UROGYNECOLOGY AND THE REFUSAL TO MOVE BEYOND OBSOLETE AND DANGEROUS MODELS OF ANATOMY AND PHYSIOLOGY

The Western medical model is built upon a mechanistic map completely outmoded by physics and the life sciences. Four hundred years of dissection and over two hundred years of pelvic floor surgery demonstrate that a machine cannot change, grow, or evolve¹. Take the Paramore Ship Model, for example:

“The support of the uterus has been likened to a ship in its berth floating on the water attached by ropes on either side of a dock (Paramore 1918). The ship is analogous to the uterus, the ropes to the ligaments, and the water to the supportive layer formed by the pelvic floor muscles. The ropes function to hold the ship (uterus) in the centre of its berth as it rests on the water (pelvic floor muscles). If, however, the water level falls far enough that the ropes are required to hold the ship without the supporting water, the ropes would break."

This model of pelvic organ support, a perennial favorite amongst reconstructive pelvic surgeons, has been heavily referenced in gynecologic literature throughout the past century and recently recycled by Ashton-Miller and DeLancey². Perhaps no one other than John O.L. DeLancey, MD, has done more to perpetuate the misrepresentation of the anatomy of the female pelvis – an error that has profound implications for women and all those who treat disorders of pelvic organ support.

These two researchers have created a biomechanical model of the female pelvis in order to demonstrate the etiology of pelvic organ prolapse³. (figure 1) Based on either cadaveric or supine subjects⁴(figure 2) the DeLancey – Ashton-Miller model does not reflect the true nature of either the female pelvis or pelvic organ support. Furthermore, because their model is dependent upon faulty anatomy, it renders obsolete any subsequent discussion of prevention or treatment.

The misrepresentation of the position of the human pelvis goes back hundreds of years and is only now being quietly corrected by medical science⁵. (figure 3) Instead of the pelvis being positioned like a “basin” with a “floor”, the horizontal sacrum (figure 4) and wide, flat pubic bones that are positioned underneath the body like straps of a saddle (figure 5) cause the pelvic outlet to be vertical (figure 6) and the pelvic diaphragm more vertical than horizontal (figure 7).

This nearly 90-degree correction of the position of the bony pelvis in the standing body causes the organs to be positioned close to the lower abdominal wall over the pubic bones rather than over an aperture covered by soft tissue. (figure 8) Moreover, prolapse can be seen for what it truly is: PELVIC ORGANS MOVED FROM FRONT TO BACK RATHER THAN HAVING FALLEN DOWN FROM ABOVE. It is a profound truth that the human spine and pelvis remained horizontal even as remarkable spinal curvatures allowed the human race to become upright. Once we accurately comprehend the skeletal anatomy of the female pelvis we will be better able to visualize how and why the organs move away from their natural positions as well as the futility of surgical repair.

No one seems more confused than Dr. DeLancey as he laments that 1 in 10 women will have surgery for disorders of pelvic organ support:

“Each of us has sat in the examining room with a woman whose prolapse has returned after we have performed an operation that we hoped would cure her problem. In trying to explain to her why the operation failed, we all say something but I suspect we each must admit to not knowing for sure what the problem was. Unfortunately, data that would uncover the true reason for failure based on scientific studies does not exist.”

How many women have you had that conversation with Dr. DeLancey? Dozens? Hundreds? A thousand? I implore you to move on from old, defective models of pelvic organ support to the dynamic reality of the living human pelvis.
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References


1) Kent C Saving the Whole Woman – Natural Alternatives to Surgery for Pelvic Organ Prolapse and Urinary Incontinence. 2003 p. 81

2) James A Ashton-Miller, John O. L DeLancey Functional Anatomy of the Female Pelvic Floor 
Annals of the New York Academy of Sciences 1101 (1) 266–296 2007

3) Chen L Ashton-Miller J Hsu Y DeLancey J Interaction among apical support, levator ani impairment, and anterior vaginal wall prolapse Obstetrics & Gynecology 108:2 324-332 2006

4) DeLancey J The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment American Journal of Obstetrics and Gynecology 192 1488-1495 2005

5) Clemente C Clemente Anatomy 4th edition Lippincott Williams & Wilkins 1997