Vaginal peritoneum fistula through pouch of Douglas during peritoneal dialysis: Case report and literature review

Abstract

Introduction

Peritoneal dialysis is the preferred approach for kidney replacement therapy. A peritoneal-vaginal fistula is a rare complication associated with peritoneal dialysis.

Case presentation

A 69-year-old woman with a history of type two diabetes and systemic arterial hypertension for twenty years is scheduled to undergo the surgical placement of a Tenckoff catheter to begin renal replacement therapy. After having thirty dialysis sessions, she was discharged to continue therapy at home. Five days later, she observed a notable rise in vaginal discharge after peritoneal dialysis. This case report investigates the etiology, diagnosis, and management of peritoneal vaginal fistula and analyzes current medical literature.

Discussion

Factors associated with the formation of peritoneum-vaginal fistula include increased intra-abdominal pressure due to dialysis, anatomical predisposition, peritonitis, and malnutrition.

Conclusions

Peritoneal vaginal fistula is an uncommon consequence of peritoneal dialysis. Diagnosis entails demonstrating the movement of dialysis fluid from the peritoneum to the vagina. Treatment should be customized according to the etiology of the fistula and the individual needs of each patient.

Highlights

• •Peritoneum-vaginal fistula is a rare side effect of peritoneal dialysis.
• •Peritoneum-vaginal fistula through the Douglas pouch is uncommon.
• •Diagnosis can involve many methods, like methylene blue or CT peritoneography.

1. Introduction

Peritoneal dialysis (PD) is the favored method of kidney replacement therapy due to its cost-effectiveness, accessibility, and convenience [1]. The cumulative incidence of patients transitioning from peritoneal dialysis to in-center hemodialysis is around 25 % after two years. Peritonitis, inadequate dialysis, mechanical problems, and social determinants of health are the main contributors to this change [2].

Douglas' pouch is a cavity between the back of the uterus and the front of the rectum, defined by folds (rectouterine and peritoneal). It consists wholly of Mullerian-origin mesothelial cells, similar to other female pelvic organs. Fluids collect in this area because of its lower position [3]. Peritoneal-vaginal fistula (PVF) through Pouch of Douglas is rare, with few documented occasions. We explain the detection and treatment of PVF through Pouch of Douglas as an early consequence of PD, following SCARE and PROCESS guidelines [4]. The current literature is reviewed and analyzed.

2. Case presentation

2.1. Patient information

A 69-year-old Mexican woman, a married housewife, resides in a rural area with access to all amenities; her education level reached incomplete primary school. The woman could improve the quality and amount of her diet by often consuming coffee or cola. She suffered from diabetes mellitus type 2 and systemic arterial hypertension for over twenty years, resulting in diabetic retinopathy and chronic kidney damage. Three years ago, she encountered an abnormal vaginal hemorrhage that had to be treated via vaginal hysterectomy (VH). Renal replacement therapy is being conducted via peritoneal dialysis, with a Tenckoff catheter inserted two months ago. The procedure was carried out under regional anesthesia through a midline incision below the navel area. She spent six days in the hospital to undergo thirty dialysis exchanges and initiate the continuous cycle peritoneal dialysis program (CCPD) at her residence.

2.2. Clinical findings and diagnostic assessment

However, five days later, she was readmitted for urinary incontinence and vaginal discharge. During her hospital stay, the vaginal leakage worsened while she was undergoing peritoneal dialysis. The dialysis had proper inflow but faced outflow obstruction.

Physical examination revealed a weight of 45 kg, a height of 1.5 m, body mass index of 20 kg/m², the presence of a Tenckoff catheter in the abdominal area, and an intact wound with no evidence of leakage. Injection of methylene blue during peritoneal dialysis caused the release of blue fluids during walking (Fig. 1). Laboratory testing revealed leukocytosis, elevated C-reactive protein, and reduced albumin levels. A CT peritoneography was conducted by instilling 50 ml of water-soluble contrast material containing 300 mg of lopamiro, diluted in 2000 ml of isotonic solution, into the peritoneal cavity. After 30 min of walking, an abdominal CT scan was conducted (Fig. 2). Sagittal slices demonstrate the catheter tip positioned close to the vaginal dome without perforating it. Contrast medium leakage into the vaginal canal through the cul-de-sac of Douglas is depicted.

Fig. 1.

illustrates the administration of methylene blue in a dialysis bag while standing, following the spontaneous emission of blue liquid through the vagina. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2.

depicts a sagittal segment of CT-peritoneography with hydrosoluble contrast material in dialysis, confirming the position of the Tenckoff catheter tip (A). Saggital slice displaying the flow of contrast material from the peritoneum to the vagina through the Douglas Pouch (arrow) (B).

2.3. Therapeutic intervention, follow-up, and outcomes

The catheter was removed while neuraxial blockade was applied, following confirmation of the peritoneum-vaginal fistula diagnosis. The procedure revealed a normal peritonea cavity with no abnormalities in the cul-de-sac of Douglas, such as lesions, tumors, or defects. The nephrology department and the patient agreed to proceed with renal replacement therapy by hemodialysis, along with nutritional monitoring. At the follow-up consultations two months later, the patient no longer had peritoneal vaginal discharge and regained 1.5 kg.

3. Discussion

PVF is an uncommon complication that may develop during peritoneal dialysis. This case is notable due to the absence of catheter tip penetration or perforation in the pelvic floor without peritonitis, along with other probable contributing factors to the development of PVF. The following arguments provide further details on this subject.

• •In individuals with a low body mass index, the tip of the Tenckoff catheter in the pelvic cavity can exert higher pressure on the pelvic floor [5].
• •When dialysate is in the peritoneal cavity, it raises the pressure inside the abdomen. When the person is lying on their back, a two-liter intraperitoneal volume has been shown to produce pressure levels between 13.2 and 18.7 cm H20. An increase of 500 ml in volume correlates with a proportional rise in pressure. Increased pressure within the abdomen and structural abnormalities in the peritoneal cavity can result in hernias, genital edema or vaginal leaks, and hydrothorax [2].
• •It is possible for malnutrition to speed up the breakdown process, cause more protein to be lost through peritoneal effluent, and waken visceral tissue, making it more likely to be damaged by transvisceral erosion and PVF formation [5].
• •The morphology and anatomical position of the Douglas pouch facilitate the accumulation of peritoneal fluids. Furthermore, it possesses passive diffusion qualities that permit substances to diffuse from free peritoneal fluids into the bloodstream [3,6]. It is for this reason that the area is prone to the formation of PVF.

Table 1 presents a summary of the most noteworthy elements from previous cases pertaining to peritoneal dialysis and PVF, which are intended for analysis. The condition is diagnosed at an average age of 30.5 ± 16.8, although cases have been reported ranging from 13 to 69 years. Renal failure can be caused by a variety of factors, such as hydronephrosis [7,8], pyelonephritis [5], Alport's syndrome [9], anti-glomerular basement membrane [10], hypertension [11,12], type 2 diabetes [11], polycystic kidney disease [1], and lupus nephritis [13]. The interval between CCPD and the onset of PVF ranged from one month to 5 years. The feature of our case, in comparison to prior occurrences, is the remarkably brief time span between CCPD and the onset of PVF, which was only five days. The lack of uterus owing to prior hysterectomy and the other indicated causes may have accelerated the development of PVF.

Table 1.

Previous case reports illustrating PVF during PD.

Author45 and year	Age	Cause of Uremia	Time in CCPD	Predisposing Factors	Clinical Presentation	Diagnosis	PVF Location	Treatment
Coward, R.A, 1982 [7]	17	Urinary trac infection, ureteric reflux and hydronephrosis	12 months	Peritonitis	Vaginal discharge	Injection of methylene blue into peritoneal cavity and its subsequent appearance at the cervix.	Leakage of dialysis fluid through the left Fallopian tube and uterus into the vagina	Laparotomy: Tube ligation and Hemodialysis
Díaz-Buxo JA, 1983 [5]	23	Bilateral vesicoureteral reflux and pyelonephritis	17 months	Bacterial peritonitis, malnutrition	Urinary incontinence, vaginal discharge which increased during peritoneal inflow	Serial roentgenograms	Tip of the catheter eroding pelvic floor through Pouch od Douglas	1.PC was removed, Hemodialysis and nutritional management. 2.Returned to CCPD.
Wright CA, 1984 [15]	34	NR	6 weeks	Fungal peritonitis (C. Albincans), abnormal tobouterine anatomy	Ooss of dialysate fluid per vaginal	Instillation of methylene blue into peritoneal cavity and its subsequent appearance at the cervix	Abnormal tubouterin anatomy?	1.Intraperitoneal amphotericin. 2.Dialysis catheter removed.
Caporale N, 1991 [9]	32	Alport's Syndrome	7 months	Peritonitis, increased intra-abdominal pressure and forced the dialysis through the Fallopian tubes	Outflow obstruction, abdominal distension, abdominal wall, and genital edema; vaginal discharge	NR	Fallopian Tubes	Tubal ligation and CCPD without any complication
Ogun, C, 1995 [8]	56	Hydronephrosis and bilateral nephrolithiasis	3 months	Infection around the catheter exit site (Staphylococcus epidermidis), peritonitis	Nausea, abdominal pain, peritoneal fluid drainage per vagina	Radiographic contrast medium	Douglas Pouch and posterior vaginal fornix	1.The catheter was removed, and the fistulous tract was debrided and repaired. 2.Hemodialysis
Bradley A J, 1997 [10]	20	Anti-glomerular basement membrane disease	8 months	Tip of the Tenckoff was found to be deep in the pouch of Douglas.	Intermittent vaginal leakage of clear fluid (tested positive for glucose)	CT peritoneography	Left vaginal fornix	1.Laparotomy: Omental pedicle patch into the pouch of Douglas, Tenckoff was placed anterior to the uterus. 2.Hemodialysis for 8 weeks 3.Returned CCPD without any leakage.
Hummeida M, 2010 [14]	46	Unknown etiology	6 weeks	Recurrent catheter tip captured by the fimbriae	Out-flow obstruction, urinary incontinence after dialysate instillation, vaginal leak,	Fluoroscopy catheterogram, MRI	Fallopian Tube	1.Laparoscopy: tubal occlusion After recurrence: 2.Laparotomy and tubal occlusion 3.Hemodialysis 4.Kidney transplant
Harrison R.F, 2015 [11]	43	Hypertension and type 2 diabetes mellitus	1 month	Intraabdominal fixation of the catheter tip to the post-hysterectomy vaginal cuff	Hypertensive urgency, pulmonary edema, abdominal pain and watery vaginal discharge	CT scan and Fluoroscopy	Vaginal cuff	1.Laparoscopic: adhesiolysis, removal of the catheter, vaginal endopelvic fascia closed in 2 layers. 2.Hemodialysis
Bakan, 2016 [12]	24	Hypertension during pregnancy	3 months	Peritonitis, Sepsis	Fever, abdominal pain, vaginal discharge	CT peritoneography	Douglas Pouch	1.CCPD was removed. 2.Hemodialysis.
Mada, 2023 [1]	15	Bilateral polycystic kidney disease	5 years	Repeated peritonitis	Abdominal pain, urinary incontinence, decrease of ultrafiltration volume, lung edema	MRI using dialysate infused into the peritoneal cavity	Fornix defect	Hemodialysis and dialysis catheter removed.
Duarsa GWK, 2023 [13]	13	Lupus nephritis	3 months	Recurrent peritonitis	Fluid leak through the vaginal when flushing the PD catheter	Abdominal ultrasound, laparoscopic diagnostic	NR	Remove the PD catheter and hemodialysis
Present case	69	Hypertension and type 2 diabetes mellitus	5 days	Malnutrition, increased intra-abdominal pressure,	Urinary incontinence, out-flow obstruction, and vaginal discharge that increased during peritoneal dialysis	Installation of methylene blue into the peritoneal cavity and its subsequent appearance at vaginal leakage; CT peritoneography	Douglas Pouch	Remove the PD catheter and hemodialysis

CCPD: Continuous cycle peritoneal dialysis; MRI: Magnetic Resonance Imaging; CT: Computer Tomography; PD: Peritoneal Dialysis; VH: Vaginal Hysterectomy.

All patients exhibited an escalation in vaginal discharge during peritoneal dialysis, along with several clinical symptoms including urinary incontinence [1,5,14], out-flow blockage [9,14], genital edema [9], fever [12], and other conditions such as hypertensive urgency [11] and pulmonary edema [1]. Dialysis fluid seeping into the vagina through the fistula connecting the bladder and rectum is what causes the symptoms of urinary incontinence, which are not real [13].

In previous cases, PVF has been linked to bacterial or fungal peritonitis [1,5,[7], [8], [9],12,13,15], increased intra-abdominal pressure from dialysis [9], erosion of the catheter tip in the pelvic floor [10,11], catheter tip channeling the fimbria or fallopian tube [14], and malnutrition [5]. Malnutrition and intra-abdominal hypertension brought on by dialysis were predisposing factors in the present case.

Variable anatomical localization of the PVF included peritonitis-induced damage to the Douglas Pouch and vaginal fornix [1,5,8,12], as well as catheter tip erosion in the vaginal fornix and vaginal stump (post-hysterectomy) [10,11]. Neither peritonitis nor erosion of the catheter tip affected the development of PVF in our specific case, which was situated in the Douglas cul-de-sac.

Evidence of dialysis fluid passing from the peritoneum to the vagina constitutes the diagnostic criteria for PVF. The subsequent investigations have been employed in this regard: CT-Peritoneography involves introducing and intraperitoneal contrast medium into the patient's cavity along with the dialysis solution [10,12]. Magnetic resonance imaging (MRI) utilizing dialysis fluid within the peritoneal cavity [1]; fluoroscopy catheterogram [14]; and injecting methylene blue into the peritoneal cavity and observing its presence at the cervix or vaginal leaks [7,15]. We diagnosed PVF clearly by using methylene blue injection and CT-Peritoneography.

Treatment for PVF is determined by the underlying etiology of the fistula. Options may include temporary or permanent replacement of renal function with hemodialysis, or a kidney transplant [[11], [12], [13], [14]]. In a few cases, bilateral tubal occlusion was required along with the removal of the catheter [7,9,14]. In situations where the catheter tip erodes into the vagina, fascia repair or pedunculated omentum path is required [10,11]. If needed, nutritional management might be used as supplementary treatment [5]. In our case, the most suitable treatment based on the clinical circumstances was catheter removal, hemodialysis, and nutritional monitoring.

4. Conclusion

PVF is an uncommon consequence of peritoneal dialysis in a susceptible patient. Diagnosis involves confirming the flow of dialysis fluid from the peritoneum to the vagina. Treatment should be tailored based on the fistula's cause and the specific requirements of each patient.

List of abbreviations

PVF

Peritoneal-vaginal fistula

VH

Vaginal Hysterectomy

CCPD

Continuous Cycle Peritoneal dialysis program

CT

Computed Tomography

MRI

Magnetic Resonance imaging

Ethical approval

Not applicable.

Funding

Awarded by the National Council for Science and Technology and the National Research System through Aguilar-Espinosa Francisco.

CRediT authorship contribution statement

All authors were involved in either data collection, drafting, revising, or finalizing the report.

Guarantor

Francisco Aguilar-Espinosa.

Declaration of competing interest

The authors declare no conflict of interest.

Data availability

The data supporting this study's findings are available from the corresponding author upon reasonable request.