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Year : 2001  |  Volume : 11  |  Issue : 4  |  Page : 217-218
Congenital perineal hernia : Radiographic findings and role of imaging in diagnosis


University college of Medical Sciences & GTB Hospital, Shahdara, Delhi 110095, Delhi University, India

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How to cite this article:
Upreti L, Bhargava S K, Kumar A. Congenital perineal hernia : Radiographic findings and role of imaging in diagnosis. Indian J Radiol Imaging 2001;11:217-8

How to cite this URL:
Upreti L, Bhargava S K, Kumar A. Congenital perineal hernia : Radiographic findings and role of imaging in diagnosis. Indian J Radiol Imaging [serial online] 2001 [cited 2019 Aug 22];11:217-8. Available from: http://www.ijri.org/text.asp?2001/11/4/217/28408
Sir,

Perineal hernias are rare; most of the lesions are seen in women of childbearing age following obstetrical treatment or pelvic surgery [1] . Primary hernia results from the spontaneous development of a defect in the muscles of pelvic floor. There have been less then 100 cases of primary perineal hernias reported in the world literature. We present a case of congenital perineal hernia in a neonate.

A twelve-day-old baby girl was referred for sonographic evaluation of a left sided gluteal mass. Clinical diagnosis was sacrococcygeal teratoma. On sonography with a linear 7.5 MHz transducer (Philips P 700), an echogenic area with reverberating shadows was seen in the region of the palpable mass, suggesting presence of bowel. No evidence of discrete solid or cystic mass lesion was present. On plain radiograph air was seen in the buttocks region. Barium enema showed herniated loops of rectosigmoid on the left side [Figure - 1],[Figure - 2]. Surgical exploration revealed a posterior perineal hernia.

Perineal hernias are exceedingly rare, with frequency of occurrence being only slightly higher than the sciatic variety, which is the rarest of all hernias [1] . These lesions are mostly secondary to pelvic surgical procedures like abdominoperineal resection, pelvic exenteration and perineal prostatectomy. Primary perineal hernias may be congenital or acquired. Most of the primary hernias are seen in the middle aged to elderly women. This is presumably due to broad pelvic outlet and weakening of the pelvic floor during pregnancy and childbirth. Chronic cough, obesity are other possible contributing factors. Congenital perineal hernia is the rarest among all subtypes. De Garthyeot described first case of perineal hernia in children in 1736.

Perineal hernias are divided into anterior and posterior, depending upon their relationship with the transverse perinei muscle. The anterior type emerges through the urogenital diaphragm in the triangle formed by the transverse perineal, ischiocavernous and bulbospongiosus muscles. These occur almost exclusively in women. The posterior type is the less common variety and emerges through a defect in the levator ani muscle or between the levator ani and coccygeus muscle. Congenital defects causing primary hernia are extremely rare. In embryonic life the cul de sac forms a large canal descending into the perineum. If this canal doesn't regress, a true hernial sac may form [2] . Clinically the congenital hernias present as reducible masses, and they increase in size with increase in the intra-abdominal pressure. The child may have loose stools and the rectal position may be abnormal on the digital examination [1],[2] .

Differential diagnosis of congenital perineal hernia includes abscess, cyst, hematoma or lipoma [2] . Ultrasound may be the first imaging modality requested by the clinician, in case of a gluteal mass because of its obvious advantage of being widely available, being economical and having the advantage of lack of radiation. It is of help in excluding lesions like abscesses, cysts and hematoma. No significant abnormality is demonstrable in the case of perineal hernia.

The perineal hernia can be demonstrated radiographically. Plain film may show an air collection in the region of the buttocks [2] . Barium enema usually provides a definitive diagnosis. Views obtained during straining may be helpful in delineating a small hernia. It shows abnormal prolapse or herniation of the rectal wall or even the entire rectum. The rectum or rectosigmoid may herniate in the gluteal region [3] . The sac may also contain loops of small bowel, bladder or omentum.

Lubert et al have described computed tomographic (CT) findings in posterior perineal hernia in adult patients [4] . These consisted of herniation of loops of bowel in the ischio-rectal fossa below the expected level of the levator ani muscle. The muscle itself was not identified on the side of the hernia. According to the authors, CT scan is of value as it shows the location of the herniated bowel directly, and provides excellent delineation of anatomy of the pelvic floor. But in neonates, the pelvic floor anatomy may not be as elegantly demonstrated due to small size and relative paucity of fat; also this modality is not widely available in our country.

In conclusion congenital perineal hernia is a rare lesion, which may present in neonate as a gluteal mass. Barium enema or CT scan can establish diagnosis. US can help by excluding other causes.

 
   References Top

1.Mathieu D, Guigui B, Valette PJ et al. Pancreatic cystic neoplasms. Radiol Clin North Am 1989; 27:163-175   Back to cited text no. 1    
2.Hubbard AM, Egelhoff JC. Posterior perineal hernia presenting in infancy as a gluteal mass. Pediatr Radiol 1989; 19:246.   Back to cited text no. 2    
3.Poon FW, Lauder JC, Finlay IG. Perineal herniation. Clin Radiol 1993; 47:49-51.  Back to cited text no. 3    
4.Lubat E, Gordon RB, Birnbaum BA, Megibow AJ. CT diagnosis of posterior perineal hernia, AJR 1990; 154:761-2  Back to cited text no. 4    

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Correspondence Address:
L Upreti
University college of Medical Sciences & GTB Hospital, Shahdara, Delhi 110095, Delhi University
India
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Source of Support: None, Conflict of Interest: None


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