Live anatomy of the perineal body in patients with third-degree rectocele

Ultrasonographic study of female perineal body and its supportive function on pelvic floor

Objectives

The study aimed to observe, measure the size and elastic value of perineal body (PB) and assess its association with levator hiatus.

Methods

Datasets were acquired in 45 nulliparous, 66 POP women and 70 postpartum women using ultrasound. The PB was measured in depth, height, and Young's modulus. The datasets were compared to assess whether there are some differences in the morphology, dimension and elastography modulus of PB among women. Pearson correlation analysis was used to evaluate the association between the morphology measurements (ΔValsalva-rest[v-r]), tissue mechanical properties (ΔValsalva-rest[v-r]) of the PB and levator hiatus area (ΔValsalva-rest[v-r]) to preliminarily explore whether PB can influence levator hiatus.

Results

Four representative manifestations of PB were presented in our study. Nulliparous women had smaller diameters and bigger Young's modulus while postpartum women had bigger diameters and smaller Young's modulus. POP and postpartum women had bigger levator hiatal distensibility and PB extensibility. There was no statistical association between PB measurements and levator hiatal area.

Conclusion

It is feasible to observe the morphology of PB and assess the dimension and elastography modulus by high-frequency ultrasound. The manifestations and measurements of PB are influenced by parity and long-term increased abdominal pressure. Our study preliminarily shows that PB has little effect on levator hiatus area.

The association between levator plate integrity and pelvic floor defaecatory dysfunction

AIMS

Levator ani deficiency has been implicated in anterior pelvic floor pathology but its association with pelvic floor defaecatory dysfunction is less clear. The aim was to examine the relationship of levator ani deficiency with anatomical abnormalities (rectocoele, intussusception, enterocoele, perineal descent) and patient symptoms (bowel, vagina) in patients with pelvic floor defaecatory dysfunction.

METHODS

The prospective observational case series of 223 women presenting to a tertiary colorectal pelvic floor unit with defaecatory dysfunction. Each underwent assessment with symptom severity and quality of life (QoL) scores, integrated total pelvic floor ultrasound (PFUS) (transvaginal, transperineal) and defaecation proctography (DP). Rectocoele, intussusception, enterocoele and perineal descent were assessed on both. Levator ani deficiency was scored using endovaginal ultrasound (score 0-18; mild [0-6], moderate [>6-12], severe [>12-18]).

RESULTS

The proportion of patients with rectocoele, enterocoele, and intussusception increased with increasing levator ani damage (mild, moderate, severe). There was a weakly positive correlation between size of rectocoele and levator ani deficiency. On PFUS, there was a weakly positive correlation between severity of intussusception and enterocoele with levator ani deficiency. On DP, there was a weakly positive correlation between perineal descent and levator ani deficiency. There was no association between bowel symptom and QoL scores and levator ani deficiency. Vaginal symptoms were associated with levator ani deficiency.

CONCLUSIONS

Anatomical abnormalities which are implicated in pelvic floor defaecatory dysfunction (rectocoele, intussusception, enterocoele, perineal descent) were associated with worsening levator ani deficiency. There was no association between bowel symptoms and levator ani deficiency. Vaginal symptoms were associated with levator ani deficiency.

Surgical anatomy of the vaginal introitus

Aim

The vaginal introitus is the entrance to the vagina, encompassing the anterior and posterior vestibules and the perineum. The surgical anatomy of the vaginal introitus, the lowest level of the vagina, has not been subject to a recent comprehensive examination and description. Vaginal introital surgery (perineorrhaphy) should be a key part of surgery for a majority of pelvic organ prolapse.

Methods

Cadaver studies were performed on the anterior and posterior vestibules and the perineum. Histological studies were performed on the excised perineal specimens of a cohort of 50 women undergoing perineorrhaphy. Included are pre‐ and postoperative studies which were performed on 50 women to determine the anatomical and histological changes achieved with a simple (anterior) perineorrhaphy.

Results

The vaginal introitus is equivalent to the Level III section of the vagina, measured posteriorly from the clitoris to the anterior perineum then down the perineum to the anal verge. The anterior and posterior vestibules, with nonkeratinizing epithelium, extend laterally to the keratinized epithelium of the labia minora (Hart's line). The anterior vestibule has six anatomical layers while the posterior vestibule has three. The perineum has an inverse trapezoid shape. Perineorrhaphy specimens were a mean 2.9 cm wide and 1.6 cm deep. They show squamous epithelium with loose underlying connective tissue. There were no important structures seen histologically, for example, ligaments or muscles. Microscopically, only 6 (12%) were completely normal with 44 (88%) showing minor changes including inflammation and scarring. Considerable anatomical benefits were achieved with such a perineorrhaphy including a 27.6% increase in the perineal length and a 30.8% reduction in the genital hiatus.

Conclusion

An understanding of the anatomy and histology of the vaginal introitus can assist with performing a simple and effective perineorrhaphy, the main surgical intervention at the vaginal introitus.

Pelvic Organ Prolapse Quantification (POP-Q) system needs revision or abandonment: The anatomy study

OBJECTIVE

To examine the female urogenital hiatus (UGH) and perineal body gross and topographic anatomy; to analyze the POP-Q recommendation for evaluating UGH and PB.

STUDY DESIGN

A prospective case series study on fifteen fresh human adult female cadavers was conducted in international settings. Stratum-by-stratum, macro-, and micro-anatomical dissections to study the UGH and PB gross-topographic anatomy. In addition, HGH and PB descriptive anatomy presented in the medical literature were analyzed. The primary outcome measured the accuracy of POP-Q in the assessment of UGH and PB. Additionally, digital photos were taken to document UGH and PB gross and topographic anatomy.

RESULTS

The present study confirmed that the urogenital hiatus was a well-described structure in the medical literature. It is an oval-shaped structure that originated at the inferior pubic bone and was inserted into the posterior anal wall and superior surface of the PB. In all subjects, the location of UGH was in the Retzius space. Therefore, the recommendation by the POP-Q to evaluate UGH from the middle urethral meatus to the posterior hymeneal ring was incorrect because it did not accurately reflect the total longitudinal diameter of UGH. The PB topographic anatomy was not appropriately described in the literature. PB was an oval-shaped, solid, muscular mass without the central point of the perineum or fascia and rested between the posterior-distal vaginal wall and the anterior anorectal wall in a horizontal orientation and was not a part of the posterior perineum as the POP-Q system indicated. Therefore, a vertical measurement of the perineal body as recommended by POP-Q was impossible to obtain due to its horizontal orientation under the posterior-distal vaginal wall; PB had to be measured horizontally. The median length was 4.2 cm ± 1.6 (SD).

CONCLUSIONS

The POP-Q system does not adequately assess UGH and PB and needs revision.

Clinical efficacy of integral theory–guided laparoscopic integral pelvic floor/ligament repair in the treatment of internal rectal prolapse in females

BACKGROUND

Internal rectal prolapse (IRP) is one of the most common causes of obstructive constipation. The incidence of IRP in women is approximately three times that in men. IRP is mainly treated by surgery, which can be divided into two categories: Abdominal procedures and perineal procedures. This study offers a better procedure for the treatment of IRP.

AIM

To compare the clinical efficacy of laparoscopic integral pelvic floor/ligament repair (IPFLR) combined with a procedure for prolapse and hemorrhoids (PPH) and the laparoscopic IPFLR alone in the treatment of IRP in women.

METHODS

This study collected the clinical data of 130 female patients with IRP who underwent surgery from January 2012 to October 2014. The patients were divided into groups A and B. Group A had 63 patients who underwent laparoscopic IPFLR alone, and group B had 67 patients who underwent the laparoscopic IPFLR combined with PPH. The degree of internal rectal prolapse (DIRP), Wexner constipation scale (WCS) score, Wexner incontinence scale (WIS) score, and Gastrointestinal Quality of Life Index (GIQLI) score were compared between groups and within groups before surgery and 6 mo and 2 years after surgery.

RESULTS

All laparoscopic surgeries were successful. The general information, number of bowel movements before surgery, DIRP, GIQLI score, WIS score, and WCS score before surgery were not significantly different between the two groups (all P > 0.05). The WCS score, WIS score, GIQLI score, and DIRP in each group 6 mo, and 2 years after surgery were significantly better than before surgery (P < 0.001). In group A, the DIRP and WCS score gradually improved from 6 mo to 2 years after surgery (P < 0.001), and the GIQLI score progressively improved from 6 mo to 2 years after surgery (P < 0.05). In group B, the DIRP, WCS score and WIS score significantly improved from 6 mo to 2 years after surgery (P < 0.05), and the GIQLI score 2 years after surgery was significantly higher than that 6 mo after surgery (P < 0.05). The WCS score, WIS score, GIQLI score, and DIRP of group B were significantly better than those of group A 6 mo and 2 years after surgery (all P < 0.001, Bonferroni) except DIRP at 2 years after surgery. There was a significant difference in the recurrence rate of IRP between the two groups 6 mo after surgery (P = 0.011). There was no significant difference in postoperative grade I-III complications between the two groups (P = 0.822).

CONCLUSION

Integral theory–guided laparoscopic IPFLR combined with PPH has a higher cure rate and a better clinical efficacy than laparoscopic IPFLR alone.

Shear Wave Elastography to Assess Perineal Body Stiffness During Labor

OBJECTIVES

The objective of this study was to evaluate perineal body stiffness intrapartum using shear wave elastography ultrasound and to study its association with maternal and labor characteristics.

METHODS

This was a prospective observational study. Pregnant women with term pregnancy who had been admitted for labor management were recruited into the study. Transperineal shear wave elastography of perineal body was performed. Maternal and labor data were retrieved from electronic medical charts.

RESULTS

Thirty-two patients' data were available for analysis. Mean (SD) melastography modulus was 15.33 (5.49). While comparing the mean elastography modulus across maternal and labor characteristics, the difference was statistically different between parity, cervical dilation, and perineal laceration presence groups (P < 0.05). The mean of elastography modulus of primiparous women with cervical dilation less than 3 cm was 21.47 kPa, whereas that of multiparous women was 13.17 kPa (P = 0.0511). Perineal laceration was more prevalent in women with stiffer perineal body. The risk of having perineal laceration compared with no perineal laceration was 29.1% higher for each additional unit increase in perineal body elastography modulus (odds ratio, 0.709; 95% confidence interval, 0.507-0.992).

CONCLUSIONS

Shear wave elastography can be used to quantify perineal body stiffness. Primiparous women in early stages of labor have stiffer perineal body than multiparous women in any stage of labor and primiparous women in late stage of labor.

Repair of damaged ligaments with tissue fixation system minisling is sufficient to cure major prolapse in all three compartments: 5-year data

AIM

The ageing population in Japan brings problems of pelvic organ prolapse (POP), bladder and bowel incontinence, and fragility as regards major pelvic surgery. Existing data from tissue fixation system (TFS) surgery show high cure rates for these conditions, but long-term data are lacking. We aimed to elucidate the usefulness of TFS by assessing 5-year postoperative outcomes.

METHODS

A total of 68 patients, mean age 70 years, underwent total pelvic floor repair. Cystocele, apical prolapse, and rectocele were variously addressed by TFS repair of pubourethral, arcus tendineus fasciae pelvis, cardinal, uterosacral, and perineal body ligaments using a mean 3.2 tapes per patient (n = 216). Patients were followed up at 12 months then yearly. We included patients with third- or fourth-degree uterine/vaginal prolapse (POP Quantification classification). We excluded patients with serious comorbid conditions.

RESULTS

The mean operating time was 88 min and the mean blood loss was 78 mL. There was minimal postoperative pain and urinary retention, as evidenced by a mean hospital stay of 0.8 days and early return to normal activities. The 5-year cure rates for urinary stress incontinence, urgency, nocturia, and frequency were 82%, 91.7%, 58%, and 52%, respectively. The surgical cure rate for POP was 87.1% at 12 months, falling to 79.0 at 60 months. The cumulative 5-year erosion rate was 0% and 1.7% for all ligaments except the perineal body (25.7%), reducing to 2.6% by year 5 following anchor placement into deep transversus perinei. Two cases of ileus were attributed to incorrect technique.

CONCLUSION

Reinforcing up to four ligaments with the TFS was sufficient for cure of third- and fourth-degree POP. The technique is minimally invasive, suitable for elderly women, and effective at 5 years for both anatomical and symptom cure.

A Prospective Observational Study of the Classification of the Perineum and Evaluation of Perineal Repair at the Time of Posterior Colporrhaphy

OBJECTIVE

The aim of this prospective observational study was to obtain a better understanding of the anatomy and to classify the observed different perineal presentations at the time of posterior colporrhaphy and to describe specific surgical techniques used.

METHODS

To classify the observed perineal findings, the Pelvic Organ Prolapse Quantification System with a newly introduced additional measurement of the perineal ridge (PR) was taken intraoperatively and postoperatively in 121 consecutive women undergoing posterior colporrhaphy. Dependent on the preoperative classification of the perineum as being normal (type 1), deficient (type 2), or with a PR (type 3), a specific surgical repair was performed for each type of perineal presentation.

RESULTS

The perineal presentations were categorized into 3 defined groups. Type 1 (normal perineum) was seen in 40%, type 2 (deficient perineum) in 13%, and type 3 (PR) in 47%. A type 1 correlates with prior cesarean section (P = 0.29), a type 2 correlates with prior vaginal delivery (P = 0.05), and type 3 perineum with prior pelvic floor surgery (P < 0.0001). When perineal type-specific surgical techniques were performed, the perineal body length increased postoperatively in type 2 (P < 0.05), decreased in type 3 (P < 0.05), and remained unchanged in those with type 1 defects.

CONCLUSIONS

This study demonstrates that the perineal region can be clearly defined into 3 categories. The distinct perineal presentation correlates with the previous gynecological history. With a specific perineal repair at the time of posterior colporrhaphy, the perineal anatomy can be restored in the short term.

The anatomy of the perineal body in relation to abdominoperineal excision for low rectal cancer

AIM

Dissection of the perineal body (PB) during abdominoperineal excision (APE) for low rectal cancer is often difficult due to the lack of a natural plane of dissection. Understanding the PB and its relation to the anorectum is essential to permit safe dissection during the perineal phase of the operation and avoid damage to the anorectum and urogenital organs. This study describes the anatomy and histology of the PB relevant to APE.

METHOD

Six human adult cadaver pelvic exenteration specimens (three male, three female) from the Leeds GIFT Research Tissue Programme were studied. Paraffin-embedded mega-blocks were produced and serially sectioned at 50- and 250-μm intervals. Sections were stained by immunohistochemistry to show collagen, elastin and smooth muscle.

RESULTS

The PB was cylindrically shaped in the male specimens and wedge-shaped in the female ones. Although centrally located between the anal and urogenital triangles, it was nearly completely formed by muscle fibres derived from the rectal muscularis propria. Thick bundles of smooth muscle, mostly arising from the longitudinal muscle, inserted into the PB and levator ani muscle (LAM). The recto-urethralis muscle originated from the PB and separated the anterolateral PB from the urogenital organs.

CONCLUSION

Smooth muscle fibres derived from the rectal muscularis propria extend into the PB and LAM and appear to fix the anorectum. Dissection of the PB during APE is safe only when the smooth muscle fibres that extend into the PB are divided.

Perineal body anatomy seen by three-dimensional endovaginal ultrasound of asymptomatic nulliparae

AIM

The perineal body (PB) plays an important role in supporting the pelvic floor and the posterior vaginal wall, but its attachments and relationships are still debated. This study aimed to assess the normal anatomy of the PB using high-resolution three-dimensional endovaginal ultrasound (3D-EVUS) in asymptomatic nulliparae.

METHOD

To validate the identification of perineal structures, 3D-EVUS was initially performed on nulliparous cadavers. Fresh frozen pelves were prepared and echogenic structures thought to be the PB, the external anal sphincter, the superficial and deep transverse perineii, pubovaginalis, puboperinealis, puboanalis, puborectalis and iliococcygeus muscles were tagged with biopsy needles, and marked with indigo carmine dye for localization during dissection. In the second part of the study, consecutive asymptomatic nulliparae were prospectively imaged with the same ultrasound modality. Interrater reproducibility was assessed off-line from stored 3D US volumes using a standardized technique.

RESULTS

Five fresh frozen pelves and 44 asymptomatic nulliparae were assessed with 3D-EVUS. The PB was seen as an ovoid structure of mixed echogenicity between the rectum and vagina. It appeared to be divided into a superficial level, in contact with the external anal sphincter, the bulbospongiousus and the superficial transverse perineii muscle and a deep level, in contact with puboperinealis and puboanalis muscles. Interobserver repeatability was excellent for the measurements of PB height [intraclass correlation coefficient (ICC) 0.927], PB depth (ICC 0.969) and PB width (ICC 0.932).

CONCLUSION

The PB is divided into two levels with different anatomical relationships with the pelvic floor muscles. 3D-EVUS yields reproducible assessment of this complex structure.

The anthropometric definition of the rectum is highly variable

PURPOSE

The precise definition of the rectum is essential for localizing colorectal pathology, yet current definitions are nebulous. The objective of this study is to determine the anthropometric definition of common pelvic landmarks in relation to patient characteristics.

METHODS

Seventy-one patients underwent open proctectomy with intra-operative measurements from the anal verge to various pelvic landmarks, and patient characteristics were evaluated. Analyses were performed using Spearman correlation and Wilcoxon rank sum.

RESULTS

The mean landmark distance was dentate line = 1.7 cm (range 0.8-4.0 cm), puborectalis muscle = 4.2 cm (range 2.0-8.0 cm), anterior peritoneal reflection = 13.2 cm (range 8.5-21.0 cm), sacral promontory = 17.9 cm (range 13.0-26.0 cm), and confluence of the taenia = 25.5 cm (range 16.0-44.0 cm). Men had longer mean distances to the dentate line (p = 0.0003), puborectalis muscle (p = 0.03), and anterior peritoneal reflection (p = 0.02). Patient weight significantly correlated with distance to all landmarks except for the confluence of the taenia, which did not correlate with any patient factor.

CONCLUSIONS

The location of common pelvic landmarks is highly variable. The use of predefined absolute measurements from the anal verge to localize rectal pathology is inaccurate and fails to account for patient variability.

Perineal body repair in patients with third degree rectocele: a critical analysis of the tissue fixation system

AIM

We describe the technique of tissue fixation system (TFS) perineal body repair in patients presenting with symptomatic third degree rectocele.

METHOD

The single sling TFS perineal body repair is performed in three surgical steps: (i) dissection of the rectum off the vagina and laterally displaced perineal body; (ii) identification of the deep transverse perineii muscles beyond their insertion point behind the descending pubic ramus; (iii) elevation and approximation of the separated and laterally displaced perineal bodies by insertion, without tension, of non-stretch 7 mm polypropylene tape into the bodies of the deep transverse perineii muscles.

RESULTS

From January 2007 to December 2009 we performed the TFS operation for 30 women, median age 61 (range 47-87) years, mean parity 2.6 (range 1-5), with third degree symptomatic low rectocele (median obstructive defaecation syndrome score 19; range 11-24). Median hospital stay was 24 (range 12-96) h. The median visual analogue scale for postoperative pain was 1 (range 1-7). Complications occurred in three cases (10%) and included a surfaced tape that was partly resected (repair maintained), a recurrence of the rectocele due to incorrect placement (failed repair) and a foreign body abscess requiring tape removal. At 12-month follow-up, 27 patients (90%) reported normal defaecation and the median obstructive defaecation syndrome score was significantly reduced to 4 (range 1-6; P < 0.001).

CONCLUSION

The TFS perineal body repair is an effective, safe, minimally invasive treatment in women with symptomatic low rectocele.