Descending perineal syndrome cure by deep transversus perinei ligament repair: surgical options

Abstract

Descending perineal syndrome (DPS) was described by Parks et al. as descent of the anus on straining, typically 3-4 cm below a line drawn from the coccyx to the lower end of the. DPS is associated with obstructed defecation, with increased bulging of the perineum with straining, although perineal descent can also be seen at rest. In their review, Chaudhry and Tarnay stated: "It is controversial whether surgical management is even an option for patients with DPS". The deep transversus perinei (DTP) ligaments are the suspensory ligaments of the perineal body (PB). DTP are approximately 4 cm long. They attach behind the upper 2/3 and lower 1/3 of the descending ramus. If, at childbirth, the PB is overstretched and displaced laterally and inferiorly, the DTP lengthens. DPS is described as descent of the anus on straining, typically 3-4 cm below a line drawn from the coccyx to the lower end of the symphysis. DPS is associated with obstructed and often, assisted defecation, with increased bulging of the perineum with straining descent of the anus on straining. The surgical methodology begins as a standard PB repair which dissects the rectum from the vagina and PB and approximates the displaced components of the PB. We added an additional step: identifying the DTPs, shortening and reinforcing them with the Tissue Fixation System (TFS) minisling or No. 2 polyester sutures. High cure rates for obstructed defecation were achieved with the TFS minisling, and initial results using No. 2 polyester sutures are favourable. The key messages from both operations is DPS is caused by stretching and elongation of DPS ligaments, and these are surgically repairable.

Keywords: Deep transversus perinei ligaments (DTP ligaments); descending perinei syndrome; perineal body sling (PB sling); wide-bore polyester sutures.

Figure 1

Perineocele with DPS. The tissues are very thin. There is virtually no separation between the vagina and the rectum which bulge downwards on straining. The components of the perineal bodies are laterally and inferiorly displaced, usually to a level below the ischial tuberosities. DTP ligaments insert behind the junction of the upper two thirds and lower one third of the descending rami, suspending the perineal body. Published with permission from Peter Petros: Personal Collection; retains ownership of copyright. DPS, descending perineal syndrome; DTP, deep transversus perinei; lig, ligament.

Figure 2

Anatomy of the perineal body. Live anatomical dissection-transverse vaginal incision just inside the hymen, looking into the introitus (4). The “V” has been dissected from the “R” which has also been dissected from the “PB” which is contiguous with DTP ligament and the “STP” muscle. The PB forms a continuum with the DTP [defined by polyglactin (Vicril) threads]. The polyglactin threads are shown elevating the PB/DTP complex upwards from behind the ischial tuberosities. The parallel line of yellow dots demonstrate the normal DTP course and attachment behind the ramus to insert into its inferior surface. Published with permission from Peter Petros: Personal Collection; retains ownership of copyright. V, vagina; R, rectum; PB, perineal body; DTP, deep transversus perinei; STP, superficial transverse perineal; RVF, recto-vaginal fascia.

Figure 3

Repair of DTP ligaments for cure of perineocele and descending perineal syndrome. (A) With descending perineal syndrome, the serosa and smooth muscle wall of the rectum are ruptured, and the rectal mucosa is spread laterally to become adherent to the vagina and deep transversus perinei. Careful dissection is required to separate the rectal mucosa. Once dissected clear, two to three interrupted sutures close the smooth muscle and serosal layers of the rectum. The “DTP” is identified and sutured with No. 2 polyester sutures as shown. As the “DTP” shortens, the perineal components fold inwards and are gently approximated with polyglactin sutures. The vagina is sutured without excision of tissue. (B) Shows repair of the DPS by a TFS minisling. After the rectal dissection, a tunnel is made to the insertion of DTP behind the descending rami, and the tapes are inserted and tightened. The tapes form a completely new collagenous DTP neoligament. Reused from Petros P. The female pelvic floor function, dysfunction and management according to the Integral Theory. 3^rd ed. Heidelberg: Springer Berlin; 2010. With permission from Peter Petros; retains ownership of the copyright. OF, obturator foramen; DTP, deep transversus perinei; A, anus; PB, perineal body; TP1, untensioned TFS tape; TP2, tensioned TFS tape; TFS, Tissue Fixation System.

Figure 4

Anatomy of the descending perineal ligaments. (A) The forceps indicates the exact position where the lax elongated right “DTP” ligament inserts behind the right descending ramus. (B) The concertina suture (red) attaches “DTP” from its origin behind the ramus, to the laterally/inferiorly displaced perineal body “PB”. The suture shortens and reinforces the “DTP”. (A) Published with permission from Peter Petros: Personal Collection; retains ownership of copyright. (B) Reused from Petros P. The female pelvic floor function, dysfunction and management according to the Integral Theory. 3^rd ed. Heidelberg: Springer Berlin; 2010. With permission from Peter Petros; retains ownership of the copyright. DTP, deep transversus perinei; OF, obturator foramen; A, anus; PB, perineal body.

Video S1

Detailed anatomy of the perineal body.

Video S2

Dissection technique for repair of the perineal body.