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GYN: RV fistulaFrom: Garry E. Siegel, M.D. (garrys@mindspring.com)Tue Aug 30 22:14:52 2005
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
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