What is a puborectalis rupture and how does it cause sexual dysfunction?

Puborectalis Rupture and Sexual Dysfunction

What is Puborectalis Rupture?

Puborectalis rupture is a traumatic avulsion (tearing away) of the puborectalis muscle from its insertion point on the pubic bone, occurring almost exclusively during vaginal childbirth, and represents a severe form of levator ani muscle injury. 1

The puborectalis is part of the levator ani muscle complex that forms the pelvic floor. During digital rectal examination, this muscle should contract during squeeze maneuvers and sits just above the internal sphincter. 2 When ruptured, the muscle detaches from its bony anchor on the pubis, causing:

• Visible deviation of the anus to the side opposite the injury (present in 96% of cases) 1
• Loss of normal pelvic floor support, leading to organ prolapse 1
• Disruption of the normal anatomical relationships between pelvic structures 1, 3

Diagnostic Features

The diagnosis requires careful clinical examination combined with imaging:

• Clinical examination reveals asymmetry with the anus pulled away from the side of rupture 1
• Palpation during digital examination shows absent or weakened puborectalis contraction on the affected side 2, 1
• Translabial ultrasound (TUI) and MRI are the gold standard imaging modalities, with good consistency between them 3
• Incidence is 13.75-25% in women after vaginal delivery 1, 3, 4
• Right-sided ruptures are most common (82.7%), followed by left-sided (13.5%) and bilateral (3.9%) 1

Sexual Dysfunction from Puborectalis Rupture

Sexual dysfunction occurs in 38.5-53.9% of women with puborectalis rupture, manifesting primarily as dyspareunia (painful intercourse) and impaired sensation during sexual activity. 1

Mechanisms of Sexual Dysfunction

The sexual problems arise through multiple pathways:

• Anatomical distortion from the muscle avulsion creates abnormal pelvic floor geometry, causing pain during penetration 1
• Loss of vaginal support leads to prolapse (colpophony in 32.7% of cases), which interferes with normal sexual function 1
• Altered pelvic floor muscle tone and coordination disrupts the normal muscular contractions involved in sexual response 1
• Associated nerve damage may occur, though the puborectalis rupture itself is primarily a mechanical/structural injury rather than a direct nerve injury 1

Associated Symptoms

Women with puborectalis rupture typically present with a constellation of pelvic floor dysfunction symptoms:

• Dyspareunia (painful intercourse): 38.5% of patients 1
• Impaired sensation during sexual intercourse: 25% of patients 1
• Obstructive defecation or excessive straining (dyschezia): 53.9% of patients 1
• Anal incontinence: 59.6% of patients, though interestingly, puborectalis avulsion itself is not directly associated with anal incontinence 1, 5
• Urinary incontinence: 48.1% of patients, though avulsion is actually associated with less stress urinary incontinence 1, 4
• Pelvic organ prolapse: Common, with visible descent of vaginal structures 1

Treatment and Outcomes

Transvaginal surgical repair of the puborectalis rupture improves sexual function in all patients, with 78.8% achieving complete restoration of normal muscle function. 1

Surgical Approach

• Transvaginal levator ani repair is the primary treatment, often combined with posterior repair and levatorplasty (50% of cases) 1
• Associated sphincter injuries are repaired simultaneously when present (63.4% of cases require sphincteroplasty) 1
• Surgery is well-tolerated with low complication rates: significant pain (5.8%), urinary retention (3.9%), hematoma (1.9%), abscess (1.9%) 1

Functional Outcomes

• Sexual function improves in 100% of patients after surgical repair 1
• Dyspareunia resolves or significantly improves following restoration of normal anatomy 1
• Dyschezia resolves in 64.3% and improves by ≥50% in another 35.7% 1
• Anal continence improves with Wexner scores reaching 0/20 in 78.8% of patients 1

Important Caveats

The diagnosis is frequently missed because it requires specific examination techniques and imaging. 1 Clinicians must actively look for:

• Asymmetry of the perineum during simulated defecation 2
• Deviation of the anal verge 1
• Weakened or absent puborectalis contraction on one side during digital examination 2, 1

Iliococcygeus muscle injury often accompanies severe puborectalis tears but is difficult to detect on ultrasound, requiring MRI for visualization. 3 This associated injury may contribute to the severity of symptoms and should be evaluated when puborectalis rupture is diagnosed. 3, 6