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TRAUMATIC CLOACAL DEFECT REPAIRED WITH MARTIUS LABIAL INTERPOSITION FLAP
Liam O'Brien
*, Sandra G. Osogobio, Jamie Cannon, Jonathan Laryea, David Sterling, S. T. Kang
Colorectal Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
Introduction:
Traumatic cloacal defect (TCD) is a rare complication of childbirth, estimated to occur in women at around 0.003%. It is frequently associated with episiotomies, large infants, and instrumentation during vaginal birth. TCD’s are characterized by loss of the perineal body, fusion of the rectovaginal septum, and sphincter complex disruption. We present here a case of a 40-year-old female with an acquired TCD.
Background:
A 40-year-old female presented to Colorectal Surgery Clinic with chief complaint of fecal incontinence, mostly to loose bowel movements, and was found to have a cloacal defect on physical exam, most likely from previous birth trauma. The patient has a history of two vaginal births, most recently about 2 decades ago, and reports a history of tears requiring suture repair during childbirth. She denied urinary issues or any personal or family history of inflammatory bowel disease. She had since had a caesarian section with a subsequent tubal ligation. On exam, she was noted to have a fused anovaginal septum that extended approximately 2 cm proximally without any signs of inflammation or infection. She had an attenuated perineum bilaterally with a thinned rectovaginal septum. Her preoperative workup included an endoanal ultrasound that revealed the known anterior sphincter defect but an otherwise normal sphincter complex.
Case Description:
The patient underwent a combination surgical case between colorectal and plastic surgery teams during which colorectal surgeons repaired the rectal and vaginal defects, while plastic surgery subsequently performed a labial interposition flap to separate the two repairs. The goal of the operation was to bulk up the perineal body that had been thinned from the traumatic cloaca, and reduce likelihood of future fistulization. In addition, colorectal surgery performed a laparoscopic diverting loop ileostomy for fecal diversion with plan for reversal in the future after rectal and perineal repairs have healed.
Conclusion: This case describes a rare complication of childbirth that can be physically, mentally, and socially detrimental to patients. Currently, there is no one repair of cloacal defect that is recommended over others and a variety of closures and flaps have been attempted to reduce complications and limit recurrent symptoms after surgery. Here we attempt to inform readers on a surgical approach to repair the defect, while addressing possible complications to consider when formulating a plan to repair future cloacal defects in the adult population.
Key Words: Traumatic cloaca, Martius, fecal incontinence
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