Perineum Research Articles

Experience of using homeopathic ointment in the treatment of patients with anal itching

Introduction. Anal contact or conduction in the anal canal and rectum is a common condition in the coloproctological field, occurring in 5% of the population that affects this country. Treatment consists of hygiene and the use of topical steroids, antibacterial and antifungal agents. No generally accepted attitude towards a private person has been developed.Aim. To study the effectiveness of using homeopathic ointment in the treatment of patients with anal itching.Material and methods. A prospective comparative randomized study was conducted in a specialized advisory center of the Clinics of Samara State Medical University. The study included 96 patients with anal itching without fungal infection of the perianal skin and concomitant purulent pathology. In the main group (n = 46), treatment was carried out using homeopathic ointment in the perianal area 2–3 times a day for 14 days. In the control group (n = 50), treatment was carried out with topical steroid ointments 2–3 times a day for 14 days.Results and discussion. From the data obtained on the use of homeopathic ointment, it follows that it is not inferior in effectiveness to topical steroid ointments in reducing symptoms of the disease (Student’s t-test = 0.35; p > 0.05 and Student’s t-test = 0.28; p > 0.05), and by the number of relapses (χ2 = 0.535; p > 0.05).Conclusion. The use of homeopathic ointment for topical application appears to be a promising new treatment for patients with anal itching and is as effective as topical steroid ointments.

Role of tactile stimulation during the preweaning period on the development of the peripheral sensory sural (SU) nerve in adult artificially reared female rat.

Maternal deprivation, as a result of the artificial rearing (AR) paradigm, disturbs electrophysiological and histological characteristics of the peripheral sensory sural (SU) nerve of infant and adult male rats. Such changes are prevented by providing tactile or social stimulation during isolation. AR also affects the female rat's brain and behavior; however, it is unknown whether this early adverse experience also alters their SU nerve development or if tactile stimulation might prevent these possible developmental effects. To assess these possibilities, the electrophysiological and histological characteristics of the SU nerve from adult diestrus AR female rats that: (i) received no tactile stimulation (AR group), (ii) received tactile stimulation in the anogenital and body area (AR-Tactile group), or (iii) were mother reared (MR group) were determined. We found that the amplitude, but not the area, of the evoked compound action potential response in SU nerves of AR rats was lower than those of SU nerves of MR female rats. Tactile stimulation prevented these effects. Additionally, we found a reduction in the outer diameter and myelin thickness of axons, as well as a large proportion of axons with low myelin thickness in nerves of AR rats compared to the nerves of the MR and AR-Tactile groups of rats; however, tactile stimulation only partially prevented these effects. Our data indicate that maternal deprivation disturbs the development of sensory SU nerves in female rats, whereas tactile stimulation partially prevents the changes generated by AR. Considering that our previous studies have shown more severe effects of AR on male SU nerve development, we suggest that sex-associated factors may be involved in these processes.

Perineoplasty for anal incontinence after obstetric anal sphincter injury repair: a case report

BackgroundThe rectal and vaginal walls are typically sutured if severe perineal lacerations with rectal mucosal damage occur during vaginal delivery. In case of anal incontinence after the repair, re-suturing of the anal sphincter muscle is standard procedure. However, this procedure may not result in sufficient improvement of function.Case presentationA 41-year-old woman underwent suture repair of the vaginal and rectal walls for fourth-degree perineal laceration at delivery. She was referred to our department after complaining of flatus and fecal incontinence. Her Wexner score was 15 points. Examination revealed decreased anal tonus and weak contractions on the ventral side. We diagnosed anal incontinence due to sphincter dysfunction after repair of a perineal laceration at delivery. We subsequently performed sphincter re-suturing with perineoplasty to restructure the perineal body by suturing the fascia located lateral to the perineal body and running in a ventral–dorsal direction, which filled the space between the anus and vagina and increased anal tonus. One month after surgery, the symptoms of anal incontinence disappeared (the Wexner score lowered to 0 points), and the anorectal manometry values increased compared to the preoperative values. According to recent reports on the anatomy of the female perineal region, bulbospongiosus muscle in women does not move toward the midline to attach to the perineal body, as has been previously believed. Instead, it attaches to the ipsilateral surface of the external anal sphincter. We consider the fascia lateral to the perineal body to be the fascia of the bulbospongiosus muscle.ConclusionsIn a case of postpartum anal incontinence due to sphincter dysfunction after repair of severe perineal laceration, perineoplasty with re-suturing an anal sphincter muscle resulted in improvement in anal sphincter function. Compared to conventional simple suture repair of the rectal wall only, this surgical technique may improve sphincter function to a greater degree.

Melanoma amelanótico em cachorro-do-mato (Cerdocyon thous)

The accelerated and disordered division of cells in the body results in neoplastic processes. Melanoma, a malignant neoplasm, is described in domestic dogs, and it has already been reported in wild carnivores. During a routine examination of an adult crab-eating fox (Cerdocyon thous), approximately 14 years old and kept at the Sorocaba Zoo, presented a mass in the perineal region. A surgical procedure was realized to remove the mass, as it presented ulceration. The patient’s recovery was satisfactory and the animal was medically discharged. Cytological, histological and immunohistochemical tests were performed, and the results indicated amelanotic melanoma. This is the first report of amelanotic melanoma in a crab-eating fox kept under human care.

Spermatic cord torsion associated with perineal hernia in a cryptorchid dog

AbstractAn 8‐year‐old male German Shepherd dog with a history of dyschezia, tenesmus and perineal swelling for 1 month was referred. The dog was known to be unilaterally abdominal cryptorchid. The normally descended testis had been surgically removed a few years ago. On physical examination, a firm, non‐painful, irreducible mass was palpable in the left perineal region. Digital rectal examination revealed rectal deviation, and the pelvic diaphragm was absent on the left. The prostate gland was normal upon palpation. Abdominal radiography revealed that the urinary bladder was present in the caudal abdomen. Based on clinical, laboratory and imaging findings, a diagnosis of perineal hernia was made. Surgical exploration revealed the presence of left spermatic cord torsion in the perineal hernia. The testis was removed, and internal obturator muscle transposition was performed for herniorrhaphy. The dog had an uneventful recovery, and the results of re‐examinations 10 days, 6 months and 12 months later were normal.

The concomitant occurrence of hidradenitis suppurativa and Fournier’s gangrene

Background: Fournier’s gangrene represents a life-threatening necrotising infection affecting the perineal region, while hidradenitis suppurativa is characterised by a chronic inflammatory skin condition. The simultaneous occurrence of both conditions is exceedingly rare. Case description: A 42-year-old female with a documented history of severe untreated hidradenitis suppurativa presented for shortness of breath, fever and lethargy, along with extensive wounds and skin breakdown involving the left axilla, perineum, lower back, lumbosacral region and bilateral gluteal areas, extending to the perineum. Upon presentation, the patient was in a state of septic shock, and a diagnosis of actively manifesting Fournier’s gangrene was established at the site of the pre-existing hidradenitis suppurativa lesions. Despite the implementation of an aggressive multidisciplinary approach incorporating surgical interventions, antibiotic therapy and intensive care measures, the patient’s condition deteriorated, culminating in septic shock, multi-organ failure and eventual demise. In this report, we discuss both clinical entities, their similarities and differences, and the possible mechanisms by which they may have co-occurred. Conclusion: The co-existence of hidradenitis suppurativa and Fournier’s gangrene poses unique challenges, given the rapid progression of Fournier’s gangrene within the context of hidradenitis suppurativa, potentially suggesting the latter as a predisposing factor. This case underscores the importance of vigilant screening and management of hidradenitis suppurativa.

Pubourethral and uterosacral male analogues suggest parallel male/female pelvic anatomy and symptom pathogenesis.

The thesis that functional/dysfunctional male/female pelvic floor anatomy are parallel, originated from two studies: a successful retropubic perineal male sling for post-prostatectomy stress urinary incontinence (SUI) and discovery of a male uterosacral ligament (USL) analogue, we named "prostatosacral ligament" (PSL). In 25 out of the studied 27 males (92.6%), it starts on both sides of the median sulcus of the prostate the ligament passes lateral to the rectum being fused with the lateral margin of the mesorectum before leaving it as it thins out to be attached posteriorly similar to the USL. The ultrasound data during straining in men and women showed the same three oppositely acting muscle vectors contracting around analogous ligaments, puboprostatic ligament (PPL) (male), and pubourethral ligament (PUL) (female). Further parallels were pubovesical ligaments (PVLs) and arc of Gilvernet as part of the continence and micturition mechanisms. Impressive evidence for parallel anatomy came from the successful cure of 22 males with post-prostatectomy SUI using a perineal retropubic tissue fixation system (TFS) minisling applied to the PPL using a similar methodology to that used in the female for PUL midurethral sling repair for cure of SUI. Laparoscopic evidence confirmed the prostate as a male analogue of the cervix, and PSLs as analogues of USLs: PSL origin from the prostate attached laterally to the mesorectum and inserted into the sacrum. Histologically, PSLs had identical features with USLs: collagen, elastin, smooth muscle, blood vessels and nerves. Virtually identical symptoms for "chronic prostatitis" (CP) and "posterior fornix syndrome" (PFS), such as chronic pelvic pain, overactive bladder (OAB), abnormal emptying, gave birth to the hypothesis, of a common pathogenesis for "CP" and "PFS", USL (or PSL) laxity. If this could be proven by "simulated operations", "CP", at least in theory, may be potentially correctible by PSL repair.

Pyoderma Gangrenosum of the Genitalia, Anus, and Perineum: Two Case Reports and a Review of Published Cases.

Pyoderma gangrenosum is an inflammatory skin disease that presents with rapidly progressive ulcers with violaceous, undermined borders. Despite most commonly affecting the lower extremities, pyoderma gangrenosum can rarely present in the genital, anal, and perineal regions. We describe 2 cases and report a review of published cases.

Longitudinal evaluation of the cutaneous and rectal microbiota of German shepherd dogs with perianal fistulas undergoing therapy with ciclosporin and ketoconazole.

Perianal fistulas are painful ulcers or sinus tracts that disproportionately affect German shepherd dogs and are proposed as a spontaneous animal model of fistulising Crohn's disease. To characterise the rectal and cutaneous microbiota in German shepherd dogs with perianal fistulas and to investigate longitudinal shifts with lesion resolution during immunomodulatory therapy. Eleven German shepherd dogs with perianal fistulas and 15 healthy German shepherd dogs. Affected dogs were evaluated and swabbed at three visits, 30 days apart, while undergoing treatment with ciclosporin and ketoconazole. Healthy German shepherd dogs were contemporaneously sampled. Sites included the rectum, perianal skin and axilla. The microbiome was evaluated following sequencing of the V4 hypervariable region of the 16S ribosomal RNA (rRNA) gene. Alpha diversity was not significantly different between healthy and affected dogs at each of the three body sites (p > 0.5), yet rectal and perianal beta diversities from affected dogs differed significantly from those of healthy dogs at Day 0 (p = 0.004). Rectal and perianal relative abundance of Prevotella spp. increased and perianal Staphylococcus spp. relative abundance decreased in affected dogs over time, coincident with lesion resolution. Changes in lesional cutaneous and rectal microbiota occur in German shepherd dogs with perianal fistulas and shift over time with lesion resolution during immunomodulatory therapy. Further investigations of the role of cutaneous and enteric microbiota in the pathogenesis of perianal fistulas, and whether manipulation of microbial populations may ameliorate disease, are needed.

PERINEAL PAIN AND DISCOMFORT: A STRANGE PHENOMENON FOLLOWING INTRAVENOUS DEXAMETHASONE

Objectives: The objectives of this study were to estimate the incidence of perineal discomfort, to assess the type of perineal discomfort, and to determine the time frame in which the discomfort started and persisted following IV administration of Dexamethasone in patients in the wards of a tertiary care teaching hospital. Methods: This study was a descriptive cross-sectional study among 235 inpatients of a tertiary care hospital in Kerala receiving IV Dexamethasone. Study setting was in-patient wards of Government Medical College, Manjeri, Kerala. The study duration was 6 months from the date of IEC approval. Results: Out of the 235 patients enrolled to the study, 126 (55.6%) were male and 109 (44.4%) were female. The mean age of the patients enrolled was 55.85±16.657. About 63 (26.8%) patients developed abnormal discomfort or symptoms following IV Dexamethasone injection. Patients presented the symptoms mainly over perineal area, perianal area, and lower abdomen. About 50 (79.4%) presented with symptoms in perineal area. All the 63 (100%) patients who experienced the symptoms had sudden and spontaneous onset of symptoms while administering the injection and the duration of the symptoms varied from few seconds to 5 min. There was no significant relationship between gender and dosage with appearance of symptoms. Conclusion: In clinical practice, health-care professionals should be aware of such transient symptoms of perineal irritation and pruritus followed by IV Dexamethasone. Even though the exact mechanism is not known, this should be kept in mind and proper dilution and slow administration of the dexamethasone should be done to reduce such symptoms.

A CASE REPORT ON ANGIOMYXOMA OF VULVA - A RARE MESENCHYMAL TUMOR IN REPRODUCTIVE AGE GROUP WOMEN

Aggressive angiomyxoma (AAM) is a mesenchymal tumor that arises from perineal or lower pelvic connective tissue. This tumor is locally aggressive. It has mostly been found in reproductive age group females. The correct diagnosis and follow-up of this tumor are very important, as it has similar presentation to many other vulvar masses and it tends to recur due to its locally aggressive nature. We report here a case of 40-year-old female P2L2, who presented with a soft, non-tender swelling on the left labia majora.

Hemorrhoidal disease: Epidemiological study and analysis of predictive factors for surgical management

There are very few French studies on hemorrhoidal disease and its management. Prospective single-center study from July to December 2021 including 472 patients. Bleeding, prolapse and pain were the main reasons for consultation. Treatment modalities were medical (44%),±instrumental (72%), and surgical (17%). After treatment, the bleeding score and prolapse score decreased significantly (P=0.002 and P≤0.0001, respectively), but improvement was more marked in the surgery group with a better rate of "very good satisfaction" (73% vs. 54%, P=0.003). Factors associated with likelihood of surgical treatment were: age>44years, hypertrophic perianal skin tags, high scores (Bristol>5, bleeding>5, prolapse>2), severe impact on quality of life, smoking and reading during bowel movements. We have developed an online application, which aims to assess the risk of requiring hemorrhoidal surgery. Less than 20% of patients who present with hemorrhoidal disease require surgical treatment, but it is associated with better effectiveness despite more complex postoperative consequences that sometimes motivate patient refusal. We have highlighted factors associated with surgical management, which can guide the practitioner in their therapeutic choices.

Incidence of Mange Infestation in Rabbits

Background: Farmers raise rabbits in abundance in Iraq. Scabies infestation is one of the most prevalent diseases in rabbits. The current study investigates the rabbits’ infestation with scabies that cause severe complications such as itchy alopecia, hyperkeratosis, anorexia, self-trauma, and weight loss. In short, the disease has high morbidity and mortality and creates heavy economic losses for farmers. Objectives: This study was designed to detect mange infestation in rabbits using microscopic examination of skin scraping. This study is the first to investigate mange infestation in rabbits in Mosul City, Iraq. Methods: A total of 130 rabbits were examined, and their skin lesions were scraped. Results: Of 130 rabbits, 56(43.1%) were infested with mange, including Sarcoptes scabiei var. cuniculi (n=50, 38.5%), Psoroptes cuniculi (n=32, 25%), Notoedres cati var. cuniculi (n=26, 20%), Demodex cuniculi (n=12, 9%), and Cheyletiella spp. (n=4, 3%), with the high infestation rate for S. scabiei var. cuniculi and the lowest rate for Cheyletiella spp. The significant lesions were hyperkeratosis followed by alopecia, then pruritus on many body areas (head, ears, abdomen, back, legs, tail, and perineal area). The highest infestation rate was found on the abdomen and back, while the lowest was on the tail and perineal area. There are significant differences according to age, while no significant differences between the males and females and among three types of infestation (single, double, and mixed). Conclusion: The rabbits were infested with several species with different percentages. There was no significant difference in infestation rates between males and females, although there was a difference between younger and older animals. Lastly, a significant difference was clear among the three types of infestation, and the double one was the dominant infestation rate with 50%.

Ulnar Ray Deficiency: A New Classification and a Unique Case Report

Summary: Ulnar ray deficiency is a rare congenital upper limb defect. We report on a unique case with hand-on-flank deformity on the one side and limb truncation on the contralateral side. The standard of care for the hand-on-flank deformity is to do humerus osteotomy to reposition the hand anteriorly. However, the right limb truncation in our patient made the senior author decide not to do the osteotomy. Final assessment showed that the posterior hand position enabled the patient to reach the ano-genital areas, the pocket, and the mouth. It was concluded that in case of hand-on-flank deformity in one limb and limb truncation of the contralateral limb, osteotomies to bring the hand anteriorly are not advised.

Aggressive Angiomyxoma of the Lower Female Genital Tract: A Review of the MITO Rare Tumors Group.

Aggressive angiomyxoma (AAM) is a rare, locally aggressive, myxoid mesenchymal neoplasm primarily found in the pelvic and perineal regions of young adult females. It is a slow growing and locally infiltrating tumor. Preoperative diagnosis is difficult due to the rarity of these tumors and absence of characteristic signs and symptoms. The primary management is tumor excision. Incomplete excision is common because of the infiltrating nature of the neoplasm and absence of a definite capsule. Other non- surgical modalities have been employed, such as radiotherapy, embolization, GnRH analogues or other anti-estrogenic agents. Local relapses occur in 30-40% of the cases, and often appear many years (sometimes decades) after the first excision. Occasional distant metastasis has also been reported. A limited number of cases have been reported in the literature, mostly in the form of small case series or isolated case reports. Therefore, the aim of this paper by a team of experts from the MITO rare tumors group is to review clinical findings, pathologic characteristics and outcome of patients affected by this rare condition in order to be able to offer up-to-date guidance on the management of these cases.

In vitro biomechanical properties of porcine perineal tissues to better understand human perineal tears during delivery.

Data concerning the mechanical properties of the perineum during delivery are very limited. Invivo experiments raise ethical issues. The aim of the study was to describe some of the biomechanical properties of each perineal tissue layer collected from sows in order to better understand perineal tears during childbirth. Samples of each perineal tissue layer were obtained from the skin, the vagina, the external anal sphincter (EAS), the internal anal sphincter (IAS), and the anal mucosa of fresh dead sows. They were tested in quasi-static uniaxial tension using the testing machine Mach-1®. Tests were performed at a displacement velocity of 0.1 mm·s-1. Stress-strain curves of each perineal tissue layer before the first damage for each sow were obtained and modeled using a hyperelastic Yeoh model described by three coefficients: C1, C2, and C3. Pearson correlation coefficients were calculated to measure the correlation between the C1 hyperelastic coefficient and the duration between the first microfailure and the complete rupture for each perineal tissue layer. Pearson correlation was computed between C1 and the number of microfailures before complete rupture for each tissue. Ten samples of each perineal tissue layer were analyzed. Mean values of C1 and corresponding standard deviations were 46 ± 15, 165 ± 60, 27 ± 10, 19 ± 13, 145 ± 28 kPa for the perineal skin, the vagina, the EAS, the IAS, and the anal mucosa, respectively. According to this same sample order, the first microfailure in the population of 10 sows appeared at an average of 54%, 27%, 70%, 131%, and 22% of strain. A correlation was found between C1 hyperelastic coefficient and the duration between the first microfailure and the complete rupture (r = 0.7, p = 0.02) or the number of microfailures before complete rupture only for the vagina (r = 0.7, p = 0.02). In this population of fresh dead sow's perineum, the vagina and the anal mucosa were the stiffest tissues. The IAS and EAS were more extensible and less stiff. A significantly positive correlation was found between C1 and the duration between the first microfailure and the complete rupture of the vagina, and the duration between the first microfailure and the complete rupture of the vagina.

Surgical management of urethral obstruction secondary to perineal liposarcoma in a dog: a case report

BackgroundSwelling of the perineal region in male dogs is most commonly caused by a perineal hernia. Clinical signs associated with perineal hernia are constipation, tenesmus or stranguria. This case report documents a rare cause of perineal swelling created by the growth of a malignant tumour leading to urethral obstruction and subsequent stranguria.Case presentationAn 11-year-old neutered male German Shepherd was presented for swelling in the perineal region and stranguria for three days. Complete blood count and serum biochemistry were unremarkable. Ultrasound revealed a heterogeneous mass in the perineal region. Retrograde urethrography showed a severe narrowing of the urethra caudal to the pelvis. A fine-needle aspirate of the mass was highly suspicious for liposarcoma. Staging was performed by computed tomography (CT) of the thorax and abdomen. Total penile amputation in combination with pubic-ischial pelvic osteotomy, transposition of the remaining urethra through the inguinal canal, V-Y-plasty cranial to the prepuce and preputial urethrostomy were performed to remove the tumour. Histopathology confirmed a well-differentiated liposarcoma with complete histological margins. Six months after the surgery the dog was doing well and there were no signs indicating local tumour recurrence.ConclusionsWide surgical excision is generally recommended for soft tissue sarcomas, however this is sometimes not feasible for large tumours. In the case reported here, tumour resection was achieved by a combination of several surgical techniques with a good clinical outcome.

Reconstruction of perianal skin defect using modified keystone flap after perianal tumor resection

PurposeThe large resection area of perianal tumor makes the skin defect hard to reconstruct. The keystone flap has demonstrated a growing application in skin defects. Herein, we aimed to explore the efficacy of keystone flap in the repair of skin defect after perianal tumor resection. MethodsThis study is a retrospective review of patients diagnosed with perianal tumor from January 2010 to November 2021. A standardized data collection template was used to collect variables. The detailed process of the reconstructive surgery is carefully described in this article. After surgery, the healing process was closely observed. ResultsTwenty patients underwent keystone flap repair. The average wound size before closure measured 3.5 × 4.9 cm2. Primary wound healing was achieved, and the flap survived during the follow up period, which ranged from 6 to 24 months. No severe complications occurred; slight edema was noticed in one patient. ConclusionThe application of keystone flap is a promising way to repair skin defect after tumor removal, and the complications rate was low after surgery. It can be concluded that this method is an effective and reliable way to repair perianal skin defect.

The study of the physicochemical properties of rectal cream samples with the carrot extract and rutin

The modern arsenal of drugs aimed at eliminating pathological processes of the anorectal zone, as a rule, consists of suppositories and soft drugs. When using suppositories, hemorrhoidal nodes may be injured, uneven distribution of the drug along the walls of the anal canal may be observed. In addition, with external and combined hemorrhoids, there is a need to apply the drug not only to the walls of the anal canal, but also to the perianal skin. Therefore, preference is given to the use of soft drugs since the process of their introduction is as easy as possible. Today, the pharmaceutical market of Ukraine has a wide range of products for the treatment of diseases of the anorectal zone, but the constant increase in the number of patients indicates that this problem has not been solved. Therefore, the study on the creation of a new rectal soft medicine that will have a complex effect on pathological processes and expand the range of domestic drugs for use in proctology is relevant. Aim. To substantiate the type of base for a soft rectal medicine by studying the organoleptic and physicochemical properties of the experimental samples. Materials and methods. The study objects were samples of a soft dosage form of various compositions and the reference drug “Procto-Glivenol Cream” (VAMPHARMA S.R.L., Italy). Samples on different carrier bases were examined by their organoleptic and textural properties; their colloidal and thermal stability, viscosity and pH were studied. Results and discussion. It has been found that the use of a sample on a gel base with Aristoflex does not ensure the presence of an optimal adhesive layer between the mucous membrane of the anorectal zone and the dispersion medium of the drug. The proxanol-188 sample does not have satisfactory thermal and colloidal stability indicators. The use of an emulsion base provides the necessary ability to spread over the surface, adhesion and cohesion. Conclusions. Therefore, for further research, it is advisable to use a sample of the rectal cream, which is an emulsion system.

Rethinking Hidradenitis Suppurativa Management: Insights into Bacterial Interactions and Treatment Evolution.

Hidradenitis suppurativa (HS), or acne inversa, is a chronic inflammatory dermatological condition characterized by painful and recurrent nodules and purulent abscesses. HS can have a devastating impact on the quality of life of patients. This condition is commonly localized to the axilla, groin, perineal, and inframammary regions, and can develop fistulas and sinus tracts over time. Its pathogenesis remains elusive and is best characterized at the moment as multi-factorial. Additionally, questions remain about the role of cutaneous dysbiosis as a primary HS trigger or as a secondary perturbation due to HS inflammation. This article features works in relation to HS and its interplay with bacterial microflora. We address current treatment approaches and their impact on HS-related bacteria, as well as areas of therapeutic innovation. In the future, disease-modifying or remittive therapy will likely combine an advanced/targeted anti-inflammatory approach with one that effectively modulates cutaneous and deep tissue dysbiosis.