Editorial Editorial: A new theory of ano-rectal function

Cover pelviperineologyThis issue of Pelviperineology has been dedicated entirely to a substantive work by Petros, Swash and their collaborators, which explains anorectal function based on a musculo-elastic theory. The concepts are developed from the Integral Theory of Petros and Ulmsten which provides an anatomic explanation for a number of functional disorders of the lower urinary tract in women. Petros has been a colourful and controversial figure since he challenged the basis of our knowledge regarding the bladder and launched the “Tension Free Sling” when he and Ulmsten presented the “intravaginal slingplasty” in 1990. [More]

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Foreword A Musculo-Elastic Theory of anorectal function and dysfunction in the female

A Musculo-Elastic Theory of anorectal function and dysfunction in the female We present a series of 13 works in 2 parts. Part 1 states the Theory, and presents 7 works which test core aspects of the Theory, in particular, the role of the suspensory ligaments and muscle forces. Part 2 directly challenges the Theory with 5 different surgical works which track the fate of anorectal and other pelvic symptoms following repair of specific suspensory ligaments and their related fascia. [More]

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Summary Part 1: Summary. Non surgical proofs of the Theory by P.Petros - M. Swash

Non surgical proofs of the TheoryThe first paper sets out in detail the anatomical basis of the musculoelastic theory “Anorectal dysfunction in the female is mainly caused by lax suspensory ligaments inactivating anorectal muscle forces”. Hypotheses are presented for anorectal function and dysfunction, and the role of specific muscles, ligaments, and fascial structures in this process. A diagnostic algorithm is presented which pictorially represents causative relationships between symptoms and specific anatomical structures. [More]

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Original Article The Musculo-Elastic Theory of anorectal function and dysfunction by P.Petros - M. Swash

Musculo-Elastic Theory of anorectal function and dysfunctionThe mechanics of defecation and fecal continence are poorly understood. Valvular theories for continence rely on raised intra-abdominal pressure to force the anterior wall of the rectum downwards to close off the anorectal junction. Such theories are not consistent with EMG and radiological data which suggest a striated muscle sphincteric mechanism. It has been demonstrated that puborectalis and external anal sphincter muscles contract during effort, indicating a role for both in fecal continence. [More]

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Original Article Experimental Study No. 1: Directional muscle forces activate anorectal continence and defecation in the female by P.Petros - M. Swash

Directional muscle forces activate anorectal continence and defecation in the femaleEMG and radiological data suggest a striated muscle sphincteric mechanism acting during fecal continence control. Though puborectalis and external anal sphincter muscles have been demonstrated to contract during effort, the role of the other pelvic floor muscles has not been elucidated. The mechanism of defecation is also poorly understood. According to one description feces enter the anal canal, stimulate stretch receptors and produce the urge to defecate.The internal and external anal sphincters relax, decreasing the pressure within the anus. [More]

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Original Article Experimental Study No. 2: A direct test for the role of the pubourethral ligament in anorectal closure by P.Petros - M. Swash

direct test for the role of the pubourethral ligamentThe series of video X-ray photographs (Study No. 1), appeared to support the Theory’s prediction of a major role for the pubourethral ligaments in the control of fecal incontinence. A serendipitous presentation of a patient with a history of stress induced fecal incontinence at Royal Perth Hospital Outpatients Gynaecology Clinic allowed this part of the Theory to be tested directly. [More]

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Original ArticleStudy No. 3: Reflex contraction of the levator plate increases intra-anal pressure, validating its role in continence by P.Petros - M. Swash

Reflex contraction of the levator plateThe Musculo-Elastic Theory defines an important role for the levator plate in anorectal closure. The radiological study demonstrated backward movement of the organs on straining. Though this backward movement can only be explained by contraction of the posterior pelvic muscles, this movement may not necessarily be a factor in anorectal closure. The aim of this study was to more precisely define the role of the levator plate (LP) in anorectal closure by measuring the pressure in the anal canal following digital stretching of the distal vagina.  [More]

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Original ArticleExperimental Study No. 4: Abdominal pressure increase during anorectal closure is secondary to striated pelvic muscle contractionby P.Petros - M. Swash

Abdominal pressure increase during anorectal closure is secondary to striated pelvic muscle contractionThough questions have been raised concerning the validity of valvular-type theories for anorectal closure, for many physicians, such theories still have currency, possibly because of their seductive simplicity: raised intra-abdominal presses the rectum down to increase the anorectal angle, and effect closure. The aims of this study were to measure the abdominal pressures during “squeezing” (which interrupts defecation) and straining (which accelerates defecation). Simultaneous with this, surface cylindrical EMG electrodes were placed in the posterior fornix of vagina to confirm (or not) pelvic muscle contraction during the pressure rise. [More]

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Original ArticleExperimental Study No. 5: A prospective endoanal ultrasound study suggests that internal anal sphincter damage is unlikely to be a major cause of fecal incontinence by P. Petros - M. Swash

endoanal ultrasound study The exact role of the internal anal sphincter (IAS) in the maintenance of fecal continence (FI) is not well understood. Controversy exists as to whether a damaged IAS can cause fecal incontinence. Bartolo and Macdonald report an incidence of up to 40% incontinence of feces and flatus in patients who had undergone complete internal sphincterotomy. Endoanal ultrasound studies in 127 patients after vaginal delivery, demonstrated IAS damage in 49 patients. Sphincteric damage was associated with fecal incontinence (FI) in 10/11 of these patients,implying causation of FI. [More]

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Original ArticleExperimental Study No. 6: Correction of abnormal geometry and dysfunction by suspensory ligament reconstruction gives insights into mechanisms for anorectal angle formation by P. Petros - M. Swash

Correction of abnormal geometry and dysfunction by suspensory ligament reconstructionIt is generally believed that raised intra-abdominal pressure presses the rectum down to increase the anorectal angle. Study No. 3 demonstrated that levator plate contraction was a likely factor in anorectal closure, and therefore would have some influence on the shape of the anorectum. In contrast, study No. 4 indicated that increased abdominal pressure per se could not be a factor in anorectal closure, and therefore would have little influence on the shape of the anorectum.  [More]

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Original ArticleStudy No. 7: Role of puborectalis muscle in anal continence. Comments on original 4D pelvic ultrasound data from Chantarasorn & Dietz by P. Petros - M. Swash

Role of puborectalis muscle in anal continenceWe report in full, an abstract of important findings by Chantarasorn V, and Dietz HP, with kind permission of Associate Professor Dietz, University of Sydney, Nepean Clinical School. The Abstract quoted was presented at ASUM Auckland 2008 (Australasian Society for Ultrasound in Medicine). The authors, Chantrasorn and Dietz, found no association between levator ani function and anatomy on the one hand and anal continence on the other hand, indicating that there may be no major role for the puborectalis muscle in anal continence.  [More]

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Summary Part 2: Summary. Surgical proofs of the Theory by P. Petros - M. Swash - B. Kakulas - I. W. Hocking - P. Richardson - B. Abendstein - C. Brugger - A. Furtschegger - M. Rieger

Surgical proofs of the TheoryThe Theory states: “Anorectal dysfunction in the female is mainly caused by lax suspensory ligaments inactivating anorectal muscle forces”.In this section, the theory is directly tested by comparing pre and post-operative symptoms, and objective tests such as anorectal manometry, pudendal nerve conduction times, and defecating proctography, following surgical placement of polypropylene tapes in the position of lax suspensory ligaments. The tapes work by creating a linear deposition of collagen to reinforce the damaged ligament. According to the theory, a competent ligament is required to restore the muscle’s ability to open or close the anorectum more efficiently. Failure to do so would severely compromise the theory. [More]

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Original ArticleExperimental Study No. 8: Stress urinary incontinence results from muscle weakness and ligamentous laxity in the pelvic floor by P.Petros - M. Swash - B. Kakulas

Stress urinary incontinenceThe cause of “idiopathic” urinary and fecal incontinence is controversial. Based on histological and electrophysiological studies, Swash and colleagues suggested that muscle damage secondary to birth-induced pelvic and perineal nerve damage may cause sphincter and pelvic floor weakness, and so lead to fecal and urinary incontinence. Smith et al. confirmed these findings, but it was also noted that many patients with genital prolapse, without impaired fecal or urinary continence, also had electrophysiological evidence of damage to the innervation of pelvic floor sphincter muscles.  [More]

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Original ArticleExperimental Study No. 9: Double incontinence, urinary and fecal, cured by surgical reinforcement of the pubourethral ligaments by by I. W. Hocking

Stress urinary incontinenceI commenced the “tension-free” midurethral sling operation in 1999, using the Tyco IVS instrument. The background to this study was a previous observation of cure whereby patients with double incontinence, stress and fecal, may both be cured with a midurethral sling. Though the main thrust of my work concerned patients with genuine stress incontinence (GSI) or mixed stress and urge incontinence, I kept specific records of any fecal incontinence (FI) symptoms also.  [More]

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Original ArticleStudy No. 10: Fecal incontinence cure by surgical reinforcement of the pelvic ligaments suggests a connective tissue aetiology by P. Petros - P. Richardson

Stress urinary incontinenceThe cause of idiopathic fecal incontinence (FI) is at present unknown. In 1985 Swash et al. published a unifying theory of urinary and fecal incontinence based on striated muscle damage. This work was inspired by evidence of pudendal nerve damage in many patients with double incontinence (urinary and fecal). In 1993, based on obstetric ultrasound studies, Sultan et al hypothesized a link between damaged internal anal sphincters and fecal incontinence.  [More]

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Original ArticleStudy No. 11: Ligamentous repair using the Tissue Fixation System confirms a causal link between damaged suspensory ligaments and urinary and fecal incontinence by B. Abendstein - P.Petros - P. Richardson

Stress urinary incontinenceIn 1990 the concept of using a plastic tape to create artificial neoligaments (‘tension-free tapes’) was introduced. We have reported how reinforcement of the pubourethral ligament (Study No. 9, this issue) and pubourethral / uterosacral ligaments with anterior/posterior “tension-free” slings successfully improved bladder and bowel symptoms.  [More]

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Original ArticleStudy No. 12: Role of the uterosacral ligaments in the causation of rectal intussusception, abnormal bowel emptying,and fecal incontinence. A prospective study. by B. Abendstein - C. Brugger - A. Furtschegger - M. Rieger - P. Petros

Stress urinary incontinenceRectoceles are common findings in patients with intractable evacuatory disorders. Typical symptoms are difficulties to evacuate, incomplete evacuation, assisted digitation to aid defecation, fecal incontinence, constipation, impression of a pelvic mass, pelvic pain and dyspareunia. Occult rectal prolapse has been found in 33% of patients with rectoceles and defecatory dysfunction. Endorectal, transvaginal, transperineal, abdominal or combined approaches are treatment options discussed for symptomatic rectoceles. [More]

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Conclusion Conclusion and future directions by P. Petros - M. Swash

Stress urinary incontinenceThe aim of Part 2 was to directly challenge the Theory by repairing specific ligaments, pubourethral only (Study No. 9), pubourethral and uterosacral (Study No. 10), pubourethral, uterosacral, ATFP, cardinal, and perineal body (Study No. 11), and uterosacral and perineal body only (Study No. 12). We used the pictorial algorithm (Fig. 1) to guide which zone to repair, anterior, middle or posterior. Clinical results from Studies 9-12 appeared to validate these assumptions. [More]

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Invited Comment Commentary by D. M. Gold

Stress urinary incontinenceSome years ago in an attempt to obtain the Holy Grail of every medic, the perfect golf swing, I found myself seduced into buying a set of instructional videos by a small town American golf instructor, Dalton McRary, who had by various observations of still images of golfers of yesteryear, where shutter speeds were not fast enough to prevent motion blur, come to the conclusion that much of the perceived and taught theory regarding the golf swing was in fact incorrect. [More]

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