Introduction Vesicovaginal fistula (VVF) are the most common acquired fistula of the urinary tract. Descriptions of vesicovaginal fistulas have been well documented since ancient times, although early attempts at repair met with little success. In 1852, Sims published his method for the surgical treatment of VVF using a transvaginal approach, followed by Trendelenburg in 1888, who successfully performed the transabdominal VVF repair.
Objectives of VVF assesmentObjectives of evaluation of Vesicovaginal fistula is to determinecertain characters of fistula including: Site Size Number Fibrosis and Scarring Recurrence Involvement of ureteric orifices Involvement of sphincteric mechanism Associated vagino-rectal fistula.
Evaluation Evaluation of VVF consists of: History General and Genital Examination 3 Swab test (Gauze test) Radiological evaluation Cystoscopic evaluation
HistoryVesicovaginal fistula is presented usually with Immediate or delayed onset of urinary leakage from the vagina post-operatively or after radiation (may take months or even years).Patients may also complain of recurrent cystitis, perineal skin irritation due to constant wetness, vaginal fungal infections.When a large VVF is present, patients may not void at all with continuous leakage.VVF must be distinguished from urinary incontinence.
HistoryHistory aims at gathering data about: Etiology: Previous history of gynaecological surgery (e.g, Vaginal or abdominal hysterectomy ) Previous history of pelvic radiotherapy Prevoius history of prolonged labour or trauma during childbirth Time of occurrence Previous Attempts of repair. Co-morbidities.
HistoryIf previous delivery is a suspected cause of VVF, detailed obstetric history should be gathered: Parity Caesarean sections and Vaginal deliveries If problem occurred after delivery Time in labour? .....days Where was delivery? Home , Hospital, on way to hospital, other Did the baby live?
HistoryPresence of urine leakageTiming of urine leakage When walking When lying down Continuous leak Stress incontinence ( e.g. cough) With urgency and frequencyany leakage of feces: Solid or liquid?any gas leakageprevious operation for a fistulaDate of most recent fistula repair OperationNumber of previous repair attempts
History Genital irritation and / or crustations any trouble walking or “footdrop” Menstural history: menstruating or not? If not: for how long ? current marital status ? Married /Separated /Divorced /Widowed sexual intercourse Age 1 st married Age 1 st delivery
Genital Examination Palpate anterior and posterior wall Use speculum. Vaginal examination may demonstrate the VVF, if large (the examining finger can reach inside the bladder).
Genital Examination Foot Drop( /5): Right –sided / Left – sided Number of Fistulas : Type of fistula: Utero –vesical ,Cervico- vesical ,Mid – vaginal ,Bladder Neck ,Urethro – vaginal ,Recto- vaginal Location: urethra / UV junction / trigone / above trigone Proximity to cervix: -- cm Length of urethra: -- cm
Genital Examination Quality of tissue: good / moderate scarring / severe scarring /inflamed Mobility of tissue: good / some mobility / poor mobility / fixed Bladder Capacity ( measure (meatus to bladder wall ) minus ( meatus to foley balloon ) : <3cm (minimal ) 3-5 (small ) / 6-8 ( moderate /8-10(normal ) />10( large) Vulva: Encrustation / Ulceration FGC: clitoris absent /labia absent / clitoris and labia absent Introitus: Normal / tight /gaping or wide Fibrosis /scar: mild, moderate ,severe, fixed to bone
Genital Examination Urethra: Normal/ fistula / Absent or completely open / Separate from bladder : Urethral fistula cm Separation from bladder -----------cm Urethral meatus : Normal /absent / not connected to urethra Vagina : Normal / fistula Vaginal fistula -----cm
Genital Examination Involvement of bladder neck Cervix: Normal /Lacerated/ fistula near cervix Uterus: Normal / large /not felt Ovaries: Felt/no felt Rectum: Normal / fistula Rectal fistula ------cm Sphincter tear: No /partial / Total Type of pelvis : Android /Gynecoid/ Anthropoid / platellypoid / Other
Genital Examination Impression A: Type I:Not involving closing mechanism Type III: Involving closing mechanism Type III: Miscellaneous : ureter and other exceptional Impression B: A:Without urethral involvement B:With urethral involvement Not circumferential Circumferential Size : <2, 2-3, 4-5, >6 Scarring : Mild , Moderate ,severe #previous Attempts: Plan
Radiological Evaluation Cystogram of limited value. IVP only if uretero-vaginal fistula is suspected.
Cystoscopic EvaluationCystoscopy is very valuable in the assesment of VVF to determine: Site of fistulae Number of fistulae Involvement of ureteric orifices
Cystoscopic evaluation- Site of VVFSite of the VVF may be:1. Supratrigonal2. Trigonal3. Involving bladder neck4. Involving urethra
Cystoscopic evaluation- Site of VVFThe bigger the size the more the fistula is complicatedLarger fistulae worse outcome use tissue interpositioningLarge fistulae repair contracted bladder.Cut-off size 4cm ??
Cystoscopic evaluation- Number of VVFs and other factors All fistulae should recognized because missing a fistulae means failure.Other Factors Scarring worse outcome use tissue interpositioning Recurrence worse outcome use tissue interpositioning Involvement of ureteric orifices reimplantation Involvement of sphincteric mechanism anti- incontinence procedure later. Associated Vagino-rectal fistulae should be repaired simultaneously ± colostomy.