Fistula

Symptoms vary depending on the location of the fistula and can range from mild to severe. Often, there are no specific symptoms until the condition becomes more advanced. Some individuals may experience one or two symptoms, while others might develop multiple symptoms simultaneously.

Commonly observed symptoms of fistula include:

• Body pain
• Pain around the anus
• Vague feeling of being unwell or uncomfortable
• Constant urine leakage from the vagina
• Irritation in the external female genital organs
• Nausea
• Abdominal pain
• Vomiting
• Fever
• Weight loss
• Diarrhea
• Constipation
• Frequent urinary tract infections

Causes of Fistula

Depending on the type and location of the fistula, there could be different reasons for occurrence. In some cases, they could be formed naturally, while in others, they could be an after-effect of an injury or surgery.

Gastrointestinal diseases: People suffering from gastrointestinal diseases such as Crohn’s disease, colitis, and irritable bowel diseases are at a higher risk of developing fistulas near the anus. Around 1 in 3 people with Crohn’s will likely develop a fistula at some time.

Diverticular diseases: Diverticular disease is a digestive condition. Diverticulosis occurs when small sacs form and push outward through weak spots in the wall of the colon.

Radiation therapy: Patients undergoing radiation therapy as a cancer treatment or otherwise are at a high risk of developing fistulas.

Certain infections: Some infections and diseases such as HIV and tuberculosis can also cause fistulas.

Women’s health and childbirth: Prolonged or obstructed childbirth, injury during pelvic surgery, and radiation treatment in the pelvic or genital area are common causes of vaginal fistulas.

Surgical and medical treatment: Certain surgical treatments can lead to fistulas. For example, complications from gallbladder surgery can lead to biliary fistulas, while radiation therapy to the pelvis can lead to vesicovaginal fistulas.

Therapeutic use: In people with kidney failure requiring dialysis, a Cimino fistula is often deliberately created in the arm to permit easier withdrawal of blood for hemodialysis. During the treatment of portal hypertension, the surgical creation of a portacaval fistula produces an anastomosis between the hepatic portal vein and the inferior vena cava, sparing the portal venous system from high pressure, which can cause many complications.

The causes for developing different types of fistulas vary according to the type and are discussed separately below:

Anal fistula: Anal fistulas are more common in men aged 30-50 years. They can be caused by damaged tissues and are often linked to cysts or infections of the anal glands.

• Clogged anal glands
• Anal abscesses
• Crohn’s disease
• Tuberculosis
• Diverticulosis
• Cancer
• Radiation therapy
• Trauma
• Sexually transmitted diseases

Vaginal fistula: In women, fistulas involve the genitals and urinary tracts. Common causes of these fistulas include:

• Prolonged or obstructed childbirth
• Injury during pelvic surgery
• Radiation treatment in the pelvic or genital area
• Infection and inflammation

Though the exact cause of fistulas is still unknown, there are conditions that put some individuals at a higher risk of developing them. Some of these risk factors include:

• Previous history of anal abscess or fistula: Anal fistulas can be caused by damaged tissues and are often linked to cysts or an infection of the anal glands.
• Crohn’s disease: Studies indicate that 70% of Crohn’s disease patients suffer from fistulas and resulting intestinal obstruction during their disease course.
• Certain infections: Some infections and diseases, such as HIV and tuberculosis, can also cause fistulas.
• Previous surgery or radiation therapy: Patients who have had surgeries in the past or are undergoing radiation therapy as a cancer treatment are at a higher risk of developing fistulas.

Fistula has characteristic symptoms. When you experience the symptoms, book an appointment with your physician at the earliest. Your doctor may ask you questions and inquire about your medical history. Based on your answers, he may suggest some medical tests and a physical examination to confirm the presence of the disease. During the physical examination, he may use a speculum (a metal or plastic device used during a pelvic exam) to look at the vaginal walls.

Medical tests that the doctor may ask you to get done:

• Urine Test: The doctor may suggest a laboratory test to confirm the presence of a urinary tract infection by taking a urine sample.
• Anoscopy: This examination of the anal canal with a scope is used to detect the presence of the fistula. A dye may be used in the vagina, bladder, or rectum to identify all signs of leakage.
• Complete Blood Count (CBC): A CBC is a blood test used to detect a wide range of disorders and infections. The test measures several components of the blood, including red blood cells, white blood cells, platelets, and others.
• X-ray Scan: Fistula can cause tissue damage at the site of infection. An X-ray produces images of the organs and confirms the presence of any tissue damage due to the fistula.
• Magnetic Resonance Imaging (MRI): This imaging test uses a magnetic field to take pictures of organs and structures inside the human body.
• CT Scan: A CT scan (computed tomography) is a machine that takes a series of X-rays to create detailed images. The scan helps to visualize bones, blood vessels, and soft tissues from different angles.
• Endoscopy: This common imaging test uses a thin, flexible, light-viewing instrument called an endoscope, allowing the doctor to examine the inside of organs, canals, and cavities in the body.
• Fistulogram: This special type of X-ray provides detailed imaging of the fistula. During this procedure, a dye is injected into the fistula to enhance imaging. If the fistula connects to the outside of the body, a catheter may be used to insert the dye. If the fistula is present in the rectum, the dye will be injected via the anus before taking the X-ray images.
• Intravenous Pyelogram: This type of X-ray is commonly used for diagnosing bladder fistulas. Prior to the procedure, you may be asked to follow a liquid diet or fast to ensure the colon does not contain any stool, which can obstruct the view of the bladder. A dye is injected into the body (usually via the arm) to obtain clearer images.

Fistulae are preventable and treatable. The risk of certain types of fistula (such as anal fistula) can be lowered by:

• Practicing good hygiene
• Carefully cleaning and treating anal/rectal wounds
• Managing the risk for other health conditions that increase the chances of fistula

According to WHO, fistulas such as obstetric fistula can be prevented by:

• Delaying the age of first pregnancy
• Cessation of harmful traditional practices
• Access to obstetric care

In many cases, the cause of fistula is unknown, making it difficult to suggest a prevention strategy. Patients with Crohn’s disease are at an increased risk of developing fistula at some point in their lives.

If proper medical care is provided to the patient, fistulas can be treated and prevented. Different treatment options for fistula include:

Surgical Treatment

• Surgical treatment: If the fistula fails to respond to medications and antibiotics, surgical treatment might be needed to remove the fistula.
• Fistulotomy: This is the most effective and common type of surgery that involves cutting along the whole length of the fistula to open it up so it heals as a flat scar. It is a surgical treatment for many fistulas (such as anal fistula) that do not pass through much of the sphincter muscles, as it may cause a risk of incontinence.
• Transabdominal surgery: A simple procedure wherein the rectovaginal septum is dissected, the fistula is divided, and the rectum and vagina are closed primarily without bowel resection.
• Laparoscopic surgery: A minimally invasive surgery that involves a tiny incision and the use of cameras and small tools to repair the fistula.
• Endorectal flap procedure: A procedure where healthy tissue is pulled over the internal side of the fistula to prevent feces or other material from reinfecting the channel.

Medications

Depending on the condition and severity of the disease, the doctor prescribes medications that include:

• Antibiotics: These help fight against bacterial infections that, if left untreated, could worsen the patient’s condition. Commonly prescribed drugs include metronidazole and ciprofloxacin, which may help reduce discharge and promote comfort.
• Anti-inflammatory medicines: Usually recommended for people with Crohn’s disease or diverticular disease, they help control the existing fistula from worsening and prevent new ones from developing.
• Immunomodulatory drugs: These have shown to help close the fistula in some cases. Commonly prescribed drugs include azathioprine, which acts slowly and may take up to 3 months to show results.
• Pain relief medications: These help reduce the pain and discomfort caused by the fistula.

Non-invasive Treatment

For small and relatively simple fistulas, doctors often use minimally invasive techniques to manage them. Commonly used non-invasive treatment options include:

• Fibrin glue: A specialized, simple, and painless therapy for small fistulas that do not require invasive treatment. It is a medicinal adhesive that activates thrombin to form a fibrin clot, sealing the fistula tract.
• Collagen plugs: Another method to seal fistulas, where the fistula is plugged using collagen, seen as a first-line treatment for patients with simple fistulas.
• Seton technique: This involves inserting surgical thread inside the fistula tract, allowing it to drain and heal completely.

Follow-up Treatment for Fistulas

Most people respond well to surgeries; however, it is recommended to follow up with your doctor to avoid any complications. Schedule follow-up appointments with your specialist or doctor to ensure the body is effectively responding to the medication and surgery and that you are recovering well.

If you have had surgery to remove the fistula, give yourself a few days to heal. You may be advised to take some medications post-surgery, so make sure you are regular with them. Most people can return to work and their normal routine a week or two after the surgery, depending on the size and severity of the fistula. To expedite the recovery process, here is what you must take note of regarding your diet:

• Eat your normal diet, unless stated by your doctor. Include bland, low-fat foods like rice, toast, and yogurt in your diet.
• Drink plenty of fluids, unless stated by your doctor not to.
• Include high-fiber foods, such as fruits, vegetables, beans, and whole grains in your diet.
• You may notice that your bowel movement is not regular right after the surgery. This is common, and you need not worry.

Here is what you must take note of regarding your activity and movement:

• Get enough sleep and rest when you feel tired. Do not overexert your body.
• Try to walk each day. Gradually increase your mobility. Walking will boost your blood flow and help prevent constipation.
• Do not hesitate to take a shower or bath. Pat your anal area dry with a towel when you are done.
• Your doctor may recommend or prescribe a barrier cream to protect your skin surrounding the wound/fistula from any infection.
• If you notice swelling, try lying on your stomach with a pillow under your hips.
• When you sit on the toilet seat, support your feet with a small step stool. This helps flex your hips and places your pelvis in a squatting position, making bowel movements easier after surgery.
• Wear loose-fitting clothing and cotton undergarments.
• Apply ice several times a day for 10 to 20 minutes at a time. Put a thin cloth between your skin and the ice.
• Try a sitz bath. Sit in 8 to 10 centimeters of warm water for 15 to 20 minutes. Then pat the area dry. Continue this as long as you have pain in your anal area.
• Wear a pad over your anal area until healing is complete.

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Fistulas can be challenging to manage as they often result in significant discomfort and pain. If left untreated, they can lead to serious complications.

• Bacterial Infection or Sepsis: As with any surgery, one of the common complications is infection, which can have severe consequences and affect various body parts. If you notice an abscess, there is a risk of developing sepsis, which can be life-threatening. Contact your doctor immediately if you observe any pus formation or signs of infection.
• Bowel Incontinence: Damage to the anal sphincter muscles can lead to bowel incontinence, resulting in fecal leakage from the rectum.
• Fistula Recurrence: Even after surgery, there is a possibility of anal fistula recurrence. The likelihood of recurrence primarily depends on the complexity and type of surgery performed.
• Bowel Obstruction: Damage to the anal sphincter muscles can also cause bowel blockage or obstruction.

Medical assistance is often recommended for treating fistulas, as they can be painful and hard to deal with. However, there are some alternative therapies that can help alleviate the symptoms and expedite the healing process. Some common home therapies that can be used for fistula include:

• Enteral diets
  People with fistulas in the small and large intestines are often prescribed a special diet called the enteral diet. In this type of diet, the person is recommended to consume only liquid food for a period of time. A liquid diet helps reduce the amount of stool that passes through the intestines and rectum while providing the body with the necessary nutrition, thereby reducing the chances of malnutrition and weakness. An enteral diet may help the fistula close on its own and has been found to heal fistulas completely.
• Tea tree oil
  Known for its antibacterial, antiviral, antiseptic, and anti-inflammatory properties, tea tree oil is an effective home remedy for fistula. It can be used as a natural ointment to kill germs and promote the growth of white blood cells. Mix tea tree oil with olive oil and dab it on the affected area. Leave it for half an hour and then wash it with cold water. Follow this regimen once a day for a few days to relieve anal fistula symptoms.
• Oregano oil
  Oregano oil has soothing and healing properties that can help cure fistula when consumed. It boosts immunity, reduces swelling, prevents bleeding, and kills bacteria around the anus. You can consume oregano oil by mixing it with lukewarm water twice a day.
• Cloves (laung)
  A common condiment in Indian kitchens, cloves possess antibacterial and antiviral properties. They are beneficial for cleansing the colon and boosting the immune system, as well as preventing parasite infections. You can boil a few cloves or clove powder in water and consume that water, or add cloves to your green tea.
• Turmeric milk (haldi doodh)
  Turmeric is a well-known natural antibacterial and antiviral agent. It helps boost the immune system, fight infections, and expedite wound healing. Boil turmeric powder with milk and consume it once a day.

Fistula can be mentally and physically challenging. Though the condition can be treated using medications and home remedies, here are some tips that could help patients with fistula in their day-to-day life.

• Regular warm baths help to relieve fistula pain and discomfort. Keep your bathtub clean to avoid any risk of infection.
• Use portable bidets (also called sitz baths) to maintain cleanliness and hygiene.
• Avoid the use of soap, perfumed products, or salts in the water as they can cause irritation and worsen the condition. Instead, use specialty soaps formulated for sensitive skin.
• Avoid the use of talc, as it may irritate the skin.
• Your doctor may recommend a barrier cream to help protect the affected area. Avoid using any other lotion or cream.
• If you have an anal or vaginal fistula, consult your doctor before using tampons.
• If you experience discharge while on medication, use pads and panty liners.
• Avoid foods that can cause constipation, as this can exacerbate the condition. Stay hydrated and include fibrous foods in your diet.

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