Re: GYN: RV fistula
From: Atkinson, Samuel M (ATKINSONS@mail.ecu.edu)
Thu Sep 1 13:56:10 2005
must consider colon carcinoma. needs MRI and Surgery (Colostomy)
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From: ob-gyn-l@obgyn.net on behalf of Dr. Ainsworth
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________________________________
Sent: Wed 8/31/2005 11:19 AM
To: Multiple recipients of list OB-GYN-L
Subject: Re: GYN: RV fistula
Love those nursing home consults with not equipment available. You
described my experiences to a "T." I think you are exactly right, she
needs a colonoscopy, exam under anesthesia and would probably benefit
from a diversion, which could be temporary if you find a repairable RV
fistula and no malignancy. Inflammatory bowel disease is also a
possible cause. At her age with poor surgical risks, she would more
likely be a candidate for a permanent diverting colostomy.
>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
>
