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:VWDWHVWKDWSURODSVHDQGSHOYLFRRUV\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]RQHFODVVLFDWLRQDQWHULRUPLGGOHDQGSRVWHULRU
Dysfunction: 'DPDJHGOLJDPHQWVZHDNHQWKHIRUFHRIPXVFOHFRQWUDFWLRQFDXVLQJSURODSVHDQGDEQRUPDOEODGGHUDQGERZHOV\PSWRPV
Diagnosis: $SLFWRULDOGLDJQRVWLFDOJRULWKPUHODWHVVSHFLFV\PSWRPVWRGDPDJHGOLJDPHQWVLQHDFK]RQH
Treatment:,QPLOGFDVHVQHZSHOYLFRRUPXVFOHH[HUFLVHVEDVHGRQDVTXDWWLQJSULQFLSOHVWUHQJWKHQWKHQDWXUDOFORVXUHPXVFOHVDQGWKHLU
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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;
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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
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mainly arise, for different reasons, from laxity in the vagina
or its supporting ligaments, a result of altered connective
tissue.1-5%LUWKUHODWHGOD[LW\JFRPSRXQGHGE\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
TreatmentLQPLOGFDVHVQHZSHOYLFRRUPXVFOHH[HUFLVHV vagina. This may cause various degrees of looseness, prolapse of the
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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 FRQWUDFWLRQ WR FDXVH SUREOHPV ZLWK FORVXUH LQFRQWLQHQFH

Bladder, bowel and uterus

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uterus with the woman in a sitting position. The organs
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the foetus, and the rectum faeces. Each organ is connected
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ORQJYDJLQDZKLFKLVFPORQJDQGWKHDQXVDERXW
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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
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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 musclesGDUNUHGJKDYHDGXDOIXQFWLRQ
$OLJDPHQWLVOLNHDWKLFNFRUGLQDVXVSHQVLRQEULGJHJ organ support, and opening and opening and closure of
,QIDFWWKHYDJLQDLVVXVSHQGHGH[DFWO\OLNHDVXVSHQVLRQ urethra and anorectum. They extend from the coccyx to the
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7KH RUJDQV J  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 PHFKDQLVPJ.7&8, 9-17
YDJLQDVXSSRUWVWKHEODGGHUVLWXDWHGDERYHLWDQGWKHUHFWXP 3XW VLPSOLVWLFDOO\ ZKHQ WKH PXVFOHV SXOO EDFNZDUGV
VLWXDWHG EHORZ LW VR DQ\WKLQJ ZKLFK GDPDJHV WKH YDJLQDO EOXHDUURZVWKHXUHWKUDDQGDQXVDUHSXOOHGRSHQYDVWO\
VWUXFWXUHFDQDOVRDIIHFWWKHEODGGHUDQGUHFWXP GHFUHDVLQJLQWUDFDYLW\UHVLVWDQFHWRWKHth power, so that the
Separating the lower end of the vagina from the rectum ZRPDQFDQTXLFNO\DQGHDVLO\HYDFXDWHKHUXULQHDQGIDHFHV
LV D VROLG PDVV RI WLVVXH WKH SHULQHDO ERG\ 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
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Some doctors routinely recommend removal of the uterus How damaged ligaments may cause incontinence or
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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
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especially evident after the menopause. Hysterectomy
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ligaments, weakening them further. All these factors

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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

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muscle forces (arrows).

So if the suspensory ligaments are loose, the muscle

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this, a patient may feel a leakage of urine, wind or faeces,
incontinence. Another related condition is failure to close
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ligaments do not allow the muscles to open these same WKH VLWXDWLRQ WKH EUDLQ VHQGV GLUHFWLRQV HLWKHU IRU FORVXUH & RU
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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 VSHFLF 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
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Most of this co-ordination occurs in automatic mode. The
patient is not aware of what is happening. Sometimes, a
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Pushing down assist emptying the urine and faeces. During
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muscles upwards. This action grips the penis, and increases
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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
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Fig. 8 - An external striated muscle opening and closure mechanism. contract or relax according to whether the urethra and anus
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IURPWKHVHPXVFOHEUHVORRSDURXQGWKHXUHWKUDDQGDQRUHFWXPWR IRU VWUHQJWK HODVWLQ IRU H[LELOLW\ VPRRWK PXVFOH IRU
activate closure and opening. contractility, and nerves to co-ordinate all these functions.

39
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vaginal tissues to varying degrees as it descends through the vagina
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ATFP=arcus tendineus fascia pelvis; USL=uterosacral ligament.
Not shown are cardinal ligament (Middle Zone) and Perineal Body
(Posterior zone).

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Fig. 11 - This diagram illustrates the cystocoele 2, rectocoele

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suspensory ligaments and their associated tissues.

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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. /DEHOOLQJLVIURQWDQGEDFNLQVWHDGRIDQWHULRUDQGSRVWHULRU


 The integral theory system

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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
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PXVFOHVSXOODJDLQVWWKHOLJDPHQWVZKLFKVXSSRUWWKHEULGJH cloth. The surgeon repairs one area, only to see it give way
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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.
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the lower end of the vagina from the rectum is the perineal
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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.
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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
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vaginal delivery patients. Loose ligaments may occur in
symptoms, there is no need for treatment. However, a patient
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with loose ligaments, or they may have a congenital defect in PD\ KDYH VHYHUH V\PSWRPV ZKLFK PD\ UHTXLUH WUHDWPHQW
WKHLUFROODJHQ$OOWKHVHFRQGLWLRQVDUHSRWHQWLDOO\FXUDEOHE\ even though the prolapse is minor.
FUHDWLRQRIDUWLFLDOOLJDPHQWVDVZLOOEHH[SODLQHGODWHU When are these symptoms and prolapses problematical?
The effect of age and menopause If a patient answers yes to one of the following, she has
Both collagen and elastin deteriorate markedly after the DSUREOHP
menopause, and this explains the vast increase in prolapse 1. You lose urine during exertion or coughing.
and incontinence which occurs after this event. A partly <RXFDQWKROGRQDQG\RXZHW\RXUVHOI
GDPDJHG OLJDPHQW ZKLFK LV RQO\ MXVW IXQFWLRQLQJ EHIRUH <RXFDQWHPSW\\RXUEODGGHUSURSHUO\
the menopause, may lose enough collagen after it, to <RXKDYHERZHOVRLOLQJ
give way. This looseness may result in organ prolapse, 5. You feel a lump in your vagina (prolapse)
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replacement therapy (HRT) helps to slow down the
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prevention of osteoporosis, hip fractures, thickening of DQGSDWLHQWVSHUFHSWLRQVYDU\$VLPSOHUXOHLVWRVHHNKHOS
the vaginal wall in sexually active patients, even perhaps LI LW LV LQWHUIHULQJ ZLWK WKH SDWLHQWV TXDOLW\ RI OLIH ,I WKH
prevention of heart disease. Vaginally inserted oestrogen SUREOHPLVPLOGDQGQRWERWKHUVRPHQRDFWLRQLVUHTXLUHG
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advantageous for every post-menopausal woman, even SHUVSHFWLYHDWRDVVHVVZKLFKOLJDPHQWVKDYHEHHQGDPDJHG
those of the most mature age. DQGEWRDVVHVVWKHVHULRXVQHVVRIWKHSUREOHP$QDFFXUDWH
Site of damage and its consequences assessment is paramount. This will vary according to the
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Algorithm, examination to assess ligamentous damage in
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loosen the ligaments (thick grey lines) in the 3 zones of the the 3 zones, and simulated operations(e.g. midurethral
YDJLQD7KHVHDUH$QWHULRU=RQHPHDWXVWREODGGHUQHFN anchoring during coughing in patients with urinary stress
0LGGOH =RQH EODGGHU QHFN WR FHUYL[ DQG WKH 3RVWHULRU incontinence or urge symptoms).
=RQH FHUYL[ WR SHULQHDO ERG\7KH QXPEHUV  LQGLFDWH Symptoms what they mean
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1. Stress incontinence $V\PSWRPLVDZDUQLQJEHOOIURPWKHEUDLQWKDWVRPHWKLQJ
2. Cystocoele LVZURQJZLWKVRPHSDUWRIWKHERG\$VUHJDUGVWKHSHOYLF
3. Prolapse of the uterus RRUPDQ\EODGGHUDQGERZHOV\PSWRPVDUHVHFRQGDU\WR
5HFWRFRHOH damage in one or more related ligaments, not from the organ
All may occur to varying degrees in the same patient. LWVHOI7KHFKDOOHQJHLVWRQGZKLFKOLJDPHQWVDUHFDXVLQJ
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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$OJRULWKPZKLFKIROORZVLVDVLPSOLHG ZLQGORVVOLTXLGVRLOLQJVROLGIDHFDOVRLOLQJ7KHUHDUHWZR
YHUVLRQRIWKDWSXEOLVKHGLQWKHWH[WERRN7KH)HPDOH3HOYLF PDLQFDWHJRULHVSDWLHQWVZLWKIDHFDOLQFRQWLQHQFHFDXVHGE\
Floor 2nd(GLWLRQ6SULQJHU+HLGHOEHUJ7RXVHWKLV DQ DQDO VSKLQFWHU WRUQ DW FKLOGELUWK DQG DQRWKHU ZKHUH QR
GLDJUDPDWLFNLVSODFHGLQHYHU\FROXPQZKLFKGHVFULEHVD REYLRXV FDXVH FDQ EH IRXQG7KH DQDO VSKLQFWHU FRQVWULFWV
SDWLHQWVV\PSWRPVDQGWKHGLDJUDPZLOOLQGLFDWHWKH]RQH the lower part of the anus. It is what a patient feels when
of damage, anterior, middle, or posterior ligaments.
VKHFRQWUDFWVKHUPXVFOHVWRGHOD\ERZHOHPSW\LQJ:KHUH
How to use the Diagnostic Algorithm. Simply tick every
FROXPQZKLFKGHVFULEHVDV\PSWRP2QHQHHGVWRWLFNDOO QR REYLRXV FDXVH FDQ EH IRXQG LW LV FDOOHG LGLRSDWKLF
the relevant columns for symptoms such as urgency and incontinence. It is idiopathic incontinence which is
emptying, which may occur in more than one column. In SRWHQWLDOO\FXUDEOHE\UHFRQVWUXFWLQJWKHDQWHULRURUSRVWHULRU
such cases, other associated symptoms which are more ligaments.
VSHFLFZLOOKHOSWRJXLGHWKHGLDJQRVLV Characteristics of lumps (prolapse) in the vagina
Definitions for Symptoms Initially, these only appear during straining. The three
Stress incontinence Urine loss on effort, such as coughing, PDLQFDXVHVRIVXFKOXPSVDUHIURPWKHEODGGHUF\VWRFRHOH
exercise. XWHUXVDQGERZHOUHFWRFRHOHJ7KHVH
Abnormal emptying ,QDELOLW\ WR HPSW\ WKH EODGGHU RU FDQRQO\EHDFFXUDWHO\GLDJQRVHGE\DYDJLQDOH[DPLQDWLRQ
DEQRUPDORZ DV QRW DOO OXPSV DUH DFFRPSDQLHG E\ V\PSWRPV :KHUH
Urgency$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'LDJUDPJ
ERZHO
Obstructed defaecation or constipation 'LIFXOW\ 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 UVW FRQFHLYHG DQRWKHU DSSURDFK WR SHOYLF
interstitial cystitis are often associated with pelvic pain. RRU H[HUFLVHV:H NQHZ IURP RXU XOWUDVRXQG VWXGLHV WKDW
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
 /RZDEGRPLQDOGUDJJLQJSDLQXVXDOO\XQLODWHUDORIWHQ SUREOHPV
right-sided :HWKHUHIRUHDGGHGVTXDWWLQJH[HUFLVHVWRWKHWUDGLWLRQDO
 /RZVDFUDOSDLQSDLQQHDUWKHWDLOERQH Kegel programme. Our target group of patients were those
Pain on deep penetration with intercourse ZLWKV\PSWRPVZKLFKZHUHERWKHUVRPHEXWQRWVXIFLHQWO\
 /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 QHHGWRUHPHPEHUWRFRQWUDFWWKHLUSHOYLFRRULQDGYDQFH
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 RRU H[HUFLVHV LV WKDW
K\SHUVHQVLWLYLW\ YXOYRG\QLD DQG SHUKDSV HYHQ VRPH W\SHV RI
EODGGHU SDLQ LQWHUVWLWLDO F\VWLWLV PD\ EH SDUW RI WKH SRVWHULRU ]RQH
ZRPHQ ZLWK \RXQJ IDPLOLHV DQG MREV VLPSO\ GR QRW KDYH
V\PSWRPFRPSOH[LQJXUHQRFWXULDXUJHQF\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 :HNQHZWKDWWKHVORZWZLWFKPXVFOHEUHVZHUHWKHSULPH
$ EXUQLQJ SDLQ RYHU WKH HQWUDQFH RI WKH YDJLQD DQG FRQWULEXWRUVWRFRQWLQHQFH6LWWLQJRQDWEDOOLQVWHDGRI
anus, with extreme sensitive to touch. This condition is D FKDLU LV D YHU\ VLPSOH DQG HIIHFWLYH H[HUFLVH WHFKQLTXH
RIWHQ DVVRFLDWHG ZLWK GUDJJLQJ ORZHU DEGRPLQDO SDLQ DQG DVLWUHTXLUHVDEDODQFHGXSULJKWSRVLWLRQZLWKFRRUGLQDWHG
VRPHWLPHVSDLQIXOEODGGHUFRQGLWLRQV
FRQWUDFWLRQ RI DEGRPLQDO EDFN DQG SHOYLF RRU PXVFOHV
Characteristics of bladder emptying difficulty 8QOLNHDOOWUDGLWLRQDO.HJHOH[HUFLVHVZKLFKUHTXLUHDWWHQWLRQ
Typical symptoms are a slow stream, starting and DQGWLPHVLWWLQJRQDWEDOOUHTXLUHVQRH[WUDWLPHWREHVHW
VWRSSLQJGULEEOLQJDIWHUPLFWXULWLRQKDVEHHQFRPSOHWHGD DVLGHGXULQJWKHGD\:HKDYHIRXQGWKDWWKHWEDOOPHWKRG
IHHOLQJWKDWWKHEODGGHUKDVQRWHPSWLHG2IWHQVXFKSDWLHQWV DSSOLHGDORQHZDVZHOODFFHSWHGDQGUHVXOWVVHHPHGHTXDOO\
have chronic urinary infections. effective in the short-term.


 The integral theory system

)LJ6LWWLQJRQDUXEEHUWEDOOLQVWHDGRIDFKDLUVWUHQJWKHQ )LJ$QH[DPSOHRIQH[WJHQHUDWLRQQRQVWUHWFKPRQRODPHQW
all the pelvic slow-twitch muscles, and their ligamentous WDSH6XFKWDSHVDUHSXUSRVHNQLWWHGQRWFXWIURPVKHHWVZLWKQHU
attachments. EULOVDQGOHVVZHLJKWSHUXQLWDUHD7KH\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)6JZDVWKHUVWPLQLVOLQJ,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 WKH797 SURODSVH 6LQFH  WKHUH KDV EHHQ D SURIXVLRQ RI RWKHU
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
WDSH WHFKQLTXH KDV UHYROXWLRQL]HG WKH WUHDWPHQW RI VWUHVV QRW RQO\ SURODSVH EXW DOVR PDQ\ V\PSWRPV IURP WKH
incontinence (SI) and prolapse surgery. The operations are 3LFWRULDO'LDJQRVWLF$OJRULWKPJ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 PRQRODPHQWWDSHJVRLWFDXVHVOHVVWLVVXHLUULWDWLRQ
KDYH IHZ SUREOHPV SDVVLQJ XULQH DIWHU WKH RSHUDWLRQ 7KH ,WXVHVDELRHQJLQHHULQJSULQFLSOHVLPLODUWRWKDWRIDEXWWUHVVHG
cure rate is high in the longer term. Later variations of these FDWKHGUDOFHLOLQJJIRUF\VWRFRHOHDQGUHFWRFRHOHUHSDLU
RSHUDWLRQV LQFOXGH WKH WUDQVREWXUDWRU 727 DSSURDFK IRU ,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,
VLJQLFDQWSUREOHPZLWKDOOWDSHPHVKLPSODQWRSHUDWLRQV 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 PLQLVOLQJ KDV EHHQ percentage of patients, as only very small segments of tape
introduced to address incontinence and organ prolapse.22 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
VXIFLHQWO\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\ J  DQG WR DSSUR[LPDWH
laterally displaced tissues.

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

ANTERIOR ZONE DAMAGE

)LJ7)6DSSOLFDWRU$S$LVWKHVRIWWLVVXHDQFKRUZKLFK In this section, we give a series of typical case reports from
VLWVRQWKHVDGGOH67KHWDSH7LVDQH[WJHQHUDWLRQQRQVWUHWFK
PDFURSRURXVPRQRODPHQWSRO\SURS\OHQHWDSH7KHSRO\SURS\OHQH SDWLHQWV ZKR FDPH WR WKH &OLQLF ZLWK SDUWLFXODU SUREOHPV
WDSHSDVVHVWKURXJKWKHXQLGLUHFWLRQDOWUDSGRRUDWWKHEDVHRIWKH 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

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VWUXFWXUH 7KH SLOODUV ERQH SURYLGH WKH DQFKRULQJ SRLQW IRU WKH
EHDPV WDSHV ZKLFK LQ WXUQ SURYLGH VXIFLHQW 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
WKH XULQH MXVW UDQ RXW7KH 'LDJQRVWLF 'LDJUDP FRQUPHG
WKDWWKHGDPDJHZDVLQWKHIURQWOLJDPHQWFROXPQJ
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
DUULYHG DW WKH WRLOHW 6KH KDG EHHQ UHIXVHG VXUJHU\ IRU KHU 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 J 
DQ XQVWDEOH EODGGHU :LWK UHIHUHQFH WR WKH 'LDJQRVWLF 7KHSDWLHQWZHQWKRPHWKHQH[WGD\HQWLUHO\GU\
'LDJUDPJLWZDVHYLGHQWWKDWVKHKDGVSHFLFPLGGOH
RUSRVWHULRU]RQHV\PSWRPVLQGLFDWLQJWKDWKHUSXERXUHWKUDO
OLJDPHQW38/ZDVSUREDEO\FDXVLQJERWKSUREOHPVVWUHVV Bedwetting from childhood caused by a lax front ligament
DQGXUJH7KLVZDVFRQUPHGZLWKDVLPXODWHGRSHUDWLRQ 0LVV 0 ZDV  \HDUV ROG SDUD  6KH KDG ZHW KHU EHG
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
XWHURVDFUDO86/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
ORRVHDQWHULRUSXERXUHWKUDOOLJDPHQW$WWKHZHHNSRVW
operative visit, all symptoms were cured, and there was a
UHPDUNDEOH WUDQVIRUPDWLRQ LQ WKH SDWLHQWV 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\
OHDNZLQGXLGRUVROLGIDHFHV

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\DQGGLIFXOW\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'9VTXHVWLRQQDLUHWKDWWKHQRFWXULD
DQGSHOYLFSDLQVKHKDGPRQWKVDJRUHPDLQHGFXUHGJ
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$7)3DQGFDUGLQDOOLJDPHQWRSHUDWLRQJ
5HOLHIRIXUJHQF\DQGLPSURYHGEODGGHUHPSW\LQJZHUH
reported immediately after the surgery.22
Comment Mrs DV is a good example of what
happens in patients with damaged ligaments. In up
to 30% of cases, repairing one part of the vagina can
EHIROORZHGE\DQRWKHUOXPSRUV\PSWRPDSSHDULQJ
weeks, months or even years later.
)LJ$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]RQHVSHFLFV\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
FRQGLWLRQP\EODGGHUHPSWLHVXQFRQWUROODEO\LPPHGLDWHO\
P\ IRRW WRXFKHV WKH RRU 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
RIDSURODSVHRIWKHXWHUXVDQGLWVVSHFLFV\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
,QWKHDXWKRUVH[SHULHQFHF\VWRFRHOHDQGSURODSVHRIWKH muscles and ligaments needed to close the urethra, hence
XWHUXVDUHPDMRUFRUUHFWDEOHFDXVHVRIDEQRUPDOHPSW\LQJ the name, tethered vagina. A skin graft placed in this
DQGFKURQLFEODGGHULQIHFWLRQV5 DUHD J  UHVWRUHG HODVWLFLW\ DQG YDVWO\ LPSURYHG KHU
Other causes of recurrent cystitis incontinence.
$Q\WKLQJ ZKLFK LUULWDWHV WKH LQVLGH RI WKH EODGGHU VXFK 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 DQG LV FDXVHG E\ H[FHVVLYH VFDUULQJ IURP SUHYLRXV
recurrent cystitis. The mesh can cause irritation per se, or
EHFRPHFDOFLHGLQWRDVWRQH,QVHUWLQJDF\VWRVFRSHLQWRWKH
EODGGHULVWKHEHVWPHWKRGIRUGLDJQRVLQJVXFKDSUREOHP
Other causes of abnormal emptying?
$Q\WKLQJ ZKLFK LQWHUUXSWV WKH PHVVDJHV IURP WKH EUDLQ
PD\FDXVHWKLVSUREOHP2QHFDXVHZKLFKLVRIWHQVWDWHGLV
GLDEHWHV+RZHYHULQWKHDXWKRUVH[SHULHQFHPDQ\SDWLHQWV
ODEHOOHG DV GLDEHWLF QHXURSDWK\ 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 $OJRULWKP 'LDJUDP J 
DQGZHUHDEOHWREHFXUHG$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

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ZHWWKHWRLOHWVHDW,KDYHSUREOHPVZLWKEODGGHULQIHFWLRQV
Mrs LM had symptoms typical of looseness in the
SRVWHULRU OLJDPHQWV J  :KHQ ZH H[DPLQHG KHU ZH
QRWHG WKDW VKH KDG VLJQLFDQW 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
PHPEUDQHWRSUHYHQWVHQVLWLYHQHUYHHQGLQJVIURPULQJRII
DW D ORZ EODGGHU YROXPH  ,W LV D YHU\ PLQLPDO WHFKQLTXH
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 VLJQLFDQWO\ 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
WKHWHQVLRQLQWKHOLJDPHQWVZKLWHDUURZV$GHTXDWHWLVVXH
WHQVLRQLVUHTXLUHGWRVXSSRUWWKHQHUYHVZKLFKFDXVHSDLQ
and urgency symptoms. Without restoring the tension, it is
)LJ0DUWLXVVNLQJUDIWDSSOLHGWRWKHEODGGHUQHFNDUHDRIWKH XQOLNHO\WKDWVXFKV\PSWRPVFDQEHFXUHG
YDJLQD VXEVHTXHQW WR H[WHQVLYH IUHHLQJ RI WKH XUHWKUD DQG YDJLQD 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
WKHSDLQEUHVZKLFKUXQLQVLGHWKHPDQGWRDQFKRU
surgeries. It is called the tethered vagina syndrome
EHFDXVH GHQVH VFDU WLVVXH LQ WKH YDJLQD WHWKHUV
the muscles, and prevents them from closing the
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recognized as originating from a scarred vagina. It
ZDVWKRXJKWWRRULJLQDWHIURPWKHEODGGHULWVHOIDQG
ZDVVWLOOLVE\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 VLJQLFDQW
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
,QGWKLVYHU\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\ WKH HQG RI WKH GD\  , DP DOZD\V JRLQJ WR WKH WRLOHW DW V\PSWRPVLQGLFDWHVHLWKHUDPLGGOHRUSRVWHULRUGHIHFW$EVHQFHRI
DF\VWRFRHOHRQYDJLQDOH[DPLQDWLRQFRQUPHGDSRVWHULRUGHIHFW


P.E.P. Petros

the muscle forces which stretch the vagina to VXSSRUWWKHSDLQEUHV$VWKHSHQLVWKUXVWVLQWRWKH

VXSSRUWWKHQHUYHVDQGYROXPHUHFHSWRUVDWEODGGHU posterior part of the vagina, it will cause pain if it
EDVH/RRVHWLVVXHVZLOOQRWVXSSRUWWKHSDLQQHUYHV VWUHWFKHVWKHXQVXSSRUWHGQHUYHEUHV
ZKLFKGURRSDQGUHRIIVHQGLQJVLJQDOVRISDLQWR
WKHEUDLQ/LNHDWUDPSROLQHZLWKGDPDJHGVSULQJV Severe Pelvic pain caused by uterosacral
loose ligaments will not allow the muscles to stretch ligament looseness.
WKHYDJLQD7KHEODGGHUQHUYHVDUHXQVXSSRUWHGDQG 0UV'ZDVD\HDUROGSDUD6KHDWWHQGHGZLWKVHYHUH
UHRIISUHPDWXUHO\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 face lit
FRQVWLSDWHG,JHWXSWLPHVDQLJKWWRSDVVXULQH,KDYH XSDIWHUVKHDQVZHUHGSRVLWLYHO\WRWKHIROORZLQJTXHVWLRQV
SUREOHPV HPSW\LQJ P\ EODGGHU 0\ ZRUVW SUREOHP LV DVVKHNQHZWKDWZHNQHZZKDWKHUSUREOHPZDV
WKDW , FDQW KDYH VH[ DQ\ PRUH$OPRVW HYHU\ 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?
5HIHUHQFH WR KHU 'LDJQRVWLF 'LDJUDP J  LQGLFDWHG 'R\RXKDYHSUREOHPVHPSW\LQJ\RXUEODGGHU"
WKDW PRVW RI 0UV 50V 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,
RILPSURYHPHQWXSWR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
WKHSRVWRSHUDWLYHYLVLW6PLOLQJDQGFRQGHQWVKHUHSRUWHG IRU WKH SDLQ ZKLFK IRU VR ORQJ KDV EHHQ P\ FHQWUH DQG
FXUHRIDOOKHUERZHOV\PSWRPVDQGDPDMRULPSURYHPHQW focus.
in her other symptoms. 7KHRSHUDWLRQJZDVVLPSOHDQGLWZDVSHUIRUPHG
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 LQ WKH YDJLQD EHKLQG WKH FHUYL[7ZR VXWXUHV JUHHQ OLQHV
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 7KLV FRQGLWLRQ VHYHUH SHOYLF SDLQ FDXVHG E\ ORRVH
QHYHUWKHLUERZHO,QVXFKFDVHVZHUHO\RQWKHRWKHU SRVWHULRU OLJDPHQWV LV VWLOO QRW ZHOO UHFRJQL]HG E\
typical symptoms to guide us as to which ligaments WKH PDMRULW\ RI J\QDHFRORJLVWV 7KH RSHUDWLRQ J
KDYHEHHQGDPDJHGDQGRQWKHJXLGLQJSULQFLSOHRI XQIRUWXQDWHO\KDVDVLJQLFDQWUHFRYHU\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
nerve endings.
Vulvodynia pain and burning at the entrance to the
vagina caused by posterior ligament looseness.
0UV 3 ZDV  \HDUV ROG SDUD ZLWK FKURQLF SHOYLF SDLQ
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\ DV VKH ZDV VHYHUHO\ GLVWXUEHG SV\FKRORJLFDOO\
that this was the reason for her pain, and there was nothing
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ODG\GLGLQGHHGWWKHGHVFULSWLRQRIKHU*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 UVWKLQWWKDWWKLVZRPDQPD\KDYHDSK\VLFDOFDXVHIRUKHU
posterior ligaments (arrows) without penetrating the skin of the SUREOHP GDPDJH WR KHU SRVWHULRU OLJDPHQWV 6KH ZRNH 
EXWWRFNV WLPHVSHUQLJKWWRHPSW\KHUEODGGHUQRFWXULDZRUHSDGV


 The integral theory system

DK\VWHUHFWRP\%\WKHWLPH0UV-0.ZDV\HDUVROGWKH
FKURQLFSHOYLFSDLQDQGORZDEGRPLQDODFKHKDGUHWXUQHG
6KHKDGGHYHORSHGSURODSVHRIWKHYDJLQDDQGEODGGHUZLWK
VLJQLFDQW 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  LJKW DWWHQGDQW KDG D ORQJ
KLVWRU\RILQDELOLW\WRHPSW\KHUEODGGHUDQGFKURQLFEODGGHU
LQIHFWLRQVGDWLQJEDFNWRKHUWHHQDJH\HDUV6KHFDPHWRXV
EHFDXVH WKH LQIHFWLRQV ZHUH EHFRPLQJ PRUH IUHTXHQW DQG
ZHUHDIIHFWLQJKHUDELOLW\WRZRUNRQORQJLJKWV+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). RRU 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\DQGKDGGLIFXOWLHV 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
VDLG WKDW KHU YDJLQD ZDV VR WHQGHU WKDW VKH FRXOGQW KDYH 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 ,QFUHDVHGGLIFXOW\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
[HG DQG WKDW WKHUH ZDV D VWURQJ SRVVLELOLW\ WKDW VRPH RI worse during period time. Though not helpful with
her symptoms would also improve with a sling inserted 0UV .% JRRG UHVXOWV LQ \RXQJ ZRPHQ KDYH EHHQ
into the posterior part of her vagina, a fairly minor day-care DFKLHYHGDWRXU&OLQLFE\HQFRXUDJLQJVXFKSDWLHQWV
procedure.29, 30 WRVTXDWLQVWHDGRIEHQGLQJDQGWRVLWRQDWEDOO
7KH UVW 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\LQJZDVLPSURYHG
$GLDJQRVLVWKDWDSDWLHQWVSDLQLVRISV\FKRORJLFDORULJLQ There is a prevalence of this condition in Nursing Homes.
LV QRW HQWLUHO\ XQUHDVRQDEOH $Q\ W\SH RI FKURQLF SDLQ LV 0DQ\SDWLHQWVUHTXLUHLQGZHOOLQJFDWKHWHUV
VXIFLHQWWRXQVHWWOHHYHQWKHPRVWUDWLRQDOSHUVRQDQGVXFK Mrs R was 87 years old, and weighed 90kg. She had had a
SDWLHQWV GR EHFRPH SV\FKRORJLFDOO\ GLVWXUEHG %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 FRQUPHG 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,
FDQ EH LPSURYHG LQ PDQ\ SDWLHQWV ZLWK D SRVWHULRU 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\LQJGLIFXOWLHV
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 GLIFXOW 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 VXIFLHQWO\ 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  \HDU ROG SDUD FRPSODLQHG RI D OXPS LQ
the vagina. She had a 2nd degree prolapse of the uterus,
urgency, and nocturia. She also had faecal incontinence,
FRQVWLSDWLRQ J DQG RFFDVLRQDO EOHHGLQJ IURP WKH
ERZHO 6KH KDG EHHQ LQYHVWLJDWHG IRU WKH EOHHGLQJ E\ D
VSHFLDOLVW ZKR IRXQG QR HYLGHQFH RI ERZHO FDQFHU ,Q WKH
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
KDGDILFWHGWKLVODG\)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 DMVs improvement in her
constipation and bleeding. The reason for improvement
LQ WKLV ODG\V FRQVWLSDWLRQ DQG EOHHGLQJ ZDV GLVFRYHUHG
VRPH\HDUVODWHUE\DQ$XVWULDQFROOHDJXH'U$EHQGVWHLQ31
:LWKUHIHUHQFHWRWKHGLDJUDPJLWLVHYLGHQWWKDWWKH
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,WLVGLIFXOWWRKDYHDQRUPDOERZHOPRWLRQZKHQ
WKHERZHOZDOOVDUHORRVHDQGVDJJLQJLQWRWKHFDYLW\RIWKH
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caused congestion of the veins close to the cavity similar to
what happens with a haemorrhoid. This congestion caused )LJ3RVWHULRU=RQH'HIHFW'LIFXOW\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
GDPDJHGWLVVXHWRGDPDJHGWLVVXHXQGHUVLJQLFDQW
ligaments and perineal body
tension. This method is very painful, and is prone to
0UV9&'  \HDUV SUHVHQWHG ZLWK D UHFWRFRHOH IDHFDO UHFXU7KH7)6UHSDLUFUHDWHVDQDUWLFLDOOLJDPHQWWR
LQFRQWLQHQFH DQG GLIFXOW\ ZLWK HPSW\LQJ KHU ERZHO J SHUPDQHQWO\MRLQWKHODWHUDOO\GLVSODFHGERGLHV
6KHVWDWHGHYHU\WLPH,QHHGWRRSHQP\ERZHOV,KDYH
WRSUHVVP\QJHUVLQWRWKHSRVWHULRUZDOORIP\YDJLQDVR Urinary urgency, pelvic pain and nocturia cured by Pelvic
,FDQHPSW\,QGWKHQHFHVVDU\K\JLHQHDIWHUFRPSOHWLRQ Floor Exercises
TXLWH XQSOHDVDQW ,Q 0UV 9&'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 RIVXIFLHQWO\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
SHULQHDO ERG\ ZDV UHSDLUHGLQWKHWUDGLWLRQDOZD\ZLWKRXW Clinic for a formal assessment. We advised her how to use a
D VOLQJ 7KH UHFWRFRHOH DQG ERZHO HYDFXDWLRQ GLIFXOW\ ODUJHUXEEHUWEDOODVDVXEVWLWXWHIRUDFKDLUDQGWRGHYHORS
ZHUH LQLWLDOO\ FXUHG EXW UHFXUUHG ZLWKLQ  PRQWKV DV GLG JRRGSHOYLFRRUKDELWVVXFKDVVTXDWWLQJZKHUHYHUSRVVLEOH
UHTXLUHPHQWWRDVVLVWHYDFXDWLRQE\SUHVVLQJKHUQJHUVLQWR 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\ ZHUH UHSDLUHG E\ WKH 7)6 7LVVXH )L[DWLRQ 6\VWHP ligament symptoms A vast improvement in symptoms
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major cause of fecal incontinence. Pelviperineology 2008; 27:

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into mechanisms for anorectal angle formation. Pelviperineology

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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
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Fig. 33 - Large rectocoele repair. Approximation of the perineal Biology 2001; 94: 264-269.
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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 [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 DUWLFLDO QHROLJDPHQW $FWD 2EVWHWULFLD HW *\QHFRORJLFD preliminary report on perioperative complications and safety J.
6FDQGLQDYLFD6XSSOHPHQW 2EVWHW*\QDHFRO5HV
 3HWURV3(1HZDPEXODWRU\VXUJLFDOPHWKRGVXVLQJDQDQDWRPLFDO +RFNLQJ , ([SHULPHQWDO 6WXG\ 1R  'RXEOH LQFRQWLQHQFH
FODVVLFDWLRQ RI XULQDU\ G\VIXQFWLRQ LPSURYH VWUHVV XUJH DQG XULQDU\ DQG IHFDO FXUHG E\ VXUJLFDO UHLQIRUFHPHQW RI WKH
DEQRUPDOHPSW\LQJ,QW-8URJ\QHFRORJ\ SXERXUHWKUDOOLJDPHQWV3HOYLSHULQHRORJ\
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/DQFHW E\OLJDPHQWRXVOD[LW\LQWKHSRVWHULRUIRUQL[RIWKHYDJLQD$XVW
 3HWURV3(8OPVWHQ85ROHRIWKHSHOYLFRRULQEODGGHUQHFN 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(8OPVWHQ85ROHRIWKHSHOYLFRRULQEODGGHUQHFN DK\SRWKHVLVEDVHGRQSURVSHFWLYHFDVHUHSRUWV$1=-2 *
opening and closure: II vagina. Int. J. Urogynecol. and Pelvic 
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9. Petros PE, Swash M. The Musculoelastic Theory of anorectal $1=-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$'LUHFWWHVWIRUWKHUROHRIWKHSXERXUHWKUDO 3HWURV 3( 5LFKDUGVRQ 3$ )HFDO LQFRQWLQHQFH FXUH E\ 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 5HH[ 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
3HWURV 3( 6ZDVK 0$ SURVSHFWLYH HQGRDQDO XOWUDVRXQG VWXG\ )D[
VXJJHVWVWKDWLQWHUQDODQDOVSKLQFWHUGDPDJHLVXQOLNHO\WREHD Email: kvinno@highway1.com.au

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