Complication of Gellhorn pessary use

A 74-year-old woman with history of stage I uterine prolapse with daily Gellhorn pessary use for 12 years and constipation with weekly suppository use presented with 7 days of stool on her pessary. Physical examination revealed an afebrile female with a benign abdomen and stool at the vaginal introitus. Laboratory examination revealed a normal white blood cells (WBC) count, and a urinalysis with positive leukocyte esterase, nitrite, and white and red blood cells. Computed tomography (CT) demonstrated contrast in the rectal vault and at the level of the vaginal introitus as well as distal colonic diverticula (Figure 1). Colonoscopy findings are given in Figure 2, Figure 3, Figure 4. During colonoscopy, the scope passed through the anterior rectal wall through a tract into the vagina and out to the bed (Figure 2). A 2 cm opening on the anterior rectal wall (red arrows, Figure 3) and a mature fistula tract (Figure 4) with granulation tissue (blue arrows) were visualized. The opening was treated with argon plasma coagulation and an over-the-scope-clip was placed. This resulted in >90% improvement in patients’ symptoms immediately and allowed for hospital discharge.

Female bowel-vaginal fistulas can be subclassified as anovaginal fistulas (AVFs) if they occur below the dentate line and true rectovaginal fistulas (RVFs) if cephalad to the dentate line. Bowel-vaginal fistulas most frequently result from obstetric trauma, especially after repair of third- or fourth-degree laceration of the perineum or following hysterectomy. Other etiologies include Crohn’s disease, radiation, diverticulitis, colon cancer, or fecal impaction. Additionally, treatment options for pelvic organ prolapse including cube pessaries and mesh repair procedures have been associated with RVFs [1].

Gellhorn pessaries are generally used for advanced stage III and VI pelvic organ prolapse. Current recommendations are pessary fitting with follow-up within 2–4 weeks to reassess fit [2]. If possible, instruction on removal and care should be provided. Women are advised to remove the pessary once a week and wash with water or mild soapy water or follow up with their provider at 3-month intervals for pessary care. Intervals for pessary replacements vary greatly and are often based on manufacturer’s recommendations. Higher complication rates have been reported for 6-month replacement interval over 3-month [3]. Long-term pessary use may lead to vaginal erosions and ulcerations, which places the patient at higher risk for development of a fistula.

This case highlights the serious complications of repeated pessary use and the importance of repeat examination and patient education regarding pessary care.