Fistula

Types Of Fistula

Fistulas can occur in different parts of the body, thereby can be defined and termed differently as well.  A fistula can form between: 

• Artery and a vein

• Cervix and the vagina

• Neck and throat

• Bile ducts and surface of the skin

• Skull and nasal sinus

• Bowel and vagina

• Stomach and the surface of the skin

• Navel and the gut

• Artery and the vein in lungs

• Uterus and peritoneal cavity (space between the abdomen and internal organs)

• Colon and surface of the body, causing feces to exit through an opening other than the anus

Based on the nature

Based on the nature, the different types of fistula:

Blind: As the name suggests, the fistula that opens in only one end and is closed at the other end is called the blind fistula. 

Complete: A complete fistula has openings both outside and inside the body. 

Horseshoe: A horseshoe fistula connects the anus to the surface of the skin after going around the rectum.

Incomplete: An incomplete fistula is a tube from the skin that is closed on the inside and does not connect to any internal structure.

Based on anatomical location 

Based on the  location, the different types of fistulae are listed below:

Anal fistulas: Anal fistulas are the most common type of fistulas. The anal fistula is developed between the anus and another organ system such as the rectum, vagina and colon. These three therefore can be defined as three subcategories of aval fistulas:

• Anorectal fistula
• Colovaginal fistula 
• Anovaginal fistula 

Intestinal fistulas: Intestinal fistula is developed between the small intestine and the skin or colon and the skin. 

Bladder or urinary tract fistula: A bladder fistula is when an opening forms between the bladder and some other organ or the skin. Commonly the bladder opens to the bowel (enterovesical fistula) or the vagina (vesicovaginal fistula).

Gastrointestinal fistula: It is an abnormal opening in the stomach of intestines that allows the leakage of contents. They can be classified as enteroenteric (where the leaks go through a part of the intestines) or enterocutaneous (where the leaks go through to the skin) fistula. 

Obstetric fistula: It is an abnormal opening formed between the birth canal (genital tract) and the urinary tract or rectum due to obstructed labor during childbirth. 

Vaginal fistulas: It is an abnormal opening that connects the vagina to another organ such as the bladder, colon or the rectum. The different types of vaginal fistulas include:

Vesicovaginal fistula: Also called bladder fistula, it is a common type of vaginal fistula. The opening develops between the vagina and urinary bladder. 

Urethrovaginal fistula: It is also called urethral fistula. This type of fistula develops between the vagina and the tube that carries urine out of the body (urethra). 

Ureterovaginal fistula: This type of fistula develops between the vagina and the ducts that carry urine from the kidneys to the ureters (bladder).  

Rectovaginal fistula: This type of fistula develops between the vagina and the lower portion of the large intestine (rectum). 

Colovaginal fistula: This type of fistula develops between the vagina and the colon.

Enterovaginal fistula: This type of fistula develops between the vagina and the small intestine.

Symptoms Of Fistula 

Symptoms vary depending upon where the fistula is located. They range from mild to serious ones. Most commonly, there will be no specific symptom until the condition becomes more advanced. However, some individuals experience one or two symptoms only. But others might develop multiple symptoms simultaneously. 

Some of the commonly observed symptoms of fistula are:

• Body pain 

• Pain around the anus

• Vague feeling of being unwell or uncomfortable 

• Constant urine leakage from the vagina 

• Irritation in the external female genital organs 

• Nausea

• Abdominal pain

• Vomiting

• Fever

• Weight loss

• Diarrhea

• Constipation

• Frequent urinary tract infection

Causes of Fistula 

Depending on the type and location of the fistula, there could be different reasons for occurrence. In some cases, they could be formed naturally and in others could be an after-effect of an injury or surgery. 

Gastrointestinal diseases: People suffering from gastrointestinal diseases such as Crohn’s disease, colitis and irritable bowel diseases are at a higher risk of developing fistulas near the anus. Around 1 in 3 people with Crohn’s will likely develop a fistula at some time.

Diverticular diseases: Diverticular disease is a digestive disease. Diverticulosis is a condition that occurs when small sacs form and push outward through weak spots in the wall of the colon. 

Radiation therapy: Patients undergoing radiation therapy as a cancer treatment or otherwise, are at a high risk of developing fistulas.

Certain infections: Some infections and diseases such as HIV and tuberculosis can also cause fistulas. 

Women’s health and childbirth: Prolonged or obstructed childbirth, injury during pelvic surgery, radiation treatment in the pelvic or genital area are common causes for vaginal fistulas. 

Surgical and medical treatment: Certain surgical treatments can lead to fistulas.eg. Complications from gallbladder surgery can lead to biliary fistulas. Radiation therapy to the pelvis can lead to vesicovaginal fistulas. 

Therapeutic use: In people with kidney failure, requiring dialysis, a cimino fistula is often deliberately created in the arm in order to permit easier withdrawal of blood for hemodialysis. During treatment of portal hypertension, surgical creation of a portacaval fistula produces an anastomosis between the hepatic portal vein and the inferior vena cava. This spares the portal venous system from high pressure which can cause many complications.

The cause for developing different types of fistulas vary according to the type and are discussed separately below:

Anal fistula: Anal fistula are more common in men aged between 30-50 years of age. Anal fistulas can be caused by damaged tissues and is often linked to cysts or an infection of the anal glands.

• Clogged anal glands
• Anal abscesses
• Crohn’s disease
• Tuberculosis
• Diverticulosis 
• Cancer
• Radiation therapy 
• Trauma 
• Sexually transmitted diseases 

Vaginal fistula: In women, fistulas involve the genitals and urinary tracts. Common causes of these fistulas are:

• Prolonged or obstructed childbirth
• Injury during pelvic surgery
• Radiation treatment in the pelvic or genital area
• Infection and inflammation

Risk Factors For Fistula

Though the exact cause of fistula is still unknown. However, there are conditions that put some individuals at a higher risk of developing fistulas. Some of these risk factors include:

Previous history of anal abscess or fistula

Anal fistulas can be caused by damaged tissues and is often linked to cysts or an infection of the anal glands. 

Crohn’s disease 

As per studies, 70% of Crohn’s disease patients suffer from fistula and resulting intestinal obstruction during their disease course. 

Certain infections 

Some infections and diseases such as HIV and tuberculosis can also cause fistulas. 

Previous surgery or radiation therapy

Patients who have had surgeries in the past or are undergoing radiation therapy as a cancer treatment or otherwise, are at a high risk of developing fistulas.

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Diagnosis Of Fistula

Fistula has characteristic symptoms. When you experience the symptoms, book an appointment with your physician at the earliest. Your doctor may ask you questions and enquire about your medical history. Based on the answers, he may suggest some medical tests and physical examination to confirm the presence of the disease. 

During the physical examination, he may use a speculum (a metal or plastic device used during a pelvic exam) to look at the vaginal walls. 

Medical tests that the doctor may ask you to get done:

 

Urine test

The doctor may suggest getting a laboratory test done to confirm the presence of a urinary tract infection by taking a urine sample. 

Anoscopy

It is an examination of the anal canal with a scope to detect the presence of the fistula. Use a dye in the vagina or bladder or rectum to find all signs of leakage

Complete blood count (CBC) 

A complete blood count (CBC) is a blood test used to detect a wide range of disorders and infections. The test measures several components of the blood, including : red blood cells, white blood cells, platelets and others.   

X-rays scan  

Fistula can cause tissue damage at the site of infection. An X ray produces images of the organs and confirms the presence of any tissue damage due to fistula. 

Magnetic resonance imaging (MRI)

It is an imaging test that uses a magnetic field to take pictures of organs and structures inside the human body. 

CT scan

A CT scan (also known as computed tomography) is a machine that takes a series of x-rays to make a picture with minute details. The scan helps to image bones, blood vessels and soft tissues from different angles.  

Endoscopy

It is a common imaging test that uses a thin, flexible, light viewing instrument called an endoscope that allows the doctor to examine the inside of the organs, canals and cavities in the body.

Fistulogram 

It is a special type of X-ray that provides a detailed imaging of the fistula. It is a procedure during which a dye is injected into the fistula to make imaging better. In a case where the fistula connects to the outside of the body, a catheter may be used to insert the dye. Whereas, if the fistula is present in the rectum, the dye will be injected via the anus before taking the X-rays images.

Intravenous pyelogram

It is a type of X-ray commonly used for diagnosing bladder fistulas. Prior to the procedure, you may be asked to follow a liquid diet or fast in order to make sure the colon does not contain any remains of stool at the time of imaging. Presence of stool can block the view of the bladder and therefore obstruct the diagnosis. In this case as well, a dye is injected into the body (usually via the arm) to get better images.

Prevention Of Fistula

Fistulae are preventable and treatable. The risk of certain types of fistula (such as anal fistula) can be lowered by:

• Practicing good hygiene 

• Carefully cleaning and treating the anal/ rectal wounds 

• Managing the risk for other health conditions that increases the chances of fistula

As per WHO, fistulas such as obstetric fistula can be prevented by:

• Delaying the age of first pregnancy

• Cessation of harmful traditional practices 

• Access to obstetric care

In many cases, the cause of fistula is unknown and therefore it becomes difficult to suggest a prevention strategy. Patients with Crohn’s are at an increased risk of developing fistula at some point in life. 

Specialist To Visit

If you observe any of the relevant symptoms, do not delay consulting a physician. The physician will ask for your medical history and do an examination to determine if a fistula exists. In most cases, the physician will examine the area around which the fistula is expected. The physician may recommend you to get some tests such as MRI or ultrasound done to get better clarity.

Depending on the location and severity of the fistula, the physician may recommend you to see a specialist such as:

• Gynecologist

• General surgeon 

• Urogynecologist

• Urologist

• Colorectal surgeon

• Gastroenterologist

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Treatment Of Fistula

If proper medical care is provided to the patient, fistulas can be treated and prevented. Different treatment options for fistula includes:

Surgical treatment 

If the fistula fails to respond to the medications and antibiotics, surgical treatment might be needed to remove the fistula.

Fistulotomy 

It is the most effective and common type of surgery that involves cutting along the whole length of the fistula to open it up so it heals as a flat scar. It is a surgical treatment for many fistulas (such as anal fistula) that do not pass through much of the sphincter muscles, as it may cause a risk of incontinence. 

Transabdominal surgery

It is the simple procedure wherein the rectovaginal septum is dissected, the fistula is divided and the rectum and vagina are closed primarily without bowel resection. 

Laparoscopic surgery

It is a minimally invasive surgery that involves a tiny incision and the use of cameras and small tools to repair the fistula. 

Endorectal flap procedure 

It is a procedure where healthy tissue is pulled over the internal side of the fistula to keep feces or other material from reinfecting the channel.

Medications

Depending on the condition and severity of the disease, the doctor prescribes medications that include:

• Antibiotics will help fight against bacterial infection that if left untreated could worsen the patient’s condition. Commonly prescribed drugs include metronidazole and ciprofloxacin that may help reduce the discharge and promote comfort.

• Anti-inflammatory medicines are usually recommended for people with Crohn’s diseases or diverticular disease. It helps control the existing fistula from worsening and prevents new ones from developing.

• Immunomodulatory drugs have shown to help close the fistula in some. Commonly prescribed drugs include azathioprine, it acts slowly therefore may take up to 3 months to show results. 

• Pain relief medications help  to reduce the pain and discomfort caused due to the fistula.

Non-invasive treatment 

For small and relatively simple fistulas, doctors often use a minimally invasive technique to manage it. Commonly used non-invasive treatment options include:

• Fibrin glue is a specialized, simple and painless therapeutic for fistulas that are small and do not require an invasive treatment. It is a medicinal adhesive that activates thrombin to form a fibrin clot that forms a clot and seals the fistula tract. 

• Collagen plugs are another method to seal the fistulas. Fistula is plugged up using collagen and is seen as a first line treatment for patients with simple fistulas. 

• Seton technique is performed by inserting surgical thread inside the fistula tract that allows it to drain and heal completely. 

Follow-up treatment for fistulas 

Most people respond well to surgeries, however it is recommended to follow up with your doctor to avoid any complications. Book follow up appointments with your specialist or doctor in order to make sure the body is effectively responding to the medication and surgery and you are recovering well.  

Home-care For Fistula

If you have had a surgery to remove the fistula, give yourself a few days to heal. You may be advised to take some medications post surgery, so make sure you are regular with them. Most people can go back to work and their normal routine a week or two after the surgery depending on the size and severity of the fistula. 

To expedite the recovery process, here is what you must take note of w.r.t your diet:

• Eat your normal diet, unless stated by your doctor. Include bland, low fat foods like rice, toast and yogurt in your diet. 

• Drink plenty of fluids (unless stated by your doctor not to)

• Include high fiber foods, such as fruits, vegetables, beans, and whole grains in your diet.

• You may notice that your bowel movement is not regular right after the surgery. It is common and you need not worry. 

Here is what you must take note of w.r.t your activity and movement :

• Get enough sleep and rest when you feel tired. Do not overexert your body.

• Try to walk each day. Gradually, increase your mobility. Walking will boost your blood flow and help prevent constipation.

• Do not hesitate to take shower or bath. Pat your anal area dry with a towel when you are done.

• Your doctor may recommend or prescribe a barrier cream to protect ypur skin surrounding the wound/ fistula from any infection.

• If you notice swelling, try lying on your stomach with a pillow under your hips. 

• When you sit on the toilet seat, support your feet with a small step stool. This helps flex your hips and places your pelvis in a squatting position. This can make bowel movements easier after surgery.

• Wear loose fitting clothing and cotton undergarments.

• Apply ice several times a day for 10 to 20 minutes at a time. Put a thin cloth between your skin and the ice.

• Try a sitz bath. Sit in 8 to 10 centimeters of warm water for 15 to 20 minutes. Then pat the area dry. Try it as long as you have pain in your anal area.

• Wear a pad over your anal area until healing is complete.

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Complications Of Fistula

Fistulas can be difficult to deal with as they cause a lot of discomfort and pain. If the fistula is left untreated, it can cause serious complications. 

Bacterial infection or sepsis

As is with any surgery, one of the common complications is infection. It can have severe consequences and affect different body parts. If you notice an abscess, there is a chance for you to develop sepsis which can be threatening. Make sure to contact your doctor immediately if you notice any pus formation or infection.

Bowel incontinence

Damage to the anal sphincter muscles causes bowel incontinence. It can cause fecal leakage from the rectum. 

Fistula recurrence

Even after surgery, there are chances of recurrence of anal fistula. However, this recurrence primarily depends on the complexity and type of surgery performed.

Bowel obstruction

Damage to the anal sphincter muscles can cause bowel blockage or obstruction.

Living With Fistula 

Fistula can mentally and physically challenging. Though the condition can be treated using medications and home remedies, here are some tips that could help patients with fistula in their day to day life. 

• Regular warm baths help to relieve fistula pain and discomfort. Keep your bathtub clean to avoid any risk of infection. 

• Use portable bidets (also called sitz baths) to keep the area clean and hygiene. 

• Avoid the use of soap, perfumed products or salts in the water as they can cause irritation and make it worse. Instead use speciality soaps formulated for sensitive skin.  

• Avoid the use of talc. It may cause irritation to the skin as well. 

• Your doctor may recommend the use of a barrier cream that can help protect the affected area. Avoid using any other lotion or cream. 

• If you have an anal or vaginal fistula, avoid the use of tampoons without confirming with your doctor. 

• If you experience discharge while you are on medication, use pads and panty liners. 

• Avoid foods that can cause constipation as it can make it worse. Stay hydrated and include fibrous foods in your diet. 

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Alternative Therapies For Fistula

Medical assistance is often recommended for treating fistulas, as they can be painful and hard to deal with. However, there are some alternative therapies that can help alleviate the symptoms and fasten the process of healing. 

Some easy and common home therapies that can be used for fistula include:

Enteral diets

People with fistulas in the small and large intestines are often prescribed with a special diet called the enteral diet. In this type of diet, the person is recommended to consume only liquid food for a period of time. Consumption of a liquid diet will help reduce the amount of stool that passes through the intestines and rectum and also provide the body with the required nutrition therefore reducing chances of malnutrition and weakness. An enteral diet may help the fistula close on its own and has been found to heal fistulas completely. 

Tea tree oil 

It is known for its antibacterial, antiviral, antiseptic and anti inflammatory properties and therefore makes it a good home remedy for fistula. Tea tree oil can be used as a natural ointment for killing germs and promoting growth of white blood cells. 

Tea tree oil can be mixed with olive oil and dabbed on the affected area. Leave it for half an hour and wash it with cold water. Follow this regime once a day for a few days to get relief from anal fistula. 

Oregano oil 

Oregano oil has soothing and healing properties that can help to cure fistula by consuming it. It helps to boost immunity, reduce swelling, prevent bleeding and kill bacteria around the anus. You can consume the oregano leaves oil by mixing it with lukewarm water twice a day. 

Cloves (laung)

A common condiment used in all Indian kitchens, cloves have antibacterial and anti-viral properties. It has been found to be beneficial in cleansing the colon and boosting the immune system. It also helps prevent the occurrence of parasite infections in the body. You can boil a few cloves or clove powder in water and consume that water. Alternatively, you can also add cloves to your green tea. 

Turmeric milk (haldi doodh)

Turmeric is a well known natural and powerful antibacterial and antiviral agent. It helps to boost the immune system, fight infections and expedite healing of wounds. You can boil turmeric powder with milk and consume it once a day.