Skip to main content
SpringerLink
Log in

Fortentwickelte Konzepte zur weiblichen (In-)Kontinenz

Pathophysiologie, Diagnostik und operative Therapie

The development of concepts of female (in)continence

Pathophysiology, diagnostics and surgical therapy

  • Weiterbildung • Zertifizierte Fortbildung
  • Published:
Der Urologe Aims and scope Submit manuscript

Zusammenfassung

Band- bzw. Fasziendefekte, die die Stützfunktion der Vagina beinträchtigen, können nach der Integraltheorie nicht nur Belastungsharninkontinenz, sondern auch Urgency und Blasenentleerungsstörungen verursachen. Im Folgenden werden die anatomischen und pathophysiologischen Grundlagen dieser Funktionsstörungen dargestellt, die durch Ersatz defekter Strukturen nach dem Prinzip „Rekonstruktion der Struktur ermöglicht Wiedererlangung der Funktion“ behandelt werden können. Wesentliche Elemente dieses therapeutischen Algorithmus sind suburethrale Bänder (retropubisch oder transobturatorisch); ferner ein posteriores Band, das durch die Fossa ischiorectales verläuft, den Scheidenabschluss in Höhe der sakrospinalen Ligamente dorsal hält und defekte sakrouterine Bänder ersetzt. Laterale und mediane Defekte bei Zystozele lassen sich durch ein vorderes Netz rekonstruieren, welches am Arcus tendineus fasciae pelvis durch seitliche transobturatorische Zügel fixiert wird. Bänder und Netze aus Polypropylen haben sich bewährt, da sie gut einheilen und durch Narbenbildung ein Neoligament bzw. eine Neofaszie erzeugen und dauerhaften Halt gewähren.

Abstract

The integral theory postulates that defect ligaments and fascias, which impair the supporting function of the vaginal wall, can cause stress urinary incontinence as well as urgency and voiding dysfunction. The anatomical and pathophysiologic basis for these dysfunctions are presented. Voiding dysfunctions can be treated by the substitution of defect structures using the principle of “restoration of structure leads to restoration of function”. Essential elements of this therapeutic algorithm are suburethral vaginal slings (retropubic or transobturatoric), further a posterior sling, which runs through the fossa ischiorectalis and suspends the vaginal vault near the sacrospinal ligaments, thus reconstructing defect uterosacral ligaments. In cystoceles, lateral and medial defects can be restored by ventral meshes, which are fixed at the arcus tendineus fasciae pelvis by lateral transobturatoric slings. The use of polypropylene slings and meshes is well-founded because they are well tolerated in the tissues and through the development of scar tissue lead to neoligaments with long-lasting therapeutic effects.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Abb. 1
Abb. 2a–c
Abb. 3
Abb. 4
Abb. 5
Abb. 6
Abb. 7
Abb. 8
Abb. 9a,b
Abb. 10
Abb. 11
Abb. 12
Abb. 13

Literatur

  1. Buller JL, Thompson JR, Cundiff GW et al. (2001) Uterosacral ligament: description of anatomic relationsships to optimize surgical safety. Obstet Gynecol 97:873–879

    CAS  PubMed  Google Scholar 

  2. Bump RC (1988) The mechanism of urinary continence in women with severe uterovaginal prolapse: results of barrier studies. Obstet Gynecol 72:291–295

    CAS  PubMed  Google Scholar 

  3. Bunne G, Öbrink A (1978) Urethral closure pressure with stress — a comparison between stress incontinent and continent women. Urol Res 6:127–134

    CAS  PubMed  Google Scholar 

  4. Cervigni M, Natale F (2001) The use of synthetics in the treatment of pelvic organ prolapse. Curr Opin Urol 11:429–435

    CAS  PubMed  Google Scholar 

  5. Constantinou CE, Govan DE (1982) Spatial distribution and timing of transmitted and reflexly generated urethral pressures in healthy women. J Urol 127:964–969

    CAS  PubMed  Google Scholar 

  6. Cosson M, Debodinance P, Boukerrou M et al. (2003) Mechanical properties of synthetic implants used in the repair of prolapse and urinary incontinence in women: which is the ideal material? Int Urogynecol J Pelvic Floor Dysfunct 14:169–178

    PubMed  Google Scholar 

  7. DeLancey JO (1989) Pubovesical ligament: a separate structure from the urethral supports (pubourethral ligaments). Neurourol Urodynam 8:57

    Google Scholar 

  8. DeLancey JO (1992) Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 166:1717–1728

    CAS  PubMed  Google Scholar 

  9. DeLancey JO (2002) Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol 187:93–98

    PubMed  Google Scholar 

  10. Delorme E (2001) Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women. Prog Urol 11:1306–1313

    CAS  PubMed  Google Scholar 

  11. Enhorning G (1961) Simultaneous recording of the intravesical and intraurethral pressure. Acta Obstet Gynecol Scand 276 [Suppl]:1–69

    Google Scholar 

  12. Fletcher TF, Bradley WE (1978) Neuroanatomy of the bladder-urethra. J Urol 119:153–160

    CAS  PubMed  Google Scholar 

  13. Flynn BJ, Webster GD (2002) Surgical management of the apical vaginal defect. Curr Opin Urol 12:353–358

    PubMed  Google Scholar 

  14. Galloway NTM, Davies N, Stephenson TP (1987) The complications of colposuspension. Br J Urol 60:122–124

    CAS  PubMed  Google Scholar 

  15. Greenwald SW, Thornbury JR, Dunn LJ (1967) Cystourethrography as a diagnostic aid in stress incontinence. An evaluation. Obstet Gynecol 29(3):324–327

    CAS  PubMed  Google Scholar 

  16. Hannestad YS, Rortveit G, Sandvik H, Hunskaar S (2000) A community-based epidemiological survey of female urinary incontinence: the Norwegion EPINCONT study. J Clin Epidemiol 53:1150–1157

    CAS  PubMed  Google Scholar 

  17. Howard D, Miller JM, DeLancey JOL, Ashton-Miller AJ (2000) Differential effects of cough, valsalva, and continence status on vesical neck movement. Am J Obstet Gynecol 95:535–540

    CAS  Google Scholar 

  18. Iglesia CB, Fenner DE, Brubaker L (1997) The use of mesh in gynecologic surgery. Int Urogynecol J Pelvic Floor Dysfunct 8:105–115

    CAS  PubMed  Google Scholar 

  19. Ingelman-Sundberg A (1949) The pubovesical ligament in stress incontinence. Acta Obstet Gynecol Scand 28:183–188

    Google Scholar 

  20. Liedl B (2004) Stressharninkontinenz der Frau. Aktuel Urol 35:485–490

    CAS  Google Scholar 

  21. Liedl B (im Druck) Z-Plastik zur Korrektur einer „tethered vagina“

  22. Lin LY, Sheu BC, Lin HH (2004) Sequential assessmaent of urodynamic findings before and after tension-free vaginal tape (TVT) operation for female genuine stress incontinence. Eur Urol 45:362–366

    PubMed  Google Scholar 

  23. Lose G (2001) Urethral pressure measurement: problems and clinical value. Scand J Urol Nephrol Suppl 207:61–66

    PubMed  Google Scholar 

  24. Minassian VA, Drutz HP, Al-Badr A (2003) Urinary incontinence as a worldwide problem. Int J Gynecol Obstet 82:327–338

    CAS  Google Scholar 

  25. Papadimitriou J, Petros P (2005) Histological studies of monofilament and multifilament polypropylene mesh implants demonstrate equivalent penetration of macrophages between fibrils. Hernia 9:75–78

    PubMed  Google Scholar 

  26. Petros PEP, Ulmsten UI (1990) An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scand 69 [Suppl 153]:7–31

  27. Petros PE, Ulmsten U, Papadimitriou J (1990) The autogenic ligament procedure: a technique for planned formation of an artificial neo-ligament. Acta Obstet Gynecol Scand 69 [Suppl 153]:43–51

  28. Petros P, Ulmsten U (1993) An integral theory and its method for the diagnosis and management of female urinary incontinence. Scand J Urol Nephrol Suppl 153:1–93

    CAS  PubMed  Google Scholar 

  29. Petros PE, Ulmsten U (1995) Urethral pressure increase on effort originates from within the urethra, and continence from musculovaginal closure. Neurourol Urodyn 12:337–346

    Google Scholar 

  30. Petros PE (1996) The intravaginal slingplasty operation, a minimally invasive technique for cure of urinary incontinence in the female. Aust NZ J Obstet Gyn 36:463

    Google Scholar 

  31. Petros PE (1997) New ambulatory surgical methods using an anatomical classification of urinary dysfunction improve stress, urge and abnormal emptying. Int J Urogynecology 8:270–278

    CAS  Google Scholar 

  32. Petros PE (1998) The pubourethral ligaments — an anatomical and histological study in the live patient. Int J Urogynecology 9:154–157

    CAS  Google Scholar 

  33. Petros PE (1998) A cystocele may compensate for latent stress incontinence by stretching the vaginal hammock. Gynecol Obstet Invest 46:206–209

    PubMed  Google Scholar 

  34. Petros PE (1999) Medium-term follow-up of the Intravaginal Slingplasty operation indicates minimal deterioration of continence with time. Aust. NZ J Obstet Gynecol 39:354–356

    CAS  Google Scholar 

  35. Petros PE, Ulmsten U (1993) The development of the Intravaginal Slingplasty procedure: IVS II-VI. Scand J Urol Nephrol 27 [Suppl 153]:61–84

  36. Petros PE (2001) Vault prolapse 1: dynamic supports of the vagina. Int J Urogynceol Pelvic Floor 12:292–295

    CAS  Google Scholar 

  37. Petros PE (2001) Vault prolaps II: restoration of dynamic vaginal supports by the infracoccygeal sacropexy, an axial day-care vaginal procedure. Int J Urogynecol Pelvic Floor 12:296–303

    CAS  Google Scholar 

  38. Petros PE (2001) The art and science of medicine. Lancet 358:1818–1819

    CAS  PubMed  Google Scholar 

  39. Petros P, Skilling P (2001) Pelvic floor rehabilitation in the female according to the integral theory of female urinary incontinence. First report. Eur J Obstet Gynecol Reprod Biol 94:264–269

    CAS  PubMed  Google Scholar 

  40. Petros PE (2003) Non-linearity in clinical practice. J Evaluation Clinical Pract 9:171–178

    Google Scholar 

  41. Petros P, Bornstein J (2004) Vulvar vestibulitis may be a referred pain arising from laxity in the uterosacral ligaments. A hypothesis based on three prospective case reports. Aust N Z J Obstet Gynaecol 44:484–485

    PubMed  Google Scholar 

  42. Petros PE (2004) The female pelvic floor. Function, dysfunction and management. According to the integral theory. Springer, Berlin Heidelberg New York Tokyo

  43. Pieber D, Zivkovic F, Tamussino K (1998) Timing of urethral pressure pulses before and after continence surgery. Neurourol Urodyn 17:19–23

    CAS  PubMed  Google Scholar 

  44. Rezapour M, Falconer C, Ulmsten U (2001) Tension-free vaginal tape (TVT) in stress incontinent women with intrinsic sphincter deficiency (ISD) — a long-term follow-up. Int Urogynecol J [Suppl 2]:S12–S14

  45. Richardson AC, Edmonds PB, Williams NL (1976) A new look at pelvic relaxation. Am J Obstet Gynecol 126:568–573

    CAS  PubMed  Google Scholar 

  46. Richardson AC, Edmonds PB, Williams NL (1981) Treatment of stress urinary incontinence due to paravaginal fascial defect. Obstet Gynecol 57:357–362

    CAS  PubMed  Google Scholar 

  47. Richardson AC (1993) The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 36:976–983

    CAS  PubMed  Google Scholar 

  48. Richter K (1998) Gynäkologische Chirurgie des Beckenbodens. Georg Thieme, Stuttgart New York, S 187–198

  49. Segal JL, Karram MM (2002) Evaluation and management of rectoceles. Curr Opin Urol 12:345–352

    PubMed  Google Scholar 

  50. Shull BL (1999) Pelvic organ prolapse: anterior, superior and posterior vaginal segment defects. Am J Obstet Gynecol 181:6–11

    CAS  PubMed  Google Scholar 

  51. Snooks SJ, Badenoch DF, Tiptaft RC, Swash M (1985) Perineal nerve damage in genuine stress urinary incontinence. Br J Urol 57:422–426

    CAS  PubMed  Google Scholar 

  52. Strohbehn K, DeLancey JOL (1997) The anatomy of stress incontinence. Oper Tech Gynecol Surg 2:7

    Google Scholar 

  53. Strohbehn K (1998) Normal pelvic floor anatomy. Obstet Gynecol Clin North Am 25:683–705

    CAS  PubMed  Google Scholar 

  54. Thind P, Lose G, Jörgenson L, Colstrup H (1991) Urethral pressure increment proceeding and following bladder pressure elevation during stress episode in healthy and stress incontinent women. Neurourol Urodyn 10:177–183

    Google Scholar 

  55. TVM Group, Berrocal et al. (2004) Conceptual advances in the surgical management of genital prolapse. The TVM technique emergence. J Gynecol Obstet Biol Reprod 33:577–587

    Google Scholar 

  56. Ulmsten U, Johnson P, Petros P (1994) Intravaginal slingplasty. Zentalbl Gynäkol 116:398–404

    Google Scholar 

  57. Ulmsten U (1997) TVT-tension-free vaginal tape: an ambulatory surgical procedure under local anesthesia for treatment of female stress urinary incontinence. Riv It Biol Med 17 [Suppl 4]:40–43

    Google Scholar 

  58. Ulmsten U, Johnson P, Rezapour M (1999) A three-year follow-up of tension free vaginal tape for surgical treatment of female stress urinary incontinence. Br J Obstet Gynecol 106:345–350

    CAS  Google Scholar 

  59. Umek WH, Morgan DM, Ashton-Miller A, DeLancey JOL (2004) Quantitative analysis of uterosacral ligament origin and insertion points by magnetic resonance imaging. Obstet Gynecol 103:447–451

    PubMed  Google Scholar 

  60. Van der Kooi JB, van Wanroy PJA, De Jonge MC et al. (1984) Time separation between cough pulses in bladder, rectum and urethra in women. J Urol 132:1275–1278

    PubMed  Google Scholar 

  61. Von Theobald P, Labbe E (2003) Three-way prosthetic repair of the pelvic floor. J Gynecol Obstet Biol Reprod (Paris) 32:562–570

    Google Scholar 

  62. Whinte GR (1909) Cystocele: a radical cure by suturing lateral sulci of vagina to white line of pelvic fascia. JAMA 53:273–277

    Google Scholar 

  63. Zacharin RF (1963) A suspensory mechanism of the female urethra. J Anatomy 97:423–427

    CAS  Google Scholar 

  64. Zacharin RF (1968) The anatomic supports of the female urethra. Obstet Gynecol 32:754–759

    CAS  PubMed  Google Scholar 

Download references

Interessenkonflikt:

Der korrespondierende Autor versichert, dass keine Verbindungen mit einer Firma, deren Produkt in dem Artikel genannt ist, oder einer Firma, die ein Konkurrenzprodukt vertreibt, bestehen.

Author information

Authors and Affiliations

  1. Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München

    B. Liedl, I. Schorsch & C. Stief

  2. Urologische Poliklinik, Ludwig-Maximilians-Universität München, Nussbaumstraße 20, 80336 , München

    B. Liedl

Authors
  1. B. Liedl
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. I. Schorsch
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. C. Stief
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to B. Liedl.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Liedl, B., Schorsch, I. & Stief, C. Fortentwickelte Konzepte zur weiblichen (In-)Kontinenz. Urologe 44, 803–820 (2005). https://doi.org/10.1007/s00120-005-0875-8

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00120-005-0875-8

Schlüsselwörter

Keywords

Search

Navigation