Persistent vaginal discharge following proctocolectomy—if there is no fistula, what is it?

Abstract

Dear Editor: Distressing vaginal discharge following conventional proctocolectomy has been reported in up to 50 % of patients. The primary evaluation of such patients includes assessing for the presence of an enterovaginal fistula. We report a case of a patient who presented with distressing vaginal discharge lasting for 2 years after a conventional proctocolectomy. The discharge was found to be a result of the pelvic floor muscle shift and compression of the vagina, with a formation of a fluid reservoir in the upper third of the vagina. A 39-year-old woman with ulcerative colitis (UC) underwent an urgent total colectomy, rectal preservation, and end ileostomy for toxic colitis. The postoperative period was uneventful. Histopathological examination confirmed the diagnosis. Due to persistent rectal mucous discharge and her reluctance to have a completion proctectomy with ileal pouch and anal anastomosis, a perineal proctectomy was performed. The operation and the postoperative period were uneventful. Following the second operation, the patient complained of new onset vaginal discharge. She described recurrent episodes of sudden drainage of copious amount of fluid from the vagina, which was often brown or bloody and had an unpleasant odor. The patient underwent a gynecologic assessment which included repeated vaginal examinations and cultures, without findings. The comprehensive evaluation included transvaginal ultrasonography, computed tomography (CT), gastrografin enema, and magnetic resonance imaging (MRI) for the assessment of an enterovaginal fistula. All of the studies failed to identify a fistula, but the ultrasound, CT, and MRI demonstrated an accumulation of fluid in the upper vagina. An examination under anesthesia was performed, which also failed to diagnose a fistula. Two years after the second procedure, the patient was referred to a vulvovaginal clinic. Detailed history revealed that since analresection, the patient also had dyspareunia and a “phantom” anal pressure sensation. Upon palpation of the levator ani muscle, a ventral migration was noted. Insertion of a speculum was disrupted by a circular narrowing of the upper vagina. Passing the narrowing resulted in the drainage of large amount of fluid. The vagina appeared normal without inflammation, and microscopic evaluation of the discharge was negative. Review of the MRI films confirmed a pelvic floor muscle shift and the compression of the vagina, with the formation of a reservoir offluidintheupper third of the vagina. The patient was referred to pelvic floor physiotherapy, and following pelvic floor muscle relaxation and voluntary emptying of her vaginal contents, she became symptom free.