- Email: [email protected]
Fistula-in-ano after episiotomy
GYNECOLOGY Fistula-in-ano after episiotomy Denise Howard, MD, MPH, John O. L. DeLancey, MD, and Richard E. Burney, MD Background: In the past 2 years, we treated three women with fourth-degree lacerations or episiotomy infections presenting with persistent pain and drainage not responding to standard treatment. Cases: These women were referred for evaluation 5 weeks, 3.5 months, and 2 years postpartum. After diagnosing fistula-in-ano, we treated them with fistulotomy and curettage, which resolved the problem. Conclusion: When a patient presents with pain or drainage at her episiotomy site, fistula-in-ano should be considered. (Obstet Gynecol 1999;93:800 –2. © 1999 by The American College of Obstetricians and Gynecologists.)
During the past 2 years, three women were referred for evaluation of episiotomy complications. The cause of their problems, fistula-in-ano, is a common surgical entity consisting of a granulated tissue-lined communication between the anal canal and the perianal skin or perineum, initiated by an infecting source, often an anal abscess.1– 4 Infection develops as a result of trauma, fissures, Crohn disease, carcinoma, radiation, tuberculosis, or other infectious agents. The fistula extends from the dentate line internally to an external site of drainage, which might be highly variable. It is kept open by fecal flow and chronic infection or inflammation. After performing a MEDLINE search of the Englishlanguage literature from 1966 to the present, using the key words “fistula-in-ano,” “rectovaginal fistula,” “perineal fistula,” “vaginal delivery,” “episiotomy,” and “pregnancy,” we were unable to locate reports of fistula-in-ano associated with birth and episiotomy. In addition, three articles that specifically addressed anorectal complications of vaginal birth and episiotomy complications did not mention this entity.5–7 We found a single reference in the surgical literature that discussed the association of perineal fistulas and episiotomy.8 In the present study, we review the clinical presentation, features, and principles of treatment of fistula-in-ano in puerperal women.
From the Departments of Obstetrics and Gynecology, and Surgery, University of Michigan Health Systems, Ann Arbor, Michigan.
800 0029-7844/99/$20.00 PII S0029-7844(98)00368-8
Figure 1. Arrow shows draining tract between anal canal and perineal skin.
Cases Case 1 A 24-year-old woman, gravida 1, para 1, presented 5 weeks postpartum with vaginal flatus and leakage of stool from her vagina. This began after a forceps delivery, during which a fourth-degree extension of midline episiotomy occurred. Three days postpartum, she developed rectal pain and burning and noticed stool in her vagina. She presented for evaluation at 5 weeks postpartum and was given a presumptive diagnosis of a rectovaginal fistula. Extensive inflammation was noted at the fistula site and she was started on Kefzol (Eli Lilly and Co., Indianapolis, IN) (500 mg) four times a day for 10 days. Four weeks later she was reevaluated. The inflammation had subsided and a small sinus tract was noted in the perineal skin (Figure 1). Methylene blue-stained gel placed in the rectum could be expressed through this tract. There was no evidence of a rectovaginal fistula. Because of severe pain, an examination under anesthesia was performed. A large, anterior anal fissure, communicating through a fistulous tract, with a small punctate skin opening near the vaginal introitus was found. Fistulotomy and curettage were performed. Three months later, she developed recurrent fistula-in-ano and right-sided perianal abscess. She underwent repeat fistulotomy with incision and drainage of the abscess. She was also found to have an anal sphincter defect that was repaired 6 months later. At follow-up she had significant improvement with only minor symptoms of fecal urgency that we thought were related to sphincteric weakness.
Obstetrics & Gynecology
Case 2 A 29-year-old woman, gravida 2, para 2, was seen 3.5 months postpartum, complaining of vaginal discharge, fecal urgency, and inability to control loose stools. An episioproctotomy had been performed during delivery, with subsequent breakdown of the entire surgical site. Examination disclosed a small, painful, pinpoint opening in the perineal body, approximately 1 cm above the anal verge. A silver probe could be passed easily from this opening into the anus, and an anal sphincter separation was visible as well. During examination under anesthesia, a complete separation of the external and internal anal sphincter and loss of the perineal body were found. Fistulotomy and curettage, anal sphincter repair, and perineal body reconstruction were performed. The curetted tract of the fistula-in-ano was left open to heal by secondary intention. At 2 weeks follow-up she was continent with good wound healing. Case 3 A 24-year-old woman, gravida 3, para 1, was referred 2 years after vaginal delivery complicated by episiotomy infection. Since delivery, she had chronic perineal drainage and pain. A perineal sinus that appeared to be connected to a blind pouch was found. During examination under anesthesia, a 2-mm sinus tract was found that opened anterolaterally to the right of the anus. Probing did not disclose a fistula, and we excised the sinus tract. Postoperative, recurrent drainage occurred from the same site. On examination, a punctate, fistulous opening was found to the right of the midline, within the perineal body. Anoscopy found a depression and scar at the level of the dentate line in the posterior anal canal. By probing, the two openings were found to communicate, confirming the presence of an anterior fistula-in-ano. Fistulotomy and curettage were performed and the site healed.
Comment Fecal soiling and drainage after childbirth are usually signs of a rectovaginal fistula. The three women with fistula-in-ano differ from women with rectovaginal fistulas in several ways, such as the chronic inflammatory process present in patients with fistula-in-ano but not in those with rectovaginal fistulas. With fistula-in-ano, chronic inflammation is manifested in a granulationlined tract (Figure 2). In rectovaginal fistula, the passage is well epithelialized. Clinically, patients with fistulain-ano have pain and inflammatory drainage, in contrast to the relatively painless drainage of patients with rectovaginal fistulas, which results from incontinence of stool rather than inflammatory exudate from the sinus tract. Although it is possible to suspect the presence of fistula-in-ano after outpatient examination, an examination under anesthesia is important to confirm the condition and plan treatment.
VOL. 93, NO. 5, PART 2, MAY 1999
Figure 2. Arrow shows opened tract with velvety chronic inflammatory lining. Second fistula-in-ano shown with probe.
Fistula-in-ano, unlike rectovaginal fistula, should not be treated by excision and primary repair. Because fistula-in-ano contains chronically infected tissue, it is best treated by incision and drainage. Fistulotomy and curettage should be done, ensuring that the entire tract is carefully traced and opened from internal to external sites. With the application of frequent moist dressings to the wound, healing occurs after several weeks by secondary intention. Unlike rectovaginal fistulas, which occur in the midline, fistula-in-ano can be complex and circuitous. The classification system proposed by Parks et al1 is widely accepted and is based on the relationship of the fistulous tract to the external anal sphincter. Parks et al defined the following four main types: intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. There might be variations of these basic types, so when operating on a fistula-in-ano, this classification should be kept in mind. Once feces or bacteria enter the intersphincteric space, as a result of infection or trauma, an inflammatory process begins that eventually exits through the skin. As recognized by Parks et al, several pathways exist.1 The simplest is direct dissection from the intersphincteric plane to the perianal skin. The most difficult fistulae to identify and treat are those that extend upward into the supralevator space before exiting. After episiotomy, particularly one in which a third- or fourth-degree laceration has occurred, these planes might be disrupted, and the course of the fistula might not be easily predicted. Risk factors for the development of obstetric-related fistula-in-ano are not well defined. They might be the same as those for rectovaginal fistulas, because these conditions are quite similar. The cases presented involve fourth-degree lacerations, wound infection, or dehiscence, suggesting contribution to the development
Howard et al
Fistula-in-Ano and Episiotomy
801
of fistula-in-ano. Avoidance of such complications might prevent the development of fistula-in-ano. Longterm outcome of patients with this problem is also unknown. Potential sequelae include fecal incontinence, if the anal sphincter is damaged either during the fistulotomy or from the birth process, dyspareunia, if significant perineal scarring results, continued drainage, if the fistulotomy is not successful, or other associated problems not identified at the time of surgery.
References 1. Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-inano. Br J Surg 1976;63:1–12. 2. Barwood N, Clarke G, Levitt S, Levitt M. Fistula-in-ano: A prospective study of 107 patients. Aust N Z Surg 1997;67:98 –102. 3. ASCRS Standards Practice Task Force. Practice parameters for treatment of fistula-in-ano. Dis Colon Rectum 1996;39:1361–2. 4. Parks AG. Pathogenesis and treatment of fistula-in-ano. BMJ 1961; 1:463–9. 5. Venkatesh KS, Ramanujam PS, Larson, DM, Haywood MA. Anorectal complications of vaginal delivery. Dis Colon Rectum 1989;32: 1039 – 41. 6. Woolley RJ. Benefits and risks of episiotomy: A review of the
Intermenstrual bleeding secondary to cesarean scar diverticuli: Report of three cases Sonya S. Erickson, MD, and Bradley J. Van Voorhis, MD Background: The differential diagnosis of intermenstrual bleeding includes structural lesions of the endometrium and cervix. Cases: Discrete diverticuli were noted in the endocervical canals of three women presenting with histories of multiple cesareans and chief complaints of intermenstrual bleeding. On ultrasound, diverticuli were diagnosed as cavities filled with heterogeneous material consistent with blood. In one case, the diverticulum was also visualized on hysterosalpingogram. Hysterectomy specimens in two cases showed diverticuli lined with fibrous tissue in previous uterine scars; in one case, this also contained endometrium. Conclusion: Uterine scar diverticuli may cause intermenstrual bleeding in women with previous cesareans. When From the Department of Obstetrics and Gynecology and Division of Reproductive Endocrinology and Infertility, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
802 0029-7844/99/$20.00 PII S0029-7844(98)00314-7
English-language literature since 1980. Part II. Obstet Gynecol Surv 1995;50:821–35. 7. Thacker SB, Banta HD. Benefits and risks of episiotomy: An interpretative review of the English language literature, 1860 –1980. Obstet Gynecol Surv 1983;38:322–38. 8. Cogan JE, Harris JW. Rectal complications after perineorrhaphy and episiotomy. Arch Surg 1966;93:634 –7.
Address reprint requests to:
John O. L. DeLancey, MD Department of Obstetrics and Gynecology University of Michigan Health Systems L4000 Women’s Hospital 1500 E. Medical Center Drive Ann Arbor, MI 48109-0276 E-mail: [email protected]
Received March 17, 1998. Received in revised form July 14, 1998. Accepted July 30, 1998. Copyright © 1999 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
performing ultrasound in this clinical setting, physicians should look for these defects. (Obstet Gynecol 1999;93:802–5. © 1999 by The American College of Obstetricians and Gynecologists.)
Uterine scar dehiscence is diagnosed in approximately 0.3–1.9% of women who have undergone cesarean.1 Typically, dehiscence is detected in a subsequent pregnancy before or during labor, with fetal death and maternal mortality the most severe consequences. Thinning of the lower uterine segment also has been found in asymptomatic pregnant women with histories of cesarean who were undergoing ultrasonography for a variety of indications.2,3 Recently, ectopic pregnancies implanted within cesarean scars have been reported.4,5 We report three women with refractory intermenstrual bleeding in whom diverticuli had developed in their previous cesarean scars. These defects were diagnosed by radiographic studies and appeared to contribute to the patients’ symptoms.
Cases Case 1 A 34-year-old woman, gravida 6, para 3– 0 –3–3, with a history of three low-transverse cesareans presented with a 2.5-year history of intermenstrual bleeding. She reported monthly
Obstetrics & Gynecology
During the past 2 years, three women were referred for evaluation of episiotomy complications. The cause of their problems, fistula-in-ano, is a common surgical entity consisting of a granulated tissue-lined communication between the anal canal and the perianal skin or perineum, initiated by an infecting source, often an anal abscess.1– 4 Infection develops as a result of trauma, fissures, Crohn disease, carcinoma, radiation, tuberculosis, or other infectious agents. The fistula extends from the dentate line internally to an external site of drainage, which might be highly variable. It is kept open by fecal flow and chronic infection or inflammation. After performing a MEDLINE search of the Englishlanguage literature from 1966 to the present, using the key words “fistula-in-ano,” “rectovaginal fistula,” “perineal fistula,” “vaginal delivery,” “episiotomy,” and “pregnancy,” we were unable to locate reports of fistula-in-ano associated with birth and episiotomy. In addition, three articles that specifically addressed anorectal complications of vaginal birth and episiotomy complications did not mention this entity.5–7 We found a single reference in the surgical literature that discussed the association of perineal fistulas and episiotomy.8 In the present study, we review the clinical presentation, features, and principles of treatment of fistula-in-ano in puerperal women.
From the Departments of Obstetrics and Gynecology, and Surgery, University of Michigan Health Systems, Ann Arbor, Michigan.
800 0029-7844/99/$20.00 PII S0029-7844(98)00368-8
Figure 1. Arrow shows draining tract between anal canal and perineal skin.
Cases Case 1 A 24-year-old woman, gravida 1, para 1, presented 5 weeks postpartum with vaginal flatus and leakage of stool from her vagina. This began after a forceps delivery, during which a fourth-degree extension of midline episiotomy occurred. Three days postpartum, she developed rectal pain and burning and noticed stool in her vagina. She presented for evaluation at 5 weeks postpartum and was given a presumptive diagnosis of a rectovaginal fistula. Extensive inflammation was noted at the fistula site and she was started on Kefzol (Eli Lilly and Co., Indianapolis, IN) (500 mg) four times a day for 10 days. Four weeks later she was reevaluated. The inflammation had subsided and a small sinus tract was noted in the perineal skin (Figure 1). Methylene blue-stained gel placed in the rectum could be expressed through this tract. There was no evidence of a rectovaginal fistula. Because of severe pain, an examination under anesthesia was performed. A large, anterior anal fissure, communicating through a fistulous tract, with a small punctate skin opening near the vaginal introitus was found. Fistulotomy and curettage were performed. Three months later, she developed recurrent fistula-in-ano and right-sided perianal abscess. She underwent repeat fistulotomy with incision and drainage of the abscess. She was also found to have an anal sphincter defect that was repaired 6 months later. At follow-up she had significant improvement with only minor symptoms of fecal urgency that we thought were related to sphincteric weakness.
Obstetrics & Gynecology
Case 2 A 29-year-old woman, gravida 2, para 2, was seen 3.5 months postpartum, complaining of vaginal discharge, fecal urgency, and inability to control loose stools. An episioproctotomy had been performed during delivery, with subsequent breakdown of the entire surgical site. Examination disclosed a small, painful, pinpoint opening in the perineal body, approximately 1 cm above the anal verge. A silver probe could be passed easily from this opening into the anus, and an anal sphincter separation was visible as well. During examination under anesthesia, a complete separation of the external and internal anal sphincter and loss of the perineal body were found. Fistulotomy and curettage, anal sphincter repair, and perineal body reconstruction were performed. The curetted tract of the fistula-in-ano was left open to heal by secondary intention. At 2 weeks follow-up she was continent with good wound healing. Case 3 A 24-year-old woman, gravida 3, para 1, was referred 2 years after vaginal delivery complicated by episiotomy infection. Since delivery, she had chronic perineal drainage and pain. A perineal sinus that appeared to be connected to a blind pouch was found. During examination under anesthesia, a 2-mm sinus tract was found that opened anterolaterally to the right of the anus. Probing did not disclose a fistula, and we excised the sinus tract. Postoperative, recurrent drainage occurred from the same site. On examination, a punctate, fistulous opening was found to the right of the midline, within the perineal body. Anoscopy found a depression and scar at the level of the dentate line in the posterior anal canal. By probing, the two openings were found to communicate, confirming the presence of an anterior fistula-in-ano. Fistulotomy and curettage were performed and the site healed.
Comment Fecal soiling and drainage after childbirth are usually signs of a rectovaginal fistula. The three women with fistula-in-ano differ from women with rectovaginal fistulas in several ways, such as the chronic inflammatory process present in patients with fistula-in-ano but not in those with rectovaginal fistulas. With fistula-in-ano, chronic inflammation is manifested in a granulationlined tract (Figure 2). In rectovaginal fistula, the passage is well epithelialized. Clinically, patients with fistulain-ano have pain and inflammatory drainage, in contrast to the relatively painless drainage of patients with rectovaginal fistulas, which results from incontinence of stool rather than inflammatory exudate from the sinus tract. Although it is possible to suspect the presence of fistula-in-ano after outpatient examination, an examination under anesthesia is important to confirm the condition and plan treatment.
VOL. 93, NO. 5, PART 2, MAY 1999
Figure 2. Arrow shows opened tract with velvety chronic inflammatory lining. Second fistula-in-ano shown with probe.
Fistula-in-ano, unlike rectovaginal fistula, should not be treated by excision and primary repair. Because fistula-in-ano contains chronically infected tissue, it is best treated by incision and drainage. Fistulotomy and curettage should be done, ensuring that the entire tract is carefully traced and opened from internal to external sites. With the application of frequent moist dressings to the wound, healing occurs after several weeks by secondary intention. Unlike rectovaginal fistulas, which occur in the midline, fistula-in-ano can be complex and circuitous. The classification system proposed by Parks et al1 is widely accepted and is based on the relationship of the fistulous tract to the external anal sphincter. Parks et al defined the following four main types: intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. There might be variations of these basic types, so when operating on a fistula-in-ano, this classification should be kept in mind. Once feces or bacteria enter the intersphincteric space, as a result of infection or trauma, an inflammatory process begins that eventually exits through the skin. As recognized by Parks et al, several pathways exist.1 The simplest is direct dissection from the intersphincteric plane to the perianal skin. The most difficult fistulae to identify and treat are those that extend upward into the supralevator space before exiting. After episiotomy, particularly one in which a third- or fourth-degree laceration has occurred, these planes might be disrupted, and the course of the fistula might not be easily predicted. Risk factors for the development of obstetric-related fistula-in-ano are not well defined. They might be the same as those for rectovaginal fistulas, because these conditions are quite similar. The cases presented involve fourth-degree lacerations, wound infection, or dehiscence, suggesting contribution to the development
Howard et al
Fistula-in-Ano and Episiotomy
801
of fistula-in-ano. Avoidance of such complications might prevent the development of fistula-in-ano. Longterm outcome of patients with this problem is also unknown. Potential sequelae include fecal incontinence, if the anal sphincter is damaged either during the fistulotomy or from the birth process, dyspareunia, if significant perineal scarring results, continued drainage, if the fistulotomy is not successful, or other associated problems not identified at the time of surgery.
References 1. Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-inano. Br J Surg 1976;63:1–12. 2. Barwood N, Clarke G, Levitt S, Levitt M. Fistula-in-ano: A prospective study of 107 patients. Aust N Z Surg 1997;67:98 –102. 3. ASCRS Standards Practice Task Force. Practice parameters for treatment of fistula-in-ano. Dis Colon Rectum 1996;39:1361–2. 4. Parks AG. Pathogenesis and treatment of fistula-in-ano. BMJ 1961; 1:463–9. 5. Venkatesh KS, Ramanujam PS, Larson, DM, Haywood MA. Anorectal complications of vaginal delivery. Dis Colon Rectum 1989;32: 1039 – 41. 6. Woolley RJ. Benefits and risks of episiotomy: A review of the
Intermenstrual bleeding secondary to cesarean scar diverticuli: Report of three cases Sonya S. Erickson, MD, and Bradley J. Van Voorhis, MD Background: The differential diagnosis of intermenstrual bleeding includes structural lesions of the endometrium and cervix. Cases: Discrete diverticuli were noted in the endocervical canals of three women presenting with histories of multiple cesareans and chief complaints of intermenstrual bleeding. On ultrasound, diverticuli were diagnosed as cavities filled with heterogeneous material consistent with blood. In one case, the diverticulum was also visualized on hysterosalpingogram. Hysterectomy specimens in two cases showed diverticuli lined with fibrous tissue in previous uterine scars; in one case, this also contained endometrium. Conclusion: Uterine scar diverticuli may cause intermenstrual bleeding in women with previous cesareans. When From the Department of Obstetrics and Gynecology and Division of Reproductive Endocrinology and Infertility, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
802 0029-7844/99/$20.00 PII S0029-7844(98)00314-7
English-language literature since 1980. Part II. Obstet Gynecol Surv 1995;50:821–35. 7. Thacker SB, Banta HD. Benefits and risks of episiotomy: An interpretative review of the English language literature, 1860 –1980. Obstet Gynecol Surv 1983;38:322–38. 8. Cogan JE, Harris JW. Rectal complications after perineorrhaphy and episiotomy. Arch Surg 1966;93:634 –7.
Address reprint requests to:
John O. L. DeLancey, MD Department of Obstetrics and Gynecology University of Michigan Health Systems L4000 Women’s Hospital 1500 E. Medical Center Drive Ann Arbor, MI 48109-0276 E-mail: [email protected]
Received March 17, 1998. Received in revised form July 14, 1998. Accepted July 30, 1998. Copyright © 1999 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
performing ultrasound in this clinical setting, physicians should look for these defects. (Obstet Gynecol 1999;93:802–5. © 1999 by The American College of Obstetricians and Gynecologists.)
Uterine scar dehiscence is diagnosed in approximately 0.3–1.9% of women who have undergone cesarean.1 Typically, dehiscence is detected in a subsequent pregnancy before or during labor, with fetal death and maternal mortality the most severe consequences. Thinning of the lower uterine segment also has been found in asymptomatic pregnant women with histories of cesarean who were undergoing ultrasonography for a variety of indications.2,3 Recently, ectopic pregnancies implanted within cesarean scars have been reported.4,5 We report three women with refractory intermenstrual bleeding in whom diverticuli had developed in their previous cesarean scars. These defects were diagnosed by radiographic studies and appeared to contribute to the patients’ symptoms.
Cases Case 1 A 34-year-old woman, gravida 6, para 3– 0 –3–3, with a history of three low-transverse cesareans presented with a 2.5-year history of intermenstrual bleeding. She reported monthly
Obstetrics & Gynecology