Our patient is a 34-year-old G2 P2002 who initially presented to our clinic with recurrent fecal incontinence and traumatic perineal ploaca following a breakdown of a fourth degree of cetric laceration repair. She had previously undergone an overlapping sphincteroplasty with some improvement of continence. However, she continued to have fecal incontinence to flatus and liquid stool as well as sexual dysfunction due to perineal pain. She was also seen by the colorectal surgeons and underwent endoanal ultrasonography showing sphincteric integrity with scarring of the anterior portion of the sphincter. Initial CRADI score was 12 out of 32. Traumatic perineal ploaca is a rare occurrence characterized by disruption of the perineal body and anal sphincter allowing communication between the anal canal and the vagina. The most common etiology is breakdown of a fourth degree obstetric laceration repair. Less commonly traumatic ploaca can be the result of rectovaginal trauma. Fecal incontinence to flatus, liquid and solid stool is characteristic of this defect. Urinary tract infections are common due to fecal contamination of the vagina and urethra. Sexual dysfunction is also a significant symptom. Combined, these symptoms lead to decreased quality of life. Several surgical techniques have been used for repair. All techniques include some variation on dissection of the rectovaginal septum and overlapping sphincteroplasty. Sphincteroplasty alone is associated with higher rates of recurrence. Reconstruction of the perineal body is paramount to the repair to provide Delancey level 3 support to the pelvic floor. After discussion with the patient, the plan was made to proceed with repair of vaginal interseal, rectoseal and perineoplasty. In conjunction with the colorectal division, the decision was made to not perform another sphincteroplasty. The patient would be evaluated postoperatively and undergo interstem if fecal incontinence persisted. An exam under anesthesia was notable for an enlarged genital hiatus measuring 4 centimeters, an attenuated perineal body measuring 0.5 centimeters, a rectoseal, posterior vaginal interseal and a patchless anus. Two Alice clamps are placed along the hymenal remnant such that once re-approximated a normal vaginal caliber would be restored and the perineal body lengthened. The posterior vaginal wall is infiltrated with 10 milliliters of 1% lidocaine with epinephrine. The posterior vaginal mucosa is dissected off the underlying rectovaginal septum that was found to be attenuated and thin. A superior transverse detachment of the septum was found in addition to a distal detachment from the perineal body. The transverse perinei muscles are dissected for full mobilization. Due to the poor tissue quality and lack of significant connective tissue, the decision is made to repair the interseal using a biologic graft. Three number zero silk sutures were placed in the posterior aspect of the cervix and tied down to the proximal edge of the Veritas biologic graft in order to recreate the rectovaginal fascia up to the vaginal apex. A midline placation of the rectovaginal septum overlying the levator ani muscles is performed in order to normalize the genital hiatus. A midline placement of the rectovaginal septum overlying the levator ani muscles is performed in order to normalize the genital hiatus. A full perineoplasty is performed by placating the bulbocavernosis and transverse perineal muscles to the midline using number one vicral sutures. A full perineoplasty is performed by placating the bulbocavernosis and transverse perineal muscles to the midline using number one vicral sutures. The distal end of the graft is trimmed and re-approximated to the perineal body with three interrupted sutures of two ovicral recreating continuity of the rectovaginal septum. The vaginal epithelium is closed with two ovicral. Rectal exam confirms integrity. The new GH measurement is three centimeters. The new PB measurement is three centimeters. The vagina is packed with metrogel soaked gauze. The patient has significant improvement in fecal continence and sexual function. She does not have any perineal pain postoperatively. Her final CRADY score was 4 out of 32.

fecal incontinence

perineal pain

obstetric laceration

sphincteroplasty

endoanal ultrasonography