Refractory diversion neovaginitis in a sigmoid-colon-derived neovagina: clinical and histopathological considerations

Abstract

Colonic segments are being used as pedicled grafts in neovaginoplasty, a surgical procedure to (re)construct a (neo)vagina. A disadvantage of using colonic grafts is the potential occurrence of neovaginal complications due to diversion from the faecal stream. Here, we report a case of severe, refractory diversion colitis of the sigmoid neovagina, so-called 'diversion neovaginitis', in a 42-year-old woman with complete androgen insensitivity syndrome. Neovaginal biopsy specimens showed colonic-type mucosa with strong increase of lymphoplasmacellular infiltrate in the lamina propria, ulceration with fibrinoid deposition and some crypt irregularity. Endoscopy showed erythematous mucosa, superficial ulceration, mucus discharge and multiple pseudopolyp-like lesions. Local application of mesalazine foam enemas and sodium butyrate enemas initially gave symptom relief. However, this was a temporary effect, ultimately necessitating removal of the neovaginal construct. It is important that all patients are informed about neovaginal bowel complications, for example, diversion neovaginitis. Regular medical and endoscopic follow-up appears recommendable.

Keywords: ABDOMINAL SURGERY; COLORECTAL DISEASES; COLORECTAL PATHOLOGY; LAPAROSCOPIC SURGERY; SURGICAL COMPLICATIONS.

Figures

Figure 1

Histological examination of H&E-stained biopsy specimens of the sigmoid neovagina at presentation (A) and 4 months thereafter (B). Both biopsy specimens show colonic-type mucosa with strong increase of lymphoplasmacellular infiltrate in the lamina propria. (A) shows ulceration with fibrinoid deposition, (B) shows some crypt irregularity, consistent with chronic inflammation (comparable with inflammatory bowel disease histology).

Figure 2

Neovaginal endoscopy performed 4 months (A) and 7 months (B) after initial presentation. (A) Erythematous mucosa, superficial ulceration, mucus-like discharge and multiple pseudopolyp-like lesions throughout the sigmoid-derived neovagina. (B) Lack of endoscopic improvement. The neovagina remained inflamed. Multiple pseudopolyps were observed in both the proximal and distal part of the neovagina, apparently to a greater extent as before. Clinically, a malodorous, brown discharge was prominent.