Editorial Editorial: A new theory of ano-rectal function
This
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]
Full Text 
Pdf
This
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] Full Text Pdf Foreword 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]
Full Text Pdf
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] Full Text Pdf Summary Part 1: Summary. Non surgical proofs of the Theory by P.Petros - M. Swash
The
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]
Full Text Pdf
The
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] Full Text Pdf Original
Article The Musculo-Elastic Theory of anorectal function and dysfunction by
P.Petros - M. Swash
The
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]
Full Text Pdf
The
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] Full Text Pdf Original Article Experimental Study No. 1: Directional muscle forces activate anorectal continence and defecation in the female by
P.Petros - M. Swash
EMG
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]
Full Text Pdf
EMG
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] Full Text PdfOriginal Article Experimental Study No. 2: A direct test for the role of the pubourethral ligament in anorectal closure by
P.Petros - M. Swash
The
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]
Full Text Pdf
The
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] Full Text PdfOriginal ArticleStudy No. 3: Reflex contraction of the levator plate increases intra-anal pressure, validating its role in continence by
P.Petros - M. Swash
The
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]
Full TextPdf
The
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] Full TextPdf Original ArticleExperimental Study No. 4: Abdominal pressure increase during anorectal closure is secondary to striated pelvic muscle contractionby
P.Petros - M. Swash
Though
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]
Full Text Pdf
Though
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] Full Text Pdf 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
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]
Full Text Pdf
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] Full Text Pdf 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
It
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]
Full Text Pdf
It
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] Full Text Pdf 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
We
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]
Full Text Pdf
We
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] Full Text Pdf 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
The
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]
Full Text Pdf
The
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] Full Text Pdf 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
The
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]
Full Text Pdf
The
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] Full Text Pdf Original
ArticleExperimental Study No. 9: Double incontinence, urinary and fecal, cured by surgical reinforcement of the pubourethral ligaments by
by
I. W. Hocking
I
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]
Full Text Pdf
I
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] Full Text Pdf Original
ArticleStudy No. 10: Fecal incontinence cure by surgical reinforcement of the pelvic ligaments suggests a connective tissue aetiology by
P. Petros - P. Richardson
The
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]
Full Text Pdf
The
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] Full Text Pdf 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
In
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]
Full Text Pdf
In
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] Full Text Pdf 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
Rectoceles
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]
Full
Text Pdf
Rectoceles
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] Full
Text Pdf Conclusion Conclusion
and future directions by
P. Petros - M. Swash
The
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]
Full
Text Pdf
The
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] Full
Text Pdf Invited
Comment Commentary by D. M. Gold
Some
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]
Full
Text Pdf
Some
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] Full
Text Pdf