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03 genital fistula isam

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fistula

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03 genital fistula isam

  1. 1. Dr Isameldin Elamin MD DOWH MBBS Assistant Professor Obstetrics & Gynaecology department
  2. 2.  Introduction.  Varieties.  Aetiology.  Clinical features.  Prevention.  Investigations.  Treatment.  Post operative instructions.
  3. 3.  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 & genital organs.  Recto-vaginal fistula: between vagina and rectum.
  4. 4.  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).
  5. 5. Fistula
  6. 6. Most common causes of vesicovaginal fistulae are: 1-gynaecological surgery in developed world.  Hysterectomy.(75% of cases).  Anterior colporrhaphy.  Laparoscopic pelvic surgery and urological surgery.
  7. 7. Risk factor during surgery are:  Previous surgery.  Fibroids or endometriosis. 2-pelvic malignancy. 3-pelvic trauma and radiotherapy. 4-obstetric trauma in the developing world. Less common: congenital. Inflammatory.
  8. 8. 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 following surgery.
  9. 9.  History of incontinence immediately or several days after delivery.  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 fistula  Metal catheter or uterine sound – passed through the urethra to appear at the fistulous opening in the vagina
  10. 10.  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
  11. 11.  Urine culture & sensitivity  Renal function test – urea & creatinine  Cystoscopy  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 known.
  12. 12.  Conservative measures.  Complex surgical procedures.  Management of symptoms.  Barrier creams incontinence pads.  Prophylactic antibiotics.
  13. 13. Bladder damage during childbirth:  Catheter for 7-10 days.  Antibiotic coverage. Established fistula:  Wait for 3 months.  Repair. Fistula following cancer:  Biopsy to be taken from the edge of fistula
  14. 14.  Latzko procedure  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.
  15. 15.  Injury of ureter most commonly following surgery:  Obstruction  Transection  Devascularisation
  16. 16.  Total obstruction  Detected early during surgery- removal of ligature and stenting  If detected late, ureter implanted into bladder  Transection  Partial – cystoscopic catheterization & stenting of ureter  Complete – reanastomosis or implantation of cut end to bladder or ureteroneocystostomy
  17. 17.  Usually caused during cesarean section.  Complain of cyclical hematuria.  Treatment is usually through abdominal route 
  18. 18. Causes in developed countries:  Anterior repair.  Vaginal hysterectomy.  Urethral diverticulum or its repair.  Bladder neck suspension procedures. Causes in developing countries:  Childbirth.
  19. 19.  Symptoms:  Higher up in the urethra  Continuous incontinence.  Fistula nearer the bladder neck  Stress incontinence .  Recurrent urinary tract infections.  Lower down  Spraying of urine at micturition or post- micturition dribble.
  20. 20.  Management:  Conservative with a urethral catheter.  Surgical repair in specialist centre.  Repair is most commonly through vaginal route.
  21. 21.  Continous bladder drainage for 14 days  Adequate antibiotics  No vaginal or speculum examination.  No intercourse for 3 months after surgery.  Cesarean section indicated following successful repair.
  22. 22.  Detect high risk factor at the earliest during ANC (contracted pelvis & malpresentation)  Avoid prolonged labor  Avoid unskilled forceps application & risky destructive operations  Detect injury to the bladder at the earliest and treatment of the same.
  23. 23.  Large RVF – incontinence of both faeces + flatus through vagina  Small RVF – incontinence of flatus through vagina  Foul smelling vaginal discharge
  24. 24.  Rectovaginal examination  Proctosigmoidoscopy  Barium enema or CT scan can delineate high RVF
  25. 25.  Pre- and post- operative preparation is very important.  Rectal enema  Low residue fluid diet 5 days before surgery  Intestinal antiseptics- neomycin  Vaginal douche
  26. 26.  Lawson tails’s operation  Cutting remaining bridge of tissue below fistula  Converting fistula into complete perineal tear  Repaired in layers like in complete perineal tear
  27. 27.  Same as described in VVF repair  Alternative procedure is to start as in perineorrhaphy for rectocele and extend the dissection above the fistula
  28. 28.  High RVF usually surrounded by dense fibrosis  Difficult to close vaginally  Best dealt by abdominal (transperitoneal)
  29. 29.  Vulva washed with antiseptic after every micturition  Low residue diet  Intestinal antiseptics  Vaginal pack removed after 24 hrs  Laxatives given to avoid constipation  Elective LSCS at term advised after RVF repair
  30. 30.  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.  http://www.uptodate.com.
  31. 31. Thank You

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