A 48-year-old woman comes to the office due to clear, watery vaginal discharge for the past 2 weeks following a hysterectomy and bilateral salpingo-oophorectomy for endometriosis. Her surgery was complicated by severe pelvic adhesions. The discharge occurs throughout the day and night, and as a result, the patient has been using several pads a day. She has no fever, vaginal bleeding, or pelvic pain. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. The patient's abdomen is soft and nontender with a well-healed laparotomy incision. Genitourinary examination shows a well-rugated vaginal mucosa and a pool of clear fluid in the vaginal canal. The vaginal apex appears normal. Wet mount microscopy shows a few squamous epithelial cells and rare leukocytes. Which of the following is the most likely cause of this patient's symptoms?

Question

A 48-year-old woman comes to the office due to clear, watery vaginal discharge for the past 2 weeks following a hysterectomy and bilateral salpingo-oophorectomy for endometriosis.  Her surgery was complicated by severe pelvic adhesions.  The discharge occurs throughout the day and night, and as a result, the patient has been using several pads a day.  She has no fever, vaginal bleeding, or pelvic pain.  The patient does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  The patient's abdomen is soft and nontender with a well-healed laparotomy incision.  Genitourinary examination shows a well-rugated vaginal mucosa and a pool of clear fluid in the vaginal canal.  The vaginal apex appears normal.  Wet mount microscopy shows a few squamous epithelial cells and rare leukocytes.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d9e6_7a49_bc81_439560ced61e_MD0003_00 This patient's continuous, painless, watery discharge after her recent pelvic surgery is most likely due to urine leakage from a vesicovaginal fistula. In industrialized countries, most vesicovaginal fistulas are due to pelvic surgery (eg, hysterectomy), particularly when complicated by distorted anatomy (eg, endometriosis, pelvic adhesions), which can cause occult intraoperative bladder injury or delayed tissue ischemia. Additional causes include pelvic radiation and childbirth (eg, obstructed labor). vesicovaginal fistulas Vesicovaginal fistulas typically cause persistent, uncontrolled urinary leakage into the vagina within a month after surgery. This results in a continuous, clear, watery discharge with normal wet mount microscopy, as seen in this patient. The diagnosis is made clinically with evidence of a visible vaginal defect or by urine leaking (ie, pooling of clear fluid) into the vagina. Some patients may only have visible granulation tissue (eg, small, red raised area). Bladder dye tests and/or cystoscopy may be performed to identify a small fistula that is difficult to detect on visual inspection. Treatment is with surgical correction. Bladder dye tests cystoscopy (Choice A) Bacterial vaginosis causes a vaginal discharge that is painless, thin, gray, and malodorous. Diagnosis includes visualization of >20% of squamous epithelial cells coated with bacteria (ie, clue cells) on wet mount microscopy, not seen in this patient. (Choice B) Pelvic abscess, a postoperative complication, presents with fever and pelvic pain. Purulent vaginal discharge with abundant leukocytes on microscopy may be seen if the abscess is located over the vaginal cuff (ie, apex), making this diagnosis unlikely. (Choice C) Trichomoniasis typically causes a frothy green discharge with motile trichomonads on wet mount microscopy. (Choice D) Vaginal cuff dehiscence, or vaginal wound separation, is a rare but serious postoperative complication after hysterectomy. Although peritoneal leakage through the vagina may be seen, the apex would appear inflamed, indurated, or open. This patient's vaginal apex appears normal. Vaginal cuff dehiscence (Choice F) Vulvovaginal candidiasis may cause pruritus and a thick, white vaginal discharge. Budding yeast and/or pseudohyphae are typically seen on wet mount microscopy. Educational objective: Vesicovaginal fistulas may occur after pelvic surgery (eg, hysterectomy) and present as a continuous, painless, watery discharge from urine leaking (ie, pooling of clear fluid) into the vagina. References: Urologic complications following obstetrics and gynecological surgery: our experience in a tertiary care hospital. (http://www.ncbi.nlm.nih.gov/pubmed/26834397) Vesicovaginal fistulas: a gynecological experience in 41 cases at a German pelvic floor center. (http://www.ncbi.nlm.nih.gov/pubmed/26001626) Out of the shadows and 6000 reasons to celebrate: an update from FIGO's fistula surgery training initiative. (http://www.ncbi.nlm.nih.gov/pubmed/29634084) Urological complications after radical hysterectomy with postoperative radiotherapy and radiotherapy alone for cervical cancer. (http://www.ncbi.nlm.nih.gov/pubmed/29595646)

A 48-Year-Old Woman Comes to the Office Due to Clear