A 28-year-old nulliparous woman comes to the office due to malodorous vaginal discharge for the last month. The patient has tried various over-the-counter vaginal douche products with no improvement. Her last menstrual period was 2 weeks ago, and she noticed no change in her symptoms during that time. In addition to the discharge, the patient has had intermittent, crampy abdominal pain and sometimes feels like gas is passing through her vagina. The patient has had no surgeries. Vital signs are normal. Speculum examination shows a malodorous, tan vaginal discharge and a patch of erythema on the posterior vaginal wall. The cervix is nulliparous and has no visible lesions or areas of friability. A sinus with purulent drainage is also present in the perianal skin. Which of the following is the most likely underlying cause of this patient's presentation?

Question

A 28-year-old nulliparous woman comes to the office due to malodorous vaginal discharge for the last month.  The patient has tried various over-the-counter vaginal douche products with no improvement.  Her last menstrual period was 2 weeks ago, and she noticed no change in her symptoms during that time.  In addition to the discharge, the patient has had intermittent, crampy abdominal pain and sometimes feels like gas is passing through her vagina.  The patient has had no surgeries.  Vital signs are normal.  Speculum examination shows a malodorous, tan vaginal discharge and a patch of erythema on the posterior vaginal wall.  The cervix is nulliparous and has no visible lesions or areas of friability.  A sinus with purulent drainage is also present in the perianal skin.  Which of the following is the most likely underlying cause of this patient's presentation?

Quizplus · Accepted Answer

11ec25c8_d3d0_b58b_bc81_6369a4214a15_MD0003_00 This patient with malodorous vaginal discharge (ie, stool), gas passing through the vagina, and a posterior vaginal lesion most likely has a rectovaginal fistula, an aberrant connection between bowel and vagina. Although rectovaginal fistula development is commonly associated with obstetric trauma or pelvic surgery, patients without these risk factors should be evaluated for additional (likely gastrointestinal) causes. rectovaginal fistula This patient's intermittent, crampy abdominal pain and perianal sinus in the setting of a rectovaginal fistula is likely due to underlying Crohn disease. Crohn disease, a transmural inflammation of the gastrointestinal tract, predisposes patients to bowel abscess, fissure, and fistula formation. Although the rectum is typically spared in Crohn disease, a nonhealing, transmural ulcer in the anal canal can progress to form a rectovaginal fistula. Crohn disease In addition to standard Crohn disease management (eg, anti-TNF inhibitors, glucocorticoids), patients with a rectovaginal fistula may require surgical correction. (Choice A) Bartholin gland cysts or abscesses can present with malodorous vaginal discharge; however, patients typically have a posterior vulvar mass located at the 4 or 8 o'clock position. In addition, Bartholin gland cysts do not cause crampy abdominal pain or passage of flatus or stool through the vagina. Bartholin gland cysts or abscesses (Choice B) Hidradenitis (chronic occlusion and inflammation of hair follicles) can cause groin abscesses with sinus tracts and associated purulent drainage. However, it is not associated with abdominal pain or malodorous vaginal discharge. In addition, it is typically multifocal and located in more than one intertriginous area (ie, axillary, inguinal, gluteal). (Choices C and D) Cervical cancer or a retained foreign body in the vagina can cause malodorous vaginal discharge and abdominal pain. However, patients typically have visible findings (eg, cervical lesion, foreign body) on speculum examination, and neither is associated with the passage of flatus through the vagina. Educational objective: A complication of Crohn disease is perianal disease (eg, abscess, fissure, fistula), including rectovaginal fistula, due to transmural inflammation of the gastrointestinal tract. Patients with a rectovaginal fistula typically have a malodorous, tan vaginal discharge; passage of flatus through the vagina; and a posterior vaginal lesion. References: Rectovaginal fistula in Crohn's disease. (http://www.ncbi.nlm.nih.gov/pubmed/17846837) Pathophysiology of fistula formation in Crohn's disease. (http://www.ncbi.nlm.nih.gov/pubmed/25133023) Fistulizing Crohn's disease: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/24917961)

A 28-Year-Old Nulliparous Woman Comes to the Office Due to Malodorous