Clinical significance and classification
Genital fistulae are considered one of the most severe gynecological diseases. They provoke multi-organ disorders, severely restrict social activity, and lead to menstrual cycle disruptions.
Abnormal tracts may connect the genital organs and pelvic cellular tissue with:
- The urinary system.
- The intestines.
- The anterior abdominal wall.
In practical gynecology, urogenital and intestinal-genital fistulae are most commonly encountered. The latter include rectovaginal, colovaginal, enterovaginal, as well as perineal-intestinal, adnexal-intestinal, and complex fistulae.
Etiology
In most cases, fistulae are of traumatic origin or result from inflammation. Basic causes include obstetric and gynecological interventions, postoperative complications, and purulent-inflammatory processes in the uterine appendages.
For the most frequent type — rectovaginal fistulae — the main factor is obstetric trauma (third-degree perineal tear). The risk of such trauma increases in:
- Macrosomia (large fetus).
- Breech presentation.
- Use of obstetric forceps.
- Embryotomy operations.
Additionally, defects can form due to violent trauma or as a complication of proctological and gynecological surgeries.
Clinical presentation of rectovaginal fistulae
Symptoms directly depend on the size and level of the defect (high, middle, or low).
Low and middle-level fistulae usually have a traumatic genesis. They are localized on the posterior or posterolateral wall of the vagina and open into the anal canal or the anal sphincter area.
- Punctate (small) fistulae manifest as involuntary passage of gas from the vagina.
- Large fistulae (greater than 1 cm) lead to incontinence of both gas and feces. Due to maceration of the mucous membrane, itching and burning occur, and colpitis develops. Gross scar deformation of the perineum and pelvic floor dysfunction are frequently observed.
High-level fistulae most commonly manifest on days 7–9 after surgical intervention due to failure of intestinal sutures. Patients complain of the passage of feces and gas through the vagina, lower abdominal pain, fever, and symptoms of intoxication. The appearance of abundant purulent discharge is characteristic, and the fistulous tract itself may be located within an inflammatory infiltrate.
Principles of Diagnosis and Treatment
To establish an accurate diagnosis, three main clinical methods are used:
- Speculum examination of the vagina — to visualize the defect.
- Bimanual rectovaginal examination — helps assess size, tissue consistency, and find the tract within the infiltrate.
- Probing — shows the direction of the canal and its relation to the anal sphincter.
The goal of the examination is to determine the exact localization, the state of surrounding tissues, and the severity of scar changes in the vagina, perineum, and anal region. To clarify the diagnosis, rectromanoscopy is used, and in the presence of fluid collections, fistulography is mandatory.
Treatment tactics depend on the condition of the pelvic floor muscles and surrounding tissues. For low and middle-level fistulae, surgical treatment is indicated. For high-level fistulae, preference is given to conservative management, including ointment applications and high enemas.
Briefly: answers to topical questions
What instrumental research methods are necessary for the comprehensive diagnosis of all types of genital fistulae, including urogenital ones?
For the diagnosis of specific types of genital fistulae, the following instrumental methods are used:
- Rectromanoscopy — for a more precise determination of the localization of a rectovaginal fistula.
- Fistulography — mandatory for fistulae with fluid collections.
- Cystoscopy and vaginography — used in diagnosing vesicovaginal fistulae.
- Renal ultrasound — included in the examination protocol for vesicovaginal fistulae.
- Excretory urography, radioisotope renography, and three-projection cystography — performed according to indications for vesicovaginal fistulae.
- Pelvic MR-fistulography — used when there is a clinical suspicion of a perianal fistula and/or abscess to clarify the fistula tract.
- Endoanal ultrasound — used to visualize sphincter damage.
What types of urogenital fistulae are distinguished in gynecological and urological practice?
In gynecological and urological practice, several main types of urogenital fistulae are distinguished.
- Vesicogenital fistulae — include vesicouterine (communication between the urinary bladder and the uterine cavity) and vesicovaginal (communication between the urinary bladder and the vagina) fistulae.
- Ureterogenital fistulae — subdivided into ureterovaginal and ureterouterine fistulae.
- Urethrovaginal fistulae — isolated communication between the urethra and the vagina.
- Combined fistulae — associated urogenital and urinocolic defects.
In what cases is the creation of a diverting colostomy indicated during the surgical treatment of complex intestinal-genital fistulae?
The creation of a diverting stoma in complex fistulae is indicated in the following cases:
- Pelvic phlegmon or grade 3–4 complex fistulae — surgical drainage is combined with the creation of a diverting colostomy.
- Complex fistulae with fluid collections and pronounced purulent inflammation — the formation of an intestinal stoma is indicated to divert the fecal stream.
- Extreme exhaustion or pregnancy in Crohn's disease — temporary creation of a diverting double-barrel ileostomy is recommended.
To memorize the triad of the basic examination for fistulae, use the rule: Specula (vaginal examination), Rectovaginal examination (assessing the infiltrate), Probing (tract direction).
Class and exam questions
Why is it difficult to estimate the true incidence of genital fistulas?
Patients with this pathology are admitted to various specialized hospitals: gynecological, urological, proctological, or general surgical, which complicates maintaining unified statistics.
What is the difference in symptoms between pinhole and large rectovaginal fistulas?
In punctate fistulae, only involuntary passage of gas occurs. Large defects (greater than 1 cm) are additionally accompanied by fecal incontinence, itching, burning, and the development of colpitis.
When and why do high-level fistulas develop?
They most commonly form on days 7–9 after surgeries. The main cause is the failure of sutures applied to the intestine.
In which cases is fistulography mandatory?
This X-ray examination is strictly necessary if there is a suspicion of a fistula with fluid collections.
What else to study on this topic
- Urogenital fistulae: etiology, classification, and clinical presentation
- Rare forms of enterogenital fistulas (adnexo-enteric, perineo-enteric)
- Surgical treatments for low and mid-level fistulas
- Conservative therapy for high-level fistulas: regimens and medications
- Complications of genital fistulas: multi-organ dysfunction and pelvic floor failure
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