VOLUME 37 • NUMBER 2 January 30, 2017 TOPICS IN OBSTETRICS & GYNECOLOGY Practical CME Newsletter for Clinicians

Rectovaginal

Sarah Zitsman, DO, MPH, and Carol A. Glowacki, MD

Learning Objectives: After participating in this CME activity, the obstetrician/gynecologist should be better able to: 1. Use the common classification system for describing rectovaginal . 2. Describe appropriate history and physical examination to identify patients with rectovaginal fistulas. 3. Initiate conservative management and explain when to refer a patient to a specialist. Key Words: Rectovaginal fistula, Classification, Treatment

A rectovaginal fistula (RVF) is an abnormal connection are derived from local trauma or infection. Alternatively, between the epithelial lined tracts of the and . “complex” RVFs are located in the upper vagina, have a The United States has a lower prevalence than developing diameter greater than 2.5 cm, or result from nontraumatic countries and the incidence seems to be declining. However, causes such as radiation, neoplasm, and inflammatory the diagnosis may cause significant distress and negative bowel disease.3,5 impact on quality of life. Therefore, all practitioners should Obstetric trauma is the most common cause of RVF. An be familiar with the etiology, diagnosis, and treatment.1-3 RVF can result from occult rectal lacerations sustained at the time of vaginal delivery. Infection and/or dehiscence of Classification of Rectovaginal Fistula third- and fourth-degree perineal repairs may also result in RVFs are classified in various ways. A common classi- RVF. Iatrogenic rectal injury may occur from an overly fication system is based on anatomic position in the extensive midline or trauma from operative vagina (Table 1). A low RVF lies near the vaginal opening vaginal deliveries. Nonobstetric surgery in the vicinity of and the posterior fourchette. Mid-level RVFs are above the rectum may also result in RVF formation. Iatrogenic the posterior fourchette but distal to the level of the . rectal injury with RVF formation has been reported after RVFs at the level of the posterior fornix are classified as gynecologic procedures, such as and pelvic high. RVFs should be differentiated from anovaginal fis- floor reconstruction with and without mesh, and colorectal tulas. An RVF communicates with the rectum above the procedures for excision of rectal tumors or hemorrhoids. dentate line. Anovaginal fistulas lie below the dentate Other etiologies include inflammatory bowel disease, infec- line.1,4 tions, neoplasm, and pelvic radiation. RVFs may develop from trauma or vaginal or rectal foreign bodies. Providers Differentiation between simple and complex RVFs may 1,6-10 be more clinically useful. “Simple” RVFs are located in the should be vigilant in sexual assault cases. lower or mid-vagina, have a diameter less than 2.5 cm, and Diagnosis Dr. Zitsman is Resident Physician, and Dr. Glowacki is Assistant Professor, Accurate diagnosis and identification of RVF is crucial in Department of Obstetrics and Gynecology, Temple University Hospital, 3401 N. formulating a treatment strategy. A thorough history is Broad St, 7th Floor, Zone B, Philadelphia, PA 19140; E-mail: carol.glowacki@ tuhs.temple.edu. critical as patients, due to embarrassment or lack of knowl- The authors and all staff in a position to control the content of this CME activity, edge, may not volunteer this information to their providers. and their spouses/life partners (if any), have disclosed that they have no financial Review of the patient’s obstetric records describing the relationships with, or financial interests in, any commercial organizations per- delivery, type of laceration, and repair may be helpful. taining to this educational activity.

Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. This activity expires on January 29, 2018. 1

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Table 1. Classification of Rectovaginal Fistulas EDITORS Fistula Type Size/Location Etiology William Schlaff, MD Simple Diameter < 2.5 cm Local trauma, infection, obstetric origin, Professor and Chair, foreign body Department of Obstetrics Any location, above dentate line and Gynecology, Thomas Complex Diameter > 2.5 cm Nontraumatic cause, inflammatory bowel Jefferson Medical College, Any location, above dentate line disease, radiation, neoplasm Philadelphia, Pennsylvania Anovaginal* Below dentate line Lorraine Dugoff, MD Low Near vaginal opening and posterior fourchette Often obstetric origin Associate Professor and Chief, Mid-level Above posterior fourchette; distal to level of Division of Reproductive cervix Genetics, Department of Obstetrics and Gynecology, High Level of the posterior fornix University of Pennsylvania *Not a rectovaginal fistula. Perelman School of Medicine, Philadelphia, Pennsylvania Patients with RVF generally report passage folds posteriorly, can signify disruption of of gas, stool, or foul-smelling discharge the anal sphincter with or without a fistula. FOUNDING EDITORS from the vagina (Table 2). They may note Rectal examination may identify a disrupted Edward E. Wallach, MD staining of their undergarments. Often anal sphincter as the source of fecal inconti- Roger D. Kempers, MD symptoms worsen with loose bowel move- nence. Close inspection of the perineum and ments. Other symptoms include vaginal introitus may reveal a low RVF in the poste- bleeding and pain.1,5,11 rior vagina proximal to the introitus. These ASSOCIATE EDITORS Vaginal pessaries rarely cause RVFs. are the most common RVFs and are typical Meredith Alston, MD Most commonly, they are associated with of RVF with obstetric origin. The vagina Denver, Colorado neglected or forgotten pessaries; however, should be thoroughly evaluated from the RVF can occur with appropriate pessary introitus to the posterior fornix, with a lighted Samantha Buery-Joyner, MD care. Patients with foul-smelling discharge, speculum if possible. Any foreign body, such Falls Church, Virginia postmenopausal bleeding, or leakage of as a pessary, should be removed. RVF result- Nancy D. Gaba, MD stool warrant evaluation for RVF. Patients ing from pessary erosion may be low, mid, or Washington, DC with a history of inflammatory or infectious high depending on the type of pessary. If the processes, such as Crohn disease or chronic patient is unable to tolerate a thorough exam- Jennifer Goedken, MD infected Bartholin cyst gland abscesses, ination, it is prudent to schedule an examina- Atlanta, Georgia with concerning symptoms, also need a tion under anesthesia.1,4-6,13,15-18 10,12-16 Veronica Gomez-Lobo, MD complete evaluation. Occasionally, patients present with symp- Washington, DC A thorough physical examination is imper- toms and clinical history strongly suggestive ative. Most RVFs encountered by the of RVF, but no identifiable RVF on exami- Star Hampton, MD gynecologist will be low or simple fistulas. nation. There are several ways to identify an Providence, Rhode Island Obstetric fistulas generally present 7 to 10 occult RVF. A rectovaginal examination Enrique Hernandez, MD days postpartum. Inspection of the perineum may localize a buttonhole defect proximal Philadelphia, Pennsylvania may reveal gross defects. The “dovetail to the introitus. A small probe can be used to sign,” when the anal mucosa appears smooth identify the fistula tract from the vagina to Nancy Hueppchen, MD anterior to the anal opening but has perianal the rectum. Office procedures, such as the Baltimore, Maryland

Bradley S. Hurst, MD The continuing education activity in Topics in Obstetrics & Gynecology is intended for obstetricians, gynecologists, and other health Charlotte, North Carolina care professionals with an interest in the diagnosis and treatment of obstetric and gynecological conditions. Topics in Obstetrics & Gynecology (ISSN 2380-0216) is published 18 times per year by Lippincott Williams & Wilkins, Inc., 16522 Peter G. McGovern, MD Hunters Green Parkway, Hagerstown, MD 21740-2116. Customer Service: Phone (800) 638-3030, Fax (301) 223-2400, or New York, New York E-mail [email protected]. Visit our website at LWW.com. Publisher, Randi Davis. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Priority Postage paid at Owen Montgomery, MD Hagerstown, MD, and at additional mailing offices. POSTMASTER: Send address changes to Topics in Obstetrics & Gynecology, Subscription Dept., Lippincott Williams & Wilkins, Philadelphia, Pennsylvania P.O. Box 1600, 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116. PAID SUBSCRIBERS: Current issue and archives from 2004 on are now available FREE online at www.topicsinobgyn.com. Christopher M. Morosky, MD Subscription rates: Personal: US $501, international $700. Institutional: US $1157, international $1356. In-training: US resident $146 Farmington, Connecticut with no CME, international $169. GST Registration Number: 895524239. Send bulk pricing requests to Publisher. Single copies: $74. COPYING: Contents of Topics in Obstetrics & Gynecology are protected by copyright. Reproduction, photocopying, and storage or William D. Petok, PhD transmission by magnetic or electronic means are strictly prohibited. Violation of copyright will result in legal action, including civil and/or Baltimore, Maryland criminal penalties. Permission to reproduce copies must be secured in writing; at the newsletter website (www.topicsinobgyn.com), select the article, and click “Request Permission” under “Article Tools” or e-mail [email protected]. Reprints: For com- James M. Shwayder, MD, JD mercial reprints and all quantities of 500 or more, e-mail [email protected]. For quantities of 500 or under, e-mail [email protected], call 1-866-903-6951, or fax 1-410-528-4434. Jackson, Mississippi Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or Editorial Board. A mention of products or services does not constitute endorsement. All comments are for general guidance only; professional counsel should be sought for specific situations. 2

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Table 2. Identification and Management of Rectovaginal Fistulas low-residue diet to follow in addition to antidiarrheal medi- Identification cations. Antibiotics are given if signs of infection are pre- Foul-smelling sent. Often, these interventions are used in preparation for Vaginal pain or bleeding surgery; however, in women with obstetric-related simple Passing gas or stool from vagina RVF, some will heal spontaneously with conservative Management measures alone.6,7,19 All Causes Begin with low-residue diet and antidiarrheal medications Conservative measures also may be appropriate for Modified according to cause patients with Crohn disease or inflammatory bowel disease. Recent obstetric trauma Regimens as described earlier are initially employed. In Antibiotics addition, treating the inflammatory etiology of the RVF has Sitz baths proven useful. Corticosteroids may be used in addition to Wound debridement Inflammatory bowel disease antibiotics to treat inflammation. Some studies show Highly tailored treatment; consider one or more of the following improvement and even complete healing with specific Antibiotics medications such as methotrexate and IV cyclosporine. Corticosteroids Recent studies also show up to 46% of RVF closed with an Immunomodulators 18-week course of the medication infliximab. Patients who Foreign body (such as pessary in atrophic vagina) Removal of foreign body do not experience resolution of their RVF may be candi- 16,18,20 Vaginal estrogen cream dates for surgical interventions. Another group of patients who may benefit from con- servative measures are the rare patients with RVFs second- air bubble test or the methylene blue tampon test, can assist ary to neglected pessary. The first step in treatment is in identification of an occult RVF. An air bubble test is per- removal of the neglected pessary. This can usually be formed by either filling the vagina with water or covering the accomplished in the clinic, but may require anesthesia. posterior vaginal wall with a soap solution. A size 20 Foley Similar to women with simple RVF, these patients benefit urinary catheter is placed in the anal canal with the 5-mL from diet modification, antidiarrheal medications, and anti- balloon inflated. Air is introduced through the catheter while biotics when indicated. Vaginal estrogen has been shown to monitoring the posterior wall for leakage of bubbles through be beneficial for the healing of RVF and can be used in a fistula tract into the vagina. The methylene blue tampon preparation for surgery as well.14,21 test entails placing a tampon in the vagina and introducing a methylene blue enema into the rectum. Using the pattern of Surgical Management staining on the tampon, the fistula can be localized.1,4,5 Some fistulas, particularly nonobstetric fistulas, warrant Surgical intervention is required for the majority of RVF. further studies and imaging. A transanal ultrasound There are many techniques for repairing RVF. Technique choice is based on location, size, and complexity of the enhanced with hydrogen peroxide may be helpful in view- 5 ing complex fistulas. A CT scan with barium enema may RVF. reveal small fistulas. Vaginoscopy or colonoscopy may also Timing and Preparation. Optimization of the patient be useful. These studies can assist in clear identification and preoperatively is imperative. The conservative measures characterization of the RVF. These steps are crucial in for- described earlier are commonly used to optimize patients for mulating a treatment strategy for each RVF.1,16 surgical repair of RVF. In addition, active infections should be treated before surgical repair. A combination of wound Treatment debridement, sitz baths, and antibiotics are standard for treating infection at the RVF site. Some sources recommend Treatment strategies for RVF range from conservative to a preparation period of 3 to 6 months to allow for healing of more invasive surgical management. Treatment course is infected and inflamed tissue. In the presence of infection, often contingent upon RVF etiology, and the size and location. particularly in complex, higher RVF, a draining seton may be beneficial for decreasing inflammation and managing Conservative Management symptoms over several weeks before attempted repair.22 Most RVFs will require surgical intervention; however, However, RVF secondary to recent obstetric trauma can be small simple RVF may heal with conservative manage- successfully repaired 6 to 7 days after initial debridement. ment. Conservative measures can include bowel regulation, Alternatively, RVF associated with Crohn disease may diarrhea control, anti-inflammatory medications, antibiot- require a 3- to 6-month preoperative preparation period. ics, immunomodulators, and vaginal estrogens (Table 2). RVF may require a temporary stoma to assist with resolu- The etiology of the RVF will determine the appropriate tion of inflammation in preparation for repair of the RVF. conservative approach.5,19 Regardless of the chosen timing of surgery, several addi- Conservative management may be appropriate for obstet- tional steps are usually taken leading up to the surgery. ric-related simple RVF. Spontaneous healing rates vary Clearing the surgical field of fecal debris is optimal in from 7% to 50% with conservative management. In most preparation for surgery. Therefore, a bowel preparation is reports, conservative management is initiated for all patients recommended. This entails a clear diet 24 to 48 hours in preparation for surgery. Patients are given a restricted, before surgery and administering a bowel prep agent such 3

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as magnesium citrate or polyethylene glycol (eg, Golytely). Conclusion In addition, a fleet or tap water enema can be administered Although RVFs are not a common occurrence in the before surgery. Antibiotic prophylaxis should be adminis- United States, when they occur, they cause significant dis- tered 30 minutes before surgery.4,5,18,19,23,24 tress and impairment of quality of life for patients. Therefore, Several surgical techniques are used to treat Techniques. practitioners need to be able to identify both apparent and RVF. Specific treatment techniques are chosen based on the occult RVFs. A thorough history and physical are crucial location, size, and type of fistula. Different approaches for making the diagnosis. The fistula should be accurately include transanal, transvaginal, perineal, and abdominal. described and classified to determine the treatment strategy. Additional procedures include modified Martius flap and Often, the patient will need to be referred to a specialist for less commonly proctectomy. No single treatment is a cure- appropriate management. Most RVFs will require surgical all. Innovative methods continue to be under investigation, management and often will require more than one proce- such as the use of a punch biopsy to assist in treating RVF.25 dure for successful long-term repair.29 The key principles for successful repair of the simple RVF are excision of the entire fistula tract and adequate References mobilization of the tissue to allow for tension-free approxi- 1. Hoffman BL, Schorge JO, Bradshaw KD, et al. Anal incontinence and mation of all layers. Some surgeons performing am RVF functional anorectal disorders. In: Hoffman BL, Schorge JO, et al, eds. repair will convert the fistula into a fourth-degree laceration Williams Gynecology, 3rd ed. New York, NY: McGraw-Hill; 2016. http:// accessmedicine.mhmedical.com/content.aspx?bookid=1758&Section before excision of the fistula tract. This method is more id=118171560. commonly used when the anal sphincter is already compro- 2. Brown HW, Wang L, Bunker CH, et al. Lower reproductive tract fistula mised and offers less benefit for patients with an intact anal repairs in inpatient US women, 1979-2006. Int Urogynecol J. 2012;23(4):403- 3-5,17,19 410. doi:10.1007/s00192-011-1653-3. sphincter. 3. Baig MK, Zhao RH, CYuen CH, et al. Simple rectovaginal fistulas. Int J Gynecologists often choose a transvaginal approach to Colorectal Dis. 2000;15(5-6):323-327. doi:10.1007/s003840000253. treat an RVF. Benefits of the transvaginal approach include 4. Aronson MP, Raymond AL. Anal incontinence and rectovaginal fistulas. In: Te Linde RW, Rock JA, Jones HW, eds. TeLinde’s Operative Gynecology. good visualization and ease of repair for RVF located in the 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003. lower portion of the rectal canal. However, there are con- 5. Rogers RG, Fenner DE. Rectovaginal fistulas. In: Sultan AH, Thakar R, cerns regarding the long-term integrity of repairs that are Fenner DE, eds. Perineal and Anal Sphincter Trauma [Electronic Resource]: Diagnosis and Clinical Management. London, England: Springer; 2007. not performed from the high-pressure rectal side. In addi- 6. Venkatesh KS, Ramanujam PS, Larson DM, et al. Anorectal complications tion, RVFs located near the apex/upper vagina are not eas- of vaginal delivery. Dis Colon Rectum. 1989;32:1039-1041. ily accessed through the vagina; instead, they are better 7. Homsi R, Daikoku N, Littlejohn J, et al. Episiotomy: risks of dehiscence and 3,18 rectovaginal fistula. Obstet Gynecol Surv. 1994;49(12):803-808. managed transabdominally. 8. Arias BE, Ridgeway B, Barber MD. Complications of neglected vaginal RVF at the distal end of the vagina may also be repaired pessaries: case presentation and literature review. Int Urogynecol J Pelvic by colorectal surgeons who prefer the transrectal approach. Floor Dysfunct. 2008;19(8):1173-1178. doi:10.1007/s00192-008-0574-2. 9. Margulies RU, Lewicky-Gaupp C, Fenner DE, et al. Complications requir- Transrectal repair methods thus start from the high-pressure ing reoperation following vaginal mesh kit procedures for prolapse. Am J side and often use a rectal mucosal flap to cover the excised Obstet Gynecol. 2008;199:678.e1. fistula tract.4,5,17,20 10. Nasser HA, Mendes VM, Zein F, et al. Complicated rectovaginal fistula secondary to Bartholin’s cyst infection. J Obstet Gynaecol Res. A transperineal approach may also be employed. Often 2014;40(4):1141-1144. doi:10.1111/jog.12294. used when a patient has failed a prior transvaginal or tran- 11. Shieh CJ, Gennaro AR. Rectovaginal fistula: a review of 11 years experi- srectal approach, this approach involves separating the ence. Int Surg. 1984;69(1):69-72. 12. Torbey MJ. Large rectovaginal fistula due to a cube pessary despite routine vaginal tissue from the rectal tissue and excising the fistu- follow-up; but what is “routine”? J Obstet Gynaecol Res. 2014;40(11):2162- lous tract. Each side is closed separately in opposing direc- 2165. doi:10.1111/jog.12476. tions to prevent reanastomosis. A more specialized trans- 13. Yong PJ, Garrey MM, Geoffrion R. Transvaginal repair and graft interposi- tion for rectovaginal fistula due to a neglected pessary: case report and perineal approach involves a modified Martius flap. After review of the literature. Female Pelvic Med Reconstr Surg. 2011;17(4):195- dissecting the posterior vaginal wall from the rectal mucosa, 197. doi:10.1097/SPV.0b013e3182282c4e. the rectal mucosa and, if indicated, anal sphincter are 14. Tarr M, Culbertson S, Lengyel E. Transverse transperineal repair of a pessary-induced mid-rectovaginal fistula. J Pelvic Med Surg. 2008;14(3): repaired. A Martius flap is developed by dissecting a seg- 199-201. doi:10.1097/SPV.0b013e318176b2e2. ment of adipose tissue from the labia majora, taking care to 15. Hanavadi S, Durham-Hall A, Oke T, et al. Forgotten vaginal pessary erod- preserve the vasculature of the internal pudendal artery. ing into rectum. Ann R Coll Surg Engl. 2004;86(6):W18-W19. 16. Hannaway CD, Hull TL. Current considerations in the management of rec- This flap is used to create a layer between the vaginal tissue tovaginal fistula from Crohn’s disease. Colorect Dis. 2008;10(8):747-755. and rectal tissue, while providing neovascularization to aid doi:10.1111/j.1463-1318.2008.01552.x. in healing. A concurrent diverting colostomy may be indi- 17. Delancey JO, Berger MB. Surgical approaches to postobstetrical perineal body defects (rectovaginal fistula and chronic third and fourth-degree lac- cated to reduce postoperative infection while allowing erations). Clin Obstet Gynecol. 2010;53(1):134-144. doi:10.1097/ wound healing.5,18,26 GRF.0b013e3181cf7488. The use of bioprosthetic fistula plugs and fibrin glue has 18. Champagne BJ, McGee MF. Rectovaginal fistula. Surg Clin North Am. 22,27,28 2010;90(1):69-82. doi:10.1016/j.suc.2009.09.003. also been reported for repair of RVF. Although they 19. Rahman MS, Al-Suleman SA, El-Yahia AR, et al. Surgical treatment of are less invasive, better tolerated options, they have had rectovaginal fistula of obstetric origin: a review of 15 years’ experience in a limited success. Fistula plugs often require repeat proce- teaching hospital. J Obstet Gynaecol. 2003;23(6):607-610. 20. Valente M, Hull T. Contemporary surgical management of rectovaginal dures. These are best reserved for patients with very small fistula in Crohn’s disease. World J Gastrointestin Pathophysiol. fistulas. Fibrin glue has found even more limited success.25 2014;5(4):487-495. doi:10.4291/wjgp.v5.i4.487.

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21. Cichowski S, Rogers RG. Nonsurgical management of a rectovaginal fis- 26. Reichert M, Schwandner T, Hecker A, et al. Surgical approach for repair of tula caused by a Gellhorn pessary. Obstet Gynecol. 2013;122(2):446-449. rectovaginal fistula by modified Martius flap. Geburtshilfe Frauenheilkde. doi:10.1097/AOG.0b013e31828aec98. 2014;74(10):923-927. doi:10.1055/s-0034-1383149. 22. Das B, Snyder M. Rectovaginal fistulae. Clin Colon Rectal Surg. 27. Ellis CN. Outcomes after repair of rectovaginal fistulas using bioprosthetics. 2016;29(1):050-056. doi:10.1055/s-0035-1570393. Dis Colon Rectum. 2008;51(7):1084-1088. doi:10.1007/s10350-008-9339-8. 23. Waaldijk K. The immediate management of fresh obstetric fistulas. Am J 28. Gonsalves S, Sagar P, Lengyel J, Morrison C, Dunham R. Assessment of the Obstet Gynecol. 2004;191(3):795-799. doi:10.1016/j.ajog.2004.02.020. efficacy of the rectovaginal button fistula plug for the treatment of ileal 24. Hankins GD, Hauth JC, Gilstrap LC 3rd, et al. Early repair of episiotomy pouch-vaginal and rectovaginal fistulas. Dis Colon Rectum. 2009; dehiscence. Obstet Gynecol. 1990;75(1):48-51. 52(11):1877-1881. doi:10.1007/DCR.0b013e3181b55560. 25. Adelowo A, Ellerkmann R, Rosenblatt P. Rectovaginal fistula repair using a 29. Pinto RA, Peterson TV, Shawki S, et al. Are there predictors of outcome disposable biopsy punch. Female Pelvic Med Reconstr Surg. 2014;20(1): following rectovaginal fistula repair? Dis Colon Rectum. 2010;53(9):1240- 52-55. doi:10.1097/SPV.0b013e3182a33194. 1247. doi:10.1007/DCR.0b013e3181e536cb.

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CME Quiz: Volume 37, Number 2 To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. Select the best answer and use a blue or black pen to completely fill in the corresponding box on the enclosed answer form. Please indicate any name and address changes directly on the answer form. If your name and address do not appear on the answer form, please print that information in the blank space at the top left of the page. Make a photocopy of the completed answer form for your own files and mail the original answer form in the enclosed postage-paid business reply envelope. Your answer form must be received by Lippincott CME Institute by January 29, 2018. Only two entries will be considered for credit. All CME participants will receive individual issue certificates for their CME participation monthly. Participants will receive CME certificates quarterly in April, July, October, and the fourth quarter in January of the following year. For more information, call (800) 638-3030. Online quiz instructions: To take the quiz online, log on to your account at www.topicsinobgyn.com, and click on the “CME” tab at the top of the page. Then click on “Access the CME activity for this newsletter,” which will take you to the log-in page for http://cme.lww. com. Enter your username and password. Follow the instructions on the site. You may print your official certificate immediately. Please note: Lippincott CME Institute, Inc., will not mail certificates to online participants. Online quizzes expire on the due date.

1. Patient A is a 29-year-old G1P1. She presents 18 days 6. Patient C is a 35-year-old nulliparous woman with a history of after vacuum-assisted vaginal delivery reporting foul- Crohn disease. She presents with new-onset, foul-smelling smelling lochia of 7 days’ duration. The patient denies vaginal discharge. Which of the following examinations fevers, chills, or abdominal pain. Which one of the following should be performed in this patient? is the first step in her care? A. Thorough pelvic examination with lighted speculum A. Obtain a urinalysis. B. Rectovaginal examination B. Reassure the patient. This is normal postpartum. C. Methylene blue tampon test or air bubble test C. Prescribe 1-week course of metronidazole. D. All of the above D. Perform a focused history—assess for vaginal pain 7. Examination of patient C confirms RVF. Which one of the and unintentional passage of flatus or stool. following types of fistula is most likely; and what additional 2. Review of the delivery record of patient A reveals a vacuum- testing might be helpful in her evaluation? assisted delivery complicated by a second-degree perineal A. Simple fistula; upright abdominal x-ray laceration. Examination confirms RVF. Which one of the B. Simple fistula; CT scan with barium enema and/or following types of fistula is most likely? transanal ultrasound enhanced with hydrogen peroxide A. Buttonhole fistula C. Complex fistula; upright abdominal x-ray B. Complex fistula D. Complex fistula; CT scan with barium enema and/or C. Simple fistula transanal ultrasound enhanced with hydrogen peroxide D. High fistula 8. For which one of the patients described previously is the 3. Initial management of patient A should include which one following management strategy appropriate? Initiate conserv- of the following? ative measures, such as low-residue diet, antidiarrheal medica- A. Schedule emergent surgical repair. tion, and anti-inflammatory medications. Optimization for B. Initiate low-residue diet, antidiarrheal medications, anti- surgery may include immunomodulator medications. Refer biotics, and sitz baths in preparation for surgical repair. to a colorectal surgeon for delayed (3–6 months) surgery C. Initiate low-residue diet, antibiotics, immunomodulators, via a transrectal or transabdominal approach. This patient and corticosteroids in preparation for surgical repair. may require a diverting colostomy. D. Initiate low-residue diet, antidiarrheal medications, A. Patient A vaginal estrogen cream, and sitz baths in preparation B. Patient B for surgical repair. C. Patient C 4. Patient B is a 77-year-old G4P4. She presents with foul- 9. For which one of the patients previously described is the smelling vaginal discharge. She was last seen 2 years following management strategy appropriate? Initiate conserv- previously. At that time, a Gellhorn pessary was placed for ative treatment with low-residue diet, antidiarrheal medica- stage III . Which one of the following tions, antibiotics, and sitz baths. Consider urgent debride- examination findings would be most consistent with a ment to remove necrotic tissue, with transvaginal repair in fistula related to her pessary? 6 to 7 days. A. Positive dovetail sign A. Patient A B. Intact anal sphincter on rectal examination B. Patient B C. Atrophic vagina C. Patient C D. Positive methylene blue tampon test 10. For which one of the patients previously described is the 5. Initial management of patient B should include which one following management strategy appropriate? Begin conserv- of the following? ative treatment with a low-residue diet, antidiarrheal medica- A. Schedule emergent surgical repair. tions, and vaginal estrogen cream. Perform surgical repair B. Initiate low-residue diet, antidiarrheal medications, via a transvaginal or transrectal approach. A transperineal antibiotics, and sitz baths in preparation for surgical approach may be necessary if other approaches fail. repair. A. Patient A C. Initiate low-residue diet, antibiotics, immunomodulators, B. Patient B and corticosteroids in preparation for surgical repair. C. Patient C D. Initiate low-residue diet, antidiarrheal medications, and vaginal estrogen cream in preparation for surgical repair. 6

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