Posted 11/29/2008 11:59 AM (GMT -7)
I have a rectovaginal fistula that will not heal. As for the bulge, I believe you are asking about the fatty tissue that was caused by my doctor doing a z-plasty on me. He evidently, had to over-compensate the flap by using my urethra tissue to give me more room between my vagina and rectum because I tore so bad during childbirth. I've been going to the Cleveland Clinic to have my fistula fixed and to have reconstructive surgery. I'm going again in February. I'm going to have my surgeon use tissue from the inside of my thigh to fix my fistula. I'm hoping this will work. The reason it won't heal is because I have too much scar tissue up there.
Here's information and the difference between a fistula and fissure: (By the way, Fissures are normally on the outside or right around the anus. Fistulas are inside and are openings between two areas.) I pulled this info from http://www.fascrs.org/patients and http://www.geocities.com/dinimerz/rectovaginal_fistula.htm
An opening that forms in the tissue between the rectum and vaginal that is lined with epithelial cells. (It resembles an empty blood vessel.) Sometimes it is so small that only gas passes. Sometimes it is larger so that feces pass too.
How is it caused?
Usually several of the following factors combine to lead to a fistula condition:
* A large baby, and a small vaginal opening
* Lots of pitocin during labor
*A large tear or a level 3 or higher episiotomy and a mid-line incision
* Forceps or another type of assisted, forced delivery
* Improper episiotomy repair
* Poor episiotomy follow-up to detect puss and infection
* Infection of the stitches of your episiotomy or tear
How is it detected?
It is usually the patient that first notices a problem - either gas or feces passing from the vagina. It is uncomfortable, unmistakable, and uncontrollable. Others notice that they have feces coming from the vaginal opening occasionally or even regularly. You may get recurring urinary tract infections caused by unusual bacteria.
An experienced colorectal surgeon can feel for granulation in your rectum. This forms at both ends of the fistula opening. The doctor can sometimes pass a narrow instrument, called a probe, through the whole fistula. Other doctors can do a dye test to see if dye passes through the opening and then shows up on a scan.
Your OB or gynecologist is usually the first to deny the problem exists or to minimize it. (That is mainly because they are largely responsible for the condition.)
When and how can it be repaired?
There is a debate among doctors about this as well. Some say you must wait a minimum period before pursuing repair options. The newer train of thought is that you only need to wait three months post-delivery. I had mine repaired at the three month mark. You should look for an experienced colo-rectal surgeon to do the repair. Look for someone who has performed at least 10 successful surgeries a year. DO NOT rely on your gynecologist or OB. Chances are that they have only RARELY successfully repaired this condition in the lifetime of their practice. (In fact, they probably cause more fistulae than repair them.)
There are two different categories of surgeries: a flap repair and a sphincteroplasty (a.k.a. peri-anal reconstruction). In a flap repair, the surgeon takes a flap of tissue from another part and patches over the fistula, or tries to "fill in" the fistula with something and burn the ends. Sometimes it works, sometimes it doesn't. (I think the success rate is about 65-70%, but you will need to do medline and webMD searches to get articles to learn more.)
The other surgery is a peri-anal reconstruction, or sphincteroplasty. For this, the surgeon will cut the fistula, and restructure all your muscles around the anus and vagina. The success for this is around 90%, but in 10% of the cases the surgery breaks down because of infection. If this happens, you will have to have a colostomy for 3-6 months until you heal. A colostomy means that your feces is rerouted to another opening, and attached to a bag that you periodically replace. A word of caution - whenever a fistula occurs at the lower end of the anal canal, it is much harder to repair with full continence.
For either surgical option, the proper prep and follow-up is necessary. Pre-surgery, you will need to flush out your intestines. You will have to fast for two days prior to surgery, and take several laxatives and enemas until you are cleaned out. (Use a squirt bottle to stay clean during this process. It will save you some of the irritation)
Post-surgery, you will be on a liquid diet for 2-4 days. After that, you may want to self-impose a low-residue diet for a week. You also will need to do three sitz baths a day and use a stool softener (like Colase) to avoid straining during a BM. (Colase is not habit forming.) In addition, you are absolutely not allowed to lift anything heavy for about a month after surgery, so you will need to get some help from family/friends with the baby - especially bathing a baby in a tub, which can be a big strain on your pelvic muscles, believe it or not.
It took me about two weeks to regain a decent amount of mobility, although I took a month off from work after surgery because I was so worried that I would screw up the surgery and have a relapse. However, another friend who had the same thing done was back at work after two weeks. You will most likely experience pinkish discharge for quite a while after surgery -- at least a few weeks. Your surgery is "draining", and this is ok and normal. However, if you suspect that the discharge is fecal, or you experience severe pain and/or a fever, call the surgeon IMMEDIATELY. DO NOT be embarrassed or think that you are bothering the doctor.
For most, the worst part of the whole thing is the bowel prep. The pain of the surgery is the equivalent of a c-section, which means that it was really not that bad after the first 4 days or so. (And you don't have to worry about gas pain as with a c-section.)
I have only heard of rare circumstances where a fistula heals on its own. I was told to stop breastfeeding by my OB to strengthen my vaginal floor to encourage it to heal on its own. There seems to be a debate among doctors as to whether this will really do the trick, but my colorectal surgeon told me that the chances of spontaneous healing post-nursing is rare.
What is an anal fissure?
An anal fissure is a small tear or cut in the skin that lines the anus. Fissures typically cause pain and often bleed. Fissures are quite common, but are often confused with other causes of pain and bleeding, such as hemorrhoids.
A simple acute fissure, transanal view.
What are the symptoms of an anal fissure?
The typical symptoms of an anal fissure are pain during or after defecation and bleeding. Patients may try to avoid defecation because of the pain.
What causes an anal fissure?
Trauma: anything that can cut or irritate the inner lining of the anus can cause a fissure. A hard, dry bowel movement is typically responsible for a fissure. Other causes of a fissure include diarrhea or inflammatory conditions of the anal area. Anal fissures may be acute (recent onset) or chronic (present for a long time or recurring frequently). Chronic fissures often have a small external lump associated with the tear called a sentinel pile or skin tag.
How can a fissure be treated?
Often treating one’s constipation or diarrhea can cure a fissure. An acute fissure is typically managed with non-operative treatments and over 90% will heal without surgery. A high fiber diet, bulking agents (fiber supplements), stool softeners, and plenty of fluids help relieve constipation, promote soft bowel movements, and aide in the healing process. Increased dietary fiber may also help to improve diarrhea. Warm baths for 10-20 minutes several times each day are soothing and promote relaxation of the anal muscles, which can also help healing. Occasionally, special medications may be recommended. A chronic fissure may require additional treatment.
Will the problem return?
Fissures can recur easily, and it is quite common for a healed fissure to recur after a hard bowel movement. Even after the pain and bleeding has disappeared, one should continue to aim for good bowel habits and adhere to a high fiber diet or fiber supplement regimen. If the problem returns without an obvious cause, further assessment may be needed.
What can be done if a fissure doesn't heal?
A fissure that fails to respond to treatment should be re-examined. Persistent hard or loose bowel movements, scarring, or spasm of the internal anal sphincter muscle all contribute to delayed healing. Other medical problems such as inflammatory bowel disease, infections, or anal growths (skin tumors) can cause fissure-like symptoms, and patients suffering from persistent anal pain should be examined to exclude these conditions.
What does surgery involve?
Surgery is a highly effective treatment for a fissure and recurrence rates after surgery are low. Surgery usually consists of a small operation to cut a portion of the internal anal sphincter muscle (a lateral internal sphincterotomy). This helps the fissure heal and decreases pain and spasm.
If a sentinel pile is present, it too may be removed to promote healing of the fissure. A sphincterotomy rarely interferes with one’s ability to control bowel movements and is most commonly performed as a short outpatient procedure. Surgical treatments do have other risks, and your surgeon will address these with you.
A chronic fissure with a skin tag and a hypertrophied anal papilla, coronal view.
How long does the healing process take after surgery?
Complete healing occurs in a few weeks, although pain often disappears after a few days.
Can fissures lead to colon cancer?
No! Persistent symptoms, however, need careful evaluation since conditions other than fissure can cause similar symptoms. Your doctor may request additional testing even if your fissure has successfully healed. A colonoscopy may be required to exclude other causes of bleeding.