Fistula

While the exact cause of fistulas is not fully understood, certain factors increase the likelihood of developing them. Risk factors include:

• A history of anal abscesses or fistulas: Previous anal abscesses or fistulas often result from damaged tissues, infections, or cysts in the anal glands.

• Crohn’s disease: Research shows that 70% of individuals with Crohn’s disease develop fistulas during the progression of the condition.

• Certain infections: Infections such as HIV and tuberculosis may lead to fistulas.

• Previous surgeries or radiation therapy: Individuals who have had surgeries or undergone radiation treatment, especially in the pelvic area or for cancer, are at a higher risk of developing fistulas.

Fistulas often present with distinct symptoms. If you experience any of these symptoms, it's important to schedule an appointment with your doctor as soon as possible. During the consultation, the doctor will likely ask about your medical history and any symptoms you're experiencing. Based on this, they may recommend certain tests and a physical examination to confirm the diagnosis.

During the physical examination, the doctor might use a speculum, a tool used during pelvic exams, to inspect the vaginal walls.

Possible medical tests your doctor may recommend include:

• Urine test: This test helps identify urinary tract infections by analyzing a urine sample.
• Anoscopy: This procedure involves using a scope to examine the anal canal for signs of a fistula. A dye may be applied in the vagina, bladder, or rectum to detect any leakage.
• Complete blood count (CBC): A CBC is a blood test that can help detect various conditions, including infections. It measures red blood cells, white blood cells, platelets, and other blood components.
• X-ray: Fistulas may cause tissue damage at the site of infection. An X-ray can reveal any damage to organs, confirming the presence of a fistula.
• Magnetic resonance imaging (MRI): MRI uses magnetic fields to capture detailed images of organs and structures inside the body.
• CT scan: A CT scan, or computed tomography, takes a series of X-rays from different angles to create detailed images of bones, blood vessels, and soft tissues.
• Endoscopy: This procedure uses a thin, flexible instrument called an endoscope to examine internal organs, canals, and cavities in the body.
• Fistulogram: A specialized X-ray that provides detailed images of a fistula. During this procedure, dye is injected into the fistula to enhance the image. If the fistula is connected to the outside of the body, a catheter may be used to insert the dye. In the case of a rectal fistula, the dye is injected through the anus before X-ray images are taken.
• Intravenous pyelogram: This X-ray is often used to diagnose bladder fistulas. Before the procedure, patients may need to follow a liquid diet or fast to ensure that the colon is clear of stool, as this could obstruct the view of the bladder. Dye is injected into the body (usually via the arm) for clearer images.

Fistulas can be prevented and treated. The likelihood of developing certain types of fistulas, such as anal fistulas, can be reduced by:

• Maintaining good hygiene
• Properly cleaning and treating anal/rectal wounds
• Managing conditions that may increase the risk of fistulas

According to the WHO, obstetric fistulas can be prevented by:

• Delaying the age of the first pregnancy
• Abandoning harmful traditional practices
• Ensuring access to proper obstetric care

Since the cause of some fistulas remains unknown, prevention can be challenging. Individuals with Crohn's disease are at a higher risk of developing fistulas over time.

Specialists to Consult

If you notice any symptoms related to fistulas, seek medical attention without delay. Your doctor will review your medical history and perform an examination to determine if a fistula is present. In many cases, they may recommend tests such as an MRI or ultrasound for further clarity.

Depending on the location and severity of the fistula, you may be referred to a specialist, such as:

• Gynecologist
• General surgeon
• Urogynecologist
• Urologist
• Colorectal surgeon
• Gastroenterologist

Fistulas can be treated and managed with appropriate medical care. The treatment approach will vary depending on the type and severity of the fistula, and can include the following options:

Surgical Treatment

If medications and antibiotics fail to resolve the fistula, surgery may be required to remove it.

• Fistulotomy: This is one of the most common and effective surgical procedures for treating fistulas. It involves making an incision along the entire length of the fistula to allow it to heal as a flat scar. This method is often used for fistulas that do not affect much of the sphincter muscle, as those are at a higher risk for causing incontinence.
• Transabdominal Surgery: A straightforward procedure that involves dissecting the rectovaginal septum, dividing the fistula, and closing the rectum and vagina without requiring bowel resection.
• Laparoscopic Surgery: This minimally invasive procedure uses small incisions, a camera, and specialized instruments to repair the fistula.
• Endorectal Flap Procedure: In this surgery, healthy tissue is moved over the inside of the fistula to prevent feces or other substances from re-infecting the channel.

Medications

The type and severity of the fistula will determine which medications the doctor prescribes:

• Antibiotics: To combat bacterial infections that could worsen the condition, commonly prescribed antibiotics include metronidazole and ciprofloxacin to reduce discharge and provide comfort.
• Anti-inflammatory Drugs: These are typically used for patients with Crohn’s disease or diverticular disease to prevent fistulas from worsening and to prevent the formation of new ones.
• Immunomodulatory Drugs: These can help close the fistula, although they may take several months to show results. Azathioprine is an example of such a drug.
• Pain Relief Medications: To alleviate discomfort and pain associated with the fistula.

Non-Invasive Treatments

For smaller and simpler fistulas, doctors often recommend less invasive options:

• Fibrin Glue: A simple and painless treatment for small fistulas, fibrin glue is a medicinal adhesive that triggers thrombin to form a fibrin clot, effectively sealing the fistula.
• Collagen Plugs: Another option for sealing fistulas, this involves using collagen to plug the fistula. This is often the first-line treatment for simple fistulas.
• Seton Technique: A surgical thread is inserted into the fistula tract, allowing it to drain and heal fully.

Follow-Up Care

Most people respond well to surgery, but it’s important to attend follow-up appointments with your doctor to monitor the healing process and avoid complications. These check-ups ensure that the body is healing well and responding to both medications and surgical procedures.

Fistulas can be both physically and emotionally challenging, causing significant discomfort and pain. If left untreated, they may lead to serious complications:

Bacterial Infections or Sepsis

Infections are a common complication associated with fistulas and surgeries. If an abscess forms, there is a risk of developing sepsis, which can be life-threatening. It's crucial to contact your doctor immediately if you notice pus or signs of infection.

Bowel Incontinence

Damage to the anal sphincter muscles can result in bowel incontinence, leading to fecal leakage from the rectum.

Recurrence of Fistula

In some cases, even after surgical treatment, anal fistulas may recur. The likelihood of recurrence depends largely on the complexity of the fistula and the type of surgery performed.

Bowel Obstruction

Damage to the anal sphincter muscles may also cause a bowel obstruction, which can make passing stool difficult.

While medical treatment is typically recommended for fistulas, some alternative therapies may help alleviate symptoms and promote healing:

Enteral Diets

• For those with fistulas in the intestines, an enteral diet (liquid foods only for a certain period) may be prescribed. This reduces stool passage through the intestines while providing necessary nutrition, helping the fistula heal and reducing the risk of malnutrition.

Tea Tree Oil

• With its antibacterial, antiseptic, and anti-inflammatory properties, tea tree oil can help treat fistulas. It can be mixed with olive oil and applied to the affected area. Leave it on for about 30 minutes before washing it off with cold water. Repeat daily for several days to relieve discomfort.

Oregano Oil

• Oregano oil, known for its soothing and healing properties, can help treat fistulas. It boosts immunity, reduces swelling, and fights bacterial infections. To use, mix oregano oil with lukewarm water and consume it twice daily.

Cloves

• Cloves have antibacterial and antiviral qualities and are beneficial for cleansing the colon and boosting the immune system. You can boil cloves in water and drink it, or add them to your green tea.

Turmeric Milk

• Turmeric is a powerful natural remedy with antibacterial and antiviral properties that aids in infection control and wound healing. Boil turmeric powder with milk and consume it once a day to support healing.

After surgery to remove a fistula, you will need time to heal. Follow your doctor’s post-surgery advice and take prescribed medications as directed. In many cases, patients can return to work and normal activities within one or two weeks, depending on the severity of the fistula.

Regarding your diet:

• Stick to your regular diet unless instructed otherwise by your doctor. Include bland, low-fat foods such as rice, toast, and yogurt.
• Drink plenty of fluids unless directed not to by your doctor.
• Incorporate high-fiber foods like fruits, vegetables, beans, and whole grains.

You might experience irregular bowel movements right after surgery, which is normal and should not cause concern.

Regarding your activity and mobility:

• Rest when you feel tired, and avoid overexerting yourself.
• Try to walk daily and gradually increase your walking distance. This will improve circulation and help prevent constipation.
• You can shower or bathe, but make sure to dry your anal area gently with a towel afterward.
• Your doctor may recommend or prescribe a barrier cream to protect the skin around the wound or fistula from infection.

If you notice swelling, lying on your stomach with a pillow under your hips may help.

• When using the toilet, consider using a small step stool to elevate your feet. This position helps flex your hips and can ease bowel movements after surgery.
• Wear loose-fitting clothing and cotton underwear.
• Apply ice to the affected area for 10 to 20 minutes several times a day, using a thin cloth between your skin and the ice.
• A sitz bath can help. Sit in 8 to 10 centimeters of warm water for 15 to 20 minutes, then gently pat the area dry. Continue using a sitz bath as long as you experience pain in the anal area.
• Use a pad over the anal area until it has fully healed.

Fistulas can be mentally and physically exhausting, but they are manageable with proper treatment and lifestyle adjustments. Here are a few tips that might help individuals with fistulas in daily life:

• Regular warm baths can help alleviate pain and discomfort associated with fistulas. Ensure that the bathtub is clean to prevent infection.
• Consider using portable bidets (sitz baths) for maintaining hygiene in the affected area.
• Avoid using soap, scented products, or salts in the water as they can irritate the area. Opt for gentle soaps designed for sensitive skin.
• Do not use talcum powder, as it may cause further irritation.
• A barrier cream may be recommended by your doctor to protect the affected area. Avoid using any other lotions or creams without consulting your doctor.
• If you have an anal or vaginal fistula, avoid using tampons unless your doctor approves.
• If you're experiencing discharge while on medication, use pads or panty liners to maintain cleanliness.
• Avoid constipation by staying hydrated and including fiber-rich foods in your diet.