Integral System Diagnostics
The Integral System Diagnostics aims to locate and identify which ligaments or fascia of the pelvic floor have been damaged. Damage to one or more connective tissue structures may cause prolapse, or dysfunction in organ closure or opening.
Pictorial Diagnostic Algorithm
Examination Sheet
Simulated Operations
Patient Questionairre
The Clinical Assessment Pathway
The Clinical Assessment pathway begins with the Pictorial Diagnostic Algorithm (below), the starting point of the Integral Theory Diagnostic System. It provides a summary guide to diagnosis and management of pelvic floor dysfunction and is especially useful for generalist surgeons who do not have access to the facilities of a specialist clinic.
This figure shows the relationship between the Pictorial Diagnostic Algorithm, the Structured Assessment Diagram and the Validation Table for 'Simulated Operations'.
The Pictorial Diagnostic Algorithm
The Pictorial Diagnostic Algorithm (below) is the starting point of the Integral Theory diagnostic system. The algorithm can be used as a framework when questioning the patient about symptoms, as a guide to the examination of the patient (fig 3-04), and to verify its predictions using the ‘simulated operations’ (fig 3-05). This technique can directly demonstrate cause and effect and thereby help validate diagnosis.
When using the Pictorial Diagnostic Algorithm, the suggested ‘zone(s)’ of damage are checked by vaginal examination (fig 3-04) and confirmed by ‘simulated operations’ (fig 3-06).
It provides a summary guide to diagnosis and management of pelvic floor dysfunction and is especially useful for generalist surgeons who do not have access to the facilities of a specialist clinic.
The area of the symptom rectangles on the chart indicates the estimated frequency of symptom causation occurring in each zone. The main connective tissue structures causing the symptoms are summarized in each zone, in order of importance. Note that there is no correlation between degree of prolapse and the severity of symptoms.
Click here to download a PDF version of the Pictorial Diagnostic Algorithm .
Examination Sheet (fig 3-04)
The vaginal examination is used to validate (or not) the zone of damage predicted by the clinician’s interpretation of the data in the patient questionnaire. Damaged structures and degree of prolapse are noted on the Clinical Examination sheet (fig 3-04). The relevant parts are transcribed to the Diagnostic Summary Sheet (fig 3-03).
When the Clinical Assessment pathway is used in conjunction with the ‘simulated operations’ technique, a very acceptable level of diagnostic accuracy can be achieved. Hence the Clinical Assessment pathway does not require expensive capital equipment, such as ultrasound or urodynamics. The vaginal examination and ‘simulated operations’ techniques are the same as for the Structured Assessment Pathway. Detailed descriptions are presented in the next section.
Click here to download a PDF version of the Clinical Assessment Sheet.
'Simulated Operations'
The Integral System is very specific: pelvic floor symptoms are mainly caused by lax suspensory ligaments.
The 'Simulated Operations' technique applies upward pressure at the site of suspensory ligaments. For example, unilateral pressure applied with the forefinger immediately behind the pubic symphysis (the site of the pubourethral ligament ‘PUL’) controls urine loss on coughing, and restores urethrovesical geometry to normal (fig3-05). If the urge component of a patient’s “mixed incontinence” originates from PUL.
This technique is especially useful when used to assess the contribution of a particular ligament (pubourethral, cardinal, uterosacral) to urgency (see ‘simulated operations’ Table below.
Once a preliminary diagnosis is made, the zone of damage can be validated (or not) by ‘simulated operations’. This is a technique which can give the surgeon an understanding of the contribution of each connective tissue structure in each zone to continence. The surgeon supports the structures in each of the three zones with artery or ring forceps, using patient sensory control (percentage diminution of urge), or direct observation (percentage diminution of urine loss with coughing) as criteria.
The clinician uses the ‘Simulated Operations’ Validation Table to record percentage decrease in urine loss with coughing (stress) or percentage decrease in urge symptoms following digital support (anchoring) of the individual structures 1-6 in the three zones. The patient should always attend with a full bladder, sufficient to cause urgency symptoms when lying down.
Click here to download a PDF version of the ‘Simulated Operations’ Validation Table.
The Patient Questionnaire
The questionnaire provides a comprehensive picture of symptoms associated with pelvic floor dysfunction.
Click here to download a PDF version of the Patient Questionnaire