A 19-year-old woman comes to the office due to continuous vaginal discharge. The patient has had a clear, slightly malodorous vaginal discharge for the past few weeks but no pelvic pain, dysuria, or vulvovaginal pruritus. She is 6 weeks postpartum from a vaginal delivery of a stillborn male infant after 3 days of labor and 4 hours of pushing. The patient had no prenatal care and delivered at home. Temperature is 36.7 C (98 F), blood pressure is 120/60 mm Hg, and pulse is 70/min. Pelvic examination shows a well-healed, third degree perineal laceration. On speculum examination, there is a small, red area of granulation tissue on the anterior vaginal wall. The cervix has no lesions and there is a pool of clear fluid in the vagina with a pH of 6. Which of the following would most likely establish the diagnosis in this patient?

Question

A 19-year-old woman comes to the office due to continuous vaginal discharge.  The patient has had a clear, slightly malodorous vaginal discharge for the past few weeks but no pelvic pain, dysuria, or vulvovaginal pruritus.  She is 6 weeks postpartum from a vaginal delivery of a stillborn male infant after 3 days of labor and 4 hours of pushing.  The patient had no prenatal care and delivered at home.  Temperature is 36.7 C (98 F), blood pressure is 120/60 mm Hg, and pulse is 70/min.  Pelvic examination shows a well-healed, third degree perineal laceration.  On speculum examination, there is a small, red area of granulation tissue on the anterior vaginal wall.  The cervix has no lesions and there is a pool of clear fluid in the vagina with a pH of 6.  Which of the following would most likely establish the diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d9e8_eb4e_bc81_475f538f3eaa_MD0003_00 This patient has a vesicovaginal fistula (VVF), a complication of obstructed labor that is common in resource-limited areas (eg, sub-Saharan Africa) due to young maternal age (ie, small pelvis) and limited or no prenatal care, which results in delayed diagnosis and labor intervention. Obstructed labor is the most common cause of VVF worldwide with an estimated >100,000 new cases yearly. In these patients, VVF develops because excessive fetal head compression during obstructed labor causes injury and necrosis to the maternal vagina, rectum, and bladder. Tissue necrosis leads to erosion and fistula development between proximal structures (eg, vesicovaginal, rectovaginal), typically occurring within the first weeks postpartum. Because of the aberrant connection between the vagina and bladder, patients with VVF have a continuous vaginal discharge with an abnormally elevated pH (ie, >4.5) due to urine, which may be malodorous due to surrounding necrotic tissue. Pelvic examination typically shows vaginal pooling of urine, a visible defect, or an area of raised, red granulation tissue on the anterior vaginal wall. vesicovaginal Bladder dye testing is performed to confirm the diagnosis, particularly in patients who have small fistulas that are not visualized on pelvic examination. During a bladder dye test, the bladder is filled with dyed fluid and patients are monitored for vaginal leakage of dye via speculum examination or tampon placement. Treatment of VVF is with surgical repair. (Choice B) Cervical nucleic acid amplification testing for chlamydia and gonorrhea is indicated in acute cervicitis, which typically presents with cervical friability and a mucopurulent cervical discharge, not seen in this patient. (Choice C) Urinalysis and urine culture are used to diagnose urinary tract infection, which is common in postpartum patients. This patient has no dysuria or suprapubic pain; therefore, these tests are not indicated. (Choice D) Viral culture is used to diagnose herpes simplex virus. Patients typically have multiple ulcers or vesicles, not a solitary raised, red area of granulation tissue. (Choice E) Bacterial vaginosis can be diagnosed by using wet mount microscopy; it causes a thin, malodorous (fishy) discharge with an elevated pH (eg, >4.5). Bacterial vaginosis does not cause vaginal pooling or granulation tissue, making this diagnosis unlikely. Educational objective: Obstructed labor in resource-limited areas is the most common cause of vesicovaginal fistula worldwide. Vesicovaginal fistula presents with a continuous, watery vaginal discharge and an area of raised, red granulation tissue on the anterior vaginal wall. Diagnosis is with pelvic examination and bladder dye test. References: Obstetric fistulae in southern Mozambique: incidence, obstetric characteristics and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/29126412) Female voiding dysfunction and urinary incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/29406060) 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) Social experiences of women with obstetric fistula seeking treatment in Kampala, Uganda. (http://www.ncbi.nlm.nih.gov/pubmed/29221527)

A 19-Year-Old Woman Comes to the Office Due to Continuous