Erythematous fistula - Causes, symptoms and treatment. MF.

Urinary fistula is a pathological connection between the organs of the urinary system( ureter, bladder) and the gastrointestinal tract( thin, thick or rectum).

Puzerno-rectal fistula

Causes of duodenal fistulas

All of the duodenal fistulas are divided into two groups: congenital and acquired. Congenital uro-fistula fistulas are noted only in patients with urethrorectal and vesicovascular fistulas, which are often combined with infection of the anus and rectum in newborns. According to the international classification, this disease was called "fistulal form of anal and anorectal agenesis."It refers to one of the abnormalities of development in males and is found in 50-90% of newborns with a high form of rectal atresia.

Among the acquired uroliths fistula are traumatic and spontaneous.
Trauma( household, industrial, transportation, operating) can be the cause of fistula formation at any level, but post-traumatic urethrorectal fistulas are especially frequent. The term "spontaneous" fistula is somewhat ambiguous, because it is caused by various complications, most often purulent-inflammatory processes in diseases of the urinary organs and intestines.

A very small group consists of patients with artificinal uroseuscular fistulas, which are formed to remove urine from the bladder into the rectum after unsuccessful plastic surgeries aimed at restoring urethral patency.

Spontaneous renal and intestinal fistulas are more common than traumatic fistulas. In this case, the renal-colonic fistula is most often formed. The main cause of their formation are kidney diseases - calculous or tuberculous pionephrosis, kidney abscess and suppuration of simple kidney cysts.

Symptoms of the duodenal fistulas

Clinical manifestations of the pathological connection between the organs of the urinary system and the intestine depend on many factors, among which, first of all, it is necessary to point out the localization of fistulous holes, the length and diameter of the fistulous course, the functional state of the kidneys, the existence of an obstruction to urine outflow along the waythe urinary tract below the fistula and numerous purulent complications.

The clinical picture of the underlying disease with spontaneous fistula and the consequences of trauma in trauma fistula can predominate over the symptoms of the duodenal fistula or serve as a background on which the characteristic signs of the pathological message come to the fore.

Despite the variety of clinical signs, the symptoms of impairment of the functions of the urinary system are most typical for urolithiasis and in a significant number of cases allow on the basis of patients' complaints to suspect their presence. Among these signs, one should first of all attribute the release of air to the urine, which most often occurs with vesicouteral fistula, less often the patient complains of this symptom with renal and ureteral-intestinal fistulas.

Significantly less air is detected with excrement of feces. At high intestinal fistulas, there is an admixture in the urine of food and bile, with a fistulous opening in the thick and thin intestine - liquid or formed feces.

The entry of urine into the intestine is a common symptom in patients with vesicoureteral and urethrectectal fistulas.

Intestinal symptoms are manifested more often by diarrhea, less often by constipation, and sometimes by both. In patients, an admixture of blood in the feces is detected.

Other symptoms include flatulence, pain along the colon or small intestine and various manifestations of partial bowel obstruction

. If the patient has such symptoms, especially after an earlier inflammatory disease of the genitourinary system, he needs to consult a urologist to exclude the diagnosis of the duodenal fistula.

Diagnosis of duodenal fistulas

In addition to careful history, examination and palpation, which is best performed under general anesthesia, a combination of endoscopic methods, including cystoscopy, colonoscopy and, with indications, laparoscopy, is mandatory.

In the diagnosis of duodenal fistulas, x-ray methods are widely used. Excretory urography performed with a double dose of radiopaque substance or by infusion technique is mandatory in all cases. It is performed after receiving an overview roentgenogram of the urinary tract, on which it is possible to detect shadows of concrements or gas in the projection of the urinary system. Excretory urography allows obtaining information about the condition and function of the kidneys, ureters and bladder, as well as ascertaining the penetration of contrast medium into the intestine and, thus, to determine the localization of the intestinal opening. To identify fistula on excretory urography, as a rule, it is possible only at a relatively large opening in the urinary organ, with a direct and short fistulous course.

More informative data is given by cystography, which is recommended to be performed in two projections before and after urination to detect not only the fistula, but also vesicoureteral reflux. X-ray examination of the intestine is mandatory, but when detecting fistula this method is much inferior to contrast radiography of the bladder, since it allows diagnosing fistula in no more than 20% of cases.
With open urethrectectal fistulas, urethrography is performed through a metal or rubber catheter inserted into the urethra, which makes it difficult to fill the fistula with a contrast medium and get an idea of ​​the localization of the fistulous opening in the urethra and the gut.

The use of endoscopy in combination with the administration of colored fluid in some cases allows the identification of fistulous holes, but the method is only additional to X-ray.

Treatment of duodenal fistulas

The only effective method of treating the disease is surgery. The volume and type of operation are determined by the size of the fistula, its location, and also the organs on which it is located.

With a small fistula opening, the operation can be limited to cutting the granulation tissue and suturing the wound on the organ. With more impressive dimensions of the pathological opening, your own tissues may not be sufficient for effective plasty. In such cases, plastics can be made with artificial materials or other tissues. For example, a small or large intestine can be used to suture a hole in the bladder, which is brought to the wound of the bladder and fixed by several serous sutures. Good for this purpose is suitable and the flap of the large omentum, which, in addition to the serous membrane, has a pronounced system of blood vessels. The latter can sprout into the anastomosis site, providing a good blood supply, which is good for healing the wound.

Surgery for excision of the fistula

With absolute contraindications to surgical intervention, patients can be offered a conservative tactics for managing the disease. For this purpose, the fistula cavity is washed daily with antiseptic solutions and ointment antibacterial compositions are administered therein. In the absence of secondary infection and a small fistula size, after some time you can hope for a spontaneous closing of the course.

Rehabilitation after

In the postoperative period, patients need to wear a urethral catheter for some time, since increased pressure in the bladder can adversely affect the healing of the wound of its wall. Patients need to learn how to correctly use the urethral catheter, regularly change it and inject antiseptic solutions, such as chlorhexidine, into the bladder cavity, which prevent the development of a secondary infection.

Features of Nutrition and Lifestyle

A special diet for the treatment of urolithiasis fistulas has not yet been developed. Unless the patient, who is contraindicated surgical intervention and who have a secretion of feces with urine, it is recommended to use coarser food, so that the liquid stools do not fall into the fistulous course.

Treatment with folk remedies

As a rule, non-native healers do not go deeper into the cause of the disease itself, but treat only the most pronounced symptoms. Because of the wrong point of applying the treatment, their therapy, often, is ineffective. A variety of broths of herbs, which they offer to wash the external genitalia, vagina and rectum, have only a temporary antiseptic effect, but do not treat pathology in any way.

Complications of the duodenal fistula

The entry of fecal contents into the lumen of the bladder can already be perceived in itself as a complication. Infection of the bladder, which is noted in this situation, causes complaints about persistent pain and eruptions during urination, as well as general weakness, malaise and fever.

Infection of the bladder can cause the infection to rise higher, affecting the kidneys. At the same time, soreness is noted, but not above the pubis, but in the lumbar region. It becomes difficult for such patients to urinate, as any urge to urinate is accompanied by unpleasant sensations and pains. This clinical situation can lead to impaired renal function and the development of acute renal failure. In the absence of adequate treatment at this stage, the disease inevitably has a lethal outcome.

Prevention of duodenal fistulas

To prevent the development of the disease, it is first of all necessary to influence causative factors. Since, urologic fistula is almost always associated with bacterial infection, patients with similar problems need to actively engage in their treatment. A short course of antibiotic therapy can completely remove questions about the risk of developing pathology.

Forecast

Forecast for life - favorable. Although lethal outcomes are described, they happen extremely rarely and are caused, as a rule, by the lack of medical care.

The prognosis for recovery is relatively favorable. It is impossible to cure the disease only in those patients who are completely counter-indicative of surgical intervention because of severe pathology of the internal organs.

The prognosis for operability is relatively favorable. At the first time after the operation, patients need to limit themselves in severe physical exertion, which can become not only a cause of worsening of the general condition, but also a relapse of the urolithic fistula.

Rev.the doctor the urologist, the sexologist-andrologist Plotnikov А.N.