Crohn’s disease is an inflammatory disease of the intestine, with the most common presentation being abdominal pain, cramping, and diarrhoea. Between 20 and 40 per cent of people with Crohn’s also have other manifestations of disease around the eyes, skin and joints, which can include the vagina and vulva in women. This is usually not addressed or recognised, and is difficult to treat.

Symptoms of gynaecological involvement in Crohn’s disease

These may present (even before a formal diagnosis of Crohn’s) as:

  • Bartholin gland abscesses
  • fistulas of the vagina, uterus, ovaries, perineum and vulva
  • genital ulcers
  • other skin conditions of the vulva, perineum, labia or vagina
  • malnutrition can cause secondary impacts such as poor wound healing

Fistulas may cause: 

  • increased urinary frequency
  • painful urination (dysuria)
  • air escaping from the urethra (pneumaturia)
  • pain above the pubic bone
  • faecal matter escaping through the vagina (faecal vaginal discharge or faecal gas expulsion through the vagina)

Diagnosis

The combination of physicians visited for this problem can complicate things, since a visit to a gynaecology or genitourinary department – when the gastrointestinal department was more appropriate – can delay diagnosis.

Diagnosis of vulvovaginal areas can be very difficult due to the mess Crohn’s can make of the pelvic region – masses, ulcerations, vulvar tissue loss or lesions are difficult to spot and diagnose, and almost half of women with Crohn’s have menstrual irregularities. Abscesses,draining of sinuses, oedema and perianal ulcers are common.

Causes

Unknown, but gynaecological symptoms are linked with vaginal birth and episiotomy (a cut made between the vagina and anus to let the baby out). Any woman with the development of fistulas after birth should have Crohn’s considered.

Treatment

Treatments have consisted of antibiotics, steroids (both topical and systemic), and immune suppressants. A trial was completed in 1998 on an anti-tumour medication, infliximab (Remicade), and was approved for use in severe Crohn’s disease, and has worked well for some types of fistulas.

Confusion may arise in diagnosis with tuberculosis, actinomycosis, lymphogranuloma venereum or cancerous lesions, and lesions can look identical to genital herpes. Attempting to cut open and drain fistulas is heavily associated with tissue breakdown, recurrence, and delaying proper treatment.

The connection with menstrual abnormalities

No periods, irregular periods, painful periods and heavy bleeding have been reported in conjunction with Crohn’s disease in women. The causes of this are suspected to be poor nutrition, chronic disease impacts, and medicines. NSAIDS are commonly used to treat period pain, but can exacerbate inflammatory bowel disease. Pains can be indistinguishable from one another.

The relationship with bowel complaints can change during the menstrual cycle, with worse abdominal pains and diarrhoea during premenstrual and menstrual days of the cycle. Several problems can co-exist, so it’s important to be clear about what disease is causing what symptoms so that issues are not overlooked based on assumptions.

Sometimes Crohn’s can cause lesions to form on the fallopian tubes or ovaries, causing pelvic pain or a mass, but also look like pelvic inflammatory disease, endometriosis, intestinal inflammation, appendicitis, diverticulitis, or ovarian diseases.

Crohn’s in children and adolescents 

The pelvis can be involved in Crohn’s even in younger people, and while children are less likely than adults to have fistulas, faecal incontinence or perineal disease, it should always be checked. Gynaecological examinations should be performed on children and adolescents.

The psychological impact of Crohn’s disease

Crohn’s disease with pelvic involvement can cause problems with sex, with pain a common feature (dyspareunia) due to abscesses and fistulas. Pressure on the rectum during intercourse can cause pain, but more frightening is the thought of the bowels spontaneously emptying themselves during the act.

Crohn’s can cause major embarrassment, poor body image, and the burden of chronic disease. Problems constantly arise from malnutrition, medication side effects and pain from diarrhoea and the bowel. The vagina can also be shifted anatomically, causing problems with heavy discharge.

If the bowel is destroyed, altered or damaged, the sphincters and bowel may not be able to hold faecal matter adequately, causing incontinence. Surgery has resulted in some very good outcomes for women, since it can remove elements of tissue that cause major problems.

 

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