Post-coital perineo-rectal fistula: case report

¹Faculty of Medicine and Biomedical Sciences, University of Garoua, Garoua, Cameroon, ²Maroua Regional Hospital, Maroua, Cameroon, ³Garoua Regional Hospital Centre, Garoua, Cameroon, ⁴Ngaoundéré Regional Hospital Centre, Ngaoundéré, Cameroon, ⁵Cameroon Association for Social Marketing, Maroua, Cameroon

^&Corresponding author
Clovis Ourtchingh, Faculty of Medicine and Biomedical Sciences, University of Garoua, Garoua, Cameroon

Introduction    

Trauma of the perineum is frequently encountered following vaginal delivery, whether natural or instrumental. Recto-vaginal fistula is the most common lesion known due to obstructed labor, and it is always associated with vesico-vaginal fistula. Isolated recto-vaginal may be caused by sexual violence in war situations or in underage marriages. Perineal tears (grade 1 to 3), injuries of the anal sphincter (grade 4), and vulvar hematomas usually occur in isolation unrelated to obstructed labor [1]. Risk factors for post-coital perineal trauma are virginity, young age, brutal nature of intercourse, penile-vaginal disproportion, anal penetration, use of aphrodisiacs, sex toys, history of vaginal surgery, nulliparity, rape, and congenital weakness of the posterior vaginal wall [2-4]. We report here an exceptional case of perineo-rectal fistula, which is a wound connecting the perineum and the rectal cavity with an intact hymen, occurring after the first sexual intercourse.

Patient and observation     

Patient information: 26-years-old female patient, divorced and nulliparous. The main symptoms were incontinence of gas and stools through the perineal wound, inability to socialize due to stool odors, and the need to wear and change pads regularly. She described the first sexual intercourse after her marriage as painful and hemorrhagic. She did not report any impalement of the perineum by a blunt object. This condition, which led to fecal incontinence, was the cause of her divorce. She spent four years in isolation, a period marked by a lack of family support and financial means. She was taken to the hospital by a humanitarian organization.

Clinical findings: weight 38 kg, height 1.47 m, BMI 17.59 kg/m² (patient wasted), blood pressure: 105/75 mmHg, pulse: 80 beats/min, temperature: 37.3°C, gynecological examination showed an intact hymen (Figure 1), the anal margin free of lesions and the anal sphincter tonic to the rectal touch. However, we found a breach between the anus and the vagina communicating with the rectal cavity in an oblique direction from top to bottom of the perineal body towards the rectum (Figure 2). The perineal body was destroyed, the hymen uninjured, and the anal sphincter preserved.

Timeline of current episode: she began to have the presence of stool on her underwear immediately after her first sexual intercourse in 2018 at 22-years-old, divorce three months later, we saw her in consultation on 15/10/2022 at 26-years-old during an obstetric fistula repair campaign organized at the Maroua Regional Hospital (Cameroon).

Diagnostic assessment: full blood count hemoglobin: 11.4 g/dL, red blood cells: 5000/mm³, platelets: 233000/mm³, blood group: rhesus O positive, fasting blood glucose: 70 mg/dL, urea: 26 mg/dL, creatinine: 0.48 mg/dL.

Diagnosis: post-coital perineo-rectal fistula with intact hymen.

Therapeutic interventions: the care was completely free as part of a project to repair obstetric fistulas. After digestive preparation with a liquid diet for two days and a rectal enema the day before surgery, we successfully performed a cure of the fistula and reconstitution of the perineal body under spinal anesthesia on 17/10/2022. The surgical procedure involved first dissecting the rectal mucosa around the breach and closing it with absorbable suture N°3/0, second reconstituting the perineal body by suturing the puborectalis muscles with absorbable suture N°2/0, and third suturing the perineum with disrupted stitches with suture N°2/0 (Figure 3). The patient was given metronidazole and ciprofloxacin 1 g per day, divided into two doses during ten days.

Follow-up and outcome of interventions: the urinary catheter was removed 24 hours after surgery. The patient performed sitz baths with povidone 10% twice daily for two weeks. She spent 14 days in hospital and was discharged with a closed fistula and good continence. Due to a lack of financial means, the patient was unable to attend her one, three and six-month post-operative appointments. We saw her again at ten months post-operatively after a new marriage with a well-healed perineum and a deflowered hymen, testifying to the resumption of regular sexual activity (Figure 4).

Patient perspective: the transcription of the patient's statements can be summarized as follows: "I am delighted with my treatment, which has given me back my dignity as a woman and has allowed me to resume my social activities. Thanks to the restoration of my perineum, I was able to get back into a relationship. Today, I am satisfied with my sexuality".

Informed consent: the patient has given her informed consent for her information and images to be used for scientific purposes.

Discussion     

We are delighted that the patient cooperated during her treatment, a testament to her commitment to her health. We are eager to see her again to assess her post-treatment progress and hear her feedback. However, we regret that it was not possible to ask the husband about the quality of the sexual activity practiced, given that they were no longer in the same relationship. The occurrence of the rectovaginal fistula is common after vaginal delivery following prolonged obstructive labor [1]. However, a few cases following sexual intercourse have been reported in the literature [5,6]. The particular case we present is that of a perineo-rectal fistula that occurred after first sexual intercourse with a young woman who was 22-years-old at the time of her marriage, with her consent. Young women aged 21 and 24 have had post-coital complications in the form of recto-vaginal fistulas [2,6,7]. Ngalame et al. and Al-Asali et al. respectively described a case of recto-vaginal fistula occurring during the first sexual intercourse with consent [5,6]. Marchand et al. on the other hand, describe a case that occurred during non-consensual intercourse [3].

Similarly, Muleta et al. in a study of 91 cases of post-coital recto-vaginal fistula in Ethiopia, found that 75% of the women were young victims of non-consensual intercourse after forced marriage [4]. Uğurel et al. reported a similar case, which occurred during the second sexual intercourse with postcoital trauma in a 24-year-old woman with a lesion extending from the vagina to the perineum and reaching the anal sphincter [2]. The clinical presentation in our patient was passive loss of stool and gas through the perineal breach, soiling the vagina by proximity. All cases reported in the literature have as symptoms the loss of gas and stool through the vagina [5-7]. Our patient presented with a perineo-rectal communication with no history of malformation or trauma to the perineum. Golbasi et al. describe a case of post-coital trauma whose manifestation was a voluminous vulvar hematoma [8]. A case of post-coital recto-vaginal fistula after a cure for vaginal agenesis is also described [9]. Sarrau et al. describe a case in a transsexual subject [10]. The intention of intercourse, in our case, was undoubtedly vaginal, given the oblique course of the fistula from top to bottom (from the perineum to the rectum). Congenital weakness of the perineal connective tissue cannot be ruled out. Except for Marchand et al. who describe anal intercourse as the cause of the fistula [3], the other authors report essentially vaginal intercourse.

The surgical procedure involved the closure of the fistula in 3 planes: the rectal mucosa, the body of the perineum, and the skin of the perineum. The management time was four years, probably because the patient was divorced and no longer had any financial support. The delay in surgical management was nine weeks in the case described by Ngalame et al. [5]. The evolution was favorable postoperatively. On the 14^th day, the patient was discharged with good continence. A colostomy can be performed but Uğurel et al. advise against it, believing that respect for the different planes during surgery is sufficient to close the fistula [2]. Postoperative recovery is generally favorable after 14 days to 2 months [5,8]. The consequences of recto-vaginal fistulas can be disastrous, even leading to divorce, as in our patient's case. Muleta et al. and Ijaiya et al. describe cases of divorce following post-coital recto-vaginal fistula [4,7].

Conclusion     

Perineo-rectal fistula is an exceptional complication encountered after sexual intercourse in a virgin woman. The diagnosis is clinical, and the lesions are assessed. By repairing the different planes, surgical management enables the fistula to be closed and fecal continence to be re-established, thereby facilitating social reintegration.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Patient management: Clovis Ourtchingh and Chantal Sadia Didjo'o; Medical observation: Stéphane Aoudi Mbardjuk and Chantal Sadia Didjo'o. Drafting of the manuscript: Clovis Ourtchingh and Salamatou Souley. Revision of the manuscript: Esther Ndeksia Soumai and Rakya Inna. All the authors read and approved the final version of this manuscript.

Figures     

Figure 1: A) intact hymen; B) perineal orifice of the fistula; C) anal margin

Figure 2: A) perineo-rectal fistula, the lower limit of the hymen between two Allis clamps; B) hegar candle n°10 showing the course of the perineo-rectal fistula

Figure 3: A) post-surgery repair, hegar candle through the intact hymen; B) repaired perineum; C) anal margin

Figure 4: A) perineum during the healing process, with the vaginal orifice; B) perineum showing significant healing after ten months; C) restored anal margin

References