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Perineal hernia after APR: what the bulge is and what can be done | CION Cancer Clinics
A perineal hernia is a soft bulge between the legs that can appear months or years after an abdominoperineal resection, because the muscle floor of the pelvis was removed with the cancer and bowel can push down into the gap. It is not the cancer returning. This page explains what it feels like, when it needs same-day care, how it is confirmed, and the repair options a surgeon may offer. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
MI
Medically reviewed by Dr. Mohammed ImaduddinConsultant Surgical Oncologist · MBBS, MS (General Surgery), MCh (Surgical Oncology) · last reviewed September 2026, next review due September 2027
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The short answer
What is a perineal hernia after APR?
A perineal hernia is a bulge between the legs, where the back passage used to be, that appears months or years after an abdominoperineal resection (APR). The operation removes the muscle floor of the pelvis, and loops of bowel can then push down into the space that is left. It is not the cancer coming back.
Why this area is weak after APR
APR takes out the rectum, the anus and the muscles around them. The wound between the legs is closed with stitches, so what holds the pelvic contents up is skin and scar, not the firm sling of muscle that used to be there. Standing, coughing and straining press the bowel down against it. Where the scar stretches, a soft swelling forms.
What this page can and cannot do
It explains what the swelling probably is, what needs checking the same day, and what a surgeon may offer. It cannot tell you whether your own swelling is a hernia. Only an examination, usually with a scan, can settle that.
A hernia at the stoma on the tummy is a different problem. See the page on parastomal hernia if the bulge is around the bag.
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One thing that cannot wait
If the bulge suddenly becomes hard, very painful or cannot be pushed back, and especially if the stoma stops working, the tummy swells or there is vomiting, a loop of bowel may be trapped inside the hernia. Go to the nearest emergency department the same day and say you have had an APR. Do not wait for a clinic appointment, do not eat while you wait, and do not try to force the swelling back yourself.
Not sure whether this applies to you?
Ask an oncologistWhat people notice
How does a perineal hernia feel?
Most start small and quiet. This is the pattern surgeons hear most often.
A bulge that comes and goes
A soft swelling between the legs that is bigger when you stand, cough or strain, and smaller or gone when you lie flat. That change with position is the most useful clue.
A dragging ache
A heavy, pulling feeling low in the pelvis by the end of the day. It is dull rather than sharp, and it eases with lying down. Sharp, constant pain is covered in the box above.
Trouble sitting
Sitting is already hard for many people after APR. A hernia makes it worse, because you are now sitting on the bowel itself.
Often also reported
- Skin soreness over the swelling
- Difficulty with tight clothing
- Pressure on the bladder
Changes in the stoma output
If bowel is caught in the hernia, output from the bag can become erratic, with cramps and bloating. A full stop in output with vomiting is an emergency, not something to watch.
The causes
Why does it happen, and could it have been prevented?
It happens because the operation created a space that the body has no muscle to close. Nothing you did caused it, and most of what raises the risk was part of treating the cancer properly.
What raises the chance
A wider removal, called extralevator APR, takes more pelvic floor muscle to get a safer margin (the rim of healthy tissue around the tumour), and leaves a bigger gap. Radiotherapy before surgery makes the tissue heal more slowly and less firmly. A perineal wound that broke down or became infected leaves weaker scar. Smoking, a long-standing cough and heavy lifting in the early months all add strain.
What surgeons do to reduce it
Some teams fill the gap at the first operation with a flap of muscle and skin from the buttock or tummy, or with a mesh. This is chosen case by case, and not for everyone, because it lengthens the operation and has its own risks. Ask your surgeon how your perineum was closed, because that shapes what can be done now.
Published rates vary widely between studies. Treat any figure you read online as a rough guide, not a personal risk.Leave a number, we will call you
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At the clinic
How is a perineal hernia confirmed?
Examination standing and lying
The surgeon looks and feels between the legs while you stand, cough and then lie down. Most hernias are obvious this way. It is normal to feel awkward about it, so bring whoever puts you at ease.
A scan, usually a CT or MRI
The scan shows what is inside the bulge and how wide the gap in the pelvic floor is. It also checks that there is no sign of the cancer having come back in the pelvis, which is the question most families are really asking.
A conversation about how much it troubles you
Treatment depends less on the size of the hernia than on what it stops you doing. Be honest about sitting, working, bathing and intimacy.
A decision with your team
Repair is discussed with the surgeon who did the APR where possible, and often with a plastic surgeon. Whether to operate, and how, is their call together with you. This page cannot make it.
What can be done
What are the treatment options?
There is no single standard repair. Each option suits some people and not others, and your surgeon will say which applies to you.
Watching, with support
A small hernia that causes little trouble is often left alone and checked at each follow-up visit. Supportive underwear, a cushion with a cut-out and sensible lifting keep most people comfortable.
Does not suit
- A hernia that is growing quickly
- Any episode of trapped bowel
- Skin breaking down over the bulge
Repair through the perineum
The surgeon reopens the scar between the legs, pushes the bowel back up and closes the gap, usually with a mesh. The tissue there is scarred and often irradiated, so healing can be slow.
Repair from above, open or keyhole
The gap is closed from inside the tummy with a mesh laid across the pelvic floor. It gives a clearer view of the bowel and is often chosen when the gap is wide.
Ask whether keyhole is an option at your centre. It is not right for every hernia.Filling the gap with a flap
Muscle and skin from the thigh, buttock or tummy is moved into the pelvis to fill the space. It is the biggest operation of the group, kept for large hernias or ones that have come back after mesh.
Commonly believed
Four things families say, and what is actually true
"A new swelling there means the cancer has come back."
A soft bulge that changes with position is far more often a hernia than a recurrence (the cancer returning). A recurrence tends to be firm, fixed and steadily painful. The scan checks for both, so ask the question directly rather than carrying it silently.
"A tight belt or bandage will hold it in and fix it."
Support can make you more comfortable, and that is reason enough to use it. It does not close the gap, and a binding that is too tight can make the skin sore or trap bowel. Use what your stoma nurse recommends, not a home-made wrap.
"It was caused by lifting my grandchild."
One lift does not cause a hernia. The gap was there from the operation, and everyday strain made it show. Guilt about a single moment is common and misplaced.
"Every hernia has to be operated on."
Many are watched for years without harm. Repair is offered when the hernia limits your life, is growing, or has trapped bowel. It carries real risks in irradiated tissue, so surgeons weigh it carefully, with you.
Questions we are asked
Common questions about perineal hernia after APR
How soon after APR can a perineal hernia appear?
Usually within the first year or two, once the wound has healed and you are back on your feet. It can appear later, and it is sometimes found on a routine follow-up scan before you have felt anything. A bulge in the first weeks is a different problem, so tell your team straight away.
Is it dangerous to leave it?
A small, soft hernia that goes back when you lie down is usually safe to watch. The danger is bowel becoming trapped and losing its blood supply, which shows as sudden hard pain, a swollen tummy, vomiting and a stoma that stops. That is rare, but it is an emergency.
Can I still sit, drive and work?
Most people can, with adjustments. A cushion with a cut-out, standing up often, and a chair that spreads the weight all help. If sitting for a shift or a long drive has become impossible, say so at the clinic. That is the kind of limit that tips the decision towards repair.
Will the scan also check for the cancer coming back?
Yes. A CT or MRI of the pelvis shows the hernia and the tissue around it, and your surgeon reads it for both. Many families worry more about recurrence than about the hernia, and it is fair to ask for that part of the answer first.
Is repair a big operation?
It can be, because the tissue has been operated on before and often irradiated. A perineal repair means a cut between the legs again and a slow-healing wound. A flap repair is the largest of the three.
Can it come back after repair?
Yes. No repair in this area holds for everyone, because the downward pull of the pelvic contents does not go away. Rates of return vary between studies and methods, and a second repair is sometimes needed.
What can I do to keep it from getting worse?
Keep your weight steady, treat any cough promptly, avoid straining, and lift with your legs rather than your back. Wear the support your stoma nurse suggests. None of this closes the gap, but it reduces the daily pressure on it.
Who do I contact first if I think I have one?
Your stoma nurse or the surgical team that did the APR. They know how your perineum was closed and can arrange the examination and scan quickly. If you cannot reach them, call the helpline and we will help you get to a surgical oncologist who can see you with your old reports.
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Sources
- Cancer Research UK — Surgery for bowel cancer
- American Cancer Society — Surgery for Rectal Cancer
- NHS — Hernia
- NHS — Colostomy
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
The Perineal Wound After APRThe wound whose closure the hernia later stretchesParastomal Hernia After APRThe other hernia after this operation, around the stomaSitting, Cushions and Comfort After APRPractical help for the sitting problem a hernia makes worseFollow-Up After APRThe visits where a hernia is usually picked upComplications and Red FlagsThe signs after any cancer operation that cannot wait
Talk to us
Noticed a new swelling after APR?
Tell us when the operation was and what you have noticed. We will help you reach a surgical oncologist who can examine you with your old reports. One helpline serves every CION centre.