Chapter 94 - Part B: Perineal Hernias: When the Pelvic Floor Fails

In this BoardsCast episode, we continue Tobias Chapter 94 — Rectum, Anus, and Perineum by reframing perineal hernias the way the boards (and real life) demand:

A perineal hernia isn’t a “hole.” It’s a structural collapse.

If you treat it like a simple defect and just “stitch it shut,” you’re anchoring sutures into tissue that already failed — which is why recurrence rates are historically ugly. This episode builds the load-bearing model of the pelvic diaphragm and shows why durable repairs come from restoring support + force vectors, not closing a gap.

You’ll learn:

• Why is a perineal hernia a biomechanical support failure (load > support), not a localized tear
• The key anatomy: levator ani, coccygeus, external anal sphincter — and why levator ani is the usual “wet tissue paper” weak link
• Why intact older males dominate the stats — the hormonal/neurologic weakening pattern (relaxin + androgens + denervation)
• The prostate connection: how prostatic disease drives tenesmus and turns pressure into a battering ram
• The geometry trap: rectal deviation → sacculation → straining pushes feces into the pocket (self-amplifying loop)
• Emergency content you must recognize: bladder retroflexion and urethral kinking/obstruction
• Why traditional “pull it together” repairs fail — tension + weak anchors = recurrence
• Why internal obturator transposition is the gold standard: vascularized muscle flap, less tension, real reconstruction
• The non-negotiables that make repairs hold: castration (recurrence risk jumps if you don’t), stool management, and complication awareness (sciatic nerve)

Key takeaway:
If you treat the gap, it comes back. If you treat the load, it stays closed.

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