Combined therapy of pessary-induced rectovaginal fistula and pelvic organ prolapse in elderly by vaginal fistula closure and modified LeFort colpocleisis – a case series

Introduction Pelvic organ prolapse (POP) presents a common benign impairment in women and is associated with significantly reduced quality of life (QoL), voiding dysfunction, incomplete emptying, urinary incontinence, urinary tract infections and ulcers of prolapsed portions. While use of pessaries presents a common first-line treatment, follow-up examinations of the device are necessary for most types. Remaining pessaries can result in perforation of adjacent organs with resulting vesico- and rectovaginal fistulas (RVF) or migration into the abdominal cavity. We present a series of three cases with large rectovaginal fistulas (up to 60mm) due to pessary perforation.

Material and methods Consecutive cases of pessary-induced RVF receiving ostomy, fistula repair, modified LeFort colpocleisis with or without ostomy closure at our institution between September 2016 and September 2019 were assessed. Consensus for therapeutic strategy was reached by an interdisciplinary board with urology, gynecology, radiology and general surgery specialists, beforehand.

Results Sizes of the fistula diameter differed between 25 and 60mm. In one patient, a two-step approach was chosen with the ileostomy being performed in a single procedure immediately before modified LeFort colpocleisis and fistula closure. Stoma closure was successful in two cases and neither fistula nor POP recurrence has occurred, since.

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

Publication History

Article published online:
07 October 2020