Fourth degree perineal tear is a complication of childbirth, spontaneous, or with instrumental help. If it is not repaired primarily, it results in a chronic fourth degree perineal tear. A rectal mucosal prolapse is a chronic condition caused by a loosening and stretching of the connective tissue attachment to the rectal mucosa, so that the rectal mucosa prolapses through the anal opening. Since the causes of the two conditions are different, there is no reason for them to occur together. We were unable to find a single case report of their co-existence. One such case is reported here.
A fourth degree perineal tear is an obstetric maternal trauma, in which the vaginal mucosa, perineal skin and body, external anal sphincter with or without internal anal sphincter, and anorectal mucosa are torn. It may occur with a normal or instrumental vaginal delivery, an extension of an episiotomy, precipitate labor or fundal pressure. A mucosal rectal prolapse is often associated with long-standing hemorrhoids, and is caused by loss of tethering of the connective tissue attachment to the rectal mucosa and its stretching. The two conditions do not occur together, except by chance. An unusual case of their co-existence is presented.
A 48 year old postmenopausal woman presented with a complaint of something coming out in the vulvar-perineal area for 2 years. She had three vaginal deliveries in the past, the last delivery being 20 years ago. She was menopausal for three years. Her past menstrual cycles had been every 28-30 days, regular, painless and with moderate flow. There was no history of bleeding per rectum. She did not give any history of fecal incontinence in the past. Her medical and surgical history was not contributory. Her general and systemic examination findings were normal. Abdominal examination revealed no abnormality. Local examination showed an old fourth degree perineal tear along with a rectal prolapse (figure 1). The external anal sphincter was torn, while the internal anal sphincter was intact. There was a mucosal type of rectal prolapse.
Investigations for fitness for anesthesia, including hemogram, urinalysis, plasma sugar levels (fasting and postprandial), liver function tests, renal function tests, thyroid function tests, electrocardiogram, chest radiograph and serological tests for syphilis, HIV, hepatitis B and hepatitis C yielded normal results. Surgical repair of the fourth degree perineal tear was done using the standard layer method of repair. After separation of the vaginal mucosa from the anorectal mucosa, the vaginal mucosa was freed for some distance from the underlying tissues. Two double-breasting sutures of No. 1 polyglactin were passed through the torn ends of the external anal sphincter and held long. The edges of the anorectal mucosa were approximated with a continuous noninterlocking suture of No. 2-0 polyglactin passed through the submucosa. This suture line was buried under another layer of submucosal tissue approximated from either side of the suture line, with a continuous suture of No. 2-0 polyglactin. Then the torn ends of the external anal sphincter were approximated by tying the pre-placed sutures. Vaginal mucosal edges were approximated with a continuous suture of No. 1-0 polyglactin. The perineal body was reconstructed with interrupted sutures of No. 1-0 polyglactin. The perineal skin was sutured with interrupted sutures of No. 1-0 polyglactin. The rectal mucosal prolapse was completely reduced with this repair (figure 2). The patient made an uneventful recovery. The repair was found to be satisfactory and the rectal mucosal prolapse cured at follow up examinations after 15 days, 1 month and 2 months.
Fourth degree perineal tear occurs due to uncontrolled tearing of tissues with a normal or instrumental vaginal delivery, an extension of an episiotomy, precipitate labor or fundal pressure. A rectal mucosa prolapse is believed to be either a sliding hernia that occurs through a pelvic fascial defect, or progression of an internal circumferential intussusception of the rectum.[3,4] It is most often associated with chronic hemorrhoids. It may be associated with chonic diarrhea, constipation, chronic obstructive pulmonary disease, multiple sclerosis, cystic fibrosis or paralysis. A rectal prolapse repair usually is best managed by an abdominal or laparoscopic approach. This is applicable mainly to a complete prolapse.[6-9]
In our case, it was deemed essential by the surgeons that the fourth degree repair be completed first and then the rectal prolape would be treated. Putting a Thiersch’s stitch along with the perineal tear repair was not considered suitable because it would interfere with the repair of the perineal body. Its recurrence rates are also high, which was not acceptable to the patient.[10-13] Two things were unusual in our case. The first one was that an old, fourth degree perineal tear and rectal mucosal prolapse coexisted. The second one was that rpair of the old, fourth degree perineal tear resulted in cure of the rectal mucosal prolapse too. The co-existence of the two conditions can be explained as a co-incidence. But cure of the prolapse with repair of the perineal tear could only suggest that the rectal mucosal prolapse was secondary to the perineal tear. A cause-effect relationship between the two could not have existed, as the perineal tear was at least 20 years old, while the rectal mucosal prolapse was not more than 2 years old. It is possible that there was fibrosis between the external anal sphincter and the anorectal mucosa after the childbirth trauma, and repair of the sphincter by double-breasting pulled up the rectal mucosa. More cases of co-existence of the two conditions need to be reported, so that a meaningful conclusion can be drawn from them.
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Parulekar SV. Coexisting Chronic Fourth Degree Perineal tear and Rectal Mucosal Prolapse. JPGO 2019. Vol 6 No. 8. Available from: https://www.jpgo.org/2019/08/coexisting-chronic-fourth-degree.html