Transcript of "Management of genitourinary fistula"
MBBS., MS. MICOG.FICOG.
Founder Principal & Controller ;
Jhalawar Medical College And Hospital , Jhalawar.
Ex. Principal & Controller;
Mahatma Gandhi Medical College And Hospital,Sitapura ,
Dr Jaya Patel (PG Student,NIMS Medical College Jaipur
• Fistula represents an extra-anatomic(
Pathological) communication between two or
more body cavities covered by Their own
epithelia; the communicating tract Is also
epithelized. This tract may also open at skin
• Classification of urinary fistula is generally based
on organ of origin in urinary tract and
termination point of fistula.
Types Of Urinary Fistula
• Congenital---Ectopic Vesicae ,Ureterovaginal Fistula.
Visio Uterine / cervical.
2. Urethra Vaginal.
3. Urethra Vaginal
4. Combined— two or more types of fistula present in
• Most common acquired fistula of urinary tract.
• Vesicovaginal fistula has been reported in a
mummy found in pyramids of Egypt ;and many
more have been described by Sims who is
claimed to Have repaired maximum vesicovaginal
fistula using his technique of “Sims triad “
Quoting That he was requested by number of
women to repair their fistula as they do not want
to go in grave with their wet bottom; they have
suffered since their child’s birth.
• Obstetrical TRAUMA ( 95 %)
• GYNAECOLOGICAL-----(0.5 -1 %)
- Prolonged and obstructed labour---pressure necrosis of bladder
neck or trig one leads to delayed onset of urinary fistula during
second week of puerperal due to constant and prolonged
compression of bladder neck by jammed up presenting part
against syphilis pubis as in cases of obstructed and prolonged
labour . Till mid 6th decade of last century; this was the
commonest cause of obstetrical urinary fistula . Change in the
management of CPD , Contracted pelvis , malpresentation
,Uterine inertia has made it a remote complication.
- Introital stenosis secondary to female circumcision ,
cephalopelvic disproportion, an android pelvis , malnutrition ,
orthopaedic disorder contribute to dystosia .
- Operative(Iatrogenic)--- forceps (Killend’s /High forceps
application ,destructive instruments used to deliver stillborn
infants and criminal abortion.
POST SURGICAL :
- Abdominal hysterectomy(1/1300patients)Simple / redical(Werthem’s.)
- Vaginal hysterectomy.
Myomectommy—cervical and broad ligament fibroids.
Laparoscpic --- fulgeration, too much heat near by bladder or ureter
- Caesarean section
- Sling operation for-incontinence of urine.
- Repair of Anterior vaginal wall prolapse -- (e.g.colporrhaphy)
- Manchester Repair.
- Circullage operation with separation of bladder at the level of internal
- Vaginal cystectomy.
- cystoscopic---Bladder biopsy , endoscopic resection , laser procedure
• Radiation induced fistula (associated with Rx
for Cancer Cervix or other pelvic malignancies)
• Vaginal foreign bodies
• Forgotten passeri
• Direct trauma from masturbation or
• Miscellaneous- Late stage of malignancy of
genital tract involving urinary tract or visa
versa. Tuberculosis , Schistosomiasis ,
Perforating bladder calculi , Endometriosis ,
Syphilis , Lymphogrannuloma venerum and
ideopathic and congenital cause.
• Constant urine drainage peer vagina.
• Most commonly recognized in first 10 days after
operation and less commonly between 10th to 20th
• constant wetness of vulva-- excoriation of Skin leads
to fungal infection , irritation , dermatitis.
• Recurrent cystitis or UTI.
• Unexplained fever ,hematuria ; discomfort in flank
and suprapubic region .
• As urea is split by vaginal flora, the vaginal pH
becomes alkaline, which precipitates greenish-gray
phosphate crystals in the vagina and on the vulva.
• Constant leakage of urine may make the patient a
social recluse; disrupt sexual relations; and lead to
depression, low self-esteem, and insomnia.
• External genitalia(Leakage of urine and
excoriation of vulva )
• Per speculum examination (Pool of urine in
vagina and fistulous opening may be visible)
• Location, number and size of fistula is to be
• In case of bladder neck fistula involvement of
internal sphincter may also be associated .
• There may be associated or combined fistulas e-g
vesico vaginal , vesicocervical and ureteric fistula.
DIAGNOSTIC OFFICE TECHNIQUES
• 1.Three swab test
• 2.OfficeUrethroscopy and cystoscopy using
gas as a distension media.
• CBC and Urine analysis
• Blood chemistry for serum creatinine , blood urea and fasting
• Urine for culture and sensitivity.
• Intravenous pyelography (Ureteric fistula ,ureteric stricture
and hydronephrotic changes)
• Ascending pyelography to fortify the findings of IVP.
• Modern imaging technique CT and MRI have limited value as
Cystoscopy ( performed)gives maximum and to the point
information about size ,shape , number and location of
• Biopsy from the edge of fistula cystoscope guided when it is
suspected to be – malignant/post radiation/tubercular
• Avoiding use of high forceps
,rotational forceps ,ventouse on
undilated cervix , neglected
shoulder,persistant occipito posterior
position ,prolonged trial in CPD/mild
contracted pelvis ,destructive
operation (excepting craniotomy in
cases of hydrocephalous)
• LSCS-proper separation of bladder
avoiding lateral and downward
vertical extension of tears of lower
• Proper identification of ureter and
bladder before applying any clamp or
ligature at the time of massive
traumatic haemorrage or repair of
rupture uterus/emergency obstetrical
• GYNAECOLOGICAL –
• Immediate detection of
bladder injury/ Ureter.
• Watertight closure of
• Extra-vesical drain
• Avoidance of vaginal
incision if possible after
recognition of bladder
• Prolonged uninterrupted
bladder drainage in
• An intrafascial technique for hysterectomy also may
protect the bladder and ureter injury .
• The use of a two-way indwelling catheter, sharp
dissection to isolate the bladder, an extraperitoneal
cystostomy when the dissection is difficult,
retrograde filling of the bladder when injury is
suspected, and repair of an overt bladder injury only
after mobilization of the injured area.
• Retrograde filling of the bladder also may help
define the border of a bladder otherwise distorted or
displaced by prior surgery or a lower uterine
• Cystitis, vaginitis, and perineal dermatitis should be treated with the
• Perineal care is important and makes the patient more comfortable
and tolerant of delayed closure.
• Frequent pad changes are required to minimize inflammation,
edema, and vulvar irritation.
• Zinc oxide ointment or a cream containing lanolin may be especially
helpful in the treatment of perineal and vulvar dermatitis.
• Indweling catheter and nursing of patient in sim’s position or in prone
position----the fistula in trigone area will be at higher level , catheter
will drain each drop of urine coming down in bladder ;so fistulous
tract will remain relatively dry .
• Keeping so –the vulva will be dry, Even small tiny fistula may close.
TIMING OF REPAIR
• Success rate for immediate repair is 98.4%.
• The traditional belief is to wait a minimum of 3 to 6
months after the inciting event or the last attempt at
• If the gynaecological fistula is recognized within the
first 48 hours postoperatively , It can be repaired
immediately as the tissue is more mobile, have less
inflammation and amenable to early repair.
• Large fistulae may be easier to repair once the tract
is allowed to heal and edema resolves.
• Fistulae arising later usually are complicated by
significant edema, inflammation, and induration. An
interval of 3 months from injury to repair in obstetric
and surgical fistulae allows inflammation and edema
to resolve and better chances of good healing.
General Principles of fistula repair
• Good exposure , spot less bright light .
• Selection of route of fistula repair depends on surgeons
experience with best route as well as location of fistula
size ,number or associated uretric fistula.
• Mobilization of bladder.
• Excision of scar tissue.
• Tension free suturing.
• Closure in layers.
• Interposition of flaps or grafts—omentum , muscle etc.
• Postoperative continuous bladder drainage for 2-3
PRINCIPLE OF FISTULA REPAIR
• Adequate exposure of fistula tract with debridement
of devitalised and ischaemic tissues .
• Removal of involved foreign bodies or synthetic
materials from region of fistula(if possible).
• Careful dissection and anatomic separation of the
involved organ cavities.
• Water tight closure.
• Use of well vascularized ,healthy tissues flaps of
repair(traumatic handling of tissue).
• Multiple layer closure.
• Tension free, non-overlapping suture lines
• Adequate urinary tract drainage and stinting urethra
• Treatment and prevention of infection(Appropriate
use of antimicrobials).
• Maintenance of haemostasis.
• Wide mobilization of the vaginal epithelium to
expose the bladder
• Excision of all scar tissue, even at the risk of
increasing the size of the fistula in an attempt to
create a fresh bladder injury• (this recommendation
is not universally acceptable)
A: Ureters have been catheterized. An incision through
the vaginal epithelium is made circumferentially
around the fistula. B: The vaginal epithelium is widely
mobilized from the bladder. The scarred fistula tract
should be excised.
C: A continuous (or interrupted) delayed-absorbable
suture inverts the mucosa into the bladder. D: A second
suture line is placed in the musculofascial layer to
reinforce the first. Vaginal epithelium is trimmed and
Latzko technique for a closure of a simple posthysterectomy
vesicovaginal fistula. (A)A circumferential incision is made
around the fistula. The fistula is not excised. B: The vaginal
epithelium is mobilized approximately 2 cm from the fistula.
C: Delayed-absorbable interrupted mattress sutures are
placed parallel to the edge of the fistula tract to invert it into
the bladder. D: One or two additional rows of suture
approximate the musculofascial layer of the bladder.
The vaginal epithelium is closed transversely
with interrupted delayed-absorbable sutures.
A: The lateral margin of the labia majora is incised vertically)
The fat pad adjacent to the bulbocavernosus muscle is
mobilized, leaving a broad pedicle attached at the inferior
C: The fat pad is drawn through a tunnel beneath the labia minor and
vaginal mucosa and sutured with delayed-absorbable sutures to the
fascia of the urethra and bladder. D: The vaginal mucosa is mobilized
widely to permit closure over the pedicle without tension. The vulvar
incision is closed with interrupted delayed-absorbable sutures.
Abdominal Approach for
Vesicovaginal Fistula Repair
A: A longitudinal incision is placed in the bladder dome. B: The incision
is extended around the fistula. The fistulous tract and its vaginal orifice
are completely excised. C: Interrupted delayed-absorbable sutures are
used to close the vagina in one or two layers.
D: Continuous delayed-absorbable suture closes the bladder mucosa
longitudinally. E: A suprapubic catheter is placed into the bladder in an
extra peritoneal location.
F: The bladder muscularis is closed with delayed-absorbable continuous
or interrupted sutures. G: An omental â€œJâ€• flap can be interposed
between the bladder closure and the vaginal closure.
• It is uncommon.
• Most common cause is surgical injury to distal
ureter(division , clamping or ligation), while
performing gynecologic procedures by
abdominal or vaginal route.
• Laparoscpic surgery – injury with electric
current, heat , laser, ligation ( avascular injury)
• LSCS, rupture uterus repair and emergency
• Urinary incontinence which is constant 1 to 4
weeks after surgery
• Normal voiding habits
Dye test --Vaginal swabs will be soaked with
urine but no staining with dye.
• Cysto urethoscopy(uretric catheterization,
dilatation of stricture part or caliectasis)
• RGP(Retrograde pylogram)
ureter opening in
A: A U-shaped incision is made through the vaginal epithelium. B: The
flap is mobilized and rotated over the fistula. C: Three interrupted
sutures of delayed-absorbable suture are placed in the sphincter region,
and the tissue inverted. D: The mucosal flap is pulled downward, and
the incision is extended on both sides.
E: The flap is rotated anteriorly and the incision edges
approximated to form a tube. F: A layer of paraurethral fascia
is plicated beneath the urethra. The vagina is approximated
over the neourethra with interrupted delayed-absorbable
G: Completion of the reconstruction, showing interrupted
suture closure of suburethral mucosa.
reconstruction of total or partial
loss of the urethral floor
A: A line of incision is made along the margins of the roof of the urethra
and extended to the bladder base. B: The urethral margins and fascia
are mobilized from the vagina to permit tension-free approximation of
the urethral mucosa. C: Urethral edges are approximated over a 12F
catheter with interrupted delayed-absorbable sutures. Mobilized
urethral fascia is sutured on each side of the total length of the urethra.
D: The lower strand of each suture is tied beneath the urethral floor,
and the upper strands of the two sutures are used to pull the fascia
E: The vaginal mucosa is closed without tension. F: For additional
reinforcement, a U-shaped labial fat pad can be developed along the
labia, leaving a broad pedicle superiorly. The vaginal mucosa between
the urethral operative site and the labial graft is resected. G: The skin
margins of the labial graft are sutured to the vaginal margins. The labial
defect is closed.
• The bladder should be drained for 10-14 days.
• Excellent hydration will ensure irrigation of the
bladder and help to prevent clots that could
obstruct the bladder.
• Catheter blockage should be prevented so that
there is no bladder distension and tension on the
• Supra-pubic catheter may be used for fistula.
• Cystogram is to evaluate the integrity of the
bladder before discontinuing the bladder
INSTRUCTION ON DISCHARGE
• Contraceptive advice for spacing for 2 years.
• Abstenence for 3 month.
• Maintain hygeine.
• If pregnancy occurs elective caesarean section is
indicated as and when foetus attains maturity.
• Woman who had repair of obstetrical fistula may
develop urinary tract infection , DUB and other
gynaecological problems like general population
in their life ,should go for medical Rx and when
pelvic surgery is indicated ; It should be done by
• Uncommon and usually occur after surgery for urethral
diverticulum, anterior vaginal wall prolapse, or urinary
incontinence, and after radiation therapy.
• The most common causes include tissue ischemia,
problems related to healing, or radiation necrosis.
• Risk factor – Operative vaginal delivery.
• Pressure necrosis, resulting in a urethrovaginal
fistula, can occur with a prolonged indwelling
• Urethrovaginal fistulae also may be
• They are rare. They are usually complications of caesarean
• The clinical presentation may be similar to VVF, with urine
egressing through the vagina.
• The examination fails to reveal a vaginal
fistula, however, and rarely urine trickles
down through the os.
• Cyclic haematuria (menouria) is common.
• An abdominal approach with interposition of
graft is for repair, using the techniques for
• The posterior wall of the urinary bladder is exposed to
• It is caused by the failure of the anterior abdominal wall
and anterior wall of the bladder to develop.
• It is due to inability of the mesoderm of the primitive
streak to migrate around the cloacal membrane
• Indwelling catheterization and anticholinergic
medication for at least 2 to 3 weeks
• Spontaneous healing is more likely when patient is
seen within 3 weeks of initial injury
• Small fistulas benefit from disruption of epithelial
layer of the fistula track
fibrin sealant + bovine collagen
Surgical repair contd..
• Postoperative cystography
• Abstinence from sexual intercourse
vaginal shortening and stenosis