Early outcomes of transverse perineal support in obstructed defecation syndrome with pathological perineal descent; a prospective cohort study

Abstract

BACKGROUND: While current surgical approaches for obstructed defecation syndrome (ODS) primarily target rectocele and rectal intussusception, excessive perineal descent (PD) may contribute to persistent symptoms and suboptimal surgical outcomes. This study aimed to evaluate early outcomes of transverse perineal support (TPS), a procedure designed to reinforce the perineum, in patients with ODS and pathological PD. PATIENTS AND METHOD: All consecutive patients with ODS and pathological PD were assessed for eligibility. After at least one year of conservative management (dietary fiber, biofeedback, laxatives) that failed to relieve symptoms, twenty-nine patients were evaluated preoperatively using the Cleveland Clinic Constipation Score (CCCS), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), perineometry, anorectal manometry, and MRI defecography. All patients underwent TPS procedure and were followed up for a minimum of 6 months. The primary outcome was the change in CCCS at 6 months. RESULTS: Significant postoperative improvements were observed. The CCCS decreased significantly, with a mean difference (Post - Pre) of -5.31 (95% CI: -6.13 to -4.48 ; p < 0.001). Postoperative PISQ-12 scores were significantly higher than preoperative scores, with median (IQR) values of 35 (34-36) and 25 (24-27), respectively (p = 0.003). Intrarectal pressure during push increased from 34.34 ± 6.03 mmHg preoperatively to 41.17 ± 5.85 mmHg postoperatively with a mean difference (Post - Pre) of 6.83 (95% CI: 5.41 to 8.24; p < 0.001). Perineal descent measured by perineometry decreased from 2.29 ± 0.55 cm preoperatively to 1.74 ± 0.51 cm postoperatively with a mean difference of -0.64 cm (95% CI: -0.75 to -0.52; p < 0.001). No mesh-related complications (erosion, chronic pain) were observed. Nine patients (31.03%) reported persistent symptoms. All had rectal intussusception. Compared with patients who improved, these patients were older, had smaller perineal bodies, and greater preoperative perineal descent. CONCLUSIONS: Transverse perineal support procedure may be an effective option for selected patients with ODS and pathological PD. Outcomes were less favorable in patients with rectal intussusception, older age (observed as an association only, not causation) or smaller perineal body dimensions, underscoring the importance of careful patient selection and individualized surgical planning. Given the small sample size and the absence of a control group, these findings should be interpreted with caution as associational rather than causal.