Update of the Integral Theory and System for Management of Pelvic Floor Dysfunction in Females

Context: The 1990 integral theory (IT) stated that urinary stress and urge symptoms mainly arise (for different reasons) from lax suspensory ligaments, a consequence of altered collagen/elastin. The first surgical application of IT was repair of the pubourethral ligament (PUL), now known as tension-free vaginal tape repair.

Objective: To update the 1990 IT to the present day (2016).

Evidence acquisition: Published data in peer-reviewed journals concerning IT evolution were evaluated.

Evidence synthesis: In its present form (2016), IT states that pelvic organ prolapse and symptoms of chronic pelvic pain and bladder and bowel dysfunction are mainly caused by laxity in five main suspensory ligaments. The IT explains cure for bladder and bowel dysfunction via the dual function of the ligaments: organ suspension and insertion points for three oppositely acting muscle forces. Lax insertion points weaken muscle forces so they cannot adequately close the urethral or anal tubes (incontinence) or evacuate them (constipation, bladder emptying), or tension the bladder and rectum sufficiently to prevent inappropriate activation of the micturition and defecation reflexes by peripheral stretch receptors (urge incontinence, tenesmus). Up to 80% cure/improvements for the above conditions have been achieved by repair of one or more damaged ligaments via precisely positioned tissue fixation system tapes: "Repair the structure (ligaments) and you will restore the function''. Exactly the same operations are performed for patients with major symptoms and minimal prolapse and major prolapse with no symptoms.

Conclusions: This method can reduce costs, improve quality of life for older women, and potentially reduce admissions to nursing homes. (C) 2017 European Association of Urology. Published by Elsevier B. V. All rights reserved.