Perineocele: symptom complex, description of anatomic defect, and surgical technique for repair

To describe the patient characteristics, physical examination and magnetic resonance imaging findings, and method of surgical repair of perineocele. A perineocele is a rare condition of an isolated central defect and herniation of the posterior perineum in patients without diffuse vaginal prolapse.

The evaluation consisted of history and physical examination and magnetic resonance imaging. With the patient in the dorsal lithotomy position, an inverted Y incision was made from the posterior vagina to the posterior rectum. The transverse perineal musculature, superficial perineal membrane, and external anal sphincter were approximated. The perineal distance from the posterior fourchette to the anus was measured preoperatively and postoperatively. Symptom and anatomic assessments were done at each postoperative visit.

A total of 6 patients were treated, with a mean follow-up of 9.5 months. The symptoms at presentation consisted of perineal pressure, severe constipation, and the need for manual perineal reduction for defecation. The physical findings included a lack of vaginal prolapse, convexity of the perineum, and an increase in the distance from the posterior fourchette to the rectum. Dynamic magnetic resonance imaging showed no anomaly of the vaginal wall. Preoperatively, the average perineal distance was 11.2 cm and postoperatively it was 4 cm. The perineocele was successfully repaired in all patients. All but 1 patient had significant relief of constipation.

Posterior levator defects can result in perineal hernia with perineal body attenuation, separation of the transverse perineal and anal sphincter musculature, and development of a perineocele. The relief of symptoms and correction of the anatomic defect can be achieved by reapproximation of these structures.