THE CASE AGAINST urethral failure is not a critical factor in female urinary incontinence. Now what? The integral theory system

Comparing combined paravaginal repair with pubocervical fascia plication versus standard anterior colporrhaphy for the treatment of stress urinary incontinence in women with anterior vaginal wall prolapse: a randomised controlled trial

BACKGROUND

Stress urinary incontinence (SUI) is prevalent among women, often occurring alongside anterior vaginal wall prolapse. This study compares the efficacy and safety of an improved vaginal wall repair technique with pubocervical fascia fixation versus standard anterior colporrhaphy for treating SUI in women with anterior vaginal wall prolapse.

METHODS

A single-centre, parallel-group, randomised controlled trial was conducted between September 2021 and June 2024. Women aged 40-70 years with symptomatic SUI and stage 2-3 anterior vaginal wall prolapse were randomised to either the improved repair group or the standard repair group. The primary outcome was patient-reported success at 12 months post-surgery, defined as 'very much improved' or 'much improved' on the Patient Global Impression of Improvement scale. Secondary outcomes included objective cure rates, quality of life scores, urodynamic parameters, anatomical outcomes, perioperative outcomes and adverse events.

RESULTS

A total of 102 women were randomised (51 in each group). At 12 months, the patient-reported success rate was significantly higher in the improved repair group (94.1% vs 78.4%, p = 0.019). The objective cure rate was also higher in the improved repair group (90.2% vs 74.5%, p = 0.038). Quality of life scores and urodynamic parameters showed greater improvements in the improved repair group. Anatomical success was achieved in 92.2% of the improved repair group compared with 80.4% in the standard repair group (p = 0.048). The improved repair technique was associated with longer operative time but lower estimated blood loss, shorter hospital stay and quicker return to normal activities. The overall complication rate was lower in the improved repair group (11.8% vs 23.5%, p = 0.043).

CONCLUSIONS

The improved vaginal wall repair with pubocervical fascia fixation demonstrates superior outcomes compared with standard anterior colporrhaphy, with higher patient-reported success rates, improved quality of life and fewer complications.

The Integral Theory, Pelvic Floor Biomechanics, and Binary Innervation

The pelvic floor biomechanics and sphincter functioning are essential for understanding pelvic floor dysfunction and the pathophysiology of the pelvic organs. The pelvic floor consists of muscles, fascial connections and ligaments. The Integral Theory Paradigm (ITP) explains the musculoskeletal entity of the sphincter mechanism and the pathophysiology of pelvic organ function. The ITP explains the pelvic floor function determined by 3 directional muscle forces: forward, backwards and downward-acting muscle vector forces that form an anterior and posterior resultant. The resultant equilibrium is essential for urinary continence, voiding and defecation. Loose ligaments disturb the equilibrium of the pelvic floor's muscular function with consequences for the organ function's continence, evacuation, and sensory perception.

Neuromodulation Improves Stress Urinary Incontinence-Like Deficits in Female Rabbits

Objective: Stress urinary incontinence (SUI) affects a third of the female population and is characterized by involuntary urine leakage during abdominal efforts such as sneezing, laughing, or coughing. Acute neuromodulation of the bulbospongiosus nerve (BsN) was shown to increase bladder efficiency in aged and multiparous rabbits. This study investigates the efficacy of sub-chronic BsN neuromodulation in alleviating SUI-like deficits in mature multiparous rabbits, characterized by increased urine leakage and reduced leak point pressure. Results: Using the voiding spot assay, we observed a 40% reduction in urine leakage events after 30 days of BsN stimulation, which correlated with a 60% increase in daily micturition volume, a 10-fold increase in voided volume, and improvements in voiding efficiency and leak point pressure compared to negative control animals. Conclusion: In multiparous rabbits, BsN neuromodulation improves important SUI-like metrics including bladder capacity and urethral closure, supporting the use of this bioelectronic modality as treatment for SUI.