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VESICO-VAGINAL

FISTULA

PRESENTED BY
DR. ESTHER ENYINDAH
INTRODUCTI0N
A fistula is defined as an abnormal
communication between two or more epithelial
surfaces.
The common gynaecological fistulae are:
-VVF, RVF and UVF. VVF being the commonest.
VVF is a pathological communication between
the bladder mucosa and vaginal epithelium which
allows free and continuous flow of urine from the
bladder to the vagina such that the woman is wet
all the time.
EPIDEMIOLOGY
Real incidence –unknown.
Related to socio-economic status in the comm.
More in teenagers
More in primipara
Accounts for 7% of Gynae. consultations in
northern parts of Nigeria.
UPTH, accounted for 9 out of 452 (1%) Gynae.
Admissions in 2001 (Annual Report)
WHO estimates 500,000 untreated cases of VVF
worldwide.
AETIOPATHOLOGY
VVF could be congenital or acquired.
In most third world countries, > 90% of fistulae are of obstetric
aetiology whereas in United Kingdom, >70% follow pelvic
surgery.
1. Prolonged obstructed labour : Commonest cause of VVF in
our environment
-Accounts for >80% of the cases.
2. Caesarean section:
-Incision involving the posterior bladder wall.
-During reflection of the bladder.
-Accidental passage of a suture through the posterior
bladder wall during repair of the incision.
3. Uterine rupture:
-Rupture of a previous caesarean section scar.
-Rupture of the unscarred uterus from obstetric manipulations.
-The bladder may be caught in the sutures during repair.
4. Direct trauma during operative vaginal delivery:
Forceps delivery, craniotomy, symphysiotomy, repair of vaginal
or cervical lacerations.
AETIOPATHOLOGY CONTD.
5. Gynaecological operations:
-Pelvic floor repair, vaginal hysterectomy,
abdominal hysterectomy, colporrhaphy
-Commonest cause of VVF in developed
countries, where it accounts for 75.3%
-Accounts for only 2.5% of VVF in Nigeria.
-Risk factors for post operative fistulae are
as shown below.
Risk factors for
post operative fistulae.
Risk factor Pathology Specific e.g.’s
1.Anatomical Fibroids, Ovarian
distortion mass
2.Abnormal tissue Inflammation Infections
adhesions Endometriosis
Pelvic surgery C/S, Vag-Hys.
Colporrhaphy
Malignancy
3. Impaired Ionizing Preop.
vascularity radiation Radiotherapy
4. Compromised H Anaemia,Nutri def.
AETIOPATH. CONTD.
6. Radiation necrosis.
7. Malignancies: Ca Cervix, vagina, rectum and bladder.
8.Traditional practices: Gishiri cut, circumcision, caustic
soda.
-Gishiri cut accounts for 10-13% of all cases of VVF in
the northern Nigeria.
9. Infections: Lymphogranuloma venerum,
schistosomiasis, tuberculosis.
10. Social factors: Early marriage and early delivery.
->50% of cases in northern Nigeria are below 20 yrs.
->50% are in their first pregnancy.
11.Others: Coital injuries, excision of a urethral
diverticulum.
Aetiology of fistulae in NE England
and SE Nigeria
Aetiology England (n=85) Nigeria (n=2,485)

1.Obstetric 11.8% 93.3%


-Obstr.labour 1.2% 81.4%
2. Surgical 75.3% 2.5%
-Abd. hyst. 42.4% 0.8%
-Vag. hyst. 2.4% 0.6%
3. Radiation 10.5% 0.0%
4.Malignancy 0.0% 2.0%
5.Miscellaneous 2.4% 2.2%
CLASSIFICATION
VVF are classified according to the site of injury;
Juxta-urethral fistula
Mid-vaginal fistula
Juxta-cervical fistula
Very large fistula
Vault fistula
Combined fistula
Circumferential fistula
Residual fistula
CLINICAL PRESENTATION
Typical history is that of total incontinence soon after
a prolonged obstructed labour, operative vaginal
delivery, or caesarean section.
In direct surgical injury to the bladder, the leakage of
urine may occur from day one.
Most surgical and obstetric fistulae symptoms
develop between 3 or 5 – 14 days.
In a review of cases from Nigeria, the average time
for patient presentation was >5yrs. And in some
cases, >35yrs. after the causative injury.
History of previous surgeries or prolonged obstructed
labour.
Secondary amenorrhoea.
Secondary infertility.
MANAGEMENT OF VESICOVAGINAL-
FISTULA
by Dr. JAMES ENIMI OMIETIMI

History
Clinical Examination
Investigations
Treatment
Clinical Presentation
Hx. of previous pelvic or abdominal surgery

Symptoms develop early, may be Day 1

Postoperative urinary leakage, oliguria,


abdominal distension, pyrexia or loin pain

Present earlier for repair than obstetric cases

Hx. of previous unsuccessful attempt(s) at


repair
FINDINGS ON
CLINICAL EXAMINATION
O\E -Ill looking, malnourished, pale
with evidence of inter current
infections
Abd. –kidneys may be enlarged &
tender
Pelvic Exam. –vulva & thigh
excoriations
(ammoniacal dermatitis)
Clinical Examination contd.
V/E –best performed in lateral position,
-may also be done in dorsal position.
-digital to precede speculum exam.
-insert speculum of appropriate size
-visualize ant. Vaginal wall & then
-post. Vaginal wall
-Do digital rectal exam. to R\O RVF
EXAMINATION UNDER
ANAESTHESIA + DYE TESTS
Digital vaginal examination and
examination with a Sim’s speculum may
not confirm or exclude a fistula, thus
necessitating examination under
anaesthesia + DYE TESTS
A malleable silver probe is passed
through openings in the vaginal wall;
-For VVF and UVF, a metallic click
against a silver catheter may be felt or
seen via a cystoscope.
-For RVF , the probe may be felt digitally
in the rectum or seen via a proctoscope.
EUA + DYE TEST Continued.

Enables assessment of available access


and the mobility of tissues for vaginal
repair.

The decision to repair vaginally or an


abdominal approach can also be taken
then.
SPECIFIC INVESTIGATIONS

DYES STUDIES
Investigations of first choice
Confirm if discharge is urinary
If leakage is extra-urethral rather than urethral
To establish the exact site of leakage
Phenazopyridine -200mg tds orally
Indigo carmine -intraveneously
Methylene blue instillation
DYE STUDIES contd.
Patient in lithotomy position
Examination best done under direct vision
‘Three Swab Test’ has limitations and is
not recommended.
Adequate distension of the urinary bladder
If clear fluid leaks after instillation of dye,
ureteric fistula is likely.
Differentiate by “two dye test”
Phenazopyridine to stain renal urine and
Methylene blue to stain the bladder urine
OTHER SPECIFIC
INVESTIGATIONS
Cystoscopy – small vvf
Cystography – vesico uterine fistulae (lat.
view)
Hysteroscopy/Hysteosalpingography-vesico
uterine fistulae ( lat.
view)
Fistulography –small intestinal fistulae
Colpography –small fistulae involving vagina

Endoanal Ultrasound, MRI –anorectal &


perineal fistulae
Barium enema, Barium meal & follow through
GENERAL INVESTIGATIONS

FBC + Blood film + Malaria Parasite


Urine for urinalysis & m.c.s.
Stool for Parasitic Infestations
CXR
Serum E/U/Cr
Intravenous Urography
PREOPERATIVE
TREATMENT
Timing of definitive repair
Improve Patient’s General Health; high protein
diet, antimalarials, antihelmintics, haematinics
& Rx inter current infections/ diseases
Rx vulval dermatitis with silicone barrier
creams, zinc oxide cream & castor oil
Bowel Preparation
Prophylactic Antibiotics/ Urinary Antiseptics
REPAIR OF VVF

Route of Repair; vaginal or abdominal


Position of Patient; lithotomy or reverse
lithotomy (knee-elbow position)
Type of suture materials; absorbable
-vicryl 2/0 or chromic catgut 2/0
Types of Repair;(1) Dissection & repair in
layers (2) Saucerization
POST OPERATIVE
MANAGEMENT
Fluid Balance; intake 3-4 litres per day
output 120-150mls/hr
Bladder Drainage; check drainage & vol. of
urine hourly
Post Operative antibiotics
Prevention of Deep Vein Thrombosis
Care of the perineum with vulva pads
Duration of Drainage; 10-14 days on the
average
Retraining of urinary bladder before discharge
Post Operative Mgt. Contd.
Instructions on Discharge
Repeat EUA & dye test on day 21 before
discharge
Refrain from sexual intercourse for
3months
Counsel for antenatal care & hospital
delivery in all subsequent pregnancies
Elective Caesarean Section next
pregnancy