Perineal Rectocele: A Cause of Constipation

Abstract

Objectives: During our study of 206 patients with constipation, we encountered 21 patients with a ballooned anterior perineum, a condition we call "perineal rectocele." The current communication studied its clinical picture, investigative results, and treatment Methods: The 21 patients were multiparous women (age 47.2 ؎ 6.3 years) reporting constipation and dragging perineal pain. They had had normal deliveries with midline episiotomy. The study included also 10 healthy women volunteers and 12 women with rectoceles as controls; both groups were multiparous and had had posterolateral episiotomy. All of the individuals were subjected to clinical examination, including digital rectal examination, anal and rectal pressure measurements as well as electromyographic (EMG) recording of the superficial and deep transverse perineal muscles (TPMs), external anal sphincter (EAS), puborectalis (PRM), levator ani (LAM), and bulbocavernosus muscles (BCMs). Perineoplasty using fascia lata graft was used for perineal rectocele repair. The patients were followed for a mean of 11.2 ؎ 3.1 months.Results: The anterior perineum in perineal rectocele was convex downward, whereas it was flat in normal and rectocele subjects. On straining, the anterior perineum ballooned only in perineal rectocele, whereas in rectocele, the whole perineum ballooned with the anus on top of the balloon; in normal subjects, the perineum showed no morphologic changes. The anal and rectal pressures in the perineal rectocele did not show a significant difference from normal or rectocele women. The EMG activity of the superficial and deep TPMs was significantly diminished at rest and on contraction, whereas the other muscles showed normal activity. Rectocele women exhibited diminished EMG activity of the LAM and BCMs. Perineoplasty gave satisfactory results in 17 of 21 patients Conclusions: Perineal rectocele is, until now, an undescribed perineal floor dysfunction, which presents with constipation and apparently results from atrophic and fibrosed perineal muscles, probably resulting from perineal body disruption and inadequate repair of a midline episiotomy. Straining is suggested to stretch these fibrosed muscles, which sag and form a perineal bulge that balloons on straining. The defect is in the anterior perineum and not in the rectovaginal septum like in rectocele. EMG activity of the perineal muscles was diminished in perineal rectocele and not in rectocele. Perineoplasty cured 80.9% of the patients.C onstipation is a common coloproctologic problem. It may be attributed to recognizable causes 1-10 ; however, there are still groups of patients in whom constipation is considered idiopathic. Studies have ascribed idiopathic constipation (IC) to psychogenic causes, disturbed hormonal balance, genetic factors, disordered absorption, and endogenous opioids. 11,12 Some morphologic evidence of neuropathic or myopathic abnormality has been provided, 13-15 but the results have demonstrated considerable variability in findings. 16 Serotonin as well as enteric and co...