Descending Perineum Syndrome: A Fresh Look at an Interesting and Complex Pelvic Floor Disorder

Abstract

Descending Perineum Syndrome (DPS) is a rare but complex clinical entity of pelvic floor dysfunction presenting mostly with defecatory dysfunction and to lesser extent can cause voiding dysfunctions. Despite early interest and well characterization of DPS in the literature, to date, there is no consensus on the best approach for treatment. Biofeedback and physical therapy can in mild cases. In this study, we constructed the cohort of patients who have been diagnosed with DPS and underwent surgical treatment at Mayo Clinic, Rochester, from January 1, 2002, through September 1, 2013. This is a historical cohort study. The Mayo Clinic Electronic Medical Record Linkage System was utilized to identify participants. The Mayo Clinic surgical index was searched using the corresponding ICD-9 codes related to sacrocolpopexy along with Halban and Moschowitz culdoplasty. This was further word searched for phrases related to DPS including “perineal descent,” “hernia of Douglas pouch,” and “peritoneocele.” Medical records were reviewed to verify the selection and document diagnosis of DPS based on criteria from magnetic resonance imaging (MRI) defecography or clinical examination of perineal ballooning. Statistical analysis was performed using JMP 9.0 software (SAS Inc., Carey, NC). Of 93 patients who were identified, only 61 had confirmed diagnosis of DPS. The median age of diagnosis was 56 years (range, 19-84 years), median parity of 2 (range, 0-9) with 9 (15%) that were nulliparas. The median BMI was 24.6 kg/m2 with 10 (16.4%) with BMI >30. Presenting symptoms included defecatory dysfunction with infrequent bowel movement in all patients, with incomplete emptying in 87%, deep perineal pain in 70%, rectal prolapse in 65%, and fecal incontinence in 36%. On MRI, evidence of anatomic abnormality in the anal internal and external anal sphincter along with puborectalis in 30% of cases while functional (Figure). All patients had surgical treatment that included a modified sacrocolpopexy with extension of the mesh the pelvic side wall in 27 patients (44.3%) while 29 patients (47.4%) had some sort of uterosacral plication with culdoplasty, and 4 patients had a combined procedure. Improvement of defecatory dysfunction was noted in 49 patients (80.3%) at their postoperative visit. DPS is a complex pelvic floor disorder. Diagnosis can be done by physical examination and confirmed by MRI defecography. Surgical treatment can help to improve defecatory dysfunction in selected patients.