title: Delayed repair of obstetric injuries of the anorectum and vagina. A stratified surgical approach.
abstract: OBJECTIVE
  We categorized the various types of post-obstetric injuries of the anorectum and vagina encountered in a five-year period. The operative procedures used to repair these injuries and the functional outcome after surgery were assessed.
  
  
  METHODS
  Between 1986 and 1991, 52 patients were surgically treated for obstetric injuries of the anorectum and vagina; 48 patients were available for follow-up study. Four clinical injury types were identified: Type I, incontinent and sphincter (11 patients); Type II, rectovaginal fistula (16 patients); Type III, rectovaginal fistula and incontinent and sphincter (11 patients); and Type IV, cloaca-like defect (10 patients). The mean age of the patients was 30 years, the mean duration of symptoms before surgery was 13 months, and the mean follow-up period was 16 months. The major component of surgical repair for each injury type was: Type I, overlap repair of external anal sphincter; Type II, rectal mucosal advancement flap; Type III, overlap repair of external anal sphincter and rectal mucosal advancement flap; and Type IV, overlap repair of external anal sphincter, anterior levatorplasty, and anal and vaginal mucosal reconstruction. Fecal diversion was not performed in any patient. Specific questions were asked at the most recent follow-up assessment to determine results.
  
  
  RESULTS
  Continence status postoperatively was classified as perfect, impaired, or poor; poor was defined as no improvement or worse. Postoperative continence (perfect impaired, or poor) was, respectively: Type I (11 patients), 64 percent, 36 percent, and 0 percent; Type II (16 patients), 56 percent, 0 percent, and 44 percent; Type III (11 patients), 64 percent, 36 percent, and 0 percent; and Type IV (10 patients), 90 percent, 10 percent, and 0 percent. Vaginal discharge of stool was eliminated in all patients with a rectovaginal fistula. Subjectively, 92 percent of the patients had excellent or good results. Complications included wound hematoma (n = 2), fecal impaction (n = 2), urinary retention (n = 1), and urinary tract infection (n = 1).
  
  
  CONCLUSIONS
  Patients with Type II injuries had the worst results (P < 0.001). These patients should be evaluated for anal incontinence before surgery to assess the need for a concomitant sphincteroplasty.
authors.affiliation: Division of Colon and Rectal Surgery, Mount Carmel Health, Columbus, Ohio.
authors.forename: K S
authors.initials: KS
authors.lastname: Khanduja
authors.forename: H J
authors.initials: HJ
authors.lastname: Yamashita
authors.forename: W E
authors.initials: WE
authors.lastname: Wise
authors.forename: P S
authors.initials: PS
authors.lastname: Aguilar
authors.forename: R F
authors.initials: RF
authors.lastname: Hartmann
mesh_terms: D000328:Adult; D000368:Aged; D036861:Delivery, Obstetric / Q000009:adverse effects*; D005242:Fecal Incontinence / Q000209:etiology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007431:Intraoperative Complications / Q000209:etiology / Q000601:surgery*; D008875:Middle Aged; D009774:Obstetrics; D011182:Postoperative Care; D011247:Pregnancy; D011300:Preoperative Care; D012006:Rectovaginal Fistula / Q000209:etiology / Q000601:surgery*; D012007:Rectum / Q000293:injuries* / Q000601:surgery*; D013524:Surgical Flaps / Q000379:methods; D013514:Surgical Procedures, Operative / Q000379:methods; D013997:Time Factors; D016896:Treatment Outcome; D014621:Vagina / Q000293:injuries* / Q000601:surgery*