Should You Be Concerned About a Perineal Hernia?
Yes, you should be concerned about a perineal hernia because it is a rare but potentially serious condition that typically requires surgical repair when symptomatic, and can lead to complications including bowel obstruction, urinary difficulties, and progressive enlargement if left untreated. 1, 2
Understanding Perineal Hernias
Perineal hernia is the protrusion of intraabdominal or pelvic contents through a defect in the pelvic floor muscles. 2 This condition is uncommon but warrants attention due to its potential complications and impact on quality of life.
Classification and Risk Factors
Perineal hernias are classified as:
- Primary (congenital or acquired): More common in females due to broader pelvic anatomy and weakening from pregnancy/childbirth 2
- Secondary (postoperative): Most commonly occurs after abdominoperineal resection or pelvic exenteration 1, 2
Primary acquired perineal hernias are associated with factors that increase intra-abdominal pressure, while congenital forms result from failure of regression of the embryonic peritoneal cul-de-sac. 2
Clinical Presentation Requiring Concern
Key Symptoms to Monitor
- Pain and discomfort in the perineal region (most common presenting symptom) 3
- Visible or palpable bulge on physical examination 3
- Intestinal obstruction (can be life-threatening) 2, 4
- Urinary difficulties including problems with urination 2
- Topical skin erosion over the hernia site 2
The presence of any of these symptoms, particularly bowel obstruction, necessitates urgent surgical evaluation. 2, 4
Diagnostic Approach
MRI scanning is the most reliable imaging modality for detecting perineal hernias and should be obtained when this condition is suspected. 3 Physical examination revealing a perineal bulge combined with appropriate imaging confirms the diagnosis. 3
Why Surgical Repair Is Typically Necessary
When symptomatic, surgical repair is warranted to prevent serious complications and restore quality of life. 1 The condition rarely resolves spontaneously and tends to progress over time. 2
Surgical Approaches Available
Multiple surgical techniques exist, with the choice depending on hernia characteristics and patient factors:
- Transabdominal approach (most commonly reported, especially with permanent mesh placement) 3
- Perineal approach 1, 2
- Combined abdominoperineal approach 1, 2
- Laparoscopic techniques 1
The majority of successful repairs require synthetic mesh, bioprosthetic graft, or autologous flap rather than primary suture repair alone. 1 Laparotomy with permanent mesh placement was the most frequently used technique in contemporary series. 3
Surgical Outcomes
The postoperative course is generally uneventful when appropriate surgical technique is employed. 3 No severe intraoperative complications were reported in recent systematic reviews of primary perineal hernia repairs. 3
Important Clinical Pitfalls
- Delayed diagnosis: The rarity of this condition can lead to misdiagnosis or delayed recognition 3
- Underestimating severity: Even small perineal hernias can cause significant symptoms and may enlarge over time 2
- Inadequate imaging: Physical examination alone may miss the full extent of the hernia defect 3
When to Seek Immediate Care
Urgent surgical consultation is required if bowel obstruction develops, as this represents a surgical emergency. 4 A 64-year-old patient with giant postoperative perineal hernia causing bowel obstruction required emergency abdominal approach with plastic perineal reconstruction. 4
Bottom Line on Level of Concern
While perineal hernias are rare, they should be taken seriously because:
- They typically require surgical intervention when symptomatic 1, 2
- They can cause significant morbidity including pain, obstruction, and urinary problems 2
- They tend to progress rather than resolve spontaneously 2
- Surgical repair has good outcomes when performed appropriately 3
If you have been diagnosed with or suspect a perineal hernia, consultation with a surgeon experienced in pelvic floor reconstruction is recommended to discuss timing and approach for repair. 1, 3