Conservative management of rectovaginal fistula caused by Gellhorn pessary.  A case report

Authors: Samaa Siyam¹, Ismaiel Abu Mahfouz ², Mais Al-Attar ¹, Ro’a khatatbeh¹, Leen Saifan¹ , Esraa Qandil¹

1- The Specialty Hospital  2- Al-Balqa Applied University

Introduction

• A rectovaginal fistula (RVF)  connect the vagina and  rectum, starting from the offending side and  making their way to the adjacent organ; following  the easiest and shortest path. They are always  pathological, and causes may include childbirth  injuries, inflammatory bowel disease, pelvic cancer,  radiation or pelvic surgeries.
• Vaginal support devices (VSD) are used in the  management of POP; their use is safe, effective and  well tolerated. The success rate is between 56% and  89%.
• The VSD are foreign objects that are placed in direct  contact with the vaginal wall which may cause  pressure effect, therefore adequate follow-up is necessary to ensure proper fitting and integrity of  the vaginal wall. This is because their use may be  associated with complications such as vaginal  erosions, adhesions, bleeding and very rarely  formation of vesicovaginal and rectovaginal  fistulae.

The case

• A 72-year-old woman presented  with several years history of worsening symptomatic pelvic organ prolapse (POP), and mixed lower urinary tract  symptoms (LUTS) predominantly overactive bladder  symptoms (OAB).
•  Examination showed stage III (POP) , Various types and  sizes of VSDs were attempted, and a Gellhorn pessary was  inserted, and she was comfortable with it. Thereafter ,she was advised to come back for  follow up after three months.
•  Unfortunately, she was not able to attend. Five months after insertion, she complained  of a passage of minimal feculent vaginal discharge, vaginal and rectal examinations showed that the knob of the Gellhorn pessary migrated through the posterior vaginal  wall causing a RVF which was around 0.8X0.8 cm in size and  located four cm proximal the hymenal ring in the centre of  the posterior vaginal wall.
•  Following  discussion with the woman, she opted for conservative  management, where oral antibiotics, topical estrogen, and  stool softeners were prescribed, and she was followed up  biweekly and examination showed a reduction in the size  of the RVF. After two months of the follow up, the RVF  healed completely.

Discussion

• Treatment options of POP may include the use  of VSD, and surgery. Current indications for pessary use include women  awaiting surgical repair, treatment of recurrence of POP, or for women who have comorbidities .
• Complications can be minimized with simple vaginal  hygiene and regular follow-up visits. The most frequent complications  associated with the use of VSD include vesicovaginal fistula, RVF vaginal impaction and vaginal evisceration of small bowel through  vagina.

Medical treatment with antibiotics , sitz baths and stool softeners is often necessary to control the local  infection. The surgical management is most frequently adopted management  option

Conclusion

• There is no published international guidance for  the best option of management. Conservative management in selected cases is a valid option.