Bridging Gaps: Insights from a Rectal Buttonhole Tear Case Series

Obstetric rectal buttonhole tears (ORBT) are isolated rectal mucosal lacerations with intact anal sphincters. These injuries are frequently overlooked during delivery, resulting in delayed diagnosis, rectovaginal fistula formation, and the need for surgical referral.

A descriptive case series was conducted on seven women referred for ORBT repair between X across Y under Z (60,000 deliveries). All patients had intact anal sphincters with confirmed rectal mucosal tears identified at the time of delivery through systematic digital rectal examination and subsequently referred for repair within 24 h of injury. Repairs were performed using a standardized three-layer closure technique by a urogynaecologist within 7 h (median 2 h) of injury. Postoperative outcomes were assessed at 3 months with physical examination and St. Mark's incontinence score. An educational video demonstrating the repair was produced for obstetric practitioner training.

Seven cases of ORBT were identified, with an incidence of 1 in 8571 deliveries (0.012%). All repairs were successful, with no rectovaginal fistula formation or complications. At 3 months, all women demonstrated complete continence (St. Mark's score 0/24).

This series emphasizes the importance of early recognition and structured management of ORBT. A standardized repair technique ensures excellent outcomes and, when combined with video-based training, can equip obstetric practitioners to manage these injuries promptly and reduce the need for surgical referral.