Physicians Patient and Public Members Annual Meeting Industry DCR About Us
Home > Physicians > Education > Core Subjects > Gynecologic And Urologic ...
Print

Gynecologic And Urologic Manifestations And Complications Of Colon And Rectal Diseases

Elizabeth Breen, M.D.
Instructor in Surgery
Harvard Medical School
Brigham and Women's Hospital, Boston, MA

The proximity of gynecologic and urologic organs to the colon, rectum and anus, can result in a disease process, benign or malignant, or complication originating in one organ system affecting another system. This chapter outlines some of the common colorectal, gynecologic and urologic diseases affecting one another within the pelvis and their treatment.

Benign Diseases

Diverticular disease
The formation of fistulas to adjacent organs is one of the complications of diverticular disease. It is believed that a localized perforation of the bowel becomes adherent to and decompresses into an adjacent organ resulting in drainage of stool and pus through that organ. The reported incidence of fistula formation in patients with diverticular disease varies widely from 5 to 33%. The most common type of fistula, a colovesical fistula, is responsible for 65% of all fistulas from diverticular disease. These can occur either in men or in women who have undergone previous hysterectomy. The symptoms of cystitis, pneumaturia and fecaluria are not always accompanied by bowel symptoms(1). A variety of diagnostic tests including colonoscopy, barium enema, cystoscopy, and cystography are often performed to evaluate the symptoms. An abdominopelvic CT scan, however, is arguably the most useful diagnostic test, as it confirms the diagnosis by demonstrating intravesical gas as well as providing information regarding any extramural inflammation from the bowel itself(2). Initial therapy often begins with an antibiotic regimen to treat any resulting infections. The definitive treatment for colovesical fistulas is a one-stage resection of the organ of origin(most often the sigmoid colon) with a primary anastomosis. If the bladder opening is viewed, it can be closed in two layers. If no obvious opening is visible the bladder can be expected to heal with simple decompression from a Foley catheter for 7 to 10 days post-operatively(1).

Crohn's Disease
Crohn's disease, an inflammatory condition potentially affecting the full thickness of the bowel anywhere from mouth to anus, can also result in fistulas to various adjacent organs within the genitourinary system. Although fistulas to almost every structure within the pelvis have been described, fistulas involving the genitourinary system usually involve the bladder, ureters or uterus. Symptoms include the passage of stool and/or gas via the genitourinary tract or infection resulting from stool contamination. Treatment involves antibiotic therapy and resection of the offending bowel of origin leaving the innocent bladder, ureter and/or uterus to heal with little to no attention(3). Rectovaginal and anovaginal fistulas can occur in 6-23% of females with Crohn's disease(4). Symptoms of passing gas and/or stool through the vagina and episodes of vaginitis are similar to the symptoms seen in all females suffering from rectovaginal fistulas. The principles of treatment, however, differ when a fistula is diagnosed in conjunction with Crohn's disease. The success of treatment for these problematic fistulas is closely linked to the disease state of the rectum. A patient whose rectum is uninvolved has a better chance of healing a fistula than one with active inflammation of the rectum. The treatment of these problematic fistulas is also dictated by the degree of symptoms the patient is experiencing. For those patients with modest to moderate symptoms, medical management is the preferred option. Medical management ranges from antibiotics, such as metronidazole, to immune modulating drugs such as 6-mercaptopurine(5) and recently, inflixmab. Inflixmab, an antibody to TNF-alpha, has been reported to close fistulas in patients with Crohn's disease in up to 55% of cases(6). For patients whose symptoms are moderate to severe and don't respond to medical management, surgical treatment is often indicated. Surgical options include local repair, advancement flaps via the anus or vagina and/or interposition grafts. It is not unusual for patients suffering from symptomatic fistulas to require a proctectomy. Unfortunately, patients with rectovaginal fistulas from Crohn's disease carry a higher complication and recurrence rate than patients without Crohn's disease(7, 8). There have been recent reports of treating complicated anorectal fistulas with fibrin glue instillation. The successful closure of up to 60% of these fistulas is encouraging and this may prove to be a novel option for patients with rectovaginal fistulas from Crohn's disease(9).

Endometriosis
Endometriosis is the abnormal growth of endometrial tissue outside of the uterine cavity. Endometrial implants can involve the bowel in 3-34% of patients with endometriosis. Often these implants are asymptomatic but the disease can progress to cause intestinal symptoms, including pain, bleeding and obstructive symptoms. It is believed that scarring of the bowel wall caused by the implants causes stricture formation resulting in partial obstruction. Once symptoms of obstruction are encountered, resection of the affected bowel with primary anastomosis is advised. Patients often undergo simultaneous hysterectomy and bilateral salpingoopherectomy although those of child bearing potential can be hormonally treated once the bowel is resected(10, 11).

Malignant Diseases

Colorectal Cancer
The mainstay of treatment for colorectal cancer is surgery. With the exception of patients who present with distant metastatic disease, the standard treatment approach is to completely resect the tumor with adequate margins. In 6-12% of patients, physical examination in combination with pre-operative staging modalities may reveal that the primary tumor is locally invading another abdominal or pelvic organ, in the absence of distant metastases. Imaging techniques currently available to assess tumor stage include abdominopelvic CT scan, endoanal ultrasound and rectal MRI. Often the true etiology of the invasion is difficult to determine even at the time of the operation. In certain circumstances the tumor itself is invading adjacent organs, while in other circumstances the invasion may merely be an inflammatory reaction to the tumor(12). Because of the desire not to transect any tumor, an en bloc resection of all gross tumor including part or all of adjacent organs is performed. The structures most commonly invaded and resected include; the left ureter in sigmoid carcinoma and the bladder, seminal vesicles, prostate, uterus, adnexa and vagina in rectal carcinoma. Although en bloc resections of all or part of adjacent viscera carries a higher post-operative morbidity, the local recurrence rate and long term disease free survival are improved over incompletely resected tumors (13, 14). In fact, there is data to support that the long term prognosis for patients with completely resected T4 lesions is equal to that of patients with T3 tumors(15).

Colorectal cancer metastases to other organs that occur by hematogenous or lymphatic spread are not usually managed surgically. One potential exception, however, is metastases to the ovaries. The 6% incidence of colorectal cancer metastases to the ovaries is felt to occur by hematogenous dissemination, not by local invasion(16). Largely because of the technical ease of the operation and the potential to alleviate any detrimental symptoms, it has been suggested that women, particularly post-menopausal women, should undergo a prophylactic bilateral oopherectomy at the time of primary tumor resection. Others, however, argue that since no local control or long term survival advantage has been shown for women undergoing prophylactic bilateral oopherectomy, it is not warranted(17).

Ovarian Cancer
In contrast to treatment recommendations for widespread intraperitoneal metastases from colorectal cancer, patients with intraperitoneal metastases originating from ovarian cancer are treated surgically. For these patients with Stage III ovarian cancer, debulking or reducing all visible disease to nodules less than 2 cm in size provides these patients with a survival advantage(18). As complete eradication of these deposits is not required, it may be possible for tumor involving the surface of the colon or rectum to be debulked without violating the integrity of the bowel. There are times, however, when the bowel is denuded or perforated and must be resected. For patients who received a pre-operative bowel preparation, a standard resection and primary anastomosis can be performed. For those without a prepared bowel, a resection with temporary colostomy or on-table lavage with primary anastomosis can be considered.

Complications

Ureteral injuries
There is a risk of intraoperative injury to the ureters during colorectal surgery. In the usual course that the ureters follow; along the surface of the psoas muscle, crossing the iliac vessels at their bifurcation and along the lateral sidewalls of the pelvis into the posterior surface of the bladder, there are several locations for potential ureteral injuries. The ureter is most often injured during ligation of the inferior mesenteric artery, dissection along the sacral promontory and/or division of the lateral stalks. The ureters may be devascularized, crushed, transected or ligated. Unfortunately, only 23-30% of ureteral injuries are recognized at the time of operation which is when repair has the highest success rate. The placement of ureteral catheters pre-operatively increases the chance of intraoperative recognition of the injury(19). For injuries not recognized at the time of surgery, retrograde pyelogram is the most sensitive diagnostic test. The principles of surgical repair are to debride any non-viable tissue and perform a tension free anastomosis, either end to end over a stent after sufficient mobilization. In situations with more extensive damage, a ureteroureterostomy or reimplantation into the bladder should be performed. These same principles and procedures are attempted to repair injuries which are not detected until after the initial operation. In this case, the success rate of the repair decreases and the rate of nephrectomy increases(20).

Gynecologic and urologic fistulas High rectovaginal fistulas
Complications of pelvic surgery can include high rectovaginal fistulas. The erroneous placement of the surgical stapler into the vagina or the inadvertent trapping of a fold of vaginal wall between the two ends of the end to end stapling device can result in such a fistula. These fistulas are best repaired via an abdominal approach resecting the original anastomosis and creating a new anastomosis with vascularized tissue interposed between the two organs(21). Post-operative infections can result in the formation of a delayed fistula. Examples include a patient with a vaginal cuff abscess following hysterectomy or one with a contained anastomotic leak after a low anterior resection that necessitates the abscess through a rectovaginal fistula. Again an abdominal approach is warranted although in the case of infection resulting from a vaginal cuff abscess, a bowel resection may not be necessary if the bowel can be repaired and a vascularized flap can be interposed between the rectum and vagina(22).

Low rectovaginal/anovaginal fistulas
Anovaginal fistulas can occur via several different mechanisms, including traumatic lacerations during childbirth, complications of radiation to the pelvis and cryptoglandular infections(23). Surgical repair of these symptomatic fistulas is usually required. Options vary from local closure to advancement flaps to interposition of vascularized flaps. The choice of operation is influenced by the size of the fistula, the amount of co-existing scar in the perineum and the presence of fecal incontinence(24).

Conclusion

The close anatomical relationship of the bowel to the organs of the gynecologic and urinary systems is primarily responsible for the occurences of a disease process originating in one of these systems affecting the other. Differentiating both the organ of origin of the disease process as well as the benign versus malignant nature of the disease allows for careful and accurate patient management.

References

  1. Woods RJ, Lavery JC, Fazio VW, Jagelman DG, Weakley FL. Internal fistulas in diverticular disease. Dis Colon Rectum 31:591-596, 1988.

  2. Jarrett TW, Vaughan ED. Accuracy of computerized tomography in the diagnosis of colovesical fistula secondary to diverticular disease. J Urol 153:44-46, 1995.

  3. Fazio VW. Indications and strategies for the surgery of Crohn's disease. Sem Col Rect Surg 5:174-192, 1994.

  4. Heyen F, Winslet MC, Andrews H, Alexander-Williams J, Keighley MRB. Vaginal fistulas in Crohn's disease. Dis Colon Rectum 32:379-383, 1989.

  5. Present DH, Korelitz BI, Wisch N, Glass JL, Sacher DB, Pasternack BS. Treatment of Crohn's disease with 6-mercaptopurine. NEJM 302:981-7, 1980.

  6. Present DH, Rutgeerts P, Targan S, Hanauer SB, Mayer L, van Hogezand RA, Podolsky DK, Sands BE, Braakman T, DeWoody KL, Schaible TF, van Deventer SJH. Inflixmab for the treatment of fistulas in patients with Crohn's disease. NEJM 340:1398-405, 1999.

  7. Radcliffe AG, Ritchie JK, Hawley PR, Lennard-Jones JE, Northover JMA. Anovaginal and rectovaginal fistulas in Crohn's disease. Dis Colon Rectum 31:94-99, 1988.

  8. Cohen JL, Striker JW, Schoetz DJ Jr, Coller JA, Veidheimer MC. Rectovaginal fistula in Crohn's Disease. Dis Colon Rectum 32: 825-828, 1989.

  9. Cintron JR, Park JJ, Orsay CP, Pearl RK, Nelson RL, Abcarian H. Repair of fistulas-in-ano using autologous fibrin tissue adhesive. Dis Colon Rectum 42:607-613, 1999.

  10. Perry EP, Peel ALG. The treatment of obstructing intestinal endometriosis. J Roy Soc Med 81;172-173, 1988.

  11. Singh KK, Lessells AM, Adam DJ, Miles WFA, MacIntyre IMC, Greig JD. Presentation of endometriosis to general surgeons: a 10 year experience. Br J Surg 82:1349-51, 1995.

  12. Hunter JA, Ryan JA, Schultz P. En bloc resection of colon cancer adherent to other organs. Am J Surg 154;67-71, 1987.

  13. Gall FP, Tonak J, Altendorf A. Multovisceral resections in colorectal cancer. Dis Colon Rectum 30:337-341, 1987.

  14. Lopez MJ, Monafo WW. Role of extended resection in the initial treatment of locally advanced colorectal carcinoma. Surgery 113:365-372, 1993.

  15. Poeze M, HoubiersJGA, Van De Velde CJH, Wobbes TH, von Meyenfeldt MF. Radical resection of locally advanced colorectal cancer. Br J Surg 82:1386-1390, 1995.

  16. 16. Birnkrant A, Sampson J, Sugarbaker PH. Ovarian metastases from colorectal cancer. Dis Colon Rectum 29:767-771, 1986.

  17. Young-Fadouk TM, Wolff B, Nivatvongs S, Metzger PP, Ilstrup DM. Prophylactic oopherectomy in colorectal carcinoma: preliminary results of a randomized, prospective trial. Dis Colon Rectum 41:277-285, 1998.

  18. DiSaia PJ and Creasman WT. Epithelail Ovarian Cancer. In Clinical Gynecologic Oncology. New York: Mosby-YEAR Book, Inc. 1997.

  19. Schoetz DJ Jr. Complications of surgical excsion of the rectum. Surg Clin N Am 71:1271-1281, 1991.

  20. Nivatvongs S. Complications of anorectal and colorectal operations. In Principles and practice of surgery for the colon, rectum and anus. St. Louis, Missouri: Quality Medical Publishing, 1999.

  21. Rex JC, Khubchandani IT. Rectovaginal fustula: Complication of low anterior resection. Dis Colon Rectum 35:354-356, 1992.

  22. Fleshner PR, Schoetz DJ Jr, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC. Anastomotic-vaginal fistula after colorectal surgery. Dis Colon Rectum 35:938-943, 1992.

  23. Homsi R, Daikoku NH, Littlejohn J, Wheeless CR Jr. Episiotomy: Risks of dehiscence and rectovaginal fistula. Ob Gyn Surg 49:803- 8, 1994.

  24. Tsang CBS and Rothenberger DA. Rectovaginal fistulas: Theraputic options. Surg Clin N Am 77:95-114, 1997.