Pressure transmission theory—The Rasputin of incontinence

BACKGROUND: Enhorning's pressure transmission theory (PTT), though mortally wounded by multiple invalidations from the 1990 Integral Theory of female urinary incontinence (IT), like Rasputin, continues to survive as a theory for continence and incontinence. AIM: To examine the questions: How has the PTT survived? What is its contribution to knowledge? METHODS: Eleven different invalidations are presented based on images, pressure readings, clinical examples, experiments by the author, and others, for example, flow mechanics, finite element models, and surgical operations. RESULTS: Each of the 11 invalidations prima facie invalidate the PTTs of enhorning and others. CONCLUSIONS: “How has the PTT survived?” Having provided a plausible explanation for all abdominal stress urinary incontinence operations since 100 years, PTT, unsurprisingly, like climate change today, had become an entrenched convention which abdicated the need for midurethral sling (MUS) surgeons to learn the very different functional surgical anatomy underlying the MUS. “Has the PTT progressed knowledge, or retarded it?” This lack of knowledge by the surgeons of how and why the MUS works could be held responsible for the large number of major complications reported by the TVT: including, transected urethras, obturator nerve damage, perforation of external iliac vessels, more than 20 deaths. The role of the sling is to strengthen the pubourethral neoligament to prevent the urethra opening out under stress, not to elevate it. Elevating the sling remains the major cause of the most frequent complication of the MUS today, postoperative urinary retention.