Genital fistula, etiology,management

1. GENITAL FISTULAS

2. DEFINITION
• A genitourinary fistula is defined as an abnormal communication between the
urinary tract (ureter, bladder,urethra) and genital tract systems (vagina,
cervix,uterus).

3. ANATOMICAL CLASSIFICATION
• Based on its anatomical communications,
Ureter Bladder Urethera
Vagina Ureterovaginal
Vesicoureterovagin
al
Vesicovaginal Uretherovaginal
Cervix Ureterocervical Vesicocervical Uretherocervical
Uterus Ureterouterine Vesicouterine Not reported

4. ETIOLOGY
Obstetric causes Surgical cause Other causes
• Prolonged /obstructed labour
• instrumental (forceps rotation)
• Manipulative deliveries –
craniotomy /symphysiotomy
• Bladder injury-
Abdominal/vaginal
Hysterectomy (Pelvic
adhesions/cervical
fibroid/sling surgery for SUI)
Radiotherapy for cancer
Tuberculosis of bladder
Ca cervix and Ca bladder
Bladder stone
Caesarean section-
Bladder injury-
• deeply impacted fetal head
• If it is not empty
• Repeat cesarean section
• Rupture uterus
Ureteric injuries-
Wertheims hysterectomy/
Cervical and broad ligament
fibroids/ PID/ pelvic
endometriosis
- Direct injury (cutting,ligating)/
Devascularization/thermal injury
Laparoscopic injuries –
Direct trocar injuries to bladder

5. CLINICAL FEATURES
Vesicovaginal fistula
(Most common)
Ureteric fistula Vesicouterine fistula (C- sec/
rupture uterus)
Constant dribbling of Urine
Excoriated vagina/ vulva
/perineum/thighs
Transection- urinary leak in
peritoneal cavity- nausea/
vomiting/abdominal
distension/paralytic ileus
Cyclical haematuria
Continence- maintained
• Knee chest position
• Bimanual examination- fixity/
extent
• Methylene blue test
Obstruction- if both ureters are
involved- oliguria/pain in flanks/
renal angle tenderness
Necrosis- late presentation (after 2
weeks)
URETHEROVAGINAL FISTULA-
Dribbles urine during the act of
micturition

6. INVESTIGATIONS
• Routine Basic Investigations- CBC, RFT, Serum Electrolytes
• Urine culture sensitivity- mandatory before surgery
• USG- Kidney/ ureter/ Bladder ( urinoma)
• Descending pyelography(IVP)
• Cystoscopy- indigo carmine excretion test(5 ml)
• Ureteric catheterization
• Methylene blue test- 3 swab test

7. METHYLENE BLUE TEST- 3 SWAB TEST
• A catheter is introduced into the bladder through the urethra, then vaginal cavity
is packed with 3 sterile swabs, 50 -100ml of methylene blue due is injected into
the bladder through the catheter.
• If dye stains the
• - uppermost swab- VVF
• Lowermost swab- urethra
• If swab do not take up the stains but wets with urine- ureter

8. MANAGEMENT - VVF
Difficult childbirth Fistula f/b Cancer- biopsy Postoperative management
Suspected case-Catheterization/
antibiotics/ supportive therapy-
Spontaneous healing
Vaginal repair-
• Latzko procedure
• Chassar Moir technique (Flap
splitting method)
• Advantage- tension free
sutures/ avoidance of
superior position of bladder
over vaginal suture
• Continuous bladder drainage
– 14 days
• Antibiotics
• No vaginal/speculum
examination for 3 months
after surgery
Established case- conservative
management for 3 months-
vascularization- Surgery
Complications
Stress urinary incontinence
- Rigid urethra/ loss of
vesicouretheral angle,small
bladder,short urethra

9. MANAGEMENT
• In case of fistula repair failure- 2nd vaginal repair can be undertaken after 3 months
• TRANSCERVICAL to Trans abdominal approach-
• Failed fistula repair( vaginal)
• Large fistula
• Fistula involving the ureteric orifice
• Urinary diversion procedures
• Extensive loss of bladder tissue
• Radiation fistula

10. URETERIC FISTULA
• Intraoperatively-
• Obstruction-
• early diagnosis – remove the ligature, Ureteric Stenting/
• Delayed diagnosis- implantation into bladder
• Transection- IVP- Percutaneous Nephrostomy
• Partial- cystoscopic catheterization- ureteric stenting
• Complete- urinary diversion f/b Nephrostomy----- surgical repair

11. MANAGEMENT
Vesicouterine fistula Uretherovaginal fistula
Abdominal repair Urethral reconstructive surgery

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