2. Reproductive Tract Fistulae
Learning Objectives
At the end of the lesson you should be able to:
• Define reproductive tract fistulae
• Classify reproductive tract fistulae
• Outline the clinical features of reproductive tract
fistulae
• Apply the acquired knowledge to diagnose
reproductive tract fistulae
• Apply the acquired knowledge to manage
reproductive tract fistulae
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3. Definition
The presence of a communication between
the urinary tract and / or the
gastrointestinal system and the
reproductive tract
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4. Epidemiology
• Prevalence data on obstetric fistula are not available for most
settings in the developing world.
• Most studies are largely hospital based and therefore cannot be fully
indicative of the magnitude of the problem
• In 1989, WHO estimated that more than 2 million girls and women
around the world had this condition, with an additional 50,000 to
100,000 new cases occurring each year.
• Mabeya et al. Kapenguria, 2004
– The prevalence of obstetric fistula was 1 per 1000 women.
– Age; range 15-46, a mean of 22.8 ( SD +/-6.6) and a median of 20
– 55%of the women were primigravida
– 59% percent had no formal education
– 72% had no occupation.
– 56% were still married at admission and
– 75% had prolonged labor
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5. Epidemiology
• Obstetric fistula is a health condition caused by an interplay of
numerous physical, socio-cultural, political and economic factors of
women.
– The physical factors; obstructed labour, accidental surgery,
injury related to pregnancy and crude attempts at induced
abortion.
– Traditional surgical procedures employed during pregnancy
and labour that lead to obstetric fistula, haemorrhage and
sepsis e.g. include female genital mutilation(FGM) and Gishiri
cut (practised in Nigeria) .
– Socio-cultural factors; early marriage, health seeking
behaviour and availability and utilization of essential obstetric
care services.
– Malnutrition leading to the stunting of the pelvis.
– Illiteracy; determines what kind of medical help is sought, high-
risk pregnancies and unwanted pregnancies
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6. Pathogenesis
• Obstetric fistulae are a result of prolonged
and obstructed labour.
• The anterior vaginal wall and the bladder
become compressed between the fetal
skull and the maternal pubic symphysis,
resulting in pressure necrosis, which gives
rise to obstetric fistula
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7. Classification
• According to aetiology
• According to site
• According to anatomic location
• According to involvement of the sphincter/
closing mechanism ( 5cm from external
urethral meatus)
• According to size of fistuale
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8. Classification
Aetiology
• Obstetrical with reference to:
– Urinary system
– Gastrointestinal system
• Surgical; iatrogenic
• Infections; LGV, TB
• Post-radiotherapy
• Congenital
• Post-traumatic, rape
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9. Classification
Site
• Vesico-vaginal fistulae( VVF)
• Recto-vaginal fistulae (RVF)
• Urethro-vaginal fistula
• Uretero-vaginal fistulae
• Vesico-utero-vaginal fistula
• Vault fistula( after hysterectomy)
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10. Classification
Anatomic location
VVF
Type I: Not involving closing mechanism
Type II: Involving the closing mechanism
A Not involving (sub) total urethra
a Without circumferential defect
b With circumferential defect
B Involving (sub) total urethra
a Without circumferential defect
b With circumferential defect
Type III: Miscellaneous, e.g. ureteric
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11. Classification
Anatomic location
RVF
1. Proximal fistula
a) Without rectum stricture
b) With rectum stricture
c) With circumferential defect( very seldom)
2. Distal fistula
a) Without sphincter ani involvement
b) With sphincter ani involvement
3. Miscellaneous, e.g. ileouterine fistulas( after
instrumental abortion)
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13. Clinical manifestations
• Obstetric fistula is the single most
dramatic aftermath of neglected childbirth
resulting in; social, physical and
psychological effects
• Psychological; most of fistula patients are
ostracized by relatives and divorced by
their husbands
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14. Clinical manifestations
• Uncontrollable urinary or fecal incontinence
• Secondary ammenorhea
• Pain
• Vulval excoriation
• Ammoniacal smell
• Infection; urinary tract infection, vaginitis
• Possible future inability to carry a child even
after repair of fistula.
• A low child survival rate has been shown to be
related to obstetric fistula
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15. Diagnosis
History
• Events of delivery; low parity, difficult or
prolonged labour
• Type of incontinence
• Seek other causes
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16. Diagnosis
Physical examination
• Vaginal inspection- visual, Sims speculum
– site, size, number, fibrosis
• Dye test
• Examination under anesthesia
• IVU if uretero-vaginal fistula is suspected
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17. Management
• 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.
• Incontinence products designed for the larger
volume associated with drainage of urine and
the low viscosity of urine.
• Zinc oxide ointment or a cream containing
lanolin may be especially helpful in the treatment
of perineal and vulvar dermatitis and
excoriations.
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18. Management
• Antibiotics incase of infections, cystitis,
vaginitis and perineal dermatitis
• Bladder catheterization
• Perineal care
• Counselling
• Surgical repair
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19. Management
Surgical Repair
• The timing of repair remains controversial.
• 3 to 6 months after the inciting event or the last
attempt at repair. The delay allows the
inflammatory or necrotic fistula margins that are
thought to be responsible for surgical failure to
resolve.
• This interim period of waiting is often very
distressing for the patient
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20. Management
Surgical Repair
• A successful repair is gauged by whether the
woman is continent of urine
• The operation could be by vaginal,
transperitoneal or transvesical approach.
• Most repairs are vaginally under regional
anaesthetic
• Repairs are generally successful- more than
90%, depending on the extent of damage and
duration of condition
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23. Massive loss of tissue
• Urethra
• Bladder neck
• Absence of vagina
• Circumferential loss
of rectum
• Anal sphincter
rupture
• Cervix fibrotic
Lost tissue
fibrosis
cloaca
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24. Urethra and continence
– Reconstruction with residual tissues have
high rate of failures
– Tabularization of bladder neck
– Flap from anterior bladder wall
– Vaginally
– Abdominally
» Vesicostomy
» Tanagho neo-urethra
» Naude neo-urethra
» Anterior bladder flap
» With and without slings
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25. Complete loss of the
bladder wall functionality
• Augmentation cystoplasty gives :
• Better volumes
• Low pressure
• Better continence
• Neo bladder
• Ilieal conduit
• Continent bladder
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26. Complete loss of the
bladder wall functionality
Neo-bladder
• Uretero-sigmoidostomy
–Classic ( pyelonephritis, acidosis)
–Mainz Pouch II ( less common
complication)
–Sigmoid bladder with colo-anal pull
through (more difficult)
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27. Rectum
Colostomy
Small fistulas can be corrected easily
with 2 layers
Colostomy can be closed 2-3 months
later
In big fistula posterior perineo-plasty is
advisable
Colo – anal anastomose is sometimes
necessary
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28. Vaginoplasty
• Free grafts
• Skin
• Bucal mucosa
• Labia minor flaps
• Skin flaps
• Muscular and fascia flaps
• Bladder
• Colon transposition
– Cecum
– Sigmoid
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29. Indications for a neo-vagina
If intercourse is not possible in a
satisfactory way
• Complex fistula
• Multiple surgeries
• Fibrosis
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30. Complete pelvic
reconstruction
1. Anal sphincter and rectum
2. Select bowel segment ( sigmoid,
cecum, ileum) and do reconstruction
3. Vagina repair or neo vagina
4. Augmentation cystoplasty
5. Ureters reimplantation
6. Urethra reimplantation
7. Sling
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31. Prevention
• Change in the status of women.
– adequate nutrition in childhood
– access to primary education
– eradication of harmful traditional practices like female genital
mutilation
– raising the age of marriage
– Avoid early child bearing.
• Essential obstetrical care; prevention of obstructed
labour, consistent and correct use of the Partograph
• An indwelling catheter for continous bladder drainage for
6 weeks in obstructed labour or fistulae less than 2cm
• Community mobilization; awareness , IEC,BCC.
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