Perineal descent syndrome

Introduction to perineal descending syndrome The perineal descending syndrome (DPS) is a pelvic floor disease. Due to various reasons, the pelvic floor muscles are degenerated and dysfunctional. The patient has a lower perineal position in a quiet state, or the perineal decline is more than normal when the patient is forced to defecate. The scope, but clinical manifestations of export constipation or fecal incontinence, often appear as a concomitant lesion of rectal intussusception and rectal prolapse. In recent years, with the widespread application of defecating angiography, reports of perineal descending syndrome have increased. basic knowledge The proportion of illness: 0.001% Susceptible people: good for women Mode of infection: non-infectious Complications: constipation

Causes of perineal decline syndrome

This syndrome was first proposed by Parks (1966). They observed a decrease in the tension of the pelvic floor muscle system, muscle atrophy, and excessive prolapse of the anterior rectal wall when observing rectal prolapse, thereby affecting rectal emptying.

Anal surgery (20%):

Most scholars agree that perineal descending syndrome is a concomitant lesion of rectal intussusception or rectal prolapse. Johansson and Berman believe that perineal descending syndrome is the same disease as rectal intussusception, with obesity, advanced age, childbirth, anal surgery or post-inflammatory stenosis. And so on.

Forced bowel movements (30%):

Long-term defecation and excessive exertion are the main causes. Under normal circumstances, the anal canal is located above the ischial tuberosity line, while the anal right angle commissure is located just below the pubic symphysis to the coccygeal line. When the body is defecation normally, the drop of the anal canal should not exceed 2.Ocm. Due to long-term excessive use of defecation, the function of the pelvic floor muscles can be weakened, the normal anorectal angle can be increased, and the anterior rectal wall can be transmitted by the anterior wall of the vicious anterior wall of the rectal prolapse. The mucosa prolapses into the upper mouth of the anal canal. This anterior wall mucosal prolapse (AMP) can lead to a lack of exhaustion, so the patient further defecates and forms a vicious circle.

Childbirth (20%):

This disease is also prone to occur after multiple births by the mother.

Pathogenesis:

Parks believes that when the abdominal wall contracts, the anterior wall of the rectum usually covers the upper part of the anal canal more closely, but does not protrude into it. It is beneficial to maintain instant self-control, that is, the flap valve self-made theory. If for some reason, the rectal emptying is not Normal, it will resort to further abdominal wall exertion. The long-term pelvic floor muscle elasticity will decline or even disappear. The whole pelvic floor will fall, and the upper part of the puborectalis and sphincter will be elongated and become funnel-shaped. The feces in the lower rectum will be pressed. In the funnel-shaped anorectal area, the force of excreting the feces opens the flap by pushing open the anterior wall of the rectum, and the feces fall into the anal canal, and then the feces are pressed through the anterior wall of the rectum to discharge the feces into the anal canal, and the rectum is drained. Normally, the reflex pelvic floor muscle contraction causes the anterior wall of the lower rectum to retreat, covering the upper part of the anal canal, and the flap is restored to close the anal canal. This is the post-surgical reduction reflex and restores the anorectal angle. If only the abdominal wall is used, If the pressure discharge is more than a few years, the pelvic floor contraction effect will decrease, and the anterior wall mucosa will not be reset, and it will stimulate the feeling of bulging, which will make the patient more forceful. Into a vicious cycle (FIG. 2), eventually formed perineum perineum declining Drop Syndrome.

Swash suggested that childbirth can cause pudendal nerve damage that dominates the pelvic floor striated muscle. The related risk factors are large body weight, extended second stage of labor, application of forceps, especially multiple births. Most primipara injuries can be recovered quickly. The childbirth can not recover due to repeated injury, resulting in difficulty in defecation to force defecation, repeated perineal lowering and pulling the pudendal nerve to cause a vicious circle, resulting in rectal intussusception, even anal incontinence, namely: vaginal delivery sphincter neurodegeneration perineum Fall intractable defecation force rectal intussusception.

When the abnormal perineum drops by 2 cm, the pudendal nerve is stretched by 20%, exceeding 12% of the reversible injury, resulting in irreversible genital nerve damage, causing anal sphincter neurodegeneration.

Regarding the relationship between perineal descending syndrome and anal incontinence, Read measured 30 patients with perineal descent syndrome and found that there was a decrease in rectal volume required to inhibit the recovery of internal sphincter tension. 40% of the saline perfusion test had a leakage of 1500 ml, which was significantly higher than that of the control. The group believes that the perineal descending syndrome has anal autonomic function damage, and the anal or mucosal resection should be performed cautiously. The perineal descending syndrome can be seen in both idiopathic anal incontinence and export constipation. In 1983 Bartolo study was abnormal. 32 cases of incontinence and 21 cases of constipation decreased in the perineum, and the degree of perineal decline was observed in the two groups. The latency of the external sphincter motor unit increased, the rectal anal inhibition reflex abnormality and the anorectal angle became dull, but the incontinent had anal canal pressure reduction. The constipation is normal, and as long as the sphincter pressure is normal, the perineal decline syndrome can be without incontinence. Later, Kiff further compares the manometry and EMG results of patients with long and short duration of perineal decline syndrome, and finds that the course is long. Patients with genital and external sphincter lesions are heavier, and later Womack and Vila also confirmed the perineal descending syndrome dimension. The key is made in the normal sphincter function.

Perineal decline syndrome prevention

Mainly from the improvement of defecation habits, in addition to the timing of defecation, it is best to defer when there is a clear sense of intention, the use of controlled segmentation of the fecal method has a better preventive effect. Eat more fresh vegetables, fruits and high-fiber foods on the diet. Long-term adherence to do anal exercises or qigong levator ani helps the recovery of pelvic floor muscle function.

Complications of perineal descending syndrome Complications constipation

Defecation is not enough, muscle tension is reduced.

Symptoms of perineal descending syndrome Common symptoms Anal bulging muscle tension reduces rectal prolapse urinary incontinence and enuresis

Because this syndrome is often accompanied by pathological changes in rectal prolapse or rectal prolapse, this syndrome can show various symptoms of rectal intussusception and rectal prolapse. In 52 cases, the authors observed that the main symptoms are not Feelings, anal bulge, difficulty in defecation, increased stools, perineal pain, partial incontinence, some patients have a history of application of various laxatives, a few have mucus and blood, defecation or walking anus with masses.

Physical examination: simulated bowel movement can be seen in the balloon bulging, the degree of anal canal is more than 2cm, and there is obvious anal canal mucosa and valgus valgus, with rectal prolapse, rectal prolapse prolapse anus, anal canal refers to anal sphincter The tension is reduced, the strength of the patient is significantly reduced when the anal canal is contracted, the anterior wall of the rectum may be paralyzed and solitary ulcers, and the anterior wall of the anal canal can be paralyzed and weakened when the rectum is protruding. Henry makes a measurable force for defecation when the anus is outside. The instrument used to measure the distance between the vaginal plane and the ischial tuberosity plane measured 103 cases of the perineum, and the perineum decreased by 1.6 cm, while the 20 patients with perineal dysfunction syndrome were 3.2 cm.

Examination of perineal descending syndrome

Endoscope

Most of the mucosa of the anterior rectal wall was loose, and it was seen by an anoscope that it blocked the end of the mirror.

2. Defecation angiography

It is a reliable method for diagnosing perineal descending syndrome. It can not only determine the position of the perineum at rest, but also measure the degree of perineal decline during defecation. In addition, it can diagnose other pelvic floor relaxing diseases often associated with perineal decline syndrome, such as Intussusception in the rectum, rectal prolapse, rectocele and so on.

The diagnostic criteria for defecation angiography of perineal descending syndrome are as follows: 1 The midpoint of the puborectal muscle incision represents the perineal position, and the horizontal line of the lower edge of the ischial tuberosity is used as a reference. The resting phase of the perineal position before defecation is 2 cm below the lower edge of the ischial tuberosity. , and / or defecation in the perineum decreased more than 3cm, 2 to the upper part of the anal canal, that is, the midpoint of the anorectal junction of the anal canal represents the perineal position, with the pubic symphysis from the lower edge to the tip of the tailbone, that is, the shame line as a reference; When resting normally, the upper part of the anal canal is located at the lower edge of the shame line. The upper part of the anal canal is 3.5cm below the shaman's tail line, the others are less than 3cm, or the defecation is more than 3cm.

There were 52 cases of perineal angiography combined with pelvic angiography. The results showed that 10 cases (19%) had normal pelvic floor morphology, 42 cases (81%) had rectal intussusception, and 23 cases were rectal mucosal sleeves. 19 cases were full-thickness rectal intussusception, and 4 cases were combined with rectocele. We also confirmed that the perineum and pelvic floor peritoneal position were significantly correlated in the control group or the perineal descending syndrome group, indicating the puborectalis muscle. The midpoint of the indentation represents the perineal position, with the horizontal line of the lower edge of the ischial tuberosity as a reference, and the measured perineal position can accurately reflect the position change of the peritoneum of the pelvic floor.

3. Anorectal manometry and electromyography

There is a decrease in anal canal pressure and an extension of the latency of the external sphincter motor unit. The above 52 patients with perineal depression syndrome have anal canal resting pressure, and the maximum systolic pressure and anal cough pressure are significantly reduced.

4. Pelvic floor muscle biopsy

Parks and Henry performed a sphincter biopsy on patients with perineal descent syndrome to confirm degeneration of the sphincter, such as muscle fiber hypertrophy.

Diagnosis and differentiation of perineal descending syndrome

diagnosis

According to the patient's long-term history of defecation, the examination revealed that the perineum can be balloon-like bulging, and the anal canal tension can be initially diagnosed. Defecation angiography can confirm the diagnosis, but it should be judged whether it is accompanied by rectal prolapse, rectal intussusception or rectocele If the pelvic floor disease is associated with anal incontinence, women should judge whether there is intrauterine prolapse or fall.

Differential diagnosis

However, it needs to be differentiated from simple internal hemorrhoids and rectal prolapse.

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