An analysis of factors associated with increased perineal descent in women

Evaluation of Perineal Descent Measurements on Pelvic Floor Imaging

Objectives: The aim of this study is to validate a uniform method for measuring perineal descent which can be used for different imaging methods, to establish cut-off values for this measurement, and to assess diagnostic test accuracy (DTA) of imaging techniques using these cut-off values. Secondly, the study aims to correlate perineal descent to symptoms, signs and imaging findings in women with obstructed defaecation syndrome (ODS) to assess its clinical relevance. Methods: Cross-sectional study of 131 women with symptoms of ODS. Symptoms and signs were assessed using validated methods. These women underwent evacuation proctography (EP), magnetic resonance imaging (MRI), transperineal ultrasound (TPUS) and endovaginal ultrasound (EVUS). Perineal descent was measured on EP and MRI as the position of anorectal junction (ARJ) with respect to the pubococcygeal line (PCL) at rest (i.e., static descent) and during evacuation (i.e., descent at Valsalva). Dynamic perineal descent was measured on all four imaging techniques as the difference between the position of the ARJ at rest and Valsalva. DTA of dynamic perineal descent was estimated using Latent Class Analysis in the absence of a reference standard. Results: Interobserver agreement of dynamic perineal descent measurements was good for MRI and EVUS (ICC 0.86 and 0.85) and moderate for EP and TPUS (ICC 0.61 and 0.59). The systematic differences in measurements between imaging techniques show the need for individual cut-off values. New established cut-off values for dynamic descent are for EP 20 mm, MRI 35 mm, TPUS 15 mm and EVUS 15 mm. Sensitivity was moderate for EP (0.78) and MRI (0.74), fair for TPUS (0.65) and poor for EVUS (0.58). Specificity was similar for all imaging techniques (0.73-0.77). Static perineal descent correlated with symptoms of pelvic organ prolapse (POP) (r = 0.19), prolapse of all three compartments (r = 0.19-0.36), presence of levator ani muscle avulsion (p = 0.01) and increased hiatal area (r = 0.51). Dynamic perineal descent correlated with excessive straining (r = 0.24) and use of laxatives (r = 0.24). Classic symptoms of ODS (incomplete evacuation and digitation) did not correlate with perineal descent measurements. Static and dynamic perineal descent were associated with presence of rectocele, enterocele, intussusception, and absence of anismus. Conclusions: Dynamic perineal descent is a reliable measurement that can be applied to different imaging techniques to allow standardisation. Static descent is more often present in women with POP and dynamic descent is more often present in women with constipation. Perineal descent does not correlate with typical symptoms of ODS. Specificity of TPUS and EVUS is comparable to EP and MRI, hence ultrasound could be used for the initial assessment of pelvic floor dysfunction.

Imaging and clinical assessment of functional defecatory disorders with emphasis on defecography

Functional defecation disorders (FDD) encompass causes of constipation associated with anorectal dysfunction, which include dyssynergia or inadequate defecatory propulsion. FDD are frequently encountered in clinical practice and may affect up to 33-50% of patients with chronic constipation. The etiology of FDD is unclear, however, it has been defined as an acquired, but subliminal behavioral disorder. Pathophysiologic mechanisms may include discoordination of rectoanal muscles, paradoxical contraction or insufficient relaxation of puborectalis and/or anal sphincter during defecation, and sluggish colonic transit. A combination of comprehensive clinical assessment, digital rectal examination and a battery of physiologic tests are needed to make an accurate diagnosis of FDD. Defecography may play a crucial role in the evaluation of FDD, especially when a balloon expulsion test (BET) and/or anorectal manometry (ARM) are equivocal or demonstrate contradictory results. In this review, we provide a thorough overview of the epidemiology, pathophysiology, diagnostic criteria, clinical and imaging evaluation, and treatment options for FDD, with an emphasis on available diagnostic imaging tools such as defecography and conventional fluoroscopic methods.

Descending Perineum Associated With Pelvic Organ Prolapse Treated by Sacral Colpoperineopexy and Retrorectal Mesh Fixation: Preliminary Results

Introduction and hypothesis: Descending Perineum Syndrome (DPS) is a coloproctologic disease and the best treatment for it is yet to be defined. DPS is frequently associated with pelvic organ prolapse (POP) and it is reasonable to postulate, that treatment of POP will also have an impact on DPS. We aimed to evaluate the subjective satisfaction and improvement of DPS for patients who have undergone a sacral colpoperineopexy associated with retrorectal mesh for concomitant POP.

Methods: This retrospective cohort study, conducted between February 2010 and May 2016 included all women who had undergone surgery to treat POP and DPS. Improvement of POP was assessed clinically and subjective satisfaction was assessed with a survey.

Results: Among the 37 operated patients, 31 responded to the questionnaire and 77.4% were satisfied with this surgical procedure. 94.6% were objectively cured for POP. There was a 60% improvement rate for constipation, 63.5 and 68% were cured or improved for ODS and the need for digital maneuvers respectively.

Conclusion: Sacral colpoperineopexy associated with retrorectal dorsal mesh appears to objectively and subjectively improve POP associated with DPS.

Correlation Between Echodefecography and 3-Dimensional Vaginal Ultrasonography in the Detection of Perineal Descent in Women With Constipation Symptoms

BACKGROUND

Defecography is an established method of evaluating dynamic anorectal dysfunction, but conventional defecography does not allow for visualization of anatomic structures.

OBJECTIVE

The purpose of this study was to describe the use of dynamic 3-dimensional endovaginal ultrasonography for evaluating perineal descent in comparison with echodefecography (3-dimensional anorectal ultrasonography) and to study the relationship between perineal descent and symptoms and anatomic/functional abnormalities of the pelvic floor.

DESIGN

This was a prospective study.

SETTING

The study was conducted at a large university tertiary care hospital.

PATIENTS

Consecutive female patients were eligible if they had pelvic floor dysfunction, obstructed defecation symptoms, and a score >6 on the Cleveland Clinic Florida Constipation Scale.

INTERVENTIONS

Each patient underwent both echodefecography and dynamic 3-dimensional endovaginal ultrasonography to evaluate posterior pelvic floor dysfunction.

MAIN OUTCOME MEASURES

Normal perineal descent was defined on echodefecography as puborectalis muscle displacement ≤2.5 cm; excessive perineal descent was defined as displacement >2.5 cm.

RESULTS

Of 61 women, 29 (48%) had normal perineal descent; 32 (52%) had excessive perineal descent. Endovaginal ultrasonography identified 27 of the 29 patients in the normal group as having anorectal junction displacement ≤1 cm (mean = 0.6 cm; range, 0.1-1.0 cm) and a mean anorectal junction position of 0.6 cm (range, 0-2.3 cm) above the symphysis pubis during the Valsalva maneuver and correctly identified 30 of the 32 patients in the excessive perineal descent group. The κ statistic showed almost perfect agreement (κ = 0.86) between the 2 methods for categorization into the normal and excessive perineal descent groups. Perineal descent was not related to fecal or urinary incontinence or anatomic and functional factors (sphincter defects, pubovisceral muscle defects, levator hiatus area, grade II or III rectocele, intussusception, or anismus).

LIMITATIONS

The study did not include a control group without symptoms.

CONCLUSIONS

Three-dimensional endovaginal ultrasonography is a reliable technique for assessment of perineal descent. Using this technique, excessive perineal descent can be defined as displacement of the anorectal junction >1 cm and/or its position below the symphysis pubis on Valsalva maneuver.

Descending perineum syndrome: a review of the presentation, diagnosis, and management

INTRODUCTION AND HYPOTHESIS

Defecatory dysfunction is a relatively common and challenging problem among women and one that practicing pelvic reconstructive surgeons and gynecologists deal with frequently. A subset of defecatory dysfunction includes obstructed defecation, which can have multiple causes, one of which is descending perineum syndrome (DPS).

METHODS

A literature search was performed to identify the pathophysiology, diagnosis, and management of DPS.

RESULTS

Although DPS has been described in the literature for many decades, it is still uncommonly diagnosed and difficult to manage. A high index of suspicion combined with physical examination consistent with excess perineal descent, patient symptom assessment, and imaging in the form of defecography are required for the diagnosis to be accurately made. Primary management options of DPS include conservative measures consisting of bowel regimens and biofeedback. Although various surgical approaches have been described in limited case series, no compelling evidence can be demonstrated at this point to support surgical intervention.

CONCLUSIONS

Knowledge of DPS is essential for the practicing pelvic reconstructive surgeon to make a timely diagnosis, avoid harmful treatments, and initiate therapy early on.