Case Series of Three Postcoital Rectovaginal Fistulae

Abstract

Background: Sex is a basic human need, and consensual vaginal coitus is a physiologic act. It normally does not lead to any significant trauma except for minor hymenal or vaginal tears sustained during vaginal penetration for the first time. The literature shows some reports of major vulval hematomas, vaginal lacerations, ruptured ectopic pregnancies, ovarian cysts, and even hemoperitoneums. Yet, no reports of rectovaginal fistulae (RVF) following consensual coitus was found in the literature. RVF can be caused by obstetric injuries, surgical complications, malignancies, or infections. It may also follow nonconsensual vaginal intercourse, but it is hard to imagine and rare to see RVF following normal consensual coital acts. Cases: This article hereby presents cases of 3 married women in whom normal consensual coital acts with their husbands led to rectovaginal fistulae. None of the women had any history suggestive of instrumentation or infection. It was the first coital act after marriage for 2 of the women but the third woman had been married for 9 years and had 2 children. Results: All 3 patients became continent of flatus and feces after surgical repair. Conclusions: Normal consensual coital acts may lead to rectovaginal fistulae in women with tight introitus or vaginismus. Clinicians should make thorough examinations when women present with bleeding and discharge following consensual coitus, to exclude the presence of rectovaginal fistulae. (J GYNECOL SURG: 29:70)

Introduction

Consensual vaginal coitus is a physiological act. Mostly, it is atrumatic but may sometimes lead to minimal hymenal or vaginal tears. The risk of coital injury is three times more in nonconsensual than in consensual vaginal intercourse.¹ Consensual coital injuries reported in the literature vary from vulvar hematomas; labial, posterior fourchette, or vaginal-wall lacerations; broad-ligament hematomas; ruptured ovarian cysts; posterior-fornix perforations with secondary peritonitis, and ruptured ectopic pregnancies with life-threatening hemorrhaging.^2,3 A literature review did not show any cases of rectovaginal fistulae (RVF) following consensual vaginal intercourse, although it has been known to occur during rape, and RVF may be extremely debilitating.⁴ RVF is usually caused by obstetric injury, surgical complications, malignancies, and infections.

This article reports three cases of RVF that occurred in women during consensual vaginal intercourse with their husbands.

Case 1

A 26-year-old para 2+0, with her last delivery at 5 years prior, presented to the emergency room (ER) of the Department of Obstetrics and Gynecology at Chhatrapati Shahuji Maharaj Medical University on May 5, 2011. She presented with a history of profuse vaginal bleeding immediately after having vaginal intercourse with her husband. This was followed by leakage of blood mixed with feces from her vagina. Her husband was under the influence of alcohol at that time. Vaginal and rectal examination revealed a fistula that measured 1 cm×1.5 cm, and its lower margin was 2 cm above the posterior fourchette. This RVF was repaired vaginally by a layered method after adequate bowel preparation. She became continent of flatus and feces by the 7th day.

Case 2

A 22-year-old nulliparous woman reported to the department of obstetrics and gynecology on May 30, 2010, with complaints of passage of stool through her vagina since her first coitus 2 months' prior. She gave a history of dyspareunia at that time. Her abdominal examination results were normal. Per speculum examination, a fistula was seen in her posterior vaginal wall. Vaginal and rectal examination revealed a communication between her vagina and rectum. The fistula was ∼1.5×1.5 cm, and its lower margin was 1.5 cm above her introitus. Her anal sphincter was intact. Diagnosis of mid-RVF was made, and transvaginal 2-layer repair was done. She became continent of flatus and feces.

Case 3

This 23-year-old nulliparous woman reported to the ER on second day of her marriage with complaints of severe pain during her first coital act, which was followed by passage of stools through her vagina. A gynecologic examination revealed an RVF measuring 2 cm×2 cm, with its lower margin 1 cm away from her posterior fourchette. The fistula was surgically repaired by a layered method after converting the RVF into a complete perineal tear. She became continent of flatus and feces.

Results

All three patients became continent of flatus and feces after surgical repair.

Discussion

Coital trauma mostly causes minor injuries that manifest as self-limiting minimal vaginal bleeding and do not require medical attention. Severe coital trauma following vaginal intercourse is seen in cases of rape but rarely in consensual coital acts. Report from hospital-based studies from Nigeria revealed that coital injuries accounted for 0.7 per 1000 gynecologic emergencies. McColgin et al. reported 5 cases of hemoperitoneum following vaginal intercourse.² Ahmed et al. studied records from 1997 to 2003 and found 33 cases of coital injuries in married women of Pakistan. These researchers found 3 vulvar hematomas; and 1 labial, 9 posterior-fourchette, and 16 vaginal-wall lacerations that were stitched. One broad-ligament hematoma, 1 ruptured ovarian cyst, 1 posterior-fornix perforation, and 1 ruptured ectopic pregnancy needed surgical intervention.³ A 5-year study from India reported only 1 traumatic fistula, a postcoital trigonal vesicovaginal fistula, among 27 genitourinary fistulae. The only two RVF in their series were caused by obstetric trauma.⁵

The three cases reported in the current article are unusual in terms of the cause of RVF. Two of the reported women developed fistulae at the time of first coital act. Tight introitus, vaginismus or misdirected coitus may have been the underlying reasons.

Conclusions

These three cases suggest that all women with postcoital bleeding or discharge should be examined thoroughly for RVF.

Footnotes

Disclosure Statement

No competing financial conflicts exist.

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