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Suggest treatment for cervical cancer

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Posted on Fri, 24 Mar 2017
Question: I sent you a question several days ago that you answered relating to a possibility of cervical cancer following a LEEP procedure and a possible STD exposure.

I had gone an done all the STD testing and a throat culture as well and everything came back negative. My wife went into have her PAP Smear done today after several years as I mentioned in a previous question and so I have no idea how that will turn out. Over the past few years she has had on and off urinary issues (pain) and what she described as a feeling that urine was coming out of the vagina and she had been to a 3 different urologists with no determination of what the issue was. The doctor today did an exam and put something into her urinary tract and found 3 tiny little holes. He indicated that she would need to see someone that could surgically repair these and that as a result she has more than likely to have some sort of bladder infection. She had several years ago been told she had IC, but nobody has ever found these.

I know that I have been tested and told I was negative, but could I have passed an STD to her that would cause this issue with the little holes causing this urine issue and infection?
doctor
Answered by Dr. Timothy Raichle (1 hour later)
Brief Answer:
This sounds like a fistula between the urethra and vagina

Detailed Answer:
First of all, thank you for the follow up question. It sounds like your wife has leakage of urine from either the bladder or urethra into the vagina. This connection is called a fistula. It is most commonly related to childbirth and, in particular, difficult childbirth (C-sections, forceps deliveries, manual extraction of placentas, etc,). Once identified, and in capable hands, this should not be too difficult to fix.

These fistulas are NOT associated with STD's or any of the concerns that you had from before. It is great that you went and got tested and I am fairly certain that her evaluation will also be negative / normal otherwise.

What other questions do you have or would you like clarification.
Dr. Tim
Above answer was peer-reviewed by : Dr. Raju A.T
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Follow up: Dr. Timothy Raichle (2 hours later)
Thank you for the follow-up. I had read up a little on this and one site indicated the #1 cause was from PID and that PID is usually caused by an STD. It also mentioned cervical cancer (which has been a big concern of mine related to the time that passed between pap smears) or ovarian cancer as a cause and then listed some other items. So, with some comfort I felt after all the negative results have again got my mind spinning that somehow I caused this or have something not being detected that she now has and has caused this issue. I think her OGYN was somewhat taken back because there were 3 and not 1 as he has usually seen in the past.

Many places (on-line) say there shouldn't be pain associated with these, but when she urinates it does cause her a lot of pain and she doesn't empty all the way. The only procedure she had a few years ago was a D&C (?) after a miscarriage, but other that there was an episiotomy with our 1st two kids 17 and 19 years ago.

Have you heard of HPV causing anything like this? I don't think I have or have ever had genital herpes, but is that a concern?

I just feel like I've done something to cause her to be going through this.
I have done some additional reading and came across a site that talked about urinary pain as a main sympton of cervical cancer because it weakens the lining of the urethera and vagina and becomes associated with regular uti's. Im now very concerned that since her last clear pap smear she actually did develop cervical cancer and none of the urologists shed been seeing ever looked further inot that as a possibility.

Youd mentioned after her Leep procudure and 3 clear pap smears it was not likely in the past 8 years that it would evolve into cancer. Do you still feel that way. The more I try to understand how this may have occurred the more scared I get she's very, very sick and we are in for a nightmare. Am I misunderstanding what I read?

doctor
Answered by Dr. Timothy Raichle (5 hours later)
Brief Answer:
You are reading way too far into this...

Detailed Answer:
Please review my answer from the original question. First, your wife had cervical dysplasia related to HPV BEFORE you had your other relationship (four years ago). Also, you were NOT sexually active with this other person - so even if the absolute worst case scenario occurs (that your wife has cervical cancer) it was a problem that was developing long before you messed around on her.

That being said, as I stated before, if she had advanced metastatic cervical cancer she would basically be on deaths door. You need to stop reading into this. Also, I have been an OB for about 20 years and I have NEVER heard of PID as a cause for fistulas from the bladder or urethra to the vagina.

Finally, if she had cervical cancer that was causing this many problems, I can pretty much guarantee you that she would have abnormal bleeding and it would have been OBVIOUS on exam recently.

Does this help?
Dr Tim
Above answer was peer-reviewed by : Dr. Kampana
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Follow up: Dr. Timothy Raichle (11 hours later)
Dr. XXXXXXX

Thank you for your response. I don't understand a lot of what can and can't be determined by Doctors on initial exams and so I am very concerned and my wife is now convinced she has cancer and is a wreck.

She just called and told me the Dr's office called and asked her to come back in 3 weeks for an additional rectal exam, since what they did yesterday said that blood had been found. What issues could that be? I asked her what all test they did and she said they did a pap smear, urine sample, cultur's (not sure what type or from where). What type of things would the doctor be looking for and about how long does it usually take to get these results back? I asked her if they gave her a timeline to get these results back and she said they didn't.

If there was cervical cancer, when you are doing an exam do you look at the cervic when taking the sample and if it was cancer is there a noticeable or different look to the cervic that you can see?

She said she asked him to sent his findings over to a urogynocologist that she has seen before that does these type of surgeries and so we will see what he has to say after his review of the notes.

I am sorry if you are frustrated with some of these questions and maybe repetition, but I am having a hard time functioning. I know that all my tests came back negative last week and a couple of years ago, but I just can't get out of my mind something was missed and I am the cause of all this pain.
doctor
Answered by Dr. Timothy Raichle (3 hours later)
Brief Answer:
This is not something that you caused...

Detailed Answer:
First of all, I am not frustrated. It can be frustrating not having a lot of the details and just guessing at what is going on.

Second, there is nothing that you have done that could explain what is going on with her.

Here is what I know from very limited facts:
1. She has a sensation of urine coming out of the vagina
2. They put XXXXXXX into the bladder and determined, I am supposing, that there was a fistula to the vaginal canal
3. Yes this is not common, but it is not rare.
4. It is in no way associated with STD's
5. If she has cervical cancer, they would have seen in on exam

If you can provide more details of the visit or what they told her, that would be great. Even better, have her call the doctor's office and get the exact name of the problem for which she is getting referred to a Urologist.

I will be happy to keep helping.
Dr. Tim
Above answer was peer-reviewed by : Dr. Raju A.T
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Follow up: Dr. Timothy Raichle (2 hours later)
Thank you for your response. I have been trying to get as much detail as I can from her, but she is feeling very overwhelmed and now scared that she has developed something that can take her life. I've been on the phone on and off with her today while I am at work and she is thinking the worst.

As I had mentioned, she had been having urinary pain for a few years and had been to 3 urologists. A couple of years ago she saw a urogynocologist about it and said it felt like urine was coming out of her vagina. He diagnosed her with urethritis and said that in most cases this is from Ghonorea, but in this case probably not. He never found the fistula. He gave her some medication that I thought worked, but she later told me that it really hadn't. There were brief periods that she would not have any pain when urinating. It would come and go, but when it didn't hurt her it would only last for 2-3 weeks at a time. This is what got me so concerned about the STD I mentioned, but I also did testing back then that all came back negative. She said that because he didn't find anything like the Fistula that she must have been imagining it and so she just dealt with it and I didn't know that she was doing this or it was hurting.

When she went in on Monday for her pap smear she told him of the problems she had been having with the urination and pain. She said that he numbed her with some stuff and then put some sort of tube into her urethera, drained any additional urine and then that is when he discovered the 3 openings into the vagina. She said he was very concerned and said that she would need to get these repaired surgically. She also said that in the procedure that the surgeon may need to do some draining of what he felt was some sort of infection (she described it as a couple of puss pockets or more, not really sure). I don't know what exactly he saw or how he was able to make that determination. She said he showed her in the mirror the openings in the vagina to the urethera. She doesn't remember exactly what he called it, but she said he showed her and said there were three openings and that he understood why this was hurting her.

She said he took the urine sample, did the PAP smear, a culture and then the rectal thing that they told her today showed some blood being present.

I asked her if he made any specific concern to anything else other than the 3 openings and she said he hadn't. I don't know if he has some other thing he is really concerned about and he did not say anything because he didn't want to upset her any more than she was at that time and that he is just waiting on the results.

She told me yesterday that he said she should go get this procedure done at the Mayo Clinic if our Insurance was part of that which has her even more worried because she thinks only people with dire illness go to the Mayo Clinic. I asked her today if they still wanted her to go to the Mayo Clinic when they told her to come back in 3 weeks regarding the rectal swab and to do it again to see if there was any blood, but she said they didn't. They wanted to see how all the tests came back, but they were sending their findings to the urogynocologist that does these type of surgeries for him to review who had looked at her a couple of years ago.

That is about as much detail as I could get out of her.

I also asked her if it hurt her when we would have sex. She said sometimes, but not always and she said she didn't want to tell me the times when it did (now I really feel horrible). I have never noticed nor has she said she has ever had any type of discharge from the vagina. We have for some time had a decent sex life and she usually is always clean and I have not ever noticed anything that would make me feel she had a vaginal infection, but how would I really know?? She has her periods usually about 28 days or so on the button and I am not aware of any bleeding or concerns she has raised between periods.

I don't know if this helps at all in any way or not, but I think this is about as much detail as I can provide at the moment.

Thank you again for taking the time to discuss this with me.
doctor
Answered by Dr. Timothy Raichle (22 hours later)
Brief Answer:
It sounds like a urethro-vaginal fistula

Detailed Answer:
Yes, STD's can cause urethritis - that is true. But you have tested negative and there is no reason to believe that you transferred an STD to her from prior activities. You need to understand that you probably did NOT do this to her.

In reviewing the causes of urogenital fistulas, the most common reasons are related to prior pelvic surgery (such as a hyterectomy which does not apply in this case) or obstetric trauma. Even though her deliveries were normal, this might be part of the explanation.

One possibility is that she had something called urethral diverticuli (small outpoochings from the lining of the urethra. These are anatomic changes that occur for no explainable reasons and they CAN get infected (the same thing occurs in the colon = colonic diverticuli or diverticular disease). I also imagine that they can eventually communicate with the vagina and thus the fistula. This would be a great explanation.

These things are uncommon enough that they should be handled by a Urologist who has experience in such surgeries. The referall to Mayo seems completely appropriate and I have sent them plenty of patients for non-cancer reasons. They do a great job evaluating complicated patients.

So I would encourage you and your wife to not assume the worst as this does NOT sound like cancer.

Does this help?
Dr. Tim
Above answer was peer-reviewed by : Dr. Arnab Banerjee
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Follow up: Dr. Timothy Raichle (21 hours later)
Thank you for your response. The urogynocologist called us last evening and he'd reviewed the notes from the OBGYN. He said he felt there was some confusion on her understanding of what the OB had said in relation to these small openings. He said that hebdoes not think it is a fistula and the OB didnt call it that either. I cant recall what he felt may be the issue, but he did not think she needed to be concerned that there was a cancer prognosis. He said that he'd need to look at her to get a better idea of these little openings. However, he did once again say that her symptoms could possibly still be consistant with urithristis and he brought up ghonorrea again as a main cause. The OB made no notes about that as a possible diagnosis because of what he observed and he also took a biopsy of that area. When he mentioned ghonorrea again she said I know I dont have that and then went on with the conversation more with him on how things feel when she tries to urinate. This whole ordeal is making me crazy. I tested 2 1/2 years ago, 2 years ago and 2 weeks ago. Everything was negative. The first two tests that i had done just did not involve throat swabs. My last one did. I just cant seem to shake that I somehow had this orally, passed it to her and there is this ticking timebomb about to wreck my family. Although, had by some way that have happened I would have certainly thought over the years I'd have gotten it back from her and I continue to test negative. Can Ghonorea stay localized to the urinary track without affecting the vagina? This pain has been going on with her for a few years now and since we done have protected sex I'd certainly think I'd have tested positive and not negative every time. Would there not be more symptoms other that just pain when urinating if it was an STD? I was tested for Chalm, Ghon, HIV and Syphilas is what the clinic does. Is there any other possible ones that thins could be that would cause these issues or that I should have been tested for? Does any form of HPV affect the urinary tract that would cause these issues?
doctor
Answered by Dr. Timothy Raichle (5 hours later)
Brief Answer:
Given everything you have told me an STD still seems very unlikely

Detailed Answer:
They are not helping your frame of mind by continuing to mention gonorrhea as a cause when this is obviously an unlikely cause in her case. You have tested negative on multiple occasions and it just would NOT be transmitted through oral intercourse after colonization of your throat. This is just not a likely means of transmission. You must be comfortable with the fact that you do not, and likely never had an STD. Your guilt is going to drive you crazy.

The small openings might simply have been the opening of two glands on either side of the urethra called the Skene's glands. Given that the OB thought that she could see this with a mirror would suggest that this is the case because these are on the outside where you could see them. They can become inflamed or blocked and would cause urethral pain. Also, the fact that they do NOT think that this is cancer is very reassuring and I would rest easy that this is a true fact. In answer to your questions, though:

1. Yes, gonorrhea, if present, could stay localized to the urethra
2. I would think that if she had gonococcal urethritis for several years it would have produced more symptoms including a urethral discharge
3. There is no other testing of you that needs to happen
4. HPV does not cause urethral symptoms

I hope that this helps. It sounds like there are some cultures / biopsies that are pending. I would wait for the results and try not to worry until you have more answers.

Dr. Tim


Above answer was peer-reviewed by : Dr. Arnab Banerjee
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Follow up: Dr. Timothy Raichle (10 days later)
It has been about a week and a half since your latest response.

The initial tests came back from the urine sample that the gynocologist took and he said she had a severe UTI and put her on some sort of antibiotic. He told her it could take up to 1-2 month's to clear. She has been on it for about 10 days. She did not say if the cause of the UTI had been identified, but I am assuming it was not. I don't think that he specifically sent the urine sample to test for an STD and my understanding is that unless it is tested for it, it won't be picked up if there is one.

She also went to see urogynocologist because of the three openings that the gynocologist saw. She said he put something into her urethura that I think also let him look at some things. He told her that he had to break loose or break up a couple of things as well and he put her on an different antibiotic for 30 days. He said he saw the 3 things the gynocologist saw, but she said he did not seem to think they were a serious issue and should heal up when the UTI cleared.

It seems the Pap smear came back Ok, because my wife has not said anything to me about an abnormal pap smear and she has gotten from what I understand all the results back from the gynocologist at this point.

She has to go back this Friday for another anal swab to see if any blood appears on this one or not.

Like I said earlier, she has been about 10 days on these antibiotics and there isn't much relief yet and I can't remember what antibiotics they are, but I know it's not the one that would clear ghon (which is what I have been concerned about).

How long would it normally take to start seeing some relief from a UTI with antibiotics?

I know that 4 years ago, 2 years ago and last month I always tested negative, but until last month I had never had a throat swab done. I understand that performing oral on a woman is a low risk to transfer to a man's throat and then also a low risk for that man to pass orally to a woman.

I just can't imagine other that what I have done that would have caused her to develop this UTI that has turned into a severe UTI. I would have thought by now fi it was something other than a UTI she would start to see some relief, so at this point I am still just completely stressed about this whole thing.
doctor
Answered by Dr. Timothy Raichle (9 hours later)
Brief Answer:
The cause of the findings in the urethra are likely not an STD

Detailed Answer:
First of all, you need to stop thinking that you somehow caused this. In reviewing all of the original questions, the chance that this is an STD is so unbelievably small that it is not worth considering as a primary diagnosis.

It is really hard to help you with these mysterious findings and no details. What do you mean they had to "break up a couple of things"?. Without a name to the condition I cannot even venture a guess. You would need to get me a name for what they found. Were they urethral diverticuli, strictures, what?? If she has a UTI, then they should have bacterial identification of the cause. What is the bacteria? What antibiotic are they using?

It is really hard to help you without more answers to what they are seeing. This does not sound like the effect of an undiagnosed STD.

Dr. Tim
Above answer was peer-reviewed by : Dr. Kampana
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Follow up: Dr. Timothy Raichle (40 hours later)
Thanks for the reply.

I wish I had more information, but I am going on the little bit that I have been told. I wasn't at the appointments. She told me the gynocologist's office called and said she has a bad/severe UTI. They gave her a prescription for Nitrofurantoin Mono/MAC, 100MG. They had her take 2 a day for a week (in the mornings) and then 1 a day for 3 more weeks. He said it may take up to 2 month's to clear. She did not mention any specific bacteria. If a test comes back as a UTI, do they re-run the test to determine the bacteria? I don't know how it works, but that is all she told me, so I don't know if the bacteria was identified or not. It seems to be they would try and identify it, but I don't know. I had a person tell me that if a woman had a UTI that unless they specifically asked for an STD test it would not be ran to determine if that was a cause, so I don't know.

I asked her then about what the urogynocologist meant about breaking things up. She said she didn't remember what he said exactly and that it was very painful when he finished his exam. He then prescribed her Amitriptyline, 25mg at night for a month.

Does this help?
doctor
Answered by Dr. Timothy Raichle (11 minutes later)
Brief Answer:
Yes that helps

Detailed Answer:
If they were worried about an STD causing these problems in the urethra, they would have prescribed either doxycycline or azithromycin. So, again, I would suggest that whatever if going on in her urinary tract is likely related to poorly treated chronic bladder infections that have nothing to do with STDs. The fact that they are using nitrofurantoin suggests that that they are treating more common causes of uncomplicated and complicated urinary tract infections.

She should get a better sense from the Urologist what they think is going on. It would not be unreasonable for her to request a copy of their notes as they certainly did not explain this well to her during her visits. If you were able to get these records, I would be happy to review them with you through this site.

Dr. Tim
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Suggest treatment for cervical cancer

Brief Answer: This sounds like a fistula between the urethra and vagina Detailed Answer: First of all, thank you for the follow up question. It sounds like your wife has leakage of urine from either the bladder or urethra into the vagina. This connection is called a fistula. It is most commonly related to childbirth and, in particular, difficult childbirth (C-sections, forceps deliveries, manual extraction of placentas, etc,). Once identified, and in capable hands, this should not be too difficult to fix. These fistulas are NOT associated with STD's or any of the concerns that you had from before. It is great that you went and got tested and I am fairly certain that her evaluation will also be negative / normal otherwise. What other questions do you have or would you like clarification. Dr. Tim