Pelvic floor dysfunction, the role of imaging and reconstructive surgery

Abstract

We are putting forward three novel concepts describing the pathophysiology concerning: • Micturition, factors that control urinary continence and different types of urinary incontinence. • Genital organs support and genital prolapse. • Defecation, causes of fecal incontinence (FI). I. Urinary continence depends on high urethral pressure (Pura) which depends upon two factors: One inherent and one acquired. 1. The inherent factor is the tough strong collagen layer constituent of the internal urethral sphincter (IUS), that creates the high wall tension necessary for keeping high urethral pressure (Pura). The IUS is a collagen-muscle tissue cylinder that extends from the bladder neck to the perineal membrane in both sexes. 2. The acquired factor, which is high alpha-sympathetic tone at the IUS gained from learning and training in early childhood, keeps it contracted and the urethra closes all the time until there is a need or a desire to void as social circumstances allow. Injury to one or both factors leads to urinary incontinence. II. The vagina is a cylinder of collagen-elastic-muscle tissues. The strong tough collagen sheet is responsible for the upright position of the vagina. The main function of the pelvic ligaments is to assign the pelvic organs to their anatomical site and keeps the pelvic organs in situ. Childbirth trauma damages the collagen layer due to overstretching of the vagina and leads to flabby and redundant vaginal walls with subsequent vaginal prolapse. When the pelvic ligaments suffer most of the trauma, the insult will lead to weakness of the pelvic ligaments, leading to vault and uterine prolapse. III. The integrity of both anal sphincters, internal anal sphincter (IAS) and external anal sphincter (EAS) is an essential factor in keeping fecal continence. Fecal continence also depends on strong pelvic floor muscles which keep an angle between the rectum and the anal canal. In addition, it depends on an acquired behavior, gained by learning and training in early childhood of maintaining high alpha-sympathetic tone at the IAS keeping the anal canal empty and closed all the time until there is a desire and/or a need to pass flatus and/ or stool and there are favorable social circumstances. The intimate relation of the IUS with the anterior vaginal wall and the IAS with the posterior vaginal wall exposes them to the childbirth trauma with subsequent damage. This will lead to stress urinary incontinence (SUI) and FI in addition to vaginal prolapse. Therefore, we have innovated an operation to treat SUI, FI and vaginal prolapse. 'Urethro-ano-vaginoplasty' repair operation. It consists of anterior and posterior sections. In the anterior section, we have corrected the SUI and the anterior vaginal wall descent through the following steps: 1. Expose the IUS and mend its torn wall. 2. Strengthen the anterior vaginal wall by overlapping the two vaginal flaps, and hence we can add extra support to the mended IUS and preserve the body collagen. In the posterior section, we have the following: 1. Exposed the IAS and mended the torn sphincter. 2. We have approximated the two-levator ani muscles. 3. Strengthened the posterior vaginal wall by overlapping the two vaginal flaps; as such, we would have also added extra support to the mended IAS and kept the natural body collagen. 4. We repaired the perineum.