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

279 Pages·2007·6.95 MB·English

by  Peter Petros MB BS (Syd) Dr. Med Sc (Uppsala) DS (UWA) MD (Syd) FRCOG FRANZCOG CU (auth.)

Peter Petros
The Female Pelvic Floor
Function, Dysfunction and Management According to the Integral Theory
Second Edition
Peter Petros
The Female
Pelvic Floor
Function, Dysfunction and Management
According to the Integral Theory
With 237 Figures and 3 Tables
123
PE Papa Petros MB BS (Syd) Dr. Med Sc (Uppsala) DS (UWA) MD (Syd) FRCOG FRANZCOG CU
Dept of Gynaecology
Royal Perth Hospital
Western Australia
ISBN 978-3-540-33663-1 Springer Medizin Verlag Heidelberg
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SPIN 11740940
Cover Design: deblik Berlin, Germany
Typesetting: TypoStudio Tobias Schaedla, Heidelberg, Germany
Printer: Stürtz GmbH, Würzburg, Germany
Printed on acid free paper 18/3160/yb – 5 4 3 2 1 0
Cover Idea by Sam Blight, Rangs Graphics
The three arrows represent the three major force vectors featured in the Integral Theory which control the
tensioning of ligaments and membranes in the pelvic fl oor.
The enclosing circular brush stroke is inspired by the traditional ‘enso’ character in Zen calligraphy which
represents non-duality or wholeness. This is to evoke the integrated approach covered in this book.
The butterfl y represents the ‘butterfl y eff ect’ concept from Chaos Theory, also known as ‘sensitive
dependence on initial conditions’, which describes how small variations in a dynamic non-linear system (such
as the pelvic fl oor) can produce a ‘cascade’ of events leading to a major change in the state of the system.
It also represents the freedom which this technology will give to women suff ering from the many pelvic
fl oor dysfunctions which can be cured by applying the Integral Theory System.
V
Life is short,
But the craft is long
Hippocrates 460-377 BC

Science is the father of knowledge, but opinion breeds ignorance.
Hippocrates 460-377 BC
Preface to 2nd Edition
I would like to express my gratitude to my colleagues around the globe for the
overwhelming support given to the fi rst edition of ‘Th e Female Pelvic Floor’. Th e
publishers inform me that Spanish, Japanese, and Chinese translations are underway,
an indication, perhaps, of the increasing acceptance of at least some of the concepts
within the book.
Since the release of the fi rst edition in September 2004, many new surgical
techniques have been developed. Th ese have extended the concepts of suspensory
slings to replace and to reinforce damaged vaginal fascia. New insights have been
gained from further application of the Tissue Fixation System. Its use in anterior and
posterior wall prolapse repair has unlocked new anatomical concepts concerning
the relationship between the cervical ring and cardinal ligaments; also, uterosacral
ligaments and rectovaginal fascia.
Th ese advances have necessitated some further additions in Chapter 2, and extensive
additions in Chapter 4, so as to better explain the anatomical basis for these recent
surgical advances, and hopefully, for the newer techniques which will inevitably
emerge in the coming years.
Notwithstanding the immense progress achieved since the 1990 publication of
the Integral Th eory, three important challenges remain: fi nding methods to more
accurately assess the degree of damage in the various connective tissue structures;
continuing to develop understanding of the interactions which lead to abnormal
symptoms in the individual patient; and further minimizing the need for surgical
operations.
A central focus for these challenges is to apply them to those most in need of
assistance, that is, the frail and the elderly, for example, Nursing Home patients.
In this context, the 2nd edition of this book is presented as an invitation to
colleagues to participate in the further development of this methodology, surgical
technique and technology.
Peter Petros, Royal Perth Hospital, Perth Western Australia, June 2006
VII
Preface
I fi rst encountered the Integral Th eory system in the early 1990’s at the Royal Perth
Hospital laboratory in Western Australia where I was working on laparoscopic
colposuspension. Even in prototype form, the IVS operation was so simple and
eff ective that I adopted it immediately. Subsequently, based on my experiences, I wrote
the following in the Medical Journal of Australia in October 1994:
(the operations) promise a new era for women, virtually pain-free cure of
prolapse and incontinence without catheters, and return to normal activities
within days.
Now, ten years later, more than 500,000 ‘tension-free’ anterior or posterior sling
operations have been performed.
One case in particular stands out from those early years. A woman patient in her
mid-50’s came to see me with a fi ve year history of urinary retention which required
an indwelling catheter. Th is woman had consulted more than a dozen medical
specialists who had told her the same story: no cure was possible. Using the Structured
Assessment of the Integral Th eory it was deduced that she had a posterior zone defect.
I performed a Posterior IVS. Th e next day the patient was voiding spontaneously with
low residuals, and she has remained well since.
At fi rst I was sceptical about some of the other predictions of the Integral Th eory,
in particular, surgical cure of nocturia, frequency, ‘detrusor instability’, chronic pelvic
pain, intrinsic sphincter defect and ‘idiopathic faecal incontinence. However, the high
cure rate obtained by following the diagnostic system described in this book soon
convinced me that the Integral Th eory framework had much wider applications than
those predicted in the original publications.
It is self-evident that the Integral Th eory has now matured into an important
medical Paradigm, every aspect of which is outlined in this book.
Th e original work on the Integral Th eory was done at Royal Perth Hospital, Western
Australia and the University of Uppsala, Sweden. However, the defi ning concepts
concerning management and surgery were done at Royal Perth Hospital. It was here
that the biomechanical and fl uid dynamic principles developed at the University of
Western Australia’s Department of Mechanical and Materials Engineering and Fluid
Dynamics were applied in practical form. For these works, Professor Petros received
his Doctor of Surgery degree in 1999.
It should be emphasized that this book is mainly clinically based. Using the
Diagnostic Algorithm and ‘simulated operations’, techniques which are thoroughly
described herein, it is possible for the generalist to achieve a high degree of diagnostic
accuracy and high cure rates. Furthermore most conditions can be treated at the clinical
level without the use of expensive diagnostic equipment or surgical facilities. Th is means
that the methods described in this book can be accessed by medical professionals in less
developed countries where resources and equipment may not be readily available.
Peter Richardson FRCOG, FRANZCOG
Immediate Past Chairman, National Association of Specialist Obstetricians and
Gynaecologists of Australia (NASOG).
Acknowledgments
It is now almost twenty years since the fi rst threads of the Integral Th eory arrived in
my consciousness. Th is book brings together these and all the other threads which
have materialized over these years. Th roughout this time, I have had the unfl inching
support of my family, my wife Margaret, and children Eleni, Angela and Emanuel,
my brother, Dr Sid Papapetros, my co-director of the Kvinno Centre, Dr Patricia M.
Skilling, and the staff at the Kvinno Centre, Carole Yelas, Linda Casey, Maria O’Keefe,
Margeurite Madigan and Joan McCredie.
No enterprise can be achieved without passion, the interest of other colleagues,
and above all, teamwork. My hospital, Royal Perth Hospital, has been immensely
supportive. Much of the experimental work was done with internal hospital support.
I am especially indebted to Dr Bill Beresford, Director of Medical Services, Drs Jim
Anderson and Richard Mendelson, Department of Radiology, Mr Ed Scull and Dr
Richard Fox Department of Medical Physics, Professor Mark Bush, Department of
Mechanical and Materials Engineering, University of Western Australia (UWA),
Professor Yianni Attikiouzel, Centre for Intelligence Processing, UWA, Professor
Byron Kakulas from the Department of Neuropathology, Professor John Papadimitriou
and Dr Len Matz from the Department of Pathology, Dr Ivor Surveyor from the
Department of Nuclear Medicine, Mr Terry York Director of the animal laboratory,
personnel from the Departments of Pathology, Morbid Anatomy, Bacteriology and
Biochemistry, Dr John Chambers, Emeritus Gynaecologist, and Dr Graham Smith,
Head of Department Gynaecology, colleagues from the Department of Surgery, UWA,
in particular Professor Bruce Gray, and Dr G Hool.
Several colleagues played a seminal role in the late 1980s and early 1990s. In
Australia, Dr Peter Richardson, Chairman of the National Association of Specialist
Obstetricians and Gynaecologists and Dr Colin Douglas Smith Emeritus Consultant
from King Edward Hospital who made a prospective case by case assessment of 85
patients on behalf of the Hospital Benefi ts Fund of Western Australia. His conclusion
that the surgical operations had largely fulfi lled the predictions of the In te gral Th eory
was a key factor in the wider propagation of the surgery. Since 1995, an ever-growing
group of Gynaecological Surgeons belonging to the Association of Ambulatory Vaginal
and Incontinence Surgeons (AAVIS) have used the Integral Th eory diagnostic system
and have learnt the various operations derived from the theory. I am indebted to the
AAVIS President, Dr WB Molloy, Secretary, Dr Bruce Farnsworth, and Treasurer,
Dr Laurie Boshell for their invaluable advice and assistance. I acknowledge a major
intellectual debt to Dr Robert Zacharin whose 1961 anatomical works provided an
inspirational starting point for the Integral Th eory.
In December, 1989 I met the late Professor Ulf Ulmsten from the University of
Uppsala. We began a close and productive collaboration lasting some years. During
this time we published the 1990 and 1993 publications of the Integral Th eory, and in
time I became Associate Professor in his department. Coming from a clinical surgical
background, it was a revelation for me to work in Uppsala in an environment which
gave such emphasis to basic science, and I hungrily absorbed this scientifi c milieu
IX
Acknowledgments
until it became part of my being. Ulf Ulmsten opened the door to many Scandinavian
works on urodynamics, to which he himself had made some major contributions.
I maintain a strong interest in urodynamics to this day. Th rough Ulf Ulmsten I
met Professor Ingelman -Sundberg, the father of Urogynaecology whose writings I
studied. In 1994 I met Professor Michael Swash who encouraged my interest in faecal
incontinence, and with whom I later collaborated in studies of myogenic changes
in patients with urinary incontinence. Another major intellectual infl uence in the
development of the anatomically-based surgical techniques described in this book
was the late Professor David Nichols, whom I knew and with whom I corresponded.
Nichols in turn acknowledged his debt to major English, American, German and
Austrian anatomists and surgeons, as do I. Over the years I have travelled widely
in Europe, Asia, North and South America, teaching and being taught. To all these
colleagues, I express my gratitude for aff ording me that privilege.
In particular, I would like to thank Dr Victoria D’Abrera, FRCPath FRCPA and
Carole Yelas for their invaluable scrutiny of the fi nal text. Th e process of writing this
book was managed by Mr Gary Burke. His insights have given the book a coherence
which I hope translates into readability. Mr Sam Blight has added his creativity to
the basic diagrams. Finally a special thanks to Yvonne Bell from Springer, whose
assistance made this book possible.
Peter Papa Petros
Perth, 2004
Foreword
Th e initial objective of this work was to reduce stress incontinence surgery from
a major surgical procedure (requiring up to ten days in hospital) to a minor day-
care operation. From the beginning it was clear that the two major impediments
to achieving this goal were post operative pain and urinary retention. Addressing
these problems became a long and winding road and culminated in the Integral
Th eory.
The IVS ‘tension-free’ tape operation was inspired by Dr Robert Zacharin’s
anatomical studies. Th ough Zacharin suggested that the ligaments and muscles around
the urethra were important for urinary continence control, he did not say how. Th e
observation that implanted foreign materials created scar tissue led to the hypothesis
that a plastic tape inserted in the position of the pubourethral ligament, would leave
behind suffi cient scar tissue to reinforce that ligament, which would then anchor the
muscles for urethral closure.
In September 1986, two prototype Intravaginal Sling operations were performed. A
Mersilene tape was inserted with neither tension nor elevation, in the position of the
pubourethral ligament. Restoration of continence was immediate and both patients
were discharged on the day following surgery without requirement for catheterization.
Th ere was minimal pain, and immediate restoration of continence. Aft er six weeks
the tapes were removed. Both patients were still continent at last review 10 years later.
Th e results appeared to confi rm the importance of a midurethral anchoring point.
Furthermore, as there was no elevation of the bladder neck, the results cast doubt on
the validity of the prevailing ‘pressure equalization theory’ of Enhorning.
In 1987, with Professor John Papadimitriou and colleagues from Royal Perth
Hospital, a series of experimental animal studies was performed to scientifi cally
analyse the safety, efficacy and modus operandi of a tape implantation. Tape
implantation was found to be safe and it worked by creating a linear deposition of
collagen in the position of implantation.
Th e fi rst of 30 operations were performed at Royal Perth Hospital, Western
Australia, between 1988 and 1989. An adjustable intravaginal Mersilene sling was
sited at midurethra. Th e sling was set in an elevated position but this caused urgency
and obstructed fl ow post-operatively. As the sling was lowered, these symptoms
disappeared, yet most of the patients remained cured of their stress incontinence.
On comparing the pre-operative and post-operative x-rays, no elevation of bladder
base was evident. Th is appeared to invalidate the ‘Pressure Equalization Th eory’
for maintenance of urinary continence. Furthermore, when the midurethral tape
was anchored by grasping it with a haemostat, the distal urethra was seen to move
forward, but the Foley balloon catheter moved backwards and downwards around
the midurethral point. From these observations the concept of two separate closure
‘mechanisms’ emerged. Over the space of a year, a theoretical framework that
integrated these disparate fi ndings with known anatomy was developed (the Integral
Th eory 1990). Th e key concepts were that the suspensory ligaments were essential for
normal bladder function, and that bladder dysfunction occurred because of connective
tissue damage within these same ligaments.