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Surgical and non-surgical cure of nocturia based on ligament reinforcement

Bernhard Liedl and Peter Petros on behalf of ISPP

We thank the editors of the Nocturia Resource Centre for the opportunity to present our experience with surgical and non-surgical cure of nocturia based on ligament reinforcement according to the Integral Theory.

The Integral Theory is a change in thinking, consistent with what Thomas Kuhn has described as a ‘paradigm shift’ in his book The structure of scientific revolutions.”    The Theory states that the cause for POP, pain, bladder & bowel dysfunctions is mainly outside of the organ, a consequence of lax pelvic ligaments because of altered collagen/elastin.  Furthermore, repair of these ligaments by shortening them and then reinforcing them with short lengths of precisely inserted tapes will reverse the cascade of events leading to the above symptoms. Since the first publication of the Theory in 1990, many authors have validated this prediction by cure of bladder, bowel and pain dysfunctions with ligament repair. Not least has been the cure of urinary stress incontinence (USI) by reinforcement of the pubourethral ligament by the midurethral sling operation, now the worldwide standard for USI.

We present the theory and peer review papers for surgical and non-surgical improvement of pelvic floor symptoms, one of which is nocturia.

Some points of differentiation with other presentations on this website.
The nocturia conditions treated best with Desmopressin and those best treated according to the Integral Theory are most likely different, the former being urology based and the latter gynecology based.

  1. The Theory does not address male nocturia or female nocturia if it is an isolated symptom. For example, diurnal polyuria or heart failure related polyuria cannot be addressed with ligament repair.
  2. Nocturia when caused by posterior ligament laxity invariably co-occurs with other symptoms, for example chronic pelvic pain, urgency, ODS, fecal incontinence.
  3. Some degree of apical prolapse MUST be present before surgical ligament repair is contemplated.

Diagnosis of ligament defect
Nocturia caused by uterosacral ligament laxity is invariably associated with other symptoms as per the pictorial algorithm.

The pictorial algorithm uses symptoms to diagnose which ligaments are loose

The pictorial algorithm uses symptoms to diagnose which ligaments are loose.

Non-surgical treatment  is by application of the squatting based pelvic floor regime.
Skilling PM,·Petros PE Synergistic non-surgical management of pelvic floor dysfunction: second report. Int J Urogyne (2004)15: 106-110

Surgical treatment  The simplest method is native issue repair, approximation of the uterosacral ligaments.

Approximation of loose uterosacral ligaments (USL)

Approximation of loose uterosacral ligaments (USL)

A full thickness 5 cm wide transverse incision is made in the posterior vaginal wall 3-4 cm below the cervix or hysterectomy scar. Using a large needle with No1 vicryl or 00 proline, the uterosacral ligaments (USL) are approximated. If these cannot be located, two sutures are inserted lateral to the edges of the incision. These are approximated and tied. The operation can be done under LA /sedation. With this native tissue method, there is a relapse of symptoms with time, up to 50% by two years. That is why we now use thin implanted tapes placed along the length of the natural ligaments to create collagenous neoligaments. These give good long term results. CL=cardinal ligament; E=enterocele.

Bernhard Liedl President: bernhard.liedl@t-online.de
Peter Petros Education: pp@kvinno.com
On behalf of ISPP (International Society for Pelviperineology).

Commentary by the Editors

We received a ‘note to the editors’ by Liedl and Petros concerning ‘surgical and non-surgical cure of nocturia based on the ligament reinforcement theory’. The authors add a couple of papers to document their theory and the potential role of ligament reinforcement in the treatment of nocturia in females. The theory is substantiated by a series of articles elaborating the theoretical concept and the results of clinical trials in which female patients have had an operation to reinforce their pelvic ligaments.

In their note the authors propose a change in thinking, consistent with what Thomas Kuhn has described as a “paradigm shift” in his book “The structure of scientific revolutions”.  However the true, overriding point of Kuhn’s book is that there is never a single truth in science, and he writes “Philosophers of science have repeatedly demonstrated that more than one theoretical construction can always be placed upon a given collection of our data.” (pag 73).

Looking at the published results of trials that studied the surgical approach of pelvic organ prolapse and the potential effect of this type of surgery on voiding symptoms as f.e. nocturia, overall the number of patients are small and do not reach sufficient power in order to claim an effect on nocturia nor any other voiding dysfunction, be it statistically nor clinically. Furthermore the evaluation in general is based on subjective parameters, and no objective tools specifically for nocturia have been used. Also these studies address a sub-group of females with prolapse and concomitant nocturia, which is a specific group that cannot be compared with the large population of females with nocturia without significant prolapse. Striking is also the large variation in results in terms of nocturia that varies between 50% and 85%.

The collection of data from various researchers around the world regarding the existence of nocturnal polyuria, its role in nocturia, and its potential avenues of treatment are at least as compelling as what Liedl and Petros are proposing. However if there are pragmatic aspects of the surgical approach of nocturia that merit our attention, we would welcome well-structured prospective trials into this topic with objective endpoints and sufficient numbers to reach at least statistical power, in order to promote the surgical cure of nocturia in females.