The pelvic floor functions as a holistic entity. The organs, bladder, bowel, smooth and striated muscles, nerves, ligaments and other connective tissues are directed cortically and reflexly from various levels of the nervous system. Such holistic integration is essential for the system's multiple functions, for example, pelvic girdle stability, continence, voiding/defecation, and sexuality. Pelvic floor dysfunction (PFD) is related to a variety of pelvic pain syndromes and organ problems of continence and evacuation. Prior to treatment, it is necessary to understand which part(s) of the system may be causing the dysfunction (s) of Chronic Pelvic Pain Syndrome (CPPS), pelvic girdle pain, sexual problems, Lower Urinary Tract Symptoms (LUTS), dysfunctional voiding, constipation, prolapse and incontinence. The interpretation of pelvic floor biomechanics is complex and involves multiple theories. Non-surgical treatment of PFD requires correct diagnosis and correctly supervised pelvic floor training. The aims of this review are to analyze pelvic function and dysfunction. Because it is a holistic and entirely anatomically based system, we have accorded significant weight to the Integral Theory's explanations of function and dysfunction.Copyright © 2021 Elsevier B.V. All rights reserved.

Anatomical damage to pelvic floor structures may cause multiple symptoms. The Integral Theory System Questionnaire (ITSQ) is a holistic questionnaire that uses symptoms to help locate damage in specific connective tissue structures as a guide to reconstructive surgery. It is based on the integral theory, which states that pelvic floor symptoms and prolapse are both caused by lax suspensory ligaments. The aim of the present study was to psychometrically validate the ITSQ.Established psychometric properties including validity, reliability, and responsiveness were considered for evaluation. Criterion validity was assessed in a cohort of 110 women with pelvic floor dysfunctions by analyzing the correlation of questionnaire responses with objective clinical data. Test-retest was performed with questionnaires from 47 patients. Cronbach's alpha and "split-half" reliability coefficients were calculated for inner consistency analysis.Psychometric properties of ITSQ were comparable to the ones of previously validated Pelvic Floor Questionnaires. Face validity and content validity were approved by an expert group of the International Collaboration of Pelvic Floor surgeons. Convergent validity assessed using Bayesian method was at least as accurate as the expert assessment of anatomical defects. Objective data measurement in patients demonstrated significant correlations with ITSQ domains fulfilling criterion validity. Internal consistency values ranked from 0.85 to 0.89 in different scenarios.The ITSQ proofed accurate and is able to serve as a holistic Pelvic Floor Questionnaire directing symptoms to site-specific pelvic floor reconstructive surgery.

To study the distribution of nitric oxide synthase (NOS) isoforms and protein levels in human haemorrhoids and rectal tissue.Protein expression of NOS1, NOS2 and NOS3 was compared between haemorrhoids (n=14) and normal rectal submucosa (n=6) using Western blot analysis. The localisation of all NOS isoforms to specific structures was determined by immunohistochemistry.Western blot analysis showed median (interquartile range) protein levels of all NOS isoforms were 1.5-2.4 times higher in haemorrhoids than rectal tissue; 121.4 (55.2-165.5) vs 50.0 (25.5-73.7) for NOS1 (p=0.020), 32.2 (23.8-140.6) vs 14.8 (9.6-34.0) for NOS2 (p=0.109), and 80.1 (62.0-139.5) vs 54.3 (48.7 -61.7) for NOS3 (p=0.015). Immunohistochemistry revealed a different distribution and location of all NOS isoforms in vascular and non-vascular structure of haemorrhoids and rectal tissues. The number of haemorrhoid specimens showing positive immunoreactivity of NOS in the vascular endothelium was significantly higher than that in rectal tissue for NOS1 (11/14 (79%) vs 1/6 (17%); p=0.018) and NOS3 (8/14 (57%) vs 0/6 (0%); p=0.042), but not for NOS2 (6/14 (43%) vs 4/6 (67%); p=0.63).Haemorrhoids have significantly higher protein levels of NOS1 and NOS3 than rectal tissue. The vascular endothelium of haemorrhoids also has significantly higher positive immunoreactivity of NOS1 and NOS3 than rectal tissue suggesting that blood vessels in haemorrhoids are exposed to higher NO concentrations than those of rectal tissue. Since haemorrhoids exhibit marked vascular dilatation and present with bleeding or swelling, a reduction in NOS - by applying NOS inhibitors - may potentially improve the symptoms of haemorrhoids.Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.

The aim of the present study was to investigate the ultrastructure and content of collagen in uterosacral ligaments and paraurethral tissues in patients with pelvic organ prolapse (POP) and stress urinary incontinence (SUI), analyzing the association between POP and collagen dysfunction. The study comprised three groups: Control, POP and POP with SUI (n=30 per group). Histological characteristics of collagen fiber were observed and the diameters were measured using light and electron microscopy to determine the Type I and Type III collagen content of the main ligament in the urethral specimens. In the POP and POP with SUI groups, observations included diffuse atrophy of smooth muscles, active fibroblast metabolism, swollen mitochondria and visible Golgi apparatus. The collagen fibril diameters in the cardinal ligaments, uterosacral ligaments and paraurethral tissues were significantly greater in the POP and POP with SUI groups compared with those in the control group (P<0.01). In addition, the expression levels of Type I and Type III collagen were significantly lower in the POP and POP with SUI groups when compared with the control group (P<0.01). In the POP with SUI group, pelvic tissues were frail, resulting in smooth muscle bundles comminuting and arranging in a disorganized pattern. Fibroblast and myoblast metabolisms were active and new microvascular cells were weak. However, the collagen fibril diameter increased. Thus, collagen and ultrastructural changes in the pelvic floor may be associated with the development of POP and SUI.

The purpose of the paper is to compare Goligher Classification with the Single Pile Hemorrhoid Classification (SPHC) to show the possible bias and limits of Goligher's use and the possible advantage with the employment of the new classification. SPHC considers the number of pathological piles(N), the characteristics of each internal pile and the characteristics of each external pile, reporting the presence of a fibrous inelastic redundant pile(F), the presence of the subversion of dentate line or the congestion of the external pile(E) and the presence of not tolerated skin tags(S). From September 2010 to December 2012, 197 consecutive patients were analysed according to both classifications. Considering pathological piles, I and II Goligher patients showed a complete agreement between pathological pile and grade, III Goligher patients had 80.5 % of pathological piles of III grade while IV Goligher patients had only 44.3 % of IV grade pathological piles (p < 0.001). Regarding the distribution of the other anatomical variables: F, E, S described in SPHC, the results showed that F was present in 18.3 % while ES was present in 46.2 %. Goligher's Classification has showed to be an inadequate tool to overview surgical outcome or to compare surgical procedure, particularly for high grades, while SPHC showed to be a feasible instrument both to describe and to compare patients affected by hemorrhoid disease.

Present an updated classification for symptomatic hemorrhoids, which not only guides the treatment of internal hemorrhoids but also the treatment of external components. In addition, this new classification includes new treatment alternatives created over the last few years.Throughout the past 7 years, the authors developed a method to classify patients with symptomatic hemorrhoids. This study, besides presenting this classification proposal, also retrospectively analyzed 149 consecutive patients treated between March 2011 and November 2013 and aimed to evaluate the association between the management adopted with Goligher classification and our proposed BPRST classification.Both classifications had a statistically significant association with the adopted management strategies. However, the BPRST classification tended to have fewer management discrepancies when each stage of disease was individually analyzed.Although there is much disagreement about how the classification of hemorrhoidal disease should be updated, it is accepted that some kind of revision is needed. The BPRST method showed a strong association with the management that should be adopted for each stage of the disease. Further studies are needed for its validation, but the current results are encouraging.

25% of all women report involuntary loss of urine, and 7% may require treatment.This review is based on a selection of pertinent literature, including guidelines and Cochrane reviews.The assessment of pelvic floor dysfunction in women begins with a basic evaluation that is followed by special diagnostic tests if indicated. The physician taking the clinical history should inquire about the patient's behavior, personality, social and other stressors, and eating and drinking habits, as well as any mental disorders that may be present, including anxiety disorders, depression, somatization disorders, and disorders of adaptation. Conservative treatment consists mainly of lifestyle changes, physiotherapy, and medication. Stress incontinence is most commonly treated with pelvic floor exercises, with a documented success rate of 56.1% vs. 6% without such treatment (relative risk 8.38, 95% confidence interval 3.67-19.07). If incontinence persists, surgery may be indicated ( implantation of suburethral tension-free slings, or colposuspension). Feedback and biofeedback training can be used to treat an overactive bladder. If these techniques and drug therapy are unsuccessful, botulinum toxin injections can be considered.Well-validated treatments for pelvic floor dysfunction are available. Psychosomatic factors must be taken into account and can have a major effect on treatment outcomes.

The pelvic floor functions as a holistic entity. The organs, bladder, bowel, smooth and striated muscles, nerves, ligaments and other connective tissues are directed cortically and reflexly from various levels of the nervous system. Such holistic integration is essential for the system's multiple functions, for example, pelvic girdle stability, continence, voiding/defecation, and sexuality. Pelvic floor dysfunction (PFD) is related to a variety of pelvic pain syndromes and organ problems of continence and evacuation. Prior to treatment, it is necessary to understand which part(s) of the system may be causing the dysfunction (s) of Chronic Pelvic Pain Syndrome (CPPS), pelvic girdle pain, sexual problems, Lower Urinary Tract Symptoms (LUTS), dysfunctional voiding, constipation, prolapse and incontinence. The interpretation of pelvic floor biomechanics is complex and involves multiple theories. Non-surgical treatment of PFD requires correct diagnosis and correctly supervised pelvic floor training. The aims of this review are to analyze pelvic function and dysfunction. Because it is a holistic and entirely anatomically based system, we have accorded significant weight to the Integral Theory's explanations of function and dysfunction.Copyright © 2021 Elsevier B.V. All rights reserved.

Objectives\n\t\t\t\t\t To define the prevalence of pelvic floor disorders in a non‐institutionalised community and to determine the relationship to gender, age, parity and mode of delivery.

Clinicians and patients have traditionally believed that elective cesarean section may protect against certain previously ineluctable consequences of labor, including a plethora of urinary, anorectal and sexual dysfunctions. We aimed to evaluate fecal, urinary and sexual symptoms 6 years postpartum, comparing uncomplicated vaginal delivery and elective cesarean delivery, and to assess their impact on quality of life. We conducted a cross-sectional study to compare perineal functional symptomatology between women having singleton elective cesarean deliveries (eCS) and singleton uncomplicated vaginal deliveries (uVD). Women who delivered 6 years before this study were chosen randomly from our hospital database. This database includes demographic, labor, and delivery information, as well as data regarding maternal and neonatal outcomes, all of which is collected at the time of delivery by the obstetrician. Four validated self-administrated questionnaires were sent by post to the participants: the short forms of the Urogenital Distress Inventory, Incontinence Impact Questionnaire, Wexner fecal incontinence scale, and Female Sexual Function Index. Current socio-demographic details, physical characteristics, obstetrical history and mode of delivery at subsequent births were also registered using a self-reported questionnaire. A total of 309 women with uVD and 208 with eCS returned postal questionnaires. The response rate was 49%. Socio-demographic characteristics and fecal incontinence were similar between groups. After eCS, women reported significantly less urgency urinary incontinence (adjusted Relative Risk 0.55; 95% confidence interval 0.34–0.88) and stress incontinence (adjusted Relative Risk 0.53; 95% confidence interval 0.35–0.80) than after uVD. No difference in total Incontinence Impact Questionnaire score was found between both modes of delivery. Lower abdominal or genital pain (adjusted Relative Risk 1.58; 95% confidence interval 1.01–2.49) and pain related to sexual activity (adjusted Relative Risk 2.50; 95% confidence interval 1.19–5.26) were significantly more frequent after eCS than uVD. Six years postpartum, uVD is associated with urinary incontinence, while eCS is associated with sexual and urination pain.

A 46-year-old otherwise healthy female patient presents with bright red blood during defecation and a lump protruding on defecation that requires manual reduction. She is the mother of 2 children and has a long history of constipation.

To compare the results of laser hemorrhoidoplasty (LHP), excisional hemorrhoidectomy (EH), and sutured mucopexy (MP).A randomized, parallel-group, double-blinded, single-center prospective study.Symptomatic 2nd- or 3rd-degree hemorrhoids patients.Computer randomization sequence, patient blinding, operating surgeon blinding, and surgeon-evaluator blinding. LHP was performed using a 1470 nm diode laser. Up to 250 J of energy delivered per 1 hemorrhoid. The procedure was performed circumferentially. MP ligations were placed in the area of visible hemorrhoidal tissue. Standard EH was performed up to the level of the hemorrhoidal pedicle. Follow-up at 1 and 6 weeks and 1 year.Recurrence of symptoms requiring treatment, intensity, and duration of pain after the operation, patients' quality of life, fecal incontinence, and patients' evaluation of treatment.A total of 121 patients. Groups were even preoperatively. LHP took 15 min (SD 5.6), MP took 16 min (SD 5.58), and EH took 29 min (SD 10.3). Recurrence requiring treatment rate was 0% after EH, 10% after LHP, and 22% after MP, p = 0.004. LHP and MP were less painful than EH, p < 0.001. Patients after LHP returned to regular activity after 15 days, after MP after 22 days, and after EH after 30 days, p < 0.001. SF-36 scores were better after EH. Symptoms of fecal incontinence improved in all the groups. Patients evaluate LHP better than EH and MP.Single-center study.Laser hemorrhoidoplasty is a safe, minimally invasive option for hemorrhoids, more effective than MP and less effective than EH. Patients evaluate this technique better than the other two.

Anal canal dilatation and sphincterotomy have been recommended besides hemorrhoidectomy to overcome the anal pressures in the management of hemorrhoids. The aim of this study to compare internal sphincterotomy and hemorrhoidectomy with hemorrhoidectomy alone with respect to manometric and clinical measures.One hundred twenty patients with hemorrhoids were randomly assigned to receive either hemorrhoidectomy with sphincterotomy or hemorrhoidectomy alone. Anal canal pressures including mean squeeze pressure, maximal resting anal canal pressure, and mean resting anal canal pressure, were recorded by manometry before the operation. The patients were evaluated one week and two weeks after the operation clinically and three months later by manometry.The patients were matched with respect to age, gender, and chief complaints. The mean+/-SD age of the patients in hemorrhoidectomy with sphincterotomy group (A) was 43.8+/-14 and in hemorrhoidectomy alone group (B) was 43.94+/-15 years. The male to female ratio was 1.1:1. One week after the operation, there was no statistically significant differences in the frequency of postoperative complications like pain and urinary incontinence between the two groups except for fecal incontinence which was more frequent in group A. After two weeks, the same results with an acceptable improvement in fecal incontinence in group A were observed. Three months after the operation, manometry showed considerable reduction in the mean resting anal canal pressure and maximal resting anal canal pressure in group A; the mean squeeze pressure did not have any changes in either group.We recommend sphincterotomy plus hemorrhoidectomy for patients with high anal canal pressure documented by manometry prior to the operation.

In 45 years, the definitions and practice of the urodynamically based overactive bladder (OAB)/detrusor overactivity (DO) system have failed to adequately address pathogenesis and cure of urinary urge incontinence, frequency and nocturia.We analysed the OAB syndrome with reference to the Integral Theory paradigm's (ITS) binary feedback system, where OAB in the female is viewed as a prematurely activated, but otherwise normal micturition caused mainly, but not entirely, by ligament damage/laxity. The ITS Clinical Assessment Pathway which details the relationships between structural damage (prolapse), ligaments and dysfunction (symptoms) is introduced.The ITS was able to "better explain" OAB pathophysiology in anatomical terms with reference to the binary model. The phasic patterns diagnostic of "detrusor overactivity" are explained as a struggle for control by the closure and micturition reflexes. The exponentially determined relationship between urethral diameter and flow explains why obstructive patterns occur, why they do not and why urine may leak with no recorded pressure. Mechanically supporting ligaments ("simulated operations") during urodynamic testing can improve low urethral pressure, negative pressure during coughing with SUI and diminish urge sensation or even DO patterns, transforming urodynamics from non-predictive test to accurate predictor of continence surgery results. High cure rates for OAB by daycare repair of damaged ligaments is a definitive test of the binary system's validity.Conceptual progression of OAB to the Integral Theory paradigms's prematurely activated micturition validates OAB component symptoms as a syndrome, explains pathogenesis, and unlocks a new way of understanding, diagnosing, treating and researching OAB.© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.

Anorectal medical disorders facing the elderly include fecal incontinence, fecal impaction with overflow fecal incontinence, chronic constipation, dyssynergic defecation, hemorrhoids, anal fissure, and pelvic floor disorders. This article discusses the latest advances in age-related changes in morphology and function of anal sphincter, changes in cellular and molecular biology, alterations in neurotransmitters and reflexes, and their impact on functional changes of the anorectum in the elderly. These biophysiologic changes have implications for the pathophysiology of anorectal disorders. A clear understanding and working knowledge of the functional anatomy and pathophysiology will enable appropriate diagnosis and treatment of these disorders. Copyright © 2014 Elsevier Inc. All rights reserved.