Vaginal Fistula

Understanding Vaginal Fistula

Vaginal fistula is an unusual opening that connects the vagina to another nearby organ in females. These openings can occur between the vagina and various organs such as the rectum, urinary bladder, urethra, ureter, and small and large intestines. This discussion focuses on the management of fistulas connecting the vagina to the rectum or bladder.

Role of Plastic Surgeons in Fistula Management

Plastic surgeons become involved in the treatment of vaginal fistulas, particularly rectovaginal or difficult recurrent vagino-bladder fistulas when other surgical specialists like gynecologists and urologists have exhausted alternative options. Fistulas located at higher positions within the abdominal region are typically managed by urologists and general surgeons.

Causes of Vaginal Fistulas

The primary cause of vaginal fistulas is damage to the tissues between the vagina and another organ due to various factors, including:

• Childbirth or labor.
• Abdominal surgeries (such as hysterectomy or cesarean section).
• Pelvic, cervical, or colon cancer .
• Radiation treatment.
• Bowel diseases like Crohn’s or diverticulitis.
• Infections (including post-episiotomy or labor-related tears).
• Traumatic injuries, such as those from car accidents.

Symptoms of Vaginal Fistula

Vaginal fistulas can be distressing for women due to symptoms such as:

• Continuous leakage and the presence of bad odors.
• Inability to control urination (incontinence) in cases of a bladder-vaginal fistula.
• Fecal matter or gas leakage from the rectum into the vagina, potentially causing bowel. control issues in cases of rectovaginal fistulas.
• Genital infections or sores.
• Painful intercourse.
• Recurrent vaginal or urinary tract infections.
• Hygiene problems.

Diagnosis of Vaginal Fistula

Diagnosing vaginal fistula involves a pelvic examination and a review of the patient’s medical and surgical history to identify risk factors such as recent surgeries, infections, or radiation therapy. Additional investigations may be necessary to confirm the diagnosis and determine the number and extent of fistulas:

• Fistulogram: An X-ray image to visualize the fistula, identify the number of fistulas, and assess the involvement of other pelvic organs.
• Dye Test (for bladder fistulas): The bladder is filled with a dye solution, and the patient is asked to cough or bear down. If a vaginal fistula is present, the dye will leak into the vagina.
• Cystoscopy (for bladder fistulas): A thin device called a cystoscope is used to inspect the bladder and urethra for signs of damage and fistula openings.
• Flexible Sigmoidoscopy (for rectum fistulas): Examination of the anal and rectal area with a sigmoidoscope, a thin, flexible tube with a tiny video camera at the tip.
• Pelvic MRI (for rectum fistulas): Detailed imaging of the rectum and vagina to provide a clearer view of rectovaginal fistulas.

Vaginal Fistula Treatment at Kayakriti

Treatment approaches for vaginal fistulas vary based on factors such as the size of the fistula and its location:

• Small vaginal fistulas may heal spontaneously. For bladder fistulas, a catheter is inserted to drain urine and allow the fistula time to heal. Antibiotics are also administered to treat associated infections.
• Very small rectal fistulas may also heal without intervention if gut sterility is maintained with medications and the patient adheres to a liquid diet.
• Large fistulas typically require surgery. The type of surgical procedure depends on the type and location of the fistula and may involve laparoscopy or abdominal surgery. These surgeries are usually performed by gynecologists, general surgeons, or urologists.
• In many cases, diversion colostomy or urinary diversion procedures are required to promote healing and prevent further complications.

Role of Plastic Surgeons in Vaginal Fistula Treatment

Plastic surgeons play a critical role when recurrent fistulas connect the vagina to the bladder or rectum. In these cases, plastic surgeons use healthy tissue from another area of the body to seal the fistula. The procedure involves bringing a well-vascularized muscle and pedicled flap from the thigh to create a proper seal between the rectum and vagina, allowing for successful healing.

Challenges in Failed Fistula Surgery

Failed fistula surgeries often involve inflamed and scarred margins of the fistula and its surrounding area, which may not hold sutures, leading to repeated fistula formation.

Procedure for Recurrent Rectovaginal Fistula

The surgery for recurrent rectovaginal fistula involves the introduction of healthy tissue from the thigh, usually in the form of a muscle and well-vascularized pedicle flap. This flap is inserted between the rectum and the vagina to promote proper healing. The procedure is typically performed under regional anesthesia in a lithotomy position and takes approximately one to two hours.