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Fistula in ano as a rare complication of mediolateral episiotomy: Report of three cases
Fistula in ano as a rare complication of mediolateral episiotomy: Report of three cases t'.mmanuel Barranger, MD, a Bassam Haddad, MD, a, b and Bernard J. Paniel, MD a
Creteil, France, and Memphis, Tennessee. Fistula in ano has been reported as a rare complication of midline episiotomy. We report here 3 cases of fistula in ano complicating mediolateral episiotomy. One was suprasphincteric and 2 were transsphincteric. All patients had perineal pain and chronic suppuration. Before referral, 2 patients underwent incision and drainage alone. As a definitive procedure fistulotomy was performed, and long-term functional results have been satisfactory. (Am J Obstet Gynecol 2000;182:733-4.)
Key words: Fistula in ano, mediolateral episiotomy
Episiotomy to prevent severe perineal tears was introd u c e d into clinical practice without strong scientific evidence for its benefits. Fistula in ano, a rare complication of episiotomy, is poorly documented in the English language literature and has been described mainly after median episiotomy. The external opening of the tract is always at o r very n e a r t h e episiotomy scar, whereas the internal opening may be found at any level in that quadrant o f the rectal wall proximate to the episiotomy site. We r e p o r t here 3 cases o f fistula in ano observed after mediolateral episiotomy between 1991 and 1996. The aftermath of the corrective surgical procedure was assessed 2 m o n t h s after treatment. Long-term results (including perineal pain, perineal suppuration, fecal and gas incontinence, and reoperative surgical procedure) were determ i n e d by telephone contacts 3, 7, a n d 9 years after the initial surgicalprocedure. C a s e reports
Case 1. A 28-year-old-woman, para 3, was delivered of an infant weighing 3920 g by forceps delivery performed because of an arrest o f descent after mediolateral episiotomy. On postpartum day 4 an episiotomy dehiscence was f o u n d and t r e a t e d by local applications of moist dressings. On postpartum day 45 a chronic suppuration with m o d e r a t e p e r i n e a l pain was n o t e d n e a r the episiotomy scar. With the patient u n d e r general anesthesia an anal fistula was diagnosed 5 months after delivery. The external opening was identified near the episiotomy scar, and the internal orifice was explored with a fine metal p r o b e . The f s t u l o u s tract was suprasphincteric, From the Department of Obstet6~s and Gynecology, CHI C~z'i~a and the Division of Materaal-Fetal Medicine, University of Tennessee.b Receivedfor publication July 14, 1999; ac~eptedSeptemher10, 1999. Reprint requests:Bassara Haddad, MD, Department of Obstetrics and Gynecology University of Tennessee, Memphis 853 Jefferson Ave, Room E102, Memphig TN 38103. Copyright © 2000 by Mosby, Inc. 0002-9378/2000 ~12.00 + 0 6/1/102960 doi:l O.1067~mob.2000.102960
F i s t u l o t o m y was p e r f o r m e d a n d p e r i n e a l b o d y reconstruction was done 2 m o n t h s later. Complete continence was n o t e d at 2 months after the final surgical p r o c e d u r e a n d again 7 years after the operation. Case 2. A 27-year-old woman, para 1, was delivered of an infant weighing 3250 g by forceps delivery p e r f o r m e d because o f an arrest o f descent after mediolateral episiotomy. Two months later the patient r e p o r t e d perineal pain a n d gas incontinence. Clinical examination showed an abscess near the perineal episiotomy scar, which was t r e a t e d with incision a n d drainage. At 9 m o n t h s the w o m a n h a d r e c u r r e n t c h r o n i c suppuration. A n anal transsphincteric fistula was diagnosed with the p a t i e n t u n d e r g e n e r a l anesthesia, a n d a small p u n c t a t e skin o p e n i n g on the perineal scar was noted. A silver probe could be passed easily from this external o p e n i n g into the anus a n d through the external sphincter mass. T h e p a t i e n t underwent a fistulotomy. Two months later she was continent and the chronic suppuration h a d been relieved. Defecation was n o r m a l and she had continence o f gas 3 years after the surgical procedure. Case 3. A 34-year-old woman, para 1, was referred because o f dyspareunia, p e r i n e a l pain, and chronic suppuration occurring 2 years after vaginal delivery. During delivery the p a t i e n t h a d u n d e r g o n e a m e d i o l a t e r a l episiotomy, which was complicated 2 months later by an abscess that was treated by incision and drainage. As in case 2, an examination with the patient u n d e r general anesthesia revealed an anal transsphincteric fistula with a p u n c t a t e o p e n i n g o n the episiotomy scar. Fistulotomy was performed. This p a t i e n t had gas incontinence at 3 m o n t h s after the fistulotomy, but complete continence was n o t e d at 9-year follow-up. Comment
Fistula in ano has b e e n r e p o r t e d to complicate midline episiotomy in only a few articles published in the English literature.], 2 We r e p o r t h e r e 3 cases o f fistula in a n o c o m p l i c a t i n g m e d i o l a t e r a l episiotomy. T h e pathologic process involved remains undea~, it may be a complica7:38
734 Barranger, Haddad, and Paniel
March 2000 AmJ Obstet Gynecol
tion of anorectal abscess after obstetric trauma that results from infected hematomas and anal gland infection or from an infection deep in the wound when a suture is inadvertently passed t h r o u g h the perirectal tissue. T h e natural history o f fistula in ano is poorly documented. As previously described, 1, 2 we found that our patients had a history o f chronic perineal pain and suppuration on or near an episiotomy scar. Such symptoms do n o t usually exist in w o m e n with rectovaginal fistula. Because of the chronic aspects o f these symptoms, the interval between episiotomy a n d final diagnosis o f fistula in ano (5, 9, and 24 months) remains important in our series. Treatment should always be surgical, with the fis-
tulous tract o p e n e d in its whole length to avoid recurrence, as in cases 2 and 3. For that reason fistulotomy is to be preferred to incision and drainage alone. Longterm functional results after repair o f fistula in ano were satisfactory in o u r series. This has n o t been previously described. However, we c a n n o t draw any firm conclusions in this regard because of the small n u m b e r o f patients. REFERENCES
1. Howard D, DeLanceyJO, Burney RE. Fistula in ano after episiotomy. Obstet Gynecol 1999;93:800-2. 2. Anderson RE, Witkowski LJ. Post-partum fistula in ano: a complication of episiotomy. Surgery 1957;41:790-3.
Creteil, France, and Memphis, Tennessee. Fistula in ano has been reported as a rare complication of midline episiotomy. We report here 3 cases of fistula in ano complicating mediolateral episiotomy. One was suprasphincteric and 2 were transsphincteric. All patients had perineal pain and chronic suppuration. Before referral, 2 patients underwent incision and drainage alone. As a definitive procedure fistulotomy was performed, and long-term functional results have been satisfactory. (Am J Obstet Gynecol 2000;182:733-4.)
Key words: Fistula in ano, mediolateral episiotomy
Episiotomy to prevent severe perineal tears was introd u c e d into clinical practice without strong scientific evidence for its benefits. Fistula in ano, a rare complication of episiotomy, is poorly documented in the English language literature and has been described mainly after median episiotomy. The external opening of the tract is always at o r very n e a r t h e episiotomy scar, whereas the internal opening may be found at any level in that quadrant o f the rectal wall proximate to the episiotomy site. We r e p o r t here 3 cases o f fistula in ano observed after mediolateral episiotomy between 1991 and 1996. The aftermath of the corrective surgical procedure was assessed 2 m o n t h s after treatment. Long-term results (including perineal pain, perineal suppuration, fecal and gas incontinence, and reoperative surgical procedure) were determ i n e d by telephone contacts 3, 7, a n d 9 years after the initial surgicalprocedure. C a s e reports
Case 1. A 28-year-old-woman, para 3, was delivered of an infant weighing 3920 g by forceps delivery performed because of an arrest o f descent after mediolateral episiotomy. On postpartum day 4 an episiotomy dehiscence was f o u n d and t r e a t e d by local applications of moist dressings. On postpartum day 45 a chronic suppuration with m o d e r a t e p e r i n e a l pain was n o t e d n e a r the episiotomy scar. With the patient u n d e r general anesthesia an anal fistula was diagnosed 5 months after delivery. The external opening was identified near the episiotomy scar, and the internal orifice was explored with a fine metal p r o b e . The f s t u l o u s tract was suprasphincteric, From the Department of Obstet6~s and Gynecology, CHI C~z'i~a and the Division of Materaal-Fetal Medicine, University of Tennessee.b Receivedfor publication July 14, 1999; ac~eptedSeptemher10, 1999. Reprint requests:Bassara Haddad, MD, Department of Obstetrics and Gynecology University of Tennessee, Memphis 853 Jefferson Ave, Room E102, Memphig TN 38103. Copyright © 2000 by Mosby, Inc. 0002-9378/2000 ~12.00 + 0 6/1/102960 doi:l O.1067~mob.2000.102960
F i s t u l o t o m y was p e r f o r m e d a n d p e r i n e a l b o d y reconstruction was done 2 m o n t h s later. Complete continence was n o t e d at 2 months after the final surgical p r o c e d u r e a n d again 7 years after the operation. Case 2. A 27-year-old woman, para 1, was delivered of an infant weighing 3250 g by forceps delivery p e r f o r m e d because o f an arrest o f descent after mediolateral episiotomy. Two months later the patient r e p o r t e d perineal pain a n d gas incontinence. Clinical examination showed an abscess near the perineal episiotomy scar, which was t r e a t e d with incision a n d drainage. At 9 m o n t h s the w o m a n h a d r e c u r r e n t c h r o n i c suppuration. A n anal transsphincteric fistula was diagnosed with the p a t i e n t u n d e r g e n e r a l anesthesia, a n d a small p u n c t a t e skin o p e n i n g on the perineal scar was noted. A silver probe could be passed easily from this external o p e n i n g into the anus a n d through the external sphincter mass. T h e p a t i e n t underwent a fistulotomy. Two months later she was continent and the chronic suppuration h a d been relieved. Defecation was n o r m a l and she had continence o f gas 3 years after the surgical procedure. Case 3. A 34-year-old woman, para 1, was referred because o f dyspareunia, p e r i n e a l pain, and chronic suppuration occurring 2 years after vaginal delivery. During delivery the p a t i e n t h a d u n d e r g o n e a m e d i o l a t e r a l episiotomy, which was complicated 2 months later by an abscess that was treated by incision and drainage. As in case 2, an examination with the patient u n d e r general anesthesia revealed an anal transsphincteric fistula with a p u n c t a t e o p e n i n g o n the episiotomy scar. Fistulotomy was performed. This p a t i e n t had gas incontinence at 3 m o n t h s after the fistulotomy, but complete continence was n o t e d at 9-year follow-up. Comment
Fistula in ano has b e e n r e p o r t e d to complicate midline episiotomy in only a few articles published in the English literature.], 2 We r e p o r t h e r e 3 cases o f fistula in a n o c o m p l i c a t i n g m e d i o l a t e r a l episiotomy. T h e pathologic process involved remains undea~, it may be a complica7:38
734 Barranger, Haddad, and Paniel
March 2000 AmJ Obstet Gynecol
tion of anorectal abscess after obstetric trauma that results from infected hematomas and anal gland infection or from an infection deep in the wound when a suture is inadvertently passed t h r o u g h the perirectal tissue. T h e natural history o f fistula in ano is poorly documented. As previously described, 1, 2 we found that our patients had a history o f chronic perineal pain and suppuration on or near an episiotomy scar. Such symptoms do n o t usually exist in w o m e n with rectovaginal fistula. Because of the chronic aspects o f these symptoms, the interval between episiotomy a n d final diagnosis o f fistula in ano (5, 9, and 24 months) remains important in our series. Treatment should always be surgical, with the fis-
tulous tract o p e n e d in its whole length to avoid recurrence, as in cases 2 and 3. For that reason fistulotomy is to be preferred to incision and drainage alone. Longterm functional results after repair o f fistula in ano were satisfactory in o u r series. This has n o t been previously described. However, we c a n n o t draw any firm conclusions in this regard because of the small n u m b e r o f patients. REFERENCES
1. Howard D, DeLanceyJO, Burney RE. Fistula in ano after episiotomy. Obstet Gynecol 1999;93:800-2. 2. Anderson RE, Witkowski LJ. Post-partum fistula in ano: a complication of episiotomy. Surgery 1957;41:790-3.