Fistula – it is an abnormal opening or tract
between two adjacent organs or structures.
Genito-urinary fistula – it is an abnormal
communication between the urinary tract &
Recto-vaginal fistula: between vagina and rectum.
Genitourinary fistula has effects on physical
and psychological health of the woman.
Genitourinary fistulae are:
Vesicovaginal (42 per cent)
Ureterovaginal (34 per cent)
Urethrovaginal (11 per cent)
Vesicocervical (3 per cent).
Most common causes of vesicovaginal fistulae are:
1-gynaecological surgery in developed world.
Hysterectomy.(75% of cases).
Laparoscopic pelvic surgery and urological surgery.
Risk factor during surgery are:
Fibroids or endometriosis.
3-pelvic trauma and radiotherapy.
4-obstetric trauma in the developing world.
Less common: congenital. Inflammatory.
Presentation and symptoms:
Incontinence of urine. (Leakage of urine).
Pruritusin the genital region and thighs.
Burning micturition / dysuria.
Complain of increased vaginal discharge if
the fistula is small.
Most common time to present is 5–10 days
History of incontinence immediately or several days
A large fistula can be seen when examining the
patient in left lateral position using sim’s speculum.
Methylene blue dye test – to differentiate between
vesicovaginal, urethrovaginal and ureterovaginal
Metal catheter or uterine sound – passed through
the urethra to appear at the fistulous opening in
3 pieces of swab kept in vagina.
200 cc of dilute methylene blue injected into
bladder via catheter
If upper or middle piece stains blue – vvf
If none of the piece stains blue but is wet
with urine – ureteric
If lower piece stained blue then -urethral
Urine culture & sensitivity
Renal function test – urea & creatinine
CT scan and intravenous urogram (IVU) to
rule out a ureterovaginal fistula.
Palpation of fistula during anaethesia.
Biopsy should be taken if the cause is not
Bladder damage during childbirth:
Catheter for 7-10 days.
Wait for 3 months.
Fistula following cancer:
Biopsy to be taken from the edge of fistula
Flap splitting technique
In case of extensive fibrosis, then omental
grafts or gracilis muscle graft is applied
In case of large and high VVF, trans
peritoneal approach is preferred.
Injury of ureter most commonly following
Detected early during surgery- removal of
ligature and stenting
If detected late, ureter implanted into
Partial – cystoscopic catheterization &
stenting of ureter
Complete – reanastomosis or implantation of
cut end to bladder or ureteroneocystostomy
Usually caused during cesarean section.
Complain of cyclical hematuria.
Treatment is usually through abdominal route
Causes in developed countries:
Urethral diverticulum or its repair.
Bladder neck suspension procedures.
Causes in developing countries:
Higher up in the urethra
Fistula nearer the bladder neck
Stress incontinence .
Recurrent urinary tract infections.
Spraying of urine at micturition or post-
Conservative with a urethral catheter.
Surgical repair in specialist centre.
Repair is most commonly through vaginal
Continous bladder drainage for 14 days
No vaginal or speculum examination.
No intercourse for 3 months after surgery.
Cesarean section indicated following
Detect high risk factor at the earliest during
ANC (contracted pelvis & malpresentation)
Avoid prolonged labor
Avoid unskilled forceps application & risky
Detect injury to the bladder at the earliest
and treatment of the same.
Large RVF – incontinence of both faeces +
flatus through vagina
Small RVF – incontinence of flatus through
Foul smelling vaginal discharge
Barium enema or CT scan can delineate high
Pre- and post- operative preparation is very
Low residue fluid diet 5 days before surgery
Intestinal antiseptics- neomycin
Lawson tails’s operation
Cutting remaining bridge of tissue below
Converting fistula into complete perineal
Repaired in layers like in complete perineal
Same as described in VVF repair
Alternative procedure is to start as in
perineorrhaphy for rectocele and extend the
dissection above the fistula
High RVF usually surrounded by dense fibrosis
Difficult to close vaginally
Best dealt by abdominal (transperitoneal)
Vulva washed with antiseptic after every
Low residue diet
Vaginal pack removed after 24 hrs
Laxatives given to avoid constipation
Elective LSCS at term advised after RVF
Gynaecology by ten teachers 19 editions.
Essential of obstetrics and gynaecology.
Hacker & Moore, fifth edition.
Obstetrics and gynaecology an evidence-
based text for MRCOG second edition.