Conclusion 8

8

Conclusion

The concepts, methods and techniques described in this book have been influenced by profound developments in scientific methodology and philosophy in recent times.

In particular, the advent of digital technology and its support of non-linear thinking in biological systems has had a major impact on the diagnostic and surgical protocols described in this book.

The contribution of Chaos Theory to non-linear methodology as well as its capacity to explain the interface between micro and macro domains, is especially acknowledged.

Chaos Theory provides a theoretical explanation of how a small alteration in initial conditions (microdomain) may have major consequences (macrodomain), the

‘butterfly effect’. It thus provides a framework which helps explain how even minor connective tissue damage may cause severe symptoms. A direct legacy of the ‘butterfly effect’ has been the development of a theoretical framework for minimalist surgical techniques. Minimalist surgical techniques have meant fewer complications. This means that surgical correction is now available even to the frail and the weak.

The Integral Theory, first developed in 1990, has provided a sound starting point for this work. In particular the perspectives on anatomy and its distinction between static and dynamic has opened the way to further exploration of the nexus between muscles, ligaments and organs. The critical role of connective tissue in pelvic floor function and dysfunction cannot be overemphasised. A key concept is the interrelation of structure and form, as well as balance and imbalance in pelvic floor functioning. It follows from this that restoration of structure and form is required to restore function.

An important development presented in this book has been the distinction between the

‘mechanical’ and the ‘neurological’ dimensions of pelvic floor function, and how both of these domains can be influenced by connective tissue damage. Focusing on the dynamics of the neurological dimension can help explain how quite severe symptoms such as pelvic pain and bladder instability may be caused by minor connective tissue damage.

A key component of this book is the Pictorial Diagnostic System. It is based on the ‘Zones of Damage’ and uses the Structured Assessment pathways to isolate the damaged connective tissues that need corrective surgery.

Use of the Pictorial Diagnostic System allows a new suite of surgical techniques to

be introduced to address both prolapse and some symptoms that were once thought

to be ‘incurable’. Major symptoms may in fact only require minor corrective surgery

to restore normal pelvic floor function. Symptoms such as stress incontinence,

frequency, urgency, nocturia, pelvic pain, abnormal bladder and bowel emptying,

even idiopathic faecal incontinence, may be improved with an 80% probability of

success by reconstructing damaged ligaments and fascia.

Chapter 8 · Conclusion ²²³

8

The surgical techniques described are the ‘tension-free’ tape techniques, and the newer and less invasive ‘tissue fixation system’ which can be performed under direct vision.

The main challenge for the future development of this system is refinement of the probability assessments for connective tissue structures identified in the diagnostic system as causing pelvic floor dysfunction. The Integral Theory Diagnostic Support (ITDS) provides a first step in this quest. It is hoped that this will be enhanced with an interactive internet website (www.integraltheory.org). This will be an important tool for continuing development of pelvic floor science as it allows for sharing of research results, general relevant information, new ideas and collaboration on a scale previously thought unimaginable. Such a system could incorporate an anonymous data collection system so that, potentially, each surgeon has the opportunity of becoming a contributor to the data base. Contributing information about the structure(s) repaired, and recording the change in symptoms and objective tests, may help to provide an improved probability rating for each structure and its contribution to a particular function or dysfunction. The FDA has already created the ‘Maude’

website for the anterior sling procedure. This is a website on which complications using the various delivery instruments are recorded. These include TVT, IVS, Sparc, and Monarc. The website URL is http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/

cfMAUDE/search.cfm. The site allows the physician to type in the device name to find out any recorded ‘events’ associated with this device. This includes all the complications recorded on the site.

There are other roles for a confidential, password accessed internet web site:

▬ data on complications for particular procedures can be quickly displayed;

▬ requests for assistance with management of a difficult case can be discussed in a confidential ‘chat room’ environment;

▬ helpful hints which may assist diagnosis and surgical techniques can be accumulated and disseminated.

Indeed the opportunities presented by the internet for ongoing international ‘interactive’

research and collaboration are unprecedented in the history of medicine.

Theory is important in setting the framework for scientific advance. The Integral Theory has served us well in this respect. Further development of the Integral Theory perspective of connective tissue damage has significantly broadened the scope of curable pelvic floor conditions; in particular pelvic pain, bladder instability, anorectal dysfunction and intrinsic sphincter defect. As Dr Richardson so kindly expressed in the preface, ‘the original Integral Theory has now matured into an important medical paradigm’. This theory, method and technique is now a complete working system for diagnosis and management of pelvic floor dysfunction.

Before this book, there has not been a complete theoretical and practical exposition

of the Integral Theory that explained its ramifications for clinical practice. One

hopes that the reader is as optimistic as the author about the prospects for future

developments in female pelvic floor science and practice that this new paradigm has

made possible.