Fistulas

Fistulas are abnormal connections (anastomosis) between two surfaces, such as blood vessels, intestines, or other hollow organs. They commonly develop around the anus.

They are caused by injury or surgery, but they can also result from an infection, inflammation, or diseases such as Crohn's disease or ulcerative colitis. Left unrepaired, fistulas can be traumatic, debilitating, and can do additional harm to the body. Fistulas can develop in various parts of the body including: the eyes, adnexa, ear, the circulatory system (pulmonary vessels, arteries), the respiratory system (pyothorax, between the trachea and the esophagus), the digestive system (salivary gland, stomach, pancreas, anus, colon), between joints, and the urogenital system.

There are three types of fistulas: blind, or sinus tracts (with only one open end), complete (with both external and internal openings) and incomplete (with an external skin opening, which does not connect to any internal organ). Although most fistulas are in the form of a tube, some can also have multiple branches.

Symptoms of Fistulas

Due to the various parts of the body where fistulas can form, there are a multitude of symptoms based on the specific fistula’s location. Some of the general telltale signs include: sepsis, nausea, vomiting, diarrhea, abdominal pain, drainage, fever, chills, and a general feeling of fatigue.

For urinary tract fistulas, the symptoms include: constant urine leakage from the vagina, irritation in the external female genital organs, frequent urinary tract infections (UTIs), leakage of gas and/or feces into the vagina, or fluid drainage from the vagina.

For anal fistula, the symptoms include: recurrent anal abscesses, pain and swelling around the anus, pain with bowel movements, bleeding, bloody or foul-smelling drainage (pus) from an opening around the anus.

External fistulas cause discharge through the skin. They’re accompanied by other symptoms, including: abdominal pain, painful bowel obstruction, fever, and elevated white blood cell count.

Internal fistulas may experience diarrhea, rectal bleeding, a bloodstream infection or sepsis, poor absorption of nutrients and weight loss, dehydration, and worsening of the underlying disease.

Etiology

The most common causes of fistulas are:

Diseases: Inflammatory bowel disease in the form of Crohn's disease are the leading causes of anorectal, enteroenteral, and enterocutaneous fistulas. A person with severe stage-3 hidradenitis suppurativa may also develop fistulas.

Medical treatment: Complications from gallbladder surgery can lead to biliary fistula. Radiation therapy can lead to vesicovaginal fistula, however, may occur due to other causes, such as trauma.

Trauma: Head trauma can lead to perilymph fistulas, whereas trauma to other parts of the body can cause arteriovenous fistulas. Obstructed labor can lead to vesicovaginal and rectovaginal fistulas. An obstetric fistula develops when blood supply to the tissues of the vagina and the bladder (and/or rectum) is cut off during prolonged obstructed labor. The tissues die and a hole forms through which urine and/or feces pass uncontrollably.

Risk Factors

Anal Fistula:

• Inflammatory bowel disease – Crohn’s disease or ulcerative colitis
• Systemic diseases – Tuberculosis, diabetes, HIV
• History of trauma to the anal region
• Previous radiation therapy to the anal region

Rectovaginal fistula:

• Place of birth and presence of a skilled birth attendant
• Duration of labor and the use of a partograph
• Lack of prenatal care, early marriage and young age at delivery
• Older age
• Prolonged and obstructed labor

Complications

Based on the type, if left unchecked, fistulas can result in:

Anal Fistula: infection, bowel incontinence, and recurrence of the fistula.
Arteriovenous Fistula: heart failure, blood clots, leg pain, and bleeding.
Rectovaginal Fistula: fecal incontinence, hygiene problems, recurrent vaginal or urinary tract infections, irritation or inflammation of your vagina, perineum or the skin around your anus, the formation of an abscess, and fistula reoccurrence.

Diagnostic Studies

Rectovaginal:

• Contrast tests
• Blue dye test
• CT Scan
• MRI
• Anorectal ultrasound
• Anorectal manometry

Anal:

• Endoscopic ultrasound
• Fistulography
• MRI
• Fistula Probe
• Anoscope
• Flexible sigmoidoscopy
• An injected dye solution

Treatments of Neuropathic Foot Ulcers

The following precautions can help minimize the risk of developing fistulas in at-risk patients and to minimize complications in patients already exhibiting symptoms:

Management:

• Catheters: Used to drain fistulas, catheters are usually employed on small fistulas to manage infection.

Non-Invasive Treatment:

• Fibrin glue: A specific medicinal adhesive used to seal fistulas.
• Plug: This is usually a collagen matrix used to fill the fistula.

Surgical Treatment:

• Transabdominal surgery: The fistula is accessed through an abdominal wall incision.
• Laparoscopic surgery: This is a minimally invasive surgery that involves a tiny incision and the use of cameras and small tools to repair the fistula.

Pharmaceutical Treatment:

Antibiotics or other medication may also be used to treat any infection associated with the fistula. Yet there is no pharmaceutical solution to eradicate fistulas. While fistulas pose a serious threat to your body, there is a high treatment success when help is immediately sought out.

Anal Fistula:

• Warm water; sitz bath after bowel movement
• Analgestics
• High-fiber diet

References

NAFC (2019). What is a fistula? National Association for Continence. Retrieved from https://www.nafc.org/fistula
National Association For Continence. Fistulas are connections nature never intended. Learn how to get your body back the way it was meant to be. NAFC. https://www.nafc.org/fistula/.
Published 2015. Accessed August 29, 2018.

The Cleveland Clinic Foundation. Anal Fistula. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/anal-fistula. Updated January 16, 2015. Accessed August 29, 2018.

Teach Me Surgery. Anal Fistula (Fistula-In-Ano). Teachmesurgery.com. http://teachmesurgery.com/general/anorectal/anal-fistula/. Last Edited December 30, 2016. Accessed August 29, 2018.

PubMed® Central. Risk factors for obstetric fistula: a clinical review. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3305871/. Published December 6, 2011. Accessed August 29, 2018.

Stanford Health Center. Complications of Fistula Repair Surgery. Stanford Health Care. https://stanfordhealthcare.org/medical-treatments/f/fistula-repair/compl.... Accessed August 29, 2018.

Mayo Clinic. Arteriovenous Fistula. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/arteriovenous-fistula/basi.... Updated May 15, 2018. Accessed August 29, 2018.

Yolanda Smith. Anal Fistula Complications. News Medical Life Sciences. http://www.news-medical.net/health/Anal-Fistula-Complications.aspx. Updated August 23, 2018. Accessed August 29, 2018.