Images in surgery

Posterior perineal hernia—An unusualsurgical complication!Joseph W. Nunoo-Mensah, FRCS(Eng), Yvonne M. Memory, MSc, N. S. Jeyagopal, FRCR(Eng), andDavid M. Richards, FRCS(Eng), Oldham, UK

From the Royal Oldham Hospital, Oldham, UK

This section features outstanding photographs of clinical materials selected for theireducational value or message, or possibly their rarity. The images are accompanied bybrief case reports (limit 2 typed pages, 4 references). Our readers are invited to submititems for consideration.

A 51-YEAR-OLD MAN presented with a 2-year history ofa swelling on the right buttock. This swelling wasprominent when he strained to defecate, and hehad to manually reduce the swelling to facilitatedefecation (Fig 1). Twelve years ago, he hadbilateral, malleable penile stents inserted for erec-tile dysfunction. A month later this procedure wascomplicated by the migration of the right stentinto the perineum. Because of the discomfort, themigrated stent was removed.

Abdominal examination, digital rectal examina-tion, and rigid sigmoidoscopy were all normal. Theclinical diagnosis of a pelvic floor hernia causingobstructive defecation was made. Barium enema,and anorectal physiologic and manometry studieswere reported as being normal. A defecatingproctogram showed a normal morphology positionof the anus and anorectal junction (Fig 2). Therewas nevertheless gross downward herniation of therectum through the pelvic floor with the rectumlying posterio-inferiorly to the anal canal. Onattempted defecation, the patient was not able toempty the rectum because of its severe malposi-

Accepted for publication May 28, 2004.

Reprint requests: Mr Joseph Nunoo-Mensah, 50 Sheffield Rd,Godley, Cheshire, SK14 2PR, United Kingdom.

Surgery 2006;139:126-8.

0039-6060/$ - see front matter

� 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.surg.2004.05.056

126 SURGERY

tion. Defecation occurred when he manually re-duced the hernia. A subsequent, dynamicmagnetic resonance imaging (MRI) scan demon-strated a large posterior perineal hernia protrud-ing through the levator ani and into theischiorectal fossa (Figs 3 & 4). The hernia saccontained loops of small bowel.

After consultation, the patient opted for a trans-abdominal repair of the perineal hernia. At lapa-rotomy, a large defect through the right levator aniwas noted (Fig 5). The rectum was mobilized tothe pelvic floor and a polypropylene mesh securedinto the defect in the levators. A Ripstein rectopexywas also performed. The patient was discharged 9days after his operation with no complications. Athis 6-week follow-up appointment, there was no

Fig 1. Perineal hernia of the right side of the patient’sbuttocks.

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Fig 2. Defecating proctogram showing a lateral view ofthe pelvis during defecating and straining.

Fig 3. A dynamic MRI T1W TSE axial view of the pelvisacquired while patient was at rest.

evidence of a recurrent perineal hernia. He washowever complaining of constipation, which wasmanaged with a combination of mild laxatives. Hewas eventually discharged from the outpatientclinic 7 months after surgery.

Fig 4. A dynamic MRI T1W FFE coronal sequence(TR220ms, TE3.5ms, flip angle 90�) acquired while thepatient was straining.

Fig 5. Intra-operative view of the pelvis before mobiliza-tion of the rectum showing a large defect through theright levator ani.

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128 Nunoo-Mensah et al

DISCUSSION

Pelvic floor hernias are rare and characterizedby the protrusion of intra-abdominal viscerathrough a defect in the pelvic floor. Three typesof hernias occur; in decreasing frequency: obtura-tor, perineal, and sciatic hernias.1 Based on itsrelationship to the transverse perineal muscles,perineal hernias may be described as being ante-rior of posterior. These hernias are typicallysecondary to abdominoperineal resection, pelvicexenteration, prostatectomy, and transpubic ure-throplasty.3 Congenital defects are extremely rarecauses of primary hernias.2 A perineal hernia asa result of a migrated malleable penile stent has toour knowledge never been reported. In our case,we postulate that the erosion and removal of themigrated penile stent created a weakness andsubsequent hernia in the posterior perineum.

A number of techniques using various materialshave been described for the repair of perinealhernias.1 Beck et al4 suggest that perineal herniasare best repaired with either an abdominal orabdominoperineal approach and with the use ofmesh. They favored these approaches as they allowmobilization of the bowel under direct vision. Themesh could then be attached to the lateralmusculature, posterior sacral periosteum, andWaldeyer’s fascia with interrupted non-absorbablesutures. Anteriorly, they describe that the meshcould be secured to the prostate capsule or vagina.

Where the urinary diaphragm has been resected,suturing the mesh to the periosteum of the pubicbone can obliterate the anterior extent of thehernia. In our case, the large defect in the levatorani and the rectum made it technically difficult toreconstruct the pelvic floor. Due to the large defectin the pelvic floor, there was very little supportivestructures to secure the mesh to as describedabove. The rectum also compounded the problemof adequately closing the defect. The mesh wastherefore used as a plug, and placed and securedin the defect. The rectopexy was undoubtedlyimportant in preventing a recurrence. Resectionof the sigmoid colon and suture rectopexy mayhave avoided the patient’s constipation, but, asa mesh was used to repair the pelvic floor, it wasthought prudent not to resect the bowel so as todecrease the risk of mesh infection.

REFERENCES

1. Cali R, Pitsch RM, Blatchford GJ, Thorson A, ChristensenMA. Rare pelvic floor hernia. Report of a case and review ofthe literature. Dis Colon Rectum 1992;35:604-12.

2. Lubat E, Gordon RB, Birnbaum BA, Megibow AJ. CTdiagnosis of posterior perineal hernia. Am J Roentgenol1999;154:761-2.

3. Bissada NK, Barry JM, Morcos R, Hefty T. Hernias aftertranspubic urethroplasty. J Urol 1986;135:1010-1.

4. Beck DE, Fazio VW, Jagelman DG, Lavery IC, McGonagle BA.Postoperative perineal hernia. Dis Colon Rectum 1987;30:21-4.