Definition and Overview
A fistula is an abnormal connection occurring between two hollow organs. A urinary fistula is a connection between any part of the urinary tract and an adjacent organ. Typically, urinary fistulae form in the lower urinary tract, either in the bladder or the urethra, connecting to the genital tract or the lower gastrointestinal tract. Fistulae can also form from the upper urinary tract, but such occurrence is less common.
Different urinary fistulae have specific names, depending on which organs are connected. Fistulae between the urinary tract and the gastrointestinal tract are called uroenteric fistulae. Common types of these are colovesical (connecting the large intestines and the bladder) and rectourethral (connecting the rectum and the urethra). These fistulae can occur in both men and women. Females can also develop fistulae between the urinary tract and the vagina (urogenital fistulae). Common types of these include vesicovaginal (connecting the bladder to the vagina) and urethrovaginal (connecting the urethra to the vagina). Fistulae can also occur between the urinary tract and the skin, which are called urocutaneous fistulae.
Cause of Condition
- Disorders of the gastrointestinal tract, such as those seen in inflammatory bowel diseases like ulcerative colitis or Crohn’s disease
- Diverticulitis, or inflammation of colonic outpouchings
- Infection, such as extrapulmonary tuberculosis
- Cancer in any part of the lower gastrointestinal tract or of the reproductive organs
- Obstruction of the urinary tract.
- Congenital anomalies of the anus and rectum
- Trauma to the pelvic organs
- Injury to the urinary tract during childbirth
- Surgery and radiation therapy for bladder, prostatic, and colorectal cancer
- Interventions in the female reproductive tract, such as Caesarian section or total hysterectomy
With urinary fistulae, waste products from one end can pass to the other end, typically from the side with the higher pressure to the side with the lower pressure. Thus, urine can pass through the genitalia, and gas or fecal material can enter the urinary tract and be excreted through the urethra. Fecaluria, or small pieces of stool coming out during urination, tends to occur quite frequently with urinary fistula connected to the colon or rectum.
Meanwhile, urinary fistula connected to the female reproductive tract tends to result in persistent leakage of urine from the vaginal opening. Patients are unable to hold their urine in, resulting in symptoms of incontinence.
Because of these, a patient with urinary fistula can experience inflammation and swelling in the pelvic area, typically associated with lower abdominal or pelvic pain. Dysuria is quite common, and flank pain may also occur. The patient may also develop febrile episodes. The patient becomes susceptible to the development of skin irritation in the pelvic area and recurrent urinary tract infections. This can cause considerable embarrassment and discomfort to the patient. In worst cases, the infection can become uncontrolled and can spread to the bloodstream, producing life-threatening sepsis.
Who to See and Types of Treatments Available
The treatment of urinary fistulae is surgery. Depending on the kind of urinary fistula that a patient has, he or she may need to consult a colorectal surgeon or a gynaecologist. These doctors will work together to diagnose and localize the urinary fistula.
In order to plan and carry out the proper management of the condition, doctors need a detailed anatomical evaluation. Various diagnostic techniques can be useful in defining the anatomy in these cases. Imaging studies, such as urethrography, computed tomography (CT) and magnetic resonance imaging (MRI) can precisely delineate the fistula and its connections. Cystoscopy makes use of a tube with a camera at the end (scope) in order to examine the urinary tract and visualize the fistula.
Once the diagnosis is confirmed, surgical intervention can then be performed. Depending on various factors, including the location and size of the fistula, surgery may either be done through the perineum or the abdomen. Abdominal surgery, in general, is technically easier and provides better exposure for the surgeon; however, perineal surgery is associated with less morbidity and faster recovery.
Initial surgery may be palliative, which refers to surgeries performed to relieve symptoms. This type of surgery typically involves diversion, which re-directs the flow of the waste products into the proper tracts. Proper drainage will allow resolution of infection, while the underlying condition is being managed.
Surgery may also be curative. This usually involves repair of the fistula and reconstruction of the urinary tract. The urinary tract and the adjacent organs are dissected off each other and separated, also removing inflamed tissues. The fistula is then identified and transected or excised. The openings on either side are then closed off. Complex cases may require more complicated reconstructions using muscle flaps. Nearby healthy muscle can be used to buttress the repair and to serve as a barrier between the two organs, so as to prevent recurrence of the fistula.
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Lentz GM. Anal incontinence. In: Lentz GM, Lobo RA, Gershenson DM, Katz VL. eds. Comprehensive Gynecology. 6th ed. Philadelphia, Pa: Mosby Elsevier; 2012:chap 22.