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The significance of cough transmission ratios (CTR) in 6 unoperated and 15 previously operated patients is discussed. It is concluded that CTR is an index of periurethral muscle contractile activity, and vaginal wall tension, rather than urethral closure.

Urinary incontinence was observed in 19 patients after bladder neck elevation or vaginal repair operations. Characteristically, patients could not suppress their urge to micturate on getting up in the morning, and they wet before arrival at the toilet. Urodynamically, a high posterior cough transmission ratio was noted. A 1.5 cm longitudinal incision in the vagina, dissected free and resutured horizontally (I-plasty), immediately cured this particular condition, but ultimately failed in 1/3 cases. Most of these failed patients were subsequently cured by further adjustment of vaginal tension under local anaesthesia (Tuck procedure). These findings confirm the emphasis given by the Integral Theory of Female Urinary Incontinence as to maintain adequate elasticity in the zone of critical elasticity (ZCE) of the supralevator vagina. The ZCE acts as an elastic hinge, allowing (i.e. facilitates) the separate and opposite contractile forces of anterior pubococcygeus, and levator plate which are necessary to close off urethra and bladder neck respectively. Inadequate elasticity at the ZCE converts the ZCE's role from facilitation to opposition. The stronger levator muscle contraction counteracts the forward section of the weaker anterior part of pubococcygeus muscle, preventing bladder neck closure.

Thirty patients with symptoms and signs of stress and urge incontinence were treated with a Combined Intravaginal Sling and Tuck procedure. Primarily, only the first part of the procedure, the Sling operation was undertaken. This procedure creates an artificial pubourethral ligament which is achieved by controlled deposition of collagen around a retropubically implanted, removable, 0.5 cm wide Mersilene tape, inserted through a special tunneler. This part, stage 1 of the combined surgical procedure is mainly performed under local anaesthesia without postoperative catheterization, and early return to work. Urgency symptoms were cured simultaneously with the stress symptoms. The 50% success rate of the sling procedure was improved to 82% when the second part (stage 2) of this operation was undertaken. This procedure, the "Tuck" operation, tightens the suburethral vagina. The results of the combined procedure indicate that both an intact pubourethral ligament and tight suburethral vagina are equally important for cure as proposed in the Integral Theory of Female Urinary Incontinence.

A new surgical principle which can safely result in the formation of an artificial neo-ligament, and induce the adhesion of tissues is described. Under certain conditions, an implanted Mersilene tape may act as a template, provoking a controlled linear deposition of collagen which remained unchanged, even after removal of the tape. This was proven by retropubic implantation of Mersilene tapes in female dogs, in the position of the pubo-urethral ligament. The procedure relies on the normally negative aspects of wound healing for its effect, such as foreign body reaction, bacterial colonization, and continued tissue breakdown and regeneration.

In this Theory paper, the complex interplay of the specific structures involved in female urinary continence are analyzed. In addition the effects of age, hormones, and iatrogenically induced scar tissue on these structures, are discussed specifically with regard to understanding the proper basis for treatment of urinary incontinence. According to the Theory stress and urge symptoms may both derive, for different reasons from the same anatomical defect, a lax vagina. This laxity may be caused by defects within the vaginal wall itself, or its supporting structures i.e. ligaments, muscles, and their connective tissue insertions. The vagina has a dual function. It mediates (transmits) the various muscle movements involved in bladder neck opening and closure through three separate closure mechanisms. It also has a structural function, and prevents urgency by supporting the hypothesized stretch receptors at the proximal urethra and bladder neck. Altered collagen/elastin in the vaginal connective tissue and/or its ligamentous supports may cause laxity. This dissipates the muscle contraction, causing stress incontinence, and/or activation of an inappropriate micturition reflex, ("bladder instability") by stimulation of bladder base stretch receptors. The latter is manifested by symptoms of frequency, urgency, nocturia with or without urine loss.

Seventeen women, 14 with urge incontinence, and 3 with debilitating sensory urgency symptoms were operated on with a combined Intravaginal Sling operation and Tuck procedure. All but three were cured of their preoperative symptoms. The reason for the high cure rate achieved may be explained by restoration of anatomical support below the bladder neck. This prevents the stretch receptors from firing off at rest. Importantly, Intravaginal Sling operation and Tuck procedure do not elevate the bladder neck, so that these stretch/pain receptors are not stimulated by the elevation process. The results accord with the Integral Theory of Female Urinary Incontinence, which states that urge as well as stress symptoms may derive from the same anatomical defect, a loose vagina.

A minor operative procedure involving the excision of bilateral small elliptical 1 x 0.5 cm pieces of vaginal mucosa is described as a proposed alternative to a Kelly Repair. Twelve month success rate was 47%. The modus operandi of the procedure is examined with reference to the Integral Theory of Female Urinary Incontinence, as are the possible reasons for the operative failure.

Ten patients are presented with symptoms of urinary stress and/or urgency. Eight were cured by approximation of the uterosacral ligaments. This supports the contention of the Integral Theory of Female Urinary Incontinence that a loosely tethered supralevator vagina may be an important element in urinary incontinence, especially following hysterectomy.

Six patients, average age 80 years, with no previous operations, presented with urinary incontinence. The predominant symptoms were "being wet all the time" and "sudden uncontrolled urine loss". They had no symptoms of urgency or stress incontinence, and no objective evidence of "detrusor instability" or urine loss on cough stress pad testing. All but one patients were cured by the simultaneous combined Intravaginal Sling and Tuck operation, indicating that the primary cause of the symptoms was an anatomical defect in the vagina and the ligamentous supports in the region of the bladder neck, as stated in the Integral Theory of Urinary Incontinence, this supplement, elderly.

This office test reinforces the Integral Theory of Female Urinary continence which states that there are two distinct anatomical segments of vagina which transmit the muscular contractions of the pelvic floor muscles, and in so doing, constitute the 1st and 2nd closure mechanisms. The test is based on tightening the loose vagina, hereby correcting the anatomical defects causing the stress incontinence. The Pinch Test, and with it, the Bonney Test, are analysed with reference to the 1st and 2nd closure mechanisms presented in the Theory of Female Urinary Incontinence described earlier in this issue.