How to Manage Fistula Medically

  

Date Posted: 7/13/2013 8:18:40 AM

Posted By: jvk  Membership Level: Silver  Total Points: 330

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Fistula
Fistula means 'a pipe'. It is defined as an abnormal, winding opening between two internal hollow organs.
The most common areas in the genital tract that may be connected abnormally are:
Vagina to bladder - Vesicovaginal Fistula (VVF)
Rectum to vagina - Rectovaginal Fistula (RVF)
Urethra to vagina - Urethrovaginal (UVF)
Urinary fistula however, can occur at many sites. Study the illustration opposite.

Some common causes of fistula include:
• Obstructed labour due to pressure by the presenting part, causing necrosis. This accounts for 85% of cases in developing countries.
• Radiation therapy for gynaecological conditions, which accounts for 15% of cases (usually many years
after treatment).
• Disease processes, such as carcinoma in advanced stages of the neighbouring organs.
• Chronic tuberculosis or syphilis.
• Congenital fistula, that is, an accessory ectopic ureter, which may open into the vagina. This condition can be recognised in childhood.
The main symptoms and diagnosis of VVF include:
• The patient keeps on complaining of constant dribbling of urine from the vagina and generally does not pass any urine by the normal route.
• On inspection with Sim's speculum, the fistula is situated in the midline half way up the anterior vaginal wall. This usually occurs as a result of prolonged labour. Postoperative fistulas are generally higher up.
• Small fistulae admit a probe with difficulty, but may be seen on cystoscopy. Large fistulae admit one or two fingers.
• Coloured fluid (methylene blue) runs into the bladder through a catheter and immediately flows out into the vagina.
This condition may also affect the individual patient in different ways. Some patients report that they do not experience any sexual enjoyment. In addition, there is the possibility of psychogenic amenorrhea and vulval excoriation with urine. The individual may feel like a social outcast.

Rectovaginal Fistula (RVF)
Most of the rectovaginal fistula are as a result of unrepaired third degree lacerations of the perineum and posterior vaginal wall,

or repairs that have broken down so that an opening is left from the rectum into the vagina. Advanced cancer of the rectum or vagina can also cause RVF but this is rare.
Common symptoms of RVF include:
• With small fistulae, only mucus from the rectum may leak into the vagina. If the fistula are larger, faeces and flatus escape into the vagina.
• The patient will complain of feculent vaginal discharge.
• An inspection of the posterior wall of the vagina and the use of a probe will demonstrate the smaller fistula.
• Perineal excoriation due to leakage of urine and
faecal matter.
• Symptoms may also depend on the site of the fistulae. If on the lower half of the vagina there is incontinence, flatus, or fluid faeces while if on the upper half there is continuous passage of faeces per vaginum.

Management of VVF and RVF
First and foremost, prevention is easier than cure. In most cases fistulae formation can be avoided by:
• Ensuring that labour does not go beyond 12 hours.
• Frequent emptying of bladder or catheterisation during normal labour since a distended bladder is easily traumatised by the pressure of the presenting part, especially in cephalic presentation.
• Control of infection and excoriation (use of infection
prevention principles).
• In the event of destructive delivery due to prolonged labour, catheters should be left in situation for 48 hours to
seven days.
• For VVF, recently formed fistulae will heal if the bladder is drained continuously for 21 to 28 days and for RVF, a low residue diet should be given for the same period.
Where surgery is indicated, it is important that fresh VVF is repaired at once. However, if it is only noticed some days after the injury, then two to three months should be allowed to elapse before the repair. This allows local damage and infection to settle and urinary infection to be eradicated. Most VVF can be closed by an operation via the vaginal route.
In the management of a patient who is due for surgical correction the pre-operative care will include:
• Blood for haemoglobin level, urea, Intravenous Pyelography (IVP) for ureteric fistula.
• Examination Under Anaesthesia (EUA) to detect the type
of fistulae.
• Dye test (methylene blue) into the bladder to detect site
of fistulae.
• Nursing care, including proper nutrition to ensure fitness for
the operation.
• The woman will need a lot of encouragement and support since it can be a very distressing time.
After surgical correction, the following specific care should be given:
• Great care should be taken to secure constant drainage of the bladder to enable the repair to heal well. The catheter should remain in situ for 10 to 14 days.
• Relieve discomfort, give analgesics.
• Prevent infection by giving
prescribed antibiotics.
• Ensure proper nutrition with increased intake of vitamin C and proteins but
low residue.
• Ensure maintenance of local cleanliness through douching, enema and warm
perineal irrigation.
• RVF is repaired after a course of antibiotics to reduce
bowel infection.
• Also sterilise the gut with tabs cabbracol 500gm BD for
five days.
• Give enema on the morning of the operation.
• After the operation, the patient should be placed on a liquid diet for two weeks.
• Liquid paraffin 10ml tds for two weeks, followed by analgesics and broad spectrum antibiotics.
Together with the above, ensure that you provide other general postoperative care, for example, regular observation and
personal hygiene.
Remember:
Once the fistula is repaired, the patient should always opt for elective caesarean section delivery.

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