Anatomy of the descending perineal syndrome. Surgery to locate and repair the DTPs (deep transversus perinei) which are the suspensory ligament of the perineal body requires a much wider dissection. Exposure of a widely laterally displaced perineal body and elongated deep transverse perineal ligament supports is made by a 5-cm full-thickness transverse incision made just inside the hymenal ring. With descending perineal syndrome, the serosa and smooth muscle wall of the rectum are ruptured, and the rectal mucosa is spread to become adherent to the vagina and deep transversus perinei. Careful dissection is required to separate the rectal mucosa. Two to three interrupted sutures close the smooth muscle layer. The DTP is identified and repaired. As the DTP shortens, the perineal bodies fold inward and are gently approximated. The vagina is sutured without excision of tissue (as shown in doi: 10.21037/atm-23-1803). DTP, deep transversus perinei.