An 82-year-old woman was admitted with feculent vaginal discharge and bleeding per vagina. Investigations revealed the presence of a rectovaginal fistula with no obvious etiology. Due to the surgical team’s previous experience with nicorandil-induced ulceration, the drug was stopped. The rectovaginal fistula healed completely within 6 months.
Nicorandil is widely used in the treatment of angina since the publication of the IONA trial (Impact of Nicorandil On Angina) in 2002. Nicorandil-induced mucosal ulceration is well documented. Awareness of its potential to cause serious surgical morbidity remains limited. There have been several reports of nicorandil-induced fistulae, including perianal, colovesical, and diverticular fistulae. We report a case of nicorandil-induced rectovaginal fistula that healed on cessation of the drug.
Case report
An 82-year-old woman presented with feculent discharge and bright-red bleeding per vagina. She had a several-month history of mild alteration in bowel habit toward looser motions and also lower abdominal discomfort. Her medical history included angina, atrial fibrillation, and hypertension. She received nicorandil, warfarin, bisoprolol, diltiazem, and isosorbide mononitrate.
Abdominal examination findings were unremarkable, and digital rectal examination did not reveal any fecal impaction or mass. On vaginal examination, she had right adnexal tenderness, and fecal matter was noted within the vagina. No gynecologic cause for bleeding was found. Plain abdominal radiograph was unremarkable. A computed tomogram of abdomen and pelvis was performed that showed a small volume of free fluid within the pelvis. Oral contrast was seen within the vagina, as well as the rectum, suggesting a communication between the 2. No obvious etiology was identified.
The patient proceeded to flexible sigmoidoscopy, which showed an abnormal appearance at approximately 14 cm, with a solitary ulcer consistent with a rectovaginal fistula ( Figure ). There was no evidence of mass lesion, inflammatory bowel disease, or diverticular disease.
Initially this presented us with a management dilemma, given that there was no obvious etiology. However, we noted that the patient was taking nicorandil, and, having previous experience with nicorandil-induced anal ulceration, we suspected that it might be the cause of her rectovaginal fistula in the absence of other pathology. The medication was stopped in consultation with a cardiologist and her cardiac medications were adjusted accordingly. The patient was treated conservatively. Four months after discharge the patient was reviewed and noted marked improvement in her symptoms, with cessation of fecal discharge per vaginum. She was reviewed after a further 2 months, when her symptoms had completely resolved. A follow-up flexible sigmoidoscopy was performed that showed normal mucosa and no evidence of the previous rectal ulceration.
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