Perforation of the uterus may occur with the insertion of the uterine tandem. This is particularly a problem for elderly patients and those who had a previous diagnostic conization procedure. When perforation is recognized, the tandem should be removed, and the patient should be observed for bleeding or signs of peritonitis. Survival may be decreased in patients who have uterine perforation, possibly because these patients have more extensive uterine disease (145). Fever may occur after insertion of the uterine tandem and ovoids. Fever most often results from infection of the necrotic tumor and occurs 2 to 6 hours after insertion of the intracavitary system. If uterine perforation was excluded by ultrasonography, intravenous broad-spectrum antibiotic coverage, usually with a cephalosporin, should be administered. If the fever does not decrease promptly or if the temperature is higher than 38.5◦C, an aminoglycoside and a bacteroides species–specific antibiotic should administered. If fever persists or if the patient shows signs of septic shock or peritonitis, the intracavitary system must be removed. Antibiotics are continued until the patient recovers, and the intracavitary application is delayed for 1 to 2 weeks.
Acute Morbidity The acute effects of radiotherapy are caused by ionizing radiation on the epithelium of the intestine and bladder and occur after administration of 2,000 to 3,000 cGy. Symptoms include diarrhea, abdominal cramps, nausea, frequent urination, and occasionally bleeding from the bladder or bowel mucosa. Bowel symptoms can be treated with a low-gluten, low-lactose, and low-protein diet. Antidiarrheal and antispasmodic agents may help. Bladder symptoms may be treated with antispasmodic medication. Severe symptoms may require a week of rest from radiotherapy.
Chronic Morbidity The chronic effects of radiotherapy result from radiation-induced vasculitis and fibrosis and are more serious than the acute effects. These complications occur several months to years after radiotherapy is completed. The bowel and bladder fistula rate after pelvic radiation therapy for cervical cancer is 1.4% to 5.3%, respectively (59,61). Other serious toxicity (e.g., bowel bleeding, stricture, stenosis, or obstruction) occurs in 6.4% to 8.1% of patients (59,61).
Proctosigmoiditis Bleeding from proctosigmoiditis should be treated with a low-residue diet, antidiarrheal medications, and steroid enemas. In extreme cases, a colostomy may be required to rest the bowel completely. Occasionally resection of the rectosigmoid must be performed.
Rectovaginal Fistula Rectovaginal fistulas or rectal strictures occur in fewer than 2% of patients. The successful closure of fistulas with bulbocavernosus ﬂaps or sigmoid colon transposition was reported (146,147). Occasionally, resection with anastomosis is feasible. Diversion resulting in colostomy may be the optimal therapy in patients who have poor vascular supply to the pelvis and a history of an anastomotic leak or breakdown from prior repairs.