Clinical Features and Associations of Descending Perineum Syndrome in 300 Adults with Constipation in Gastroenterology Referral Practice

Abstract

Background: Outlet obstruction constipation accounts for about 30% of chronic constipation (CC) cases in a referral practice.

Aims: To assess the proportion of patients with CC diagnosed with descending perineum syndrome (DPS) by a single gastroenterologist and to compare clinical, radiological, and associated features in DPS compared to patients with constipation.

Methods: We conducted a review of records of 300 consecutive patients evaluated for constipation by a single gastroenterologist from 2007 to 2019, including medical, surgical, and obstetrics history, digital rectal examination, anorectal manometry, defecation proctography (available in 15/23 with DPS), treatment, and follow-up. DPS was defined as > 3 cm descent of anorectal junction on imaging or estimated perineal descent on rectal examination. Logistic regression with univariate and multivariate analysis compared factors associated with DPS to non-DPS patients.

Results: Twenty-three out of 300 (7.7%, all female) patients had DPS; these patients were older, had more births [including more vaginal deliveries (84.2% vs. 31.2% in non-DPS, p < 0.001)], more instrumental or traumatic vaginal deliveries, more hysterectomies, more rectoceles on proctography (86.7% vs. 28.6% non-DPS, p = 0.014), lower squeeze anal sphincter pressures (p < 0.001), and lower rectal sensation (p = 0.075) than non-DPS. On univariate logistic regression, history of vaginal delivery, hysterectomy, and Ehlers-Danlos syndrome increased the odds of developing DPS. Vaginal delivery was confirmed as a risk factor on multivariate analysis.

Conclusions: DPS accounts for almost 10% of tertiary referral patients presenting with constipation. DPS is associated with age, female gender, and number of vaginal (especially traumatic) deliveries.

Keywords: Pelvic floor retraining; Rectal examination; Vaginal deliveries.

Figure 1.

Classification of defecatory disorders, after exclusion of rectal or colonic obstruction (e.g. by mucosal lesions or strictures).

Figure 2.

Magnetic resonance proctogram of patient with descending perineum syndrome. MR proctogram pictures obtained at (A) rest and (B) strain. Red line delineates pubococcygeal line (PCL); white line delineates anorectal junction (ARJ); thick blue line measures descent of the ARJ below PCL; A) Rest image shows a 1.2cm descent of ARJ. B) During simulated evacuation, there is 6.4cm descent of the ARJ below the PCL.