Peritoneal vaginal fistula and contrast extravasation during MRI

Abstract

Gynecological malignancies including primary cervical cancers are frequently treated with chemotherapy and radiation. Fistulas affecting the gynecological organs and surrounding cavities are a known consequence of radiotherapy due to focal necrosis of the regional mucosa. In this report, we will demonstrate a rare case of a posterior vaginal wall rupture with resulting fistulization into the peritoneal cavity in a 50-year-old female patient with squamous cell carcinoma of the cervix status postchemoradiotherapy. Magnetic resonance imaging (MRI) showed a discontinuity in the posterior vaginal wall near the fornix with extravasation of ultrasound gel used as contrast into the intraperitoneal compartment. Patient later presented with peritonitis like signs and symptoms and was treated successfully with antibiotics. Vaginal gel should be used with caution in patients with prior history of radiation due to the possibility of vaginal rupture which may lead to peritoneal vaginal fistula and contrast extravasation.

Keywords: Fistula; MRI; Peritoneum; Ultrasound gel; Vagina.

Fig. 1

Sagittal T2-weighted image from pretreatment MRI (A) showing the large locally advanced cervical tumor with extension into the posterior fornix and invasion through the posterior wall of the vagina (arrow). Follow-up MRI after chemoradiation (3 months later) shows complete response with no residual tumor in the cervix and intact posterior wall of the vagina (arrow in B). Most recent MRI (about 17 months after the second/post-treatment MRI showing no tumor recurrence, a discontinuity in the posterior wall of the vagina (white arrow in C) and extravasation of gel (high T2 signal) into the intraperitoneal compartment (dashed white arrow in C). A 7-day follow-up image (D) shows reabsorption of the gel and unchanged discontinuity of the posterior vaginal wall (white arrow in D).