**11. The association of pelvic floor dysfunctions and different zones of connective tissue looseness at the pelvic floor (figure 8)**

The three zones of connective tissue looseness (see above) are associated with different symptoms. Petros (2010) developed the diagnostic algorithm (Figure 8) through considering the pathophysiology of dysfunctions and through practical experiences with the patients that had different forms and degrees of descensus/prolapse of the vaginal wall.

Many symptoms are associated with these different forms of descensus/prolapse: stress urinary incontinence, abnormal emptying of the bladder, urgency and frequency, nocturia, faecal incontinence, obstructed defecation and pelvic pain.

The Role of Altered Connective Tissue in the Causation of Pelvic Floor Symptoms 15

indication of the prevalence (probability) of the symptom. Stress urinary incontinence is mainly caused by anterior defects. Defects in the posterior zone cause different dysfunctions like abnormal emptying of the bladder, frequency and urgency, nocturia, fecal incontinence, obstructed defecation, pelvic pain known as the "posterior fornix syndrome" (Petros & Ulmsten 1993). Nocturia and pelvic pain are specific for posterior zone. Cystoceles mainly are associated with symptoms of abnormal emptying of the bladder and frequency and urgency. The significance of the association between zones and the respective symptoms has been

Fig. 8. Diagnostic algorithm. Pictorially elaborates the association between connective tissue looseness at different zones, their relationship with specific prolapses and symptoms, and how repair of the ligaments/fascia in each zone may cure or improve both the prolapse and the symptom(s). The size of the bars gives an approximate indication of the prevalence

In the past surgery has only been performed for prolapse and stress incontinence. We now recognise that symptoms of different degrees and combinations can be present in different forms and degrees of prolapse, as seen in Figure 8. Because of the peripheral neurological origin of some symptoms such as urgency and pain, major symptoms may occur with only minimal prolapse. Therefore the new anatomical and functional findings, as summarized in

(probability) of the symptom. (modified after Petros 2010, by permission)

Figure 8 have to be considered in modern pelvic floor surgery.

**12. Consequences of the diagnostic algorithm for surgical treatments** 

shown by Hunt et al. (2000) using Bayesian networks and decision trees.

Fig. 7. Pelvic pain caused by loose uterosacral ligaments (USL). Especially in the standing position, the uterus or vaginal vault prolapses under the influence of gravity 'G'. The unmyelinated nerves which run along the USLs are stretched by 'G', causing pain. (from P Petros 2010, by permission)

This algorithm summarizes the relationship between structural damage (prolapse) in the three zones and the respective functions (symptoms). The size of the bar gives an approximate

Fig. 7. Pelvic pain caused by loose uterosacral ligaments (USL). Especially in the standing position, the uterus or vaginal vault prolapses under the influence of gravity 'G'. The unmyelinated nerves which run along the USLs are stretched by 'G', causing pain. (from P

This algorithm summarizes the relationship between structural damage (prolapse) in the three zones and the respective functions (symptoms). The size of the bar gives an approximate

Petros 2010, by permission)

indication of the prevalence (probability) of the symptom. Stress urinary incontinence is mainly caused by anterior defects. Defects in the posterior zone cause different dysfunctions like abnormal emptying of the bladder, frequency and urgency, nocturia, fecal incontinence, obstructed defecation, pelvic pain known as the "posterior fornix syndrome" (Petros & Ulmsten 1993). Nocturia and pelvic pain are specific for posterior zone. Cystoceles mainly are associated with symptoms of abnormal emptying of the bladder and frequency and urgency. The significance of the association between zones and the respective symptoms has been shown by Hunt et al. (2000) using Bayesian networks and decision trees.

Fig. 8. Diagnostic algorithm. Pictorially elaborates the association between connective tissue looseness at different zones, their relationship with specific prolapses and symptoms, and how repair of the ligaments/fascia in each zone may cure or improve both the prolapse and the symptom(s). The size of the bars gives an approximate indication of the prevalence (probability) of the symptom. (modified after Petros 2010, by permission)
