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
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Dysfunction: 'DPDJHGOLJDPHQWVZHDNHQWKHIRUFHRIPXVFOHFRQWUDFWLRQFDXVLQJSURODSVHDQGDEQRUPDOEODGGHUDQGERZHOV\PSWRPV
Diagnosis: $SLFWRULDOGLDJQRVWLFDOJRULWKPUHODWHVVSHFLÀFV\PSWRPVWRGDPDJHGOLJDPHQWVLQHDFK]RQH
Treatment:,QPLOGFDVHVQHZSHOYLFÁRRUPXVFOHH[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\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
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• Diagnosis- how to diagnose which damaged ligaments
are causing which prolapse and which symptoms.
• TreatmentLQPLOGFDVHVQHZSHOYLFÁRRUPXVFOHH[HUFLVHV
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closure muscles and their ligamentous insertions. With
more severe cases, polypropylene tapes applied through
“keyhole” incision using special instruments, reinforce the
damaged ligaments, restoring structure and function.
PART 1
THE DYNAMIC ANATOMY OF NORMAL FUNCTION
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severely stretching ligaments and other tissues in and outside the
vagina. This may cause various degrees of looseness, prolapse of the
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to any surgical treatment is the approximation of laterally displaced
tissues, and the strengthening of damaged suspensory ligament(s).
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to it. Muscles pull against the ligaments to close or open the
urethra. Therefore loose ligaments may weaken the muscle
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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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vagina. Urine and faeces pass through the urethra and anus.
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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.
Pelviperineology 2010; 29: 37-51 http://www.pelviperineology.org
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37
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Fig. 3 - Unsuspended ligaments have no shape, strength or
function.
or opening (evacuation of urine). Figure 3 indicates what
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no structure, no strength, and no function.
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the ligaments are attached to the vagina and/or uterus. The
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Separating the lower end of the vagina from the rectum
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The uterus is an anchoring point for the ligaments it needs to be preserved where possible
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Some doctors routinely recommend removal of the uterus
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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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ATFP=arcus tendineus fascia pelvis; USL=uterosacral ligament.
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predispose to prolapse, and development of posterior zone
symptoms.
The pelvic muscles GDUNUHG ÀJKDYHDGXDOIXQFWLRQ
organ support, and opening and opening and closure of
urethra and anorectum. They extend from the coccyx to the
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forwards to close them.
An external striated muscle opening and closure
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power. Normally all the organs, even the vagina, are kept in
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* The closure mechanism is a little more complex than that depicted
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How damaged ligaments may cause incontinence or
emptying disorders. :H VDZ IURP WKH VXVSHQVLRQ EULGJH
diagram, that the muscles pull against the ligaments.
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the arch, and the whole structure is put at risk of a downward
collapse.
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
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disorder”.
A Symphony Orchestra
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the conductor, and ensures that all the instruments work
harmoniously to produce the right music. Every instrument
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instrument will affect the performance. 7KH EUDLQ GLUHFWV
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opening (O). Like instructions from the orchestra conductor, these
directions, “C” and “O”, engage all the muscles, nerves, ligaments
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perceived as urgency, a desire to go to the toilet.
* I am grateful to Dr Alfons Gunnemann for the orchestra analogy
The brain and its nerves- a sophisticated feedback system
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exchange. Think of the nerves as telephone wires going out
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set of nerves, to inform it as to what is happening. The
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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
Fig. 8 - An external striated muscle opening and closure mechanism.
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activate closure and opening.
The structure of ligaments
A ligament is a complicated contractile structure which
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contract or relax according to whether the urethra and anus
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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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straining.
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ligaments (ATFP& cardinal) are not shown in this diagram. There
are 3 columns, one for each ligament group and the symptoms
and prolapses (lumps) associated with damage to these ligaments.
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The integral theory system
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strength. The elastin content gives them elasticity. It is the
change in collagen which is the ultimate cause of prolapse
and incontinence.
How ligaments are stretched and damaged during
pregnancy and labour
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emptying or faecal incontinence.
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softening accelerates, and the collagen rods lose 95% of their
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these collagen rods. Of course, the rods “re-glue” soon after
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position. Neither the ligaments nor the muscles can now
work properly, and this may lead to prolapse of the uterus,
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vaginal delivery patients. Loose ligaments may occur in
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with loose ligaments, or they may have a congenital defect in
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The effect of age and menopause
Both collagen and elastin deteriorate markedly after the
menopause, and this explains the vast increase in prolapse
and incontinence which occurs after this event. A partly
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the menopause, may lose enough collagen after it, to
“give way”. This looseness may result in organ prolapse,
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replacement therapy (“HRT”) helps to slow down the
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prevention of osteoporosis, hip fractures, thickening of
the vaginal wall in sexually active patients, even perhaps
prevention of heart disease. Vaginally inserted oestrogen
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advantageous for every post-menopausal woman, even
those of the most mature age.
Site of damage and its consequences
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loosen the ligaments (thick grey lines) in the 3 zones of the
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1. Stress incontinence
2. Cystocoele
3. Prolapse of the uterus
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All may occur to varying degrees in the same patient.
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lesser extent. This explains appearance of a cystocoele, for
example, months or years after apparently successful surgery
for prolapse of the uterus. Further prolapse can occur in
perhaps 30-50% of cases after a successful vaginal repair.
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cloth. The surgeon repairs one area, only to see it give way
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A cystocoele´EDOORRQVµRXWIURPDERYHÀJ7KHFDXVH
is damage to the middle ligaments (ATFP and/or cardinal
ligaments) and the anterior wall of the vagina.
A rectocoele,ÀJEDOORRQVRXWIURPEHORZ6HSDUDWLQJ
the lower end of the vagina from the rectum is the perineal
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rectocoele.
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cardinal and uterosacral ligaments.
A perspective on organ prolapse
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symptoms, there is no need for treatment. However, a patient
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even though the prolapse is minor.
When are these symptoms and prolapses problematical?
If a patient answers “yes” to one of the following, she has
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1. You lose urine during exertion or coughing.
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5. You feel a lump in your vagina (prolapse)
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How serious is the problem?
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Assessment by the clinic. The doctor has a different
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assessment is paramount. This will vary according to the
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Algorithm, examination to assess ligamentous damage in
the 3 zones, and “simulated operations”(e.g. midurethral
anchoring during coughing in patients with urinary stress
incontinence or urge symptoms).
Symptoms – what they mean
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damage in one or more related ligaments, not from the organ
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P.E.P. Petros
The Diagnostic Algorithm indicates which ligaments are
causing symptoms and prolapse
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of damage, anterior, middle, or posterior ligaments.
How to use the Diagnostic Algorithm. Simply tick every
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the relevant columns for symptoms such as urgency and
emptying, which may occur in more than one column. In
such cases, other associated symptoms which are more
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Definitions for Symptoms
• Stress incontinence Urine loss on effort, such as coughing,
exercise.
• Abnormal emptying ,QDELOLW\ WR HPSW\ WKH EODGGHU RU
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• Urgency$QXQFRQWUROODEOHGHVLUHWRSDVVXULQH
• Frequency Going more than 8 times a day to the toilet to
pass urine.
• Nocturia Getting up twice or more per night to pass urine.
• Faecal incontinence Uncontrolled soiling from the
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• Obstructed defaecation or constipation 'LIÀFXOW\ LQ
HPSW\LQJWKHERZHO
• Pelvic pain.3DLQLQWKHORZHUDEGRPHQORZHUSRVWHULRU
or during intercourse. Some types of vulvodynia and
interstitial cystitis are often associated with pelvic pain.
Symptoms occur in groups – an aid to diagnosis
For example, urgency symptoms are indicated in all 3
columns. Symptom grouping is the only way we can deduce
which column (ligament) is causing the urgency. Fortunately,
urgency almost always occurs in tandem with at least one
other symptom.
Characteristics of pain* caused by posterior
ligament looseness
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right-sided
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• Pain on deep penetration with intercourse
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• Tiredness
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down
• Pain is reproduced on pressing the cervix or the posterior
wall of the vagina if a patient has had a hysterectomy.
* There is growing evidence that some types of introital
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emptying.
Characteristics of ‘vulvodynia’
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anus, with extreme sensitive to touch. This condition is
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Characteristics of bladder emptying difficulty
Typical symptoms are a slow stream, starting and
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have chronic urinary infections.
Characteristics of faecal incontinence
Typical symptoms, in order of severity, are uncontrolled
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the lower part of the anus. It is what a patient feels when
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incontinence”. It is “idiopathic incontinence” which is
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ligaments.
Characteristics of lumps (prolapse) in the vagina
Initially, these only appear during straining. The three
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symptoms accompany the prolapse, the symptoms may
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patient has a lump plus nocturia, pelvic pain and urgency, it
is highly likely that she has weak posterior ligaments, as per
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New time efficient pelvic floor exercises
strengthen muscles and ligaments
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the traditional Kegel methods were NOT addressing the
posterior closure muscles, which stretch, rotate, and close
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exercises the very same muscles which close the urethra
during coughing. We also reasoned that strengthening a
pelvic muscle would also strengthen the ligament against
which it contracted, and we knew from the surgery, that it
was ligament weakness which was causing the incontinence
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Kegel programme. Our target group of patients were those
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however, was that those patients who were cured, did not
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They coughed, and did not leak.19-21
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time to perform them regularly. Even with our highly
motivated group, the dropout rate was 50%. Because of
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effective in the short-term.
The integral theory system
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all the pelvic slow-twitch muscles, and their ligamentous
attachments.
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less likely to surface in the wound.
Surgery based on the Integral Theory System
“Tension-free” techniques Beginning in the late 1980s
an entirely new surgical method for stress incontinence
was introduced. Polypropylene tapes were placed around
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little later, the posterior ligaments (infracoccygeal sacropexy,
“PIVS”).5 This method, now known as the “tension-free
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incontinence (SI) and prolapse surgery. The operations are
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hospital stay is reduced to 1 or 2 days, and patients generally
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cure rate is high in the longer term. Later variations of these
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SI (very successful), and the addition of mesh sheets to the
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was partial or total rejection of the tape/mesh. More recently,
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introduced to address incontinence and organ prolapse.22
Minislings- a new horizon for stress incontinence, and
repair of cystocoele, rectocoele, and prolapse of the uterus.
7KH7)6ÀJZDVWKHÀUVWPLQLVOLQJ,WZDVDSSOLHGLQODWH
2003 to a patient with stress incontinence and uterovaginal
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minislings introduced for cure of stress incontinence, for
example, TVT-Secur, Mini Arc, Ophira, and many others.
Because the TFS is a tensioned sling, it can also address
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Like other minislings, the TFS uses only small sections of
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with large mesh. As with all polypropylene implantations,
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immune mechanisms. However, this occurs only in a small
percentage of patients, as only very small segments of tape
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
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With the infracoccygeal sacropexy (“posterior IVS”),
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The TFS minisling, was designed to precisely
reconstruct and tension the 5 main structures which support
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laterally displaced tissues.
PART 3
ILLUSTRATIVE CASE HISTORIES
The following illustrative case histories are taken from the
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clinic in the world to apply the Integral Theory System.
ANTERIOR ZONE DAMAGE
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displaced ligaments and fascia towards the midline.
In this section, we give a series of typical case reports from
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looseness, in particular, stress incontinence. We also discuss
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P.E.P. Petros
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VWUXFWXUH 7KH SLOODUV ERQH SURYLGH WKH DQFKRULQJ SRLQW IRU WKH
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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
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“Mixed” stress and urge incontinence from
front ligament looseness
Mrs JC, was a 38 year para 2. She had stress incontinence,
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DUULYHG DW WKH WRLOHW 6KH KDG EHHQ UHIXVHG VXUJHU\ IRU KHU
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gently pressing an instrument upwards on one side in the
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This controlled her urine loss on coughing, and greatly
GLPLQLVKHGKHUXUJHV\PSWRPV6KHZDVFXUHGRIERWKVWUHVV
and urge with a polypropylene sling placed around the
middle of her urethra to strengthen the front ligament.
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 &/ XWHURVDFUDO 86/ DQGDOVRWKHSHULQHDOERG\ 3% Fig. 21 - Anterior Zone defect The tick indicates only front ligament
damage. A TFS polypropylene tape was inserted through a very
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Bedwetting from childhood caused by a lax front ligament
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with coughing and exercise, and with urge. Ultrasound
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IURQW OLJDPHQW SXERXUHWKUDO ZDV ORRVH +HU EODGGHU
symptoms were cured with a TFS sling which reinforced
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Fig. 22 - The “mini” or “micro” sling is inserted exclusively from
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
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and faecal incontinence. On examination, her urine loss
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operative visit, all symptoms were cured, and there was a
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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
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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
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)LJ $QWHULRU =RQH 'HIHFW 6WUHVV DQG IDHFDO LQFRQWLQHQFH
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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
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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
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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.
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DUHERWKPRVWOLNHO\FDXVHGE\GDPDJHWRWKHIURQWOLJDPHQW%HFDXVH
urge symptoms may derive from all 3 zones, all 3 spaces are ticked.
'LDJQRVLVRIDQWHULRU]RQHGHIHFWZDVPDGHE\GHGXFWLRQXVLQJWKH
SUHVHQFHRI6,DQGDEVHQFHRIRWKHU]RQHVSHFLÀFV\PSWRPV
Recurrent or chronic cystitis – its relationship to
abnormal emptying, cystocoele and prolapse of the uterus
Whilst there are many causes of cystitis, this presentation
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.
Fig. 25 - Middle Zone Defect The ticks indicated a middle or
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RIDSURODSVHRIWKHXWHUXVDQGLWVVSHFLÀFV\PSWRPVQRFWXULDDQG
SHOYLFSDLQLQGLFDWHGLWZDVDPLGGOHOLJDPHQWSUREOHP
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ligaments in the middle or posterior parts of the vagina.
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DQGFKURQLFEODGGHULQIHFWLRQV5
Other causes of recurrent cystitis
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mesh after a surgical procedure for incontinence can cause
recurrent cystitis. The mesh can cause irritation per se, or
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some years earlier. She offered the cardinal symptom of this
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morning.” She also lost urine on standing up from a chair,
RUEHQGLQJGRZQ
On examination, she did NOT lose urine during coughing,
a common feature of this condition. The large amount of urine
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RIWKLVODG\·VSUREOHP7KHUHZDVYHU\OLWWOHPRYHPHQWRI
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muscles and ligaments needed to close the urethra, hence
the name, “tethered vagina”. A skin graft placed in this
DUHD ÀJ UHVWRUHG HODVWLFLW\ DQG YDVWO\ LPSURYHG KHU
incontinence.
Comment The “tethered vagina” syndrome is still not
a well-recognized condition. It is entirely iatrogenic,
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Other causes of abnormal emptying?
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uterosacral ligaments which prevented the opening muscles
from working properly. Such patients had accompanying
symptoms such as nocturia, urgency and pelvic pain, as
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Severe wetting on getting out of bed in the morning caused
by excessive scarring from previous surgery “tethered
vagina” – a hitherto unrecognised problem
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worsening incontinence over the previous 2 years. She had
Fig. 27 - The diagram shows how a cystocoele “2”, droops
downwards in a sac, preventing it from emptying. The urine pool
gets infected over time, leading to chronic cystitis.
The integral theory system
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“tethered vagina syndrome”.
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ZHWWKHWRLOHWVHDW,KDYHSUREOHPVZLWKEODGGHULQIHFWLRQVµ
Mrs LM had symptoms typical of looseness in the
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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
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DW D ORZ EODGGHU YROXPH ,W LV D YHU\ PLQLPDO WHFKQLTXH
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only an overnight stay in hospital, and she returned to work
in 7 days. When reviewed at 9 months, she was getting up
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ORZDEGRPLQDOSDLQZDVVWLOOSUHVHQWEXWZDVEHWWHU
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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
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and urgency symptoms. Without restoring the tension, it is
XQOLNHO\WKDWVXFKV\PSWRPVFDQEHFXUHG
Comment on the causation of urgency, nocturia and
pain by damaged ligaments
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surgeries. It is called the “tethered vagina syndrome”
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the muscles, and prevents them from closing the
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recognized as originating from a scarred vagina. It
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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,
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emptying are found as accompaniments to the prolapse.
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prolapse.
Laxity in the uterosacral ligaments associated with
uterovaginal prolapse nocturia, urgency,
abnormal emptying and pelvic pain
0UV/0\HDUVROGVWDWHG´,JHWXSWLPHVDQLJKW
,ÀQGWKLVYHU\WLULQJDV,KDYHWRZRUNQH[WGD\,KDYHD
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Fig. 29 - Posterior Zone Defect Ticks in the posterior column are
typical for symptoms from damaged uterosacral ligaments. Ticks
are inserted in all column for urge and emptying. Grouping of
V\PSWRPVLQGLFDWHVHLWKHUDPLGGOHRUSRVWHULRUGHIHFW$EVHQFHRI
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P.E.P. Petros
the muscle forces which stretch the vagina to
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loose ligaments will not allow the muscles to stretch
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ÀUHRIISUHPDWXUHO\FDXVLQJXUJHDQGIUHTXHQF\
Pain during intercourse and bowel problems
caused by posterior ligament looseness.
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KDYHXUJHQF\WRHPSW\P\ERZHOEXW,DPDOVRIUHTXHQWO\
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examination, however, there was very minimal prolapse.
This was consistent with the Theory, which states that major
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sling. No predictions were made for the urge to empty her
ERZHODQGKHUFRQVWLSDWLRQ6KHZDVDGYLVHGWKHVHFRXOGEH
due to many other causes, so we were reluctant to predict
cure for these symptoms. A posterior TFS “minisling” was
inserted to repair the posterior ligaments. Mrs RM was
discharged the next day with very little pain, and she went to
ZRUNWKHIROORZLQJZHHN6KHDWWHQGHGZLWKKHUKXVEDQGIRU
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in her other symptoms.
Comment on losing faeces during intercourse
This patient was a challenge to us, as some of her
symptoms were not the typical symptoms seen in the
Diagnostic Diagram. We had encountered women
RSHQLQJWKHLUEODGGHUGXULQJLQWHUFRXUVHEHIRUHEXW
QHYHUWKHLUERZHO,QVXFKFDVHVZHUHO\RQWKHRWKHU
typical symptoms to guide us as to which ligaments
KDYHEHHQGDPDJHGDQGRQWKHJXLGLQJSULQFLSOHRI
this type of surgery, “repair the structure, and you
will repair the function”.
Comment on pain with intercourse
Earlier we discussed how a loose ligament will not
Fig 30 - The TFS posterior minisling repairs and tightens the
posterior ligaments (arrows) without penetrating the skin of the
EXWWRFNV
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posterior part of the vagina, it will cause pain if it
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Severe Pelvic pain caused by uterosacral
ligament looseness.
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SDLQLQWKHULJKWVLGHRIKHUDEGRPHQ6RPH\HDUVSUHYLRXVO\
she had previously attended a London hospital which had
developed an international reputation using psychological
tests to prove that such pain was psychological in origin.
0UV'KDGUHDGZLGHO\RQWKHVXEMHFWRISDLQ+HUIDFLDO
expression indicated a person who was guarded. Her face lit
XSDIWHUVKHDQVZHUHGSRVLWLYHO\WRWKHIROORZLQJTXHVWLRQV
DVVKHNQHZWKDWZHNQHZZKDWKHUSUREOHPZDV
“Do you have pain on deep penetration with intercourse?
“Do you get up more than twice per night to pass urine?
´'R\RXKDYHSUREOHPVHPSW\LQJ\RXUEODGGHU"
“Do you have urgency?”
Positive answers to at least some symptoms other than pain
DUHUHTXLUHGEHIRUHZHFDQSUHGLFWWKDWWKHSDLQLVFDXVHGE\
damage to the posterior ligaments. There are, after all, many
other causes of chronic pelvic pain in the 30 plus age group,
IRUH[DPSOHHQGRPHWULRVLVLQIHFWLRQLQWKH)DOORSLDQWXEHV
SUREOHPVZLWKODUJHLQWHVWLQHWRQDPHMXVWDIHZ
7KLVLVZKDWVKHVDLGRQHZHHNDIWHUKHUSDLQZDVFXUHGE\
a small operation which tightened her posterior ligaments.28
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RQP\ULJKWVLGH,WKDVQRZEHHQDZHHNVLQFHWKHRSHUDWLRQ
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focus.”
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entirely under local anaesthesia. A 3 cm incision was made
LQ WKH YDJLQD EHKLQG WKH FHUYL[7ZR VXWXUHV JUHHQ OLQHV were inserted to tighten the ligaments (white arrows).
Comment
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it approximates damaged tissue to damaged tissue.
Insertion of a polypropylene sling gave a higher
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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
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that this was the reason for her pain, and “there was nothing
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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
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SUREOHP GDPDJH WR KHU SRVWHULRU OLJDPHQWV 6KH ZRNH WLPHVSHUQLJKWWRHPSW\KHUEODGGHU QRFWXULD ZRUHSDGV
The integral theory system
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collagen, and weakening of the posterior ligaments, a longWHUPSUREOHPLQSDWLHQWVZKRKDYHKDGK\VWHUHFWRP\
Fig. 31 - Approximation of uterosacral ligaments A small 3cm
WUDQVYHUVHLQFLVLRQLQWRWKHYDJLQDMXVWEHORZWKHFHUYL[JDYHDFFHVV
for tightening her loose posterior ligaments (white arrows).
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Examination revealed a prolapse of the posterior part of her
vagina. The entrance to the vagina was hypersensitive- she
UHFRLOHGZKHQJHQWO\WHVWHGZLWKDFRWWRQEXGWKHFODVVLFDO
test for “vulvodynia” (pain at the entrance of the vagina).
:HGLGQRWFODLPWKDWZHFRXOGFXUHWKLVODG\·VSDLQDV
there are many other causes for pelvic pain. Nevertheless,
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her symptoms would also improve with a sling inserted
into the posterior part of her vagina, a fairly minor day-care
procedure.29, 30
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and calm. Her pain was gone, as was her urgency and faecal
incontinence. Her nocturia had reduced to 2 per night, and
KHUEODGGHUHPSW\LQJZDV´LPSURYHGµ
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Comment
We do not claim that all vulvodynia patients have this
causation. However, if other symptoms of posterior
OLJDPHQW ORRVHQHVV VXFK DV QRFWXULD DEQRUPDO
EODGGHUHPSW\LQJDQGXUJHQF\DUHJURXSHGZLWKWKH
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sling for repair of the posterior ligaments.
Hysterectomy for lower posterior ache and pelvic pain
caused by posterior ligament looseness.
Mrs JMK developed chronic lower posterior pain and
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her second child 50 years ago, when she was 27 years old.
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specialist gynaecologist. He told her that she needed to have
Abnormal emptying and chronic bladder infection caused
by looseness in the posterior ligaments
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KLVWRU\RILQDELOLW\WRHPSW\KHUEODGGHUDQGFKURQLFEODGGHU
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had reached a stage where she felt forced to consider leaving
her profession. She was diagnosed as having congenitally
weak posterior ligaments. She did not respond to our pelvic
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
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returned to normal emptying immediately after the surgery,
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afterwards
Comment on abnormal bladder emptying in the
younger woman Congenitally weak posterior
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as these women do not generally have a cystocoele.
,QFUHDVHGGLIÀFXOW\LQHPSW\LQJWKHEODGGHUDWSHULRG
time in such women is highly suggestive that the
cause is looseness in the posterior ligaments. Other
symptoms such as pelvic pain, urgency and nocturia
DUH IUHTXHQWO\ SUHVHQW DQG WKHVH PD\ EHFRPH
worse during period time. Though not helpful with
0UV .% JRRG UHVXOWV LQ \RXQJ ZRPHQ KDYH EHHQ
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strengthening the pelvic muscles and ligaments.
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-catheterisation caused by posterior ligament looseness.
There is a prevalence of this condition in Nursing Homes.
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Mrs R was 87 years old, and weighed 90kg. She had had a
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degree prolapse of the vagina. We inserted a posterior sling,
SHUIRUPHGDUHFWRFRHOHUHSDLUDQGSHULQHDOERG\UHSDLU6KH
passed urine immediately after the surgery. Her nocturia,
previously 5 times per night, reduced to twice per night.
Comment on how age causes ligament looseness and
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The tissues of the vagina and its supporting ligaments
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this is that many older women, especially those in
1XUVLQJ +RPHV FDQQRW HPSW\ WKHLU EODGGHU DQG
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a major cause of chronic cystitis, as they introduce
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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,
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ERZHO 6KH KDG EHHQ LQYHVWLJDWHG IRU WKH EOHHGLQJ E\ D
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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
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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
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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
EOHHGLQJLQWRWKHERZHOFDYLW\IURPWLPHWRWLPH
The tape lifted up and tightened the attachments of the
XWHUXVYDJLQDDQGUHFWXPWRWKHWDLOERQHLQWKHVDPHZD\
a guy rope does to the apex of a tent. This tightened the
tissues, restored the function and improved her symptoms.
Bowel emptying problems cured by repair of posterior
ligaments and perineal body
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the rectocoele to protrude into the vagina as a sac containing
faeces. That is why she had to press into the lower part of
her vagina to facilitate evacuation.
Her posterior ligaments were repaired with a sling, and her
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the posterior wall of her vagina. The faecal incontinence
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action of the posterior sling. The rectocoele and lax perineal
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returned to normal, and the rectocoele remained cured at her
2year review.
Comment Why a tape was necessary for repair of
the perineal body7KHUHDUHUHDOO\SHULQHDOERGLHV
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50
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the vagina. The traditional method relies on suturing
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tension. This method is very painful, and is prone to
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Urinary urgency, pelvic pain and nocturia cured by Pelvic
Floor Exercises
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symptoms of urgency, pelvic pain and nocturia at the age
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to work”. Finally she contacted our Clinic through an
intermediary. She worked overseas, and could not attend the
Clinic for a formal assessment. We advised her how to use a
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Comment Non-surgical treatment of posterior
ligament symptoms A vast improvement in symptoms
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DQG QRFWXULD KDV EHHQ DFKLHYHG LQ PDQ\ SDWLHQWV
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especially effective in the younger woman.
The integral theory system
Fig. 33 - Large rectocoele repair. Approximation of the perineal
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RVF=rectovaginal fascia; CL=cardinal ligament.
Permission to publish
The Editors grant permission for any individual, group or
company to reproduce any text or document in this series
of articles, with the sole condition that this article is quoted
as a literature reference, and any diagram is appropriately
acknowledged in the text.
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6XSSOHPHQW
2. Petros P E, Ulmsten U. An Integral Theory and its Method, for
the Diagnosis and Management of female urinary incontinence,
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3. Petros P E, The International Continence Society and Integral
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DQ DUWLÀFLDO QHROLJDPHQW $FWD 2EVWHWULFLD HW *\QHFRORJLFD
6FDQGLQDYLFD6XSSOHPHQW
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FODVVLÀFDWLRQ RI XULQDU\ G\VIXQFWLRQ LPSURYH VWUHVV XUJH DQG
DEQRUPDOHPSW\LQJ,QW-8URJ\QHFRORJ\
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/DQFHW
3HWURV3(8OPVWHQ85ROHRIWKHSHOYLFÁRRULQEODGGHUQHFN
opening and closure: I muscle forces, Int. J. Urogynecol. and
3HOYLF)ORRUO
3HWURV3(8OPVWHQ85ROHRIWKHSHOYLFÁRRULQEODGGHUQHFN
opening and closure: II vagina. Int. J. Urogynecol. and Pelvic
)ORRU
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3HWURV3(6ZDVK0$'LUHFWWHVWIRUWKHUROHRIWKHSXERXUHWKUDO
ligament in anorectal closure. Pelviperineology 2008; 27: 98.
3HWURV 3( 6ZDVK 0 5HÁH[ FRQWUDFWLRQ RI WKH OHYDWRU SODWH
increases intra-anal pressure, validating its role in continence.
Pelviperineology 2008; 27: 99.
3HWURV 3( 6ZDVK 0 $EGRPLQDO SUHVVXUH LQFUHDVH GXULQJ
anorectal closure is secondary to striated pelvic muscle
contraction. Pelviperineology, 2008; 27:100-101.
3HWURV 3( 6ZDVK 0$ SURVSHFWLYH HQGRDQDO XOWUDVRXQG VWXG\
VXJJHVWVWKDWLQWHUQDODQDOVSKLQFWHUGDPDJHLVXQOLNHO\WREHD
major cause of fecal incontinence. Pelviperineology 2008; 27:
102.
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G\VIXQFWLRQE\VXVSHQVRU\OLJDPHQWUHFRQVWUXFWLRQJLYHVLQVLJKWV
into mechanisms for anorectal angle formation. Pelviperineology
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FRQWLQHQFH FRPPHQWV RQ RULJLQDO ' SHOYLF XOWUDVRXQG GDWD
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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
Biology 2001; 94: 264-269.
20. Petros PE and Skilling 30 7KH SK\VLRORJLFDO EDVLV RI SHOYLF
ÁRRUH[HUFLVHVLQWKHWUHDWPHQWRIVWUHVVXULQDU\LQFRQWLQHQFH%U
-2EVWHW*\QDHFRO
21. Skilling PM, Petros PE. Synergistic non-surgical management of
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$EHQGVWHLQ % 3HWURV 3( 5LFKDUGVRQ 3$ /LJDPHQWRXV UHSDLU
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damaged suspensory ligaments and urinary and fecal incontinence.
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6LYDVOLRJOX $$ 8QOXELOJLQ ( $\GRJPXV 6 &HOHQ ( 'ROHQ
, $ 3URVSHFWLYH 5DQGRPL]HG &RPSDULVRQ RI 7UDQVREWXUDWRU
Tape and Tissue Fixation System Minisling in the Treatment of
Female Stress Urinary Incontinence: 3 Year Results, 2010, J.
Pelviperineology (in press).
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< 2XWSDWLHQW PLG XUHWKUDO WLVVXH À[DWLRQ V\VWHP VOLQJ IRU
urodynamic stress urinary incontinence, The Journal of Urology
2009; 182:2810-3.
25. Petros PE Richardson PA. A 3 year follow-up review of uterine/
vault prolapse repair using the TFS minisling. ANZJOG 2009;
,QRXH + 6HNLJXFKL < .RKDWD < 6DWRQR< +LVKLNDZD.
7RPLQDJD7 DQG 2RED\DVKL 0 7LVVXH )L[DWLRQ 6\VWHP 7)6 to repair uterovaginal prolapse with uterine preservation: A
preliminary report on perioperative complications and safety J.
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SXERXUHWKUDOOLJDPHQWV3HOYLSHULQHRORJ\
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referred pain arising from laxity in the uterosacral ligamentsDK\SRWKHVLVEDVHGRQSURVSHFWLYHFDVHUHSRUWV$1=-2 *
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PE, Role of the uterosacral ligaments in the causation of rectal
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a prospective study. Pelviperineology 2008; 27;118-121.
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reinforcement of the pelvic ligaments suggests a connective
tissue aetiology. Pelviperineology 2008; 27: 111-113.
Correspondence to:
Professor Peter Petros
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Email: kvinno@highway1.com.au
51