Indomethacin Suppositories

Abstract

To the Editor: —Indomethacin suppositories are well known to produce rectal ulceration and bleeding.1,2 However, we are not aware of any reports of fistula formation. An 84-year-old woman presented to the Flinders Medical Centre with a three-week history of pain and discharge in the vulval region. She had a five-year history of rheumatoid arthritis and had used indomethacin suppositories nightly. She continued to insert the suppository up until the time of admission. There had been no history of rectal bleeding. There was a history of fecal soiling but no diarrhea. Examination of the perineum revealed a 1.5-cm elliptical ulcer on the posterior aspect of the (r) vulva. Subsequent examination under anesthesia revealed that the vulval ulcer connected with the lower rectum. Biopsy of the ulcer and rectum showed chronic inflammatory changes. Subsequent treatment of sitz baths, cathartics, and adequate analgesia resulted in healing of the vulval side of the fistula in four weeks. However, sigmoidoscopy performed at 20 weeks showed evidence of continuing granulation tissue in the rectum suggesting that the fistula has not yet completely healed. Local rectal irritation, mucosal inflammation, and necrosis with profuse bleeding can occur after the use of indomethacin suppositories. Fistula formation occurred in this case most likely because of continued use despite severe perineal pain. Elderly patients are well known for their stoicism and inflexibility toward taking of drugs despite the presence of side effects. This previously unreported side effect is a further example of a rigid behavior pattern toward medication in the elderly.