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Journal of the Korean Society of
Coloproctology
www.coloproctol.org 195
An Analysis of Factors Associated with Increased Perineal
Descent in Women
Jina Chang, Soon Sup Chung
Department of Surgery, Ewha Womans University School of Medicine, Seoul, Korea
Original Article
J Korean Soc Coloproctol 2012;28(4):195-200
http://dx.doi.org/10.3393/jksc.2012.28.4.195
Purpose: Treatment of descending perineal syndrome is focused on personal etiology and on improving symptoms. How-
ever, the etiology of increased perineal descent (PD) is unclear. erefore, the aim of the present study was to evaluate fac-
tors associated with increased resting and dynamic PD in women.
Methods: From January 2004 to August 2010, defecographic ndings in 201 female patients were reviewed retrospectively.
Patient’s age, surgical history, manometric results and defecographic ndings were compared with resting and dynamic PD.
Results: Age (P < 0.01), number of vaginal deliveries (P < 0.01) and resting anorectal angle (P < 0.01) were correlated with
increased resting PD. Also, ndings of rectoceles (P < 0.05) and intussusceptions (P < 0.05) were signicantly correlated
with increased resting PD. On the other hand, increased dynamic PD was correlated with age (P < 0.05), resting anal pres-
sure (P < 0.01) and sigmoidoceles (P < 0.05). No signicant correlation existed between non-relaxing puborectalis, history
of pelvic surgery and increased PD. Also, no signicant dierences in PD according to the symptoms were observed.
Conclusion: Increased number of vaginal deliveries and increased resting rectoanal angle are associated with increased
resting PD whereas increased resting anal pressure is correlated with increased dynamic PD. Older age correlates with both
resting and dynamic PD. Defecographic ndings, such as rectoceles and intussusceptions, are associated with resting PD,
and sigmoidoceles correlated with dynamic PD. ese results can serve as foundational research for understanding the
pathophysiology and causes of increasing PD in women better and for nding a fundamental method of treatment.
Keywords: Perineum; Women; Defecography; Manometry
complete defecation results in more excessive straining, and the
weakened pelvic oor results in increased perineal descent, result-
ing in a vicious cycle [1, 2]. Other authors have noted that the ab-
normal descent of the perineum not only causes constipation, but
also frequently causes fecal incontinences, anal pain, and other
symptoms [3-5].
For the management of descending perineum syndrome, surgi-
cal treatment has shown little ecacy, leading to the administra-
tion of various forms of conservative treatments, such as changes
in diet, regulating defecation habits, use of purgatives, and bio-
feedback treatment. According to the study of Hur et al. [6], bio-
feedback has an approximately 92% success rate, shows symptom-
atic improvement and can be considered to be the most suitable
method of treatment. In addition, D’Amico and Angriman [7] ar-
gued that a complete recovery from descending perineum syn-
drome was dicult to expect and that treatment should focus on
improving symptoms according to the individual patient. From
such a perspective, an analysis of the causes of the descending
perineum syndrome is important. Causes in women are known
INTRODUCTION
Descending perineum syndrome was observed in patients with
chronic constipation and was rst dened as a relaxation of the
pelvic oor by Parks et al. [1] in 1966. While the cause of increased
perineal descent is believed to be excessive straining upon defeca-
tion, excessive straining causes the anterior rectal wall to protrude
towards the anal canal, in turn inducing incomplete defecation
and a weakness of the pelvic oor muscle. In addition, such in-
Received: July 12, 2012
•
Accepted: August 2, 2012
Correspondence to: Soon Sup Chung, M.D.
Department of Surgery, Ewha Womans University Mokdong Hospital,
1071 Anyangcheon-ro, Yangcheon-gu, Seoul 158-710, Korea
Tel: +82-2-2650-2517, Fax: +82-2-2644-7984
E-mail: colonclinic@ewha.ac.kr
©
2012 The Korean Society of Coloproctology
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-
Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-
commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Journal of The Korean Society of
Coloproctology
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An Analysis of Factors Associated with Increased Perineal Descent in Women
Jina Chang and Soon Sup Chung
to be associated with the number of vaginal deliveries, cases of
obstructed labor, and anorectal surgery [8, 9] while rectoceles and
intussusceptions are also known to induce excessive straining,
causing constipation and resulting in a descent of the perineum.
In addition, Pucciani et al. [10] showed that a total abdominal
hysterectomy was also associated with perineal descent in women.
Within such a context, we aimed to investigate the association be-
tween various factors and increased perineal descent in women.
METHODS
Study subjects
e subjects of this study were women with defecation disorder
visiting the Department of Surgery, Ewha Womans University
Mokdong Hospital, from January 1, 2004 to August 30, 2010. Pa-
tients showed symptoms of constipation, fecal incontinence, and
anal pain. Tests were performed with the use of defecography.
Radiologic examinations
Defecography
For subject patients, defecography was administered, and the width
of the anorectal angle and the perineal descending movement were
measured. Without preparation, patients were placed in a le lat-
eral position, and a Foley catheter was inserted through the anus.
Fiy mL of barium sulfate suspension was injected into the rec-
tum by using an enema syringe connected to a catheter, and the
contrast medium paste was injected until the subject had an urge
to evacuate. e contrast medium paste was obtained by mixing
potato starch and barium with water. e contrast medium paste
had the consistency of normal stool or more uid to permit ease
of injection into rectum. e patient was placed on a uoroscopic
toilet laterally and asked to gently defecate. e examination was
performed by lming the dynamics of defecation step by step with
short radioscopic sequences and radiographs. e phases of defe-
cography are 1) during rest with lled anal bulb, 2) during maxi-
mum contraction of the anal sphincter and the pelvic oor mus-
cles, 3) during straining without evacuation, 4) during evacuation,
and 5) during rest when evacuation is completed. e patient must
be instructed to empty the rectum completely and without inter-
ruption.
For the anorectal angle, the posterior anorectal angle, which is
the angle between the anal canal axis and a line parallel to the pos-
terior rectal wall, was used. For the width of the perineal descend-
ing movement, the vertical distance from the pubococcygeal line,
which was from the top of the symphysis pubis to the bottom of
the coccyx, to the point of the anorectal connection was measured
(Fig. 1), while the dynamic perineal descent was dened by sub-
tracting the resting phase value from the defecation value. In ad-
dition, rectoceles, intussusceptions or sigmoidoceles were diag-
nosed through defecography. Non-relaxing puborectalis was also
assessed. Non-relaxing puborectalis indicates that upon attempt-
ing defecation, puborectalis relaxation does not occur, causing an
indentation of the puborectalis. It, also, prevents the anorectal an-
gle from widening or causing an increase, and cases where the
anal canal did not open were diagnosed as cases of non-relaxing
puborectalis.
Anorectal manometry
Some patients underwent anorectal manometry. The anorectal
manometer consisted of an 8-channel water perfusion pump sys-
tem (PIP-4-8 SS, Mui Scientic Inc., Ontario, Canada) and a bal-
loon-attached catheter (Zinetics Manometric Catheter, Medtronic
Inc., Minneapolis, MN, USA). e pressure measured through the
catheter was converted into minute electric currents and recorded
on a computed polygraph (Insight Manometry System S98-2000P
and BioVIEW Analysis, Sandhill Scientic Inc., Highlands Ranch,
CO, USA). e Patient was placed in the lateral position without
preparation, and the catheter was inserted through the anus. e
channel of catheter was positioned 6 cm distally from the anus,
and the resting, squeezing and pushing phase pressures were mea-
sured. As the catheter was being removed by 1 cm sequentially, the
pressure was measured using the same method. e mean resting
pressure and the maximal voluntary contraction pressure were
calculated. e mean squeezing pressure was dened by subtract-
ing the mean resting pressure from the maximal voluntary con-
traction pressure.
Data collection and statistical analysis
e ages of the patients, number of vaginal deliveries, surgical his-
tories and radiologic results were reviewed through medical re-
cords and analyzed retrospectively. Statistical signicance was ver-
ied through the student t-test, Pearson correlation test and anal-
ysis of variance test while all analyses were conducted through
SPSS ver. 16.0 (SPSS Inc., Chicago, IL, USA). Results with a P-value
Fig. 1. Technique used for the measurement of perineal descent and
anorectal angle; (A) pubococcygeal line, (B) perineal descent, (C)
anorectal angle.
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Volume 28, Number 4, 2012
J Korean Soc Coloproctol 2012;28(4):195-200
under 0.05 were seen to have statistical signicance.
RESULTS
Patients’ characteristics
ere were 201 patients with a mean age of 50.4 ± 15.4 years (range,
18 to 81 years). As for the major symptoms for the patients, 127
patients (63.2%) showed constipation, 49 patients (24.4%) showed
fecal incontinence, 11 patients (5.5%) had anal pain, and 14 pa-
tients (6.9%) exhibited other symptoms. The mean number of
vaginal deliveries was 1.84 ± 1.44 (range, 0 to 5) (Table 1).
Defecographic ndings
As to the mean anorectal angle measured in defecography, in the
resting phase, it was 103.7 ± 15.2 degrees, in the squeezing phase,
it was 86.9 ± 18.1 degrees, and in the defecation phase, it was 122.5
± 18.3 degrees. e mean dynamic anorectal angle, the dierence
between the angles for the defecation and the resting phase, was
18.8 ± 16.3 degrees. e mean width of the perineal descent was
5.5 ± 1.3 cm for the resting phase, 4.7 ± 3.2 cm for the squeezing
phase, and 7.0 ± 1.8 cm for the defecation phase; the dynamic per-
ineal descent was 1.5 ± 1.3 cm (Table 2). In addition, there were
124 cases (61.7%) of non-relaxing puborectalis syndrome, 138
cases (68.3%) of rectoceles, 41 cases (20.4%) of intussusceptions
and 49 cases (24.4%) of sigmoidoceles.
Correlation between perineal descent and factors
We analyzed factors that correlated with the resting phase of peri-
neal descent in patients. Age, number of vaginal deliveries, and
the size of the resting-phase anorectal angle showed significant
correlations while the resting-phase or the squeezing-phase anal
pressure did not have a statistically signicant correlation (Table
3). Within the correlation analysis between the dynamic perineal
descent and factors, age and anal pressure of the resting phase had
a signicant correlation (Table 4).
In addition, the perineal descent was compared between patient
groups that showed non-relaxing puborectalis, rectoceles, intus-
susceptions and sigmoidoceles and a group of normal patients.
Also, the group of patients with a history of having once received
perineal surgery was compared with the group of patients with no
history of perineal surgery. e groups that showed a statistically
signicant dierence within resting-phase perineal descent were
the groups with rectoceles and intussusceptions. e resting-phase
perineal descents for the groups with rectoceles and intussuscep-
tions were signicantly larger than it was for the normal group,
and those dierences were statistically signicant. A comparison
of the dynamic perineal descents showed a statistically signicant
Table 1. Patients’ characteristics
Characteristic Value
Age (yr) 50.4 ± 15.4 (18-81)
No. of vaginal deliveries (time) 1.84 ± 1.44 (0-5)
Symptom
Constipation 127 (63.2)
Fecal incontinence 49 (24.4)
Anal pain 11 (5.5)
Other 14 (6.9)
Finding on defecography
Non-relaxing puborectalis 124 (61.7)
Rectocele 138 (68.3)
Intussusception 41 (20.4)
Sigmoidocele 49 (24.4)
Values are presented as Mean ± SD (range) or number (%).
Table 2. Anorectal angles and perineal descents on defecographic
ndings
Defecographic finding Mean ± SD (range)
Anorectal angle (°)
Resting 103.7 ± 15.2 (50.0–140.0)
Squeezing 86.9 ± 8.1 (35.0–135.0)
Pushing 122.5 ± 18.3 (75.0–163.0)
Dynamic change 18.8 ± 16.3 (-20.0–69.0)
Perineal descent (cm)
Resting 5.5 ± 1.3 (2.8–11.4)
Squeezing 4.7 ± 3.2 (1.5–9.6)
Pushing 7.0 ± 1.8 (2.9–13.5)
Dynamic change 1.5 ± 1.3 (-2.0–5.5)
Table 3. Correlations between perineal descent at rest and factors
Factor Correlation coefficient P-value
Age 0.216 <0.01
No. of vaginal deliveries 0.545 <0.01
Anorectal angle at rest 0.201 <0.01
Anal pressure at rest -0.049 NS
Anal pressure at squeezing -0.007 NS
NS, non-specific.
Table 4. Correlations between dynamic perineal descent and factors
Factor Correlation coefficient P-value
Age -0.144 <0.05
No. of vaginal deliveries -0.099 NS
Anorectal angle change 0.129 NS
Anal pressure at rest 0.299 <0.01
Anal pressure at squeezing 0.070 NS
NS, non-specific.
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An Analysis of Factors Associated with Increased Perineal Descent in Women
Jina Chang and Soon Sup Chung
larger result in the patient group with sigmoidoceles (Table 5).
Dierence in perineal descent with symptoms
ere was no signicant dierence in either the resting or the dy-
namic perineal descent between the three groups, although the
mean resting perineal descent of the fecal incontinence group was
larger than it was for the other groups (Table 6).
DISCUSSION
Descending perineum syndrome, one of the functional causes of
idiopathic chronic constipation, can be understood to be a relax-
ation of the pelvic oor resulting from excessive straining upon
continuous defecations. Consequently, while this is a cause of con-
stipation, it reversely is also a phenomenon furthered due to chronic
constipation. Excessive perineal descent also results in anorectal
pain or fecal incontinence.
e degree of perineal descent can be measured by administer-
ing defecography and denes the perpendicular distance from the
anorectal connection, in other words, from the contact point where
the distal rectal posterior line and the central axis of the anus canal
meet to the pubococcygeal line [11, 12]. However, as the measure-
ment of the anorectal angle or perineal descent within defecogra-
phy has poor reproducibility and dierences exist between exam-
iners, objective measurement through identical standards is im-
portant [13]. In addition, the denition of a signicant increase of
the perineal descent diers by author. In the case of Landmann and
Wexner [14], an abnormal increased perineal descent was diag-
nosed in instances where the resting phase was over 4 cm and the
dynamic perineal descent was over 3 cm, and Parks et al. [1] diag-
nosed a signicant increase when the resting phase was over 3 cm
and dynamic perineal descent was also over 3 cm while Kim et al.
[15] diagnosed cases of signicant increase when the resting phase
was over 5 cm and the dynamic perineal descent was over 4 cm.
e perineal descent observed in a defecography has generally
been seen as a phenomenon occurring due to various diseases
that cause pelvic outlet obstruction rather than a disease occur-
ring independently [3, 16], and clear explanations of descending
perineum syndrome or related factors have yet to be given. Many
previous studies attribute the cause to a weakening of the pelvic
oor caused by external damage to the perineum or by trauma to
the pudendal nerve caused by delivery in women [9, 14, 17, 18].
In addition, there have also been opinions that it is related to sur-
gical history, such a hysterectomy and repair of rectoceles and cys-
toceles [18]. In the present study, the association between the past
history of patients and the amount of perineal descent was inves-
tigated. Increasing age, increasing number of vaginal deliveries,
and increasing resting-phase perineal descent showed a statisti-
cally signicant association, but surgical history did not show any
correlation. Within research on association with dynamic perineal
descent, while a relationship was shown with increasing age, no
relationship was shown with number of vaginal deliveries or sur-
gical history. In addition, Ahn et al. [19] reported that defecogra-
phy for patients with defecation disorders showed various over-
lapping findings, particularly numerous cases of excessive peri-
neal descent being accompanied by rectoceles, non-relaxing pu-
borectalis or sigmoidoceles. In that study, however, no such sig-
nicant relationships were discovered. e results of the present
study showed a statistically-signicant correlation between rest-
Table 5. Correlations between perineal descent and other defecographic
ndings, as well as surgical history
Factor
Resting perineal
descent (cm)
Dynamic perineal
descent (cm)
Mean ± SD P-value Mean ± SD P-value
NRPR NS NS
Absent 5.54 ± 1.33 1.76 ± 1.40
Present 5.53 ± 1.35 1.36 ± 1.23
Rectocele <0.05 NS
Absent 5.12 ± 1.02 1.51 ± 1.45
Present 5.72 ± 1.42 1.52 ± 1.24
Intussusception <0.05 NS
Absent 5.42 ± 1.22 1.48 ± 1.32
Present 5.98 ± 1.67 1.65 ± 1.28
Sigmoidocele NS <0.05
Absent 5.65 ± 1.48 1.67 ± 2.55
Present 5.75 ± 1.55 1.72 ± 1.08
History of pelvic surgery NS NS
Absent 5.06 ± 0.90 1.72 ± 0.76
Present 5.38 ± 0.79 1.48 ± 0.88
NRPR, non-relaxing puborectalis; NS, non-specific.
Table 6. Dierences in perineal descent according to the symptoms of the patients
Symptom No.
Resting perineal descent (cm) Dynamic perineal descent (cm)
Mean ± SD P-value Mean ± SD P-value
Fecal incontinence 49 5.84 ± 1.44 0.073 1.30 ± 1.19 0.411
Constipation 127 5.49 ± 1.33 1.58 ± 1.34
Other 25 5.12 ± 1.06 1.61 ± 1.35
Total 201 5.54 ± 1.34 1.51 ± 1.31
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J Korean Soc Coloproctol 2012;28(4):195-200
ing-phase perineal descent and resting anorectal angle while a sta-
tistically signicant increase in resting-phase perineal descent was
observed in patients with rectoceles or intussusceptions. On the
other hand, the increase in dynamic perineal descent had no sta-
tistically significant relationship with diagnosis found through
defecography except sigmoidoceles.
In addition, regarding the hypothesis that there was a relation-
ship between the neuropathy of the puborectalis and descending
perineum syndrome, the increased perineal descent might have
occurred due to a weakening of the pelvic oor caused by perineal
nerve damage. Research ndings have indicated that patients show-
ing signs of descending perineum syndrome exhibit nerve conduc-
tion delays on pudendal nerve terminal motor latency (PNTML)
tests and that these ndings have a signicant relationship [20], but
other authors have concluded the opposite by arguing that there is
no significant relationship [21]. In addition, Lee and Park [17]
suggested that increased perineal descent could be due to puden-
dal nerve damage following vaginal delivery, but abnormalities as
shown on PNTML test was recovered within 2 months and in-
creased perineal descent could continue for 6 months. e nd-
ings of the two tests could be different depending on the time-
frame of clinical observation.
e PNTML test was not included in the present study. How-
ever, the correlation between anal pressure and nerve or sphincter
damage was investigated. e resting-phase perineal descent had
no relationship with either the resting or the squeezing anal pres-
sure. However, the dynamic perineal descent had a signicant re-
lationship with the resting anal pressure. is result suggests that
nerve injury could have an eect on dynamic perineal descent, but
the reason for the dierent resting perineal descents is not clear.
e cause of increased perineal descent, excessive straining dur-
ing defecation, weakened perineal muscle and excess perineal de-
scent, are believed to make a vicious cycle. During the cycle, the
perineal muscle would be weakened more, and fecal incontinence
would be present as a late symptom of the cycle. Therefore, we
suppose that patients with symptoms of fecal incontinence may
have larger perineal descent. In the present study, the mean rest-
ing-phase perineal descent of patients with fecal incontinence was
larger than it was for patients with other symptoms, but the dier-
ences were not statistically signicant.
As mentioned before, rather than occurring independently, most
cases of increased perineal descent are accompanied by various
diseases that cause the onset of defecation disorder. As such, most
forms of treatment focus on easing the symptoms of defecation
disorder or remedying diseases believed to be a direct cause of the
increased perineal descent rather than on the increased perineal
descent itself. Cundi et al. [22] reported that within descending
perineum syndrome patients with accompanying vaginal prolapse,
the results of clinical observations of 11 patients who underwent
abdominal sacral colpoperineopexy showed improved symptoms
in 8 patients, with perineal descent returning to normal ranges.
Most studies, however, have argued that descending perineum syn-
drome must be improved through conservative treatment rather
than surgical xation and have reported biofeedback to be partic-
ularly eective. Such ecacy of biofeedback resulted in improved
symptoms regardless of constipation or fecal incontinence [23-25].
However, because the eects of such treatments are clear in the
early stages where the increase in perineal descent is not severe,
early treatment of the disorder through adequate examinations of
patients with defecation disorder is important [18]. However, bio-
feedback focuses on improving symptoms rather than being a fun-
damental treatment. Consequently, studies on more fundamental
forms of treatment are required for patients who have continuing
or recurring symptoms aer treatment.
e focus of the present study was to reveal factors associated
with the increasing perineal descent frequently found in female
patients with defecation disorders. e results of the study showed
a statistically signicant dierence in factors associated with in-
creased resting and dynamic perineal descent. e results show
that with a better understanding of the pathophysiology of descend-
ing perineum syndrome, a fundamental method of treatment can
be achieved. Additional studies are necessary to address factors
not included in the present study so that a better understanding
of relevant medical practices can be achieved.
CONFLICT OF INTEREST
No potential conict of interest relevant to this article was reported.
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