Integral Theory

The Integral Theory System.

A simplified clinical approach with illustrative case histories
PETER E. PAPA PETROS(1,2)
(1)
University of Western Australia

Abstract: The integral theory:VWDWHVWKDWSURODSVHDQGSHOYLFRRUV\PSWRPVVXFKDVXULQDU\VWUHVVXUJHDEQRUPDOERZHODQGEODGGHUHPSW\LQJ

and some forms of pelvic pain, mainly arise, for different reasons, from laxity in the vagina or its supporting ligaments, a result of altered
connective tissue. Normal Function: 7KHRUJDQVDUHVXVSHQGHGE\OLJDPHQWVDJDLQVWZKLFKPXVFOHVFRQWUDFWWRRSHQRUFORVHWKHRXWOHWWXEHV
XUHWKUDDQGDQXV7KHVHOLJDPHQWVIDOOQDWXUDOO\LQWRD]RQHFODVVLFDWLRQDQWHULRUPLGGOHDQGSRVWHULRU
Dysfunction: 'DPDJHGOLJDPHQWVZHDNHQWKHIRUFHRIPXVFOHFRQWUDFWLRQFDXVLQJSURODSVHDQGDEQRUPDOEODGGHUDQGERZHOV\PSWRPV
Diagnosis: $SLFWRULDOGLDJQRVWLFDOJRULWKPUHODWHVVSHFLFV\PSWRPVWRGDPDJHGOLJDPHQWVLQHDFK]RQH
Treatment:,QPLOGFDVHVQHZSHOYLFRRUPXVFOHH[HUFLVHVEDVHGRQDVTXDWWLQJSULQFLSOHVWUHQJWKHQWKHQDWXUDOFORVXUHPXVFOHVDQGWKHLU
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keyhole incision using special instruments reinforce the damaged ligaments, restoring structure and function.
Problems which can be potentially addressed by application of the Integral System: Urinary stress incontinence; Urinary urge incontinence;
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interstitial cystitis; Organ prolapse.
Key words: Integral Theory; diagnosis; minisling; ligaments; connective tissue; pictorial algorithm.

INTRODUCTION
The Integral Theory states that prolapse and most pelvic
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mainly arise, for different reasons, from laxity in the vagina
or its supporting ligaments, a result of altered connective
tissue.1-5%LUWKUHODWHGOD[LW\JFRPSRXQGHGE\DJHLQJ
are the principal causes of ligament laxity.
The Integral Theory has evolved into the Integral Theory
System, which applies the damaged ligament theory to
Function the role of competent suspensory ligaments in
organ support and function.
Dysfunction-how damaged ligaments upset the
musculoelastic control mechanism to cause prolapse and
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Diagnosis- how to diagnose which damaged ligaments
are causing which prolapse and which symptoms. )LJ   %LUWKUHODWHG OD[LW\ 7KH GLDJUDP VKRZV WKH EDE\V KHDG
severely stretching ligaments and other tissues in and outside the
TreatmentLQPLOGFDVHVQHZSHOYLFRRUPXVFOHH[HUFLVHV vagina. This may cause various degrees of looseness, prolapse of the
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closure muscles and their ligamentous insertions. With to any surgical treatment is the approximation of laterally displaced
more severe cases, polypropylene tapes applied through tissues, and the strengthening of damaged suspensory ligament(s).
keyhole incision using special instruments, reinforce the
damaged ligaments, restoring structure and function. 7KHEODGGHUVLWVRQWRSRIWKHYDJLQDDQGLVSDUWO\DWWDFKHG
to it. Muscles pull against the ligaments to close or open the
PART 1 urethra. Therefore loose ligaments may weaken the muscle
THE DYNAMIC ANATOMY OF NORMAL FUNCTION FRQWUDFWLRQ WR FDXVH SUREOHPV ZLWK FORVXUH LQFRQWLQHQFH

Bladder, bowel and uterus

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uterus with the woman in a sitting position. The organs
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the foetus, and the rectum faeces. Each organ is connected
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vagina. Urine and faeces pass through the urethra and anus.
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them open for emptying.
The importance of suspensory ligaments
Problems of bladder, bowel, prolapse, and some types
of pelvic pain, mainly originate from the vaginal ligaments,
not from the organs themselves- Integral Theory 1996. )LJ7KHRUJDQVDQGWKHLURXWOHWWXEHV

Pelviperineology 2010; 29: 37-51 http://www.pelviperineology.org 37

P.E.P. Petros

Fig. 3 - Unsuspended ligaments have no shape, strength or )LJ   )RXU OLJDPHQWV VXVSHQG WKH RUJDQV IURP DERYH OLNH D
function.
or opening (evacuation of urine). Figure 3 indicates what
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predispose to prolapse, and development of posterior zone
symptoms.
no structure, no strength, and no function. The pelvic musclesGDUNUHGJKDYHDGXDOIXQFWLRQ
$OLJDPHQWLVOLNHDWKLFNFRUGLQDVXVSHQVLRQEULGJHJ organ support, and opening and opening and closure of
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the ligaments are attached to the vagina and/or uterus. The
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forwards to close them.
An external striated muscle opening and closure
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VWUXFWXUHFDQDOVRDIIHFWWKHEODGGHUDQGUHFWXP GHFUHDVLQJLQWUDFDYLW\UHVLVWDQFHWRWKHth power, so that the
Separating the lower end of the vagina from the rectum ZRPDQFDQTXLFNO\DQGHDVLO\HYDFXDWHKHUXULQHDQGIDHFHV
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EXOJHIRUZDUGVLQWRWKHYDJLQDDVDUHFWRFRHOH power. Normally all the organs, even the vagina, are kept in
The uterus is an anchoring point for the ligaments - WKHFORVHGSRVLWLRQE\VORZWZLWFKPXVFOHFRQWUDFWLRQ
it needs to be preserved where possible * The closure mechanism is a little more complex than that depicted
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Some doctors routinely recommend removal of the uterus How damaged ligaments may cause incontinence or
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XWHUXV ZKHUHYHU SRVVLEOH DV PDQ\ LPSRUWDQW OLJDPHQWV diagram, that the muscles pull against the ligaments.
are attached to it. During the menopause, the ovaries cease
production of oestrogen. Since oestrogen is essential for
maintaining the strength of the ligaments, the detrimental
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especially evident after the menopause. Hysterectomy
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ligaments, weakening them further. All these factors

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36 SXELF V\PSK\VLV6 VDFUXP 38/ SXERXUHWKUDO OLJDPHQW the arch, and the whole structure is put at risk of a downward
ATFP=arcus tendineus fascia pelvis; USL=uterosacral ligament. collapse.

38
 The integral theory system

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muscle forces (arrows).

So if the suspensory ligaments are loose, the muscle

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this, a patient may feel a leakage of urine, wind or faeces,
incontinence. Another related condition is failure to close
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ligaments do not allow the muscles to open these same
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disorder.
A Symphony Orchestra
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 7KH EUDLQ LV perceived as urgency, a desire to go to the toilet.
the conductor, and ensures that all the instruments work
harmoniously to produce the right music. Every instrument
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instrument will affect the performance. 7KH EUDLQ GLUHFWV
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opening (O). Like instructions from the orchestra conductor, these
directions, C and O, engage all the muscles, nerves, ligaments
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* I am grateful to Dr Alfons Gunnemann for the orchestra analogy
The brain and its nerves- a sophisticated feedback system
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WKH RUFKHVWUD WR RSHQ WKH EODGGHU DQG ERZHO RU WR FORVH exchange. Think of the nerves as telephone wires going out
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LQFRQWLQHQFHRUVKHPD\QRWEHDEOHHPSW\KHUEODGGHU set of nerves, to inform it as to what is happening. The
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Fig. 8 - An external striated muscle opening and closure mechanism.
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activate closure and opening.
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Most of this co-ordination occurs in automatic mode. The
patient is not aware of what is happening. Sometimes, a
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Pushing down assist emptying the urine and faeces. During
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muscles upwards. This action grips the penis, and increases
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PART 2
DYSFUNCTION - THE ROLE OF LAX LIGAMENTS IN
THE CAUSATION OF SYMPTOMS AND PROLAPSE
The structure of ligaments
A ligament is a complicated contractile structure which
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contract or relax according to whether the urethra and anus
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contractility, and nerves to co-ordinate all these functions.
39
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vaginal tissues to varying degrees as it descends through the vagina
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ATFP=arcus tendineus fascia pelvis; USL=uterosacral ligament.
Not shown are cardinal ligament (Middle Zone) and Perineal Body
(Posterior zone).

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Fig. 11 - This diagram illustrates the cystocoele 2, rectocoele

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suspensory ligaments and their associated tissues.

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and posterior (uterosacral) ligaments are in purple. The middle
ligaments (ATFP& cardinal) are not shown in this diagram. There
are 3 columns, one for each ligament group and the symptoms
)LJ$F\VWRFRHOHEXOJLQJRXWRIWKHYDJLQDOHQWUDQFHGXULQJ and prolapses (lumps) associated with damage to these ligaments.
straining. /DEHOOLQJLVIURQWDQGEDFNLQVWHDGRIDQWHULRUDQGSRVWHULRU



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strength. The elastin content gives them elasticity. It is the
change in collagen which is the ultimate cause of prolapse
and incontinence.
How ligaments are stretched and damaged during
pregnancy and labour
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emptying or faecal incontinence.
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The integral theory system
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lesser extent. This explains appearance of a cystocoele, for
example, months or years after apparently successful surgery
for prolapse of the uterus. Further prolapse can occur in
perhaps 30-50% of cases after a successful vaginal repair.
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cloth. The surgeon repairs one area, only to see it give way
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A cystocoeleEDOORRQVRXWIURPDERYHJ7KHFDXVH
is damage to the middle ligaments (ATFP and/or cardinal
ligaments) and the anterior wall of the vagina.
A rectocoele,JEDOORRQVRXWIURPEHORZ6HSDUDWLQJ
the lower end of the vagina from the rectum is the perineal
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softening accelerates, and the collagen rods lose 95% of their
strength.18'XULQJGHOLYHU\WKHEDE\VKHDGJUHDWO\VWUHWFKHV
these collagen rods. Of course, the rods re-glue soon after
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position. Neither the ligaments nor the muscles can now
work properly, and this may lead to prolapse of the uterus,
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rectocoele.
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cardinal and uterosacral ligaments.
A perspective on organ prolapse
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vaginal delivery patients. Loose ligaments may occur in
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with loose ligaments, or they may have a congenital defect in
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The effect of age and menopause
Both collagen and elastin deteriorate markedly after the
menopause, and this explains the vast increase in prolapse
and incontinence which occurs after this event. A partly
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the menopause, may lose enough collagen after it, to
give way. This looseness may result in organ prolapse,
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replacement therapy (HRT) helps to slow down the
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prevention of osteoporosis, hip fractures, thickening of
the vaginal wall in sexually active patients, even perhaps
prevention of heart disease. Vaginally inserted oestrogen
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symptoms, there is no need for treatment. However, a patient
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even though the prolapse is minor.
When are these symptoms and prolapses problematical?
If a patient answers yes to one of the following, she has
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1. You lose urine during exertion or coughing.
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5. You feel a lump in your vagina (prolapse)
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How serious is the problem?
Assessment by the patient. 7KLVTXHVWLRQKRZVHULRXVLV
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Assessment by the clinic. The doctor has a different
advantageous for every post-menopausal woman, even SHUVSHFWLYHDWRDVVHVVZKLFKOLJDPHQWVKDYHEHHQGDPDJHG
those of the most mature age.
Site of damage and its consequences
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loosen the ligaments (thick grey lines) in the 3 zones of the
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assessment is paramount. This will vary according to the
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Algorithm, examination to assess ligamentous damage in
the 3 zones, and simulated operations(e.g. midurethral
YDJLQD7KHVHDUH$QWHULRU=RQHPHDWXVWREODGGHUQHFN anchoring during coughing in patients with urinary stress
0LGGOH =RQH EODGGHU QHFN WR FHUYL[ DQG WKH 3RVWHULRU incontinence or urge symptoms).
=RQH FHUYL[ WR SHULQHDO ERG\7KH QXPEHUV  LQGLFDWH Symptoms what they mean
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1. Stress incontinence $V\PSWRPLVDZDUQLQJEHOOIURPWKHEUDLQWKDWVRPHWKLQJ
2. Cystocoele LVZURQJZLWKVRPHSDUWRIWKHERG\$VUHJDUGVWKHSHOYLF
3. Prolapse of the uterus RRUPDQ\EODGGHUDQGERZHOV\PSWRPVDUHVHFRQGDU\WR
5HFWRFRHOH damage in one or more related ligaments, not from the organ
All may occur to varying degrees in the same patient. LWVHOI7KHFKDOOHQJHLVWRQGZKLFKOLJDPHQWVDUHFDXVLQJ
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P.E.P. Petros

The Diagnostic Algorithm indicates which ligaments are Characteristics of faecal incontinence
causing symptoms and prolapse Typical symptoms, in order of severity, are uncontrolled
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of damage, anterior, middle, or posterior ligaments.
How to use the Diagnostic Algorithm. Simply tick every
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the relevant columns for symptoms such as urgency and
emptying, which may occur in more than one column. In
such cases, other associated symptoms which are more
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Definitions for Symptoms
Stress incontinence Urine loss on effort, such as coughing,
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the lower part of the anus. It is what a patient feels when
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incontinence. It is idiopathic incontinence which is
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ligaments.
Characteristics of lumps (prolapse) in the vagina
Initially, these only appear during straining. The three
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exercise.
Abnormal emptying ,QDELOLW\ WR HPSW\ WKH EODGGHU RU
DEQRUPDORZ
Urgency$QXQFRQWUROODEOHGHVLUHWRSDVVXULQH
Frequency Going more than 8 times a day to the toilet to
pass urine.
Nocturia Getting up twice or more per night to pass urine.
Faecal incontinence Uncontrolled soiling from the
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Obstructed defaecation or constipation 'LIFXOW\ LQ
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Pelvic pain.3DLQLQWKHORZHUDEGRPHQORZHUSRVWHULRU
or during intercourse. Some types of vulvodynia and
interstitial cystitis are often associated with pelvic pain.
Symptoms occur in groups an aid to diagnosis
For example, urgency symptoms are indicated in all 3
columns. Symptom grouping is the only way we can deduce
which column (ligament) is causing the urgency. Fortunately,
urgency almost always occurs in tandem with at least one
other symptom.
Characteristics of pain* caused by posterior
ligament looseness
 /RZDEGRPLQDOGUDJJLQJSDLQXVXDOO\XQLODWHUDORIWHQ
right-sided
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symptoms accompany the prolapse, the symptoms may
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patient has a lump plus nocturia, pelvic pain and urgency, it
is highly likely that she has weak posterior ligaments, as per
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New time efficient pelvic floor exercises
strengthen muscles and ligaments
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the traditional Kegel methods were NOT addressing the
posterior closure muscles, which stretch, rotate, and close
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exercises the very same muscles which close the urethra
during coughing. We also reasoned that strengthening a
pelvic muscle would also strengthen the ligament against
which it contracted, and we knew from the surgery, that it
was ligament weakness which was causing the incontinence
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 /RZVDFUDOSDLQSDLQQHDUWKHWDLOERQH Kegel programme. Our target group of patients were those
Pain on deep penetration with intercourse
 /RZDEGRPLQDODFKHWKHQH[WGD\DIWHULQWHUFRXUVH
Tiredness
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down
Pain is reproduced on pressing the cervix or the posterior
wall of the vagina if a patient has had a hysterectomy.
* There is growing evidence that some types of introital
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however, was that those patients who were cured, did not
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They coughed, and did not leak.19-21
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emptying.
Characteristics of vulvodynia
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anus, with extreme sensitive to touch. This condition is
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Characteristics of bladder emptying difficulty
Typical symptoms are a slow stream, starting and
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have chronic urinary infections.

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time to perform them regularly. Even with our highly
motivated group, the dropout rate was 50%. Because of
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effective in the short-term.

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all the pelvic slow-twitch muscles, and their ligamentous
attachments.
Surgery based on the Integral Theory System
Tension-free techniques Beginning in the late 1980s
an entirely new surgical method for stress incontinence
was introduced. Polypropylene tapes were placed around
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The integral theory system
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less likely to surface in the wound.
Minislings- a new horizon for stress incontinence, and
repair of cystocoele, rectocoele, and prolapse of the uterus.
7KH7)6JZDVWKHUVWPLQLVOLQJ,WZDVDSSOLHGLQODWH
2003 to a patient with stress incontinence and uterovaginal
SURODSVH 6LQFH  WKHUH KDV EHHQ D SURIXVLRQ RI RWKHU
RSHUDWLRQ WR UHLQIRUFH WKH SXERXUHWKUDO OLJDPHQWV WKHQ D minislings introduced for cure of stress incontinence, for
little later, the posterior ligaments (infracoccygeal sacropexy, example, TVT-Secur, Mini Arc, Ophira, and many others.
PIVS).5 This method, now known as the tension-free Because the TFS is a tensioned sling, it can also address
WDSH WHFKQLTXH KDV UHYROXWLRQL]HG WKH WUHDWPHQW RI VWUHVV QRW RQO\ SURODSVH EXW DOVR PDQ\ V\PSWRPV IURP WKH
incontinence (SI) and prolapse surgery. The operations are 3LFWRULDO'LDJQRVWLF$OJRULWKPJLQFOXGLQJXUJHQF\
FRQGXFWHGYLDFPLQFLVLRQVLQWKHDEGRPLQDOVNLQMXVWDERYH QRFWXULDDEQRUPDOHPSW\LQJDQGSHOYLFSDLQ
WKHSXELFERQHJURLQRUSHULQHXP7KHUHLVPLQLPDOSDLQ Like other minislings, the TFS uses only small sections of
hospital stay is reduced to 1 or 2 days, and patients generally PRQRODPHQWWDSHJVRLWFDXVHVOHVVWLVVXHLUULWDWLRQ
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cure rate is high in the longer term. Later variations of these FDWKHGUDOFHLOLQJJIRUF\VWRFRHOHDQGUHFWRFRHOHUHSDLU
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SI (very successful), and the addition of mesh sheets to the DQGVRLWLVQRWVXEMHFWWRWKHDGKHVLYHFRPSOLFDWLRQVVHHQ
727 DQG 3,96 WHFKQLTXHV QRW VR VXFFHVVIXO 7KH RQO\
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was partial or total rejection of the tape/mesh. More recently,
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introduced to address incontinence and organ prolapse.22
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with large mesh. As with all polypropylene implantations,
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immune mechanisms. However, this occurs only in a small
percentage of patients, as only very small segments of tape
are used, and the anchor prevents slippage into the wound,
a major cause of erosion.
Only a tensioned minisling can reliably improve symptoms
Essential to cure of posterior zone symptoms with the
posterior tension-free sling was restoration of tissue
WHQVLRQ E\ DSSUR[LPDWLRQ RI ODWHUDOO\ GLVSODFHG WLVVXHV5
With the infracoccygeal sacropexy (posterior IVS),
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The TFS minisling, was designed to precisely
reconstruct and tension the 5 main structures which support
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laterally displaced tissues.
PART 3
ILLUSTRATIVE CASE HISTORIES
The following illustrative case histories are taken from the
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clinic in the world to apply the Integral Theory System.
ANTERIOR ZONE DAMAGE
In this section, we give a series of typical case reports from
SDWLHQWV ZKR FDPH WR WKH &OLQLF ZLWK SDUWLFXODU SUREOHPV
WDSHSDVVHVWKURXJKWKHXQLGLUHFWLRQDOWUDSGRRUDWWKHEDVHRIWKH ZKLFK PDLQO\ GHULYH IURP IURQW SXERXUHWKUDO OLJDPHQW
DQFKRU 7KLV RQHZD\ V\VWHP RI WLJKWHQLQJ EULQJV WKH ODWHUDOO\ looseness, in particular, stress incontinence. We also discuss
displaced ligaments and fascia towards the midline. RWKHUOHVVW\SLFDOSUREOHPV


P.E.P. Petros

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tensioned TFS tapes provide a much stronger support than meshes
which have a tendency to sag.

Stress incontinence (leaking during coughing) is the main

symptom for front ligament looseness.
Mrs CYL,was 55 years old, and she had had 3 normal
GHOLYHULHV 7KH XOWUDVRXQG VKRZHG WKDW KHU EODGGHU DQG
XUHWKUD EHFDPH RQH ODUJH IXQQHO ZKHQ VKH FRXJKHG DQG
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Mixed stress and urge incontinence from
front ligament looseness
Mrs JC, was a 38 year para 2. She had stress incontinence,
DQGVKHDOVRZHWZLWKXUJHQF\WLPHVDGD\EHIRUHVKH Fig. 21 - Anterior Zone defect The tick indicates only front ligament
DUULYHG DW WKH WRLOHW 6KH KDG EHHQ UHIXVHG VXUJHU\ IRU KHU damage. A TFS polypropylene tape was inserted through a very
VWUHVV LQFRQWLQHQFH EHFDXVH D XURG\QDPLF WHVW KDG VKRZQ VPDOO LQFLVLRQ LQ WKH YDJLQD WR UHSDLU WKH IURQW OLJDPHQW J 
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gently pressing an instrument upwards on one side in the
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This controlled her urine loss on coughing, and greatly
Bedwetting from childhood caused by a lax front ligament
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DVDFKLOG%HGZHWWLQJFOHDUHGDWSXEHUW\EXWVKHVWLOOZHW
with coughing and exercise, and with urge. Ultrasound
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GLPLQLVKHGKHUXUJHV\PSWRPV6KHZDVFXUHGRIERWKVWUHVV IURQW OLJDPHQW SXERXUHWKUDO ZDV ORRVH +HU EODGGHU
and urge with a polypropylene sling placed around the symptoms were cured with a TFS sling which reinforced
middle of her urethra to strengthen the front ligament. KHUSXERXUHWKUDOOLJDPHQWV

Fig. 20 - The TFS minisling (Tissue Fixation System) a new

DSSURDFK WR VXUJHU\ IRU SURODSVH ,W ZRUNV E\ DSSUR[LPDWLQJ
ODWHUDOO\ GLVSODFHG WLVVXHV DQG E\ UHLQIRUFLQJ WKH  VXVSHQVRU\
OLJDPHQWVRIWKHYDJLQD38/SXERXUHWKUDO$7)3FDUGLQDO&/ Fig. 22 - The mini or micro sling is inserted exclusively from
XWHURVDFUDO86/DQGDOVRWKHSHULQHDOERG\3% the vagina. It avoids most complications of tension-free slings.


 The integral theory system

Bedwetting from childhood and faecal incontinence

caused by a lax front ligament
In contrast, Miss G, 18 years old, had continued wetting
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and faecal incontinence. On examination, her urine loss
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operative visit, all symptoms were cured, and there was a
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state.
Stress faecal incontinence caused by a lax front ligament
0UV7\HDUVROGFDPHWRVHHXVEHFDXVHVKHORVWXULQH
and solid faeces on coughing. Again, symptom grouping
gave us the clue that her symptoms originated from
SXERXUHWKUDO OLJDPHQW GDPDJH +HU DVVHVVPHQW LQGLFDWHG
she had damaged front ligaments, which was successfully
addressed with a polypropylene midurethral sling.27
Comment
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If a ligament is loose, the muscles which close the
ERZHO FDQQRW ZRUN SURSHUO\ DQG WKH SDWLHQW PD\
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MIDDLE ZONE DAMAGE (CYSTOCOELE)
In this section, a series of typical case reports is presented
from patients who came to our Clinic with particular
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urge symptoms may derive from all 3 zones, all 3 spaces are ticked.
'LDJQRVLVRIDQWHULRU]RQHGHIHFWZDVPDGHE\GHGXFWLRQXVLQJWKH
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zone sympotms indicates anterior ligament damage.
looseness. Mostly patients with a cystocoele, only complain
of a lump in the vagina. However, they sometimes have
V\PSWRPVRIXUJHQF\DQGGLIFXOW\LQHPSW\LQJWKHEODGGHU
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Urge incontinence caused by cystocoele occurring
after prolapse repair
Mrs DV was 53 years old. She had had a successful repair
of the uterosacral ligaments for prolapse of the uterus 12
months earlier. She came to see us, stating that her symptoms
had reappeared in the past few weeks.
,WZDVQRWHGIURP0UV'9VTXHVWLRQQDLUHWKDWWKHQRFWXULD
DQGSHOYLFSDLQVKHKDGPRQWKVDJRUHPDLQHGFXUHGJ
25. When she was examined, it was evident that her posterior
ligaments (uterosacrals)were intact. There was no prolapse
of the uterus. However, a cystocoele was seen just inside the
vaginal entrance on straining. Her urgency symptoms were
UHOLHYHGE\JHQWO\VXSSRUWLQJWKHF\VWRFRHOHLQGLFDWLQJWKDW
this was the cause of her urge symptoms. The cystocoele
ZDVFXUHGE\7)6$7)3DQGFDUGLQDOOLJDPHQWRSHUDWLRQJ
5HOLHIRIXUJHQF\DQGLPSURYHGEODGGHUHPSW\LQJZHUH
reported immediately after the surgery.22
Comment Mrs DV is a good example of what
happens in patients with damaged ligaments. In up
to 30% of cases, repairing one part of the vagina can
EHIROORZHGE\DQRWKHUOXPSRUV\PSWRPDSSHDULQJ
weeks, months or even years later.
Recurrent or chronic cystitis its relationship to
abnormal emptying, cystocoele and prolapse of the uterus
Whilst there are many causes of cystitis, this presentation
FRQFHUQVSDWLHQWVZKRKDYHUHFXUUHQWF\VWLWLVEHFDXVHWKH\

P.E.P. Petros

)LJ7KHFHLOLQJMRLVWSULQFLSOHIRUF\VWRFRHOHUHSDLU6FKHPDWLF
view into the anterior wall of the vagina. The horizontal tape
provides structural support to the proximal half of the anterior
vaginal wall and recreates the cervical ring. The vertical U-sling
joins with existing ATFP structures to provide structural support to
the distal half of the vagina.

KDG  SUHYLRXV RSHUDWLRQV IRU SURODSVH DQG LQFRQWLQHQFH

some years earlier. She offered the cardinal symptom of this
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morning. She also lost urine on standing up from a chair,
RUEHQGLQJGRZQ
Fig. 25 - Middle Zone Defect The ticks indicated a middle or On examination, she did NOT lose urine during coughing,
SRVWHULRUGHIHFWIRU0UV'97KHSUHVHQFHRIDF\VWRFRHOHDEVHQFH
RIDSURODSVHRIWKHXWHUXVDQGLWVVSHFLFV\PSWRPVQRFWXULDDQG a common feature of this condition. The large amount of urine
SHOYLFSDLQLQGLFDWHGLWZDVDPLGGOHOLJDPHQWSUREOHP PHDVXUHGZLWKDKRXUSDGWHVWYDOLGDWHGWKHVHULRXVQHVV
RIWKLVODG\VSUREOHP7KHUHZDVYHU\OLWWOHPRYHPHQWRI
KHU EODGGHU QHFN GXULQJ VWUDLQLQJ ZLWK XOWUDVRXQG WHVWLQJ
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ligaments in the middle or posterior parts of the vagina. QHFN DUHD RI KHU YDJLQD 7KLV VFDUULQJ LPPRELOL]HG WKH
,QWKHDXWKRUVH[SHULHQFHF\VWRFRHOHDQGSURODSVHRIWKH muscles and ligaments needed to close the urethra, hence
XWHUXVDUHPDMRUFRUUHFWDEOHFDXVHVRIDEQRUPDOHPSW\LQJ the name, tethered vagina. A skin graft placed in this
DQGFKURQLFEODGGHULQIHFWLRQV5 DUHD J  UHVWRUHG HODVWLFLW\ DQG YDVWO\ LPSURYHG KHU
Other causes of recurrent cystitis incontinence.
$Q\WKLQJ ZKLFK LUULWDWHV WKH LQVLGH RI WKH EODGGHU VXFK Comment The tethered vagina syndrome is still not
DV D SRO\S D EODGGHU VWRQH RU SHQHWUDWLRQ RI D SODVWLF a well-recognized condition. It is entirely iatrogenic,
mesh after a surgical procedure for incontinence can cause DQG LV FDXVHG E\ H[FHVVLYH VFDUULQJ IURP SUHYLRXV
recurrent cystitis. The mesh can cause irritation per se, or
EHFRPHFDOFLHGLQWRDVWRQH,QVHUWLQJDF\VWRVFRSHLQWRWKH
EODGGHULVWKHEHVWPHWKRGIRUGLDJQRVLQJVXFKDSUREOHP
Other causes of abnormal emptying?
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ODEHOOHG DV GLDEHWLF QHXURSDWK\ LQ IDFW KDG GDPDJHG
uterosacral ligaments which prevented the opening muscles
from working properly. Such patients had accompanying
symptoms such as nocturia, urgency and pelvic pain, as
SHU WKH 3LFWRULDO 'LDJQRVWLF $OJRULWKP 'LDJUDP J 
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Severe wetting on getting out of bed in the morning caused
by excessive scarring from previous surgery tethered
vagina a hitherto unrecognised problem
Fig. 27 - The diagram shows how a cystocoele 2, droops
0UV (0  \HDUV ROG ZDV UHIHUUHG ZLWK D KLVWRU\ RI downwards in a sac, preventing it from emptying. The urine pool
worsening incontinence over the previous 2 years. She had gets infected over time, leading to chronic cystitis.


 The integral theory system

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Mrs LM had symptoms typical of looseness in the
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QRWHG WKDW VKH KDG VLJQLFDQW SURODSVH RI WKH XWHUXV EXW
it was not protruding. A TFS minisling was inserted to
reinforce the damaged uterosacral ligaments. The advantage
of the TFS method is that it can precisely tighten the vaginal
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DW D ORZ EODGGHU YROXPH  ,W LV D YHU\ PLQLPDO WHFKQLTXH
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only an overnight stay in hospital, and she returned to work
in 7 days. When reviewed at 9 months, she was getting up
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ORZDEGRPLQDOSDLQZDVVWLOOSUHVHQWEXWZDVEHWWHU
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infections since the operation.
The posterior TFS minisling operation is performed
entirely from the vagina, which makes it minimally invasive
and less painful than other sling procedures which pierce the
skin. It has a one-way tightening system, so it can restore
WKHWHQVLRQLQWKHOLJDPHQWVZKLWHDUURZV$GHTXDWHWLVVXH
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and urgency symptoms. Without restoring the tension, it is
)LJ0DUWLXVVNLQJUDIWDSSOLHGWRWKHEODGGHUQHFNDUHDRIWKH XQOLNHO\WKDWVXFKV\PSWRPVFDQEHFXUHG
YDJLQD VXEVHTXHQW WR H[WHQVLYH IUHHLQJ RI WKH XUHWKUD DQG YDJLQD Comment on the causation of urgency, nocturia and
IURP DGKHVLRQV WR WKH SXELF ERQH DQG HDFK RWKHU LQ D FDVH RI pain by damaged ligaments
tethered vagina syndrome. 6WURQJXWHURVDFUDOOLJDPHQWVDUHUHTXLUHGWRVXSSRUW
WKHSDLQEUHVZKLFKUXQLQVLGHWKHPDQGWRDQFKRU
surgeries. It is called the tethered vagina syndrome
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the muscles, and prevents them from closing the
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recognized as originating from a scarred vagina. It
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course, cannot succeed, as the cause is mechanical.
Treatment involves restoration of elasticity in the
EODGGHUQHFNDUHDRIYDJLQDXVLQJVRPHVRUHRIVNLQ
graft. Restoration of continence following skin graft
surgery is the ultimate proof of the Integral Theory .

POSTERIOR ZONE DEFECTS

In this section, some typical case reports from patients
DUH SUHVHQWHG IURP SUREOHPV ZKLFK PDLQO\ GHULYH IURP
posterior (uterosacral) ligament looseness.
Structural and functional consequences of laxity
in the uterosacral ligaments
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ligament damage are usually far more complicated and
serious, than those seen with damaged anterior or middle
ligaments. Sometimes patients complain of just a lump
in the vagina without accompanying symptoms. However,
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emptying are found as accompaniments to the prolapse.
+RZHYHU WKHVH V\PSWRPV PD\ RFFXU ZLWKRXW VLJQLFDQW
prolapse.
Laxity in the uterosacral ligaments associated with
uterovaginal prolapse nocturia, urgency,
abnormal emptying and pelvic pain
0UV/0\HDUVROGVWDWHG,JHWXSWLPHVDQLJKW Fig. 29 - Posterior Zone Defect Ticks in the posterior column are
,QGWKLVYHU\WLULQJDV,KDYHWRZRUNQH[WGD\,KDYHD typical for symptoms from damaged uterosacral ligaments. Ticks
GUDJJLQJSDLQRQWKHULJKWVLGHZKLFKFDQEHTXLWHGLVWUDFWLQJ are inserted in all column for urge and emptying. Grouping of
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P.E.P. Petros
the muscle forces which stretch the vagina to
VXSSRUWWKHQHUYHVDQGYROXPHUHFHSWRUVDWEODGGHU
EDVH/RRVHWLVVXHVZLOOQRWVXSSRUWWKHSDLQQHUYHV
ZKLFKGURRSDQGUHRIIVHQGLQJVLJQDOVRISDLQWR
WKHEUDLQ/LNHDWUDPSROLQHZLWKGDPDJHGVSULQJV
loose ligaments will not allow the muscles to stretch
WKHYDJLQD7KHEODGGHUQHUYHVDUHXQVXSSRUWHGDQG
UHRIISUHPDWXUHO\FDXVLQJXUJHDQGIUHTXHQF\
Pain during intercourse and bowel problems
caused by posterior ligament looseness.
0UV50ZDVD\HDUROGSDUD6KHVWDWHG,DOZD\V
KDYHXUJHQF\WRHPSW\P\ERZHOEXW,DPDOVRIUHTXHQWO\
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SUREOHPV HPSW\LQJ P\ EODGGHU 0\ ZRUVW SUREOHP LV
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examination, however, there was very minimal prolapse.
This was consistent with the Theory, which states that major
V\PSWRPVPD\EHFDXVHGE\PLQLPDOSURODSVHDQGDKLJKUDWH
VXSSRUWWKHSDLQEUHV$VWKHSHQLVWKUXVWVLQWRWKH
posterior part of the vagina, it will cause pain if it
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Severe Pelvic pain caused by uterosacral
ligament looseness.
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SDLQLQWKHULJKWVLGHRIKHUDEGRPHQ6RPH\HDUVSUHYLRXVO\
she had previously attended a London hospital which had
developed an international reputation using psychological
tests to prove that such pain was psychological in origin.
0UV'KDGUHDGZLGHO\RQWKHVXEMHFWRISDLQ+HUIDFLDO
expression indicated a person who was guarded. Her face lit
XSDIWHUVKHDQVZHUHGSRVLWLYHO\WRWKHIROORZLQJTXHVWLRQV
DVVKHNQHZWKDWZHNQHZZKDWKHUSUREOHPZDV
Do you have pain on deep penetration with intercourse?
Do you get up more than twice per night to pass urine?
'R\RXKDYHSUREOHPVHPSW\LQJ\RXUEODGGHU"
Do you have urgency?
Positive answers to at least some symptoms other than pain
DUHUHTXLUHGEHIRUHZHFDQSUHGLFWWKDWWKHSDLQLVFDXVHGE\
damage to the posterior ligaments. There are, after all, many
other causes of chronic pelvic pain in the 30 plus age group,
RILPSURYHPHQWXSWRZDVSRVVLEOHZLWKDSRVWHULRU
sling. No predictions were made for the urge to empty her
ERZHODQGKHUFRQVWLSDWLRQ6KHZDVDGYLVHGWKHVHFRXOGEH
due to many other causes, so we were reluctant to predict
cure for these symptoms. A posterior TFS minisling was
inserted to repair the posterior ligaments. Mrs RM was
discharged the next day with very little pain, and she went to
ZRUNWKHIROORZLQJZHHN6KHDWWHQGHGZLWKKHUKXVEDQGIRU
WKHSRVWRSHUDWLYHYLVLW6PLOLQJDQGFRQGHQWVKHUHSRUWHG
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in her other symptoms.
Comment on losing faeces during intercourse
IRUH[DPSOHHQGRPHWULRVLVLQIHFWLRQLQWKH)DOORSLDQWXEHV
SUREOHPVZLWKODUJHLQWHVWLQHWRQDPHMXVWDIHZ
7KLVLVZKDWVKHVDLGRQHZHHNDIWHUKHUSDLQZDVFXUHGE\
a small operation which tightened her posterior ligaments.28
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RQP\ULJKWVLGH,WKDVQRZEHHQDZHHNVLQFHWKHRSHUDWLRQ
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focus.
7KHRSHUDWLRQJZDVVLPSOHDQGLWZDVSHUIRUPHG
entirely under local anaesthesia. A 3 cm incision was made
This patient was a challenge to us, as some of her
symptoms were not the typical symptoms seen in the
Diagnostic Diagram. We had encountered women
RSHQLQJWKHLUEODGGHUGXULQJLQWHUFRXUVHEHIRUHEXW
QHYHUWKHLUERZHO,QVXFKFDVHVZHUHO\RQWKHRWKHU
typical symptoms to guide us as to which ligaments
KDYHEHHQGDPDJHGDQGRQWKHJXLGLQJSULQFLSOHRI
this type of surgery, repair the structure, and you
will repair the function.
Comment on pain with intercourse
Earlier we discussed how a loose ligament will not
Fig 30 - The TFS posterior minisling repairs and tightens the
posterior ligaments (arrows) without penetrating the skin of the
LQ WKH YDJLQD EHKLQG WKH FHUYL[7ZR VXWXUHV JUHHQ OLQHV
were inserted to tighten the ligaments (white arrows).
Comment
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it approximates damaged tissue to damaged tissue.
Insertion of a polypropylene sling gave a higher
V\PSWRPDWLFFXUHUDWHE\FUHDWLQJDFROODJHQRXVUH
LQIRUFHPHQWEHWWHUDEOHWRVXSSRUWWKHXQP\HOLQDWHG
nerve endings.
Vulvodynia pain and burning at the entrance to the
vagina caused by posterior ligament looseness.
0UV 3 ZDV  \HDUV ROG SDUD ZLWK FKURQLF SHOYLF SDLQ
diagnosed as having a psychological cause. Her General
Practitioner, an empathetic and caring man rang the doctor
EHIRUH VKH DUULYHG DQG DVNHG WKDW ZH KDQGOH KHU YHU\
FDUHIXOO\ DV VKH ZDV VHYHUHO\ GLVWXUEHG SV\FKRORJLFDOO\
that this was the reason for her pain, and there was nothing
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had visited many specialists over the years for her pain.
She had undergone several diagnostic laparoscopies, even
a hysterectomy, and had attended a pain clinic. None of
these treatments had helped her pain. The consensus from
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ZDVSV\FKRORJLFDO+HUUHSOLHVWRWKHTXHVWLRQQDLUHJDYHWKH
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Fig. 31 - Approximation of uterosacral ligaments A small 3cm
WUDQVYHUVHLQFLVLRQLQWRWKHYDJLQDMXVWEHORZWKHFHUYL[JDYHDFFHVV
for tightening her loose posterior ligaments (white arrows).
FRQWLQXDOO\DVVKHZHWWLPHVSHUGD\DQGKDGGLIFXOWLHV
HPSW\LQJKHUEODGGHU6KHDOVRKDGIDHFDOLQFRQWLQHQFH:H
DVNHGKHULIVKHKDGWROGKHU*HQHUDO3UDFWLWLRQHUDERXWKHU
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Examination revealed a prolapse of the posterior part of her
vagina. The entrance to the vagina was hypersensitive- she
UHFRLOHGZKHQJHQWO\WHVWHGZLWKDFRWWRQEXGWKHFODVVLFDO
test for vulvodynia (pain at the entrance of the vagina).
:HGLGQRWFODLPWKDWZHFRXOGFXUHWKLVODG\VSDLQDV
there are many other causes for pelvic pain. Nevertheless,
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[HG DQG WKDW WKHUH ZDV D VWURQJ SRVVLELOLW\ WKDW VRPH RI
her symptoms would also improve with a sling inserted
into the posterior part of her vagina, a fairly minor day-care
procedure.29, 30
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and calm. Her pain was gone, as was her urgency and faecal
incontinence. Her nocturia had reduced to 2 per night, and
KHUEODGGHUHPSW\LQJZDVLPSURYHG
$GLDJQRVLVWKDWDSDWLHQWVSDLQLVRISV\FKRORJLFDORULJLQ
LV QRW HQWLUHO\ XQUHDVRQDEOH $Q\ W\SH RI FKURQLF SDLQ LV
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SDWLHQWV GR EHFRPH SV\FKRORJLFDOO\ GLVWXUEHG %XW WKLV
GLVWXUEDQFHLVXVXDOO\VHFRQGDU\WRWKHSDLQ
The integral theory system
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6KHKDGGHYHORSHGSURODSVHRIWKHYDJLQDDQGEODGGHUZLWK
VLJQLFDQW EODGGHU V\PSWRPV XUJHQF\ DQG QRFWXULD 7KH
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collagen, and weakening of the posterior ligaments, a long-
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Abnormal emptying and chronic bladder infection caused
by looseness in the posterior ligaments
0UV .% D  \HDU SDUD  LJKW DWWHQGDQW KDG D ORQJ
KLVWRU\RILQDELOLW\WRHPSW\KHUEODGGHUDQGFKURQLFEODGGHU
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had reached a stage where she felt forced to consider leaving
her profession. She was diagnosed as having congenitally
weak posterior ligaments. She did not respond to our pelvic
RRU UHJLPH DQG VKH UHTXHVWHG VXUJLFDO UHFRQVWUXFWLRQ
of the ligaments. We agreed, having advised her that she
may need a caesarian section if she fell pregnant, as any
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returned to normal emptying immediately after the surgery,
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afterwards
Comment on abnormal bladder emptying in the
younger woman Congenitally weak posterior
OLJDPHQWVPXVWDOZD\VEHFRQVLGHUHGDVDFDXVHRI
DEQRUPDOEODGGHUHPSW\LQJLQWKH\RXQJHUZRPDQ
as these women do not generally have a cystocoele.
,QFUHDVHGGLIFXOW\LQHPSW\LQJWKHEODGGHUDWSHULRG
time in such women is highly suggestive that the
cause is looseness in the posterior ligaments. Other
symptoms such as pelvic pain, urgency and nocturia
DUH IUHTXHQWO\ SUHVHQW DQG WKHVH PD\ EHFRPH
worse during period time. Though not helpful with
0UV .% JRRG UHVXOWV LQ \RXQJ ZRPHQ KDYH EHHQ
DFKLHYHGDWRXU&OLQLFE\HQFRXUDJLQJVXFKSDWLHQWV
WRVTXDWLQVWHDGRIEHQGLQJDQGWRVLWRQDWEDOO
DWZRUNLQVWHDGRIDFKDLU7KHVHH[HUFLVHVZRUNE\
strengthening the pelvic muscles and ligaments.
$Q\HDUROGZRPDQQRWDEOHWRSDVVXULQHUHTXLULQJVHOI
-catheterisation caused by posterior ligament looseness.
There is a prevalence of this condition in Nursing Homes.
0DQ\SDWLHQWVUHTXLUHLQGZHOOLQJFDWKHWHUV
Mrs R was 87 years old, and weighed 90kg. She had had a
K\VWHUHFWRP\\HDUVHDUOLHU)RUVRPH\HDUVVKHQHHGHGWR
VHOIFDWKHWHUL]HWLPHVDGD\DVVKHFRXOGQRWSDVVXULQH
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Comment
We do not claim that all vulvodynia patients have this
causation. However, if other symptoms of posterior
OLJDPHQW ORRVHQHVV VXFK DV QRFWXULD DEQRUPDO
EODGGHUHPSW\LQJDQGXUJHQF\DUHJURXSHGZLWKWKH
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sling for repair of the posterior ligaments.
Hysterectomy for lower posterior ache and pelvic pain
caused by posterior ligament looseness.
Mrs JMK developed chronic lower posterior pain and
SDLQ ZLWK LQWHUFRXUVH DIWHU D GLIFXOW IRUFHSV GHOLYHU\ RI
her second child 50 years ago, when she was 27 years old.
7KHSDLQZRUVHQHGDIWHUWKHELUWKRIKHUWKLUGFKLOG\HDUV
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KDG ZRUVHQHG VXIFLHQWO\ WR UHTXLUH FRQVXOWDWLRQ ZLWK D
specialist gynaecologist. He told her that she needed to have
UHWDLQHGLQWKHEODGGHUDIWHUSDVVLQJXULQH2QWHVWLQJZH
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degree prolapse of the vagina. We inserted a posterior sling,
SHUIRUPHGDUHFWRFRHOHUHSDLUDQGSHULQHDOERG\UHSDLU6KH
passed urine immediately after the surgery. Her nocturia,
previously 5 times per night, reduced to twice per night.
Comment on how age causes ligament looseness and
EODGGHUHPSW\LQJGLIFXOWLHV
The tissues of the vagina and its supporting ligaments
PD\ ORRVHQ FRQVLGHUDEO\ ZLWK DJH 7KH HIIHFW RI
this is that many older women, especially those in
1XUVLQJ +RPHV FDQQRW HPSW\ WKHLU EODGGHU DQG
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a major cause of chronic cystitis, as they introduce
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P.E.P. Petros

Faecal incontinence, constipation and bleeding

caused by caused by posterior ligament looseness.
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the vagina. She had a 2nd degree prolapse of the uterus,
urgency, and nocturia. She also had faecal incontinence,
FRQVWLSDWLRQ J DQG RFFDVLRQDO EOHHGLQJ IURP WKH
ERZHO 6KH KDG EHHQ LQYHVWLJDWHG IRU WKH EOHHGLQJ E\ D
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early days where the Diagnostic Algorithm was applied,
we sometimes encountered patients with symptoms whose
origin we did not fully understand. One example of this is
WKH FRQVWLSDWLRQ IDHFDO LQFRQWLQHQFH DQG EOHHGLQJ ZKLFK
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the Diagnostic Diagram at that time. In all such cases, we
followed the principles of the Theory, repair the structure,
and you will improve the symptoms. We repaired the
SURODSVHRIWKHXWHUXVE\UHLQIRUFLQJWKHSRVWHULRUOLJDPHQWV
with a polypropylene sling. Mrs DMV had a good result. Her
faecal incontinence was cured, her constipation improved,
DQGKHUEOHHGLQJGLVDSSHDUHG31, 32
Explanation for Mrs DMVs improvement in her
constipation and bleeding. The reason for improvement
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uterosacral ligaments, like the apex of a tent. If the guy rope
of the tent (posterior ligament) is loose, the wall of the tent
will sag inwards, in this case, the wall of the vagina and
UHFWXP,WLVGLIFXOWWRKDYHDQRUPDOERZHOPRWLRQZKHQ
WKHERZHOZDOOVDUHORRVHDQGVDJJLQJLQWRWKHFDYLW\RIWKH
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caused congestion of the veins close to the cavity similar to
what happens with a haemorrhoid. This congestion caused
EOHHGLQJLQWRWKHERZHOFDYLW\IURPWLPHWRWLPH
The tape lifted up and tightened the attachments of the
XWHUXVYDJLQDDQGUHFWXPWRWKHWDLOERQHLQWKHVDPHZD\
a guy rope does to the apex of a tent. This tightened the
tissues, restored the function and improved her symptoms.
Bowel emptying problems cured by repair of posterior
ligaments and perineal body
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the rectocoele to protrude into the vagina as a sac containing
faeces. That is why she had to press into the lower part of
her vagina to facilitate evacuation.
Her posterior ligaments were repaired with a sling, and her
SHULQHDO ERG\ ZDV UHSDLUHGLQWKHWUDGLWLRQDOZD\ZLWKRXW
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SXVKHGDVLGHE\FKLOGELUWKWKHUHFWXPSURWUXGHVLQWR
the vagina. The traditional method relies on suturing
GDPDJHGWLVVXHWRGDPDJHGWLVVXHXQGHUVLJQLFDQW
tension. This method is very painful, and is prone to
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SHUPDQHQWO\MRLQWKHODWHUDOO\GLVSODFHGERGLHV
Urinary urgency, pelvic pain and nocturia cured by Pelvic
Floor Exercises
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symptoms of urgency, pelvic pain and nocturia at the age
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to work. Finally she contacted our Clinic through an
intermediary. She worked overseas, and could not attend the
Clinic for a formal assessment. We advised her how to use a
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the posterior wall of her vagina. The faecal incontinence ZDVUHPDUNDEOHYLUWXDOO\DOOKHUV\PSWRPVGLVDSSHDUHGDQG
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action of the posterior sling. The rectocoele and lax perineal Comment Non-surgical treatment of posterior
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returned to normal, and the rectocoele remained cured at her
2year review.
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ligament symptoms A vast improvement in symptoms
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especially effective in the younger woman.
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major cause of fecal incontinence. Pelviperineology 2008; 27:

102.
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into mechanisms for anorectal angle formation. Pelviperineology

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from Chantarasorn & Dietz. Pelviperineology, 2008; 27;105.
17. Petros PE, Swash M, Kakulas B. Stress urinary incontinence
results from muscle weakness and ligamentous laxity in the
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changes in the cervix during normal pregnancy and pregnancy
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1988; 71:563-567.
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to the Integral Theory of Female Urinary Incontinence- First
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Fig. 33 - Large rectocoele repair. Approximation of the perineal Biology 2001; 94: 264-269.
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RVF=rectovaginal fascia; CL=cardinal ligament.
Permission to publish
The Editors grant permission for any individual, group or
company to reproduce any text or document in this series
of articles, with the sole condition that this article is quoted
as a literature reference, and any diagram is appropriately
acknowledged in the text.
REFERENCES
1. Petros P E, Ulmsten U. An Integral Theory of female urinary
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6XSSOHPHQW
2. Petros P E, Ulmsten U. An Integral Theory and its Method, for
the Diagnosis and Management of female urinary incontinence,
Scandinavian Journal of Urology and Nephrology 1993; 27
Supplement No 153 1-93.
3. Petros P E, The International Continence Society and Integral
Theory systems for management of the incontinent female -a
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20. Petros PE and Skilling 30 7KH SK\VLRORJLFDO EDVLV RI SHOYLF
RRUH[HUFLVHVLQWKHWUHDWPHQWRIVWUHVVXULQDU\LQFRQWLQHQFH%U
-2EVWHW*\QDHFRO
21. Skilling PM, Petros PE. Synergistic non-surgical management of
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damaged suspensory ligaments and urinary and fecal incontinence.
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, $ 3URVSHFWLYH 5DQGRPL]HG &RPSDULVRQ RI 7UDQVREWXUDWRU
Tape and Tissue Fixation System Minisling in the Treatment of
Female Stress Urinary Incontinence: 3 Year Results, 2010, J.
Pelviperineology (in press).
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< 2XWSDWLHQW PLG XUHWKUDO WLVVXH [DWLRQ V\VWHP VOLQJ IRU
urodynamic stress urinary incontinence, The Journal of Urology
2009; 182:2810-3.
25. Petros PE Richardson PA. A 3 year follow-up review of uterine/
vault prolapse repair using the TFS minisling. ANZJOG 2009;

,QRXH + 6HNLJXFKL < .RKDWD < 6DWRQR< +LVKLNDZD.
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opening and closure: I muscle forces, Int. J. Urogynecol. and
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opening and closure: II vagina. Int. J. Urogynecol. and Pelvic
)ORRU
9. Petros PE, Swash M. The Musculoelastic Theory of anorectal
function and dysfunction. Pelviperineology, 2008; 27: 89-93.
10. Petros PE, Swash M. Directional muscle forces activate anorectal
continence and defecation in the female, Pelviperineology 2008;

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ligament in anorectal closure. Pelviperineology 2008; 27: 98.
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increases intra-anal pressure, validating its role in continence.
Pelviperineology 2008; 27: 99.
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anorectal closure is secondary to striated pelvic muscle
contraction. Pelviperineology, 2008; 27:100-101.
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to repair uterovaginal prolapse with uterine preservation: A
preliminary report on perioperative complications and safety J.
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referred pain arising from laxity in the uterosacral ligaments-
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PE, Role of the uterosacral ligaments in the causation of rectal
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a prospective study. Pelviperineology 2008; 27;118-121.
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reinforcement of the pelvic ligaments suggests a connective
tissue aetiology. Pelviperineology 2008; 27: 111-113.
Correspondence to:
Professor Peter Petros
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Email: kvinno@highway1.com.au
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