Letters to the Editor.

Dear Editor,

I would like to congratulate the authors and CEJU on their ground-breaking publication, cure of overactive bladder (OAB) symptoms by tissue fixation system (TFS) repair of cardinal and uterosacral ligaments [1]. An increasing number of pelvic surgeons have been following the Integral Theory System (ITS) on which the OAB paper is based [1]. I can say that as a whole, results from the surgeons who have been practicing within the concept of ITS are concordant with those published [1]. The importance of this paper is that OAB is not considered to be surgically curable by major incontinence and urology associations. Rather, OAB is generally treated with anticholinergic drugs which are mainly ineffective long term.

Those physicians who follow other paradigms may doubt the data presented and its conclusions, that OAB as defined by the authors is surgically curable with a high degree of probability [1]. However, these data have been confirmed in the literature by other authors, albeit with much smaller numbers, using similar techniques to repair the posterior suspensory ligaments of the vagina [2-5].

The most impressive validations of the Integral Theory ligament methodology for patient and physician alike is that it is non-surgical, you can perform 'simulated operations', it supports specific ligaments and you can observe the clinical effect. The best known method is to digitally press upwards on one side of the urethra at its mid point to control urine loss on coughing. Another is to support the uterosacral ligaments with a speculum or a roll of gauze in patients with 'posterior fornix' symptoms (frequency, nocturia, urgency, chronic pelvic pain).

ISPP members who follow the Integral System regularly use the following technique as a predictor for posterior ligament surgery in patients with OAB.

Ask the patients to attend with a bladder sufficiently full to provoke symptoms of urgency. Insert the lower half of a bivalve speculum very gently into the posterior fornix of the vagina. The aim is to stretch back any minimal prolapse and therefore to support the posterior fornix. We found that in approximately 70–80% of cases, the patient stated that the urge had abated, sometimes almost completely. The examiner needs to be aware, however, that any excessive pressure may worsen the urgency. Another method is to digitally support the bladder base, again very gently.