Perineal Hernia: Symptoms, Types, Causes and Treatment

Perineal hernia is a rare, often under-recognized condition that can significantly impact quality of life. Whether arising spontaneously or following pelvic surgery, perineal hernias present unique challenges in diagnosis and management. In this comprehensive article, we’ll explore the symptoms, types, causes, and treatment options for perineal hernia, synthesizing the most up-to-date scientific research and clinical experience.

Symptoms of Perineal Hernia

Perineal hernia symptoms can be subtle at first, but often progress to more noticeable and disruptive issues. Recognizing these symptoms early can lead to a quicker diagnosis and better outcomes for patients.

Symptom	Description	Severity	Source(s)
Bulging	Noticeable swelling or mass in perineum	Varies	1 4 10
Pain	Discomfort or pain in the perineal area	Mild–severe	1 2 10
Bowel symptoms	Diarrhea, constipation, obstruction	Mild–severe	1 2 10
Urinary issues	Difficulty urinating or urinary incontinence	Mild–moderate	2 5 10
Skin changes	Skin necrosis, erosion, discharge	Mild–severe	1 10

Table 1: Key Symptoms

Common Presenting Symptoms

Perineal hernias most frequently present as a bulge or swelling in the perineal area—sometimes only noticed when standing, straining, or coughing. The swelling is often soft and may change in size with body position or pressure. In some cases, the hernia can be mistaken for other perineal or pelvic conditions, such as rectal prolapse or sciatic hernia, making clinical evaluation and imaging essential for diagnosis 4 5.

Pain and Discomfort

Pain is another common complaint. This can range from mild discomfort to severe pain, especially if the hernia contents are compressed or if complications like strangulation or obstruction occur. Pain may increase during activities that raise intra-abdominal pressure, such as lifting, coughing, or defecation 1 2.

Gastrointestinal and Urinary Symptoms

When the hernia contains bowel or bladder tissue, it can lead to more serious symptoms:

• Bowel symptoms: Diarrhea, constipation, or even signs of intestinal obstruction (cramping, nausea, vomiting) can occur if the herniated intestine becomes kinked or trapped 1 2 10.
• Urinary symptoms: Difficulty urinating, urinary frequency, or incontinence may develop if the bladder is involved 5 10.

Skin and Soft Tissue Changes

Chronic hernias can lead to skin changes, such as redness, ulceration, or even skin necrosis, particularly if the hernia is large or if there is persistent pressure or friction. Discharge or infection can also develop in these cases 1 10.

Types of Perineal Hernia

Perineal hernias are classified based on their anatomical location, timing of occurrence, and underlying cause. Understanding the types helps in determining the best diagnostic and treatment approach.

Type	Description	Prevalence	Source(s)
Anterior	Hernia anterior to superficial transverse perineal muscle	Very rare	2 4
Posterior	Hernia posterior to superficial transverse perineal muscle	More common	2 5
Primary	Occurs spontaneously (congenital/acquired)	Extremely rare	2 4 5
Secondary	Occurs after pelvic surgery or trauma	More frequent	1 2 3 10

Table 2: Perineal Hernia Types

Anatomical Classification: Anterior vs. Posterior

• Anterior perineal hernia: Located in front of the superficial transverse perineal muscle, these hernias are rare, often presenting as a bulge in the labia or perineal area, particularly in women 2 4.
• Posterior perineal hernia: Found behind the superficial transverse perineal muscle, these are slightly more common and can involve herniation of the bladder, rectum, or bowel 2 5.

Etiological Classification: Primary vs. Secondary

• Primary perineal hernia: This type develops spontaneously and can be either congenital (due to developmental defects in the pelvic diaphragm) or acquired (due to factors like increased intra-abdominal pressure or pelvic floor weakening) 2 3 4 5.
• Secondary perineal hernia: Far more common, secondary hernias result from surgical disruption or trauma to the pelvic floor, especially after extensive pelvic operations such as abdominoperineal resection or pelvic exenteration 1 2 3 10.

Special Populations

• Peripartum perineal hernia: Although exceedingly rare, there are reports of perineal hernias developing after childbirth, particularly following traumatic deliveries or pubic symphysis rupture 8.
• Veterinary perspective: In dogs, perineal hernia is relatively common in intact males and may present differently than in humans 7 9 11.

Causes of Perineal Hernia

A variety of factors can contribute to the development of perineal hernia, ranging from congenital anomalies to acquired weaknesses in the pelvic floor.

Cause	Mechanism	Risk Factors	Source(s)
Congenital defect	Failure of pelvic diaphragm development	Embryologic factors	2 4
Acquired (primary)	Pelvic floor weakening, increased pressure	Female sex, childbirth	2 4 10
Secondary (surgical)	Disruption of pelvic floor during surgery	Abdominoperineal resection, pelvic exenteration, radiation	1 2 3 10 12 13 14 15
Obstetric trauma	Injury during or after childbirth	Symphyseal rupture	8
Chronic conditions	Chronic constipation, prostatic hyperplasia (in dogs)	Male sex, older age	7 9 11

Table 3: Perineal Hernia Causes

Congenital and Primary Causes

Some perineal hernias are present from birth, resulting from developmental failure in the pelvic floor muscles or supporting structures. This is extremely rare in humans but can occur due to persistence of embryonic structures, leading to a weak spot through which abdominal or pelvic contents can herniate 2 4.

Acquired Primary Hernias

Acquired hernias that are not related to surgery most often develop due to chronic increases in intra-abdominal pressure—such as from chronic coughing, constipation, obesity, or heavy lifting. Women are at higher risk, likely due to the broader female pelvis and the weakening effects of pregnancy and childbirth on the pelvic floor muscles 2 4 10.

Secondary (Postoperative) Hernias

The vast majority of perineal hernias are secondary, arising after pelvic surgery. Procedures such as abdominoperineal resection (removal of rectum and anus), pelvic exenteration, and radical cancer surgeries can disrupt or remove parts of the pelvic diaphragm, creating a defect through which herniation occurs 1 2 3 10 12 13 14 15. Additional risk factors for postoperative hernias include:

• Extensive surgical dissection
• Wound infection
• Neoadjuvant (pre-operative) radiotherapy
• Large pelvic defects
• Female sex (wider pelvis) 10 12

Obstetric and Traumatic Causes

Obstetric trauma, such as pubic symphysis rupture during a difficult vaginal delivery, can create a defect in the pelvic floor and lead to perineal herniation, although this is exceedingly rare 8.

Animal Context

In veterinary medicine, especially in dogs, perineal hernias can result from chronic straining (constipation), prostatic hyperplasia, and hormonal influences. Castration in affected male dogs has been shown to reduce recurrence rates 7 9 11.

Treatment of Perineal Hernia

The treatment of perineal hernia is tailored to the patient’s symptoms, the type and cause of hernia, and the presence of complications. Surgical repair remains the mainstay for symptomatic cases.

Approach	Technique/Material	Recurrence Complication	Source(s)
Perineal	Direct repair or mesh/flap	Higher recurrence	1 6 12 13 15
Abdominal	Open or laparoscopic, mesh	Lower recurrence	6 12 13 14 15
Combined	Abdominoperineal, mesh/flap	Lowest recurrence	6 8 15
Mesh Type	Synthetic > Biologic (lower recurrence)	Synthetic preferred	6 12 13 15
Flap Reconstruction	Autogenous tissue (muscle flaps)	Used for complex cases	1 12 13 15
Non-surgical	Watchful waiting (mild cases)	Limited role	10

Table 4: Treatment Approaches

Indications for Treatment

Not all perineal hernias require immediate surgery. Treatment is typically recommended when patients experience:

• Significant symptoms (pain, obstruction, urinary or bowel dysfunction)
• Skin breakdown or risk of infection
• Progressive enlargement of the hernia
• Complications such as strangulation or incarceration 10

Surgical Approaches

Perineal Approach

The perineal approach involves direct access to the hernia via the perineum. It can be performed using primary suturing, mesh repair, or tissue flaps. While it is technically straightforward and often preferred for small or less complex hernias, studies show this approach is associated with higher recurrence rates compared to abdominal or combined approaches 1 6 12 13 15.

Abdominal and Laparoscopic Approaches

The abdominal approach—either open or laparoscopic—allows for better visualization of the pelvic anatomy and facilitates secure mesh placement. Laparoscopic repair, in particular, is minimally invasive, associated with shorter hospital stays, lower recurrence rates, and fewer complications 6 12 13 14 15.

Combined Abdominoperineal Approach

For complex or recurrent hernias, a combined abdominal and perineal approach may be chosen. This method achieves the lowest recurrence rates, especially when synthetic mesh is used to reinforce the repair 6 8 15.

Mesh and Flap Reconstruction

• Synthetic mesh: Most commonly used, associated with the lowest rates of recurrence 6 12 13 15.
• Biologic mesh: Sometimes used, but associated with higher recurrence and cost 6 12 13 15.
• Autologous flaps: In complex cases or when infection risk precludes mesh, autologous tissue (such as muscle flaps) can be used for reconstruction 1 12 13 15.

Postoperative Outcomes and Complications

Recurrence rates after repair vary widely (from 0% to 66.7%) depending on technique, mesh type, and approach. Overall complication rates are high, with wound infection, seroma, and mesh extrusion among the most common issues. Flap reconstruction can reduce recurrence, particularly in complex or previously infected fields 1 6 12 13 15.

Special Considerations

• Veterinary management: In dogs, the standard perineal repair technique has a high success rate, and castration is recommended to reduce recurrence 11.
• Non-surgical management: Rarely indicated, except in asymptomatic or high-risk surgical patients 10.

Conclusion

Perineal hernia is a rare but significant condition that requires a high index of suspicion for diagnosis and tailored management for optimal outcomes. Here’s a summary of the main points:

• Symptoms are variable and include perineal bulging, pain, bowel or urinary disturbances, and skin changes.
• Types include anterior/posterior and primary/secondary hernias, with most being secondary to pelvic surgery.
• Causes range from congenital defects to acquired weaknesses (especially post-surgical), with risk factors including female sex, childbirth, pelvic surgery, and chronic straining.
• Treatment is primarily surgical, with synthetic mesh and abdominal or combined approaches offering the best outcomes; recurrence and complication rates remain significant, underscoring the need for individualized care.

Advances in surgical techniques continue to improve outcomes, but further studies are needed to establish gold-standard treatment algorithms for this challenging condition.