FISTULAS

Fistulas occur in about 1% of patients with advanced cancer. They may be due to malignancy or to a complication of radiotherapy (particularly to the pelvic organs).

Palliative colostomy should be considered whenever possible for a recto-vaginal fistula (which causes a distressing continuous leakage of feces from the vagina).

If the patient is too ill to consider surgery management involves:

• Regular cleaning (saline douches)

• Regular change of pads (large pads at night)

• Metronidazole to reduce smell (see Smells)

• Anti-fungal pessaries if thrush develops

• Barrier creams (to prevent skin soreness)

• Bowel regulation

Bowel regulation means avoiding oral fecal softening agents and emptying the rectum every third day by using oral stimulant laxatives such as senna tablets at bedtime, or suppositories.

A vesico-vaginal fistula causes a continuous dribble of urine from the vagina. Urinary diversion procedures (ileal conduit, ureterosigmoidostomy) should be considered if the patient is fit enough. If not, management involves either pads and pants or a urinary catheter. A vaginal tampon is only helpful if the leakage is minimal.

High bowel fistulas contain digestive enzymes. Use barrier creams to prevent skin excoriation.

A leakage of bile onto the skin surface can be very difficult to contain. Bile tends to leak through dressings and seals. A useful technique is to apply a colostomy bag that contains absorption flakes. These expand into a gel and “pull” the bile down into the bag, reducing leakage.

A colostomy bag (which must be drainable) can be applied over fistulas to collect fluid. This is a very useful technique to reduce discomfort and smell.

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.