Pelvic Fistula

What a pelvic fistula is

A fistula is a tunnel lined with tissue that connects two spaces that are normally separate. In the pelvis, the bladder, ureters, uterus, vagina, rectum and lower colon lie very close together, so an injury, infection or tumor in one can break through into its neighbor.

Types of pelvic fistula

A fistula draining into the groin or near the anus is usually an anal fistula or a fistula from Crohn's disease rather than a urogenital fistula. One opening onto the abdominal skin is an enterocutaneous fistula.

Symptoms of a fistula in the pelvis

• Constant dribbling of urine from the vagina, often in addition to normal urination
• Passing gas or stool through the vagina
• Foul-smelling vaginal discharge
• Bubbles in the urine or urine that looks cloudy with particles
• Repeated urinary tract or vaginal infections
• Soreness, rash and irritation of the vulva and inner thighs
• Pelvic pain or fever if an abscess forms

Symptoms after surgery usually appear 1 to 3 weeks later, when injured tissue breaks down.

Causes and risk factors

Childbirth (obstetric fistula)

Prolonged, obstructed labor, lasting days without access to a cesarean, crushes the tissue between the baby's head and the pelvic bone. The tissue dies and leaves a hole into the bladder, rectum or both. Obstetric fistula remains common in parts of sub-Saharan Africa and South Asia, where the World Health Organization estimates hundreds of thousands of women live with it. It is rare where emergency obstetric care is available. Severe tears during delivery can also cause rectovaginal fistulas anywhere.

Pelvic surgery

In the US and Europe, most vesicovaginal fistulas follow hysterectomy, usually an unnoticed injury to the bladder. Cesarean sections, prolapse and incontinence surgery and bowel surgery can also cause them.

Radiation

Radiotherapy for cervical, uterine, bladder or rectal cancer damages blood supply. Fistulas may appear months to years after treatment and are harder to repair.

Bowel disease

• Diverticulitis is the leading cause of colovesical and colovaginal fistulas.
• Crohn's disease causes fistulas from the bowel to the vagina, bladder, skin or around the anus.

Cancer and other causes

Advanced cervical cancer, colorectal or bladder cancer, pelvic infection and trauma are less common causes.

How it is diagnosed

1. Pelvic exam with a speculum to see a hole or leakage.
2. Dye tests: a blue dye is placed in the bladder with a tampon in the vagina. A blue-stained tampon suggests a bladder fistula. A tampon wet but not blue suggests a ureter fistula.
3. Cystoscopy: a camera in the bladder to locate the opening.
4. CT scan or CT urogram: shows air in the bladder, abscesses, diverticulitis and ureter injuries.
5. MRI of the pelvis: especially for rectovaginal and Crohn's fistulas.
6. Colonoscopy or sigmoidoscopy to look for diverticular disease, Crohn's or cancer.
7. Biopsy if there is any history of cancer.

Treatment

First steps

• A urinary catheter for several weeks may allow a small, fresh vesicovaginal fistula to heal on its own.
• Antibiotics and drainage for infection or abscess.
• Skin protection with barrier creams and continence pads.
• Medical treatment of Crohn's disease, which can close some fistulas.

Surgery

Most pelvic fistulas need surgery to close the hole with healthy, well-supplied tissue:

• Vesicovaginal fistula repair: through the vagina or abdomen, sometimes robotic. Success rates for first repairs of simple fistulas are around 90 percent.
• Rectovaginal repair: through the vagina, the perineum or the abdomen, sometimes with a muscle flap.
• Colovesical fistula: removing the diseased part of the colon and closing the bladder hole.
• Ureter reimplantation for ureteric fistulas.
• Temporary colostomy may protect a complex bowel repair.

Radiation fistulas and repeat repairs have lower success and may need tissue flaps or urinary diversion.

Living with a pelvic fistula

Constant leakage causes skin damage, odor, isolation and depression. Obstetric fistula in particular carries stigma and is linked to a stillbirth in most cases. Counseling, pelvic floor therapy and good continence products help while waiting for repair, and after a successful repair most women return to normal activities. Future pregnancies after fistula repair are usually delivered by planned cesarean.

Prevention

• Access to skilled birth attendants and timely cesarean section prevents obstetric fistula.
• Careful surgical technique and checking the bladder during pelvic surgery.
• Prompt treatment of diverticulitis and Crohn's disease.

Frequently asked questions

What are the symptoms of a fistula in the pelvis?

Common symptoms are constant urine leaking from the vagina, gas or stool coming from the vagina, foul vaginal discharge, air bubbles or debris in the urine and repeated urinary infections. Skin irritation and pelvic pain or fever can occur if infection develops.

Is a fistula in the groin a pelvic fistula?

Not usually. A draining opening in the groin or near the anus is most often an anal fistula, an infected hair follicle tract, or a fistula from Crohn's disease. Pelvic or urogenital fistulas connect internal organs such as the bladder and vagina. A doctor can tell them apart with an exam and imaging.

Can a pelvic fistula heal on its own?

Some small fistulas heal with a catheter draining the bladder for a few weeks, or with treatment of Crohn's disease. Most, especially larger or older ones, need surgical repair. Radiation-related fistulas rarely close without surgery.

What causes a vesicovaginal fistula?

In high-income countries, most follow hysterectomy or other pelvic surgery. Worldwide, the main cause is prolonged obstructed labor without timely cesarean. Radiation therapy and pelvic cancers are other causes.

How successful is fistula surgery?

First repairs of simple vesicovaginal fistulas succeed in about 90 percent of cases. Success is lower for large, complex, radiation-related or previously repaired fistulas, which may need several operations or specialist centers.