My aim is neither to go into sophisticated description of detailed functional anatomy nor to explain again the integral theory according to P.P. Petros [1]. I just want to stress out the main structures responsible for pelvic static in order to explain how LSCP can help to repair POP.

On Fig. 3.1, you see the pelvic fascia underlined by the elevator muscles. The pelvic fascia is a hammock stretched out between the pubis and the sacrum at the top of the elevator muscles. The anterior part is fragile because three orifices cross the hammock; one for the urethra, one for the vagina and one for the anal canal. Most POPs occur through the main defect, the vaginal slot.

The posterior part of the fascia is very resistant because nothing opens it and the elevator plate underneath is very resistant.

Laterally, you notice the arcus tendineus fascia pelvis.

On Fig. 3.2, you see how the rectum is positioned. The anal canal goes through the hammock whilst the proximal part of the rectum is lying on the resistant part of the structure, the elevator plate. An increase of intra-abdominal pressure coming from above (arrow) will push the rectum against the elevator plate instead of pressing it through one of the orifices. The rectum can be maintained above the elevator plate by small forces due to fascia adhesion.

On Fig. 3.3, you see the shape of the vagina, starting as a vertical slot at the vulva, crossing the elevator muscles and the pelvic fascia, kinking just above and lying on the rectum and the pelvic fascia, becoming a horizontal flat structure attached laterally to the fascia and to the arcus tendineus fascia pelvis. Here again, a pressure coming from above will press the vagina as the rectum on the elevator plate as long as there are some anchoring structures, securing the vagina to this position.

Figure 3.4 shows similar positioning of the bladder above the elevator plate. But, unfortunately, due to its anterior position, a large part of the posterior wall of the bladder stays just above the fragile part of the hammock, above the vaginal slot. This explains easily why the bladder is so frequently involved in POP. Lateral attachment of the bladder to the arcus tendineus fascia pelvis is usually strong as is its fixation to the cervix (both in blue lines).

You notice that the cervix is surrounded by many attachments: to the vesicovaginal fascia anteriorly, laterally to the Cardinal ligaments and posteriorly to the rectovaginal fascia and to the uterosacral ligaments. This constitutes the pericervical ring which acts like a keystone to the pelvic floor.

Figure 3.5 shows how the structures articulate to each other.

Figure 3.6 shows how it changes at stress, the anteverted uterine body is pushed anteriorly towards the pubis bone, the uterine cervix is pushed backwards with the vaginal cul de sac and the rectum and thus, the vesicovaginal fascia is stretched in order to avoid cystocele. The rectovaginal fascia is stretched as well. This is to demonstrate the usefulness of the uterus to prevent POP and to explain why vaginal vault prolapse is so frequent.

Figure 3.7 shows the three levels of fixation of the pelvic organs: level 1 is every structure securing the cervix and the vaginal posterior cul de sac. It includes mainly the uterosacral ligaments, the lateral Cardinal ligaments and the fascial adhesions to the elevator plate. Level 2 fixation id relaying on the vesicovaginal and the rectovaginal fascias and on their insertions to the lateral attachments (arcus tendineus fascia pelvis) and to the pericervical ring. Level 3 is holding the distal part of the pelvic organs, below the pelvic fascia. Adhesion or fusion of the three organs among a dense muscular and fibrous structure (perineal body in grey) constitutes the perineum.