6. Fibrin Glue Repair of a Traumatic Rectovaginal Fistula in a Pediatric Patient

Rectovaginal fistulas (RVFs) in pediatrics are often secondary to congenital anorectal malformations. Acquired RVFs are especially uncommon in this population. There is a paucity of data in the literature regarding the optimal treatment for acquired RVF . Here, we report an atypical presentation of a RVF in a developmentally delayed child that was repaired with fibrin glue.

A 7 year old presented to the ER with her mother for sudden onset acute right hip pain. She had a history of postnatal meningitis with multiple cerebral infarctions, seizure disorder, spastic quadriparesis and central hypotonia with global developmental delay. A CT scan of the abdomen and pelvis demonstrated a hairpin protruding from the proximal vagina into the rectum. Pediatric gynecology and pediatric surgery teams were consulted. The findings were discussed with the state's child protection system and the patient's mother. The findings were consistent with accidental penetration and allegations of abuse were dismissed. The patient underwent an examination under anesthesia (EUA) and vaginoscopy. The hairpin was identified in the distal posterior vaginal mucosa penetrating through the rectovaginal space, and perforating the anterior wall of the rectum into the lumen. The hairpin was removed and stool was noted on the prong tips. An anorectal speculum examination confirmed that the posterior rectal wall was intact and without defect. Vaginoscopy revealed a 2-3 mm defect at the 5 o'clock position of the distal vaginal mucosa, probe-patent to the rectum. Inspection of the remainder of the vagina was otherwise unremarkable. A fibrin sealant was inserted into the tract using a 14 gauge angiocatheter. A suitable fibrin plug was created in the tract. The vaginal mucosa was imbricated over the plug in an interrupted fashion using 5-0 vicryl suture. Hemostasis was achieved. The procedure and postoperative course were overall uncomplicated. She was discharged on hospital day 2. An EUA was completed by the original surgical team after one year. Direct visualization with a 9.5 French Cystourethroscope demonstrated no defect of the posterior vaginal wall. A Hegar dilator was placed in the rectum, directed anterior and caudal, and further demonstrated lack of a vaginal mucosal defect.

This is the first report of RVF repair with fibrin glue in a pediatric patient. Fibrin glue therapy may be a minimally invasive and safe alternative to surgical excision for the repair of small RVF in pediatric patients. Further research is needed to determine the size of defect amenable to a minimally invasive approach using fibrin glue and the long term outcomes of this therapy in this population.

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