Rectovaginal fistula secondary to an erosive pessary

The pessary is one of the oldest medical devices used for the nonsurgical management of various pelvic floor support defects as a temporary or as a permanent manner [1]. Although the pessary is an extremely safe device, it is still a foreign body and complications can occur with neglect or poor follow-up [2]. Serious complications due to an erosion of a pessary are rare. This is the seventh reported case of an isolated rectovaginal fistula secondary to pessary erosion. An 82-year-old patient reported to her gynecologist for removal of a pessary which had been inserted approximately 5 years ago due to uterine prolapse. The patient had no follow-up since the insertion of the pessary, but complained of vaginal bleeding and stress urinary incontinence for 3 months. She had no gastrointestinal symptoms suggestive of inflammatory bowel disease or any other gastrointestinal pathology. During attempted removal of the pessary, it was noted that the pessary was impacted and had eroded into the rectum. On rigid proctosigmoidoscopy, a pessary protruding into the rectum located 7 cm from the anal verge was visualized. One week later, the patient underwent colonoscopy (unremarkable except pessary erosion) and vaginal removal of the impacted pessary, a transanal repair of the rectovaginal fistula which measured approximately 2.5 cm and a laparoscopic loop ileostomy for diversion. The tissues around the pessary were inflamed with questionable blood supply; therefore, a concomitant diversion was created. One month later, a gastrografin enema was performed to assess the repair. This revealed a persistent rectovaginal fistula. Therefore, a second transanal repair was attempted. This was unsuccessful, and 5 months after her original repair, the patient underwent a low anterior resection with takedown of the rectovaginal fistula, a coloanal anastomosis and a coloplasty. Her loop ileostomy was closed 6 weeks later. The patient is asymptomatic for the last 5 years. A pessary is a good nonsurgical option as temporary or definitive therapy for symptomatic genital prolapse in selected patients. Common complications of pessary use include vaginal irritation, ulceration, allergic reactions, leukorrhea, bleeding and bowel and bladder dysfunction [1, 2]. These complications involve erosion of pessaries into bowel or bladder [2]. They usually occur after years of neglect and can be extremely difficult to treat. The Gellhorn and doughnut type of pessaries have more commonly been implicated in these complications [3]. As the elderly segment of the population continues to grow, pessary use can be expected to increase. It is not uncommon for patients to forget that there is a pessary in the vagina, and this is especially liable to happen in the elderly and demented. Patients with pessaries are advised to have follow-up with their physicians every 3 months or every 6 months if they take care of their pessaries themselves. Our patient did not follow-up for 5 years after her pessary insertion. Among the reported cases which had an isolated rectovaginal fistula secondary to erosion from a pessary, only two of the cases were symptomatic and were passing feces through the vagina [2, 4, 5]. Patients should undergo a colonoscopy to rule out comorbidities, such as prior pelvic irradiation, inflammatory bowel disease and colorectal neoplasia. Our patient failed two transanal rectal repairs under a covering stoma. In Kankham and & G. Ozuner ozunerg@ccf.org