Perineum & perineal body reconstruction
What is the perineum?
The perineum is a diamond shaped area that lies superficially in the area immediately below the anal margin and extending to the forchette of the vagina and the inferior aspects of the left and right labia majora.
What is the perineal body?
The perineal body is part of the levator ani group of muscles. It is a fusion of the distal (furthest from the middle of the body) part of this muscle group where they meet in the midline. It lies centrally and deep to the perineum and has attachment to the transverse perineal muscles, external anal sphincter, external urinary sphincter and bulbospongiosus muscle.
An intact, undamaged, functioning perineal body is essential if a woman is to be able to squeeze the muscle tight, thus pulling up and narrowing the lower part of the entrance to the vagina. An inability to contract the perineal body confers some disadvantages to the woman affected. From a visual point of view it is more likely that the introitus will look open or patulous. From a functional aspect, the woman will find it difficult to tighten the vaginal introitus during intercourse, potentially resulting in reduced sensation during intercourse. Other symptoms that may occur include air entry into the vagina, passage of vaginal flatus and a reduction in the ability to empty the rectum. Failure of the perineal body predisposes women to pelvic organ prolapse.
Indications for reconstruction of the perineum
- Scar tissue resulting from birth trauma.
- Scar tissue arising from previous surgery.
- Scar tissue arising from some other injury.
- Scar tissue arising from skin conditions such as lichen sclerosus when the response to conservative measures has not been satisfactory.
- As the superficial part of a perineal body reconstruction.
Indications for perineal body reconstruction
- Symptomatic perineal body detachment.
- Impression of an open, patulous vagina.
- Scar tissue replacing muscle in the perineal body.
Intact perineal body and perineum
When the perineal body is intact and the perineum of normal length, the vaginal introitus will often appear closed in the resting state. Ultimately, the integrity or otherwise of the perineal body has to be demonstrated through physical examination and manipulation.
Damaged perineal body and perineum
The perineal body has been disrupted and the introitus appears open in the resting state. Inspection of the perineum reveals that it is depressed, evidence of failure of muscle support, and in some cases, scarred.
The perineum, depressed from the introitus to the upper border the anal margin. This reflects disruption of the perineal body below.
Grade 2 rectocele visible at the introitus in the resting position. When the patient strains, it descends out of the vagina unrestricted by the loss of muscle support at the upper aspect of the perineal body.
Complete proccidentia of the uterus. The damaged perineal body allows not only the uterus to descend but for the vaginal walls to present beyond the introitus.
The perineum is scarred by lichen sclerosus that has not been responsive to steroid treatment. The perineal body is intact. The lichen sclerosus extends to the tissues of the upper perineum and forchette resulting in painful intercourse.
Demonstrating the degree and areas of perineal body detachment
Two finger distraction of the introitus demonstrates how patulous the entrance to the vagina is and the degree of muscle support failure.
Two finger depression of the lower posterior vaginal wall towards the rectum demonstrates the absence of perineal muscle support; in this case, extending all the way down to the superior aspect of the external anal sphincter.
Combined Sims speculum and two finger assessment of the posterior vaginal wall defects, identifying the enterocele, rectocele and perineal body detachment.
Single digit assessment of the degree of lateral avulsion of the perineal body. A sulcus has formed where the muscle has been disrupted.
Repairing the perineal body and refashioning the perineum
In this case there are multiple defects; a large enterocele presenting very low in the posterior vaginal wall, a small rectocele immediately below the enterocele and detachment of the perineal body with a shortened perineum.
There are numerous techniques and approaches to surgery. The technique employed will be influenced by:
- Surgeons experience
- Clinical findings
- Specific patient symptoms
- Associated or incidental pathology
Identification of the enterocele through careful dissection.
Closure of the enterocele and repair of the rectocele.
The perineal body has been reconstructed and the perineum refashioned with the correct distance between forchette and anal margin corrected.
The refashioned perineum immediately after completion of surgery.
- The procedure is carried out in an accredited hospital.
- General or regional anaesthesia combined with local anaesthetic infiltration.
- Rapid return to normal work activities.
- Use of dissolvable sutures on the perineum that do not require removal.
- Heavier sutures to reconstruct the perineal body with an overlay technique for added strength.
- No coitus for 6 weeks.
- No digitation of the vagina.
- No strenuous activities for 6 weeks.
- Gentle dabbing of area for cleansing without rubbing.
- You may be required to have a wound dressing for a few days.
- You may be required to use oral antibiotics for a few days.
Potential complications include:
- Partial or complete breakdown of reconstruction; usually resulting from wound infection because of the proximity of the scar to the anal margin.
- Infection without wound breakdown.
- Temporary painful coitus.
- Surgical division of reconstruction required to achieve coitus.
- Recurrence of symptoms.
Perineal body reconstruction and refashioning of the perineum can be carried out as part of an admission for other pelvic reconstructive surgery procedures such as vaginoplasty, labioplasty, uterine/vaginal vault suspension, hysterectomy and endometriosis surgery.