Rectovaginal fistulas as a result of a neglected and non-neglected pessary: a case series

Objectives: Describe cases of rectovaginal fistula formation from pessary use for symptomatic pelvic organ prolapse. Discuss minor and major complications of long-term pessary use.

Methods: This study is a retrospective chart review at a single high-volume metropolitan urogynecology clinic from January 2019 - July 2022. Patients with rectovaginal fistulas from pessary use were identified and their clinical courses reviewed.

Results: Case one details a two centimeter rectovaginal fistula from a non-neglected Gelhorn pessary over a one month time frame in a patient who had used the device for three years with routine office follow-up. The patient had multiple medical comorbidities, including breast cancer. She did not receive intervention and underwent expectant management for the fistula after pessary removal due to her chronic medical and oncologic issues. Case two details a Gelhorn pessary neglected for five years that formed a five centimeter rectovaginal fistula in a patient who regularly used tobacco products but was otherwise healthy. This resulted in three surgeries over the course of six months. The first surgery was for pessary removal and ileostomy creation, the second for fistula repair and colpocleisis, and the third for ileostomy takedown.

Conclusions: Pessaries are an excellent non-surgical option for pelvic organ prolapse and urinary incontinence, but can cause potentially morbid outcomes such as rectovaginal fistulas. Additional studies are required to further characterize and identify patients at higher risk of developing these morbid complications to help guide physician discussions and patient awareness.