Vaginal fistula

Overview

A vaginal fistula is an unusual opening that forms between the vagina and another organ, such as the bladder, colon or rectum. Your healthcare professional might describe a vaginal fistula as a hole in the vagina that lets urine, gas or stool pass through the vagina.

Vaginal fistulas can form after childbirth or after an injury, a surgery, an infection or radiation treatment. You may need surgery to fix a fistula.

There are various types of vaginal fistulas. They are named based on the location of the fistula and organs they affect:

• Vesicovaginal fistula. Also called a bladder fistula, this opening forms between the vagina and urinary bladder. This is one of the most common fistulas.
• Ureterovaginal fistula. This type of fistula happens when an unusual opening forms between the vagina and the tubes that carry urine from the kidneys to the bladder. These tubes are called ureters.
• Urethrovaginal fistula. The opening forms between the vagina and the tube that carries urine out of the body, called the urethra. This type of fistula also is called a urethral fistula.
• Rectovaginal fistula. In this type of fistula, the opening is between the vagina and the lower portion of the large intestine, called the rectum.
• Colovaginal fistula. The opening happens between the vagina and colon.
• Enterovaginal fistula. The opening is between the small intestine and the vagina.

Symptoms

Vaginal fistula symptoms can include:

• Leaking of urine or stool, or passing of gas, through the vagina.
• Urinary tract infections that happen often.
• Urine that has an unusual odor or contains blood.
• Vaginal fluid called discharge that looks or smells unusual.
• Pain during sex.
• Pain, swelling or irritation in the area between the vagina and the anus, called the perineum.
• Repeated infections of the vagina.

The exact symptoms a person has depend in part on the location of the fistula.

When to see a doctor

Get a healthcare checkup if you think you have symptoms of a vaginal fistula. Tell your healthcare professional if you have symptoms that affect your daily life, relationships or mental health.

Causes

Vaginal fistulas have many possible causes, including certain medical conditions and problems that can happen because of surgery. These causes include the following:

• Surgery complications. Surgeries that involve the vaginal wall, anus or rectum can lead to vaginal fistulas. So can surgery on the area between the vagina and anus, called the perineum. Fistulas can form for reasons such as injuries during surgery and infections after surgery. Skilled surgeons can repair injuries while operating, which lowers the risk of fistula. But complications such as fistulas are more common after surgery in people with diabetes or in people who use tobacco.

  Surgery to remove the uterus, called a hysterectomy, is an example of an operation that can raise the risk of a vaginal fistula. The risk is higher if the hysterectomy is more complex. For example, the risk rises if the surgery takes longer than five hours, or if it involves larger blood loss or the removal of more surrounding tissue.

• Childbirth injuries. A vaginal fistula could stem from tearing that sometimes happens when a baby's head comes through the opening of the vagina. Or a fistula might form due to an infection of a surgical cut made between the vagina and the anus to help deliver a baby. This cause is not common in developed countries.

  Being in labor a long time because the baby can't move into the birth canal can raise the risk of a vaginal fistula, mainly in developing countries. That's partly because access to emergency delivery measures such as C-section may be limited.

• Crohn's disease. This condition inflames tissue that lines the digestive tract. If you follow your Crohn's treatment plan, you're not likely to get a vaginal fistula. Crohn's is a type of inflammatory bowel disease (IBD). Another type of IBD called ulcerative colitis also may lead to vaginal fistulas, but the risk of that happening is even lower.
• Certain cancers and radiation therapy. Cancer of the anus, rectum, vagina or cervix can lead to a vaginal fistula. So can damage from radiation therapy for the treatment of cancer in the pelvic area.
• Diverticulitis. This condition involves small, bulging pouches in the digestive tract. Diverticulitis that leads to a vaginal fistula is more common in older people.
• A large amount of stool stuck in the rectum. This condition is known as a fecal impaction. It also is more likely to cause a vaginal fistula in an older person.

Risk factors

A vaginal fistula has no clear risk factors.

Complications

Vaginal fistulas can lead to other health conditions called complications. Complications of vaginal fistulas include:

• Fistulas that keep coming back.
• Ongoing pelvic infections.
• Narrowing of the vagina, anus or rectum. This also is called stenosis.
• Trouble becoming pregnant.
• Loss of a pregnancy after 20 weeks, also called stillbirth.

Prevention

There are no steps you need to take to prevent a vaginal fistula.

Diagnosis

Your healthcare professional has many ways to find out if a vaginal fistula is the cause of your symptoms. You'll be asked questions about your medical history. You'll get a physical exam, which may include a pelvic exam. You also may need other tests.

During the physical exam, your healthcare professional checks the outside of your vagina, anus and the area between the two, called the perineum. Your healthcare professional looks for symptoms such as scarring, irregular vaginal discharge, leaking urine or stool, and pockets of pus called abscesses.

A pelvic exam also may be done to check the health of your outer vagina and your reproductive organs. During the exam, your healthcare professional inserts one or two lubricated, gloved fingers into your vagina with one hand. At the same time, the other hand presses gently on the outside of your lower stomach. A device called a speculum may be used to spread open the walls of your vagina and see inside it.

Tests

If a vaginal fistula isn't found during a physical exam, you may need other tests. These could include the following:

• Dye test. In this test, your healthcare professional fills your bladder with a dye solution and asks you to cough or bear down. If you have a vaginal fistula, dye appears in your vagina. You also may see traces of the dye on a tampon after physical exercise.
• Cystoscopy. During this exam, your healthcare professional uses a hollow device equipped with a lens. The device is called a cystoscope. With the cystoscope, your healthcare professional can see inside your bladder. The inside of the small tube that carries urine outside the body, called the urethra, also can be seen. This lets your healthcare professional check for any problems.
• Retrograde pyelogram. In this test, your healthcare professional injects a substance into your bladder and the tubes that connect the bladder to the kidneys, called the ureters. Then an X-ray is taken. The X-ray image can show your healthcare professional if there's an opening between a ureter and the vagina.
• Fistulogram. A fistulogram is an X-ray image of the fistula. This test may help your healthcare professional see if you have more than one fistula. Your healthcare professional also may be able to see what other pelvic organs may be affected by a fistula.
• Flexible sigmoidoscopy. During this test, your healthcare professional uses a thin, flexible tube with a tiny video camera at the end. This device is called a sigmoidoscope. It lets your healthcare professional check the anus and rectum.
• Computerized tomography (CT) urogram. In this test, you have a contrast material injected into a vein. Then your healthcare professional uses a CT scan to make images of the vagina and urinary tract.
• Magnetic resonance imaging (MRI). MRI uses a magnetic field and radio waves to make detailed images of organs and tissues in the body. With a pelvic MRI, your healthcare professional can see the path of a fistula between the vagina and rectum.
• Colonoscopy. This uses a flexible, camera-tipped tube to check for changes in the large intestine and rectum.

If imaging tests find a vaginal fistula, your healthcare professional may remove a small sample of tissue. This is called a biopsy. A lab checks the biopsy sample for signs of cancer. It's not common, but some vaginal fistulas can be due to cancer.

You also may need lab tests to help find the cause of your symptoms. These could include tests of your blood and urine.

Treatment

Treatment for a vaginal fistula depends on factors such as the type of fistula you have, its size and whether the tissue that surrounds it is healthy.

For a simple vaginal fistula or one with few symptoms, some procedures may help the fistula to heal on its own. A simple vaginal fistula may be one that's small or one that's not linked with cancer or radiation therapy. Procedures to help a simple vaginal fistula heal include:

• Placement of urinary catheter. A catheter is a medical device that sometimes can treat small fistulas between the vagina and bladder. A urinary catheter is a flexible tube that drains the bladder. You might need to use it for more than three weeks.
• Ureteral stenting. This procedure can treat some fistulas between the vagina and the ureters. A hollow tube called a stent is placed inside the ureter to keep it open.

For a simple fistula between the vagina and rectum, you may need to change your diet too. Your healthcare professional also may recommend supplements to make stool softer and easier to pass.

Most often, surgery is needed to treat a vaginal fistula. Before surgery can be done, any infection or swelling in tissue around the vaginal fistula needs to be treated. If tissue is infected, medicines called antibiotics can clear up the infection. If the tissue is inflamed due to a condition such as Crohn's disease, medicines such as biologics are used to control the swelling.

Surgery for a vaginal fistula aims to remove the fistula tract and stitch together healthy tissue to close the opening. Sometimes, a flap made of healthy tissue is used to help close the area. Surgery may be done through the vagina or stomach area. Often, a type of surgery that involves one or more small cuts can be done. This is called laparoscopic surgery. Some surgeons also control robotic arms with an attached camera and surgical tools.

Some people with fistulas between the vagina and the rectum need surgery to fix damage to a ring of nearby muscle called the anal sphincter. When the anal sphincter is healthy, it keeps the anus closed as stool collects in the rectum.

Less often, people with fistulas between the vagina and the rectum need a procedure called a colostomy before surgery. With a colostomy, an opening is made in the stomach area through which stool can leave the body and collect in a bag. This helps the fistula heal. The procedure usually is temporary. The colostomy opening is closed a few months after fistula surgery. Rarely, the colostomy is permanent.

Surgery to repair a vaginal fistula often is successful, especially if you haven't had the fistula for a long time. Still, some people need more than one surgery to get relief.