Vaginal fistula are pathological fistula connecting the vagina with the intestines or urinary organs (bladder, ureter, urethra). Through the fistula passages, the contents of the intestine and urinary tract (feces, gases, urine) enter the lumen of the vagina. Vaginal fistula is diagnosed according to the results of gynecological examination, endoscopic and X-ray examinations of the pelvic organs. Treatment of fistulas is surgical, aimed at eliminating the pathological communication of the vagina with other organs.
Vaginal fistulas are a serious complication, often found in obstetrics and gynecology. The vaginal wall is in direct contact with the walls of the rectum and urinary organs, therefore, when a pathological communication occurs between them, a fistula defect is formed.
Among the vaginal fistula, there are vesicovaginal, ureterovaginal, urethrovaginal, rectovaginal, colonic-vaginal, small-intestinal-vaginal. According to the location, vaginal fistulas are divided into low (in the lower third of the vagina), medium (in the middle third) and high (in the upper third of the vagina). Most vaginal fistulas have acquired character, while the features of development and clinical signs of the disease depend on the causes of the defect formation.
The most common – traumatic vaginal fistulas occur as a result of damage to the intestinal wall, urinary tract and vagina during invasive manipulations and operations in urology, obstetrics and gynecology. Urogenital fistulas are usually a complication of reconstructive operations with urethral diverticula, stress urinary incontinence, prolapse of the anterior wall and vaginal cysts, radical hysterectomy, supravaginal amputation of the uterus, etc.
Rectovaginal fistulas are more often formed as a result of obstetric trauma or trophic disorders in pathological childbirth. Trauma or rupture of the birth canal when they do not match the size of the fetus, pelvic presentation of the fetus, surgical delivery may be accompanied by damage to the walls of the vagina, rectum and its ligamentous-muscular apparatus. The development of vaginal fistulas may be based on prolonged ischemia and necrosis of soft tissues due to their compression between the fetal head and pelvic bones during prolonged labor and a prolonged anhydrous interval.
Inflammatory fistulas are usually formed as a result of opening abscesses into the vaginal lumen or perforation of acute paraproctitis or diverticulitis. Less often, the causes of vaginal fistulas can be burns (chemical, electrical), household trauma of the rectovaginal septum, ectopia of the ureter, Crohn’s disease, irradiation of the pelvic organs during radiation therapy, tumor diseases of the pelvic organs.
The course of vaginal fistulas, as a rule, has a chronic, recurrent character. With urogenital fistulas, patients are concerned about involuntary partial or complete urinary incontinence due to its leakage from the vagina, frequent urinary tract infections. There is maceration of the epidermis in the perineum and thighs, swelling and hyperemia of the vaginal mucosa.
Leakage of urine with preserved urination usually indicates punctate or highly located fistulas. When there are urethro-vaginal fistulas in the middle or proximal part of the urethra, urine cannot be held either in the vertical or horizontal position of the patient. With the progression of pathology, pain is observed in the vagina and bladder. With intestinal-vaginal fistulas, complaints of incontinence of gases (with spot fistulas) and feces (with large fistulas), the discharge of gases and feces through the vagina, burning and itching of the genitals due to irritation of the mucous membrane around the fistula are characteristic.
Constant infection of the vagina from the rectum is manifested by frequent exacerbations of colpitis, vulvitis, provoking pain in the perineum at rest and during sexual intercourse. Rectovaginal fistulas are often accompanied by gross scarring of the posterior wall of the vagina and perineum, failure of the pelvic floor muscles and a defect of the rectal sphincter.
With vaginal fistulas of purulent-inflammatory genesis, there may be a deterioration in the general condition, fever, pain in the lower abdomen and pubic area, radiating into the rectum or lower back, purulent white, loose stools with an abundance of mucus and pus in the feces, dysuria, pyuria, sometimes menuria. Symptoms of vaginal fistulas cause physical discomfort and are often accompanied by psychoemotional disorders.
Diagnosis of any vaginal fistula begins with a thorough collection of anamnesis data and gynecological examination of the patient. In the case of low-lying vaginal fistulas, when examined in mirrors, you can see a retracted scar (fistula), from which urine or intestinal contents are excreted. Determination of the height and direction of the fistula stroke is performed by probing with a button probe. To clarify the localization of vaginal fistulas, urethrocystoscopy and chromocystoscopy with indigocarmine are performed.
In the diagnosis of vaginal fistulas of inflammatory genesis, ultrasound of the pelvis and ultrasound of the kidneys, laboratory tests of blood and urine are shown. With difficult-to-diagnose high and spot vaginal fistulas, excretory and retrograde urography, renography, cystography, and, if necessary, vaginography are additionally performed. In the case of rectogenital fistulas, a rectovaginal examination is performed to determine the size, consistency of the fistula, the volume of scarring of surrounding tissues, the degree of insufficiency of the anal sphincter, the presence of infiltration, the possibility of abscess development.
Mandatory endoscopic examination, clarifying the location of the vaginal and intestinal fistulas, is a rectoromanoscopy, if necessary, differentiation of the diagnosis – colonoscopy. With complex fistulas, contrast X-ray examinations are performed: irrigoscopy, fistulography, which help to see the branches and fistula congestion.
Diagnosis of vaginal fistulas may include cytological or histological examination of the affected tissues taken during biopsy, CT. Assessment of the rectoanal reflex is carried out using instrumental methods – sphincterometry, electromyography, anorectal manometry.
The tactics of treating vaginal fistula depends on the main characteristics of the fistula, the condition of the surrounding tissues, pelvic floor muscles and rectal sphincter. Small cystovaginal fistulas can heal themselves after conservative treatment; spot fistulas of the urethra and bladder can be closed by electrocoagulation.
In most genitourinary fistulas, 3 to 6 months after the injury, when the inflammatory processes subside, surgical excision of the cicatricial lesion in the fistula area is indicated, followed by separate suturing of defects in the vaginal wall, bladder or urethra with the use of flap plasty. In the case of ureterovaginal fistula, ureterocystoneostomy is performed. Acute rectovaginal injuries are urgently eliminated within the first 18 hours: after preliminary treatment of the wound edges, non-viable tissues near the fistula are excised and levators, rectal and vaginal walls are sutured in layers.
Surgical intervention with formed vaginal and rectal fistulas is determined by the specific situation and is performed by vaginal, perineal or rectal accesses, with a significant scar lesion – laparotomy. After excision of scar tissue and fistula, anterior levatoroplasty is performed, if necessary, it is combined with vaginoplasty, with a pulp defect, sphincteroplasty is performed with subsequent suturing of intestinal and vaginal defects. With scarring or purulent process in the area of the fistula, a colostomy is first applied for 2-3 months to remove fecal masses from the area of the future operation.
Prognosis and prevention
Serious postoperative complications of vaginal fistulas are the failure of intestinal sutures and recurrence of fistula, requiring repeated radical surgery. The prognosis for working capacity and quality of life after removal of vaginal fistulas is relatively favorable. Women after the closure of the vaginal fistula are recommended to deliver the next pregnancy by caesarean section no earlier than 2-3 years after the operation.
Prevention of vaginal fistulas consists in the prevention of obstetric injuries, qualified management of obstetric and gynecological operations, timely treatment of genital inflammation.