Long-Term Effects of Recto-Urethral Fistula
A recto-urethral fistula after prostate surgery can result in a number of physical, social, psychosexual and urinary symptoms. In this article we explore the long-term effects of prostate surgery complicated by a recto-urethral fistula in more detail.
Physical problems
Unpleasant symptoms can arise from abdominal wall weakness, which can in turn lead to herniae developing at the site(s) of previous surgery. It is likely the patient will be advised against a hernia repair because it would be a hazardous undertaking with a risk of recurrence.
But while the herniae remain in place, they are at risk of strangulating and of causing problems with abdominal adhesions, which can cause pain and bowel obstruction to varying degrees. They can also enlarge with increased pressure within the abdomen – something which can happen with, for example, heavy lifting. The patient will therefore be advised to avoid any lifting of heavy objects.
Abdominal herniae will not spontaneously resolve and in all probability will continue to enlarge, causing discomfort. Corsets can be used to help with this. The consequences of a strangulated hernia are quite severe and will require the re-opening of an already weak abdominal wall to correct any bowel obstruction from adhesions or incisional herniae.
Social activities
Due to the patient's physical limitations, he will be restricted in what type of social activities they can participate in. As mentioned above, any sort of heavy lifting is prohibited. This also applies to any strenuous activities, such as gardening and playing sport. This can impact significantly on an individual's quality of life, as hobbies that were once enjoyed must be given up. The patient must instead find other ways to keep fit and reduce the risk of cardiovascular disease.
On the balance of probabilities, the patient will experience these restrictions for the rest of their life. This is because of the risk of the herniae worsening. If the hernia occurred after prostate surgery, the patient will also find that anything that requires straining will also cause him to leak urine due to 'stress incontinence'.
Psychosexual effects
The patient may find that he is not able to have sexual intercourse after surgery. The reasons for this are twofold. Firstly, the presence of an incisional hernia makes any form of straining produce deformity and 'ballooning' of the abdomen. This inhibits sexual intercourse and limits self-confidence. Secondly, the patient might be expected to have a degree of erectile dysfunction from prostate surgery, even if the erectile nerves are spared. This nearly always happens after prostate surgery, although if the erectile nerves have been spared, a degree of erectile function can return with the use of medication.
However, when a recto-urethral fistula is repaired, any remaining erectile function will be destroyed through unavoidable trauma to the erectile nerves as they course peri-urethrally into the penis. Trauma and scarring of these nerves is unavoidable.
Sexual dysfunction is unlikely to resolve spontaneously. In order to restore erectile function, treatments for erectile function and psychosexual counselling may be necessary. Nevertheless, such treatment will not be effective in patients whose erectile nerves and blood vessels have been affected, as they will not respond. Instead, the patient will require penile injection therapy, vacuum pump therapy or penile prosthesis implantation. Each of these have different cost implications.
Urinary incontinence
Following prostate surgery, the patient should be told to expect a degree of urinary incontinence. This occurs because of some inadvertent trauma to the urethral sphincter. Most often this resolves to an acceptable level after approximately a few months, especially if pelvic floor exercises are rigorously practiced. Even then, many men wear one pad for 'security' during the day. A small proportion need even further investigation and surgery for troublesome incontinence. This amounts to around 2-3% of patients.
If a patient has marked persisting urinary stress incontinence, it is almost certainly due to the repair of the recto-urethral fistula. Not only would there have been direct trauma and scarring of the external urethral sphincter from the repair surgery, but the patient would have been unable to do any pelvic floor exercises to regain urinary control because of the presence of the recto-urethral fistula. Both these factors will compound the degree of urinary incontinence the patient suffers. Stress incontinence means that anything that puts pressure on the bladder and raises its pressure above the resistance provided by a weakened/damaged urethral sphincter will cause urinary leakage.
The patient's urinary incontinence will probably not improve. He can choose to contain his incontinence with urinary appliances, which can include drainage bags, dribble-stop devices and urinary incontinence pads. There may also be the option of active surgical treatment in the form of an artificial urinary sphincter, or a pho-urethral sling.
Claiming compensation for your damages
These side-effects will have a devastating impact upon the patient's life, especially as they are unlikely to improve in the future.
Unfortunately a recto-urethral fistula is an accepted risk of prostate surgery, although it is very rare. If the complication does arise, medical practitioners must be quick to recognise the problem. It should be evident from the patient's catheter which will be collecting urine which has faeces in.
Once recognised, the patient should be fitted with a colostomy (as well as the catheter). This will give the tissues time to heal, and will enable medical practitioners to see if the fistula heals of its own accord. If the fistula does not repair itself (which is improbable), a surgical repair must be conducted.
Sometimes medical practitioners will not follow this course of action, causing the patient to suffer more severe side-effects. For example, there may have been a delay in diagnosis, a delay in surgery, or it may be that a repair was attempted too early (when the tissues were still damaged from surgery).
If you believe your recto-urethral fistula was caused or exacerbated by medical errors, you need to speak to a solicitor about the care you received. You could be entitled to compensation for the damages you wrongfully incurred.
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