Problems and Symptoms

There are 4 major structures which influence organ prolapse. These are the ATFP, cardinal, uterosacral ligaments and the perineal body. There is a 6 year multicentre experience from Europe, Asia, Australia, and more recently the Americas, that a tensioned TFS mini-sling applied in the exact position of these structures gives high longer term cure rates even 3rd or 4th degree organ prolapse, avoiding the problems associated with large mesh insertions. Also, there is a concomitant cure of symptoms such as nocturia, pelvic pain and abnormal bladder emptying, bowel incontinence and evacuation problems.

Urinary Incontinence has two main components, stress (SI) and urge (UI) incontinence. The term “mixed Incontinence” is confusing in that it implies that it is a single entity. Our experience of 25 years indicates that each symptom is to be viewed separately. Both are surgically curable, but it is important to diagnose the anatomical cause of UI. When UI occurs uniquely with SI, with no other symptoms such as nocturia, pelvic pain and abnormal bladder emptying, high cure rates for both may be achieved using only a midurethral sling, with an expected 90% cure rate for SI, and up to 70% for UI. The pictorial diagnostic algorithm (see later) helps to assign other causes of UI, for example cystocoele (lax cardinal ligaments) or apical uterine prolapse (lax uterosacral ligaments).

Frequency of urination is defined as a problem when it occurs more than eight times per day. Causation is aid to be unknown and it is treated with drugs or bladder training, both of which are not effective in the longer term. As interpreted by the Integral System, frequency is really more of a side effect of an overactive bladder than a primary symptom, as any patient with urgency will also empty her bladder more frequently.

Nocturia is defined as a problem when it occurs more than two times per night, and urge incontinence when a patient is unable to control her desire to pass urine. Where urgency or urge incontinence occurs in the absence of SI, it generally occurs with one or more other symptoms such as nocturia, pelvic pain and abnormal bladder emptying. Though nocturia is said to derive from the posterior pituitary and is said to be incurable, according to the Integral System, nocturia occurs because of uterosacral ligament laxity. Furthermore, nocturia and pelvic pain are specific for uterosacral ligament laxity. The combination of these symptoms with urge and/or abnormal emptying is known as the “Posterior Fornix Syndrome”, and all can be potentially cured or improved by reinforcing the uterosacral ligaments with a posterior polypropylene sling.

Abnormal bladder emptying can be defined as difficulty in bladder evacuation. It has two major causes, lax uterosacral ligaments, and cystocoele. It can present as chronic urinary infection due to a high residual urine. Conventionally it is treated with urethral dilatation, even though there is no obstruction and the treatment is not very effective.

If the cause is from cystocoele, urgency may be associated, and the problem can be cured/improved by repairing the anatomical defects, in particular, lax cardinal ligaments. A standard well-conducted vaginal repair often works well, but in our experience, the best treatment is site specific repair of damaged cardinal/ATFP ligaments using tensioned minislings.

If the cause is from laxity in the uterosacral ligaments, pelvic pain and nocturia are often associated (“Posterior Fornix Syndrome”), and all are potentially curable with a posterior polypropylene sling.

Chronic pelvic pain of otherwise unknown origin* is characterized by a ‘dragging ‘ pain, of varying severity, often one-sided. The incidence can be as high as 20% of women. Though the cause is said to be unknown and thought to be psychological, we have a 20 year experience that it is part of the “Posterior Fornix Syndrome”, and is potentially surgically curable with a posterior polypropylene sling.

* low abdominal or sacral dragging ache relieved on lying down, deep dyspareunia continuing the next day. Clearly endometriosis, PID and other proven causes are excluded.

The prevalence of all bowel dysfunctions in women varies between 10 and 20%.Bowel dysfunction has two elements, difficulty with evacuation (‘constipation’) and incontinence, involuntary loss of wind or faeces (FI). “Idiopathic FI”* causation is said to be unknown, but we have a 20 year experience to show that both conditions can be substantially improved or cured by reconstruction of the suspensory ligaments pubourethral and/or uterosacral ligaments(USL) and USL and perineal body for abnormal anorectal evacuation.

* anal sphincter damage is excluded

‘Interstitial Cystitis’ (IC) and ‘Vulvodynia’ are debilitating conditions. The cause is unknown and no long term effective treatment is known. However, recent data indicates that there is a link between these conditions, and chronic pelvic pain, urgency, frequency and abnormal emptying. The latter are classical symptoms of the “Posterior Fornix Syndrome”. We hypothesized that bladder pain and vulvodynia were a referred pain from lax uterosacral ligaments (USL). Injection of local anaesthetic into the USLs resulted in disappearance of the pain for about 20 minutes. It is hypothesized that lax USLs cannot support the afferent pain fibres, resulting in distension and pelvic pain. It is hypothesized that bladder pain and urgency may be caused by laxity in the cardinal ligament support of bladder base, as evidenced by alleviation of urgency symptoms by digital support of bladder base.