Re: GYN: RV fistula
From: R. Daniel Braun (rd.braun@gmail.com)
Tue Aug 30 23:29:54 2005
Diverting Colostomy and do an exam in the OR with biopsies of the edges of
the "Hole"
Dan
On 8/30/05, Garry E. Siegel, M.D. <garrys@mindspring.com> wrote:
>
> 84 YO P2002 in nursing home (unsure why) was hospitalized a local small
> hospital with severe pneumonia, and is just out of ICU. My practice was
> called for a consult for severe vulvar pain and a history of an RV
> fistula. All things considered, the patient is a pretty good historian,
> and that is pretty much where my information is from.
>
> She had an RV fistula diagnosed by the "nurse" at the nursing home in
> March, 2005. She is incontinent of stool, had vaginal deliveries, and
> never has had radiation, etc. Since March, she really hasn't had much
> vulvar irritation or pain except once, and now since being in the
> hospital.
>
> This is about all the history I took, frankly.
>
> On exam in the hospital bed on an inverted bedpan (no pelvic tables in
> this hospital, and the only light is with a flashlight), there is stool
> everywhere. After cleaning up (several nurses/aides/me), the vulva is
> diffusely edematous and erythematous, and the perineal body is intact.
> On a spec exam with a plastic, lighted ER speculum, stool immediately
> fills it. On a digital exam, there is a hole in the vaginal floor,
> around 1.5 cm., just below the cervix.
>
> So. . .
>
> Does anyone have any suggestions here? Obviously, it would be nice to
> examine her properly, I suppose, and see if there is a reason
> (malignancy) for the fistula. She is really not a surgical candidate,
> and I have zilch experience here. There is a part of me that almost
> thinks she needs a diversion. . .
>
> In the meantime, I made the assumption that this is probably yeast that
> has gotten bad after the antibiotics killed her flora, and thus I have
> given her Diflucan 150 mg. every 3 days for 3 doses, and suggested
> Mycolog II cream and trying Silvadene.
>
> Any thoughts on comfort measures or anything else welcome.
>
> Garry
>
> --
> Garry E. Siegel, M.D.
> Private Practice
> Roswell, GA
>
--
R. Daniel Braun
Kinky for Governor
