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GENITO-URINARY
FISTULAS


 Yashar Najiaghdam
               M.D
Definition
   Abnormal communications between urinary
    & genital organs.
   Remember 2 golden rules
       1st rule: urine may escape from
           ureter  tube, uterus, cervix, vagina
           bladder   tube, uterus, cervix, vagina
           urethra  always vaginal.
       2nd rule in naming a fistula,
           Part of the urinary tract is 1st to be described
 genito urinary fistula
Varieties
1.   Vesico-vaginal
2.   Uretero-vaginal
3.   Urethro-vaginal
4.   Vesico-cervical
5.   Uretero-cervical
6.   Uretero-uterine
VESICOVAGINAL FISTULA
(The Commonest)
Aetiology
   Congenital: very rare.
   Traumatic fistula
     Obstetric trauma

         Necrotic obstetric fistula

         Traumatic obstetric fistula

     Surgical trauma

     Direct trauma

   Inflammatory disease
   Malignant neoplasms
   Radium necrosis
Necrotic Obstetric Fistula
   Prolonged compression of soft tissues between
    head & brim of a narrow pelvis.
   → ischaemia, pressure necrosis & sloughing of
    base of the bladder.
   Urethra is also often involved.
   Slough takes some days to separate
   → Incontinence develops 5-7 days after labour
   Such fistulae are often surrounded by dense
    fibrosis
Traumatic Obstetric Fistula
   Direct injury to bladder wall by sharp
    instrument (perforator or decapitation hook)
    during a difficult labour
   Forceps rarely cause it
   Incontinence Appears immediately After
    Labour
Traumatic Fistula
   Surgical trauma: Bladder may be injured
     during vaginal operation as anterior
       colporrhaphy
     during abdominal operations as hysterectomy.

   Direct trauma: is a rare cause, but cases have
    occurred as a result of impalement.
Other Causes
   Inflammatory disease: result from
       Bilharziasis of bladder
       Tuberculosis of bladder.
       A pelvic abscess may open into bladder & vagina
   Malignant neoplasms:
       As advanced carcinoma of cervix or of bladder, or
        vagina
       By direct invasion of the wall and ulceration.
   Radium necrosis:
       Sloughing of the bladder
       As a complication of radium treatment used for cure of
        malignant disease in pelvis
Symptoms
   Incontinence of urine
       Complete (large fistula) OR
       Partial (small or high fistula)
           DD: uretero-vaginal fistula.
   Symptoms of vulvitis:
       Pruritus, burning pain due to continuous
        discharge of urine.
   Cystitis
       Due to ascending infection from vulva
Diagnosis
   History of incontinence following labour or operation.
     Several days after labour      necrotic obstetric
       fistula
     Immediately after difficult labour    traumatic
       fistula.
   Palpation of anterior vaginal wall:
     Large fistula Can be felt

     Small fistulas cannot be felt, but surrounding
       fibrosis is usually palpable
Diagnosis
   Inspection of the anterior
    vaginal wall
       In Sims’ position or left
        lateral (semi-prone)
        position
       With the use of Sims’
        speculum.
Diagnosis
   For small and high fistula
       Dye test: Injection of methylene blue into
        bladder by a catheter to outline the fistula while
        anterior vaginal wall is inspected by use of
        Sim’s speculum.
       DD: uretrovaginal fistula
   Sometimes a metal catheter or sound is passed
    through the urethra to appear at the fistulous
    opening.
Management
Prophylaxis:
  Antenatal:
     Diagnosis of abnormalities that possibly result in fistula
      formation
           contracted pelvis
           malpresentations
   During labour
      Diagnose and deal with:
           prolonged labour
           contracted pelvis
           Malpresentations
       Risky operations should all be avoided
           high forceps
           forceps with incompletely dilated cervix
           risky destructive operations.
Management
   If injury to the bladder is discovered during a
    difficult labour,
       Don’t suture the tear due to tissue oedema and
        friability.
       fix rubber catheter for 10 days
       The tear may heal completely or be much smaller
   If the injury is detected some time after labour, as
    in cases of necrotic fistulas,
       operations done except at least 3 months after delivery
        to allow for maximum involution of the tissues.
Preoperative Preparation
   Treat vulvitis:
       Cover skin of the vulva, and inner thighs by a thick
        layer of Vaseline, zinc oxide ointment or any bland
        ointment, to prevent maceration of the skin by the
        continuous discharge of urine.
   Renal function tests:
   Culture of urine,
       if pathogenic organisms are found, patient is given
        urinary antiseptics until urine is sterile.
Methylene blue test
   to differentiate a small vesico-vaginal fistula from a
    uretero-vaginal fistula.
       3 pieces of gauze are placed in the vagina
       200 cc of sterile fluid coloured with methylene blue is Injected
        into the bladder
       The lowest piece of gauze is discarded as it is usually
        stained during filling the bladder.
       If the middle or upper pieces stain → fistula is vesical
       If none of the pieces stain and the upper one is wet with
        uncoloured urine → fistula is ureteric.
       If all are dry and unstained → excludes vesical or ureteric
        fistula.
Methylene
blue
test
Cystoscopy
   Determine relation of the fistula to ureteric openings in
    bladder
   Exclude multiple fistulas
   Reveal associated bladder pathology.
   Chromocystoscopy
     IV Injection of 4 c.c. of 0.4%
      indigocarmine solution
     If kidney function is good →
      Blue efflux from the ureter in 4
      minutes.
Operation
flap-splitting operation, or dedoublement
   Circular incision around the fistula.
   The 2 short longitudinal cuts
    upwards and downwards                   Long.
                                            incision
   Through the thickness or the vagina
    but not the bladder.
   → 2 flaps of vaginal wall.              Circular
                                            incision
   Free mobilization of the vaginal
                                            Fistula
    flaps from the bladder over a wide
    area, at least 1.5 cms around the
    fistula.
Operation
   The hole in bladder is then closed by 2
    layers of interrupted sutures going through
    muscle wall only & not piercing the mucous
    membrane.
   The vagina is then closed by interrupted
    sutures going through its whole thickness.
   A rubber catheter is fixed in the urethra
   Tight vaginal pack to prevent reactionary
    haemorrhage.
 genito urinary fistula
The saucerisation operation
(Sim’s operation)
   Indicated
       If tissues are too adherent and fibrosed to do flap
        splitting
       After failure of the flap splitting.
   Technique:
       Edge of the fistula is excised removing a wider part of
        the vagina than of the muscle wall of the bladder
       Edges of both organs are simultaneously coapted
        together by the use of nonabsorbable sutures
   Certain high fistulae are better treated by
    abdominal (transperitoneal or transvesical) repair.
Postoperative Care
   Recumbent position
   The bladder should be constantly empty.
   Fluids (3 litres/day).
   Urinary antiseptics & antibiotics.
   Vaginal pack is removed 24 hours after operation.
   Catheter is removed after 10 days.
   After its removal the patient is instructed to void urine
       every two hours by day &
       every four hours by night,
       to avoid over-distension of bladder & disruption of suture line.
Subsequent Management
   Patient is instructed to
       avoid sexual intercourse for 3 months
       avoid pregnancy for 1 year
   Caesarean section is almost absolutely
    indicated.
URETERO-VAGINAL FISTULA
   Cause:
       Injury to ureter during a gynaecological operation as
        hysterectomy
       may develop following a difficult labour.
   It leads to incomplete incontinence
       Urine from affected ureter escapes from vagina while
        bladder fills up & empties normally from other ureter
   It is always small & high up in vagina lateral to
    cervix.
   Differentiated from a vesico-vaginal fistula by:
       by methylene blue test.
       Cystoscopy shows ureteric efflux on one side only.
Prophylaxis
   Ureteric injury can be avoided by
       pre-operative intravenous pyelography
       ureteric catheterization
       proper surgical technique.
Treatment
   Abdominal re-implantation of ureter into
    bladder.
   If not possible, ureter is transplanted into
    sigmoid colon.
   If kidney function is very poor on the
    affected side → kidney can be sacrificed.
Kidney Function Tests
   Blood urea: Normally 20-40 mg%.
   Specific gravity of urine before and after water administration
    (water concentration test):
       Normally high before, low after
       In chronic nephritis → low fixed S.G. of about 1010.
   Urea concentration test: Normally urea in urine' should be 2%
    or over after administration of 15 grams of urea by mouth.
   Urea clearance test: It is a delicate test.
       It indicates the no. of cm3 of blood cleared of urea per minute
       Average = 70-120%
       < 50% → renal impairment.
   Intravenous pyelography.
Types Of Incontinence Of Urine
1.   True incontinence      genito-urinary fistula.
2.   Stress (Sphincter) incontinence      weakness of
     Internal urethral sphincter.
3.   Urgency incontinence       severe inflammation
     leading to marked irritation of bladder & so urge
     to pass urine cannot be inhibited & some urine
     will pass involuntary while patient is in her way to
     W.C.
4.   False incontinence      retention with overflow
5.   Nocturnal enuresis.
Causes Of Retention Of Urine
   Cause of urinary retention is an impacted
    pelvic mass.
   Diagnosis is made clear by attention to
    associated symptoms
Associated Conditions
      Condition                             Diagnosis
Primary amenorrhea     → Haematocolpos
Secondary amenorrhea →  Retroverted gravid uterus
Menorrhagia            → Uterine fibroid
No menstrual upset     → Ovarian or broad ligament tumour
Irregular bleeding     → (1) threatened abortion from a retroverted
                       gravid uterus,
                       → (2) pelvic haematocele
                       → (3) pelvic abscess
Labour                 → Descent of the foetus to from a pelvic
                       tumour

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genito urinary fistula

  • 2. Definition  Abnormal communications between urinary & genital organs.  Remember 2 golden rules  1st rule: urine may escape from  ureter tube, uterus, cervix, vagina  bladder tube, uterus, cervix, vagina  urethra always vaginal.  2nd rule in naming a fistula,  Part of the urinary tract is 1st to be described
  • 4. Varieties 1. Vesico-vaginal 2. Uretero-vaginal 3. Urethro-vaginal 4. Vesico-cervical 5. Uretero-cervical 6. Uretero-uterine
  • 6. Aetiology  Congenital: very rare.  Traumatic fistula  Obstetric trauma  Necrotic obstetric fistula  Traumatic obstetric fistula  Surgical trauma  Direct trauma  Inflammatory disease  Malignant neoplasms  Radium necrosis
  • 7. Necrotic Obstetric Fistula  Prolonged compression of soft tissues between head & brim of a narrow pelvis.  → ischaemia, pressure necrosis & sloughing of base of the bladder.  Urethra is also often involved.  Slough takes some days to separate  → Incontinence develops 5-7 days after labour  Such fistulae are often surrounded by dense fibrosis
  • 8. Traumatic Obstetric Fistula  Direct injury to bladder wall by sharp instrument (perforator or decapitation hook) during a difficult labour  Forceps rarely cause it  Incontinence Appears immediately After Labour
  • 9. Traumatic Fistula  Surgical trauma: Bladder may be injured  during vaginal operation as anterior colporrhaphy  during abdominal operations as hysterectomy.  Direct trauma: is a rare cause, but cases have occurred as a result of impalement.
  • 10. Other Causes  Inflammatory disease: result from  Bilharziasis of bladder  Tuberculosis of bladder.  A pelvic abscess may open into bladder & vagina  Malignant neoplasms:  As advanced carcinoma of cervix or of bladder, or vagina  By direct invasion of the wall and ulceration.  Radium necrosis:  Sloughing of the bladder  As a complication of radium treatment used for cure of malignant disease in pelvis
  • 11. Symptoms  Incontinence of urine  Complete (large fistula) OR  Partial (small or high fistula)  DD: uretero-vaginal fistula.  Symptoms of vulvitis:  Pruritus, burning pain due to continuous discharge of urine.  Cystitis  Due to ascending infection from vulva
  • 12. Diagnosis  History of incontinence following labour or operation.  Several days after labour necrotic obstetric fistula  Immediately after difficult labour traumatic fistula.  Palpation of anterior vaginal wall:  Large fistula Can be felt  Small fistulas cannot be felt, but surrounding fibrosis is usually palpable
  • 13. Diagnosis  Inspection of the anterior vaginal wall  In Sims’ position or left lateral (semi-prone) position  With the use of Sims’ speculum.
  • 14. Diagnosis  For small and high fistula  Dye test: Injection of methylene blue into bladder by a catheter to outline the fistula while anterior vaginal wall is inspected by use of Sim’s speculum.  DD: uretrovaginal fistula  Sometimes a metal catheter or sound is passed through the urethra to appear at the fistulous opening.
  • 15. Management Prophylaxis:  Antenatal:  Diagnosis of abnormalities that possibly result in fistula formation  contracted pelvis  malpresentations  During labour  Diagnose and deal with:  prolonged labour  contracted pelvis  Malpresentations  Risky operations should all be avoided  high forceps  forceps with incompletely dilated cervix  risky destructive operations.
  • 16. Management  If injury to the bladder is discovered during a difficult labour,  Don’t suture the tear due to tissue oedema and friability.  fix rubber catheter for 10 days  The tear may heal completely or be much smaller  If the injury is detected some time after labour, as in cases of necrotic fistulas,  operations done except at least 3 months after delivery to allow for maximum involution of the tissues.
  • 17. Preoperative Preparation  Treat vulvitis:  Cover skin of the vulva, and inner thighs by a thick layer of Vaseline, zinc oxide ointment or any bland ointment, to prevent maceration of the skin by the continuous discharge of urine.  Renal function tests:  Culture of urine,  if pathogenic organisms are found, patient is given urinary antiseptics until urine is sterile.
  • 18. Methylene blue test  to differentiate a small vesico-vaginal fistula from a uretero-vaginal fistula.  3 pieces of gauze are placed in the vagina  200 cc of sterile fluid coloured with methylene blue is Injected into the bladder  The lowest piece of gauze is discarded as it is usually stained during filling the bladder.  If the middle or upper pieces stain → fistula is vesical  If none of the pieces stain and the upper one is wet with uncoloured urine → fistula is ureteric.  If all are dry and unstained → excludes vesical or ureteric fistula.
  • 20. Cystoscopy  Determine relation of the fistula to ureteric openings in bladder  Exclude multiple fistulas  Reveal associated bladder pathology.  Chromocystoscopy  IV Injection of 4 c.c. of 0.4% indigocarmine solution  If kidney function is good → Blue efflux from the ureter in 4 minutes.
  • 21. Operation flap-splitting operation, or dedoublement  Circular incision around the fistula.  The 2 short longitudinal cuts upwards and downwards Long. incision  Through the thickness or the vagina but not the bladder.  → 2 flaps of vaginal wall. Circular incision  Free mobilization of the vaginal Fistula flaps from the bladder over a wide area, at least 1.5 cms around the fistula.
  • 22. Operation  The hole in bladder is then closed by 2 layers of interrupted sutures going through muscle wall only & not piercing the mucous membrane.  The vagina is then closed by interrupted sutures going through its whole thickness.  A rubber catheter is fixed in the urethra  Tight vaginal pack to prevent reactionary haemorrhage.
  • 24. The saucerisation operation (Sim’s operation)  Indicated  If tissues are too adherent and fibrosed to do flap splitting  After failure of the flap splitting.  Technique:  Edge of the fistula is excised removing a wider part of the vagina than of the muscle wall of the bladder  Edges of both organs are simultaneously coapted together by the use of nonabsorbable sutures  Certain high fistulae are better treated by abdominal (transperitoneal or transvesical) repair.
  • 25. Postoperative Care  Recumbent position  The bladder should be constantly empty.  Fluids (3 litres/day).  Urinary antiseptics & antibiotics.  Vaginal pack is removed 24 hours after operation.  Catheter is removed after 10 days.  After its removal the patient is instructed to void urine  every two hours by day &  every four hours by night,  to avoid over-distension of bladder & disruption of suture line.
  • 26. Subsequent Management  Patient is instructed to  avoid sexual intercourse for 3 months  avoid pregnancy for 1 year  Caesarean section is almost absolutely indicated.
  • 27. URETERO-VAGINAL FISTULA  Cause:  Injury to ureter during a gynaecological operation as hysterectomy  may develop following a difficult labour.  It leads to incomplete incontinence  Urine from affected ureter escapes from vagina while bladder fills up & empties normally from other ureter  It is always small & high up in vagina lateral to cervix.  Differentiated from a vesico-vaginal fistula by:  by methylene blue test.  Cystoscopy shows ureteric efflux on one side only.
  • 28. Prophylaxis  Ureteric injury can be avoided by  pre-operative intravenous pyelography  ureteric catheterization  proper surgical technique.
  • 29. Treatment  Abdominal re-implantation of ureter into bladder.  If not possible, ureter is transplanted into sigmoid colon.  If kidney function is very poor on the affected side → kidney can be sacrificed.
  • 30. Kidney Function Tests  Blood urea: Normally 20-40 mg%.  Specific gravity of urine before and after water administration (water concentration test):  Normally high before, low after  In chronic nephritis → low fixed S.G. of about 1010.  Urea concentration test: Normally urea in urine' should be 2% or over after administration of 15 grams of urea by mouth.  Urea clearance test: It is a delicate test.  It indicates the no. of cm3 of blood cleared of urea per minute  Average = 70-120%  < 50% → renal impairment.  Intravenous pyelography.
  • 31. Types Of Incontinence Of Urine 1. True incontinence genito-urinary fistula. 2. Stress (Sphincter) incontinence weakness of Internal urethral sphincter. 3. Urgency incontinence severe inflammation leading to marked irritation of bladder & so urge to pass urine cannot be inhibited & some urine will pass involuntary while patient is in her way to W.C. 4. False incontinence retention with overflow 5. Nocturnal enuresis.
  • 32. Causes Of Retention Of Urine  Cause of urinary retention is an impacted pelvic mass.  Diagnosis is made clear by attention to associated symptoms
  • 33. Associated Conditions Condition Diagnosis Primary amenorrhea → Haematocolpos Secondary amenorrhea →  Retroverted gravid uterus Menorrhagia → Uterine fibroid No menstrual upset → Ovarian or broad ligament tumour Irregular bleeding → (1) threatened abortion from a retroverted gravid uterus, → (2) pelvic haematocele → (3) pelvic abscess Labour → Descent of the foetus to from a pelvic tumour