Diagnosis and Treatment of Fistulae: Comparison
Please note this is a comparison between Version 1 by Maciej Stanisław Walędziak and Version 2 by Wendy Huang.

Gynecological fistulae are a rare but severe complication of radiation therapy, pelvic surgery, prolonged labor, cesarean deliveries, or inflammatory bowel diseases. A gynecological fistula is an abnormal pathway formed between the urinary and gynecological tract, most commonly located between the urinary bladder and vagina. Vesico-uterine and vesicovaginal fistulae are an important health issue, common in women of reproductive age in developing countries with limited access to obstetrical care. Various surgical techniques have been described for vesicovaginal fistula (VVF) repair, depending on the location, severity, and cause of the fistula and the surgeon’s experience.

  • diagnosis
  • fistulae
  • treatment
  • vagina
  • bladder

1. Introduction

A pathological connection between the vagina and other surrounding organs, such as the bladder, rectum, or uterus, is defined as a gynecological fistula. The connection enables urine or feces to enter the vagina, which can lead to leakage and many associated symptoms. Radiation therapy, pelvic surgery, delivery complications, or inflammatory illnesses such as Crohn’s disease are the most common factors responsible for gynecological fistulae [1]. Locally advanced gynecological malignancies, such as cervical cancer, and previous radiation therapy due to pelvic malignancies, are among the causes of an abnormal pathway between the urinary and gynecological tract and are most commonly located between the urinary bladder and vagina. There are also many cases of vesico-uterine fistulae, mostly in younger women with a previous history of pelvic surgical procedures [2].
The most important types of genitourinary fistulae are vesicovaginal, urethrovaginal, vesico-uterine, urethrocutaneous, or combined (multiple) fistulae. Vesicovaginal fistulae (usually secondary to a prolonged second stage of labor) are most common in communities with a high rate of out-of-hospital births. With urbanization and a consequent tendency of births to occur in a hospital setting, there has been an increase in the frequency of this kind of fistulae secondary to medical interventions, such as cesarean sections, hysterectomies, and others, as well as secondary to malignant diseases, caused by the diseases themselves or by the treatment interventions. The latter fistulae are more often of the urethrovaginal or vesico-uterine type [3].
Vesicovaginal fistula (VVF), which is a connection between the bladder and vagina, is the most prevalent type of fistula. In most cases, it is caused by obstetrical and gynecological damage or interventions. VVFs cause persistent urine leakage from the vagina, which immensely deteriorates the patient’s quality of life (QUALY). Gynecological surgery is the most important factor responsible for VVFs in higher-income countries, with the most common cause of VVFs being a bladder injury during a hysterectomy [4].
An endometriotic lesion in the rectum or other part of the larger intestine leads to an inflammation process, tissue damage, and the development of a pathological connection between the bowel and vagina [5]. A connection between the rectum and vagina is called rectovaginal fistula (RVF), which is responsible for such symptoms as feces or urine incontinence, pathological vaginal discharge, recurrent pain, and chronic infections due to bacteria transfer from the intestinal lumen to the vagina. Vesico-uterine fistulae can occur after hysteroscopy, in association with endometriosis, intrauterine device migration, inflammatory bowel disease, or due to urinary bladder tuberculosis [2].

2. Diagnosing Fistulae

The visualization of fistulae using radiology imaging is of great utility both in diagnosis and therapy planning. Gynecological fistulae can be found using a variety of techniques. Radiological imaging allows identifying both the fistula itself and the possible lesions in the surrounding tissues, such as the bladder, urethra, or rectum. It can also be used in deciding about the optimum treatment plan and the surgery protocol. Ultrasound examination can identify intestinal, bladder, ovarian, or uterus abnormalities, being non-invasive and providing preliminary information [6]. Conventional radiography scans can identify calcifications or other bone alterations that may be related to a fistula in the pelvic or urinary tract, even though it is not typically used as the primary imaging technique for fistula diagnosis. The conventional vaginography exam is a radiographic technique that has been used in diagnosing vaginal fistulae since the 1960s as a simple and accurate method. Contrast is injected into the vagina and images are acquired to detect the possible presence of a fistula. Computer tomography vaginography is a more precise method that allows the evaluation of anatomy and permeability of the fistula and can help the surgeon to plan the optimum surgical approach. The resulting images can show the position and size of the fistula, as well as any alterations in surrounding structures, such as the intestine, bladder, or urethra [7]. Magnetic resonance imaging (MRI) is the method of choice in diagnosing fistulae, as it allows detailed visualization of the pelvic and perineal structures, including the anal sphincter muscles. MRI affords the possibility to distinguish between malignant tissue, post-surgical fibrosis, acute inflammatory changes, or abscesses. Thus, if the patient’s clinical parameters allow it, MRI is the suggested imaging technique to investigate the presence of suspected urethro-, ano-, and recto-vaginal fistulae [8].

3. Treatment of Fistulae

There are different methods of treatment of VVF, including fulguration, occluding devices, prolonged catheterization, open repair, and laparoscopic or robotic surgery [9][10][11][12][9,10,11,12]. The typical treatment for gynecological fistulae is the surgical excision of the abnormal connection to reestablish normal function. Laparoscopy is of great advantage when compared to open surgery, including a lower postoperative pain level, smaller incisions, lower blood loss, a shorter hospital stay, and faster recovery. It is associated with a lower incidence of postoperative complications, including infections and improper wound healing [13][14][13,14]. Physiotherapy is of great importance in achieving full recovery. In a clinical trial by Castille et al., where the effect of postoperative physiotherapy was compared to a placebo, patients in the control group were much more likely to experience postoperative urine incontinence than patients in the physiotherapy group. Additionally, the physiotherapy group had chances of full postoperative recovery 2.72 times higher than the control group [15]. Healing of a fistula is defined as its closure and the return of continence. In the case of a more complex fistulae, healing is not always successful after the first attempt. Moreover, reoperations may have lower success rates than initial repairs. The results of the operation depend on the degree of scarring and tissue loss, the size and location of the fistula, and the surgeon’s experience. In many countries, access to skilled professionals capable of repairing a fistula remains limited, and very few hospitals are providing the service [16]. Other issues that reduce the chance of a successful surgery and postoperative period are the lack of constant care and long waiting lists for the surgery [17]. Adequate health education and physiotherapy programs improve the likelihood of a successful outcome after the surgical repair of an obstetric fistula [15]. A study by Gebremedhin et al. showed that women with no formal education have been seeking care less often compared to those with a formal education [18]. This may be because women with no formal education are more likely to have a low economic status, tend to be economically dependent on others, and may lack household decision-making power. The low educational status may limit women’s awareness about the existence of treatment for fistulae as well. Adolescent girls are also less likely to seek care for fistula treatment. Only about 74% of women in the study attained complete continence after surgery, which suggests the suboptimal quality of the surgical care or the presence of other contextual factors that may limit surgical closure (e.g., malnutrition) in the region. Facility-based studies conducted in Ethiopia, Rwanda, Nigeria, and Guinea reported complete continence rates to range between 83% and 89% after the surgical closure of fistulae, however, it is difficult to compare figures between different countries due to different surgical approaches.
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