Mapping the Dynamics of Connective Tissue Dysfunction

Abstract

In 1976, the International Continence Society (ICS) introduced the first definitions for urodynamic testing. This was a seminal step in the history of pelvic floor science, as it established the principle of objective assessment of the lower urinary tract. Moreover, by creating standard definitions, a common language for investigators was created. Subsequent advances in ultrasound, radiology, MRI and biomechanics have provided additional tools for the clinician to identify damaged structures, and to proceed some way towards quantification of the damage. This section shows how such tools may be used to more accurately identify damaged structures. Accurate mapping of function and dysfunction (as opposed to diagnosing specific structural defects) is a far more difficult problem, as not all apparently damaged structures necessarily cause dysfunction. For example, not all patients with ‘funnelling’ during straining (anterior zone defect) necessarily have stress incontinence: Some patients with major degrees of prolapse (posterior zone defect) have no symptoms associated with lax posterior ligaments, yet others with minor degrees of prolapse may ‘complain bitterly’ of their symptoms (Jeffcoate 1962). ‘Detrusor instability’ may be found in up to 70% of normal patients (Van Doorm 1992), yet it is absent in up to 50% of patients with bladder instability symptoms. In order to overcome such problems, the concept of ‘simulated operations’ is introduced. This technique helps the clinician to more accurately assess function by observing the change following anchoring of a specific connective tissue structure.