Rectovaginal fistula after fourth degree perineal tear (transperineal ultrasound)

Case contributed by Gamal Elsayed Abdelmoamen Fares
Diagnosis certain


Gravida 6 parity 6, last delivery 26 years ago, all normal vaginal deliveries, complained of involuntary defecation, history of perineal tears during her deliveries.

Patient Data

Age: 65 years
Gender: Female

On bi-digital examination of vagina and rectum, a perineal body defect was detected and stool leakage from vaginal orifice was detected with good levator ani contraction on the Kegel test.

Images of 3D pelvic floor US (images 1 and 2 ) show fusion of vaginal and anal orifices with no separation (internal, external and superficial anal sphincters avulsed with absence of vaginal mucosa and superficial transverse perineii muscle which means perineal body avulsion).

Images of 3D pelvic floor US (images 3 to 7) show discontinuity of rectovaginal separation at the level of puborectalis muscle with separation of both edges of superficial and external anal sphincter in images 3 and 4.

Images 8 to 10 show good rectovaginal separation with preserved rectal mucosa (hypoechoic area).

The last two images show tomographic US study (the deepest level to the most superficial level), the start of the defect is from the 4th image onwards.

Case Discussion

A rectovaginal fistula is an abnormal connection between the rectum and the vagina. Rectovaginal fistulas are often the result of trauma during childbirth (in which case it is known as an obstetric fistula), with increased risk associated with significant lacerations or interventions are used such as episiotomy or operative (forceps/vacuum extraction) deliveries or in situations where there is inadequate health care.

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