POST COITAL FOURTH DEGREE RECTOVAGINOPERINEAL TEAR: A RARE CASE REPORT

POST COITAL FOURTH DEGREE RECTOVAGINOPERINEAL TEAR: A RARE CASE REPORT

Shashidhar Boraiah, Sheela S.R. and Krishna Shetty M.V.

Sri DevrajUrs Medical College, Kolar-563101, Karnataka, India

ABSTRACT

Postcoital vaginal rupture or tear is a well-known entity to the gynecologist. We highlight case of a marital post coital rectovaginal tear with fecal incontinence and complete avulsion of anal sphincters. Patient underwent layered repair and sphincter reconstruction after bowel preparation. Postoperatively she had a satisfactory continence over flatus and feces.

Recto Vaginal fistula

INTRODUCTION: Non obstetric vaginal lacerations differ greatly from lacerations sustained during childbirth and are generally classified into two types. The first type is relatively minor and is associated with normal sexual intercourse. These lacerations usually resolve with minimal treatment. The second type of laceration is deeper and more extensive, often resulting in significant vaginal bleeding. This condition can be life threatening and requires immediate intervention.

Case report: We present a case of a 24 year old patient referred to our University Teaching Hospital early morning with the history of severe pain abdomen and profuse bleeding per vagina following intercourse with her husband. She was married for 8 years with three children and her last delivery was 9 months back, all the deliveries were full term vaginal delivery and was tubectomised one month after delivery.

On examination she was severely pale and her pulse rate was 90 beats/min, BP110/80 mm Hg, oxygen saturation 100% at room air, temperature 37.4°C, and respiratory rate 21 cycles/min per abdominal examination was normal. Local examination revealed her underclothes was blood stained and soiled with fecal matter and she had a fourth degree perineal tear involving both the external and internal  anal sphincters with midline vertical laceration of about 6cms involving both the vaginal mucosa and the rectum.

Speculum and vaginal examination were difficult and unsatisfactory due to the significant tenderness. Speculum examination had to be discontinued because of severe pain. Gentle per rectal examination revealed lacerated anal sphincters with lacerated anal canal and decreased anal tone. She was put on injectable antibiotics and NBM for 3 days.

She underwent transvaginal two-layered repair of the injury and sphincter reconstruction after bowel preparation (figure 1 & 2). Postoperatively she had a satisfactory continence over flatus and feces. She is still on follow-up. Both pelvic and rectal examination findings were normal during this period

FIG. 1: RECTOVAGINOPERINEAL TEAR WITH FECAL IN-CONTINENCE

FIG. 2: RECTOVAGINAL TEAR INVOLVING THE ANAL SPHINCTERS                                                                                                           

DISCUSSION: Postcoital vaginal rupture or tear is a well-known entity to the gynecologist. Most are minor injuries that manifest as self-limiting minimal vaginal bleeding, which do not require medical attention. Abasiatta ¹ et al reported in his 10 year study that coital injuries accounted for 0.7 per 1000 gynecological emergencies of which rape was the commonest etiological factor.

It was more common in nulliparous patients while the common predisposing factors to coital injuries include rough coitus, first sexual intercourse, penovaginal disproportion, and use of aphrodisiacs as vaginal lubricants, puerperium, and inadequate emotional and physical preparation of women for sexual intercourse ^{2, 3}. A review of the literature has shown that severe upper vaginal injuries following coitus, causing massive haemoperitoneum, pneumoperitoneum or haemo-pneumoperitoneum are becoming a common medical emergency. Bowel or omentum may prolapse through a posterior vaginal wall tear ⁴. Rectal injury, resulting in recto-vaginal fistula may also be seen ⁵. It has been strictly recommended that a rectal examination should routinely be performed in the presence of a posterior vaginal wall tear following coitus. A differential diagnosis of severe upper vaginal injury should be kept in mind in females who present with an acute abdomen with or without vaginal bleeding following coitus.

CONCLUSION: A detailed sexual history is extremely important as it provides a good clue. It is critical that such patients receive a prompt diagnosis to provide efficient management. It needs only simple surgical skills to cure the injury if the vital signs are stable. However, those survivors may need further psychological consultation to prevent negative impact on their future sexual functioning.

Conflict of interest: There is no conflict of interest.

REFERENCES:

1. Abasiattai AM, Etuk SJ, Bassey EA, Asuquo EE, Department of Obstetrics and Gynaecology, University of Calabar Teaching Hospital, Calabar, Nigeria, ”Vaginal injuries during coitus in Calabar , a 10-year review” The Nigerian Postgraduate Medical Journal. 2005 Jun; 12(2):140-4.
2. Cisse CT, Dionne P, Cathy A, Mendes V, Diadhiou F, Ndiaye PD ”Vaginal injuries during coitus” Dakar Medical. Abasiattai AM, Etuk SJ, Bassey EA, Asuquo EE, Department of Obstetrics and Gynaecology, University of Calabar Teaching Hospital, Calabar, Nigeria, ”Vaginal injuries during coitus in Calabar , a 10-year review” The Nigerian Postgraduate Medical Journal.1998;43(2):135-8.
3. Dao B, Diouf A, Bambara M, Bah MD, Diadhiou F ”Vaginal injuries during coitus: 98 cases” Contraception Fertilite 1995 Jun; 23(6):420-2.
4. Lal P, Mohan P, Sharma R, Sehgal A, Aggarwal A.” Postcoital vaginal laceration in a patient presenting with signs of small bowel perforation: report of a case. Surgery Today.2001; 31(5):466-7.
5. Ijaiya, AM Mai, AP Aboyeji, V Kumanda, MO Abiodun, HO Raji , “ Rectovaginal fistula following sexual intercourse.  A case report. Annals of African medicine.2009; March Vol 8(1):59-60.
   

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   How to cite this article:

   Boraiah S, Sheela SR and Shetty MVK: Post Coital Fourth Degree Rectovaginoperineal Tear: A Rare Case Report. Int J Pharm Sci Res. 3(11); 4372-4373.

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