Is surgical treatment or conservative management best for rectovaginal fistula?

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Posted on Tue, 22 Sep 2015 in Women's Health
Question: Hi doctor... I'm 28 years old and I gave birth to a girl baby on jun 19-2015 and it was forceps delivery with epitsomy. The tear was very sever and extended until anus. Soon after delivery on my first defication, I found motion leak from vagina. My doctor wasn't ready to accept my symptoms. Day by day I started noticing the leak and at the end of 2nd month I was identified with rectovaginal fistula of very small size.I m asked to Wait for 3 months to see whether it heals on its own. I also get lot of gas passing through vagina instead of anus.I'm. Totally depressed of these problems as I had difficult labour and it took 2 months to heal and still I m getting pain in perineum .can you please advise me on how to proceed further on this.and the steps to be taken for auto healing or is surgery required.
doctor
Answered by Dr. Shanti Vennam 47 minutes later
Brief Answer:
Can wait until 12 weeks to allow natural healing.

Detailed Answer:
Hello,

Thanks for posting your query.

I can understand the difficulty you are going through right now. The standard protocol for the treatment of fistulas developed after delivery includes conservative management followed by surgical treatment.

Natural healing is usually possible for small fistulae and hence a healing time period of 6-12 weeks after the onset is allowed. During this period, local healing is enhanced with local sterilization, antibiotics, rest and good nourishment. You can start perineal exercises to enhance the perineal floor strength. Sitz baths also help in tissue healing and relief from the pain.

If natural healing has occurred during this waiting period, more likely since you have a very small fistula, further management through surgical correction is not needed; only periodic follow up is advised with diet and exercise.

If natural healing has failed, and/or the fistula has worsened, surgical correction is done. There are several techniques available.

Hope your query has been answered. Please feel free to contact for further clarifications. I will be happy to help.

regards,
Shanti.V.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Shanti Vennam 7 hours later
Thanks for the update doctor. I am given only multi vitamin tablet, clean vagina with perineum wash-clingen wash,sitz bath with potassium permanganate on alternate days and doing Kegel excercise.
1. Can you give me tips and steps to be followed for natural healing to be successful.
2.what caused this issue. Is that due to weak stiches?
3.I'm also facing fecal incontinence. Even after going to motion in morning I m feeling the 'feel to go' for the rest of the day often. Sometimes this change into gas and comes via vagina.
4.I'm not given any antibiotics. Can you please suggest any which is safe during breast feeding.
5.if natural healing doesn't help.is the surgical process a complicated one?? I read in net that the success rate is very less.how long will it take to heal after surgery.


I'm seriously help less and crying daily right from the delivery. I'm not able to come out of the depression. I'm. Not even pampering my child. Becoming mad on what will be the net result,each check up by doctor is painful.
doctor
Answered by Dr. Shanti Vennam 5 hours later
Brief Answer:
Several methods of surgery are available and are safe.

Detailed Answer:
Hello,

Thanks for writing back.

Here are your answers:

1. For natural healing to progress, you should rest the part, take plenty of fresh fruit and vegetables, take nutritional supplements with vitamin C to help tissue healing. This should be in addition to the procedure you are already following.

2. When forceps is applied to deliver the baby, a larger episiotomy needs to be given; otherwise there may be an irregular tear which may extend into the anal canal. Even with proper precaution, there may be a tear if the perineum is shorter in length or if the forceps is larger in size as compared to the perineum. Improper assistance during delivery is another likely cause.

3. Fecal incontinence is usually due to lack of muscle tone in the perineal floor. Kegel's exercises help to strengthen this part. The feeling of incomplete emptying is usually due to protrusion of the bowel into the vagina. This is also the cause of passage of gas through the vagina.

4. You may not need any antibiotic now. It may have been given already at the time of delivery.

5. Several surgical methods are available which can be performed either through the abdominal or vaginal route. They are generally acceptable in many.

Hope your queries have been answered. You may need to take counselling in order to overcome the puerperal depression.

regards,
Shanti.V.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Shanti Vennam 8 hours later
Thanks a lot dr for the advice. I'm doing Kegel excercise on daily basis, I'm always in a rush to go to toilet in the morning for passing motion. I don't have controlling power. Is that due to weak muscle tone? Will Kegel helps to relieve? Or is this issue a permanent one?
2. As said in above answer, the incompleteness is due to protrusion. Will this stop once fistula closes?
3.this leak. Of feaces or gas will not create any infection to vagina or utreus???
4. How will be sex life after these Complications. Will it be bk to normal or we will be having any compromise ?? The vaginal tissue when being re cut for surgery (if needed) can further weaken the prenium part?

5. Each morning alone,I feel some pain in lower abdomen after defication. Is that due to fistula or utreus shrinking or something I ve to scan?

6. 2 months 1 week are over after delivery and still these much issues exist.will I be back to normal? How long is the recovery period? Can you suggest some good specialist in XXXXXXX if at all I need to go for surgery. Also which type of surgeon would do this successfully?
doctor
Answered by Dr. Shanti Vennam 47 minutes later
Brief Answer:
Perineal floor repair helps regain muscle tone mostly.

Detailed Answer:
Hi,

Thanks for writing again.

Here are your answers.

1. The weak controlling power is due to loss of sphincter tone as a consequence of weakened perineal floor. This can be recovered as the muscle tone is built up and further if needed, after perineal floor repair. Please do not worry, this issue resolves as you are younger with good generalized muscle tone.

2. Once the fistula closes and the rectocele is repaired, this feeling of incompleteness vanishes. You can also ease the passage of stool by increasing the dietary fiber. Hard stool increases the feeling of incomplete evacuation.

3. Leak of feces into the vagina can cause infection. Hence, it is necessary to maintain good genital hygiene.

4. For the time being, you will have to avoid sexual intercourse. Once the fistula heals, be it in natural way or through surgery, you can resume normal life after giving time for healing. If vaginal tissue needs to be removed in part, you can be given dilators to stretch the tissue during the healing phase.

5. The pain can be due to strain on the ligaments, abdominal muscles and involution of the uterus, but, please get it examined by an expert to assess the reason and plan further management.

6. You can approach the Apollo Hospitals since you have a reputed surgeon available there. You will be back to normal. Such issues do happen in many cases and tissue healing is so good that there are very few after effects. You can approach a specialist in fistula repair to deal this problem.

Hope this helps.

regards,
Shanti.V.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Shanti Vennam 4 days later
Hello doctor,
As advised I will wait for 12 weeks. In addition to the above queries, I have few more issues too.
1. I'm not able to control stool and I'm not also trying to do as it may strain fistula now.I'm running to toilet each time I get the feel.why this happens and how can I recover from this.this is upsetting my morning daily.
2. I'm having pains in my tail bone and in front pelvic bone where the forceps were applied.when will I get relief from such pains. I'm feeling difficult even to wear pant balancing in single leg.

3. Yesterday I noticed that the length of prenium is less compared to what was there before delivery. Is this due to epitsomy??
Are all these normal? Or will I be needing any steps to be taken immediately.because, as of now as part of all the issues listed from top I'm takin calcium and multi vitamin tablet along with sitz and cligen wash.Am I delaying anything? Please advise
doctor
Answered by Dr. Shanti Vennam 37 minutes later
Brief Answer:
Please continue with the treatment.

Detailed Answer:
Hi,

Thanks for writing again.

There are a few possibilities regarding the inability to control stool. Firstly, the anal sphincter may have been involved during the episiotomy if it got accidentally extended. If this had occurred, the muscle tone is partly lost and it takes time to regain this. As you are already doing the Kegel's exercises, you can expect the tone to recover in course of time. Secondly, the fistula can cause the feel of fecal incontinence.

The bony pains are likely to be related to post delivery pains as the lax joints and ligaments recover their strength. The possibility of tissue trauma during the application of the forceps also exists.

If a neat episiotomy wound heals, there should not be any deficiency in the perineal size. Only, if there is some tissue loss or if tissues have been approximated tightly owing to irregular tears, is this likely to happen.

As of now, you seem to be doing whatever is necessary to be done, so please continue with it. Remain in touch with your consultant to update any changes to be made.

Hope this helps.

regards,
Shanti.V.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Shanti Vennam 32 hours later
Hello doctor,
Sorry to bother you again. I have only 20 days remaining for the end of 12 weeks. I'm not noticing any significant improvement in leakage till now.I keep on reading net about this as my mind isn't staying calm n keep on pondering on this. I'm worried a lot and can't even able to sleep.if further surgery is needed (if at all), is the success rate less?? As I'm reading in net that this type of surgery fails and repitative repair is done.:-(.
2. I'm breastfeeding, will surgery be done under this situation? And how long will be the recovery approx? As I have to apply for Leave.
3. Yes,as u said my sphincters are teared in the birth and sutured back.will this cause anus burning? I feel burning sensation over anus area sometimes post bowel and apply t bact for temporary relief.
4.I'm taking full rest as of now and sit only for very few hours.
I'm going mad..... And restless. Please relieve me.
doctor
Answered by Dr. Shanti Vennam 1 hour later
Brief Answer:
May need surgical intervention if no further improvement even after 12 weeks.

Detailed Answer:
Hello,

Thanks for writing back.

I can completely understand your difficulty. It is not so easy to bear up with a fistula while nursing a baby. I have given you a link below which has details about the fistula and its management. Please go through this.

http://www.womenshealthsection.com/content/urogvvf/urogvvf008.php3

I have done this since you are browsing the net and there is a lot of information available which can create confusion. I want you to go through standard information, not everything available on net.

Well, here are your answers:

---Surgery can be done even if you are still nursing your child, if this is deemed necessary. Observation is usually done postoperatively for about two weeks. You can plan your leave after discussing with your surgeon. You will need sufficient rest, perhaps for 4-6 weeks.

---Burning sensation over the anal region while passing stool could be due to tissue trauma, mostly due to passage of hard stool. You can try local analgesic gels like Xylocaine jelly or sucralfate anal cream. Increase the intake of fiber in the diet to make the stool soft and bulky.

Hope your queries are answered. Please feel free to ask if you need any more information. I will be glad to oblige.

regards,
Shanti.V.
Above answer was peer-reviewed by : Dr. Raju A.T
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Answered by
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Dr. Shanti Vennam

OBGYN

Practicing since :1989

Answered : 7515 Questions

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