Perineal Hernia - Causes, Symptoms, Diagnosis, and Treatment

Introduction

The perineal hernia is a medical condition that occurs when the organs and muscles of the pelvic floor are pushed into the abdominal cavity. The condition is more likely to occur after pelvic surgeries, or it may also occur in pregnancy, from injuries, or may be congenital. It is a rare complication but can cause severe pain while sitting and thus require surgical treatment. The word perineal hernia means

Perineal- The skin area (also known as perineum) between the anus and the outer part of the genitals, that is, the vagina in females and the scrotum in males.

Hernias- They usually occur when a fatty tissue or organ pushes through a weak or delicate area in the fascia or muscle. The fascia and muscle are part of the musculoskeletal system, and fascia is a connective (fibrous) tissue that supports the organs, muscles, bones, nerves, and blood vessels.

What Are the Various Types of Perineal Hernias?

Perineal hernias are of the following types:

• Congenital- This is a very rare type of perineal hernia and is present at birth.

• Acquired- This perineal hernia develops after an illness, injury, or pregnancy.

• Secondary- This is a postoperative hernia that occurs after surgery.

What Are the Causes of Perineal Hernia?

The perineal hernia is caused when damage to the fascia and muscle in the pelvic floor makes the tissue weaken or stretch. The damage can occur due to pregnancy, illness, injury, or significant pelvic surgeries. The pelvic floor consists of a group of muscles that supports the organs in the pelvis, including the bladder and rectum. It also supports the uterus and vagina in women and the prostate in men.

Perineal hernia primarily develops after major surgeries requiring large incisions in the abdomen. These major procedures often involve stretching or cutting many tissues and muscles in the pelvic floor, thus weakening the tissues and muscles. Therefore, this increases the risk of organs in the pelvic region pushing through the pelvic floor.

The perineal hernia is expected to occur six months to five years post-pelvic surgery.

What Are the Symptoms Caused by Perineal Hernia?

The symptoms of perineal hernia may not occur in some people, but it can cause discomfort and pain if they appear. The symptoms include

• Discomfort while standing and a pulling sensation.

• Difficulty pooping and peeing.

• Swelling in but cheek on one side.

• Large bowel or intestinal obstruction.

• Small bowel obstruction.

Who Is at Risk of Developing Perineal Hernia?

The risk of perineal hernia increases with the following factors:

• History of smoking.

• Use of immunosuppressant drugs.

• Being a woman.

• Hysterectomy.

• Radiation therapy, chemotherapy, and other cancer treatments.

• Rectal tumors and cancers.

What Type of Surgeries Can Cause Perineal Hernia?

Perineal hernia can develop after certain surgeries, such as

• Low Anterior Resection or Proctectomy- This surgery is performed in the lower abdomen by making an incision to remove all or a part of the cancerous rectum.

• Prostatectomy- This surgery is indicated for prostate cancer and involves the removal of the prostate gland. This surgical method includes laparoscopic prostatectomy or open radical prostatectomy.

• Abdominoperineal Resection- This surgical procedure treats anal or rectal cancer and therefore involves the removal of the rectum, anus, and a part of the large intestine (sigmoid colon). Patients may be treated with laparoscopic abdominoperineal resection involving multiple small incisions. In addition, open abdominoperineal resection is done with one large incision in the abdomen. Both these surgical treatment methods can cause a perineal hernia.

• Pelvic Exenteration- This procedure involves the removal of the rectum along with surrounding organs such as the uterus, prostate, or bladder. In females, pelvic exenteration is also indicated for vaginal, cervical, vulvar, and uterine cancer. In males, apart from rectal cancer, pelvic exenteration is also recommended for prostate cancer.

What Are the Organs Affected by Perineal Hernia?

The organs affected by perineal hernia include

• Large intestine.

• Small intestine.

• Bladder.

• Uterus.

• Omentum or layer of fat covering stomach, intestines, and liver.

How Is Perineal Hernia Diagnosed?

The doctor diagnoses the perineal hernia with CT (computed tomography) scans, MRI (magnetic resonance imaging), and herniorrhaphy. CT scans for perineal hernia show rectum into the ischioanal fossa or protrusion of loops of the sigmoid colon, whereas MRI shows omental herniation.

How Is Perineal Hernia Treated?

The perineal hernia is treated with surgical procedures to put the protruding tissue or organ back into place and suture the weakened fascia and muscle. In addition, the muscle flap and the synthetic mesh material are also stitched into the pelvic floor to provide additional support to the organs. Surgical treatments for a perineal hernia include

• Robotic Surgery- It involves a robotic device and laparoscope.

• Laparoscopy- This procedure involves laparoscopy or a thin-scope device with an attached camera and multiple small incisions.

• Transperineal- It involves a small incision into the perineal.

• Transabdominal- It involves an incision in the abdomen at the site of the hernia.

How Can Perineal Hernia Be Prevented?

Perineal hernias are the most common cause of significant surgeries that are life-saving and, therefore, medically necessary. A person should strictly follow the healthcare provider’s advice post surgeries about the recommendations for lifting heavy objects and restarting physical activities. In addition, pelvic floor exercises or Kegel exercises can also help a person strengthen the pelvic floor muscles. All these preventive measures can help reduce the risk of developing a perineal hernia.

Conclusion

The perineal hernia is a rare complication in humans and can occur in almost 0.34 % of the population undergoing pelvic trauma, injuries, or surgeries. The perineal hernia can affect any gender but is more common in females or assigned females at birth (AFAB) than males or assigned males at birth (AMAB). Various surgical treatments are advocated for perineal hernia, and the success rate of these surgeries is also good if any additional complication is not present. Therefore, necessary precautions and doctor’s advice should be followed by the person after pelvic surgeries to reduce the risk of developing a perineal hernia.