Genitourinary fistulas are abnormal connections between the urinary and genital tracts that cause involuntary urine leakage. The most common type is a vesicovaginal fistula between the bladder and vagina, usually resulting from prolonged obstructed labor without medical intervention. Symptoms include continuous urinary leakage from the vagina. Treatment involves identifying the fistula location and surgically repairing the tissues in layers with continuous bladder drainage via catheter. Success requires a single, small fistula without significant scarring or tissue loss.

1. GENITO-URINARY FISTULA

2. • Fistula – abnormal communication b/w two or
more epithelial surfaces.
• Genitourinary fistula – abn communication
b/w urinary & genital tract either acquired or
congenital with involuntary escape of urine
into the vagina.
• Incidence – 0.5 – 3% among gynae admissions

4. Types:
• The communication may occur b/w
Bladder
Urethera Genital tract
Ureter
• Bladder
 Vesicovaginal (commonest)
 Vesicourethrovaginal
 Vesicouterine
 vesicocervical

5. • Urethera
Urethrovaginal
• Ureter
Ureterovaginal
Ureterouterine
ureterocervical

6. Vesicovaginal fistula:
• Communication b/w bladder & vagina and
urine escapes into the vagina causing true
incontinence.
This is the commonest type of genitourinary
fistula
• Causes :
Obstetrical
Gynaecological

7. Cause of obstetric fistula
• Obstructed labour
• Forceps delivery
• Cesarean
• Destructive surgeries
• symphysiotomy

8. Unrelieved Obstructed Labour
Prolonged pressure of the babies head
crushes the base of the bladder against the
pubic bone

9. • The devitalized area separates as a slough,
usually between the 3rd and 10th day of the
puerperium, with resulting fistula formation
and incontinence.

10. Gynaecological:
• Operative injury:
In surgeries like Ant.colporrhaphy, Abdominal
Hysterectomy
• Traumatic:
fall on pointed object; #pelvic bones; retained
& forgotten pessary

11. • Malignancy:
Ca cervix , vagina & bladder
• Radiation:
ischemic necrosis (Ca Cervix treated by
radiation)
• Infective:
vaginal TB, LGV

12. Types:
• Simple:
healthy tissue with good access
• Complicated:
tissue loss; scarring; difficult access;
associated with RVF

13. Depending upon site of fistula
• Juxtacervical(close to the cervix):
supratrigonal region of bladder = vagina
• Midvaginal :
base(Triogone) of bladder = vagina
• Juxtauretheral :
neck of bladder = vagina

15. Clinical features:
• Patient profile – young primiparous with H/O
difficult labour or instrumental del.
• Symptoms:
- continous escape of urine per vaginum is the
classical symptom
- patient has no urge to pass urine
- if fistula small, escape of urine occurs in certain
position, pt can pass urine normally
- pruritus vulvae

16. • Signs:
- escape of watery discharge per vaginum of
ammoniacal smell
- excoriation of vulval skin
Internal exam:
- if fistula is big enough its position, size and
tissues at the margins are to be noted

17. Diagnosis:
• History
• Local examination
• Investigations
Urinalysis and urine culture
Intravenous urography
Dye Test
Cystourethroscopy

18. The four cardinal principles of investigation are
(1) confirm that the discharge is urinary;
(2) confirm that leakage is extra-urethral;
(3)identify site of leakage; and
(4) identify or exclude multiple or complex
fistulous tracks.

19. Dye Test
• Identification of the site of a fistula is best
carried out by the instillation of coloured dye
(usually methylene blue) into the bladder,
with the patient in the lithotomy
position and any leakage directly visualised.

20. 3 swab test (Moir)-
• 3 large pledgets of cotton wool placed in the vagina,
one above the another
• Methylene blue solution run into the bladder
• If only the lowest swab stains-fistula is urethral
• Middle or upper swab stains-fistula is vesical
• None of the swabs stain but upper one is wet-fistula
is ureteric

21. Investigations:
• Intravenous urography
- for diagnosis of ureterovaginal fistula
• Cystoscopy
- exact level and location of fistula and its
relationship to ureteric orifices and bladder
neck

22. Treatment:
• Preventive:
- adequate antenatal care to screen out ‘at risk’
mothers likely to develop obstructed labour
- partographic management and monitoring of
labour
- catheterisation for 5-7 days in postnatal period
in a case of long standing obstructed labour
- avoid injury to bladder during pelvic surgery

23. • Immediate management:
- continous catheterisation for 6-8 weeks
- helps spontaneous closure of fistula tract
- unobstructed outflow tract helps
epithelialisation, provided tissue damage is
minimum

24. Operative:
• Local repair of fistula is the surgery of choice
- preoperative assessment
- preoperative preparation
- definitive surgery

25. Preoperative assessment:
• Fistula status – site; size; no.; mobility and
status of margins of the fistula
• Uretheral involvement is assessed by
introducing metal catheter through ext
uretheral meatus into bladder
• To ascertain position of ureteric openings in
relation to big fistula.
• To exclude associated RVF or CPT
• CHG, RFT are done

26. Preoperative preparation:
• Improvement of general condition of pt.
• Local infection treated
• UTI should be treated

27. Definitive surgery(old obstetric VVF):
• Ideal time of surgery is after 3 months
following delivery
• Surgical fistula if recognised within 24hrs,
immediate repair may be done provided small

28. Local repair by flap splitting method:
• Principals of surgery:
 Perfect asepsis and good exposure of fistula
 Excision of scar tissue round the margins
 Mobilisation of bladder wall from vagina
 Suturing the bladder wall without tension in two layers
 Apposition of the vaginal walls by interrupted sutures
 To maintain continous bladder drainage by indwelling catheter.

30. Latzko technique:
• Vaginal mucosa dissected off bladder wall
around fistula site
• Fistula tract is excised
• Bladder mucosal edges are approximated
• Two additional suture layers are used to
appose the muscle and fascia
• Vaginal mucosa closed by interrupted sutures
• Bladder drainaige(catheter) for 10-14 days

31. Special postop care:
• Urinary antiseptics
• Catheterisation for 10-14 days
• Pt advised to pass urine frequently (2hrly)
following removal of catheter. Interval is
gradually increased

32. Criteria for successful repair:
CRITERIA GOOD PROGNOSIS UNCERTAIN PROGNOSIS
No. of Fitula single Multiple
Site VVF RVF
Mixed (RVF & VVF)
Size < 4cm > 4cm
Uretheral Involvement Absent Present
Vaginal Scarring Absent Present
Tissue loss Minimal Extensive
Ureter involvement Ureters draining inside
bladder
Ureters draining into
vagina

33. Advice during discharge:
• To pass urine more frequently
• To avoid intercourse for 3 mth
• Defer pregnancy for 1 yr
• If conceives – mandatory antenatal checkup &
hospital delivery
- a successful repair should have an abdominal
delivery
if repair fails – local repair again attempted after 3
months

34. Other routes of repair of bladder
fistula:
• Transperitoneal – Vesicouterine fistula
• Transvesical – fistula unapproachable per
vaginum
• Transperitoneal or transvesical approach is
preferred when the fistula margins are close
to the ureteral orifices

35. Principles in the management of
gynaecological VVF:
• Detected during operation : to repair
immediately in two layers
• Detected in postoperative period : catheterise
for 10-14 days, if fails repair after 3 months
• Malignant or postradiation fistula:
- Ileal bladder ; ant. Exenteration ; Colpoclesis
• Infective fistula : eradication of specific
infection f/b local repair

36. Urethrovaginal fistula:
• Causes:
- same as VVF
- Injury during ant. Colporrhaphy,
uretheroplasty, suspension or sling operation
for stress incontenence
- residual fistula left after vesicourethrovaginal
fistula

37. Diagnosis:
• Pt has urge to pass urine but urine dribbles
out into vagina during the act of micturition
• Metal catheter passed through ext uretheral
meatuscomes out through uretherovaginal
opening
• In case of confusion with VVF or UVF, three
swab test may be employed

38. Treatment:
• Surgical repair in two layers f/b continous
bladder drainage as in VVF repair.