Fistulae: Gastrointestinal and Urinary Tract

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Chapter 85 Fistulae: Gastrointestinal and Urinary Tract

INTRODUCTION

Description: A fistula is an abnormal communication between two cavities or organs. In gynecology, this usually refers to a communication between the gastrointestinal or urinary tract and genital tract. (Connections directly to the skin are not discussed here.)
Prevalence: Gastrointestinal fistulae are uncommon; urinary tract fistulae are estimated to occur after 1 of 200 abdominal hysterectomies.
Predominant Age: Reproductive and beyond.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Urinary tract fistulae may result from surgical or obstetric trauma, irradiation, or malignancy, although the most common cause by far is unrecognized surgical trauma. Roughly 75% of urinary tract fistulae occur after abdominal hysterectomy. Signs of a urinary fistula (watery discharge) usually occur from 5 to 30 days after surgery (average 8 to 12), although they may be present in the immediate postoperative period. Fistulae between the gastrointestinal tract and vagina may be precipitated by the same injuries that cause genitourinary fistulae; most common are obstetric injuries and complications of episiotomies (lower one third of vagina). Fistulae may also follow hysterectomy or enterocele repair (upper one third of vagina). Inflammatory bowel disease or pelvic radiation therapy may hasten or precipitate fistula formation.
Risk Factors: Gastrointestinal—obstetric tears, puncture wounds, inflammatory bowel disease, intra-abdominal surgery, carcinoma, radiation therapy, perirectal abscess. Although Crohn’s disease, lymphogranuloma venereum, or tuberculosis are recognized risk factors, these are uncommon. Urinary tract—surgery or radiation treatment. Urinary tract fistulae are most common after uncomplicated hysterectomy, although pelvic adhesive disease, endometriosis, or pelvic tumors increase the individual risk.

CLINICAL CHARACTERISTICS

Signs and Symptoms

Gastrointestinal Fistulae

• Foul vaginal discharge
• Marked vaginal and vulvar irritation
• Fecal incontinence and soiling and the passage of fecal matter or gas from the vagina, pathognomonic
• Dyspareunia common
• Dark-red rectal mucosa or granulation tissue apparent in vaginal canal at the site of the fistula

Urinary Tract Fistulae

• Continuous incontinence (occasionally made worse by position change or an increase in intra-abdominal pressure as with a cough or laugh)
• Vaginal and perineal wetness and irritation
• Granulation tissue at site of fistula

DIAGNOSTIC APPROACH

Differential Diagnosis

Gastrointestinal Fistulae

• Inflammatory bowel disease (Crohn’s disease)
• Pilonidal sinus
• Perianal or other abscess
• Rectal carcinoma

Urinary Tract Fistulae

• Overflow incontinence
• Urge incontinence

Associated Conditions: Inflammatory bowel disease, bacterial vaginitis, dyspareunia, vaginitis, vulvitis, and urinary tract infection.

Workup and Evaluation

Laboratory: No evaluation indicated. (Evaluation of renal function [serum creatinine] is prudent but not diagnostic.)
Imaging: If inflammatory bowel disease is suspected, lower gastrointestinal series. Intravenous or retrograde pyelography may be useful.
Special Tests: Gastrointestinal fistulae—methylene blue may be instilled in the rectum with a tampon in place; staining indicates a communication. Sigmoidoscopy should be considered. Urinary tract fistulae—a tampon placed in the vagina with dye instilled into the bladder or dye given, usually intravenously, to be excreted by the kidney may be used to help find a fistula. Cystoscopy may help identify vesicovaginal fistulae.
Diagnostic Procedures: History, physical examination, probe of fistulous tract. Anoscopy, proctoscopy, sigmoidoscopy, or intravenous or retrograde pyelography may be helpful. Cystoscopy may be required to evaluate the location of a urinary tract fistula in relation to the ureteral opening and bladder trigone and to exclude the possibility of multiple fistulae.

Pathologic Findings

Inflammation and granulation changes from chronic infection. Tract may be single or multiple. Chronic bacterial vaginitis is generally present. Fistulae may be from the vagina to the bladder (vesicovaginal), to the urethra (urethrovaginal), or to the ureter (ureterovaginal). Rarely, communication between the bladder and the uterus (vesicouterine) may also occur.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Gastrointestinal fistulae—evaluation, stool softening, treatment of vaginitis. Urinary tract fistulae—urinary diversion (see the following text), protection of the vulva from continuous moisture (zinc oxide cream or diaper rash preparations).

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Specific Measures: Gastrointestinal fistulae—for those that do not heal spontaneously (three fourths of fistulae), the only effective treatment is surgical. When the fistula is small, this is often carried out with the patient under general or spinal anesthesia in an ambulatory surgery unit. Fistulectomy or fistulotomy should not be performed in the presence of tissue edema or inflammation, diarrhea, or active inflammatory bowel disease. Urinary tract fistulae—vesicovaginal fistulae that occur in the immediate postoperative period should be treated by large-caliber transurethral catheter drainage. Spontaneous healing is evident within 2 to 4 weeks (20% of patients). Similarly, in patients with a ureterovaginal fistula, prompt placement of a ureteral stent, left in place for 2 weeks, allows spontaneous healing for roughly 30% of patients. When these conservative therapies fail, full surgical correction is required.
Diet: Low-residue diet advisable for patients with a gastrointestinal fistula.
Activity: No restriction. (Pelvic rest after surgical repair, until healing is completed.)
Patient Education: Perianal care, sitz baths; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP081 (Urinary Incontinence).

Drug(s) of Choice

Although the only effective treatment is surgical, the use of stool softeners is often beneficial. If diarrhea is present, diphenoxylate hydrochloride (Lomotil) or a similar drug should be used to control symptoms. Treatment of coexisting vaginitis should be instituted.
Urinary antisepsis should be considered when necessary.

FOLLOW-UP

Patient Monitoring: Patients with a gastrointestinal fistula should be closely followed during the postoperative period (hospital discharge is generally delayed until after the first bowel movement). Maintain routine health care. When a ureteral fistula has been repaired, follow-up intravenous pyelography should be planned for 3, 6, and 12 months to check for delayed stricture.
Prevention/Avoidance: Careful surgical and obstetric techniques including preoperative and perioperative bladder drainage, good visualization, careful dissection, and care in placement of hemostatic sutures.
Possible Complications: Upper genital tract infection, recurrence, ascending urinary tract infection (including pyelonephritis).
Expected Outcome: Healing is generally good after surgical excision, although recurrence, when the original fistulae were caused by underlying disease or radiation therapy, is common.

MISCELLANEOUS

Pregnancy Considerations: No direct effect on pregnancy, although some causal processes may result in lower fertility or other effects on reproduction.
ICD-9-CM Codes: 619.1 (Gastrointestinal), 619.0 (Urinary tract).

REFERENCES

Level II

Alexander AA, Liu JB, Merton DA, Nagle DA. Fecal incontinence: transvaginal US evaluation of anatomic causes. Radiology. 1996;199:529.

Meeks GR, Sams JO4th, Field KW, et al. Formation of vesicovaginal fistula: the role of suture placement into the bladder during closure of the vaginal cuff after transabdominal hysterectomy. Am J Obstet Gynecol. 1997;177:1298.

Level III

Alvarez RD. Gastrointestinal complications in gynecologic surgery: a review for the general gynecologist. Obstet Gynecol. 1988;72:533.

American College of Obstetricians and Gynecologists. Urinary incontinence in women. ACOG Practice Bulletin 63. Obstet Gynecol. 2005;105:1533.

Bassford T. Treatment of common anorectal disorders. Am Fam Physician. 1992;45:1787.

Gerber GS, Schoenberg HW. Female urinary tract fistulas. J Urol. 1993;149:229.

Katz VL. Postoperative counseling and management. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:681.

Lentz GM. Anatomic defects of the abdominal wall and pelvic wall. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:530.

Michelassi F, Melis M, Rubin M, Hurst RD. Surgical treatment of anorectal complications in Crohn’s disease. Surgery. 2000;128:597.

Saclarides TJ. Rectovaginal fistula. Surg Clin North Am. 2002;82:1261.

Smith RP. Gynecology in primary care. Baltimore: Williams & Wilkins, 1997;577.

Smith RP, Ling FW. Procedures in women’s health care. Baltimore: Williams & Wilkins, 1997;153. 163, 175, 201.

Symmonds RE. Incontinence: vesical and urethral fistulas. Clin Obstet Gynecol. 1984;27:499.

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