A practical ligament-based diagnostic system for cure of pelvic symptoms and prolapse

Introduction

The key points of the article are summarized in the video abstract (Videos S1-S3).

“It is not sufficient to describe an anatomical structure. An answer is required to the question, what is it for.”—Salvador Gil-Vernet (1892–1987) Famous Spanish Anatomist and Urologist and Nobel Prize nominee.

The Diagnostic System of the Integral Theory Paradigm (ITP) (1,2) is a practical guide designed for everyday clinical use (Figure 1). It is structured, anatomical, and symptom-based.

Figure 1 The diagnostic system flow chart has 4 parts: (I) the validated patient questionnaire ITSQ; (II) the pictorial diagnostic algorithm; (III) vaginal examination; (IV) simulated operations. Reused from (1). With permission from Peter Petros; retains ownership of the copyright.ITSQ, Integral Theory Symptom Questionnaire; S, sacrum; B, bladder; PS, pubic symphysis; PCM, pubococcygeus muscle; PUL, pubourethral ligament; UT, uterus; R, rectum; USL, uterosacral ligament; RVF, rectovaginal fascia; PB, perineal body; PRM, puborectalis muscle; EAS, external anal sphincter; LMA, conjoint longitudinal muscle of the anus; LP, levator plate; EUL, external urethral ligament; PCF, pubocervical fascia; CL, cardinal ligament; ATFP, arcus tendineus fascia pelvis; H, suburethral vaginal hammock; C, closed; O, open.

Why the ITP structured diagnostic system is different?

The ITP flow chart (Figure 1), is the only diagnostic system for diagnosing the anatomical causation of bladder/bowel/pain symptoms in existence. It is a 4-step comprehensive diagnostic system.

Why is a structured diagnostic system necessary?

Simply stated, patients complain of only one main problem, the “tip of the iceberg” (3) (Figure 2). Only a structured questionnaire can identify all patient symptoms. In Figure 2, the main complaint in 198 women (3) was chronic pelvic pain (CPP). The other pelvic symptoms were “under the surface” and were diagnosed by the use of the Integral Theory Symptom Questionnaire (ITSQ) (4). The structured diagnostic system (Figure 1 flow chart), located many other bladder/bowel/pain symptoms which were present “below the surface”, but were not volunteered by the patients.

Figure 2 The Pescatori Iceberg diagram applied to CPP. Reused from (3). Copyright 2017, with permission from the Pelviperineology. The presenting symptom was CPP. Symptom prevalence is graphically indicated in the iceberg diagram. Latent symptoms are below the waterline, are numbered according to their prevalence and were derived from the ITSQ (4). CPP, chronic pelvic pain; ITSQ, Integral Theory Symptom Questionnaire; ODS, obstructive defecation syndrome; SUI, stress urinary incontinence; FI, fecal incontinence.

The structured assessment diagnostic system is summarized in a diagnostic flow chart

It is a comprehensive clinical assessment, recording and testing tool to determine ligamentous causes of pelvic symptoms and prolapse.

Figure 1 comprises 4 parts: (I) the validated ITSQ, locates symptoms; for the (II) diagnostic algorithm for initial diagnosis of ligament causation; which guides the (III) vaginal examination to confirm specific prolapses and ligament damage; which guides performance of (IV) “simulated operations” to confirm ligament pathogenesis: hemostat test to (i) relieve urine loss on coughing, speculum test to relieve urge and chronic; (ii) CPP, which more securely guides surgical or nonsurgical treatment.

Part I of the flow chart—the validated patient questionnaire (ITSQ)

With reference to the diagnostic flow chart (Figure 1), the Structured Assessment System begins with a completed questionnaire (4) (Figure 3) which uses an actual clinical case as an example: a parous woman with symptoms of stress urinary incontinence (SUI), overactive bladder (OAB) (urge, frequency, nocturia), abnormal emptying, CPP, and 4th degree cystocele and uterine prolapse.

Figure 3 Self-administered patient questionnaire. A,M,P (A_nterior, M_iddle, P_osterior), on the left side of the questionnaire, indicate zones of connective tissue (ligament) looseness. The numbers 1–11 in the left column of the questionnaire explain the anatomical basis of the questions. This part is for the physician only and is located at the end of each questionnaire (see Appendix 1). The red writing shows the post-operative symptom results from midurethral and uterosacral sling operations. Reused from (1). With permission from Peter Petros; retains ownership of the copyright.

Please note: the same clinical case example in the questionnaire [1], is used for the Algorithm [2] and for the examination sheet [3]. The results from pubourethral ligament (PUL) and uterosacral ligament (USL) surgery are written in red in the questionnaire.

How to use the ITSQ

The ITSQ (Figure 3) is a validated questionnaire and was designed to be self-administered (4). However, experienced clinicians advise more clarity of the answers can be achieved by direct questioning by the physician. “Sometimes” answers are ticked in the algorithm columns, even when incidence is low.

A,M,P (A_nterior, M_iddle, P_osterior), on the left side of the questionnaire, indicate zones of connective tissue (ligament) looseness. The appropriate columns, A,M,P, are ticked in the algorithm (see marked example, Figure 4). “TVS” on the left side signifies the question relates to the Tethered Vagina Syndrome (TVS), a condition caused by scarring or tightness in the bladder neck area of the vagina (middle zone), usually iatrogenic.

Figure 4 Patient algorithm has three zones of causation (ligament damage). It is marked with ITSQ answers. The prolapses in the algorithm correlate with ligament damage in the columns. Symptom groupings in the columns help deduce which ligaments cause which symptoms. Anterior zone runs from the external meatus to the bladder neck, and comprises EUL, PUL, suburethral vaginal hammock, and dislocated collagenous insertion of PCM also known as “levator avulsion”. Middle zone runs from the bladder neck to the anterior cervical ring and comprises PCF, CL, and ATFP. Posterior zone runs from the cervix to the PB. It comprises USL, RVF, and PB. Reused from (1). With permission from Peter Petros; retains ownership of the copyright. S, sacrum; B, bladder; PS, pubic symphysis; PCM, pubococcygeus muscle; PUL, pubourethral ligament; UT, uterus; R, rectum; USL, uterosacral ligament; RVF, rectovaginal fascia; PB, perineal body; PRM, puborectalis muscle; EAS, external anal sphincter; LMA, conjoint longitudinal muscle of the anus; LP, levator plate; EUL, external urethral ligament; PCF, pubocervical fascia; CX RING, cervical ring; USL, uterosacral ligament; ITSQ, Integral Theory Symptom Questionnaire; CL, cardinal ligament; ATFP, arcus tendineus fascia pelvis.

The diagnosis of ligament looseness and prolapse is then visually read off from the algorithm (see marked example, Figure 4).

The numbers 1–11 in the left column of the questionnaire explain the anatomical basis of the questions. This part is for the physician only and is located at the end of each questionnaire (see Appendix 1). The red writing shows the post-operative symptom results from midurethral and uterosacral sling operations.

Part II of the flow chart—the diagnostic algorithm

With reference to the diagnostic flow chart (Figure 1), answers from the questionnaire have been marked in each of the three columns (zones) of the algorithm (Figure 4). The algorithm indicates that the patient has four potentially damaged ligaments, PUL, cardinal ligament (CL), USL, perineal body (PB), and potential prolapses in all three zones:

• Anterior zone: suburethral vaginal hammock and external urethral ligament (EUL);
• Middle zone: cystocele;
• Posterior zone: uterine/apical prolapse and enterocele.

A diagnosis of ligament causation of symptoms and prolapse is indicative of pathogenesis, but it has to be checked by vaginal examination and “simulated operations” (Figure 1 flow chart).

Adoption of the diagnostic algorithm as a standard assessment tool in women with bladder/bowel/pain symptoms accurately guides ligament causation and helps guide decisions for surgery (see Appendix 2 for a clear copy of the diagnostic algorithm).

The algorithm used as a stand alone diagnostic tool

The diagnostic algorithm (Figure 4) can be used by itself, as a simple stand-alone diagnostic tool as part of every vaginal operation. The clinician uses the algorithm as an “aide memoire” and asks the questions directly. The algorithm is sufficiently accurate from a diagnostic perspective, and it ensures that every symptom and every prolapse is searched and recorded (see Table 1).

Part III of the flow chart: vaginal examination

This is a “how to” instruction of what the ligament defects and prolapses predicted by the algorithm in each zone look like. At the end of the vaginal examination, the clinician completes the examination sheet for each individual patient, where the clinician records the findings for all the three zones. The examination sheet records ligament defects and degree of prolapse. It also serves as an aide memoir to ensure all three zones are examined.

Figure 5 is the actually completed examination sheet record of the ligament defects and degree of prolapse found in each of the three zones of the patient’s ITSQ completed questionnaire (Figure 3, see Appendix 3 for a clear copy of the examination form, see Appendix 4 for a clear copy of the questionnaire form).

Figure 5 Completed examination sheet record. Completed examination sheet record for anatomical defects found in each of the three zones (for the completed ITSQ patient questionnaire). Reused from (1). With permission from Peter Petros; retains ownership of the copyright. ITSQ, Integral Theory Symptom Questionnaire; EUL, external urethral ligament; PUL, pubourethral ligament; PB, perineal body; EAS, external anal sphincter; ATFP, arcus tendineus fascia pelvis.

Typical examination findings of anatomical defects in the 3 zones

The Figures 3-5, which are generic figures, demonstrate what to look for in the vaginal examination; they are not necessarily related to the ITSQ patient example given previously.

Anterior zone examination for PUL damage

PUL laxity, the main cause of SUI, cannot be visually confirmed by the presence of a prolapse. It can only be confirmed by the hemostat test (Figure 6).

Figure 6 Anterior zone: Hemostat test. The hemostat test mechanically prevents elongation of the PUL in the same way as a midurethral sling. This is a 3-dimensional sagittal view of the bladder base and trigone supported by the vagina below (broken lines); PUL laxity “L”, allows PUL to stretch downwards; in the absence of a firm PUL anchoring point, the normal LP/LMA contraction which closes the bladder neck now forcibly opens the posterior wall of the urethra, from “C” (closed) to “O” (open), so urine is lost on effort. The hemostat mechanically prevents extension of the PUL, exactly as does a midurethral tape, so the bladder neck and distal urethra are closed as per normal. With permission from Peter Petros (1); retains ownership of the copyright. PUL, pubourethral ligament; PCM, pubococcygeus muscle; LP, levator plate; LMA, conjoint longitudinal muscle of the anus; H, suburethral vaginal hammock; C, closed; O, open; PS, pubic symphysis.

The patient is asked to cough; if urine loss during coughing is prevented by a hemostat gently pressed upward immediately behind the pubic bone, in the position of the midurethra, a diagnosis of lax PUL can be made (Figure 6) (see Video S4). This is recorded along with findings for vaginal hammock and the EUL.

Unilateral hemostat support, immediately behind the symphysis at the origins of the PUL, prevents the causative elongation of the PUL to “L”, and so controls urine loss on coughing (Video S4).

Anterior zone examination for EUL damage, and hammock laxity

The function of these structures is to seal the urethra. Laxity (Figure 7, right) needs to be repaired otherwise patients may say that SUI is cured but they still leak small amounts of urine, feeling like a bubble escaping.

Figure 7 Anterior zone: EUL defect. Left: normal EUL. The urethral meatus (M) is well supported horizontally by the EUL (arrows) which attach it to the anterior surface of the symphysis. The hammock is in the normal plane. Note: the external urethral ligament is also called, “anterior pubourethral ligament”. Right: lax EUL and hammock. The urethral meatus (M) is lax and has caused the urethral mucosa to become everted. The lateral EUL supports are seen “drooping” downwards (arrows). The hammock is lax and angulated downwards. “Simulated operation”. Gentle mechanical support of EULs (“simulated operation”) will usually cause the everted mucosa to retract. With permission from Peter Petros (1); retains ownership of the copyright. EUL, external urethral ligament.

Middle zone examination for transverse cardinal (CL) defect cystocele

A transverse cardinal defect cystocele usually has rugae and prolapses lateral to the cervix (Figure 8A).

Figure 8 Middle zone: transverse defect. Findings of prolapsed vagina lateral to the CX, confirms CL dislocation or tearing. With permission from Peter Petros (1); retains ownership of the copyright. (A) Vaginal prolapse lateral to the cervix contains prolapsed “CL” as per (B); (B) pathogenesis: the vagina’s PCF, is torn from the “CL” and, now unsupported, prolapses down like a trapdoor as a “lateral defect” or “high” cystocele. r, rupture of the “CL”; PCF, pubocervical fascial layer; CL, cardinal ligament; CX, cervix.

Pathogenesis of transverse defect cystocele

The CL attachment onto the anterior cervix is stretched or torn and prolapses downwards, lateral to the cervix, taking the prolapsed vagina with it (Figure 8A). The vaginal prolapse is caused by tearing of the pubocervical fascial (PCF) attachment to the CL (Figure 8B). The pubocervical layer and the underlying vagina descend downwards like a trapdoor as a transverse defect or “high” cystocele. The examination results are recorded in the examination sheet.

Clinical test for CL dislocation cause of transverse defect cystocele

With two Allis forceps, very gently grasp each side of the prolapsed vagina, lateral to the cervix (Figure 8), and approximate them to the midline of the cervix. The cystocele disappears.

Caution: this test must be performed with extreme gentleness so as not to cause pain.

Middle zone examination for central cystocele

Characteristically, there is a large bulge with shiny vaginal epithelium, with no obvious rugae. Invariably, there is also a transverse defect (Figure 9, see curved arrows, “cervical ring”).

Figure 9 Middle zone: central defect cystocele and uterine prolapse. A large central defect (4^th degree) extends laterally. Prolapse of the dislocated CL is seen around the CX (curved arrows), characteristic of CL/cervical ring defect. The central cystocele invariably has shiny vaginal epithelium. It is most likely caused by dislocation of the PCM from the symphysis. The central defect remained after the Allis forceps test to approximate displaced CLs and restore transverse defect. Posterior zone: uterine prolapse and cystocele, both 4^th degree. The uterus is totally externalized. A dislocated CL is seen around the CX (curved arrows), characteristic of CL/cervical ring. With permission from Peter Petros (1); retains ownership of the copyright. BN, bladder neck; CX, cervix; CL, cardinal ligament; PCM, pubococcygeus muscle.

Pathogenesis of central defect is essentially unknown

Repair of dislocated puboccygeus muscles to cure a diverted urinary stream with a USling (5), cured a central cystocele. Repeated confirmation of cure of a central cystocele as in Figure 9, by a USling, by several surgeons, caused us to hypothesize that its pathogenesis may be pubococcygeus muscle dislocation from the symphysis.

Posterior zone examination for USL laxity

In Figures 9,10, uterine prolapse of 4^th degree is evident. Figure 10 also shows that with a large degree of uterine prolapse, the CL must also be stretched equivalently. More difficult to confirm is minimal prolapse, 1^st and 2^nd degree, which often has the worst symptoms, and is usually only confirmed in the OR by pulling down the cervix. Clinical confirmation of such cases is by elevating the anterior vaginal wall with a speculum and asking the patient to strain down. Appearance of an enterocele confirms USL elongation. Not diagnosable by vaginal examination is the frequent co-occurrence of anterior rectal wall intussusception with uterine/apical prolapse which requires diagnosis by X-ray proctogram (6) or by ultrasound (see “Simulated operations” paper in this series).

Figure 10 Posterior zone: 3^rd degree uterine prolapse. Damage or weakening of the USL and CL at the entry to the birth canal contribute to uterine prolapse. Elongation of USLs also causes them to spread laterally, to cause an enterocele. It is important to remember that USLs attach to the lateral wall of the rectum with fine ligaments. As the uterus prolapses down, the anterior rectal wall may descend also, often as an intussusception. Surgical shortening and reinforcement of the USLs will also restore both the uterine prolapse and also, the intussusception (6). With permission from Peter Petros (1); retains ownership of the copyright. USL, uterosacral ligaments; CL, cardinal ligaments.

Video S5 demonstrates that the CL plays a causative role equivalent to the USL, in 4^th degree uterine prolapse, as indicated in Figure 10. Note in Video S5, how there was significant restoration of the uterine prolapse when Professor Sekiguchi tightened the CL TFS tape. Professor Sekiguchi’s restoration of uterine prolapse and cystocele by shortening and reinforcing the CL and USL (Figure 10), is, in fact, a more modern version of Fothergill’s Manchester Repair operation (Video S5 is by permission of Professor Sekiguchi).

Diagnosis of minimal USL laxity

In the outpatient clinic, lifting up the anterior vaginal wall with a speculum, and asking the patient to strain down hard can provoke an enterocele bulge in the posterior wall to confirm USL laxity.

Posterior zone examination for perineal body damage

There is a considerable bulge of the perineum on straining (Figure 11) (see Video S6). Rectal examination usually confirms that there is very little tissue between the vagina and the rectum.

Figure 11 Posterior zone: rectal examination. DTP ligaments insert behind the junction of the upper 2/3 and lower 1/3 of the descending rami to suspend the perineal body. Reused from (1). With permission from Peter Petros; retains ownership of the copyright. DPS, descending perineal syndrome; DTP, deep transversus perinei.

Pathogenesis of perineocele and descending perineal syndrome

Rectal examination confirms flattening and lateral displacement of the perineal bodies which are usually to be found below the ischial tuberosity. The cause is elongation of the deep transversus perinei (DTP) ligaments (Figure 12). The lateral displacement of these structures allows protrusion of the rectum into the central space which presents as a low rectocele or perineocele. Often the serosal layer of the rectum has been breached. This allows the rectal mucosa to spread laterally and to adhere to the vagina, DTP ligaments and even the pelvic bones. If the damage is sufficient, the perineal body itself descends as “descending perineal syndrome” (7,8).

Figure 12 Posterior zone: pathogenesis of perineocele and descending perineal syndrome. Overstretching of the perineum at delivery may cause elongation of the DTP ligaments, with consequent displacement of the perineal bodies to below the ischial tuberosity. The rectum protrudes in the space of the displaced “PBs” and if the rectum’s muscular and serosal layers are ruptured, the rectal mucosa, often 1-mm thick, may adhere closely to the vagina, “PB” and pubic rami. Reused from (1). With permission from Peter Petros; retains ownership of the copyright. DTP, deep transversus perinei; OF, obturator fossa; PB, perineal body; A, anus.

How accurate was the algorithm in predicting examination findings?

Figure 13 compares the examination sheet findings (Figure 5) with the algorithm predictions from Figure 4, (both from the ITSQ patient example):

• Anterior zone prediction—SUI confirmed by hemostat supporting the PUL.
• Middle zone prediction—cystocele confirmed.
• Posterior zone prediction—uterine prolapse, enterocele, lax perineum confirmed.

Figure 13 Testing symptom predictions of ligament damage. Comparing algorithm, Figure 4 (left) with vaginal examination, Figure 5 (right). Reused from (1). With permission from Peter Petros; retains ownership of the copyright. USL, uterosacral ligament; PUL, pubourethral ligament; EUL, external urethral ligament; ATFP, arcus tendineus fascia pelvis; CL, cardinal ligament; LMA, conjoint longitudinal muscle of the anus; LP, levator plate; S, sacrum; B, bladder; PS, pubic symphysis; PCM, pubococcygeus muscle; PRM, puborectalis muscle; RVF, rectovaginal fascia; UT, uterus; PCF, pubocervical fascia; EAS, external anal sphincter; PB, perineal body; R, rectum; CX, cervix.

What this means: a clinician experienced in the diagnostic system can figure out fairly accurately which ligaments may be causing patient problems purely from the symptoms, especially where there is minimal prolapse. For example, SUI = PUL damage; pain and nocturia = USL damage; bladder emptying/retention = USL or CL, often both.

Part IV of the flow chart—simulated operations

Though simulated operations follow vaginal examination in the flow chart (Figure 1), they are actually performed during the vaginal examination. Specific structures such as PUL and USL, and bladder base, are mechanically supported and the change in symptoms of stress incontinence, urge and pain are observed. Many simulated operations are possible, and these are presented in detail in this Annals of Translational Medicine series in the paper, “Simulated Operations apply mechanical support to structures to confirm symptom causation”. Simulated operations for PUL and USL, are presented here, as they have become part of a standard vaginal assessment.

Simulated operation for stress and mixed incontinence

A hemostat applied behind the symphysis mechanically supports a weak PUL and prevents PUL elongation on coughing or straining, as in Figure 6. If it prevents urine loss on coughing, it predicts a midurethral sling should cure or improve SUI. If the hemostat test reduces urge also, it can be predicted that the urge component of “mixed incontinence” (stress plus urge) will also be cured or improved in 50% of such women.

Confirming urinary urge and CPP objectively:speculum test (simulated operation)

The speculum test (Figure 14) is a simple and available test for determining USL pathogenesis of CPP and urgency.

Figure 14 Speculum test (simulated operation). Gentle insertion of the speculum mechanically supports stretch receptors “N” to control urge. The speculum also supports lax USL and the VP to control pain. This test relieves pain and urge in 70–80% of women who have these symptoms. The pink wavy lines indicate weakened muscle forces, a consequence of the “LP” and “LMA” contracting against weakened USLs (L). Reused from (1). With permission from Peter Petros; retains ownership of the copyright. USL, uterosacral ligament; VP, visceral plexuses; PUL, pubourethral ligament; PCM, pubococcygeus muscle; ATFP, arcus tendineus fascia pelvis; CL, cardinal ligament; LMA, conjoint longitudinal muscle of the anus; LP, levator plate.

Confirming nocturia objectively

Shkarupa et al. (9) successfully used a gauze roll inserted during the day and overnight to test eligibility of patients with OAB symptoms for CL/USL plication (9) (see Appendix 5 for further references which surgically validate the predictive value of the diagnostic system).

Adding objective testing to clinical assessment

Objective investigative assessment is essentially the same as the four-part clinical assessment but adds more investigative information and objective tests. Examples in Figure 15, are patient diaries, pad tests (10) 2D or 3D transperineal ultrasound (11), specific urodynamic tests such as “interventional urodynamics” which mechanically support a ligament during urodynamic testing while observing the changes in the graphs (12,13). Such objective testing is standard practice in many tertiary academic centres. In some cases, such as TVS, tests such as 2D ultrasound monitoring during straining, add a substantial layer of diagnostic certainty.

Figure 15 Tertiary referral centre investigative assessment tool. Reused from (1). With permission from Peter Petros; retains ownership of the copyright.

With the caveat of variability inherent in all short objective tests such as diaries, urodynamics, pad tests, the protocols detailed in Figure 15 could be used as a starting base for a future “evidence-based” artificial intelligence (AI) diagnostic system. For example, the prototype Bayesian Network learning model (Figure 6), is potentially configurable for an individual demographic. Figure 15 is a more expanded assessment tool than the clinical Structured Assessment System (1) (Figure 1).

Future directions: AI/Bayesian network learning

The Decision Tree Diagnostic System (Figure 16), contains percentage probabilities for specific input parameters. The decision tree worked accurately in the specialist referral environment where it was created. So as the decision could be more generally applied to other clinics which may have a different patient clientele, a machine learning system based on Bayesian networks which could be trained for a different environment and different clientele was developed by Curtin University School of Engineering, Perth, Western Australia, working with P.P. from Royal Perth Hospital (14). Matlab and the BN Toolbox were used to build the Bayesian networks. The Bayesian networks were trained using a majority of the data samples and then tested on the balance, ensuring that the test data was unseen by the network during training (14). Tests were also done using the training data. The results obtained by querying the network, for any individual case, were compared with the diagnosis obtained from the human expert (Peter Petros). These comparisons formed the basis of the evaluation of the system. In most cases, Bayesian networks were found to be at least as accurate as using Decision Trees, for example, Figure 16. An advantage of using Bayesian networks is that the accuracy, specificity and sensitivity will improve as the number of test cases available for training increases. In contrast, using Decision Trees is a relatively static process that is not easy to enhance incrementally.

Figure 16 Schema for Bayesian Network output nodes. Top row: predicting the likelihood of defects in the anterior (a), middle (m), or posterior (p) zones, or a diagnosis of Tethered Vagina Syndrome (t). Intermediate diagnosis and test, and patient questions and clinical test nodes are as shown. Reused from (1). With permission from Peter Petros; retains ownership of the copyright.

Problems and some possible future directions

Each city, suburb, medical practice will have a different mix of patients. It is envisaged that a Bayesian-based learning machine will be able to train the diagnostic system to be more specific for a location, and, therefore, more accurate.

Conclusions

The ITP has a 25-year track record of curing or improving bladder/bowel/pain symptoms when it can be demonstrated they may be caused by ligament laxity, even when prolapse is minimal. Prior to undertaking any treatment, an accurate diagnostic protocol is required. The structured diagnostic flow chart is entirely clinical. It uses symptoms to diagnose anatomical defects, vaginal examination to confirm damage, and simulated operations to validate that a specific ligament is causing a specific symptom.

Acknowledgments

We would like to express our thanks to Vani Bardetta for her proofreading and administrative services for this article.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the International Society for Pelviperineology for the series “Integral Theory Paradigm” published in Annals of Translational Medicine. Peter Petros (Editor) and Vani Bardetta (Assistant Editor) served as the unpaid Guest Editors of the series. The article has undergone external peer review.

Peer Review File: Available at https://atm.amegroups.com/article/view/10.21037/atm-23-1759/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-23-1759/coif). The series “Integral Theory Paradigm” was commissioned by the International Society for Pelviperineology without any funding or sponsorship. Peter Petros serves as an unpaid editorial board member of Annals of Translational Medicine from October 2022 to September 2024. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for the publication of this article and accompanying images. Human participation in the video was by patient permission on the basis it was deidentified.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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