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Thursday, August 28, 2014

Forgotten vaginal pessaries cause fistula formation


A pessary is a medical device inserted into the vagina, either as a method of delivering medication, or to provide structural support. When properly maintained (ideally, they should be removed and cleaned every 6 weeks), pessaries have been shown to be safe for long-term care of vaginal prolapse, a condition where a portion of the vaginal canal protrudes from the opening of the vagina. However, neglected pessaries can cause complications such as vaginal irritation, impaction, ulceration and even fistula formation (a fistula is an abnormal connection - an opening or canal - that forms between two organs, such as an intestine and the skin, or the vagina and the urinary bladder). Rarely, a rectovaginal fistula can form - and believe me, this is literally a BIG pain in the butt.

 

Vaginal pessaries. (Image from: Wikipedia)


An article by Powers et al. presents the case of a 70-year-old woman who was found to have an impacted pessary that could not be removed due to pain. Examination under anesthesia revealed that the device had become firmly lodged within the rectum. It was removed through the anus, leaving a large rectovaginal fistula. The patient was scheduled for reparative surgery, but she cancelled the day before.

Hanavadi et al. describe another case of a forgotten vaginal pessary that ate its way into the elderly wearer's rectum. This one is quite disgusting, actually. An 88-year woman was referred urgently to the surgical clinic with a history of vaginal discharge containing feces. Her practice nurse noticed that following an enema, it had expelled through the vagina. The lady also reported 6-8 weeks of constipation alternating with diarrhea and fecal incontinence. Earlier, her bowel habits had been normal.

On examination, she was frail, but well oriented. Abdominal examination was normal. Digital rectal examination showed fecal loading and a hard object was felt through the rectal wall. Feces were present within the vagina, along with a hard object high up, which turned out to be a pessary. However, the patient could not remember ever having been fitted with such a device. 


She was examined more closely under anesthesia and it was determined that the handle of the forgotten pessary had eroded through the vaginal wall into the lower rectum, 8 cm from the anal verge. After the pessary was removed, something had to be done about the large rectovaginal fistula (just imagine passing feces through the vagina - ugh). Because the patient was too frail for reconstructive surgery, a colostomy was performed. Recovery was uneventful.

The article contained the following photo. I'm afraid it's pretty graphic. A red rubber tube has been passed into the elderly patient's rectum, through the defect and out of the vagina, demonstrating the abnormal connection between these anatomical structures.



Literature:

Hanavadi S, Durham-Hall A, Oke T, Aston N. (2004) Forgotten vaginal pessary eroding into rectum. Ann R Coll Surg Engl. 86(6): W18–W19. 

Powers K, Grigorescu B, Lazarou G, Greston WM, Weber T. (2008) Neglected pessary causing a rectovaginal fistula: a case report. J Reprod Med. 53(3): 235-7.]

Wikipedia: Pessary


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