The Relationship Between Uterosacral Ligament Laxity, OAB , Chronic Pain and Bowel Dysfunction - Expert Commentary

This commentary outlines the anatomical basis for surgical cure of OAB as reported by Liedl et al., in a multicentre study (n=611) in the Central European Journal of Urology1. This is the first substantive study aimed to challenge the Integral Theory’s predictions that OAB and other pelvic symptoms are mainly caused by loose suspensory ligaments2, are a consequence of deficient collagen/elastin within them, and are potentially curable surgically, Table1, by use of a polypropylene tape to create a collagenous neoligament 3. The first application of this neoligament methodology 3 was reinforcement of damaged pubourethral ligaments 4 as part of the midurethral sling operation, ‘TVT’ 4 for cure of urinary stress incontinence.


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Note

The technique for TFS uterosacral ligament repair detailed in the CEJU 1 paper is essentially a “reverse TVT” using a tensioned mini sling. This surgical methodology, application of a discrete tape, is not related in any way to the mesh sheets which are applied behind the vaginal membrane and which are currently the subject of a major medicolegal controversy. 

Clarification
The nocturia described as part of OAB 1 is prolapse based and was associated with at least a minimal degree of apical prolapse, plus (variably) with other pelvic symptoms, Table1 1. No specific tests were done to isolate nocturnal polyuria, though, because of the age of the population (70 years) there would inevitably have been some patients who would have had nocturnal polyuria. Ideally, such a pre-operative test would need to be performed in any future studies.



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Fig1. Trampoline analogy for bladder control. 3D sagittal view.  PUL=pubourethral ligamentz; USL=uterosacral ligaments; ATFP=arcus tendineus fascia pelvis; N=bladder base stretch receptors.

Continence Requires Intact Suspensory Ligaments 
The bladder has only two normal modes, closed and open’ fig1 2.  With reference to fig1, urethral closure is maintained by inherent tissue elasticity and reflexly, by 3 oppositely acting slow twitch muscle forces (arrows) which pull against intact pubourethral ligaments (PUL) and uterosacral (USL) to mechanically close the urethra in two places, distally and bladder neck 4.  The same 3 vectors (arrows), fig1, reflexly stretch the vaginal membrane like a trampoline to support the bladder stretch receptors ‘N’ from below, preventing activation of the micturition reflex.  

Normal opening (micturition) At a certain bladder volume, the afferent impulses from ‘N’ overcome central inhibition (white arrow) to activate the micturition reflex. The micturition reflex reflexly relaxes the forward vectors (broken circle), fig1, which during resting closure, stretch vagina forward to close posterior urethral wall from behind. At the same time, posterior vectors (arrows) pull against the uterosacral ligaments (USL) to open out the now released  posterior urethral wall (broken lines); this lowers internal resistance to urine flow exponentially (Poiseuille’s Law). EMGs show urethral opening precedes urine flow. 

Bladder Dysfunction is Caused by Loose Suspensory Ligaments
Defective closure  (USI) If PUL is loose, the muscle vectors which pull against it weaken; the urethra cannot fully close; the woman loses urine during effort (USI). 

Defective opening (‘obstructed micturition) If USL is loose, the posterior vectors cannot fully open out the posterior urethral wall (broken lines), fig1; the detrusor has to contract against a relatively unopened urethra with high internal resistance; the cortex interprets this as ‘obstruction’, with symptoms such as slow flow, stopping and starting, incomplete emptying, even retention.

Abnormal bladder control “OAB”. The Integral Theory defines OAB as being essentially a prematurely activated, but otherwise normal micturition reflex 4,5,6. Like loose trampoline springs, loose PUL or USL, fig1, may weaken vaginal support for  ‘N’, so ‘N’ fires off at a low bladder volume and more often (‘frequency’); the ‘afferent’ signals, fig1, are interpreted as sensory urgency; if the closure reflex cannot control the micturition reflex, ‘efferent’ signals, fig1, the urgency becomes uncontrollable and urine leaks out (urge incontinence).  The process is no different from a normal continent person with an over full bladder ‘hanging on” excessively and leaking.

Bladder Dysfunction is Reversed by Using Tapes to Repair Loose Ligaments 
Tapes placed in the exact position of PUL (midurethral sling) 4 or USL (posterior sling) 1 create collagenous neoligaments, to reverse pathogenesis and restore normal function.

Written By: Peter Petros DSc DS (UWA) PhD (Uppsala) MB BS MD (Syd) FRCOG (Lond) FRANZCOG Reconstructive Pelvic Floor Surgeon and Certified Urogynaecologist. University of NSW Professorial Dept of Surgery, St Vincent’s Hospital Sydney 

Read the Full Text Article - Is Overactive Bladder in the Female Surgically Curable by Ligament Repair?

References
  1. Liedl B, Inoue H, Sekiguchi Y, et al. Is overactive bladder in the female surgically curable by ligament repair? Citation: Cent European J Urol. 2017; 70: 51-57.
  2. Petros PE & Ulmsten U. An Integral Theory of female urinary incontinence. Acta Obstetricia et Gynecologica Scandinavica, 1990; 69; Supp.153: 1-79. 
  3.  Petros PE & Ulmsten U, Papadimitriou J, The Autogenic Neoligament procedure: A technique for planned formation of an artificial neo-ligament. Acta Obstetricia et Gynecologica Scandinavica, Supplement 153, Vol 69, (1990), 43-51.
  4. Ulmsten U, Petros P,   Intravaginal slingplasty (IVS): an ambulatory surgical procedure for treatment of female urinary incontinence. Scand J Urol Nephrol. 1995 Mar;29(1):75-82.
  5. Petros PE & Ulmsten U. Bladder instability in women: A premature activation of the micturition reflex. Neurourology and Urodynamics 12, 235-239 (1993).
  6. Petros PE Detrusor instability and low compliance may represent different levels of disturbance in peripheral feedback control of the micturition reflex. Neurourol and Urod (1999) 18:81-91.
 

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