Rectovaginal Fistula Treatment

A fistula occurs when two internal structures of the body are abnormally
connected. A rectovaginal fistula is an abnormal connection of the rectum
and the vagina. This embarrassing condition can cause a woman to pass
gas or stools through her vagina. Possible causes include complications
from childbirth, a side effect of cancer treatment such as radiation and
Crohn's disease. Surgery is the most common treatment.

Symptoms

Symptoms of a rectovaginal fistula vary in severity and frequency

depending on its size and location. By the far the most disconcerting
symptom is the ability to pass gas, feces, and pus through the vagina,
as well as a foul-smelling discharge. Other possible symptoms include
urinary tract infections; vaginal infections; pain in the vagina, vulva, or
perineum (area between anus and vagina); and incontinence.

Should the rectovaginal fistula occur alongside a vesicovaginal fistula

(involving the bladder), urine may leak into the vagina as well.

Medication

Given the high chance of infection and inflammation surrounding the

skin of the vagina, the patient may require medication before
undergoing surgery. Generally, a simple course of antibiotics is
administered. If the patient also suffers from Crohn's Disease, the
antibiotic infliximab may be prescribed to relieve inflammation.

Possible side effects of the medications include fever and chills; chest
pain; hives and associated itching; flushing; and trouble breathing.

Before Surgery

The bowels must be cleansed before a patient can undergo

rectovaginal fistula. This may involve taking laxatives, going on an all-
liquid diet for several days and/or using an enema.

In some cases, the surgeon may require a colostomy before

performing the surgery. A colostomy alters the path through which the
body expels feces, forcing them out of the abdomen rather than the
rectum. A colostomy is typically required if the patient had suffered
tissue damage from prior surgery or radiation treatments. Should a
colostomy need to be performed, the surgeon may require a two-to-
three month waiting period before the operation.
 Surgery

The surgery to repair a rectovaginal fistula will be performed by either

a gynecologist or a colorectal surgeon. It involves removing the fistula
pathway and closing the opening by sewing healthy tissue around it.
The tissue used to make the repair may be taken from another part of
the body. Alternatively, the surgeon may take healthy tissue and fold a
flap of it over the fistula opening.

Another form of surgery is a sphincteroplasty, which involves cutting

the fistula and restructuring the muscles around the anus and vagina.
A colostomy will be required during the three-to-six-month healing
process.

After Surgery

After surgery, patients will be put on an all-liquid diet for three days,
followed by a low-fiber diet for several weeks to reduce the frequency
of bowel movements. They may also be asked to take stiz baths, in
which the pelvic region is immersed in warm water.
Urinary Tract Infection [UTI]

Urinary tract infection (UTI) is defined by > 5 × 104 colonies/mL in a

catheterized urine specimen, or in older adolescents by repeated voided
specimens with > 105 colonies/mL. In younger children, UTIs are
frequently caused by anatomic abnormalities. UTI may cause fever, failure
to thrive, flank pain, and signs of sepsis, especially in young children.
Treatment is with antibiotics. Follow-up imaging studies of the urinary
tract are obtained.

Mechanisms that maintain the normal sterility of the urinary tract include
urine acidity and free flow, a normal emptying mechanism, intact
ureterovesical and urethral sphincters, and immunologic and mucosal
barriers. Abnormality of any of these mechanisms predisposes to UTI.

Etiology and Pathophysiology

One to 2% of neonates develop UTI, and the female:male ratio is 1:5.

Predisposing factors include malformations and obstructions of the
urinary tract, prematurity, indwelling catheters, and lack of circumcision.

UTIs occur in 3 to 6% of children 2 mo to 2 yr of age. The female:male

ratio rises with age, being about 2:1 between 2 mo to 1 yr, 4:1 during the
2nd year, and > 5:1 after 4 yr. In girls, infections usually are ascending
and less often cause bacteremia. The marked female preponderance is
attributed to the shorter female urethra; male circumcision may decrease
boys' risks. Other predisposing factors for UTI in children include
indwelling catheters, constipation, Hirschsprung's disease, and anatomic
abnormalities of the urinary tract. Risk factors in older children include
diabetes, trauma, and, in adolescents, sexual intercourse.

UTIs in children are a marker of possible urinary tract abnormalities (eg,

obstruction, neurogenic bladder, ureteral duplication); these are
particularly likely to result in infection if vesicoureteral reflux (VUR—see
also Congenital Renal and Genitourinary Anomalies: Vesicoureteral reflux)
is present. The likelihood of VUR varies inversely with age at the 1st UTI.
About 30 to 40% of infants and toddlers with UTI have VUR. Severity of
reflux may determine the probability of subsequent hypertension and
renal failure (caused by repeated infection), but proof is lacking. VUR is
classified by grade (see Table 4: Infections in Infants and Children: Grades
of Vesicoureteral Reflux* ). Reflux of infected urine into the renal pelvis
or presence of infected urine behind an obstruction can lead to chronic
pyelonephritis, renal scarring, poor kidney growth, and renal failure.
Many organisms cause infection in anatomically abnormal urinary tracts.
In relatively normal urinary tracts, the most common pathogens are
strains of Escherichia coli with specific attachment factors for transitional
epithelium of the bladder and ureters. E. coli causes > 75% of UTIs in all
pediatric age groups. The remaining causes are other gram-negative
enterobacteria, especially Klebsiella , Proteus mirabilis, and Pseudomonas
aeruginosa. Enterococci (group D streptococci) and coagulase-negative
staphylococci (eg, Staphylococcus saprophyticus) are the most frequently
implicated gram-positive organisms. Fungi and mycobacteria are rare
causes, mainly in immunocompromised hosts. Adenoviruses rarely cause
UTIs, predominantly hemorrhagic cystitis.

A urinary tract infection is an infection of any of the organs in the urinary

tract, which consist of the bladder, the ureter, the urethra, and the
kidneys.

A urinary tract infection (UTI) may occur in the:

Bladder - Cystitis is an infection of the bladder. This is the most common

form of UTI; it can be aggravated if the bladder does not empty
completely when you urinate.

Symptoms of cystitis often include:

• Burning sensation in the middle of urination

• Fever
• Lower abdominal pain
• Funny smell, color, or appearance (cloudy, dark, blood tinged) of urine

Urethra - Urethritis is infection/inflammation of the urethra. This can be

due to other things besides the organisms usually involved in UTI’s; in
particular, many sexually transmitted diseases (STD’s) appear initially as
urethritis.

Symptoms of urethritis often include:

• Burning sensation at the start of urination

Ureter – Ureteritis is infection of a ureter. This can occur if the bacteria

entered the urinary tract from above, or if the ureter-to-bladder valves
don’t work properly and allow urine to “reflux” from the bladder into the
ureters.
Kidney – Pyelonephritis is an infection of the kidney itself. This can
happen with infection from above, or if reflux into the ureters is so bad
that infected urine refluxes all the way to the kidney.

Symptoms of Pyelonephritis often include: Other symptoms of UTI’s:

• Pain in back, flanks, or abdomen • Uncomfortable pressure

• Fever above pubic bone
• Nausea • Fullness in rectum (in
• Vomiting men only)
• Small amount of urine,
despite urge to urinate
• Irritability (in children
People more susceptible to UTI’s: only)
• Abnormal eating (in
• Diabetics because of changes in the immune system children only)
• Infants who are born with abnormalities of the urinary tract
• Women who use a diaphragm
• Women whose partners use a condom with spermicidal foam
• A person who has already had a UTI
• Pregnant women
• Post-menopausal women - the loss of estrogen thins the lining of the urinary
tract, which increases susceptibility to bacterial infections.
• Women on birth control pills
• Women with lowered immunity
• Women with prolapsed urethra or bladder
• Women with obstructions in the urinary tract

Tests:

A urine sample is usually collected to perform the following tests:

• Urinalysis is done to look for white blood cells, red blood cells,
bacteria, and to test for certain chemicals, such as nitrites in the
urine.
• Urine culture Then the bacteria are grown in a culture and tested
against different antibiotics to see which drug best destroys the
bacteria. This last step is called a sensitivity test.

• Clean catch- By washing the genital area and collecting a

"midstream" sample of urine in a sterile container. CBC and a blood
culture may be done.
• Blood Culture. Two samples of blood are taken to look for any
bacteria in the blood, which is normally sterile. The blood samples
are incubated in a broth medium at body temperature and
examined at regular intervals for bacterial growth. When a person is
septic from a urinary tract infection, the same microorganism is
 found in both the blood and the urine cultures. Susceptibility testing
will provide information on which antibiotic will eradicate the
pathogen from both the blood and the urine.
• Intravenous pyelogram (IVP) - used to look at the whole urinary
tract. An opaque dye is injected into a vein, then travels to the
kidney and bladder. A series of x-rays are taken, which may reveal
obstructions or structural abnormalitie

How is UTI treated?

UTIs are treated with antibacterial drugs. The choice of drug and length of
treatment depend on the patient's history and the urine tests that identify
the offending bacteria. The sensitivity test is especially useful in helping
the doctor select the most effective drug. The drugs most often used to
treat routine, uncomplicated UTIs are trimethoprim (Trimpex),
trimethoprim/sulfamethoxazole (Bactrim, Septra, Cotrim), amoxicillin
(Amoxil, Trimox, Wymox), nitrofurantoin (Macrodantin, Furadantin), and
ampicillin (Omnipen, Polycillin, Principen, Totacillin). A class of drugs
called quinolones includes four drugs approved in recent years for
treating UTI. These drugs include ofloxacin (Floxin), norfloxacin (Noroxin),
ciprofloxacin (Cipro), and trovafloxin (Trovan).

Recurrent UTI

A woman who has frequent recurrences (three or more a year) can ask
her doctor about one of the following treatment options:

• Take low doses of an antibiotic such as TMP/SMZ or nitrofurantoin

daily for 6 months or longer. If taken at bedtime, the drug remains
in the bladder longer and may be more effective. NIH-supported
research at the University of Washington has shown this therapy to
be effective without causing serious side effects.
• Take a single dose of an antibiotic after sexual intercourse.
• Take a short course (1 or 2 days) of antibiotics when symptoms
appear.

Nursing interventions Patient teaching Nursing care plans for

Urinary tract infections (UTIs)

• Administer antibiotics specific to the invading organism as ordered

• Watch for GI disturbances from antimicrobial therapy. If ordered,
administer nitrofurantoin macrocrystals with milk or meals to
prevent such distress.
• If the patient experiences perineal discomfort, sitz baths to the
perineum may increase comfort.
 • If sitz baths don’t relieve perineal discomfort, apply warm
compresses sparingly to the perineum, but be careful not to burn
the patient.
• Apply topical antiseptics on the urethral meatus as necessary.
• Collect urine specimens for culture and sensitivity testing carefully
and promptly.
• Encourage patients to increase fluid intake to promote frequent
urination
•

10 Ways to Prevent Urinary Tract Infections

How to Reduce Your Risk of UTI

Nine million doctor's office visits each year are due to urinary tract
infections, or UTIs. The only thing patients visit the doctor for more often
are respiratory tract infections, such as the common cold. Unfortunately,
the majority of cases of UTI occur in women.

What can you do to help prevent urinary tract infections from interfering
with your life? According to the National Institutes of Health, health
professionals recommend the following tips to reduce your risk of
developing a UTI.

1. Water helps flush your urinary tract, so make sure you drink plenty
of plain water daily.

2. Don't hold it when you need to urinate! Women are often guilty of
trying to finish a task before they go to the bathroom. Holding it
when you need to go can help any bacteria that may be present
develop into a full-fledged urinary tract infection.
3. You've probably heard that you should wipe from front to back after
a bowl movement. This is especially important to help prevent
bacteria from the anus from entering the vagina or urethra.
4. Taking showers instead of baths helps prevent bacteria from
entering the urethra and causing a UTI.
5. Always wash your genital area both before and after sexual
intercourse to help prevent transferring bacteria to the urethra or
vaginal area, which can create a breeding ground for a UTI.

6. Feminine hygiene sprays and douches, particularly scented

douches, can irritate the urethra and possibly lead to a UTI.
Avoiding these products will help prevent not only urinary tract
infections, but also other infections and irritations that these
products may cause.

7. Drinking cranberry juice is a fairly well-known and natural way to

both help prevent urinary tract infections, as well as help speed the
recovery process when a UTI develops. Cranberries contain
chemicals called proanthocyanidins (PACS) which prevent E. coli
bacteria from adhering to the cells lining the urinary tract. E. coli is
responsible for 85% of UTIs and 90% of pyelonephritis which is an
inflammation of the kidneys and its' pelvis caused by a bacterial
infection.
8. Another nutritional route that may help prevent UTI is regularly
taking vitamin C supplements. Vitamin C increases the acidity level
of urine, which in turn helps decrease the number of harmful
bacteria that may be present in your urinary tract system.
9. Always wear panties with a cotton crotch. Cotton fabric lets
moisture escape while other fabrics can trap moisture, creating a
potential breeding ground for bacteria.