle Zone	p. 125
The Methods - Surgical Repair of the Middle Zone	p. 125
4.3.3 Surgery of the Posterior Zone	p. 142
The Structures of the Posterior Zone	p. 142
Indications for Posterior Zone Surgery: Damage to the Uterosacral Ligaments	p. 148
The Methods: Surgical Repair of the Posterior Zone	p. 148
Repair of Rectovaginal Fascia (level 2) and Perineal Body (PB) (level 3)	p. 155
Potential Complications of Posterior Zone Repair	p. 159
4.4 Post Operative Monitoring: Strategies For Managing Recurrent Or New Symptoms	p. 160
The Origins of Subclinical Damage - How One Zone May Decompensate After Repair of Another Zone	p. 160
The Dynamics of Symptom Formation	p. 161
Managing Persisting Symptoms - An Anatomical Approach	p. 162
Post-operative Middle Zone Symptoms	p. 166
Post-operative Posterior Zone Symptoms	p. 166
Future Directions for the Objective Diagnosis of Zone Of Connective Tissue Damage	p. 166
4.5 Summary Chapter 4	p. 167
Chapter 5 Pelvic Floor Rehabilitation	p. 168
5.1 Introduction	p. 168
5.2 The Integral Theory System for Pelvic Floor Rehabilitation	p. 169
5.2.1 Indications	p. 169
5.2.2 Design	p. 170
First Visit	p. 170
Second Visit	p. 170
Third Visit	p. 170
Maintenance PFR	p. 171
Comments	p. 171
5.2.3 Conclusions	p. 172
5.3 Summary Chapter 5	p. 172
Chapter 6 Mapping the Dynamics of Connective Tissue Dysfunction	p. 173
6.1 Mapping Function and Dysfunction of the Pelvic Floor	p. 173
6.1.1 Urodynamics - An Anatomical Perspective	p. 174
The Basis of Urodynamics: Urethral Resistance	p. 174
The Anatomical Basis of Urodynamic Measurement	p. 175
Urethral Resistance and the Pressure-Flow Relationship	p. 176
The Dynamics of Urethral Pressure Changes	p. 177
Urethral Pressure	p. 178
The Urodynamics of Micturition	p. 180
Urodynamic Bladder Instability - Premature Activation of the Micturition Reflex	p. 181
Voluntary Control of the Micturition Reflex	p. 182
Normal Micturition and 'After Contraction'- A Sign of Normal Tissue Elasticity	p. 184
'Outflow Obstruction'	p. 185
Limitations of Existing Tests: The Need for a Finite Element Model for urodynamics	p. 185
6.1.2 The Chaos Theory Framework - Its Impact on the Understanding of Bladder Control and Urodynamic Charting	p. 186
Fractals	p. 186
Extreme Sensitivity to Initial Conditions (The 'Butterfly Effect')	p. 186
6.1.2 A Non-Linear Perspective of the Neurological Control of the Micturition Reflex	p. 188
Normal Function	p. 188
Dysfunction	p. 189
Bladder Instability - A Struggle between the Opening and Closure Reflexes	p. 189
Mathematical Testing of Feedback Control of the Micturition Reflex	p. 191
Example of Iterations of a Simple Feedback Equation	p. 192
6.1.3 Transperineal Ultrasound	p. 193
Ultrasound Assessment of the Anterior Zone	p. 194
Ultrasound Assessment of the Middle Zone	p. 194
Ultrasound Assessment of the Posterior Zone	p. 196
6.1.4 The Role of X-rays in the Diagnosis of Ligamentous and Connective Tissue Defects	p. 197
Anterior Zone X-rays	p. 197
Middle and Posterior Zone X-rays	p. 198
Abnormal Middle and Posterior Zone Anatomy X-rays	p. 199
6.2.4 Dynamic Mapping with 'Simulated Operations': A Clinical Example	p. 199
Background to the Clinical Example	p. 199
The Intervention - 'Simulated Operation'	p. 200
The Post-Intervention Results - Anchoring One Structure at a Time	p. 201
Post intervention Results - Two Structures Anchored Simultaneously	p. 201
Comment	p. 202
Conclusion	p. 205
6.3 Summary Chapter 6	p. 205
Chapter 7 Current and Emerging Research Issues	p. 206
7.1 Introduction	p. 206
7.2 Improvements in the Diagnostic Decision Path	p. 208
7.3 The Integral Theory Diagnosis Support System (ITDS)	p. 209
7.4 Possible Clinical Associations	p. 209
7.4.1 Vulvar Vestibulitis (Vulvodynia)	p. 209
7.4.2 Interstitial Cystitis	p. 210
7.4.3 Unresolved Nocturnal Enuresis and Daytime Incontinence	p. 210
7.4.3 Vesico-Ureteric Reflux	p. 211
7.5 Faecal Incontinence	p. 211
The Nerve-Damage and Connective Tissue Hypotheses for Causation of Faecal Incontinence in Context	p. 212
Study No. 1 Observational Videomyogram Data During Anorectal Closure and Defaecation	p. 213
Study No. 2 Prevention of Cough Stress FI with Midurethral Anchoring (A Case Report)	p. 217
Study No. 3 The Role of the Levator Plate in Anorectal Closure	p. 217
Study No. 4 The Role of the Internal Anal Sphincter in the Causation of Faecal Incontinence	p. 218
Study No. 5 Paradoxical Contraction of the Puborectalis Muscle	p. 219
Study No. 6 Pelvic Ligament Reconstruction and Cure of Faecal Incontinence without Changes in Anal Pressure or Pudendal Nerve Conduction Times	p. 220
Chapter 8 Conclusion	p. 222
Appendix 1 Patient Questionnaires and Other Diagnostic Resource Tools	p. 224
Patient Questionnaire	p. 225
Quality of life grading	p. 227
Explanatory Code for Physicians - Significance of '50% filter' (column 3)	p. 228
Explanatory Notes for the Numbers Preceding the Questionnaire Responses	p. 228
Comprehensive 24 Hour Urinary Diary*	p. 229
'Objective' Tests	p. 230
Pad tests	p. 230
Pad Test Methodology Explanatory Notes	p. 230
Post-Treatment Questionnaire	p. 231
Example of a completed Diagnostic Summary Sheet	p. 234
Example of a completed Clinical Examination Sheet	p. 235
Appendix 2 References and Further Reading	p. 236
Chapter 2 p. 237
Chapter 3 p. 239
Chapter 4 p. 241
Chapter 5 p. 244
Chapter 6 p. 245
Chapter 7 p. 247
Index	p. 249

Available:*

On Order

Summary

Summary

Author Notes

Table of Contents