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pISSN 2093-7822 eISSN 2093-7830
www.coloproctol.org
Journal of the Korean Society of
Coloproctology
www.coloproctol.org 395
Clinical Significance of Perineal Descent in Pelvic Outlet
Obstruction Diagnosed by using Defecography
Hyun Nam Baek, Yong Hee Hwang, Yong Hwan Jung
Department of Surgery, Sahm Yook Medical Center, Seoul, Korea
Original Article
J Korean Soc Coloproctol 2010:26(6);395-401
DOI: 10.3393/jksc.2010.26.6.395
Purpose: e aim of this study was to evaluate the clinical signicance of perineal descent (PD) in pelvic outlet obstruc-
tion patients diagnosed by using defecography.
Methods: One hundred thirty-six patients with pelvic outlet obstruction (POO; median age 49 years) had more than one
biofeedback session aer defecography. Demographic nding, clinical bowel symptoms and anorectal physiological stud-
ies were compared for PD at rest and PD with dynamic changes.
Results: Age (r = 0.33; P < 0.001), rectocele diameter (r = 0.31; P < 0.01), symptoms of incontinence (P < 0.05) and num-
ber of vaginal deliveries (r = 0.46; P < 0.001) were correlated with increased xed PD. However, the female gender (P <
0.005), rectal intussusceptions (P < 0.05), negative non-relaxing puborectalis syndrome (P < 0.00005) and rectocele (P <
0.0005) were correlated with increased dynamic PD. Duration of symptoms, number of bowel movements, history of pel-
vic surgery and dicult defecation were not related with PD. ere was no signicant correlation between xed and dy-
namic PD and success of biofeedback therapy.
Conclusion: Age, vaginal delivery and diameter of the rectocele are associated with increased xed PD. Female gender,
rectal intussusceptions and a rectocele are correlated with increased dynamic PD. Biofeedback is an eective option for
POO regardless of severity of PD.
Keywords: Perineal descent; Pelvic outlet obstruction; Biofeedback
but also in fecal incontinence, idiopathic anal pain syndrome,
and solitary rectal ulcer syndrome patients. It is generally ac-
cepted to be a secondary phenomenon associated with various
diseases causing pelvic outlet obstruction rather than an inde-
pendent disease inducing chronic constipation.
Pelvic outlet obstruction, together with colonic inertia caused
by dysfunction of colon movement, is a major cause, excluding
organic causes, of idiopathic chronic constipation. In the past,
the representative disease causing pelvic outlet obstruction was
anismus; it is a concept referring to entire dyschezia and has
been mixed with terms such as pelvic oor dyssynergia, spas-
tic pelvic oor syndrome, paradoxical puborectalis contraction,
rectoanal dyssynergia, and nonrelaxing puborectalis syndrome
[6]. Nevertheless, on account of the introduction of the anorec-
tal function test, which has been performed widely from the
mid-1980s, studies on the functional causes inducing pelvic
outlet obstruction have been conducted actively. Based on the
results of such studies, presently, non-relaxing puborectalis
syndrome, a rectocele, rectal intussusception, sigmoidocele,
anal dyschezia are understood to be diseases associated with
pelvic outlet obstruction. erefore we examined the associa-
INTRODUCTION
Perineal descent is a phenomenon associated with constipation,
and it is considered to be the last stage of excessive straining
for defecation over several years. Such abnormally increased
perineal descent was observed by Porter [1] in 1962 for the rst
time, and aerward, it was accepted as a denite entity by Parks
et al. [2] in 1966, and it was described as a relaxed pelvic oor
in chronic constipation patients. Subsequently, other investiga-
tors [3-5] have reported that increased perineal descent is a
general symptom observed not only in constipation patients
Received: August 31, 2010 Accepted: October 20, 2010
Correspondence to: Yong Hee Hwang, Ph.D.
Department of Sugery, Sahm Yook Medical Center, 29-1 Hwigyeong 2-dong,
Dongdaemun-gu, Seoul 130-711, Korea
Tel: +82-2-2210-3563, Fax: +82-2-2249-0403
E-mail: hwangyon@hotmail.com
© 2010 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
www.coloproctol.org396
Clinical Significance of Perineal Descent in Pelvic Outlet Obstruction Diagnosed by using Defecography
Hyun Nam Baek, et al.
tion of the level of perineal descent with pelvic outlet obstruc-
tion and the eect of perineal descent on its treatment.
METHODS
Among patients who visited the Anorectal Clinic at the Sahm
Yook Medical Center for symptoms of dyschezia from June
2005 July 2008, the study was conducted on 136 patients who
had been diagnosed as having pelvic outlet obstruction by us-
ing the anorectal physiological function test and who had re-
ceived biofeedback treatments for more than 2 times. Pelvic
outlet obstruction was diagnosed by using both defecography
and cinedefecography. Anal manometry and anal electromy-
ography (EMG) were also performed simultaneously on the
patients.
For defecography without pretreatments, patients were put in
the le lateral position and the inner wall of the rectum and anal
canal were coated by injecting 50 mL of barium sulfate solution
(Solotop, soln; Taejoon Pharm., Seoul, Korea) through the anus,
and semi-solid dye prepared in advance was injected into the
rectum until the patient felt the sensation of defecation. Aer-
ward, the patient sat on a defecography chair, and under uo-
roscopy, radiographs were taken at rest, squeeze, and push. For
cinedefecography, the entire defecation process was videotaped
with a video camera attached to the uoroscopy. As a semi-solid
dye, barium sulfate suspension (Solotop 120%) mixed with
starch at the ratio of 1:1, was used. Psychological dyschezia fac-
tors were minimized by performing all procedures by remote
control. e patient was isolated in a test room, and the area
was dimmed.
In defecography and cinedefecography, non-relaxing puborec-
talis syndrome was diagnosed as cases in which clear impres-
sions in the puborectalis muscle are shown during defecation,
the antorectal angle is not changed in comparison with the an-
gle at rest or rather becomes smaller, and when defecation is
attempted, perineal descent hardly occurs, and the opening of
the anal canal and the excretion of more than 80% feces are
delayed for more than 20 seconds. A rectocele whose diameter
is bigger than 2 cm and in which, despite several attempts at
defecation, the contrast is not excreted from the rectocele is
considered to be a signicant rectocele.
For the diagnosis of a sigmoidocele, a rst-degree sigmoido-
cele was dened as one located below the sacral promontory
but above the pubococcygeal line. A second-degree sigmoido-
cele was dened as one located between the pubococcygeal line
and the ischiococcygeal line. A third-degree sigmoidocele was
dened as one located below the ischiococcygeal line. Sigmoid-
oceles of higher than second degree were considered to be clin-
ically signicant. Rectal intussusception was dened as the rec-
tum showing a funnel-shaped depression within the anal canal
during push.
Fixed descent and dynamic descent were measured by using
scout lm imaging during the rest period and the push period
of defecography. A line was drawn on the tangential line of the
distal rectal posterior margin and the central axis of the anal
canal. e distance to reach the pubococcygeal line, at a right
angle, from the point where the above two lines met was mea-
sured as the perineal descent. e distance of perineal descent
during the rest period was dened as xed descent, and the dif-
ference between the perineal descent during the rest period and
that during the push period was dened as dynamic descent.
e device used to measure anal pressure was a water-lled
perfusion device. e test catheter was a custom-made polyvi-
nyl catheter 4.5 mm in diameter that had six side holes; 4 side
holes, 0.8 mm in diameter, were arranged on the same level at
90° angles, and the other 2 side holes were located within a
balloon at the tip of the catheter. e rate of water perfusion
was regulated at 0.5 mL/channel/minute by using a microper-
fusion device with a 15-PSI pressure. e measured pressure
was transmitted to the PC Polygraph HR (Sandhill Scientic
Inc., Littleton, CO, USA) by using a pressure converter device,
re-entered into a computer, and analyzed by using installed
soware.
For the test, without pretreatment, patients were positioned
in the le lateral position. Aer the pressure of the system had
been adjusted, and while taking care to prevent bending, the
catheter was placed at a position such that its side hole were
located at a site 6 cm away from the anal verge. Anal manome-
try was performed using the station pull-through technique,
and at 1-cm intervals, including anal manometry at rest, anal
manometry was performed at squeeze and at push. e length
of the high-pressure zone of the anal canal, in which the pres-
sure was elevated by more than 20 mmHg in more than 50%
of the measured channel (for example, for 4 channels, more
than 2 channels) the presence or absence of anorectal inhibi-
tory reex, the sensory threshold of the lower rectum, and the
volume and compliance of the rectum were measured.
For anal electromyography (EMG), without pretreatment,
patients were positioned in the le lateral position, a surface
electrode 12 mm in diameter and 45 mm in length (Perry me-
ter anal EMG sensor EPS-21; Perry Meter Systems, Straord,
PA, USA) was inserted into the anus, and the electric activity
levels at rest, squeeze, and push were measured. For biofeed-
back treatments, the Perry meter anal EMG sensor EPS-21, 12
mm in diameter and 45 mm in depth, and a surface electrode
were connected to the Kontinence biofeedback computer (HMT
Co., Seoul, Korea), and EMG-based biofeedback treatments
were performed. e anal EMG sensor was inserted into the
anal canal in order to measure the movement of the puborec-
talis muscle and the anal sphincter. e surface electrode was
attached to the abdominal wall in order to measure constric-
tion and relaxation of abdominal muscles as a marker of defe-
cation. e patients were educated concerning the constriction
and relaxation of the anal sphincter, and for smooth defecation,
Journal of The Korean Society of
Coloproctology
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Volume 26, Number 6, 2010
J Korean Soc Coloproctol 2010:26(6);395-401
relaxation of the anal sphincter was learned. In addition, high-
ber diets and a sucient intake of water (more than 8 cups
per day) were recommended. e routine use of other laxatives,
stimulatory constipation drugs, or suppositories was not allowed.
Biofeedback treatments, 30-60 minutes per treatment at one
week intervals, were administered by one specialist for all pa-
tients who visited outpatient clinics.
Aer treatments, the patients were asked to evaluate the results
by using one of the following classications: loss of symptoms,
improvement of symptoms, continuous symptoms, and worse
symptoms. Loss and improvement of symptoms were consid-
ered as the treatment success group. Continuous symptoms and
worse symptoms were considered as the failure group.
To examine the correlation of perineal descent to pelvic out-
let obstruction, we measured, compared and analyzed demo-
graphic factors, clinical symptoms including defecation symp-
toms, the past history of anorectal surgery and obstetrical sur-
gery, and the anorectal physiological function for xed perineal
descent and dynamic perineal descent. In defecography, the ano-
rectal angle at rest, squeeze, and push, the dierence between
the push period and the rest period, the presence or absence of
a rectocele, the size of the rectocele, and the presence or absence
of rectal intussusception, sigmoidocele, and non-relaxing pu-
borectalis syndrome were compared and analyzed. In anal elec-
tromyography, the electric activities of the puborectalis muscle
and the anal sphincter at the rest, squeeze, and push phase were
analyzed. To examine the eect of perineal descent on the treat-
ment of pelvic outlet obstruction patients, during xed peri-
neal descent and dynamic perineal descent, the perineal de-
scent level was determined and analyzed for the success group
and the failure group.
For statistical analysis, descriptive statistics, t-test and regres-
sion test, were applied. All statistical analyses were performed
by using an analysis tool pack (Microso Excel 97, 4.00.950,
Microsoft Korea, Seoul, Korea). P-values less than 0.05 were
considered to be statistically signicant.
RESULTS
e number of patients that visited the Anorectal Clinic at the
Sahm Yook Medical Center for dyschezia, were diagnosed as
having pelvic outlet obstruction by using defecography, and
received biofeedback treatment for more than 1 time was 136
(male:female, 27:109). eir mean age was 49 years (range, 7
to 84 years), and the symptomatic period was an average 6.4
years. e major symptoms of the subjects were dyschezia, sen-
sation of incomplete defecation, hard stool, anal hemorrhage,
discharge of mucus, and anal pain. Additional symptoms were
decrease in the diameter of stool, an anal lump, abdominal pain,
abdominal distention, and a change in defecation habit. Some
patients underwent adjuvant defecation therapy, such as laxa-
tives, enemas, and digitations. As for the past disease history,
diabetes patients were 6 cases, hypertension patients were 14
cases, back pain patients were 11 cases, patients with disorder
of the central nervous system were 3 cases, patients under psy-
chotherapeutic medication were 5 cases, patients under anal-
gesic medication were 7 cases, patients with abdominal surgery
unrelated to the rectum were 10 cases, patients with obstetrical
surgery were 6 cases, and patients with anorectal surgery were
9 cases. When the disease groups were classied based on the
result of the anorectal physiological function test, patients with
rectoceles, rectal intussusceptions, sigmoidoceles, and non-re-
laxing puborectalis syndrome were 77 cases (56%), 28 cases
(20%), 10 cases (7%), and 66 cases (48%), respectively. In the
defecography test, the distance of the average xed perineal de-
scent was 6.2 ± 2.4 cm, and the average distance of the dynamic
perineal descent was 1.1 ± 1.4 cm.
In regard to xed perineal descent, the older was the age (r =
Fixed PD (cm)
Age (yr)
0 50 100
25
20
15
10
5
0
Fig. 1. Age and xed perineal descent (PD; r = 0.33, P < 0.001).
Y
Predicted Y
Fixed PD (cm)
No. of vaginal deliveries
0 2 4 6
25
20
15
10
5
0
Fig. 2. Vaginal delivery and xed perineal descent (PD; r = 0.46, P <
0.001).
Y
Predicted Y
Journal of The Korean Society of
Coloproctology
www.coloproctol.org398
Clinical Significance of Perineal Descent in Pelvic Outlet Obstruction Diagnosed by using Defecography
Hyun Nam Baek, et al.
0.33, P < 0.001) (Fig. 1), the larger was the diameter of the rec-
tocele (r = 0.31, P < 0.01), and the more frequent was the num-
ber of vaginal deliveries (r = 0.46, P < 0.001) (Fig. 2), the lon-
ger was its length. e length of xed perineal descent was lon-
ger in patients showing symptoms of fecal incontinence than
in patients showing symptoms of constipation (P < 0.05) (Table
1). In addition, the anorectal angle at rest (r = 0.67, P < 0.001)
(Fig. 3), the anorectal angle at squeeze (r = 0.62, P < 0.001), the
length of perineal descent at squeeze (r = 0.41, P < 0.001), the
length of the puborectalis at rest (r = 0.49, P < 0.001), the length
of the puborectalis muscle at squeeze (r = 0.34, P < 0.001), and
the value of anal electromyography at squeeze were signicantly
associated with the length of xed perineal descent.
In female patients (P < 0.005) (Table 2), rectal intussusception
patients (P < 0.05) (Table 3), and rectocele patients (P < 0.0005)
(Table 4), the length of dynamic perineal descent was signi-
cantly longer. On the other hand, in non-relaxing puborectalis
syndrome cases, the length of dynamic perineal descent was sig-
nicantly shorter (P < 0.0005) (Table 5). e dierence in the
length of the puborectalis muscle between the push phase and
the rest phase (r = 0.69, P < 0.001) and the contrast retention
during the push period of the rectocele (P < 0.0005) (Table 6)
correlated signicantly with dynamic descent.
e anorectal angle during the push phase (r = 0.61, P < 0.001,
xed; r = 0.33, P < 0.001, dynamic) (Fig. 4) and the length of
Table 1. Symptoms and perineal descent
Perineal descent (cm) Constipation Incontinence P-value
Fixed 6.1 ± 2.5 8.3 ± 2.3 0.0012
Dynamic 1.1 ± 1.5 0.3 ± 1.2 0.117
Table 2. Gender with perineal descent
Perineal descent (cm) Male (27) Female (109) P-value
Fixed 6.0 ± 2.1 6.2 ± 2.2 0.7599
Dynamic 0.4 ± 1.4 1.3 ± 1.4 0.0016
Table 3. Rectal intussusception and perineal descent (PD)
Rectal intussusception Yes No P-value
Fixed PD (cm) 6.2 ± 2.2 6.1 ± 2.4 0.892
Dynamic PD (cm) 1.6 ± 1.6 1.0 ± 1.3 0.0482
Table 4. Rectocele and perineal descent (PD)
Rectocele Yes No P-value
Fixed PD (cm) 6.3 ± 2.7 6.0 ± 2.0 0.42
Dynamic PD (cm) 1.5 ± 1.3 0.5 ± 1.3 0.0001
Table 5. Non-relaxing puborectalis syndrome and perineal descent
(PD)
Non-relaxing
puborectalis syndrome Yes No P-value
Fixed PD (cm) 6.0 ± 2.0 6.3 ± 2.7 0.367
Dynamic PD (cm) 0.5 ± 1.2 1.7 ± 1.4 0.00001
Table 6. Signicant rectocele and perineal descent (PD)
Significant rectocele Yes No P-value
Fixed PD 6.5 ± 2.2 5.9 ± 2.1 0.172
Dynamic PD 1.6 ± 1.2 0.8 ± 1.5 0.0004
Table 7. Biofeedback and perineal descent (PD)
Biofeedback Success Failure P-value
Fixed PD (cm) 6.3 ± 2.5 5.8 ± 1.9 0.46
Dynamic PD (cm) 1.1 ± 1.5 1.1 ± 1.1 0.9
Fixed PD (cm)
Rest angle (degree)
0 100 200
25
20
15
10
5
0
-5
Fig. 3. Rest angle and xed perineal descent (PD; r = 0.67, P < 0.001).
Y
Predicted Y
Dynamic PD (cm)
Rest angle (degree)
0 100 200
8
6
4
2
0
-2
-4
-6
Fig. 4. Push angle and dynamic perineal descent (PD; r = 0.33, P <
0.001).
Y
Predicted Y
Journal of The Korean Society of
Coloproctology
www.coloproctol.org 399
Volume 26, Number 6, 2010
J Korean Soc Coloproctol 2010:26(6);395-401
the puborectalis muscle during the push phase (r = 0.48, P <
0.001, xed; r = 0.45, P < 0.001, dynamic) correlated signi-
cantly with both xed and dynamic perineal descent. e symp-
tomatic period, the number of defecations, the disease history
of pelvic surgery, and dyschezia did not correlate with perineal
descent.
One hundred six patients (78%) responded that the symptoms
were improved after biofeedback treatments, and 26 out of
those 106 patients (25%) reported the loss of symptoms. Both
xed perineal descent and dynamic perineal descent of the suc-
cess group showed no statistically signicant dierences from
the failure group. us, neither xed nor dynamic perineal de-
scent was found to have any eect on the result of biofeedback
treatments for pelvic outlet obstruction (Table 7).
DISCUSSION
Perineal descent is a phenomenon associated with constipa-
tion and is considered to be the last stage of excessive straining
for defecation continued for several years. Such abnormally
increased perineal descent may be considered as the relaxation
of the pelvic oor observed in chronic constipation patients.
erefore, other investigators [3-5] have reported that increased
perineal descent is a general symptom observed not only in
patients with constipation but also in patients with fecal incon-
tinence, idiopathic anal pain syndrome, and solitary rectal ulcer
syndrome. It is generally accepted as an secondary phenome-
non associated with various diseases causing pelvic outlet ob-
struction rather than an independent disease inducing chronic
constipation. In addition, it is detected not only in constipation
patients but also in approximately 75% of fecal incontinence
patients [7]. Excessive straining for defecation for a long time
or delivery causes a protrusion of the anterior rectal wall into
the anal canal, resulting in the sensation of incomplete defeca-
tion and a weakening of the pelvic oor muscles. Such sensa-
tion of incomplete defecation and weakening of the pelvic oor
muscles result in more powerful and more excessive straining
and more weakening of the pelvic oor muscles, eventually lead-
ing to a vicious circle [8].
In dyschezia patients, perineal descent and pudendal neurop-
athy are frequently observed. Parks et al. [9] reported that chronic
excessive straining caused entrapment and stretch injury to the
nerves due to the gradual descent of the pelvic oor. Other stud-
ies reported that the excess descent of the perineal area could
stretch the length of pudendal nerves by more than 20%, which
was sufficient to induce nervous hindrance [10, 11]. Finally,
injury to the pudental nerves may be a major cause of the weak-
ening of the anal sphincter. e entrapment and stretch theory
has been widely supported over the past 15 years. Nonetheless,
despite of the existence of such a widely accepted theory, some
authors have reported that a signicant association could not
be elucidated readily. Furthermore, the primary correlation of
perineal descent with pudendal neuropathy has been charac-
terized in only two studies. Jones et al. [12] examined 60 idio-
pathic fecal incontinence patients. e results showed that the
level of perineal descent was associated with pudendal neurop-
athy only when perineal descent was measured at push. Ho
and Goh [13] analyzed 141 patients showing perineal descent.
Among those patients, constipation was present in 84 patients,
neurogenic fecal incontinence in 31 patients, rectal mucosal pro-
lapse in 17 patients, and female stress urine incontinence in 9
patients. The results show that an independent variable that
could predict perineal descent at rest was age. Only at push, was
the primary correlation of perineal descent to pudendal neu-
ropathy observed. However, Jorge et al. [14] conducted a pro-
spective study on the latent association of increased perineal
descent with pudendal neuropathy in 213 dysfunction patients
who exhibited constipation (115 patients), idiopathic fecal in-
continence (58 patients), chronic incurable anal pain (40 pa-
tients), etc. As a result, no patients showed a signicant corre-
lation between the extent of descending perineal syndrome and
pudendal nerve terminal motor latency (PNTML). Consequen-
tly, these authors were unable to demonstrate any correlation
between the increased descending perineal syndrome and the
functional insuciency of the pudendal nerve, both of which
were assumed to be independent findings. The discrepancy
between the two results is thought to be due to the dierences
in the methods used to measure perineal descent.
Perineal descent may be detected by physical examination,
and it can be quantied with the use of physical measurements
or defecography. A perineometer with a central latex cylinder
that can vertically move freely and measure the movement dis-
tance in centimeters was designed by Henry et al. [3]. e cyl-
inder is immobilized by two parallel vertical stainless-steel rods.
Patients are positioned in the le incumbent position, the two
stainless-steel rods are placed in the ischial tuberosity, and the
cylinder is placed in the anal verge. e location of the perineal
area at rest is measured by using the scale of the latex cylinder.
e patients are asked to perform the action of defecation, and
the new location of the perineal area is measured. e dierence
in the values between the rst and the second measurements is
the extent of perineal descent. Henry et al. [3] dened cases in
which, during the act of defecation, the perineal surface repre-
sented by the anal verge descends below the ischial tuberosity
as abnormal perineal descent. e device is a clinical way to
quantify the extent of perineal descent without exposure to ra-
diation.
Fixed perineal descent and dynamic perineal descent could be
imaged by scout photography, which takes images at the time
of rest and the action of defecation while performing defecog-
raphy. In other words, lines were drawn tangent to the poste-
rior verge of the distal rectum and to the central axis of the anal
canal, and the angle formed by the two lines was measured as
the anorectal angle. Perineal descent is defined as a distance
Journal of The Korean Society of
Coloproctology
www.coloproctol.org400
Clinical Significance of Perineal Descent in Pelvic Outlet Obstruction Diagnosed by using Defecography
Hyun Nam Baek, et al.
reaching the pubococcygeal line at a right angle from the point
where these two lines meet. e perineometer could be consid-
ered to be an insensitive tool in comparison with defecography.
In other words, perineal descent is measured based on the anal
verge instead of the anorectal angle, and dierences are gener-
ated due to the shortening of the anal canal during defecation
action. In addition, errors in the distance from the ischial tu-
berosity to the skin may be made in obese patients, and plac-
ing the cylinder precisely without inference of adjacent tissues
is dicult. Compared with the perineometer, defecography has
advantages in that an actual exclusion of contrast occurs; thus,
the measurement during the act of defecation may be more ac-
curate.
Increases in xed perineal descent show signicant correla-
tions to age and the frequency of vaginal deliveries. e result
suggests that xed perineal descent may be a consequence as-
sociated with aging or physiological phenomena rather than an
independent disease. Nonetheless, more studies are required.
On the other hand, the anorectal physiological function test
showed increases in xed perineal descent to be signicantly
associated with the anorectal angle at rest, the anorectal angle
at squeeze, the length of perineal descent at squeeze, the length
of the puborectalis muscle, and an increase in the value of anal
electromyography, which is thought to reect the change in each
parameter during defecography due to changes in the morphol-
ogy and the location of the rectum and each pelvic organ with
increasing xed perineal descent.
On the other hand, the increase in dynamic perineal descent
correlated with rectal intussusception and the presence of a rec-
tocele and inversely correlated with non-relaxing puborectalis
syndrome. ese suggest the mutual association of a change in
dynamic perineal descent with the development of rectal in-
tussusception and the presence of a rectocele.
Regardless of the methods used to measure perineal descent,
perineal descending syndrome is not a disease that can be cor-
rected surgically. For its treatments, the correction of diet habit,
laxatives, enemas, biofeedback treatments, the use of support
for the perineal area and other non-surgical conservative treat-
ments are performed. Guillemot et al. [15] treated 16 fecal in-
continence patients, including 7 perineal descending syndrome
patients, with biofeedback treatments and 8 fecal incontinence
patients, including 3 perineal descending syndrome patients,
with only medications, and the mid- to long-term outcomes
from 6 months to 30 months were compared. In patients treated
with biofeedback treatments, 12 patients (75%) showed a less-
ening of the symptoms. In the patient group treated with only
medications, only 1 patient (13%) showed a lessening of the
symptoms. Harewood et al. [16] reported that 39 perineal de-
scending syndrome patients were treated with biofeedback treat-
ments and that excellent results were obtained from 64% of the
patients. In particular, the lesser was the descent level, the bet-
ter was the treatment outcome. In our cases [17-19] similarly,
pelvic outlet obstruction patients associated with perineal de-
scent were treated with biofeedback treatments, and 60-80% of
the patients showed improvement lessening of symptoms. On
the other hand, in our cases, the perineal descent level and the
treatment score did not show a signicant correlation; thus, we
conclude that even if perineal descent is conspicuous, biofeed-
back treatments may be attempted. D’Amico and Angriman [20]
reported that a complete cure for perineal descent syndrome is
dicult and that treatment should be focused on relieving of
symptoms individually according to the cause of the disease of
each patient.
In conclusion, fixed perineal descent showed a significant
correlation to age, the frequency of vaginal delivery, and the
diameter of the rectocele. Dynamic perineal descent showed a
signicant correlation to rectal intussusception, the rectocele
and being female. e level of perineal descent did not aect
the outcome of biofeedback treatment for pelvic outlet obstruc-
tion; thus regardless of the level of perineal descent, biofeedback
may be an eective treatment method.
CONFLICT OF INTEREST
No potential conict of interest relevant to this article was re-
ported.
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