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患者14岁,学生,住院号23581。该患出生时外阴未发现异常。一个月后发现左侧外阴部有一小包块,破溃后流出似脓性分泌物,后开始漏粪至今,瘘孔随年龄增长而逐渐增大。检查:发育营养智力均正常,第二性征呈青春期发育,尚未行经。外阴发育正常,阴毛稀少,在左外阴部相当4点钟处,大小阴唇之间,有一椭圆形瘘孔,直径2.5cm 与阴道相通;拨开阴道口,见阴道后壁左侧有一直径1.2cm 之瘘孔与直肠相通,可见红色直肠粘膜。子宫略小,附件未见异常,肛门括约肌功能良好。诊断先天性直肠阴道外阴瘘。
Patient 14 years old, student, hospital number 23581. The patient had no abnormalities in the vulva at birth. A month later found that there is a small mass of the left genitals, after ulceration outflow like purulent secretions, began to leak manure so far, the fistula hole increases with age and gradually increased. Check: developmental nutrition intelligence are normal, secondary sexual characteristics showed puberty development, has not yet passed. Vulva development is normal, sparse pubic hair, quite at 4 o’clock in the left vulva, the size of the labia, there is an oval fistula, diameter 2.5cm and vaginal communication; open the vaginal opening, see the left side of the vaginal wall has a diameter of 1.2cm The fistula hole connected with the rectum, showing red rectal mucosa. Slightly smaller uterus, attachment no abnormalities, anal sphincter function well. Diagnosis of congenital rectovaginal fistula.