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
- 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
- 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.
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.
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
- 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.