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

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

The Role of Altered Connective Tissue in the Causation of Pelvic Floor Symptoms 17

Looking at the bladder neck closure mechanism the midurethral tape should be positioned along the pubourethral ligament, which inserts retropubically. This seems especially

Fig. 9. The use of tensioned tapes to strengthen the principal connective tissue structures which support the vagina, bladder, uterus and rectum: pubourethral ligament (PUL), arcus tendineus fascia pelvis (ATFP), cardinal ligament (CL), uterosacral ligaments (USL), perineal body (PB). These 5 structures are the effective insertion points of the directional muscle forces (arrows) which support the organs, and which open and close the urethra and anorectum, anteromedial part of pubococcygeus muscle (PCM), levator plate (LP) and

The transobturatoric approach for tape insertion may be an option for mild and moderate cases. New techniques using mini tissue anchors are promising. The TFS (Tissue Fixation System) tensioned tapes (Petros 2010) accurately reinforce the main suspensory ligaments – pubourethral (PUL), uterosacral (USL), cardinal (CL), arcus tendineus fascia pelvis (ATFP) and perineal body (PB) while bringing the laterally displaced tissues towards the midline (figure 9). This action more precisely restores the musculoelastic tension required to also restore function. The meshes with sling fixation transobturatorially or at the sacrospinous ligaments only produces long lasting barriers. At the moment the pelvic floor surgery is in a

longitudinal muscle of the anus (LMA). (from P Petros 2010, by permission)

important in patients with severe stress urinary incontinence or recurrence.

In daily practice, first, the different symptoms have to be identified with the help of a standardized questionnaire, for instance using Petros`s questionnaire (Petros 2010, pages 270-273). Then the existing pelvic floor defects are assessed. Very helpful are the diagnostic algorithm (Figure 8) and "simulated operations" (Petros 2010) to indicate the appropriate surgery. An example of a "simulated operation" is the controlled urine loss on coughing by applying unilateral digital pressure at midurethra (Pinch-Test). Another is exposure of latent stress incontinence by pushing the prolapse back into the vagina, and asking the patient to cough.

"Restoration of form (structure) leads to restoration of function" (Petros 2010). This principle directly applies Gordon's Law: exact restoration of the insertion points of the pelvic floor muscles allows the muscles to act optimally. The function – even if complex – should thus have the optimal chance to recover.

When repair of weak tissues by conventional techniques such as suturing is not possible (for example repair of a pubourethral ligament for cure of USI), or the recurrence rate is too high, the use of alloplastic materials is an option. Because normal function requires a neurologically complex co-ordination of smooth and striated muscle, any surgery must mimic the natural anatomy as closely as possible if it is to restore function.

The axis of the posterior vagina is nearly horizontal because the uterosacral ligaments insert dorsally between S2-4. Elevation of the vagina to the promontorium is too cranial, while fixation of the vagina to the sacrospinous ligament is too caudal. It is a surgical compromise to use these areas for easy and safe fixation but the site of the uterosacral ligament remains the optimal site for its reconstruction. The uterus needs to be conserved whenever possible. It is the central anchoring point for the posterior ligaments, the rectovaginal fascia and the pubocervical fascia. The descending branch of the uterine artery is a major blood supply for these structures, and should be conserved where possible even if subtotal hysterectomy is performed.

It is important to understand that tissue structure is often displaced laterally (e. g. cardinal ligaments, uterosacral ligaments, rectovaginal fascia, pubocervical fascia, hammock, perineal body). Surgical techniques, which bring the tissues together in the midline or bridge it with alloplastic tapes at the anatomically correct position, should be applied and further developed. Simply applying a large mesh provides a barrier to the prolapse and does not restore the damaged anatomy or function. Instead, such meshes have the tendency to shrink and reduce elasticity of tissues. Furthermore, they obliterate the organ spaces. This may cause pain, dyspareunia, and erosions and may negatively affect the dissection required in cases where the patient develops rectal or bladder carcinoma. The use of alloplastic materials has to be reduced to the necessary amount and their application sites carefully considered. The conventional techniques have to be evaluated following these fundamental principles (Liedl 2010, Wagenlehner et al. 2010)

In order to minimize pain, surgery to the perineal skin and tension when suturing the vagina should be avoided. Vaginal excision should be avoided even in patients with large bulging prolapse. After repair of underlying ligamentous fascial defects, the vaginal wall contracts and will be more elastic than after excision. Tightness or elevation of the bladder neck area of the vagina as well as indentation of the urethra with a midurethral sling should be avoided in order to avoid urinary retention.

In daily practice, first, the different symptoms have to be identified with the help of a standardized questionnaire, for instance using Petros`s questionnaire (Petros 2010, pages 270-273). Then the existing pelvic floor defects are assessed. Very helpful are the diagnostic algorithm (Figure 8) and "simulated operations" (Petros 2010) to indicate the appropriate surgery. An example of a "simulated operation" is the controlled urine loss on coughing by applying unilateral digital pressure at midurethra (Pinch-Test). Another is exposure of latent stress incontinence by pushing the prolapse back into the vagina, and asking the

"Restoration of form (structure) leads to restoration of function" (Petros 2010). This principle directly applies Gordon's Law: exact restoration of the insertion points of the pelvic floor muscles allows the muscles to act optimally. The function – even if complex – should thus

When repair of weak tissues by conventional techniques such as suturing is not possible (for example repair of a pubourethral ligament for cure of USI), or the recurrence rate is too high, the use of alloplastic materials is an option. Because normal function requires a neurologically complex co-ordination of smooth and striated muscle, any surgery must

The axis of the posterior vagina is nearly horizontal because the uterosacral ligaments insert dorsally between S2-4. Elevation of the vagina to the promontorium is too cranial, while fixation of the vagina to the sacrospinous ligament is too caudal. It is a surgical compromise to use these areas for easy and safe fixation but the site of the uterosacral ligament remains the optimal site for its reconstruction. The uterus needs to be conserved whenever possible. It is the central anchoring point for the posterior ligaments, the rectovaginal fascia and the pubocervical fascia. The descending branch of the uterine artery is a major blood supply for these structures, and should be conserved where possible even if subtotal hysterectomy is

It is important to understand that tissue structure is often displaced laterally (e. g. cardinal ligaments, uterosacral ligaments, rectovaginal fascia, pubocervical fascia, hammock, perineal body). Surgical techniques, which bring the tissues together in the midline or bridge it with alloplastic tapes at the anatomically correct position, should be applied and further developed. Simply applying a large mesh provides a barrier to the prolapse and does not restore the damaged anatomy or function. Instead, such meshes have the tendency to shrink and reduce elasticity of tissues. Furthermore, they obliterate the organ spaces. This may cause pain, dyspareunia, and erosions and may negatively affect the dissection required in cases where the patient develops rectal or bladder carcinoma. The use of alloplastic materials has to be reduced to the necessary amount and their application sites carefully considered. The conventional techniques have to be evaluated following these

In order to minimize pain, surgery to the perineal skin and tension when suturing the vagina should be avoided. Vaginal excision should be avoided even in patients with large bulging prolapse. After repair of underlying ligamentous fascial defects, the vaginal wall contracts and will be more elastic than after excision. Tightness or elevation of the bladder neck area of the vagina as well as indentation of the urethra with a midurethral sling should

mimic the natural anatomy as closely as possible if it is to restore function.

fundamental principles (Liedl 2010, Wagenlehner et al. 2010)

be avoided in order to avoid urinary retention.

patient to cough.

performed.

have the optimal chance to recover.

Looking at the bladder neck closure mechanism the midurethral tape should be positioned along the pubourethral ligament, which inserts retropubically. This seems especially important in patients with severe stress urinary incontinence or recurrence.

Fig. 9. The use of tensioned tapes to strengthen the principal connective tissue structures which support the vagina, bladder, uterus and rectum: pubourethral ligament (PUL), arcus tendineus fascia pelvis (ATFP), cardinal ligament (CL), uterosacral ligaments (USL), perineal body (PB). These 5 structures are the effective insertion points of the directional muscle forces (arrows) which support the organs, and which open and close the urethra and anorectum, anteromedial part of pubococcygeus muscle (PCM), levator plate (LP) and longitudinal muscle of the anus (LMA). (from P Petros 2010, by permission)

The transobturatoric approach for tape insertion may be an option for mild and moderate cases. New techniques using mini tissue anchors are promising. The TFS (Tissue Fixation System) tensioned tapes (Petros 2010) accurately reinforce the main suspensory ligaments – pubourethral (PUL), uterosacral (USL), cardinal (CL), arcus tendineus fascia pelvis (ATFP) and perineal body (PB) while bringing the laterally displaced tissues towards the midline (figure 9). This action more precisely restores the musculoelastic tension required to also restore function. The meshes with sling fixation transobturatorially or at the sacrospinous ligaments only produces long lasting barriers. At the moment the pelvic floor surgery is in a

The Role of Altered Connective Tissue in the Causation of Pelvic Floor Symptoms 19

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**2** 

**Epidemiology of Urinary** 

Steinar Hunskaar and Guri Rortveit

*Department of Public Health and Primary Health Care,* 

Stian Langeland Wesnes,

*University of Bergen,* 

*Norway* 

**Incontinence in Pregnancy and Postpartum**

Urinary incontinence is a common condition in pregnancy and postpartum. There are published more than a thousand articles on urinary incontinence (UI) in pregnancy. Incidence and prevalence figures of UI in association with pregnancy vary substantially.

Not many reviews have focused solely on incidence and prevalence of UI in association with pregnancy. One report gives a range of prevalence of UI in pregnancy from 32 to 64 % (Milsom et al., 2009). There are published few reviews on incident UI postpartum, most of them are based on a small number of studies. However, one systematically review (Thom & Rortveit, 2010) and several traditional reviews have been published on prevalence of UI

This chapter on epidemiology of urinary incontinence in pregnancy and postpartum reviews the incidence and prevalence of UI in pregnancy and postpartum on the basis of a non-systematic PubMed search. The selected articles are chosen due to relevance, quality,

Published articles will be listed in tables. Tables will contain data on author and article, country of origin of the study, type of study, number of participants, time point in pregnancy and postpartum of information gathering, means of information gathering (questionnaire, interview, objective testing), and prevalence and incidence figures. Parity is an established risk factor for UI. Tables will therefore be stratified for primiparous and parous women. Large studies of good quality are referred to in the text. We will summarize incidence and prevalence figures from single papers; both range of all figures and a more narrow range of figures without the two highest and lowest outliers will be given. We will

Prevalence and incidence estimates of UI in association with pregnancy vary very much and with a factor of 7 – 10. We will discuss study design, characteristics of the study population, biases, definitions and other methodological reasons for the diverging estimates, and try to help the reader understand why estimates differ. Hopefully this will give a better

**1. Introduction** 

postpartum.

citation and sample size.

also give estimates from former reviews.

