title: 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.
abstract: OBJECTIVE
  Surgical technique and outcomes report.
  
  
  BACKGROUND
  Three to eight per cent of vaginal deliveries are complicated by third- or fourth- degree perineal lacerations, resulting in a cloaca-like deformity in up to 0.3%. These three-dimensional defects result in often debilitating incontinence and symptoms similar to a rectovaginal fistula because of the lack of the distal rectovaginal septum.
  
  
  METHODS
  Between 2001 and 2006, 12 women (median age 37, range 20-57) with faecal incontinence and a postobstetric-injury-associated cloaca-like deformity underwent an ano-vaginal and perineal reconstruction with X-flaps and sphincteroplasty without primary faecal diversion.
  
  
  RESULTS
  The patients presented 13.0 +/- 2.9 years (range 0.5-29 years) after the obstetric injury. The median Cleveland Clinic Florida faecal incontinence score was 16 (range 12-19). In addition, one patient complained of vaginal discharge, another of dyspareunia. All patients had an open rectovaginal communication with a large anterior sphincter defects (mean 160.2 +/- 22.8 degrees, range 113-180). Resting/squeeze pressures were 28.0 +/- 4.4/63.2 +/- 8.1 mmHg, respectively. Pudendal neuropathy was present in five patients. The median length of hospital stay after surgery was 5.3 +/- 0.7 days. Three patients experienced a postoperative rectovaginal fistula, two of which closed spontaneously, whereas the third required faecal diversion and a bulbocavernosus flap. After surgical follow-up of 9.8.3 +/- 2.8 months and long-term follow-up of 38.9.0 +/- 6.9 months, all the patients were satisfied with regards to overall function, continence and cosmetic result.
  
  
  CONCLUSIONS
  Cloaca-like deformity resulting from severe obstetric injury is often not given appropriate attention. Reconstruction of the original anatomy is complex but achieves good results and does not require a prophylactic faecal diversion.
authors.affiliation: Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA. akaiser@usc.edu
authors.forename: A M
authors.initials: AM
authors.lastname: Kaiser
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000601:surgery*; D015331:Cohort Studies; D036861:Delivery, Obstetric / Q000009:adverse effects / Q000379:methods; D005242:Fecal Incontinence / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015601:Injury Severity Score; D008875:Middle Aged; D007744:Obstetric Labor Complications / Q000175:diagnosis / Q000601:surgery*; D017060:Patient Satisfaction; D010502:Perineum / Q000293:injuries / Q000601:surgery; D011182:Postoperative Care / Q000379:methods; D011247:Pregnancy; D019651:Plastic Surgery Procedures / Q000379:methods*; D020127:Recovery of Function; D012006:Rectovaginal Fistula / Q000209:etiology / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment; D013524:Surgical Flaps; D016896:Treatment Outcome; D055815:Young Adult