PERINEAL LACERATIONS

And Recto-vaginal Fistula

Department of Obstetrics &
gynaecology
Cairo University
ANATOMY OF THE PERINEAL BODY

The perineal body is the

pyramidal shaped mass of
tissue wedged in be-tween the
vagina and the lower part of
the rectum. It is composed of
the following layers from
without inwards.
• Skin and Subcutaneous fat
• Superficial perineal muscles:
the external anal sphincter, the
bulbocavernosus (sphincter
vaginae), the transversus
perinei, and the
ischiocavernosus.
ANATOMY OF THE PERINEAL BODY

• All except the

ischiocavernosus have
one insertion in the
central part of the
perineal body.
• The decussation of the
levator ani muscles (deep
perineal muscles) be-
tween the vagina and
rectum forms the apex of
the perineal body.
 CAUSES OF PERINEAL LACERATION

A) Child birth trauma:

• 1. Large Head:
• Idiopathic; as in large for gestational age and macrosomic foetuses.
• Abnormal attitude of the foetal head; (face presentation, direct O.P.
positions and extended after-coming head in breech).

• 2. Narrow vaginal introitus:

• Rigid perineum (elderly primigravida, or scars of previous perineal
repair)
• Contracted pelvic outlet (narrow sub-pubic arch pushes the head
posteriorly leading to great stretching of perineal muscles).
• Severe oedema of the vulva with friable easily torn tissue (as in pre-
eclampsia).
 CAUSES OF PERINEAL LACERATION

• 3. Rapid delivery of the head through birth canal: (as

in precipitate labour).
• 4. Bad management of the 2nd stage of labour: This
is by far the most important cause, especially when rapid
delivery of the head occurs at the peak of uterine
contraction, or an instrumental delivery is performed
without proper perineal support.

• B) Other causes:
• Direct external trauma; as with fall from a height or car
accidents.
• Defloration injuries.
 DEGREES OF PERINEAL TEARS
• First degree tears involving the
skin and SUPERFICIAL
PERINEAL MUSCLES.

• Second degree tears:

LEVATORS ANI is involved as
well i.e., involving the whole
perineal body, but not going
through the anal sphincter. Both
the above types are included
under the term incom-plete tears.

• Third degree tears (Complete

perineal tear): the anterior portion
of THE SPHINCTER ANI is
involved. The rectal wall may be
torn leading to prolapse of the
rectal mucosa.
 SEQUELAE OF PERINEAL
TEARS
• Postpartum haemorrhage, due to bleeding from lacerations.

• Infection may occur in the laceration site (puerperal sepsis).

• Complete tears may lead to Incontinence to stools and flatus due to

division of the sphincter ani muscle. After sometime, some patients
will learn to contract the levator muscles and can control the
passage of solid faecal matter, but remains incontinent to liquid
stools and flatus.

• Residual rectovaginal fistula.

• Dyspareunia from a tender scar in the vagina.

 SEQUELAE OF PERINEAL
TEARS
• Patulous vaginal
introitus with
persistent
leucorrhoea, and
unsatisfactory sexual
function.
• Incomplete tears; may
predispose to genital
prolapse (due to loss
of pelvic floor
support).
 PREVENTION OF PERINEAL
LACERATIONS

• Proper management of 2nd stage of

labour. Maintain flexion of head until
crowning occur + slow delivery of head in
between uterine contractions.
• Episiotomy, when the perineum threatens
to tear.
MANAGEMENT OF PERINEAL
LACERATIONS
Every perineal tear, however, small,
should be repaired. Primary suture is
possible if done within the first 24 hours If
the case is seen later than that, it is
considered as a septic wound, and left to
heal by granulation, Repair in such cases
is postponed until all signs of infection
have disappeared, usually 3-6 month later.
 MANAGEMENT OF PERINEAL
LACERATIONS
• Perineorrhaphy in cases of a recent complete
tear consists of suturing the different layers
involved in the laceration in the following order:
• The rectal wall: is sutured in 2 layers by delayed
absorbable type of sutures, first continuous then
interrupted sutures not going through the
mucous" membrane. The sutures should extend
well above the apex of the laceration.
• The cut ends of the anal sphincter are identified,
and are sutured together.
 MANAGEMENT OF PERINEAL
LACERATIONS
• The levator ani are
approximated by at
least three interrupted
sutures.
 MANAGEMENT OF PERINEAL
LACERATIONS
• The superficial
perineal muscles
and fascia are
approximated with
interrupted sutures.
 MANAGEMENT OF PERINEAL
LACERATIONS
• The vagina and skin
are finally is sutured.
• The post-operative care
after perineorrhaphy will
be described later. It aims
at keeping the wound
DRY AND CLEAN to
encourage healing by
primary intention
 First degree tears
• Repair of superficial perineal layers The vaginal mucosa and
perineal skin are re-approximated with a continuous stitch of 3-0
delayed absorbable suture.
 Second degree tears
• Repair of a second degree laceration:
• A first-degree laceration involves the fourchette, the perineal
skin, and the vaginal mucous membrane.
• A second-degree laceration also includes the muscles of the
perineal body. The rectal sphincter remains intact.
 Third degree tears
• Repair of the
sphincter after a
third-degree
laceration:
• A third degree
laceration extends
not only through
the skin, mucous
membrane, and
perinal body, but
includes the anal
sphincter.
Interrupted figure-
of-eight sutures
should be placed in
the capsule of the
sphincter muscle.
 fourth-degree obstetric laceration
• Layered primary closure of a
fourth-degree obstetric
laceration
• (A) The anal mucosa is first
closed with a running or
interrupted layer of a 4-0
delayed absorbable suture.
• (B) The retracted ends of the
internal anal sphincter are
reunited with a running layer of
a 3-0 delayed absorbable
suture.
• (C) An end-to-end anastomosis
of the external anal sphincter
(EAS) is accomplished using
four or five interrupted 2-0
delayed absorbable sutures
placed through the capsule of
the EAS.
• (D) The rectovaginal fascia and
puborectalis fibers are
approximated with a running 2-
0 delayed absorbable suture.
 fourth-degree obstetric laceration

• Repair of rectal mucosa • Internal anal sphincter and

external anal sphincter.
 OLD COMPLETE PERINEAL
TEARS
• If a complete perineal tear is
not sutured after labour, the
wound heals by granulation.
• The patient regains control
over the passage of hard
stools, but remains incontinent
to flatus, and usually
complains of persistent
leucorrhoea.
• In spite of this, many patients
feel sufficiently comfortable not
to seek any treatment.
DIAGNOSIS OF OLD COMPLETE
PERINEAL TEARS
• A defect is noted in the perineal body,
extending to the anal opening.
• If the rectal wall is also torn, the bright red
colour of the rectal mucosa is apparent in
the lower part of the defect.
• On each side of the anus a small shallow
pit is seen in the skin. These two dimples
indicate the site of the cut retracted ends
of the anal sphincter.
DIAGNOSIS OF OLD COMPLETE
PERINEAL TEARS

• Absence of the normal corrugations

around the anus, except posteriorly.
• A finger introduced in the anus will confirm
absence of sphincteric control if the
patient is asked to contract her muscles.
 PRE-OPERATIVE PREPARATION

• The patient is admitted to hospital 5 days before the

operation, during which she is given the following
treatment:
• A purge is given on admission to empty the bowel.
• She is kept on a non-residue fluid diet (free of milk).
• An intestinal antiseptic such as neomycine,
sulphasuccidine, streptomycine by mouth or
chloramphenicol are given singly or in combination.
• Daily cleansing enema and vaginal douche. These are
repeated on the morning of the operation.
 OPERATION

• An H-shaped incision is made in the skin, with

the horizontal limb of the H at the junction of the
rectum with the vagina and the 2 vertical limbs;
at the site of the 2 dimples. The incision is
deepened to expose the various structures of
the perineal body, and the vagina is separated
from the rectum. Perineorrhaphy is then
performed following the steps described above.
A tight vaginal pack is left. A catheter may be left
in the urethra to avoid soiling of the area.
 AFTER-CARE

• After every micturition, or three times daily, the

vulva is washed with dettol solution, dried,
painted with alcohol. This is to keep the wound,
dry and clean.
• The low residue diet is continued, as well as the
intestinal antiseptic.
• Antibiotics against wound infection.
• The vaginal pack is removed after 24 hours.
 AFTER-CARE
• On the fifth night the patient is given 50 ml.
castor oil. Next morning when she feels the
desire to defecate, 150 ml. of olive oil are
introduced into the rectum using rubber catheter,
never the enema nozzle, and retained, in order
to lubricate the stools. After that the patient is;
given paraffin oil daily to avoid constipation.
• In the event of subsequent pregnancy, a
postero-lateral episiotomy should be done
before delivery of the head to avoid recurrence
of the laceration
 RECTO-VAGINAL FISTULA
AETIOLOGY
• 1. Congenital recto-vaginal fistulae are very rare.
• 2. Traumatic causes:
• a. Obstetric trauma: the commonest cause of a recto-
vaginal fistula is badly healed, complete perineal tear:
the lower part of the tear heals satisfactorily, but the
upper part breaks down due to sepsis or bad technique
in suturing, resulting in a communication between the
two passages.
• b. Surgical trauma: as injury to the rectum during
colpoperineorrhaphy or panhysterectomy.
• c. Other forms of trauma include Impalement injuries,
and the ulceration of an ill-fitting neglected pessary.
 AETIOLOGY OF RECTO-
VAGINAL FISTULA
• 3. Inflammatory conditions: as following rupture
of a perirectal or peri-anal abscess. Tuberculous
and syphilitic ulceration of the rectum are rare
causes.
• 4. Ulceration and direct extension of malignant
disease of the cervix, vagina, or anterior rectal
wall.
• 5. Post-irradiation fistulae are frequently seen
as complications of radium treatment. They are
always associated with symptoms of severe
proctitis.
 RECTO-VAGINAL FISTULA

Abnormal communication between the rectum and the vagina

 SYMPTOMS

• Large recto-vaginal fistulae produce very

distressing symptoms. The patient loses
voluntary control over passage of faeces and
flatus, and she suffers from a persistent
leucorrhoea, due to the associated secondary
vaginitis.
• If the fistula is small, the patient’s only complaint
may be involuntary escape of flatus, which she
feels as coming from the vagina
 TREATMENT

• In non-malignant cases, the fistula should be

closed by plastic opera-tion. Preparation of the
patient for operation as well as postoperative
care are as important as meticulous operative
technique. Essentially the pre-and post-
operative management is the same as has
already been described under complete perineal
tears.
 TREATMENT
• a. Fistulas in the lower
third of the vagina
• Lawson Tait’s (1845-
1899) operation:
consists of cutting the
remaining bridge of tissue
below the fistula, thus
converting the fistula into
a complete peri-neal tear.
The tear is now sutured in
layers, in the same
manner and order
described under repair of
complete tears.
 Fistulas in the lower third of the vagina

• Repair of a small rectovaginal fistula through a transvaginal

approach
 Fistulas in the lower third of the vagina

• Repair of a small
rectovaginal fistula
through a
transvaginal
approach: An
elliptical incision is
made about the fistula
tract
 Fistulas in the lower third of the vagina

• Repair of a small
rectovaginal fistula
through a
transvaginal
approach: The
posterior vaginal wall
is sharply mobilized
off of the anterior
rectal wall.
 Fistulas in the lower third of the vagina

• Repair of a small
rectovaginal fistula
through a
transvaginal
approach: The fistula
tract is excised,
including the adjacent
vaginal and rectal
mucosa.
 TREATMENT
• b. Fistulas in the middle third.
• These may he closed in the same manner as
has already been described for dealing with
vesico-vaginal fistulae. An alternative procedure
is to start the operation as in perineorrhaphy for
rectocele and to extend the dissection of the
recto-vaginal septum upwards above the fistula.
The hole in the rectum is then closed, and the
operation continued as a perineorrhaphy.
 TREATMENT
• c. Fistulas in the upper third:
• High recto-vaginal fistulas are usually
surrounded by dense fibrosis, and are
difficult to close vaginally. They are usually
best dealt with by an abdominal (trans-
peritoneal) operation