Understanding Fistula and Its Impact on Pelvic Health

Image by: erpete

By: Kim Buonomo

When I was asked to write a blog article, I wasn’t sure what topic I should write about. I read a lot of our previous articles for inspiration and realized a couple things: 1) The women who work here really know their stuff about the pelvic floor; and 2) No one has written an article about fistulas yet! I love having the opportunity to discuss this interesting and impactful condition, and the role that pelvic floor physical therapy (PT) can play in fistula management.

What is a fistula?

The National Association for Continence defines a fistula as an abnormal connection or passageway that connects two organs or vessels that do not usually connect. They can develop anywhere between an intestine and the skin, between the vagina and the rectum, or any other organs in the body.¹ So, your intestines decided to say hi to your skin (or any two other organs), and built a little tunnel through all kinds of muscle and connective tissues to get there. The World Health Organization (WHO) estimates that there are 50,000-100,000 new cases of fistulas worldwide every year.² This sounds like a problem worth talking about!

Fistulas can develop for many reasons and often occur as a result of an abscess. An abscess happens when bacteria enter the body. Your immune system sends white blood cells to fight the infection. This causes swelling (inflammation) at the site of infection and the death of nearby tissue. As a result, a cavity is created which fills with white blood cells, dead cells, and bacteria.³ When this happens near the skin, you can think of it as a big pimple that got out of control. If left untreated, the abscess can get bigger and cause other problems.

If you have a weakened immune system, you may be at a disadvantage when it comes to fighting off bacteria, which would make you more prone to developing abscesses and fistulas. However, they can happen to anyone, as 15% to 25% of gastrointestinal fistulas form without a known cause.⁴

Some things that make you more prone to developing a fistula include (not a complete list).^{2, 4}

Cancer
Radiation treatment to your abdomen
A bowel obstruction
Surgical suture problems
Incision site problems
An abscess
An infection
A hematoma, or blood clot under your skin
A tumor
Malnutrition
Certain gastrointestinal conditions such as Crohn’s disease or diverticular disease

Kinds of Fistula
There are two main kinds of fistula that we help manage as physical therapists.

Gastrointestinal fistula
This refers to a fistula in your digestive system. As pelvic floor physical therapists, we commonly help with management when the perineal or perianal area is affected. Types of gastrointestinal fistula include external or cutaneous fistula where gastric fluid leaks through the skin or a complex fistula which occurs in more than one organ.⁵ External gastrointestinal fistulas can be further categorized by where they pass in relation to the anal sphincter complex.⁶ See the image below for some examples of perianal fistula pathways. The blue lines of this image indicate the path of the fistula tract from the rectum to the skin, including its anatomical relation to the sphincter muscle.

Armin Kübelbeck via Creative Commons

⁷.

Obstetric Fistula
Obstetric fistula is a fistula that develops related to the birthing process. They involve the birth canal and either the bladder or rectum.⁸ They tend to occur more frequently in countries where traumatic labors are common. Factors leading to a higher likelihood of traumatic labor include lack of access to medical care, birth at a younger age, and poor health education. Obstetric fistula is a known problem in many sub-saharan African countries. Prolonged obstructed labor is estimated to account for 76% to 97% of obstetric fistula and is also a major cause of maternal mortality. There are an estimated 2 million women worldwide with an obstetric fistula.⁹

How would I know if I had a fistula?

Symptoms of fistula include:^{1, 10}

Recurrent anal abscesses
Pain and swelling around the anus
Pain with bowel movements
Bleeding
Bloody or foul-smelling drainage (pus) from an opening around the anus (the pain may decrease after the fistula drains)
Irritation of the skin around the anus due to persistent drainage
Fever, chills, and a general feeling of fatigue
Constant urine leakage from the vagina
Irritation in the external female genital organs
Leakage of gas and/or feces into the vagina
Abdominal pain

If you have these symptoms, you should see your doctor right away for an assessment. There are many kinds of doctors that work with fistula and an interdisciplinary approach is often helpful. This team may include a primary care provider, gastroenterologist, colorectal surgeon, gynecologist, urologist, nutritionist, mental health provider or other specialists, depending on what organs are affected by the fistula. We recommend adding a pelvic floor physical therapist into the team as early as possible, but often we will come into the picture after the patient has been treated medically/surgically. Your treatment team will be able to work together to determine the best course of action in your specific situation.

I have a fistula… What now?

There are many medical procedures that can be done to manage a gastrointestinal fistula. Melinda touched on this topic in her article Scrotal Recall . In that case, her patient had a fistulotomy, which healed his fistula but possibly contributed to his pelvic pain. Your medical team will be able to discuss the options with you and determine the best option for your individual case and any relevant potential side effects. Sometimes medications such as antibiotics are used to manage a fistula, but at this time the recommended treatment of a fistula involves surgery. There are enough options of surgical treatment that it could take a whole other blog post to cover them, but for now, you can find some more information about surgical treatments for fistula here ¹¹. The goals of any gastrointestinal fistula surgery that involves the perianal area are to repair the anal fistula completely to prevent recurrence and to protect the sphincter muscles, as damage to the sphincter can lead to fecal incontinence (which is the inability to control bowel movements).

How can PT help me?

PT’s can help with many of the factors that come into play with a perianal gastrointestinal or obstetric fistula.

Scar tissue can form along the fistula tract regardless of surgical intervention, but any time that you make an incision into the body, you will create scar tissue. That incision site is often the tip of the iceberg and a PT is knowledgeable in knowing how to address the underlying impairments to manage and prevent some of the other kinds of dysfunction that can arise from restrictions that have been unaddressed. Melinda did a great job explaining how PT’s can impact scar tissue here.

Depending on the path of the fistula tract in relation to the sphincter, the patient may struggle to achieve successful bowel movements without incontinence or excessive straining. PTs are specifically trained to assess the quality of pelvic floor contraction and improve the patient’s ability to use their pelvic floor appropriately to facilitate complete bowel emptying without straining. We often call this type of work motor control or neuromuscular re-education. Because of this, we can help to prevent increased pressure and dysfunction to the fistula site, which I believe may play a role in decreasing the likelihood of recurrence of fistula (not much evidence out there to support this, but stay tuned!). A pelvic floor PT can also prescribe pelvic floor uptraining (contraction) or downtraining (relaxation) exercises in order to either improve strength or decrease overly high tone in the pelvic floor, based on what is appropriate for your particular case.

If the patient struggles with excessive drainage from the fistula site, this can lead to skin irritation and breakdown. As providers who work in this region of the body on a daily basis, we can make recommendations about appropriate skin care, maintenance of function and lifestyle changes that can improve a patient’s quality of life as they adjust to their condition.

Another benefit of pelvic floor physical therapy is that we are lucky to spend so much time with our patients! As a result, we often get a good sense of what the patient is struggling with and can consult with the rest of the treatment team to coordinate the best care possible for the patient.

Fistulas are a condition that people don’t often talk about, and this can lead to feelings of isolation or depression. Research has suggested that the social and psychological impact of fistula leaves scars that are not easily healed, even when fistula repair is successful.¹² It can be very helpful to seek treatment and to know that you are not alone. If you have a fistula, I encourage you to reach out to one of our offices to see how we can help you.

References:

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.