Urogenital fistulas: causes and treatment methods

Causes of fistula formation

In 97% of cases, the formation of abnormal canals in the genitourinary system is associated with injuries during childbirth and surgical interventions. According to statistics, 85% of fistulas occur after gynecological operations, 11% after childbirth, 4% after radiation.

The appearance of neoplasms as a result of obstetric operations is facilitated by secondary weakness of labor and an anatomically and functionally narrow pelvis. In such cases, childbirth without obstetric intervention lasts from 2 to 8 days or more. They often occur when the water breaks early and the bladder is full, which greatly contributes to the formation of fistulas.

In the pathogenesis of defects that develop during protracted labor, the main role is played by trophic disorders, prolonged ischemia of the urethral wall, which is caused by compression of the soft tissues between the fetal head and the pubic bones.

Fistulas are detected with equal frequency during the first and repeated births. During repeated births, the risk of defects increases in the presence of inflammatory or cicatricial deformation of the tissues of the genital canal and the tissue surrounding the urinary organs.

They do not occur immediately after childbirth, but after 1-3 weeks or later. This depends on the degree of ischemia and the size of the damaged area of ​​the bladder, and the rate of sequestration of necrotic tissue.

Epidemiology

Worldwide, 75 percent of urogenital fistulas are obstructive birth fistulas. The average age of a woman who develops a fistula as a result of a long labor is 28 years. The average age of a woman who develops a fistula for other reasons is 42 years.[8] Women with a small pelvis are more likely to develop a fistula. Although rare, a fistula can occur after minimally invasive egg removal as part of fertility treatment.[14] Urogenital fistulas (vesicovaginal) caused by surgical complications occur with a frequency of 0.8 per 1000.[1]

What are the symptoms of a fistula?

One of the main symptoms of a urethral fistula in men is urine leakage (involuntary), the nature and characteristics of which depend on the size, shape, and location. The amount of urine excreted depends on the size of the formation. With small sizes of the abnormal channels, natural urination can be preserved to a greater extent, but at the same time involuntary release of urine is observed. With significant defects, all urine flows out. If the fistula has a tortuous or funnel-shaped shape, or a valve shape, patients in a certain position (horizontal or vertical) can partially retain urine.

Patients with large defects always have severe inflammatory changes in the bladder, vagina, and external genitalia. Due to chronic irritation by infected urine, many women experience maceration and even purulent inflammation of the inner thighs.

The following symptoms are often observed: fever, sharp pain in the lumbar region and lower abdomen, vaginal itching in women, inflammation of the genital organs in men, etc.

Causes of urethral fistula

The reasons for the formation of fistulas may be an increase in pressure in the urethra or damage to the mucous membrane, as a result of which, under the influence of various factors, tissue perforation occurs to the surface of the skin or mucous membrane.

Thus, fistulous urethral tracts can be a consequence of:

• injuries of the urethra (domestic injuries of the genital organ, sexual incest);
• infectious and inflammatory diseases with perforation of the wall of the urethra;
• tumors of the genital organ, prostate gland, urethral mucosa;
• urethral strictures;
• iatrogenic causes (erroneous formation of fistulas due to improper performance of surgery on the pelvic organs);
• intentionally formed fistulas for therapeutic purposes in adenoma, prostate cancer, and other tumors localized in the pelvic area.

Laboratory and instrumental diagnostic methods

Only a vaginal examination can determine the number, location, shape, size and nature of the fistula. Most often, single formations are found, but there may be multiple ones. During a vaginal examination, pathological changes such as granulating and encrusted surfaces, ulcers, thread residues, funnel-shaped defects, and scar growths are revealed.

During a bimanual vaginal examination, mobility, rigidity, and soreness of the walls of the vagina and bladder are determined. If there is no inflammatory process in the vagina and its tissues are not sclerotic, it is not difficult to recognize genitourinary fistulas.

Simple and common diagnostic methods include the introduction of colored solutions into the urethra, followed by monitoring their flow through the fistula into the vagina. A vaginal speculum and lift are used for tracking, and a colored liquid is injected into the bladder. If there is a fistula, fluid will flow into the vagina.

In order to identify pinpoint formations, the urethra is filled with a liquid colored with methylene blue, and a tampon is inserted into the vagina, which is stained in the presence of a fistula.

Endoscopic research methods also provide certain information. If the bladder is sufficiently filled, during cystoscopy it is possible to determine the size of the fistula, its location, relationship to the openings of the ureters, the internal opening of the urethra, as well as assess the condition of the mucous membrane of the bladder and perform chromocystoscopy.

The functional capacity of the kidneys and upper urinary tract can be judged by laboratory and radiological methods. The complex of clinical examination includes: determination of biochemical blood parameters, microbiological examination of vaginal flora and (if possible) urine from the bladder.

Treatment of fistulas (urinary, etc.)

The only effective treatment for vaginal fistulas (urethro-vaginal, vesicovaginal, enterovaginal, etc.) today is surgery. Other tactics can not only lead to relapse, but also aggravate the situation.

Of particular importance are:

• competent preparation for surgery and subsequent rehabilitation;
• the specialist has the necessary qualifications (including the skills of a plastic surgeon, successful experience in closing the most complex combined and post-radiation fistulas, skills in working in non-standard situations, etc.);
• availability of modern equipment and various diagnostic methods.

Only such an integrated approach allows the patient to return to their usual lifestyle without the risk of relapse. Treatment of a urinary fistula, like a rectovaginal one, comes down to its excision and separate suturing of the organs between which the anastomosis has formed. You can get specialist advice and choose individual treatment by signing up for a free appointment.

How are fistulas treated?

In rare cases, small fistulas (about 3 mm in diameter) close on their own. The effectiveness of conservative treatment reaches 2.5%. Therefore, the main method of treating patients is surgery.

Surgical and drug treatment

To close genitourinary fistulas (fistuloplasty), three main methods are used - through the bladder, peritoneum or vagina. Sometimes various combinations of these methods are used.

Regardless of which method of fistula closure is chosen, first of all it is necessary to eliminate the sources of inflammation in the genitourinary system. To do this, anti-inflammatory therapy is carried out, taking into account the sensitivity of microorganisms to antibiotics and chemotherapy. Before treatment you need:

• identify microorganisms in urine and determine their sensitivity to antibiotics;
• remove inlays;
• eliminate the inflammatory process in the vagina and external genitalia;
• peel off necrotic masses in the area of ​​the fistula.

This process lasts for 4-6 months. By that time, local inflammatory changes in the tissues disappear, and plastic surgery is possible. Depending on the specific situation, the recommended timing may be changed.

For fistulas caused by the influence of radiation and chemicals, surgery should be performed no earlier than after 1 year. Fistulas of the genitourinary system formed due to tumors are not subject to surgical correction.

The main steps in closing genitourinary fistulas are excision of the scar tissue that surrounds the edges of the opening and splitting of the edges of the fistula (until the vaginal wall is completely separated from the bladder wall).

To ensure primary healing, it is necessary to align the edges without tension so that the adjacent surfaces consist of anatomically homogeneous tissues, and the suture lines on the wall of the bladder and vagina do not coincide.

Traditional medicine in the treatment of fistulas

On the Internet you can find a wide variety of folk remedies for the treatment of fistulas: from douching with chamomile to tampons with St. John's wort tincture. But, as all urologists and gynecologists note, such methods can disrupt the vaginal microflora, provoke the occurrence of ulcers, inflammatory processes, but cannot cure the fistula. A fistula can only be removed through surgery; all other methods for eliminating inflammation and pain are important to discuss with your doctor. Self-medication can only worsen the situation and even lead to cancer.

Care

Surgery is often required to correct a fistula leading to the vagina. Conservative treatment with a home catheter may be effective for small and recently formed urinary fistulas. The success rate is 93%.[1][4] Collagen plugs have been used but have been unsuccessful.[6] Corrective surgical treatment can be approached in different ways. Surgery through the vagina is successful in 90% of cases. Surgical correction can be accomplished by abdominal surgery, laparoscopic surgery, or robotic laparoscopic surgery.[13] Different types of treatment vary in frequency. The transvaginal approach is used in 39% of cases, the transabdominal/transvaginal approach is used in 36% of cases, the laparoscopic/robotic approach is used to treat 15% of urogenital fistulas, and the combination transabdominal-transvaginal approach is used in 3% of cases. time.[1]

Features of the recovery period

When a diagnosis of “vesico-vaginal fistula” is made, the patient, with consent, undergoes surgical intervention - fistuloplasty; in the presence of stones, surgical intervention is supplemented with cystolithotomy. When the expected results are achieved (restoration of adequate urodynamics of the lower and upper urinary tract), patients undergo rehabilitation measures. In case of unsatisfactory results of treatment, complications that have arisen are treated, or sanitation of the genitourinary organs is carried out and, if necessary, repeated surgical treatment. A follow-up examination is carried out 3 months after surgery, a year later and annually thereafter.

How to avoid fistula tracts

The question of how to avoid the appearance of abnormal canals in the genitourinary system is relevant for many men and women who are concerned about their health. You can avoid the occurrence of fistula tracts:

• avoiding infectious diseases during the postpartum and postoperative period;
• if there are injuries, consult a doctor immediately and undergo a course of treatment;
• after surgery, observe all restrictions: diet (foods that will not cause constipation and bloating), lack of physical activity, etc.