Urethrovaginal fistula following vaginal prolapse of a pedunculated uterine myoma: a case report.

BACKGROUND: Urethrovaginal fistulas are usually secondary to a foreign body in the vagina or to vaginal gynecologic surgeries. We present a case of an urethrovaginal fistula secondary to vaginal prolapse of a huge pedunculated submucosal uterine myoma. CASE PRESENTATION: A 25-year-old black African woman with a past history of huge uterine fibroids and an uncomplicated vaginal delivery 5 weeks prior to presentation consulted for a difficult micturition that occurred 2 days earlier. A vaginally prolapsed huge uterine myoma was diagnosed. The fibroid was easily twisted off per vagina. Around 9 days after prolapse of the fibroid or 5 days after its removal, she complained of a vaginal leaking of urine during micturition. An urethrovaginal fistula was diagnosed using a blue dye test. The fistula was successfully repaired with polyglactin and she was discharged on day 15. CONCLUSIONS: To the best of our knowledge, this is the first case of urethrovaginal fistula secondary to delivered uterine myoma. We recommend close postpartum follow-up of women carrying huge uterine fibroid and urgent management of a vaginally prolapsed uterine fibroid to reduce the risk of urethrovaginal fistula.

[Treatment of fistulating pouchitis with tumour necrosis factor-alpha-inhibitor (infliximab)]. / Behandling af fistulerende pouchitis med tumornekrosefaktor-alpha-hsemmer (infliximab).

The surgical first choice treatment for patients with ulcerative colitis (UC) involves total proctocolectomy with ileal pouch-anal anastomosis (IPAA). Postoperative development of pouch-related fistula is a rare complication, but it is associated with significant morbidity, a high recurrence rate and is a major cause of pouch failure. We report the use of infliximab, a monoclonal antibody to tumour necrosis factor-alpha, in three patients who developed pouch-related fistula after undergoing IPAA surgery for UC.

Fistula response to methotrexate in Crohn's disease: a case series.

BACKGROUND: Controlled trials have demonstrated the efficacy of methotrexate in the induction and maintenance of remission in luminal Crohn's disease; however, its effect on fistulizing disease is unknown. AIM: To describe the response to methotrexate therapy in a series of patients with fistulizing Crohn's disease. METHODS: A retrospective chart review was conducted of all patients with Crohn's disease receiving methotrexate in one practice. The response of patients with fistulizing and luminal disease was assessed using clinical and laboratory criteria. Fistula response was categorized as either complete or partial closure. RESULTS: Thirty-seven courses of methotrexate therapy were given to 33 patients with luminal and/or fistulizing Crohn's disease. In 16 patients with fistulas, four (25%) had complete closure, five (31%) had partial closure and all had failed or were intolerant to 6-mercaptopurine therapy. Overall, response to methotrexate was seen in 23 of 37 (62%) treatment courses in patients with luminal and/or fistulizing Crohn's disease. Two of the 33 patients (6%) had a significant adverse event. CONCLUSIONS: In this case series, 56% of patients with Crohn's fistulas on methotrexate showed a complete or partial response to therapy. Further studies are needed to confirm the role of methotrexate alone, and in combination with other therapies, for the treatment of fistulizing Crohn's disease.

Response of fistulating Crohn's disease to infliximab treatment assessed by magnetic resonance imaging.

AIMS: To assess fistula track healing after infliximab treatment using magnetic resonance imaging. METHODS: Magnetic resonance imaging and clinical evaluation were performed before and after three infliximab infusions given over a 6-week period. Magnetic resonance images were evaluated for abscesses and fistula tracks. Paired magnetic resonance image examinations were rated 'better', 'unchanged' or 'worse'. Magnetic resonance imaging and clinical outcomes were then compared. RESULTS: Of the 12 referred patients, pre-treatment magnetic resonance imaging detected abscesses in three (two not treated). Of the 10 treated patients, seven had peri-anal fistulas, two of whom also had recto-vaginal fistulas, and three had abdominal wall entero-cutaneous fistulas. After infliximab, four were in remission, one had a response and five were non-responders. One developed a peri-anal abscess. Magnetic resonance imaging improved in six, was unchanged in two and was worse in two. In four of the six with improvement in magnetic resonance imaging, the fistula track resolved, but two of these had clinically persistent entero-cutaneous fistulas. The clinical outcome and magnetic resonance imaging correlated in seven of the 10 patients; in three (two entero-cutaneous and one peri-anal), there was discordance. CONCLUSIONS: Magnetic resonance imaging identifies clinically silent sepsis. Fistulas may persist despite clinical remission. Clinical response to infliximab and clinical correlation with magnetic resonance imaging were poor in patients with abdominal entero-cutaneous fistulas.

[Bilateral hydronephrosis secondary to ileocolic Crohn's disease]. / Hidronefrosis bilateral secundaria a enfermedad de Crohn ileocólica.

Unilateral hydronephrosis can complicate a far from negligible number of patients with Crohn's disease. Bilateral hydronephrosis associated with Crohn's disease is a much more unusual entity. In the other hand, the treatment for this condition is still controversial. We present the case of a 44 year old female with several bowel obstruction episodes caused by ileocolic Crohn's disease. During the last episode she was also diagnosed of bilateral hydroureter and hydronephrosis. After the resolution of the bowel obstruction and the placement of a double J catheter in both ureters, the patient was operated. Ileocolic resection and bilateral ureterolysis with omental wrapping were performed. Although urinary and wound infection complicated the postoperative course, and a enterocutaneous fistula had to be medically treated one year later, the patient is now free of symptoms and her renal function is normal.

Endosonographic evidence of persistence of Crohn's disease-associated fistulas after infliximab treatment, irrespective of clinical response.

PURPOSE: Infliximab has been reported to improve fistulizing Crohn's disease. Moreover, prompt healing of mucosal ulcers has been described. Whether fistulas disappear or remainders of fistulas persist is unknown. This study documents fistulous tracts before and after infliximab therapy by means of hydrogen peroxide-enhanced endosonography METHODS: Eight patients with perianal, vaginal, or perineal fistulas were treated with a triplet of infliximab 5 mg/kg infusions. At baseline, and at Week 4 after the last infusion, fistulas were documented by local inspection, digital examination, and hydrogen peroxide-enhanced anal or vaginal endosonography. RESULTS: Patients with vaginal or perineal fistulas did not respond clinically to therapy, whereas patients with perianal fistulas improved considerably. However, in all patents remainders of fistulous tracts were demonstrated by endosonographic techniques. CONCLUSIONS: Short-term treatment of Crohn's disease-associated fistulas with infliximab does not induce disappearance of fistulous tracts, irrespective of therapeutic response.

Rapid closure of Crohn's disease fistulas with continuous intravenous cyclosporin A.

Fistulas complicating Crohn's disease often are refractory to medical management. Immunosuppressive therapy is sometimes effective but requires several months before efficacy can be determined. We treated five patients with Crohn's disease complicated by chronic draining fistulas unresponsive to previous surgery, steroids, antibiotics, total parenteral nutrition, 6-mercaptopurine, or azathioprine with continuous infusion cyclosporin A (CyA). The five patients had a total of 12 fistulas (five enterovaginal, three perianal, three enterocutaneous, one enterovesical). CyA was administered initially at 4 mg/kg/day for 6-10 days, after which oral dosing was begun at 8 mg/kg/day and adjusted to maintain trough serum levels of 100-200 ng/ml. All fistulas responded to CyA infusion with decreased drainage and with improvement in both perifistular inflammation and patient comfort. Complete resolution of drainage was seen in 10 of the 12 fistulas. Initial response was seen after a mean of 3.6 days (range, 2-5 days) with complete cessation of drainage in the 10 fistulas after a mean of 7.9 days (range, 3-28 days). Therapy was continued for a mean of 6.2 months (range, 1.5-18 months). Relapse was seen in two perianal fistulas (3 wk and 7 months) and in two enterovaginal fistulas (1 and 2 months). Two of these recurrences corresponded to lowered serum levels of CyA. An enterocutaneous fistula also recurred after 2.5 months, associated with a distal stricture that required resection. Side effects were minor except for a mycotic aneurysm in one patient which occurred after 7 months of treatment. Intravenous CyA may prove to be a useful agent in the initial management of refractory Crohn's disease fistulas, although relapse as serum levels are lowered and infectious complications are limiting factors for long-term use as a single agent.

[Conservative treatment of urogenital fistula following gynecological surgery: the value of fibrin glue]. / Traitement conservateur des fistules urogénitales après chirurgie gynécologique: intérêt de la colle de fibrine.

Ureteric and bladder vaginal fistulas are recognized complications of gynaecologic surgery. We report on 4 cases of fistulas (2 uretero-vaginal and 2 vesico-vaginal) successfully treated by urinary drainage associated with plugging of fistula with fibrin sealant. Efficiency of conservative treatments is directly related to early application. Mechanical and biological properties of fibrin sealant explain its possible role in recovery, without increasing risk of viral transmission.

Favorable effect of 6-mercaptopurine on fistulae of Crohn's disease.

Fistulae are distressing chronic complications of Crohn's disease which have served as one of the most common indications for surgical resection. While steroids and sulfasalazine have not been successful in closing fistulae, in a previous double-blind study 6-mercaptopurine (6-MP) was more effective than placebo in accomplishing this goal (31% vs 6%). Thirty-four patients with Crohn's disease fistulae were treated with 6-MP for a minimum period of 6 months. In 13 patients (39%) the fistulae closed completely, and in another 9 (26%) there was obvious improvement. All types of fistulae responded to 6-MP with the most impressive closures occurring in patients with fistulae of the abdominal wall and enteroenteric fistulae. The mean time to respond was 3.1 months, with 23% of patients taking longer than 4 months to show any response. Response was not related to other drugs (steroids, sulfasalazine) used in conjunction with the 6-MP. The site of intestinal involvement with Crohn's disease did not appear to play a significant role in the frequency or degree of response to 6-MP, but patients without prior resection and fistulae did better than those with fistulae occurring after surgery. The long-term response to fistulae was good if 6-MP was maintained, whereas exacerbation eventually followed discontinuation of 6-MP. 6-Mercaptopurine is an effective and useful drug in the treatment of fistulae, as it is in other manifestations of chronic unrelenting Crohn's disease.