Obstetric

Fistulae/gynaetresia

Definition
A fistula is defined as a pathological
communication between two epithelial
surfaces.
Obstetric fistulae are fistulae developed
in the course of pregnancy and
childbirth.
Common types seen in obstetrics are
vesico-vaginal fistula (VVF), rectovaginal
fistula (RVF), Ureterovaginal fistula (UVF)

Vesico-Vaginal fistula
Commonest type of obstetric fistula in
Tanzania.
Aetiology-prolonged obstructed labor
(CPD), ruptured uterus, caesarean
hysterectomy, operative vaginal delivery
(forceps, destructive operation),
symphysiotomy

 Non obstetric causes-pelvic floor

repair, vaginal hysterectomy, genital
and bladder cancers, irradiation,
congenital, coital injuries,pelvic
fractures, caustic agents.

Pathology
Pressure necrosis
Ischaemia-necrosis-sloughing off btw
3 to 10 days-urinary incontinence.
RVF- compression of rectovaginal
septum btw the fetal skull and sacral
promontory.

Anatomic classification

Juxta urethral
Mid vaginal
Juxta cervical
Large fistula
Circumfrential juxta urethral
Vault fistula

RVF

High RVF (upper half of vagina)

Low RVF (lower half )
3rd degree perineal tear.
Large (greater than half of post wall

Other clasification

Small fistula less than 2cm

Medium 2-3 cm
Large 4-5 cm
Extensive greater than 6cm

Clinical presentation
Hx of prolonged obstructed labor
rsulting in stillbirth/CS/OPVD
Total incontinence 3-10 days later
There may be associated feacal
incontinence (RVF)
Weakness in the lower limbs.

 Pt is unkempt, smells of urine,

miserable looking. May have cs scar
Vulva is wet, vulvar
excoriation( ammoniacal dermatitis)
May have vaginal stenosis from
scarring, so do digital exam before
speculum.

Investigations
FBC, Hiv screening, E & U, CR, renal
uss, cystoscopy, pippette specimen
urine for mcs.

Differential diagnosis

Stress incontinence
Urge incontinence
Ureterovaginal fistula(UVF)
Overflow incontinence.

3 swab test
Use to diferentiate btw UVF, VVF and
stress incontinence
Place 3 swab in the vagina
Instill 100ml methylene blue into
bladder
Move around for 10-15 min
Lower swab wet & blue-SI, upper swab
wet & blue-VVF, upper swab wet but not
blue-UVF.

Mgt

VVF repair
Psychological support
Physiotherapy
If follow obstructed labor wait for 3 mths
to allow slough to separate, inflamation
to subside and new tissue plane to form.
If due to cs injury, repair immediately.
Optimise patient before repair.

Post op mgt

Catheterise for 10-14 days

Monitor urinary output hourly
6 litres of fluid per day.
Antibiotics
Analgesics
All future delivery should be by CS

Complications

Haemorrhage
Infection
Clot retention
Catheter blockage
Occlusion of ureters

Prevention
Good nutrition for girls
Avoid early mariage
Adequate ANC/ emergency obstetric
care
Education of populace
Family planning-reduce parity

RVF
May coexist with VVF
Repair vvf first
High fistula-colostomy first

Preoperative mgt
Bowel preparation- neomycin 1 g,
low residue diet 3 days b4 operation,
rectal wash out night before.

Postoperative mgt
Low residue diet for 5days
Liquid paraffin
Deliver subsequent babies by CS

Gynaetresia

Narrowing or occlusion of the vagina

May be congenital or acquired
Acquired is more common in the tropics.
Incidence 7 per 1000. peak age 20-30
years.
Commonest cause here is chemical
vaginitis from caustic pessaries
May follow vvf/rvf repair,
FGM,colporrhaphy, irradition

Clinical presentation
Dyspareunia
Apreunia
Vaginal stenosis/ occlusion

Management
Vaginoplasty- one stage, mc IndoleRead,williams.
Simple dilatation

prevention
Community based education to
discourage harmful practices.