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Vesicovaginal fistula evaluation
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Vesicovaginal fistula evaluation

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Vesicovaginal fistula evaluation

Vesicovaginal fistula evaluation

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  • 1. 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.
  • 2. 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.
  • 3. Algorhythm formanagement of VVF 
  • 4. Evaluation Evaluation of VVF consists of:  History  General and Genital Examination  3 Swab test (Gauze test)  Radiological evaluation  Cystoscopic evaluation
  • 5. HistoryVesicovaginal 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.
  • 6. HistoryHistory 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.
  • 7. HistoryIf 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?
  • 8. HistoryPresence of urine leakageTiming of urine leakage  When walking  When lying down  Continuous leak  Stress incontinence ( e.g. cough)  With urgency and frequencyany leakage of feces: Solid or liquid?any gas leakageprevious operation for a fistulaDate of most recent fistula repair OperationNumber of previous repair attempts
  • 9. 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
  • 10. 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).
  • 11. 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
  • 12. 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
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. 3 swab test (Vaginal Gauze test)Three separate sponge swabs are placed into the vagina one above the other.The bladder is then filled with a coloured agent such as methylene blue, and the swabs are removed after 10 minutes ©
  • 17. Results of 3 swab test1. Discoloration of topmost swab is caused by vesico-vaginal fistula.2. uppermost swab wetting but not discolouration suggest ureterovaginal fistula3. Discolouration of only the lowest swab suggests low urethral fistula or from back flow into the introitus. ©
  • 18. Radiological Evaluation Cystogram  of limited value. IVP  only if uretero-vaginal fistula is suspected.
  • 19. Cystoscopic EvaluationCystoscopy is very valuable in the assesment of VVF to determine: Site of fistulae Number of fistulae Involvement of ureteric orifices
  • 20. Cystoscopic evaluation- Site of VVFSite of the VVF may be:1. Supratrigonal2. Trigonal3. Involving bladder neck4. Involving urethra
  • 21. Cystoscopic evaluation- Site of VVFThe bigger the size the more the fistula is complicatedLarger fistulae  worse outcome  use tissue interpositioningLarge fistulae repair  contracted bladder.Cut-off size  4cm ??
  • 22. 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.