Rectovaginal Fistula Research Articles

Postoperative rectovaginal fistula: Can colonic pull-through delayed coloanal anastomosis avoid the need for definitive stoma? An experience of 28 consecutives cases.

Management of rectovaginal fistula (RVF) remains a challenge, especially in cases of postoperative RVF as they are often large and surrounded by inflammatory and fibrotic tissue, making local repair difficult or even impossible. In this situation, colonic pull-through delayed coloanal anastomosis (DCAA) could be an interesting option. The aim of this study was to assess the results of DCAA for RVF observed after rectal surgery. All patients who underwent DCAA for RVF were reviewed. Success was defined as a patient without stoma and without any symptoms of recurrent RVF at the end of follow-up. From January 2010 to December 2020, 28 DCAA were performed for RVF after rectal surgery for rectal cancer (n=21) or endometriosis (n=7). Ten patients (36%) had at least one previous local procedure before DCAA. DCAA was associated with temporary ileostomy in 22/28 cases (79%). After a mean follow-up of 23 ± 23 (2-82) months, the success rate was 86% (24/28): three patients (11%) required a definitive stoma because of poor functional results (n=1), chronic pelvic sepsis with anastomotic leakage (n=1) or stoma reversal refused (n=1). Another patient (3%) presented with recurrence of RVF, 26months after DCAA. Although not significant, the success rate was higher in cases of DCAA with diverting stoma (20/22, 91%) than without (4/6, 67%) (p=0.191). In cases of postoperative RVF, DCAA is a safe option which can avoid definitive stoma in the great majority of the patients. Concomitant use of a temporary stoma appears to slightly increase the success rate.

New Method for Genital Aesthetic Surgery: An Easy-to-Learn 2-Step Approach With Acellular Dermal Matrix.

Vaginal laxity, usually accompanied with prolapse symptoms, affects women's sexual satisfaction and quality of life. Vaginal tightening surgery aims to reinforce perivaginal muscle strength and restore normal vaginal anatomy. The aim of this study was to introduce a new surgical approach to vaginal tightening that uses acellular dermal matrix. In this retrospective study, data from 80 patients with vaginal laxity who underwent surgery between April 2017 and April 2021 were analyzed. Three-dimensional transvaginal ultrasound was performed and the Female Sexual Function Index was evaluated. The mean age of the patients was 44.6 years. The mean patient follow-up was 13.2 months. No infection, rectovaginal fistula, or implant explantation occurred. Transvaginal ultrasound examination demonstrated a significant reduction of introital diameter on a maximum Valsalva maneuver (2.3 cm vs 4.1 cm; P < 0.05) and the reconstruction of acute vaginal angulation. The Female Sexual Function Index orgasm subscore increased significantly. Vaginal tightening with acellular dermal matrix is a minimally invasive surgery that offers a safe and effective treatment for patients with vaginal laxity.

Acquired Rectovaginal Fistula and Faecal Incontinence Following Sexual Assault in a 4-Year-Old Girl

Background: Child Sexual Abuse (CSA) is a crime against children. It is largely under-reported and commonly goes unpunished in our society.&#x0D; Case report: The patient is a 4-year-old girl who presented to our emergency paediatric unit with 14 hours duration of faecal incontinence following sexual assault by her landlord’s son. She also complains of pelvic pain and difficulty in walking. The landlords’s son forced his penis into her anus and inserted his fingers through her vagina.&#x0D; On examination of her anal region, there was anal sphincter tear at six 0’ clock, extending exteriorly to the right measuring 1 cm long and 0.5 cm deep with a rectovaginal fistula. Vaginal examination revealed minor laceration and excoriation on the right lateral wall and floor of the vagina, with mild bleeding. She had a left hymenal tear at the lower aspect and a vagina floor tear. Results of urine microscopy culture and sensitivity (MCS) revealed white blood counts (WBC) 2+, leucocytes 2+, epithelial cells+, Staphylococcus aureus was isolated which was sensityive to amoxiciilin.&#x0D; The child was resuscitated and given antibiotics and analgesics and prophylactic antiretroviral drugs. She had a perineal tear repair by the paediatric surgeon. She was placed on sitz bath and she responded well with good healing and recovery. She was discharged after 2 weeks on admission and came back for follow-up.&#x0D; This report highlights the management of a case of rectovaginal fistula in a child as a result of sexual assault.

Surgical correction of fistulas in patients with cervical cancer after radiation therapy

The aim of this study was to analyze currently available information on the risks of fistulas in patients with cervical cancer after radiation therapy and possible treatment options.This review includes data from Russian and foreign articles devoted to this problem. It covers the frequency of fistulas of after radiation therapy in cervical cancer patients, as well as some treatment methods.Attempts to change the approaches to radiation therapy for advanced cervical cancer were unsuccessful; therefore, patients with cervical cancer will be at high risk of developing fistulas in the next few years. Different treatments for fistulas demonstrate contradictory results and dictate the need for a tailored-approach in such cases. The development of new surgical methods for the correction of vesicovaginal and rectovaginal fistulas is still highly relevant.

Robotic-assisted vesicovaginal fistula repair using a vaginal cuff flap

Vesicovaginal fistula (VVF) is an abnormal communication between the bladder and the vagina. Complex fistulae include those after failed repair attempts, radiotherapy, measuring ≥ 2 cm, located in the trigone, or with concomitant ureteric strictures or fistulae. We aimed to describe a technique for the robotic repair of a complex VVF using a vaginal cuff flap. A 56-year-old woman with a history of ovarian debulking surgery and radiotherapy underwent repair for VVF and rectovaginal fistula. In lithotomy, cystoscopy was performed for fistulous tract cannulation. Port placement, extensive adhesiolysis, and robot docking followed. The vaginal apex was dissected, the VVF excised, and the bladder closed. The rectum was separated from the posterior vaginal wall, the rectovaginal fistula excised, and the rectum closed. A vaginal cuff flap was harvested and interposed between the bladder and the vagina. Operative time was 9 h, estimated blood loss was 300 cc, and no intraoperative complications occurred. The patient was discharged on postoperative day 8. Further management included 37 sessions in a hyperbaric chamber and a transvesical endoluminal bladder closure 10 months after the initial surgery. Follow-up at 30 months shows no fistula recurrence. Vaginal cuff flaps represent a feasible interposition tissue in patients with hysterectomy for managing complex VVF in the case of omentum unavailability.

Short-term outcomes in patients undergoing laparoscopic surgery for deep infiltrative endometriosis with rectal involvement: a single-center experience of 168 cases.

The surgical management of deep infiltrative endometriosis (DE) involving the rectum remains a challenge. The objective of this study was to assess the outcomes from a single tertiary center over a decade with an emphasis on the role of a protective loop ileostomy (PI). A retrospective review of outcomes for 168 patients managed between 2008 and 2018 is presented including 57 rectal shaves, 23 discoid excisions, and 88 segmental rectal resections. The nodule size (mean±standard deviation) in the segmental resection group was 32.7±11.2 mm, 23.4±10.5 mm for discoid excision, and 18.8±6.0 mm for rectal shaves. A PI was performed in 19 elective cases (11.3%) usually for an ultra-low anastomosis <5 cm from the anal verge. All Clavien-Dindo grade III/IV complications occurred after segmental resections and included 5 anastomotic leaks, 6 rectovaginal fistulas, 2 ureteric fistulas, and 1 ureteric stenosis. Of 26 stomas (15.5%), there were 19 PIs, 3 secondary ileostomies (after complications), and 4 end colostomies. The median time to PI closure was 5.8 months (range, 0.4-16.7 months) in uncomplicated disease compared with 9.2 months (range, 4.7-18.4 months) when initial postoperative complications were recorded (P=0.019). Only 1 patient with a recurrent rectovaginal fistula had a permanent colostomy. In patients with DE and rectal involvement a PI is selectively used for low anastomoses and complex pelvic reconstructions. Protective stomas and those used in the definitive management of a major postoperative complication can usually be reversed.

Outcomes of Modified Tissue Selection Therapy Stapler in the Treatment of Prolapsing Hemorrhoids

ObjectiveTissue selection therapy staplers (TSTs) are widely used to treat prolapsing hemorrhoids; however, some disadvantages exist. We describe a modified technique for the treatment of prolapsing hemorrhoids, with the aim of minimizing the risk of anal stenosis and anal incontinence and reducing the impact of postoperative complications from the stapling technique. We applied a modified TST procedure, and the preliminary data were used to test the efficacy and safety of this new technique.MethodsWe conducted a retrospective study of patients who underwent modified TST for prolapsing hemorrhoids at our department between January 2018 and January 2020. All patients received a modified TST. Most prolapsing hemorrhoids were not segmentally resected and were instead selectively removed. The demographics, preoperative characteristics, postoperative complications, therapeutic effects, and patient satisfaction were collected and analyzed.ResultsA total of 106 patients were included in the study; 53 were men and 53 women (mean age, 49.24 years). The mean operative time was 55.01 min, and the mean hospital stay was 7.82 days. After surgery, three patients experienced bleeding (2.83%), 2 patients experienced anal discharge (1.89%), 2 patients experienced tenesmus (1.89%), and 5 patients experienced anal tags (4.72%). Anal incontinence, persistent post stapler pain, rectovaginal fistula and anal stenosis did not occur. Two patients developed recurrent symptomatic hemorrhoids (1.89%). The total effective rate of the surgery and the total satisfaction rate of the patients was 97.17%.ConclusionsThe modified tissue selection therapy stapler technique was a satisfactory and economical treatment for prolapsing hemorrhoids at a follow-up period of 1 year. The modified TST was associated with reduced anal stenosis and anal incontinence, less persistent post stapler pain and a minimal risk of rectovaginal fistula.

Morbidity of diverting stoma during colorectal surgery for deep infiltrating endometriosis – an observational study

PurposeTo evaluate stoma-related complications after rectal resection and colorectal anastomosis with diverting stoma for deep infiltrating colorectal endometriosis. MethodsAll the consecutive adult women who underwent colorectal resection with low anastomosis and diverting stoma for deep infiltrating endometriosis in one center between 2013 and 2020 were retrospectively included. Stoma-related complications were retrieved during the stoma period and after stoma reversal. Results33 patients (mean age = 32 years (±6, range=24–45 years) were included. After the first surgery, overall and surgical morbidities were observed in 42% and 30% of patients, including stoma-related complications in 3 patients (9%): high output (n = 2) and prolapse (n = 1). One patient presented with rectovaginal fistula, requiring several unplanned surgeries. No anastomotic leakage was observed.All the patients underwent stoma reversal, after mean delay of 3 months (±3, range=1–20 months). Overall morbidity after stoma closure occurred in 9 patients (27%), including 1 major morbidity (digestive bleeding). Long-term results were obtained after a mean follow-up of 21 months (±9, range=14–34 months). Four patients presented with hernia at the stoma site (12%). The cumulative rate of stoma-related complications was 45%. ConclusionThere is no consensus about the impact of diverting stoma after rectal resection with colorectal anastomosis for deep infiltrating colorectal endometriosis. Stoma-related complications are frequently observed but there are major in only 12% of patients. High risk patients of rectovaginal fistula and/or anastomotic leakage need to be identified to better indicate the diverting stoma, waiting for randomized trials evaluating the real impact of diverting stoma.

Genital surgical procedures for feminization in gender dysphoria

The necessity and the benefits of genital approximating surgery in gender dysphoria are established, therefore the indications after careful diagnostics are indisputable. For vaginoplasty, the method of choice is penile inversion, in which the penile skin is inserted as a pedicled flap into the prepared vaginal space. Alternatively, free skin grafts or intestinal segments can be used. Lifelong bougienage of the vagina is obligatory for all methods. The spectrum of complications after vaginoplasty is broad. Of particular note, although rare, is injury to the anterior rectal wall, from which rectovaginal fistulas can result. During the course strictures of the urinary meatus or also the neovagina occur. Corrections must often be surgically undertaken but conservative measures, e.g. intensified bougienage and topical estrogen treatment, can also be successful. Neovaginal infections are treated analogously to infections of a native vagina. A special situation is inflammation of the intestinal neovagina, which must be treated with mesalazine.

Feasibility and safety of transvaginal specimen extraction in deep endometriosis colorectal resectional surgery and analysis of risk factors for postoperative complications

The aim of the present study was to demonstrate that transvaginal specimen extraction is a feasible and safe approach in colorectal resection for deep endometriosis (DE) and to assess the risk factors for postoperative complications. This retrospective cohort study included all the consecutive patients undergoing segmental bowel resection for symptomatic endometriosis at "La Paz" University Hospital (Madrid, Spain) and at "Hospital General Universitario de Valencia" (Valencia, Spain) from January 2014 to December to 2017. Patients were grouped according to specimen extraction approach into those who had transvaginal extraction (Group I) and those who had suprapubic extraction (Group II). Clinic-demographical, surgical and post-surgical data were recorded. Intra- and postoperative complications were classified according to Clavien-Dindo criteria. Postoperative data were compared between groups. Risk factors associated with surgery were investigated. Out of 99 female patients included (average age 36.91 ± 5.36years), 23 patients (23.2%) had transvaginal and 76 (76.8%) had suprapubic specimen extraction. The groups were comparable regarding operative time, nodule size, level of anastomosis, hospital stay and intraoperative complications. We observed no statistically significant differences in postoperative complications and rectovaginal fistula rate between the groups. Binary logistic regression analyses determined that vaginal endometriosis is an independent risk factor for postoperative complications (OR: 2.63, 95% CI [1.10-6.48], p = 0.03). Transvaginal specimen extraction is a safe and feasible technique in DE colorectal surgery and should be taken into consideration whenever vaginal endometriosis exists. Nevertheless, vaginal endometriosis can be an independent risk factor for postoperative complications in DE surgery.

A systematic review of the patient burden of Crohn\u2019s disease-related rectovaginal and anovaginal fistulas

BackgroundCrohn’s disease (CD)-related rectovaginal fistulas (RVFs) and anovaginal fistulas (AVFs) are rare, debilitating conditions that present a substantial disease and treatment burden for women. This systematic literature review (SLR) assessed the burden of Crohn’s-related RVF and AVF, summarizing evidence from observational studies and highlighting knowledge gaps.MethodsThis SLR identified articles in PubMed and Embase that provide data and insight into the patient experience and disease burden of Crohn’s-related RVF and AVF. Two trained reviewers used pre-specified eligibility criteria to identify studies for inclusion and evaluate risk of bias using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for observational studies.ResultsOf the 582 records identified, 316 full-text articles were assessed, and 16 studies met a priori eligibility criteria and were included. Few epidemiology studies were identified, with one study estimating the prevalence of RVF to be 2.3% in females with Crohn’s disease. Seven of 12 treatment pattern studies reported that patients had or required additional procedures before and/or after the intervention of interest, demonstrating a substantial treatment burden. Seven of 11 studies assessing clinical outcomes reported fistula healing rates between 50 and 75%, with varying estimates based on population and intervention.ConclusionsThis SLR reports the high disease and treatment burden of Crohn’s-related RVF and AVF and identifies multiple evidence gaps in this field. The literature lacks robust, generalizable data, and demonstrates a compelling need for substantial, novel research into these rare and debilitating sequelae of CD.Registration The PROSPERO registration number for the protocol for this systematic literature review is CRD42020177732.

Morbidity of Temporary Loop Ileostomy in Patients with Colorectal Cancer.

Leakage of low colorectal anastomoses after total mesorectal excision is a dreaded complication. Hence, an ileostomy is commonly performed during anterior resection especially in patients who have received neoadjuvant radiation. The aim of this study was to quantify the temporary loop ileostomy-related benefits as well as morbidity in patients with colorectal cancer. We did a retrospective study including all patients who underwent anterior resection with diversion ileostomy for biopsy-proven rectal carcinoma at our institute from 1 Jan 2016 to 31 Dec 2017 with follow-up of 2years. A total of 104 patients were included in the study. In our series, 6.7% patients had an anastomotic dehiscence which precluded patients from stoma reversal. 12.5% of the patients had a stoma-related complication. 5.7% patients had complications following a stoma reversal. Eighty percent of the patients who developed clinically evident dehiscence in the immediate postoperative period were managed conservatively because of the presence of stoma. We did not have any mortality related to the stoma. 18.3% patients did not have their stomas reversed. The stoma non-reversal due to anastomotic dehiscence or stricture could be attributed to in 7.7% patients. 3.8% had to have their ileostomies converted to a permanent colostomy due to either a rectovaginal fistula or dehiscence or stricture. The complications associated with ileostomy are not insignificant. In our study, the tumor location in lower rectum was the only significant factor for non-reversal. We have to objectively identify patients who are at low risk for leakage and avoid ileostomy in them, and also try to minimize the morbidity of ileostomy by methods like early closure.

Massive gastrointestinal bleeding due to rectovaginal fistula: A rare case report

Rectovaginal fistula is usually observed due to obstetric traumas during giving birth, rectal or gynecologic malignities or after surgical therapy of malignant lesions or radiotherapy. Rectovaginal fistulas are not common in general surgery and gynecology clinics. However, these lesions are rarely seen during gastroenterology practice. In gastroenterology practice, we may face with rectovaginal fistula during Crohn’s disease’s course. These lesions deteriorate patients’ quality of life and increase morbidity and mortality. Endoscopy may be used to detect the localization of fistula and may help to choose correct treatment modality. Endoscopy sometimes may also be used to treat rectovaginal fistula via endoclips or stents. Typical complaints for rectovaginal fistulas are air, gas, or mucus discharge from vagina. Dyspareunia, perineal pain, or recurrent vaginal infections may also be seen. Rectal bleeding is not a common complaint for rectovaginal fistulas. Herein we report a rare case with rectovaginal fistula presenting with massive rectal bleeding after debulking surgery for ovarian carcinoma.

Rectovaginal Fistula Due to an Erosive Pessary: A Case Report

Background: Pelvic organ prolapse (POP) occurs when pelvic organs protrude through the vagina due to displacement from their normal anatomic position, as a result of a weakening of the pelvic muscles. Pessaries have long been used to treat POP, but they may result in rectovaginal fistulas as a rare complication. The Case: We report a rare case of a rectovaginal fistula following vaginal ring pessary use in an 82-year-old G7P7 woman. She had a past medical history of bipolar disorder, and initially presented for nursing care and psychiatric support. A trained psychologist evaluated her, and found no psychological morbidity. A two-day history of a fall, diffuse abdominal pain, and chronic urinary incontinence were rather identified. Gynecological pelvic examination revealed a rectovaginal fistula and impacted stools in the vagina. Conclusion: The use of ring pessaries, though a conservative management option for POP, may lead to a rectovaginal fistula, a rare but severe complication.

Vesico-Vaginal and Recto-Vaginal Fistula and Death Caused by a Vaginal Foreign Body in a Body-Packer

Foreign body retained for long duration sometimes causes vesico-vaginal and recto-vaginal fistula. We report a 60-year-old woman with vaginal foreign body causing vesico-vaginal and recto-vaginal fistula; she died after foreign body removal due to septic shock. The patient had vaginal purulent discharge, abdominal pain, and a septic shock. A fragment of stone (limestone) was present in the vagina, which was removed. The patient developed urinary incontinence and fecal incontinence after removal of the foreign body. The examination demonstrated the presence of vesico-vaginal and recto-vaginal fistula. The patient died four days after removal of the foreign body due to septic shock and multi-visceral failure. During the extraction foreign body, bacteria could be disseminated into the systemic circulation and might cause septic shock. Thus, wide-spectrum antibiotic therapy must be used before the procedure, which may decrease the chance of septic shock.

Modified Martius graft - a renaissance of surgical procedure.

The rectovaginal fistula (RVF) is relatively uncommon and by clinical manifestations grave illness. The surgery treatment of RVF is extremely demanding and represents the subject of frustration for many surgeons. Miscellaneous etiology of RVF and various heights of fistula in a rectovaginal septum are crucial for the choice of surgical procedure. Despite targeted treatment, more than one-half of rectovaginal fistulas recurs. We evaluated the frequency of recurrences after surgical treatment by modified Martius graft and its influence on continence and quality of life. The necessity of concomitant colostomy when performing modified Martius graft was the secondary aim. We collected and analyzed 8 years of data from our patient database. There were admitted 21 female patients with diagnosis RVF to the Surgery department of Faculty Hospital Trnava. Unfortunately, only 5 patients, concerning the etiology of disease and clinical state, were indicated for surgery by modified Martius graft. All RVFs were low and a defect in the rectovaginal septum wouldn't exceed 1.5 cm in diameter. Due to the small sample and non-confirmation of normality in all variables, nonparametric comparison tests were chosen for paired samples differences. We used the Wilcoxon sign-rank test and counted the effect sizes expressed the success of the treatment. Each female patient with low RVF included in this study has healed. The mean value of a complete healing of RVF in our cohort was 12 weeks. We had discovered one recurrence after surgery, that was successfully repaired by contralateral modified Martius graft. The significant decrease of Wexner fecal incontinence score in the observed group (p<0.05, r=0.639) and slightly elevated Cleveland Clinic Constipation Scoring System (p<0.05, r=-0.577) were confirmed. The protective colostomy was performed just once. Only two sections of the SF-36 Health Survey - the physical functioning and the bodily pain, were without significant changes. The rest of the watching sections of SF-36 have changed significantly. Treatment of low rectovaginal fistulas (LRVF) by modified Martius graft is followed by a low percentage of recurrences. It should be the first-line therapy in the algorithm of surgical treatment of LRVF, without the necessity of protective colostomy (Tab. 2, Fig. 3, Ref. 27).

Rectovaginal Fistula in Crohn's Disease: When and How to Operate?

Rectovaginal fistula (RVF) occurring during the course of Crohn's disease (CD) constitutes a therapeutic challenge and is characterized by a high rate of recurrence. To optimize the outcome of CD-related RVF repair, the best conditions for correct healing should be obtained. Remission of CD should be achieved with no active proctitis, the perianal CD activity should be minimized, and local septic complications should be controlled. The objective of surgical repair is to close the fistula tract with minimal recurrence and functional disturbance. Several therapeutic strategies exist and the approach should be tailored to the anatomy of the RVF and the quality of the local supporting tissues. Herein, we review the medical and surgical management of CD-related RVF.

How to do it: laparoscopic intersphincteric resection for unhealed recto-vaginal fistula after previous ultralow anterior resection.

Rectovaginal fistula in previous ULAR. Appendix S1: Supplementary Information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Pre-operative high-dose-rate brachytherapy in early-stage cervical cancer: long-term single-center results.

PurposeThe aim of the study was to report the outcomes of pre-operative high-dose-rate brachytherapy (pHDR-BT), followed by hysterectomy in patients with early cervical cancer.Material and methodsFrom January, 1998 to December, 2003, 113 women with IB1, IB2, and IIA1 cervical cancer (according to International Federation of Gynecology and Obstetrics [FIGO] 2018) were treated with pHDR-BT, and 6 to 8 weeks later followed by radical hysterectomy. Patients found to have positive lymph nodes, residual cervical cancer, involved parametria, or lymphovascular space invasion (LVSI) received post-operative adjuvant therapy.ResultsPost-operatively, 81.4% of patients had a complete response to pHDR-BT in the cervix, and 18.6% had residual cervical cancer. Failures occurred in 11/113 (9.7%) patients (all were stage IIA1), with pelvic recurrences in 5/113 (4.4%) and distant metastasis (DM) in 6/113 (5.3%). The 5- and 10-year disease-free survival (DFS) rates were 100% for IB1 and IB2, and 86.4% and 81.3% for IIA1, respectively. Lymph node involvement and/or residual cervical cancer correlated with worse DFS. Two vesicovaginal fistulas were observed (one in a patient treated only with pHDR-BT and one in a woman, who underwent adjuvant external-beam radiotherapy [EBRT]). Two rectovaginal fistulas and one case of proctitis were observed in patients treated with adjuvant EBRT.ConclusionspHDR-BT in early cervical cancer is well-tolerated and effective in sterilizing tumor cells in the cervix. The growing number of publications in this area may help define an optimal therapeutic scheme, but randomized trials are required to determine the best candidates for this treatment modality.In our opinion, cervical cancer patients with FIGO stage IIA1 are not good candidates for pHDR-BT, and could be given this treatment only after rigorous selection, including assessment with state-of-the-art imaging, due to higher probability of treatment failure.

Where Is the Vagina? A Rectal Stricture after a Presumed Cloacal Repair Turns Out to be the Mobilized Vagina and a Missed High Rectovaginal Fistula

We present a case of a rare complication in a 10-month-old female referred to our institution for an anal stricture after primary cloacal repair as an infant. Multimodal imaging, careful physical exam, and endoscopic evaluation revealed her vagina had been pulled through to the location of her anal sphincter muscle complex. We describe the correction of this problem, including identification of her rectum.