Review

A review of the Integral Theory of Pelvic Organ Prolapse and proposed concept of repair: Part 1 - Structural components and damage

  • DARREN M. GOLD
  • DAVID ENDE

Pelviperineology 2016;35(3):74-76

Aim:

To explain the structural basis of the Integral Theory, how pelvic organ support requires 5 competent ligaments, uterosacral (USL), cardinal (CL) arcus tendineus fascia pelvis (ATFP), pubourethral (PUL) and perineal body (PB) and how damage to these ligaments may cause pelvic organ prolapse ‘POP’ (cystocele, uterine prolapse, rectocele), bowel, bladder and pain symptoms.

Biomechanics:

The ligaments attach the organs to the skeleton from above. Pelvic muscles stretch them from below. Ligaments are strong and relatively inelastic, breaking strain 300 mg/mm2; vagina is weak and elastic 60 mg/mm2.

Pathogenesis:

Dislocation/stretching of vagina and CL from the cervix are principal causes of cystocele; stretching of USL &CL cause uterine prolapse. Dislocation/stretching of vagina from USL and PB may cause rectocele as may separation of the PB bodies.

Conclusions:

The pelvis functions like a suspension bridge. Organ support is derived by adequately tensioned ligaments from above and muscle contraction from below. If the ligaments are damaged they need to be reinforced in the position and along the axis of the natural ligament. Shortening and strengthening the ligaments also restores the directional muscle forces which contract against these ligaments to restore organ support from below.

Keywords: POP; Ligaments; Pelvic muscles; ATFP; Cardinal ligament; Uterosacral; Perineal body.