Crohn’s disease: what to do when a fistula occurs?

Fistulas are a common complication of Crohn’s disease. These are atypical tunnels that form on the intestinal walls or other organs. People with Crohn’s disease may see fistulas form in different parts of the intestine, with another organ, such as the bladder, or all the way to the surface of the skin.

People with fistulas may experience unwanted side effects, such as:

– diarrhea
– pain
– discomfort

An anal fistula is the most common type of fistula. Symptoms include a tender swelling or bump around the anus that may drain and pain that worsens with movement. Read this article to learn more about the different types of fistulas, including symptoms, causes, and treatment options.

Types of fistulas

Fistulas are very common in people with Crohn’s disease, since they affect 1 in 3 individuals with this disease. A fistula is a narrow passage that occurs when inflammation causes sores, or ulcers, to form. These passages can connect one organ to another or to the outer surface of the body.

Different types of fistulas can occur at different places in the body. Here are a few :

– Anal (perianal): This fistula connects the anal canal or rectum to the surface of the skin near the anus.

– Vaginal: There are different types of vaginal fistulas, which can atypically connect the vagina to the bladder, rectum, colon or small intestine.

– Colovesical (from the intestine to the bladder): A rare route between the colon and the bladder, which can allow the appearance of feces in the urine.

– Gastrointestinal (gut to gut): This fistula connects the gut to an adjacent organ or surface.

– Enterocutaneous (from the intestine to the skin): An atypical fistula between the intestinal tract or the stomach and the skin.

Diagnose types of fistulas

The diagnosis of fistulas varies depending on their type. A doctor will need to gather information, such as:

– the place where the fistula opens
– the course of the fistula
– the number of tunnels present
– if the fistula crosses the sphincter muscles
– if there is an infection

anal fistula

An anal fistula is a small tunnel that develops between the end of the intestine and the skin near the anus.

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Symptoms of an anal fistula are:

– irritation of the skin around the anus
– a stabbing pain that may worsen with movement, defecation or coughing
– a smelly discharge near the anus
– discharge of pus or blood
– swelling and redness around the anus
– difficulty controlling bowel movements.

These symptoms are more likely to occur in people with Crohn’s disease. Other causes may be as follows:

– diverticulitis
– complications from surgery near the anus
– tuberculosis or HIV infection


To diagnose this type of fistula, a doctor will perform a physical examination of the skin surrounding the anus, as fistulas often appear as small holes or red bumps. He may also press on the skin to determine if there is a leak of pus or feces. Doctors may perform the diagnosis under general anesthesia so that the area is completely relaxed. Sometimes doctors use a probe to determine the course of the fistula and whether it passes through the sphincter muscles. Several tests can also attempt to determine this, including

– a pelvic MRI
– an endoanal ultrasound
– fistulography, which involves using a dye in the anus to find signs of leakage.

Vaginal fistula

A vaginal fistula is a duct or hole that has opened up from the vaginal wall and is connected to another organ in the body. The most common types of vaginal fistula are:

– vesicovaginale, a tract connecting the vagina and the bladder
– rectovaginale, a fistula connecting the vagina and the rectum
– colovaginale, a tract that connects the vagina and the colon
– enterovaginale, a fistula that connects the vagina and the small intestine.

Symptoms may include fluid leaking from the vagina, smelly gas discharge from the vaginal area, or infection in the genital area.

The fistula itself may not cause pain or discomfort. However, urine, stool, or air can pass through the vagina, which can lead to incontinence issues. Continuous leakage in the vaginal area can also lead to infection or pain.

A fistula usually develops as a result of trauma to the area, such as:

– surgery of the vagina, anus or rectum
– hysterectomy
– inflammatory bowel disease (IBD), mainly Crohn’s disease
– radiotherapy for pelvic cancer
– injuries due to childbirth, such as a tear or infection.


Symptoms are most helpful in helping doctors diagnose a vaginal fistula. A doctor will discuss the symptoms and any surgery, trauma, or illness that may be causing it. For the physical exam, a healthcare professional will use a speculum to examine the vaginal walls. As with an anal fistula, diagnostic tests include an MRI, ultrasound, and fistulography, which involves adding a dye to the vagina.

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Intestinal-bladder fistula

A bladder fistula, or colovesicular fistula, occurs when an opening forms between the bladder and another organ or the skin. The most common types of bladder fistulas occur between the bladder and the bowel or between the bladder and the vagina.

Symptoms include:

– urine that looks or smells like stool
– persistent urinary tract infections
– gas from the urethra

This type of fistula can occur as a result of Crohn’s disease, injury or trauma to the bladder, bowel or gynecological cancer, or radiation therapy.


To detect this type of fistula, the urologist performs a physical examination and takes a medical history. Doctors can place a long, thin camera in the urethra to view the bladder – a procedure called cystoscopy. X-rays or CT scans can also be used to check the bladder and surrounding areas.

Bowel to bowel fistula

A gastrointestinal (GI) fistula, or gut-to-gut fistula, connects the intestine to an adjacent organ or surface. Digested food cannot flow through the body properly if a person has a gastrointestinal fistula. The fistula can also cause fluid leakage. Symptoms may include:

abdominal pain
About 85-90% of gastrointestinal fistulas are due to surgical complications. Other possible causes are

infections, such as diverticulitis
Crohn’s disease
an ulcer in the intestine
an injury to the abdomen


A doctor can perform an x-ray of the upper and lower intestine. He will administer barium orally or by enema before performing the x-rays. If there are signs of leakage in the intestines, this will confirm the presence of a fistula. A fistulogram, which involves injecting dye into the area of ​​the fistula where the skin is open and leaking, can help reveal any blockages.

Intestinal fistula to the skin

An enterocutaneous fistula, or intestinal skin fistula, is an atypical connection between the intestinal tract or stomach and the skin. Due to this connection, the contents of the stomach or intestines can drain to the skin. Symptoms include diarrhea, dehydration and malnutrition. These fistulas usually occur after bowel surgery, but other causes are possible:

perforated peptic ulcer
Crohn’s disease
an abdominal injury or trauma, such as a stab or gunshot.


Tests, such as a CT scan or fistulogram, can also help doctors diagnose this type of fistula. A barium test, which involves swallowing barium or taking it as an enema before an X-ray, can help confirm the presence of a fistula.

Treatment Options

Treatment for a fistula depends on the type of fistula present and whether or not the person is receiving treatment for another bowel condition. Most fistulas can be treated with medication, surgical procedures, or a combination of both.

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There are different medications that doctors prescribe to people with fistulas. These include:

– antibiotics
– biological drugs
– steroids
– laxatives, usually for anal fistulas.

Non-surgical treatment

Fibrin glue is currently the only non-surgical treatment for anal fistulas. It consists of the surgeon injecting glue into the fistula under general anesthesia. The glue helps seal the fistula and promotes its healing. This treatment is generally less effective than surgical procedures, and results may not be long-lasting. It can be a useful option for fistulas that cross the anal sphincter muscles, as they do not need to be cut.

Surgical intervention

Doctors can remove fistulas through different surgical procedures, including:

Fistulotomy: This is an effective strategy for treating most fistulas. However, doctors cannot perform this procedure when the fistula passes through the anal sphincter muscles.

Transanal mucosal advancement flap: This method involves removing the fistula and covering the hole with a flap of tissue from inside the rectum. However, this procedure has a lower success rate than fistulotomy.

Intersphincteric tract ligation (LIFT): Doctors make an incision in the skin above the fistula and move the sphincter muscles apart. Although LIFT has shown promising results so far, with fistula closure rates of 57-94%, more research is needed to determine its short- and long-term success.

Laser surgery: This treatment involves using a small laser beam to seal the fistula. There are uncertainties about its effectiveness, but there are no major safety concerns.

Seton placement: A common treatment for anal fistulas that involves placing a seton, a thin rubber drain, into the fistula, allowing the tunnel to heal slowly. Often, doctors place several over time for gradual healing.

What to expect from procedures

Currently, none of the fistula procedures have a guaranteed success rate. However, the success rate for many of these procedures is generally high, with fistula relapse occurring in one in three people. This means that people may need more than one operation to try to treat their fistula.


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