Fistulas

Fistula Disorders at a Glance

• A fistula is a connection or hole that forms between two organs
• In women, a fistula can occur as a result of prolonged childbirth, connecting the bladder and vagina, or the rectum and vagina
• Fistulas can form when the blood supply to the tissue is cut off, causing the tissue to disintegrate
• With vesicovaginal fistulas (a connection between the bladder and vagina), uncontrolled urinary incontinence is a likely symptom
• With rectovaginal fistulas (a connection between the rectum and vagina), uncontrolled fecal incontinence through the vagina is a likely symptom
• Fistulas are preventable and treatable

What are fistulas?

A fistula is an abnormal connection via a tunnel-like hole between two organs or vessels. Fistulas can occur in various parts of the body. In women, fistulas involving the genital and urinary tracts are the most common and happen due to prolonged or obstructed childbirth, injury during pelvic surgery, infection, inflammation, or radiation treatment in the pelvis or genital area.

The most common fistulae in women is one that occurs between the bladder and vagina (known as a vesicovaginal fistula) and one that occurs between the rectum and vagina (known as a rectovaginal fistula). A vesicovaginal fistula is usually associated with urinary incontinence, or leakage of urine into the vagina which can be quite severe. A rectovaginal fistula can lead to fecal incontinence or leakage of feces into the vagina.

Fistulas can also involve other genital organs:

• Cervical (either an abnormal opening into the cervix or in the neck)
• Enterovaginal (between the bowel and vagina)
• Metroperitoneal (between the uterus and peritoneal cavity)
• Recto-uterine (between the uterus and bowel)
• Vesico-uterine (between the uterus and bladder)
• Ureterovaginal fistulas (between the ureter and vagina)
• Anal fistula (a small tunnel with an internal opening in the anal canal and an external opening in the skin near the anus)

What are the causes of fistulas?

The most common cause of a connection between the vagina and the bladder in the United States is injury to the bladder during pelvic surgery, particularly hysterectomy. While the symptom may occur immediately after surgery, something they cab be delayed for 1-2 weeks. Rectovaginal fistula can occur after childbirth associated with a large vaginal tear.

In developing countries, fistula are most commonly associated with prolonged labor. The World Health Organization has called fistulas "the single most dramatic aftermath of prolonged or neglected childbirth,"" estimating that more than 2 million women live with fistulas worldwide. In the developing world, the problem arises during prolonged labor (lasting up to three to five days), with the unborn child pressing against the mother's birth canal very tightly, cutting off blood flow to the tissues between the vagina and rectum and/or bladder. This causes the tissues to disintegrate and rot away, allowing an opening to form.

Urogenital and colorectal fistulas can also be caused by abortions; pelvic fractures; cancer or radiation therapy targeted at the pelvic area; abscess of the glands near the rectum; inflammatory bowel disease such as Crohn's Disease and ulcerative colitis; and infected episiotomies after childbirth. Sexual abuse and rape can also be a factor.

What are the symptoms of fistulas?

A vesicovaginal fistula, or a leak between the bladder and vagina, can be painless but will cause uncomfortable incontinence problems that cannot be controlled as urine continuously dribbles into the vagina upon entering the bladder.

The genital area may also become sore or infected and there may be pain during intercourse.

Women with a rectovaginal fistula, or a leak between the rectum and vagina, may include the passage of foul-smelling gas, stool or pus from the vagina, as well as pain during intercourse.

Other symptoms common to both vaginal fistulas and rectovaginal fistulas include:

• Frequent infections
• Diarrhea
• Abdominal pain
• Fever
• Weight loss
• Nausea
• Vomiting

What are the treatment options of fistulas?

Proper medical care makes fistulas both treatable and preventable.

Your doctor will want to talk about the symptoms and what may have caused them. As part of a physical exam, the doctor may check for a urinary tract infection, conduct blood tests and use a dye to locate all areas of leakage. An X-ray or scope may also be used to get a clear look and check for all possible tissue damage.

Fistulas generally do not heal on their own. Some small vesicovaginal fistulas that are detected early may be treated by placing a catheter in the bladder for a period of time. However, the treatment for most fistulas is surgical repair.

Most often vesicovaginal fistula can be repair by a minimally invasive vaginal approach. In some cases a minimally invasive laparoscopic or robotic or open surgical approach maybe preferred.

During surgery, the doctor will check the damaged area for cellulitis, edema or infection, while also removing any scar tissue and ensuring proper blood supply. After surgery, antibiotics or other medications may be prescribed.

If you have been diagnosed with fistulas or are experiencing symptoms associated with fistulas, contact us to request an appointment with one of our urogynecologists to learn more about your treatment options.