Comprehensive Management of Obstetric Rectal Buttonhole Tears: Insights From a Case Report and Literature Analysis

BACKGROUND Obstetric rectal buttonhole tears (ORBT) are rare and underreported complications during vaginal births. They offen go undiagnosed, as they appear with intact perineum or with a low-degree perineal laceration. If missed, they can progress to a rectovaginal fistula. They are not a part of the Sultan classification and there is no consensus on their management. Various repair techniques have been proposed, but the limited evidence and experience make it challenging to standardize an approach. CASE REPORT We present a case of a 2-cm ORBT with intact anal sphincters revealed after a digital rectal examination in a primigravida patient from our institution after a vacuum-assisted delivery. A 3-layer repair technique of the rectal wall with continuous Vicryl 3-0 sutures, the rectovaginal fascia with interrupted PDS 3-0 sutures, and the vaginal wall with continuous Vicryl 2-0 sutures was applied. Additionally, a review of the literature was performed. The PubMed/MEDLINE, Cochrane Library and Google Scholar databases were assessed, yielding 27 case reports (including our case report). CONCLUSIONS The repair techniques used varied among reports, showing the lack of consensus on their management. A 3-layer repair was used in 52% of cases, 2-layer repair in 40%, and the technique was unspecified in 7% of the reported cases. This case report underscores the importance of a digital rectal examination after vaginal births and proposes an evidence-based 3-layer closure to provide better tissue alignment and strength, potentially reducing the risk of a rectovaginal fistula.