Repair of a rectovaginal cloacal defect

Document Type

Conference Proceeding

Publication Date

4-2024

Publication Title

Am J Obstet Gynecol

Abstract

INTRODUCTION: Acquired rectovaginal cloacal defects are an uncommon condition encountered by Urogynecologists, Female Urologists, and Colorectal Surgeons. They are thought to occur following third and fourth-degree obstetric anal sphincter lacerations. Patients typically present with fecal or flatal incontinence, pelvic pain, or dyspareunia. On physical examination, providers may notice absence or near loss of the perineal body, abnormalities with the anal sphincter, or distal posterior vaginal wall prolapse.

OBJECTIVE: To review and demonstrate the surgical repair of a rectovaginal cloacal defect.

METHODS: We review a case of a 68-year-old G7P7007 Yemeni woman with a chief complaint of flatal incontinence. She has a history of three prior vaginal deliveries followed by four cesarean sections, and was unsure if she had any significant obstetric anal lacerations following her deliveries. She started to experience flatal incontinence approximately 5-6 months before her initial consult after she sustained a fall with impact to the perineum and vagina. She denied any fecal or urinary incontinence and was found to have near loss of her perineal body and stage II posterior vaginal wall prolapse on physical examination. Following counseling, she elected to proceed with surgical repair.

RESULTS: Our patient signed an informed consent to have the procedure recorded and presented. A J-shaped incision was created on the posterior vaginal epithelium and sharply dissected to separate the overlying epithelium from the underlying structures. A perianal skin incision was then performed bilaterally to help gain access to the levator muscles and anal sphincter complex. Sharp and blunt dissection was then conducted to develop the ischiorectal fossa and access the levator muscles. The puborectalis muscle was then tagged bilaterally with suture for later identification. The anal sphincter complex remnants were then dissected bilaterally. The puborectalis muscles were then brought together in the midline. An overlapping sphincteroplasty was then performed, paying attention to not apply excess tension and maintain a normal anal caliber. The bulbocavernous muscle, transverse perineal muscle, and subcutaneous tissues were then repaired to complete perineal body reconstruction. A posterior repair was then repaired in standard fashion. The overlying posterior vaginal wall epithelium and perineal body epithelium was then closed to complete the repair. The patient was discharged home on post-operative day one. She was seen in clinic two weeks following her surgery and had no further complaints of flatal incontinence.

CONCLUSIONS: Acquired rectovaginal cloacal defects are an uncommon condition. These defects require a detailed understanding of perineal anatomy to complete surgical repair. Our video aims to discuss a possible patient presentation, outline relevant surgical anatomy, and demonstrate an approach to repair a rectovaginal cloacal defect.

DISCLOSURE: No.

Volume

230

Issue

4

First Page

S1299

Last Page

S1300

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