Large rectovaginal fistula due to a cube pessary despite routine follow-up; but what is 'routine'?

Fistulae Secondary to Vaginal Pessary Use for Pelvic Organ Prolapse: A Systematic Review

INTRODUCTION AND HYPOTHESIS

Urogenital and rectovaginal fistulae are rare complications of pessary use for pelvic organ prolapse (POP). This systematic review investigates the prevalence of these complications in patients using pessary for POP, potential risk factors and approaches to their investigation and management.

METHODS

All studies in English reporting urogenital or rectovaginal fistulae secondary to pessaries for POP were eligible for inclusion. AMED, CINAHL, MedLine, Scopus and Web of Science databases were searched from inception to March 2024. Risk of bias was assessed using validated tools: Murad et al.'s tool for case series/reports and ROBINS-I for non-randomised studies. Quantitative synthesis of descriptive statistics and narrative summary were performed.

RESULTS

Two retrospective studies and 60 case series/reports were included, describing 76 fistulae (34 urogenital, 42 rectovaginal). The retrospective studies estimated the prevalence of fistulae to be 3%. Of reported fistulae, 45% occurred with Gellhorn, 16% with ring, 11% with shelf and 9% with cube pessaries. Fifty percent were associated with neglected pessary care. Conservative management resulted in size reduction or resolution in 69% of fistulae: this approach should be considered. Vaginal (88%) and abdominal (100%) vesicovaginal fistula repairs were successful. Diverting ostomies were popular for rectovaginal fistulae but often resulted in permanent stoma without reducing mortality, recurrence or repair failure. Colpocleisis represents an effective procedure for managing co-existing POP.

CONCLUSIONS

The prevalence of fistulae from pessary use is likely < 1% but may rise to 3% with risk factors present, including Gellhorn pessaries and neglected care. Both conservative and surgical management are viable treatment options.

Combined clinical and radiological remission of rectovaginal fistulas using fractional CO2 vaginal laser: a case series and medium-term follow-up

INTRODUCTION

Despite the advances in surgical and clinical approaches, there is no consensus regarding the best line of treatment from rectovaginal fistula (RVF). Faced with a challenging scenario in the approach of RVF, the fractional CO2 laser receives attention as a possible form of treatment.

OBJECTIVES

A single-center, prospective, open-label study evaluating the effectiveness and safety of laser therapy for RVF treatment.

SUBJECTS AND METHODS

The total of 15 patients was recruited at the Juiz de Fora University Hospital between August 2018 and July 2022. Inclusion criteria were presence of clinically suspects RVF of any etiology confirmed by pelvic magnetic resonance image (MRI) and gynecological examination. Five fractional CO2 laser sessions with monthly interval followed by complete evaluation through clinical examination and pelvic MRI were performed for all patients after the completion of treatment. Analysis of sexual function before and after the treatment was performed using Female Sexual Quotient (FSQ).

RESULTS

The evaluation through physical examination showed no persistent inflammatory signs in the vagina for all patients. Additionally, 10 of out 15 (67.7%) patients achieved clinical remission of RVF symptoms, while 33.3% patients reported significant improvement. Of note, five patients who did not have previous sexual activity returned to regular sexual activity while seven patients who have baseline sexual activity had improvement in their sexual function as assessed by the FSQ. Three out of four ostomized patients had their ostomy reversed and remained without complains. All six patients with RVF secondary to Crohn's disease reported a marked improvement in symptoms and sexual function. In seven (47%) patients radiological remission was confirmed by pelvic MRI.

CONCLUSION

CO2 fractional laser can be considered a promising and safe therapeutic alternative for the management of RVF.

Complications of Pessaries Amenable to Surgical Correction: Two Case Reports and a Systematic Review of the Literature

BACKGROUND

Forty percent of women will experience prolapse in their lifetime. Vaginal pessaries are considered the first line of treatment in selected patients. Major complications of vaginal pessaries rarely occur.

METHODS

PubMed and Embase were searched from 1961 to 2022 for major complications of vaginal pessaries using Medical Subject Headings (MeSH) and free-text terms. The keywords were pessary or pessaries and: vaginal discharge, incontinence, entrapment, urinary infections, fistula, complications, and vaginal infection. The exclusion criteria were other languages than English, pregnancy, complications without a prior history of pessary placement, pessaries unregistered for clinical practice (herbal pessaries), or male patients. The extracted data included symptoms, findings upon examination, infection, type of complication, extragenital symptoms, and treatment.

RESULTS

We identified 1874 abstracts and full text articles; 54 were assessed for eligibility and 49 met the inclusion criteria. These 49 studies included data from 66 patients with pessary complications amenable to surgical correction. Clavien-Dindo classification was used to grade the complications. Most patients presented with vaginal symptoms such as bleeding, discharge, or ulceration. The most frequent complications were pessary incarceration and fistulas. Surgical treatment included removal of the pessary under local or general anesthesia, fistula repair, hysterectomy and vaginal repair, and the management of bleeding.

CONCLUSIONS

Pessaries are a reasonable and durable treatment for pelvic organ prolapse. Complications are rare. Routine follow-ups are necessary. The ideal patient candidate must be able to remove and reintroduce their pessary on a regular basis; if not, this must be performed by a healthcare worker at regular intervals.

Self-management of vaginal cube pessaries may be a game changer for pelvic organ prolapse treatment: a long-term follow-up study

INTRODUCTION AND HYPOTHESIS

Loss of anatomical support for the pelvic organs results in pelvic organ prolapse (POP). We hypothesized that daily self-management of a cube pessary might be a safe, feasible long-term treatment in women with symptomatic POP.

METHODS

A cohort of 214 symptomatic POP patients (stage 2+) were enrolled prospectively (January to December 2015). Each patient was size-fitted with a space-filling cube pessary and completed a questionnaire online or by phone ≥5 years after her initial fitting. Change in quality of life (QoL) was measured with the Patient Global Impression of Improvement (PGI-I).

RESULTS

Of 185 women included in our analyses, 174 (94%) were continuing to use their pessary 4 weeks post-insertion. Among those, 143 (82.2%) used the pessary successfully for ≥5 years. A large majority of these patients (88.8% [127 out of 143]) described their condition as much or very much improved compared with their pretreatment status (PGI-I). Adverse secondary effects (ASEs) were infrequent [15.4% (22 out of 143)]; when they did occur, they were mild, including smelly vaginal discharge (15 out of 22) and slight vaginal bleeding caused by the fitting procedure (6 out of 22).

CONCLUSIONS

Daily self-management of cube pessaries was found to be a safe and effective treatment for improving POP-related symptoms and QoL in the long term.

Rare complications of pessary use: A systematic review of case reports

Introduction

Pessaries are desirable for its overall safety profiles. Serious complications have been reported; however, there is little summative evidence. This systematic review aimed to consolidate all reported serious outcomes from pessaries usage to better identify and counsel patients who might be at higher risk of developing these adverse events.

Methods

We performed a systematic literature review using search terms such as 'prolapse', 'stress urinary incontinence' and 'pessary or pessaries or pessarium' on PubMed, Embase and CINAHL. A total of 36 articles were identified. Patient-level data were extracted from case reports to further describe complications on an individual level.

Results

Overall median age of the patients was 82 years (range 62-98). The most frequent complications were vesicovaginal fistula (25%, n = 9/36), rectovaginal fistula (19%, n = 7/36), vaginal impaction (11%, n = 4/36) and vaginal evisceration of small bowel through vaginal vault (8%, n = 3/36). In the vesicovaginal fistula cohort, none of the patients had a history of radiation, and two had histories of total abdominal hysterectomy (22%). In the rectovaginal fistula cohort, one patient had a history of pelvic radiation for rectal squamous cell carcinoma, and another had a history of chronic steroid use for rheumatoid arthritis. No other risk factors were reported in the other groups. Ring and Gellhorn were the most represented pessary types among the studies, 16 (44%) and 12 (33%), respectively. No complications were reported with surgical and non-surgical treatment of the complications.

Conclusion

Pessaries are a reasonable and durable treatment for POP with exceedingly rare reports of severe adverse complications. The ideal candidate for pessary should have a good self-care index. Studies to determine causative factors of the more serious adverse events are needed; however, this may be difficult given the long follow-up that is required.

A retrospective case series on transvaginal repair of rectovaginal fistula performed by a urogynaecology operative team in Australia

BACKGROUND

Rectovaginal fistula (RVF) is an abnormal epithelialised connection between the rectum and vagina. It is a common condition in limited resource settings and is caused almost exclusively by obstetric injury. In contrast, RVF is uncommonly seen in high resource settings.

AIMS

This study aims to review the aetiology and effectiveness of RVF management in the high resource setting, identifying predictors for repair success and long-term outcomes.

MATERIALS AND METHODS

A retrospective case series study of patients who underwent transvaginal RVF repairs at two secondary healthcare facilities over a 14-year period by one operative group.

RESULTS

A total of 41 patients underwent 46 surgical repairs. All patients presented with flatal and/or faecal incontinence and aetiology was identifiable in 78.0% (n = 32). Obstetric cause was implicated in 26.8% (n = 11) and other causes include 26.8% (n = 11) from vaginal and abdominal surgery, 14.6% (n = 6) from perianal abscess, 7.32% (n = 3) as complications of Crohn's disease and 2.44% (n = 1) as a complication of a cube pessary. Fistula was cured in 38 of 41 cases (92.7%) with a primary repair closure rate of 80.5% (n = 33). Post-operative symptoms were limited to flatal incontinence in 4.88% (n = 2), faecal incontinence in 2.44% (n = 1), and persistent perineal pain in 7.32% (n = 3). The success of the surgical repair was not significantly impacted by fistula size, aetiology, presence of a stoma for diversion, history of prior repair, duration since RVF formation or repair technique.

CONCLUSIONS

This review identifies aetiology for RVF in the high resource setting and highlights the role of earlier surgical repair to minimise patient morbidity with good success in closure and reduction of post-operative symptoms.

Rectovaginal Fistula in Women With Pessary for Pelvic Organ Prolapse: A Case Series and Literature Review

OBJECTIVE

In this study, we present a series of 2 cases of rectovaginal fistula (RVF) due to the use of a ring-type pessary in the conservative treatment of pelvic organ prolapse and a literature review on the management of RVF related to the use of pessaries.

METHODS

Two patients were selected from the medical records of the urogynecology service, and their demographic and clinical data were retrieved. An updated literature review was included presenting cases of RVF induced by or after use of a pessary.

RESULTS

Both patients evolved with removal of the pessary and correction of the fistula. The surgical procedures of choice were Le Fort Colpocleisis and posterior colporraphy without major complications. In the literature review, we selected 17 studies with a total of 23 cases reporting RVFs induced or followed by the use of pessaries.

CONCLUSIONS

Although the pessary is commonly indicated for the conservative treatment of pelvic organ prolapse, this device is not exempt from generating complications.

Therapy of pessary-induced rectovaginal fistula and pelvic organ prolapse in elderly patients by vaginal approach and modified LeFort colpocleisis: a case series

PURPOSE

Pelvic organ prolapse (POP) presents a common benign condition in women associated with reduced quality of life (QoL). The use of pessaries is considered a first-line treatment of POP. However, pessaries can cause perforations into adjacent organs resulting in fistulas. We present a series of three cases of rectovaginal fistulas (RVF) due to pessary perforation.

METHODS

Three consecutive cases of pessary-induced RVF in patients with POP stage IV were assessed between September 2016 and September 2019. Consensus for therapeutic strategy was reached by an interdisciplinary board.

RESULTS

The RVF were located in the posterior vaginal wall and had a diameter of up to 60 mm. In one of three patients, a two-step approach was chosen with the ostomy being performed at the same time as fistula closure and modified LeFort colpocleisis. It was followed by ostomy closure 3 months later. In two patients, a three-step approach was chosen with the ostomy performed separately due to a local tissue inflammation around RVF. Neither fistula nor POP recurrences have occurred so far.

CONCLUSION

Combined temporary gastrointestinal diversion, RVF closure and POP therapy can be performed as a two- or three-stage approach. Lack of evidence and standardized algorithms in RVF therapy make further clinical studies essential. We encourage the preoperative assessment of any case of complex rectovaginal fistula by an interdisciplinary board for determining an individualized treatment.

Feasibility and safety of self-expandable metal stent in nonmalignant disease of the lower gastrointestinal tract

In recent years, self-expandable metal stents (SEMSs) have been employed to treat benign gastrointestinal strictures secondary to several conditions: Acute diverticulitis, radiation colitis, inflammatory bowel disease (IBD), and postanastomotic leakages and stenosis. Other applications include endometriosis and fistulas of the lower gastrointestinal tract. Although it may be technically feasible to proceed to stenting in the aforementioned benign diseases of the lower gastrointestinal tract, the outcome has been reported to be poor. In fact, in some settings (such as complicated diverticulitis and postsurgical anastomotic strictures), stenting seems to have a limited evidence-based benefit as a bridge to surgery, while in other settings (such as endometriosis, IBD, radiation colitis, etc.), even society guidelines are not able to guide the endoscopist through decisional algorithms for SEMS placement. The aim of this narrative paper is to review the scientific evidence regarding the use of SEMSs in nonmalignant diseases of the lower gastrointestinal tract, both in adult and pediatric settings.