A practical ligament-based diagnostic system for cure of pelvic symptoms and prolapse.

The Integral Theory Paradigm (ITP) has a 25-year track record of successfully treating bladder/bowel/pain symptoms caused by laxity in specific ligaments, even when the prolapse is minimal. The ITP-based treatment involves ligament support and can be nonsurgical or daycare surgical. An accurate diagnostic protocol is required. The Integral Theory Diagnostic system is performed in an outpatient setting. It a step-by-step "how to" resource for clinicians who wish to learn a practical anatomical diagnostic method which can quickly and accurately identify a ligament cause for bladder/bowel/pain symptoms, and therefore, potentially cure them. The structured ITP diagnosis flow chart uses symptoms to diagnose anatomical defects. It comprises 4 related steps. The ITP is holistic, and bladder, bowel, pain symptoms co-occur. The first step, therefore, is to establish all possible symptoms for transfer to the Diagnostic Algorithm which is the second step. Because patients complain of one main symptom, other symptoms must be located by direct questioning, using the Diagnostic Algorithm as an aide memoire, or a questionnaire to locate bladder, bowel, pain symptoms. Second step: symptoms are placed into 3 anatomical zones: anterior zone, pubourethral ligament (PUL) [stress urinary incontinence (SUI)]; middle zone, cardinal ligament (CL) (transverse defect cystocele); posterior zone, uterosacral ligament (USL) (uterine prolapse and enterocele). The third step is a vaginal examination to confirm the ligament damage (prolapses) in the three zones predicted by the algorithm. The fourth step is "simulated operations" (mechanical support of specific ligaments per vaginam) to validate the particular ligament indicated by the diagnostic algorithm, is indeed causing that symptom. For SUI, a hemostat test at midurethra supports PUL vaginally to stop urine loss on coughing; the lower blade of a bivalve speculum gently inserted into the vagina can relieve urge and pain.

Simulated operations (SOs) apply mechanical support to structures to confirm symptom causation.

Simulated operations (SOs) are a direct application of the Integral Theory (IT) mantras, "structure and function are related" and "restore the structure and you will improve the function". SOs performed in a clinic setting, are the most effective way possible to test the validity of the IT predictions: stress urinary incontinence (SUI) and urge are mainly caused by laxity in the vagina or its supporting ligaments. The SUI prediction of the IT is validated if a hemostat applied vaginally in the position of the midurethra to mechanically support the pubourethral ligament (PUL) immediately stops urine loss on coughing. The urge and chronic pelvic pain (CPP) predictions of the IT are similarly validated if a patient states her urge and pain symptoms are relieved by insertion of the bottom blade of a bivalve speculum which supports the uterosacral ligaments (USLs). An important use of SOs is to preoperatively assess (by the hemostat test) whether sling surgery for SUI is likely to cure the patient. Similarly, the speculum is very useful for diagnosing whether severe urge or pain symptoms in a woman with minimal prolapse are originating from weak USLs. If digital support of a cystocele relieves urge symptoms, the patient can reasonably be informed that a cystocele repair should improve the urge as well her cystocele prolapse. Used intraoperatively under spinal anesthesia, SOs can determine whether a sling is sufficiently tight to reverse the loose PUL which is causing the SUI. Approximating both cardinal ligaments (CLs) intraoperatively can result in a remarkable disappearance of a transverese defect cystocele; approximating USLs intraoperatively can give an indication of how effective a USL plication would be surgically.

Non-Hunner's Interstitial Cystitis Is Different from Hunner's Interstitial Cystitis and May Be Curable by Uterosacral Ligament Repair.

BACKGROUND: The posterior fornix syndrome (PFS) was first described in 1993 as a predictably occurring group of symptoms: chronic pelvic pain (CPP), urge, frequency, nocturia, emptying difficulties/urinary retention, caused by uterosacral ligament (USL) laxity, and cured by repair thereof. SUMMARY: Our hypothesis was that non-Hunner's interstitial cystitis (IC) and PFS are substantially equivalent conditions. The primary objective was to determine if there was a causal relationship between IC and pelvic organ prolapse (POP). The secondary objective was to assess whether other pelvic symptoms were present in patients with POP-related IC and if so, which ones? How often did they occur? A retrospective study was performed in 198 women who presented with CPP, uterine/apical prolapse (varying degrees), and PFS symptoms, all of whom had been treated by posterior USL sling repair. We compared their PFS symptoms with known definitions of IC, CPP, and bladder symptoms. To check our hypothesis for truth or falsity, we used a validated questionnaire, "simulated operations" (mechanically supporting USLs with a vaginal speculum test to test for reduction of urge and pain), transperineal ultrasound and urodynamics. KEY MESSAGES: 198 patients had CPP and 313 had urinary symptoms which conformed to the definition for non-Hunner's IC. The cure rate after USL sling repair was CPP 74%, urge incontinence 80%, frequency 79.6%, abnormal emptying 53%, nocturia 79%, obstructive defecation 80%. Our findings seem to support our hypothesis that non-Hunner's IC and PFS may be similar conditions; also, non-Hunner IC/BPS may be a separate or lesser disease entity from "Hunner lesion disease". More rigorous scientific investigation, preferably by RCT, will be required.

Symptoms of voiding dysfunction and other coexisting pelvic floor dysfunctions: the impact of transvaginal, mesh-augmented sacrospinous ligament fixation.

INTRODUCTION AND HYPOTHESIS: The objective was to investigate the prevalence for voiding dysfunction and if symptom improvement can be achieved by adequate pelvic floor surgery. METHODS: We evaluated the Propel Study data from 281 women with pelvic organ prolapse (POP) stage 2-4. Bother caused by obstructive micturition, voiding dysfunction, and coexisting pelvic floor symptoms were assessed using the Pelvic Floor Distress Inventory (PFDI) preoperatively and 6, 12, and 24 months after vaginal prolapse repair. Successful reconstruction (Pelvic Organ Prolapse Quantification [POP-Q] stage 0-I throughout the 2-year follow-up at all compartments, "responders"), was compared with all others ("non-responders"). RESULTS: Prevalence of voiding dysfunction was significantly reduced after surgery for all patients with "moderate" to "quite a bit" of bother ("R2") regarding all examined PFDI questions. Defects of the posterior/apical compartment and lower stage defects were found to cause obstructive micturition, which improved significantly after POP surgery. Six months after surgery, the prevalence of R2 for voiding dysfunction symptoms was reduced significantly for responders compared with non-responders. Significant reduction of R2 in patients with rectoceles could be shown for some PFDI questions, whereas the rate was lower in patients with cystoceles. Other pelvic floor symptoms often coexisted in patients with voiding dysfunction symptoms and improved significantly after surgery as well. CONCLUSIONS: Symptoms of voiding dysfunction are frequent in female patients with POP and can significantly improve after vaginal mesh-augmented prolapse repair even for posterior and minor defects. Before counseling patients to undergo POP surgery because of their obstructive symptoms, other causes of voiding dysfunction must first have been ruled out.

The impact of sacrospinous ligament fixation on pre-existing nocturia and co-existing pelvic floor dysfunction symptoms.

INTRODUCTION AND HYPOTHESIS: To evaluate whether nocturia and coexisting pelvic floor symptoms in women with pelvic organ prolapse (POP) can be improved by ligamentous fixation of apical vaginal prolapse to the sacrospinous ligament. METHODS: We evaluated the PROPEL study data from 281 women with pelvic organ prolapse stage > 2. Bothersome nocturia and coexisting pelvic floor symptoms were assessed with the Pelvic Floor Disorder Inventory (PFDI) questionnaire preoperatively and at 6, 12 and 24 months after successful vaginal prolapse repair. Women with successful reconstruction (POP-Q stage < 1 at all compartments throughout the 2-year follow-up), defined as anatomical "responders," were compared to the anatomical "non-responders." RESULTS: Among the patients completing all PFDI questions (N = 277), anatomical responders and non-responders were the groups of interest for our analysis. We found the occurrence rates of "moderate" or "quite a bit" of nocturia was significantly reduced after surgery in all subgroups (48.7% at baseline vs. 19.5% after 24 months). The occurrence of nocturia was halved for responders compared to non-responders (45.4% and 48.3% at baseline vs. 14% and 29.5% after 24 months). Anatomical non-responders still had a relevant improvement of POP-Q stages, especially in the apical compartment. Prevalence rates of co-existing over- and underactive bladder, fecal incontinence, defecation disorders and pain symptoms were also significantly reduced postoperatively. CONCLUSION: Nocturia can be associated with symptomatic POP, with improvements seen following vaginal ligamentous prolapse repair. We caution providers, however, when advising patients of the possible resolution of nocturia following POP reconstruction, that all other traditional etiologies of nocturia must first be ruled out.

How do elevated levels of testosterone affect the function of the human fallopian tube and fertility?-New insights.

Excess testosterone levels affect up to 20% of the female population worldwide and are a key component in the pathogenesis of polycystic ovary syndrome. However, little is known about how excess testosterone affects the function of the human fallopian tube-the site of gamete transport, fertilization, and early embryogenesis. Therefore, this study aimed to characterize alterations caused by long-term exposure to male testosterone levels. For this purpose, the Fallopian tubes of nine female-to-male transsexuals, who had been undergoing testosterone treatment for 1-3 years, were compared with the tubes of 19 cycling patients. In the ampulla, testosterone treatment resulted in extensive luminal accumulations of secretions and cell debris which caused ciliary clumping and luminal blockage. Additionally, the percentage of ciliated cells in the ampulla was significantly increased. Transsexual patients, who had had sexual intercourse before surgery, showed spermatozoa trapped in mucus. Finally, in the isthmus complete luminal collapse occurred. Our results imply that fertility in women with elevated levels of testosterone is altered by tubal luminal obstruction resulting in impaired gamete transport and survival.

Cure of Underactive and Overactive Bladder Symptoms in Women by 1,671 Apical Sling Operations Gives Fresh Insights into Pathogenesis and Need for Definition Change.

INTRODUCTION: To check evidence that symptoms identical with those constituting "underactive bladder" (UAB) and "overactive bladder" (OAB) are caused by apical prolapse and cured by repair thereof. MATERIAL AND METHODS: After repair of apical prolapse by mesh tape reinforcement of lax uterosacral ligaments (USL) data form 1,671 women were retrospectively examined to determine the presence of OAB and UAB symptoms and to check, how many were cured surgically. Thereby 3 different techniques were performed: elevate (n = 277), "Posterior IVS" (n = 1,049), and TFS cardinal (CL)/USL (n = 345). RESULTS: Symptoms identical with those comprising UAB and OAB were cured in up to 80% of cases following surgical repair of the CL/USL complex. CONCLUSIONS: These symptoms may be consistent with symptoms of the posterior fornix syndrome, which comprises 4 main symptoms: micturition difficulties, urge/frequency, nocturia, chronic pelvic pain, all consequent on USL laxity. Surgical cure of OAB and UAB is inconsistent with existing definitions, which imply pathogenesis of the detrusor muscle itself. A reconsideration and reformulation of existing definitions may be required. Altering UAB definition to "bladder emptying difficulties" and return to former definitions for OAB such as "detrusor" or "bladder instability" may help to restore compatibility with surgical cure of these conditions.

Can surgical reconstruction of vaginal and ligamentous laxity cure overactive bladder symptoms in women with pelvic organ prolapse?

OBJECTIVE: To examine the extent and intensity of the coexistence of overactive bladder (OAB) symptoms in women with pelvic organ prolapse (POP) and to evaluate the likelihood of OAB symptom improvement after surgical POP reconstruction over a period of 2 years. PATIENTS AND METHODS: The effectiveness of the transvaginal, single-incision 'Elevate' technique for anatomical cure of anterior/apical and posterior/apical vaginal prolapse has been previously reported in a prospective, multicentre study. This technique uses mesh arms attached to the sacrospinous ligaments to recreate apical ligamentous support. Using the same sample population as that used in the multicentre study (n = 281), we conducted the present sub-analysis focusing on estimating the extent of comorbidity between POP and OAB symptoms, as well as the effects of subsequent pelvic floor reconstruction on OAB symptoms over a long period. Assessments of POP and OAB symptom severity before and after surgery at 6, 12 and 24 months were obtained using the Pelvic Floor Distress Inventory (PFDI) questionnaire. RESULTS: Preoperatively, 70% of all POP patients reported moderate to severe OAB symptoms, with almost half (49.5%) noting severe OAB bother ('quite a bit bothersome') for one or more of the classic OAB symptom domains on the PFDI: 'daytime urinary frequency'; 'urinary urgency'; 'urinary urgency incontinence'; and/or 'nocturia'. In fact, across all four OAB symptom domains evaluated, there were significantly more severe symptoms ('quite a bit bothersome') than moderate ('moderately bothersome') or mild ('somewhat bothersome'): 26-31%, 13-21%, and 17-19% of patients, respectively. In patients with symptomatic POP >stage 2, there was no relationship between further degree of prolapse and presence of severity of OAB symptoms; however, patients with POP stage 2 had significantly more complaints regarding the items 'daytime urinary frequency' and 'urinary urgency incontinence' compared with those with stage 3-4 POP. Pelvic floor reconstructive surgery resulted in significant improvement in all OAB symptoms, which seemed to be stable over time. The cure rate of moderate-to-severe OAB complaints ranged between 60% and 80%, which was a durable improvement noted throughout 24 months. CONCLUSION: Results showed that POP was to a high degree accompanied by moderate-to-severe OAB complaints. Significant long-lasting improvements in bothersome OAB symptoms occurred after adequate surgical reconstruction of anterior/apical and posterior/apical vaginal support.

Is overactive bladder in the female surgically curable by ligament repair?

INTRODUCTION: Overactive bladder (OAB) symptoms (urge, frequency, nocturia) are not generally considered surgically curable by learning institutions. The Integral Theory hypothesizes that OAB is a prematurely activated, but normal micturition reflex caused by loose suspensory ligaments and potentially curable surgically by repairing such ligaments. To test this hypothesis by surgical repair of loose cardinal and uterosacral ligaments in patients with 2nd degree or greater uterine/apical prolapse. MATERIAL AND METHODS: Multicenter prospective case control audit. 611 females, mean age 70. Inclusions: symptomatic apical prolapse of 2nd or greater degree, (POPQ stages 2-4), and at least two pelvic symptoms. Exclusions: Comorbid medical problems known to cause chronic pelvic pain (e.g., infection), sphincter tears, neurological bladder conditions. Surgery: minimally invasive cardinal/uterosacral ligament repair using the TFS (Tissue Fixation System). Primary outcome: Uterine prolapse cure; Secondary outcomes; bladder, bowel, and pain symptoms improvement. RESULTS: 90% prolapse cure in 611 patients. Symptom incidence (% Cure at 12 months in brackets) was: urge incontinence: n = 310 (85%); frequency: n = 317 (83%); nocturia: n = 254 (68%); chronic pelvic pain (CPP): n = 194 (77%); fecal incontinence: n = 93 (65%). Statistics: McNemar x2-tests to test for significant changes in the symptoms' incidence-frequency from baseline (preoperative) to the postoperative phase. For each symptom the null hypothesis H0: P(baseline) = P(12 months after surgery)versus H1: P(baseline) ≠ P(12 months after surgery) was tested, with P indicating prevalence or incidence rate. CONCLUSIONS: Bladder & bowel incontinence and chronic pelvic pain occur in predictable groupings and are associated with apical prolapse. OAB symptom improvement with the TFS ligament repair provides a good alternative to anticholinergics, especially when considering their association with dementia causation. Application of the Integral Theory System has the potential to significantly improve clinical practice, QoL for ageing women, delaying entry into Nursing Homes and creating new scientific research directions. The take home message is that symptoms of chronic pelvic pain, bladder and bowel dysfunction occur in relatively predictable groups, caused by lax suspensory ligaments and can be cured or improved by TFS mini sling ligament repair.

Current treatment of pelvic organ prolapse correlated with chronic pelvic pain, bladder and bowel dysfunction.

PURPOSE OF REVIEW: The purpose of this review is to critically analyze the relationship between symptoms of abnormal emptying of the bladder, urgency, pelvic pain, anorectal dysfunction and pelvic organ prolapse (POP) and to present evidence in order to show how many of the above mentioned symptoms can be cured or substantially improved by repair of specific pelvic ligaments. RECENT FINDINGS: In this review, we provide evidence to show how often these dysfunctions occur and how they can be cured in 42-94% by appropriate pelvic floor surgery in the longer term, up to 2 years. Laxity in ligaments and/or vaginal membrane due to damaged connective tissue may prevent the normal opening and closure mechanism of urethra and anus, because muscles need finite lengths to contract properly. Hypermobility of the apex can irritate the pelvic plexus causing chronic pelvic pain. In consequence, dysfunctions as abnormal emptying of the bladder, urgency, pelvic pain, fecal incontinence and obstructed defecation can occur in women with different degrees of POP. SUMMARY: In conclusion, it has to be recognized that women bothered by these symptoms should be examined for POP and appropriately advised for possibility of cure by pelvic floor surgery after careful selection. VIDEO ABSTRACT.

Effects of Elevated ß-Estradiol Levels on the Functional Morphology of the Testis - New Insights.

Elevated estradiol levels are correlated with male infertility. Causes of hyperestrogenism include diseases of the adrenal cortex, testis or medications affecting the hypothalamus-pituitary-gonadal axis. The aim of our study was to elucidate the effects of estradiol treatment on testicular cellular morphology and function, with reference to the treatment regimen received. Testes samples (n = 9) were obtained post-orchiectomy from male-to-female transsexuals within the age range of 26-52 years. Each patient had a minimum of 1-6 years estradiol treatment. For comparison, additional samples were obtained from microscopically unaltered testicular tissue surrounding tumors (n = 7). The tissues obtained were investigated by stereomicroscopy, histochemistry, scanning electron microscopy (SEM) and immunohistochemistry. Our studies revealed that estradiol treatment significantly decreased the diameter of the seminiferous tubules (p < 0.05) and induced fatty degeneration in the surrounding connective tissue. An increase in collagen fiber synthesis in the extracellular matrix (ECM) surrounding the seminiferous tubules was also induced. Spermatogenesis was impaired resulting in mainly spermatogonia being present. Sertoli cells revealed diminished expression of estrogen receptor alpha (ERα). Both Sertoli and Leydig cells showed morphological alterations and glycoprotein accumulations. These results demonstrate that increased estradiol levels drastically impact the human testis.

Probe-based confocal laser endomicroscopy (pCLE): a preclinical investigation of the male genital tract.

The aim of this study was to assess the potential of probe-based confocal laser endomicroscopy (pCLE) as a new diagnostic imaging technique for the male genital tract. For this purpose, testes, epididymides, and vasa deferentia were obtained during transsexual surgery of healthy patients (n = 10, 26-52 years). Prior to this, testes of rats (n = 10, Sprague-Dawley) and mice (n = 8, wild-type) were examined. Ex vivo tissues were investigated by pCLE after topical fluorescence staining. Images and pCLE real-time video sequences were compared to images acquired by confocal laser scanning microscopy (CLSM); this allowed the identifying of corresponding microstructures. Interestingly, the seminiferous tubules of transsexual humans contained mainly spermatogonia due to long-term estrogen treatment, whereas the seminiferous tubules of the murine and rat spermatogenesis-related cell types were differentiated. Mosaicking improved the inspection potential by wide-angle views. Similarly, the microarchitecture of the epididymis and the vas deferens was successfully visualized in situ and on a cellular level by pCLE. In summary, pCLE allows for real-time identification of relevant microstructures responsible for spermatogenesis under ex vivo conditions. Additionally, pCLE enabled to localize vital spermatozoa in the testis thus opening up new ways to improve sperm retrieval rates during assisted reproduction. Both clinically relevant experiences hold promise to introduce this diagnostic method into a clinical study, and to investigate its potential as a clinical diagnostic procedure to expedite and improve the medical situation.

Probe-based confocal laser endomicroscopy (pCLE) - a new imaging technique for in situ localization of spermatozoa.

In azoospermic patients, spermatozoa are routinely obtained by testicular sperm extraction (TESE). However, success rates of this technique are moderate, because the site of excision of testicular tissue is determined arbitrarily. Therefore the aim of this study was to establish probe-based laser endomicroscopy (pCLE) a noval biomedical imaging technique, which provides the opportunity of non-invasive, real-time visualisation of tissue at histological resolution. Using pCLE we clearly visualized longitudinal and horizontal views of the tubuli seminiferi contorti and localized vital spermatozoa. Obtained images and real-time videos were subsequently compared with confocal laser scanning microscopy (CLSM) of spermatozoa and tissues, respectively. Comparative visualization of single native Confocal laser scanning microscopy (CLSM, left) and probe-based laser endomicroscopy (pCLE, right) using Pro Flex(TM) UltraMini O after staining with acriflavine.

A finite element model validates an external mechanism for opening the urethral tube prior to micturition in the female.

PURPOSE: Existing theories for micturition in the female mandate total relaxation of the pelvic floor while detrusor pressure pushes the urethra open. However, video X-ray and electromyogram data indicate that micturition is preceded by active outwards opening of the outflow tract by backward-/downward-acting muscle vectors. If the detrusor pressure alone is enough to expand the tube, why does the active opening take place? The aim was to model the urethral tube in detail to assess the relative importance of the active opening mechanism and detrusor pressure. METHODS: Finite element methods were used to model the urethral tube in detail. Nonlinear-elastic properties similar to urethral component tissues were taken from the literature. The boundary conditions applied to the tube model included internal pressure due to detrusor contraction (60 cm H2O) and various displacements and constraints such as pubourethral and pubovesical ligament attachments. RESULTS: In order to achieve opening dimensions similar to those in the lateral X-ray under the action of detrusor pressure alone, the pressure had to be increased by two orders of magnitude above normal levels. CONCLUSIONS: Normal detrusor pressure alone is not sufficient to achieve opening of the urethra against the elasticity of the constituent tissues, suggesting that normal micturition requires an active mechanism provided by backward-/downward-acting pelvic floor muscles, as predicted by the integral theory.