Advice please: Post op development of rectal-vaginal fistula sans infection

[SarahAdcock]

Hello everyone
I'd appreciate your thoughts on some post op drama I am experiencing.
I had SRS with Dr Chett on April 2 and I am now at 5 weeks post op and am back home.  The surgery was described by Dr Chett as "exemplary" and my recovery in Thailand was problem free and ahead of expectations. 

Two days ago, lying on the couch, I realised that when passing wind, I could feel gas escaping from my vagina.  I had undies and a pad on so I wasn't sure of what I was feeling.  Later, after dilating, I went to the toilet and emptied my bowel, after which I had a bit of a look at things with a mirror and torch.  What I saw appeared to be faeces about 20mm or so into the vagina around a suture. 

In a state of a little panic we went to emergency at our local public hospital.  Five hours later, I was seen by a Dr who did an examination with a speculum and couldn't see anything. She was supportive, sympathetic (in a little awe of Dr Chett's work) and ordered a blood test to check for infection which came back negative.  After a very rough night, we went home.

Later that day after dilating, I again emptied my bowel and again had a look with a mirror and torch.  To my dismay, I saw material identical to the faeces I had just passed coming from around a suture.  I wiped it away and when I bore down, saw more worming its way out form the same suture.  Took photos of this and took a sample of what I wiped off straight back to emergency.

This time I eventually saw a surgeon who had no idea what he was looking at and wouldn't believe me that faeces was coming passed the suture into the vagina despite photographic evidence... 

Long story short, we finally got to see our GP who hadn't been taking appointments but eventually did see us.  By this time we had spoken to Dr Chett on the phone (so reassuring) who was surprised this had happened but agreed it is a rectal-vaginal fistula and provided an email detailing how to proceed.  Essentially the prognosis is now to sit tight on antibiotics, clean the area four times a day and allow everything to heal.  After this, I will have an exam, maybe under GA, by a local surgeon (who we will meet with prior – we have an appointment – and explain the procedure and assess his suitability) with a view to repairing the area. 

The likelihood is the fistula will heal as a passage between the bowel and vagina and will therefore need further treatment.  The condition did not exist until the last few days and I don't believe it's a fault of Dr Chett's but rather I'm just very unlucky....

One more thing.  Today, as usual, I dilated and douched.  Shortly after I emptied my bowel and then in the usual goop of lube, there was some blood.  Not heaps and not continually running out but way more than the few little smears I have been experiencing.

Sorry for the long winded post. 

So, questions:
Has anyone else experienced a fistula like this and what happened?
Is this blood discharge normal or anything to worry about? Is it likely to be the result of the internal exam and will slow healing...? Should I refrain from using the larger dilator (the third on four dilators) for a while?

Thanks heaps
Sarah

[Monica_M]

Sad to hear about your experience with the fistula Sarah but as you mentioned it was just unluck.
I'm 2 months post op Chetgirl and have had some pain and bleading when dilating. Not much but enough to make me worried. I think I sometime used to much force or to little lube. Once this happened I stopped dilating for a day or two so my vagina could heal and then started carefully again with the smallest stent and worked my way up slowly to size 2 and 3. I think I learned I have to be more carefully and sort of listen to my body. I'm also much pleased with my vagina. All the swelling is gone and the  labias has shrunk to normal size and it looked real good.

[Julieb1]

Sorry to hear the news its the one thing we all dread im so worried myself that I mite develop one and check myself 3 times a day when dilating and are very careful with the angle aswell .

I did get some bowel pain and blood out of that end and was concerned but it was my piles playing up and causing problems even so im still worried it could happen.

Is it possible the vaginal canal is to close to the rectum mine seems miles away till the end of the canal also the fact when you last posted there was no poo coming out maybe its healing and you mite be ok.

Good luck x

[Vicky]

On the blood discharge issue, I had both blood tinged drainage, and some small actual bleeding for about three months on a daily basis, and then occasionally until 6 months.  My early dilations contained "color" as well as an occasional suture piece that looked like ? and was a bit scary for what I thought it could be, but it was suture material. Small blood clots (more like small scabs on a skinned elbow) also can come out in the first few weeks and you will not recognize them for what they are.  I did not have suture problems post op, but did get a yeast infection that made life miserable. 

A younger friend who just had her surgery with the same surgeon I did, developed an incision line separation, but hers has been looked at and it is a matter of the wound healing from the bottom up and should be fine in a short time (7 -10 days). She is half my age and in superior physical shape, but she will be delayed in increasing her dilator size for a week or so. 

Since your condition has been diagnosed by a physician, the best thing for you to do is relax and follow their instructions and medications. It is early in your healing and if you are in otherwise good health, the thing may repair itself in a short time without much ado.  Keep poking and worrying, and it will be worse for sure.  Good luck and keep calm.  I am 15 months post by now but it seemed this day was going to be impossible back on day 3 to me too.

[SarahAdcock]

Well, I'm now 4 months post op and three months since I discovered the fistula and there has been some progress...

First, the blood after dilation was, of course, the result of me pushing too hard and has been totally fine ever since.

The fistula on the other hand is sadly a part of my life.  I live in a regional city in Australia and people with complications after having SRS are almost as thin on the ground as surgeons with relevant experience and skills.... so it took some time to find someone to look at me.  Finally I saw a lower bowel specialist who did an exam under GA and confirmed a tiny hole connecting the lower bowel with the neo-vagina where the peri-anal skin meets the graft for the vaginal canal.  The surgeon then consulted a number of colleagues, including a Dr Heartsch who is a Sydney based SRS surgeon (I had been told he'd retired...) to whom I was then referred.

I also contacted Dr Chett (my SRS surgeon) via email seeking his input but I never heard back.

A couple of weeks ago I saw Dr Heartsch who did a quick exam and suggested I should only dilate to the stent I find comfortable (for me, this is #3 of a set of 4 dilators) as stretching the vagina also stretches the fistula. I should let things heal until I am 6 months post op and then see him again for an internal exam under GA and probable surgical repair.  In this time the fistula will not close itself but it will shrink to the point it will hopefully be asymptomatic (hence the dilation advice).

In all of this, no one can offer a reason for the fistula developing one month after SRS.  It's my suspicion damage was done to my bowel during surgery -  probably the tiniest if nicks and easily missed.  Dilation stretched this hole which connected with the hole in the graft around a suture (the faeces was seen entering the vagina past/around a suture before it dissolved) and so the fistula was formed and healed forming the passage... and here I am.  Just a theory....

Other than this, the surgery has been a complete success and has met all my expectations.