HIV-positive African children with rectal fistulae☆

Materials and methods 

The Department of Paediatric Surgery, University of Natal, in Durban, South Africa, saw 39 patients with HIV-related rectal fistula from 1996 to 2001 inclusive, on an in- and out-patient basis.

Of the 39 children with rectal fistulae, 37 were girls with ages ranging from 4 weeks to 11 years (mean, 15.5 months). All patients were born with a patent anus initially had normal passage of stool. The passage of stool per fistula was preceded by a severe diarrhoeal episode. In most, the fistula opened in the vagina, but a few were noted to track into the labia majora and perineum (Fig 1).

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Fig. 1. Rectal fistula opening on lower vagina/perineum.

Two boys were seen in this period. The first was a fit 4 year old. He presented with the passage of stool per urethram after a severe diarhoeal illness at the age of 3 years. The second boy, a wasted 1 year old, presented with drainage of urine per urethram and per rectum. When he was born he passed urine through the urachus as a result of posterior urethral valves, but after a severe bout of diarrhoea, this had decreased, leaving him with a watery stool smelling of urine.

Results 

Of the total 39 patients seen, only 13 patients were admitted, and the remainder were treated conservatively and reviewed on an out-patient basis.

Examination of the girls showed the fistula to be situated at the dentate line and tracking ventrally into the vagina or perineum. Those admitted for an examination under anaesthesia were noted to have fistulae ranging from pin size to 5 mm diameter. The rectal mucosa usually was irregular and inflamed with histology that showed nonspecific inflammatory features with ulceration and acute on chronic proctitis. No features of tuberculosis were seen, but 3 patients had a cytomegaloviral infection of the rectal mucosa.

Initially, girls with an acquired rectovaginal fistula were admitted for investigation and given a colostomy to divert the faecal stream before an attempted closure of the fistula. The various attempts at closing the fistulae were not successful in any girls because of poor wound healing and in many they were made worse. Once the fistulae were found to be HIV related and surgery unlikely to be successful, diverting colostomies were no longer done in girls, unless compelled by septicaemia or advancing perineal disease.

Two boys were seen and both were proven to be HIV positive on enzyme-linked immunosorbent assay (ELISA) tests. Examination under anaeasthesia showed the fistulae to be intersphincteric. The fistulae opening in the rectum were situated at the dentate line and found to track into the prostatic urethra, as shown on micturating cystourethrogram (Fig 2), in both patients on the right side of the verumontanum.

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Fig. 2. MCUG shows leakage through rectoprostatic urethral fistula.

The older child was given a diverting sigmoid colostomy for the rectourethral fistula. He subsequently underwent a “Peña approach,” separating the anterior rectum from the prostatic urethra, to close the fistula. His colostomy also has since been closed successfully. The younger boy was found to have one large “Y”-shaped intersphrinteric rectal fistula. The 2 ventral prongs of the fistula led into the prostatic urethra and bladder. The urethral valves were fulgurated, but the parents refused further treatment for the fistulae and he was sent home.

Histology of these fistulae showed an acute on chronic proctitis. In the older boy there was a nonspecific focal cryptitis, and colonic biopsy showed replacement of smooth muscle and nerve fibres by fibrous tissue. Viral and bacteriologic findings in both patients were negative. No other pathologic features were identified.

Discussion 

Since HIV disease was first diagnosed in Southern Africa, there has been a steady increase in the number of patients affected. Although the official incidence in our area (Province of KwaZulu-Natal) has reached 36% in the year 2000,2 the true incidence of HIV disease among children in our population cannot be defined. However, an increase in number of patients with HIV-related rectal fistulae has been noted over the last years, from 5 patients in 1996 to 11 in 2001. An escalation in HIV-related rectal fistulae in girls has been well documented in Southern Africa.3, 4, 5, 6 No reports of a similar pathology in boys have to date been found in the literature.

The pathophysiology of HIV-related rectal fistulae is not known. Such fistulae have been noted to arise from the dentate line, and anal gland infections are proposed as the initiating factor.7 There is, however, a recognized clinical pattern in these patients, in which HIV-related rectal fistula follows a diarrhoeal infection, but the mechanism of this process has not been elucidated. Furthermore the significance of the female preponderance and the broad intimate relationship between the vagina with the rectum as opposed to the low male incidence and the comparatively thicker and smaller surface between anorectum and anterior male structures is a matter of speculation.

The management of girls with rectovaginal fistulae has changed over the years because of our inability to close these acquired fistulae surgically. These fistulae were found to have minor local effects; this, and the lack of systemic sequelae in the girls, has lead us not to intervene at all. These girls now are reviewed on an out-patient basis for systemic complications. None have been noted to date.

Our experience with the boys has been different, because the mixing of faeces and urine had given rise to urinary tract infections and urinary incontinence. A temporary diverting colostomy in one boy gave him relief. The subsequent closure of the fistula and later the colostomy has greatly improved the quality of life of this child, although his general condition is deteriorating in consequence of his HIV.

With the spread of HIV more children will be affected and the full spectrum of HIV-related acquired rectal fistulae will become more common. It is important to focus on the needs of the child and not be overwhelmed by the condition.