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Annals of African Medicine, Vol. 8, No. 1, March, 2009, pp. 59 - 60 Rectovaginal Fistula Following Sexual Intercourse: a Case Report 1M. A.Ijaiya, 2A. M.Mai, 1A. P.Aboyeji, 2V.Kumanda, 1M. O.Abiodun and 1H. O.Raji 1Departmen of Obstetrics and
Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Nigeria Abstract Female genital fistula is an important feature of the developing countries gynecology. Most of the rectovaginal fistulae encountered in the tropics are due to obstetrics causes and genital malignancies. In developed countries, radiation injury and Crohn’s disease are also common etiological factors. The index case is reported to highlight the rare situation, where a 24-year old married nullipara sustained low rectovaginal fistula following normal coitus. She was later divorced by her husband. Key words: Coitus, vaginal injury, rectovaginal fistula Résumé La fistule de l’organe génital de la femme est un important trait de la gynécologie des pays en développement. La plupart des fistules rectovaginales des régions tropicales sont dûes à des effets obstétriques et des malignités génitales. Dans les pays développés, les blessures dûes aux radiations et à la maladie de Crohn sont aussi des facteurs étiologiques fréquents. Le cas servant de repère est celui concernant la rare situation où une femme mariée nullipare de 24 ans a pu supporter une faible fistule rectovaginale après un coit normal. Son maria a à cet effet divorcé d’elle. Mots clés: Coitus, dommages vaginaux, fistule de rectovaginal Vaginal injuries that occur during sexual intercourses are usually mild and are associated with self-limiting vaginal bleeding that do not require medical attention.1The incidence rate of vaginal injuries during coitus is 30 cases and 32 cases per year in Senegal2 and United States3 respectively. The most common site of vaginal injuries at coitus is the vaginal vault particularly the posterior fornix. Other sites include right fornix, left fornix and lower vagina.3 Occasionally, it affects the posterior vaginal wall but seldom extends to the rectum to cause flatus/faecal incontinence. The main causes of rectovaginal fistula are obstetric injury, genital malignancy, inflammatory bowel disease, operative trauma and radiotherapy.4 This paper is the report of a case of rectovaginal fistula following sexual intercourse encountered at the Federal Medical Centre, Yola, North Eastern Nigeria. Case report A 24-year-old nullipara, presented with leakage of flatus and faeces per vaginam of 15 months duration. She first noticed vaginal bleeding immediately after having sexual intercourse with her husband, which was her second coital experience with him. The bleeding was mild and subsided spontaneously at home. About a week later she started passing flatus and faeces per vaginam. The coital activity was performed in dorsal position and in a relaxed mood. Neither the patient nor her spouse was under the influence of alcohol. No antecedent history of abnormal vaginal discharge, weight loss or haematochezia. There was no urinary incontinence. There was no past history of vaginal surgery. Since the onset of her problem, she had stopped going to the market and attending social functions. At the time of presentation, Mrs. RH had been divorced. She was living with and supported by her parents. There was no abnormality detected on abdominal examination. Vaginal and rectal examination revealed a communication between the vagina and rectum. The vaginal defect was about 1x1cm (admitted a finger tip) and 2cm above the introitus. The uterus was normal in size and the cervix was healthy looking on speculum examination. The anal sphincter was intact and normal. Diagnosis of low rectovaginal fistula was made. She had transvaginal two-layer repair after bowel preparation was done. The procedure was successful and she became continent of flatus and faeces. She had an uneventful two year follow-up. Both pelvic and rectal examination findings were normal during this period. Discussion Vaginal trauma at sexual intercourse is an everyday occurrence. Most are minor injuries that manifest as self-limiting minimal vaginal bleeding, which do not require medical attention. Report from Hospital based studies from Calabar, Nigeria revealed that coital injuries accounted for 0.7 per 1000 gynecological emergencies5 while Cissse et al in Dakar, Senegal and Dao et al in New York, USA, reported 32 cases2 and 30 cases of vaginal injuries6 per year respectively. Vaginal trauma due to coitus seldom extends into the rectum to cause rectovaginal fistula. Fish (1956) reviewed about twenty-one published studies on vaginal injuries due to coitus from different centers and reported only one case of posterior vaginal wall perforation that extended to the rectum.7 However, Muleta and Williams in Addis Ababa fistula Hospital reported 91 cases of rectovaginal fistula sustained from coitus within marriage or rape that were successfully managed over a seven year period due to Ethiopian’s societal tradition where ladies were abused under the cover of marriage.8 Our patient is a nullipara, whose biodata was typical of patients with high risk of coital injury vis-à-vis low parity (0-1) and age group of 15-30 years.1 The possible contributory factor to her coital injury could be the dorsal decubitus position she was at the time of intercourse, which is the most implicated position in coital injuries.2 However, the only case of rectovaginal fistula following coitus reported in Fish’s review was in a 19-year old lady that had sexual intercourse in standing position.7 The common predisposing factors to coital injuries include rough coitus, first sexual intercourse, penovaginal disproportion, use of aphrodisiacs as vaginal lubricants, puerperium, and inadequate emotional and physical preparation of women for sexual intercourse.1,2,7 Apart from obstetric cause of rectovaginal fistula, which is the most common aetiology worldwide. The order of frequency of other causes varies from region to region namely cancer of the cervix, radiation injury, inflammatory bowel disease (especially Crohn’s disease), operative trauma and rectal cancer.4 Just as in vesicovaginal fistula, rectovaginal fistula is associated with psychosocial problems particularly divorce/separation9 as seen in the patient presented. Our patient had successful rectovaginal fistula repair and hope to return back to her husband to continue her normal life. References
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