This document provides an overview of vesico-vaginal fistula (VVF), including its prevalence globally and in Nigeria, historical perspectives, causes, classifications, management approaches, prevention strategies, and VVF centers in Nigeria. It discusses that VVF is most common in Asia and Sub-Saharan Africa, with an estimated 50,000-100,000 new cases annually. Nigeria accounts for 40% of global VVF cases. The document outlines classifications of VVF based on anatomy, severity, and size. Surgical repair is the primary management approach and can be performed vaginally or abdominally depending on the fistula. Post-operative care and prevention strategies aimed at reducing poverty, illiteracy and harmful practices are also

1. MANAGEMENT OF VESICO-
VAGINAL FISTULA
DR YAMANI MAIMUNA ABBA
DEPT OF OBSTETRICS AND
GYNAECOLOGY
FEDERAL MEDICAL CENTRE JALINGO
06/06/2023 1

2. OUTLINE
• INTRODUCTION
• PREVALENCE
• HISTORICAL PERSPECTIVES
• CAUSES
• PREDISPOSING FACTORS
• CLASSIFICATION
• MANAGEMENT
• PREVENTION
• CONCLUSIONS
06/06/2023 2

3. INTRODUCTION
•Genitourinary fistula is
an abnormal
communication between
the urinary and genital
tract( vagina or uterus),
with involuntary escape
of urine 06/06/2023 3

4. GLOBAL PREVALENCE
• The exact magnitude of VVF worldwide is unknown. However
according to WHO, over 20 million women are living with this
condition, mainly in Asia and Sub-Saharan Africa
• Estimated 50,000 to 100,000 new cases each year.
• Nigeria accounts for 40% of fistula cases worldwide.
• Incidence rate in specialist hospital Maiduguri is 18.3%(Dr
Geidam,Barka)
• More than 400,000 women remain untreated in Nigeria
• UNFPA annually repairs about 3,000 fistula cases in Nigeria
06/06/2023 4

5. HISTORICAL PERSPECTIVES
• 2050 BC- Mummy of Egyptian Queen, Queen Henhenit
dissected in 1923 had a contracted pelvis with a large VVF from
obstructed labor
• 1849- First successful repair by Dr James Marion Sims
• 1855- The 1st fistula hospital by Sims in New York
• 1975- 2nd fistula hospital in Ethiopia
06/06/2023 5

6. CAUSES
• CONGENITAL: very rare
• ACQUIRED:
• Obstetrical
• Gynaecological
• Infection
• Malignancy
• Radiation
06/06/2023 6

7. PREDISPOSING FACTORS TO OBSTETRIC
FISTULA
• Early pregnancy & childbirth
• Childhood malnutrition
• Harmful traditional practices
• Illiteracy and ignorance
• Poverty
• 3 delays
• Poor health infrastructure/ skills for caesarean delivery when
needed 06/06/2023 7

8. CLASSIFICATION OF VESICO-VAGINAL FISTULA BASED
ON ANATOMY
06/06/2023 8

9. CLASSIFICATION BASED ON SEVERITY
06/06/2023 9
Simple Complex
• <2.3cm in size >3cm
• Supra trigonal Trigonal or below
• No hx of pelvic malignancy or
radiation
Hx pelvic malignancy or radiation
• Vaginal length is normal Vaginal length shortened
• Healthy tissue Associated with scarring, involving
urethra, bladder neck, ureter or
Intestine
• Good access Previous unsuccessful attempt of
repair

10. CLASSIFICATION BASED ON SIZE
•Small: <2cm
•Medium : 2-3cm
•Large: 4-5cm
•Extensive: >6cm
06/06/2023 10

11. CLINICAL FEATURES
•History - location, age, parity, hx
of difficult labour or instrumental
delivery in recent past
• Symptoms
• True incontinence in pt with large
fistula
11

12. CLINICAL FEATURES CONT..
• Small fistula- leakage in certain position and can also pass
urine normally
• Leakage after surgical injury occur from the first day post-
op
• Leakage from Obstetric fistula may takes 7-14days to
develop
• Delayed onset of leakage post pelvic radiations (months up
to years) 06/06/2023 12

13. • Cyclic heamaturia (menouria) at time of menstruation
• Vulval excoriation (ammonical dermatitis)
• Features of UTI
• Bladder stones
• Secondary amenorrhea
• Obstetric palsy(foot drop)
• Pressure ulcers on buttocks
• Infertility
• Depression
06/06/2023 13

14. •General physical examination
•Abdominal examination
•Pelvic examination -
•Speculum examination
•Number, size and site of the fistula will be seen.
•Small fistula or fistula high up in vagina might be
difficult to appreciate.
06/06/2023 14

15. • Often, the bladder mucosa may be visibly prolapsed through a
big fistula
• The condition of the vaginal epithelium and the state of the
tissue surrounding the fistula (edematous, scarred or fixed to
bone),
• The state of the urethra and patency
• The ureteric orifices (if visible at the edges of a massive VVF)
• And finally the accessibility of the fistula for purpose of repair
through the vagina 06/06/2023 15

16. THREE SWAB TEST
16

17. • DYE TEST: methylene blue injected into bladder by a
catheter is seen coming out through the fistula opening
• Metal catheter: passed through the external urethral
meatus into the bladder, when it comes out through the
fistula in the vagina suggests v.v.f and patency of urethra.
• EUA – Identify small fitulae. A metallic probe may be used
for exploration
06/06/2023 17

18. •Investigations performed are:
•FBC, Serum E.U.Cr, Urinalysis, Urine M/C/S
•Intravenous urography
•Retrograde pyelography
•Cystography
•HSG
•Endoscopy studies- cystourethroscopy
06/06/2023 18

19. MANAGEMENT OF VVF
Multidisplinary (gynaecologist, urologist, general surgeons
and psychiatrist, nutritionist, physiotherapist and the
physicians)
After detailed hx and comprehensive clinical evaluation
• Conservative management
• Surgical management
06/06/2023 19

20. CONSERVATIVE MANAGEMENT
• Indications
• Small fistula <2cm, diagnosed within 7 days and unrelated to
carcinoma/radiation
• Bladder should be continuously drained by transurethral or
suprapubic catheter, for up to 30days
a. Small fistula may resolve spontaneously
b. If fistula decreases in size-drainage for additional 2-3weeks
c. If no improvement in 30days-surgery
06/06/2023 20

21. PRINCIPLES OF SURGICAL MANAGEMENT OF VVF
• Preparation of patient for surgery
– improve nutrition
– treat infections
– treat other existing complications
• Perform operation
– by trained surgeon
– hospital admission up to 2 weeks after surgery
• Scrupulous postoperative care 06/06/2023 21

22. Preparation of patient for surgery.
• Improvement of patient’s:
•General health, nutrition and hygiene
•Treatment of infection
•Administration of haematinics
•Counselling and social support
06/06/2023 22

23. • Vulvo-perineal dermatitis prevention/rx:
–topical application of petroleum jelly, or
–zinc oxide and castor oil cream
–estrogens may be given to soften extensive
fibrosis
06/06/2023 23

24. INTERVAL BEFORE SURGERY:
•Usually three months for obstetrics fistula
•Surgical fistulas- Repair should be Immediate
if recognised within 24hrs,
•For radiation induced- Repair should be 12
months post radiation
•Anaesthesia- G.A or spinal depending on
choice of surgeon 06/06/2023 24

25. GUIDING PRINCIPLES OF SURGICAL REPAIR OF VVF
•Appropriate pre-op preparation
•Timely repair
•Free from infection, inflammation and necrosis
•Skilled surgeon and use of appropriate route for
surgery conversant by surgeon
06/06/2023 25

26. • Adequate light source
• Adequate exposure of the fistula by appropriate choice of
positioning (Lawsons, Jack-knife, Lithotomy, Knee chest)
• Adequate blood supply
• Appropriate surgical instrument and suture material
• Effective intra-op haemostasis
• Excision of all scar tissue
• A tension-free, water-tight, multi-layered closure
06/06/2023 26

27. • Avoidance of overlapping suture lines
• Interposition of healthy vascularised tissue between the
bladder and vaginal suture lines if indicated, using grafts or
flaps e.g Martius grafts, omental flaps etc
• Continuous postoperative bladder drainage (12-14 days).
• Avoiding blockage of catheter at all cost
• Avoiding pressure on suture line by catheter balloon through
traction
• Adequate post op hydration
06/06/2023 27

28. 6/6/2023 28

29. OPERATIVE TECHNIQUES
• VAGINAL SURGERY
1. Saucerization technique (sim’s
Operation)
2. Flap-splitting technique
3. Urethral reconstruction
06/06/2023 29

30. ABDOMINAL SURGERY
• INDICATIONS: -
• High inaccessible fistula
• Multiple fistula
• Involvement of uterus or bowel
• Need for ureter re-implantation
• Complex fistula
• Associated pelvic pathology requiring simultaneous abdominal
surgery
• Surgeon preference
06/06/2023 30

31. • Other techniques include:
• Transperitoneal-vesicouterine
• Trans vesical- high fixed fistula
• Laparoscopic surgery
• Combined abdomino-vaginal repair
• Colpocleisis
• Electrocautery fulguration
• Robotic surgery
• Use of fibrin glue sealant
06/06/2023 31

32. • Ureteric surgery
•Simple repair
•Resection and anastomosis
•Reimplantation
•Transplantation
06/06/2023 32

33. VAGINAL VS ABDOMINAL APPROACH
• Vaginal-avoids laparotomy and splitting of the bladder
• Recovery is shorter with less morbidity,
• Less blood loss and postoperative bladder irritability.
• Procedure can be done in an outpatient setting;
• Postoperative pain is minimal
• Results is as successful as those of the abdominal
approach.
06/06/2023 33

34. FACTORS AFFECTING SUCCESSFUL REPAIR
• Adequate urinary tract drainage.
• Prevention of infection(appropriate use of antimicrobials).
• Maintenance of haemostasis.
• Wide mobilization of the vaginal epithelium to expose the
bladder
• Excision of scar tissue.
06/06/2023 34

35. URINARY DIVERSION
• Not all fistulas can be healed
• Ureterosigmoidostomy
• Intestinocutaneous ureterostomy (Ileal conduit)
• Mainz pouch (ileo-caecal)
• Urethral plugs for stress incontinence
• Bladder augmentation procedures
06/06/2023 35

36. POST-OPERATIVE CARE:
06/06/2023 36
Aim- keep patients draining, drinking and dry
• Catheterization-Transurethrally or Suprapubic
• Duration for primary repair is 14days
• Fluid intake-
• I.V. Infusion 4-6L daily for the 1st 24-48hrs depending
when oral fluid intake is resumed
• Hourly, 2-4hrly urine output monitoring
• Target urine output of at least 100mls/hr

37. 06/06/2023 37
•Antimicrobial use:
•Prophylactic or based on urine culture
•Continued during post-op period up to 10
days or entire duration of catheterization
•Post-op urine cultures repeated every 2-3days
interval, the last beign of the tip of removed
catheter

38. • Ambulation: should be customized to patient’s
situation.
• Some as early as a day after repair or
• late for patients with transabdominal repairs and
urethral reconstruction
• Vulvo-vaginal Toileting: twice daily and after bowel
movement.
• Vaginal packing should be removed on 2nd day post-
op 06/06/2023 38

39. •Outcome determination:
•2 hours after catheter removal, the vestibule
is inspected for normality, stress incontinence
or introital urine leakage.
•If there is introital leakage: patient is
reassured and re- catheterization for further
7-10 days.
06/06/2023 39

40. • If stress incontinence: repair is regarded as partially
successful
• patient is counselled and encouraged to void urine at
hourly intervals until reviewed each day.
• If no leak or stress incontinence: repair is adjudged
successful
• Bladder training-improve its capacity, urine storage
and voidance capability
• should void urine at hourly intervals and progressively
extended until a convenient schedule is attained.
06/06/2023 40

41. • Patients with partial or complete success be counselled on:
• Resumption of coitus after three months
• Use of contraceptives for at least 1 year
• Early antenatal care when pregnant and her detail history
told to clinic attendants.
• Subsequent deliveries should be by elective caesarean
section but never deliver at home.
• Patient is discharged to her relatives if available,
otherwise, she is transferred to the adjacent
rehabilitation centre for the requisite care & support.
06/06/2023 41

42. POST-OP COMPLICATIONS
• EARLY:
• Excessive bleeding
• Surgical wound infection
• Urinary tract infection
• Continued urine leakage through the fistula
• LATE:
• Risks of abdominal and pelvic adhesions (if abdominal approach is
used)
• Risks of dyspareunia and tenderness (if vaginal approach is used)
• Reduced vaginal length/ shortening and stenosis(if vaginal approach is
used) 06/06/2023 42

43. Management of other problems co- existing with fistula
A. Obstetric palsy:
• Physiotherapy
• Shoe calipers and foot elevators
B. Secondary Amenorrhea:
Tx of underlying causes:
•Hypothalamic dysfunction
•Sheehans syndrome
•uterine synaechia
C. Sexual dysfunction: (Gynaetresia)
• By counselling and
• Use of lubricants during sexual intercourse ( Xylocaine cream).
06/06/2023 43

44. PREVENTION ALWAYS BETTER THAN CURE
STRATEGIES
• Alleviate: Poverty, illiteracy
and harmful traditional
practices
• Improve health system and
social infrastructures
ACTIVITIES
• Advocacy to policy makers and
governments
• Information, education and
counselling of public
• Fundraising to support prevention
and treatment of obstetric fistula
06/06/2023 44

45. CONCLUSION
• Genital fistula is an ancient human affliction that has been
successfully controlled in most parts of the developed countries,
but still a menace in developing countries.
• Prevention through safe motherhood initiative is the way
towards elimination of obstetrical fistula. Success will require
fundamental changes: in tradition and cultural practices more
so regarding early marriage
• Further progress is best made by training of doctors in fistula
surgery by the skilled surgeons. 06/06/2023 45

46. VVF CENTERS IN NIGERIA
1. KANO- LAURE MADAKI VVF CENTER, MURTALA MUHAMMAD SPECIALIST H
2. KATSINA- BABBAN RUGA NATIONAL OBSTETRIC FISTULA CENTRE
3. SOKOTO- MARYAM ABATCHA FISTULA HOSPITAL
4. KEBBI- GESSE VVF CENTER BIRNIN KEBBI
5. EBONYI- NATIONAL OBSTETRICS FISTULA CENTER, ABAKALIKI
6. JOS- EVANGEL VESICO-VAGINAL FISTULA CENTER
7. ZAMFARA- FARIDAT YAKUBU GENERAL HOSPITAL
8. BAUCHI- NATIONAL OBSTETRICS FISTULA CENTER, NINGI
9. JIGAWA- JAHUN VVF CENTRE
10. SOKOTO- MARYAM ABATCHA WOMEN AND CHILDREN HOSPITAL
11. CROSS RIVER- OGOJA GENERAL HOSPITAL
12. KWARA- SOBI SPECIALIST HOSPITAL, ILORIN
13. OYO- UNIVERSITY COLLEGE HOSPITAL, IBADAN
14. OYO- ADEOYO GENERAL HOSPITAL, IBADAN
06/06/2023 46

47. THANK YOU
FOR LISTENING
06/06/2023 47

48. REFERENCE
• 1. Comprehensive gynaecology in tropics. 2nd edition. E.
Kwawukume, E. Emuveyan
• 2. Gynaecology illustrated. 6th edition. Cartina bain, kevin burton, C
jay mcgavigan.
• 3. DC dutta’s textbook of gynaecology. 6th edition. Edited by hiralal
konar.
• 4. Dewhurt’s textbook of obstetrics and gynaecology. 9th edition.
Keith Edmonds, Christopher lees, tom bourne. 06/06/2023 48

49. CONT..
• 5. Powerpoint note, genital fistula by dr. Ayyuba labaran
• 6. Powerpoint note, obstetrics fistula by dr. Samba ali
• 7. USAID fistula care plus. Nigeria. Http://fistulacare.Org
• 8. Fistula foundation. Nigeria. Http://www.Fistulafoundation.Org
• 9. Powerpoint note, principles of management of vvf by Dr Habiba
Isa Ladu
06/06/2023 49