Teaching Case

A 55-year-old female presented with symptoms of obstructed defecation.

A 55-year-old female presented with symptoms of obstructed defecation. The defecography done showed an abnormal perineal descent during straining (more than 3.5cm).

An abnormal perineal descent is present when the anorectal junction is 8 cm or more below the pubococcygeal line (line drawn from the anterosuperior aspect of the pubis to the coccyx) at rest or when the difference between the anorectal position at rest and during straining is more than 3.5 cm. In the descending perineum syndrome, the muscle tone of the pelvic floor is diminished and obstructive constipation and sometimes tenesmus are present. The syndrome of the descending perineum was first observed by Porter in 1962 and subsequently recognised as a definite entity by Parks and colleagues in 1966. Excessive perineum descent is a physical sign indicative of pelvic floor weakness. Patients with an abnormally increased perineum descent may present with rectal prolapse, partial or major incontinence, obstructed defecation, solitary rectal ulcer syndrome or vague symptoms of incomplete evacuation or rectal pain. Abnormally increased perineum descent, both at rest and during evacuation, is found in approximately 75% of patients with faecal incontinence as well as in patients who usually strain when passing stool but have no significant incontinence.