VVF and RVF BY MWEBAZA VICTOR 2022 OBGYN.pptx

M W E B A Z A
VICTOR.J
MBchB5th yearBMS/9114/172/DU
Ugandan. 23 AUG 2022 9:00AM presentation
®
mwebazavictor1997@gmail.com
www.nhsla.com
www.rcog.org.uk.
U n d e r t h e c a r e o f K a m p a l a
I n t e r n a t i o n a l u n i v e r s i t y - w e s t e r n
c a m p u s a n d
JINJA site light
JINJA REGIONAL REFERAL HOSPITAL JRRHosp
G E N I TA L F I S T U L A
P R E S E N TAT I O N
O B S / G Y N D e p t
Supervisor/modulators
DR.ADAM
( OBS/GYN CONSULTANTS mwebazavictor1997@gmail.com MWBZA VICTA

Prognosis
• Cure rates should approach 100% in
nonmetastatic and low-risk metastatic
GTD
• Intensive multimodality therapy has
resulted in cure rates of 80-90% in
patients with high-risk metastatic GTD

Follow-up After Successful
Treatment
• Quantitative serum hCG levels should be
obtained monthly for 6 months, every two
months for remainder of the first year,
every 3 months during the second year
• Contraception should be maintained for at
least 1 year after the completion of
chemotherapy. Condom is the choice.

Genitofistula line up
1. History of VVF, introduction,
dedication, and special thanks
2. definition of GUF
3. incidence of GUF
4. epidemiology
5. types of GUF
6. vesicovaginal fistula
6.1. definition
6.2. causes
6.3. types
6.4. symptoms
6.5. associated clinical features
6.6. confirmation diagnosis
6.7. VVF repair
6.8. medical and supportive mng in
VVF
6.9. Surgical Transvaginal VVF
repair
7. rectovaginal fistula RVF
7.1. definition
7.2. causes
7.3. diagnosis
7.4. investigations
7.5. mng
8. vesicourethrovaginal fistula
9. urethrovaginal fistula
10. vesicocervical fistula
11. ureterovaginal fistula
12. Vesicouterine fistula
13. urethrorectal fistula
14. post operative care of fistula patient
15. possible complication of surgical
treatment
16. Further Links
16. reference
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1.1 History ON VVF.
Before the 19th century, women who suffered
from VVF were judged harshly and rejected by
society.
Throughout the 19th century, treatment for VVF was
limited because the practice of gynaecology was
perceived as taboo.
Doctors were almost entirely male at this time and
looking at a nude female, even for medical purposes,
was seen as divergent from 19th-century values.
One of the most famous gynaecological surgeons of
this time was Dr. J. Marion Sims, who developed a
successful technique for treating VVF in the mid-1800s,
for which he is hailed as a pioneer of gynaecology.
B l a c k e n s l a ve d w o m e n i n t h e Am e r i c a n
S o u t h w e r e p a r t i c u l a r l y p r o n e t o V V F
b e c a u s e t h e y w e r e d e n i e d p r o p e r
n u t r i e n t s a n d m e d i c a l c a r e .
Sims performed on these women without
anaesthesia, which had not been introduced until
after he started his experiments, and which in its
infancy Dr. Sims hesitated to use. (Ether anaesthesia
was publicly demonstrated in Boston in 1846, a year after
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1.2 INTRODUCTION
obstetric fistula camp held at kamuli
mission hospital in kamuli eastern
region of Uganda Busoga. In 2018
However many NGOs and
many organizations are set in motion to
eradicate and treat fistulas across the
world commonly in developing countries
with poor ANC ,INC,PNC, early
pregnancy as fistula campus for
example EngenderHealth, The Fistula
Care Project (FCP )by USAID, Maternal
Health Task Force (MHTF), CHAMPION
Project, PEPFAR, IPPF, UNDP, AVSC,
JhPiego etc mwebazavictor1997@gmail.co
m MWBZA VICTA

Dr kees waaldijk who was the
head of the fistula camp :- his
communication
Finally, I am most grateful to the following hospitals
that have so willingly allow ed me to
operat e and t ake phot ographs f or
use in t his publicat ion .
1. Uganda: Kamuli Mission Hospital, Biogas
District; Kitovu Mission Hospital, Masaka
District; Nsambya Mission Hospital, Kampala;
Lira Government Hospital, Northern Uganda.
2. Nigeria: Katsina Hospital.
3. Ethiopia: The Addis Ababa Fistula Hospital.
4. Sierra Leone: Kambia District Government
Hospital; Princess Christian Maternity Hospital
Freetown.
5. Mercy ships: in Gambia, Sierra Leone and Benin
(mercyships.org).
Dr Kees Waaldijk
operating in 58 Katsina,
Northern Nigeria. In an
obstetric fistula camp
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1.3 DEDICATION
Special dedication to my
Beautiful loving mother, my
baby sister and my bothers
MY FAMILY FIRST.
1.4 SPECIAL THANKS
Special thanks to
1. DR.KOMUGHUMU
2. DR. NAMALA ANGELA
3. DR. ADAM.KIU-WC
4. DR. PETRUS.KIU-WC
5. DR. Augustine Muhwezi
6. DR. Samuel Kiirya
7. DR. Kenneth Mutesasira
8. DR. Vineeta Gupta
9. DR. Kees Waaldijk
10. DR. Dinah Nakiganda
11. DR. Mugasa Anthony
12. DR. Tagoola Abner
13. DR. Ononge sam
14. DR. Paul Kiondo
15. DR. Mwanga willison
16. DR . Lukula patrikic mwebazavictor1997@gmail.com MWBZA
VICTA

2. DEFINATION OF GENITAL FISTULA
A fistula is an abnormal
communication Between two or
more epithelial surfaces.
Genitourinary fistula (GUF) is an abnormal
communication between the urinary and genital
tract either acquired or congenital with
involuntary escape of urine into the vagina.
mwebazavictor1997@gmail.com MWBZA
VICTA

3. Incidence of GUF
It is considered a disease of poverty because of
its tendency to occur in women in poor
countries who do not have health resources
comparable to developed nations.
An estimated 2 million women in sub-Saharan
Africa, Asia, the Arab region, and Latin America
and the Caribbean are living with this injury,
and some 50,000 to 100,000 new cases
develop each year.
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In developed countries, the majority of women
with obstetric fistula suffer rectovaginal fistula
(RVF). This is caused by episiotomy and
forceps/vacuum extraction of the baby from the
vagina. Over 80% of RVFs in the USA are
obstetric and either preventable or treatable,
followed in frequency by Crohn's disease and
radiation.
A fistula is almost entirely preventable. According
to health advocates, its persistence is a sign
that health systems are failing to meet
women’s essential needs.
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4. Epidemiology
Each year between 50 000 to 100 000 women
worldwide are affected by obstetric fistula.
It is estimated that more than 2 million young
women live with untreated obstetric fistula in
Asia and sub-Saharan Africa(SSA).
(WHO 19/2/ 2021)
© Within SSA, Uganda has the highest known
prevalence with an estimated lifetime prevalence
of 19,2 per 1000 women of reproductive age
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We included 19 surveys in our analysis, including 262
100 respondents.
Lifetime prevalence was 3·0 cases (95% credible
interval 1·3–5·5) per 1000 women of reproductive
age.
Ethiopia had the largest number
of women who presently have
symptoms of vaginal fistula.
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According to WHO most cases of fistula
can be avoided,
firstly by delaying the age of first pregnancy
and secondly by access to obstetric care
mwebazavictor1997@gmail.com MWBZA VICTA

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5. TYPES OF GUF
The communication may occur between the
bladder, urethra or ureter and genital tract.
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1. vesicovaginal
2. vesicourethrovaginal
3. ureterovaginal
4. vesicocervical
5. ureterovaginal
6. Vesicouterine
7. Rectovaginal fistula
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6.1 Vesicovaginal fistula VVF™
There is communication
between the bladder
and the vagina and the
urine escapes into the
vagina causing true
incontinence
This is the commonest
type of genitourinary
fistula.
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6.2 Cause of VVF
Obstetrical causes of VVF:-
1. Ischaemic ®obstructed labour.
2. Traumatic ®instrumental vaginal delivery, abdominal
operations such as hysterectomy for rupture uterus.
Gynecological causes of VVF:-
1. Operative injury ® anterior colporrhaphy,AT for benign
or malignant lesions or removal of the Gartner's cyst.
2. Traumatic®anterior vaginal Wall and bladder maybe
injured following fall on a pointed object, criminal
abortion,fracture of pelvic bone.

3. Malignancy®advanced ca cx
4. Infection®vaginal Tb, lymphogranuloma
venereum ,schistosomiasis, thus the fistula
tract may be lined by fibrous, granulation
tissues.
5. Radiation, due to ischaemic necrosis by
endarteritis obliterans due to the effect of
the radiation, when the ca is Rxed by
radiotherapy
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6.3 Types of VVFs.
Fistula may be classified as—
1. Simple (Healthy tissues with good access)
2. Complicated (tissue loss, scarring, difficult access,associated
with RVF).
Depending upon the site of the fistula, it
may be:
1. Juxtacervical (close to the cervix)—The communication is
between the supratrigonal region of the bladder and the
vagina (vault fistula).
2. Midvaginal—The communication is between the base
(trigone) of the bladder and vagina.
3. Juxtaurethral—The communication is between the neck of
the bladder and vagina (may involve the upper urethra aswell).
4. Subsymphysial—Circumferential loss of tissue in the region
of bladder neck and urethra. The fistula margin is fixed to the
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Depending on Size Fistulae may be:
1. tiny (admitting only a small probe)
2. small (0.5–1.5 cm)
3. medium (1.5–3 cm)
4. large (>3 cm): these usually involve loss of
most of the anterior vaginal wall and a
circumferential loss of the urethro-vesical
junction
5. extensive
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6.4 Symptoms and signs.
Continuous escape of urine per vaginum (true
incontinence) is the classic symptom,
Dermatis of the perineum
Signs: Vulval Inspection
Escape of watery discharge per vaginum of ammoniacal
smell is characteristic.
Evidences of sodden and excoriation of the vulval skin.
Varying degrees of perineal tear may be present.
Internal examination: If the fistula is big enough, its
position, size and tissues at the margins are to be
noted.
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6.5 Associated clinical features
that may be present in cases of
such fistula
1. Secondary amenorrhea of hypothalamic
origin (Menstruation resumes following
successful repair).
2. Foot-drop due to prolonged compression of
the sacral nerve roots by the fetal head
during labor.
3. Complete perineal tear or rectovaginal
fistula.
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6.6 The confirmation of diagnosis is
by;
Dye test
Three-swab test
Dye test—
A speculum is introduced and the anterior vaginal wall is
swabbed dry.
When the methylene blue solution is introduced into the
bladder by a catheter, the dye will be seen coming out
through the opening.
A metal catheter passed through the external urethral meatus
into the bladder when comes out through the fistula not only
confirms the VVF but ensurespatency of the urethra.

Procedure of Three Swab Test -
o Three cotton swabs are placed in the vagina
o one at the vault, one at the middle and one
justabove the introitus.
o The methylene blue is instilled into the
bladderthrough a rubber catheter.
o The patient is asked to walk for about 5
minutes
o She is then asked to lie down and the swabs
areremoved for inspection
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6.7 Repair of VVF
Vesicovaginal fistulae are typically repaired
either transvaginally or
laparoscopically, although patients who
have had multiple Transvaginal procedures
sometimes attempt a final repair through a
large abdominal incision, or laparotomy.
The laparoscopic (minimally invasive) approach
to VVF repair has become more prevalent
due to its greater visualization, higher
success rate, and lower rate of complications.
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6.8 Medical and supportive
management in VVF
1. Antibiotics
2. IV fluids
3. Monitor vitals
4. A high fluid intake is essential
5. Continues bladder drainage and urine outlet
6. monitoring
7. Psychosocial care or support
8. Nutritional support
9. Personal hygiene
10. Prevent having sex (vaginal or anal sex)
11. Family planning
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6.9 ©Surgical Transvaginal VVF
repair
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7.1 RECTOVAGINAL FISTULA
Abnormal communication between the
rectum and vagina with involuntary escape
of flatus and/or feces into the vagina is
called rectovaginal fistula (RVF)
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7.2 causes of RVF:
acquired Obstetrical
1. Incomplete healing or unrepaired recent CPT is the
commonest cause of RVF.
2. Obstructed labor—The rectum is protected by
peritoneum of pouch of Douglas in its upper-third,
by the perineal body in the lower-third and by the
curved sacrum in the middle-third. However, if the
sacrum is flat, during obstructed labor the
compression effect produces pressure necrosis
infection sloughing fistula.
3. Instrumental injury inflicted during destructive
operation.
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Gynecological
1. Following incomplete healing of repair of old
CPT(commonest).
2. Trauma inflicted inadvertently and remains
unrecognized in operations like—perineorrhaphy,
repair of enterocele, vaginal tubectomy, posterior
colpotomy to drain the pelvic abscess,
reconstruction of vagina, etc.
3. Fall on a sharp pointed object.
4. Malignancy of the vagina (common), cervix or
bowel. e.Radiation.
5. Lymphogranuloma venereum or tuberculosis of
thevagina.
6. Diverticulitis of the sigmoid colon bursts into the
vagina.abscess
7. Inflammatory bowel disease: Crohn’s disease
involving the anal canal or lower rectum.

7.3 Diagnosis of RVF
1. Involuntary escape of flatus and/or feces into
the vagina. If the fistula is small, there is
incontinence of flatus and loose stool only but
not of hard stool.
2. Rectovaginal examination reveals the site and
size of the fistula.
3. Confirmation may be done by a probe passing
through the vagina into the rectum. If
necessary, methylene blue dye is introduced
into the rectum which is seen escaping out
through the fistula into the vagina. Examination
under anesthesia may be conducted to
facilitate clinical diagnosis.
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7.4 Investigations on RVF
o Barium enema.
o Barium meal and follow through may be
needed to confirm the site of intestinal
fistula. Sigmoidoscopy and proctoscopy
are helpful for the diagnosis of
inflammatory bowel disease or for taking
biopsy of fistula edge.
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7.5 Management of RVF
After diagnosing rectovaginal fistula, it is best
to wait for around 3 months to allow the
inflammation to subside.
For low fistulae, a vaginal approach is best,
while an abdominal repair would be
necessary for a high fistula at the posterior
fornix. Repair by flap method ® surgical.
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Recall®
8. Vesicourethrovaginal
9. Urethrovaginal
10. Vesicocervical
11. Vesicouterine
12. ureterovaginal
13. urethrorectal fistula
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9.Urethrovaginal fistula
A urethrovaginal fistula is an abnormal
passageway between the urethra and the
vagina. It results in urinary incontinence as
urine continually leaves the vagina.
It can occur as an obstetrical complication,
catheter insertion injury or a surgical injury
"Medical Definition of URETHROVAGINAL".
www.merriam-webster.com.
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11. Vesicouterine fistula/
Youssef Syndrome
Vesicouterine fistula refers to an abnormal
communication between the bladder and uterus.
The first case of vesicouterine fistula was reported
in 1908.
It is characterized by;
1. a vesicouterine fistula above the level of the
internal os,
2. absence of menstrual bleeding,
3. cyclical presence of blood in urine
4. absence of urinary incontinence with a patent
cervical canal following a lower segment
caesarean section.
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Pathology of VUF
Vesicouterine fistula is the least common type of
urogenital fistula accounting for 1-4% of
urogenital fistulas.
It occurs following lower segment caesarean
section and the incidence is increasing due to
the increasing incidence of caesarean
deliveries.
The occurrence of menoruria in the absence of
vaginal bleeding or passage of urine from the
vagina is attributed to a sphincteric mechanism
of the uterine isthmus.
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Jozwik and Jozwik classified
vesicouterine fistula into three types
based on the route of menstrual flow;
I - Menstrual flow from the bladder only
without urinary incontinence
II - Menstrual flow from both the bladder and
vagina with urinary incontinence
III - Normal menstrual flow from the vagina
only (no menouria) with urinary incontinence
Youssef syndrome corresponds to a type I
vesicouterine fistula.
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Causes of UVF
o Vesicouterine fistulas occur most commonly
after lower segment caesarean sections
(about 83-93% of cases).
The possible mechanisms by which
vesicouterine fistulas occur following
caesarean sections include undetected
bladder injury during caesarean section,
inadvertent placement of a suture through the
bladder during the repair of the uterus and
abnormal blood vessel connections following
multiple caesarean sections.
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Causes of VUF Continue
o It may also present following use of obstetric
forceps, manual placenta removal, external
cephalic version, morbidly adherent placenta,
surgical removal of fibroids, rupture of the
uterus, perforation of the uterus and radiation
therapy in the treatment of cervical cancer.
o Vesicouterine fistula can also occur as a birth
defect in conjunction with vaginal atresia.
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Diagnosis of VUF
The diagnosis of a vesicouterine fistula is made
by demonstrating an abnormal connection
between the cavities of the bladder and
uterus. It can be diagnosed using
hysterosalpingography, hysterography,
cystography, magnetic resonance imaging
(MRI) and computerised tomography.
MRI has been found to have 100%
accuracy in the diagnosis of vesicouterine
fistula. It is also less invasive than other
modalities and is considered the gold
standard for diagnosis.
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Treatment of VUF
The options of treatment include watchful waiting for
spontaneous resolution of the fistula, use of medications
that can stop menstrual periods such as oral contraceptive
pills, progesterone and gonadotropin releasing hormone
analogs.
Surgery can be carried out through the vagina, bladder or
peritoneum and can be done via laparoscopic or robotic
surgery.
Watchful waiting is the treatment of choice in case of small
fistulas. The bladder is catheterised for a period of 4 to 8
weeks in order to allow spontaneous closure of the
vesicouterine fistula. Fulguration
of the fistula can also be done via cystoscopy in cases of small
fistulas. mwebazavictor1997@gmail.com
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12. Ureterovaginal fistula UtVF
A ureterovaginal fistula is an abnormal
passageway existing between the ureter
and the vagina. It presents as urinary
incontinence. Its impact on women is to
reduce the "quality of life dramatically.
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Cause OF UtVF
A ureterovaginal fistula is a result of trauma,
infection, pelvic surgery, radiation treatment
and therapy, malignancy, or inflammatory
bowel disease.
Symptoms can be troubling for women
especially since some clinicians delay
treatment until inflammation is reduced and
stronger tissue has formed. The fistula may
develop as a maternal birth injury from a long
and protracted labor, long dilation time and
expulsion period.
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Difficult deliveries can create pressure
necrosis in the tissue that is being pushed
between the head of the infant and the
softer tissues of the vagina, ureters, and
bladder.
Radiographic imaging can assist clinicians in
identifying the abnormality.
A Ureterovaginal fistula is always indicative
of an obstructed kidney necessitating
emergency intervention followed later by
an elective surgical repair of the fistula.
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Treatment and risks associated
with repair of UtVF
Newer treatments can include the placement of a
stent and is usually successful.
If the fistula cannot be repaired, the clinician may
create a permanent diversion of urine or urostomy.
Risks associated with the repair of the fistula are
also associated with most other surgical
procedures and include the risk of adhesions,
disorders of wound healing, infection, ileus, and
immobilization. There is a recurrence rate of 5%–
15% in the surgical operation done to correct the
fistula.
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14. POSTOPERATIVE CARE
OF THE FISTULA PATIENT
The patient must at all times be:
1. draining
2. drinking
3. dry
On addition to post operative antibiotics,
psychosocial support,
ambulation,
personal hygiene, etc.
Physiotherapy if necessary
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15. Possible Complications of
Surgical Treatment
1. Recurrent formation of the fistula
2. Injury to ureter, bowel, or intestines
3. Vaginal shortening
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UN. United Nations on
obstetric fistulas
Educating individual women and men, girls and boys,
communities, policymakers and health professionals
about how obstetric fistula can be prevented and
treated, and increasing awareness of the needs of
pregnant women and girls, as well as of those who
have undergone surgical fistula repair, including their
right to the highest attainable standard of mental and
physical health, including sexual and reproductive
health, by working with community and religious
leaders, traditional birth attendants and midwives,
including women and girls who have suffered from
fistula, the media, social workers, civil society,
women’s organizations, influential public figures and
policymakers...
[UN member states 2021 oct]
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A GIRL
CHILD
NEED TO BE
LOVED AND
CARED
FOR.
FEMALE
LIVES
MATTER –
M WEBA ZA
VICTOR
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External links
1. Fistula Vesico Vaginal Information in Spanish about Fistula
Vesico Vaginal. Caracas, Venezuela
2. Worldwide Fistula Fund is a non-profit organization that
provides free fistula surgeries and prevention outreach in
Danja, Niger
3. The International Organization for Women and Development is
a non-profit organization that assists in Niger
4. One By One - a nonprofit organization working to eliminate
obstetric fistula.
5. FORWARD - a charity that works to eliminate VVF/fistula and
gender-based discriminatory practices such as FGM and child
marriage which can cause VVF
6. Fistula Foundation - supporting the work of the Hamlin Fistula
Hospitals in Ethiopia.
7. Women's Health and Education Center
8. Urinary Fistula
9. Bladder - Vaginal Fistula Surgeons
10. "James Marion Sims (1813-1883)” by A. Andrei at the
Embryo Project Encyclopedia

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