A Musculo-Elastic Theory of anorectal function and dysfunction in the female

We present a series of 13 works in 2 parts. Part 1 states the Theory, and presents 7 works which test core aspects of the Theory, in particular, the role of the suspensory ligaments and muscle forces. Part 2 directly challenges the Theory with 5 different surgical works which track the fate of anorectal and other pelvic symptoms following repair of specific suspensory ligaments and their related fascia. In this series of papers, we bring together two apparently divergent concepts for the causation of fecal incontinence in the female, the muscle damage theory, and the ligament/ connective tissue damage theory. Data from a blinded muscle biopsy/midurethral sling study provided the key to our theory. It indicated that where there are lax ligaments, there were also histological pattern of muscle damage due to several different mechanisms. The implications of these findings are that (1) Lax ligaments will cause muscle dysfunction by unloading the relevant muscles, as in tenotomy, and (2) This muscle dysfunction is potentially reversible by surgical reinforcement of the damaged ligament, even when there are major changes histologically in the pelvic floor muscles.