V53 - Repair of Total Perineal Defect Fourteen Years After Obstetric Injury

CME Eligible

Purpose/Background: Total perineal defect is a spectrum of tissue loss from the perineal body and rectovaginal septum. First described as a "traumatic cloaca", this is typically seen in after perineal lacerations during vaginal delivery. Patients typically present 13.0 years after injury with pain, sexual dysfunction and fecal incontinence. Sphincteroplasty has been shown to significantly improve continence. We present a video showcasing rectovaginal fistula (RVF) with complete perineal body loss repaired by overlapping sphincteroplasty and perineal reconstruction.

Methods/Interventions: A 45-year-old woman with well controlled diabetes presented with severe fecal and urinary incontinence for the past 3 years. She reported multiple daily episodes of passing stool and flatus without sensation, and frequent urinary leakage. Obstetric history included three vaginal deliveries; the last was 14 years prior complicated by a perineal laceration that was repaired primarily. Exam showed complete absence of the perineal body with the posterior vaginal wall in continuity with anorectal mucosa. The anal sphincter was absent anteriorly, with minimal tone. MR defecating proctogram confirmed a full-thickness defect involving nearly the entire anterior sphincter complex. Perineal reconstruction with an overlapping sphincteroplasty and diverting ostomy was planned with Urogynecology.

A diverting loop ileostomy (DLI) was created laparoscopically and then she was placed in high lithotomy position. The junction of anorectal and vaginal mucosa was incised and the recto-vaginal plane developed bilaterally until the anal sphincter edges were identified. Muscle stimulation assisted with sphincter identification. After mobilizing the sphincters off the fat and scar to ensure a tension-free repair, the internal sphincter was repaired followed by the external sphincter using polydioxanone mattress sutures and 2 cm overlap for both. The vaginal and rectal mucosa were each reapproximated with interrupted polyglactin sutures. The horizontal perineal incision closed in an upside-down Y manner with interrupted polyglactin sutures.

Results/Outcomes: She was discharged after an uneventful overnight stay. Two weeks postoperatively she was treated with antibiotics for a UTI. Three weeks postoperatively she developed a candidal skin infection and opening of the wound at skin level. She was treated with wound care and fluconazole. Four months postoperatively, the skin wound was healed. Exam under anesthesia revealed intact perineal reconstruction with 2mm persistent rectovaginal fistula at the proximal extent of the repair. Stitches were placed on the vaginal and rectal mucosa to close the persistent fistula. Her urinary incontinence was addressed with a retropubic mid-urethral sling. While her urinary continence improved, she had 4 UTI episodes over the next several months. Eight months postoperatively, exam under anesthesia confirmed complete healing of the fistula. DLI closure will take place at one year postoperatively, delayed due to insurance concerns.

Conclusion/Discussion: Our case highlights multidisciplinary management of a patient with total perineal defect and severe fecal and urinary incontinence 14 years after obstetric injury. Her postoperative course included recurrent UTIs, superficial wound breakdown, and candidal infection. Ultimately, eight months after overlapping sphincteroplasty, perineal reconstruction and DLI, the RVF healed, and she is awaiting DLI reversal.

Total perineal defect
Tissue loss from the perineal body and the rectovaginal septum. Earlier described as a "traumatic cloaca".
Overlapping Sphincteroplasty
After ensuring adequate mobilization of the external anal sphincters, the edges are reapproximated with a 2 cm overlap.