Toilet training in early childhood leads to acquiring and keeping high sympathetic tone at the IUS and the IAS causing their contraction and the urethra and the anal canal are empty and closed all the time until there is a need/or a desire to expel at proper social circumstances.

Pelvic floor dysfunction

It is better called pelvic organs dysfunction, there are anatomical derangement of the pelvic organs and physiological changes [1-9]. Trauma especially child birth trauma (CBT) disturbs the anatomy and physiology of the pelvic organs.

Micturition, urinary continence and incontinence

Urinary continence depends on a closed and empty urethra. An empty closed urethra depends on two factors, one is inherent and the other is acquired. The inherent factor is a strong intact internal urethral sphincter (IUS) [1-5]. The acquired factor is gaining high sympathetic tone at the IUS from toilet training early in childhood. The IUS is a collagen-muscle tissue cylinder that extends from the bladder neck to the perineal membrane in both sexes. High sympathetic tone (T10-L2) at the IUS through neuro-transmitter (norepinephrine) that acts on receptors on the plain muscle fibers constituents of the IUS keeping the sphincter in a state of sustained contraction until there is a desire and/ or a need to void at suitable social circumstances.

Clinically we proved that toilet training induces and keeps high sympathetic tone at the IUS. Using urodynamic studies we recorded the urethral pressure profile at rest (UPP), then we gave an alphasympathetic blocker (5 mg phentolamine, Regitine) the pressure dropped significantly. Furthermore we by IV drip gave nor-adrenaline the pressure rose up immediately [4].

Sometimes there is a deficiency in secreting the neuro-transmitter, this will lead to a relaxed IUS and an open urethra with unwilling voiding (nocturnal enuresis) which can be partial (only at night) or complete (day and night). This can be treated by giving ephedrine which stimulate the sympathetic nerve endings to produce and secretes nor-epinephrine, and also acts as sympathomimetic on the receptors on the muscle fibers to the IUS causing its sustained contraction [2].

Clinically we studied the structure of the IUS both histologically and by imaging. We proved the presence of a strong collagen chassis of the IUS in normal continent women, and torn chassis in incontinent women.

In women the IUS is intimately lying on the anterior vaginal wall. Vaginal delivery (CBT) may cause damage and lacerations of the strong collagen chassis of the vagina resulting in redundant weak vaginal wall with subsequent vaginal prolapse. CBT will also lacerate the strong collagen chassis of the IUS causing its weakness so it cannot stand against sudden rise of abdominal pressure allowing urine to enter the urethra. The lacerations are usually in the upper part of the IUS causing funneling of the bladder neck and gives false impression of descent of the bladder neck. Urine entering the open upper part of the urethra induces an urgent need to void and/or urinary incontinence (over active bladder OAB). There is increased frequency and nocturia, the amount of urine is usually small. OAB is the clinical term, the urodynamic term of such condition is detrusor instability, detrusor over activity (DI, DO). Also sudden increase of abdominal pressure leads to stress urinary incontinence (SUI). As soon as the woman feels wet, reactive sympathetic activity will increase the already existing sympathetic tone at the IUS preventing further leak of urine. When the lacerations in the chassis of the IUS affect the entire length of the IUS there is a mixed type of SUI which is the commonest type of SUI. In men with prostatic enlargement there is uneven constriction of the upper part of the urethra that causes irregular widening of the uppermost part of the urethra, allowing some urine to enter the urethra leading to urgent desire to void, frequency and urge incontinence. Hesitancy occurs from the compression on the urethra, especially more apparent with any annoying factors that increase the sympathetic tone further closing the urethra interrupting the stream.

Fecal continence and fecal incontinence (FI)

Fecal continence depends on a closed and empty anal canal. An empty closed anal canal depends on two factors, one is inherent and the other is acquired [6,7]. The inherent factor is the presence of a strong intact internal anal sphincter (IAS), which is a collagen-muscle tissue cylinder that surrounds the anal canal and is surrounded in its lower part with the external anal sphincter (EAS). The muscle is plain muscle fibers has its nerve supply from the thoraco-lumbar sympathetic nerves (T10- L2) through the inferior hypogastric plexus. Toilet training leads to gaining and keeping high sympathetic tone at the IAS that maintains its contraction, thus keeping the anal canal empty and closed all the time. The IAS is closely related to the posterior vaginal wall. CBT causes invisible lacerations of the strong collagen chassis of the posterior vaginal wall leading to a redundant prolapsed posterior vaginal wall, and the intimately lying IAS lacerating its strong collagen chassis and causing FI.

Diagnosis

Medical history and clinical examination, in the local examination two important observations are kept in mind, if you see the anterior and/or the posterior vaginal wall without asking the patient to strain this means vaginal wall prolapse. In addition, the direction of the external urethral meatus is important, normally it is directed directly anterior [1-7], if it looks up and forward this means loss of posterior urethra-vesical angle. In addition, investigations to be done, an important note is structural damage is seen by medical imaging and functional changes are demonstrated by urodynamic studies.

Reconstructive surgery

Urethro-Ano-Vaginoplasty is a novel reconstructive operation to help restore the normal anatomy and functions. It consists of two parts, an anterior division and a posterior one. In the anterior part we dissect the anterior vaginal wall clear from the torn IUS, then we mend the torn IUS with simple interrupted sutures. We do overlapping of the bisected anterior vaginal wall over the mended IUS [8,9]. In the posterior section we mend the torn IAS after dissecting it free from the posterior vaginal wall. We approximate the levator ani muscles by two or three sutures not to be tied until we did the overlapping of the posterior vaginal wall. We approximate the levators and tie the sutures and then repair the perineum.