Rectovaginal fistula and Perineal tear in females

1. Rectovaginal Fistula (RVF)
AND
Perineal Tear
ABDULLAH ALMUHAYMIDI
ABDULLAH ALMAZED

2. Objectives
♦ Define, Identify the degrees,
List the causes & Lines of
management of RVF.
♦ Enumerate Causes, Types,
Complications & Lines of
management of perineal tear.

3. Rectovaginal Fistula
Etiology
1. Traumatic
 Obstetrical trauma*
 Surgical trauma.
 Direct trauma.
2.
Inflammatory:
 Pelvic abscess.
 TB.
 Crohn’s disease.
3. Neoplastic
4. post-
irradiation
An Abnormal communication between the rectum and the vagina.
* Most Common

4. Classification
ACCORDING TO THE LOCATION
 Low RVF is between the lower third of
the rectum and the lower half of the
vagina ⇒ closest to the anus and can
be corrected with a perineal approach
 High RVF is between the middle third
of the rectum and the posterior vaginal
fornix ⇒ a transabdominal approach
for repair
ACCORDING TO THE SIZE
 Small-sized fistulas are less than 0.5 cm
in diameter
 Medium-sized fistulas are 0.5-2.5 cm
 Large-sized fistulas exceed 2.5 cm.

6. Clinical Presentation
Most patients report passage of flatus or stool through the vagina, vaginitis or cystitis,
foul-smelling vaginal discharge develops.
The clinical picture may include fecal incontinence due to associated anal sphincter damage.
Physical Examination
This usually confirms the diagnosis and affords much information regarding the size and
location of the fistula, the function of the sphincters, and the possibility of IBD or local
neoplasm.

7. Diagnosis
Flexible endoscopy (sigmoidoscopy or colonoscopy) is used to fully evaluate
the possibility of IBD or malignancy.
When IBD is in the differential diagnosis, endoscopy with biopsies must
precede any operative approach to the fistula because the treatment
varies, depending upon the diagnosis.
Management
1. Medical Therapy
Acute fistulas of traumatic origin like obstetric and operative trauma and fistulas
complicated by secondary infection or of infectious origin with local care drainage of
abscesses, and directed antibiotic therapy , Allow tissues to heal for 6-12 weeks.
Dietary modification and supplemental fiber can greatly diminish symptoms during
this period.
Many fistulas resulting from obstetric or operative trauma heal completely,
requiring no further therapy.
Radiation origin initially recommended Diet and fiber are the mainstays of therapy.

8. Management
2. Surgical
 Local repair methods
 Transanal advancement flap repair: using the operating anoscope.
 Conversion to complete perineal tear: with layer closure.
 Simple fistulotomy: for small anovaginal fistulas, in which no
sphincter is involved in the tract.
 Transabdominal approaches ;used for high RVFs when the fistula
originates from a neoplasm, radiation, IBD
 Fistula division and closure without bowel resection: Interposition
of healthy tissue, such as omentum, may be used to separate the
suture lines.

9. Perineal tear
-A laceration of the skin and other soft tissue structures which
separate the vagina from the anus.
-Perineal tears mainly occur in women as a result of
vaginal childbirth, which strains the perineum.
-A perineal tear is distinct from an episiotomy, in which the perineum
is intentionally incised to facilitate delivery.
Definition

11. Causes ?

12. Causes
Non-obstetric causes : RTA – Rape
Obstetric causes:
1. Instrumental vaginal deliveries (vacuum, forceps) : Forceps delivery is
likely to cause injury as the instrument occupies almost 10% more space
in the pelvis. The shanks of the forceps stretch the perineum and can
cause injury, particularly to the anal sphincter when pulling in the
posterolateral direction to encourage flexion of the head
2. Macrocosmic baby : Birthweight of more than 4 kg is associated with
maternal perineal injury, especially third- and fourth-degree tears

13. Causes
4-Malposition and malpresentation : Malposition, particularly the
persistent occipitoposterior position, leads to a larger presenting
diameter and is associated with difficult delivery. Face and brow
presentations are known risk factors for anal sphincter injury
5-Duration of labour and rate of delivery
6-Birthing position : There is evidence that delivery in the standing
delivery position may be associated with a higher incidence of
perineal injury

14. Classification
1 First-degree tear – involving the perineal or vaginal skin only
2 Second-degree tear – perineal skin and muscles torn, but intact anal sphincter
3 Third-degree tear – perineal skin, muscles and anal sphincter are torn
a – less than 50% of the external anal sphincter thickness is torn
b – more than 50% of the external anal sphincter thickness is torn, but internal
anal sphincter intact
c – both external and internal anal sphincters are torn, but anal mucosa intact
4 Fourth-degree tear – perineal skin, muscles, anal sphincter and anal mucosa
torn

16. If left untreated
 Hemorrhagic Shock.
 Infection.
 Predispose factor for genital prolapse.
 Persistent dyspareunia, dilated vaginal introitus,
vaginitis & sexual dissatisfaction.
 Cosmetic Disadvantage.
 Psychological depression.
3rd & 4th degree tears if left untreated may lead to fecal incontinence.
Incomplete healing of 4th degree may leads to RVF.
Complications

17. Management
First Degree : Based on the current evidence, non-suturing
is recommended only for first-degree perineal tears that
are not actively bleeding and have regular and well-
approximated wound edges.
Episiotomy and second degree :
1-Episiotomies and second-degree tears are conventionally
sutured in three stages (the traditional technique)
2- continuous non-locking (Fleming’s technique)
Notes : Following the repair of episiotomy or second-
degree perineal injury, adequate analgesia such as
diclofenac suppositories is recommended. If there are
associated urethral, labial, clitoral or vaginal tears, or if the
repair is difficult, insertion of an indwelling catheter for 24
hours is recommended to prevent acute urine retention.

18. MANAGMENT
Third and Forth degree : They should be conducted in the operating theatre, with good
lighting, appropriate equipment and aseptic conditions. The full extent of the injury should
be evaluated , General or regional (spinal, epidural, caudal) anaesthesia is an important
prerequisite, particularly for overlap repair, as the inherent tone in the sphincter muscle
can cause the torn muscle ends to retract within its sheath. Muscle relaxation is necessary
to retrieve the ends, especially if overlapping of the muscles without tension is intended
Intravenous antibiotics (cefuroxime 1.5 g and metronidazole 500 mg) should be
commenced intraoperatively and continued orally for 1 week

19. Follow-up and subsequent pregnancies
following third- and fourth-degree tears
All women should be warned of the possible sequelae of
anal sphincter disruption, and ideally should be assessed
6–12 weeks post-partum by anorectal physiology tests
and anal ultrasonography.

20. Thank you for
your attention