The Female Pelvic Floor: Function, Dysfunction and Management According to the Integral Theory, 3rd Edition

354 Pages·2010·37.99 MB·English

PeterPetros
TheFemalePelvicFloor
Function,DysfunctionandManagementAccording to theIntegralTheory
ThirdEdition

PeterPetros
The Fema e
Pelvic Floor
Function, Dysfunction and Management
According to the Integral Theory
With365Figuresand2Tables
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Springer
PEPapaPetrosMBBS(Syd)PhD(Uppsala)DS(UWA)MD(Syd)FRCOGFRANZCOGCU
RoyalPerthHospitaland UniversityofWesternAustraliaa
ISBN978-3-642-03786-3 Springer-VerlagBerlinHeidelbergNewYork
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ThethreearrowsrepresentthethreemajorforcevectorsfeaturedintheIntegralTheorywhichcontrolthe
tensioningofligamentsandmembranesinthepelvicfloor.
Theenclosingcircularbrushstrokeisinspiredbythetraditional'enso'characterinZencalligraphywhich
representsnon-dualityorwholeness.Thisistoevoketheintegratedapproachcoveredinthisbook.
Thebutterflyrepresents the'butterflyeffect'conceptfromChaosTheory,alsoknownas'sensitive
dependenceoninitialconditions:whichdescribeshowsmallvariationsinadynamicnon-linearsystem(such
asthepelvicfloor)canproducea'cascade'ofeventsleadingtoamajorchangeinthestateofthesystem.
Italsorepresentsthefreedomwhichthistechnologywillgivetowomensufferingfromthemanypelvic
floordysfunctionswhichcanbecuredbyapplyingtheIntegralTheorySystem.
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Preface to 3rd edition
Once more,Ithank the growing number of colleaguesaround the world for their
supportofwhathasnow becomethe"IntegralSystem".
Translationsofthe 2nd editioninto German,Italian,Spanish,Polish,Romanian,
Japanese,Chinese, and Korean lend growinginternationalsupport to the concepts
underlying this book.
A DVD, included for the first time, uses video to better explain function/
dysfunction,diagnosis,'simulatedoperations'andthetensionedmini-slingoperations
forincontinenceand prolapseaccordingtothe"IntegralSystem".Sincepublicationof
the2ndeditionin2006,there havebeen severalimportantvalidationsoftheIntegral
Theory'spredictions.Bladderbasestretchreceptorshavenowbeen discoveredinthe
urothelium.Dynamic3Dultrasoundand MRIhaveconfirmedthelateralseparation
ofhiatal structures, which the theory states isthe major cause of organ prolapse.
Validation thatconnectivetissue, not muscledamage,isthe primecauseofurinary
and faecalincontinencehasbeen documentedby3Dultrasoundstudieswhichshow
that,evenin patientswith torn pubovesicalmuscles,there wasno increaseinstress
orfaecalincontinence.Interstitialcystitis,vulvodynia,andpelvicpainsymptomsand
tenderness(Chapter7)wererelievedbylocalanaestheticinjected into theuterosacral
ligaments, indicatingthat at least someof theseconditionsmay be due to referred
pain from uterosacral ligament laxity.Recently published works confirm many of
the Theory's predictions asregards idiopathic faecalincontinencecausationbylax
suspensoryligaments.
Xraysand EMGsadded to Chapter2moreclearlydelineate the externalstriated
muscle mechanism which opens the urethral tube for micturition, and closes it
for continence.Chapters 3 and 4 (diagnosisand surgery) have been updated and
expanded. Chapter 5 (pelvic floor rehabilitation) describes in more detail how
symptomssuch aspelvicpain,nocturiaand urgencycan besignificantlyimproved
with new,time-efficientexercises.
One ofthe majorchallengesidentifiedinthe prefacetothe 2nd edition,washow
toaddress urinaryandfaecalincontinenceinthe ageingpopulation.Therehasbeen
steadyprogressinthisdomain,especiallyinJapan,usingtensionedminislingmethods.
It ishoped that the anatomicallybased concepts presented in this3rd edition will
provideabasisfor further progress in pelvicfloor scienceandsurgery.
Thanksto Joan McCredie forher assistance in the preparationofthe textandto
SamBlightwho hasfulfilledadoubleroleinthisedition-editorand illustrator.
PeterPapaPetros,
December2009,Perth WesternAustralia.
VII
Foreword to the 3rd Edition
ByDrBernhardLiedl,President,ICOPF(InternationalCollaborationof
PelvicFloorSurgeons)
This book continues the development of the Integral System towards ever more
minimalandeffectivemethodsformanagementofpelvicfloordisorders.TheIntegral
System is based on two major scientific discoveries. In the 1990s,an entirelynew
theory,the"IntegralTheory",byPetros (Australia)and Ulmsten(Sweden)proposed
thatboweland bladderproblemsoriginatemainlyfrom damagedvaginalligaments,
notfromthebladderorbowelitself.The2nddiscoverybyPetrosand Papadimitriou,
wasa methodfor repairing these ligamentsbycreation of artificial ligaments.This
had theeffectofconvertingmajoroperationswith largeincisionstorelativelyminor
proceduresperformedthrough"keyholeincisions':
Application of these twin discoveries has revolutionized the treatment ofstress
incontinence,withmorethan 1,500,000operationsperformedtodate.Theexperience
ofmyself and other surgeons world-wide,confirms that this method can cure or
improve manyother conditionsbesidesstress incontinence,for instance,prolapse,
andsymptomssuchasurgency,nocturia,pelvicpain,bowelandbladderincontinence.
Manyoftheseconditionswerepreviouslyconsideredincurable.
Ittakesmanyyearsforsucharadicalchangeinthinkingtobecomewidelyknown.
Thisbook istimely.It informs anyone interested in the pelvic floor how damaged
vaginalligamentscancausespecificproblems,andhowsuchproblemscanbecuredor
improvedwith atime efficient pelvicfloor regime,orwith stateoftheart minimally
invasivesurgery.
DrBernhardLiedl,
President,
InternationalCollaboration ofPelvicFloorSurgeons,
Munich,Germany,September2009
Foreword to the 2nd Edition
The initial objective of this work wasto reduce stress incontinence surgeryfrom
amajorsurgical procedure (requiringup to ten daysin hospital) to aminorday
care operation.From the beginningit wasclear that the two majorimpediments
to achievingthis goalwerepost operativepain and urinaryretention.Addressing
these problems became a long and winding road and culminated in the Integral
Theory.
The IVS'tension-free' tape operation was inspired by Dr Robert Zacharin's
anatomicalstudies.ThoughZacharinsuggestedthattheligamentsandmusclesaround
the urethrawereimportantforurinarycontinencecontrol,hedid not sayhow.The
observationthatimplantedforeignmaterials createdscartissueledtothehypothesis
thataplastictapeinsertedinthe positionofthepubourethralligament,would leave
behindsufficientscartissuetoreinforcethatligament,whichwouldthen anchorthe
musclesforurethralclosure.
InSeptember1986,twoprototypeIntravaginalSlingoperationswereperformed.
AMersilene tape was inserted with neither tension nor elevation, in the position
of the pubourethralligament. Restoration of continencewasimmediateand both
patients were discharged on the day following surgery without requirement for
catheterization.There wasminimalpain, and immediaterestorationofcontinence.
After sixweeksthe tapes were removed. Both patients were still continent at last
review10yearslater.Theresultsappearedtoconfirmtheimportanceofamidurethral
anchoring point. Furthermore, asthere wasno elevation of the bladder neck, the
results castdoubton the validity ofthe prevailing'pressureequalizationtheory'of
Enhorning.
In 1987,with Professor John Papadimitriou and colleagues from RoyalPerth
Hospital,aseriesofexperimentalanimalstudieswasperformedtoscientificallyanalyse
the safety,efficacyand modus operandi ofatape implantation. Tapeimplantation
wasfound tobesafeand itworked bycreating alinear depositionofcollageninthe
positionofimplantation.
The first of 30 operations were performed at Royal Perth Hospital, Western
Australia, between 1988and 1989.An adjustable intravaginal Mersilene sling was
sitedatmidurethra.Theslingwassetinanelevatedpositionbutthiscausedurgency
and obstructed flow post-operatively. Asthe sling was lowered, these symptoms
disappeared, yetmost ofthe patientsremainedcured oftheir stressincontinence.
On comparing the pre-operative and post-operative x-rays, no elevation of
bladder base was evident. This appeared to invalidate the 'Pressure Equalization
Theory'formaintenanceofurinarycontinence. Furthermore,whenthemidurethral
tape wasanchored bygrasping it with a haemostat, the distal urethra wasseen to
move forward, but the Foleyballoon catheter moved backwards and downwards
aroundthe midurethralpoint.Fromtheseobservationstheconceptoftwoseparate
closure'mechanisms'emerged.Overthespaceofayear,atheoretical framework that
integratedthesedisparatefindingswithknown anatomywasdeveloped(theIntegral
Theory1990).Thekeyconceptswerethatthesuspensoryligamentswereessentialfor
IX
Forewordtothe2ndEdition
normalbladderfunction,and thatbladderdysfunctionoccurredbecauseofconnective
tissue damagewithinthese same ligaments.
In 1990acollaborationwith Professor Ulf Ulmsten began. Furtherstudieswere
performed,andthe firstformulation ofthe IntegralTheorywaspublished:
Fordifferentreasons,stressandurgederive mainlyfrom laxityinthevagina orits
supportingligaments,aresultofalteredcollagen/elastin.
Separateurethralandbladderneck closure mechanismsweredescribed.Abdominal
ultrasoundstudiesin 1990demonstratedthatthe urethrawasclosedfrom behindby
thehammockclosuremechanism.Bladderinstabilityinthenon-neurologicalpatient
wasdefinedasaprematureactivationofthe micturition reflex.
In 1993the secondexpositionofthe IntegralTheorypresented radiologicaland
urodynamicstudiesandbroughtahigherlevelofproof.
Fiveprototypesuburethralslingoperationsforstressincontinencewereanalysed
withreferencetomodusoperandiandsurgical methodology(1993IntegralTheory).
Aproblemthatremainedwasthe relativelyhigh rate ofMersilenetape erosion.This
waslargelysolvedin1996byProfessorUlmsten'sScandinaviangroup(Ulmstenetat.
1996)throughuseofapolypropylenemeshtape.The'posteriorfornixsyndrome'was
described (1993IntegralTheory).Reconstructionoftheposteriorligamentsimproved
symptomsofurge,nocturia,abnormalemptyingand pelvicpain.Thesefindingswere
seminalin the constructionofthe PictorialDiagnosticAlgorithm.
The ten years to 2003 has seen a consolidation and international acceptance of
manypartsofthe IntegralTheory, inparticular,the treatmentofstressincontinence
with a midurethral sling. The Theory framework has expanded to include faecal
incontinence, abnormal emptying, and sometypes ofpelvic pain. New ultrasound
and urodynamic techniques promise to improve diagnostic accuracy, especially
when used with the 'simulated operations' technique described later in this book.
Improvements in surgical methodologyhave been running on a parallel pathwith
the expansion ofthe Integral Theory.These new methods were developed because
traditional vaginal surgerymethods ofexcision and approximation were unable to
restore tissue strength sufficientlyto restore structure, asdescribed by the Integral
Theorysystem. Toovercomethis deficiency,double layered techniques such as the
'bridge'repair, which recyclesexcessvaginal tissue (Petros 1998),and the Posterior
IVS(Petros 2001)weredeveloped.Tighteningthesuburethralhammockinaddition
toamidurethralslinghasincreasedthecure rateforstressincontinenceandintrinsic
sphincterdefect (Petros 1997).The posteriorsling has been further improved and
simplified.
In particular,the new tissue fixation system (TFS) appearsto beamajoradvance
on the existing 'tension-free tape' slings in that it ispossible to repair anyligament
or fascialdefect in the pelvicfloor.The TFSoperationsaremoreanatomical,farless
invasive,andtheyareable to beperformedunderdirectvision.
This bookhasbeenwritteninthe hopethatitwillfurtherclarifyanddisseminate
the ideas ofthe Integral Theory and help provide the basis required for further