Rectovaginal Fistula Associated with Fecal Impaction

To the Editor:—Rectovaginal fistula is a well known entity. The causes include: congenital anomalies, trauma, infections, inflammatory bowel disease, pelvic irradiation and neoplasms.1 Fecal impaction is common and occurs mainly in incapacitated or institutionalized elderly people. Complications of this situation include: fecal incontinence, urinary tract infections, obstructions of large bowel, stercoral ulcers, bleeding and perforations.5 We have recently had the opportunity in our geriatric department to treat two elderly patients with fecal impaction and rectovaginal fistula. We think that fecal impaction can be added to the list of causes of rectovaginal fistula. Patient 1: B.M. was a 70-year-old woman with a history of hypertension and congestive heart failure. Four months before hospitalization on our ward she developed quadriparesis because of cervical cord compression due to protrusion of three cervical discs. She refused any operative procedure. Soon after, she developed right hemiplegia and motor aphasia. On physical examination pertinent findings were obesity, quadriplegia with flaccid right side and spastic left side, motor aphasia, a fecal discharge from the vagina, and fecal impaction. Vaginal examination revealed feces, a rectovaginal fistula 2 cm above the sphincter (Figure 1), and a fecalith 5 cm in diameter that was evacuated during the examination. Biopsy from the fistula's rim did not show signs of malignancy. The patient died because of sepsis due to fulminant pyelonephritis. Post-mortem examination was refused by the patient's family. A rectovaginal fistula 2 cm above the sphincter. Patient 2: G.S., an 81-year-old had the following problems: severe congestive heart failure with recurrent pulmonary edema due to severe mitral regurgitation, aortic stenosis and coronary heart disease. She had a past history of cholecystectomy, right femoral-popliteal bypass operation, and sub-acute bacterial endocarditis. On physical examination, pertinent findings were dyspnea, orthopnea, mitral regurgitation, aortic stenosis and fecal impaction. After a few days of hospitalization, vaginal bleeding occurred, and a rectovaginal fistula was found on vaginal examination, 5 cm above the sphincter (Figure 2). Biopsy from the fistula's rim was negative for malignancy. The patient refused any surgical intervention. She developed gangrene of the right foot and died because of pulmonary edema. Post-mortem examination was not permitted by the family. A rectovaginal fistula 5 cm above the sphincter. By its pressure and ischemic necrosis of the wall of the colon, fecal impaction may cause stercoral ulceration and perforation. We propose that the same mechanism can cause rectovaginal fistula, especially in elderly persons.