The painful truth about Fistula

I recently read the book The Hospital By The River by Catherine Hamlin and l was left stunned. The book is about a hospital in Ethiopia called the Addis Ababa Fistula Hospital which does surgery helping women who from long, obstructed labor suffer complicated fistulas that cause them to constantly leak urine or stool. They are then abused by their husbands and family and even abandoned. So what is fistula?

Fistula is an abnormal passageway in the body. The fistula may go from the body surface into a blind pouch or into an internal organ or go between two internal organs. There are numerous types of fistula.

They are usually designated by the organs or parts they connect. Fistulas may form abnormally in the body as a result of disease. Fistulas can form anywhere in the body, and there are three basic types, referred to as blind, complete, and incomplete. Blind fistulas have only one open end, while complete fistulas have openings externally and internally. Incomplete fistulas have an external opening but don't attach to anything.

An obstetric fistula develops when blood supply to the tissues of the vagina and the bladder (and/or rectum) is cut off during prolonged obstructed labor. The tissues die and a hole forms through which urine and/or feces pass uncontrollably. Women who develop fistulas are often abandoned by their husbands, rejected by their communities, and forced to live an isolated existence. The WHO has called fistula "the single most dramatic aftermath of neglected childbirth". In addition to complete incontinence, a fistula victim may develop nerve damage to the lower extremities after a multi-day labor in a squatting position. Fistula victims also suffer profound psychological trauma resulting from their utter loss of status and dignity.

The four types of fistulas are:

• Enterocutaneous: This type of fistula is from the intestine to the skin. An enterocutaneous fistula may be a complication of surgery. It can be described as a passageway that progresses from the intestine to the surgery site and then to the skin. The majority of entero-enteral or enterocutaneous fistulas are the result of surgery. A significant minority result from trauma, especially penetrating traumas. Most fistulas will close on their own after a period of weeks to months. Depending on the clinical situation, patients may require IV nutrition and a period of time without food to allow the fistula time to close.

• Enteroenteric or Enterocolic: Enteroenteric fistulas are the most common, occurring between two sites of small intestine. Enteroenteric fistulas usually create a rather short bypass and may have no nutritional complications or clinical symptoms. Enteroenteric fistula itself is not an indication for surgery.

• Rectovaginal: A rectovaginal fistula is an abnormal connection between the lower portion of your large intestine, rectum and vagina. Contents of your bowel can leak from the fistula, meaning you might pass gas or stool through your vagina. The symptoms of a rectovaginal fistula often cause emotional distress as well as physical discomfort. A rectovaginal fistula may result from an injury during childbirth, a complication following surgery, cancer or inflammatory bowel disease, such as Crohn's disease. Rectovaginal is treated through medicine and if complex then surgery is required.

• Enterovesicular: This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract infections, or the passage of gas from the urethra during urination. Sepsis has been reported in 70% of patients with urinary outlet obstruction. The fistula may be asymptomatic and is seldom accompanied by dramatic or sudden abdominal symptoms or diarrhea. In most series, patients have been treated for recurrent UTI for 4-12 months before a fistula is diagnosed.

Symptoms: These symptoms vary based on the severity and location of the fistula.

• Pain
• Fever
• Tenderness,
• Itching
• Generally feeling poorly.
• The fistula may also drain pus or a foul-smelling discharge.

Treatments for fistulas vary depending on their location and severity of symptoms. Medicinal treatments include:

• Medicines: Flagyl (an antibiotic), 6-MP (an immunosuppresant), or Remicade.
• Enteral diet: This may be prescribed for enterovaginal, enterocutaneous, and enterovesicular fistulas. An enteral diet is liquid nutrition that is taken by mouth or given through a feeding tube. These liquid nutrition formulas replace solid food and contain vital nutrients. With no solid food there is less stool passing through the anus, which helps the fistula to heal and maybe even close.
• Surgery: Fistulas that don't respond to any of the above therapies may require surgery. If the fistula is in a healthy part of the gut, it may be removed without taking out any part of the intestine. If the fistula is in a very diseased part of the bowel, a resection may have to be performed. A resection may result in a temporary ileostomy. Stool is diverted through the ileostomy, giving the part of the intestine with the fistula time to heal. This type of surgery is most often done on rectovaginal or enterovesicular fistulas.

The next clinic or hospital may be several days' walk away and there is no guarantee that that clinic has trained personnel to carry out an emergency Caesarean. Many women die. Ethiopia's maternal death rate is relatively high: 720 out of 100,000 live births. Still higher is the number of women who survive delivery, but who sustain serious injuries and permanent damage to their health, such as obstetric fistulas.  

(Sources: ibdcrohns.about.com, medterms.com, wisegeek.com, fistulafoundation.org, inwent.org, health.nytimes.com, mayoclinic.com, emedicine.com)