B A
Figure 1. A. Postpartum traumatic cloaca. B. Repair with overlapping technique.
Immediate repair of acute postpartum anal sphincter tear:
Case report
Oscar D. Brosutti1, Emilio M. Garcia Calcaterra2, Mauricio A. Minetti2,
Ariel M. Rigo3
1 Adjunct Professor of Surgey - FCM – UNL
2 General Surgeon
3 General Surgery Resident
General Surgery Service, Hospital J. B. Iturraspe, Ciudad deSanta Fe, Santa Fe, Argentina.
ABSTRACT
Obstetric anal sphincter injuries can occur spontaneously or as a consequence of an episiotomy during vaginal delivery. Their risk is estimated at 26% and they are the most frequent cause of anal incontinence in young women. Sultan grade 4 injuries, also called traumatic cloaca, involve complete rupture of the sphincter and communication of the vaginal cavity with the anal canal. The repair is always surgical, for which different techniques have been described, although none have proven to be superior. We present the case of a 23-year-old primiparous patient with a postpartum traumatic cloaca. Surgical repair was performed immediately with an overlapping technique. The postoperative period was without complications and one year later she presents complete anal continence.
Key words: traumatic cloaca, obstetric sphincter injury, anal tear, anal incontinence, childbirth complications
INTRODUCTION
Obstetric anal sphincter injuries (OASIs) can occur both spontaneously during vaginal delivery and as a result of an episiotomy. They are the most common cause of anal incontinence in young women. OASI have a variety of long-term complications, of which anal incontinence is the most distressing and disabling.1
The WHO Classification of Diseases reported an incidence of 4 to 6.6% of all vaginal deliveries. Risk factors may be maternal, delivery, and fetal factors.1
Diagnosis is made with a thorough examination of the perineum and bimanual digital rectal examination, which should be performed in all women before being sutured. A meta-analysis of 103 studies showed that 1 in 4 primiparous women have an anal sphincter defect diagnosed by ultrasound, between 3 and 6 months after delivery. The risk is increased 4-fold in deliveries assisted with forceps or vacuum.2 This study estimated a 26% risk of postpartum anal sphincter defects, including those not detected during routine clinical examination, which comprise 13%.
In 1999 Sultan3 classified postpartum perineal tears into 4 degrees, ranging from lesions of the vaginal epithelium or perineal skin to complete disruption of the anal sphincter complex and anorectal mucosa (traumatic cloaca).
The authors declare no conflicts of interest.
Correspondence: Emilio M. Garcia Calcaterra. drgarciaemilio@gmail.com. Pedro Vittori 3545, 9F, Ciudad de Santa Fe, Argentina. Ph: (+54)3404-636377
Oscar D. Brosutti: ORCID0000-0002-1859-9299; Emilio M. Garcia Calcaterra: ORCID 0000-0002-2425-2726; Mauricio A Minetti: ORCID 0000-0001-6389-3406; Ariel M. Rigo: ORCID 0000-0002-5601-6402
The repair of these injuries is always surgical. Although there are studies that compare different surgical techniques, the current literature does not recommend one technique over another.
We present a patient with severe grade 4 obstetric trauma, successfully repaired immediately with an overlapping technique.
CASE
A 23-year-old primiparous pregnant woman with a gestational age of 40 weeks was admitted to the Obstetrics service in labor. Her height was 161 cm, weight 66 kg, and BMI 25.46. The vital signs of the patient and the fetus were normal.
After delivery, an emergency consultation with the general surgery service is performed due to pain and fecal incontinence associated with a perineal injury compatible with a tear of the anal sphincter. The delivery had not been dystocic, no forceps or vacuum had been used and the newborn weighed 3380 g, with a height of 48 cm and a head circumference of 34 cm.
Perineal examination, performed by a surgeon trained in Coloproctology, revealed a laceration in the anal mucosa that extended through the entire thickness of the sphincter complex to the vagina. The ends of the sphincter were retracted laterally. There was minor bleeding from the lacerated edges of the perineal muscles. The remainder of the vaginal examination was normal. OASI Sultan grade 4 or “traumatic cloaca” was diagnosed (Fig. 1).
B A
Figure 1. A. Postpartum traumatic cloaca. B. Repair with overlapping technique.
A primary repair under spinal anesthesia was decided. Lithotomy position was used and a sterile field was performed with povidone iodine. Initially, the puborectalis muscles were sutured with 3-0 polypropylene sutures to provide more support for the posterior sphincteroplasty. The lacerated ends of the external anal sphincter were identified and grasped with Allis forceps. The sphincter ends were mobilized enough
to achieve overlap, but not too much to avoid compromising vascularity and innervation and then repaired with interrupted 3-0 polypropylene sutures. The vaginal epithelium was repaired with 3-0 polyglactin 910 sutures and the perineal wound was closed longitudinally to separate the anus from the vaginal introitus (Fig. 2). A 10 Fr silicone subcutaneous drain was placed to prevent collections and repair failure.
B A
Figure 2. Repair of obstetric injury. A. Immediate postoperative period. B. Control at one year.
In the postoperative period prophylactic intravenous antibiotics for aerobic and anaerobic germs were prescribed for 48 hours, as well as analgesics and habitual mobility. Twenty-four hours after the procedure, a liquid diet was started. The drain was removed at 48 hours and the patient was discharged at 72 hours with only analgesics. Postoperative control was performed by weekly physical examination during the first month and quarterly thereafter for up to a year. At that time, Wexner's score was 1/20, indicating almost complete continence.
DISCUSSION
In the present case, the anal sphincter defect was repaired immediately after trauma. Spinal anesthesia was used, a particularly important requirement for the overlap repair as sphincter muscle tone can cause the lacerated ends to retract. Muscle relaxation is necessary to recover the ends and overlap them without tension. We chose polypropylene suture because, being monofilament, it has less risk of infection compared to braided suture.
There were no postoperative complications and the control at one year showed a minimum score of incontinence according to the scale of Jorge and Wexner.4
The incidence of these injuries depends on many variables such as the use of episiotomy, the type of delivery (spontaneous or assisted), the type of instrument used (forceps, vacuum), parity, ethnicity, etc.
Accurate diagnosis and proper management are crucial to prevent anal incontinence and are now an essential part of obstetric training.2 If not properly diagnosed and repaired, they can cause hygienic, social, and psychological problems in patients, resulting in poor quality of life and high healthcare costs.1
OASIs Sultan grade 4 must always be surgically repaired and although no repair technique has currently been shown to be superior to another, we believe that every surgeon and/or obstetrician should be familiar with all of them. Two meta-analyses report that the two most commonly used techniques (overlapping or end-to-end suture) have the same future risk of anal incontinence (45 vs. 49%, respectively). In addition, the guidelines recommend pelvic floor physiotherapy as a complement to surgical treatment.1,2 Unlike other published cases,5 in ours the repair was not delayed, obtaining good results and avoiding unnecessary discomfort in the patient.
If the obstetrician does not have sufficient experience repairing third and fourth-degree tears and an experienced surgeon is not immediately or locally available, repair can be delayed 8 to 12 hours without affecting anal continence and pelvic floor symptoms (IA recommendation). If repair is delayed, a center with more experience may be required.1 This suggests that obstetricians need to undertake a more comprehensive postpartum examination and possess OASIs repair skills acquired through structured training.
With any method of repair, there is still a high risk of persistent anal sphincter defects, which could indicate the need for routine endoanal ultrasonography after delivery, especially in those women at increased risk of injury.2
REFERENCES
1. Harvey MA, Pierce M, Alter JE, Chou Q, Diamond P, Epp A, et al. Obstetrical anal sphincter injuries (OASIS): prevention, recognition, and repair. J Obstet Gynaecol Can. 2015; 37:1131-48. Erratum in: J Obstet Gynaecol Can. 2016; 38:421.
2. Sideris M, McCaughey T, Hanrahan JG, Arroyo-Manzano D, Zamora J, Jha S, et al. Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020; 252:303-12.
3. Sultan A. Editorial: Obstetric perineal injury and anal incontinence. Clin Risk. 1999; 5:193-96.
4. Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum. 1993; 36: 77-97.
5. Balmaceda R, Galvarini M, Affroti L, Kerman J, Fermani C, Kerman A. Reparación de cloaca traumática. Reporte de un caso y revisión de la bibliografía. Rev Argent Coloproct. 2022; 33:90-5.
COMMENT
Less than 30% of women with fecal incontinence seek help and the lack of information on effective solutions is a major barrier for both patients and professionals.
From this article I would like to highlight two facts: that OASIs are more frequent than is thought and often under diagnosed, and that they are associated with impaired quality of life. This is a prevalent obstetric condition, with important consequences on quality of life and very high health costs. The need for knowledge of the subject of the intervening obstetrician is highlighted and it is necessary to emphasize the need for interdisciplinary work.
Immediate repair by a specialist in coloproctology is recommended. Regarding immediate or delayed repair, there is much controversy, and the publications support either procedure.
It is my personal opinion that, as stated in this article, it should be done immediately, mainly because it minimizes the discomfort suffered by the patient, although it requires the availability of a professional trained in the matter. Although this does not guarantee complete continence, like the one obtained in the case presented, it is associated with the best results, minimizing costs and reducing the incidence of litigation.
Another relevant piece of information is the diagnosis, which could be earlier and more accurate by means of intrapartum ultrasound.
It has been shown that the degree of continence decreases with medium and long-term follow-up; however, fortunately, the quality of life would not suffer such deterioration. This statement leads in turn to the implementation of complementary strategies such as sacral neuromodulation or stimulation of the posterior tibial nerve.
As a final comment, we recommend reading the publication by García-Armengol et al.4 who perform a comprehensive repair of the sphincter complex, thus achieving satisfactory results in a longer term, although randomized studies are needed to support it.
Dr. Federico Carballo Hospital Ignacio Pirovano
1. Muñoz-Duyos A, Galofré-Recasens M, Avilés-Arias M, Hinojosa-Jano J, Baanante JC, Lagares-Tena L. Overlapping sphincteroplasty and perineal repair of an obstetric ano-vaginal cloaca - a video vignette. Colorectal Dis. 2023. doi: 10.1111/codi.16494. Epub ahead of print. PMID: 36719255.
2. García Fernández N, Navarro Morales L, Reyes Díaz ML, Ramallo Solís I, María Jiménez Rodríguez R, De la Portilla De Juan F. Sphincteroplasty for the treatment of faecal incontinence after an obstetric injury - a video vignette. Colorectal Dis. 2021; 23:2199-200.
3. Hubert T, Cardaillac C, Fritel X, Winer N, Dochez V. Définitions, épidémiologie et facteurs de risque des lésions périnéales du 3e et 4e degrés. RPC Prévention et protection périnéale en obstétrique CNGOF .Gynecol Obstet Fertil Senol. 2018; 46:913-21.
4. de García-Armengol J, Martínez-Pérez C, Roig-Vila JV. Anatomic sphincteroplasty with combined reconstruction of internal and external anal muscles in the anal incontinence surgical treatment. Cir Esp (Engl Ed). 2022; 100:580-84.
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