Generality
The perineum is an anatomical region located in the lower part of the pelvis .
This area has a rhomboid shape : the perineum extends, in a sagittal sense, from the inferior margin of the pubic symphysis to the apex of the coccyx ; transversely, it is included between an ischial tuberosity of the iliac bone and the other. To be clear, when using the bicycle, this is the area of the body that is placed on the saddle.
The perineum consists of a set of soft tissues and muscle-fascial formations, arranged on three levels, to form a sort of "net" that closes the abdominal and pelvic cavity. The structure thus organized is crossed by the terminal part of the digestive system, posteriorly ( anal or anorectal perineum ), and from the urinary tract and genitals, anteriorly ( perineum urogenital ).
The perineum performs various functions: the most important task is performed by the muscles and consists in supporting the internal organs (bladder, uterus and rectum). This region also contributes to urinary and fecal continence, plays an important role in sexual life and, during the birth, favors the release of the unborn child.
Given its particular position, the perineum can be involved in trauma, inflammation and various other pathological processes both in men and in women.
What's this
What is Perineum?
The perineum is the set of soft tissues, muscles and fibers that closes the pelvis, in its lower district.
To describe it in detail, it is necessary to observe the body in a supine position (lying on its back), with thighs flexed and enlarged.
From the anatomical point of view, the perineum is an area of rhomboid shape, bounded at the top by the pubic symphysis, below by the coccyx and laterally by the two ischial tuberosities.
If an ideal line is drawn from one ischial tuberosity to another, in the perineal region we can distinguish:
- An anterior portion (or urogenital region, containing the vagina in the woman and the scrotum in the man);
- A posterior portion (or anal region ).
As a whole, the perineum consists of:
- Skin rich in sebaceous and sweat glands, covered with hair after puberty;
- Subcutaneous connective tissue ;
- Muscles : the main ones are the external sphincter of the urethra, the sphincter of the anus, the elevator of the anus and the ischio-coccygeal. Together with the ligaments and aponeurotic bands they contribute to the statics and dynamics of the perineum, therefore they keep in suspension and stabilize the pelvic organs (intestine, uterus and bladder);
- Aponeurosis : envelop the muscles, contributing to the closure of the lower strait of the pelvis. There are three muscle-aponeurotic planes in the perineum:
- Superficial perineal aponeurosis;
- Mean perineal aponeurosis;
- Deep perineal aponeurosis or pelvic fascia.
The muscles of the perineum constitute the so-called "pelvic floor", a sort of very robust "net" on which bladder, uterus and intestine rest; the ligaments participate giving stability to the system.
Perineo: how is it organized?
The perineum is a very complex structure, consisting of several tissues arranged on three superimposed planes to form three diaphragms:
- Pelvic diaphragm : deeper layer formed by the levator ani and ischio-coccygeal muscles. At this level, the perineum is crossed by the rectum, the urethra and, in the female, the vagina. In the woman, below the pelvic diaphragm, there is the average perineal aponeurosis, between whose two pages is included the deep transverse muscle of the perineum which, with the urethral constrictor, contributes to form the urogenital trigone;
- Urogenital trigon (or middle perineal plane): fibrous bundle in whose thickness the membranous urethra (intermediate part of the male urethra) runs with the bulb-urethral glands;
- Superficial perineum plane : it is composed of four muscles. The external sphincter of the anus occupies the posterior perineum, surrounding and closing the anal opening; anteriorly, instead, there are the bulbocavernosus (constrictor of the vagina), ischiocavernosus and transverse superficial muscles of the perineum.
Localization and relations with other structures
The perineum is located in the middle position between the root of the thighs and corresponds to the lower wall of the trunk. In practice, this region goes from the pubic bones, anteriorly, to the coccyx, posteriorly.
In both sexes, the perineum is related to the last portions of:
- Urinary system ;
- Genital apparatus ;
- Digestive system .
Did you know that...
The muscles of the perineum move in synchrony with the diaphragm during breathing:
- During inhalation, the diaphragm descends to make room for the lungs; at the same time, the perineum induces the increase of pressure inside the abdomen, lowering itself.
- During exhalation, the diaphragm rises and, in turn, the perineum returns to the starting point.
Perineum Conformation
The perineum has the shape of a rhombus (or a lozenge), with a major anteroposterior axis, where the boundaries are represented by:
- Four corners:
- Anterior vertex : pubis (inferior margin of the pubic symphysis);
- Posterior vertex: apex of the coccyx ;
- Lateral extremes: two ischial tuberosities of the iliac bone.
- Four sides:
- Forward (front sides): two ischiopubic branches ;
- Back (back sides): correspond to the sacrotuberous ligaments, that is two lines that join the apex of the coccyx to the ischial tuberosities.
If a transversal line is ideally drawn to join the two ischial tuberosities (ie the rhombus is subdivided medially into two triangles ), then, the perineum is separated into:
- An anterior triangle that coincides with the urogenital perineum ;
- A posterior triangle that corresponds to the anorectal perineum .
Urogenital perineum
The urogenital or anterior perineum is characterized by the presence of external genitalia and presents a different morphology in the two sexes. This triangular area is crossed by the urethra in the male and by the urethra and by the vagina in the female. The urogenital perineum includes the muscles associated with the penis in the male and with the clitoris in the woman (m. Ischiocavernosus and bulbocavernosus).
Anorectal perineum
In the anorectal or posterior perineum the anal orifice and the inferior end of the rectum are included. This portion has a similar morphology in the male and in the female, except for some small differences: in humans, the anal orifice is located more posteriorly, due to the relationship with the bulb of the urethra.
The ano-rectal perineum allows the passage of the anal canal whose terminal portion is surrounded by the external sphincter of the anus, which controls defecation.
What is it for?
Perineum functions
The functions performed by the perineum are different:
- Support, protection and containment of internal organs. The perineal region represents a support plane for the organs of the abdominal and pelvic cavity (bladder, urethra, rectum and, in women, uterus and vagina). In addition to having a basic tone capable of keeping the pelvic organs in place, the muscles that make up the "pelvic floor" act in synergy and are also able to contract voluntarily, guaranteeing a solid and secure support.
- Urinary and fecal continence. The perineum is perfectly capable of maintaining intra-abdominal pressure and managing any changes with an automatic contraction mechanism. The muscles of the perineal region run to the sides of the urethra (channel that carries urine from the bladder to the outside) and react by contracting, interrupting urination, or relaxing, allowing it to be resumed. The perineum thus contributes to maintaining urinary continence, in sync with the sphincter of the urethra. In similar ways, the region contributes to good fecal continence, regulating the closure and opening of the sphincters. If the muscles of the perineum are tonic and strong, these functions are guaranteed both at rest and during exertion (coughing, running, laughing, etc.).
- Pregnancy and childbirth. During gestation, the perineum assumes a particular importance, as it helps to support the weight of the fetus. During the birth, however, this region supports the release of the unborn child.
- Sexuality . The perineal region plays an important role in the sexual life: in addition to being considered an erogenous zone, when it is tonic it prevents both male and female sexuality problems . In man, the muscles of the perineum allow a control of ejaculation during sexual intercourse: in particular, when they contract voluntarily, sperm release is blocked. In women, the perineum allows the vagina to contract voluntarily, participating in the motor phase of orgasm, making it more or less intense.
Pathologies of the Perineum: Causes
The perineum can be affected by multiple pathological processes and disorders that compromise normal functioning .
Among the factors most responsible for these problems are the conditions that cause damage to both the muscular and nervous tissue afferent to the perineal region, such as vaginal delivery and pregnancy itself.
The health of the perineum can also be compromised by a series of events that lead to an increase in intra-abdominal pressure, such as chronic cough, constipation, allergic rhinitis, tobacco smoke, too intense sporting activity (especially if it foresees a strong impact on the ground and the contraction of abdominal muscles) and excessive effort (such as carrying heavy objects).
Did you know that…
An intense and frequent cough, in fact, exerts excessive and constant force on the perineum. The muscles so stressed meet, over time, a weakness, which makes them less efficient in the task they have to perform.
Other relevant risk factors for the appearance of perineum disorders are:
- Overweight / obesity ;
- Recurrent urinary infections
- Sedentary life ;
- Surgical interventions in the pelvic organs ;
- Surgical incisions made during vaginal delivery (such as episiotomy ).
Emotional tensions can also affect the muscles of the region. This state can be perceived as a pain in the perineum and can occur during some particularly stressful periods from a psycho-physical point of view. Some people also have less resistant supporting tissues due to hereditary or constitutional factors .
Finally, aging and menopause cause a relaxation of the muscles and a decrease in estrogen which make the perineum less tonic.
Perineum Traumas
The perineum can be affected by traumas, particularly frequent in women.
During vaginal delivery, for example, lacerations may occur. Depending on the case, the length of these lesions may affect only the skin or even the underlying muscles.
Perineal Ptosis
As we age, when the muscle-fascial structures lose their tonicity and reactivity, the perineal support may be less effective, which can lead to urinary losses or, in the most serious cases, to the ptosis of the region. This latter condition, also known as the descending perineum syndrome, is often associated with:
- Lowering of the organs (prolapse) : consists of the descent downwards and, in the female sex, sometimes outside the vaginal entrance, of one or more pelvic structures (uterus, bladder and rectum), in combination with different levels of gravity. Genital prolapse is a particularly common condition after menopause.
- Urinary incontinence : when the pelvic floor muscles are weak and unable to contract to tighten the urethra, involuntary leakage of urine may occur.
Pregnancy
In young women, the main risk factors for the weakening and development of perineum dysfunctions are pregnancy and childbirth.
The compression exerted by the uterus and the very fact of having to support the weight of the fetus contributes to mechanical modifications of the static of the region.
Furthermore, during gestation, changes in the hormonal setting occur that can contribute to muscle tension. In particular, during pregnancy, the body produces relaxin, a hormone that loosens the pubic symphysis and pelvis to adapt it to the child's progressive growth in the uterus and prepare them for the elasticity necessary for the expulsive phase of childbirth. As a result, the adaptation of these structures can affect the support that the perineum is normally supporting and makes the muscles more susceptible to pain.
DYSPAREUNIA
An additional problem related to perineal dysfunctions is dyspareunia, or persistent and recurring genital pain during sexual intercourse.
The disorder can occur both in fertile age and in the post-menopausal period.
Prostate diseases
In men, therapies used to manage prostate diseases can weaken the perineum temporarily or permanently.
Inflammation of the Perineum
Inflammation of the perineum is often invasive. If the inflammatory process follows the course of the muscular sheaths, in fact, perineal phlegm can arise, which can become complicated in fistulae in the rectum or outside .
Symptoms and Complications
Depending on the etiology, pathologies of the perineum can involve various symptoms, including:
- Perineal pain;
- Urinary tract symptoms and urination disorders, including:
- Urinary incontinence;
- Urinal urgency;
- Prolapse of the pelvic organs:
- cystocele;
- rectocele;
- Fecal incontinence.
Perineum disorders can also be related to:
- Sexual dysfunction:
- vaginismus;
- Vulvodynia;
- Erectile dysfunction;
- Pelvic pain.
Diagnosis
What tests allow you to evaluate the health of the Perineum?
The diagnosis of perineum pathologies is fundamentally based on the direct observation of the structures involved, to evaluate their strength, muscle tone, length and symmetry. The physical examination also foresees to ascertain the position, the degree of flexibility and the mobility of the abdominal, lumbar and pelvic soft tissues, at rest and during the contraction.
During the visit, the doctor concentrates on identifying dysfunctions or abnormalities in the conformation of the genital area and perineum, such as swelling, hyperemia, cysts, purulent collections, alterations in skin color, scars and other skin lesions.
The evaluation of the perineum continues with tests aimed at determining the functionality of the bladder and rectum. These procedures allow doctors to decide on the most appropriate treatment option between drug therapy and surgery.
In the case of difficult urination or incontinence, for example, an optical fiber probe is used to observe the inside of the bladder ( cystoscopy ) or urethra ( urethroscopy ). If lesions are present in the perineum, a sample can be taken for microscopic examination ( biopsy ) and the presence of neoplastic cells can be verified.
Treatment and Remedies
The treatment of disorders affecting the perineum depends on the triggering causes.
If a tear is needed, for example, surgery is the most probable solution and is based on the immediate suture of the lesion ( perineorrhaphy ) or on the reconstruction of the perineal floor ( perineoplasty ).
To counteract a painful symptomatology affecting the perineal region, it is always advisable to consult your doctor who can indicate the most suitable drug therapy or recommend simple steps to be taken in daily life. In some cases, for example, diet and perineal rehabilitation sessions are sufficient to solve the problem. Other times, it is possible to intervene with other strategies such as: physiotherapy sessions, massages, Kegel exercises, taking a correct posture and yoga.
Perineum rehabilitation: what does it consist of?
The rehabilitation of the perineum is a set of rehabilitation techniques that allow to strengthen the pelvic floor muscles, with the aim of recovering the reduced or altered function of the structures contained in the pelvic cavity. This approach represents the main conservative tool for the treatment and prevention of gynecological, andrological and coloproctological dysfunctions involving the perineal region.
Furthermore, in order to keep the perineum healthy, it is a good idea to identify habits that affect the pelvic floor alterations and adopt appropriate or alternative behaviors to the incorrect ones.
The main interventions concern:
- Check body weight: excess pounds can weigh on the perineum;
- Avoid smoking: cough is a stress to the perineum;
- Prevent constipation by eating high-fiber foods and drinking adequate amounts of water;
- Avoid lifting heavy weights;
- Exercise the muscles of the perineum daily.
