Impaired healing of a vaginal tear in a patient with schistosomiasis

Schistosoma hematobium mainly infests the urinary system but can also affect the genitalia. Infestation of the bladder wall with bilharzia ova can interfere with the normal process of healing after surgery (1). In this report we present a patient in whom vaginal schistosomiasis is likely to have contributed to the impaired healing of a vaginal tear after delivery. A 26-year-old para II was seen in the outpatient department three weeks after delivery of her second child. She complained of a badly healed tear with widening of the vagina. A second degree perineal tear had been repaired in the dispensary where she gave birth. On examination, a gaping vaginal orifice was seen with an improperly healed perineal wound. It was decided to excise scar tissue and perform primary closure. During surgery a sessile polyp, with a diameter of 0.5 cm, was removed among the scar tissue. It was immediately inspected under the microscope as a crushed specimen. The polyp appeared to contain several terminal spined ova. Examination of urine and a cervical smear did not reveal schistosome ova. There was no history of hematuria and the patient had not been treated for schistosomiasis before; she was given praziquantel in a single dose of 40 mg/kg. The day after surgery the patient went home and subsequently was lost to follow-up. Histologically the polyp showed Schistosoma haematobium (SH) ova and remains of ova without an inflammatory tissue reaction (Fig. 1). The scar tissue showed a granulating reaction with fibrosis. Vaginal polyp with terminal spined ova and remains of ova of Schistosoma haematobium. Infestation of the female genital tract is common in women with urinary schistosomiasis. Vagina and cervix are mostly infected (2). A study, performed in an area endemic for S. haematobium in West-Africa, showed a prevalence of vaginal schistosomiasis of 75% in women in one village (3). Vaginal infestation with schistosoma ova can lead to the formation of warts, polyps, granulomatous lesions (sometimes resembling carcinoma) and cysts (2). As to schistosomiasis being the cause of vesico-vaginal fistulas (VVF’s), opinions differ. A relation between schistosomal infestation and failure in the healing of VVF’s after repair has been reported (1). Deposited bilharzia ova evoke an inflammatory tissue response. Initially an often granulomatous reaction takes place around viable ova, eventually leading to fibrotic changes around dead ova and egg shells; inflammation takes place even beyond the confines of the primary site of egg deposition (1, 2). The change from an inflammatory reaction to a scar tissue reaction seems to be a continuous process. In a recent study in Malawi this spectrum of reactions was seen in patients with female genital schistosomiasis (FGS) (4). Endometriosis, episiotomy granulation polyps and carcinoma formation have been mentioned as other causes of impaired healing (5-8). The patient, described in this report, was found to have a vaginal polyp containing schistosoma ova in an improperly healed vaginal tear. Changes due to the infestation with schistosome ova, in the polyp and its surrounding tissue, are likely to have contributed to the impaired healing of the vaginal wound after delivery.