A 25-year-old woman, gravida 1 para 1, comes to the office due to malodorous vaginal discharge for the past 2 weeks. She tried over-the-counter topical vaginal cleansers with no improvement of her symptoms. Four weeks ago, the patient had a forceps-assisted vaginal delivery complicated by a third-degree laceration, which was repaired with absorbable suture. After delivery, vaginal packing was placed for 24 hours to tamponade the traumatized vaginal tissue. Her lochia stopped a week ago, and she has had no additional bleeding. Vitals signs are normal. On pelvic examination, the perineum is intact, and there is a small, dark red, velvety area on the posterior vaginal wall with an associated malodorous, tan-brown discharge. Which of the following is the most likely diagnosis in this patient?

Question

A 25-year-old woman, gravida 1 para 1, comes to the office due to malodorous vaginal discharge for the past 2 weeks.  She tried over-the-counter topical vaginal cleansers with no improvement of her symptoms.  Four weeks ago, the patient had a forceps-assisted vaginal delivery complicated by a third-degree laceration, which was repaired with absorbable suture.  After delivery, vaginal packing was placed for 24 hours to tamponade the traumatized vaginal tissue.  Her lochia stopped a week ago, and she has had no additional bleeding.  Vitals signs are normal.  On pelvic examination, the perineum is intact, and there is a small, dark red, velvety area on the posterior vaginal wall with an associated malodorous, tan-brown discharge.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_da81_cffa_bc81_997e9744897b_MD0003_00 This patient with malodorous, tan-brown vaginal discharge and a posterior vaginal lesion likely has a rectovaginal fistula (RVF), an aberrant connection between the rectum and vagina. RVFs most often occur after third- or fourth-degree perineal lacerations with inadequate wound repair or wound infection and breakdown. aberrant connection perineal lacerations A large perineal laceration, as in this patient, can cause abnormal healing of the rectovaginal septum. Because of the proximity of the rectum to the vagina, rectal mucosa may infiltrate and form a fistulous tract during healing, resulting in rectal mucosa being visible on the posterior vaginal wall, often appearing as a dark red, velvety lesion. As the fistula gradually develops (over weeks to months) and expands, flatus and fecal material pass through the vagina, resulting in a malodorous, tan-brown discharge. Diagnosis is typically clinical and based on visualization of a posterior vaginal defect; for patients with an unclear presentation, imaging may be performed. Treatment is with surgical repair. (Choice A) Bartholin gland abscesses can present with malodorous discharge due to purulence; however, affected patients have an associated painful, indurated posterior vulvar mass located at the 4- or 8-o'clock position. Bartholin gland abscesses (Choice C) A retained foreign body (eg, gauze) can cause malodorous vaginal discharge but is typically seen on examination because it obstructs visualization of normal pelvic structures (eg, posterior vaginal wall). (Choices D and F) Symptomatic Trichomonas vaginitis causes yellow-green, frothy, malodorous vaginal discharge. Vulvovaginal candidiasis can cause thick, white vaginal discharge. However, both conditions typically have generalized vulvovaginal inflammation with erythema rather than a discrete, velvety lesion. Trichomonas vaginitis Vulvovaginal candidiasis (Choice E) Vesicovaginal fistulas present with clear, watery vaginal discharge (ie, urine) and a fistulous tract on the anterior, rather than the posterior, vaginal wall. Vesicovaginal fistulas Educational objective: Rectovaginal fistulas may occur after obstetric trauma (eg, third- or fourth-degree perineal lacerations), and patients typically have incontinence of flatus and feces (eg, a malodorous, tan-brown discharge) through the vagina. Dark red, velvety rectal mucosa may be seen on the posterior vaginal wall. References: Presentation and management of rectovaginal fistulas after delivery. (http://www.ncbi.nlm.nih.gov/pubmed/26476822) Rectovaginal fistulae. (http://www.ncbi.nlm.nih.gov/pubmed/26929752)

A 25-Year-Old Woman, Gravida 1 Para 1, Comes to the Office