Liedl_subbed.qxp 16/3/09 10:37 am Page 62
Overactive Bladder and Incontinence
Prolapse Repair and Stress Urinary Incontinence
a report by
Bernhard Liedl,
1
Florian Wagenlehner
2
and Peter Petros
3
1. Head, Urological Department, Pelvic Floor Centre, Munich; 2. Consultant Urologist, Urology and Paediatric Urology Clinic, Justus-Liebig University, Giessen;
3. Reconstructive Pelvic Floor Surgeon and Urogynaecologist, Royal Perth Hospital
The female pelvic floor is very complex. It enables support of the pelvic insertion areas the muscle actions are weakened. Childbirth, age and
organs and provides multiple functions, for example urinary continence, congenital collagen defects are major causes of lax ligaments and fascias
bladder emptying, faecal continence, defecation, sexual intercourse and and of vaginal prolapse and bladder and bowel dysfunction.
childbirth. In order to achieve all of these functions, the pelvic floor is
extremely active and responds immediately to changes of pressure or During childbirth, forcible lateral displacement of the uterosacral ligaments
weight.
1
The pelvic floor itself comprises 3D muscle architecture, which (USL), the perineal body (PB), the rectovaginal fascia, the pubourethral
essentially contracts against a net of ligaments and fascias. The pelvic floor ligament (PUL), the arcus tendineus fascia pelvis (ATFP), the cardinal
and its organs are intimately linked to the central nervous system through (CL)/cervical ring and the pubocervial fascia can be responsible for
multiple afferent and efferent neuronal systems. Damage at all levels (central connective tissue laxities. Both age-related degeneration of collagen and
nervous system, peripheral nervous system, organs and pelvic floor) can depolymerisation of collagen during pregnancy contribute to these
cause problems; however, the most important damage is caused by problems. It is of immense importance for the modern clinician to
anatomical lesions at the pelvic floor itself, which can be repaired surgically. understand that these laxities and the abnormal symptoms that accompany
In the last few years our understanding of the pelvic floor has increased, with them can be repaired (see Figure 1). The nine main sites of connective tissue
concomitant changes in pelvic floor surgery. defects that can be surgically repaired are outlined in the pictorial
diagnostic algorithm (see Figure 1).
Lax Suspensory Ligaments and Fascias Cause
Muscle Actions to Deteriorate and Dysfunction There are four main muscle groups that are of great importance for muscle
An important discovery was that looseness or laxity of ligaments and action. The anterior part of the pubococcygeus muscle (PCM) inserts into
fascias are the main causes of vaginal prolapse and dysfunction.
2
The the lateral part of the distal vagina and contracts forwards against the PUL
pelvic organs, urethra, vagina and rectum have no inherent form, and the PB (see Figure 2). The levator plate (LP) complex inserts into the
structure or strength; rather, these are created by the synergistic action posterior wall of the rectum and stretches the organs backwards, acting
of ligaments, fascia and muscles. With normal location of their insertion against the PUL, USL and PB. The longitudinal muscle of the anus (LMA)
areas the pelvic floor muscles can work normally; with dislocated connects the LP, PCM and puborectalis to the external anal sphincter and
creates a downward vector, which acts against the USL (see Figure 2).
These muscles act during coughing and straining. The fourth muscle is the
Bernhard Liedl is Head of the Urological Department at the
Pelvic Floor Centre in Munich and Chairman of the
puborectalis, which is part of the anorectal continence mechanism.
3
It is
International Collaboration of the Pelvic Floor (ICOPF).
also the muscle activated by ‘squeezing’, which elevates the whole LP and
Dr Liedl is a member of the German Society of Urology
also the rectum, vagina and bladder upwards and forwards (see Figure 3).
(DGU), the European Association of Urology (EAU) and the
Deutsche Kontinenz Gesellschaft. With increasing abdominal pressure the muscle activity of the levator
muscles increases promptly, mediated by neurogenic reflexes; this has been
E: liedl@bbzmuenchen.de
shown by in patients during laparoscopy.
1
Florian Wagenlehner is a Consultant Urologist at the
Urology and Paediatric Urology Clinic at the Justus-Liebig
Stress Urinary Incontinence Is Caused by
University in Giessen. His main scientific work is infectology Pelvic Floor Muscle Action
in urology and pelvic floor surgery. Dr Wagenlehner is a
In the past, stress urinary incontinence (SUI) was thought to be caused,
member of the German Society of Urology (DGU) and the
European Association of Urology (EAU).
at least partially, by passive transmission of the abdominal pressure to
the proximal urethra.
4,5
It is clear that abdominal pressure brings forces
E: Florian.Wagenlehner@chiru.med.uni-giessen.de
against the pelvic floor, but passive transmission is not important.
Muscle actions are responsible for the closure of the urethra. Criticisms
Peter Petros is a Reconstructive Pelvic Floor Surgeon and
Urogynaecologist at the Royal Perth Hospital. He is
of the transmission theory are:
co-author of the Integral Theory of Female Urinary
Incontinence, with Ulf Ulmsten, and of the Musculoelastic
• under straining, the rise in intra-urethral pressure precedes the rise in
Theory of Anorectal Function and Dysfunction in the Female,
with Michael Swash. Based on these theories, a series of intra-abdominal pressure by 160–240ms;
6–8
minimally invasive operations for the cure of urinary and
• the urethral pressure rise is higher than the pressure rise in
faecal incontinence, other pelvic symptoms and utero-
vaginal prolapse have been developed.
the bladder;
9
• the highest pressure rise is usually in the distal urethra and not in the
proximal urethra;
6
62 © TOUCH BRIEFINGS 2008
Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84  |  Page 85  |  Page 86  |  Page 87  |  Page 88  |  Page 89  |  Page 90  |  Page 91  |  Page 92  |  Page 93  |  Page 94  |  Page 95  |  Page 96  |  Page 97  |  Page 98  |  Page 99