Update of the Integral Theory and System for Management of Pelvic Floor Dysfunction in Females

Abstract

ContextThe 1990 integral theory (IT) stated that urinary stress and urge symptoms mainly arise (for different reasons) from lax suspensory ligaments, a consequence of altered collagen/elastin. The first surgical application of IT was repair of the pubourethral ligament (PUL), now known as tension-free vaginal tape repair. ObjectiveTo update the 1990 IT to the present day (2016). Evidence acquisitionPublished data in peer-reviewed journals concerning IT evolution were evaluated. Evidence synthesisIn its present form (2016), IT states that pelvic organ prolapse and symptoms of chronic pelvic pain and bladder and bowel dysfunction are mainly caused by laxity in five main suspensory ligaments. The IT explains cure for bladder and bowel dysfunction via the dual function of the ligaments: organ suspension and insertion points for three oppositely acting muscle forces. Lax insertion points weaken muscle forces so they cannot adequately close the urethral or anal tubes (incontinence) or evacuate them (constipation, bladder emptying), or tension the bladder and rectum sufficiently to prevent inappropriate activation of the micturition and defecation reflexes by peripheral stretch receptors (urge incontinence, tenesmus). Up to 80% cure/improvements for the above conditions have been achieved by repair of one or more damaged ligaments via precisely positioned tissue fixation system tapes: “Repair the structure (ligaments) and you will restore the function”. Exactly the same operations are performed for patients with major symptoms and minimal prolapse and major prolapse with no symptoms. ConclusionsThis method can reduce costs, improve quality of life for older women, and potentially reduce admissions to nursing homes. Patient summaryThis paper introduces a new way of thinking. Many bladder and bowel symptoms not considered curable via existing methods may be caused by loose pelvic ligaments, and thus are potentially curable by reinforcing the ligaments. These symptoms include an inability to hold on to the bladder (urge incontinence), going frequently to pass urine during the day (frequency), getting up at night to pass urine (nocturia), involuntary soiling from the bowel, and chronic pelvic pain. These symptoms are major indications for nursing home admission. In this paper we give examples of cure of these conditions in a group of 70-yr-old Japanese women whose ligaments were strengthened using a tissue fixation system (TFS) in a very minimal way. The TFS involves insertion of a thin (7mm wide) tape through the ligaments that support the uterus. The tape creates new collagen to strengthen damaged ligaments. The new ligaments act as efficient anchoring points for muscles that open and close the urethra and anus, so these can now function more efficiently. A minimum cure rate of 72% was achieved for all the above symptoms. The method is different from large mesh insertions. Only a thin tape is used to repair damaged ligaments. This method can reduce costs, improve quality of life for older women, and potentially reduce admissions to nursing homes.