Surco perineal: un viejo poco conocido / Perineal groove: a little-known old man

Introducción: El surco perineal es una malformación infrecuente dela línea media. Se trata de un surco húmedo, mucoso y no queratinizado localizado en la línea media del periné desde la horquilla vulvar hastael borde anal anterior. Es una malformación infrecuente, usualmente asintomática y de resolución espontánea en la mayoría de los casos. Esta anomalía es frecuentemente confundida con otras malformaciones por lo que su reconocimiento es fundamental para evitar yatrogenia. Caso clínico: Se presenta el caso de una recién nacida con una lesión asintomática en la línea media del periné sospechosa de malformación anorrectal. Tras valoración por el Servicio de Cirugía Pediátrica se diagnosticó de surco perineal. Comentarios: Debido a la infrecuencia y escasa documentación bibliográfica del surco perineal, esta malformación es desconocida paramuchos sanitarios. Este caso expone la importancia de tener presente estaanomalía para evitar diagnósticos erróneos, tratamientos innecesarios y estrés familiar.(AU)

Introduction: Perineal groove is an infrequent midline malformation. It is a humid, mucosal, non keratinized groove located at theperineal midline, extending from the vulvar fourchette to the anterioranal border. It is rare and usually asymptomatic, and it heals spontane-ously in most cases. It is frequently mistaken for other malformations,which means correctly identifying it is essential to avoid iatrogenesis. Clinical case: We present the case of a female newborn with anasymptomatic lesion at the perineal midline consistent with anorectal malformation. Following assessment by the Pediatric Surgery Department, she was diagnosed with perineal groove. Discussion: Perineal groove is a little known malformation amonghealthcare professionals as it is infrequent and there are not many publications in the literature about it. This case demonstrates how importantit is to keep this abnormality in mind to avoid erroneous diagnoses, unnecessary treatments, and family stress.(AU)

Misdiagnosis of Congenital Posterior Urethroperineal Fistula and Comparison With Urethral Duplications and Rectourethral Fistula.

Congenital posterior urethroperineal fistula (CUPF) is a urothelium-lined tract between the posterior urethra and perineum. This condition is rare and has been proposed to be a urethral duplication variant. A case of CUPF that was misdiagnosed and surgically treated as a rectourethral fistula is presented. The clinical presentation, diagnosis, and treatment of CUPF are discussed and compared with those of Y-type urethral duplications and H-type rectourethral fistulas.

Anal canal duplication in children: a monocentric experience of 12 cases.

PURPOSE: Anal canal duplication is a rare malformation characterized by a second perineal opening positioned behind the anus, which is generally observed at 6 o'clock in the lithotomy position. The purpose was to describe six new cases of anal canal duplication (in addition to our previously reported series of six patients) with the aim of providing further clinical information about this anomaly. METHODS: We described 6 new cases of anal canal duplication in terms of symptoms, anatomical disposition, imaging results, and histopathology. Clinical details of these cases and those already reported (n = 12) were summarized and compared to existing literature. RESULTS: A total of 12 cases were reported over 34 years. 17% of the patients were male, constituting the only subgroup to present a communication with the digestive tract. A single patient, diagnosed at 12 years, was symptomatic. Half of the patients had at least one associated malformation. All patients underwent surgery, either with a posterior sagittal or perineal approach. CONCLUSION: Diagnosis of anal canal duplication should be suspected when a perineal opening positioned behind the anus is present, and necessitates further exploration by a comprehensive clinical examination and imaging. Surgery is always required, typically performed via a posterior sagittal approach. The postoperative course is usually uncomplicated.

A double blind randomized controlled trial using copper impregnated maternity sanitary towels to reduce perineal wound infection.

OBJECTIVE: To investigate the effect of copper impregnated sanitary towels on the infection rate following vaginal delivery (VD). DESIGN: Single center double blind randomized controlled trial. PARTICIPANTS: Women aged 18 or over who had a sutured second-degree tear or episiotomy following VD. INTERVENTIONS: All women were randomized to receive either a copper-oxide impregnated sanitary towel (study group) or a non-copper sanitary towel (control group). MAIN OUTCOME MEASURES: The primary study outcome was the incidence of wound infection within a 30-day period from VD, assessed via telephone questionnaire. Secondary outcomes were length of hospital stay and risk factors of infection. RESULTS: 450 women were enrolled in the study of whom 225 were randomized to the copper impregnated sanitary towel (study group) and 225 to the non-copper sanitary towel (control group) group. Follow-up rate was 98.2%. A total of 102 women (23.1%) developed an infection within 30 days following VD, 19 in the study group (8.6%) and 83 (37.4%) in the control group (P = <0.001, absolute risk reduction (ARR) of 28.8%). The incidence of superficial/deep and organ/space infections was significantly lower in the study group (7.7% vs. 30.2%, P = <0.001 and 4.6% vs. 31.5%, P = <0.001 respectively) with an ARR of 22.5% and 27.0% respectively. Multivariable analysis reported Asian ethnicity and prolonged rupture of membranes as significant risk factors; for the development of infection (OR 1.91, P = 0.03 and OR = 1.97, P = 0.04 respectively). CONCLUSIONS: This is the first study to demonstrate a significant reduction in infection rate following VD with the use of copper impregnated sanitary towels.

Perineal Groove: An Anorectal Malformation Network, Consortium Study.

OBJECTIVE: To review the Anorectal Malformation Network experience with perineal groove (PG) focusing on its clinical characteristics and management. STUDY DESIGN: Data on patients with PG managed at 10 participating Anorectal Malformation Network centers in 1999-2019 were collected retrospectively by questionnaire. RESULTS: The cohort included 66 patients (65 females) of median age 1.4 months at diagnosis. The leading referral diagnosis was anal fissure (n = 20 [30.3%]): 23 patients (34.8%) had anorectal malformations. Expectant management was practiced in 47 patients (71.2%). Eight (17%) were eventually operated for local complications. The median time to surgery was 14 months (range, 3.0-48.6 months), and the median age at surgery was 18.3 months (range, 4.8-58.0 months). In the 35 patients available for follow-up of the remaining 39 managed expectantly, 23 (65.7%) showed complete or near-complete self-epithelization by a mean age 15.3 months (range, 1-72 months) and 4 (11.4%) showed partial self-epithelization by a mean age 21 months (range, 3-48 months). Eight patients showed no resolution (5 were followed for ≤3 months). Nineteen patients (28.7%) were primarily treated with surgery. In total, 27 patients were operated. Dehiscence occurred in 3 of 27 operated patients (11.1%). CONCLUSIONS: PG seems to be an underestimated anomaly, frequently associated with anorectal malformations. Most cases heal spontaneously; therefore, expectant management is recommended. When associated with anorectal malformations requiring reconstruction, PG should be excised in conjunction with the anorectoplasty.

Descenso vaginal vía perineal asistido por laparoscopia en paciente con atresia vaginal distal / Laparoscopically assisted pull-through surgery in a patient with distal vaginal atresia

La atresia vaginal distal es una anomalía infrecuente que deriva de la falta de desarrollo de los 2/3 distales de la vagina a partir del seno urogenital. Presentamos una paciente de 14 años con amenorrea primaria, abdominalgia, masa palpable en hipogastrio y ausencia de orificio vaginal. La ecografía abdominal y la RMN evidenciaron hematometrocolpos secundario a agenesia vaginal distal, con una distancia al periné de 5cm, sin otras malformaciones. Se realiza un drenaje vaginal transuretral y descenso vía perineal asistido por laparoscopia. Evolución favorable con calibre vaginal adecuado y normalización de la menstruación a los 6 meses

Distal vaginal atresia is an uncommon disorder that results from the lack of development of the distal 2/3 of the vagina from the urogenital sinus. The case is presented on a 14 year-old patient with primary amenorrhoea, abdominal pain, a palpable mass in the hypogastrium, and an absent vaginal opening. The abdominal ultrasound and magnetic resonance imaging showed haematometrocolpos secondary to distal vaginal agenesis, with a distance of 5cm to the perineum, with no other malformations. A transurethral vaginal drainage and laparoscopic assisted pull-through were performed. Her follow-up was favourable with an adequate vaginal calibre and normal menstruation after 6 months

Atypical rectoscrotal and rectoperineal fistula in male anorectal malformations: a case series of non-detaching strategies for preventing urethral injury.

Anorectal malformations (ARM) represent a broad spectrum of patients with different level of the rectum and type of a fistula. Standardized approaches are usually successful, but patients occasionally present with an unusual course of fistula which requires a modified surgical strategy. We present here three male ARM patients with an atypical fistula which did not have connection with the urinary tract, but ran near the fistula. Case 1 has a low-type ARM with a rectoscrotal fistula running deep and partly involved in the corpus spongiosum. Anorectoplasty was performed through an anterior sagittal incision and the anterior wall of the fistula was laid open leaving the posterior wall undetached. Case 2 was diagnosed with an intermediate-type ARM with a long rectoscrotal fistula running near and parallel the urethra. Posterior sagittal anorectoplasty (PSARP) was performed leaving the fistula untouched. Case 3 presented with an intermediate-type ARM with a rectoperineal fistula adherent to the urethra. The patient was treated by PSARP leaving the fistula and part of the muscle coat of the rectum in situ. All the cases were smoothly discharged and no urological complication nor problem associated with the residual fistula was observed at the latest follow-up (17 months-2 years). Preoperative distal colostography with the aid of diverting colostomy was importantly useful for deciding surgical procedure.

Clinical characteristics and conservative treatment of perineal groove.

PURPOSE: Perineal groove is a rare congenital anomaly of the perineum, and only a few papers describing a small number of cases have been reported in the medical literature. This study aimed to evaluate the clinical characteristics and proper management of perineal groove. METHODS: We performed a retrospective review of 26 pediatric patients who were diagnosed with perineal groove between January 2012 and October 2018 at our institution. RESULTS: Perineal groove was extremely prevalent among the females: 25 of the 26 patients were girls, and only one patient was a boy. All the patients presented with an unusual lesion at the anus or perineum, but no symptoms related to this anomaly. The median age at the first visit to our clinic was 1.5 month (range, 0.3-11.4 month). Two types, complete and partial, were used to categorize the appearance of perineal groove. In a sample group, 55% (12/22) of the patients had complete perineal groove while 45% (10/22) had partial perineal groove. One patient underwent an anoplasty at another hospital following the diagnosis of an imperforate anus. One male and 13 female patients were followed beyond the age of two, and 10 patients (71%) showed a natural healing process. CONCLUSION: Perineal groove manifested as two types of appearance and showed excellent results with conservative treatment in our study. A natural healing process can be expected in the long-term follow-up. Perineal groove must be differentiated from other defects to avoid unnecessary surgical treatment. LEVELS OF EVIDENCE: Therapeutic Study, Level IV.

Delayed diagnosis of anorectal malformations in neonates.

BACKGROUND: Anorectal malformations (ARM) are common congenital abnormalities of the terminal hindgut. Ideally, ARM should be diagnosed at, or shortly following, birth by careful physical examination of the perineum. Delayed diagnosis has been implicated as a risk factor for complications, including intestinal perforation. This study aimed to determine the rate of delayed diagnosis and associated intestinal perforation in ARM. METHODS: A retrospective review was performed for all ARM patients managed at The Royal Children's Hospital over a 16-year period (2000-2015). Data collected included ARM type, timing of diagnosis and complications. Delayed diagnosis was defined as being at more than 24 h of age. RESULTS: A total of 243 ARM patients (male 146/243, 60%) were included. The most frequent ARM types were perineal fistula (83/243, 34%) and rectovestibular fistula (40/243, 16%). Diagnosis was delayed beyond 24 h of age in 92 of 243 (38%) patients. The ARM type most commonly delayed in diagnosis was perineal fistula (37/83, 45%). Two patients in whom diagnosis was delayed suffered an intestinal perforation. CONCLUSION: Delayed diagnosis in ARM patients remains a common, and potentially fatal, occurrence. Improved assessment of newborns is required to ensure timely diagnosis of ARM, and avoidance of complications associated with delayed diagnosis.

Four Cases of Perineal Groove-Experience of a Greek Maternity Hospital.

Perineal groove is a well-defined clinical entity that belongs to a broader group of anorectal malformations. It is characterized by a non-epithelialized mucous membrane that appears as an erythematous sulcus in the perineal midline, extending from the posterior vaginal fourchette to the anterior anal orifice. The defect is gradually cicatrized, unless there are complications like infection, defecation disorders, trauma, and bleeding. The differential diagnosis includes several other conditions like trauma, infection, irritant dermatitis, lichen sclerosis, and ulcerated hemangioma. Since it is a rare malformation, it is often misdiagnosed and its presence often elicits unnecessary diagnostic workup and intervention. In this respect, neonatologists, dermatologists, or pediatric surgeons may under- or overestimate it. We report four cases of perineal groove out of 2250 live births at a Greek Maternity Hospital between September 2016 and April 2019. The "high" incidence of perineal groove cases in our Department allowed us to familiarize with this rare defect and minimize our clinical interventions.

Risk factors for the recurrence of perineal canal.

PURPOSE: The aim of this study was to investigate risk factors for recurrence in the perineal canal (PC). METHODS: Patients with PC who underwent operations were enrolled in this study and were divided into recurrence and non-recurrence groups. Preoperative infection, the age at the operation, the presence of colostomy and the treatment procedure for fistula were retrospectively investigated. Regarding the treatment procedure for fistula, either closure of the rectal wall with stitches or ligation of fistula in the rectum was performed. These factors were compared between the two groups. RESULTS: Six of 17 patients with PC who underwent surgical treatment had recurrence. There were no significant differences in the incidence of preoperative infection, age at operation or presence of colostomy (p = 0.60, 0.38, 1.00, respectively). In the recurrence group, all patients were treated by closure of the rectal wall. In the non-recurrence group, five were treated by the closure of the rectal wall with stitches and six by ligation of the fistula. There was a significant association between recurrence and the treatment procedure for fistula (p = 0.04). CONCLUSION: Closure of the rectal wall with stitches is a risk factor for the recurrence of PC.

Gynecological anomalies in patients with anorectal malformations.

PURPOSE: The association of gynecological anomalies in all anorectal malformations (ARM) is firmly established. Our goal is to study this pathology in our patients to focus attention to this important issue. METHODS: Retrospective study of female patients operated for ARM and who underwent magnetic resonance imaging in our center. The type of malformation, the presence and type of vaginal, uterine, tubaric and urological anomalies were studied. RESULTS: 63 patients were included: 34.9% cloaca, 28.6% vestibular and 12.7% perineal. Half of patients had some type of müllerian anomaly; 19 vaginal, most frequent being the longitudinal vaginal septum (66.7%); 30 had uterine alterations, most frequent being the uterus didelphys (60%). Eighty percent of patients with complex ARM (cloaca, exstrophy) presented some type of gynecological malformation compared to 21.8% found in simple ARM (stenosis, perineal, vestibular) (p < 0.001). Vaginal anomalies are associated with a uterine anomaly in 100% of cases. Conversely, patients with uterine anomalies have concurrent vaginal anomaly in 63.3% of cases. CONCLUSION: Screening for gynecological anomalies is indicated in all patients with ARM. We recommend a vaginal examination in any girl with ARM during definitive repair and a subsequent MRI during follow-up. Collaboration with a gynecologist is essential.

A cloacal anomaly is not a disorder of sex development.

AIM OF THE STUDY: Misdiagnosing a cloaca as a disorder of sex development may lead to inappropriate testing, treatment, and negative emotional consequences to families. We were impressed by the fact that a significant number of patients suffering from a cloaca were referred to us with the diagnosis of a "disorder of sex development" previously referred as "ambiguous genitalia" or "intersex". On re-evaluation, none of them truly had a disorder of sex differentiation. This prompted us to conduct the following retrospective review to try to find the cause of the misdiagnosis and the way to prevent it. METHODS: A retrospective review of our colorectal database was performed to identify the total number of patients with cloacas and the number initially diagnosed as "ambiguous genitalia, intersex"/disorder of sex development. The external appearance of their genitalia and unnecessary testing or treatment received were recorded. MAIN RESULTS: A total of 605 patients with cloacas were identified. Of these, 77 (12.7%) were referred to us with the diagnosis of "ambiguous genitalia" and 13 of them (17%) went on to receive an intervention that was not indicated: karyotyping (10), steroids (3), and ovarian biopsy (1). The karyotype result in all patients was XX. The misdiagnosis was triggered by the external appearance of the perineum, simulating a case of virilization with a hypertrophic clitoris, but was simply prominent labial skin. Careful examination of the perineal structure allowed us to determine that it consisted of folded skin with no evidence of corpora. CONCLUSION: Patients born with a cloaca are at risk for mismanagement from being erroneously labeled as disorders of sex development. The diagnosis of a cloacal anomaly is a clinical one. The practitioner must distinguish between phallus-like clitoral hypertrophy and a normal clitoris with prominent labial skin.

Development of a New Incontinence Containment Product and an Investigation of Its Effect on Perineal Dermatitis in Patients With Fecal Incontinence: A Pilot Study in Women.

Research related to the design and development of new incontinence containment products for women is scarce. PURPOSE: The purpose of this 2-part study was to 1) develop a new incontinence containment product for fecal incontinence and 2) examine the effect of this new product on the occurrence of incontinence-associated dermatitis (IAD). METHODS: In part 1, a new incontinence containment product was designed, developed, and trialed among 10 healthy female volunteers. The product was comprised of a double layer of polypropylene nonwoven fabric and 100% cotton interlock fabric with a 3-ply 100% cotton interlock fabric added into the perianal section. Participants wore the product for 8 hours and were asked to defecate into the product and evaluate its comfort, ability to contain liquids and protect privacy, any personal allergic reaction, and air permeability. In part 2, after any product modifications, 12 bedridden women treated in the neurology unit of a hospital in western Turkey who had an indwelling urinary catheter and fecal incontinence and who did not have diabetes mellitus, a darkly pigmented area in the perianal area, pressure injury, or erythema were randomized to 2 groups (study product and control, a premium adult diaper) and monitored for 8 days for the development and severity of perineal dermatitis (scored from 0 [no erythema] to 4 [broken, abraded skin]) using a skin assessment tool. Any type of erythema was considered IAD. Skin care (cleansing with a washcloth and water) was provided daily and after each defecation to all study participants. Data were collected via paper-and-pencil completion of the perineal skin integrity assessment and patient observation forms and entered into and analyzed by a computerized statistical program. Fisher's exact test and the chi-squared test were used to analyze the difference in IAD incidence and severity between the 2 groups, and the Mann Whitney U test was used to detect differences in the number and consistency of defecations. RESULTS: No statistically significant differences were noted among the characteristics of the 12 participants (6 in each group) except for age; patients in the study product group were significantly older (70.66 ± 10.36 vs 52.20 ± 16.78 years; P <.05. Four (4) patients in the study group exhibited 13 areas of perineal dermatitis (degree 1 = 6 areas; degree 2 = 6 areas; degree 3 = 1 area; and degree 4 = 0); 1 patient in the control group had 4 areas with degree 1. CONCLUSION: This prototype product is not sufficient to be used in clinical practice in patients with fecal incontinence, but further study in a larger population is warranted..

Hernias perineales / Perineal hernias

Introducción: Las hernias perineales son excepcionales y predominan ampliamente en el sexo femenino. Se clasifican en anteriores o posteriores según su localización con respecto al músculo transverso del periné. Etiológicamente pueden ser primarias (congénitas o adquiridas), de las cuales se han descrito alrededor de 100 casos, y secundarias sobre todo a operaciones previas (resección adbominoperineal). Objetivo: Actualizar los conocimientos sobre las hernias perineales por lo infrecuente de este padecimiento. Métodos: Se realizó una revisión bibliográfica a partir de la consulta de artículos relacionados con el tema, publicados en Pubmed, Hinari, SciELO y Medline mediante el localizador de información Endnote. Se utilizaron 51 citas para la revisión, 41 de ellas de los últimos cinco años. Se incluyeron tres libros y una cita del propio autor. Conclusiones: Las hernias perineales son extremadamente raras. Existe poca experiencia reportada en la bibliografía, por lo que aún no es posible determinar la mejor forma terapéutica. Pueden abordarse por vía abdominal, perineal o combinada. Las técnicas empleadas son: cierre simple, transposición de colgajos musculares, colocación de mallas y retroflexión del útero o vejiga para cerrar el defecto. Aunque no existe suficiente experiencia, la cirugía laparoscópica se ha utilizado en algunos casos y podría ser la vía de elección en el futuro(AU)

Introduction: Perineal hernias are exceptional and predominate widely in the female sex. They are classified into anterior or posterior, based on their location with respect to the transverse muscle of the perineum. Etiologically speaking, they can be primary (congenital or acquired), of which about 100 cases have been described, and secondary above all to previous operations (abdominoperineal resection). Objective: To update the knowledge about perineal hernias, due to the infrequent nature of this condition. Methods: A literature review was carried out in the articles about the topic and published in Pubmed, Hinari, SciELO and Medline using the Endnote information locator. We used 51 citations for the review, 41 of which belonged to the last five years. Three books and a citation by the author were included. Conclusions: Perineal hernias are extremely rare. There is little experience reported in the literature, so it is not yet possible to determine the best therapeutic form. They can be treated by an abdominal or perineal approach, or combined. The techniques used are: simple closure, transposition of muscle flaps, placement of meshes, and retro-flexion of the uterus or bladder to close the defect. Although there is not enough experience, laparoscopic surgery has been used in some cases and could be the gold standard in the future(AU)

Hernias perineales / Perineal hernias

Introducción: Las hernias perineales son excepcionales y predominan ampliamente en el sexo femenino. Se clasifican en anteriores o posteriores según su localización con respecto al músculo transverso del periné. Etiológicamente pueden ser primarias (congénitas o adquiridas), de las cuales se han descrito alrededor de 100 casos, y secundarias sobre todo a operaciones previas (resección adbominoperineal). Objetivo: Actualizar los conocimientos sobre las hernias perineales por lo infrecuente de este padecimiento. Métodos: Se realizó una revisión bibliográfica a partir de la consulta de artículos relacionados con el tema, publicados en Pubmed, Hinari, SciELO y Medline mediante el localizador de información Endnote. Se utilizaron 51 citas para la revisión, 41 de ellas de los últimos cinco años. Se incluyeron tres libros y una cita del propio autor. Conclusiones: Las hernias perineales son extremadamente raras. Existe poca experiencia reportada en la bibliografía, por lo que aún no es posible determinar la mejor forma terapéutica. Pueden abordarse por vía abdominal, perineal o combinada. Las técnicas empleadas son: cierre simple, transposición de colgajos musculares, colocación de mallas y retroflexión del útero o vejiga para cerrar el defecto. Aunque no existe suficiente experiencia, la cirugía laparoscópica se ha utilizado en algunos casos y podría ser la vía de elección en el futuro(AU)

Introduction: Perineal hernias are exceptional and predominate widely in the female sex. They are classified into anterior or posterior, based on their location with respect to the transverse muscle of the perineum. Etiologically speaking, they can be primary (congenital or acquired), of which about 100 cases have been described, and secondary above all to previous operations (abdominoperineal resection). Objective: To update the knowledge about perineal hernias, due to the infrequent nature of this condition. Methods: A literature review was carried out in the articles about the topic and published in Pubmed, Hinari, SciELO and Medline using the Endnote information locator. We used 51 citations for the review, 41 of which belonged to the last five years. Three books and a citation by the author were included. Conclusions: Perineal hernias are extremely rare. There is little experience reported in the literature, so it is not yet possible to determine the best therapeutic form. They can be treated by an abdominal or perineal approach, or combined. The techniques used are: simple closure, transposition of muscle flaps, placement of meshes, and retro-flexion of the uterus or bladder to close the defect. Although there is not enough experience, laparoscopic surgery has been used in some cases and could be the gold standard in the future(AU)