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Notes on Gender Transition
Living With A Rectovaginal Fistula
Editor's Note: February 12, 2004
I am happy to report that Sarah returned to psychotherapy and eventually was able to get beyond her fears of trying reparative surgery. Her primary concern was the possibility of reopening the fistula. In January 2000 after consulting with several other surgeons, she returned to her original surgeon for the surgery. Her vagina was successfully reopened and lined using a skin graft. The healing process was similar to ordinary sex reassignment surgery. You can read her follow up story, TEN YEARS AFTER at http://www.avitale.com/Sarahtenyearslater.htm
October 17, 1996
Sex-Reassignment Surgery (SRS) is a complex and difficult surgery that is fraught with risk. Unfortunately, many transsexuals contemplating such surgery do not examine the possibility that something will go wrong, and so are completely unprepared when they discover a problem with their surgery. Possible complications of SRS are numerous, but perhaps the most common, and also the most troublesome, is a rectovaginal fistula. A fistula of this type is an opening between the rectum and the newly-created vagina, and can occur if the surgeon dissects too deeply or the patient dilates improperly. Whatever the cause, the problem must be addressed immediately to avoid further complications.
Discovering that one has a rectovaginal fistula is unpleasant. Symptoms include intrusion of intestinal fluids, gases and feces into the vagina, and often intestinal distress. For a small fistula, the only clue may be a brown discharge appearing on a pad. A larger fistula makes its presence well known. Upon discovery of a fistula, the patient should immediately be examined by a doctor--if not the doctor who performed the SRS, then a competent physician. The possibility of infection is very high.
Repair of a fistula can be time-consuming and expensive. If the fistula is large, an immediate temporary colostomy may be required so that a repair can be effected. The colostomy is necessary to divert feces away from the injured area so that it may heal properly after being repaired. For smaller fistulas, doctors occasionally may wish to wait for a few months to allow the SRS site to heal before attempting a repair. Even for smaller fistulas, however, a temporary colostomy lasting a couple of weeks may be required.
A fistula forces the patient to face challenges undreamed of before she went off to surgery. Not only are the physical problems daunting, but the emotional duress can sometimes be even more trying. Yet, with patience, support, and some self-esteem, it is possible to get through it all, as long as some simple rules are obeyed.
In dealing with my own fistula, I learned how to deal with the physical ignominy of it rather well. As long as one takes some extra care in their personal habits, a fistula can be managed. Obviously, it is necessary to stop the dilation routine immediately. Although this means that stenosis (constriction of the vagina, resulting in loss of depth) will occur, there is no alternative. Continuing dilation may enlarge the fistula and turn a messy problem into a life-threatening one. It is possible to recover depth via surgery using a skin graft at a later date, if one so desires.
It is also very important to keep the vagina clean. This means douching carefully using a diluted betadine solution, or other solution if the patient's doctor recommends one. Also, "sitz baths," like the kind commonly recommended after surgery, can be beneficial. Depending on the size of the fistula, one will have to choose a pad that can accommodate the discharge. I recommend maxipads that are impregnated with baking soda to keep the odor down. Always keep a couple of extra pads in one's purse in case they are needed; having an extra pair of underwear available is also not a bad idea.
A surprising fact of dealing with a rectovaginal fistula is the necessity to modify one's diet. One soon discovers what foods to stay away from, as the intestinal tract becomes quite sensitive. It is imperative that one keep stools soft; to do this, I suggest ensuring that the diet is rich in fiber. In my case, that was easily done with fiber bars, and later with the addition of a fiber cereal to my diet. The fiber also seems to help stabilize the intestinal tract, making occurrences of gas or diarrhea less frequent. I also found that eating at the same hours each day meant that I knew when to expect possible problems down below. Avoid foods that are spicy; they tend to irritate the now-sensitive system. Drink lots of water, as well. Avoid alcohol and carbonated drinks.
The mental stress of living with a fistula can be extreme, and must never be ignored. In my case, I took my fistula to be divine intervention, or "fate" if you will, that I was not supposed to live as a woman. Although I told myself that I was being ridiculous, that feeling took hold and began to eat away at my self-esteem. I began to hate myself in the extreme, and withdrew from life. I worried extensively about the scarring that would occur in repair, and the fact that I wasn't "normal" physically. This eventually led to a suicide attempt, and after that, I began to wake up to the fact that my surgery was not who I was. Having something that one has put so much time and effort into go wrong isn't an easy fact to live with. But, eventually, I began to realize that I had done what I needed to do, which was transition. SRS was just meant to be the final step, and in most respects, I accomplished what I needed from that, too. Now, I am learning to live life again.
Fortunately, most transsexuals have a better measure of self-esteem than I did, and will deal with the mental exigencies better than I did. It is imperative that one not withdraw from their life--keep up contacts with friends and family. With a few concessions, life can continue much as it had prior to the fistula. If you need help, do not be afraid to ask for it, whether it be from friends or a counselor. Remember, the fistula is temporary, and it can be repaired. All you need to do is pay extra attention to yourself for awhile.
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