seminar results

1. GENITO-URINARY
FISTULAS
Yashar Najiaghdam
M.D

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

5. VESICOVAGINAL FISTULA
(The Commonest)

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.

19. Methylene
blue
test

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