**10. Pelvic pain**

12 Urinary Incontinence

tension of the vagina below the bladder base, the stretch receptors can be activated by afferent nerves, the cortex gets the information of full bladder and this creates the sensation of urge. Prematurely the micturition reflex can be activated and even urge incontinence can

Many patients with vaginal vault or uterine prolapse – even if of a minor degree – complain about nocturia. Figure 6 explains the mechanism that leads to nocturia.. When the patient is asleep, the force of gravity pulls down the bladder base. Normally, with firm uterosacral ligaments, the bladder is held high (dotted line in Figure 6). When the patient is asleep and the uterosacral ligaments are loose, the pelvic floor muscles are relaxed, the bladder descends

posteriorly, the bladder base is stretched and the stretch receptors "N" are stimulated.

Fig. 6. Mechanism of nocturia- schematic view- patient asleep. The pelvic muscles (arrows) are relaxed. As the bladder fills, it is pulled downwards by the force of gravity 'G'. In the normal patient, bladder descent is limited by the uterosacral ligaments "USL". If "USLs" are loose, the bladder descends more, the stretch receptors "N" are stimulated, the micturition reflex is activated at a low bladder volume, "nocturia". (from P Petros 2010, by permission)

The anecdotal observation that midurethral slings and repair of loose uterosacral ligaments can cure fecal incontinence has led Petros and Swash (2008) to establish a new theory of anorectal function. A new complex musculo-elastic sphincter mechanism was detected. Its

**9. Anorectal function, fecal incontinence and obstructive defecation** 

occur.

**8. Nocturia** 

Many patients with vaginal vault prolapse or uterus prolapse report pelvic pain, a low abdominal dragging pain which occurs mainly in an upright position and is generally relieved in a lying position. This pain may be associated with vulvodynia. Both types of pain have been temporarily relieved by injection of local anaesthetic into the uterosacral ligaments (Bornstein et al 2005, Petros et al 2004), supporting the hypothesis that this pain is a referred pain arising from the inability of lax uterosacral ligaments to support the nerves running along the ligament (figure 7). These nerves are stretched by gravity or during intercourse to cause pain. This pain is almost invariably associated with other symptoms deriving from posterior zone laxity, Figure 8. In a recent study, restoration of uterosacral ligament tension using a posterior tensioned sling showed improvement in posterior zone symptoms as follows: nocturia >2/night 83%; urge-incontinence >2/day 78%; abnormal emptying, 73% ; pelvic pain, 86% fecal incontinence, 87% (Petros PEP, Richardson PA, 2010)
