Home Page Home Article Read Close close

Figures in Expert Opinion by PETER PETROS

The International Continence Society and Integral Theory Systems for management of the incontinent female. A comparative analysis



(Fig. 1)

Neuro-musculo-elastic bladder control
Fig 1. Neuro-musculo-elastic bladder control.
Bladder in ‘open’(micturition) position. The closed phase ‘C’ is indicated by broken lines and the open phase ‘O’ by unbroken lines. Micturition Afferent impulses ‘O’ activate the cascade of events for micturition: relaxation of the PCM and de-activation of the inhibitory centre and closure reflex ‘C’. LP/LMA vectors actively open out the posterior urethral wall.
Urethrovesical closure ‘C’ activates the cascade of events for closure: activation of the inhibitory centres and contraction of PCM to close the urethra from behind. LP/LMA vectors stretch the bladder base backwards/downwards around the pubourethral ligament (PUL) to close the proximal urethra. Note the identical position of LP and LMA in closure and micturition. N = stretch receptors, PCM = pubococcygeus muscle, LMA = longitudinal muscle of the anus, LP = levator plate, X= fascial attachment of bladder base to vagina, USL=uterosacral ligament.



Close close


(Fig. 2 )

The Integral Pictorial Diagnostic Algorithm

Fig. 2 The Integral Pictorial Diagnostic Algorithm is designed to be copied and used by the clinician as a record. It summarizes the relationships between structural damage and pelvic floor symptoms in the three zones. The size of the bar gives an approximate indication of the prevalence (probability) of the symptom. The same connective tissue structures in each zone (red lettering) may cause prolapse and abnormal symptoms.

Anterior zone: External urethral meatus to bladder neck. Middle zone: bladder neck to cervix.
Posterior zone: vaginal apex, posterior vaginal wall and perineal body.
Arrows= directional muscle forces; LP=m.levator plate; LMA= m.longitudinal muscle of the anus; PCM = m.pubococcygeus; PRM=m.puborectalis; PUL =pubourethral ligament; USL=uterosacral ligament; PCF=pubocervical fascia; cx ring = cervical ring; ATFP=arcus tendineus fascia pelvis; EAS = external anal sphincter. R=rectum; RVF=rectovaginal fascia; PB=perineal body.



Close close

(Fig. 3 )

The Integral Surgical 3 zone clinical examination sheet

Fig. 3 – The Integral Surgical 3 zone clinical examination sheet is designed to be copied and used by the clinician as a record. Findings in a patient with stress incontinence and prolapse. Each structure is assessed and notated, if possible as 1st, 2nd or 3rd degree prolapse,. PUL, EUL, hammock, PB,, EAS, are designated ‘normal’ or ‘lax’. The % figures in the anterior zone refer to perceived % reduction in urine loss on anchoring each structure sequentially during coughing. Labelling as in figure 2.



Close close

(Fig. 4 )

The Integral Surgical System

Figure 4 – The Integral Surgical System –a site-specific method for pelvic floor repair.
This is a 3D figure of the pelvis seen from above and behind. Polypropylene mesh slings, in this instance, TFS (Tissue Fixation System), have been applied to correct ligamentous/fascial defects in the 3 zones of the vagina: anterior zone (midurethral sling for stress incontinence), middle zone (central and lateral cystocele) and posterior zone (vault prolapse). Labelling as in figure 2.



Close close

(Fig. 5 )

Urodynamic bladder instability premature activation

Figure 5 – Urodynamic bladder instability premature activation of the micturition reflex. Microtransducers in bladder (B) and midurethra (U). CP=closure pressure (U-B). Note how urgency precedes urethral relaxation (x) which precedes detrusor contraction (y).



Close close

(Fig. 6 )

Peripheral neurological control of micturition – ‘trampoline analogy’

Figure 6 – Peripheral neurological control of micturition – ‘trampoline analogy’.
Lax ligaments may unbalance the system to cause urge incontinence. Like a trampoline, the vaginal membrane cannot be stretched by the muscle forces (arrows) to support the stretch receptors ‘N’; these fire off at a low bladder volume: ‘premature activation of the micurition reflex’. The cortex perceives the afferent impulses as ‘urgency’ symptoms. Gentle digital support of the anterior vaginal wall at ‘N’, may suppress urgency by decreasing the afferents to the brain. PUL = pubourethral ligament; USL = uterosacral/cardinal ligament; ATFP = arcus tendineus fascia pelvis; N = stretch receptors.



Close close


All  figures  published  in  this  article  are  reprinted  with  the permission  of  the  author.