Is overactive bladder in the female surgically curable by ligament repair?

Abstract

Introduction: Overactive bladder (OAB) symptoms (urge, frequency, nocturia) are not generally considered surgically curable by learning institutions. The Integral Theory hypothesizes that OAB is a prematurely activated, but normal micturition reflex caused by loose suspensory ligaments and potentially curable surgically by repairing such ligaments. To test this hypothesis by surgical repair of loose cardinal and uterosacral ligaments in patients with 2^nd degree or greater uterine/apical prolapse.

Material and methods: Multicenter prospective case control audit. 611 females, mean age 70. Inclusions: symptomatic apical prolapse of 2^nd or greater degree, (POPQ stages 2-4), and at least two pelvic symptoms. Exclusions: Comorbid medical problems known to cause chronic pelvic pain (e.g., infection), sphincter tears, neurological bladder conditions. Surgery: minimally invasive cardinal/uterosacral ligament repair using the TFS (Tissue Fixation System). Primary outcome: Uterine prolapse cure; Secondary outcomes; bladder, bowel, and pain symptoms improvement.

Results: 90% prolapse cure in 611 patients. Symptom incidence (% Cure at 12 months in brackets) was: urge incontinence: n = 310 (85%); frequency: n = 317 (83%); nocturia: n = 254 (68%); chronic pelvic pain (CPP): n = 194 (77%); fecal incontinence: n = 93 (65%). Statistics: McNemar x²-tests to test for significant changes in the symptoms' incidence-frequency from baseline (preoperative) to the postoperative phase. For each symptom the null hypothesis H₀: P_(baseline) = P_{(12 months after surgery)}versus H₁: P_(baseline) ≠ P_{(12 months after surgery)} was tested, with P indicating prevalence or incidence rate.

Conclusions: Bladder & bowel incontinence and chronic pelvic pain occur in predictable groupings and are associated with apical prolapse. OAB symptom improvement with the TFS ligament repair provides a good alternative to anticholinergics, especially when considering their association with dementia causation. Application of the Integral Theory System has the potential to significantly improve clinical practice, QoL for ageing women, delaying entry into Nursing Homes and creating new scientific research directions. The take home message is that symptoms of chronic pelvic pain, bladder and bowel dysfunction occur in relatively predictable groups, caused by lax suspensory ligaments and can be cured or improved by TFS mini sling ligament repair.

Keywords: Integral Theory; Over active bladder; TFS; apical prolapse; chronic pelvic pain; fecal incontinence; nocturia; urge incontinence.

Figure 1

TFS ligament repair system. 3D sagittal section. Insert TFS adjustable tape and soft tissue anchor set on applicator. The TFS tapes are inserted into all 5 ligaments: pubourethral (PUL), arcus tendineus fascia pelvis (ATFP), cardinal (CL) uterosacral (USL) and perineal body (PB). This study concerns only the posterior ligaments, cardinal (CL) and uterosacral (USL). The red rectangle defines the TFS implants as used in this study to reinforce CL & USL.

Figure 2

Simplified Pictorial Diagnostic Algorithm. Relates structural damage (prolapse) to symptoms: 1: stress incontinence; 2: cystocele; 3: uterine prolapse; 4: rectocele. The size of the bar gives an approximate indication of the prevalence (probability) of the symptom. Ligaments which can be repaired are: pubourethral ligament (PUL); CX ring/cardinal ligament (CL); arcus tendineus fascia pelvis (ATFP); uterosacral ligament (USL); perineal body (PB). The main symptom for ‘Tethered vagina syndrome’ is massive urine loss immediately following getting out of bed in the morning. The cause is excessive tightness in the bladder neck area of the vagina. Because pain and urgency have a peripheral neurological origin, even minimal vaginal prolapse may cause major symptoms.

Figure 3

The Pelvic Symptom pyramid – Symptoms occur in predictable groupings. The Relationship of symptoms within this grouping of 611 patients who had cardinal/uterosacral ligament laxity is expressed as a pyramid.

Figure 4

Urge incontinence – a premature activation of a normal micturition reflex. Loose suspensory ligaments (PUL, USL, CL) are unable to suspend the vagina adequately. The muscles (wavy arrows)* which insert into the loose ligaments lengthen ‘L’; their contractile force weakens; they cannot stretch the vagina sufficiently to support the stretch receptors ‘N’; ‘N’ fire off increased afferent impulses at a low bladder volume and this is perceived by the cortex as urgency. If the afferents are sufficient to activate the micturition reflex, the efferents are activated and the patient may uncontrollably lose urine (‘urge incontinence’). PUL – pubourethral ligament; USL – uterosascral ligament; CL – cardinal ligament. The backward downward arrows are wavy, to emphasize their weakened muscle force.

Figure 5

Gordon’s Law. A striated muscle contracts optimally over a short length only, ‘E’, red square. Lengthening the muscle ‘L’, results in a rapid loss of contractile force, black rectangle.