Last week in Triage, I signed up for a patient whose chief complaint was listed as “vaginal discharge”. As I walk to her room, I think of the common stuff: yeast infections, bacterial vaginosis, spotting. When I pulled back the curtain, I found myself faced with a lovely and adorable elderly woman who was radiating worry. “What brings you in today, Ms. B?” I ask. Long story short, over the past couple days, she’s had more than your run of the mill vaginal discharge. My elderly friend had (*STOP* reading here if you are grossed out easily…) stool-like material coming from her vagina. You read it right; my sweet little patient had poopy vajayjay. Let me tell you – this was not my most pleasant pelvic exam…
Anyway, I’m sure you’re wondering “How on earth does that happen?” It’s called a fistula. A track from the vagina is formed to the rectum or colon where stool is passing by. And again, you ask “How on earth does that happen?” Well, anytime you have an area of long-standing inflammation between these two areas, a connection can form. This inflammation can come from diverticulosis (bulging pockets in the colon that form with constipation), surgery, infection, radiation injury or cancer.
Upon delving further into her medical records, I find that she has a distant history of endometrial cancer. She had her uterus taken out 15 years ago for this reason. After her surgery, she was told the cancer had been entirely removed. No need for chemo or radiation. Upon hearing this, my team was convinced. “It’s her cancer. She’s had a recurrence. And now she has a fistula because of it.” I protested. Maybe it was because she was so cute and I wanted her to have anything BUT cancer. Maybe it was because I tired of delivering bad news. But I was stubborn. “I don’t think she has cancer. She is old and constipated and I think she just has diverticulosis.” Being an intern and the lowest on the totem pole, my theory was not taken seriously. I’m a newbie, that’s fine. I get it.
Ms. B was admitted to the hospital that night. She was admitted to the GYN Oncology service and a CT scan was ordered to look for suspicious masses.
The next day I stroll into work per my usual routine. Ms. B had been on my mind. I logged into the computer system and pull up her file. The CT results were in. I open up the final reports and scroll down to look at the impression. Final diagnosis? Rectovaginal fistula secondary to DIVERTICULOSIS! “Yes!” I shout, as I fist pump the air. I literally do a victory dance in the middle of triage.
There are not many times when you are right as an intern. So when that rare occasion comes, you’ve gotta own it. And I owned it that day. Oh yes I did.