EP242 - Repair of traumatic cloaca with botulinum toxin. Case report

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Purpose/Background: Traumatic cloacal deformities are the result of a major obstetric injury and usually occur after a third or fourth degree perineal laceration involving all layers of the recto vaginal septum, producing a complete communication between the rectal lumen and the vagina. Although it occurs in 1 in 5000 deliveries, the effect on patients is devastating, resulting in genitourinary and vaginal infections, fecal incontinence, and significant sexual dysfunction due to dyspareunia and patient abstinence, in addition to having a significan impact on quality of life and mental health. The only treatment for this type of lesion is surgical repair.

There are several reports and series in the literature describing techniques for traumatic cloaca repair; a variety in terms of the use or not of flaps and the use or not of fecal diversion. However, repair of these deformities can be challenging and complex since it involves a precise and layered approach to the damaged structures and tissues. Partial failure of the repair can result in a recto-vaginal fistula and complete failure leads to re-formation of the cloaca.

The objective is to present a cloacal repair technique using 200 IU of botulinum toxin, demonstrating lower rates of dehiscence of the perineal suture and muscle flaps, which improve the results in continence, aesthetics and sexual function.

Methods/Interventions: Report of 4 cases of women treated for complete perineal tear of the cloaca type. During the procedure, the remaining rectovaginal septum was dissected, regardless of the surgical technique to be performed, 200 IU of botulinum toxin was applied to the muscle flaps for myorelaxation and finally closure of the anal and vaginal mucosa and skin. The patients were left with daily dressings with clinical signs of wounds and were discharged after 7 days.

Results/Outcomes: 4 patients underwent surgery in early 2024. On physical examination, all of them presented a perineal cloaca. Surgical management was performed with application of 200 IU of botulinum toxin for myorelaxation of muscle flaps. Transoperatively, one patient had partial wound dehiscence, which was managed with wound clinic cures. Follow-up at 3 months showed adequate evolution and patient satisfaction.

Conclusion/Discussion: Although surgical management has significant rates of improved continence, good aesthetic results and acceptable results in sexual function, there is insufficient evidence as to which technique is best for traumatic cloacal repair. Therefore, today, the most feared complication of any technique is wound dehiscence.

Considering that cloacal repair remains a challenge, 4 cases are presented using botulinum toxin in surgical management, achieving good results in aesthetics, wound dehiscence and improvement in the quality of life of patients. Although there is no evidence of the use of botulinum toxin for this type of procedure, it is considered a technique that can be standardized, which would require further studies