Anorectal / Bowel Dysfunction
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Obstetric traumatic cloacal defect (TCD) occurs in women that have sustained a third or fourth degree tear during vaginal delivery.The incidence of Obstetric TCD is 0.003% and is characterized by disruption of the anal sphincter complex, loss of the perineal body and distal rectovaginal septum . Risk factors include operative forcep delivery, large fetal weight and median episiotomies. [2, 3] Severe damage to the sphincter and perineal body can cause significant anatomical and functional abnormalities that have a significant impact on women. Common symptoms include fecal incontinence, perineal pain, sexual dysfunction and recurrent urinary infections [2, 3]. This can have serious psychological and social consequences on the affected individual.
We present a case of a 45 year old female with an Obstetric Traumatic Cloacal Defect secondary to a vaginal delivery with a fourth degree tear. She presented with several episodes of postcoital bleeding. On examination, it became clear that she had sustained an Obstetric TCD. She had no other complaints and denied Fecal incontinence. Her Wexner Score was 2.
The aim of this case is to describe the repair of an obstetric traumatic cloacal defect remote from delivery.
The procedure started with an inverted U incision in order to facilitate access to the sphincter complex. The sphincter complex was carefully dissected. It was noted that the right sphincter complex was more retracted and atrophied than the left. Therefore the left sphincter complex had to be mobilized to compensate for this. The distal vagina was divided above the thinnest area on the posterior vaginal wall and continued apically in order to adequately mobilize the posterior vaginal mucosa in order to sufficiently cover the reconstructed posterior vaginal wall and perineal body. A standard overlapping sphincteroplasty was done. Care was taken to maintain a normal anal calibre. The rectal muscularis layer was reinforced. The noted rectocele was repaired and a levatorplasty was done. Care was taken not to narrow the vaginal introitus. The perineal body reconstruction was continued with the approximation of the bulbocavernosus muscle and perineal fascia. The skin was then closed. The immediate postoperative course was uncomplicated. The patient was not experiencing any fecal incontinence at the 6 week postoperative visit.
Obstetric traumatic cloacal defect repair is challenging, particularly when remote from delivery. The anatomic deformities and atrophy of the sphincter muscles can make it difficult to identify and repair the structural defects. Our video demonstrates this rare presentation and the surgical approach to its repair.
Herand Abcarian, Charles P. Orsay, Russell K. Pearl, Richard L. Nelson, Susan C. Briley. Traumatic cloaca. Dis Colon Rectum 1989; 32:783-7.Venkatesh KS, Ramanujam P. Surgical treatment of traumatic cloaca. Dis Colon Rectum 1996; 39: 811-6.Kaiser AM. Cloaca-like deformity with faecal incontinence after severe obstetric injury--technique and functional outcome of ano-vaginal and perineal reconstruction with X-flaps and sphincteroplasty. Colorectal Dis. 2008 Oct;10(8):827-32. doi: 10.1111/j.1463-1318.2007.01440.x. Epub 2008 Jan 16. PMID: 18205849
Continence 2S2 (2022) 100305DOI: 10.1016/j.cont.2022.100305