Letters to the Editor.

Those who practice the Integral Theory System have often been scrutinized for shortage of high level evidence to support the hypothesis of Professor Petros's Integral Theory. This important study has laid down several major milestones for Pelvic Floor Medicine.

1st milestone. The authors convincingly proved that symptoms which at present are treated separately by urologists (bladder dysfunctions), gynecologists (pelvic organ prolapse) and proctologists (bowel dysfunctions) are all potentially curable holistically, by shortening and reinforcing loose pelvic ligaments, all with a high probability of being curative [1].

2nd milestone. The authors have demonstrated that symptoms of chronic pelvic pain, bladder and bowel symptoms are interrelated and occur in predictable groupings ('pyramid diagram', Figure 3) [1]. These groupings, in turn, indicate which ligaments are damaged (Pictorial Algorithm, Figure 2) [1]. However, these symptoms must be sought out by questionnaires or direct questioning as patients present with one main symptom or complaint [2]. The other symptoms remain 'below the surface' as in an iceberg, a phenomenon described as the Pescatori Iceberg [2]. For example, in 198 patients presenting with chronic pelvic pain and pelvic organ prolapse (POP) degrees 1–4, 64% had frequency, 34% had voiding dysfunction, 33% had urinary stress incontinence (USI), 32% had nocturia, 31% had obstructed defecation, 28% had urge urinary incontinence and 28% had fecal incontinence [2]. Similar cure rates were obtained after placing a posterior sling, ranging from 54% for voiding dysfunction to >95% for USI and POP [1].

Similar patterns of symptom co-occurrence and cure with tensioned TFS slings were obtained by other investigators as well [3, 4], with special reference to the cure of chronic pelvic pain [5].

3rd milestone. In our opinion, the most important point of all is that this study has seriously challenged the urodynamic paradigm which has been unquestionably followed by the majority of urologists around the world for almost 50 years. Other than stress incontinence, most other pelvic symptoms, including chronic pelvic pain, bladder and bowel dysfunction, have been considered incurable.

The large audit (n = 611), and the multinational nature of this study, have countered a principal criticism of the Integral Theory System to date - the surgical proofs did not reach statistical significance due to small numbers [1].

The potential consequences of these milestones are profound. In the future, there needs to be only one type of pelvic floor surgeon. One with a well-rounded training, whatever their original specialty is (urology, gynecology or proctology), that has a deep comprehension of the pelvic floor and understanding that the key for diagnosis and repair lies with damaged pelvic ligaments.