The Perianal area Or perineum is the area of soft tissue that covers the muscles and ligaments of the pelvic floor between the vagina and the anus in women and between the scrotum and the anus in men.
The perineum is the region between the lower thighs and the pelvic diaphragm. The boundaries of this region are the same as for the pubic symphysis, the ischiopubic branches, the sacrotuberous ligaments, and the coccyx.
The perineum has a roof formed by the pelvic diaphragm and a floor of fascia and skin. It also contains the muscles and neurovasculature associated with the urogenital structures and the anus.
The perineal or perianal area is the narrowest region between the proximal parts of the thighs and when the lower limbs are in abduction, it is a diamond-shaped area extending forward from the mount of Venus, medial surfaces within the Thighs and glutes, and the upper end of the gluteal cleft.
There are two ways of describing the perineum boundaries. Anatomical edges refer to their exact bone margins. The superficial borders describe the superficial anatomy that marks the edges of the perineum.
Anatomical borders of the perineum
- Anterior-pubic symphysis.
- Posterior- The tip of the coccyx.
- Laterally - Lower pubic branch and lower sciatic branch, and sacrotuberous ligament.
- Roof - The pelvic floor.
- Base - Skin and fascia.
The perineum can be subdivided by a theoretical line drawn transversely between the ischial tuberosities. This division forms the anterior and posterior urogenital triangles. These triangles are associated with different components of the perineum.
Frontiers of the surface of the perineum
For clinical purposes, it is important to know the superficial anatomy that marks the limits of the perineum. These boundaries are best shown when the lower limbs are abducted, and a diamond shape is represented.
The limits of the skin of the perineum:
- Previously: Mount of Venus in the females and base of the penis in males.
- Laterally: Medial surfaces of the thighs.
- Subsequently: Upper end of the intergluteal groove.
Pain in the perianal area
Pain in the perianal area occurs adjacent to the anus. Usually, the pain or discomfort is found in the area between the anus and vagina in women, and between the anus and scrotum or penis in men.
Perianal pain is often caused by gastrointestinal problems such as anal fissures, hemorrhoids, etc. Perineal pain can vary in severity. Perineal pain can be severe or feel alone as a mild perineal discomfort.
Common causes of chronic perineal pain in men include prostatitis / pelvic pain syndrome and urinary tract obstruction in men. Perineal pain in women is often associated with interstitial cystitis syndrome and pelvic pain in women. It can also be caused by neuropathic pain
Causes of perianal pain in men
-Prostatitis
Prostate stones
- Benign prostatic hypertrophy (enlarged prostate)
-Education of ejaculatory duct
Urinary dysfunction
- Pelvic floor dysfunction
-Neuropathic pain
Musculoskeletal pain or
Causes of perianal pain in women
-Vulvodynia
-Infections of the urinary tract
-Neuropathic pain
Musculoskeletal pain or
- Pelvic floor dysfunction
- Urinary tract dysfunction
Causes common to men and women
Pain syndromes such as urethral syndrome, perineal pain syndrome.
Interstitial cystitis.
- Anal fissures.
- Pernicious nerve entrapment syndrome.
Ischiorectal clearance.
Perineal descent
Perineal descent is a condition in which the perineum prolapses (bulges down) or descends below the bony exit of the pelvis. Perineal descent is often associated with chronic effort in patients with chronic constipation.
Other conditions that weaken the pelvic floor musculature may also lead to symptomatic perineal descent. An amount of perineal descent is often present along with pelvic organ prolapse.
Treatment begins with identifying and treating the underlying cause. As mentioned earlier, constipation and the need for chronic deformity is often identified and treated. Physical therapy of the pelvic floor to strengthen the floor of the pelvis can sometimes be used to help better the symptoms.
If surgery is performed, the focus is on elevation of the perineum and pelvic floor with a Da Vinci sacrocolopoperineopexy or posterior placement of the vaginal mesh with perineorrhaphy and elevation of the perineum. The choice of surgery depends on the presence of other conditions such as uterine prolapse.
Perianal area skin
The skin of the perianal area is very sensitive and susceptible to injury and damage from diarrhea and constipation. Irritation of the perianal area can occur with persistent diarrhea.
Diarrhea itself can be caustic and burn the skin, and repeated cleaning with toilet paper can cause more trauma. Treating diarrhea and then keeping the area clean and dry are important for curing the perianal skin.
Diseases and Conditions of the Perianal Zone
Diseases and conditions that can affect the perianal skin include:
External hemorrhoids
Hemorrhoids that occur outside the anus can be painful, itchy, and bleed. Hemorrhoids can occur due to liver disease, constipation, diarrhea, or during pregnancy.
Symptoms may worsen during bowel movements. In many cases, hemorrhoids improve with home treatment, but in some cases may need to be treated by a gastroenterologist or colorectal surgeon. If a blood clot occurs, the hemorrhoid can become thrombosed and cause more pain and swelling.
Crohn's disease
Crohn's disease can occur anywhere in the digestive system, and the perianal area can also be affected. Approximately 24% of patients with Crohn's disease have disease in the perianal area.
People with Crohn's disease may also have skin tags, hemorrhoids or, in extremely rare cases, cancer in the perianal area. In many cases, a colorectal surgeon will need to be consulted in the care of patients presenting with complications of Crohn's disease
Perianal abscess
An abscess is a sum of blood and pus that can occur anywhere in the body, including the perianal area. People with inflammatory bowel disease, especially those with Crohn's disease, are more at risk of developing a perianal abscess.
A perianal abscess can begin after a break in the anus, and some bacteria enter the body through that break. The symptoms of perianal abscess are swelling, pain, fever and loss of bowel control. Abscesses in the perianal area are usually treated by draining them, and then with antibiotics.
Perianal fistula
The fistula is the tunnel that forms under the skin and connects the infected glands clogged to an abscess. A fistula can be present with or without an abscess and can only connect to the skin of the buttocks near the anal opening.
A possible complication of a perianal abscess, generates the development of a fistula in the area, a fistula that can sometimes become chronic. A fistula may also form after a trauma or as a complication of Crohn's disease, anal fissures, cancer, radiation therapy, actinomycosis, tuberculosis or chlamydia infection.
Symptoms include a rupture of the skin, swelling, pain and drainage (of pus or faeces) in the area. The treatment can be with surgery (fistulotomy) or the placement of a setón through the fistula.
References
- Tresca, A. (2016). What Is The Perianal Area? . 11-1-2017, from verywell.com Website: verywell.com.
- Buckmire, M. (2015). Abscess and Fistula Expanded Information. 11-1-2017, from DCR Journal Website: fascrs.org.
- Fidoe, S. (2016). The Perineum Boundaries. 11-1-2017, from The TeachMe Series Website: teachmeanatomy.info.
- Shasoua, G. (2014). Perineal descent. 11-1-2017, Austin Urogynecology Website: teachmeanatomy.info.
- Shteynshlyuger, A. (2013). Treatment of Perineal Pain. 11-1-2017, from New York Urology Specialists Website: newyorkurologyspecialists.com.