Obstetric Rectal Buttonhole Tear: Case Series, Literature Review, and Management Recommendations

Obstetric rectal buttonhole tear (ORBT) is a rare but serious complication of vaginal delivery, associated with rectovaginal fistula and fecal incontinence. Standardized management protocols are lacking.

We conducted a retrospective study of 3 institutional ORBT cases (2018-2024) managed with primary transvaginal layered repair and synthesized data from 40 published cases (1993-2024).

Among 43 patients, 77.8% were primiparous; the median neonatal weight was 3570 g. ORBT occurred after spontaneous vaginal delivery (58.1%), operative vaginal delivery (34.9%), breech extraction (4.7%), or cesarean section (2.3%). Lateral episiotomy was present in 46.5% of cases, midline in 7.0%. Diagnosis was immediate postpartum (58.1%), during the second stage (34.9%), or delayed (7.0%). Primary transvaginal layered repair was performed in 81.4% of cases with favorable outcomes; colostomy was required in 2.3% after delayed diagnosis. Postoperative antibiotics and laxatives were administered in 86.0% and 72.1%, respectively. Complications occurred in 4.7% (wound dehiscence and rectovaginal fistula).

ORBT can occur irrespective of delivery mode, birth weight, or episiotomy but is more frequent in primiparas. Avoidance of rapid descent of the fetal head through the birth canal is recommended. Early diagnosis and primary layered repair by experienced surgeons under anesthesia (with transfer or short delay ≤ 12 h if necessary) optimize outcomes and minimize the need for colostomy. Perioperative antibiotics, structured bowel care, and adequate analgesia are recommended.