genito urinary fistula


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genito urinary fistula

  1. 1. GENITO-URINARYFISTULAS Yashar Najiaghdam M.D
  2. 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
  3. 3. Varieties1. Vesico-vaginal2. Uretero-vaginal3. Urethro-vaginal4. Vesico-cervical5. Uretero-cervical6. Uretero-uterine
  4. 4. VESICOVAGINAL FISTULA(The Commonest)
  5. 5. Aetiology Congenital: very rare. Traumatic fistula  Obstetric trauma  Necrotic obstetric fistula  Traumatic obstetric fistula  Surgical trauma  Direct trauma Inflammatory disease Malignant neoplasms Radium necrosis
  6. 6. 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
  7. 7. 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
  8. 8. 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.
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. Diagnosis Inspection of the anterior vaginal wall  In Sims’ position or left lateral (semi-prone) position  With the use of Sims’ speculum.
  13. 13. 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.
  14. 14. ManagementProphylaxis: 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.
  15. 15. 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.
  16. 16. 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.
  17. 17. 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.
  18. 18. Methylenebluetest
  19. 19. 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.
  20. 20. Operationflap-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.
  21. 21. 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.
  22. 22. 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.
  23. 23. 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.
  24. 24. Subsequent Management Patient is instructed to  avoid sexual intercourse for 3 months  avoid pregnancy for 1 year Caesarean section is almost absolutely indicated.
  25. 25. 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.
  26. 26. Prophylaxis Ureteric injury can be avoided by  pre-operative intravenous pyelography  ureteric catheterization  proper surgical technique.
  27. 27. 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.
  28. 28. 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.
  29. 29. Types Of Incontinence Of Urine1. 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 overflow5. Nocturnal enuresis.
  30. 30. Causes Of Retention Of Urine Cause of urinary retention is an impacted pelvic mass. Diagnosis is made clear by attention to associated symptoms
  31. 31. Associated Conditions Condition DiagnosisPrimary amenorrhea → HaematocolposSecondary amenorrhea →  Retroverted gravid uterusMenorrhagia → Uterine fibroidNo menstrual upset → Ovarian or broad ligament tumourIrregular bleeding → (1) threatened abortion from a retroverted gravid uterus, → (2) pelvic haematocele → (3) pelvic abscessLabour → Descent of the foetus to from a pelvic tumour