PSEUDODIARRHEA CAUSED BY VAGINAL PESSARY IN AN ELDERLY PATIENT

Abstract

To the Editor: Diarrhea and fecal incontinence are common complaints in the geriatric population and are often challenging to evaluate and manage. We report here an obscure cause of diarrhea in an older woman that may be more common than realized and easily missed by physicians. An independent 94-year-old woman with a history of hypothyroidism, paroxysmal atrial fibrillation, and vaginal prolapse following a prior hysterectomy presented to the emergency department with weakness, lightheadedness, and 1 day of intractable, frequent bowel movements. The patient reported severe fecal urgency, with small bowel movements occurring every 10 minutes. She denied a history of recent constipation, abdominal pain, hematochezia, fever, or melena. She noted changes in her bowel movements consisting of occasional episodes of mild diarrhea dating back 6 months but no prior episode as severe as this one. These episodes had been investigated on an outpatient basis, with prior stool studies negative for clostridium difficile toxin, and a colonoscopy, which revealed only mild left-sided diverticuli. Upon admission, the patient was found to be in atrial fibrillation. Her serum electrolytes, thyroid tests, complete blood count, cardiac enzymes, and liver function tests were all normal. Her physical examination was unremarkable except for a hard extrinsically protruding object detected on digital rectal examination. This object turned out to be a vaginal pessary, placed approximately 8 months before for treatment of urinary incontinence. A radiograph of the patient's abdomen demonstrating the location of the device is shown in Figure 1. X-ray demonstrating the position of the vaginal pessary. Upon removal of the pessary, the patient's symptoms resolved. We have presented a case of fecal urgency, loose bowel movements, and incontinence caused by a vaginal pessary in an elderly woman. To our knowledge, there is only one other report in the literature of such an occurrence.1 There are several mechanisms by which this patient's symptoms may have been produced. First, the force of the pessary pressing on the rectal mucosa may have caused obstruction with paradoxical diarrhea, as occurs with fecal impaction. Secondly, when the pessary exerted pressure on normal anatomical features, such as the internal and external anal sphincter muscles, it might have stretched the anatomy and altered the normal mediators of fecal continence. Lastly, the presence of the pessary might have produced the sensation of full rectum, elucidating a defecation reflex. The patient in this case had “pseudodiarrhea,” which is defined as increased stool frequency (>3 daily) with a normal daily stool weight of less than 300 g. Conditions commonly associated with pseudodiarrhea include paradoxical diarrhea secondary to fecal impaction and irritable bowel syndrome. Physicians should be aware that there are many different symptoms that patients term as “diarrhea,” and these should be differentiated in the history taking. They include fecal incontinence, urgency, liquidity of the stool, frequency, and volume of stool. Patients are likely to define diarrhea as stool liquidity. The strict scientific definition of diarrhea is stool quantity greater than 300 g/d, although most clinicians generally also consider increased stool frequency (>3/d) as part of the definition.2