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Clinical Aspects of Fistula Care
- What are the types of genital fistula?
- Why are some fistula repairs considered simple and others more difficult?
- Sometimes a repair procedure does not close the fistula. Why does this occur?
- Why do some women require multiple surgeries?
What are the types of genital fistula?
- Obstetric: Caused by prolonged or obstructed labor. This is the most common cause of genital fistula. During labor, the constant pressure of the baby’s head against the vaginal and bladder or intestinal wall tissue leads to necrosis (death of the tissue), which causes a fistula to develop. The fistula results in the uncontrolled passage of urine and/or feces into the vagina.
- Iatrogenic: Caused by tearing of the vaginal tissues during obstetric or obstetric or gynecologic surgery, such as cesarean delivery or hysterectomy. This cause occurs less frequently than prolonged or obstructed labor.
- Fistula caused by violent sexual assault, including rape and forced insertion of objects into a woman’s vagina: A fistula resulting from sexual violence is an example of “traumatic gynecologic fistula.
Why are some fistula repairs considered simple and others more difficult?
Fistula repairs vary, depending upon the nature of the damage; repairs fall along a continuum from simple to moderate to complicated. For instance, a simple repair typically involves a single small fistula that affects only the vagina and the bladder. Tissue loss and scar tissue formation are minimal. In the hands of a competent surgeon, most fistulas are closed in one surgery.
In contrast, some fistula repairs are more complicated. The woman may have multiple fistulas, and one or more may be large. Sometimes tissue loss and scar formation are significant. Vaginal and bladder capacity may be reduced. In some cases, repair has been attempted previously, but the fistula has not been closed. Compared to simpler conditions, complicated fistulas occasionally involve other parts of the body, such as the rectum, the cervix, or the urethra.
The differences between simple and more difficult repairs will be better defined once a standardized classification system has been created. The Fistula Care project is part of a consortium that is reviewing and validating an internationally recognized system; other members are the World Health Organization, the United Nations Population Fund, and the Johns Hopkins Bloomberg School of Public Health.
Sometimes a repair procedure does not close the fistula. Why does this occur?
Some fistulas are very difficult to repair. Complicated cases may take more than one attempt; a few fistulas may never be closed. Also, some are almost entirely closed but still have occasional leakages.
The success of fistula repair also depends on the quality of postoperative management. Problems such as the blockage of a catheter can reverse the gains made in the operating room. This is why postoperative nursing care is critical for women recovering from fistula repair.
Sometimes a woman’s actions after surgery can compromise a repair. For instance, the woman may resume sexual intercourse too soon or use vaginal tampons causing the repaired site to break down.
Why do some women require multiple surgeries?
Before fistula repair can be attempted, some women require other procedures such as colostomies or removal of bladder stones. In complicated cases, the surgeon may choose to perform multiple operations.
Sometimes, repair attempts do not close the fistula, resulting in the need for additional surgery. This can occur for several reasons, including:
- The damage is extensive.
- The surgeon lacked the skills needed to close the fistula.
- Postoperative care was inadequate.
In some cases, women try vaginal delivery after repair, rather than the recommended planned cesarean delivery. During a vaginal birth, the scar tissue resulting from the repair may not stretch enough, causing a tear; in such cases, fistula may recur.
