3. Fistula – it is an abnormal opening or tract
between two adjacent organs or structures.
Genito-urinary fistula – it is an abnormal
communication between the urinary tract &
genital organs.
Recto-vaginal fistula: between vagina and rectum.
4. Genitourinary fistula has effects on physical
and psychological health of the woman.
Genitourinary fistulae are:
Vesicovaginal (42 per cent)
Ureterovaginal (34 per cent)
Urethrovaginal (11 per cent)
Vesicocervical (3 per cent).
7. Most common causes of vesicovaginal fistulae are:
1-gynaecological surgery in developed world.
Hysterectomy.(75% of cases).
Anterior colporrhaphy.
Laparoscopic pelvic surgery and urological surgery.
8. Risk factor during surgery are:
Previous surgery.
Fibroids or endometriosis.
2-pelvic malignancy.
3-pelvic trauma and radiotherapy.
4-obstetric trauma in the developing world.
Less common: congenital. Inflammatory.
9. Presentation and symptoms:
Incontinence of urine. (Leakage of urine).
Pruritusin the genital region and thighs.
Burning micturition / dysuria.
Complain of increased vaginal discharge if
the fistula is small.
Most common time to present is 5–10 days
following surgery.
10.
11. History of incontinence immediately or several days
after delivery.
A large fistula can be seen when examining the
patient in left lateral position using sim’s speculum.
Methylene blue dye test – to differentiate between
vesicovaginal, urethrovaginal and ureterovaginal
fistula
Metal catheter or uterine sound – passed through
the urethra to appear at the fistulous opening in
the vagina
12. 3 pieces of swab kept in vagina.
200 cc of dilute methylene blue injected into
bladder via catheter
If upper or middle piece stains blue – vvf
If none of the piece stains blue but is wet
with urine – ureteric
If lower piece stained blue then -urethral
13. Urine culture & sensitivity
Renal function test – urea & creatinine
Cystoscopy
CT scan and intravenous urogram (IVU) to
rule out a ureterovaginal fistula.
Palpation of fistula during anaethesia.
Biopsy should be taken if the cause is not
known.
15. Bladder damage during childbirth:
Catheter for 7-10 days.
Antibiotic coverage.
Established fistula:
Wait for 3 months.
Repair.
Fistula following cancer:
Biopsy to be taken from the edge of fistula
16. Latzko procedure
Flap splitting technique
In case of extensive fibrosis, then omental
grafts or gracilis muscle graft is applied
In case of large and high VVF, trans
peritoneal approach is preferred.
17.
18. Injury of ureter most commonly following
surgery:
Obstruction
Transection
Devascularisation
19. Total obstruction
Detected early during surgery- removal of
ligature and stenting
If detected late, ureter implanted into
bladder
Transection
Partial – cystoscopic catheterization &
stenting of ureter
Complete – reanastomosis or implantation of
cut end to bladder or ureteroneocystostomy
20. Usually caused during cesarean section.
Complain of cyclical hematuria.
Treatment is usually through abdominal route
21.
22. Causes in developed countries:
Anterior repair.
Vaginal hysterectomy.
Urethral diverticulum or its repair.
Bladder neck suspension procedures.
Causes in developing countries:
Childbirth.
23. Symptoms:
Higher up in the urethra
Continuous incontinence.
Fistula nearer the bladder neck
Stress incontinence .
Recurrent urinary tract infections.
Lower down
Spraying of urine at micturition or post-
micturition dribble.
24. Management:
Conservative with a urethral catheter.
Surgical repair in specialist centre.
Repair is most commonly through vaginal
route.
25. Continous bladder drainage for 14 days
Adequate antibiotics
No vaginal or speculum examination.
No intercourse for 3 months after surgery.
Cesarean section indicated following
successful repair.
26. Detect high risk factor at the earliest during
ANC (contracted pelvis & malpresentation)
Avoid prolonged labor
Avoid unskilled forceps application & risky
destructive operations
Detect injury to the bladder at the earliest
and treatment of the same.
27.
28. Large RVF – incontinence of both faeces +
flatus through vagina
Small RVF – incontinence of flatus through
vagina
Foul smelling vaginal discharge
30. Pre- and post- operative preparation is very
important.
Rectal enema
Low residue fluid diet 5 days before surgery
Intestinal antiseptics- neomycin
Vaginal douche
31. Lawson tails’s operation
Cutting remaining bridge of tissue below
fistula
Converting fistula into complete perineal
tear
Repaired in layers like in complete perineal
tear
32.
33.
34. Same as described in VVF repair
Alternative procedure is to start as in
perineorrhaphy for rectocele and extend the
dissection above the fistula
35.
36.
37. High RVF usually surrounded by dense fibrosis
Difficult to close vaginally
Best dealt by abdominal (transperitoneal)
38. Vulva washed with antiseptic after every
micturition
Low residue diet
Intestinal antiseptics
Vaginal pack removed after 24 hrs
Laxatives given to avoid constipation
Elective LSCS at term advised after RVF
repair
39. Gynaecology by ten teachers 19 editions.
Essential of obstetrics and gynaecology.
Hacker & Moore, fifth edition.
Obstetrics and gynaecology an evidence-
based text for MRCOG second edition.
http://www.uptodate.com.