[Clinical applications of the comprehensive theory of urinary incontinence]

Currently, urinary incontinence cannot be treated without taking into consideration the comprehensive theory of urinary incontinence. According to this theory, stress incontinence, urge incontinence and alterations in bladder emptying result from alterations in the elements of suburethral support, ligaments and muscles of the pelvis floor. Alterations in the forces applied by muscles and ligaments to the fascia adjacent to the vaginal wall and the urethra cause the vesical neck and the urethra to open or close. Alterations in the forces applied to the vagina can also cause premature activation of the micturition reflex, triggering involuntary contractions of the detrusor muscle. Knowledge of the anatomic substrate of the upper, intermediate and lower layers of the pelvic floor and of the main pubourethral, urethropelvic and uterosacral ligamentous elements is essential before any surgical approach of incontinence can be attempted. Depending on the location of the fascial or ligamental muscle lesion and of the sensitivity of the local nerve endings, stress incontinence, urge incontinence, altered bladder emptying or combinations of these conditions can develop. There are 6 basic defects which should be systematically investigated: defect in the suburethral support ("Hammock"), tethered vagina syndrome, distended pubourethral ligaments, distended uterosacral ligaments and support of the vaginal apex, lesions of vaginal insertion of pubococcygeal muscles, lesions of the striated muscles of the pelvic floor levator plate.