MENAGEMENT OF BUTTONHOLE RECTAL INJURY AFTER VAGINAL DELEVERY - A CASE REPORT

Abstract

Abstract Introduction. A special form of higher degree perinealtear is a laceration of the anorectal epithelium with in-tact external anal sphincter muscle (“buttonhole tear”). This is very rare but, when not treated, carries the risk of a rectovaginalfistula. Case Report. We present a case of a nullipara, in which a spontaneous vaginal delivery of a fetus in the vertex presentation was complicated by a buttonhole rectal tear with a partial lesion of the sphincters. It was recognized on the 4thpostpartum day, and a recon-struction of the lesion with a diversing colostomy was made soon. Upon returning the colostoma, the patient at 6 months postpartum has good continence and is in a good condition. Discussion. There are very few cases reporting an isolated rectal lesion during parturition. Several factorsmay play a role in the etiology of these lesions, inclu-ding instrumentation, birth weight of more than 4 kilo-grams, midline episiotomy, persistent occipitoposterior presentation, nulliparity, tissue factors, and second sta-ge >1 hour. Obstetric anal sphincter and rectal injuriescan be missed if rectal examination is not carried out asa standard procedure prior to suturing. This can have a devastating effect on the physical and emotional well-being of women.Conclusion. Careful examination of the vagina and the rectum should be performed in all cases of perineal tears following a vaginal delivery. Buttonhole injuries, although rare, should be considered as severe traumas similar to the 4th degree lacerations and managed prom-ptlyby experienced surgeons.