Skip to main content

Practical use of transanal decompression tube following the repair of fourth-degree perineal tears associated with vaginal delivery



Fourth-degree perineal tears associated with vaginal delivery (PTAVD) occur in approximately 0.25 to 6% of vaginal deliveries. A persistent challenge in treating fourth-degree PTAVD is the high incidence of anastomotic leakage, leading to impaired quality of life, marked by incontinence, rectovaginal fistula, and painful sexual intercourse. Thus, effective interventions are necessary. Herein, we report our successful approach in repairing a fourth-degree PTAVD, involving the placement of a transanal decompression tube (TDT) during the early postoperative period.

Case presentation

Five patients underwent the repair of fourth-degree PTAVD by suturing the mucosal and muscular layers of the rectum, and the vaginal wall in layers. Subsequently, a TDT was placed in the rectum, positioned 10–15 cm from the anal verge. The TDT was allowed to drain spontaneously without suction. Gastrografin enema examination was performed through a TDT, followed by a computed tomographic scan on postoperative days 3–4. After unfavorable complications were ruled out, the TDT was removed and the patients were transitioned to a normal diet.


All patients showed favorable outcomes with no occurrence of vaginal fistula or incontinence.


This simple intervention demonstrates potential efficacy in reducing anastomotic leakage following the repair of fourth-degree PTAVD.


The American College of Obstetricians and Gynecologists classifies perineal tears associated with vaginal delivery (PTAVD) into four degrees based on injury severity. Fourth-degree PTAVD involves anal and rectal laceration [1], and occurs in 0.25–6% of vaginal deliveries [2]. Surgical repair is necessary, but a significant challenge is the frequent occurrence of anastomotic leakage [3], leading to complications such as fecal incontinence, painful sexual intercourse, and rectovaginal fistula [1, 4, 5]. Meticulous anatomic approximation during repair of all disrupted layers is recommended to minimize the leakage [5]. However, approximately 25% of patients with third- and fourth-degree PTAVD still experience anastomotic leakage [3]. The challenge of anastomotic leakage is parallel to the challenges of anal-sparing surgery for rectal cancer near the anus, where the incidence reaches to approximately 20%[6]. Severe anastomotic leakage results in lifelong defecation disturbances, such as fecal incontinence. Thus, to prevent anastomotic leakage, the creation of temporary stomas has been prompted. While numerous studies have proven the effectiveness of temporary stomas[7], stomas pose risks such as small bowel obstruction, high output, skin excoriation, herniation, prolapse, and associated surgical closure risks[8, 9]. Therefore, a transanal decompression tube (TDT) is proposed for anastomotic management during rectal surgery [10, 11]. In this study, a TDT was implanted to decompress the anastomosis after repair of 4th degree PTAVD and prevent infection due to stool contamination. The effectiveness of the TDTs was investigated and the results of the initial five cases are reported herein.

Case presentation

Five cases of fourth-degree PTAVD underwent surgical repair in our hospital between January 2019 and May 2022 (Table 1). The median age was 34 years (range: 29–38), median body mass index (BMI) was 21.72 (range: 17.58–36.63), and the median birth weight of the delivered infants was 3345 g (range: 2756–3650 g). All cases involved primiparous individuals, with vacuum-assisted delivery performed in four cases. Postoperatively, all patients received second-generation cephalosporin for 3–5 days. After cleansing the wound, the rectal mucosa and muscular layers were individually closed with 3-0 absorbable sutures. Subsequently, the posterior vaginal wall was closed with 3–0 absorbable sutures (Fig. 1). Finally, a TDT (10 mm soft pleated drain) was placed in the rectum, positioned 10–15 cm from the anal verge (Fig. 2). The TDT was left unaspirated and allowed to excrete spontaneously. Gastrografin, a water-soluble contrast agent was administered through TDT for the enema examination. Immediately after the examination, a plain computed tomographic scan (CT) was performed (Fig. 3) to check for contrast leakage, disruption of wall continuity, and abscesses. After unfavorable complications were ruled out, the patients resumed their normal diet. The median period from operation to gastrografin enema through TDT was 4 days (range: 1–8 days), and the median postoperative hospital stay was 11 days (range: 4–12 days). Case 3, who initially had fourth-degree PTAVD at another hospital, experienced anastomotic leakage seven days postoperatively following the initial suturing. The patient was sent to our hospital for further treatment. Due to the highly contaminated wound, we performed colostomy alongside TDT insertion, considering the high risk of anastomotic leakage despite careful resuturing.

Table 1 Patients background
Fig. 1
figure 1

A Fourth-degree perineal tears associated with vaginal delivery. The finger passes from anal to vagina. B Suture of the rectal mucosal layer with 3-0 absorbable sutures. C Suture of the rectal muscular layer with 3-0 absorbable sutures

Fig. 2
figure 2

A soft pleated drain was inserted 10–15 cm from the anal verge and secured to the skin using 2-0 silk thread

Fig. 3
figure 3

Gastrografin enema (A) using a water-soluble contrast medium through the transanal decompression tube, followed by a plain computed tomography (B)


In most cases, the TDT drained a minimal amount of stool. All patients demonstrated no evidence of anastomotic leakage on gastrografin enema and CT. Except for Case 3, all patients received laxatives post-TDT extraction. Over a median follow-up period of 2.7 years (range: 1.1–3.9), none of the patients developed rectovaginal fistula or fecal incontinence.


While 0.1–5% of overall PTAVD patients experience anastomotic leakage, the incidence rises significantly to approximately 25% among patients with third- and fourth-degree PTAVD, with 20% facing wound infections within six weeks post-repair surgery [3]. Adequate laceration repair is crucial to prevent rectovaginal fistulas, as around 9% of rectovaginal fistulas in the United States are associated with PTAVD [5]. Postoperative management for third- and fourth-degree PTAVD remains relatively unexplored. Anastomotic leakage is often attributed to wound contamination, infection susceptibility, and unconscious increases in anorectum pressure, frequently disrupting rest at the suture site [12,13,14,15]. Intrarectal pressure can rise to 40–60 mmHg, causing involuntary anal contraction [16]. While antibiotics and laxatives are recommended as countermeasures [17], their effectiveness is limited. Therefore, taking more effective measures in preventing anastomotic leakage in fourth-degree PTAVD is essential. A key strategy we developed was to maintain the sutured rectum at rest immediately after suturing. This is considered necessary to prevent anastomotic leakage in anal-sparing surgery for low-lying rectal cancer. Temporary stomas have been utilized and have been proven effective. However, impaired cosmesis and complications, such as intestinal obstruction and skin disorders present as challenges. Furthermore, additional surgery will be required for closure. As a less invasive alternative, TDT offers a promising solution to prevent anastomotic leakage in fourth-degree PTAVD.

The use of TDT as an alternative to diverting stomas was first introduced by Rack et al. in 1966[18]. TDT involves the insertion of a drainage tube through the anus into the rectum to facilitate the expulsion of gas and stool during the early postoperative period. Both temporary stoma and TDT aim to reduce intra-rectal pressure and keep the suture sites at rest. Several studies have compared the effectiveness of temporary stomas and TDT, consistently reporting similar efficacy in reducing the occurrence of anastomotic leakage. [10, 11, 19,20,21,22,23,24]. However, TDTs may not reduce AL overall in patients undergoing rectal cancer surgery, and they are hardly a replacement for colostomy [22, 25]. Because PTAVD occurs in pregnant women, the disease is not pretreated as it is before rectal cancer surgery, and because of the low anastomosis close to the anus, the usefulness of TDTs may be higher in the treatment of PTAVD than after rectal cancer surgery. However, future case studies are needed.

Previous reports in rectal cancer surgery have suggested TDT indwelling periods ranging from 3 to 7 days, though the optimal duration remains unknown. Complications from TDT are rare; however, intestinal perforation has been reported in cases of long-term indwelling [26]. Early return to normal activities for breastfeeding and childcare is important for patients with perineal lacerations. Therefore, we adopted a strategy of removing the TDT 3 to 4 days after surgery, with the exception of case 3 where failure suture occurred once. Before removal, an enema test using gastrografin and CT was performed to examine for any signs of anastomotic leakage or damage caused by the TDT.

A normal diet was started after the enema test using gastrografin and CT, and no issues were identified in any cases. Once no problems were identified, a normal diet could be started, and long-term outcomes were good. Because adequate nutritional intake is essential for nursing mothers, the contrast method using a TDT suggests the possibility of clarifying when it is safe to start a normal diet.


We adopted a transanal decompression tube for postoperative management after repair of fourth-degree perineal tears associated with vaginal delivery. The new treatment was safely administered in five cases. Further studies are necessary to confirm their clinical efficacy.

Availability of data and materials

All the data and materials used in this study were obtained from publicly available sources or databases, and all cited literature is accessible through PubMed.



Perineal tears associated with vaginal delivery


Computed tomographic


Transanal decompression tube


Body mass index


  1. Reid AJ, Beggs AD, Sultan AH, Roos AM, Thakar R. Outcome of repair of obstetric anal sphincter injuries after three years. Int J Gynaecol Obstet. 2014;127(1):47–50.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Cunningham FG, Leveno K, Bloom SL. Williams obstetrics. 24th ed. New York: McGraw-Hill; 2014. p. 549.

    Google Scholar 

  3. Lewicky-Gaupp C, Leader-Cramer A, Johnson LL, Kenton K, Gossett DR. Wound complications after obstetric anal sphincter injuries. Obstet Gynecol. 2015;125(5):1088–93.

    Article  PubMed  Google Scholar 

  4. Priddis H, Dahlen HG, Schmied V, Sneddon A, Kettle C, Brown C, et al. Risk of recurrence, subsequent mode of birth and morbidity for women who experienced severe perineal trauma in a first birth in New South Wales between 2000–2008: a population based data linkage study. BMC Pregnancy Childbirth. 2013;8(13):89.

    Article  Google Scholar 

  5. Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin No. 198: prevention and management of obstetric lacerations at vaginal delivery. Obstet Gynecol. 2018;132(3):e87–102.

    Article  Google Scholar 

  6. Cong ZJ, Hu LH, Bian ZQ, Ye GY, Yu MH, Gao YH, et al. Systematic review of anastomotic leakage rate according to an international grading system following anterior resection for rectal cancer. PLoS ONE. 2013;8(9): e75519.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg. 2007;246(2):207–14.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Bakx R, Busch OR, Bemelman WA, Veldink GJ, Slors JF, van Lanschot JJ. Morbidity of temporary loop ileostomies. Dig Surg. 2004;21(4):277–81.

    Article  CAS  PubMed  Google Scholar 

  9. Kaiser AM, Israelit S, Klaristenfeld D, Selvindoss P, Vukasin P, Ault G, et al. Morbidity of ostomy takedown. J Gastrointest Surg. 2008;12(3):437–41.

    Article  PubMed  Google Scholar 

  10. Gurjar SV, Forshaw MJ, Ahktar N, Stewart M, Parker MC. Indwelling trans-anastomotic rectal tubes in colorectal surgery: a survey of usage in UK and Ireland. Colorectal Dis. 2007;9(1):47–51.

    Article  CAS  PubMed  Google Scholar 

  11. Ha GW, Kim HJ, Lee MR. Transanal tube placement for prevention of anastomotic leakage following low anterior resection for rectal cancer: a systematic review and meta-analysis. Ann Surg Treat Res. 2015;89(6):313–8.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Herter FP, Slanetz CA Jr. Influence of antibiotic preparation of the bowel on complications after colon resection. Am J Surg. 1967;113(2):165–72.

    Article  CAS  PubMed  Google Scholar 

  13. Morgenstern L, Yamakawa T, Ben-Shoshan M, Lippman H. Anastomotic leakage after low colonic anastomosis: clinical and experimental aspects. Am J Surg. 1972;123(1):104–9.

    Article  CAS  PubMed  Google Scholar 

  14. Nesbakken A, Nygaard K, Lunde OC. Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer. Br J Surg. 2001;88(3):400–4.

    Article  CAS  PubMed  Google Scholar 

  15. Qu H, Liu Y, Bi DS. Clinical risk factors for anastomotic leakage after laparoscopic anterior resection for rectal cancer: a systematic review and meta-analysis. Surg Endosc. 2015;29(12):3608–17.

    Article  PubMed  Google Scholar 

  16. Lee JT. Shackelford’s surgery of the alimentary tract, vol. 2. 8th ed. Amsterdam: Elsevier; 2019.

    Google Scholar 

  17. Duggal N, Mercado C, Daniels K, Bujor A, Caughey AB, El-Sayed YY. Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial. Obstet Gynecol. 2008;111(6):1268–73.

    Article  PubMed  Google Scholar 

  18. Rack RJ. Advantages of an indwelling rectal tube in anterior resection and anastomosis for lesions involving the terminal portion of the colon. Dis Colon Rectum. 1966;9(1):42–8.

    Article  CAS  PubMed  Google Scholar 

  19. Xiao L, Zhang WB, Jiang PC, Bu XF, Yan Q, Li H, et al. Can transanal tube placement after anterior resection for rectal carcinoma reduce anastomotic leakage rate? A single-institution prospective randomized study. World J Surg. 2011;35(6):1367–77.

    Article  PubMed  Google Scholar 

  20. Zhao WT, Hu FL, Li YY, Li HJ, Luo WM, Sun F. Use of a transanal drainage tube for prevention of anastomotic leakage and bleeding after anterior resection for rectal cancer. World J Surg. 2013;37(1):227–32.

    Article  PubMed  Google Scholar 

  21. Challine A, Cazelles A, Frontali A, Maggiori L, Panis Y. Does a transanal drainage tube reduce anastomotic leakage? A matched cohort study in 144 patients undergoing laparoscopic sphincter-saving surgery for rectal cancer. Tech Coloproctol. 2020;24(10):1047–53.

    Article  CAS  PubMed  Google Scholar 

  22. Tamura K, Matsuda K, Horiuchi T, Noguchi K, Hotta T, Takifuji K, et al. Laparoscopic anterior resection with or without transanal tube for rectal cancer patients—a multicenter randomized controlled trial. Am J Surg. 2021;222(3):606–12.

    Article  PubMed  Google Scholar 

  23. Zhao S, Zhang L, Gao F, Wu M, Zheng J, Bai L, et al. Transanal drainage tube use for preventing anastomotic leakage after laparoscopic low anterior resection in patients with rectal cancer: a randomized clinical trial. JAMA Surg. 2021;156(12):1151–8.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Rondelli F, Avenia S, De Rosa M, Rozzi A, Rozzi S, Chillitupa CIZ, et al. Efficacy of a transanal drainage tube versus diverting stoma in protecting colorectal anastomosis: a systematic review and meta-analysis. Surg Today. 2022.

    Article  PubMed  Google Scholar 

  25. Fujino S, Yasui M, Ohue M, Miyoshi N. Efficacy of transanal drainage tube in preventing anastomotic leakage after surgery for rectal cancer: a meta-analysis. World J Gastrointest Surg. 2023;15(6):1202–10.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Hiraki M, Tanaka T, Okuyama K, Kubo H, Ikeda O, Kitahara K. Colon perforation caused by transanal decompression tube after laparoscopic low anterior resection: a case report. Int J Surg Case Rep. 2021;80:105640.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


We thank all the authors who contributed to this topic.


Not applicable.

Author information

Authors and Affiliations



HM wrote the initial draft of the manuscript. MS supervised the writing of the manuscript. HM, TK, MH and TY performed the surgery and HM followed up the patient. HM, TK, MH and TY participated in the treatment of the patient. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Hisanori Miki.

Ethics declarations

Ethics approval and consent to participate

The retrospective study protocol was approved by The Institutional Review Board for Clinical Research of Kansai Medical University Hospital (2023344). The patient provided informed consent prior to receiving the treatment. The patient also provided informed consent for the publication of this case report and any accompanying images.

Consent for publication

Written informed consent was obtained from the participant for publication of this article and any accompanying tables/images. A copy of the written consent is available for review by the Editor of this journal.

Competing interests

The authors have declared that no competing interest exists.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Miki, H., Toshinori, K., Masahiko, H. et al. Practical use of transanal decompression tube following the repair of fourth-degree perineal tears associated with vaginal delivery. surg case rep 10, 167 (2024).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: