Descending perineum syndrome: control defecogram with a "perineum device", perspective in prevention and conservative therapy.
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Constipation↗
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The effect of saddle design on stresses in the perineum during cycling.
PURPOSE: Repetitive internal stress in the perineum has been associated with soft-tissue trauma in bicyclists. Using an engineering approach, the purpose of this study was to quantify the amount of compression exerted in the perineum for a range of saddle widths and orientations. METHODS: Computer tomography was used to create a three-dimensional voxel-based finite element model of the right side of the male perineum-pelvis. For the creation of the saddle model, a commercially available saddle was digitized and the surface manipulated to represent a variety of saddle widths and orientations. The two models were merged, and a static downward load of 189 N was applied to the model at the region representing the sacroiliac joint. For validation purposes, external stresses along the perineum-saddle interface were compared with the results of pressure sensitive film. Good agreement was found for these external stresses. The saddles were then stretched and rotated, and the magnitude and location of maximum stresses within the perineum were both recorded. In all cases, the model of the pelvis-perineum was held in an upright position. RESULTS: Stresses within the perineum were reduced when the saddle was sufficiently wide to support both ischial tuberosities. This supporting mechanism was best achieved when the saddle was at least two times wider than the bi-ischial width of the cyclist. Stresses in the anterior of the perineum were reduced when the saddle was tilted downward, whereas stresses in the posterior were reduced when the saddle was tilted upward. CONCLUSIONS: Recommendations that saddles should be sufficiently wide to support the ischial tuberosities appear to be well founded. Recommendations that saddles be tilted downward (i.e., nose down) are supported by the model, but with caution, given the limitations of the model.
Animals↗
Ultrasound assessment of the female perineum: technique, methods, indications and ultrasound anatomy.
PURPOSE: To present and promote the use of ultrasound in the evaluation of perineal disorders. MATERIALS AND METHODS: The technique and methodology for a correct ultrasound examination of the perineum, starting from the preparation of patient and equipment, are reported in detail. Ultrasound accesses to the perineum are the following: perineal or vulvar; introital; vaginal; transrectal. The transducers used also vary in technical features and morphology. There is no general agreement as to which access and transducer should be used in the ultrasound assessment of the perineum. We believe that each type of access and transducer has advantages and disadvantages over the others and that the opposition among supporters of different accesses and transducers should be overcome. The various systems should be considered complementary with one another and can all be used to reach a better ultrasound diagnosis. ULTRASOUND ANATOMY OF THE PERINEUM: A detailed description of the possible indications and of the ultrasound anatomy of the pelvic floor in relation to the type of transducer and access that can be used is reported. It is suggested that each ultrasound examination of the perineum should be performed following fast abdominal ultrasound evaluation. Perineal scans should be obtained during all functional phases: at rest, during abdominal straining and contraction. When a perineal access is used, it is always advisable to visualize the pubis as it is an important anatomical landmark for dynamic biometric evaluations. We believe that urethral ultrasound, performed during the dynamic phases, is the most accurate method for evaluating cervico-urethral mobility and is thus extremely useful for a correct pre-operative analysis. An increase in normal urethral mobility is correlated with female urinary incontinence, particularly with stress incontinence. Further-more, ultrasound proves to be valuable in the evaluation of other disorders, such as urogenital prolapses, especially enterocele, and anal sphincter defects. In the latter case, when a specific rotating endoanal probe for anal sphincter dysfunctions is not available, perineal ultrasound may be a useful adjunct for correct evaluation if complemented by a sensible use of clinical data. CONCLUSIONS: As in other anatomical fields, ultrasound proves to be inexpensive, harmless and well tolerated by patients. The wealth of information provided by this method in the assessment of the main anatomic and functional alterations of the perineum makes the use of more invasive and expensive radiographic techniques unnecessary. Its correct use, following an adequate training period, significantly reduces the need for conventional radiography and MR contrast-enhanced examinations which should be regarded as second-line examination tools.
Female↗
Differences in anorectal manometry between patients with haemorrhoids and patients with descending perineum syndrome: implications for management.
Anorectal manometry was carried out at rest, during balloon distension of the rectum and during rectal infusion of saline in 19 patients with haemorrhoids, 30 patients with descending perineum syndrome and 21 controls. Basal and squeeze pressures were significantly higher in patients with haemorrhoids than patients with the descending perineum syndrome. A lower rectal volume was required to inhibit internal sphincter tone in patients with descending perineum syndrome compared with control subjects or patients with haemorrhoids. During rectal infusion of saline basal and peak anal pressures in patients with the descending perineum syndrome were lower than in haemorrhoid patients. Peak rectal pressure was abnormally high in both groups. These differences in anorectal function suggest that despite a similar presentation, the two conditions have a different pathogenesis. Moreover, inappropriate anal sphincter stretch or mucosal excision in patients with descending perineum syndrome may lead to severe incontinence.
Anal Canal↗
Relationship between the length of the perineum and position of the anus and vaginal delivery in primigravidae.
The aim of the study was to determine perineal length and anal position in primigravidae and to evaluate their effect on vaginal delivery. The distances between the fourchette and each of the center of the anal orifice and the inferior margin of the coccyx were measured in 212 primigravidae with singleton term pregnancies during the first stage of labor. Anal position index was calculated by dividing the first measurement by the second. The mean +/- SD length of perineum was 4.6 +/- 0.9 cm. The mean +/- SD anal position index was 0.49 +/- 0.12. Women with a short perineum (<4 cm) or a small anal position index (<0.42) had significantly higher rates of episiotomy, perineal tears and instrumented delivery. This association was also significant by multiple logistic regression analysis. It was concluded that a short perineum and anterior displacement of the anus were associated with traumatic vaginal delivery in primigravidae.
Adult↗
Effect of antiseptic agents on skin flora of the perineum of men with spinal cord injury.
Male patients with spinal cord injury are frequently colonized with P. aeruginosa and K. pneumoniae on the perineum. Regular bathing with bar soap has not influenced this colonization. We have attempted to remove these bacteria using antiseptic agents. The number of P. aeruginosa, K. pneumoniae and total aerobic bacteria on the perineum and the penile shaft was determined before and after cleaning with bar soap, chlorhexidine, povidone-iodine and pHresh. Povidone-iodine and chlorhexidine had no advantage over bar soap or pHresh in the removal of P. aeruginosa or K. pneumoniae from the perineum of patients with spinal cord injury.
Adolescent↗
Correlation of bacteriological flora of the urethra, glans and perineum with organisms causing urinary tract infection in the spinal injured male patient.
Positive urine cultures are common and often asymptomatic in the male spinal injured patient performing self clean intermittent catheterisation. It is possible that the positive urine cultures result from contamination from the colonised urethra at the time of catheterisation. This contamination could result in true infection of the bladder urine or yield false positive results, explaining the frequently seen asymptomatic cases. In a prospective study positive urine cultures were found on 58 occasions (74%) in 10 asymptomatic patients studied. In 19% of screenings, with positive urine cultures, an identical organism was cultured from the catheter specimen of urine, the perineum and the urethra. The flora of the anterior urethra is strongly correlated to that of the perineum (37.1%), as well as that of the bladder (52.6%). In 4 patients a correlation also existed between the urethra and fingers, and the perineum and fingers. This was associated with an increased incidence of positive urine culture in these patients. Suprapubic aspirates of urine before and after catheterisation cultured the same organisms. However, quantitative culture revealed colony counts that approached a 10-fold increase following catheterisation in one patient. This suggests that catheterisation is at least partially responsible for ascending infection in this group of patients. Catheter specimens were found to be a good representation of the bladder urine, with an 87.5% correlation.
Adult↗
Necrotizing gangrene of the genitalia and perineum.
BACKGROUND: Necrotizing gangrene of the genitalia and perineum is a fulminant, life-threatening condition. This infection is usually polymicrobial and may be idiopathic or secondary to local trauma or surgery. Histologically, it is characterized by obliterative endarteritis and thrombosis of the subcutaneous vessels, fascial necrosis, and leukocytic infiltration. Mortality rates of 25-75% have been reported. Most cases of necrotizing gangrene begin insidiously, with scrotal discomfort and malaise. Later, erythema, increasing pain, and swelling, associated with fever and chills, develop. A biopsy is useful to confirm the clinical diagnosis and to obtain culture samples. Ultrasound imaging may reveal gas or testicular involvement and may help to distinguish this infection from other causes of scrotal pathology. MATERIALS AND METHODS: Fifteen patients with necrotizing gangrene of the genitalia and perineum, seen at the Dermatology and Plastic Surgery Sections of our Institutions between 1994 and 1999, are described. RESULTS: This series included 11 men (73%) and four women (27%), aged 39-68 years (mean, 51 years). In our series, Clostridium perfingens, Staphylococcus aureus, Proteus mirabilis, Pseudomonas aeruginosa, Streptococcus viridans, Acinetobacter baumani, Escherichia coli, and Candida albicans were isolated. Hemodynamic stabilization and monitoring were performed in all patients. Intravenous antimicrobial therapy was promptly instituted. In most cases, two or more drugs were used. Concurrent surgical debridement of all necrotic areas was always required. When needed, split-thickness skin grafts were used to cover the penile shaft. Expanded mesh grafts were used to reconstruct the vulva and other denuded beds. The survival rate in this series was 87%. CONCLUSIONS: Necrotizing gangrene of the genitalia and perineum continues to be a diagnostic and therapeutic challenge. The usual polymicrobial infection with vascular involvement demands hemodynamic stabilization, systemic antimicrobial therapy, and surgical debridement. In some patients, genital, perineal, and abdominal wall reconstruction is also required.
Adult↗
Descending perineum syndrome: audit of clinical and laboratory features and outcome of pelvic floor retraining.
OBJECTIVE: Our aim was to retrospectively analyze the Mayo Clinic experience of descending perineum syndrome from 1987-1997. METHODS: Clinical records were abstracted for demographic features, risk factors, results of anorectal and defecation tests, and a mailed questionnaire evaluated outcome and current symptoms. RESULTS: All results are mean +/- SD. Clinically, 39 patients (38 women, one man), mean age 53+/-14 yr, presented with constipation (97%), incomplete rectal evacuation (92%), excessive straining (97%), digital rectal evacuation (38%), and fecal incontinence (15%). Laboratory tests showed anal sphincter resting pressure was 54+/-26 mm Hg, and squeeze pressure was 96+/-35 mm Hg; expulsion from the rectum of a 50-ml balloon required > 200 g added weight in 27%; perineal descent was 4.4+/-1 cm (normal < 4 cm) by scintigraphy. Scintigraphic evacuation, rectoanal angle change during defecation, and perineal descent were abnormal in 23%, 57%, and 78% of the patients, respectively. Associated features included female gender (96%), multiparity with vaginal delivery (55%), hysterectomy or cystocele/rectocele repair (74%). On follow-up, 64% responded; 17 of these 25 responders underwent pelvic floor retraining. At 2-yr median follow-up (range, 1-6 yr), 12 still experienced constipation or excessive straining; their perineal descent was greater than in patients who responded to retraining (p = 0.005). CONCLUSIONS: Descending perineum syndrome is identifiable by clinical history and examination, and the most prevalent abnormality on testing is perineal descent > 4 cm; rectal balloon expulsion is an insensitive screening test for descending perineum syndrome. Pelvic floor retraining is a suboptimal treatment for this chronic disorder of rectal evacuation; the extent of perineal descent appears to be a useful predictor of response to retraining.
Anal Canal↗
Computed tomography of the perineum.
The value of computed tomography (CT) in the assessment of pelvic malignancy is well established. However, the importance of scanning caudad to the symphysis pubis to include the perineum has not been emphasized. The CT anatomy of the perineum in the transverse, coronal, and sagittal planes planes in normal subjects and in cadaver specimens is reviewed, and experience in 22 patients with pelviperineal pathology is reported. Malignancies in 16 patients were of the cervix (seven), vulva (six), vagina (two), and a recurrent mesenchymoma (one). Six patients had abscesses; one of these had cellulitis and skin ulcers. CT clearly depicts the perineal anatomy and is the imaging method of choice for the evaluation of malignancies and abscesses originating from or extending into this anatomic space. failure to include the perineum in the CT scanning of the pelvis will result in underestimation of disease extent. Multiplanar CT display of pelviperineal anatomy has great potential application in clinical work when high resolution coronal and sagittal reconstruction of transverse scans becomes available.
Adult↗
Total pelvic exenteration and reconstruction for locally invasive recurrent sarcoma of the perineum.
Extensive primary tumors and locally recurrent tumors of the pelvis or perineum are difficult to manage. We describe the techniques necessary to perform total pelvic exenteration with en bloc resection of the perineum and genitalia for treatment of recurrent sarcoma of the perineum. Wide excision of the sarcoma with negative margins can be achieved by resecting the inferior portion of the pubic symphysis. An absorbable mesh sling may be used to suspend the small bowel above the pelvis, facilitating postoperative radiation. A catheterizable continent urinary reservoir avoids the necessity of two stomas and improves quality of life. Adequate tissue coverage can be attained by myocutaneous gracilis flaps that promote wound healing.
Adult↗
Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women.
OBJECTIVE: To investigate the influence of the traditional hands-on versus the innovative hands-poised method on the risk of perineal trauma during vaginal delivery and on neonatal outcomes. STUDY DESIGN: In a prospective, randomized, multicenter study, 1,161 of 1,505 women giving birth at the Departments of Obstetrics and Gynecology of the University Hospital of Vienna and Semmelweis Women's Hospital, Vienna, between February and September 1999, were randomized into the trial. In the hands-on method, the left hand of the midwife puts pressure on the infant's head, and the right hand is placed against the perineum. In the hands-poised method, the midwife guides the parturient through the birth without touching the perineum, prepared to apply light pressure on the infant's head. RESULTS: One hundred eighty-seven of 574 women (32.5%) in the hands-on group and 180 of 502 women (35.8%) in the hands-poised group experienced perineal tears (P = .5). Sixteen women (2.7%) treated with the hands-on method developed third-degree perineal tears as compared with five women (0.9%) treated with the hands-poised method (P < .05). In the hands-on group, 103 women (17.9%) underwent episiotomy as compared with 51 cases (10.1%) in the hands-poised group (P < .01). No significant differences in neonatal outcomes were observed between the two groups. CONCLUSION: Our data suggest that a policy of hands-poised care is more suitable for preserving the perineum during birth and is a safe and effective birthing alternative for women.
Adult↗
[Anatomy of the anterior male perineum].
The central nucleus of the perineum. Having carefully studied the anatomy of the central nucleus of the perineum on 27 male pelvises, the authors discuss the fibromuscular nature of this structure which extends from the peritoneal cul-de-sac to the perineal fascia, between urogenital pathways in front and digestive pathways in back. The connections to all the pelvic-perineal organs are discussed. The middle perineal adoneurosis. A personal conception. The study of twenty seven male perineums has permitted the authors to formulate a personal conception of the anatomy of the middle perineal aponeurosis. It is made up of adjoining structures organized in front and in back of the urethrae; above all it includes a smooth fibromuscular part in back of this canal, whereas in front, it behaves as a vessel-carrying sheath, where the dorsal pack of the penis and the Santorini plexus pass.
Adult↗
The pelvic floor musculature in the descending perineum syndrome.
We have studied 20 patients with the descending perineum syndrome, half of whom were incontinent of faeces. Objective criteria were established in 103 control subjects for determining the relationship of the perineum to the bony pelvis. The anal reflex latency was increased in the 10 patients in whom perineal descent was associated with faecal incontinence, but not in the 10 without incontinence. However, there was hypertrophy of the muscle fibers in external anal sphincter muscle biopsies in all the patients. Thus, abnormal degrees of perineal descent are associated with changes in the external anal sphincter muscle, consistent with damage to its nerve supply.
Adult↗
Construction of a neovagina for patients with a flat perineum.
Vaginal dilatation affords an acceptable functional success rate for women with vaginal agenesis, provided there is an introitus with a pouch or dimple. In contrast, women with a flat perineum who lack labia majora, labia minora, and vaginal introitus have no alternative to development of a vagina-like orifice other than surgical vaginoplasty. This study addresses the anatomic and functional success rate of these women after undergoing modified McIndoe technique. Thirty-four patients with microphallus were assigned the female gender as the sex of rearing at the Johns Hopkins Hospital between 1951 and 1987. A majority of patients underwent surgical revision of the external genitalia and gonadectomy before 2 years of age. Family counseling was begun at birth. Of these patients, 15 (17 to 25 years old) who requested the ability to have sexual relations underwent modified McIndoe vaginoplasty. All 15 of these women have experienced satisfactory coitus. All but one patient have an adequate size vagina. Results of this group indicate that patients with ambiguous genitalia as a result of male hermaphroditism or microphallus can achieve functional success after vaginal creation with a modified McIndoe technique despite the presence of a flat perineum.
Coitus↗
Does DeLee suction at the perineum prevent meconium aspiration syndrome?
OBJECTIVE: We attempted to determine the impact of "early" (before delivery of the chest) oronasopharyngeal DeLee suctioning at the perineum in the prevention of meconium aspiration syndrome and to confirm that meconium aspiration syndrome is a postnatal event. STUDY DESIGN: We compared infants with meconium-stained fluid who underwent "early" oronasopharyngeal DeLee suctioning with a similar group of infants whose airways were suctioned "late" (after chest delivery). Practicing obstetricians did not know the study was being conducted by the pediatric staff, and an independent observer documented whether obstetricians performed "early" or "late" oronasopharyngeal DeLee suctioning. Immediate postnatal tracheal suctioning was performed in both groups. The study was conducted in a private tertiary care center averaging 5800 deliveries annually. A consecutive sample of 438 infants with meconium-stained fluid was analyzed. Of these infants, 221 received "early" oronasopharyngeal DeLee suctioning, while 217 infants were suctioned "late". RESULTS: Of the 438 infants with meconium-stained fluid, meconium aspiration syndrome developed in 38 (9%). These infants had higher rates of fetal distress (i.e., abnormal fetal heart rates) and lower Apgar scores (< or = 6) than infants without meconium aspiration syndrome (58% vs 17% and 65% vs 13%, respectively; p < 0.001). Forty-five percent of the infants with meconium aspiration syndrome had renal failure during the first 20 hours of life. In spite of "early" oronasopharyngeal DeLee suctioning, 53% of the infants in this group had meconium below the vocal cords and meconium aspiration syndrome developed in 7%. The time of oronasopharyngeal DeLee suctioning did not affect the rate of meconium aspiration syndrome or the presence of meconium below the vocal cords. CONCLUSIONS: We concluded that "early" oronasopharyngeal DeLee suctioning at the perineum does not affect the rate of meconium aspiration syndrome. We speculate that meconium aspiration syndrome is predominantly an intrauterine event associated with fetal distress and that meconium in the airways is merely a "marker" of previous fetal hypoxia.
Chi-Square Distribution↗
Transmission of afferent information from urinary bladder, urethra and perineum to periaqueductal gray of cat.
The micturition reflex pathway is a supraspinal pathway. Anatomical tracing evidence is compatible with an involvement of the periaqueductal gray (PAG) in the ascending limb of this reflex. We tested the involvement of the PAG in receiving urinary tract- or perineum-related information and attempted to characterize this ascending path in terms of what type of information is being conveyed. Electrical stimulation of the pelvic nerves, which carry afferent information from the urinary bladder, evoked maximum field potentials in the caudal third of the PAG, primarily in the dorsal part of the lateral PAG and in the ventrolateral PAG. Since the regions activated by pelvic nerve stimulation differed from those activated by stimulation of the sensory pudendal or superficial perineal nerves, it is possible that specific pathways for different nerve inputs to the PAG exist. Sacral spinal cord neurons ascending to the PAG were identified by antidromic activation and then tested for inputs from pelvic, sensory pudendal or superficial perineal nerves. Of 18 units identified, only five received inputs from any of the peripheral nerves tested and only two projecting neurons received a pelvic nerve input. Thus the PAG may receive inputs from bladder and perineum, but the small proportion of cells with direct projections to the PAG receiving inputs from our test nerves implies that the major part of this pathway is not directly related to lower urinary tract function.
Afferent Pathways↗
Care of the perineum in the second stage of labour: a study of views and practices of Australian midwives.
OBJECTIVES: to seek the views of midwives on the practices related to the perineum in the second stage of labour; to identify predictors of their practices and to identify their actual practices in the second stage of labour, prior to a randomised trial of second stage perineal massage. PARTICIPANTS AND SETTING: independent midwives in South Australia and 194 midwives working in the delivery suites and birth centres of seven public hospitals in four states of Australia. DESIGN: midwives were surveyed using a questionnaire which sought their views on, and practices relating to, second stage perineal massage, delivery of the head and reasons for cutting an episiotomy. FINDINGS: one third of the respondents 'never' practised perineal massage in the second stage of labour, 43% were 'undecided' as to its value and 19% disagreed with the practice. Over half agreed that its use should be decided by the woman and her partner. When invited to select the five statements they most agreed with, and the five they most disagreed with, out of a possible 24, equal numbers (26%) were for and against the statement referring to such massage as helping to stretch the perineum and prevent tearing. More than half (55%) disagreed with the statement which predicted they would find the practice distasteful, while only 1.6% agreed with this statement. During delivery of the head, 71% of respondents attempted some form of flexion. There was 100% agreement that fetal distress almost always or frequently was an indication for cutting an episiotomy. CONCLUSIONS: there is little evidence from randomised trials to support many of the second stage practices, and further research will clarify those which are most effective. This sample of midwives demonstrated considerable variation in their views on, and practices in, the second stage of labour. Although one-fifth disagreed with the practice of second stage perineal massage, and 40% agreed that the midwife should decide, more than half (57%) believed it was a matter of choice for the woman and her partner. All were supportive of episiotomy use for fetal distress.
Female↗