The Integral Theory of Pelvic Floor Dysfunction, also known as the Integral System brings a new perspective to the management of dysfunction in the female pelvic floor. It emphasizes the role of the connective tissue of the vagina and its supporting ligaments in both function and dysfunction. The surgical approach deriving from the Integral Theory is minimally invasive, yet it addresses a large spectrum of pelvic floor dysfunction in the female – urinary and faecal, as well as prolapse and some types of pelvic pain. It presents some new concepts and realigns much existing knowledge on bladder and bowel dysfunction, especially in anatomy, biomechanics and urodynamics.

The Integral System views normal pelvic floor function as a balanced, interrelated system composed of muscle, connective tissue (CT) and nerve components, with connective tissue being the most vulnerable damage. In summary, the Integral Theory may be stated thus:

Symptoms of stress, urge, and abnormal emptying mainly derive, for different reasons, from laxity in the vagina or its supporting ligaments, a result of altered connective tissue.

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Integral System

  • gives an anatomical explanation for normal function and dysfunction.

  • provides a pictorial diagnostic algorithm which uses symptoms to locate¬†specific zones of damage

  • provides a revolutionary squatting-based pelvic floor exercises with a proven 50% improvement rate for bladder/bowel/chronic pelvic pain in premenopausal women.

  • provides a set of Day-Care surgical techniques guided by the diagnostic algorithm and characterized by reduced pain and urinary retention and early return to normal activities.

    • for pre-menopausal women, plication of cardinal, uterosacral ligaments.

    • for post-menopausal women, using tapes to repair damage in the 5 main ligaments of the pelvis: pubourethral, cardinal, uterosacral, deep transversus perinei attachments of perineal body to the descending ramus, ATFP/ dislocated pubococcygeus muscle.

  • An important principle is that major symptoms can be caused by minimal prolapse. The same protocol as above is followed in such women.

Structure and Function

To help explain the theory, two analogies are used, the suspension bridge for structure, and the trampoline for function. The suspension bridge analogy is used to show how the organs and fascia are given form, shape and strength by tensioning them against a fixed point (bones). The trampoline analogy is used to explain the relationship between ligaments (springs), vagina (membrane) and muscles (stretching forces). Just as a loose spring on a trampoline may prevent the membrane being stretched, so loose ligaments may prevent the stretching of the connective tissue to open or close the urethra, thereby causing dysfunction.

The clinical application of the Integral System culminates in the Pictorial Diagnostic Algorithm which provides the framework for surgical techniques that are minimally invasive.

The Integral System categorises the pelvic floor into three zones of function and three levels of structure. The pictorial diagnostic algorithm provides the surgeon with a guide as to which specific ligaments are causing dysfunction. The surgical techniques developed from the Integral System focus on reinforcing damaged ligaments and fascia, and preserving vaginal tissue and elasticity, especially in the bladder neck area of the vagina. This approach reduces pain and urinary retention and allows the surgery to be performed on a day-care or overnight stay basis.