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From question on page 1817
Rectoscopy showed a rectal stricture (white arrow), 3 cm cephalic to the dentate line, a rectal ulcer (blue arrow) (fig 1), and a rectovaginal fistula (yellow arrow) (fig 2), through which the vagina was visualised (black arrow) (fig 3). She was treated surgically. A diagnosis of rectovaginal fistula (RVF) secondary to ergotamine suppositories was retained as no other aetiology was found.
In the past 20 years there have been several cases of “anorectal ergotism” which were reported as proctitis, rectal ulcers, perianal ulceration, rectal stenosis, and rarely RVF.1,2 Because ergotamine acts on the arterial and venous tree of the capillaries, local rather than systemic damage is more likely to be seen with suppository use.3 Ischaemia induced by vasoconstriction leads to local inflammation (“anorectal ergotism”) which may lead to RVF that can easily occur because the vagina and rectum are separated by a thin septum. Normally, anorectal ergotism resolves after discontinuation of the drug. Only rectal stricture and RVF have to be treated endoscopically or surgically.