From the Guidelines
Perineal dysfunction should be managed with a stepwise approach, starting with conservative therapies such as diet, fluids, and bowel training, which can benefit approximately 25% of patients, as recommended by the Clinical Gastroenterology and Hepatology study 1. When considering treatment options for perineal dysfunction, it's essential to prioritize a stepwise approach to minimize invasiveness and maximize patient outcomes.
- The initial management should focus on conservative therapies, including dietary adjustments, adequate fluid intake, and techniques to improve evacuation, as well as a bowel training program to manage diarrhea and constipation with diet and medications if necessary.
- For patients who do not respond to conservative measures, pelvic floor retraining with biofeedback therapy is recommended, as it can help patients learn proper muscle control and improve symptoms 1.
- In cases where conservative measures and biofeedback therapy fail, perianal bulking agents such as intraanal injection of dextranomer may be considered, or sacral nerve stimulation for patients with moderate or severe symptoms who do not have contraindications to these procedures 1.
- Lifestyle modifications, such as avoiding prolonged sitting, using cushioned seats, wearing loose-fitting clothing, and maintaining proper hydration and fiber intake, can also help alleviate symptoms and prevent exacerbations.
- It's crucial to address the underlying cause of perineal dysfunction, whether it be childbirth trauma, surgery, chronic tension, neurological conditions, or pelvic floor disorders, to ensure effective treatment and improve patient outcomes.
From the Research
Perineal Dysfunction
- Perineal dysfunction can cause a range of symptoms, including voiding and defecation problems, pelvic organ prolapse (POP), sexual dysfunction, and pelvic pain 2.
- Pelvic floor physical therapy (PFPT) is a program of functional retraining to improve pelvic floor muscle strength, endurance, power, and relaxation in patients with pelvic floor dysfunction, and can improve or cure symptoms of urinary incontinence, POP, fecal incontinence, and hypertonic pelvic floor disorders 2.
- Vulvar pain affects up to 20% of women at some point in their lives, and most women with vulvar pain have associated pelvic floor impairments, making PFPT a useful treatment option 3.
- Pelvic floor imbalance and incoordination are major features of pelvi/perineal and perianal pain syndromes, and PFPT can help to address these issues 4.
- PFPT is an evidence-based, low-risk, and minimally invasive intervention that can be used to prevent, treat, and manage pelvic floor dysfunction, including perineal dysfunction 5.
Diagnosis and Evaluation
- Ultrasound assessment of the female perineum can be used to evaluate perineal disorders, including urethral mobility and anal sphincter defects 6.
- Ultrasound accesses to the perineum include perineal or vulvar, introital, vaginal, and transrectal, and the choice of access and transducer will depend on the specific indication and ultrasound anatomy of the pelvic floor 6.
- Ultrasound evaluation of the perineum should be performed following a fast abdominal ultrasound evaluation, and perineal scans should be obtained during all functional phases, including at rest, during abdominal straining and contraction 6.