fistula

1. Dr Isameldin Elamin MD DOWH MBBS
Assistant Professor
Obstetrics & Gynaecology department

2.  Introduction.
 Varieties.
 Aetiology.
 Clinical features.
 Prevention.
 Investigations.
 Treatment.
 Post operative instructions.

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.  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. Fistula

7. 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.

8. 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.

9. 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.

11.  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

12.  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

13.  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.

14.  Conservative measures.
 Complex surgical procedures.
 Management of symptoms.
 Barrier creams
incontinence pads.
 Prophylactic antibiotics.

15. 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

16.  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.

18.  Injury of ureter most commonly following
surgery:
 Obstruction
 Transection
 Devascularisation

19.  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

20.  Usually caused during cesarean section.
 Complain of cyclical hematuria.
 Treatment is usually through abdominal route


22. Causes in developed countries:
 Anterior repair.
 Vaginal hysterectomy.
 Urethral diverticulum or its repair.
 Bladder neck suspension procedures.
Causes in developing countries:
 Childbirth.

23.  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.

24.  Management:
 Conservative with a urethral catheter.
 Surgical repair in specialist centre.
 Repair is most commonly through vaginal
route.

25.  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.

26.  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.

28.  Large RVF – incontinence of both faeces +
flatus through vagina
 Small RVF – incontinence of flatus through
vagina
 Foul smelling vaginal discharge

29.  Rectovaginal examination
 Proctosigmoidoscopy
 Barium enema or CT scan can delineate high
RVF

30.  Pre- and post- operative preparation is very
important.
 Rectal enema
 Low residue fluid diet 5 days before surgery
 Intestinal antiseptics- neomycin
 Vaginal douche

31.  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

34.  Same as described in VVF repair
 Alternative procedure is to start as in
perineorrhaphy for rectocele and extend the
dissection above the fistula

37.  High RVF usually surrounded by dense fibrosis
 Difficult to close vaginally
 Best dealt by abdominal (transperitoneal)

38.  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

39.  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.

40. Thank You