Descending perineum syndrome

Overview

Descending perineum syndrome (DPS) is a pelvic floor disorder characterized by the abnormal downward displacement of the perineum, the area between the anus and the genitals, during straining, typically while attempting to defecate. This descent is more than what is considered physiologically normal and can lead to difficulties with bowel movements, pelvic discomfort, and other symptoms related to pelvic floor dysfunction. It is more common in women, especially those who have experienced multiple childbirths or chronic constipation.

Causes

Descending perineum syndrome is usually the result of chronic straining and weakening of the pelvic floor muscles. Common contributing factors include:

• Chronic constipation: Frequent and forceful straining during bowel movements increases pressure on the pelvic floor.

• Multiple vaginal deliveries: Can stretch and damage the pelvic floor muscles and nerves.

• Aging: Natural loss of muscle tone and connective tissue support in the pelvic region.

• Pelvic surgery: Previous surgeries, such as hysterectomy, may alter pelvic support structures.

• Neurological disorders: Conditions like pudendal neuropathy can impair nerve signals to pelvic muscles.

Symptoms

Symptoms of descending perineum syndrome are primarily related to bowel function and pelvic discomfort. These may include:

• Sensation of incomplete evacuation: Feeling that the rectum is not fully emptied after a bowel movement.

• Straining during defecation: Excessive effort required to pass stool.

• Pelvic pressure or heaviness: Especially noticeable when standing or at the end of the day.

• Perineal bulging: A visible or palpable bulge in the perineal area during straining.

• Anal pain or discomfort: Can occur during or after bowel movements.

• Incontinence: In some cases, fecal incontinence or urgency may develop.

Diagnosis

Diagnosing descending perineum syndrome involves a combination of clinical evaluation, imaging, and functional testing. Diagnostic tools may include:

• Physical examination: A rectal or pelvic exam can detect perineal descent during straining.

• Defecography (dynamic MRI or fluoroscopic): A specialized imaging study to observe pelvic floor movement and perineal position during defecation.

• Anorectal manometry: Measures muscle tone and coordination of the rectum and anal sphincter.

• Electromyography (EMG): Assesses nerve and muscle activity in the pelvic floor.

• Colonoscopy: May be done to rule out other causes of bowel symptoms.

Treatment

Treatment for descending perineum syndrome aims to improve bowel function, relieve symptoms, and prevent further pelvic floor damage. Common treatment strategies include:

• Pelvic floor physical therapy: Core strengthening and biofeedback to improve muscle control and coordination.

• Bowel retraining: Establishing regular, non-straining bowel habits through timed toileting and proper posture.

• Dietary modifications: Increasing fiber and fluids to soften stool and reduce straining.

• Laxatives or stool softeners: Used judiciously to promote easier bowel movements.

• Surgical intervention: In severe or refractory cases, procedures like rectopexy or perineorrhaphy may be considered to support the pelvic structures.

Prognosis

The prognosis for descending perineum syndrome varies depending on severity and response to treatment. Many individuals experience significant symptom relief with conservative measures like physical therapy and lifestyle changes. However, the condition can be chronic and may require long-term management. In advanced cases, surgery may offer structural correction but carries risks and may not fully restore function. Early diagnosis and a multidisciplinary approach improve outcomes and prevent progression.