Pathways to causation and surgical cure of chronic pelvic pain of unknown origin, bladder and bowel dysfunction - an anatomical analysis

Abstract

Introduction: Current thinking is that chronic pelvic pain of unknown origin (CPPU) is poorly understood and its treatment is empirical and ineffective. According to the Integral Theory System (ITS), however, CPPU is secondary to uterosacral ligament (USL) laxity which is associated with bladder and bowel symptoms and all are potentially curable by surgical reinforcement of USLs.

Material and methods: We applied the ITS to anatomically explain the pathogenesis and cure of these conditions.

Results: The first mention of CPPU being caused by lax USLs was in the pre- WWII German literature by Heinrich Martius. CPPU was first described in the English literature in 1993 as one of the four pillars of the posterior fornix syndrome (PFS) (CPPU, urgency, nocturia and abnormal bladder emptying). Surgical cure/improvement of CPPU was achieved by shortening and reinforcing USLs initially with USL ligament plication and later with tensioned tapes because of deteriorating cure rates. Non-invasive 'simulated operations' which support USLs in the posterior fornix help predict USL causation.

Conclusions: USL tapes cure/improve CPPU, bladder and bowel dysfunctions by reinforcing the USLs against which the 3 directional forces contract. Weak suspensory ligaments may invalidate these forces to cause incontinence, emptying and pain symptoms, all of which can be potentially reversed by using tapes to reinforce the damaged ligaments, as demonstrated.

Keywords: bladder emptying; chronic pelvic pain of unknown origin; fecal incontinence; integral theory; overactive bladder; posterior fornix syndrome; uterosacral ligaments.

Figure 1

Relationship of symptoms and prolapse to damaged ligaments in chronic pelvic pain of unknown origin. (CPPU) almost invariably co-occurs with bladder symptoms and bowel symptoms, proportionally as indicated on the left figure. Three directional forces (arrows) contract against pubourethral (PUL) anteriorly and uterosacral (USL) ligaments posteriorly to close or open (broken lines) urethral and anal tubes. Loose ligaments may cause specific symptoms as indicated. Height of bar indicates frequency of occurrence with either PUL or USL laxity. Right upper figure: Frankenhauser T11–L2 (F) and sacral (S) S2–4 plexuses. If utero- sacral ligaments (USL) are loose, these cannot be supported and fire off to cause pain. Right lower figure: ratio of individual posterior zone symptoms caused by USL defect. EUL – external urethral ligament; ATFP – arcus tendineus fascia pelvis; CL – cardinal ligament; USL – uterosacral ligament; PB – perineal body