Negative Pressure Wound Therapy

ISSN: 2334-184X (Print) / 2334-1858 (Online)

VOL.1 NO.1
JANUARY 2014
http://www.researchpub.org/journal/npwt/npwt.html

Complex Posttraumatic Perineal Wound with

Rectovaginal Fistula - Treatment with Negative
Pressure Therapy
Nikodem Horst MD, PhD*,Tomasz Banasiewicz MD, PhD, Piotr Krokowicz MD, PhD

wounds that present difficult clinical problem. It is well documented that this treatment results in faster growth of granulating tissue, stimulation of angiogenesis, better blood flow
after the therapy and a greater reduction of wound surface in
comparison to wounds treated in a regular way [1-5].
Constant research on negative pressure therapy and its
common use as an initial dressing especially on the battlefield
encouraged clinicians to apply this kind of wound management
to complex perineal wounds caused not only by trauma but also
by soft tissue infections such as Fourniers gangrene [6-13]. We
report the negative pressure therapy treatment of a women aged
49, that was admitted to the hospital three days after initial
complex perineal trauma with complete lesion of the perineal
body, anal sphincters, distal part of rectum, and rectovaginal
septum resulting in posttraumatic rectovaginal fistula. The
final result of negative pressure treatment was complete closure
of the large rectovaginal opening and significant healing of the
wound including the perineum. The anal sphincters were left
for later proceeding.

Abstract The case of successful treatment of posttraumatic rectovaginal fistula with negative pressure therapy is
presented. The female, 49 y.o., was admitted to the hospital
due to symptoms of general infection that occurred more
than three days after the trauma of perineal region. Physical examination revealed a total tear of rectum and anus
and rectovaginal fascia defect. Hartmanns procedure was
not effective in the management of major exsudation from
the perineal wound, that was responsible for hypoproteinemia resulting in fluid in abdominal and pleural cavities. A successful attempt was made to perform secondary
closure of rectovaginal fistula and the rectum with support
of negative pressure therapy. The repairment of anal
sphincters was left for later proceeding. The general patient
condition did not improved as well as we would expect and
two months after admission patient was moved to the thoracic surgery department due to recurring respiratory
problems.

II. CASE PRESENTATION

In September 2013 a 49-year-old female was admitted to the
Emergency Department of our hospital due to pain in the anal
area, fever up to 39.6C, loss of appetite and general weakness. According to her, she sustained injury to the perianal area
more than three days before admission after she tried to jump
on the bed and felt on element projecting from beds corner.
The patient didnt come in the day of the trauma because she
claimed that there was no pain to the injured part of the body.
The patient was taking drugs for mild hypertension, and had
undergone 3 operations - in 1983 because of a left ovarian cyst,
in 2001 due to Bartholins abscess (also left side) and in 2012
for arthroscopy of the left knee. She was allergic to iodine and
doxycycline (skin rash). In her history many years ago there
was an obsolete episode of sarcoidosis suspicion, but the patient did not have any medical records concerning that diagnosis nor was she diagnosed with it.
On admission she presented with signs of general infection:
tachycardia (HR 135), SBP 110/80 and body temperature raised
to 38,0C. Blood results were as follow: leukocytosis 6.2 G/L,
hemoglobin 6.5 mmol/L, hematocrit 31.2%, C-reactive protein

Keywords VAC, vacuum assisted therapy, negative

pressure therapy, complex perineal trauma, rectovaginal
fistula

I. INTRODUCTION
egative pressure therapy is well known and widely
used in different type of wounds. Since its first description in 1997 by Argenta and Morykwas [1],
vacuum assisted closure therapy (VAC) became a successful
method for the management of complex and contaminated

Date of submission: 15th January 2014

Poznan University of Medical Sciences, Pozna, 60355 Poland.
*Correspondence to Nikodem Horts (email: nvhorst@gmail.com).

17

Negative Pressure Wound Therapy

ISSN: 2334-184X (Print) / 2334-1858 (Online)

VOL.1 NO.1
JANUARY 2014
http://www.researchpub.org/journal/npwt/npwt.html

212.8 mg/L, creatinine 79 mol/L, glucose 7.0 mmol/L. The

levels of sodium, potassium and transaminases were within the
norm. INR and APTT were 1.01 and 28.8s respectively.
Her overall condition was quite good. She claimed that her
symptoms can be normal after she had the trauma.
Physical examination revealed a large wound of the perineal

both buttocks in the perianal region (Fig.1, Fig. 2, Fig. 3).

Sphincter activity was limited to faint contractions in the coccygeal area.

Fig. 3: Another view of injured region, one day after admission.

The patients abdomen including suprapubic region was soft,

without tenderness. Ultrasound did not show any fluid inside
the abdominal cavity. It is worth noting that the patient did not
report any pain during physical examination, including DRE.
On the night of admission the wound as well as the rectum and
vagina were cleaned of pus and feces, necrotic debris was also
removed. The patient was given broad-spectrum antibiotics. A
urinary catheter was applied. As a result of an improvement in
the patients condition the next day we decided to prepare the
patient for Hartmanns operation. The wound was inspected at
least twice a day and total parenteral nutrition was initiated.
Nevertheless we did not succeed in managing the patients
hypoproteinemia (TP 47 G/L, albumins 17 G/L) that was responsible for patients increasing problems with breathing due
to accumulation of fluid in the pleural cavities. Fluid had also
accumulated in the abdominal cavity (USG).
Four days after admission laparotomy and colostomy on the
sigmoid colon was performed. The distal part of the large bowel
was closed with a linear stapler and the perineal wound was
revised. Intraoperative rectoscopy revealed total tear of the
anus with multiple injuries to the anal sphincters and proximal
part of the rectum, denuded coccyx, multiple radial tears and
lacerations of full thickness on the rectal wall, of which one, 3
cm long in the anterior part of the rectum, was penetrating into
the upper of the vagina. The wound, rectum and vagina were
cleaned, necrotic tissue were removed and absorbable stitches
were placed the vaginal wall to close the rectovaginal fascia
defect. The perianal tissues were contaminated and inflamed,
thus surgical management of that are was not possible.
During the following days the patient felt worse and with
aggravated respiratory problems. The wound was producing
significant amounts of non-clear exudate (500 mL/day) and
abundant amounts of clear serous fluid was observed following
abdominal drainage (600 mL/day). Furthermore fluid in the

Fig. 1: The wounded perineum on the day of

admission.

region with total tear of the proximal anterior part of the rectum
and anus, including anal sphincters and perineal body. In DRE
at 4 cm there was a 1,5 cm tear of the rectovaginal septum. The
lower of what previously was the rectovaginal septum was
almost completely destroyed and was only formed by vaginal
mucosa and some infected tissues. Bruising was also present on

Fig. 2: Vulvar vestibule, lesion of rectovaginal

wall marked with arrow.

18

Negative Pressure Wound Therapy

ISSN: 2334-184X (Print) / 2334-1858 (Online)

VOL.1 NO.1
JANUARY 2014
http://www.researchpub.org/journal/npwt/npwt.html

chest cavity was visualized during a chest x-ray; in repeated

pleural punctures more than 5 liters of clean serous fluid was
obtained during 5 days. In our opinion, which was agreed with
by the consulting thoracic surgeon and pulmonologist, recurrent fluid in the pleural cavities was caused by low protein level
because of exudation from the wound. According to consultants
the pleural punctures should be avoided, but without these
punctures the patient would have rapidly developed respiratory
insufficiency.
The wound was inspected daily by the operator. One week
after the operation, physical examination of the perineal area
revealed local worsening. Despite thorough check-ups, wounds
in the rectum and soft tissues of the perineum became infected.
Rectovaginal septum was formed in the lower exclusively by
a thin layer of vaginal mucosa. The stitches put on the vaginal
wall had gone. The rectovaginal defect recurred and was even
bigger than that on the day of admission (Fig. 4)
Fig. 5: Rectovaginal defect nine
days after 1st operation

Fig. 6: View of injuried region

one week after first operation.
Note periurethral pressure sore.

A second operation was performed 10 days after the first one,

almost two weeks after the initial trauma. During the second
operation the whole perianal area, rectal stump and vagina were
cleaned. Due to the pressure sore at the external orifice of the
urethra, the urinary catheter was removed and a suprapubic
tube was applied. Necrotic tissues were removed from the
wound itself and the margins of the rectovaginal defect were

Fig. 4: Injured region one week after first operation. Note the
pressure sore of urethral orifice.

The catheter put into urethra started to form a pressure sore in

the external orifice (Fig. 5, Fig. 6, Fig. 7). There was significant
swelling of the vulvar region.
Because of worsening of the patients general condition and a
continuous decline of total protein and albumin level as well as
gross fluid loss into the pleura, abdomen and the wound itself,
intensive therapists decided to admit the patient into the Intensive Care Unit. Before this, the decision was made to apply
negative pressure therapy to the injured site as the final attempt
of surgical treatment for that patient, taking into account her
condition and treatment possibilities.

Fig. 7: Rectivaginal defect

nine days after 1st operation.
Rectovaginal fascia is formed
only by thin tissue layer in its
lower 1/3.

Fig. 8: Perineal defect after

second surgery. External fragment of silicone layer put into
reconstructed rectovaginal
fascia marked with arrow.

refreshed. Application of the rectoscope allowed stitching of

the rectal wall and separately its mucosa. Single stitches were
applied to the vaginal injury. Between the reconstructed rectal
19

Negative Pressure Wound Therapy

ISSN: 2334-184X (Print) / 2334-1858 (Online)

VOL.1 NO.1
JANUARY 2014
http://www.researchpub.org/journal/npwt/npwt.html

and vaginal wall a thin layer of silicone was inserted with its
proximal ending being left slightly outside the reconstructed
septum to make future removal possible. The perineal body was
then repaired.
Because of the high tension of the tissues after reconstruction
and limited possibility of removing suspicious tissues in the
perianal area, that in our opinion were prone for further infection, we decided not to repair the anal sphincters and only approximation of appropriate tissues was performed (Fig. 8).
When the surgical part of procedure was complete, we prepared the operated area for the application of vacuum assisted
therapy. A large Pezzer drain was put into the rectum as a
guide.

Fig. 10: Injured site after four days

of VAC therapy.

Fig. 11: Injured site two weeks

after second operation.

The wound was checked daily, the vagina and rectum were
gently irrigated with saline solution and octenidine.
Healing of the wound after V.A.C. therapy was uneventful.
The rectovaginal fistula healed completely. The scar after the
rectovaginal fistula was of the same consistency and thickness
as the rest of the surrounding tissues of the vaginal wall.
The perineal wound as well as rectal and vaginal wounds
healed one week after the second operation and remain unchanged (Fig. 11). Two months after admission the patient was
transferred to another hospital due to persisting breathing
problems.
Fig. 9: VAC dressing. Stomahesive paste visible around Pezzer drain
and in posterior part of vulvar vestibule to provide airtightness.

III. DISCUSSION
V.A.C. WhiteFoam dressing was put over the reconstructed
perineum. Adhesive ostomy paste was used to make the
dressing airtight around the drain and the posterior part of
vulvar vestibule (posterior labial commissure). Clear V.A.C.
Drape and TrackPad was placed on the perineal dressing
(Fig. 9) and the system was checked for airtightness. The
V.A.C. unit (KCI) was set to continuous mode with a pressure
setting of 175 mmHg at an intensity level of 3.
After the second operation patient was admitted to the Intensive Care Unit. The patients condition was stable and the respiratory problems related to recurring fluid in the pleural cavities required the application of chest tubes.
The V.A.C. dressing remained airtight and was removed four
days after the second operation. The examination revealed
proper healing of the vaginal and rectal wounds with part of the
stitches over the healed vaginal and rectal mucosa being removed. Moderate swelling of vulva was also present. The thin
silicone layer was removed from the rectovaginal fascia. We
decided not to prolong the V.A.C. therapy, as the result obtained was more than satisfactory (Fig. 10). The wound was
cleaned, granulating tissue was present and there was no evidence of infection.

Complex perineal wounds still pose a challenge for proper

treatment. To our knowledge there is no literature about
treatment of posttraumatic perineal wounds in females or on
complete healing of posttraumatic rectovaginal fistulas with
negative pressure therapy [11,12].
In our patients case the situation was worsened by her delay
in seeking medical assistance.
The Hartmanns operation performed more or less one week
after the trauma (4 days after admission) was insufficient. The
patient condition worsened in comparison to her condition on
the day of admission due to large exudation and severe local
infection at the injured site despite its exclusion from being
contaminated by stool and urine. Excessive loss of fluids into
the peritoneum and pleural cavities as a consequence of low
protein levels aggravated the situation. As a result the wound
instead of healing, despite total parenteral nutrition, started to
become anergic and infected with a strong disposition for the
soft pelvic tissues. After judging all the possibilities of surgical
management of the wound, taking into account weaken patient-related mechanisms of wound healing and limited possibilities for surgical debridement in this localization, we decided
to apply negative pressure therapy.
20

Negative Pressure Wound Therapy

ISSN: 2334-184X (Print) / 2334-1858 (Online)

VOL.1 NO.1
JANUARY 2014
http://www.researchpub.org/journal/npwt/npwt.html

[7] Pastore AL, Palleschi G, Ripoli A, Silvestri L, Leto A, Autieri D, Maggioni

C, Moschese D, Petrozza V, Carbone A. A multistep approach to manage
Fournier's gangrene in a patient with unknown type II diabetes: surgery, hyperbaric oxygen, and vacuum-assisted closure therapy: a case report. J Med
Case Rep. 2013; 7(1): 1.
[8] Zagli G, Cianchi G, Degl'innocenti S, Parodo J, Bonetti L, Prosperi P, Peris
A. Treatment of Fournier's Gangrene with Combination of Vacuum-Assisted
Closure Therapy, Hyperbaric Oxygen Therapy, and Protective Colostomy.
Case Rep Anesthesiol. 2011; 2011: 430983.
[9] Czymek R, Schmidt A, Eckmann C, Bouchard R, Wulff B, Laubert T,
Limmer S, Bruch HP, Kujath P. Fournier's gangrene: vacuum-assisted closure
versus conventional dressings. Am J Surg. 2009; 197(2): 168-76.
[10] Yeo ES, Kam MH, Eu KW. Management of Fournier's gangrene with
Vacuum Assisted Closure dressing. Ann Acad Med Singapore. 2010; 39(10):
806-8.
[11] Milcheski DA, Zampieri FM, Nakamoto HA, Tuma Jnior P, Ferreira
MC. Negative pressure wound therapy in complex trauma of perineum. Rev
Col Bras Cir. 2013; 40(4): 312-317.
[12] Ozer MT, Coskun AK, Ozerhan IH, Ersoz N, Yildiz R, Sinan H,
Demirbas S, Kozak O, Uzar AI, Cetiner S. Use of vacuum-assisted closure
(VAC) in high-energy complicated perineal injuries: analysis of nine cases.
Int Wound J. 2011; 8(6): 599-607.
[13] Use of vacuum assisted closure (VAC) system in perineal gangrene:
presentation of a case. Flores Corts M, Lpez Bernal F, Valera Snchez Z,
Prendes Sillero E, Pareja Ciur F. Cir Esp. 2011; 89(10): 682-3.
[14] Al Fadhli A, Alexander G, Kanjoor JR. Versatile use of vacuum-assisted
healing in fifty patients. Indian J Plast Surg. 2009; 42(2): 161-8.

VAC therapy proved to be successful in healing or at least

primary treatment of many difficult wounds of different origin
[1,6-14]. By applying VAC in our patient we expected to improve her condition by diminishing inflammation and exsudation in the perineal region and to exclude the perineal wound
from any suspicions of being responsible for the patient condition.
Rectovaginal repair was done in order to separate severely
injured rectum from vaginal secretions. After the second operation we noted evidences of proper wound healing. Surprisingly, after only four days of negative pressure therapy the local
condition of the perineal wound had improved more than what
we had expected. There were no signs of inflammation. The
rectovaginal defect was firmly closed and granulating tissue
was present at the sites we previously thought were prone to be
ischaemic. Taking into account all the factors mentioned above,
including others and also a few people in our hospital that were
able to handle VAC therapy we decided not to prolong VAC
treatment. There is no doubt, that the wound itself, after application of VAC, could be ruled out from factors responsible
for the patients general condition. C-reactive protein levels
started to diminish three days after the second operation and
remained low until the end of patients stay in hospital.
The patients general condition did not improve as much as we
would have expected. Her greatest problems were related to the
respiratory system which required chest drainage and pleurodeses (unsuccessful), and were the main reasons for which
the patient was admitted to the thoracic surgey department after
2 months.

IV. CONCLUSION
VAC therapy proved to be successful in the treatment of complex perineal lesions including posttraumatic rectovaginal fistula.
Acknowledgments: Conflicts of Interests: there are no disclaimers and sources of support

References
[1] Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for
wound control and treatment: clinical experience. Ann Plast Surg. 1997; 38(6):
563-76; discussion 577.
[2] Chen SZ, Li J, Li XY, Xu LS. Effects of vacuum-assisted closure on wound
microcirculation: an experimental study. Asian J Surg. 2005; 28(3): 211-7.
[3] Wackenfors A, Gustafsson R, Sjgren J, Algotsson L, Ingemansson R,
Malmsj M. Blood flow responses in the peristernal thoracic wall during
vacuum-assisted closure therapy. Ann Thorac Surg. 2005; 79(5): 1724-30;
discussion 1730-1.
[4] Wackenfors A, Sjgren J, Gustafsson R, Algotsson L, Ingemansson R,
Malmsj M.Effects of vacuum-assisted closure therapy on inguinal wound
edge microvascular blood flow. Wound Repair Regen. 2004; 12(6):600-6.
[5] Saxena V, Hwang CW, Huang S, Eichbaum Q, Ingber D, Orgill DP. Vacuum-assisted closure: microdeformations of wounds and cell proliferation.
Plast Reconstr Surg. 2004; 114(5): 1086-96; discussion 1097-8.
[6] Polly DW Jr, Kuklo TR, Doukas WC, Scoville C.Advanced medical care for
soldiers injured in Iraq and Afghanistan. Minn Med. 2004; 87(11): 42-4.

21