RECTO-PERINEO-VAGINAL RECONSTRUCTION FOLLOWING SEVERE OBSTETRIC TRAUMA – CASE REPORT

Case presentation A 56-year-old female patient with fecal and gas incontinence and recurrent urinary tract infections was diagnosed with a laceration of the rectum, anal sphincter, perineal body, and the distal third of the vagina. Obstetric history includes four vaginal deliveries with the use of forceps. Proctological examination revealed labiated anterior rectal and posterior vaginal mucosa, with a complete rupture of the musculature between these organs and rectal prolapse. Digital rectal examination showed the absence of anterior sphincteric musculature—an open ring—with complete hypotonia. Rectocele was present. Endoanal ultrasound confirmed the anterior sphincter injury and perineal body injury. Anorectal manometry showed decreased internal and external sphincter pressures without paradoxical contraction of the puborectal muscle. The surgery involved individualization of the vagina and rectum up to the cul-de-sac and cervix, lateral dissection of the rectum, with medial mobilization of the rectal wall, reconstruction of the posterior vaginal wall over 7 cm, longitudinal plication of the anterior rectal wall over 8 cm to correct the rectocele, reconstruction of the distal anterior rectal wall, dissection of all damaged musculature (perineal body and sphincters) as a block, and medial mobilization. The musculature was sutured using X stitches without tension, followed by perineal skin closure. The patient was discharged on the second postoperative day.

Discussion Fecal incontinence (FI) has a prevalence of 15% in the population, primarily affecting multiparous and elderly women. Sphincter injuries may occur in 0.5-5% of vaginal deliveries, and 33-59% of these patients will develop FI as they age, significantly impacting their quality of life. Obstetric injuries can vary and may be complex, involving different pelvic compartments, innervation, organs, and supporting structures, leading to a range of clinical presentations. The goal of surgical intervention is to restore the damaged anatomy. The earlier the intervention, the better the results, with 40% of patients showing excellent outcomes within 5 years post-surgery. However, symptoms may recur due to changes typical of menopause. Physiotherapeutic rehabilitation is essential for better functional results.

Conclusion Proper preparation during pregnancy is essential to prevent injuries during vaginal delivery. Postpartum injuries can be repaired immediately by a qualified professional. Chronic injuries should be studied with attention to the pelvic floor as a functional unit to ensure treatment is strategic and multidisciplinary.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
25 April 2025