Genital fistulas secondary to diverticular disease of the colon: a review

Colovaginal Fistulas: Presentation, Evaluation, and Management

OBJECTIVE

The objective of this study was to review a single institution's experience with colovaginal fistulas to provide guidance toward identification and management of this problem.

METHODS

Patients with colovaginal fistulas treated by 2 senior surgeons between January 1, 1990, and June 31, 2011, were identified. A retrospective chart review was then performed to determine presenting characteristics and history, evaluation for the fistulas, and treatment outcomes.

RESULTS

Nineteen patients were identified. The mean age was 63.5 years and median parity of 2. 37% complained of flatus per vagina, 89% reported stool per vagina, and 68% noted vaginal discharge. Ninety-five percent had previously undergone hysterectomy. The fistulas were identified at the left vaginal apex in 90% of the subjects. Self-reported history and/or operative findings suggested diverticulitis as the most common etiology (79% of the subjects). All subjects underwent sigmoid resection with primary anastomosis, with complete symptom resolution in 84%.

CONCLUSIONS

Patients with colovaginal fistulas commonly present for primary evaluation by gynecologists. A triad of symptoms and history should trigger a high index of suspicion for colovaginal fistulas: (1) complaints of stool or flatus per vagina or foul-smelling vaginitis resistant to treatment, (2) previous hysterectomy, and (3) history of diverticulitis. The fistulas can often be visualized on speculum examination at the left vaginal apex. Rolling the patient from left to right lateral decubitus positions during a contrast enema study can improve its sensitivity. Repair of colovaginal fistulas via rectosigmoid resection and primary reanastomosis is safe and effective. We recommend multidisciplinary management involving colorectal surgery and gynecology.

Influence of hysterectomy on fistula formation in women with diverticulitis

Background

Diverticulitis is a risk factor for fistula formation but little is known about the influence of hysterectomy in this association. A population-based nationwide matched cohort study was performed to determine the risk of fistula formation in hysterectomized women with, and without, diverticulitis.

Methods

Women who had a hysterectomy between 1973 and 2003, and a matched control cohort, were identified from the Swedish Inpatient Register. Incidence of diverticulitis and fistula surgery was determined by cross-linkage to the Register, and risk was estimated using a Cox regression model.

Results

In a cohort of 168 563 hysterectomized and 614 682 non-hysterectomized women (mean follow-up 11·0 and 11·5 years respectively), there were 14 051 cases of diverticulitis and 851 fistulas. Compared with women who had neither hysterectomy nor diverticulitis, the risk of fistula surgery increased fourfold in hysterectomized women without diverticulitis (hazard ratio (HR) 4·0 (95 per cent confidence interval (c.i.) 3·5 to 4·7)), sevenfold in non-hysterectomized women with diverticulitis (HR 7·6 (4·8 to 12·1)) and 25-fold in hysterectomized women with diverticulitis (HR 25·2 (15·5 to 41·2)).

Conclusion

Diverticulitis, and to a lesser extent hysterectomy, is strongly associated with the risk of fistula formation. Hysterectomized women with diverticulitis have the highest risk of developing surgically managed fistula.

Management of diverticular fistulae to the female genital tract

OBJECTIVE

Fistulae to the female genital tract are an infrequent but severe complication of diverticular disease. The purpose of this study was to evaluate treatment and outcome in patients with diverticular colo-genital fistulae.

METHOD

Sixty women treated for diverticular fistulae (DF) to the female genital tract during 1992-2004 were identified. Clinic and operative charts were reviewed. Mean age was 70 years and mean follow-up time after surgery was 1 year.

RESULTS

Most common presenting symptoms were vaginal discharge of faeces or gas (95% of patients) and abdominal pain (43%). About 75% of patients had undergone a hysterectomy. Forty-six patients underwent at least one radiological contrast study and the fistula was demonstrated in 35 (76%) patients. Fifty-seven patients had surgery, and findings included colo-vaginal fistulae (n = 47), colo-uterine fistulae (n = 2) and multiple fistulae involving vagina and other organs (n = 8). A sigmoid resection and primary anastomosis was performed in 51 and a Hartmann procedure with colostomy in six patients. Sixteen (28%) patients experienced morbidity after surgery, including anastomotic dehiscence (n = 4) and ureteric injury (n = 3). There was no mortality.

CONCLUSION

Diverticular fistulae to the female genital tract usually occur in elderly patients with a prior hysterectomy. Radiological contrast studies demonstrate the fistulous tract in most cases. Sigmoid resection and primary anastomosis results in a satisfactory outcome in the majority of patients.

[Bening enterogenital fistulas arising from the digestive tract: three cases]

Fistulas between the female genital tract and the digestive tract occur after obstetrical, oncological, or post-operative complications. We report herein 3 rare cases of enterogenital fistulas: one colouterine fistula and one colotubal fistula in a patient with diverticulitis, and one ileovaginal fistula in a patient with Crohn's disease. Vaginal discharge was frequent and incited patients to consult a gynecologist. Better knowledge of enterogenital fistulas is necessary to enable earlier diagnosis and apply specific treatment. The incidence of colovaginal fistulas is increasing in diverticular disease because of increased prevalences of hysterectomies and diverticular disease.

Emphysematous epididymitis as presentation of unusual seminal vesicle fistula secondary to sigmoid diverticulitis: case report

This case report describes a sigmoid diverticulitis with torpid development, long-term symptoms of bladder irritability, and an emphysematous epididymitis caused by a direct seminal vesicle fistula. The diagnosis was suggested by scrotal ultrasound visualizing gas in the scrotum; the complex pelvic fistulous tract was specifically delineated by multislice computed tomography. This may be the first reported case of seminal vesicle fistula directly related to colonic diverticulitis and causing emphysematous epididymitis.