**Part 1**

**The Basics** 

**1** 

*Germany* 

*1Pelvic Floor Centre Munich,* 

*2Urological Clinic of the University of Giessen, 3Urological Department Klinikum Detmold,* 

**The Role of Altered Connective Tissue** 

**in the Causation of Pelvic Floor Symptoms** 

B. Liedl1,\*, O. Markovsky1, F. Wagenlehner2 and A. Gunnemann3

The pelvic floor consists of muscles and connective tissue. In the past, the components' relative contribution to the structural support of the pelvic floor and its functions has been a subject of controversy (Corton 2009). With increasing age women can develop vaginal and pelvic organ prolapse as well as symptoms such as stress urinary incontinence, voiding dysfunction, urgency and frequency and nocturia, and may also develop fecal incontinence, obstructive defecation and pelvic pain (Petros 2010). All of these symptoms can be

What events are responsible for these defects? One theory says that an important cause of prolapse and pelvic floor dysfunction is likely to be partial denervation (Swash et al 1985, Smith et al. 1989). But Pierce et al. (2008) demonstrated in nulliparous monkeys that bilateral transection of the levator ani nerve resulted in atrophy of denervated levator ani muscles but not in failure of pelvic support. This indicates that connective tissue components could compensate for weakened pelvic floor muscles. According to South et al. (2009), in up to 30 percent of all vaginal childbirths, pelvic floor muscles are partially denervated. However, such functions are known to recover and reinnervate often within

In a direct test of the question, "connective tissue or muscle damage?", Petros et al 2008 performed a blinded prospective study with muscle biopsies of m.pubococcygeus taken at the same time as a midurethral sling operation for urinary stress incontinence (USI) was done, an operation which works by creating an artificial collagenous neoligament (Petros PE, Ulmsten U, Papadimitriou 1990). Out of 39 patients with histological evidence of muscle damage, 33 (85%) were cured immediately after surgery, indicating that connective tissue,

Further, the muscle itself can change. It is known that the number and density of urethral striated muscle fibers declines with age (Huisman 1983, Perucchini et al. 2002), an idea that has been confirmed in studies about the vastus lateralis muscle (Lexell et al. 1988). Muscle

associated - to a greater or lesser extent - with pelvic floor defects.

not muscle damage was most likely the major cause of the USI.

months (Snooks et al 1984, Lin et al. 2010) .

**1. Introduction** 

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Corresponding Author
