An Unusual Case of Vaginal Dialysate Leak After Peritonitis in a Patient on Peritoneal Dialysis (PD)

Introduction: Patients undergoing peritoneal dialysis (PD) are at increased risk of hernia formation and dialysate leakage due to elevated intraperitoneal pressure. Vaginal leakage of peritoneal dialysate is a rare but recognized complication. In this report, we present a case of vaginal dialysate leakage secondary to peritoneal adhesions and catheter positioning near the left fallopian tube, following an episode of peritonitis. Case Description: 28 year old female with SLE, ESRD on PD for 5 years presented with abdominal pain while being treated for peritonitis for the past 2 weeks. She was unable to perform PD due to pain. Effluent cell count was checked upon presentation and persistent peritonitis was roled out. Central venous catheter was placed and initiated on hemodialysis. Upon trial to flash PD catheter a few days later, fluid was seen coming out of her vagina and wetting her clothes. Abdominal image was obtained after injecting Tc-99m sulfur colloid through PD catheter, the injected material remained confined to the left lower quadrant of the abdomen/the left upper pelvis, findings favor a loculated fluid collection in the left lower quadrant of the abdomen/upper pelvis, and adhesion around the PD catheter. No vaginal fistula noted. PD catheter was removed and the patient continued on hemodialysis. Discussion: Vaginal fluid leakage during peritoneal dialysis (PD) is a complex and uncommon complication. Most cases are associated with peritoneo-vaginal fistulas and/or follow episodes of bacterial peritonitis. In our case, the leak occurred during flushing of the PD catheter, which was performed twice. Initially, a vaginal fistula was suspected; however, abdominal imaging revealed fluid collection and adhesions localized to the left pelvic region. These findings suggest that the leak may have occurred via the fallopian tubes, rather than through a fistulous tract. No evidence of a fistula was seen on abdominal peritoneography. This serious complication developed following an episode of peritonitis. It has been documented that dialysate can leak into the vagina as a rare PD complication, sometimes resulting from fallopian tube capture of the catheter tip. It is crucial to differentiate between this mechanism and a true peritoneo-vaginal fistula, the latter often necessitating laparotomy for tract debridement and surgical repair